1. D R A F T UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS) EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS) Hearing and Balance in adults Training Programme and Logbook October 2012 / revised October 2013/August 2014 Subspecialty working group: Kajsa-Mia Holgers Ligija Kise Ulf Schönsted-Madsen Rene Dauman Heikko Löppönen Eva Raglan

2. Consensus curriculum This document presents the contents of the hearing and balance and peadiatric audiovestibular modules based on the curriculum for audiovestibular medicine, specialty concerned with investigation, diagnosis and management of disorders of balance, hearing,tinnitus and auditory communication. The aim of the curriculum is to define the core competencies including knowledge, skills and attitudes for a specialist practicing that subject as applied to adults and childrfen ( subdividing it into basic and advanced parts ) Basic section is to be used primarily within general ORL speciality training curriculum and advanced section would constitute the curriculum for the additional years of training. Paediatric audiology although an integral part of audiovestibular medicine in some countries,is practiced separately in the others or in conjunction with phoniatrics in some other countries.

3. Curriculum General internal medicine and neurosciences form the basic foundations for Hearing and Balance module. Modern care for hearing and balance disorders requires the whole system approach in which the “ ear “ problem is not considered in isolation but as part of the patient’s overall health. Multidisciplinary team

4. Curriculum This curriculum adapted from the Audiovestibular Medicine Curriculum of the Royal College of Physicians of England 2010/2013, comprises two main fields of clinical practice, that of Adult/ Child Hearing and Balance/Vestibular. In addition and common to all the fields are the background knowledge, generic skills and experience in related medical disciplines. Training in those specific areas can occur either before or during specialist training. This training program is a guide for trainers and trainees, and is endorsed by the International Association of Audiovestibular Physicians.

5. CONTENT -logbook of training sections 1.Background Knowledge i.Basic Sciences ii.Preventive Medicine iii.Instrumentation 2.Generic skills i.Clinical skills ii.Communication skills iii.Patient approach 3.Core Fields i.Adult Hearing Section ii.Adult Balance Section 4.Practical procedures i.Adult hearing disorders ii.Adult balance disorders

6. CONTENT 5 Related medical disciplines i.Otorhinolaryngology ii.Neurology iii.Ophthalmology iv.Psychology/ psychiatry v.Genetics vi.Care of the elderly vii.Immunology and allergy viii.Radiology 6.Pediatric Hearing Module 7. Knowledge, skills 8.Pediatric Vestibular Module 9.Learning and teaching, training programs i.Diploma in Audiovestibular medicine ( relevant modules) ii.Requirements of training posts 7. Assessments

7. 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.

8. Knowledge Performance Category DateSignature Trainer General principles of primary, secondary and tertiary preventionB Screening principles, methods and practice; including setting up a screening programme, dealing with screen failures, monitoring and audit. B A Screening for hearing loss — newborn, school, industrial, elderly etc.A Timeline for the support of hearing disorders.A Noise and its effect on the audio-vestibular system, damaging noise levels, sources of such noise and prevention of exposure including noise surveys, hearing conservation, ear protection and international standards B A Ototoxicity; substances, drugs, industrial toxins that affect the audio-vestibular system and their effects. B A Genetics affecting predisposition to ototoxic agents.A Epidemiology and prevention of hearing loss.B A Role of immunization and therapy in the prevention of hearing and balance disorders.B A 1 b) PREVENTIVE MEDICINE

9. Knowledge Performance Category DateSignature Trainer Principles, technology and limitations of auditory and vestibular test equipment.B A Principles, function of analogue, digital hearing aids, including body worn, post aural, in the ear, in-the-canal, totally-in-the-canal, vibrotactile aids, bone-anchored hearing aids, frequency compression,frequency transposition aids, CROS (contralateral routing of signal) and BICROS aids and implantable hearing aids including middle ear, bone conduction and cochlear implants B A Hearing aid fitting formulae and real ear measurements.A The effects of various parts of hearing aid system (hooks, moulds, tubing etc) on sound amplification. A Assistive devices available including the radio aid and FM soundfield systems, alarm systems, loop systems. B A Methods of assessing benefit of amplification.A 1 c) INSTRUMENTATION Practice of hearing and balance specialist requires a comprehensive knowledge of auditory and vestibular test equipment, amplification, including assistive listening devices.

