1. A fascinating journey through Audiovestibular Medicine
Development of AVM and Audiology in UK
Ewa Raglan
St. George’s / Great Ormond Street Hospitals, London
XVIth Symposium in Audiological Medicine, IAPA Beijing, CHINA
October 2012

3. AVM - bird’s eye view Audiovestibular Medicine
Audiovestibular Physician- role, training,manpower
Audiologists role, training, manpower
Scientific discoveries in Audiology
Development in technology
Development of knowledge of medical conditions
Development of service provision
Development of care pathways
Now and future: translational research

4. Audiovestibular Medicine
A medical speciality concerned with investigating, diagnosing and managing disorders of hearing and balance in both ,children and adults
Training : AVM MSc in AVM
Developmental Paediatrics
Geriatrics
Medical Genetics
Neurology
Ophthalmology
Otolaryngology
Psychiatry

5. Dizziness Hearing Loss Tinnitus
WHY MEDICAL FOUNDATION TO THE SPECIALITY?
Endocrinology Ophthalmology
Renal medicine Haematology
Neurology Cardiovascular medicine
Psychiatry
Genetics
Psychology
Rheumatology
Dizziness
Hearing Loss
Tinnitus

6. Prevalence in the UK
Hearing loss: most common sensory disability in developed world
9 millions hard of hearing adults in UK,only 2mln have a hearing device(Davis 2007)
3 in children (aged 0-16) suffer permanent hearing loss,those with severe impairment 4 times more likely to be unemployed (AoHL 2011)
80% of children under 4 years have an episode of middle ear dysfunction
Tinnitus : 5 millions sufferers
Dizziness/Balance: most common reason for visits to a doctor by patients over 65
affects 30-40% population by 60 years of age.
Social, economic, occupational costs of hearing and balance disorders on the individual, society, health services are profound
The collective goal of all employed in audiology( from basic sciences, applied research, service development, service delivery) is to improve the lives of adults and children with hearing, communication and vestibular problems.(Munro 2012)

7. WHAT IS THE SIZE OF THE PROBLEM?
ESTIMATE OF WORLD BURDEN OF
DISABLING HEARING IMPAIRMENT
= 250 million persons
From World Health Assembly Resolution WHA48.9, 1995
on Prevention of hearing impairment

8. Presbyacusis

9. PROGRESS in Audiovestibular Medicine
2004/5
2007/8
2012
Surgery vs.
medicine
Scientific discoveries
Development of technology
Development of new diagnoses
ENT surgery vs. AVM
Development of services
MDT
46 (+20)
AVP 3
MMC (medical)
training changes
3000
Technician in Audiology
Audiologist
MSC training changes
Consultant Clinical Scientist

10. Progress in AVM 1970’s …
Audiovestibular Physician- role,training,
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

11. Role of Audiovestibular Physician
Diagnosis,aetiology of hearing loss, tinnitus, imbalance in Isolated ear disease or multisystem disease
Provide specific medical management, holistic medical care
Ensure AVM input in service provision and rehabilitation via MDT
Initially: +hands-on testing, hearing aid provision
Now: diagnosis, management, procedures

12. Training in the UK - AVP In the 1970’s Currently
ENT (FRCS) or General Medicine (MRCP) + 5years AVM
Currently
Foundation training for all(FY1/FY2)
Core Medical/ or Paediatric Training
2 years in CMT or ST1/ST2
3 years in core paediatric training (ST1, ST2, ST3)
Specialty Training (ST3 – ST7)
5 years in AVM + Diploma/ Degree in AVM
Assessments - CCT

13. Progress in AVM 1970’s - 2012… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

14. Audiologists 1970 - Technicians
(shortage, inconsistent quality, O levels + courses + practical training)
Career progression on duration of years worked
2000 – Audiologists
BSc in Audiology - 10 schools (300/yr)
MSc in Audiological sciences
2010/12 - Modernisation of scientific careers
Change of training (BSc, MSc, HSST, PhD - career progression path towards Consultant Audiological Scientist on merit (knowledge & skills)

15. Modernising Scientific Careers: Career and Training Pathways
Three separate blocks:
Assistants & Associates
Practitioners
Scientists
Direct entry to each block is possible based on qualifications and experience
Progression across blocks will be possible
Equivalence will recognise skills, knowledge & experience in some cases for progression
Clear description of opportunities for awards & qualifications at all levels
Transparent view of progression and career development
Career pathways (shown in following slides) with opportunities for research & innovation training to quickly bring new techniques into clinical practice 15

