1. D R A F T* UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS) EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS) Hearing and Balance in adults and children (subspecialty of ORL-HNS) Training Programme and Logbook Subspecialty UEMS working group (ORL or affiliated): Eva Raglan (UK) Heikki Löppönen (Finland) Ulf Schönsted-Madsen / Michael Lüscher (DK) Ligija Kise (Latvia) René Dauman (France) and, at earlier step, Kajsa-Mia Holgers With contributions from three EFAS Board members (all PhD) Jan Wouters (Belgium) Martin Kompis (Switzerland) Kurt Stephan (Austria) * To be approved at Dubrovnik (next UEMS section and Board meeting, 3 October 2014)

2. Framework of this training programme Similarly to UEMS ORL-HNS training programme, is expected to serve as a guideline for training centres Main difference with the UEMS ORL-HNS training programme: subspecialty Among characteristics : length of education (6 years for MD, 5 years for ENT, 2 years for subspecialty = 13 years) Can be shortened to 12 years if started last year of ORL-HNS training (cost for society and successful individuals) 2

3. Fields of interest in training Investigation, diagnosis and management of Adults with – disorders of hearing and balance – tinnitus – auditory communication problems The same disorders in Children are part of the programme, though paediatrics is also practised by other medical subspecialties in some countries (all ENT-related: phoniatrics, audiovestibular medicine) and non-medical audiologists in other countries (PhD scientists) 3

4. Overlap with other professions as major issue in audiology Training programmes involving different professions, especially at European level, can soften antagonisms or rivalries Proposals: (1) to include EFAS PhD scientists in this European training programme; (2) to integrate more EFAS PhD scientists in PhD thesis for ORL-HNS trainees (or post-graduates) Such interactions already exist in some countries, but their influence appears rather limited 4

5. This training programme takes account of individual’s overall health (ear is not isolated) Whenever we deal with patients, this basic principle needs to be emphasized, because it is intimately linked to patients’ needs and public health prevention 5

6. Overview of logbook training content 1.Background knowledge i.Basics sciences (partly already taught in former education for ORL-HNS) ii.Preventive medicine iii.Instrumentation (test equipment and rehabilitation) 6

7. i. Basic sciences Auditory and vestibular systems (embryology, physiology, neurochemistry, pharmacology) Age-related changes in postural control Psychology of hearing and balance Repair/regeneration in relation to cochlea and vestibular system (stem cell research, genetic manipulation) Theoretical basis for auditory and vestibular tests Basic acoustics including physics of sound and room acoustics Principles of auditory and vestibular rehabilitation and instrumental rehabilitation (AN stimulation, electroacoustic properties of hearing aids) 7

8. ii. Preventive medicine (public health) Primary, secondary and tertiary prevention Screening for hearing loss (newborn, school, industrial, elderly) Timeline for the support of hearing disorders Noise and its effect on audio-vestibular system, damaging noise-levels, sources of such noise and prevention of exposure Ototoxicity Genetics affecting predisposition to ototoxic agents Epidemiology and prevention of hearing loss Role of immunization and therapy in prevention of hearing and balance disorders 8

9. iii. Instrumentation Practice of hearing and balance specialist requires a comprehensive knowledge of auditory and vestibular test equipment, amplification, including assistive listening devices (FM soundfield systems, loop systems), CROS aids, implantable hearing aids, middle ear, bone conduction and cochlear implants Skills: being able to critically review audiometric and vestibular test results, determine appropriateness and type of amplification (team work), refer appropriately for amplification Practical experience of: selecting devices (team work), measuring benefit of amplification, particles repositioning manoeuvres, instructing patient in appropriate exercises 9

10. Overview of logbook training content 1.Background knowledge 2.Generic skills i.Clinical skills ii.Communication skills iii.Patient approach 10

