Audacity Issue 12 by Audacity magazine

Audacity ...a British Society of Audiology Publication

issue 12 September 2018 ...................................

08 Nathan Clarke Towards a collaborative future...

23 Josephine Marriage A case study in unilateral hearing loss...

Audiology in South Africa: “It always seems impossible unitl it is done”...

58 Ear to the ground - for all things ear-related in the media...

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3 Jane Wild, Editor-in-Chief On behalf of the editorial team E: jane.wild@wales.nhs.uk

Dr Ted Killan PhD CS (Audiology) Chair Audiological Science and Education (ASE) Group Lead & Deputy Head of Specialist Science Education Department (SSED) LICAMM, Faculty of Medicine & Health University of Leeds

Welcome to the 12th Edition of Audacity.

Chair’s Message - September 2018

I’m writing this editorial on a beautifully sunny late July afternoon, conscious that you’ll be reading it in September and I’m referring to it as the Autumn edition. I hope you were able to enjoy the lovely sunshine, that I think we all experienced this summer, and that you’re heading into Autumn rested and refreshed. So what does the Autumn 2018 edition of Audacity have in store for you? We continue to be impressed by the number and quality of submissions we receive, we’ve had a particularly high number of submissions from around the world for inclusion in our Ear Globe section, some of which we’ve had to hold back for the next edition. It’s great to see such an active audiology community across the world and that they’re keen to share their stories in the BSA magazine. Once again we have two featured articles, both quite different but equally interesting. Josephine Marriage’s article, ‘What Phoebe has Taught Me’, is a fascinating case study in unilateral hearing loss, whilst the Hearing and Cognition Special Interest Group reports on the views of UK Audiologists on cognitive assessment in Audiology. We’re really pleased that John Day is introducing his first Top Ten Q written by Kris English and Molly Smeal on the use of a Question Prompt List (QPL) within audiological counselling. We’re hoping this will become a regular and recognised feature. I just want to take this opportunity to apologies for the editor’s note that slipped through the net within the introduction to Top Ten Q in the last edition. Specific apologies to Harriet Crook whose excellent Top Ten Q on Hearing Aids for Music, followed that introduction. The BSA Today section is jam packed, including updates from the BSA Special Interest Groups (SIGs); the Professional Guidance Group (PGG) and the new Conference Group (CG). Take a look at the fantastic work they’ve been doing over the last six months and at what they have planned going forward. Research Round up has focussed on the great work completed by trainees within the scientist training programme and we have the usual Clinical Catch Up and Ear to the Ground sections. We’ve continued to keep the essential information section out of Audacity so that we can maximise the 64 pages and include as many articles as we can. All of the essential information is on the BSA website. Limiting Audacity to 64 pages is one of the measures we have taken to try and minimise the cost of Audacity and ensure its sustainability. We’re also pursuing a fully online version that will enable interactivity, whilst making significant savings on printing costs. We’ll be looking at this for the Spring 2019 edition and so may be requesting that you include links and other interactive features within future audacity submissions. We’ll keep you informed as things progress, watch this space! I hope you enjoy this edition of Audacity and that the sun is still shining in September when you’re reading it.

This is my first Chair’s message, having had the baton (medal of office) passed to me by Liz Midgley at June’s AGM. Liz is now our Immediate Past Chair, and I am grateful that I have her knowledge and experience to draw from during my time as Chair. You will be reading this message at what I feel is an incredibly important time for audiology. I say this for a number of reasons. First, audiology has the potential to play a significant role in efforts to minimise the impacts of headline-grabbing health conditions, such as dementia and mental health problems. Mid-life hearing loss has been identified as the largest modifiable risk factor for dementia, with hearing aid (HA) use being shown to reduce the risk of developing dementia. Second, advances in technology have the potential to change perceptions about HAs. They are no longer unattractive beige devices associated with older age. They are now ‘smart’ wearable devices that can enhance modern lifestyles that could increase earlier uptake in the increasingly tech-savvy population. Finally, high profile evidence has recently been produced within our field. A Cochrane Review (considered to be the top level in scientific evidence) has shown that HAs are an effective intervention for people with mild-moderate hearing loss. We also have high profile guidance within our sector, following publication of NICE guidance for the management and treatment of adult hearing loss. The importance of these developments has not gone unnoticed. At a number of recent meetings, I have been struck by a common desire amongst those within our sector to use these developments as an opportunity to work more collaboratively with a unified, influential voice. This can only improve the lives of people with hearing and balance problems. I feel the BSA is extremely well placed to play a substantial role in achieving unification within our sector. We are (and are seen by others to be) an objective, multi-disciplinary organisation, with a well-deserved reputation for advising and influencing policy and practice, based on high-quality evidence. I am therefore keen that the BSA plays a key role in efforts to shape our discipline for the future. Changing the subject, plans for our second e-Conference are now well advanced by the time you are reading this message. It starts on the 2nd December and its title is ‘Global Connections’. This feels like an appropriate title for an innovative conference that enables international interaction and networking from your home or office! When writing this message, plans for the programme were already looking exciting - further information will be available on our website soon.

Editor in Chief and Chair’s Welcome

Contents 3

Editor in Chief and Chairâ&#x20AC;&#x2122;s welcome

BSA Today

Expert writing about topical areas in audiology

Ear Globe â&#x20AC;&#x201C; audiology around the world

Information and updates from all aspects of the work of the BSA

Featured articles

Ear Globe

meet the team

BSA Today

BSA Today BAA BSA BSHAA Joint Event Review

Towards a collaborative future - a big step forward Nathan Clarke

On February 7th, the first collaborative event between the British Society of Hearing Aid Audiologists (BSHAA), British Academy of Audiology (BAA) and British Society of Audiology (BSA) was held in Leeds City Centre. Titled ‘Towards a Connected Future’, the event was supported by Sivantos and Cochlear Europe. Nearly 200 audiology professionals spent the day networking, attending various educational talks, and, during coffee breaks, gathering keenly around the exhibition to discuss the informative lectures they had just seen. To fully embrace the connected future theme, delegates took part in real-time votes, enabling them to express their opinions on current hot topics. With results immediately available, this provided an engaging twist for the audience. One such vote was around what may have the largest impact on hearing healthcare over the next decade; a topic discussed by many speakers at the event Phonak’s Director for Digital Experience, Francois Julita outlined Phonak’s view of digital innovations that would likely be making their way into the industry and innovative methods that are already providing tangible patient benefits. He also appealed to attendees to reflect on impending technological changes and maintain an open view about the models of service that they might facilitate. Dr Mel Ferguson, (Nottingham, NIHR Biomedical Research Centre) delivered an engaging talk about the use of mobile and online learning platforms, including C2Hear, a collection of innovative multimedia educational tools that her research group are pioneering in this area. The Ear Foundation chief executive, Mel Gregory, presented her views of the value of hearing healthcare and its role in the future. She was followed by Dr Piers Dawes (University of Manchester), who brought delegates up to speed on the latest literature surrounding the

BSA Today

relationship between sensory impairment and dementia. Gemma Twitchen (Action on Hearing Loss) then updated about the charities’ ongoing work and Jane Wild introduced the BSA’s Sound Practice database - a virtual library aiming to support the provision of adult hearing rehabilitation. The final invited speaker was Curtis Alcock of hearing thinktank, Audira, who spoke about the importance of collaboration and language considerations within the sector. Gold sponsors, Cochlear Europe and Sivantos, also updated on their latest news, products and developments. The day was closed with an expert panel discussion, answering questions from delegates and those received on social media. Liz Midgley, chair of the British Society of Audiology, said: “I really enjoyed the day and the buzz created by so many enthusiastic audiology professionals. I was extremely encouraged by the presentations of all the hard work going on out there by very talented people who are driven to make sure our practice is as evidence-based as possible.” Sue Falkingham, president of the British Academy of Audiology, added: “The buzz in the room from the delegates was immediate and sustained. One of my favourite moments was when the sessions broke for lunch and delegates were too interested in their table discussions to get up and leave.” Hanna Jeffery, chair of BAA Service Quality Committee,Clinical Scientist in Audiology, Royal Gwent Hospital, Aneurin Bevan University Health Board: “The theme was explored in various interpretations throughout the day. ‘Connections’ have the potential to link technology with people, integrate people into society, unite the profession and change the way that audiologists and clients interact” BSHAA President, Sarah Vokes, provided a superb summary, highlighting the importance of collaboration: “Thank you to everyone who came along and supported delegates, speakers, our gold sponsors and exhibitors. Everyone contributed to a very successful event. We’re looking forward to hearing delegates’ views through our post-event survey and we all now need to build the momentum that has been generated. The three organisations are in the same space, not in competition but very much in collaboration.”