10. Skills: To be able to Perform ance Category DateSignature Trainer Critically review audiometric and vestibular test results B A Determine the appropriateness / type of amplification (including cochlear implant) through discussion with audiological colleagues, patients B A Discuss the current best technology with patients, their families, and other professionals B Refer appropriately for amplification B To have practical experience of: Perform ance Category DateSignature Trainer Selecting various hearing aids, devices including BAHA and cochlear implants B A Measuring benefit of amplification, inclusive of active middle ear and bone conduction implants B A Particles repositioning manoeuvres egg. Epley, Semont etc. Instructing the patient in appropriate exercises e.g. Cawthorne- Cooksey, Brandt- Daroff, customised/ protocols for visual vertigo B A 1.c) INSTRUMENTATION Continued

11. Clinical Skills: To be able to: Performance Category DateSignature Trainer History Take detailed history of auditory and vestibular disorders and associated problems including a developmental or psychosocial history. B A Examination Perform clinical examination, ENT, neuro-otological, oculomotor, neurological. B A Select / interpret Audiological, vestibular, etiological tests appropriate to the patient’s presentation, age and additional difficulties. B A Select/ interpret Appropriate multidisciplinary assessments including speech and language, psychometric or physiotherapy assessment. B A Integrate The history, examination, investigative findings, formulate a diagnosis and management plan. B A Management strategies Select appropriate management strategies through multidisciplinary team discussion and discussion with the patient and careers; e.g. hearing aids, tinnitus instruments, cognitive therapy, relaxation, pharmacological options, physiotherapy, occupational therapy, educational strategies, surgical options - depending on the cause and impact of the problem and the age and additional disabilities of the patient. B A The impact of a management Assess the impact of a management strategy using appropriate outcome measures B A Disability Assess disability accurately and judge occupational fitness e.g. use of machinery and fitness to drive B A Identify additional medical problems which may be causative or may adversely affect rehabilitation e.g. visual defects, neurological disease, endocrine disease, joint pathology, cardiac disease, developmental delay B A Identify psychological problems needing psychology/psychiatric referral. B A Identify syndromic and genetic causes of hearing and balance disorders. Elicit sensitive information from the parent/patient relevant to management B A 2. GENERIC SKILLS Aside from the generic skills required of all practicing doctors there are specific required generic skills These are an integral part of training in all aspects of the work.

12. 2 b Communication Skills: to be able to: Performance Category DateSignature Trainer Communicate effectively with patients of all ages, including the children and elderly. B A o with disorders of hearing B A o with poor speech production due to deafness or other disorders of speech and language B A o with visual disorders including the deaf-blind B A o with intellectual disability B A o With those needing sign language or spoken language interpretation B A Communicate effectively with colleagues within the multidisciplinary team and with specialists in other disciplines B A Determine the communication abilities and needs of the congenitally deaf and the deaf/blind patient and where needed use finger spelling and some basic signs B A Counsel the patient/parent/ carer appropriately B A 2. GENERIC SKILLS - Continued

13. The need for an empathetic, tactful and positive approachPerformance Category DateSignature Trainer The impact of disorders of hearing and balance on the individual and their family with regard to everyday function including employment, psychology and social interaction B A The impact of disorders of hearing on the development and maintenance of speech and language and education B A The combined effect of deafness or /and balance, dizziness disorders with other difficulties, such as visual defects, learning disability etc. B A The importance of holistic care The importance of the history including family history & developmental history in making a diagnosis. B A The importance of a social, educational and psychological history in managing individuals with audiovestibular impairment. B A Referral routes of patients with hearing/ dizziness/balance problems egg psychology, social services, neurology, cardiology, ophthalmology, physiotherapy, occupational therapy. B A The importance of education of significant others to aid rehabilitation.B A The value of multidisciplinary team working both within and outside the clinic.B A The attitudes of those within the Deaf Community.B A The use and value of complementary medical approaches to holistic management of tinnitus and of otitis media with effusion. B A The importance of patient confidentiality and informed consent.B A The importance of effective multidisciplinary team work and communication with colleagues both verbally and in writing. B A The importance of sharing information with patients and their careers The existence of national guidelines and their values and limitations. B A The value of voluntary agencies in supporting the patient with hearing and balance disorders and their family/careers. B A 2.C Patient Approach The specialist must recognize and understand:

14. 3. CORE FIELDS 3.i. Adult “ Hearing” module ( inclusive of adolescents, younger, older adults and elderly) 3.i.i Clinical Topics - Knowledge Base TinnitusPerformance Category DateSignature Trainer Etiological and triggering factors B A Current pathophysiological theories about tinnitus generation B A Prevalence of tinnitus and its natural history of habituation. B A Audiometric and etiological investigations B A Psychological effects on the patient and how these can be managed B A Management of patients with tinnitus including instrumentation B A Sudden hearing lossPerformance Category DateSignature Trainer Presentation and causes. B A Audiological and etiological investigations B A The psychological impact of sudden hearing loss, particularly if permanent and bilateral. B A Current evidence based management of acute presentation B A Management including indications for surgery, amplification, communication strategies and hearing tactics B A

