D R A F T UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS)

D R A F TUNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS)EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS)

Hearing and Balance in adults Training Programme and Logbook

October 2012 / revised October 2013Subspecialty working group: Chair Kajsa-Mia HolgersLigija KiseUlf Schönsted-MadsenRene DaumanHeikko LöppönenEva Raglan

Consensus curriculum• This document presents the content of the hearing and balance module

based on the curriculum for audiovestibular medicine, speciality 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.

• Paediatric audiology although an intergral part of audiovestibular medicine in some countries ,is practiced separately in the others or in conjuction with phoniatrics in some other countries. ( the curriculum for peadiatric audiology is within the Phoniatrics training program and logbook document).

•

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

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 Hearing and Adult Balance/Vestibular.

• In addition and common to all the fields are the backround 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. .

CONTENT -logbook of training sections

• 2.1 Background Knowledge • • a/Basic Sciences• b/Preventive Medicine • c/ Instrumentation•

– Generic skills• • a/ clinical skills• b/ communication skills• c/ attitudes•

– Core Fields• • a/ Adult Hearing Section • a/1/ knowledge base, skills and attitudes• • b/ Adult Balance Section • b/1/ knowledge base, skills , attitudes•

• 2.4. Practical procedures•

• a/ for specialist in adult hearing disorders• b/ for specialist in adult balance disorders• •

CONTENT

• 2.5 Related medical disciplines

• a/ otolaryngology• b/ neurology c/ophthalmology• d/psychology/ psychiatry • e/genetics• f/care of the elderly• g/ immunology and allergy• h/ radiology•

• 3. Learning and teaching , training programs• • a/ Diploma in Audiovestibular medicine ( relevant modules)• b/ Requirements of training posts •

• 4. Assessments•

Knowledge Performance Category

Date Signature Trainer

Detailed anatomy, physiology, neurochemistry and pharmacology of the auditory and vestibular systems, their central pathways and connections and related systems or organs.

Embryological development of the above.

Psychology of hearing and balance including psychoacoustics.

Basic acoustics including room acoustics.

Requirements for sound proofing.

Standards relating to acoustics, calibration and audiological medicine.

Physics of sound, waves and motion.

Basic electroacoustic properties of hearing aids.

Recent advances in molecular biology: repair and regeneration in relation to the cochlea and vestibular system, stem cell research in relation to the ear, genetic manipulation etc.

2. BACKGROUND KNOWLEDGE

a) BASIC SCIENCES A sound and comprehensive knowledge of the basic sciences subserving the audiological and vestibular systems is essential to practice.



General principles of primary, secondary and tertiary prevention

Screening principles, methods and practice; including setting up a screening programme in a district, dealing with screen failures, monitoring and audit

Screening for hearing loss — newborn, school, industrial, elderly etc.

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

Ototoxicity; substances and drugs that affect the audio-vestibular system and their effects, including industrial toxins

Genetics affecting predisposition to ototoxic agents

Epidemiology and prevention of hearing loss

Role of immunisation and therapy in the prevention of hearing and balance disorders

b) PREVENTIVE MEDICINE



Principles, technology and limitations of auditory and vestibular test equipment

Analogue and digital hearing aids, including body worn, post aural, in the ear, in-the-canal, totally-in-the-canal aids, vibrotactile aids, bone-anchored hearing aids (BAHA), frequency transposition aids, CR05 (contralateral routing of signal) and BiCR0S aids and implantable hearing aids including cochlear implants

Hearing aid fitting formulae and real ear measurements in adult practice

The “plumbing system” (hooks, moulds, tubing etc) and its effect on sound amplification

Assistive devices available including the radio aid and FM soundfield systems, alarm systems, loop systems

Methods of assessing benefit of amplification in adults

c) INSTRUMENTATION

Practice of hearing and balance specialist requires a comprehensive knowledge of auditory and vestibular test equipment, and of amplification, including assistive listening devices for adults .

Skills: To be able to: Performance Category


Critically review audiometric and vestibular test results Determine the appropriateness and type of amplification (including cochlear implant) through discussion with audiological colleagues, patients

Discuss the current best technology with both patients, their families, and other professionals

Refer appropriately for amplification

To have practical experience of: Performance Category


Selecting, testing and fitting of hearing aids including BAHA and cochlear implants in adults

Measuring benefit of amplification

Use of hearing aid test box for testing hearing aids and measuring insertion gain and RECD

c) INSTRUMENTATION Continued

Clinical Skills: To be able to: Performance Category


Take an accurate, relevant and detailed history of auditory and vestibular disorders and associated problems from the patient or their carer including a developmental or psychosocial history.