11. i. Clinical skills History, examination Select/interpret audiological, vestibular, etiological tests appropriate to patient’s presentation, age and additional difficulties Select/interpret multidisciplinary assessments including speech and language, psychometric and physiotherapy Assess disability accurately Management strategies (multidisciplinary team discussion) Identify/suspect additional medical problems (e.g. visual defects, neurological disease, developmental delay, psychological problems, syndromic causes of hearing and balance disorders) 11

12. ii. Communication skills Communicate effectively with patients with all ages, including the children and the elderly – with disorders of hearing – with poor speech production – with visual disorders (deaf-blind) – with those needing sign language or spoken language interpretation Communicate effectively in multidisciplinary team Determine communication abilities and needs of congenitally deaf Counsel patient/parent/career appropriately 12

13. iii. Patient approach Need for empathetic, tactful and positive approach Understand impact of disorders on individual and their family with regard to everyday function (including employment, psychology and social interaction) Importance of social, educational and psychological history Attitudes of those within the Deaf Community Importance of patient confidentiality and informed consent Importance of effective multidisciplinary team work Value of voluntary associations in supporting the patient with hearing and balance 13

14. Overview of logbook training content 1.Background knowledge 2.Generic skills 3.Core fields i.Adult hearing section ii.Adult balance section iii.Pediatric hearing section iv.Pediatric balance section 14

15. i. Adult hearing section (or module) Tinnitus (etiological and triggering factors, current pathophysiological theories, prevalence and natural habituation, audiometric investigation, psychological effects, management) Sudden/fluctuating/progressive hearing loss Unilateral and bilateral hearing loss (impact on patient and significant others, current evidence based pharmacological, audiological rehabilitation, and/or surgical management) Auditory processing disorders, auditory neuropathy/dysynchrony 15

16. i. Adult hearing section (continuing) Congenitally deaf adult (communication, Deaf culture and local support facilities, environmental aids) Hearing problems in the elderly: causes, effects of general ageing on auditory system, other problems affecting rehabilitation (loss of join mobility, blindness, poor memory) Associated problems such as balance disturbance and falls Psychosocial issues (feeling of isolation, avoidance) 16

17. ii. Adult balance module Physiology of vestibular system, its central connections and interactions with the visual and oculomotor systems Clinical presentation of various conditions presenting with dizziness/unbalance Differentiation of peripheral and central vestibular causes of vertigo and definition of site of lesion within CNS Assessment of impact on the individual Factors likely to affect rehabilitation 17

18. ii. Adult balance module (continuing) Acute vertigo Recurrent disequilibrium (sensorimotor physiology involved in balance maintenance, factors hindering vestibular compensation, psychological impact, vestibular tests, management) Chronic imbalance (range of centralvestibular disorders, multisensory imbalance, drugs causing chronic imbalance, management) Drop attacks (mechanisms, investigation, pharmacotherapeutic options, law aspects) Falls in the elderly (pharmacological and physiotherapeutic management option) 18

19. Paediatric auditory and vestibular medicine Normal child development including normal speech and language and balance development, impact of deafness on speech and language development When and to whom to refer children with hearing difficulties and additional problems Principles and practice of screening Value of multidisciplinary working Existence of national/international guidelines and their value and limitations 19

20. Congenital and prelingual deafness Signs, symptoms and presentation Etiology of hearing disorders including involvement of other systems Etiological investigations Impact of deafness on speech and language development, education, social and emotional development of the child, management of deaf child including alternative modes of communication and educational needs Psychological and cultural issues surrounding deafness 20

21. Progressive, sudden or late onset deafness Signs, symptoms, aetiology and management Psychological sequelae Impact of progressive, sudden or late onset hearing loss on speech and communication skills, education and school performance Changing educational needs of the child Appropriate audiovestibular and aetiological investigations When to refer to other allied healthcare professionals Indications, benefits, limitations and side-effects of any medication used for progressive or sudden hearing loss 21

22. Fluctuating hearing loss, including OME Signs and symptoms Aetiology including ear pathology and its pathogenesis, immunology and allergy Impact of OME on emerging speech/language skills/behaviour, balance and its management Impact on education, emotional and social development Current best evidence for medical, audiological and surgical management of fluctuating deafness 22