BSA Today

9 Profile of a Trustee Yvonne Noon Consumer Specialist: Advanced Bionics UK E: yvonne.noon@advancedbionics.com

Biography I qualified as an audiologist many years ago and have enjoyed seeing all the changes and developments within our profession. I was introduced to cochlear implants in the mid-90s by Gerald Armstrong-Bednall and have never looked back! I have a real passion for adult services and have concentrated my efforts on trying to improve these alongside the transition from paediatric to adult care. After a long career in the NHS I was looking for a change and an opportunity with Advanced Bionics (AB) became available. There has never been a dull moment! I started off raising CI awareness in Scandinavia, then worked directly with NHS Clinicians and Surgeons. I’ve developed and managed a group of volunteers, developed a private service and now work as part of a team on business development. I often get asked about the transition between NHS and corporate sector, and my advice is: You’ll know when/if you’re ready for a change, and go for it, I’ve never looked back! Current interests Access to cochlear implant services for recipients at a local level: People often still have to travel long distances to access their CI services and anything that can help ease the NHS workload, and provide local care is worth considering. I’m working on delivery services to enable patients to access e-healthcare and local services more readily. I still have a keen passion for CI awareness and engaging professionals who work in the community, NHS and private sector. As a result, I travel the UK and Ireland and have got used to long drives and overnight stays! Working with our group of volunteers always reminds me of why I branched into CI. Hearing their inspirational stories and life changing events is so moving and motivates me to deliver the best service I can. Role as a trustee I am the Membership Lead for BSA, which is a wonderful opportunity, as is being a member of BSA. I’m looking into ways to attract new members, engage current members in BSA activity and opportunities for membership growth,

across all professional disciplines involved in audiology, hearing and balance science. It’s not an easy role and I’m still surprised by how many people need convincing of the importance of membership! Why wouldn’t you be a member? BSA is an internationally recognised learned society, which influences, guides and sets clinical practice for hearing and balance sciences. We are respected leaders in research, the only interdisciplinary organisation in audiology which unites everyone with an interest in hearing and balance across all sectors and professions and we’re joint owners of the International Journal of Audiology! That’s my answer and I hope it helps you too. Always happy to talk and share my experiences and knowledge, so please don’t hesitate to get in touch.

Online Learning Group Sara Coulson Online Learning Group (OLG) E: sara.coulson@dmu.ac.uk

The BSA aims to advance audiological research, learning, practice and impact. For a number of years, the Learning Events Group (LEG) created opportunities for this to occur both face-to-face and remotely, through recordings and articles. In order to maintain this focus on high quality learning opportunities, it was decided recently to split LEG into a dedicated conference group and an on-line learning group (OLG). OLG is being led by Sara Coulson and supported by some former members of LEG. Sara has worked as an Audiologist for 20 years in the NHS and private practice. She joined De Montfort University Audiology programme as a lecturer in 2015 and joined BSA LEG in 2017. The group is passionate about maintaining high standards of patient care in audiology. Continuous professional devel-

BSA Today

10 opment and lifelong learning, through sharing the latest research findings and highlighting their clinical applications, are essential for this aspiration. There is a library of work available on BSA Grow (available to members on the BSA website), which can be accessed any time of day and can form the basis for individual study or group discussion. Many areas of audiology and research are covered, often in the format of short recordings allowing a quick look at new developments. OLG intends to build upon this work and create longer, more in-depth learning that can help develop skills and understanding. OLG will also be sharing the work done by BSA Special Interest Groups. In order to support these groups as well as events organised by the BSA, OLG is looking to develop and expand its materials and resources in 2018. We wish to respond to the needs of the audiological community and therefore welcome your suggestions for subjects you want to know more about, or skills you wish to acquire and improve. Please direct your suggestions to bsa@thebsa.org. uk If you would like to be part of OLG and shape the direction of learning with the BSA please get in touch. The only requirement is that you have a passion for education and sharing knowledge!

Conference Group Siobhán Brennan Conference Group (CG) E: siobhan.brennan@manchester.ac.uk

There is a new BSA conference group! This group focuses on planning and delivering the BSA conferences, including our new flagship e-conference and joint ventures such as the recent ENTUK/BSA Global Outreach SIG collaboration. Key components of the work include networking with a range of organisations, planning new and innovative ways of delivering conferences and arranging speakers for various events. The online conference has expanded our interaction with speakers from all over the world. The next BSA e-conference is in December 2018 so do let us know if there is a particular speaker you would like us to approach. Collaborations with other organisations has always been a

BSA Today

focus of the BSA and this can include joint conferences, such as the successful BAA/BSHAA/BSA event held in February 2018. The perspectives of these different groups deliver an interesting event and a combination of delegates who may not often meet together. One of the challenges of working with the conference group is timings. There’s a lot of activity both by the BSA and outside the BSA and the juggling has to ensure that key events don’t clash! The issue with timings doesn’t stop at the calendar. During the e-Conference in 2017 we held a small number of live events, including international speakers. This created challenges associated with the time differences across the globe. For a live event at lunch time in the UK, some speakers stayed up very late and others got up very early to speak to us! During face-to-face meetings the timings for parallel sessions are also tricky to allow delegates to move between sessions. For all of us struggling with lack of time one of the draws of working with the conference committee is that it is time limited – it is possible to be involved in a single event and then take a view as to whether you would like to contribute to any others or not. If you would like to get involved do get in touch with us at bsa@thebsa.org.uk; we would love to have you on board.

Professional Guidance Group Donna Corrigan Professional Guidance Group (PGG) E: donna.corrigan@dmu.ac.uk

2018 is proving to be a busy year for the PGG as there are 29 documents in the review/creation process. Auditory Processing Disorder (APD) Position Statement and Practice Guidance on the verification of hearing aids using probe microphone measurements have been published, with special thanks to both teams of authors and advising experts as well as everyone that contributed to the documents during the public consultation phases. The Recommended Procedure for Pure tone air and bone conduction threshold audiometry with and without masking will be published in the early Autumn alongside Practice Guidance The Acoustics of Sound Field Audiometry in Clinical Audiological. What documents are in process? On the next page is a summary of documents within the review/creation process at the moment:

BSA Today

11 Type of document

Total number

Under review

Current

Proposed new

Recommended Procedures

Practice Guidance

Accreditation

Position Statement

Policy

Totals

What are the different types of documents? • Recommended procedure - This provides a standard for the conduct of a specified audiological technique involving a specified group of patients/clients in a specified context. •

Minimum training guidelines - Guidance on training relating to BSA accreditation of training courses.

•

Practice guidance - This provides broader principles and themes on the topic.

•

Position statement - This represents a brief synthesis of the current evidence base and consensus on the topic.

Please check the BSA website regularly for both the public consultations of documents as well as the newly published ones as they go live!

SIG update Electro-physiology Interest Group (EP SIG) Dr John E FitzGerald Electro-physiology Interest Group (EP SIG) E: john.fitzgerald@nnuh.nhs.uk

Members of the Steering Group have had a productive and busy 2018, focusing on completing a number of BSA Recommended Procedures and Practice Guidance documents. Between January to March we submitted the following to the Professional Guidance Group (PGG) for consideration; • Recommended Procedure for ABR Testing in Babies • Recommended Procedure for Cochlear Microphonic Testing • Recommended Procedure for Assessment and Management of ANSD in Young Infants.

PGG comments have been received on the ‘Recommended Procedure for Otoacoustic Emissions Testing in paediatric and adult audiology’ and these are currently being addressed. A working group, led by Dr Siobhan Brennan, is progressing the revision of the ‘Guidelines for the early audiological assessment and management of babies referred from the newborn hearing screening programme’. A new working group, led by Dr Michelle Foster, has been formed to work on the document ‘Practice Guidance for surveillance and audiological referral of infants and children following the newborn hearing screen’ and is due to hold their first ‘virtual meeting’ in the near future. The regular short articles of interest that I had planned to e-mail to EP SIG members during 2018 have been postponed temporarily due to the focus on the above work and as it will be better to start this after the release of the revised protocols, so the clinical importance of the changes in the protocols can be highlighted and explained.

The PGG fed back comments on these documents which were addressed and the documents have now been sent for external peer review.

We have welcomed two new members to the EP SIG Steering Group, Rachel Beeby, clinical scientist from the Dorset County Hospital and Vivian Thorpe, clinical scientist in paediatrics from the Royal Hospital for Children in Glasgow.

PGG comments have also been addressed on the ‘Recommended Procedure for ABR testing for post newborn and adult’ and this document is now also undergoing external peer review.

If you are interested developing your expertise and skills in electrophysiology work why not join the EP SIG as a member, just e-mail to find out more. Membership is open to all BSA members.

• Practice Guidance on Principles of external peer review of auditory electrophysiological measurements.

