Audacity Issue 2

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Audacity ...a British Society of Audiology Publication issue 2 december 2013 ..................................

23 Infant sucking Response

30 Tinnitus in Children

39 Research Round-up: Goodbye to Brian Moore and the Auditory Perception Group

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audacity@thebsa.org.uk

British Society of Audiology

www.thebsa.org.uk

KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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Audacity is published by: The British Society of Audiology 80 Brighton Road, Reading, RG6 1PS, UK. E: audacity@thebsa.org.uk W: www.thebsa.org.uk Design: Pinpoint Scotland Ltd

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Editorial “The method of the enterprising is to plan with audacity and execute with vigour.”

Christian Nestell Bovee

O

n behalf of a vigorous editorial team I would like to welcome you to the second edition of Audacity, the BSA publication that replaces BSA News. The first edition was well-received and we would like to thank everyone who provided feedback. We have made small changes based on your comments and hopefully we will continue to refine and improve the publication.

Whilst it is not a specific intention to have a set theme for each edition, you will find that the following pages have a focus on some interesting and challenging aspects in paediatric audiology. Graham Sutton and Amanda Hall deliver an excellent critical appraisal of the Infant Sucking Response. Both Wayne Wilson and Johanna Barry discuss and review testing and management of auditory processing disorders in children and Claire Benton and Alice Emond highlight the prevalence of tinnitus in children and provide a model for good practice.

Within Research Round-up we focus on Cambridge: past, present and future. With his recent retirement, Professor Brian Moore describes the valuable contribution made to audiology by his auditory perception group. We wish Brian a fulfilled and happy retirement. Meanwhile, ‘the beat goes on’ in Cambridge and Bob Carlyon and his collaborators describe the hearing research that takes place at the Cognition and Brain Sciences unit.

Ear Globe highlights the changes that have taken place to the structure of audiology in the Republic of Ireland and within Twitterarty we again get help to feed and follow the Twitter movement. For this edition we have

Martin O’Driscoll Editor-in-Chief On behalf of the editorial team E: martin.odriscoll@cmft.nhs.uk

introduced a Clinical Catch-up section with contributions from Graham Sutton on the work of the Newborn Hearing Screening Group, Rhys Meredith who reports on pass rates of the school entry hearing screen in Swansea and Lisa Cockman who walks us through superior canal dehiscence.

Audacity remains a work in progress. We welcome feedback and suggestions for articles or sections that you would like to see included. If you would like to be a guest editor for a particular section or be involved in the editorial team then please let us know.

We would like to thank all who contributed to this second edition. Please look out for the interactive pdf that will be available shortly. We welcome your opinions about the accessibility and readability of the electronic-only version.

Finally, the editorial team wish you a very happy Christmas and a successful 2014.

from the editor

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Contents meet the editorial team...

3

Editorial Martin O’Driscoll

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Chairman’s Message Kevin Munro

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Conference Update David Furness

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Martin O’Driscoll E: martin.odriscoll@cmft.nhs.uk

SIG Segment information and updates from BSA Special Interest Groups Section Editor: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk

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Knowledge Learning Practice Impact information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG)

Rachel Booth E: rachel.booth@cmft.nhs.uk

Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk

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Featured Articles expert writing about topical areas in audiology Section Editors: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk Rachel Booth / E: rachel.booth@cmft.nhs.uk

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Research Round-up a spotlight on major ongoing research projects in the Audiology community worldwide.

Dion Jones E: dion.jones@cmft.nhs.uk

Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

47

Lunch & Learn a summary of the latest bite size online seminars for you to get your teeth into!

Section Editor: Shahad Howe / E: shahad.howe@cmft.nhs.uk

Jenny Griffin E: jenny.griffin@cmft.nhs.uk

E: audacity@thebsa.org.uk

W: www.thebsa.org.uk

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welcome to

Audacity ....a British Society of Audiology Publication

meet the editorial team...

54 Ear to the Ground a guide to all things Ear-related in the media‌ Section Editor: Dion Jones / E: dion.jones@cmft.nhs.uk

62 Ear Globe an opportunity to learn more about audiology around the world. Explore a different country in every issue!

Section Editor: Julie Reading / E: Julie.reading@cmft.nhs.uk

Rachel Hopkins E: rachel.hopkins@cmft.nhs.uk

65 Ear Reach find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved.

Section Editor: Jenny Griffin / E: jenny.griffin@cmft.nhs.uk

68 Clinical Catch-up Short articles on relevant clinical topics Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

Shahad Howe E: shahad.howe@cmft.nhs.uk

73 Hearsay News from Regional Groups and BSA Members Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

78 Essentials Key information for the membership Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk Danny Kearney E: danny.kearney@cmft.nhs.uk The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics.

Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information.

Audacity is published in April, August and December. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; The Editor, Audacity, 80 Brighton Road, Reading, RG6 1PS. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings.The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

W: www.thebsa.org.uk

E: audacity@thebsa.org.uk

Julie Reading E: julie.reading@cmft.nhs.uk

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chairman’s message

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Chairman’s Message Connect, communicate and contribute ploit the benefits of a diverse membership in order to achieve our common goals.

Participants at the 2013 annual conference had the opportunity to hear my presentation on ‘BSA Update: turning words into actions’ (https://connect.sonova.com/p5ngs0c7ggf/).

This allowed me to summarise our strategic aims, our action plan and to highlight our activities for the coming year (some already completed, some in progress, and others yet to commence). Running through all areas of our work are cross-cutting activities including ‘engagement’. There has been a tendency for BSA to provide information but not actively communicate. In this regard, we have been weighed, measured and found wanting. We are actively addressing this weakness with a variety of innovations.

Kevin J Munro Chairman

Innovation Forum At the 2013 conference, we ran a one-hour event referred to as an ‘Innovation Forum’. This was on the topic of ‘engagement’ and was supported by a professional facilitator. The event provided me with an opportunity to ‘test the readiness’ of members to provide constructive engagement and I am pleased that around 40 individuals accepted the invitation. This was a small and friendly environment with individuals contributing in a way that would have been much too intimidating within the main conference hall. There was discussion about the need for BSA to prioritise and lead. At the other end of the continuum, there was discussion of the ‘softer side’ of our work as collaborators, achieving success in partnership without the need for prestigious recognition. In the closing plenary session of the Innovation Forum, a number of substantive issues came to light. One important issue was concerned with the multiple identities of BSA. The example that was cited was the potentially differing aspirations and expectations of practitioners and researchers. There can be no doubt that diverse membership brings challenges in consensus and coherence of direction.

Despite the challenges, this does not mean that it is wrong to mobilise the exchange of ideas and knowledge amongst members. BSA is open to anyone with a shared interest in audiology; therefore, we need to escape from our functional silos and ex-

chairman’s message

At its core, the Society should strive to provide an interface between researchers and healthcare practitioners as well as other groups (educationalists, government, independent sector, professional bodies, patient groups and third sector organisations). The benefit of a diverse membership is to use our different perspectives and unite around a common action. Not only would the output be important but the process of working together on a common cause could also be beneficial. As I mentioned in an earlier communication, one way this could be achieved is the formation of an ‘Expert Advice Team’ that is flexible and responsive. For example, UK audiology currently lacks a coordinated approach to ‘hearing and deafness’ across the research continuum that linked to clinical delivery, education and learning and dissemination. The BSA is well placed to provide advice on the formation of such a body and to facilitate its development. This also has the potential to shift BSA from a predominantly reactive to proactive mode. The benefits of working together is age old, but we could learn much from the relatively recent literature on ‘Communities of Practice’ (http://wenger-trayner.com/wpcontent/uploads/2012/01/06-Brief-introduction-to-communities-of-practice.pdf) where pulling of resources to work together on a common activity can be an extremely powerful way to achieve a shared goal.

BSA as a ‘dating agency’ One novel idea for increasing engagement between members, which was suggested at the Innovation Forum, was the concept of BSA as a ‘dating agency’. This could build bridges by encouraging a better understanding and respect for each other’s roles, and establish longstanding links between a network of members.

BSA could, for example, establish and fund a ‘pairing scheme’ where individuals from different professional backgrounds spend time in each other’s working environments.

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7 Before dismissing the ‘dating agency’ as a crazy idea, I encourage you to visit the website of the Royal Society (http://royalsociety.org/training/pairing-scheme). Since 2001, the Royal Society has been organising and supporting a pairing scheme to encourage engagement and understanding between science and

politics. MPs and civil servants take part in a pairing scheme with scientists where they make reciprocal visits to each other’s working environment. MPs and civil servants familiarise themselves with the process of scientific understanding and the issues that affect scientists and universities. On the other hand, researchers become aware of the ways in which they can influence science policy. The scheme has grown from six pairs in 2001 to up to 30 pairs in 2012 and attracts national and local media coverage.

Another suggestion from the Innovation Forum was to hold a short event at the annual conference where individuals from a variety of backgrounds (e.g., practitioners, researchers, third sector) have the opportunity to discuss and share information about their respective roles.This suggestion (along with the request to run another Innovation Forum) has been shared with the organising committee of the 2014 annual conference: Keele University, 1-3 September 2014.

The repetition of behaviour is habit forming for individuals, organisations and Society. The advantage of habitual practices is that these save effort, because we don’t need to be continually making decisions, and this frees up resources for other tasks.

However, as Charles Dughill, Pulitzer Prize winning writer at the New York Times, points out, habits can be as much a curse as a benefit (Duhigg, 2013). The suggestions from the Innovation Forum help us to review existing practices, identify bad habits and adopt new behaviours.

The blurring of strategic and operational activities The hallmark of a good organisation, and of a charity such as BSA, is that it continually seeks ways of improving performance and efficiency, and learns new and better ways of delivering its mission. However, each new development means more (or a reallocation of) resources including time. A critical issue for BSA is the delegation of responsibility for operational matters.

Trustees, all unpaid volunteers, are currently responsible for strategy along with running day-to-day operations. We have a

great asset in the Trustees (and Secretariat), who devote considerable time and energy to BSA, but it is a concern that the blurring of strategic and operational responsibilities means Trustees are not being used to maximum effect. Trustees have a duty of care for ensuring our activities are run properly. Effective handling of operational matters is vital in order to avoid disasters and decline, but it reduces the capacity of Trustees to focus on strategy.

A possible way forward, yet to be discussed and agreed by Council, is the appointment of an Operations Officer. It would be for Council to decide the role of the Operations Officer but the position would enable Trustees to better direct strategy and to be more responsive to challenges and opportunities.

Fewer decisions and actions would need to be done via committee. By way of an example, the ‘dating agency’ suggestion from the September Innovation Forum could have been established by now with a proactive Operations Officer. Also, each area of the Action Plan (e.g., publicity and communications) could be written by the Operations Officer and could become an agenda item for Trustees to approve at Council, as opposed to a work strand led by a Trustee. The role of the Operations Manager should be seen as an investment rather than a cost: a

good Operations Officer will bring in more, over time, than money in the BSA bank account e.g., through a range of sources such as cost savings and new sources of income. A self-employed individual with experience across a variety of sectors (public, private and/or voluntary) and with skills in marketing, report writing and networking could bring much to the BSA. Before committing to such a venture, Trustees would need to carefully consider the financial commitment, but any appointment could be based on annual targets such as growth of membership, expanding the international market etc. A strategic development such as this would provide the BSA with a strong future trajectory and would be a fitting legacy for Council. I would be interested to know if you think this development would be a good use of your membership fee.

New opportunities We are currently seeking nominations for Vice Chair, to replace Huw Cooper when he becomes Chairman in September 2014.

We are also looking to replace Andrew Reid as Treasurer when he stands down in March 2014. There is a common fallacy that these positions need to be filled by someone relatively senior who is already a Trustee.This is unfounded: I became Vice Chair

chairman’s message

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8 without having been a BSA Trustee. If you are motivated and enthusiastic with a commitment to making a difference, then please consider standing for either of these positions. I would be very happy to speak with anyone who would like to discuss this further.

Comments or Contributions And finally…

There have been a number of changes within the Secretariat and we are all united in our praise for the sterling work of Oumou Bou, who was appointed as finance and administration manager earlier this year and is now our interim office manager.

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to

Keep abreast of the work of BSA by visiting our website: www.thebsa.org.uk. The general mail address for contacting the Society is: bsa@thebsa.org.uk and you can contact Council at: contactcouncil@thebsa.org.uk. Please share this message with non-members and encourage them to support BSA (go to ‘Joining the Society’ link on the website for a new and simplified membership application). As always, I welcome your views and you can contact me at kevin.munro@manchester.ac.uk By the way, if you are looking for something to read on a dark evening, you might be interested to read the article in The Economist (19-25 October 2013) called ‘unreliable research: trouble at the lab’. Finally, take a moment to check that you are receiving emails from the BSA secretariat: we do not want to lose touch with you when we reduce our paper mailings after December 2013.

Audacity ...a British Society of Audiology Publication issue 1 august 2013 .............................

10 Update on the BSA Annual Conference

38 Research Round-up Who are the ‘EAR Team’?

68 Essay Competition deadline 31st October 2013

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Audacit y

audacity@thebsa.org.uk

British Society of Audiology

www.thebsa.org.uk

My best wishes,

KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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References Duhigg C. 2013.The power of habit: why we do what we do and how to change. London: Random House Books

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Contact the Editorial Team at: audacity@thebsa.org.uk

chairman’s message

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Conference Report

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British Society of Audiology Annual Conference 2013

Dr David N Furness Keele University (on behalf of the organisers)

This year the fourth joint Annual Conference was held at the University of Keele, 4th – 6th September, and was followed by a symposium of the Auditory Processing Disorder special interest group on the 7th September. Both meetings attracted an excellent number of delegates.

The Annual Conference comprised plenary lectures, themed oral sessions, poster sessions and clinical/sponsor workshops. There were more than 250 delegates, a figure similar to previous years, and nearly 30 exhibitors with their stands, who provided key support for the entire event.

The conference opened on the first day with a session on hearing loss and hearing aids, starting with a plenary talk by Professor Ruth Bentler, selected oral presentations and closing with a keynote lecture by Professor David McAlpine. This

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was followed by three (!) glasses of wine and the Twilight Lecture in which Dr Marcelo Rivolta took us through his latest research on auditory stem cells and transplantation.

Over the next two days there were further plenary lectures and themed sessions.

The second day opened with the Thomas Simm-Littler lecture, given by Professor Brian Moore and then updates from Professor Adrian Davis on global health and audiology, and Professor Kevin Munro on current BSA strategy. In the afternoon, a second session on hearing loss and hearing aids with a parallel session on tinnitus took place. The day ended with talks from Action on Hearing Loss and the awards ceremony.

The last day started with a balance themed session, opened with a plenary lecture by Dr Leonardo Manzari and was followed by a dedicated poster session. After lunch, the Ted Evans lecture was given by Professor Robert Fettiplace, opening the Hair Cells to Cortex themed session in parallel with the Cortex: Psychophysics, Imaging and Perception session.

Throughout the conference programme there were also special events: an Innovation Forum where new ideas for BSA strategy and activities were discussed, and a New/Younger Member session, where ideas on how to conduct research in a busy clinical job, writing grants, and publishing papers were presented by three old (no offence intended) hands. Of course the Annual General Meeting of the society also took place where officers brought members up to date on the current status of the organisation.

Keele turned out to be a very good venue, with the posters and exhibition area next to each other, and all within sight of the lecture theatres and break-out/workshop

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11 rooms. Our sponsors were good humoured and important contributors, offering the usual free pens and lots of advice on their new products. Cheap and reasonable quality accommodation was within a five minute walk and the campus

was its usual leafy self, a welcoming place in a warm early autumn.

The idea is to come back to Keele next year (1st – 3rd September), although some changes are in the offing as we plan our programme to once again meet the challenge of bringing together basic, translational and clinical researchers. We hope that you will be there to see us meet that challenge.

Poster Prizes from The BSA Conference Early hearing loss and language abilities in children with Down Syndrome Keyword: Hearing loss G. Laws*and A.J. Hall§, *Department of Experimental Psychology, University of Bristol, UK, §Children’s Hearing Centre, University Hospitals Bristol NHS Foundation Trust, UK

This study aims to investigate the impact of early hearing loss on language outcomes for children with Down Syndrome. Although many children with Down syndrome experience hearing loss (Marcell & Cohen, 1992 ; Roizen, 1997) there has been little research to investigate its impact on speech and language development. The results of studies that have investigated the association give inconclusive results (e.g. Abbeduto et al, 2003; Jarrold & Baddeley, 1997; Laws, 2004). There is a clinical need for research

in this area so that parents and clinicians can make informed decisions about how to manage and treat early hearing loss.

Retrospective audiology clinic records and parent report for 41 children with Down syndrome were used to categorize them as either having had hearing difficulties from age 2 to 4 years or satisfactory hearing. Differences between the groups on measures of language expression and comprehension, receptive vocabulary and speech accuracy were investigated.

After accounting for the contributions of chronological age and nonverbal mental age to children’s scores, children with hearing difficulties had significantly worse language measures than those with satisfactory hearing.

Early hearing loss in children with Down Syndrome was associated with poorer language development. Future research should examine the effectiveness of language and hearing interventions for this group of children.

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12 Acknowledgements This research was completed with the support of the Wellcome Trust (grant numbers 07250 and 08/RPM/43510765 20). Alison Fisher, Stephanie Guillaume, Frances Lombard, and Joanna Nye contributed to language assessments. Philippa Hough contributed to data entry. The authors thank Audiology staff who sent data: Adrian Dighe, Janine Matthews, Elizabeth Midgley, Chris Till, Anne Thomas and Alison Watson, and acknowledge the contributions of children, their parents and teachers.

References 1. Abbeduto L., Murphy M.M., Cawthon S.W., Richmond E.K. Weissman M.D., Karadottir S. & O’Brien A. 2003. Receptive language skills of adolescents and young adults with Down or Fragile X syndrome. Am J Ment Retard, 108, 149-160.

2. Jarrold C. & Baddeley A. D. 1997. Short-term memory for verbal and visuospatial information in Down’s syndrome.

Cogn Neuropsychiatry, 2, 101-122.

3. Laws G. 2004. Contributions of phonological memory, language comprehension and hearing to the expressive language of adolescents and young adults with Down syndrome. J Child Psychol Psychiatry, 2, 45, 1085-1095.

4. Marcell M.M. & Cohen S. 1992. Hearing abilities of Down syndrome and other mentally handicapped adolescents.

Res Dev Disabil, 15, 533-551.

5. Roizen N. 1997. Hearing loss in children with Down syndrome: A review. Down Syndrome Quarterly, 2, 1-4.

study presents three aproaches to link a model-based fast-acting dynamic compression algorithm binaurally on different stages. The first approach couples the level estimation for both ears before gain calculation, the second one matches the calculated gains by choosing the minimum of both ears, the third finally applies a posthoc filter after amplification in each channel in order to compensate for fast artificial ILD alterations. Aim of the objective evaluation was to assess the success of binaural synchronization on preserving ILDs and speech intelligibility in spatial masking conditions in comparison to conventional bilateral fitting, therefore spatially symmetric and asymmetric masking conditions were used. ILDs were calculated in Matlab, speech intelligibility was assessed using a model of binaural speech perception (Beutelmann et al, 2010). In addition subjective speech reception thresholds were obtained of 17 hearing impaired listeners aided individually with the bilateral and the level estimation coupled algorithm.The objective results indicate good ILD preservation for all three coupling aproaches and a small benefit of binaural coupling on speech intelligibility in spatially distributed masking conditions. However no benefit of binaural-synchronization could be found in the subjective data, suggesting a dominant role of the better ear in all experimental conditions.

Acknowledgements Supported by BMBF 13EZ1127D and DFG FOR1732.

References 1. Wiggins, I.M. & Seeber, B.U. 2012. Effects of dynamic-range compression on the spatial attributes of sounds in normalhearing listeners. Ear. Hear. 33, 399-410 2. Beutelmann, R., Brand,T., & Kollmeier, B. 2010. Revision, extension, and evaluation of a binaural speech intelligibility model. J. Acoust. Soc. Am. 127, 2479-2497

Evaluation of different methods for binaural synchronization of dynamic-range compression algorithms in hearing aids Tinnitus, sound textures, and cochlear implants Keyword: Hearing Aids (including cochlear implants) S.M.A. Ernst*#, M. Buhl*, G. Grimm* and B. Kollmeier*#, #Cluster of Excellence "Hearing4all", *Department of Medical Physics and Acoustics, University of Oldenburg, Oldenburg, Germany Binaural cues such as interaural level differences (ILD) are used, among other cues, to organize auditory perception and to segregate sound sources in complex acoustical environments. Dynamic-range compression working independently at each ear in a bilateral hearing aid, however, can alter these ILDs (Wiggins & Seeber, 2012), potentially affecting sound source segregation.

Binaural synchronization of compression algorithms might thus be necessary to preserve potentially beneficial spatial cues.This

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P.A Gomersall* §, R. E. Turner‡, D. M. Baguley§, J. M. Deeks*, and R. P. Carlyon* *MRC Cognition & Brain Sciences Unit, 15 Chaucer Rd., Cambridge, UK §Cambridge University Hospitals, Hills Rd., Cambridge, UK ‡Dept. Engineering, University of Cambridge, Trumpington Street, Cambridge, UK

We are developing and investigating novel ‘sound texture’ stimuli for use in the management of chronic debilitating tinnitus in those who have received a cochlear implant (CI). Sound textures in the form of environmental sounds (e.g., wind, rain, running streams) are widely used in the management of tinnitus

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13 (Baguley et al. 2013). Unfortunately, these sounds do not appear to help CI patients, probably because the modulations that distinguish these different sounds are poorly encoded by contemporary CIs. The need for effective management of tinnitus in CI patients is underlined by the results of a bespoke questionnaire performed as the initial stage of our study. This showed that 37% of respondents rated tinnitus amongst the top two most distressing aspects of their hearing loss.

We have used a flexible generative model to create a range of auditory textures that may be better suited to CI patients.

Given that relatively little research has focused on auditory texture perception, we have measured the psychophysical properties of sound textures in normal hearing individuals in addition to CI users.This has revealed the range of parameters that both sets of listeners are sensitive to. The general pattern of results is very similar for the two groups, but with CI patients performing worse overall. Our next goal is to use this information to create user-adjustable tinnitus-alleviating sounds for users of CIs. Acknowledgements This research is being supported by a grant from Action on Hearing Loss (formerly Deafness Research UK).

References 1. Baguley, D., McFerran, D. & Hall, D., 2013. Tinnitus. The Lancet, 6736 (13), pp.1–8.

Society Awards Members can make nominations for prizes and awards throughout the year. The final date for nominations to be considered in a given calendar year is 18 May (except for the Thomas Simm Littler lectureship which is 31 December of the previous year). In order to nominate a member, you should submit a letter of support (250 word limit) including a citation for the award and a CV or brief biography (100 word limit). *The winner of each award and prize is determined by the Trustees of the Society, usually at the June Council meeting of each year. The awards and prizes are made at the Annual Conference in September. Nominations should be sent to BSA, 80 Brighton Road, Reading, RG6 1PS or by email to bsa@thebsa.org.uk. *In the case of the Jos Millar Shield, the editorial team should submit the article along with a letter of support instead of a CV or biography.

Awards that are nominated by Trustees of the Society:Thomas Simm Littler Lectureship, George Harris Award, Denzil Brooks Trophy, Honorary Life Membership.

Awards that are nominated by Members of the Society:Thomas Simm Littler Prize and Ruther Spencer Prize.

Awards that a nominated by the editorial team of Audacity: Jos Millar Shield All Awards and Trophies carry a Certificate and are presented during the Annual Conference. The Thomas Simm Littler Lecture, Thomas Simm Littler Prize, Ruth Spencer Prize and the George Harris Award also carry a monetary award.

These awards honour members of our profession, who, in their own different ways, made a significant contribution to Audiology.

Through these awards, we are now able to honour our own contemporaries who have done valuable work in the field of Audiology.

Thomas Simm Littler Prize and Lectureship As a result of the generous gift of £1,000 to the Society by the organizing committee of the IX International Congress in Audiology held in London in 1968, the lectureship and prize fund was set up in honour of the late Dr Thomas Simm Littler, a pioneer in British Audiology. The awards are made in recognition of academic contributions to Audiology.

• The Lectureship is awarded every two years. It carries an honorarium of £300 and a Memorial Certificate.

• The prize is awarded annually. It carries an honorarium of £150 together with a Memorial Certificate.

Ruth Spencer Prize The prize was established to honour the memory of Ruth Spencer, who, until her death in 1974, was a senior audiology technician at the University of Southampton. The prize carries an honorarium of £75 together with a Memorial Certificate.

Jos Millar Shield Jos Millar, Chief Audiologist at the Waveney Hospital, Ballymena, retired after many happy years spent in audiological practice.

Jos wished to commemorate these happy years by making an award to the British Society of Audiology in the form of a Shield.

The Jos Millar Award was first presented at the Millennium Celebration held in Blackpool, and thereafter awarded annually, for the best article to be published in the BSA News (now Audacity). Jos was the recipient of the Ruth Spencer Prize in 1997.

The George Harris Award This Award was set up in 20065 as a result of a sum of £1,000 bequeathed by the late George Harris. The Will states that the money is to be awarded by the Awards Committee of the Society to any individual or individuals making a notable contribution to Hearing Aid Audiology in any one year, such amount to be paid to such individuals at such time as the Society shall in its absolute discretion think fit.

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14 Denzil Brooks Trophy The Denzil Brooks Trophy was purchased following a sum being given by his widow, Barbara. Denzil, who died in September 2006, was a pioneer in the provision of hearing aids within the NHS. The Trophy is an antique ear trumpet, mounted on an engraved plinth.

Honorary Life Membership Nominated by Trustees. The award carries a certificate.

Thomas Simm Littler Bursary One or more grants of up to £300 per year can be awarded to a member or members of the Society to assist in achieving training or related professional goals. Examples of uses to which the Awards could be put are – to help with travel costs to enable the results of a research project to be presented at an academic meeting, or to help with accommodation costs so that attendance at a conference can be extended to include a visit

to another department.

Applications should be submitted by 1st April or 1st October each year for consideration by the Awards Panel prior to the June or December Council Meeting. Applicants must explain in detail the purpose and nature of their intended activity and justify their request for an award. They should also provide a written reference from an employer or supervisor in support of their application, and if they are visiting another centre, confirmation that the department concerned agrees in principle to the visit. Preference will be given to less experienced people and to those who are unable to obtain the necessary financial help from their employers or elsewhere.

Applicants will be notified of the success or otherwise of their application within three weeks of the relevant Council meeting.

Payment will be made in arrears on production of copies of the appropriate receipts and/or invoices.

BSA Award Winners 2013 BSA is proud to announce the following Awards for this year which were presented at a ceremony prior to the Annual Conference Dinner at Keele.

• Thomas Simm Littler Lecture Brian C J Moore • Thomas Simm Littler Prize Michael Akeroyd for his contribution to research on binaural psychophysics and hearing impairment • Ruth Spencer John FitzGerald for leading the SONAR paediatric diagnostic ABR peer review • Denzil Brooks Trophy Daniel Rowan for his outstanding contribution as a member and Chairman of the Professional Practice Committee

Conference Report

• Jos Millar Shield Marshall Chasin for his article Setting Hearing Aids for Music in BSA News, Issue 68, April 2013 • Honorary Life Membership Mark Lutman in recognition of services to the Society

• Chairman’s Award A Special Chairman’s Award was presented to Brian Moore, Michael Stone, Brian Glasberg and Thomas Baer

Audacity Dec13_Layout 1 05/12/2013 13:25 Page 15

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SIG segment

16

SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Group

BSA Auditory Processing Disorder (APD) Special Interest Group Nicci Campbell Chair of the Auditory Processing Disorder (APD) SIG

To celebrate our 10th Anniversary, we hosted an APD Satellite Day, titled ‘APD and other Childhood Neuro-developmental Disorders’ as part to the BSA Annual Conference at Keele University, on Saturday 7th September 2013. The day, open to professionals of all disciplines was well attended, and we received very positive delegate feedback.

culties and learning disability. Carol Miller suggested that there is a ‘commonality’ between these disorders and both she and Stuart Rosen explored the relationships between these disorders. Dave Moore presented the neuroscience underlying auditory processing emphasising that not only the afferent auditory pathways but also the efferent pathways play a significant role. Lorna Halliday discussed APD, language and literacy in children with mild to moderate sensorineural hearing loss. Doris-Eva Bamiou provided an overview of current APD tests and their limitations while Johanna Barry introduced delegates to the new Evaluation of Children’s Listening and Processing (ECLiPS), which is due for release

Prof Kevin Munro, Chair of BSA, officially opened the meeting and reflected on the 10 years of the APD SIG, also thanking the sponsors who generously supported the event. The keynote speakers were Prof Dave Moore (USA), Dr Carol Miller (USA) and Prof Stuart Rosen, and the invited speakers were Dr Doris-Eva Bamiou, Dr Lorna Halliday, Dr Johanna Barry, Ms Pauline Grant and Dr Nicci Campbell.

