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)
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
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
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
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
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
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
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
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
Overview of logbook training content
1. Background knowledge
2. Generic skills
i. Clinical skills
ii. Communication skills
iii. Patient approach
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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)
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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
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
Overview of logbook training content
1. Background knowledge
2. Generic skills
3. Core fields
i.
ii.
iii.
iv.
Adult hearing section
Adult balance section
Pediatric hearing section
Pediatric balance section
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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
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
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
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 central vestibular
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
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
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
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
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
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
Other hearing difficulties in children
• Auditory processing disorders/ANSD
• Tinnitus Dyssacuses/Hyperacusis
• Complex medical/developmental problems
• Speech and language problems and hearing
abnormalities
24
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
Overview of logbook training content
1.
2.
3.
4.
Background knowledge
Generic skills
Core fields
Practical procedures
i. Adult/pediatric hearing disorders
ii. Adult/pediatric balance disorders
26
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
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
Overview of logbook training content
1.
2.
3.
4.
5.
Background knowledge
Generic skills
Core fields
Practical procedures
Related medical disciplines
29
Related medical disciplines
•
•
•
•
•
•
•
Neurology
Ophthalmology
Psychology/psychiatry
Genetics
Care of the elderly
Immunology and allergy
Radiology
AUDIOVESTIBULAR
MANIFESTATIONS
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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
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.
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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.
Knowledge
Performance
Category
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.
Theoretical basis of auditory and vestibular tests.
BA
Principles of auditory and vestibular rehabilitation, knowledge of external support
agencies, voluntary bodies and policies inclusive of employment support
BA
Principles of instrumental rehabilitation including auditory nerve stimulation and
basic electroacoustic properties of the hearing aids.
Basics acoustics including physics of sound waves and room acoustics.
B A
Standards relating to acoustics, calibration and sound proofing.
A
BA
A
Date
Signature
Trainer