BSA Today

12 Adult Rehabilitation Interest Group (ARIG) Jane Wild Adult Rehabilitation Interest Group (ARIG) E: Jane.Wild@wales.nhs.uk

I’m really pleased to be able to write this update as the new ARIG Chair. I just want to start by saying a huge thank you to Mel Ferguson who has been an amazing ARIG Chair and is an impossibly hard act to follow. Mel’s leadership over the last few years has put the group in a great position and I hope it’s something I can continue to take forward with the same enthusiasm and commitment. Mel hasn’t gone too far away, staying on as a member of ARIG and of course taking on the new role of BSA vice chair. ARIG continues to make good progress in bringing new developments to Adult Rehabilitation. Outcome measures toolkit. This will be a what, why, how, when and for whom of outcome and assessment measures for adult rehab services. If the CCG investigations into hearing aid rationing have taught us anything over the last few years, it is that we need to demonstrate clearly how adult rehab services make a real difference to people’s lives. We have recently completed an online survey to scope the national landscape relating to outcome measures. I hope you were able to find the time to complete this important survey and a big thank you if you did. We’ve had a good response with a total of 72 (42%) questionnaires returned This followed direct emailing to 170 departments plus a general call on social media and includes returns from the previous FOI. Keep an eye out for the results that will be published later this year. We are also collating information on key aspects of the most commonly used outcome measures, and how they are to be used. The toolkit will be the ‘go-to’ place for adult rehab outcomes in the UK. Sound Practice. Development of this virtual library (http://bsa-soundpractice.org.uk/) of adult rehabilitation clinical and service ideas, innovations and interventions continues. The aim is to inspire and support hearing healthcare professionals in exploring and delivering new approaches to service delivery and clinical practice. We continue to develop the Beta version of the Sound Practice website, ironing out technical problems and improving the usability. A number of people

BSA Today

have been invited to register and upload schemes as part of this initial development phase. If you are interested in registering or uploading a scheme to showcase innovative work you are doing, then please take a look. The formal launch will be at the BAA conference in November. BSA Grow. We have collated a series of key resources relevant to AR, which are freely available to BSA members within the BSA Grow Library. These have been categorised within three areas: key commissioning advice; information to support service delivery; and systematic reviews of the scientific literature. We will continue to expand these resources as more come online. Again, we see this as the ‘go-to’ place for AR information and resources. Please email me if you have any documents that would be useful. Practice Guidance. The “Common Principles of Rehabilitation for Adults in Audiology Services” (2016) will be updated in light of the NICE Guidelines on Hearing Loss, that were published on 21st June. Finally, as ARIG continues to take these (and other) exciting projects forward we’re looking to expand our team. There has been a recent call for new members which closed on the 20th July. As I write this I’m not aware of the outcome but hope to be introducing you to some new ARIG members in the next update. Please continue to stay in touch with what ARIG are doing and keep a look out for our tag line #inspringaudiologists.

Balance Interest Group (BIG) Andrew Wilkinson Balance Interest Group (BIG) E: andrew.wilkinson@uhbristol.nhs.uk

We have had busy times as ever with the Balance Interest Group. Firstly, we have welcomed two new members to the committee: Ben Adams and Darren Whelan. Darren and Ben have tons of experience and expertise, which we will be tapping into for the good of the group and the BSA. We are now in the very fortunate position to have a truly multidisciplinary team, that encompasses clinical audiologists/ clinical scientists (including from clinical engineering), physiotherapy, neurology, academia, commercial experience, and charity (Meniere’s Society). The breadth

BSA Today

13 and scope of our work can be developed further, as we consider collaboration with the Paediatric Audiology Interest Group (PAIG). It is likely that one or more members of the committee may leave the group over forthcoming months due to longevity of service. This can make way for some “new blood”, so ‘watch this space’ for possible advertisements for new recruits. The group has been very busy with writing documents. I would particularly like to thank Vicki Kennedy for the huge amount of work she has done with co-ordinating the updates for the revised Recommended Procedure for Calorics (nearly there!); Simon Howe for his excellent recent write up of the Technical Note for vHIT (head impulse test) for Audacity; Debbie Cane and Amanda Male for their groundbreaking work toward a vestibular rehabilitation guidance document, and Paul Radomskij for his ongo-

Paediatric Audiology Interest Group (PAIG) Verity Hill Paediatric Audiology Interest Group (PAIG) E: verity.hill@uhcw.nhs.uk

Hello to all Audacity readers from PAIG. First of all, I would like to introduce our new PAIG member. Claire Lingard who is a Scientist in Birmingham is our most recent member of PAIG. Within minutes of her agreeing to be a member she got stuck in and agreed to work on the NHSP Guidelines for surveillance and audiological referral of infants and children following the newborn hearing screen Version 5.1 with the EPSIG team which Michelle Foster is leading on. Welcome to PAIG Claire. We had a change this year in the way we have our PAIG meetings. We have changed them to PAIG working days and we have about 4 a year. On a PAIG working day we have a meeting in the morning to discuss what we are working on and future plans. In the afternoon we ‘buddy up’ with another PAIG member and we work on any project that was discussed in the morning meeting. We had our first working day in April and we worked on the BOA guidance which is now complete and has gone back to the PGG. Verity Hill from Coventry and Veronica Roscoe from Warwick did not get chance to look on the impression guideline for under 5 years due to PAIG having a shortage of members that day, but this will hopefully be a job for us at the

ing work on a combined procedure for VEMPs (vestibular evoked myogenic potentials). Thanks go of course also to all members of the committee, who have worked for the greater good in their own unique ways. The Balance Interest Group is not going to be holding its own conference next year, but instead we have an exciting opportunity in that there is a planned BSA BIG session to take place at the forthcoming BAA conference in Liverpool, 8-9 November 2018. At the time of writing this the programme is yet to be finalised, but the session is likely to include talks on postural control, paediatric balance, and mindfulness. We are also working toward our contributions to the BSA e-Conference later this year. There is always so much more that can be done. We are looking forward with relish to taking on the new challenges and opportunities that lie ahead.

next meeting. Karen Willis from Nottingham and Vanessa Sharp from Brighton have started working with the Electrophysiology SIG on the review of ‘Guidelines for the early audiological assessment and management of babies referred from the NHSP’. I must say that the way Siobhan and John have broken this document down and shared out the workload amongst relevant professionals must be congratulated and the PAIG will certainly be stealing with pride and using their tactic on future PAIG projects. To support the BSA and PAIG I attended the BSA/BAA/ BSHAA conference earlier this year in February. For a paediatric person it was very adult based but I didn’t feel I was in over my head and it was interesting to see what technology is out there particularly in the private sector. The NHS is 70 years old and I have been working in the NHS since 1989. The NHS had been going for 40 years before I started. In the 30 years since I have been in the NHS there have been many changes. Most of them to be embraced. When I started it was all BE18’s and BE19’s. Now there is talk about how audiologists and patients can use their smart phone to connect to patients hearing aids in their homes or work and babies are now being fitted with hearing aids at 2 months rather than 2 years. So Happy Birthday to the NHS and we audiologists should all be proud of how we have contributed to its success.

More information about our Special Interest Groups and its members is available on the BSA website.

www.thebsa.org.uk

BSA Today

14 Tinnitus and Hyperacusis Group (TH SIG) Derek Hoare Tinnitus and Hyperacusis Group (TH SIG) E: derek.hoare@nottingham.ac.uk

The objectives of the TH SIG remain focused on the development of evidence based guidance and recommended procedure, and raising standards across the private and public sectors. The long awaited ‘Clinical practice guidance for tinnitus in adults’ has been produced and I hope all BSA members with an interest and responsibility for tinnitus care have their say during the consultation process. The guidance covers everything from audiological and ENT assessment, questionnaires, and management options, to individual management planning and developing your service. Next, the TH SIG are revising the ‘Recommended procedure for measuring uncomfortable loudness levels’ so that it accounts for patients who have tinnitus and/or hyperacusis. Again, we look forward to member contributions during the consultation process. Finally, a ‘Recommended procedure for fitting combination hearing aids for tinnitus’, is imminent. This has drawn together evidence from various sources involving a patient survey, and a 3-round Delphi review completed by 36 experienced clinicians.

At our next TH SIG meeting (October 2018) we will turn our attention to the development of guidance, and priority recommended procedures, for hyperacusis. So, right now is the time to get in touch with the TH SIG and tell us what you really need to support your practice! Priorities will be informed, in part, by the results of the BSA-funded James Lind Alliance Hyperacusis Priority Setting Partnership for hyperacusis (www.hearing.nihr.ac.uk/research/hyperacusisPSP). This project identified a set of priority research questions on various aspects of hyperacusis including assessment, management, and healthcare delivery. Over 500 patients and clinicians contributed and voted for their personal priorities during the project, ultimately giving us a ‘Top-10’ list of questions that researchers and research funders will now prioritise. This project has told us a lot about what clinicians in the field need, e.g. in terms of specific guidance, but also highlighted a general lack of awareness about hyperacusis, and what usual care for hyperacusis looks like.There is clearly work to do just to understand the current landscape of hyperacusis care in the NHS. We look forward to presenting the results of the Priority Setting Partnership for hyperacusis to you at this year’s BAA conference and the BSA e-conference. Finally, we are delighted to welcome back Alice Davies, returning from maternity leave, as secretary of the TH SIG. If you have any comments, suggestions, or questions for the TH SIG, would like more information or would like to become a member then please do get in touch.