16. Audiovestibular Multidisciplinary Team ( MDT)
Audiovestibular Physician
Audiologist Scientist
ENT Specialist
Other members of MDT (specialists doctors and therapists)
ENT Specialist

17. Progress in AVM 1970’s - 2011… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

18. Recent Developments
Phenotypic, molecular study  genetic hearing impairment
Discovery of molecular mechanisms of the cochlea lead to understanding of damage, regeneration & treatment
Discovery of OAE  allow detailed study of cochlea function
Stem cell research (future auditory applications)

19. Genetics of deafness
Identification of genes associated with deafness/balance disorder, understanding the pathological mechanisms underlying deafness, determination of their function (Karen Steel & others)
Role of AVP- careful description of the phenotype- clinical audiovestibular status, which help geneticist with a diagnosis

20. For clinical practice-REACHING THE DIAGNOSIS
Describe the clinical presentation:
Hearing loss, vestibular status, radiology
Exclude syndromic causes of Hearing loss
Consider GJB2 mutation screen in all nonsyndromic cases with unknown aetiology
Consider mitochondrial inheritance in multigeneration families unless there is clear evidence of transmission from a male

21. Molecular mechanisms of the cochlea
Understanding the mechanism of hearing damage in the cochlea helps in discovery of new treatments or protection against noxious agents

22. Auditory System Ext Ear Middle Ear Inner Ear VIIIth Nerve SOC…IC
Cochlea
Retrocochlea
Conductive
Sensorineural
Sensory
Neural
VIIIth n
Central
Brainstem
Temp lobe
Lower
Upper

23. OAE

24. Otoacoustic emissions in baby with auditory neuropathy [ANSD]
Cochlear microphonic and ABR in baby with ANSD
Otoacoustic emissions in baby with auditory neuropathy [ANSD]

25. OAE- use Screening for cochlear damage
cisplatin treatment, ototoxic drugs
mobile users/ noise exposure
Screening for hearing loss- neonates, difficult to test, learning disability
Progression of disease- Meniere’ s disease
Impaired cochlea- normal PTA+ Tinnitus
Malingering
Diagnosis of auditory neuropathy

26. From Tuning Fork to……

27. ….. video head impulse test (vHIT)
Detects vertical semicircular canal dysfunction as well as horizontal
H. MacDougall; L McGarvie, M Halmagyi, I Curthoys, K. Weber (2012)

28. Important research - findings
Yoshinaga- Itano = critical time for language development = first 6 months of life
Anu Sharma = congenital deafness leads to an atypical organisation of the auditory nervous system, there is cross modal plasticity of the nervous system. There is a defined period (sensitive period) of central auditory reorganisation benefiting children with CI

29. Progress in AVM 1970’s - 2011… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

30. Development of new technology
Hearing aids - digital
Cochlear implants
Brainstem implants
BAHA( bone anchored hearing aids)
Vestibular implants
Emerging technologies of assessing vestibular mechanisms
VEMP (vestibular evoked myogenic potentials)
HTT (Head thrust test)
VAT (vestibular-auto rotation test)
New range of motorised Barany chairs with
computerised analysis

31. Recent Service Development
MHAS/MCHAS – Modernisation of Hearing Aid Services for Adults and Children
Digital Sound Processing
Bone Anchored Hearing Aids programme
Cochlear Implant programme
Newborn Hearing Screening Programme [NHSP]

32. Earlier identification of hearing loss - 2000
In 2000, the Joint Committee on Infant Hearing issued a new position statement, which included a recommendation that hearing loss in infants be identified by the age of 3 months and that intervention be initiated by the age of 6 months

33. UK Perspective 2012
All areas of England have been offered neonatal hearing screening since March 2006
Over 4 million babies have been screened since the programme started
A rigorous Quality Assurance Programme ensures that all hearing screening services around the country are assessed on a regular basis to check that they are effective and safe

34. Identification
Screening at birth – TOAE and Automated ABR (99.7% of all births)
Follow up TEOAE and diagnostic ABR as necessary and screening output set < 12 weeks

35. Fitting of Hearing Aids
Target – amplification within 4 weeks of identification
Upper limit – 4 months but usually less
NHSP Annual Report

36. Amplification-Hearing Aids

37. Amplification-Implantable Devices

38. Progress in AVM 1970’s - 2011… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

39. Development of new diagnoses and treatment
Auditory neuropathy
Auditory processing disorders
Migraine related dizziness
Dehiscence of semicircular canal
New methods of vestibular rehabilitation - from Cawthorne-Cooksey (1940’s) to customised / visual vertigo exercises
Positioning manoeuvre for treatment of BPPV (Epley’s / Semont / Gans etc…)
Virtual reality and OKN desensitisation treatment for visual vertigo
Brainport ?