Perform a relevant and detailed clinical examination, including ENT, neuro-otological, oculomotor, neurological, and full general examination.

Select and interpret audiological, vestibular and aetiological tests appropriate to the patient’s presentation, age and additional difficulties

Select and interpret appropriate multidisciplinary assessments including speech and language assessment, psychometric assessment

Integrate the history, examination and investigative findings and formulate a diagnosis and management plan

Select appropriate management strategies through multidisciplinary team discussion and discussion with the patient and carers; 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

Assess the impact of a management strategy using appropriate outcome measures

Assess disability accurately and judge occupational fitness e.g. use of machinery and fitness to drive

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

Identify psychological problems needing psychology/psychiatric referral

Identify syndromic and genetic causes of hearing and balance disorders

3. 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. a. SKILLS

Communication Skills: to be able to: Performance Category


Communicate effectively with patients of all ages, including the elderly

o with disorders of hearing

o with poor speech production due to deafness or other disorders of speech and language

o with visual disorders including the deaf-blind

o with intellectual disability

o needing sign language or spoken language interpretation in order to explain clearly to all patients and their carers the results of investigations, the management options and the prognosis of audiovestibular problems so that they understand and can make informed decisions, where able to do so.

Communicate effectively with colleagues within the multidisciplinary team and with specialists in other disciplines

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

Counsel the patient appropriately

3. GENERIC SKILLS - Continued

The need for an empathetic, tactful and positive approach Performance Category


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

The impact of disorders of hearing on the development and maintenance of speech and language and education

The combined effect of deafness with other difficulties, such as visual defects, learning disability etc.

The importance of holistic care The importance of the history including family history & developmental history in making a diagnosis.

The importance of a social, educational and psychological history in managing individuals with audiovestibular impairment

The importance of education of significant others to aid rehabilitation The value of multidisciplinary team working both within and outside the clinic

The attitudes of those within the Deaf Community The use and value of complementary medical approaches to holistic management of tinnitus and of otitis media with effusion

The importance of patient confidentiality and informed consent. The importance of effective multidisciplinary team work and communication with colleagues both verbally and in writing

The importance of sharing information with patients and their carers

The value of voluntary agencies in supporting the patient with hearing and balance disorders and their family/carers

b. ATTITUDES The specialist must recognise and understand:

4.. CORE FIELDS a. Adult “ Hearing” module

Clinical Topics - Knowledge Base

Tinnitus Performance Category


Aetiological and triggering factors Current pathophysiological theories about tinnitus generation Prevalence of tinnitus and its natural history of habituation. Audiometric and aetiological investigations Psychological effects on the patient and how these can be managed

Management of patients with tinnitus including instrumentation

Sudden hearing loss Performance Category


Presentation and causes. Audiological and aetiological investigations The psychological impact of sudden hearing loss, particularly if permanent and bilateral.

Current evidence based management of acute presentation Management including indications for surgery, communication strategies and hearing tactics

Unilateral hearing loss, progressive or fluctuating unilateral or bilateral hearing loss

Performance Category


Presentation and causes

Audiometric and aetiological investigations

Identification of site of lesion

Impact on the patient

Current evidence based pharmacological management

Indications for surgical referral.

Clinical Topics - Knowledge Base - Continued

Hearing problems in younger adults Performance Category


Conditions leading to hearing problems in younger adults Audiometric and aetiological investigations Current evidence-based management of hearing problems including pharmacological, surgical, audiological and rehabilitative

The possible impact of the hearing problems on the individual’s life and the effect on immediate family members, including psychosocial and speech & language issues

Management including: i. appropriate instrumentation and the benefits and limitations

e.g. Hearing aids, BAHA, CI, tactile and environmental aids

i. non instrumental rehabilitation e.g. Hearing tactics, speechreading

External support agencies, voluntary bodies and policies including employment support

Congenitally deaf adult Performance Category


Causes of congenital deafness/hearing impairment Effects on speech & language and communication Impact on individuals and significant others, including psychosocial effects