The main take home messages of the day are that APD in children often co-exists with conditions such as specific language impairment, dyslexia, attention and memory diffi-

SIG segment

Figure 1 provides a breakdown of the professional backgrounds of the 108 delegates.

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17

Figure 2: The keynote and invited speakers

in the near future. The ECLiPS, a UK home-based questionnaire has been standardised for use with children aged 611 years. It has been validated for children with listening difficulties associated with hearing impairment, language impairment, dyslexia and APD. Leading on from this, Nicci Campbell discussed the value of multi – or interdisciplinary approaches and presented the different management options currently available, citing evidence levels, and new programmes and software that are becoming available.

Pauline Grant gave the final presentation of the day and offered practical advice about management within the educational setting.

My term of office comes to an end in January 2014. I would like to welcome our new chair, Pauline Grant, and also thank all of the APD SIG steering committee members for their enthusiasm, hard work and commitment over the past three years.

I would also like to thank Kevin Munro and David Baguley (Past Chair of BSA) for their invaluable guidance and

support. It has been a truly wonderful experience working together as a team and moving the field of APD forward both nationally and internationally, and fostering collaboaration.

Looking back, we have published a peer reviewed Position Statement (2011), Practice Guidance Document (2011), plus a ‘White Paper’ (2013) with an international set of commentaries and collaborated with the American Academy of Audiology (AAA) to present a successful APD day as part of the AAA conference held in Boston in March, 2012. This one-day event, titled ‘Global Perspectives on (C)APD’, was co-chaired by Frank Musiek (USA) and Doris-Eva Bamiou (UK) and saw over 250 delegates engage with over 75 presentations on APD by international speakers from a wide range of disciplines.

I am delighted to announce that due to the success of the AAA conference, a further global conference is being arranged, titled ‘Clinical Populations with Central Auditory Processing Disorder: What We Know and What Lies Ahead’, which will take place on Saturday, 29th March 2014, in Orlando, Florida.

For more information, please visit the American Academy of Audiology website http://www.audiologynow.org/program/cap dconference.html

Report by: Nicci Campbell/Chair APD SIG members: Roshini Alles, Doris-Eva Bamiou, Nicci Campbell (Chair), David Canning (Past Chair), Sandra Duncan, Pauline Grant (Vice Chair), Dave Moore, Pam Murray, Stuart Rosen,Tony Sirimanna, Dilys Treharne, and Kelvin Wakeham, APD SIG Advisor: Prof Anne O’Hare (Paediatrician, University of Edinburgh)

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18 BSA Special Interest Group for Cognition in Hearing Piers Dawes Chair of Cognition & Hearing SIG

The special interest group in hearing and cognition is the youngest, being officially ratified by the BSA council in June 2013.The aim of the SIG is to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment, and intervention. During this short time, I am pleased to report several exciting developments: i) A discussion paper on 'listening effort' for the International Journal of Audiology has been submitted – look forward to seeing that in print soon! ii) Dr Ariane Leplante-Levesque from Eriskholm delivered a very interesting BSA lunch and learn seminar on per-

Hearing and brain plasticity SIG segment

ceptions of age and cognitive status on hearing helpseeking on 7th October. iii) The SIG had met with interested delegates for a discussion session at the BSA annual conference in Keele last September. Johanna Barry and Scott Richards represented the SIG at a conference stand and most of the interim management committee of the SIG attended. iv) A very successful BSA Twilight series meeting on "Hearing and Cognition: Updates in Research and Clinical Implementation" was held on the 7th November in Birmingham, organised by Melanie Ferguson. An introduction was given Scott Richards from the SIG. Speakers included Dr Douglas Beck, from Oticon Inc, who spoke on issues in cognition and audition, Professor Sven Mattys from York University, speaking on cognitive demands of listening in adverse conditions and Dr Helen Henshaw from the NIHR Nottingham Hearing Biomedical Research Unit, who spoke about the benefits of auditory and cognitive training to real-world listening.

I look forward to letting you know of further progress in 2014.

in the next edition of audacity

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Knowledge Learning Practice Impact BSA Professional Practice Committee Update Paul James MSc Chief Audiologist NHS Clinical Leadership Fellow E: Paul.James@uclh.nhs.uk or p.james1@nhs.net or ppcadmin@thebsa.org.uk

WOULDN’T IT BE NICE? - What NICE accreditation of the BSA means, and why it is important The PPC has been busy over the last year working on an application for NICE accreditation of the BSA. Accreditation does not accredit the content of individual products or documents, but awards a seal of approval – the Accreditation Mark – to the BSA as a guidance producer. Although accreditation will not relate to the content of BSA guidance documents, as it is the processes used to produce it which are accredited, individual guidance documents will bear the Accreditation Mark. The NICE Accreditation Mark clearly identifies that the content of guidance has been produced via accredited processes.

As NICE accreditation is a very rigorous assessment of the quality of the processes followed by guidance producers, it means that users of BSA guidance documents can be totally assured that the BSA is a source of information of the highest quality. The rigour of the accreditation process is reflected in the requirement to meet 25 key assessment criteria, organised in six domains. Each domain captures a separate dimension of the quality of the process used to develop guidance documents.

Users of the guidance and others it affects can be more assured that the document is of high quality and less likely to have certain biases (e.g. arbitrary preferences of au-

thors) because it requires rigorous methodology for development and review of a document. The methodology, for example, ensures that users and others affected have had a say on a guidance document before it is published (although we already do that well). There will also be greater and more assured consistency because the production or review of all documents will follow the same accredited processes. The requirement to follow the accredited process does not in any way limit the type and range of BSA guidance documents. Moreover, NICE accreditation not only raises the quality of information produced by the BSA, but ultimately should result in improved patient outcomes.

On a broader scale, one of the objectives of the NICE accreditation is to enable access to authoritative clinical and non-clinical evidence and best practice. Accredited providers’ documents are flagged up on NHS Evidence and NICE websites. This means there will be links from these sites to the BSA website, thus promoting NICE endorsement of the BSA, and the NICE Accreditation Mark will be prominently displayed. This in turn enhances the status of BSA practice guidance documents both for new documents and for revision of existing documents.

Broader still, NICE accreditation raises the profile, standing and status of the BSA to the wider world of healthcare.

The Department of Health is much more likely to listen to accredited evidence providers and they are invited to participate in activities that influence and disseminate policy that non-accredited providers do not. NICE accreditation is therefore also good for audiology as a whole.

Knowledge, Learning, Practice, Impact – NICE accreditation ticks all the boxes.

In addition to our work on NICE, the Professional Practice Committee continues to work on producing documents,

knowledge learning practice impact

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N O I T A T I L I B A H E R T L s ach d U e e f e needs o ms.

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ilita gy prof of the trategie ffective b a h Re udiolo effects reed s w to e o a g the (s) of (i) m, (ii) a d (iii) h r n e othe d probl ffects a gies. e e e relat e these se strat e c redu ment th p e velo impl e d to ent i l c the p l e nh a c oach selves. r p p ed a elp them r t n t-ce ys to h n e i l A c tive wa effec

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With special thanks to Phonak for their design

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knowledge learning practice impact

21 which are all available on the BSA website. We are holding off starting new documents for now until the NICE accreditation application is complete, which we hope will be early 2014.

We would particularly like to draw your attention to two documents: •

•

BSA Recommended Procedure: Tympanometry (August 2013), which updates the 1992 document and incorporates NHSP guidelines for high frequency tympanometry.

BSA Practice Guidance: Common principles of rehabilitation for adults with hearing- and/or balancerelated problems in routine audiology services (August 2012) This document shows the BSA working at its best, drawing on a wealth of national and international knowledge to collaboratively produce practice guidance for identifying individual needs, setting joint goals, making shared and informed decisions and supporting self management. It is essential reading for everyone practicing audiology.

The eagerly-awaited VRA recommended procedure will also be completed very soon.

As always, the work of the PPC is collaborative with you, the reader, and your input is vital and valued. On behalf of the PPC, I would like to say a massive “Thank you” to everyone who has helped us with consultation of documents. I would also encourage more of you to have your say on documents that will ultimately affect your practice.

All opinions are valued and none are ignored, but ultimately we can not produce high quality documents without your collaboration. With this in mind, we would also like to draw to your attention to a brand-new recommended procedure produced by the Balance Interest Group on eye movement assessment, which will be out for consultation soon. We look forward to hearing your comments!

Acknowledgement: I would like to thank Daniel Rowan and Barry Downes for their assistance in writing this article.

BSA Learning and Events Group Update Mel Ferguson Learning and Events Group Lead E: melanie.ferguson@nottingham.ac.uk

The Learning and Events Group (LEG) recently superseded the BSA Progamme Committee, and aims to develop and expand the range and variety of organised events to deliver learning opportunities that meet the broad and diverse membership of the BSA.The members

of LEG (Roulla Katiri, Liz Arram, Shahad Howe and Chris Cartwright) are developing and co-ordinating a programme of events over the coming year that will focus on a range of subjects. These will include patient centred care, cochlear implants, balance and vestibular function, dementia and hearing loss.

The rebranded BSA Twilight Series (previously known as the London Evening Meeting) is taking place bi-annually in various places across the UK to increase accessibility to members outside of London. The first of these national meetings, organised by LEG, was held in November at the Queen Elizabeth Hospital, Birmingham, hosted by Huw Cooper. The meeting on Hearing and Cognition was a great success. It was arranged specifically to promote the

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22 opportunity to bring together a range of hearing professionals to share and discuss a variety of views, which will be made available to the wider community through Audacity.

A joint BSA meeting with the Ida Institute is being held in March on patient centred care.This meeting will follow on from the publication of the BSA Practice Guidelines on Common Principles for Rehabilitation for Adults with Hearing or Balance-related problems in September 2012.

The meeting, organised by Mel Gregory, Paul James and I (teaming up together again after our previous ventures with BAA conferences) will include talks from clinicians and researchers, as well as interactive workshops and breakout sessions to stimulate discussion between delegates. The focus will be on recent developments in patient centred care, and one of the aims is to consider how this can be further developed in future.

recently formed BSA Cognition in Hearing Special Interest Group, which was introduced by Scott Richards. Dr Doug Beck, live by video link from Texas, gave a fascinating overview of cognitive issues relevant for audiologists in the clinic, and invited us all back to his pad afterwards for a five-course meal and cocktails. Prof Sven Mattys (York University) demonstrated the neuroscience underpinning how cognitive load can affect processing of the auditory signal when listening to speech. The analogy of having a conversation whilst driving, and its effect on one’s cognitive load didn’t stop Helen and I chatting all the way on the drive back to Nottingham however. And last, but not least, Dr Helen Henshaw (Nottingham Hearing Biomedical Research Unit) showed that auditory training improves complex cognition (attention and memory) and self-reported listening abilities for people with mild hearing loss and hearing aid users. The instructions for a competing speaker task – “As is the case in real life, I want you to listen to the woman and ignore the man” – was a novel example of real world listening! There was an excellent turnout with over 50 people attending. The next meeting will take place in May. Look out for the ads.

One of the upcoming activities that will take place in spring is the first BSA Journal Club, which is being organised by Jane Wild (Wrexham Maelor Hospital) and Dr Helen Henshaw.The meeting will take place at the NIHR Nottingham Hearing Biomedical Research Unit, and will be on the hot topic of Adult Hearing Screening. This meshes nicely with the Hearing Screening for Life campaign for the over 65s currently being spearheaded

by MP Stephen Lloyd. The journal club will provide an

knowledge learning practice impact

The BSA Annual Conference 2014 will be held once again in the green and pleasant surroundings of Keele University on September 1-3rd.The conference committee, chaired by Dave Furness, brings together researchers from basic (Mike Akeroyd, Stefan Bleeck) and translational research (me), audiologists (Andy Reid) and the commercial sector (Christ Cartwright) to fully represent those who actively contribute to this conference. More dedicated time will be given to the poster sessions, which provide unparalleled opportunities for a large number of delegates to present their research in a forum that encourages informal discussion and exchange of ideas.

Themed sessions reflecting the range of research activities from experimental science to clinical research are also planned.

Finally, keep an eye out for the Lunch and Learn e-seminars, organised by Shahad Howe.These continue to gain momentum, with a line-up of national and internationally invited speakers planned for 2014. LEG has lots of ideas for future events, but we are always keen to hear BSA member suggestions. If you would like to organise an event under the BSA banner, drop me a line (melanie.ferguson@nottingham.ac.uk).

Don’t be shy!

Mel Ferguson, Lead of the Learning and Events Group

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Can the infant sucking response be used to evaluate hearing?

Note from the Editors: There has been increased focus at recent conferences in the UK on behavioural observation audiometry and the use of the infant sucking response to evaluate hearing. Work has been presented by Jane Madell PhD, Paediatric Audiology Consultant with comprehensive information about the technique and personal experience available on her website (www.janemadell.com).

But there has been debate and discussion about how much information about hearing levels can really be obtained from such early responses to sound. Audacity welcomes and encourages scientific debate. We had hoped to have an article talking about the evidence for the use of the response but unfortunately that did not work out. In the article ‘Can infant sucking response be used to evaluate hearing’ Sutton and Hall review the literature and express their opinions about the evidence base. We encourage comments or articles from those who have experience of the infant sucking response in their clinical practice.

CD

Authors and Correspondence Graham Sutton MA PhD CS, Clinical Scientist (Audiology) Newborn Hearing Screening Programme England

Amanda Hall PhD CS, Clinical Scientist (Audiology) Children’s Hearing Centre, St Michael’s Hospital Bristol & University of Bristol

Take home message: Looking for behavioural responses (including sucking) to sound can be clinically useful but results cannot be taken as hearing thresholds. ABR is still the gold standard for assessing thresholds in early infancy.

There is a school of thought, led by Madell (2011) that Behavioural Observation Audiometry (BOA) using in particular the sucking response should be performed along with ABR in assessment, and used to monitor aided responses in babies with hearing loss. Madell asserts that ABR is not a true test of hearing but BOA is (‘Testing hearing in children’ - see http://www.janemadell.com/publications). She believes that hearing thresholds can be obtained accurately by using BOA.

months of age” (Madell 2011). As evidence she has illustrated a few cases where BOA thresholds have been in good agreement with later VRA thresholds, and stated these are typical (Madell 2008).

The BOA test protocol she uses (see website) is as follows : 1. Baby resting comfortably in mother’s arms or in infant seat 2. Begin nursing, feed using baby bottle, or use pacifier.

3. Observe changes in sucking. A response can be either starting or stopping sucking. Babies are consistent in how they respond. Some respond to the start of the sound, and some to the stop.

4. Start at a loud level where you think the baby will hear.

When you see a response, make the sound softer. Keep making the sound softer until there are no more responses.Then start making the sounds louder until you see the response again 5. Responses should be observed 2-3 times before it is considered a response.

The need for evidence before introducing new tests We are all in favour of innovation and development. But claims about a new test or treatment must be approached in a scientific spirit. Evidence is essential - innovations need to be trialled and proved to be effective before they are brought into routine clinical practice. The history of medicine is littered with examples of the harm that can result when advice, tests or treat-

“When carefully performed, using appropriate criteria including using changes in sucking as an indication of a response, behavioral observation audiometry can be used by clinicians to accurately measure thresholds in infants cognitively less than 6

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24 ments are introduced on the basis of assertion, authority or plausible arguments rather than evidence. The excellent book Testing Treatments (Evans et al 2011) gives some vivid examples.

When bringing a new test into clinical practice we need evidence that the test is valid, accurate and reliable (Greenhalgh 1997); and also that including the test improves patient outcomes for the better (Ferrante di Ruffano et al 2012).

or from 40 to 66 dB (1 to 4kHz) above eventual VRA thresholds (as calculated using the MRLs for VRA in NHSP VRA guidance 2008 Table 1).These babies were very young, up to 5 days old, but the evidence is strong that the gap between other BOA minimal response level and true (sensory) hearing threshold only closes gradually over the next 6-8 months (Tharpe & Ashmead 2001, Werner 2007). Figure 1 illustrates data from some of these studies at 4kHz.

So, what is the evidence that BOA can measure hearing threshold in infants?

History of BOA BOA has long been part of the armoury of the paediatric audiologist. The careful search for any repeatable change in eye turns, eye widening, stilling, limb movement, crying, Moro reflex, or sucking in response to sound can add useful information and is included in NHSP guidance (NHSP 2001). Nonetheless the evidence is unequivocal that all these responses only occur at raised stimulus levels in the early months, gradually falling with age (e.g. Olsho 1988, Werner & Marean 1991,Tharpe & Ashmead 2001 – see their Fig 4 for a summary of other data).They cannot be taken to be true sensory thresholds. We will focus on the sucking response but the questions to be answered are the same for any BOA response.

The non-nutritive sucking response in infants The technique of using changes in non-nutritive sucking behaviour to study a baby’s development, including responsiveness to sound, was developed by developmental psychologist researchers in the 1960s and called High Amplitude Sucking.

Studies using these techniques examined changes in sucking following moderate to high level intensity sounds (e.g. Keen 1964).

Under controlled, experimental conditions they showed significant changes in the sucking response in response to sound.

In searching the literature the only study we found using sucking responses to measure babies’ lowest responses to sound was

by Eisele et al (1975).They examined 100 full-term infants (age range 24 to 108 hours) using an electronic pressure nipple to control the stimulus level. The average minimal response levels of these infants are shown in Table 1.

Table 1: Mean (SD) minimal hearing response level (dB SPL) (from Eisele et al, 1975)

1 kHz

2 kHz

4 kHz

59.2 (7.4)

62.0 (7.4)

67.7 (7.1)

So the mean responses from normal hearing babies were at moderate sound levels. These are approximately 50 dB above the ABR thresholds for normal newborns (Sininger et al 1997),

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Figure 1. Elevation of BOA minimal response levels at 4kHz above adult hearing threshold in various studies We have used this term rather than ‘threshold’ to avoid confusion between the lowest or minimal level at which a response is seen and true sensory threshold

1

Do we have enough evidence to use the BOA sucking response to measure hearing thresholds in clinic?

We apply the criteria referred to above: Validity - does the test measure what it’s intended to measure?

We could find no evidence that the BOA sucking response can measure sensory hearing threshold. Rather the minimal response levels reported (Eisele et al 1975) were well above presumed sensory thresholds and what would be measured

by ABR or on later VRA or PTA. The same is true for other carefully controlled BOA (Tharpe & Ashmead 2001).

It is not enough to present one or two cases where thresholds for sucking are close to later VRA results as evidence of accuracy. We would expect to see data from a well-designed, peer-reviewed study presenting the range of minimal response levels on a good size sample of normal-hearing babies with clearly defined corrected age bands.

Reliability – if the same test is repeated on the same baby on two occasions, how different will the results be?

This is not known but is key to interpretation of test results.

We need data on this.

Observer bias – were testers “blind”?

We would expect to see control no-sound (‘catch’) trials in any protocol and discussion of the serious danger of bias when the observer is not blinded –something even the best clinician is subject to.

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25 Patient benefit – does inclusion of this test change management and improve patient outcomes?

This has not been examined in a systematic way but it seems unlikely. The difficulties are best illustrated with a clinical scenario. How would we interpret absence of a BOA response in an infant with sensorineural hearing loss wearing hearing aids? If behavioural responses are not observed at a low sound level, it does NOT necessarily mean the baby has a raised threshold. There are practical implications and we would not increase the gain of the hearing aids on this basis as it could lead to damaging overamplification.

In summary there is a lack of peer-reviewed evidence to support the use of the BOA sucking response as a suitable technique for measuring hearing thresholds in infants.

The Auditory Brainstem Response (ABR) test In contrast to BOA, there is overwhelming evidence of the validity, reliability and accuracy of the ABR in predicting behavioural thresholds. The evidence for this has been carefully reviewed in the NHSP Early assessment guidance (NHSP 2013).

The meta-analysis by Stapells (2000), examining the relationship between ABR and behavioural thresholds, showed 95% confidence intervals of about ±15dB (i.e. we can be 95% confident that the behavioural hearing thresholds are within 15 dB either way of the measured ABR threshold). More recent data from Stevens et al (2013) support the Stapells results.

Given these studies are affected by a number of extraneous factors including the behavioural test reliability, temporary conductive hearing loss, delayed neural maturation, and progression of hearing loss after the neonatal stage, we consider this to be a very acceptably tight range, and no worse than the variability we would expect in estimates from the sucking response (the 95% confidence intervals in the Eisele data in Table 1 above are also about ±15 dB).

The exception where ABR does not give true thresholds is in cases of Auditory Neuropathy Spectrum Disorder (ANSD). But it is unfair to damn ABR for this, and we have good tests to identify when ANSD is present so we do not fall into error on these cases.

Gaps in our testing and the future In audiology there is an inconvenient gap in our testing of infants between about 3 months (when ABR becomes difficult under natural sleep) and 6 months (when head turns become more reliable). A reliable test to measure an infant’s hearing threshold in this gap would be marvellous. We do agree more needs to be done and we would encourage researchers to design and perform studies to look for more sensitive behavioural tests.

The possibility (Mattsson 2009) that eye-tracking technology might be used to bring down the age at which we can reliably perform VRA is exciting.

Audiologists should never ignore behavioural responses when they see them but they must be reliable and repeatable. We

would also encourage audiologists to use changes in sucking response as part of general behavioural observation when looking for aided responses in young babies with hearing loss, but it would be dangerous to routinely interpret results as thresholds.

References 1. Eisele WA, Berry RC, Shriner T (1975). Infant sucking response patterns as a conjugate function of changes in the sound pressure level of auditory stimuli. J Speech Hear Res 18, 296-307 2. Evans I,Thornton H, Chalmers I, Glasziou P (2011).Testing Treatments. Better research for better healthcare. 2nd edition. Free download at www.testingtreatments.org 3. Ferrante di Ruffano L, Hyde CJ, McCaffery KJ, Bossuyt PM, Deeks JJ (2012). Assessing the value of diagnostic tests: a framework for designing and evaluating trials. BMJ 344:e686. doi: 10.1136/bmj.e686.

4. Greenhalgh T (1997). How to read a paper. Papers that report diagnostic or screening tests. BMJ 315(7107), 540-3 5. Keen R (1964). Effects of auditory stimuli on sucking behavior in the human neonate. J Exp Child Psychol 1(4), 348-354.

6. Madell JR (2008). Using behavioral observation audiometry to evaluate hearing in infants from birth to six months.

In Flexor C, Madell JR (eds). Paediatric Audiology: Diagnosis, Technology and Management. Thieme.

7. Madell JR (2011).Testing Babies:You Can Do It! Behavioral Observation Audiometry (BOA). Perspectives on Hearing and Hearing Disorders in Childhood, 21(2), 59-65.

8. Mattsson L (2009). Prototype of infant hearing test using eye tracking. Master of Science Thesis, KTH Industrial Engineering and Management, Machine Design, Stockholm http://www.diva-portal.org/smash/get/diva2:542820/FULLTEXT01.pdf 9. Newborn Hearing Screening Programme (England) (2001-2013). Guidelines including Behavioural Observation Audiometry; Early audiological assessment and management of babies referred from the Newborn Hearing Screening Programme; Visual Reinforcement Audiometry testing of infants. http://hearing.screening.nhs.uk/audiologicalassessment 10. Sininger YS, Abdala Y, Cone-Wesson B (1997). Auditory threshold sensitivity of the human neonate as measured by the auditory brainstem response. Hear Res 104, 27-38.

11. Stapells DR (2000). Threshold estimation by the toneevoked auditory brainstem response: A literature metaanalysis. J Speech-Lang Path & Audiology 24(2), 74-83.

12. Stevens J, Boul A, Lear S, Parker G, Ashall-Kelly K, Gratton D (2013). Predictive value of hearing assessment by the auditory brainstem response following universal newborn hearing screening. Int J Audiol 52(7), 500-506 13. Tharpe AM, Ashmead JH (2001). A longitudinal investigation of infant auditory sensitivity. Am J Audiol 10(2), 104112 14. Werner LA, Marean GC (1991). Methods for estimating infant thresholds. J Acoust Soc Am, 90(4), 1867–1875.

15. Werner LA (2007) Human Auditory development. http://faculty.washington.edu/lawerner/sphsc462/Development.pdf

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Tinnitus Counselling with Children CD

Authors and Correspondence Dr Alice Emond Clinical Psychologist Nuffield Hearing & Speech Centre RNTNE Hospital Royal National Throat Nose & Ear Hospital 3330 Gray’s Inn Road London WC1C 8DA E: alice.emond@uclh.nhs.uk Ms Rosie Kentish Consultant Clinical Psychologist Child Psychology, Nuffield Hearing and Speech Centre

Take-home message: The Child Friendly Tinnitus Model provides a useful clinical framework for tinnitus assessment, counselling and intervention in children and young people.

Individualising the model, using developmentally appropriate language, and tailoring information giving to address the specific questions about tinnitus raised by the child and family is important for effective tinnitus counselling with children.

Introduction Contrary to popular belief, tinnitus is surprisingly common in children. Prevalence rates of tinnitus in children have been reported as 3-13% in children with normal hearing and up to 76% of children with hearing loss (Sheyte & Kennedy, 2010).

Although many children are not troubled by tinnitus, for some tinnitus can have a significant impact on their physical and psychological well-being, affecting their mood (Holgers & Juul, 2006) sleep and concentration (Kentish, Crocker & McKenna, 2000). The Good Practice Guidelines for the Management of Tinnitus in Children and Teenagers (Kentish et al, currently under development) recommend routine child friendly assessment of tinnitus in paediatric clinics and specialist counselling for those children concerned or distressed about tinnitus.

Why is tinnitus counselling with children important?

Children are usually keen to share their tinnitus story, as they would like their family and professionals to understand their tinnitus experience and the impact that the tinnitus has on their lives. Many children also have questions about tinnitus or mis-

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conceptions that need addressing to reduce associated distress.

Tinnitus counselling helps the child and family increase their knowledge and understanding of tinnitus, which can reduce feelings of helplessness and increase motivation to participate in self-care. Following a medical and audiological assessment, tinnitus counselling can be an effective intervention to reduce tinnitus-related distress and promote resilience and positive adjustment to the tinnitus, preventing it becoming a more entrenched and difficult-to-treat problem in adulthood.

Health counselling with children Effective information sharing about a child’s health condition, like tinnitus, is an interactive process with the family.

It involves 1) finding out what the child and the family already know 2) what they would like to or need to know i.e. specific questions to be addressed 3) providing relevant information 4) checking the child’s and familys’ interpretations of the information given (Edwards & Titman, 2010).

In providing information about tinnitus, consideration needs to be given to the child’s age, and cognitive and language abilities to ensure that the child is engaged and understands the information. The use of pictures alongside text helps to make the information more interesting for the child and also improves understanding and retention of the information (Edwards & Titman, 2010).

Theoretical models can be useful to explain the factors contributing to the onset, development and maintenance of different health conditions and to provide guidance on how to intervene to help improve outcome. While different models have been proposed for tinnitus in adults (e.g. Jastreboff ’s neurophysiological model (JNM), Jastreboff, 1990); A Psychological Model of Tinnitus (McKenna, Baguley & McFerran, 2010), to date, no theoretical models of tinnitus have been developed specifically for children.