40. Visual vertigo treatment (Pavlou)

41. Progress in AVM 1970’s - 2012… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of pathways
Developments: translational research

42. Development of services
Modernisation of NHS Hearing Aid Programme  introduction of digital hearing aids
Introduction of NHSP  OAE + ABR  new  auditory neuropathy
Paediatric balance/dizziness services
Central auditory processing services
Triaging for vestibular disorders (head thrust test)
Screening for hearing disorders (hearing screening device)

43. Recent Developments (Cont)
Development of Paediatric Vestibular Science and Services
Development of a screening test battery in children
Development of new testing techniques allows more precise assessment of child’s vestibular organ and plan better customised vestibular therapy
Assessment of vestibular function in patients with hearing impairment complements phenotypic presentation of a disorder thus helping with a diagnosis.

44. Vestibular Science / Disorders

46. Diagnostic Tests of VOR
Caloric Test (low frequency) [0.001Hz]
Whole body passive rotation [ Hz]
VAT (active rotation) [2-6Hz] A H
OVAR
SVV
Otolith
VAT
active rot
[2-6Hz] P
VEMP – cervical & ocular

47. Somatosensory Vision Graviceptors Learning Hearing Labyrinths
CNS
Interpretation
Learning
Adaptation
Compensation
Balance control
Spatial orientation
Foot sole pressure
Somatosensory
Vision
Hearing
Graviceptors
Labyrinths
Image stabilisation

48. Cognitive behavioural Therapies
Diagnostic Process
Symptoms
Assessment
Diagnostics
Management
Dizziness
Vertigo
Disequilibrium
± Auditory
± Neurological
± Cardiac/ Vascular
± Other
Vestibulometry Audiometry Radiology
Haematology
Biochemistry
Site of lesion
Dehiscency of SCC, dilated vestibular aqueduct
Medical
Surgical
Rehabilitative 
Underlying Medical Condition
Cognitive behavioural Therapies
Physical

49. Clinical service quality assurance
Clinical Governance
Protocols / Guidelines
Audit
Clinical Research
Appraisal / Revalidation

50. Progress in AVM 1970’s - 2012… AVP- role, training, manpower
Audiologists- role, training, manpower, career
Scientific Discoveries in Audiology
Developments in technology
Developments - knowledge of medical conditions
Developments in service provision
Development of patient pathways
Developments: translational research

51. 51

52. We clarified our referral criteria….

53. We improved our patient pathway….

54. Balance/Tinnitus/ Hearing Commissioning Pathways
Care nearer to home i.e. primary care
Easier access eg NHS direct, self referral
Broader use of healthcare professionals
More rapid progress through care pathway
Seamless transfer through primary to tertiary care
Competency based provision of care
Cost effectiveness

56. Balance Network Sub-specialist Level of Care :
Adults with dizziness, vertigo, unsteadiness or falls
Local Balance Service
Specialist Level of Care :
Specialist Hospital Clinic
Sub-specialist Level of Care :
University or Regional Centre
REVIEW
REVIEW
REVIEW
DISCHARGE
GP, Physiotherapy, OT, NHS Direct, other medical discipline referrals
Adults triaged by GP or other healthcare professionals using standard criteria etc
Adults triaged by GP with special interest or other hearing specialist professionals using standard referral criteria etc
Referral for specialised balance assessment etc
Supraspeciality expertise with specialist clinics etc

57. Good Practice Guides
Adult hearing (including complex presentation)
Paediatric hearing and balance disorders
Tinnitus
Balance/dizziness

58. QUALITY of SERVICE: Benchmarks (QET / IQIPs)
Tools to support assessment/provide a framework to enable audiology services to become self improving
It is built into commissioning framework / visible to the service provider as a measure of quality of audiology services
Its standards are used as a base to an accreditation process 58

59. Quality Enhancement Tool (QET)
Technology
Performance Management &
redesign of
Systems and Process
Clinical Quality
Quality of the Patient Experience
Workforce and Training
Adult Hearing Services
Paediatric Services
Vestibular Services
Tinnitus Services
Auditory Processing
Etc …
The aim is to make the material in the 5 domains above as general as possible, but some additional standards for other areas (that fit into the domains above) will be required 59