Auditory Processing Disorder Special Interest Group (APD SIG) Nicci Campbell Auditory Processing Disorder Special Interest Group (APD SIG) E: N.G.Campbell@soton.ac.uk

We have recently advertised for new members to join our BSA APD SIG Steering Group. Applications are currently being reviewed and successful applicants will be announced shortly on the BSA website. Two former Steering Group members, Dave Moore and Doris Bamiou, will now serve on our APD SIG Reference Group. We would like to thank them both for their tremendous contributions and look forward to our future collaboration. We have also invited a second parent to serve as an advisor. Figure 1 offers a quick overview of the BSA APD SIG’s new structure (from: BSA SIGS Terms of Reference, 2017)

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In recent months we have received an increasing number of enquiries about APD services available in the UK and about setting up APD services, for which we are referring people to the BSA APD Position Statement & Practice Guidance 2018. We are currently collating a list of APD Services in the UK. Please contact me if you would like us to add your service and contact details to the list. We are planning an APD Day for interested stakeholders (e.g. Health, Education, researchers, clinicians, charities, individuals with APD, parents and other interested parties). The aim will be to facilitate discussion about evidence-based practice and collaboration in the UK. This will include an update on the status of APD as a field, a review of current evidence, considerations when setting up an APD service and how we can enable progress with regards to access to support and assistive listening devices (ALDs)/remote microphone technology. Parallel to this we are in the early planning stages of developing an evidence-based BSA guidance document on the use of ALDs for individuals with APD.

BSA Today

Figure 1: BSA APD SIG structure

BSA APD SIG: Nicci Campbell (Chair), Pauline Grant, Stuart Rosen (Vice Chair) and Tony Sirimanna BSA APD SIG Reference Group and Advisors: Doris Bamiou, Dave Moore, Andrew Strivens

APD continues to be an area of dynamic change but also some ongoing controversy. Several groups around the world have now issued APD statements, guidelines and/or white papers. At this time there is no universally agreed diagnostic procedure for APD but all of the documents published worldwide contribute to international debate

and better understanding. High calibre research, alongside (inter)national and interdisciplinary dialogue, is imperative for informing future evidence-based practice. For more information please see the BSA APD Position Statement & Practice Guidance 2018, available on the BSA website http://www.thebsa.org.uk/bsa-groups/group-apdi/

Global Outreach Special Interest Group (GO SIG) Gemma Twitchen Global Outreach Special Interest Group (GO SIG) E: bsaglobaloutreachchair@gmail.com

BSA and ENT UK Inaugural Global Health Conference It’s been a really exciting year so far for the global outreach SIG. The BSA and ENT UK Inaugural global health conference 2018 was a great success and exceeded expectations with around 109 people in attendance from both the UK and internationally. We were really honoured to have Jim Fitzpatrick MP (Chair of All Parliamentary Group on Deafness) open the conference and Shelly Chadha from the World Health Organisation (WHO) spoke about the key issues related to hearing loss globally and the important work from WHO, including the resolution on hearing loss. We also had a great host of other key speakers working in the field of global health, including our own Wendy McCracken from the GO SIG, who spoke about sustainability of projects aimed at helping people with hearing loss in low and middle income countries and the harm that can be done by projects that are short term or not well thought out. We received very positive feedback about the day and it was a great opportunity to network with leaders in the

field of global health – it’s certainly given us some food for thought about not only our next event, but also key areas in which we could work and collaborate. We have since met virtually as a group and plan to meet in person to fully explore these options and next steps in more detail. Basic audiology course in South Africa We are also looking at whether we can assist in reviewing and developing content for a South African basic audiology course. There are a few such courses across Africa, but a great need to train people in basic audiology as there is a high incidence of hearing loss across the continent. This course is modular and a lot of it can be done online - we have been asked to review, provide feedback and offer support, which we are exploring. 3rd Stakeholders meeting for WHO on prevention of deafness and hearing loss In a few weeks’ time, The WHO will be holding their 3rd stakeholders meeting following the publication of the resolution on hearing loss. Gemma Twitchen Chair of GO SIG will be attending the conference to represent the BSA on a self-funded trip to Geneva. The meeting will offer lots of opportunities to engage on international best practice and network with key leaders in international hearing loss in order to drive forward an improvement policy on hearing loss.

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16 ENT UK & BSA Inaugural Global Health Meeting 2018 Gemma Twitchen, Chair of BSA Global Outreach SIG (GO SIG)

Dr Diego Santana-Hernandez, CBM

Wahid Zaman, GO SIG

Steve Crump, CEO, DeafKidz International

Wendy McCracken, GO SIG

Bhavisha Parmar, Sound Seekers

Dr Robin Youngs, ENT UK

The BSA’s Global Outreach SIG and ENT UK’s Global Health Committee are delighted to have jointly organised the Inaugural Global Health meeting which was held on 11th May in London. It aimed to mobilise and improve knowledge amongst delegates, and share the importance of hearing loss, D/deafness, ENT conditions and the challenges being faced on the global health stage. It was also the perfect environment to network with peers who are dedicated to shining a light on these issues and changing the lives of those affected with hearing loss and D/deafness globally. Over 100 delegates attended and the event attracted high-profile speakers which helped spark engaging discussions and potential collaboration opportunities. Jim Fitzpatrick, MP and chair of The All Party Parliamentary Group (APPG) on Deafness, opened the meeting with an inaugural address. This provided the background to the parliamentary group on deafness and highlighted the key priorities of the Government. The keynote speech by Dr Shelly Chadha (World Health Organisation - WHO) established the framework for the programme and goals of WHO. She oversees work on prevention, advocacy for prioritisation of hearing care, technical support to countries for development of hearing care strategies and development of tools and guidance.

UK Global Health Committee, provided a background of the committee that was set up at the request of the Trustees of ENT UK in 2015 in recognition of the tremendous interest in this field shown by British ENT Surgeons. The committee has worked to promote activities in the field of Global Health, which has been facilitated by the alliance with the BSA. The group has launched a Global Health Fellowship Programme and has been represented at the Global Surgical Frontiers meeting and at the Tropical Health and Education Trust (THET) annual conference. A sub-group has been established to coordinate and advise on research opportunities in ENT Global Health. Parallel sessions in the afternoon saw the BSA Global Outreach SIG organise and host a session with the following speakers: Wendy McCracken – The presentation ‘Do no harm’ focused on being aware of the ‘iceberg’, outlining what is needed to ensure that work is relevant, sustainable and in the long term interest of those in low and middle income countries. Some groups and companies donate large numbers of hearing aids, unaware that the ability to fit aids, have earmoulds made or get batteries is compromised, making

We also heard from Jo Hart and Lucy Byrne-Davis who gave us a practical insight into how behavioural change is an important factor in international health and how scientists are collaborating in this field to understand and drive changes in provider behaviour. Caris Grimes, a consultant General Surgeon and Commissioner on the Lancet Commission on Global Surgery outlined research strategies, which included the advantages and disadvantages of qualitative and quantitative research. Dr Robin Youngs, the first Lead for ENT

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L-R: Shelly Chadha - WHO, Sian Tesni - CBM, Robin Youngs - ENT UK, Wendy McCracken - GO SIG and Gemma Twitchen - GO SIG

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17 their long-term use unsustainable. Essentially the fitting of hearing aids is the ‘tip of the iceberg’ and there needs to be a raft of support under this if amplification is to be maintained and make a positive difference. One very practical example of a programme that has been trialled and works is available at www.wwhearing.org. The real challenge for children is how they are able to learn to listen and make sense of the world of sound around them once hearing aids have been fitted. In Sri Lanka there is only one oral school for the deaf and where all training relates to children using sign language. In Sri Lanka and Mynamar, cochlear implants are being provided, however no follow on support is available or teachers are inadequately trained in managing CI’s or supporting the development of listening skills using amplification. In Rwanda two children were fitted with donated top of the range hearing aids, but living in remote villages with no electricity, parents did not understand the need to change batteries, nor had the money or opportunity to buy them. Many countries have no reliable electricity supply and no one who can develop management protocols, replace broken equipment or advocate for hearing care services. Bhavisha Parmar - The session provided an overview of Sound Seeker’s projects with a focussed snapshot of the work carried out in Lusaka, Zambia in 2017 including the development of the first paediatric audiology clinic and ENT national strategic plan. She also highlighted the importance of raising awareness of the impact of hearing loss, the ways hearing loss can be prevented and the need for this information to be shared amongst service users, policy makers and health care workers in low resourced countries. She emphasised the need for transparent and consistent processes, allowing a global network of shared ideas and evidence-based practice. Dr Diego Santana-Hernandez (of Christian Blind Mission – CBM) – In this session the audience learnt about the concept of CBM’s Comprehensive Programme in the area of Ear and Hearing Care (EHC) and the technological advances and practical tools accessible in low and middle income countries (including online and offline resources). CBM recommended interventions address all levels of health care provision, education and community based approaches, as well as Audiological, Speech Therapy and other interdisciplinary services. However, particular emphasis was placed on the need to contribute towards making Primary Health Care services truly accessible and inclusive, from the point of view of EHC. CBM is one of many organisations working

in the field of EHC across the world. The current momentum in the international scene, endorsed by the new World Health Assembly Resolution on Prevention of Deafness and Hearing Loss, provides an excellent opportunity to work together and engage with Governments and other stakeholders to advocate towards inclusive health, and ultimately a more inclusive society, echoing CBM’s motto, “Together we can do more”. Steve Crump (CEO of DeafKidz International) – The presentation highlighted the endemic abuse and exploitation that Deaf children and young people endure in low resource and complex settings. Low levels of newborn hearing screening results in few children being assessed and diagnosed as Deaf. Consequently, many children are seen as ‘retarded’ or ‘stupid’ and marginalized accordingly. Local stigma and culture reinforces this abuse and neglect. Unable to acquire language, they lack the means to reduce their risk and vulnerability to abuse. At DeafKidz International, a four-part response to this abuse has been developed and is being implemented in Pakistan and Jamaica. The response •

Screening - To identify children that are Deaf, ascertain levels of hearing loss and ensure access to services.