A Psychological Model of Tinnitus (Figure.1) (McKenna et al., 2010) highlights the role of attention and emotion in the development of tinnitus-related distress. In our clinical experience, this seems to fit with many of the presentations of paediatric tinnitus. With consent from the authors, A Psychological Model of Tinnitus, has been developed into a Child Friendly Tinnitus

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27 Model (Emond & Kentish, in preparation) to use in tinnitus counselling with children and young people and their families.

Mckenna and colleagues conceptualise tinnitus as a fault in the filtering mechanism in the central auditory system, which allows random spontaneous electrical activity in the ear or auditory nerve to reach conscious awareness. We become aware of a sound sensation, which is commonly referred to as ‘Tinnitus’.

Figure 1. A Psychological Model of Tinnitus (Mckenna et al., 2010)

Figure 2. The Child Friendly Tinnitus Model (Emond & Kentish, in preparation)

This sound sensation can activate emotional pathways in the brain, which can lead to an autonomic ‘fight’ or ‘flight’ response.

The increase in autonomic activity makes our senses, including our hearing, more acute and results in increased awareness of the tinnitus. The more we notice the tinnitus, the greater the emotional response to it, which results in several vicious feedback loops.

The Child Friendly Tinnitus Model (Emond, Kentish, in preparation) (Figure 2.)

The Child Friendly Tinnitus Model is a developed pictorial version of a Mckenna and colleague’s Psychological Model of Tinnitus.

The images were piloted with children (618 years old) and their families in tinnitus counselling sessions in our clinic by Clinical Psychologists over the last 18 months. The images have been reported to have content validity across this age range and also for adults. We have added an additional box ‘the worry box’ (Box 6.) to the model to help explain how other stresses in the child’s life can both trigger and exacerbate the tinnitus.

At the Nuffield Hearing and Speech Centre, we use the model as a framework to structure our clinical psychology assessments of a child’s experience of tinnitus, gathering information about each box in the model. In a follow-up tinnitus counselling session, the child and family are invited to collaboratively draw the child’s individualised tinnitus model with the psychologist. We talk through the model together using the child’s words and images for the tinnitus. It is helpful to slowly build up the model for the family, rather than present it in its complete form. We start with Part A, explaining the first three boxes, which refer to tinnitus awareness.

These boxes help to address the frequently asked questions “What are these sounds?” and “Why can I hear them?”.Then we go on to talk about Part B, the tinnitus and worry cycle.

Examples of child friendly language that we use to explain each box are presented in italics below. Additional information about each box can be added for young people and parents, although they often also benefit from simple explanations.

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28 Tinnitus counselling helps the child and family increase their knowledge and understanding of tinnitus, which can reduce feelings of helplessness and increase motivation to participate in self-care.

PART A: ‘I hear sounds in my ears/head (Tinnitus Awareness) Box 1. Ear Noises Different parts of our body make special noises when they are working.You might have heard your tummy rumble when you are hungry or your heart beat if you run fast. In a really quiet room, almost all children and adults can hear the special noises that their ears make. Everyone’s ears make these noises, because they are still working even when there is no sound in the room.

It can be helpful, particularly with older children and parents, to talk about the experiment carried out by Morris Heller and Moe Bergen, cited in Mckenna et al (2010). The experiment found that around 94% of adults, who did not have tinnitus, experienced a sound sensation (hissing, ringing or buzzing) when listening hard in a silent sound proof room. The idea that these tinnitus-like sensations or ‘ear noises’ are present in almost everyone, but just below the level of conscious awareness, helps to normalise the experience of tinnitus and can alleviate concerns that there is something terribly wrong with the child’s ears or body.

Box 2. Noise Traffic Light The part of our brain that helps us to hear noises has a special filter, like a noise traffic light. It tells us which noises are important to listen to and which ones can be safely ignored. When the traffic lights turn green, we can hear the noise. When the traffic lights turn red, we can’t hear the noise.

The traffic lights turn green when our brain thinks it is an important noise for us to hear (e.g. a lion’s roar!) to warn us of danger. Our traffic lights turn red for noises that can be safely ignored, such as our ear noises and most of our body noises. Have you

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noticed that you can only hear your tummy rumble when you are very hungry and it is important for you to eat?!

Box 3. I can hear my ear noises Some noise traffic lights do not work very well and they make mistakes. They turn green for ear noises when they should be on red as ear noises can be safely ignored.

Sometimes, the traffic lights change back to red quickly and the noise stops. Sometimes, the traffic lights stay on green and you can hear the ear noises for longer. People who do not have tinnitus, their traffic lights are always on red for their ear noises.

We explain that lots of children have traffic lights that make mistakes, and explain that we do not know exactly what causes the noise traffic light (filtering mechanism) to make mistakes.

We talk about some factors that may be relevant for that child, including hearing change from sensori-neural or conductive hearing loss (e.g. If you can’t hear very well, the traffic light turns green more often to allow you to hear more noise but more ear noise also gets let through) or exposure to loud noise and the role of emotional stress (see below).

PART B: The Tinnitus and Worry Cycle Box 4. Dislike of ear noises (Tinnitus related-distress) Ear noises are not dangerous for us to listen to. Some children find it okay to hear their ear noises, but some do not like hearing them.

Children tell us that they can feel different emotions, like sad, worried or angry, when they hear these ear noises.

We invite the child to draw faces of and talk to us about how hearing the tinnitus makes them feel and which emotion they feel the most.

Box 5. Body alarm When we feel very worried or angry about something, our brain thinks that we could be in danger and sets off an alarm in our body. This alarm tells the body to get ready to ‘fight’ the dangerous thing, or ‘flight’, run away from it as if it was a lion. Our body alarm can go off by just having a really scary thought about ear noises, even when there is no real danger. Our brain gets confused and can think the ear noises are as dangerous as a wild animal!

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29 Our body alarm clock helps us to see and hear better, so we can look and listen out for danger. But this means that we can hear our ear noises even more! Our brain also tells us to listen really carefully to the ear noises, because it thinks they are dangerous.

Summary The Child Friendly Tinnitus Model provides a useful clinical framework for tinnitus assessment, counselling and intervention in children and young people. Individualising the model, using developmentally appropriate language, and tailoring information giving to address the specific questions about tinnitus raised by the child and family is important for effective tinnitus counselling with children.

Box 6. My worry box All children have things that they worry about. Having an argument with a friend, having to do tests or exams at school, or changing school can all make children feel worried or stressed. When there is a lot of worry or stress around, children can feel more worried about their ear noises. Children tell us that their ear noises also start or get louder sometimes when they are thinking about or doing something that worries them.

Acknowledgement Special acknowledgement and thanks to Adrian Williams, Medical Illustrations, Royal National Throat, Nose & Ear Hospital (UCLH) for providing the images for The Child Friendly Tinnitus Model.

It is important to find out what kind of things are in child’s worry box that might be contributing to their stress levels and tinnitus. Asking about what is happening when the tinnitus is and is not around can help to identify things that make the tinnitus worse and better.

The Tinnitus and Worry Cycle If we put all of the boxes and arrows together, we can see that it makes two circles:

References 1.

Edwards, M., & Titman, P. (2010). Promoting Psychological Well-being in Children with Acute and Chronic Illness.

Jessica Kingsley Publishers, London.

2.

Emond, A & Kentish, R (in preparation). The Child Friendly Tinnitus Model.

3.

Holgers, K.M., & Juul, J. (2006). The Suffering of tinnitus in childhood and adolescence. International Journal of Audiology, 45, 267-271.

4.

Jastreboff, P.J. (1990). Phantom auditory perception (tinnitus): mechanisms of generation and perception. Journal of Neuroscience Research, 8, 221-54.

5.

Kentish, R., Crocker, S., & McKenna, L. (2000). Children’s experience of tinnitus: a preliminary survey of children presenting to a psychology department. British Journal of Audiology, 34, 335-340.

6.

Kentish, R., Kennedy, V., Benton, C., Rogers, C., Rosenberg, J., Salvage, S., Munro, C., & Phillips, J. (Currently under development). Tinnitus in Children and Teenagers. A Good Practice Guide. Paediatric Tinnitus Working Group.

7.

McKenna, L., Baguley, D., McFerran, D. (2010). Living with Tinnitus and Hyperacusis. London, Sheldon Press.

8.

Sheyte, A., & Kennedy, V (2010). Tinnitus in Children; an uncommon symptom? Archives of Disease in Childhood, 95, 645-8.

Circle 1: The more we listen to our ear noises and the more we dislike the noises, our body alarm keeps ringing and the more we notice the noises!

Circle 2: The more we listen to our ear noises, our brain thinks that these are important noises for us to listen to. It keeps the traffic lights on green, which means we hear more ear noises and dislike these noises more.

These circles can go round and round, making the ear noises a bigger and bigger problem as we listen to them more and worry about them. But the good news about circles is that you can break them in different places.

Talking through the tinnitus and worry cycle with a child and their family invites ideas about how they can work together to break the circles to help the noise traffic light stay red for ear noises. For more information on how to use The Child Friendly Tinnitus Model in tinnitus therapy with children, please contact Dr Alice Emond, Clinical Psychologist (details above).

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30

Tinnitus in Children: Guidelines for Good Practice

CD

Authors and Correspondence Claire Benton Nottingham University Hospitals NHS Trust on behalf of the Paediatric Tinnitus Working Group.

Paediatric Working Group Members: Rosie Kentish, University College London Hospital Veronica Kennedy, Bolton NHS Foundation Trust Charlotte Rogers, Nottingham University Hospitals NHS Trust Joy Rosenberg, Mary Hare Training Services John Phillips, Norfolk and Norwich University Hospital Sue Salvage, Chime Social Enterprise, Exeter Caroline Munro, University College London Hospital Claire Benton, Nottingham University Hospitals NHS Trust

A recent survey carried out concluded that many professionals were unhappy with their level of knowledge and management skills of tinnitus in children. Therefore the Paediatric Audiology Interest Group of the British Society of Audiology set up a multidisciplinary working group to develop guidelines for working with children with troublesome tinnitus.

Challenges: There are many different service models for Paediatric Audiology across the UK. Different professionals are involved in different services at different levels. The working group seek to reflect this and ensure the guidelines produced are not too prescriptive when it comes to job roles.

It is recognised that there is a lack of research in the area of tinnitus in the paediatric population, thus a strong evidence base for the guidelines will be challenging. However, good evidence from the adult population where appropriate is taken and many parallels can be drawn from work in childhood chronic pain and anxiety (Mahrer et al, 2012, Kim et al, 2012).

Take home message: Whilst there is limited research into tinnitus in children at the moment, this is not a reason to assume that children are not distressed by their experiences of tinnitus. It is important that children are assessed and managed by those with good skills in paediatric audiology to ensure that the child is treated in a holistic way. Healthcare Professionals should not be afraid to tackle the issue.

Aims of the Guidelines: The guidelines aim to describe child friendly approaches to the assessment of tinnitus and its impact. They also give advice on management tools for both home and school environments to improve standardisation across services.

Background: Contrary to popular belief tinnitus is as prevalent in children as it is in adults. Results from studies looking at the prevalence of tinnitus in children vary from 12%-36% in children with normal hearing and up to 66% in children with hearing loss (Sheyte & Kennedy, 2010).The evidence base for the management of paediatric tinnitus, however, is scarce. While the underlying principles of managing tinnitus in adult patients can be applied to the management of tinnitus in children and young people, there are important differences in the aetiology, presentation and management of tinnitus in a child. However, the main areas of tinnitus impact are similar in children as adults, namely concentration, well being and sleep.

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The aforementioned survey highlighted that not all professionals felt there was a need to address childhood tinnitus. There was a proportion who felt that children do not suffer from tinnitus distress. By asking a child whether they experience tinnitus it is felt one would simply create many false positives and you might raise anxiety and generate a problem rather than help to manage an existing one. The working group feel these concerns may arise from professionals own lack of confidence and knowledge in this area or a concern that a need that the service can not accommodate will be generated. Practice in established services shows that this latter concern is not the case, most children’s and families’ concerns can be easily addressed by a clear explanation of tinnitus within their first appointment. Bartnik et al (2012) state that all children attending for hearing assessment should be asked whether they have tinnitus.

Recommendations: The key recommendations given in the guidelines are as follows: • Those working in a Paediatric Tinnitus Service should be experienced in working clinically with children • Children should be seen in a paediatric setting not in an adult clinic • All children seen within audiology should be routinely asked whether they experience tinnitus • Educational concerns should be assessed and advice given to schools regarding management where appropriate • The child should be directly involved in the assessment

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31 Assessment: It is important for healthcare professionals to be aware of the ways a child can present with tinnitus, it is not always as simple as asking a direct question. For example, the history taking may suggest a child has equal difficulties listening in quiet and noise with normal hearing, or previous audiological assessment showed variable results, child reports dislike of one ear or a feeling of 'something' in their ear. In all cases where tinnitus is suspected or reported a thorough history into the impact and nature of the tinnitus is necessary. Using a visual analogue scale to gauge the amount of distress the tinnitus is causing can be very useful and even young children can grasp the concept well.

Management: The appropriate management of a child with tinnitus will depend on the level of tinnitus distress present (Figure 2). It is suggested that for those with Level 1 & 2 distress most professionals will be able to manage the child appropriately. For children with Levels 3 or 4 distress it is recommended they are seen within a specialist service. Those with Level 4 distress are likely to need onward referrals into their local CAMHS team for extra support, especially in services without access to clinical psychology.

All children seen within audiology should be routinely asked whether they experience tinnitus Summary: The guidelines will contain resources for use within clinic and school settings. It will include case studies to give practical examples of strategies, resources and skills used to help children and their families with their anxiety, sleep disturbances, and difficulties in school.

Figure 1. Assessment checklist for Healthcare Professionals

It is important for all children to have a full audiological assessment. Some children with tinnitus find audiometry very stressful and may become increasingly anxious in clinic when asked to carry this out. Plenty of time and reassurance needs to be given to obtain accurate results. A simple check list of all areas to cover within an appointment for healthcare professionals is included in the guidelines, Figure 1.

When history and assessment indicate, further referral to the appropriate professional, such as ENT or Children and Adolescent Mental Health Services (CAMHS) should be carried out.

Throughout the guidelines these have been highlighted as red flags.

The working group hope that the first draft of the guidelines will be ready for comment at the beginning of 2014. More practical training in this area was requested and workshops will be running at conferences this year, with a view to setting up a more formal training event in 2014.

References: 1. Bartnik G, Stepien A, Raj-Koziak D, Fabijanska A, Niedzialek I, Skarzynski H. 2012.Troublesome Tinnitus in Children:Epidemiology, Audiological Profile and Preliminary Results of Treatment. Int J Pediatr, 2012:945356. Epub 2011 Jul 19 2. Kim YH, Jung HJ, Kang SI, Park KT, Choi JS, Oh SH. 2012.

Tinnitus in children: Association with stress and trait anxiety. Laryngoscope, 122(10): 2279-84.

3. Mahrer NE, Monta単o Z, Gold JI. 2012. Relations between anxiety sensitivity, somatization, and health-related quality of life in children with chronic pain. J Pediatr Psychol. 37(7), 808-16 4. Shetye A, Kennedy V. 2010. Tinnitus in children: an uncommon symptom? Arch Dis Child. Aug;95(8):645-8

Acknowledgements: The working group would like to acknowledge the support of the Paediatric Audiology Interest Group of the British Society of Audiology and the British Tinnitus Association in the development of these guidelines.

Figure 2. Levels of tinnitus distress

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32

Auditory Processing Disorder the pursuit of a gold standard test

CD

Author and Correspondence Dr Johanna Barry Senior Research Scientist Institute of Hearing Research Nottingham E: johanna.barry@ihr.mrc.ac.uk

Take home message: Clinical assessment relies on access to tests that are sufficiently sensitive and specific to the referral problem.

Website recommendations: http://www.ihr.mrc.ac.uk/pages/studies/epic-q/index http://www.youtube.com/watch?v=0zNA-GG6HJY Assessment – the systematic collection of information about a referral problem – is central to clinical practice. It has two main functions: to gauge the severity of the referral problem, and to support decisions about the treatment and / or management strategy required to minimise the impact of the problem on a patient’s quality of life.To effectively address these functions, clinicians require assessment tools that are sufficiently reliable and informative. Ideally, an assessment test battery will include a gold standard test i.e. a benchmark which offers a high degree of sensitivity and specificity for the referral problem. Currently, no such gold standard test exists for assessing children referred for auditory processing disorder (APD). This is deeply frustrating for clinicians, for service providers and perhaps most of all for the parents of these children. Much of IHR’s work over the past decade has focused on trying to address this clinical need through research targeted on further understanding APD, while at the same time, developing better assessment tools to support clinical practice.

Defining APD APD is defined as normal hearing but disproportionate difficulty understanding speech when listening in noisy conditions. The name of the disorder suggests it is distinct from other neurodevelopmental disorders and also that it develops out of an underlying difficulty with processing auditory inputs. The name however is deceptive. At least in the UK, while there is no doubt that children referred for APD have difficulties, there is considerable debate about whether they should be seen by a paediatric audiologist. This debate arises because, in addition to difficulty understanding speech in noise, children referred for APD typically also have poor short-term memory and deficits

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in attention.These symptoms are more typically associated with other neurodevelopmental disorders such as with dyslexia, language impairment (LI), and autism (ASD). It has consequently been suggested that APD may simply be an artefact of referral route (Ferguson, Hall, Riley, & Moore, 2011). Yet the fact remains that children with apparent similarities in symptoms follow one referral route rather than another.This suggests referral is being influenced by qualitative differences between neurodevelopmental disorders. It also supports the notion that development of a gold standard test specific to APD may be a feasible goal for research.

As a first step towards developing a gold standard test for APD, it is important to establish the theoretical construct to be systematically targeted by the test.There has consequently been a lot of research focused on understanding and defining the nature of the disorder. Reflecting the outcomes from this research, definitions of APD have changed from being highly exclusive (e.g. The British Society of Audiology, 2007), where only difficulties specific to the auditory system were considered relevant, to being highly inclusive (e.g. The British Society of Audiology, 2011), where difficulties are understood to be broad ranging and occurring within the context of other neurodevelopmental disorders. This change in understanding reflects the findings of a nationwide study (the IMAP study) carried out by the MRC Institute of Hearing Research (Moore, Ferguson, Edmondson-Jones, Ratib, & Riley, 2010).The study took the highly original approach of assessing auditory abilities at the level of the population to determine which auditory tests would be most sensitive to the presence of APD.The ultimate aim of the study was to develop a well-validated benchmark diagnostic test battery for everyday clinical use (Barry, Ferguson, & Moore, 2010).

Following the 2007 BSA definition of APD, the auditory tests in the IMAP study were designed to exclude linguistic and attentional confounds in test performance. Separate measures of attention, language and literacy were however obtained, together with measures based on parental report of everyday language and listening abilities. These latter measures were to be used to further current understanding of the cognitive and communication profile characteristic of children with APD. Disappointingly, performance on the auditory tests in the IMAP test battery did not predict the problems that led parents to seek clinical support. These findings are perhaps not surprising given that tests of auditory perception are highly susceptible to a range of differences located at the level of the individual (Barry, Weiss, & Sabisch, 2013), even when tests have been carefully designed to minimise cognitive or linguistic demands.

While the IMAP study failed to deliver on its main aim of pro-

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34 viding clinicians with a standardised benchmark test battery for supporting clinical assessment, it was in many respects a resounding success. A key conclusion from the study was that differences in cognitive abilities are intrinsically linked to differences in auditory abilities. It is more appropriate to think of APD as a disorder of listening, rather than a disorder specifically of auditory processing. Moore et al. (2010) further hypothesised that APD may derive from difficulties with attention rather than difficulties specifically with listening. These findings were seminal in shaping current understanding of APD (The British Society of Audiology, 2011). From a clinical perspective, the study underlines the importance of assessing the cognitive abilities of children referred for APD. Both the IMAP study and a study by Ferguson, Moore et al. (2011) provided evidence suggesting that parental report may be more reliable in explaining why children may follow different referral routes. We hypothesise that this is because referral route is largely determined by specific combinations of presenting symptoms (Moore, Rosen, et al., 2013). A reliable measure of presenting symptoms may therefore represent a key first step towards the development of a gold standard test for APD (Moore et al., 2013).

To test our hypothesis, a parental report based metric of everyday listening difficulty is required i.e., a scale. A number of scales currently exist for APD. However, items within them are not easy for parents to understand (Atcherson, Richburg, et al., 2013). They are also not particularly informative about the range of difficulties experienced by a child since many of the subscales are better described as being comprised of ‘bloated specifics’ (Young and Barry, 2013) – essentially single items paraphrased multiple times.

Speech & Auditory Processing (listening skills), Memory & Attention, Language/Literacy/Laterality, Pragmatic & Social Skills (socially appropriate communication), Environmental & Auditory Sensitivity.

Moore et al. (2013) have argued that a well-validated measure of presenting symptoms would provide a novel gold standard test for APD.The ECLIPS is wellvalidated and informative about a wide range of abilities relevant to APD.

Figure 1: Summary of the five factors identified in the ECLIPS

However, for it to acquire the status of a gold standard test, one would further require that one factor at least in the scale would be definitive for the disorder.

Comparison of response profiles across different neurodevelopmental groups does not offer strong support for this requirement (Figure 2). The behavioural profiles of children considered to only have listening difficulties demonstrate similarities both with children with LI and children with ASD. Moreover, differences among the groups are largely quantitative (differences in severity) rather than

To address the problems identified with existing scales, we recently developed a new scale which we call ECLIPS (Evaluation of Children’s Listening and Processing Skills).

The final content of a scale largely depends on the theoretical construct upon which it is based.

Since we based our scale on the BSA position statement for APD (2011) where APD is considered in the context of other neurodevelopmental disorders, the ECLIPS has relevance for assessing children with a wide range of difficulties, not just APD. It comprises five main factors encompassing a range of behaviours (Figure 1):

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Figure 2 – Profiles on the ECLIPS of groups of age-matched children with different neurodevelopmental disorders based on parental report. Positive numbers indicate higher levels of difficulty.

LI-only = Language Impairment only; ASD-only = Autism; APD-only = listening difficulties but with language abilities in the normal range; LI/APD = Language and Listening difficulties.

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35 qualitative (differences in profile shape). The shape of the profiles for each group of children as mapped out by the ECLIPS raise interesting questions regarding the nature of difference among developmental disorders. More practically, while the ECLIPS seems broadly sensitive to differences among neurodevelopmental disorders, our preliminary results suggest it may be too much to claim gold standard status for it. Instead, we would argue that the value in the scale lies primarily in the extent to which it can inform about the severity of difficulty and about the key areas to target when developing a treatment programme or management strategy.

The quest for a gold standard test remains an interest for our group. Drawing on the idea that APD may derive from difficulties with attention, we are now focusing on questions regarding the nature and role of attention deficits in suspected APD relative to other neurodevelopmental disorders. We have developed a language free test of auditory attention (Zhang, Barry, et al., 2013) and initial work to validate the measure has been completed. The work is only in its early stages. It will be interesting to see in the coming years whether this work ultimately leads to the development of a test worthy of being considered a gold standard test for APD. References 1. Atcherson, S. R., Richburg, C. M., Zraick, R. I., & George, C. M. (2013). Readability of questionnaires assessing listening difficulties associated with (central) auditory processing disorders. Language, Speech and Hearing Services in Schools, 44(1), 48-60.

2. Barry, J. G., Ferguson, M. A., & Moore, D. R. (2010). Making sense of listening: The IMAP test battery. Journal of Visu-

alized Experiments, 44, http://www.jove.com/index/details.stp?id=2139.

3. Barry, J. G., Weiss, B., & Sabisch, B. (2013). Psychophysical estimates of frequency discrimination: About more than just limitations of auditory processing. Brain Sciences, 3(3), 1023-1042.

4. Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R. (2011).

Communication, listening, speech and cognition in children with auditory processing disorder (APD) or specific language impairment (SLI) Journal of Speech, Language and Hearing Research, 54(Feb), 211-227.

5. Moore, D. R., Ferguson, M. A., Edmondson-Jones, A. M., Ratib, S., & Riley, A. (2010). The nature of auditory processing disorder in children. Pediatrics, 126(2), e382-390.

6. Moore, D. R., Rosen, S., Campbell, N., Bamiou, D.-E., & Sirimanna, T. (2013). Evolving concepts of developmental auditory processing disorder (APD). International Journal of Audiology, 52(1), 3-13.

7. The British Society of Audiology. (2007). Auditory processing disorder. from http://www.thebas.org.co.uk /apd/home.htm #working%20def 8. The British Society of Audiology, B. (2011). Position statement: Auditory processing disorder (APD). from http://www.thebsa.org.uk/images/stories/docs/BSA_APD _PositionPaper_31March11_FINAL.pdf 9. Young, M. L., & Barry, J. G. (2013). The Children’s Auditory Performance Scale: Bloating specifics does not a scale make! Paper presented at the British Society of Audiology.

10. Zhang, Y.-X., Barry, J. G., Moore, D. R., & Amitay, S. (2013).

A New Test of Attention in Listening (TAIL) Predicts Auditory Performance. Plos One, 7(12), e53502.

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Auditory processing disorder: are you keeping up?

Introduction Recent BSA publications and developments within the field of Auditory Processing Disorder (APD) have had a positive ripple across the globe, stimulating international collaboration, good quality research and evidence-based practice. To share these developments, we have commissioned Dr Wayne Wilson (Senior Lecturer in Audiology, School of Health and Rehabilitation Sciences, The University of Queensland, Australia) to offer his reflections and share some of the new developments from ‘Down Under’. Wayne, a leading APD expert in Australia, has published over 60 research papers, book chapters and patents and given over 125 keynote and other presentations at scientific conferences, both nationally and internationally.

Nicci Campbell Chair of the BSA APD SIG

CD

Author and Correspondence Dr Wayne J Wilson BSc(Hons), PGDipAud, PhD, GAICD, MAudSA (CCP) Senior Lecturer School of Health & Rehabilitation Sciences The University of Queensland 4072 Australia E: w.wilson@uq.edu.au

Take-home message: As you try to keep up with the latest information on APD, be sure to look beyond your region and your discipline as international and interdisciplinary collaborations into how to identify and treat APD has never been stronger.

Website list: http://capd.nal.gov.au/

Public demand for auditory processing disorder (APD) services continues to soar in the United Kingdom and in many countries around the world (if you don’t believe me, try googling APD: you will get almost 1.5 million hits!). To meet this demand, researchers and clinicians alike are collaborating more than ever to provide evidenced-based options for screening, assessing and managing APD. In this brief essay, I hope to review some of this collaboration and how it is informing the way we approach APD. Perhaps one of the clearest findings to come from recent APD

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collaborations is that APD still “means different things to different people” (Jerger, 2009, p. 10).This appears to stem from the history of APD itself with up to five historical approaches currently in play. Jerger (2009) describes the first three approaches as: 1) the audiological approach, which is based on the concept that a person with brain injury exhibits certain behaviours; ergo, if tests reveal these same behaviours, then a link to brain injury is established; 2) the psychoeducational approach, which is based on the concept that a set of primary (discrete) auditory abilities exist that can be tested by appropriate techniques; and 3) an approach based on the possible impact APD could have on language acquisition and learning. A further two approaches can be added on the back of very recent data: 4) an approach based on the conclusion that APD is primarily an attention problem and its diagnosis and management should be based on this premise (Moore, Ferguson, Edmondson-Jones, Ratib, & Riley, 2010), and 5) an approach based on the suggestion that we should focus less on defining APD (as consensus is unlikely to be reached) and more on diagnosing and managing specific listening difficulties (Dillon, Cameron, Glyde, Wilson, & Tomlin, 2012).