15. Unilateral hearing loss, progressive or fluctuating unilateral or bilateral hearing loss. Performance Category DateSignature Trainer Presentation and causes B A Audiometric and etiological investigations B A Identification of site of lesion B A Impact on the patient and significant others B A Current evidence based pharmacological,audiological rehabilitative or / and surgical management B A Clinical Topics - Knowledge Base - Continued

16. Dysacuses, auditory processing disorders (APD) and auditory neuropathy/dysynchrony (AN/AD) Performance Category DateSignature Trainer Presentation and causes of dysacuses, APD and AN/ADA Investigation and management of dysacuses and their causesA Methods of testing the function of the different parts of the central auditory pathway A The rehabilitative approaches available for APD and AN/ADA The psychosocial effects of these hearing difficultiesA Intellectually disabled adult Performance Category DateSignature Trainer Audiological or neuro-otological problems that may be associated with intellectual handicap and the specific effects that such problems may have A Presentation, diagnosis, investigation and management of hearing problems in adults with learning difficulties A Rehabilitative approaches available for such patientsA Issues concerning ‘consent’ in these patientsA Clinical Topics - Knowledge Base - Continued

17. Congenitally deaf adult Performance Category DateSignature Trainer Causes of congenital deafness/hearing impairment B A Effects on speech & language and communication B A Impact on individuals and significant others, including psychosocial effects B A Associated symptoms such as tinnitus or balance difficulties B A Alternative communication systems A Deaf culture and the local support facilities for deaf people A Hearing aids and environmental aids B A Rapid advances in the research of genetic deafness and its impact on patient management A Hearing problems in the elderly Performance Category DateSignature Trainer Causes of hearing impairment in the elderly. B A Effects of the general ageing process on the auditory system B A General medical problems or other impairments which might affect rehabilitation e.g. Loss of tactile sensitivity, joint mobility, blindness, poor memory B A Associated problems such as balance disturbance and falls B A Psychosocial issues including feelings of isolation and avoidance B A Rehabilitative approaches in the elderly ( inclusive of auditory and vestibular) B A External support agencies, voluntary bodies and policies e.g. Social workers B A Clinical Topics - Knowledge Base - Continued

18. Background Knowledge Specific to the Field Performance Category DateSignature Trainer The anatomy and physiology of the vestibular system, its central connections and interactions with the visual and oculomotor systems. An understanding of vestibular test equipment, investigative techniques, selection of appropriate set of investigations and interpretation of results B A Clinical presentation of various conditions presenting with dizziness/ unbalance Differentiation of peripheral from central vestibular causes of vertigo and definition of site of lesion within CNS Assessment of impact of the balance disorder on the individual Factors likely to affect rehabilitation B A 3b. Adult “ Balance “ Module

19. Acute vertigo Performance Category DateSignature Trainer Causes, presentation and natural history of acute vertigo B A Associated eye movement abnormalities B A Audiovestibular and etiological investigations B A Management options, including rehabilitation, dietary manipulation, pharmacological and surgical B A Recurrent disequilibrium Performance Category DateSignature Trainer The sensorimotor physiology involved in balance maintenance B A Causes of peripheral and central vestibular disorders with remitting and relapsing courses B A Factors hindering vestibular compensation including pathology in other stabilizing sensory and motor effector systems B A The psychological impact of recurrent disequilibrium B A Vestibular tests and etiological investigation B A Management options including pharmacological, physical rehabilitation and psychological /psychiatric interventions B A Adult Balance - Clinical Topics - Knowledge Base

20. Chronic imbalance Performance Category DateSignature Trainer The range of central vestibular disorders causing chronic imbalanceA Pathology in the stabilizing sensory systems which give rise to multisensory imbalance A Pharmacotherapeutic agents causing chronic imbalanceA Etiological and vestibular investigationsA Management optionsA Adult Balance - Clinical Topics - Knowledge Base Blackouts/drop attacks Performance Category DateSignature Trainer The mechanisms of epilepsy, pseudo-epilepsy, syncope, vasovagal attacks, and blackouts, and to know the etiological factors involved A The investigation protocol and type of abnormalities found for each of the above A The pharmacotherapeutic options available to treat each causeA The law regarding black-outs and syncope and fitness to driveA

21. Falls in the elderly Performance Category DateSignature Trainer The effects of ageing and neurological disorder on the postural and righting reflexes A The causes of black-outs and drop attacks including cardio- and cerebrovascular pathology A The musculo-skeletal disorders impairing maintenance of the upright posture and locomotion A Audiovestibular and etiological investigations A The pharmacological and physiotherapeutic management options A

22. Knowledge: Performance Category DateSignature Trainer Theoretical basis of audiological testing (See Basic Sciences section ) Indications for the various audiological tests Values, limitations and practical difficulties of audiological testing 5. PRACTICAL PROCEDURES a.– specialist in adult hearing disorders