•

Communication support - Training in manual and sign language communication skills so that the children can communicate their needs.

•

Parenting support - Empowering parents to embrace and support their Deaf child, as opposed to rejecting and abandoning them.

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Victim and survivor support - Where abuse has occurred, supporting Deaf children and young people to access clinical, social welfare and criminal justice support.

This integrated response is delivered within a child protection construct that sees all professionals receive appropriate safeguarding training. The key take home message was that all professionals working in ear and hearing care have a duty to ensure the protection and safeguarding of Deaf children in their care, and that if physical, sexual, emotional abuse or neglect is suspected, concerns should be disclosed locally to the identified safeguarding authority and ensure the child is safe from further harm. We received very positive feedback about the event and are already making plans for the next Global Health meeting. We’d like to thank all of our speakers and delegates and we look forward to seeing you at the next one.

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18 Video Head Impulse Test (vHIT): A Technical Note

E: simon.howe3@nhs.net please contact Simon or BSA BIG for the full list of references for this article Introduction The vHIT is a test of high frequency vestibulo-ocular reflex (VOR) function, and is a relatively new addition to the vestibular function test battery. Several models of equipment are now available commercially in the UK. There have been many peer-reviewed publications investigating the clinical utility of the test, and Halmagyi et al.1 provides a detailed overview. Scope This article is not intended as a recommended procedure or guidance document on the practicalities of performing the vHIT. Work on a recommended procedure is currently under consultation with national experts in the field. Instead this technical note is intended as an introduction and resource for those performing the test, to avoid the common pitfalls associated with obtaining and interpreting accurate vHIT results. There are considerable technical differences in how impulses should be performed when using different equipment and how software calculates VOR gain2, and therefore the reader should refer to the manufacturerâ&#x20AC;&#x2122;s guidance for the specific equipment used. This article is concerned with the performance of the vHIT in adults. It is recognized that the test can be applied safely and successfully to the paediatric population3-5. There is additional evidence to support its usefulness for diagnosing vestibular disorders in children6, 7. Cautions vHIT is a non-invasive test which would not be expected to induce dizziness and as such there are no real contraindications suggested in the literature. However, particular care should be taken when testing patients with neck complaints. The amplitude of each impulse should only be 10-20Â° and so should be comfortably within the range of movement of patients with all but the most restrictive neck problems. However, it would seem prudent to avoid testing those with cervical spine problems (such as cervical instability, rheumatoid arthritis, or radiculopathy), or those who have undergone recent vascular surgery on the neck. Testing patients with strabismus can be challenging, as if target fixation changes from one eye to the other during the recording window after an impulse then this may manifest as a saccade. In some cases this potential source of artefact

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can be overcome by patching one eye. It would therefore be prudent for a pre-test protocol to include not just questions regarding the presence of neck complaints or strabismus, but also a neck screen, eye movement examination and cover test; details of which can be found in other BSA guidance documents8, 9. The effects of betahistine and prochlorperazine on results of the vHIT are unknown. Although published data suggests that cinnarizine does not affect the results in healthy individuals10, its impact on vHIT results of those with a vestibular lesion are unknown. Sources of technical error Goggle slippage If the equipment uses goggles these must be fitted as tightly as possible. Loosely fitting goggles will cause slippage artefacts which can manifest as artificially high gain (Fig. 1), a phase shift in the eye movement, or bumps in the trace during the acceleration/deceleration phases of the head movement 11, 12. Goggle slippage can also be avoided by taking care not to touch the goggle strap during testing. Figure 1: High gain as a result of goggle slippage

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Simon Howe written on behalf of the BSA Balance Interest Group

Right Lateral (RL) ms

Calibration error As with all oculography, inaccurate calibration can lead to under- or over-estimation of eye movement amplitude, and in the case of vHIT can therefore lead to calculation of artificially high or low gain values. Poor head impulse technique Increased tester experience reduces response variability2. The risks of incorrect data interpretation can therefore be minimized for those less experienced with the test by performing a greater number of impulses for each plane. Impulses of insufficient peak velocity (<100Â°/s) can generate eye movement response curves which give the appearance of good VOR function, even in cases of total peripheral vestibular loss. This is because, at low velocity, smooth pursuit eye movements are capable of substituting for VOR function.

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Figure 2: Eyelid artefact causing a biphasic response in an individual impulse

Left Anterior (LA) ms

Right Posterior (RP) ms

account for both high (Fig. 5) or low (Fig. 6) VOR gain, without refixation saccades. When testing vertical canals, measured VOR gain is known to be affected by horizontal eye position. In the primary gaze position, vertical head movements will induce mainly torsional eye movement, which cannot be measured by 2-D oculography, and therefore gain will appear artificially low (Fig. 6). Therefore the eyes should be aligned laterally to the plane of the canals being tested, to ensure any eye movements will be mainly vertical and the measured gain will, in healthy individuals, approximate unity23. Figure 5: High VOR gain without refixation saccades

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Figure 3: Eyelid artefact causing peak clipping of the response

Figure 4: Low VOR gain with refixation saccades

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Eyelid artefact When generating vertical head impulses, the eyelid can interfere with accurate pupil tracking1. This may cause incursions into the usual bell-shaped eye movement trace and transforming it into either a biphasic response (in the case of anterior canal impulses; see Fig. 2), or artificially reducing the gain through clipping of the peak of the eye movement trace (in the case of posterior canal impulses; see Fig. 3). Eyelid artefact can be a particular challenge in patients with ptosis. Micropore tape can be used to tape back the upper eyelid. Less commonly, biphasic responses can also occur as a result of LED reflection artefact when using some vHIT equipment.

Right Posterior (RP) ms

Normative age-stratified data is available in the peer-reviewed literature for all vHIT systems commercially available in the UK13-17. Normative values for VOR gain from one system cannot be applied to another however, due to significant differences in the methods used to calculate gain18, 19. Low VOR gain with refixation saccades This is the most common abnormal finding on the vHIT and will usually, although not always, indicate a genuine vestibular pathology20, 21 (Fig. 4). However, recent alcohol-intake can also result in this pattern22. In some cases of unilateral vestibular deficit, there can be a slight gain reduction of the contralateral VOR. High or low VOR gain without refixation saccades There are several sources of technical error which can

Figure 6: Low VOR gain without refixation saccades

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Interpretation

Right Lateral (RL) ms

Right Posterior (RP) ms

Normal gain with refixation saccades Saccades can be present when measured VOR gain is within the normal range (Fig. 7). This may be due to the effects of ageing on the vestibular system24-26, or may represent a dysfunctional VOR27, 28. At present, making the distinction

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20 between pathological and non-pathological saccades in the presence of normal gain is difficult, although a peak velocity of 110°/s has been suggested as a lower cut-off for pathological saccades29. Figure 7: Normal VOR gain with refixation saccades

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Bilateral hypofunction vHIT can be particularly helpful in diagnosing incomplete bilateral vestibular loss; where only certain canals are completely affected45, 46 or where all canals are impaired, but only partially40, 47, 48.

Right Lateral (RL) ms

Overt vs. covert saccades Saccades can either be classified as covert (occurring before the end of the impulse) or overt (occurring after the end of the impulse); see Fig 8. The shorter latency of covert saccades implies that they are pre-programmed, and therefore covert saccades suggest a good degree of functional compensation from the associated vestibular deficit30.

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Figure 8: Distinction between covert saccades (a) and overt saccades (b)

Central vestibular disorders A positive finding on the vHIT does not necessarily imply peripheral vestibular dysfunction, as central lesions have also been shown to result in reduced VOR gain and refixation saccades45, 49-52. Future Work vHIT is an emerging clinical technique and greater understanding is required of how results represent VOR function. Clinicians should therefore interpret results with care, and should not interpret normal vHIT results to represent healthy functioning of the peripheral vestibular system. It is likely that the future of vHIT analysis will focus on saccade parameters such as latency, velocity, and temporal clustering, which may provide a more faithful representation of VOR status than gain measurements. Key Reading

Right Lateral (RL) ms

Relationship to the wider test battery Although both the vHIT and caloric test assess the horizontal VOR, they do so at different frequencies and therefore there is often dissociation between the results of the two tests31-35. This dissociation is particularly well documented in Meniere’s disease36, 37, vestibular schwannoma38, and chronic vestibular deficits39, 40, where vHIT results will often be normal. The vHIT and caloric test should therefore be regarded as complementary tests. This should not deter clinicians from the use of the vHIT as a screening test41, as the short time taken to perform the test allows identification of gross vestibular deficits and a positive finding of vestibular dysfunction on the vHIT may in some cases preclude the need to perform a caloric test33. vHIT remains the only commercially-available means of assessing vertical semi-circular canal function42, and as such is capable of identifying isolated posterior and ante-

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rior semi-circular canal lesions which might otherwise be missed43, 44. However, there appears to be equipment-specific differences in the ability to track vertical eye movements, and therefore the sensitivity to detect vertical canal dysfunction. This may be related to differences in recommended HIT methodology or recording/analysis methods2.