Following on from these historical approaches, several groups around the world have issued APD reports, statements, guidelines and/or white papers. This includes the American Speechlanguage, Hearing Association (ASHA, 2005), the American Academy of Audiology (AAA, 2010), the British Society of Audiology (BSA, 2011a, 2011b; Moore, Rosen, Bamiou, Campbell, & Sirimanna, 2012), the German Society of Phoniatrics and Pediatric Audiology (Nickisch et al., 2007), and the Canadian Interorganizational Steering Group for Speech-Language Pathology and Audiology (2012). Updates on the BSA position

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37 of peripheral hearing impairment). Perhaps the British perspective’s biggest point of difference with its American counterpart is its statement that cognitive factors such as language, memory and attention could make a significant contribution to APD, and that behavioural characteristics (if measured by a carefully constructed and well validated questionnaire) could serve as an index against which other methods of testing could be compared.

Given the emerging differences in the American and British perspectives, BSA initiated and collaborated with AAA to present an APD event titled “Global Perspectives on Figure 1: Some of the international presenters at the Global Perspectives on (C)APD conference held in Boston, USA, in March, 2012.

(C)APD” as part of the AAA conference held in Boston in March, 2012. This one-day event was co-chaired by Frank Musiek (USA) statement and practice guidance documents are due soon as and Doris-Eva Bamiou (UK) and saw over 250 delegates enare new documents from groups in Australia and New Zealand. gage with over 75 presentations on APD by international speakThe latter is of particular interest as it is partly in response to ers from a wide range of disciplines (Figure 1). Its success has The National Foundation for the Deaf in New Zealand apinvigorated international and interdisciplinary collaboration on proaching the United Nations to claim that children with APD APD with AAA now planning to repeat the event biennially in New Zealand cannot gain rehabilitation to achieve access to alongside its national conferences in those years. education and social interaction. In other words, the NFD sees a perceived lack of APD services in their country as breaching One of the results of invigorated collaboration on APD has the United Nations Convention on the Rights of Persons with been the rapid development and dissemination of both new Disabilities! test and treatment options. An example recently receiving much interest is the Listening in Spatialized Noise–Sentences Test A general impression (justified or not) coming from the various reports, statements, guidelines and/or white papers on APD is one of an “American perspective” (AAA, 2010; ASHA, 2005) versus a “British perspective” (BSA, 2011a, 2011b; Moore et al., 2012).The American perspective states that APD refers to difficulties in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more skills including sound localization and lateralization, auditory discrimination, auditory pattern recognition, temporal aspects of audition, auditory performance in competing acoustic signals, and auditory performance with degraded acoustic signals. It also states that APD is not due to higher order language, cognitive or related factors (although these factors can co-exist and interact), and behavioural characteristics are not specifically diagnostic of APD.

“The best answers to how we should identify and treat APD will come from international and interdisciplinary collaboration and research”

The British perspective states that APD has its origins in impaired neural function, is characterised by poor perception of sounds and impacts on everyday life primarily by reducing the person’s ability to listen. It differentiates three types of APD: developmental (presenting in children with no known aetiology or risk factors), acquired (associated with a known post-natal event), and secondary (occurring in the presence, or as a result,

(LiSN-N) and its associated treatment program, the Listening and Learn, developed by Dr Sharon Cameron PhD and colleagues at the National Acoustics Laboratories in Sydney, Australia (http://capd.nal.gov.au/). The LiSN-S is a PC-based test used to diagnose spatial processing disorder or (SPD) in persons aged 6 to 60 years, with SPD being a specific type of APD re-

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38 sulting from an inability to use spatial cues to hear speech-innoise. The LISN & Learn is a PC-based auditory training software package that creates a three-dimensional auditory environment to successfully treat the SPD. Collaborative efforts amongst many researchers have resulted in the LiSN-S now being available in Australia, New Zealand, the United Kingdom, Canada and the USA (the latter two in North American-accented English), having corrections for persons with hearing loss, and soon to be offered with non-speech stimuli for nonEnglish speakers.

Another result of the invigorated collaboration on APD has been the publication of several evidenced-based reviews of how it is assessed and treated. One such example is Wilson and Arnott’s (2012) “review of the reviews” on APD treatment.

These authors concluded that some “bottom-up” direct auditory interventions could improve AP in school-age children with APD, but there is little evidence that this leads to subsequent improvements in spoken language and/or reading skills.

All is not lost, however, with McArthur, Ellis, Atkinson and Coltheart (2008) arguing that remediating such bottom-up AP skills could put the child in a better position to learn (as they can process sounds more efficiently), but they still have to go on to do the actual learning. If this is the case, then we will need to start treating APD in younger children (preschool-age) as many speech pathologists argue it might be too late for school-aged children whose language processes and compensations could be too entrenched to benefit from bottom-up AP training. As well as providing some stark evidence on what does and does not work for APD, such reviews reveal the ongoing need for large-scale, randomised, controlled studies into APD that are both international and interdisciplinary.You can rest assured that groups such as the British Society of Audiology are at the forefront of just such efforts.

So, are you keeping up with APD (have you read those 1.5 million websites on APD yet)? By reading this essay I hope you realise that this is no easy task, and whether you decide to favour an American or British perspective (or German, Canadian, New Zealand, Australian, or other), the best answers to how we should identify and treat APD will come from international and interdisciplinary collaboration and research.

References 1. AAA. (2010). American Academy of Audiology clinical practice guidelines: Diagnosis, treatment and management of children and adults with central auditory processing disorder. From http://www.audiology.org /resources/documentlibrary/Documents/CAPD%20Guid elines%208-2010.pdf 2.

ASHA. (2005). (Central) auditory processing disorders. www.asha.org/policy/TR2005-00043.htm.

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3.

BSA. (2011a). Position statement: Auditory processing disorder (APD). From http://www.thebsa.org.uk/ docs/docsfromold/BSA_APD_PositionPaper_31March11 _FINAL.pdf

4.

BSA. (2011b). Practice guidance: An overview of current management of auditory processing disorder (APD).

Draft document to Council for approval to press ahead with consultation. From http://www.thebsa.org.uk/ docs/docsfromold/BSA_APD_Management_1Aug11_FI NAL_amended17Oct11.pdf

5.

Canadian Interorganziational Steering Group for SpeechLanguage Pathology and Audiology. (2012). Canadian guidelines on auditory processing disorder in children and adults: assessment and intervention. From www.cshhpbc.org/docs/canadian_guidelines_on_auditory_processing_disorder_in_children_and_adults_english_final_2012. pdf

6.

Dillon, H., Cameron, S., Glyde, H., Wilson, W., & Tomlin, D. (2012). An opinion on the assessment of people who may have an auditory processing disorder. Journal of the American Academy of Audiology, 23(2), 97-105.

7.

Jerger, J. (2009). The concept of auditory processing disorder: A brief history. In A. T. Cacace & D. J. McFarland (Eds.), Controversies in central auditory processing disorder (pp. 1-14). San Diego: Plural Publishing.

8.

McArthur, G. M., Ellis, D., Atkinson, C. M., & Coltheart, M. (2008). Auditory processing deficits in children with reading and language impairments: Can they (and should they) be treated? Cognition, 107(3), 946-977.

9.

Moore, D. R., Ferguson, M. A., Edmondson-Jones, A. M., Ratib, S., & Riley, A. (2010). Nature of auditory processing disorder in children. Pediatrics, 126(2), E382-E390.

10. Moore, D. R., Rosen, S., Bamiou, D., Campbell, N. G., & Sirimanna, T. (2012). Evolving concepts of developmental auditory processing disorder (APD): A British Society of Audiology APD Special Interest Group 'white paper'. International Journal of Audiology, 52(1), 3-13.

11. Nickisch, A., Gross, M., Schönweiler, R., Uttenweiler, V., am Zehnhoff-Dinnesen, A., Berger, R., . . . Ptok, M. (2007). Auditive Verarbeitungsund Wahrnehmungs-störungen. Konsensus-Statement der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. HNO, 55, 61-72.

12. Wilson, W. J., & Arnott, W. (2012). Evidence about the effectiveness of interventions for auditory processing disorder. In L. Wong & L. Hickson (Eds.), Evidence-based practice in audiology: Evaluating interventions for children and adults with hearing impairment (pp. 283-308): Plural Publishing.

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Research Round-up The contribution to audiology of the ‘auditory perception group’ at Cambridge

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Author and Correspondence

Brian C. J. Moore Department of Experimental Psychology University of Cambridge Downing Street, Cambridge CB2 3EB Websites: http://hearing.psychol.cam.ac.uk/ http://hearing.psychol.cam.ac.uk/SWPTC/SWPTC.htm

On September 13th, 2013, I officially retired from my position as Professor of Auditory Perception at Cambridge University, although I will continue to conduct research for some time to come. I was asked to write an article describing some of the contributions of my group to auditory research.The longest standing (or sitting) members of the group are Brian Glasberg, Tom Baer and Michael Stone, each of whom received a special “Chairman’s Award” at the 2013 annual meeting of the BSA, held in Keele. Aleksander (“Olek”) S k has also spent much time as part of the group. My group has made contributions both to basic knowledge of human hearing and to applied aspects, including audiology. I focus here on

selected aspects of audiology.

One contribution has been in the development of automatic gain control (AGC) systems for hearing aids. Up to the 1970s, most hearing aids were linear, or incorporated only single-channel AGC. Such aids did not compensate adequately for the effect of the loudness recruitment that is commonly experienced by people with sensorineural hearing loss. My group conducted one of the first clinical trials of a behind-the-ear two-channel compression hearing aid, developed by Roger Laurence (Laurence et al., 1983). The results indicated performance that was clearly superior to that obtained when the same aid was modified to operate as a linear aid. The positive results found in that trial spurred further developments of multi-channel compression, including the introduction of the Resound two-channel compression hearing aid, that also gave good results in a clinical trial (Moore et al., 1992) and enjoyed strong commercial success.

Figure 1. Block diagram of the dual-loop AGC system developed in Cambridge

Another contribution of

my group was in the development and evaluation of dual-time-constant (“dualloop”) AGC systems (Moore and Glasberg, 1988; Moore et al., 1991; Stone et al., 1999) that combine slow- and fast-acting AGC.These were intended to overcome some of the disadvantages of multi-channel fast-acting AGC (Stone and Moore, 2004). A block diagram of one of the systems is shown in Figure 1. With dual-loop AGC, the gain is usually changed only slowly in responses to changes in the level of the input signal; the effect is similar to slowly changing the volume control to deal with different listening situations.

However, in response to a sudden increase in sound level, the fast system rapidly takes over and reduces the gain, preventing uncomfortable loudness. If the increase in level is temporary (e.g. a door slamming), the gain returns to the value determined by the slow system.The dualloop AGC system is the standard AGC system used in Advanced Bionics Cochlear implants (Boyle et al., 2009) and similar systems are used in many current hearing aids.

My group contributed to development of the concept of “dead regions” in the cochlea; these are regions with few or no functioning inner hair cells and/or neurons (Moore, 2004). For example, exposure to intense sounds such as gunshots, can lead to a dead region at the basal end of the cochlea, as illustrated in Figure 2. The base usually responds to high frequencies. If an intense high-frequency tone is presented, it may be detected via a functioning region of the cochlea that is tuned to lower frequencies. This is called “off-place listening” or “off-frequency listening”. Tests for diagnosing dead regions assess whether off-frequency listening is occurring. My group introduced a simple test for rapid diagnosis of dead regions in the clinic.This involves measuring the threshold for

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40 sive continuous dead regions detecting test tones of varstarting at a relatively low ious frequencies in a special frequency (≤ 1.5 kHz), there “threshold-equalising may be little or no benefit noise”. Hence the test is from amplification of high called the “TEN” test. If the frequencies. Rather, to avoid threshold for detecting a problems with distortion test tone is more than 10 and acoustic feedback, gain dB above the nominal TEN should be reduced for frelevel, this suggests the presquencies more than about ence of a dead region at 1.7 times the edge frethe test tone frequency.The quency of the dead region. first version of the TEN test However, if there is a dead used levels calibrated in dB “island” (a dead region at SPL, and is now called the just one or two test freTEN(SPL) test (Moore et al., quencies) of if the dead re2000). A later version of Figure 2. Cochlea of a young man who had been exposed to intense sounds (gunshots). gion is “patchy”, then the test was intended to be The thin dark lines are neurons. Neurons are missing from the base of the cochlea, indiamplification should be apeasier for the clinician to cating a high-frequency dead region. plied over the widest freuse, and employed levels quency range that is possible calibrated in dB HL; hence (Cox et al., 2012; Malicka et it is called the TEN(HL) test above the detection threshold in quiet). al., 2013). Estimation of the edge fre(Moore et al., 2004). Both of these tests The level of a narrowband masker requency of a dead region may also be usewere recorded on CDs that had to be quired to mask the signal is determined ful in selecting candidates for combined replayed via an audiometer. In recent as a function of the masker centre freacoustic and electric stimulation (via a years, several manufacturers have incorquency. When the signal frequency does cochlear implant), and for selecting the porated the TEN test into their audiomenot fall in a dead region, the tip of the frequency range over which acoustic amters.

PTC (the masker centre frequency at plification is provided (Moore et al., 2010; which the level required to mask the sigZhang et al., 2013).

Another way of diagnosing dead regions nal is lowest) lies close to the signal freis via the measurement of psychophysical quency. When the signal frequency falls in Digital hearing aids delay audio signal by tuning curves (PTCs).To measure a PTC, a dead region, the tip of the PTC is varying amounts. A series of studies led the sinusoidal signal is fixed in frequency shifted away from the signal frequency.

by Michael Stone has characterised the and level (usually it is presented at 10 dB PTCs measured in the traditional way are maximum time delays that can be actime-consuming. We developed a “fast” cepted by users of hearing aids, in terms method for measuring PTCs that can be of speech perception and speech proused with any PC equipped with a goodduction (Stone and Moore, 2005; Stone et quality sound card and headphones (Sek al., 2008). et al., 2004; Sek and Moore, 2011). The software implementing the “fast PTCs” My group has developed a model of test can be downloaded free from loudness perception applicable to cases http://hearing.psychol.cam.ac.uk/SWPTC/S of cochlear hearing loss (Moore and GlasWPTC.htm. Fast PTCs provide a more acberg, 1997; 2004). This model has been curate way than the TEN test of estimatused to design methods for fitting hearing ing the edge frequency of a dead region, aids, including NAL-NL1, NAL-NL2, but they take more time than the TEN CAMEQ, CAMREST and CAM2.The last test. of these provides gain recommendations for hearing aids with an extended highResearch findings on the utility of the difrequency response, and simulated hearagnosis of dead regions for the fitting of ing aids fitted using CAM2 have been hearing aids may appear to be somewhat shown to be preferred over simulated contradictory. However, I believe that this aids fitted using NAL-NL2 by most peois not the case (Moore and Malicka, ple with mild-to-moderate hearing loss 2013). The data suggest that, for adults (Moore and Sek, 2013).

(Vickers et al., 2001; Baer et al., 2002) or children (Malicka et al., 2013) with extenPerhaps the greatest contribution of my

Perhaps the greatest contribution of my group has been in the training of Ph.D. students who have gone on to become leading auditory researchers.

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The longest standing (or sitting) members of the group are Brian Glasberg, Tom Baer and Michael Stone, each of whom received a special “Chairman’s Award” at the 2013 annual meeting of the BSA, held in Keele.

group has been in the training of Ph.D. students who have gone on to become l eading auditory researchers. Examples include Bob Carlyon, Kathryn Hopkins, Karolina Kluk, Andrew Oxenham, Chris Plack, Brian Roberts, and Michael Stone.

References 1. Baer, T., Moore, B. C. J., Kluk, K., 2002.

Effects of lowpass filtering on the intelligibility of speech in noise for people with and without dead regions at high frequencies. J. Acoust. Soc. Am. 112, 1133-1144.

2. Boyle, P. J., Büchner, A., Stone, M. A., Lenarz, T., Moore, B. C. J., 2009. Comparison of dual-time-constant and fast-acting automatic gain control (AGC) systems in cochlear implants.

Int. J. Audiol. 48, 211-221.

3. Cox, R. M., Johnson, J. A., Alexander, G. C., 2012. Implications of high-frequency cochlear dead regions for fitting hearing aids to adults with mild to moderately severe hearing loss. Ear Hear. 33, 573-587.

4. Laurence, R. F., Moore, B. C. J., Glasberg, B. R., 1983. A comparison of behind-the-ear high-fidelity linear aids and two-channel compression hearing aids in the laboratory and in everyday life. Br. J. Audiol. 17, 31-48.

5. Malicka, A. N., Munro, K. J., Baer, T., Baker, R. J., Moore, B. C. J., 2013. The effect of low-pass filtering on identification of nonsense syllables in quiet by school-age children with and without cochlear dead regions. Ear Hear.

34, 458-469.

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6. Moore, B. C. J., 2004.

Dead regions in the cochlea: Conceptual foundations, diagnosis and clinical applications. Ear Hear.

25, 98-116.

7. Moore, B. C. J., Glasberg, B. R., 1988. A comparison of four methods of implementing automatic gain control (AGC) in hearing aids. Br. J. Audiol. 22, 93-104.

8. Moore, B. C. J., Glasberg, B. R., 1997. A model of loudness perception applied to cochlear hearing loss. Auditory Neurosci. 3,

289-311.

9. Moore, B. C. J., Glasberg, B. R., 2004. A revised model of loudness perception applied to cochlear hearing loss. Hear.

Res. 188, 70-88.

10. Moore, B. C. J., Glasberg, B. R., Schlueter, A., 2010. Detection of dead regions in the cochlea: Relevance for combined electric and acoustic stimulation. In: van de Heyning, P., Kleine Punte, A. (Eds.), Cochlear Implants and Hearing Preservation. Advances in ORL, 67, Karger, Basel, pp. 43-50.

11. Moore, B. C. J., Glasberg, B. R., Stone, M. A., 1991. Optimization of a slowacting automatic gain control system for use in hearing aids. Br. J. Audiol. 25, 171-182.

12. Moore, B. C. J., Glasberg, B. R., Stone, M. A., 2004. New version of the TEN test with calibrations in dB HL. Ear Hear. 25, 478-487.

13. Moore, B. C. J., Huss, M., Vickers, D. A., Glasberg, B. R., Alcántara, J. I., 2000.

A test for the diagnosis of dead regions in the cochlea. Br. J. Audiol. 34, 205-224.

14. Moore, B. C. J., Johnson, J. S., Clark, T. M., Pluvinage, V., 1992. Evaluation of a dual-channel full dynamic range compression system for people with sensorineural hearing loss. Ear Hear. 13, 349-370.

15. Moore, B. C. J., Malicka, A. N., 2013.

Cochlear dead regions in adults and children: Diagnosis and clinical implications. Sem. Hear. 34, 37-50.

16. Moore, B. C. J., Sek, A., 2013. Comparison of the CAM2 and NAL-NL2

hearing-aid fitting methods. Ear Hear.

34, 83-95.

17. Sek, A., Moore, B. C. J., 2011. Implementation of a fast method for measuring psychophysical tuning curves.

Int. J. Audiol. 50, 237-242.

18. Sek, A., Moore, B. C. J., Alcántara, J. I., Kluk, K., Wicher, A., 2004. Evaluation of a fast method for determining psychophysical tuning curves. In: Proceedings of the 18th International Congress on Acoustics, ICA, Kyoto, pp.

19. Stone, M. A., Moore, B. C. J., 2004.

Side effects of fast-acting dynamic range compression that affect intelligibility in a competing speech task. J. Acoust. Soc. Am. 116, 2311-2323.

20. Stone, M. A., Moore, B. C. J., 2005.Tolerable hearing-aid delays: IV. Effects on subjective disturbance during speech production by hearing-impaired subjects. Ear Hear. 26, 225-235.

21. Stone, M. A., Moore, B. C. J., Alcántara, J. I., Glasberg, B. R., 1999. Comparison of different forms of compression using wearable digital hearing aids. J. Acoust. Soc. Am. 106, 3603-3619.

22. Stone, M. A., Moore, B. C. J., Meisenbacher, K., Derleth, R. P., 2008. Tolerable hearing-aid delays.V. Estimation of limits for open canal fittings. Ear Hear.

29, 601-617.

23. Vickers, D. A., Moore, B. C. J., Baer, T., 2001. Effects of lowpass filtering on the intelligibility of speech in quiet for people with and without dead regions at high frequencies. J. Acoust. Soc. Am. 110, 1164-1175.

24. Zhang, T., Dorman, M. F., Gifford, R., Moore, B. C. J., 2013. Cochlear dead regions constrain the benefit of combining acoustic stimulation with electric stimulation. Ear Hear. (submitted).

25. Vickers, D. A., Moore, B. C. J., 2001.

Effects of lowpass filtering on the intelligibility of speech in quiet for people with and without dead regions at high frequencies. J. Acoust. Soc. Am. 110, 1164-1175.

26. Zhang, T., Dorman, M. F., Gifford, R., Moore, B. C. J., 2013. Cochlear dead regions constrain the benefit of combining acoustic stimulation with electric stimulation. Ear Hear. (submitted).

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The beat goes on: Hearing research in Cambridge CD

Authors and Correspondence Bob Carlyon MRC Programme Leader E: bob.carlyon@mrc-cbu.cam.ac.uk

David Baguley Consultant Clinical Scientist Cambridge University Hospital NHS Foundation Trust Matt Davies Programme leader, Hearing, Speech and Language Group Cognition and Brain Sciences Unit Rich Turner Lecturer in Computer Vision and Machine Learning, Department of Engineering University of Cambridge Ian Winter Senior Lecturer Department of Physiology Development and Neuroscience University of Cambridge

Back in the 1950s, Donald Broadbent identified a question that is still relevant today to the study of how we hear and of the problems suffered by those with a hearing loss: How do we untangle the mixtures of sounds that reach our ears and determine which parts of the mixture belong to the same source? Hearing research in Cambridge has continued to flourish since those early experiments at the Applied Psychology Unit (APU) – including the classic experiments on auditory filter shapes carried out by Roy Patterson at the APU, and the distinguished contributions of Brian Moore’s group, featured on page 39 of this issue.

Here we highlight some of the other ex-

citing research going on in Cambridge, including that at the APU’s successor, the MRC Cognition & Brain Sciences Unit (CBU). But hearing research in Cambridge spans a wide range of groups, including those based at the Engineering, Psychology, and Physiology departments of Cambridge University, and at Addenbrooke’s hospital. The result is a multidisciplinary approach that not only probes the fundamentals of auditory science, but also addresses issues that are at the heart of the disabilities experienced by users of hearing aids and of cochlear implants.

How does the healthy auditory system estimate pitch?

Broadbent’s experiments showed that listeners use pitch differences between competing speakers to determine whether or not two speech “formants” come from the same voice. So pitch is very important when listening to mixtures of sounds, such as at a cocktail party (or – even more fun - at a poster session at the BSA conference). But how does the brain compute the pitch of a sound? It’s been known for a long time that for a complex sound, such as a vowel, we estimate the fundamental frequency (pitch) by combining information from different frequency components (harmonics). At the CBU, Hedwig Gockel has used a subjective tone called Huggins Pitch to help identify the neural basis for this “pitch of the missing fundamental”. A Huggins pitch can be produced by pre-

senting a noise that is exactly the same in each ear, except for a narrow frequency region where the noise in the two ears are uncorrelated. Because each ear receives just a noise, the Huggins pitch must be derived by regions of the brain – such as the Medial Superior Olive (MSO) – that compares sound reaching the two ears. Hedwig showed that the listeners can readily combine a Huggins pitch with a “regular” harmonic and hear a pitch corresponding to the missing fundamental.This means that the brain must compute pitch in a region that receives input from the MSO. Hedwig has also been studying the neural basis of pitch perception by measuring the Frequency Following Response (FFR) – sometimes called the “complex ABR”.

The FFR is measured using scalp electrodes that record the brainstem response to sound. Because the FFR often contains a periodicity corresponding to the perceived pitch, it’s often assumed that it reflects the result of pitch processing by the brainstem. However her results – obtained with Bob Carlyon of the CBU and Chris Plack of the University of Manchester – show that this is not the case. Indeed, by presenting frequency components to opposite ears it’s possible to produce two sounds with very different pitches and very similar FFRs, or, conversely, similar FFRs and different pitches.

The research shows that information that the brain might use to compute pitch is present at the level of the brainstem and can be recorded using the FFR, but that the many reported findings obtained using the FFR do not show that pitch is actually extracted at the level of the brainstem.

A different approach to studying pitch perception comes from Ian Winter’s group in the PDN department at Cambridge University. By obtaining single cell recordings his research sheds light on the

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Cognition & Brain Sciences Unit (CBU)

neural computations important for pitch.

For example, Ian and a new Ph.D. student, Sami Alsindi, will soon obtain direct recordings from the MSO in order to investigate how the brain processes the interaural decorrelation that is necessary for the perception of a Huggins pitch.

Ian’s group has a long history of, and continued interest in, the neural basis of pitch perception, and has involved a wide range of collaborators including, initially, Roy Patterson and Lutz Wiegrebe and then latterly with Jesko Verhey, Veronika Neuert, Bob Carlyon, and Mark Sayles.

Ian’s group has also been studying another aspect of auditory scene analysis, relevant to our ability to distinguish signals from background noise - something that has important survival consequences such as when detecting a predator (either in the wild, or at the BSA conference). Interestingly background noise is often not random but slowly fluctuates in time and it appears that the auditory system has evolved to make use of these slow fluctuations. For example, we are much better at detecting a signal when it is accompanied by a fluctuating noise than a non-fluctuating noise. However, it is equally important that these fluctuations are coherent in time across different frequency regions of the cochlea. For example, listeners are better at detecting a tone in a background noise when the noise fluctuations are the same

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in all frequency regions – a phenomenon known as comodulation masking release (CMR). Until recently, it was not known how the brain processes sound so as to take advantage of these coherent fluctuations. Ian’s research has shown that brainstem processes may play a pivotal role, and has identified neurons in the cochlear nucleus whose responses reflect the CMR experienced by human listeners (Figure 1).

companies are trying to improve the way that their devices represent pitch information by implementing new speechprocessing algorithms. At the CBU we bypass the speech processor and present simplified stimuli – such as regular pulse trains presented to a single electrode – to the CI user.This approach has revealed that there are limitations inherent to CI users that limit pitch perception and that can’t be overcome by even the latest speech-processing algorithms. For example, if we gradually increase the frequency of a pulse train presented to a CI user, s/he will typically say that the pitch increases only up to a rate of about 300 Hz. Bob Carlyon and John Deeks have been studying the neural basis for this “upper limit” by recording auditory nerve activity and measuring pitch discrimination with the same subjects and stimuli.

They’ve found that even when pitch perception is poor, such as at high pulse rates, there is plenty of information present in the auditory nerve. Hence the limitation must occur more centrally. In collaboration with Steve and Julie Bierer (Univ. Washington), Ian Winter and Bob Carlyon are planning to probe progressively higher stages of the auditory system to find out more accurately where the limitation lies.

CIs usually stimulate the auditory nerve using symmetric pulses, consisting of a positive (anodic) and a negative (cathodic) phase in quick succession. During his Ph.D. at the University of Leuven, co-supervised by Jan Wouters and Bob Carlyon, Olivier Macherey showed that it is the anodic phase that effectively stimulates the auditory nerves of Figure 1 A receptive field of a single auditory neuron CI users. At the CBU Olivier and recorded in the ventral cochlear nucleus. The red solid line Bob then showed that it’s possimarks the extent of the excitatory response whilst the solid ble to use this finding to “steer” blue lines mark the boundaries of the inhibitory areas. neural excitation to a more apical site than is possible with conventional (symmetric) waveforms. This Why is pitch perception by cochlear imallowed them to increase the range of plant (CI) users so poor? Can we do pitches that patients could hear, both as anything to help? a direct result of shifting the “place of exPoor pitch perception remains one of the citation”, but also because selective stimchief complaints of CI users, and limits ulation of the apex increased the range their enjoyment of music and their ability of pulse rates over which pitch continued to separate competing voices. Implant to increase.

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45 What’s wrong with Auditory Brainstem Implants = and can we do anything to help?

