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Dermatologic Evaluation
Chest and Abdomen
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 5: Physical Evidence of Torture and Ill-Treatment > The Physical Examination > Head and Neck

Head and Neck

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Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, must not be mistaken for them.

Lesions are common over bony points, especially the eyebrows and the cheekbones. These may be associated with a fracture of the malar bone (cheekbone). Bruises and scars in the scalp can be difficult to find, especially if the hair is thick. Bruises will normally be tender to touch. Broken or missing teeth are often shown by individuals as evidence of assault, but where the general oral hygiene is poor this usually makes this sign unhelpful. Petechiae of the palate may be evidence of forced oral intercourse. Slaps to the ear can sometimes damage the eardrum. However, the finding of scars of the tympanic membrane (eardrum) does not exclude childhood infections.

Eyes

Conjunctival hemorrhage, lens dislocation, subhyeloid hemorrhage, retrobulbar hemorrhage, retinal hemorrhage, and visual field loss may all be observed following torture. Referral to an ophthalmologist is recommended whenever there is a suspicion of ocular trauma or disease.

Ears

Blunt trauma to the external ear may result in haematoma. Cartilage necrosis and infection are likely sequelae if the ear is left untreated. Lacerations of the pinna vary from those of minor significance to complete amputation. Rupture of the tympanic membrane is a frequent consequence of harsh beatings. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 mm in diameter, as they can heal within 10 days. About 80% of traumatic tympanic membrane perforations diagnosed within 14 days of injury will have healed spontaneously.

The short and long term sequelae of significant injury to the middle and inner ear are hearing loss, vertigo, tinnitus, unsteadiness and, less commonly, facial nerve paralysis. An audiogram should be performed to assess injury to the ossicles and inner ear. A conductive hearing loss is usually due to a tear in the tympanic membrane and blood in the middle ear. A hearing loss of less than 40 dB suggests an ossicular chain dislocation. Sensorineural loss indicates cochlear or retrocochlear damage.

Fluid may be observed in the middle and/or external ear. If otorrhea is confirmed by laboratory analysis to be CSF (cerebrospinal fluid), then MRI or CT should be performed, if possible, to determine the fracture site. The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best determined by CT, then hypocycloidal tomography, and lastly linear tomography.

Nose

The nose should be evaluated for alignment, crepitation, and deviation of the nasal septum. Initially soft tissue swelling may make interpretation difficult and it may be necessary to re-examine nose after 48 hours when this has subsided. Frequently there is an associated deviation of nasal septum which may result in nasal obstruction. For simple nasal fractures, standard nasal radiographs should be sufficient. Sometimes the fracture of the nasal bone includes the frontal process of the maxilla, and sometimes it extends to include ethmoid labyrinth. For complex nasal fractures and when the cartilaginous septum is displaced, and when rhinorrhea is present, CT and/or MRI are recommended.

Jaw, Oropharynx and Teeth

The oral cavity must be carefully examined. During the application of electric current to the mouth, the tongue, gingiva or lips may be bitten. Lesions might also be produced by forcing objects or materials into the mouth. Temporomandibular joint syndrome can be caused by electric current and blows to the face. It will produce pain in the temporomandibular joint, limitation of jaw movement, and in some cases subluxation of this joint.

A careful dental history should be taken and, if dental records exist, these should be requested. The patient should be referred to a dentist if there is any damage to the teeth. Mandibular fractures, avulsions or fractures of the teeth, broken prostheses, swelling of the gums, bleeding, pain, or loss of fillings from teeth can all result from direct trauma or electric shock torture. Dental caries and gingivitis should also be noted. Poor quality dentition may be due to conditions in detention, or may have preceded it. X-rays and MRI are suggested for determining the extent of soft tissue, mandibular and dental trauma.

Dermatologic Evaluation
Chest and Abdomen
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  • Istanbul Protocol Model Medical Curriculum