1. Halmagyi, G. M., Chen, L., MacDougall, H. G., Weber, K. P., McGarvie, L. A. and Curthoys, I. S. (2017). The video head impulse test. Frontiers in Neurology 8, 258. 11. Mantokoudis, G., Saber Tehrani, A. S., Kattah, J. C., Eibenberger, K., Guede, C. I., Zee, D. S. and Newman-Toker, D. E. (2015). Quantifying the vestibulo-ocular reflex with video-oculography: nature and frequency of artifacts. Audiology & Neurotology 20(1), 39-50. 23. McGarvie, L. A., Martinez-Lopez, M., Burgess, A. M., MacDougall, H. G. and Curthoys, I. S. (2015a). Horizontal eyes position affects measured vertical VOR gain on the video head impulse test. Frontiers in Neurology 6, 58. 28. Korsager, L. E. H., Faber, C. E., Schmidt, J. H. and Wanscher, J. H. (2017). Refixation Saccades with Normal Gain Values: A Diagnostic Problem in the Video Head Impulse Test: A Case Report. Frontiers in Neurology 8, 81. 37. McGarvie, L. A., Curthoys, I. S, MacDougall, H. G. and Halmagyi, G. M. (2015c). What does the head impulse test versus caloric dissociation reveal about vestibular function in Meniere’s disease?. Annals of the New York Academy of Sciences 1343, 58-62. 41. van Esch, B. F., Nobel-Hoff, G. E. A., van Benthem, P. P. G., van der Zaag-Loonen, H. J. and Bruintjes, Tj. D. (2016). Determining vestibular hypofunction: start with the video-head impulse test. European Archives of Otorhinolaryngology 273(11), 3733-39.

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21 Lunch and Learn Feature

Help Teens Take Charge of Their Hearing Healthcare This short communication is based on the online BSA Lunch and Learn seminar by Bert Meijers (Project Manager) and Ena Nielsen (Associate Director) at the Ida Institute. E: brme@idainstitute.dk E: enni@idainstitute.dk

The teenage years can be a challenging time for any young person. Add hearing loss into the mix, and teens have more to deal with than just the usual growing pains. Often, they are developing the skills, knowledge and self-confidence to self-manage their hearing healthcare. Parents, caregivers and hearing care professionals are an important source of support in this transition to autonomy. A key aim should be empowering young people to take responsibility for their healthcare needs and to connect with the people and services that are available to them. Research indicates that transition planning can have a “positive return on investment” for both young people and healthcare providers. When transition plans were used consistently, patients were more likely to comply with recommendations and understand their role in the patient-professional relationship. Most importantly, patients who engaged in transition planning participate more actively in the adult-care system.

Ida Telecare for Teens is a suite of online tools that aims to help young people develop the skills and confidence need-

ed to self-manage hearing loss as they transition to adulthood. The tools help to give teens a voice so that they can become advocates for their own hearing health. By reflecting on where they are now and where they are going next, teens can think about their short- and long-term goals and plan the steps to get there. The skills and understanding they acquire can help them develop a sense of independence that will sustain them as they learn to manage key decisions and life choices about their hearing health. Ida Telecare for Teens consists of three tools, designed for use at home, on their own or with their family, as they prepare for appointments: Living Well for Teens, My Turn to Talk for Teens and Why Improve My Communication? Easy-tofollow videos and instructions explain the purpose and use of the tools.

Living Well for Teens creates frameworks that enable young people to form a concept of their hearing loss within a variety of relevant personal, lifestyle and school-related contexts. This helps them to identify where and when it is most important for them to communicate well. By encouraging young people to think about their needs and concerns, Living Well for Teens helps to prepare them for more productive and focused appointments. My Turn to Talk for Teens provides a simple, visual way for teens to indicate who it is most important for them to communicate well with in daily life. In the second part of the tool, teens are asked to complete four sentences including “I’m happy about…”, “I hope…”, “I want to talk about…” and

“I’m concerned about…” to help them organize their thoughts and ensure their concerns are addressed during the appointment.

Why Improve My Communication? helps young adults think about how important it is to them to improve their communication in situations that matter to them. Scenarios in which they find it difficult to communicate are identified and teens are asked to indicate how important it is for them to communicate well in each scenario selected. Teens then consider what would happen if they do nothing or if they took active steps to improve their communication through the use of hearing technology or communication strategies. Each of the tools allows teens to download completed sessions to bring to their appointment or email in advance to assist their hearing care professional in preparing for the appointment. This ensures that individual needs are addressed and guides hearing care professionals in discussing possible options and recommendations for treatment and rehabilitation. The Ida Telecare for Teens tools and resources are freely available in the Ida Toolbox at www.idainstitute.com. References: i. National Children’s Bureau. (2005). Spotlight Briefing: Supporting children and young people through transition [Brochure]. London: National Children’s Bureau. ii. Pajevic, E., & English, K. (2004, November). Teens as Health-Care Consumers: Planned Transition and Empowerment. Audiology Today, 15-18.

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A case study in unilateral hearing loss: What Phoebe has taught me CD

Author and Correspondence Josephine Marriage, BSc Speech Science, MSc Audiology, PhD, CAC, RHAD Clinical Scientist in Audiology, Director of Chear Ltd www.chears.co.uk Correspondence address: Chear Ltd 30 Fowlmere Road, Shepreth, Royston, Herts SG8 6QS E: josephine@chears.co.uk

Phoebe was born in September 2007 and was referred from her new-born hearing screen. An audiological assessment using auditory brainstem responses (ABR) suggested normal hearing in the right ear and a moderate to severe sensori-neural hearing loss (SNHL) in her left ear. There was no family history of permanent hearing loss, and her parents requested an audiological opinion on possible cause of the unilateral hearing loss (UHL) and options for management of the hearing on the left side. The audiological physician explained that Phoebe’s UHL did not fulfil the NHS criteria for hearing aid provision in the left ear. The physician also suggested that anecdotal evidence indicated that hearing aid use for UHL was not found to be beneficial by many paediatric users (though this was based on detection of hearing loss at school-age rather than newborn screening). She believed that Phoebe’s speech progress was likely to be typical, as she had normal hearing in the right ear. However, Phoebe’s parents requested some further opinions on what to do about the UHL. This was because they noticed that Phoebe was less responsive to sounds than her siblings. For example, Phoebe sometimes startled when people came into view as if she hasn’t heard them approach; and she could not localise to sound. Phoebe’s parents’ met Jacqueline Stokes, an auditory verbal therapist, who recommended that her parents consider amplification, if there was aidable hearing in the left ear. I first saw Phoebe at 9 months of age, to assess if there was usable hearing in the left ear. This was completed using masked VRA with inserts and bone conduction, and results showed

Figure 1 Phoebe doing masked VRA with inserts at 10 months and her audiometry results

hearing that may benefit from amplification in the left side (see Figure 1, above). Investigations into the cause of hearing loss were completed. An MRI showed an enlarged vestibular aqueduct (EVA) on the left side, and the right side was normal.This raised the possibility that the hearing on the left side might fluctuate, and possibly deteriorate. She did not have Pendreds Syndrome. Phoebe was fitted with a behind-the-ear (BTE) hearing aid on a shell ear mould at 10 months of age. While we could verify the hearing aid output using real ear measurement, it was difficult to know if Phoebe was getting benefit from the amplification. I monitored her progress closely. Phoebe tolerated the aid well and did not attempt to remove it or show discomfort with raised sound levels. Phoebe started to develop vocalisations with babble consonants but had no words at one year of age. Phoebe spontaneously developed some signs at home and dropped the sign once she developed the spoken word.