23. Skills Performance Category DateSignature Trainer Select appropriately and interpret correctly all the following audiological tests. B A Practical experience of all the following tests. Competency in performing particular tests will depend on the specific clinical practice of the country. A o Psychoacoustic tests of hearing and auditory function: o Pure tone audiometry (air conduction, bone conduction with or without masking) A o Behavioral and conditioning techniques for soundfield and ear specific audiometry in learning disabled adults A o Speech perception tests including speech in noiseA o Tests of auditory processingA o Objective tests of auditory function o Acoustic immitance measures and middle ear reflex measuresA o Otoacoustic emissions (transient, distortion product, spontaneous, contra- lateral suppression) A o Evoked responses (electro-cochleography, auditory brainstem responses, middle latencies, cortical responses, auditory steady state responses etc) A a. PRACTICAL PROCEDURES – specialist in adult hearing disorders - Continued

24. Knowledge: Performance Category DateSignature Trainer Theoretical basis of vestibular testing( see Basic Sciences section ) B A Indications for vestibular testing B A Values, limitations and practical difficulties of vestibular testing in adults. A Skills: Performance Category DateSignature Trainer To be able to select appropriately and interpret correctly all the following vestibular tests in adults. B A To have practical experience of all the following tests. Competency in performing particular tests will depend on the specific clinical practice of the country A o Dix-Hallpike testing B A o Video-nystagmography A o Caloric irrigations A o Posturography, Head trust test, Visual Dynamic Acuity A o ENG/EOG recordings during visuo-vestibular stimulation A o Vestibular evoked myogenic potentials (VEMPs, cervical and ocular) A To be able to integrate the results of audiological, vestibular and aetiological tests to formulate a diagnosis and a management plan B A b. PRACTICAL PROCEDURES- Specialist in adult balance / vestibular disorders

25. Objectives: Performance Category DateSignature Trainer To gain a detailed knowledge of pathology and management of otological conditions To observe audiology related ENT surgery such as grommet insertion, mastoidectomy, tympanoplasty, cochlear implantation, bone anchored hearing aids vestibular schwannoma. To be experienced and competent in use of ENT referral criteria To gain knowledge of rhinological, oropharyngeal, upper airway and other head & neck conditions that may affect the audiovestibular system and speech. Knowledge: Performance Category DateSignature Trainer Embryology, anatomy, physiology of the ear and head & neck Pathology, appropriate investigations (including imaging) and management of congenital, acquired and other conditions of the ear including indications, risks, outcomes and complications of surgery Head and neck conditions that may produce aural symptoms including conductive hearing loss, and their appropriate management 6. RELATED MEDICAL DISCIPLINES 6 a OTORHINOLARYNGOLOGY(requirement in relation to training program of specialist in audiovestibular disorders)

26. Skills: To be able to: Performance Category DateSignature Trainer Take a full otological/ENT history relevant to the audiovestibular system and speech. Perform an accurate and comprehensive examination of the ear, nose, oral cavity, pharynx and head & neck including use of otoscope, operating microscope, head mirror Identify and treat causes of otalgia, external and middle ear dysfunction. Perform intratympanic injections of medications To be competent at: Performance Category DateSignature Trainer Removal of wax and debris from the external auditory canal using appropriate instruments, syringing or suction either under direct vision or using the operating microscope as appropriate a, OTORHINOLARYNGOLOCY - Continued

27. Objectives Performance Category DateSignature Trainer To make an accurate neurological assessment of a patient To know when to refer a patient to a neurologist or a neurosurgeon Knowledge Performance Category DateSignature Trainer Causes of central audiological and vestibular disorders Neurological disorders with neuro-otological manifestations Investigation protocols for the above disorders Pharmacological treatments and side-effects of common neurological disorders with neuro-otological manifestations Skills: To be able to: Performance Category DateSignature Trainer Take a complete neurological history and perform competently a full neurological examination Recognise neuro-otological manifestations of neurological disorders and select appropriate investigations b. NEUROLOGY

28. Objectives: Performance Category DateSignature Trainer To know how to screen a patient for ophthalmological and oculomotor disorders To know when to refer a patient with such symptoms Knowledge: Performance Category DateSignature Trainer Ophthalmological disorders with associated audiological and neuro-otological manifestations Eye movement disorders Impact of visual disorders on balance and the confounding effect upon vestibular test procedures Impact of visual problems on communication for the hearing impaired Management of common visual problems Causes, impact and management (including the role of voluntary bodies) of dual sensory impairment Skills: To be able to: Performance Category DateSignature Trainer Take a history of ophthalmological symptoms from a patient Make an accurate assessment of a strabismus, latent nystagmus, saccades, smooth pursuit, spontaneous and optokinetic nystagmus Perform a full ophthalmological examination and correctly recognise optic field defects, papilloedema, conjunctivitis, choroiditis, iritis, retinitis and disordered eye movements Recognise relevant and common visual disorders i.e. Altered visual acuity. strabismus, benign intracranial hypertension, glaucoma, presby- and hyper- metropia c. OPHTHALMOLOGY