Some profoundly deaf patients cannot receive a CI because their auditory nerve is damaged – for example as a result of tumour removal in cases of neurofibromatosis type 2 (“NF2”). Most of these patients have very poor speech perception, and, usually, it is not possible to stimulate all electrodes so as to produce a sufficiently loud sound without producing undesirable side effects (non-auditory sensations).Together with Colette McKay (previously at the University of Manchester; now at the University of Melbourne) Bob Carlyon and John Deeks have been probing the basic psychophysics of how the auditory brainstem responds to electrical stimulation. In some ways, this turns out to be very different from a CI – for example, increasing pulse rate from 250 to 1000 pps greatly reduces thresholds in CI users, but has almost no effect for ABI users. On the other hand, we’ve shown that, like CI users, ABI patients respond primarily to the anodic phase of a biphasic pulse. This means that it might be possible to extend the range of pitches heard by ABI users, in the same way as we’ve shown for CIs. Does what we know affect how we organise the auditory world?

Usually, sound segregation is studied by psycho-acousticians using very artificial sounds such as sequences of pure tones.

This has led to some interesting findings such as the fact that, when we present listeners with a sequence of tones that alternate in frequency, they can split into two separate “auditory streams”, such that listeners cannot hear the composite rhythm formed by the two tones, and are very poor at detecting differences in the relative timing of the tones in the two streams. This auditory streaming is exploited by composers of polyphonic music to allow the same instrument to play two separate melodies. However, until recently it wasn’t known whether this streaming operates automatically, or whether it depends on higher-level cognitive processes. To study this, Ph.D. student Alex Billig played listeners repeating sequences of syllables, such as the word “stem” and the non-word “sten”, and

found that the initial “s” would stream off so that the listener heard a sequence of “s” sounds and another stream comprising the remainder of the syllable.

(This is an example of the “verbal transformation effect”, first discovered by Richard Warren at the APU in 1959!). Importantly, he showed that the tendency for a syllable to stream apart was greater for non-words than for words. This effect of lexicality was measured not only using subjective reports but also using an objective task: when the sequences CI patient testing streamed apart it was harder to detect an extra gap inserted bedruke” is a real word and given the optween the “s” and the rest of the syllable, portunity to consolidate their knowledge and, because words streamed apart less overnight. frequently than non-words, gap detection was better for the words. What this The results of another MEG study that means is that auditory sound segregation are well explained by predictive coding isn’t a one-way street: streaming doesn’t was run by a CBU PhD student Ediz Sojust organise the incoming speech into hoglu jointly supervised by Matt Davis, separate voices so that we can underBob Carlyon and Jonathan Peelle. Listenstand what is being said, but is also ers heard spoken words that were destrongly influenced by what we know graded by noise vocoding in a way that about the language. simulates speech as transduced by a CI. Depending on the number of channels in Predicting and understanding speech the vocoder – analogous to the elecsounds trodes in an CI – spoken words sound Listeners may use the words that they clearer or more degraded. Words that know (and other forms of knowledge) are physically clearer produce a larger renot only to affect sound segregation – as sponse in auditory regions of the brain – in the study described above – but also particularly in the superior temporal to predict upcoming speech sounds. By gyrus (STG, a brain area just above the comparing their predictions to the ear that responds preferentially to sounds that they hear listeners can make speech). However, words that sound optimal sense of incoming speech – for clearer because listeners are given a writinstance, recognising a word like catheten clue as to which word they are heardral before they have heard more than ing (analogous to TV subtitles) produced “cathed…”. Since there is only one word a smaller response in the STG. This patthat matches this beginning, the final tern of results is well explained by ‘presounds can be predicted with confidictive coding’ – speech that sounds dence.This ‘predictive coding’ account has clearer can produce an increased rebeen shown by Matt Davis at the CBU sponse if it contains additional acoustic to predict brain responses to speech as information, whereas speech that is premeasured using Magnetoencephalogradicted produces less prediction error and phy (MEG). For example, working with hence a reduced brain response. Ed SoPierre Gagnepain and Rik Henson, Matt hoglu is currently analysing a study of showed that hearing an unexpected changes in the brain response that occur word ending (such as “cathedruke”) proas listeners are taught to make sense of duces a brain response correlated with vocoded speech. This study provides a prediction error. Predictions are refined laboratory analogue of the rehabilitation – and hence brain responses decrease – process experienced when a post-linwhen participants are taught that “cathe-

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46 gually deafened individual receives a cochlear implant and has to learn to hear speech again. Previous work led by Matt Davis has shown how written subtitles can not only enhance immediate perception of degraded speech, but also support perceptual learning which allows for better comprehension even when subtitles are not available. By understanding how brain responses for prediction and prediction error support learning may help guide interventions that enhance rehabilitation in CI users.

Auditory scene analysis, inference, and the statistics of sounds Several of the studies described above reveal the principles that the auditory brain uses to untangle mixtures of sounds into their component sources.

However, some aspects of Donald Broadbent's original question still remain

out of reach. For example, we do not know how the plethora of streaming principles believed to be at play act in combination in complex real world environments – what causes one principle to win out over another? Nor do we understand how the brain has arrived at these principles in the first place. Rich Turner from the Computational Perception Group in the Department of Engineering is investigating a tantalising hypothesis that may provide the answer to these questions. The “inferential” hypothesis predicts that the auditory brain reasons about the composition of incoming stimulus based on knowledge of the statistics of naturally occurring sounds.

Consider the famous “continuity” illusion as an example. Here a tone stops abruptly and is immediately followed by a loud noise burst which is sufficient to have masked the tone. Contrary to the physical stimulus, listeners perceive the tone as continuing into the noise for about 100ms. This is consistent with the idea that they have learned that tonal sounds in the natural environment tend to vary slowly over time, and so when the noise burst begins the brain “predicts” that the tone is persisting. Rich has shown that a computational model, which makes inferences based upon the statistics of natural sounds, reasons in the same way about the continuity illusion therefore lending support to the hypothesis that streaming principles are intimately related to the statistics of natural sounds.

Sound Lab

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Interestingly, the same model of natural sounds is excellent at describing a class of sounds called auditory textures. In fact, the model can produce synthetic, but natural sounding versions of textures including running water, pattering rain, roaring fire, and howling wind.

This is a cute trick - but does it have practical use? Well, auditory textures often contami-

nate sounds of interest like speech, and Rich Turner has shown that the statistical model can be used in these cases to tease apart the noise from the signal of interest. In effect, this process trades off streaming principles using a knowledge of the statistics of sounds, and Rich therefore expects it to shed light on the basis of human perception in complex acoustic environments, thereby taking us one step closer to resolving Donald Broadbent's foundational question. In addition, Phil Gomersall, a Ph.D. student funded by Action on Hearing Loss, is using Rich’s model to generate sounds that may be used to alleviate tinnitus in cochlear implant users. In a collaboration spanning three Cambridge research groups, Phil is jointly supervised by Rich Turner, Bob Carlyon, and by David Baguley – a tinnitus expert and head of the audiology department at Addenbrookes hospital.

Clinical research in Cambridge Clinical and translational hearing and balance research is thriving in Cambridge.

Collaborations between clinicians at Cambridge University Hospitals and basic research groups in the city include research on tinnitus and cochlear implants, as well as projects with Bob Carlyon on optimising auditory brainstem implants and CIs, with a focus on poor and mediocre performers with hearing implants. There are also several current themes based primarily at the main hospital site. The first of these is the pharmacological treatment of acute tinnitus using an intra-tympanically administered glutamate antagonist. We are also investigating the impact of single sided deafness and appropriate interventions (including cochlear implants), and specifically considering access to music for such individuals. A collaboration with academic Neurology colleagues is investigating the MEG imaging of musical hallucinations, and attempting to identify patterns of neural activity associated with this symptom. All of this research at Cambridge University Hospitals is upheld by multi-disciplinary collaboration between Audiology, Hearing Implant, Otology and Auditory Neuroscience colleagues.

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Lunch and Learn update

CD

Facilitators and Correspondence Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

If you would like to contribute a seminar, have any queries or would like regular email updates, please email one of the facilitators above.

BSA Lunch and Learn eSeminars An exciting series of online presentations covering current topics of interest and clinically relevant research findings in Audiology and related professions, free of charge to all BSA members and non-members.

Recent bites

Coming up on the menu

These and other earlier seminars are available to access at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive/. You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

To go live on the first Monday of every month for access by the emailed link, via the BAA or Audiology Northwest England Facebook pages, or archived at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive/. You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

October 2013 How adults with hearing impairment perceive the role of aging and cognition in help-seeking and rehabilitation › Ariane Laplante-Lévesque, Eriksholm Research Centre, Denmark and Linköping University, Sweden

November 2013 Other things your hearing is good for, especially if you are visually impaired › Daniel Rowan, University of Southampton

16th December 2013 – Christmas special Avenues for improvement in hearing aids › Brian C.J. Moore, Department of Experimental Psychology, University of Cambridge, UK

January 2014 New technologies and measured outcomes from hearing aid manufacturers › Josephine Marriage, Chear

December 2013

February 2014

Music and cochlear implants: opening the lid to look at signal processing strategies › Professor Colette McKay, University of Manchester

Health Literacy, Older Adults and Hearing Aid User Guides › Andrea Caposecco, School of Health and Rehabilitation Sciences, The University of Queensland

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Roger Bridging the understanding gap

Zero hassle. Maximum performance. Full compatibility.

Roger, the new digital standard from Phonak, eliminates the hassle and complexity of yesterday’s FM systems. Thanks to its unique digital communication protocol, channel management headaches and connection complexity are a thing of the past. So instead of managing channels and pairing devices, you can focus on what’s really important - helping children to hear better in the home environment.

• No frequency planning • One-click connection • Software-free To have hands-on demonstrations, please speak to your Regional Sales Manager.

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New technology in audiology: matching patient needs to technology 3.

Author and Correspondence

CD

Dr Josephine Marriage Director of Chear Clinical Scientist (Audiology) E: Josephine@chears.co.uk

4.

5.

6.

7.

8.

Better clarity of speech through hearing aids, and methods of knowing whether speech is clearly discriminated Better speech understanding in group situations Waterproof hearing aids for swimming, bath time and general water play No ear moulds!

Smaller, more discrete hearing aids for older children and teenagers New apps for monitoring function and measuring hearing in real world and hearing aid use

So we put our collective heads together to see what is available.

There is so much new and innovative technology being developed around hearing aids and assistive listening devices that it is hard to keep up with it. When a patient or family describes a specific life situation which is constraining their communication, we tend to start by reviewing the hearing aid options we are familiar with. We are very lucky to have the calibre of hearing aid technology available in the NHS contract hearing aids that we have in the UK. However there are always new solutions and additions that are available, which may give important benefit to your patient. Patients need advice and help in knowing what may be helpful or that can make their NHS technology be more appropriate to their needs, without having to purchase private hearing aids. Good advice is available to through charities like Action of Hearing Loss (AoHL) and National Deaf Children’s Society (NDCS) as well as other commercial providers, like Connevans, but patients still need advice from their main audiology-care professional on what features to look for and where they can access them.

What types of new technology do you want to see for your patients?

At a recent paediatric audiology conference we had a session in which NHS audiologists were asked to make a wish-list of features that they would ideally like for the children with hearing loss in their care. The list included the following: 1.

2.

Use of Bluetooth and wireless connectivity for older children and teenagers for phones, iPads and television Smaller remote microphones for mild hearing losses, special educational needs and preschool children

Bluetooth connectivity: Many BTE and open fit hearing aids have blue tooth receivers in them with a streamer that is worn around the neck.This includes many Oticon (eg Safari and Spirit Zest plus), Siemens (Impact Pro) and Phonak (Naida W and Nathos W) hearing aids. The streamers can have the child’s radio receiver plugged directly into it and therefore receive input from their radio aid microphone, without needing radio aid shoes on their hearing aids.The streamers pick up from any paired Bluetooth source, including phone, television, laptop, tablet and all the other social necessities for teenagers in the 21st century.

Smaller remote microphones: When it isn’t practical for a child to have a streamer around their neck, for example with a small child, or learning disability, can we have a remote microphone?

There is now a small sized lapel microphone that can be used without a streamer, on the Alera GN Resound and Verso hearing aids. The microphone is small and very wearable for example by a parent, when the child is in the car, or playing, so that the mother’s voice is transmitted to the child, with an open or standard hearing aid fitting. This has many potential applications for cases of auditory neuropathy, speech and language delay and diagnostic conundrums, to explore the potential benefit of improved speech access, without having to wait for educational funding for radio aid technology to explore this option.

Better clarity of speech for the wearer (and being able to demonstrate it): Hearing aid signal processing is utilising many new strategies of trying to improve speech perception despite

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Figure 1. Widex 440 Baby, which doesn’t need custom ear moulds.

the constraints of distorted cochlea function. One example is the use of frequency lowering to increase audibility of high frequency speech sounds, as used, for example, by Widex (through frequency transposition), Starkey (through Spectral IQ), Bernafon, Siemens and Phonak (through frequency compression) of high frequency speech information. Frequency lowering can have added benefits for management of acoustic feedback, but it is the improved discrimination that is key here.

garden play. For older children, swimming coaching, sailing and kayaking are part of many school activities. Now there is a new digital water-proof hearing aid made by Siemens called Aquaris, which can be used with moderately-severe extents of hearing loss. There is also a water-proof cochlear implant made by Advanced Bionics, which shows that the technology is developing and should become available for different extents and types of hearing loss in the near future.

New measures of speech outcomes: There are a number of new speech test materials available to help the informed clinician to evaluate change in benefit for each individual case.

For example, there is the Phonak S-test, or plural test, which demonstrates whether the hearing aid wearer has improved audibility of /s/ and /z/ in real words, eg cat vs cats.This test CD has the added benefit of having the Ling sounds (mm, oo, ar, ee, sh and s) pre-recorded onto it, allowing a myriad of uses for motivated and creative paediatric audiologists with prerecorded Ling signals.

NO EAR MOULDS! Wouldn’t this change the job of a paediatric audiologist? We know that the UK positive support study reported that the major reason for inadequate hearing aid amplification and use, was due to poorly fitting, shallow ear moulds (Uus, 2006). Ear moulds continue to be the lowtechnology constraint and the major stress factor for families with hearing impaired children. However, there ARE now hearing aids for babies which do not need ear moulds. The Widex Baby 440 hearing aid has a tip that fits into the infant’s ear, and no ear mould. This has additional potential benefits for sloping high frequency hearing loss, so that the canal is not blocked by a shell mould, which otherwise will reduce hearing in better low frequencies for the child. In general, better feedback cancellation techniques across all manufacturers, help to reduce susceptibility to acoustic feedback even for more severe extents of hearing loss, and to maintain appropriate amplification characteristics.

Better speech understanding in groups and noisy situations: This has always been the single greatest challenge for hearing aid design. The use of directional microphones has benefits in some situations, and noise reduction techniques have shown reduced listening effort, but most hearing aid users continue to have major problems conversing in a noisy environment. No one strategy is likely to improve this alone. However there are some new strategies using pencil-like pointers which can be directed towards the talker by the wearer and highly effective noise reduction, for example, in the Phonak Roger technology.

Watch closely for the evidence-base around these new innovations and approaches.

Water proof hearing aids: While many hearing aids offer better water resistance than previously available, many families ask for water-proof hearing aids, for swimming, bathing, paddling and

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Smaller, more discrete hearing aids for older children and teenagers: There are times in life when appearance matters a great deal to self-image and social acceptance. The transition to secondary school can be very challenging for hearing aid wearers, regardless of how reliant they are on their technology, as they aim to reduce the visible difference between themselves and their peers. Every audiologist has been asked at some point whether in-the-ear hearing aids are feasible for young ears.The news is that the size, robustness and quality of amplification

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Figure 2. A computer aided design of an in-the-canal device for a child with severe hearing loss

through in-the-ear, in-the-canal and even invisible-in-the-canal (iic) hearing aids are evolving, for example see Oticon Intigai or Phonak Nano.

ITE hearing aids can have wireless receivers, and can therefore be used with a Bluetooth streamer for radio aid use. There are improvements in directional hearing from having the microphone positioned in the concha, rather than above the pinna as in a BTE hearing aid. The constraining effects of ear mould acoustics are reduced with the receiver in the canal.

There are good reasons why families may choose to explore ITE hearing aids for their child, rather than watch the achievements of primary school be eroded by poor use of amplification in secondary school.The child’s audiologist is wellplaced to be able to give professional and impartial advice, even if families wish to supplement the technology that is standard and freely available through NHS provision. Families have access to a huge range and diversity of information about resources for their children, and it is helpful for them to have current and informed advice from trusted professionals.

New apps for monitoring function and measuring outcomes in real world hearing aid use: There is an explosion in development of apps for every aspect of technology.There will be new applications by which hearing aid function is monitored by smart-phone or tablet. For families there is currently a McCormick toy test available as an App from iTunes, called Early Ears, which allows parents to screen their child’s functional hearing at any time. As this runs on an iPad, it is also a great asset for audiologists needing to screen children with atypical development or autistic spectrum condition (ASC). There is likely to be a big increase in the number of interesting and innovative speech measures over the next couple of years, so audiologists need to know what they want to measure and

how the tests need to be carried out for maximum effectiveness.

This brief review of some of the innovations that are happening in hearing aid development doesn’t aim to be comprehensive and I’m sure there are many equally relevant and inspiring strategies that we have not included. However we can only keep abreast of the rapid changes by sharing information that we individually come across and experience.

Please feel free to let me know any other suggestions, or, even better, by doing your own review article to add to the shared resource-base.

Reference 1. Uus K, Bamford JM (2006). Effectiveness of population-based newborn hearing screening in England: Ages of interventions and profile of cases. Pediatrics, 117, e887-893. eScholarID: 1d10763.

Josephine Marriage is Founder and Director of Chear, an independent centre for second opinion of hearing and hearing aids for infants and children. She is a clinical paediatric audiologist and conducts research around amplification strategies and speech testing in children. Chear has two clinical bases in the UK, the first is based just south of Cambridge, and the second is with Auditory-Verbal UK in London which is a new initiative, supported by Phonak, called Listen and Talk as One. She lectures in Paediatric Audiology and other Master-classes at UCL Ear Institute in London. She is a research associate with Professor Brian Moore at Cambridge University.

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Auditory steady state responses in normal-hearing and hearing-impaired adults: matching patient needs to technology

CD

Author and Correspondence Tim Wilding, PhD Lecturer Audiology & Deafness Research Group School of Psychological Services University of Manchester UK E: tim.wilding@manchester.ac.uk

This short communication is based on the on-line BSA Lunch and Learn seminar by Timothy Wilding, PhD, 8th April 2013.

The recording is available at www.thebsa.org.uk

The auditory steady-state response (ASSR) can be utilised for hearing threshold estimation and has been shown to be a good predictor of behavioural thresholds (Rance et al., 1995). In ASSR threshold estimation test signals can be presented to one, or both, ears simultaneously at multiple test frequencies, allowing the possibility of more rapid threshold estimation compared to testing one ear and frequency at a time.The pure tone signals are modulated in frequency (FM), amplitude (AM) or both frequency and amplitude (AMFM). The modulated pure tone at each frequency is considered to have been detected by the test subject’s auditory system when the electroencephalogram (EEG), recorded at scalp electrodes, contains significantly higher energy at the modulation rate of the tone compared with the adjacent frequencies considered to be noise. The presence or absence of the response within the EEG is therefore entirely objective as it does not rely upon the subjective judgement of the test operator. However, as with all statistical tests, there is a chance that type I (false positive), and type II (false negative) errors will occur. False positive, and negative, detection of responses could lead to errors in estimation of hearing threshold. The chance of errors can be manipulated by altering the parameters of the statistical test and the manner in which the test is performed (Luts et al. 2008,

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Sturzebecher et al. 2005, Wilding et al. 2012).

The presence or absence of an ASSR can be determined from test protocols that utilise fixed or variable recording duration.

Variable duration protocols are usually referred to as “stop when significant” paradigms. In a “stop when significant” paradigm, the test continues for a fixed duration in the absence response detection, but stops prematurely as soon as a significant response is detected. There is a trade-off between using fixed test time protocols, which give the lowest chance of type I errors but require longer duration test times, and variable test time protocols which increase the chance of type I errors but have shorter test times.

The test parameters must be optimised in order to obtain threshold estimates close to true behavioural threshold. The highest chance of response detection is obtained by maximising response amplitude, and minimising EEG noise. Response amplitudes can be maximised by selecting the modulation type and rates that have been shown to give the highest response amplitudes. Provisional guidelines for using ASSRs for auditory threshold estimation, in infant assessment, give guidance on test time and response detection paradigm, but no firm protocols exist (Stevens et al. 2009).

The ASSR can be a good predictor of behavioural thresholds We recorded ASSRs from 95 Hz exponentially amplitude modulated 2 kHz pure tones at 50 dB SL in normal hearing adults, and 20 dB SL in hearing-impaired adults (Wilding et al.

2012). We performed offline analysis to examine: response amplitude repeatability, noise, and the recording time to response detection for a range of detection paradigms. In 57

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Figure 1.

F-test significance levels shown against test time (number of sweeps) for forty recordings in normally hearing subjects at 50 dB SL (two recordings for twenty subjects).

Individual shaded rectangles represent the calculated significance level at each position in the recording. Rows represent individual recordings with two recordings for each subject. Columns represent the number of sweeps

out of 60 recordings the noise level exceeded the 10 nV limit suggested as the maximum noise floor for threshold estimation in the infant provisional guidelines. This data demonstrates the need for separate adult guidelines. The response amplitudes were highly variable with a repeatability coefficient (upper confidence interval of difference) of 40% and 97% of mean amplitude for the normal hearing and hearing-impaired subjects respectively. False response detection was analysed by calculating the significance of a random chosen frequency (87 Hz) within the EEG compared to its surrounding noise. The offline analysis of true and false response significance was obtained across each increasing consecutive sweep (16 second segment of the recording), and is shown in Figure 1 for the normal hearing subjects.The false positive rate for the 5% “stop when significant” protocol was 25% of the 60 recordings.

Whereas the error rate at the 2% “stop when significant” protocol was 8.3% of recordings.The mean response detection time was 67.2 seconds (4.2 sweeps) using a 2% “stop when significant protocol”, which is a 72% reduction in test time compared to the full 4 minute (15 sweep) fixed test time.

The findings of this study, along with other work, demonstrate the need for clear understanding of the statistical methods used, and the need for further work to define clear strict ASSR

included in the response calculation. The left panel shows the false responses detected at 87 Hz and the right panel shows true response detection at the stimulus modulation frequency of 95 Hz. White shading indicates response amplitudes not significant (5% level), light grey significant between 2% and 5%, dark grey significant between 2% and 1%, and black significant at <1%. Source: Wilding et al. (2012).

protocols such as those available for infant ABR threshold estimation.

References

1.

2.

3.

4.

5.

Luts H,Van Dun B, Alaerts J & Wouters J (2008).The influence of the detection paradigm in recording auditory steady-state responses. Ear Hear, 29, 638-50.

Rance G, Rickards FW, Cohen LT, Devidi S & Clark GM (1995).The automated prediction of hearing thresholds in sleeping subjects using auditory steady-state evoked potentials. Ear and Hearing, 16, 499-507.

Stevens J, Brennan S & Lightfoot G (2009). Provisional guidelines for using Auditory Steady State Responses (ASSR) in babies.

Available: http://hearing.screening.nhs.uk/cms.php? folder=4113 [Accessed 28 July 2009].

Sturzebecher E, Cebulla M & Elberling GC. (2005). Automated auditory response detection: statistical problems with repeated testing. Int J Audiol, 44, 110-7.

Wilding TS, McKay CM, Baker RJ & Kluk (2012). Auditory Steady State Responses in Normal-Hearing and HearingImpaired Adults: An Analysis of Between-Session Amplitude and Latency Repeatability, Test Time, and F Ratio Detection Paradigms. Ear and Hearing, 33, 279-290.

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Ear to the ground for all things ear-related in the media In this issue, Ear to the Ground has a roundup of relevant stories that have appeared in the media in recent months. This edition includes news of a frog with an unique middle ear substitute, a Strictly Come Dancing interview and much more...

The Charity Focus section reviews four audiology charity websites. The sites to be highlighted cover many aspects of audiology, including adult rehabilitation, paediatrics, vestibular and implantable devices.

Of course, there are many more charities doing excellent work that are not mentioned; each one deserves recognition. Audacity will continue to point to these in the Ear Reach section.

Amanda Hall's #Audpeeps piece looks at the activity of the Audiology community on the social media

Lost in Translation The best and worst of sign language interpreters are demonstrated in the following articles. A blog in the New York Times highlights the work that ASL interpreter Lydia Callis has done improving hearing services in New York. She gained exposure as NYC Mayor Michael Bloomberg's interpreter when he delivered safety warnings to citizens as Hurricane Sandy approached the city in 2012. For a short time she became a celebrity figure, and used her popularity to raise awareness about hearing services in the US. The blog is centred on Ms Callis' new role leading deaf tours at the New York Public Library and is available at http://cityroom.blogs.nytimes.com/2013/08/25/callis-by-vivian-yee/.

Interpret this with caution At the other end of the spectrum is an article published on 'the poke' website in 2011, which details the sacking of former BBC interpreter Leslie Grange. They reported that she lost her job on the BBC news channel for providing deaf viewers with "wildly different versions" of current affairs. The article can be found online at http://www.thepoke.co.uk/2011/08/17/bbc-sign-language-interpreter-sacked-for-changing-the-news/. It includes examples of deviations she made, such as reporting sightings of radioactive zombies near the nuclear reactor in Japan following the tsunami. Disappointingly, the story was a hoax. However, this was not recognized by news agencies in France, who ran the piece online, on radio and on television before realizing their error! Some of the headlines and clips can be viewed at http://www.thepoke.co.uk/2012/01/20/the-poke-fools-france/

A life changing experience An article recently published in the Daily Mail relates the story of 22 month old Emily McMullen, who received a cochlear implant from the CI unit of Crosshill Hospital in Kilmarnock. The article, which includes quotes from Emily's family about the positive effect of the implant on their family life, recognizes the impact cochlear implants can have, and the importance of identifying hearing loss as early as possible. The article is a true feel good piece, though scientific purists may argue that it does not provide the reader with a balanced view of implants, as the limitations of devices are not discussed. There is an opportunity to read and comment on the piece online at http://www.dailymail.co.uk/health/article-2409924/Now-hear-tell-I-love-Father-hailsmiracle-implant-given-deaf-daughter-working-ear.html.

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55 The world's first natural BAHA? An interesting popular science story that has appeared in several media is a study published in the Proceedings of the National Academy of Sciences that discovered a new hearing mechanism in the Gardiner's frog, which was until recently assumed to be deaf as it has no external ear. The BBC news website and the Independent newspaper both ran articles explaining that the amphibians' mouth cavity resonated to amplify sounds sufficiently to transmit vibrations through tissue in the mouth to the inner ear via bone conduction, effectively performing the function of the middle ear in most animals.

The articles can be viewed at http://www.bbc.co.uk/news/science-environment-23897430 and http://www.independent.co.uk/environment/nature/im-all-mouth-how-1cmlong-gardiners-frog-gets-by-without-a-middle-ear-8795369.html.

Hearing Dogs for the Deaf There have been several recent items in the media highlighting hearing charities. One such article appeared in the Guardian newspaper, detailing the case of Steven Taylor to highlight the work of Hearing Dogs for Deaf People. The account is well-balanced, informative, and good publicity for the charity. The article appears on the Guardian's website at http://www.theguardian.com/lifeandstyle/2013/oct/13/hearing-dogs-ears-deafness-training-impaired-independence.

New charity founded Another charity piece appearing online recently was on the BBC news website, introducing a new charity, Signal. This is a joining of Shropshire's Woodford Foundation and the Shropshire Deafness Association, aiming to empower hearing impaired people in sub-Saharan Africa. The article also makes reference to the Deaflympics, an event which recently took place in Sofia, Bulgaria.