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24 Of interest, on one occasion when she was 18 months old she took her hearing aid off and gave it to her mother. Her mother checked the aid and found that the battery was dead. This was the first clear positive indication that Phoebe was benefiting from her amplification. Her family also noted that she was more responsive to sounds. At 20 months of age, Phoebe had a vocabulary of around 50 words that were intelligible to her family. She was understanding simple instructions at home from both the right and left sides, however she could not always localise the direction that somebody was talking from. Phoebe was seen by a speech therapist, and concerns regarding muscle tone around the mouth, and expressive and receptive speech delays were identified. Ling sounds (mm, oo, ar, ee, sh, ss) were presented with a low voice level at close range with Phoebe, with her repeating the sounds back from the right and left sides. Speech discrimination testing was assessed at 45 and 50 dB A using familiar words and Phoebe could identify these items presented from either side. At 2 years 2 months of age, Phoebe was wearing her hearing aid through all waking hours, and her speech clarity was improving. She had an ear infection in her left ear at around 3 years of age and was not able to wear her hearing aid for a week. Phoebe specifically asked on Sunday night “Please can I have my hearing aid back now?”. As Phoebe shows some startle responses for sudden sounds, like coughing or sneezing, when wearing her hearing aid, we adjusted the hearing aid fitting to match NAL/NL2 targets rather than using the more typical DSL prescription. The overall loudness density of DSL is greater than amplification with the NAL prescription. When we put the hearing aid back on with the new NAL prescription setting, she said “my hearing aid is not working now”. A hearing aid check found it to be working well. I believe this is because the overall perceptual level was less than her hearing of audible speech in her normal hearing ear, and therefore she was not aware that the hearing aid was on. I interpreted this as a functional demonstration of the Stenger principle.

The Stenger effect is a known perceptual effect whereby a sound is delivered to both ears simultaneously and is heard only in the ear with the higher intensity signal.Thus, it is interesting to note, that for Phoebe’s hearing configuration, the overall perceptual level for a NAL fitting is slightly less than for normal hearing (that she has in the right ear), while DSL has a slightly higher perceptual level than normal hearing. A second possible explanation for Phoebe’s jumpiness to loud sounds was also discovered. Was her jumpiness to sudden sounds less with the NAL hearing aid fitting? Her mother clarified that Phoebe was jumpy to sudden sounds both with and without her hearing aid on. When I discussed this event with David McAlpine at the Ear Institute, he directed me to a paper describing this effect (McAlpine et al, 1997). The paper described the impact of UHLs and the lack of suppression at the level of the inferior colliculus to the contralateral (normal hearing) ear. This was new learning, as what I had always considered to be a “normal-hearing ear,” in fact had reduced suppression, and sensitivity to sudden high levels of sound. On reviewing file notes of my other children with UHL, I found that this was consistently reported by many of their parents.

Figure 3 showing the effect of hearing loss on binaural neurons in deafened ferrets (With thanks to David McAlpine for permission to use this figure)

At 3 years of age, speech discrimination testing using computerised presentation of four words (CCT) on a touchscreen was completed. When tested with and without her hearing aid, Phoebe scored 82% in both conditions. To access more high frequency sounds, Phoebe was fitted with a new hearing aid that had frequency lowering technology. Phoebe was fitted with DSL, as this seemed to be less associated with startling to loud sounds. With her new hearing aids, she scored 90%. (Figure 4.) At 3 ½ years Phoebe started in Nursery and chose to use her hearing aid throughout the school day. She liked it particularly in group settings, and during phonics. Her hearing in her left ear remained stable and unchanged.

Figure 2 NAL and DSL Curves for Phoebe’s Hearing Loss

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Phoebe was able to provide clear reports of hearing difficulties with following conversation in noisy environments (e.g. family

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Figure 4 Phoebe doing speech testing at 3 years with her left hearing aid on

group or restaurant). Phoebe began to report on her localisation abilities. She reported that sometimes she could localise to sounds with the hearing aid, but in other situations she could not. Phoebe shared a wonderful experience from school saying, “Do you know, there is a girl in my school who has two hearing aids. How lucky is she?”

Figure 5. Hearing levels deteriorated in both the left and right ears

By 4 years of age, Phoebe could complete speech discrimination testing with open-set speech tests with masking noise in her good ear, to assess her speech discrimination for each ear separately. On open-set speech test, Phoebe scored 100% correct at 65 dB and 80% correct at 50 dB presentation level listening through her left hearing aid. At 6 years of age, Phoebe was changed from a full shell ear mould to a receiver-in-the-canal (RIC) hearing aid. This was for improved comfort and for better access to high frequency speech sounds. In addition, Phoebe used a radio aid receiver in her left ear, for easier access to the teacher’s voice in the classroom. Phoebe advocated well for herself at school; she had a buddy system and was insightful about the best position for her in the classroom. At the age of 8 ½ years, Phoebe noticed a change in her hearing on the left side. This was of concern because Phoebe was known to have enlarged vestibular aqueduct (EVA) with an increased possibility of fluctuations in cochlear hearing. According to the literature, 30% of enlarged vestibular aqueduct condition had evidence of endolymphatic hydrops. In addition, research has reported that where the MRI shows a unilateral enlarged vestibular aqueduct, there can be susceptibility to bilateral deterioration in hearing. A hearing assessment revealed that her hearing had deteriorated on the left side by between 15 - 20 dB across all frequencies. Because of this decrease, Phoebe’s hearing aid was changed to a superpower receiver in the left ear. Also, of particular concern, were her hearing levels in her right ear. They were now fluctuating, and were just outside the normal hearing range (Figure 5.) At 9 years, 2 months of age Phoebe had an episode that she described as “blurry hearing.” This occurred during in a lesson

Figure 6. Audiometric thresholds at 9 years

in the school day and improved over the course of the week. In her normal cheery way, Phoebe described that “No one could tell me off for five days.” This appeared to be an early indication of cochlear hydrops, which gave rise to a further deterioration in hearing in both ears (Figure 6). Phoebe was seen by her audiological physician, and her family were advised that they should reduce sugar and salt in her diet to reduce susceptibility to hydrops attacks. To address the changes in hearing in her right ear, Phoebe was fitted with an open fit hearing aid with an integrated radio receiver. Given the deterioration in her left ear, and the uncertainty regarding the stability of hearing in her right ear, her audiological physician recommended the family consider a cochlear implant in the left ear. As part of the family’s consideration, Phoebe attended a Cochlear Implant Information day at the Ear Foundation, spoke to the Cochlear Implanted Children’s Support Group (CICS), and met other children of her age with cochlear implants. Initially, she was reluctant to think about a cochlear implant. She was seen by Professor Shak Saeed at UCL who recommended a left sided cochlear implant. While the current

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26 NICE guidelines from the NHS do not include cochlear implant for UHL, the fluctuating hearing in her right ear made this a more compelling consideration for Phoebe and her family. At 9 years, 4 months of age, Phoebe was seen by a neurologist. This was because she had had a migraine, dizzy spells and tinnitus in both ears over the Christmas holidays. She described the tinnitus in her right ear as sounding like a lamb sound “baa,” while the left ear had intermittent high-pitched tinnitus. Unfortunately, the left hearing aid no longer provided any benefit for Phoebe. She continued to use her right hearing aid, and this was helpful in the classroom. While Phoebe was able to maintain her progress in school, she struggled socially. She couldn’t interact with friends at lunch or in the playground and was very tired by the end of every school day. In April 2017 at the age of 9 and 6 months of age, Phoebe received a cochlear implant in her left ear. Unfortunately, Phoebe had vertigo (a “vomit-o-thon”) for about 10 days following the cochlear implant surgery. This was a recognised potential complication from cochlear implant surgery in EVA. Although some studies have indicated significant variation in tolerance, and speed of adoption of a cochlear implant, Phoebe reported that it sounded like normal speech after only one day. Even after only a few weeks of use she said the implant was “Worth it 100 times over!” She also stated that her hearing was “so much better than previously with her hearing aid.” Phoebe was actively involved in the programming of her CI device, and reported that the clarity of speech on her left side was “great”. While Phoebe is not using a radio aid or Bluetooth streamer, she is thriving in school including in dictation. She reports that sudden noises are still sometimes too loud and that the worst listening situations for her are large family dinners. Phoebe reported that she listens to music through her Implant, without any distortion. Phoebe finds her one-piece speech processor less visible than her previous hearing aid because the colour blends with her hair. She also feels it is much more comfortable than her hearing aid, as there is no piece over her ear.

Phoebe currently has a moderate low-frequency sensorineural hearing loss in her right ear. She has had a period of normal hearing over about 2 months which then became moderately impaired again. She uses a hearing aid on the right side when needed but uses her cochlear implant on her left ear through all waking hours. What have I learned from Phoebe over the last 10 years? 1. The importance of optimising hearing where there is potential benefit from amplification. Phoebe has taught me to be creative in finding ways to functionally verify hearing of speech through hearing aids. A unilateral hearing aid can be tolerated well, even loved, if introduced from under a year. 2. Her family have shown me the importance of managing hearing, both for neural stimulation and for improving functional hearing on a day-to-day and week-by-week basis. Her father once asked the group of students at an Ear Institute course on unilateral hearing loss “If your child was blind in one eye and you could do something about it, you would, wouldn’t you? Why is that any different to hearing loss in one ear?” 3. Phoebe has taught me how resilient young people are and how they can drive the process when necessary. If we hadn’t aided Phoebe’s left ear all those years ago we wouldn’t have had the same opportunity for benefit from cochlear implantation when the hearing deteriorated in both sides. About 8 months post-op, Phoebe said ”No one will ever understand the difference this implant has made to my life.” 4. I understand a bit more about the perceptual loudness from different prescriptions (NAL and DSL) for hearing aid fittings and how the Stenger effect that we use for clinical testing impacts on everyday functional listening. 5. I’ve learned that I need to be following the evolving science in auditory perception. For example, that unilateral hearing loss has reduced suppression at the level of the inferior colliculus, that EVA on one side can give rise to fluctuating hearing loss in both ears, and that hydrops may co-occur in about 30% of cases with EVA. Being a paediatric audiologist always gives opportunities for us to learn and I’m so grateful for having had this chance to know Phoebe and her family in her extraordinary journey so far. Reference McAlpine D, Russell M, Mossop J, Moore D. (1997) Response properties of neurons in the inferior colliculus of the monaurally deafened ferret to acoustic stimulation of the intact ear. J Neurophysiol 78:767-779.