    • Preface
      • Copyright and Acknowledgements
      • Resources
      • Glossary
    • Introduction
      • Curriculum Materials
      • Summary of Content
      • How to Use These Educational Resources
    • Module 1: International Legal Standards (Overview)
      • Torture
        • What is Torture
        • Purpose of Torture
        • History of Torture
        • Other Definitions
        • Cruel Inhuman & Degrading Treatment & Punishment (CID)
        • Prohibition of Torture in International Law
        • The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984
        • Torture in the World Today
        • Country-Specific Legal Standards and Torture Practices
        • The Perpetrators
        • Common Situations for Torture Allegations
        • Where Does Torture and Ill-treatment Occur?
        • Obligation to Investigate and Bring Justice
        • Formal Inspection of Detention Facilities
        • Official Complaints to Human Rights Bodies and Other Organizations
        • Recently Released Detainees
        • NGO Information Gathering
        • Late Allegations
      • Prevention and Accountability
        • Prevention
        • Accountability
        • Reparation
      • International Supervisory Machinery and Complaints Procedures
        • The Human Rights Committee
        • The UN Committee against Torture
        • Regional Mechanisms
        • Other monitoring mechanisms
        • The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment
        • International criminal courts and tribunals
        • The International Committee of the Red Cross (ICRC)
      • Safeguards Against Torture for Those Deprived of Their Liberty
        • Notifying people of their rights
        • Use of officially recognized places of detention and the maintenance of effective custody records
        • Avoiding incommunicado detention
        • Humane conditions of detention
        • Limits on interrogation
        • Access to a lawyer and respect for the functions of a lawyer
        • Access to a doctor
        • The right to challenge the lawfulness of detention
        • Safeguards for special categories of detainees
      • Module 1 Presentation: International Legal Standards
      • Self-Assessment and Quiz
        • Module 1 Answers
    • Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • The Istanbul Protocol
        • About the Istanbul Protocol
        • Brief History
        • International Recognition of the Istanbul Protocol
      • An Overview of the Istanbul Protocol
        • Legal Investigation of Torture
        • General Considerations for Interviews
        • Physical Evidence of Torture
        • Psychological Evidence of Torture
        • Interpretation of Findings and Referrals
        • Misuse of the Istanbul Protocol
        • Procedural Safeguards for Detainees
      • Medical Ethics
        • Introduction
        • Duties of the health professional
        • International Codes
        • Ethical rules directly prohibiting involvement in torture
        • Primary loyalty to the patient
        • Dual Obligations
        • The treatment of prisoners and detainees
        • Issues surrounding examinations of individuals in the presence of security forces
        • Abusive medical treatment
        • Consent and confidentiality
        • Security
        • Involvement of other health professionals in torture
        • Seeking further information and support
        • Country-specific legal responsibilities of health professionals for forensic documentation of torture and ill-treatment
      • General Guidelines for Gathering Evidence and Documenting Findings
        • The aims and goals of investigation
        • Multidisciplinary approach to documentation
        • Role of the health professional in the team
        • Role of the lawyer in the team
        • Role of the NGO member in the team
        • Role of judges and prosecutors
      • Documenting the allegations
        • The aim of medical documentation
        • Types of evidence
        • Medical evidence
        • Gathering of evidence
        • Essential information
        • Quality of information
        • Comparing records
      • Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • Self-Assessment and Quiz
        • Module 2 Answers
    • Module 3: Interview Considerations
      • Preliminary Considerations
        • Purpose of Medical Evaluations
        • Interview Settings
        • Trust
        • Informed Consent
        • Confidentiality
        • Privacy
        • Empathy
        • Objectivity
        • Safety and Security
        • Procedural Safeguards for Detainees
        • Risk of Re-traumatisation
        • Gender Considerations
        • Interviewing Children
        • Cultural and Religious Awareness
        • Working with Interpreters
        • Transference and Counter-Transference Reactions
      • Conducting Interviews
        • Types of questions
        • Cognitive Techniques
        • Summarising and clarifying
        • Difficulties Recalling and Recounting
        • Assessing Inconsistencies
      • Interview Content
        • Identification and Introduction
        • Psychosocial History (Pre-Arrest)
        • Past Medical History
        • Summary of Detention(s) and Abuse
        • Circumstances of Detention(s)
        • Prison/Detention Place Conditions
        • Allegations of Torture and Ill-treatment
        • Review of Symptoms
        • Psychosocial History (post-arrest)
        • Assessments of Physical and Psychological Evidence
        • Physical Examination
        • Closing
        • Indications for Referral
      • Module 3 Presentation: Interview Considerations
      • Self-Assessment and Quiz
        • Module 3 Answers
    • Module 4: Torture Methods and their Medical Consequences
      • Introduction
      • Torture Methods
        • Beatings/Falanga
        • Ear Trauma
        • Eye Trauma
        • Restraint, Shackling and Positional Torture
        • Suspension
        • Crushing and Stretching Injuries
        • Burning
        • Electrical injuries
        • Asphyxiation
        • Violent Shaking
        • Sexual Assault
        • Sexual Humiliation
        • Prolonged Isolation and Sensory Deprivation
        • Sleep Deprivation
        • Temperature Manipulation
        • Sensory Bombardment
        • Threats of Harm
      • Psychological Consequences of Torture
        • Introduction
        • The Paradox of Psychological Consequences of Torture
        • The Psychological Consequences of Torture
        • Social, Political and Cultural Context
        • Risk factors for Trauma and Torture-Related Disorders
        • Psychological Symptoms
      • Module 4 Presentation: Torture Methods and their Medical Consequences
      • Self-Assessment and Quiz
        • Module 4 Answers
    • Module 5: Physical Evidence of Torture and Ill-Treatment
      • Physical Evidence of Torture
        • Medical history
      • The Physical Examination
        • Dermatologic Evaluation
        • Head and Neck
        • Chest and Abdomen
        • Musculoskeletal System
      • Neurological Examination
        • Head Trauma and Post-traumatic Epilepsy
        • Nerve Damage
      • Examination of Women
        • Examination Following a Recent Assault
        • Examination After the Immediate Phase
        • Follow-up
        • Genital Examination of Women
      • Genital Examination of Men
      • Perianal Examination
      • Medical Photography
        • Assessment for Referral
      • Diagnostic Tests
      • Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 5 Answers
    • Module 6: Psychological Evidence of Torture and Ill-Treatment
      • The Central Role of the Psychological Evaluation
        • Conducting the Psychological Evaluation
        • Psychological Findings and Diagnostic Considerations
        • Components of the Psychological/Psychiatric Evaluation
      • Children and Torture
        • Introduction
        • Developmental Considerations
        • Clinical Considerations
        • Role of the Family
      • Apendix I: Sample Psychological Evaluations
        • Psychological Evaluation #1
        • Psychological Evaluation #2
      • Apendix II: ICD-10
      • Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 6 Answers
    • Module 7: Case Example #01
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 7 Presentation: Case Example #01
      • Self-Assessment and Quiz
        • Module 7 Answers
    • Module 8: Case Example #02
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 8 Presentation: Case Example #02
      • Self-Assessment and Quiz
        • Module 8 Answers
    • Module 9: Report Writing and Testifying in Court
      • Written Reports
        • General Considerations
        • Content of Written Reports
        • Conclusions
        • Inconsistencies
      • Providing Testimony in Court
      • Appendix: Court Testimony Guidelines and Maxims
      • Module 9 Presentation: Report Writing and Testifying in Court
      • Self-Assessment and Quiz
        • Module 9 Answers
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