Otolaryngology fantastica: the ear, nose, and throat manifestations of Munchausen's syndrome

[Psychosomatic aspects in otorhinolaryngology-historical milestones]

BACKGROUND

This investigation examined the development of psychosomatics in the field of otolaryngology in Germany using the examples of psychogenic deafness and chronic tinnitus by means of literature research. The focus of the study was on the period 1948-2022.

METHODS

A literature search was carried out in the PubMed database from 1948 and antiquarian ENT textbooks were evaluated. The search terms used were "ENT and psychosomatics," "tinnitus," "retraining therapy," "analytical psychology," "behavioral therapy," and "sensory systems."

RESULTS

Psychosomatic phenomena were mentioned in the treatment of nasal diseases and ear ailments in writings of Byzantine and medieval medicine. Even older are references to tinnitus in ancient Egyptian and Indian scripts. From the nineteenth to the mid-twentieth century, psychological abnormalities in ENT symptoms were assigned to the term hysteria. From the middle of the twentieth century, a paradigm shift in the assessment of psychosomatic disorders in otolaryngology became apparent. In the 1950s, a broad psychosomatic discussion was opened in individual lectures and book contributions on mental abnormalities in ENT diseases. With the implementation of the Psychosomatics Working Group of the German Society of Otorhinolaryngology, Head and Neck Surgery, psychosomatics in the field of ENT received the framework for scientific and clinical activity at the turn of the millennium. Psychosomatics is scientifically represented and part of the continuing education regulations for otolaryngology in Germany and at European level. It shows high standards in research, qualification of otolaryngologists, and patient care.

CONCLUSION

As of 2022, psychosomatics in otolaryngology has been steadily developing for over 70 years. The standards achieved are to be further expanded and research on cognition, affectivity, and sensory analogies intensified.

Recurrent ear bleed with profound bilateral sensorineural hearing loss: A case of Munchausen syndrome

Factitious disorders and Munchausen syndromes present with history and physical symptoms to all specialties, and they are often extensively evaluated. Diagnosis of Munchausen syndrome is a challenge and patients often do not receive the correct diagnosis and appropriate care especially in settings where access to mental health professionals is difficult. We present a case of recurrent bleed from the right ear, bilateral profound hearing loss and jerky movement of limbs that was extensively evaluated and followed up for 4 years until a diagnosis of Munchausen syndrome was reached. This case reports the risk of harm to the patient and wastage of healthcare resources unless physicians begin to actively evaluate for factitious disorders.

Unexplained destructive nasal lesions in half-brothers: A possible case of Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) is a condition diagnosed when a caregiver knowingly fabricates or inflicts illness on another for his/her own gain. Typical cases of MSBP detected by otolaryngologists involve facial trauma or otologic injury, while descriptions involving the nose are rare. Destructive nasal lesions have a broad differential diagnosis and may require visits to numerous specialists, placing strain on both the patient and the healthcare system. Early recognition of MSBP in patients with chronic nasal destruction may prevent such unnecessary strain. We present a case of MSBP involving two half-brothers with unexplainable nasal destruction and discuss the literature and current recommendations for managing the diagnosis.

Factitious disorder: a systematic review of 455 cases in the professional literature

OBJECTIVE

Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature.

METHOD

A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD.

RESULTS

A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD.

CONCLUSIONS

Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Sensorineural Hearing Loss Associated with a Factitious Disorder

Factitious disorders are characterized by intentionally abnormal physical and/or psychological behavior, and affected patients often make up their symptoms and clinical histories. The most serious and chronic type of factitious disorder is Munchausen syndrome. We report the case of a 24-year-old woman with a 2-year history of sensorineural hearing loss (SNHL) who later confessed to feigning her hearing loss. She was eventually diagnosed with a factitious disorder. During those 2 years, she was able to induce her SNHL by exposing herself to excessive noise or high doses of aspirin. To the best of our knowledge, this is the first report describing an association between a factitious disorder and SNHL.

Fabricated or induced illness in the oral cavity in children. A systematic review and personal experience

Introduction

Münchausen syndrome by proxy (MSBP) describes a pattern in which a caregiver induces a disease in a child. The symptoms may manifest in the oral cavity.

Material and methods

PubMed was researched for articles between 1990-2014, presenting manifestations of MSPB, following PRISMA 2009 guidelines, and an in-house case of MSBP with oral manifestations was presented.

Review

Among 66 articles presenting MSBP symptoms, four included descriptions of oral lesions in five children. They included: tooth loss, ulcerations and ulcers on oral mucosa, scars due to old, healed lesions, bleeding, black tongue, polysialia, and discolouration and swelling in the lips. Münchausen syndrome by proxy with participation of the mother was diagnosed in four cases.

Case

A 13-year-old girl was hospitalised because of a non-healing ulcer of the septum, loose and lost mandibular teeth, skin lesions, and suspected immunodeficiency. She had been hospitalised numerous times at other facilities. Consultations and diagnostic tests did not confirm an organic disease. The patient and her mother agreed to undergo all examinations, and some symptoms ‘went away’ during the examinations. The behaviour of the patient and her mother during hospital stays, ambulatory care, and the psychiatric observations all pointed towards MPSB. They refused further treatment at the present facility.

Conclusions

A dentist should take into account the potential ‘fabrication’ of symptoms in a child by the latter or by a caregiver. Consultations with a paediatrician or psychiatrist enable a diagnosis and treatment.

Munchausen syndrome by adult proxy: a review of the literature

BACKGROUND

Munchausen syndrome by proxy (MSBP), more formally known as factitious disorder imposed on another, is a form of abuse in which a caregiver deliberately produces or feigns illness in a person under his or her care so that the proxy will receive medical care that gratifies the caregiver. Although well documented in the pediatric literature, few cases of MSBP with adult proxies (MSB-AP) have been reported. This study reviews existing literature on MSB-AP to provide a framework for clinicians to recognize this disorder.

METHODS

We searched Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO, supplemented by bibliographic examination.

RESULTS

We identified 13 cases of MSB-AP. Perpetrators were caregivers, most (62%) were women, and many worked in healthcare. The age range of the victims was 21 to 82 years. Most were unaware of the abuse, although in 2 cases the victim may have colluded with the perpetrator. Disease fabrication most often resulted from poisoning.

CONCLUSIONS

MSB-AP should be included in the differential diagnosis of patients presenting with a complex constellation of symptoms without a unifying etiology and an overly involved caregiver with suspected psychological gain. Early identification is necessary so that healthcare providers do not unknowingly perpetuate harm through treatments that satisfy the perpetrator's psychological needs at the proxy's expense.

Munchausen syndrome by proxy presenting as hearing loss

Objective:

To review the diagnosis of Munchausen syndrome by proxy, a factitious disorder, in which symptoms are induced or feigned, usually in a child, by the caregiver. The involved caregiver seeks to gain attention or sympathy and often has a psychological need to maintain the sick role. We highlight the diagnostic difficulties and factors that may help with diagnosis in an otolaryngology setting.

Method:

We present the case of Munchausen syndrome by proxy presenting with hearing loss in a five-year old boy, who was diagnosed eight years after his initial presentation. A literature review of Munchausen syndrome by proxy cases presenting with ENT symptoms is provided.

Conclusion:

Munchausen syndrome by proxy is a diagnosis that otolaryngologists should be aware of, particularly where recurrent or persistent illnesses in children, especially those involving otological symptoms, are refractory to the usual treatments.