29. Objectives: Performance Category DateSignature Trainer To understand the psychological difficulties and psychiatric disorders associated with deafness and hearing impairment and the presentation of these disorders in the deaf patient To understand the psychological difficulties and psychiatric disorders associated with tinnitus, dysacuses, vertigo and imbalance To obtain an adequate psychological profile, to recognise manageable conditions and refer appropriately To acquire appropriate counseling skills Knowledge: Performance Category DateSignature Trainer Psychiatric disorders with audiological and vestibular manifestations How psychotropic medication may influence audiovestibular disorders Psychological/psychiatric morbidity of neuro-otological disorders, tinnitus, dysacusis and sudden hearing loss Pathogenesis and presentation of non-organic hearing loss. Psychological morbidity of hearing impairment including dual sensory impairment Presentation of psychological problems and psychiatric disorder in the congenitally deaf patient Skills: To be able to: Performance Category DateSignature Trainer Identify behavioural disturbances and psychiatric disorder from the clinical presentation Discuss psychological/psychiatric disorder appropriately with patient d. PSYCHOLOGY/PSYCHIATRY

30. Objectives: Performance Category DateSignature Trainer To obtain an understanding of genetics in audiovestibular disorders and the role of the clinical geneticist Knowledge: Performance Category DateSignature Trainer Inheritance patterns of hearing loss. Genetics of and available tests for conditions associated with audiovestibular disorders. The psychological impact of genetic disorders. Skills: To be able to: Performance Category DateSignature Trainer Elicit and record correctly a detailed family tree. Interpret correctly a diagnostic DNA report together with its implications e. GENETICS

31. Objectives: Performance Category DateSignature Trainer To obtain an overview and understanding of the medical conditions affecting the elderly including falls, multi-system disease, cognitive and visual impairment Knowledge: Performance Category DateSignature Trainer Common causes of falls and imbalance in the elderly. The effect of ageing on cognition and memory The impact of multi-system disease and its pharmacological management Roles of other members of the multi-disciplinary teams caring for the elderly. f. CARE OF THE ELDERLY

32. Objectives Performance Category DateSignature Trainer To understand the effect of disordered immunity and allergy on the audiovestibular system Knowledge: Performance Category DateSignature Trainer The pathophysiology, presentation, diagnosis, management and prognosis of auto-immune diseases that affect the audiovestibular system The pathophysiology, presentation, diagnosis and management of allergy affecting audiovestibular function, in particular allergic rhinitis Immune deficiency disorders affecting the audiovestibular system - their pathophysiology, diagnosis and management g. IMMUNOLOGY & ALLERGY

33. Objectives Performance Category DateSignature Trainer To appreciate the value of imaging in the diagnosis and management of audiovestibular disorders Ability to select and request optimal imaging technique and views for specific disorders Knowledge The congenital and acquired abnormalities of the petrous temporal bone and central nervous system that can be identified by radiological imaging techniques, such as CT scan, MRI scan, fMRl scan and PET scans. h. RADIOLOGY

34. PAEDIATRIC AUDIOLOGICAL MEDICINE Fundamental to practice in this field is a sound knowledge of developmental pediatrics, otorhinolaryngology, pediatric neurology, pediatric ophthalmology, child psychology/psychiatry and genetics as detailed in Section 5 As well as background knowledge in Basic Sciences, Preventive Medicine and Instrumentation (Section 1). Generic skills, as they apply to a pediatric practice, outlined in section 2 underpin practice in this area. Training in child protection is essential.

35. 7.Background Knowledge- Pediatric Hearing Module 7 a. Normal child development including normal speech and language development Performance category Date Signature Trainer The impact of deafness on speech and language development A When and to whom to refer children with hearing difficulties and additional problems e.g. psychology, education, neurology, endocrinology, cardiology, ophthalmology etc. B A Country specific statutory educational provision for children with special educational needs, including hearing loss, speech & language disorders, balance disorders and learning disability. A Principles and practice of screening for hearing loss see also preventive medicine 3b A Value of multidisciplinary working B A Existence of national/international guidelines and their value and limitations. A

36. 7 b. Clinical Topics - Knowledge Ba se Congenital and prelingual Deafness: Performance category Date Signature Trainer Signs, symptoms and presentation B A Etiology of hearing disorders including involvement of other systems A Etiological investigations A Impact of deafness on speech and language development, education, social and emotional development of the child B A Management of a deaf child including alternative modes of communication and educational needs A Psychological and cultural issues surrounding deafness, its diagnosis and management. A