Links to the charity's website as well as the Deaflympics are available alongside the article at http://www.bbc.co.uk/news/ukengland-shropshire-24315532.

Strictly Come Hearing The Daily Mirror newspaper recently published an interview with Strictly Come Dancing contestant Ben Cohen, in which he talks about his hearing loss and tinnitus. The former international rugby player discusses communication tactics that he employs with his new dance partner and how he was encouraged by Elton John to look into trialling hearing aids!

Despite some frustrating audiological misnomers and shameless endorsement for a certain hearing aid manufacturer, the interview makes for an interesting read in parts.

The article is available on the Mirror's website, http://www.mirror.co.uk/lifestyle/health/strictlys-ben-cohen-elton-john-2355004.

Donâ&#x20AC;&#x2122;t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

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56 Radio 4 NHS debate The cost of the NHS is applicable to everyone, and this summer, NHS England called for a public debate into ways of revitalising the service. With a reported funding gap of ÂŁ30bn by 2020 if current care models continue, Radio 4 recently aired a special programme examining the growing demands in the NHS and the scope for savings without compromising care. As audiologists begin to feel the effects of Any Qualified Provider, it is worth considering the financial position of other NHS services. Presenter Julian Worricker is joined on the programme by guests including Andrew Dillon, the chief executive of NICE and Sir David Nicholson, the chief executive of NHS England, among others.

The programme can be accessed via the BBC's iPlayer service at http://www.bbc.co.uk/programmes/b03b0qb2.

Inner ear "link to ADHD" The BBC News website reported recently on a study published in Science that found that suppressing the activity of a particular gene in the inner ear of healthy mice caused an increase in their physical activity.

This was after they noticed that a population of mice with a mutation of the Slc12a2 gene were constantly chasing their tails. The scientists, from the Albert Einstein College of Medicine in New York, assert that this is the first evidence of a sensory impairment inducing molecular changes in the brain that cause maladaptive changes to behaviour. Many clinicians would typically ascribe behavioural problems in children with hearing loss as the product of a lack of sensory input, and this research could potentially give this assertion a scientific basis. Dr Anita Thapar acts as a cautionary voice in the article, warning that neuropsychiatric disorders cannot be fully explained by one genetic mutation.

Read the article at http://www.bbc.co.uk/news/health-23972137.

Tuning out A short article which appeared recently on Audiology Worldnews describes a new approach to cutting out background noise in hearing aids. Richard Turner, from the department of Engineering at the University of Cambridge, is developing technology which uses a statistical approach to identify and selectively remove sounds before it is transmitted into the ear. Turner explains that the technology is still in early stages of development, but the advantages of this technique will be clear to any clinician who has heard the complaint that a patient can hear background noise louder than speech.

The article is available at http://www.audiology-worldnews.com/news/724-intelligent-hearing-aids-technology-to-tune-out-backgroundnoise.

... And on a lighter note If you find yourself with a free evening, what better way to spend it than pointing out audiological inaccuracies in a comedy series to your slightly bemused and disinterested partner? This was an opportunity recently afforded to me when watching the Channel 4 series, Friday Night Dinner. As the title implies, the sitcom is centred on the Friday night mealtime of a suburban Jewish family. The father of the family is a unilateral hearing aid user, enabling the audiologically aware viewer to play "guess the aetiology?" based on the situations he is struggling in, and wondering why his earmould isn't properly in place. As an added bonus, the programme is actually very funny.

It is available via Channel 4's online catch up service 4od http://www.channel4.com/programmes/friday-night-dinner/4od.

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Charity Focus Action on Hearing Loss Website: www.actiononhearingloss.org.uk Action on Hearing Loss, formerly the RNID, is a UK charity that provides information and support to those with hearing loss. They offer advice on all aspects of hearing loss, from deafness and tinnitus to hearing aids and assistive listening devices. There are several regional branches to the charity, each focussing on services in the local area.

The website is as comprehensive as any patient could ask for, with factsheets on a number of hearing related topics and advice for patients wishing to access a range of services including Access to Work, social care and befriending services.

There are discussion boards which allow patients and families to discuss hearing related topics with people in similar situations. The website even boasts a shop where customers can buy assistive listening devices to help in many situations.

The Action on Hearing Loss website is easy to navigate, with dropdown menus from the home page linking to all the relevant sections. A contact helpline is clearly visible on the homepage, though other contact details are a little trickier to navigate to, with a small 'contact us' link at the very top of the page.

There are several ways of donating online to Action on Hearing Loss, including a one off donation, payroll donations and leaving a donation in your will. Donations can be made online and details of how to donate are given on the website's 'Donate' section.

The Ear Foundation Website: www.earfoundation.org.uk The Ear Foundation charity aims to bridge the gap between the hearing technologies provided in clinics and the situations in which they are used in everyday life. All too often technology is not used to its full potential and the Ear Foundation works with patients and communities to change this. The main focus of this charity is on implantable devices such as cochlear implants and bone anchored hearing aids; indeed, the charity was initially set up to fund and provide the first cochlear implants in the UK in 1989. They also provide information and advice about hearing aids and FM systems.

The website is easy to navigate, and contains information about education courses and advice days run by the charity.

There is also a wealth of information about cochlear implants and BAHAs, which is presented in a clear and patient friendly way. One of the most useful features on the website is a forum for both implant and BAHA users, which enables patients to get advice from other users and parents.

There is an opportunity to donate on their website, by clicking on the Support Us tab, and selecting donate now. The Support Us tab also explains different opportunities that are available to help the charity.

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58 Ménière’s Society Website: www.menieres.org.uk The Ménière’s Society provides support and information to those with dizziness and balance disorders, and also fund research into all aspects of vestibular disorders. Spin, a quarterly magazine published by the charity, keeps people informed about the latest treatments and research in the area, as well as a platform for members to share their experiences.

The website is clearly split into sections providing information about vestibular conditions, research funded and run by the Society, the benefits of membership and ways to support the charity. There are also sections with news and background of the charity. In particular the ‘Information and Support’ section is a really useful tool for patients to get a real understanding of their condition, and can be a great resource for clinicians to direct patients to if they want more information.

It is possible to donate to the charity online or via text. A banner at the top of each page on the website offers a link to the donation page and the option to text the message “VEST18 £4” to 70070 to donate that amount on your mobile phone.

National Deaf Children’s Society Website: www.ndcs.org.uk The NDCS aims to create a world without barriers for children and young people with a hearing loss. One of the fundamental beliefs of the charity is that given the right support, deaf children should be able to do anything that other children can do. It is made up of a network of families, parents and carers who provide practical support. This includes a free helpline which provides families with advice and information.

A huge amount of information and advice is also available on the website. Despite the amount of material available, the website is relatively easy to navigate, with separate areas for different age groups and needs. The search function which is available from the homepage is also a useful tool for parents to find pieces that are relevant to them. There is also a really interesting News section, which gives updates of the latest research, campaign results and fundraising events held

by NDCS. Online donations are possible via the Donate Now link on the homepage. It is also possible to sign up to become a member of the NDCS and information about campaigns in each area in the UK.

Next edition - focus on Education ear to the ground

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#audpeeps @HallAmandJ introduces you to the audiology Twitter community

This edition’s focus is on the #Audiology and #AudPeeps community on twitter, with some ideas of who to follow and highlights from discussions and debates in the Audiology twittersphere.

Happy Tweeting!

#AudPeeps on twitter There are many #AudPeeps on twitter – see below for a selection. This is not an exhaustive list and if any #AudPeeps would like a mention in the next edition let me know.

@BSAudiology1 @TinaTheAuD @stellahpe @IdaInstitute @HarpendenHear @cmcniece @darren_cordon @geco1970 @hlh1 @KidsAudiologist @just_aud_stuff @ryanwmccreery @jasongalster @radicalaud

@hearingmatters @NielsSJensen @ResearchOAEs @hearingnihr @BeReadyHear @swimto40 @audiologyonline @Brickers13 @HelenPryce @audiology_soton @earsurgeonuk @BAAudiology @hearingtweets

Audiology hashtags Using a hashtag # on twitter is a way of a labelling a tweet as a topic of interest.Twitter has a search facility, so you can look for all tweets labelled with a particular # label. If you’re looking for tweets relating to Audiology, have a look for tweets labelled:

#AudPeeps #Audiology #HearingLoss #HearingAids #Tinnitus #Dizziness #Vertigo #Cochlearimplants #Deafness #vestibular #hyperacusis

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60 Highlight of #AudPeeps news and views on Twitter

It was good to see that the first issue of Audacity was well received…

Recent debates include how many paediatric audiology services we need...

And that one of the authors from the second issue has been hard at work on her article!

….and how we deliver paediatric audiology networks..

#AudPeeps have been sharing research ….

Get tweeting…

You don’t have to be invited to join the conversation – just get stuck in.Your first tweets might be Retweeting or RT (forwarding on) something of interest to your followers. Press the Retweet button at the bottom of the post you want to share and it will be reposted, with a label at the bottom showing it’s a Retweet.

....and resources...

You may want to answer a tweet or join a debate, in which case press the Reply button of the tweet you want to respond to. A box will open up with the @username(s) of the person you’re replying to and space for your post. Once posted, your Reply will be linked to the tweet of the @username you’re replying to.

For further information, have a look at the Twitter help pages: https://support.twitter.com/

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Audiology in Republic of Ireland

FACTFILE...

Population: 4.59 million (as of 2011) Total area: 84,421 km2 Capital: Dublin Population with significant hearing impairment: 246,811 Population aged 65+: 535,393

CD

Authors and Correspondence Dr Gary Norman AuD, MSc, BSc National Clinical Lead Audiology (Ireland) E: gary.norman@hse.ie

Aisling Heffernan E: aisling.heffernan@hse.ie

Roulla Katiri, BSc, MSc E: rkatiri@mater.ie

It is, without a doubt, a very exciting time for an audiologist to find themselves working in Ireland. The much-needed drive for change was warmly welcomed by all clinicians who are tirelessly endeavoring to improve the service provision.

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The Audiology Clinical Care Programme The Audiology Clinical Care Programme (ACCP), one of a number of programmes under the Clinical Strategy and Programmes Directorate (CSPD), was set up in 2011 to take forward the recommendations from the National Audiology Review Group (NARG) report (April 2011) which was chaired

by Professor John Bamford.

The ACCP consists of a Programme Manager (Aisling Heffernan), and the National Clinical Lead for Audiology (Gary Norman), who took over in March 2013 from Professor John Bamford, who was the interim lead and is now an external consultant for the Health Service Executive (HSE: Irelandâ&#x20AC;&#x2122;s public health service provider).The HSE Executive Lead for the programme is Brian Murphy, National Primary Care.

National Audiology Review Group (NARG) The NARG identified a number of serious inadequacies and inconsistencies in the attempts of the existing services to meet the needs of adults and children with hearing and balance problems. These included severely fragmented services, long waiting lists, late diagnoses of congenital hearing loss, lack of clinical leadership, poor clinical governance, lack of service improvement and evaluation, and poor (or absent) cost management. The review group designed a comprehensive set of new care pathways and made 52 recommendations in four areas: clinical services; patient focus; workforce, structure and governance; and infrastructure and support.

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63 Service Structure Audiological service provision in Ireland is divided into a number of community services run by the HSE.They provide a wide range of diagnostic and (re)habilitative services for children and adults. Diagnostic services (ENT, balance assessment) are provided in acute hospitals, which may be voluntary or HSE hospitals. There are approximately 72 audiologists in Ireland with an approximate 50:50 split between community and acute services.

Ian Oâ&#x20AC;&#x2122;Neill and Aisling Heffernan with the Cochlear Trainer

All patients can access the acute diagnostic services; however waiting lists are significant extending up to 2 years in some areas. Access to hearing aid services is based upon whether an individual has a HSE medical card.This is provided automatically for children but is based upon age and financial status for adults.

People with a medical card have access to the full range of rehabilitative services. Non-medical card holders access the commercial sector. All adults in employment who have contributed towards Pay Related Social Insurance (PRSI) are entitled to a state grant of 500 euro/aid, which is reviewable on a four yearly cycle.

There is currently no official registration for audiologists or hearing aid dispensers. However the professional bodies; the Irish Academy of Audiology and the Irish Society of Hearing Aid Audiologists, are working towards this with the Department of Health.

The hearing aids provided by the HSE are modern digital devices, which have recently been procured through a national tendering exercise. The hearing aid services are fortunate to have a national engineering department who provide full repairs to hearing aids both on-site and via a courier service.

Additionally, we are unique in having a service that provides bone anchored hearing aid (BAHA) repairs on-site and via a courier service for Cochlear and Oticon devices.

Bone Anchored Hearing Aid (BAHA) Service BAHA services in Ireland had developed in a rather ad hoc manner, apart from one or two centres of excellence. Following an expression of interest exercise from the ACCP, the National BAHA programme was developed. There are now 6 sites throughout Ireland following consistent protocols and methodology, with the ACCP centrally managing the budget for 100 BAHAs per year. It is a good example of an initiative where the money follows the patient. A national BAHA working group provides medical and clinical staff the opportunity to review progress and discuss service related issues.

Universal Newborn Hearing Screening (UNHS) UNHS was introduced in April 2011, as one of the key recommendations of the NARG report. It has been introduced on a phased basis and will be fully implemented nationally by November 2013.

An open tender for the screening service was implemented and managed by the ACCP. It was awarded to Northgate

Information Systems, who now provide the hearing screening.

The UK Newborn Hearing Screening Programme (NHSP) dual stage screening methodology (OAE/AABR) is utilised.

The introduction of UNHS required upskilling of clinicians to ensure high quality immediate diagnostic assessments. This was provided by the expert NHSP team from the UK and organised

by University College Cork with financial support from the ACCP. Cochlear Implant Programme The National Cochlear Implant Programme, based at Beaumont Hospital, provides a public service for all paediatric, adolescent and adult patients. There is also an Auditory Brainstem Implant Programme, which is linked to the Neurosurgery Directorate.

A business case for additional funding has recently been submitted to the HSE to implement a bilateral simultaneous implant programme, as well as managing a substantial cohort of paediatric patients requiring assessment for sequential cochlear implantation.

Domestic Training for Audiologists Whilst the NARG report referred to potential development of a BSc and MSc programme in Ireland, post NARG work indicated that an MSc programme would be more appropriate.

The ACCP has worked closely with the Higher Education Authority to prepare an expression of interest to select a suitable Higher Education Institute (HEI) to set up an MSc programme in Audiology and have selected University College Cork as the preferred provider, pending agreement on funding.

Career Structure The audiology career structure previously consisted of

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64

Derek Clarke in the Hearing Aid Lab

audiologists and audiological scientists, the latter having an MSc in Audiology. The structure has proved unhelpful for both patients and professionals and there has recently been approval for a unified career structure which amalgamates the two structures and pay scales. The proposed structure is: Assistant Audiologist, Audiologist, Senior Audiologist, Clinical Specialist, Assistant National Lead and National Clinical Lead.

Paul Hendrick in the Baha Lab

audiology has seen an increase of 17 WTEs by Q4 of 2013!

Audiology staff across the country have worked collaboratively, leading to improved care pathways and quality of services. With the engagement of clinicians at all levels, this is an exciting time for the development of integrated audiology services in Ireland.

Restructuring Audiology Services Following the NARG report, audiology services required restructuring to place audiologists into fewer teams with larger critical mass in order to deliver better clinical governance and efficient care pathways. A thorough review of existing services, locations and skill mix required will be undertaken following the appointment of the four Assistant National Clinical Leads in audiology, one for each region, with the objective to development integrated services, rather than autonomous and separate units.

Dr Gary Norman Gary initially trained as an Audiology Technician in Birmingham and subsequently qualified with an MSc in Audiology from the Institute of Sound and Vibration Research (Southampton) in 1988. He spent 5 years at the Royal Liverpool University Hospital, moving to a joint post with Manchester Royal Infirmary/ Manchester University. In 1995 he moved to Ireland, leading the National cochlear implant programme. In 2007 he returned to Birmingham as Head of Audiology at Heartlands Hospital and has since returned to Ireland to take up the role of National Clinical Lead in Audiology.

National and Assistant National Lead Posts The ACCP was delighted to welcome Dr Gary Norman, the newly appointed National Clinical Lead for Audiology in March 2013. The Assistant National Clinical Lead posts have been advertised and were interviewed for at the end of April 2013.

These posts are critical for the overseeing of clinical governance in audiology.The posts will be 50% clinical and 50% managerial.

The 50% clinical support is very important for a profession that is chronically understaffed.

Aisling Heffernan Aisling Heffernan has over fifteen years experience working within healthcare and is currently working as a Programme Manager with the Irish Health Service Executive (HSE) Clinical Strategy & Programmeâ&#x20AC;&#x2122;s Directorate (CSPD) and carries the management brief for both the audiology and radiology programmes. Aisling commenced her career in healthcare as a speech and language therapist and later gained a number of postgraduate qualifications in both speech and language therapy and healthcare management.

National Patient Management System for Audiology Departments range from having no formal audiology patient management system, through to a fully networked state of the art service such as that at the Mater Hospital. A business case has been developed to look at the introduction of a national audiology patient management system, covering both community and acute locations.

Summary Within the context of the current financial climate, audiology has seen tremendous developments in recent years. Whilst there has been a moratorium on appointing staff in to the HSE,

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Roulla Katiri Roulla gained her MSc in Audiology at the University of Manchester in 2007. She subsquently worked as part of the Adult Diagnostics team at the Royal National Throat, Nose and Ear Hospital for four years before moving to Ireland. In Dublin she worked in Paediatric Diagnostics for a year at Temple Street Childrenâ&#x20AC;&#x2122;s University Hospital before moving back to Adult Diagnostics at the Mater Misericordiae University Hospital. Her current role entails providing audiology support to acute services, as well as developing the vestibular service and facilitating the work of the National Bone Anchored Hearing Aid Program.

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Ear & Hearing health services in North Korea CD

Author and Correspondence Glyn Vaughan Director - All Ears Cambodia Programme Manager - All Ears North Korea Founder & Trustee - All Ears International E: info@allearscambodia.org W: www.allearscambodia.org

Acknowledgements Thank you to the Korean Federation for the Protection of the Disabled, European Union Program Support, Unit 7 in Pyongyang, Mr. Simon Browning, Consultant Otolaryngologist at the Medical School of Abertaw Bro-Morgannwg University, Jake Kim, Karl Storz GmbH and the staff and patients of the DPRK National Health Service

Several reports have emerged in recent years from human rights groups, aid workers and North Korean defectors regarding health services in the hermit kingdom. Most of them are scathing. Descriptions of barely-functioning hospitals void of medicines and chronic malnutrition are given. They describe beer bottles used as IV drips and broken legs splinted with sticks instead of plaster. Amputations carried out without anaesthetic, dirty hypodermics being reused and surgeons operating in subzero temperatures and without running water. The health system certainly appears to have crumbled and languished over the past few decades amid deepening poverty and desolation.

Government health-spending ranks among the lowest in the world. One WHO estimate puts it at less than $1 per person.

North Korea, officially the Democratic Peopleâ&#x20AC;&#x2122;s Republic of Korea (DPRK), occupies the northern half of the Korean Peninsula. Its capital is Pyongyang.The aid organisation, All Ears Cambodia, hosted a delegation from the DPRK in 2011 at the Institute of Audiology and Primary Ear Health Care in Phnom Penh. It included representatives from the Korean Federation for the Protection of the Disabled (KFPD) and a number of otolaryngologists based at central hospitals in Pyongyang. The KFPD subsequently invited All Ears International (AEI) to visit North Korea to conduct a needs-assessment the following year.

The assessment focused on audiology and otology services in the DPRK and aimed to establish what development of those services was required and how collaboration might take place.

The end result would be a self-sustaining service improvement that could be carried forward by North Korea in the spirit of self-reliance that underpins the national philosophy known as the Juche Idea.

The state health service has definitely seen better times. Under Kim Il Sung, it underwent a restructuring and enlargement in the late 1940s after the fall of Japanese rule. It was modernised to reflect the Soviet section-doctor system and ostensibly, is free to the people. With the expansion of doctor numbers, North Korea set up an army of household doctors, each responsible for overseeing basic health within their communities.

Tens of thousands of these physicians still exist today with one family doctor responsible for ~250 households. Each clinic covers an area of about two ris or dongs (a residential area is called a ri (~village) in the provinces and a dong (~neighbourhood) in urban settings.)

Above this level are the hospitals. These have a number of different titles reflecting their position in a hierarchy of sophistication and skill. In the cities the lowest tier is the district hospital.

Above this is the city hospital and the highest is the central hospital. There are three of these in Pyongyang and they are allied to universities. At provincial level, the district hospitals also exist but only have a provincial hospital above them.This higher hospital corresponds with a city hospital in a municipal area. The assessment by AEI focused on ENT and audiology services through this hospital tier system in Pyongyang and the provinces of South Pyongan and Kangwon.

Despite the comprehensive network, the healthcare system in North Korea has been in steep decline since the 1990s - owing to natural disasters, economic upheaval and food and energy shortages. Many hospitals now lack essential medicines, equipment and electricity. Most North Koreans have access to water but it's often undrinkable. Infectious diseases such as tuberculosis, malaria and hepatitis B are endemic. Reportedly, 49% of North Koreans don't have enough food to eat. The 2011 census revealed 5.8% of a population of 24 million has a disability.

Accurate data regarding the prevalence of disabling hearing loss in North Korea is unavailable. From the WHO world map of prevalence of disabling hearing loss for all populations (using selected regions, 2011), the figure for the DPRK lies between 4.42 and 6.13%. This equates to 1.11 to 1.53 million people in North Korea with disabling loss. Anecdotal evidence suggests a greater burden.

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66 Reassuringly, the doctor-patient ratios are favourable. All of the hospitals are staffed by ENT surgeons of some type. All ENT doctors undergo a six-year medical school course and a further three years of ENT training. The smaller hospitals usually have two specialists while the city and central hospitals boast eight or more. Referral routes are strictly linear with hospitals referring up to the next level.

There is, however, a shortage of surgical instruments for standard ENT procedures not least equipment and medicine in the Out Patient Departments (OPDs). Even in the gleaming capital, some health facilities appear to be a throwback to another time. Hulking machines and ageing equipment arrived decades ago when the flow of medical supplies from the former Soviet Union was steady. Pyongyang's nuclear ambitions have resulted in further isolation and years of crushing sanctions. Humanitar-

ian aid is not supposed to be affected but officials say the embargos have made it difficult to import medicine and supplies.

Good quality pharmaceuticals are lacking. There is widespread practice of puffing ampicillin powder into the nose for sinonasal infection. Lower level clinics use topical spirit for aural toilet despite its known ototoxicity in perforated ears as antibiotics such as quinolones are unavailable (although on hand at central hospitals.) Streptomycin is bought cheaply and prescribed freely particularly at the lower levels. This combination has led to an epidemic of ototoxic deafness. The central- and city-level hospitals deny using it at all. They are aware of its effects and estimate that ototoxicity is the second highest cause of hearing loss after chronic otitis media. Educational campaigns have been launched by the KFPD but it is too early to determine their effect.

ENT outpatients department

Diagnostic audiology is archaic. Only a few units have audiometers and these are in poor condition and long out of calibration.

ENT surgeons perform the hearing tests as there are no audiologists in North Korea. There were no sound-treated rooms in any of the facilities visited.The city- and district-level hospitals have no diagnostic services other than tuning forks. There are no advanced electrophysiological diagnostics at any level or any awareness of paediatric behavioural tests. Although there is a paucity of audiological equipment across the state health service, the ENT medics have some knowledge of basic test procedures and are keen to develop their professional acumen.

ear reach

Hearing aid services in North Korea are non-existent. Bodyworn hearing aids were manufactured in country in the 1980s but production halted as the health service declined. In 2008, ~500 analogue hearing aids were donated from China although presently the state health service has none.Typical cases receiving hearing aids were those with presbyacusis, pre-lingual SNHL, chemical trauma and NIHL (common in the coal mining industry).There are no ear mould manufacturing facilities or hearing aid repair services in North Korea.

There are eight schools for the deaf in the DPRK. The school in Wonsan, Kangwon province, was established in 1959. It has

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Audiology Unit, City Hospital, Pyongyang.

125 students aged 9-24 years and 16 teachers. Younger deaf children stay at home and only enter special education at age nine. The adult students were identified late and are in the process of completing the several years of school education.

All students are resident; ~60% are female. The DPRK has developed its own sign language and vocational training for deaf students also exists. School leavers are provided job opportunities with the help of the government. Skills include tailoring, dressmaking and the production of handicrafts.

As well as the need for new technology there is a prerequisite for developing human resources. Overall, the level of knowledge of the senior ENT staff at the central hospitals is good although they are in need of refreshing their knowledge base.

There were certain diseases that they were unfamiliar with (e.g. malignant otitis externa, glomus tumours) and others where their information was outdated. In general, however, they were keen to learn and willing to acquire knowledge of practice outside North Korea.

AEI returned to the DPRK this year to deliver ENT OPD instruments and oto-surgical equipment as well as to sign a formal Memorandum of Understanding with the KFPD. Development of existing services is required and the KFPD has secured a site for the new Audiology and Primary Ear Health Care centre â&#x20AC;&#x201C; to be based at the Kim Jong Suk Factory Hospital in Pyongyang. The service provision team will comprise of 3 ENT doctors, 3 science degree graduates, 2 school leavers from the School for the Deaf (to be given training in ear mould manufacture) and 2 auxiliary nursing staff. Relevant equipment will

be shipped in the coming weeks.The aim will be (1) to develop audiology as a specialty in its own right and, in time, to establish a degree-level university course; (2) to train the ENT doctors (as well as the graduates) to a higher level of skill in diagnostic and rehabilitative audiology through study at home and in Cambodia while audiology is developed; and (3) concomitant development of otolaryngology facilitated through further visits and workshops and study visits to the UK and Cambodia.These three strands form the All Ears North Korea project. AEI will return in early 2014 to launch the first of the audiology training courses.

School for the deaf in Wonsan

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The NHSP Clinical Group what have we done?

CD

Author and Correspondence Graham Sutton Consultant Audiological Scientist Newborn Hearing Screening Programme (England)

A brief history 2006-2013.

August 2013 Any screening programme is only as good as its weakest link.

For the newborn hearing screening programme a vital link is audiological assessment of babies referred by the screen, which needs to be accurate, definitive and timely. Other links in the quality chain are well-fitted hearing aids and family-centred intervention and medical assessment It was clear that audiologists and other clinicians would need help and guidance to manage the much younger babies coming through from the screen. Although some audiology centres had previously operated SCBU-based screens or had participated in early trials of universal screening, many had little or no experience of testing babies at a few weeks of age, deciding who needed further follow up, sharing the news of hearing loss with parents, fitting hearing aids based on ABR data, and assessing hearing aid performance on babies. This was a very steep learning curve. From around 1999, NHSP produced protocols and guidance on an ad hoc basis but with the national rollout around 2005, we needed a more proactive and systematic approach. The NHSP Clinical group was formed by Graham Sutton in 2006 with agreement of Adrian Davis (Director) to ensure the best evidence-based guidance and advice was available to those in the field.

It meets 4 times a year. Members are invited as leading clinicians and experts - Audiological scientists, Audio-Vestibular Physicians and Paediatricians working in Audiology: they attend on a personal basis not representing any professional bodies.

I’d also like to mention and thank former members -Clare Robertson, John Stevens, Kai Uus, Roger Green and Sally Minchom.

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Current membership (at August 2013): • Graham Sutton (Chairman, Clinical Scientist, NHSP), • Sally Wood (Secretary, Clinical Scientist, NHSP) • Siobhan Brennan (Clinical Scientist, Sheffield).

• Rachel Booth (Clinical Scientist, Manchester) • Rachel Feirn (nee Foley) (Clinical Scientist), • Guy Lightfoot (Clinical Scientist, Sheffield), • Rhys Meredith (Clinical Scientist, Swansea) • Glynnis Parker (Audiological Physician) • Amanda Roberts (Paediatrician, Newborn Hearing Screening Wales) • Tony Sirimanna (Audiological Physician)

The small group format means that detailed and often lively discussions are possible and the group has been fruitful and productive (see list of outputs below).