Associated symptoms such as tinnitus or balance difficulties Alternative communication systems Deaf culture and the local support facilities for deaf people Hearing aids and environmental aids Rapid advances in the research of genetic deafness and its impact on patient management

Hearing problems in the elderly Performance Category


Causes of hearing impairment in the elderly. Effects of the general ageing process on the auditory system General medical problems or other impairments which might affect rehabilitation e.g. Loss of tactile sensitivity, joint mobility, blindness, poor memory

Associated problems such as balance disturbance and falls Psychosocial issues including feelings of isolation and avoidance Rehabilitative approaches in the elderly External support agencies, voluntary bodies and policies e.g. Social workers


Dysacuses, auditory processing disorders (APD) and auditory neuropathy/dysynchrony (AN/AD)

Performance Category


Presentation and causes of dysacuses, APD and AN/AD

Investigation and management of dysacuses and their causes

Methods of testing the function of the different parts of the central auditory pathway

The rehabilitative approaches available for APD and AN/AD

The psychosocial effects of these hearing difficulties

Intellectually disabled adult Performance Category


Audiological or neuro-otological problems that may be associated with intellectual handicap and the specific effects that such problems may have

Presentation, diagnosis, investigation and management of hearing problems in adults with learning difficulties

Rehabilitative approaches available for such patients Issues concerning ‘consent’ in these patients


Background Knowledge Specific to the Field Performance Category


An understanding of vestibular test equipment, investigative techniques, and interpretation of results

The anatomy and physiology of the vestibular system, its central connections and interactions with the visual and oculomotor systems.

When and to whom to refer adults with balance problems e.g. psychology, social services, neurology, cardiology, ophthalmology, physiotherapy, occupational therapy etc.

An understanding of multidisciplinary working and its value The existence of national guidelines and their value and limitations.

b. Adult “ Balance “ Module

The specialist should be able to Performance Category


Determine the cause of acute and chronic vertigo, chronic imbalance, drop attacks and falls in the elderly

Assess the impact of the balance disorder on the individual Select and interpret an appropriate set of investigations Identify factors likely to affect rehabilitation Define a management plan Explain to the patient the likely cause and outcome of the problem Identify those patients for whom the condition affects their fitness to drive

Acute vertigo Performance Category


Causes, presentation and natural history of acute vertigo

Associated eye movement abnormalities

Audiovestibular and aetiological investigation

Management options, including rehabilitation, dietary manipulation, pharmacological and surgical

Recurrent disequilibrium Performance Category


The sensorimotor physiology involved in balance maintenance Causes of peripheral and central vestibular disorders with remitting and relapsing courses

Factors hindering vestibular compensation including pathology in other stabilising sensory and motor effector systems

The psychological impact of recurrent disequilibrium Vestibular tests and aetiological investigation Management options including pharmacological, physical rehabilitation and psychological /psychiatric interventions

Adult Balance - Clinical Topics - Knowledge Base

Chronic imbalance Performance Category


The range of central vestibular disorders causing chronic imbalance

Pathology in the stabilising sensory systems which give rise to multisensory imbalance

Pharmacotherapeutic agents causing chronic imbalance

Aetiological and vestibular investigations

Management options


Blackouts/drop attacks Performance Category


The mechanisms of epilepsy, pseudo-epilepsy, syncope, vasovagal attacks, and blackouts, and to know the aetiological factors involved

The investigation protocol and type of abnormalities found for each of the above

The pharmacotherapeutic options available to treat each cause

The law regarding black-outs and syncope and fitness to drive

Falls in the elderly Performance Category


The effects of ageing and neurological disorder on the postural and righting reflexes

The causes of black-outs and drop attacks including cardio- and cerebrovascular pathology

The musculo-skeletal disorders impairing maintenance of the upright posture and locomotion

Audiovestibular and aetiological investigations The pharmacological and physiotherapeutic management options

To be able to: Performance Category


Distinguish peripheral from central vestibular causes of vertigo and define site of lesion in the CNS

Carry out particle repositioning manoeuvres e.g. Epley, Semont etc

Instruct the patient in appropriate exercises e.g. Cawthorne-Cooksey, Brandt-Darroff, customised, exercises and protocols for visual vertigo


Skills With regard to the above stated clinical topics a specialist in addition to the generic skills outlined in Section 2.2 needs:

Attitude With regard to the above stated clinical topics a specialist in this filed, needs to develop the attitudes outlined in Section 2.2.c.