37. To be able to detect, investigate, diagnose and manage progressive or sudden deafness in children Knowledge The signs, symptoms, aetiology and management B A The psychological sequelae B A The impact of progressive, sudden or late onset hearing loss on speech and communication skills, education and school performance A The changing educational needs of the child A The appropriate audiovestibular and aetiological investigations A When to refer for further medical opinions and to other allied healthcare professionals A Local and national guidelines covering the identification, management and investigation of progressive or sudden hearing loss A The indications, benefits, limitations and side effects of any medication used for progressive or sudden hearing loss B A 7.c. Progressive, Sudden or Late Onset Deafness

38. To be able to detect, investigate, diagnose and manage fluctuating deafness, including otitis media with effusion, in children Performance dateTrainer To demonstrate knowledge of:: The signs and symptoms B A The aetiology including otopathology and its pathogenesis, immunology and allergy B A The impact of otitis media with effusion on emerging speech / language skills/ behaviour, balance and its management B The impact on education, emotional and social development B A Evidence based and appropriate audiovestibular and aetiological investigations B A Current best evidence for medical, audiological and surgical management of fluctuating deafness, including local and national guidelines B A The indications, benefits, limitations and side effects of medication that can be used for fluctuating deafness B A When to refer for further medical opinions and to other allied professionals A 7.d Fluctuating Deafness, Including Otitis Media with Effusion

39. To be able to detect, investigate, diagnose and manage non-organic hearing difficulties in children Knowledge Performance datetrainer The developmental/history profile of children presenting with non organic hearing difficulties B A The factors in presentation which are commonly seen in non-organic hearing difficulties B A Correct management of non-organic hearing difficulties A When to refer for further medical opinions and to other allied professionals A Local child protection pathways B A Skills : Take an accurate history and carry out an accurate audiovestibular, development and general examination; to include a clear profile of psychological and educational achievements B A 7.e. Non-Organic Hearing Difficulties

40. To be able to suspect, diagnose and manage auditory processing problems in children Knowledge Performance datetrfainer The signs and symptoms of APD and how it can affect the child’s educational progress and behaviour A The conditions that may cause or be associated or co-existent with APD A Central neural processing of information presented through auditory and other domains, including interactions and influence of higher level processes such as attention, concentration and long and short-term memory (i.e. information storage and retrieval) A The importance of multidisciplinary assessment of children with suspected APD A The indications, application, difficulties and interpretation of audiological test batteries for APD A Methods of habilitation of children with APD A 7.f. Auditory Processing Disorders (APD)

41. To be able to suspect, diagnose and manage auditory neuropathy spectrum disorder in children Knowledge Performance dateTrainer The presentation, natural history and diagnosis of ANSD A Diagnostic tests for ANSD A How ASND can affect the child’s language development and educational progress A How to use tests to investigate the site of the lesion with regard to predicting the outcome of interventions such as cochlear implantation A The conditions that may cause or be associated with ANSD A Methods of rehabilitation of children with ANSD including the value of cochlear implant A The educational needs of children with ANSD A 7.g Auditory Neuropathy Spectrum Disorder (ANSD)

42. To be able to suspect, diagnose and manage tinnitus, dysacusis and hyperacusis in children Knowledge Performance DateTrainer How tinnitus, dysacusis and hyperacusis may present in children A The prevalence of tinnitus, dysacusis and hyperacusis and the natural history of habituation A The different conditions which can cause or trigger tinnitus, dysacusis or hyperacusis A Current pathophysiological theories about tinnitus, dysacusis and hyperacusis generation A The psychological effects of tinnitus, dysacusis and hyperacusis on the child and family and how these can be managed A The possible effects of tinnitus, dysacusis or hyperacusis on education A How to manage a child with tinnitus, dysacusis or hyperacusis in the context of the multi-disciplinary team A 7.hTinnitus, Dysacusis and Hyperacusis in Children

43. To be able to carry out an accurate assessment of those children To be able to suspect and investigate additional medical and developmental problems in children with a diagnosis of deafness To be able to diagnose and manage deafness in these children Knowledge Performance datetrainer The signs and symptoms of hearing loss in children with complex medical problems including visual impairment A Possible psychological /educational issues for children with additional difficulties and hearing loss, particularly in relation to their special needs, and their immediate and long term management A The impact of additional medical and developmental problems for the deaf child and family A Methods of assessing benefit and problems with amplification A Possible psychological /cultural issues surrounding deafness, particularly in relation to the child’s additional difficulties, and their immediate and long term management A 7.h Children with Complex Medical or Developmental Problems and Others who are “Difficult to Assess”