Before finalising a new document we try to get a wide selection of views, and where possible we publish consultation versions prior to formal adoption. Comments received between versions are held for consideration in the next revision.

More instant advice and help has also been available through the NHSP helpdesk with experts rapidly answering screening audiological and medical queries by phone or email. This has now changed to a cross-programme helpdesk covering all antenatal and newborn screens.

The transition from a ‘startup’ to a ‘maintenance’ phase has continued with the move of the screening programmes into Public Health England (PHE) in April 2013. Also, from 2015 the remit of NHSP will be only up to the point of screen referral to Audiology. Further updating of many of our protocols and guidelines therefore now needs to switch to professional bodies, and BSA has issued (or is about to issue) updates of the tympanometry and VRA documents. Discussions are also under way with BAA and BSA about for Quality assurance and Quality improvement of post-screen diagnostic testing after 2015.

A Clinical Advisory Group will remain in the NHSP and now led by Sally Wood, to ensure that practice remains up to date and in line with new evidence and developments. All our guidance and advice can be found at http://hearing.screening.nhs.uk

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69 Documents produced, actions and outcomes Test Guidelines and Protocols • Guidance on Auditory Neuropathy Spectrum Disorder assessment & management (revised 2013) • Guidance on ABR testing in babies (2008, revised 2010 & 2012) • Guidance on ASSR testing in babies • Guidance on Early assessment and management of babies referred by the newborn hearing screen (2006, revised 2010 & 2013) • Guidance on Surveillance and audiological monitoring/referral of infants & children following newborn hearing screen (revised 2006, 2009, 2012) • Guidelines on Follow up of babies diagnosed with bacterial meningitis and/or septicaemia (2009, revised & included in surveillance doc 2012).

• Guidance on Tympanometry in babies under 6 months (2006, 2008) • Guidance on Visual Reinforcement Audiometry in infants (revised 2008, 2010) • Guidance for Aetiological investigation (via BAAP/BAPA) • Protocol for Cochlear Microphonic testing • Hearing aid fitting guidance in babies • Use of eHL values in DSL • Use of DPOAEs in assessment of babies

• Guidance on use of Fsp in ABR interpretation • Revision of Map of medicine care pathways for screening, assessment and hearing aid fitting and follow up • Masking calculator for ABR (Guy Lightfoot) • Model report forms and worksheets for assessment • Articles in professional media on masking, decision criteria, eHL, equipment problems Peer review • Model system for ABR Peer review Equipment • Equipment-specific parameters for ABR • ABR Calibration specification • Recommended ABR calibration data • Recommended ABR calibration labs • ABR systems – routine Stage A checks Policy & research • List of Research priorities for discussion with universities • Discussion of Accreditation and Quality Standards • Consultation on minimum numbers of tests for early assessment

Semicircular Canal Dehiscence CD

Author and Correspondence Lisa Cockman Senior Vestibular Audiologist Ear Science Institute Australia

Three semicircular canals, the superior, posterior and lateral, are responsible for detecting rotational movements of the head.

The canals are filled with fluid and embedded in the temporal bones of the skull, creating a closed environment. A dehiscence occurs when there is a thinning of the bone surrounding the canal, creating a “mobile third window” and changing the way that pressure waves travel in the inner ear.

Symptoms of SCD fall into two categories: auditory and vertiginous. Auditory symptoms usually relate to an unusual awareness of own body sounds. The patient may report that they can hear their eyeballs moving1, their pulse, or the sound of their heel strike when running2.

Hearing loss, tinnitus and vertigo are well known symptoms of inner ear pathology, but some more unusual symptoms are beginning to be understood since the discovery of a condition known as semicircular canal dehiscence (SCD).

The mobile third window changes the transmission of soundwaves through the inner ear. It allows air conducted sound pressure (sound arriving through the ear canal in the regular way) to escape through the dehiscence resulting in reduced

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70 stimulation of the basilar membrane. Additionally it causes bone conduction stimulation (sound arriving through vibrations in the skull bones) to be greater on the scala vestibuli (non-dehiscence) side of the cochlea compared to the scala tympani (dehiscence) side, resulting in greater stimulation of the basilar membrane. This results in a deterioration in air-conduction thresholds, but an improvement in bone-conduction thresholds.

Bone conduction thresholds may be lower than 0 dB3 and a conductive hearing loss may be observed in audiometric testing4.

be caused by bone resorption in the inner ear or by a series of microtraumas across a lifetime. The dehiscence may also onset following a sudden traumatic event, such as a head injury or a sudden change in pressure, perhaps brought on by vigorous nose blowing or suddenly straining to lift1. Childbirth has also been identified as a precipitating event for SSCD7. In many cases SSCD patients are able to identify such an event at the onset of their symptoms1.

SCD is diagnosed by an ENT specialist using high-resolution CT scans, audiometry and vestibular function testing, particularly vestibular evoked myogenic potentials (VEMPs). Full vestibular assessment can assist with differential diagnosis or identify other co-morbid vestibular conditions.

SCD is a treatable condition, although many people find that once they understand the cause of their symptoms they do not need any treatment at all3. Instead many people are able to manage their condition by avoiding their symptom triggers.

Courtesy of the Vestibular Disorders Association www.vestibular.org

Vertiginous symptoms are usually described, not as a spinning vertigo, but as brief sensations of disequilibrium or non-spinning vertigo which may be accompanied by oscillopsia (a visual sensation that the world is oscillating or bouncing). In SCD the disequilibrium is triggered by changes in pressure – either from sound, referred to as Tullio’s phenomenon3, or from increases in intracranial or middle ear pressure, which is referred to as Hennebert’s symptom. These symptoms occur because the “mobile third window” allows pressure to disperse through the semicircular canal, stimulating false sensations of movement. Patients may report that they feel dizzy during nose-blowing or when straining to lift.

Sufferers of SCD may experience vestibular symptoms, auditory symptoms or both.

SCD is most common in the superior semicircular canal due to its position in the temporal bone. Although much rarer, there are documented cases of SCD in both the lateral and posterior canals5.

There are two conditions that are required to develop superior semicircular canal dehiscence (SSCD).The first is that the bone overlying the canal is thinner than normal. This is thought to be caused by either a congenital or developmental abnormality5, 3.

The abnormality in bone development is present from an early age, however symptoms of SSCD do not usually emerge until adulthood so a thinner than normal bone alone is not sufficient for developing SSCD. Therefore there must be a process or an event that causes the dehiscence of the already thin bone, allowing the transmission of pressure through the canal.

It has been found that there is a statistically significant increase in dehiscence with age and a trend, but not a statistically significant increase, in thinning with age6.This has been postulated to

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For those who are not able to manage the condition with trigger avoidance and who report diminished quality of life from their symptoms, surgical intervention may be an option3. Surgery involves resurfacing the dehiscence to close the mobile third window or plugging the dehiscent canal. Surgery can be effective in improving both auditory8, 9 and vestibular9,10 symptoms and is carried out by an ENT specialist.

References 1. Minor, L.B. (2000). Superior canal dehiscence syndrome.

American Journal of Otology, 21, 9-19.

2. Minor, L.B., Cremer, P.D., Carey, J.P., Della Santina, C.C., Streubel, S-O. & Weg, N. (2001) Symptoms and signs in superior canal dehiscence syndrome. Annals of the New York Academy of Sciences, 942, 259-273.

3. Banerjee, A., Whyte, A. & Atlas, M.D. (2005). Superior canal dehiscence: review of a new condition. Clinical Otolaryngology, 30, 9-15.

4. Minor, L.B., Carey, J.P., Cremer, P.D., Lustig, L.R. & Streubel, SO. (2003). Dehiscence of bone overlying the superior canal as a cause of apparent conductive hearing loss. Otology & Neurotology, 24, 270-278.

5. Chien, W.W., Carey, J.P. & Minor, L.B. (2011) Canal dehiscence.

Current Opinion in Neurology, 24, 25-31.

6. Nadgir, R.N., Ozonoff, A., Devaiah, A.K., Halderman, A.A. & Sakai, O. (2011). Superior semicircular canal dehiscence: Congenital or acquired condition? American Journal of Neuroradiology, 32, 947-949.

7. Watters, K.F., Rosowski, J.J., Sauter, T. & Lee, D.J. (2006). Superior semicircular canal dehiscence presenting as postpartum vertigo. Otology & Neurotology, 27, 756-768.

8. Crane, B.T., Lin, F.R., Minor, L.B. & Carey, J.P. (2009). Improvement in autophony symptoms after superior canal dehiscence repair. Otology & Neurotology, 31,140-146.

9. Beyea, J.A., Agrawal, S.K. & Parnes, L.S. (2012). Transmastoid semicircular canal occlusion: A safe and highly effective treatment for benign paroxysmal positional vertigo and superior canal dehiscence. The Laryngoscope, 122, 1862-1866.

10.Amoodi, H.A., Makki, F.M., McNeil, M. & Bance, M. (2011).

Transmastoid resurfacing of superior semicircular canal dehiscence. The Laryngoscope, 121, 1117-1123.

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School Entry Hearing Screening Factors affecting the Pass Rate CD

1.9-23.4%) and a yield for permanent hearing loss of 1.4% of those referred1.

Author and Correspondence Rhys Meredith Consultant Audiological Scientist Singleton Hospital Swansea SA2 8QA E: rhys.meredith@wales.nhs.uk T: 01792 285270

Background A recent reorganisation of Audiology services in the Neath Port Talbot and Swansea area, involved the Audiology Department being given responsibility for the School Entry Hearing Screen. An analysis of basic performance statistics of the local school entry hearing screen was carried out to provide some benchmark statistics.

School Entry Hearing Screening in the UK The Health Technology Assessment (HTA) reported that 88% of areas in the UK continue to offer a universal school entry screen, (SES)1. Although it has been recognised that the yield of SES has diminished since the introduction of Universal Newborn Hearing Screening, it may still serve an important role in detecting late onset hearing loss, unilateral hearing loss1 and other cases missed by the neonatal hearing screen2.

The prevalence of permanent bilateral childhood hearing loss is estimated to rise from around 1 per 1000 live births to around 2 per 1000 children by the age of 9 years1. A study in the East of London found approximately 3.5 per 1000 children at school entry age had some form of permanent hearing impairment of which 1.9 in 1000 require identification after the newborn screen1. The role of the SES screen in detecting unilateral hearing loss may be more important in Wales where the screening protocol is less likely to detect unilateral hearing loss3 than its counterpart in England*.

There is variability in the methodology of SES across the UK in terms of the age of screening, test methods, screening environment and referral criteria1,4. The majority of SES screens are carried out on children between the ages of 4 and 6 years, using pure tone audiometry. Generally, children are referred for further assessment when they fail a pure-tone frequency sweep of 25dBHL in either ear on two occasions1.

Review of local procedures and data analysis Screening in the Neath, Port Talbot and Swansea area is carried out by two Assistant Technical Officers who visit the schools during reception year (children aged 4-5 years).The screen is a pure tone test at levels of 25dBHL for 1, 2 and 4 kHz and 30dBHL at 500Hz. Children failing any frequency in either ear are re-screened at a later date. Children failing the screen twice are referred for audiological assessment at Community audiology clinics. The cohort is approximately 4000 and coverage 90%. The screen fail rate is about 10% which is higher than the UK mean fail rate of 7.9%, as reported by the HTA survey1.

An analysis was performed on data from 142 schools visited between October 2012 and July 2013 in the Swansea and Neath Port Talbot area. Data from the first screening visit to each school was from children who were being screened for the first time. Data from subsequent visits mainly comprised the results of children that required a re-screen, but also included a small number of children being screened for the first time, due to absence from school at a prior screening visit.

3597 children were screened at the first screening visit to the schools. The overall pass rate at the first visit was 75.3% (95% CI 73.9-76.7).The overall pass rate at the 2nd screening visit was 65.0% (95% CI 62.2-67.9).

93 schools had a first screening visit in the Autumn/Winter period (Oct-Feb), during which, 2463 screens were carried out.

A further 49 schools were visited for the first time in the Spring/Summer period (Mar-Jul) during which 1134 screens were carried out. There was a mean difference of 4.8 months between the dates of the individual screening tests carried out during these two periods. Due to administrative issues, two schools were not visited during 2012/13 and were scheduled for the following academic year.

Analysis of the screening statistics showed significant differences in the pass rates for autumn/winter compared to spring/summer for both screeners. The pass rates of each screener were also found to be significantly different, (see table 1 and figure 1).

The HTA survey reported the coverage of UK SES to be around 90-95%, with a mean referral rate of 7.9% (range Footnote: * In Wales, well babies pass the neonatal screen with a clear response in one ear.

In England a bilateral clear response is required.

Table 1. Number of pass/fail results following first screening visits with Chi Square values

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72 manent childhood hearing losses. It is possible that future screening will be moved to coincide with the Spring and Summer months.

It is worth knowing that the National Institute for Health Research is undertaking a project to evaluate the cost effectiveness of screening for hearing impairment at school entry. The findings are expected to contribute to decisions regarding the continued implementation of school-entry screening and the form that it should take14.That project is expected to conclude in 2014/15.

Figure 1. Pass rates for the 1st screening visit (+/- 2 standard errors)

Discussion Otitis Media with Effusion (OME) is a very common childhood condition and is thought to be a major contributor to SES failure rates. There are reports that as many as 80%5 and 91%6 of children will have at least 1 episode of OME sometime during their childhood. In the 2–6 year age group around 20% of children can be affected at any given time7. Studies that have demonstrated that the prevalence/incidence of OME is lower in the Summer months8,9,10 and that there is a decline in the prevalence and incidence of OME with age,11,12. Fortunately in most cases, OME is transient and resolves spontaneously without the need for treatment. The mean duration of effusions is 6– 10 weeks13.

There are anecdotal reports that screening at primary year 1 (children aged 5-6) rather than in reception year results in a lower referral rate. In the present study, the Spring/Summer screens Young child performing her school entry were on average, carried hearing screen out nearly 5 months after the Autumn/Winter screens. The small but statistically significant reduction in the school screen failure rate for both the school screeners in this study was therefore expected. Unfortunately due to the format in which the data was available, it was not possible to separate out the potentially confounding influences of season and age.

Although both screeners received very similar training and support and follow the same screening procedures, an unexpected difference in their pass rates was observed.The reasons for this are currently unknown but observation of methodology, supervision and support is planned.

More data collection will be carried out on the next cohort of children to establish the repeatability of the seasonal or age effects on the pass rate noted above. Retrospective case audits will also be used to provide evidence of the local yield of per-

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References 1. Bamford, J. et al. Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen. Health Technology Assessment 2007; Vol. 11: No. 32.

2. Dedhia K, Kitsko D, Sabo D, Chi DH. Children with Sensorineural Hearing Loss after Passing the Newborn Hearing Screen. JAMA Otolaryngol Head Neck Surg. 2013;139(2) :119-123 3. Newborn Hearing Screening Wales. http://www.wales.nhs.uk /sitesplus/980/page/54163 Last accessed 27th August 2013 4. Fonseca S, Forsyth H, Neary W. School hearing screening programme in the UK: practice and performance. Arch Dis Child 2005;90:154–156.

5. Casselbrant ML, Mandel E. Epidemiology. In Rosenfeld RR, Bluestone CD, editors. Evidence-based otitis media. Hamilton and London: BC Decker; 2003. pp. 147–62.

6. Teele DW, Klein JO, Rosner B and Greater Boston Otitis Media Study Group Epidemiology of Otitis Media During the First Seven Years of Life in Children in Greater Boston: A Prospective, Cohort Study J Infect Dis. (1989) 160 (1): 8394 7. Haggard M, Hughes E. Screening children's hearing: a review of the literature and implications of otitis media, HMSO, London 1991 8. Fiellau-Nikolajsen, M. 1979.Type of care as an epidemiological factor in secretory otitis media and tubal dysfunction in unselected populations of 3-year- old children Arch Otolaryngol 1979; 105:46 1-6. 67 9. Ingvarsson L, Lundgren K, Olofsson B, Wall S. Epidemiology of acute otitis media in children. Acta Otolaryngol Suppl.

1982;388:1–52.

10. Tos M. Epidemiology and spontaneous improvement of secretory otitis. Acta Otorhinolaryngol Belg 1983; 37:31-43.

11. Bluestone CD & Klein JO Otitis Media, Atelactasis and Eustachian Tube Dysfunction in Pediatric Otolaryngology 2nd ed 1990; pages 320 12. Pukander J, Luotonen J, Sipilä M, Timonen M, Karma P. Acta Otolaryngol. 1982 May-Jun;93(5-6):447-53. Incidence of acute otitis media.

13. Surgical management of otitis media with effusion in children National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence February 2008 14. The diagnostic accuracy of hearing tests and cost-effectiveness of school entry hearing screening programmes. RCT in progress. ISRCTN61668996 http://www.controlledtrials.com/ISRCTN61668996 http://www.controlled-trials. com/ISRCTN61668996Last accessed August 2013

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Hearsay Ann Allen Retires cated just around the corner from where Ann lives with her husband Brian, a proximity which has proved a great asset to the Society over the years.

Ann continued with us as Administrative Secretary until she retired from full time employment with the BSA in 2005. Ann subsequently remained extremely active with Society in a number of roles which included proof reading the newsletters, managing mailings and ensuring they went out on time and covering for office staff in their absence.

After many years of working for the British Society of Audiology our former Administrative Secretary Ann Allen has decided to retire. Ann has worked for the Society in a number of capacities for more than 35 years, during which time many of us will have had the pleasure of knowing her and becoming close friends.

Ann became responsible for providing our secretarial support when she accepted the position of Administrative Secretary to the BSA at the time our offices were established in Reading in 1987.

This however was not the beginning of Annâ&#x20AC;&#x2122;s relationship with the BSA. Prior to the opening of our offices, the BSA had obtained its secretarial services through Harvest House in Reading, which at that time was home to The Society of General Microbiology (SGM).The SGM then provided secretarial staff to a large number of organisations similar to ourselves.

Ann had previously been employed by the SGM, at Harvest House, where her duties had included providing some of the support given to the BSA. Also, while working at the SGM, Ann had been asked if she would be agreeable to becoming minutes secretary to the BSA and the SGM had agreed this.

As the SGM expanded, it was found that they could no longer meet the needs of the BSA and the Society was told that they would need to find alternative support or accommodation.

Hearing of the impending move Ann had offered her services to the BSA provided they were to remain in Reading. Ann was subsequently offered the position of Administrative Secretary in March 1987 which she accepted. Ann, with her usual enthusiasm, actually helped the BSA to find suitable local accommodation and the BSA then moved into our current premises at 80 Brighton Road. This is conveniently lo-

Ann has witnessed and experienced many changes within the Society during her time with us and she has played a major part in its growth and continued success. Her energy and commitment have inspired many and I know that the work loads of others involved in the administration of the Society have been greatly lightened by her support and enthusiasm. If something needed to be done we could always rely on Ann to do it, usually without having to ask her.

I know that Ann has many happy memories from working with the Society and of the people she has met during this time, particularly from her attendance at meetings and annual conferences. I am often reminded of events which have taken place at these times; in 1996 the conference was held at the Guildhall in Winchester. On this occasion, accommodation for delegates had been prearranged at Sparsholt College and some young delegates, who arrived for registration, had not made a reservation.

Ann, who will always help in any way she can, agreed to give up her room in the knowledge that there was alterna-

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74 tive accommodation available close to the conference venue. When Ann went to confirm the alternative accommodation however, she was told that residents there were not allowed to return to their rooms after 9 p.m. and she then decided that it would be possible to drive back home to Reading, returning the following day. At a Mayoral reception, held that evening, Ann’s situation was mentioned, at which point the Town Crier, in full ceremonial dress, leapt forward and offered Ann a room in his home. Ann accepted without hesitation. I should point out the Town Crier had cleared it with his wife before they left. This demonstrates how Ann would go out of her way to help members in any way she could, even though it did

generate a lot of gossip the following day.

and grandchildren so I know she will find plenty of things to occupy her time.

Recently, Ann has written, collated, edited and published an extremely comprehensive, interesting and entertaining “History of the British Society of Audiology” for which we are greatly indebted. I cannot recommend this book highly enough and copies are available through our Secretariat.

Ann’s involvement with the Society will be greatly missed by us all, particularly at meetings and conferences where she never failed to welcome us with a smile and a cheerful positive attitude. I know that you will all join me in thanking Ann for all her hard work and her continued commitment and devotion to the Society and also in wishing her a long and happy retirement.

In her private life Ann has always maintained a keen interest in growing fuchsias and frequently participates in the activities of fuchsia societies. You would often find a splendid display of colour in the back area of our Reading office. She also loves to spend time with her family

Good Luck Ann! Written by Graham Frost

The BSA 2013 Conference from a new member’s perspective Kimberley Drain Audiologist Leighton Hospital Audiology department

I would definitely recommend the BSA conference as it was

tions of some tech-

great value for money and time well spent. There was a varied

nological

timetable of lectures, industry exhibitor stands, research posters

used in hearing aids.

and events. It felt slightly daunting at first being at a conference

Dr Marcelo Rivolta's

with some of the biggest names in audiology but I found every-

twilight lecture had

one approachable and enjoyed meeting a good mix of people

the audience capti-

with different roles in the field.The experiences taken from the

vated with his cutting

three days at the conference will enhance my clinical practice

edge work on using

and have developed my knowledge on a range of the latest re-

stem cells to func-

search topics in audiology. Here are my thoughts on my first

tionally repair dam-

BSA conference.

aged cochlea. It was

features

inspiring to hear the Kimberley outside Keele Hall

Speakers & Events

work of internation-

Professors Ruth Bentler and Brian Moore gave engaging and

ally renowned scientists and it refreshed my enthusiasm for my

practical talks which questioned the knowledge we take for

own clinical work. Lectures were running throughout the con-

granted in hearing research and hearing aid technology. These

ference on topics from cochlear implant processing strategies

lectures made me think about the evaluation process of new

to vestibular receptors contributing to cortical evoked poten-

hearing aids and I am now more aware of the potential limita-

tials. My favourite lecture was on paediatric tinnitus.

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75 At the Innovation Forum attendees were invited to discuss what they would like to see the BSA become, how it can improve and develop in the future. Small groups discussed ideas and fed back into the main group and the Chairman of the BSA responded directly. It was nice to feel like I could contribute my ideas in this way.

There were plenty of other workshops and events including a New Members (and newly qualified) session focused on how to go about doing research in a clinical setting: from applying for funding to tailoring a research question to writing a quality journal paper. This was a wonderful opportunity for those interested in undertaking research in an academic or clinical setting but who may be relatively new to conducting research.

An interactive poster presentation

From this session and through reading the research posters I was encouraged to perform research again.

Socialising and Networking There was lots of time to network and meet other attendees.

It was great to listen to the perspectives of people from different areas of audiology and from different parts of the country.

At the poster viewing sessions I could chat to the actual researchers and ask them questions about their studies.The manufacturer exhibitors were also good to talk to and a font of knowledge on products I use on a daily basis. I also enjoyed meeting people from a company who provided sign language books and deafness awareness training. Of course a well organised dinner on both nights over the three days was another enjoyable way to chat to new people and catch up with friends.

Plenty of time for good food and a chat with delegates and exhibitors

The formal dinner was held in the beautiful Keele Hall ballroom and the food and the dance floor made for an entertaining evening.

Final thought...

I cannot convey everything I enjoyed and learned during the conference in just a few paragraphs but I hope this has given you a flavour of my conference experience. Overall I would encourage anyone from this field to attend due to the high quality research content and the great networking opportunities.

Contributing at the professionally facilitated Innovation Forum

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News from Regional Groups and BSA Members Kathryn Lewis

BSA North committee

Report from the BSA North Group Evening Meeting 6th November 2013 The BSA North group held their second meeting on Wednesday 6th November at the Lass O’Gowrie, a traditional pub in the centre of Manchester. The meeting was kindly sponsored by Phonak and a hot buffet was provided. A good number of people attended the meeting representing the NHS, the private sector and Higher Education.

The theme for the meeting was ‘Public Engagement’ with the aim of exploring how to promote the profession both to other disciplines and the general public.

This theme links with a key project the BSA is working on over the coming year.

Professor Kevin Munro opened the evening by giving an overview of what the BSA would like to achieve in terms of Public Engagement and also related some of the current research that is taking place. Jacqueline Downie from Phonak then gave a short presentation on Phonak’s support to the NHS for marketing and promotion of services.

Kathryn Lewis from University Hospitals South Manchester told the group about her involvement as a STEM (Science, Technology, Engineering and Maths) Ambassador. This involves visiting schools to talk about the science of hearing and about professions in Audiology and Healthcare Science. The role also involves attending careers fairs in secondary schools and increasing awareness of the range of healthcare careers available in the NHS. Kathryn

Our next meeting will be in February 2014 hopefully in a pub somewhere in the North!

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also spoke about other Public Engagements activities such as setting up a patient forum and going to talk to GP practices and local social groups like luncheon clubs, Asian Women’s and over 60’s groups.

Tracey Adams from Cochlear ran a lively discussion session for small groups to look at ways we may be able to get involved in public engagement. There were a number of really interesting ideas and the group is looking to set up some working parties to set these in motion. Some of the ideas included; an App for members of the public to estimate their ‘hearing age’, a You Tube video, attending music festivals to promote hearing health, campaigning for schools to include the ear and related areas on the curriculum, targeting particular groups to contact and getting involved in Science weeks and career fairs.

So watch this space……

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BSA Twilight Series Meeting Scott Richards

Member, Cognition in Hearing Special Interest Group

Hearing and Cognition: Updates in Research and Clinical Implementation 7th November 2013 A twilight series meeting on Hearing and Cognition was held at the Queen Elizabeth Hospital, Birmingham on the 7th November 2013. A very interesting programme had been arranged by the organisers and the event was very well attended with many delegates travelling considerable distances.

The meeting was chaired by Dr Huw Cooper.

Scott Richards, member of the recently formed Special Interest Group (SIG) for Cognition in Hearing outlined the present work being undertaken by the group and discussed planned further work. The aim of the group is to develop a better understanding of cognition and how it impacts on hearing and how to assess it in research and clinical contexts.

Dr Douglas Beck speaking from his home in America gave an

excellent overview of the complex area of cognition with a presentation entitled ‘The tide’s turning: issues in cognition and audition’. It was a comprehensive examination of the many potential issues surrounding cognition and how a pure tone audiogram is a starting point for rehabilitation but does not provide anywhere near the whole picture. Expanding on this theme Doug outlined many of the key areas of research that may have a bearing on effective patient management. The audience were all invited back to Doug’s at the end of the meeting, an offer which he was very safe in making.

Professor Sven Mattys, from the Department of Psychology at York University gave a very thought provoking and engaging talk on ‘A typology of speech recognition in adverse conditions: focussing on cognitive load’. Using worked examples he demonstrated in a very clear, interactive and understandable manner ideas on divided attention tasks, the effects of stress and how there is a ‘lexical drift’ when cognitive loading is increased. From a personal perspective it was very interesting to get an input on cognitive challenges from an area of research not directly within audiology.

The last speaker was Dr Helen Henshaw delivering ‘Auditory and cognitive training: assessing the benefits to real-world listening abilities of people with hearing loss.’ A highly informative talk (utilising audience participation) included a review of past research surrounding auditory training and how there was need for further high quality work in this area.

Work undertaken previously by Helen and the team from Nottingham was presented looking at transferability of training amongst many other themes. Ongoing and future work was discussed, the results of which are eagerly anticipated.

Dr. Helen Henshaw and Professor Sven Mattys at the BSA twilight series meeting held at the Queen Elizabeth Hospital, Birmingham on the 7th November 2013.

The meeting closed with Huw thanking all the speakers, the organisers of the meeting and Chris Cartwright for managing the link with Doug in the US. In view of the current high level of interest in cognition, it was a timely, informative and highly successful twilight meeting that was very well supported.