Knowledge: Performance Category


Theoretical basis of audiological testing See Basic Sciences section 2.1a

Indications for the various audiological tests

Values, limitations and practical difficulties of audiological testing

5. PRACTICAL PROCEDURES

a. PRACTICAL PROCEDURES – specialist in adult hearing disorders

Skills Performance Category


Select appropriately and interpret correctly all the following audiological tests.

Practical experience of all the following tests. Competency in performing particular tests will depend on the specific clinical practice of the country.

Subjective tests of hearing and auditory function: o Pure tone audiometry (air conduction, bone conduction with or without

masking)

o Behavioural and conditioning techniques for soundfield and ear specific audiometry in learning disabled adults

o Speech perception tests including speech in noise o Tests of auditory processing Objective tests of auditory function o Acoustic immitance measures and middle ear reflex measures o Otoacoustic emissions (transient, distortion product, spontaneous, contra-

lateral suppression)

o Evoked responses (electro-cochleography, auditory brainstem responses, middle latencies, cortical responses, auditory steady state responses etc)

a. PRACTICAL PROCEDURES – specialist in adult hearing disorders - Continued



Theoretical basis of vestibular testing see Basic Sciences section 3a

Indications for vestibular testing

Values, limitations and practical difficulties of vestibular testing in adults.

Age-related changes in postural control and responses to visuo-vestibular stimulation

Skills: Performance Category


To be able to select appropriately and interpret correctly all the following vestibular tests in adults.

To have practical experience of all the following tests. Competency in performing particular tests will depend on the specific clinical practice of the country

o Dix-Hallpike testing o Video-nystagmoscopy o Caloric irrigations o Posturography , HTT, VDA o ENG/EOCJ recordings during visuo-vestibular stimulation o Vestibular evoked myogenic potentials (VEMPs) To be able to integrate the results of audiological, vestibular and aetiological tests to formulate a diagnosis and a management plan

b. PRACTICAL PROCEDURES- Specialist in adult balance / vestibular disorders

Objectives: Performance Category


To gain a detailed knowledge of pathology and management of otological conditions

To observe audiology related ENT surgery such as grommet insertion, mastoidectomy, tympanoplasty, surgery for cochlear implantation, bone anchored hearing aids and 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.



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

a, OTORHINOLARYNGOLOCY



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

Examine the ear competently using a microscope and describe and identify abnormalities accurately.

Identify and treat causes of otalgia, external and middle ear dysfunction

Perform intratympanic injections of medications

To be competent at: Performance Category


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

Objectives Performance Category


To make an accurate neurological assessment of a patient

To know when to refer a patient to a neurologist or a neurosurgeon



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



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



To know how to screen a patient for ophthalmological and oculomotor disorders

To know when to refer a patient with such symptoms



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



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



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



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



Identify behavioural disturbances and psychiatric disorder from the clinical presentation

Discuss psychological/psychiatric disorder appropriately with patient

d. PSYCHOLOGY/PSYCHIATRY



To obtain an understanding of genetics in audiovestibular disorders and the role of the clinical geneticist



Inheritance patterns of hearing loss. Genetics of and available tests for conditions associated with audiovestibular disorders.

The psychological impact of genetic disorders.



Elicit and record correctly a detailed family tree. Interpret correctly a diagnostic DNA report together with its implications

e. GENETICS



To obtain an overview and understanding of the medical conditions affecting the elderly including falls, multi-system disease, cognitive and visual impairment



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



To understand the effect of disordered immunity and allergy on the audiovestibular system



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



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

Training programsDiploma / 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 4.1 – Pathology, 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

Training programsRequirements of the training posts

• In 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 responsability • 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,

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 intergrated 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.

Assessments methods

• Workplace based assessments• MSF – multisource feedback• Mini-Cex-miniclinical evaluation exercise• CBD - case based discussion• DOPS – direct observation of practical skills• PS - patient survey• TO - teaching observation

Assessments methods

• MSF- communication, leadership,team working, reliability

• Mini-CEX competencce 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,

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

• Diploma/ MSc in Audiovestibular Medicine , UCL, London

http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/Audiological-Medicine.aspx



D R A F T UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS)

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