44. To be able to identify speech/language disorder/delay in children and participate in joint assessment with a specialist speech and language therapist To perform appropriate medical investigation of children who present with speech and language disorders. Knowledge Performance DateTrainer : The signs, symptoms and pathologies associated with speech, language and communication disorder/delay in children A The difference between delayed and disordered speech development A The difference between delayed and disordered language development A The association of developmental disorders of speech and language with other developmental and processing disorders A The educational needs of children with speech and language disorder/delay and statutory assessment of educational needs A The specialist provision and range of educational provision for children with speech language and communication disorders A 7.i Children with Speech and Language Problems (ST6 & ST7)

45. To be able to manage a young person with audiovestibular problems through the process of transition and transfer Knowledge Performance dateTrainer The process of transition B A The needs of deaf teenagers and their approach to their need for care A The need to provide a seamless transfer of care from the paediatric to the adult services for children with long-standing disorders of hearing and balance A The needs of the learning disabled child during transition and transfer into adult services A Skills Discuss the young person’s hearing or balance difficulties with them and enable them to make decisions regarding their future care through transition A Provide a supportive and informative clinical atmosphere in which the young person can raise sensitive issues about their audiovestibular problems, and associated issues, in their own right A Offer and explain the value of additional investigation into the aetiology of their hearing and balance problems, if appropriate A Facilitate seamless and appropriate transfer to adult services at the right time for the young person A Communicate effectively with the adult services about transfer of care 7.j Transition and Transfer of Adolescents

46. 8. a Skills / Patient approach Undertake an accurate and reliable audiological, neuro-otological, developmental and general clinical examination of a child at all ages A The needs of the deaf adolescent during transition and transfer Performance category Date Signature Trainer The cultural issues and parental views with regards to deafness and its management A The anxiety and stress caused by suspected deafness and the possible natural reactions surrounding the diagnosis, in particular the grief reaction A The anxiety and stress caused by progressive or sudden deafness and the possible natural reactions surrounding the diagnosis for both the child and parents A The effect of audiological and aetiological uncertainty following identification of significant deafness in the newborn period especially with the diagnosis of an/ad A The importance of sensitivity to parents’ and patient’s response to a ‘non-organic’ diagnosis A With regard to the above stated clinical categories a specialist in pediatric audiological medicine, in addition to the generic skills outlined in Section 4, needs to be able to recognise:

47. To gain a comprehensive knowledge of audiological testing in children To gain practical skills in testing children. To gain a critical appreciation of the value and limitations of audiological tests in children Knowledge Performance datetrainer To demonstrate knowledge of:: The anatomy and physiology of the ear and auditory pathways including central connections B A The theoretical basis of audiological testing including physics, acoustics and psychoacoustics A The normal development of behavioural responses to sound in children B A The indications for the various audiological tests in children A The values, limitations and practical difficulties of audiological testing in children A Skills 7.k Practical Procedures in Paediatric Audiological Medicine

48. 7.l Practical Procedures specific to pediatric assessments ( Skills) Select appropriately and interpret correctly in the context of the clinical picture, all the audiological tests mentioned below  Identify inaccurate, artefactual or spurious results, understand why these might have occurred and suggest remedial or alternative action.  Perform competently:  Distraction testing on normal and ‘difficult to test’ children  Behavioural observation of hearing responses in an infant  Clinical speech perception tests  Have performed under supervision:  Visual reinforcement audiometry  Conditioning techniques for soundfield and ear specific audiometry  Pure tone audiometry (air conduction, bone conduction with or without masking)  Acoustic immitance measures  Otoacoustic emissions (transient evoked, spontaneous, distortion product and contralateral suppression)  Middle ear reflex measures  Speech audiometry including speech in noise  Auditory brainstem responses (ABR) Have observed :  Tests of auditory processing  Evoked responses (electro-cochleography, middle latencies, cortical responses)  ASSR (Auditory Steady State Responses) if possible

49. 8 Paediatric Vestibular Medicine 8.1. Imbalance in Children objectives Knowledge Performance datetrainer The sensori-motor physiology maintaining balance B A The development of postural control in childhood B A The association between sensorineural hearing loss and abnormal vestibular function A The ways in which a child may express their symptoms of imbalance A The causes of imbalance in a child including neurological, musculo- skeletal, developmental and vestibular causes A The impact of imbalance on a child particularly with regard to education and social integration A Techniques available to investigate balance disorders in children of different ages A Diagnostic investigations to establish aetiology and how to interpret the results in the light of age related changes A The treatment options and vestibular habilitation/rehabilitation approaches for children A When to refer to a paediatrician, paediatric neurologist, ENT surgeon, geneticist, physiotherapist or occupational therapist for an opinion A