23. Non-organic hearing difficulties Development/history profile of children presenting with non-organic hearing difficulties Factors in presentation which are commonly seen in non-organic hearing difficulties Correct management of non-organic hearing difficulties When to refer for further medical opinion and to other allied professionals 23

24. Other hearing difficulties in children Auditory processing disorders/ANSD Tinnitus Dyssacuses/Hyperacusis Complex medical/developmental problems Speech and language problems and hearing abnormalities 24

25. Paediatric vestibular medicine Causes of dizziness/ inbalance Childhood presentations of dizziness/ inbalance Developmentally appropriate balance assessment Techniques suitable for investigations of children of different ages/Interpretation Treatment options and vestibular rehabilitation approaches in children 25

26. Overview of logbook training content 1.Background knowledge 2.Generic skills 3.Core fields 4.Practical procedures i.Adult/pediatric hearing disorders ii.Adult/pediatric balance disorders 26

27. i. Adult / paediatric hearing disorders Knowledge on theoretical basis of audiological testing, values-limitations-and practical difficulties of audiological testing Skills: select appropriately / perform and interpret correctly the following audiological tests (pure tone audiometry, behavioral and conditioning techniques for soundfield and ear specific audiometry in learning disabled adults, speech perception tests including speech in noise, objective tests of auditory function, acoustic immittance measures, middle ear reflex measures, OAEs, evoked responses) 27

28. ii. Adult / paediatric vestibular disorders Skills: select appropriately and interpret correctly the following vestibular tests (Dix-Hallpike testing, video-nystagmography, caloric irrigations, posturography, head trust / impulse test, ENG/EOG recording during visuo-vestibular stimulation, vestibular evoked myogenic potentials (VEMPs) etc. Be able to integrate the results of audiological, vestibular and aetiological tests to formulate a diagnosis and a management plan 28

29. Overview of logbook training content 1.Background knowledge 2.Generic skills 3.Core fields 4.Practical procedures 5.Related medical disciplines 29

30. Related medical disciplines Neurology Ophthalmology Psychology/psychiatry Genetics Care of the elderly Immunology and allergy Radiology AUDIOVESTIBULAR MANIFESTATIONS 30

31. Suggestions for training posts Training post must provide the evidence that required supervision and assessments can be achieved The sequence of training should ensure appropriate progression in experience and responsibility The trainees have access to all facilities required to gain practical competencies Trainee has an educational and clinical supervisor Learning through observation, clinical practice, attendance at regional training days, attendance at lectures, tutorials, journal reviews, research projects, regular meetings with educational supervisor 31

32. Suggestions for assessment methods It is expected that trainees will undergo regular assessment of competencies in the various areas of the curriculum covered according to the training requirement of the individual country The integrated assessment system should comprise both workplace assessments and knowledge based assessments Workplace assessments should take place throughout the training program to allow trainee to continually gather evidence of learning and to provide trainee with formative feedback. 32

33. Knowledge Performance Category DateSignature Trainer Anatomy, physiology, neurochemistry, pharmacology of the auditory and vestibular systems, their central pathways, connections and related systems / organs. B Embryology.B Age related changes in postural control and responses to visuo-vestibular stimulation.B Psychology of hearing and balance including psychoacoustics.A Advances in molecular biology: repair / regeneration in relation to the cochlea and vestibular system, stem cell research in relation to the ear, genetic manipulation etc. B A Theoretical basis of auditory and vestibular tests.B A Principles of auditory and vestibular rehabilitation, knowledge of external support agencies, voluntary bodies and policies inclusive of employment support B A Principles of instrumental rehabilitation including auditory nerve stimulation and basic electroacoustic properties of the hearing aids. B A Basics acoustics including physics of sound waves and room acoustics.A Standards relating to acoustics, calibration and sound proofing.A 1 BACKGROUND KNOWLEDGE 1a) BASIC SCIENCES A sound and comprehensive knowledge of the basic sciences subserving the audiological and vestibular systems is essential to practice.