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Essentials Calibration Services ACOUSTIC METROLOGY LIMITED AML is UKAS accredited and ISO9001 approved for the calibration of Audiometers both on site and at our laboratory in Glasgow. AML provide on site calibration and Medical Equipment Safety Testing to BS EN 62353:2008 for all audiometric equipment and an all makes repair service at our Laboratory. AML are approved calibration and repair partners with Interacoustics UK Ltd and Biosense Medical Ltd. Contact: Jennifer White, Acoustic Metrology Limited, Technical Centre, 46 Eastmuir Street, Glasgow G32 0HS. Tel: 0845 465 0141 or 0141 764 0069, Fax: 0141 778 4612.

Email: info@a-met.com Website: www.a-met.com

AMPLIVOX Amplivox are an ISO 13485 and ISO 9001 accredited company with over 80 yearsâ&#x20AC;&#x2122; proven experience in the support of audiological equipment. Amplivox provides calibration services at competitive rates for a range of audiometric equipment. Please contact sales@amplivox.ltd.uk for further details.

For further details please contact the Sales Department, Amplivox Limited, 29-30 Station Approach, Kidlington, Oxon OX5 1JD. Tel: 01865 842411, Fax: 01865 841853.

Email: sales@amplivox.ltd.uk Website: www.amplivox.ltd.uk

CAMPBELL ASSOCIATES LIMITED CA offer UKAS and traceable calibration of measurement microphones (sensitivity, frequency response and capacitance) as well as sound calibrators (single and multi-frequency), and sound level meters (including frequency filters if required). Also, traceable calibration of ear simulators and audiometric couplers.

For a competitive quotation and current turnaround times please Email: patsy@campbell-associates.co.uk Campbell Associates Limited Sonitus House, 5b Chelmsford Road Industrial Estate, Great Dunmow, Essex, CM6 1HD. Tel: 01371 871030 Website: www.campbell-associates.co.uk

GN OTOMETRICS (UK) Whilst manufacturing the widest range of audiology and balance assessment systems, the company also provides comprehensive technical support for both their equipment and most other makes of equipment in these categories. This includes Calibration, Fault Repair and PAT Testing. The UK Service team are both ISO9001 accredited and HIMSA Certified.

For more information and a quotation please Email: info@gnotometrics.co.uk. We are based at Unit 4, Cambridge Terrace, St James Road, Brackley, Northamptonshire, NN13 7XY. Tel: 0870 9000 675, Fax: 01280 709670.

Website: www.gnotometrics.co.uk

GUYMARK UK LIMITED Now UKAS Accredited for the Calibration of Audiometers. The Guymark repair and calibration service covers all audiological equipment including sound field installations.

Contact: Guymark UK Veronica House, Old Bush Street, Brietley Hill, West Midlands.

Tel: 01384 890600, Fax: 01384 890609.

Email: service@guymark.com Website: www.guymark.com

OTODYNAMICS LIMITED Otodynamics provides a service for the calibration and repair of its Echoport and Otoport precision instruments. Each system is calibrated using measuring equipment traceable to national standards. Otodynamics is certified to ISO 9001:2008 and ISO 13485.

Contact: Otodynamics Limited 36-38 Beaconsfield Road, Hatfield, Herts. AL10 8BB. Tel: 01707 267540.

Email: support@otodynamics.com Website: www.otodynamics.com

P C WERTH LIMITED One of the UKâ&#x20AC;&#x2122;s leading audiometric companies, providing calibration, servicing and PAT Testing for a wide range of audiometric instruments and SLM including Maico, Kamplex, Interacoustics, Otovation and Audioscan equipment. An ISOaccredited repair and calibration laboratory offering in-house and on-site services via the highly trained and experienced technicians. The company offers cost effective solutions to ensure valuable instrumentation remains at peak effectiveness, performance and compliance.

For more information contact: P C Werth Limited Audiology House, 45 Nightingale Lane, London SW12 8SP. Tel: 020 8772 2700, Fax: 020 8772 2701.

Email: calibrationservicegroup@pcwerth.co.uk Website: www.pcwerth.co.uk

PURETONE LIMITED All make repair and calibration service of audiometers and tympanometers.

Puretone are certified to ISO 9001:2008 and ISO13485:2003.

Contact: Puretone Limited 9-10 Henley Business Park, Trident Close, Medway City Estate, Rochester, Kent. ME2 4FR. Tel: 01634-719427, Fax: 01634-719450.

Email: info@puretone.net Website: www.puretone.net

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Essentials Examination Passes The following students have passed accredited BSA courses over recent months:

BSA Certificate in Industrial Audiometry (Albacare) Sheila Hammond Max Wilkinson Sylwia Wesolowska Daria Ruminska Rosemary Donachie Elizabeth Higgins Filipe Rodrigues

Jennifer Neil Katarzyn Wesolowska Robert Nowak Svanbjorg Palsdottir Alison Ross Angela Bayne

Heather Hilsdon Paul Raine Damian Melisa Jessica M Smyrl Lesley Willcox Jessica Taylor

BSA Certificate in Industrial Audiometry (Audio-Training) Kauvilen Cunee Robert Baldock

Robert Vesty Alice Dolan

Paul Dunne Peter Russell

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Audio-Training) Peter Russell Debbie Selmi Melanie Jinks Sarah Johnson Alex Reddick Adi Watkins Daisy Mansbridge

Rob Baldock Barbara Finnigan Julie Clarke Emma Jobin Philip Mason Michael Franklin

Alice Dolan Helen Kennedy Lena Batra Hannah Gregory Katie Mason Mark Finch

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Mary Hare) Sara Wright Christine Haigh Fred Marinus

Keith Hamilton Gayle Leeson Syed Naveed Haider

Azra Parveen Linda Felix

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Hidden Hearing) Halema Begum Katherine Marsh

Gwen Green Kate Purvis

Kaya Ince Mandy Spackman

Congratulations to all candidates Details of all accredited course providers, together with information on providing accredited courses, are available from the BSA office and via the BSA Website. The BSA also retains a list of delegates who have completed accredited courses.

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Essentials Council Members / Meeting Dates Officers

Council Advisors

Dr Kevin Munro – Chairman Dr Huw Cooper – Vice Chairman Dr David Baguley – Immediate Past Chairman Dr David Furness – Secretary Mr Andrew Reid – Treasurer

Dr Nicci Campbell (Chair, Auditory Processing Disorders SIG)

Elected Trustees Dr Michael Akeroyd Mr Peter Byrom Mr Chris Cartwright Mr John Day Dr Heather Fortnum* Dr Sebastian Hendricks Dr Martin O’Driscoll (Audacity Editor-in-Chief) Ms Helen Pryce Dr Nick Thyer Ms Tracey Twomey *Chair of the Applied Research Fund Committee

Ms Debbie Cane (Chair, Balance Interest Group) Professor Adrian Davis (IJA Council Representative) Dr Piers Dawes (Interim Chair, Cognition and Hearing SIG) Ms Mel Ferguson (Coordinator Learning & Events Group) Ms Lucy Handscomb (Chair, Adult Rehabilitation SIG) Dr Sebastian Hendricks (Chair, Paediatric Audiology Interest Group) Mrs Shahad Howe (Coordinator of Lunch and Learn seminars) Mr Paul James (Chair, Professional Practice Committee) Kathryn Lewis (Chair, BSA Northwest Group) Mr Jason Smalley (Web Administrator) Ms Charlotte Turtle (New members representative) Dr Peter West (IJA Council Representative)

Council Meeting Dates for 2014 Tuesday 18th March - Ewing Seminar Room, University of Manchester Tuesday 10th June - Ewing Seminar Room, University of Manchester Wednesday 3rd September - Annual Conference, Keele Tuesday 9th December - Ewing Seminar Room, University of Manchester Council from 11.00am to 4.30pm Housekeeping Meetings Tuesday 25th February Tuesday 20th May Tuesday 12th August Thursday 23rd October The above meetings will be held at the Secretariat in Reading or by teleconference. Venues to be confirmed Professional Practice Committee Meeting Dates for 2014 Monday 3rd March Monday 2nd June Monday 22nd September Monday 24th November Hearing and Balance UK Meeting Dates for 2014 Wednesday 26th February Wednesday 4th June Wednesday 16th October

Meeting dates may be liable to change.... essentials

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Essentials useful names & addresses ACTION ON HEARING LOSS

(formerly Royal National Institute for Deaf People (RNID)) 19-23 Featherstone Street London EC1Y 8SL Tel: 020 7296 8000 Textphone: 020 7296 8001 Fax: 020 7296 8199 RNID Helpline: 0808 808 0123 Textphone: 0808 808 9000 Monday to Friday (9.30am to 5pm) Tinnitus Helpline (Mon to Fri 9am to 5pm) Tel. 0808 808 6666 (freephone) Textphone: 0808 808 0007 Library: Librarian – Alex Stagg 330/332 Gray’s Inn Road London WC1X 8EE Tel: 020 7915 1553 (voice and textphone) Fax: 020 7915 1443 Email: a.stagg@ucl.ac.uk ASSOCIATION OF INDEPENDENT HEARING HEALTHCARE PROFESSIONALS (AIHHP)

Membership Secretary – Shona Jackson House of Hearing 51 Bank Street Galashiels TD1 1EP Tel: 01896 755474 Email: shona@houseofhearing.co.uk BRITISH ACADEMY OF AUDIOLOGY

President – Will Brassington Blackburn House Redhouse Road Seafield West Lothian EH47 7AQ Tel: 01625 290046 Fax: 01506 811477 Website: www.baaudiology.org bid SERVICES

Deaf Cultural Centre Ladywood Road Birmingham B16 8SZ Tel: 0121 246 6100 Minicom: 0121 246 6101 Fax: 0121 246 6189 Email: henry.skinner@bid.org.uk Website: www.bid.org.uk BRITISH ASSOCIATION OF AUDIOLOGICAL PHYSICIANS

Honorary Secretary - Dr Peter West Audiology Dept.

Queen Alexandra Hospital Cosham Portsmouth PO6 3LY

BRITISH ACADEMIC CONFERENCE IN OTOLARYNGOLOGY (BACO) BRITISH ASSOCIATION OF OTORHINOLARYNGOLOGY – Head & Neck Surgery (BAO-HNS) (T/A BACO & BAO-HNS)

The Royal College of Surgeons of England Administrative Manager – Nechama Lewis 35/43 Lincoln’s Inn Fields London WC2A 3PE Tel: 020 7611 1732 Fax: 020 7404 4200 Email: entuk@entuk.org Website: www.entuk.org BRITISH ASSOCIATION OF EDUCATIONAL AUDIOLOGISTS

(BAEA) Chairman – Peter Keen 4 Durnford Close Chilbolton Hampshire SO20 6AP Tel: 01264 860571 Email: peter.keenhearing@btinternet.com BRITISH ASSOCIATION OF PAEDIATRICIANS IN AUDIOLOGY (BAPA)

Previously known as British Association of Community Doctors in Audiology (BACDA) Secretariat: Mrs Pam Williams 23 Stokesay Road Sale Cheshire M33 6QN Tel: 0161 962 8915 Fax: 0161 291 9398

BRITISH HEARING AID MANUFACTURERS’ ASSOCIATION

Chairman - Mr Lawrence Werth c/o P C Werth Limited Audiology House 45 Nightingale Lane London SW12 8SP Tel: 0208 772 2700 Email: info@bhama.org.uk Website: www.bhama.org.uk BRITISH SOCIETY OF HEARING AID AUDIOLOGISTS

Secretary – Mrs Jill Humphreys 9 Lukins Drive Great Dunmow Essex CM6 1XQ Tel/Fax: 01371 876623 Email: secretary@bshaa.com Website: www.bshaa.org BRITISH STANDARDS INSTITUTION

389 Chiswick High Road London W4 4AL Tel: 020 8996 9000 Fax: 020 8996 7400 Email: cservices@bsigroup.com BRITISH TINNITUS ASSOCIATION

Unit 5 Acorn Business Park Woodseats Close Sheffield S8 0TB Tel: Freephone 0800 018 0527 Email: info@tinnitus.org.uk

BRITISH ASSOCIATION OF TEACHERS OF THE DEAF

CITY LIT

President – Gary Anderson Executive Officer – BATOD - Paul Simpson 21 Keating Close Rochester Medway Kent ME1 1EQ Tel & Fax: 0845 6435181 Email: secretary@batod.org.uk Website: www.batod.org.uk

The Faculty of Deaf Education and Learning Support 1-10 Keeley Street Covent Garden London WC2B 4BA Tel: 020 7492 2725/6 (voice) 020 7492 2746 (minicom) 020 7492 2745 (fax) Email: deafday@citylit.ac.uk

BRITISH COCHLEAR IMPLANT GROUP

Website: www.bcig.org.uk BRITISH DEAF ASSOCIATION

Head Office Coventry Point – 10th Floor Market Way Coventry CV1 1EA Email: headoffice@bda.org.uk Website: www.bda.org.uk

DEAFNESS RESEARCH UK Action on Hearing Loss

19 - 23 Featherstone Street London EC1Y 8SL Tel: 020 7296 8000 Textphone: 020 7296 8001 Fax: 020 7296 8199 Email: information.line@hearingloss.org.uk Website: www.deafnessresearch.org.uk

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82 DEPARTMENT OF HEALTH

HEARING DOGS FOR DEAF PEOPLE

For general information Dept. of Health Health Care (Administrative Division) Wellington House 135-155 Waterloo Road London SE1 8UG Tel: 020 7972 2000

The Grange Wycombe Road Saunderton Princes Risborough Bucks HP27 9NS Tel: 01844 348 100 (voice and minicom) Fax: 01844 348 101 Email: info@hearingdogs.org.uk Website: wwwhearingdogs.org.uk

For technical matters Dept of Health Medical Devices Directorate 14 Russell Square London WC1B 5EP Tel: 020 7636 6811 Hearing Aids - informal guidance: Policy Division Dept of Health Tel: 020 7972 4120 Contact for the supply of hearing aids NHS Hearing Aids NHS Supplies, North West Division Headquarters - 80 Lightfoot Street Chester CH2 3AD Tel: 01244 586715 Fax: 01244 505050 Customer services and orders Lister Road Runcorn Cheshire WA7 1SW Tel: 01928 858532 Fax: 01928 580053

INSTITUTE OF ACOUSTICS

Chief Executive – Mr Allan Chesney St Peter’s House 45-49 Victoria Street St Albans Herts AL1 3WZ Tel: 01727 848195 Fax: 01727 850553 Email: ioa@ioa.org.uk Website: www.ioa.org.uk MIDLANDS COCHLEAR IMPLANT PROGRAMME

Children’s Service: Aston University Day Hospital Aston University Birmingham B4 7ET Tel: 0121 204 3830 Fax: 0121 204 3840 Adult Service: Queen Elizabeth Hospital Audiology Centre University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Medical Centre Birmingham B15 2TH MRC INSTITUTE OF HEARING RESEARCH

Scottish Healthcare Supplies Trinity Park House South Trinity Road Edinburgh EH5 3SH Tel: 0131 551 8590 (helpline) Fax: 0131 552 6535 EAR FOUNDATION

Marjorie Sherman House 83 Sherwin Road Lenton Nottingham NG7 2FB Tel: 0115 942 1985 Fax: 0115 924 9054 Email: ear@earfoundation.org.uk Website: www.earfoundation.org.uk EUROPEAN FEDERATION OF AUDIOLOGY SOCIETIES (EFAS)

Contact BSA’s Secretariat for details

University Park Nottingham NG7 2RD Tel: 0115 922 3431

HEARING LINK

27-28 The Waterfront Eastbourne East Sussex BN23 5UZ Tel: 0300 111 1113 SMS: 07526 123255 Fax: 01323 471260 Email: enquiries@hearinglink.org Website: www.hearinglink.org

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NATIONAL PHYSICAL LABORATORY

Hampton Road Teddington Middlesex TW11 0LW Customer Services: +44 20 8943 8631 Email: acoustics_enquiries@npl.co.uk Website: www.npl.co.uk ROYAL COLLEGE OF SPEECH AND LANGUAGE THERAPISTS

2 White Hart Yard London SE1 1NX Tel: 0207 378 1200 Email: bulletin@rcslt.org Website: www.rcslt.org SCOTTISH SENSORY CENTRE

Moray House School of Education University of Edinburgh Holyrood Road Edinburgh EH8 8AQ Tel: 0131 651 6501 Textphone: 0131 651 6067 Fax: 0131 651 6502 Website: www.ssc.education.ed.ac.uk SENSE

101 Pentonville Road London N1 9LG Tel: 0845 127 0060 Fax: 0845 127 0061 Textphone: 0845 127 0062 Email: info@sense.org.uk Website: www.sense.org.uk SOUNDSEEKERS

Honorary Secretary – Mr Paul Tomlinson P.O. Box 50 Amersham Bucks HP6 6XB Fax: 01305 262591 Website: www.nadp.org.uk

Chairman – Dr John Fincham BA PhD 34 Buckingham Palace Road London SW1W 0RE Tel: 020 7233 5700 Fax: 020 7233 5800 Email: sound.seekers@btinternet.com Website: www.sound-seekers.org.uk

NATIONAL DEAF CHILDREN’S SOCIETY

THACKRAY MUSEUM

15 Dufferin Street London EC1Y 8UR Switchboard: 020 7490 8656 (voice and textphone) Fax: 020 7251 5020 Email: helpline@ndcs.org.uk NDCS Freephone Helpline (Mon-Fri 9.30am-5pm; Sat 9.30am - midday): 0808 800 8880 (voice and textphone) Website: www.ndcs.org.uk

Beckett Street Leeds LS9 7LN Tel: 0113 244 4343 Senior Curator – Jim Garretts Librarian – Alan Humphries Email: info@thackraymuseum.org Website: www.thackraymuseum.org

NATIONAL ASSOCIATION OF DEAFENED PEOPLE

HEARING AND BALANCE UK (HABUK)

Secretariat - 80 Brighton Road Reading RG6 1PS Tel: 0118 966 0002 Fax: 0118 935 1915

OR Level 1A City Tower Piccadilly Plaza Manchester M1 4BD

UNITED KINGDOM NOISE COUNCIL NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE)

MidCity Place 71 High Holborn London WC1V 6NA NICE reception: 0845 003 7780 NICE enquiries: 0845 003 7781 NICE press office: 0845 003 7782 NICE publications: 0845 003 7783 Email: nice@nice.nhs.uk Website: www.nice.org.uk

Mr A D Wallis Cirrus Research plc Acoustic House Bridlington Hunmanby North Yorkshire or: Mr B F Berry National Physical Laboratory Teddington Middlesex TW11 0LW

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Essentials Sponsor Members The partnership with Sponsor members of the British Society of Audiology (BSA) is of fundamental importance to the Society. As the largest multidisciplinary society concerned with hearing and balance in the UK, the BSA seeks to include commercial colleagues and organisations in its mission to promote knowledge, research and clinical practice in these areas. Being a Sponsor member places an organisation in close dialogue with senior members of the BSA, supporting meetings and publications. The outworking of this are yearly meetings between the Officers of the BSA and the Sponsor members to share information and perspectives on the strategic direction of the BSA. Sponsor members have direct input to the Programmes Committee, and their input is especially valued in the organisation of meetings and supporting exhibitions, these being a crucial element of successful events.

ACOUSTIC METROLOGY LIMITED P.O. Box 94 Middlesbrough Cleveland TS7 8XP Tel: 01642 325382 Fax: 01642 271555 Email: info@a-met.com Website: www.a-met.com AMPLIVOX LIMITED 29-30 Station Approach Kidlington Oxford OX5 1JD Tel: 01865 842411 Fax: 01865 841853 Email: n.court@amplivox.ltd.uk Website: www.amplivox.ltd.uk AUDITDATA LIMITED Centurion House London Road Staines Middx TW18 4AX Email: uksupport@auditdata.com Website: www.auditdata.com BIOSENSE MEDICAL LIMITED 10â&#x20AC;&#x201C;11 Eckersley Road Chelmsford CM1 1SL Tel: 0845 2266442 Fax: 0845 2263457 Email: biosensemedical.com Website: www.biosensemedical.com (please note revised website address) ECKEL INDUSTRIES OF EUROPE LIMITED Half Moon Street Bagshot Surrey GU19 5AL Tel: 01276 471199 Fax: 01276 453333 Email: general@eckeleurope.co.uk Website: www.eckeleurope.co.uk or www.audiologyrooms.com GUYMARK UK LIMITED Veronica House Old Bush Street Brierley Hill West Midlands DY5 1UB Tel: 01384 410848

Fax: 01384 410898 Email: sales@guymark.com Website: www.guymark.com INDUSTRIAL ACOUSTICS COMPANY LTD IAC House Moorside Road Winchester Hants SO23 7US Tel: 01962 873000 Fax: 01962 873111 Email: info@iac-acoustics.com Website: www.industrialacoustics.com/uk OTICON LIMITED P.O. Box 20 Hamilton Lanarkshire ML3 7QE Tel: 01698 283363 Fax: 01698 284308 Email: info@oticon.co.uk Website: www.oticon.co.uk OTODYNAMICS LIMITED 30-38 Beaconsfield Road Hatfield Herts AL10 8BB Tel: 01707 267540 Fax: 01707 262327 Email: sales@otodynamics.com Website: www.otodynamics.com PHONAK UK Cygnet Court Lakeside Drive Warrington WA1 1PP Tel: 01925 623600 Fax: 01925 245700 Website: www.phonak.co.uk PURETONE Limited 9-10 Henley Business Park Trident Close Medway City Estate Rochester Kent ME2 4FR Tel: 01634 719427 Fax: 01634 719450 Email: info@puretone.net Websiite: www.puretone.net

GN RESOUND LIMITED Unit 4 Cambridge Terrace St James Road Brackley Northamptonshire NN13 7XY Tel: 0870 9000 675 Fax: 01280 709670 Email: info@gnresound.co.uk Website: www.gnresound.co.uk SIEMENS HEARING INSTRUMENTS LIMITED Platinum House Sussex Manor Business Park Gatwick Road Crawley RH10 9NH Tel: 01293 423700 Email: info-hearingaids.shi.ukhealthcare@ siemens.com SPECSAVERS La Villiaze St Andrews Guernsey GY6 8YP STARKEY LABORATORIES LIMITED William F Austin House Bramhall Technology Park Pepper Road Hazel Grove Stockport SK7 5BX Tel: 0161 483 2200 Freephone: 0500 262 131 Fax: 0161 483 9833 Email: sales@starkey.co.uk THE TINNITUS CLINIC 121 Harley Street London W1G 6AX Tel: 0203 326 1777 Website: www.thetinnitusclinic.co.uk P C WERTH LIMITED Audiology House 45 Nightingale Lane London SW12 8SP Tel: 020 8772 2700 Fax: 020 8772 2701 Website: www.pcwerth.co.uk Email: sales@pcwerth.co.uk

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Essentials Applications for Membership (Council Meeting June 2013)

FULL Members Name

Address

Membership No.

Crichlow, Miss C Chum, Mr R Dawson, Dr S Elias, Dr G A Evans, Mr C Halden, Ms J R Kitterick, Dr P T Manchaiah, Dr V Nee, Miss K Topass, Dr N

Leicester Royal Infirmary Focus Research Ltd, Croydon UCL Ear Institute Scunthorpe General Hospital Cwm Taf Community Office, Heol Draw Woodside Centre, Welwyn Garden City NIHR Nottingham Anglia Ruskin University, Cambridge Leeds University Royal Surry County Hospital

4677 4689 4681 4687 4676 4682 4688 4684 4679 4680

Name

Address

Membership No.

McGarrigle, Mr R

Manchester University

4678

STUDENT Members

STUDENT Members re-grading to full Name Nash, Mrs JS

Address

Membership No.

University of Southampton

4212

RETIRED Membership Name

Address

Membership No.

Matby, Mrs M Richard, Mr R Tomlin, Mrs M

Cambridge Stevenage Hereford

3836 1539 2811

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Essentials Membership and Advertising Fees (with effect from 1st June 2013 to 31st May 2014)

MEMBERSHIP GRADES

FULL/ASSOCIATE MEMBERS UNITED KINGDOM FULL/ASSOCIATE MEMBERS OVERSEAS: Full/Associate including airmail (excluding Europe) Full/Associate including airmail (Europe) Full/Associate Surface Mail (excluding Europe)

STUDENT MEMBERS UNITED KINGDOM STUDENT MEMBERS OVERSEAS Student including airmail (excluding Europe) Student including airmail (Europe) Student Surface Mail (excluding Europe)

RETIRED/REDUCED RATE MEMBERS UNITED KINGDOM (with Journal) RETIRED/REDUCED RATE MEMBERS UNITED KINGDOM (without Journal) RETIRED/REDUCED RATE MEMBERS OVERSEAS (with Journal) Retired/Reduced including airmail (excluding Europe) Retired/Reduced including airmail (Europe) Retired/Reduced Surface Mail (excluding Europe) RETIRED/REDUCED RATE MEMBERS OVERSEAS (without Journal) Retired/Reduced including airmail (excluding Europe) Retired/Reduced including airmail (Europe) Retired/Reduced Surface Mail (excluding Europe)

Cheque

Direct Debit

£69

£64

£98 £88 £89

£93 £83 £84

£15

£10

£44 £34 £35

£39 £29 £30

£40 £26

£40 £26

£69 £59 £60

£69 £59 £60

£55 £45 £46

£55 £45 £46

No mailings will be sent after 1st September 2013 if full payment of subscription has not been received.

The BSA Financial Year runs from 1st June to 31st May. Subscription rates are subject to change in June each year.

Members will be notified of any changes in the BSA’s April Mailing.

• If you wish to pay by direct debit, a Direct Debit Mandate form can be downloaded from the BSA website www.bsa@thebsa.org.uk or by email bsa@thebsa.org.uk (the BSA Admin Office) • It is worth remembering that your subscription can be claimed back against income tax if you are in employment • The International Journal of Audiology is sent under separate cover direct from the publisher.

EXHIBITION FEES (charges below are a guideline only and will vary depending upon the venue) Sponsors

NameNon-sponsors

£220 per two metre stand per day (minimum) £440 per two metre stand per day (minimum)

NB: An additional charge of £20 will be added to cover administration costs

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86 ADVERTISING RATES : MAILINGS AND AUDACITY

Cost

1. Scheduled Mailing Print and Mail a single-sided A4 sheet in monochrome Print and Mail a single-sided A4 sheet in colour Print and Mail a single-sided A4 sheet in monochrome plus advertising on BSA Website Print and Mail a single-sided A4 sheet in colour Print and Mail a double-sided A4 sheeet in monochrome Print and Mail a double-sided A4 sheet in monochrome plus advertising on BSA Website

£381 £420 £443 £482 £476 £538

2. Special Mailing If the Scheduled Mailing dates are unsuitable BSA can offer a Special Mailing which would be despatched from our Admin Office within 7 working days from receipt of the advert electronically.

Print and Mail a single-sided A4 sheet in monochrome Print and Mail a single-sided A4 sheet in monochrome plus advertising on BSA Website

£824 £886

3. Website Advertising

£412

4. Mailing only – Insert supplied: i. Scheduled Mailing Mail a single A4 sheet Mail a single A4 sheet plus advertising on BSA website ii. Special Mailing Mail a single A4 sheet Mail a single A4 sheet plus advertising on BSA website

£294 £355 £742 £798

5. Advertising of Meetings/Events on the BSA Website – External Events Calendar:

£43

6. Bulk email to BSA members

£60

7. Equipment or services advertised in Audacity Full A4 page Sponsors Non-Sponsors Black and white Colour

£160 £474

£273 £948

Half A4 page Sponsors Non-Sponsors £118 £294

£237 £592

8. Advertising Audacity/Website package available to Sponsor members only Contact the BSA Admin Office for further information British Society of Audiology 80 Brighton Road Reading, Berkshire RG6 1PS, UK Tel: 0118 966 0622, Email: bsa@thebsa.org.uk

Please ensure an Order Number and Invoice Address is supplied when booking advertising NB.VAT must be added to all prices quoted.

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Audacity Dec13_Layout 1 05/12/2013 13:30 Page 87

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