50. 8 2. Dizziness in Children To differentiate between vertigo and other causes of dizziness or ‘funny turns’ in children To determine the cause of episodes of dizziness in children To instigate and interpret an appropriate set of investigations and define a management plan To assess the impact of the attack on the individual and family and manage appropriately Knowledge Assessment MethodsGMP The various otological, neurological, general medical and psychological causes of acute and recurrent dizziness and ‘funny turns’ in children and how to differentiate between them A 1 The different causes and pathomechanisms of acute and recurrent attacks of vertigo/dizziness in a child A 1 The ways in which a child may express their symptoms of dizziness in sign, gesture and spoken language and how parents may interpret these symptoms second hand when the child has inadequate vocabulary to describe the episode A 1,3 The impact of recurrent vertigo/dizziness on a child particularly with regard to education and social integration A 1 The eye movement abnormalities that may be associated with vestibular disorders A 1 Appropriate audiovestibular tests and aetiological investigations for acute and recurrent vertigo/dizziness A 1 The techniques available to investigate vestibular disorders, which are suitable for children of different ages A 1 The age related changes in balance function and how this is expressed in investigative results. A The treatment options and vestibular rehabilitation approaches for children A 1 The life style changes and pharmacological options available to treat acute and recurrent vertigo including the role of diet and the place of prophylaxis in patients with migraine, and specific treatment of episodic ataxia type 2 A 1 When to refer the patient to a paediatrician, paediatric neurologist, cardiologist, ENT surgeon, geneticist, occupational therapist or psychologist for advice on management A 1 The natural history of acute and recurrent vertigo in childrenCbD, Dip., mini-CEX1

51. 8.3. Practical Procedures in Paediatric Vestibular Medicine To gain a comprehensive knowledge of vestibular testing in children To gain practical skills in testing children To gain a critical appreciation of the value and difficulties of vestibular tests in children Knowledge Performance datetrainer The anatomy and physiology of the vestibular system and the central vestibular pathways B A The theoretical basis of vestibular testing B The indications, value, limitations and practical difficulties of vestibular testing in children A Age-related changes in postural control and responses to visuo-vestibular stimulation B To demonstrate the ability to: Select appropriately and interpret correctly all the vestibular tests listed below in children A Adopt a flexible approach to testing and be prepared to adapt strategies in order to obtain the information required A Integrate the results of history and examination with audiological, vestibular and aetiological tests to formulate a diagnosis and a management plan A Explain the results of testing to patient and parents A Identify spurious results and those due to immaturity, lack of concentration or poor testing technique and know how to obtain optimal testing conditions (troubleshooting) A Be able to perform competently and independently:  Hallpike testing  Examination of eye movements using nystagmoscopy or Frenzel’s glasses  Halmagyi head thrust testing BABA Have performed under supervision  Caloric irrigations  ENG/EOG recordings during visuo-vestibular stimulation including rotational tests  Posturography AAAAAA Have observed (where possible)  Vestibular evoked myogenic potentials (VEMPs) A

52. Training programs Diploma / MSc in Audiovestibular Medicine ( UCL) SYLLABUS( Diploma) Module 1 – Audiovestibular Physics – Module 1.1 Physics and Acoustics. – Module 1.2 Statistics and Research Methodology. Module 2 – Anatomy and Physiology. Module 3 – Audiovestibular Diagnosis. Module 4 – Clinical Disciplines Allied to Audio vestibular Medicine – Module 4.1Pathology, Speech and Language, Genetics & Radiology. – Module 4.2 Evidence based Medicine, Immunology, Ophthalmology, Psychology/Psychiatry. Module 5 - Vestibular Medicine. Module 6 - Clinical Auditory Medicine – Children and Adults.

53. Training programs Requirements of the training posts At institutions with appropriate standard of clinical governance. Training posts must provide the necessary clinical exposure. Training posts 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. Training should take place in a range of district general hospitals,teaching hospitals, community clinics. Trainee has an educational and clinical supervisors. Learning through observation, clinical practice, attendance at regional training days, presentations, national audit meetings, attendance at lectures, tutorials, journal reviews, additional courses, research projects.

54. ASSESSMENT METHODS Principles 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 work based assessments and knowledge based assessments ( Diploma or similar course) 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.

55. Assessments methods Workplace based assessments MSFmultisource feedback Mini-Cexmini-clinical evaluation exercise CBD case based discussion DOPSdirect observation of practical skills PSpatient survey TO teaching observation

56. Assessments methods MSF communication, leadership, team working, reliability Mini-CEX competence in practical skills, essential good clinical care CbD competence in clinical reasoning, decision making, application of medical knowledge to patient care. PS behaviour of the doctor, effectiveness of the consultation, assessment of interpersonal skills, communication skills, professionalism.

57. Reference: Specialty Training Curriculum for Audiovestibular Medicine May 2010/2013. Joint Royal College of Physicians Training Board http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/Audiological- Medicine.aspx http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/Audiological- Medicine.aspx Diploma/ MSc in Audiovestibular Medicine, UCL, London