Figure 7. Phoebe with her cochlear implant

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The views of UK audiologists on cognitive assessments in audiology CD

Authors and Correspondence Rebecca Millman1, Douglas Beck2, Sarah Bent3, SiobhĂ n Brennan1,4, Christian FĂźllgrabe5, Helen Henshaw 5,6, and Piers Dawes1 1. Manchester Centre for Audiology and Deafness, University of Manchester; 2. Executive Director of Academic Sciences, Oticon Inc.;

correspondence address:

3. North Wales Audiology Service, BCU Health Board;

Dr Rebecca Millman Dr Millman is a member of the the BSA special interest group for Cognition in hearing and is a Lecturer in Audiology at the University of Manchester E: rebecca.millman@manchester.ac.uk

4. Sheffield Teaching Hospitals; 5. Medical Research Countil Institute of Hearing Research, School of Medicine, University of Nottingham; 6. NIHR Nottingham Biomedical Research Centre, University of Nottingham. Recent discussion articles advocated addition of cognitive assessment (and/or dementia screening) as part of routine audiological consultations for older adults [1-3]. The suggestion that clinical audiologists should routinely assess cognition follows publicity about a potential causal contribution of hearing impairment to cognitive decline [4, 5], high co-morbidity of hearing and cognitive impairment [6], the impacts of cognitive impairment on communication and the potential to individualise (and better manage) audiological rehabilitation for people with cognitive impairment [7]. There are several potential benefits of cognitive assessment in audiology clinics. Cognitive screening in audiology clinics may facilitate early detection and management of dementia [3]. Inclusion of information about cognitive function may provide insight into an individual patientâ&#x20AC;&#x2122;s communication difficulties. Incorporating information about cognitive function may lead to improved outcomes from audiological rehabilitation (e.g. by selection of specific hearing aid technology and/or indicating a need for patient-tailored, specific support [8]).

audiology clinics. BSA members who were clinical audiologists that work with adults were invited to participate via email in 2017. The survey was completed via an on-line survey tool. 37 people responded to the survey. No information was available about the demographics of respondents. Results Our survey showed that the majority of respondents were supportive of cognitive screening in audiological assessment and management and would appreciate clinical guidance on how to apply cognitive testing. Cognitive assessment, carried out in the audiology clinic by audiologists, would be useful in informing hearing rehabilitation and management options.

The possibility of improving outcomes for people with hearing impairment by addressing both audiological and cognitive factors is intriguing. However, if audiologists are to expand the scope of practice to include cognitive assessment and/or dementia screening, questions remain about the clinical utility of cognitive data in audiological rehabilitation, acceptability to patients of cognitive tests in audiology clinics, availability of suitable cognitive tests, expertise in administering and interpreting the results of cognitive tests, and awareness and use of appropriate screening pathways for those who fail a cognitive screening test.

Clinical guidelines on assessing and using information about cognitive function in audiological settings would be useful.

The British Society of Audiology (BSA) Special Interest group (SIG) on Cognition in Hearing ran a survey of BSA members to gauge attitudes towards carrying out cognitive screening in

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28 However, there was mixed opinion on whether or not cognitive testing would be acceptable to patients, with almost a third of respondents indicating they were unsure:

I know how to use the results from cognitive assessment for audiological management.

Cognitive testing would be acceptable to audiology patients.

I am aware of, and would be able to use, appropriate referral pathways for patients who failed the cognitive screening test.

Despite the agreement that cognitive assessment would be of use to the audiological rehabilitation process, the majority of respondents reported a lack of awareness, training or expertise for implementation of a cognitive screening tool in clinical practice. The majority of respondents also reported that they were not aware of, or might not be able to use appropriate referral pathways for people who failed a cognitive screening test: I am aware of cognitive screening tests that could be used by audiologists.

selection of specific amplification technologies, protocols, aural rehabilitation, referral and follow-up). ii. Identification of appropriate care pathways and closer inter-professional working with related disciplines References 1. Shen, J., et al., Using cognitive screening tests in audiology. American Journal of Audiology, 2016. 25(4): p. 319-331.

I have the training and expertise to administer and interpret the results of a cognitive screening test.

2. Beck, D., B. Weinstein, and M. Harvey, Issues in Cognitive Screenings by Audiologists. The Hearing Review, 2016. 23(2): p. 36. 3. Beck, D., B. Weinstein, and M.A. Harvey, Dementia Screening: A Role for Audiologists. The Hearing Review, 2018. July. 4. Lin, F.R., Hearing loss in older adults. Whoâ&#x20AC;&#x2122;s listening? JAMA, 2012. 307(11): p. 1147-1148. 5. Maharani, A., et al., Visual and hearing impairments are associated with cognitive decline in older Americans, Britons and Europeans. Age and Ageing, 2018. 6. Allen, N.H., et al., The effects of improving hearing in dementia. Age and Ageing, 2003. 32(2): p. 189-193.

Conclusions The results of this survey suggest that there is recognition of the value of cognitive assessment in the audiological rehabilitation process. However, there is a clear need for clinical guidance on the use of cognitive assessment in audiology, and provision of formal training and development of appropriate care pathways. To begin to address this, we require: i. Evidence for how cognition assessment might impact audiological practice with respect to management (e.g.

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7. Souza, P., Arehart, K., & Neher, T. (2015)., Working memory and hearing aid processing: Literature findings, future directions, and clinical applications. Frontiers in Psychology, 2015. 6: p. 1894. 8. Lunner, T. and E. Sundewall-ThorĂŠn, Interactionss between cognition, compression, and listening conditions: Effects on speech-in-noise performance in a two-channel hearing aid. Journal of the American Academy of Audiology, 2007. 18(7): p. 604-617.

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Places shall be available on a first come basis, so early applications are advised. For further informatioin please contact: Justin Chater E: justin@pinpoint-scotland.com www.earandtechnology.com

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Audiology in South Africa â&#x20AC;&#x2DC;It always seems impossible until it is doneâ&#x20AC;?: The Ndlovu Wits Audiology Clinic and Outreach Programme (Limpopo Province, South Africa) FACTFILE... Limpopo is a South African province, bordered by Zimbabwe, Mozambique and Botswana, with a population of 5.8 million. In South Africa hearing impairment is the third highest reported disability

Author and Correspondence

Dr Karin Joubert PhD, M(ECI), BA(Hons) Psychology Blog: Karin.Joubert@wits.ac.za Programme Manager: Ndlovu Wits Audiology Clinic and Outreach Programme Senior Lecturer: Department of Speech Pathology and Audiology, University of the Witwatersrand, Johannesburg, South Africa

The average coverage rate for the newborn hearing screening programme is 93% the referral rate of 3.55%. The prevalence rate of disabling hearing impairment in the Sub-Saharan African region is four times that of high income countries such as the United Kingdom (World Health Organisation [WHO], 2018). Situated at the southernmost part of South Africa, hearing impairment is the third highest reported disability after visual impairment and physical disability. Despite the high prevalence of hearing impairment, the number of audiologists has decreased from 1.021 per 100,000 people in 2009 to 0.827 in 2015. Conversely there has been a slight increase in the number of otorhinolaryngologists from 0.417 per 100,000 people to 0.46 in the same period (Mulwafu et al., 2017). The majority of these ear and hearing care professionals work in the private health care sector that serves

ear globe: audiology around the world

just 14% of the population, therefore access to ear and hearing care services is limited, especially in the rural, under resourced areas of South Africa. The Ndlovu Wits Audiology (NWA) Clinic and Outreach Programme was established in 2014 to ensure that residents in the Sekhukhune District, the second poorest district in South Africa, were provided access to ear and hearing health services. This endeavour, the brain child of Dr Karin Joubert, in part-

Khomotjo Kgare (audiologist) conducting diagnostic testing

ear globe: audiology around the world

31 The screening personnel were recruited from the community and trained to perform hearing screening and educate the community on ear and hearing health. nership with the Ndlovu Care Group (a non-governmental organisation) and the University of the Witwatersrand, is generously supported by the Oticon Foundation. The NWA programme strives to improve the quality of life for individuals in this rural community by providing comprehensive, family-centered, quality ear and hearing health services, to individuals of all ages and reduce the negative impact of hearing impairment on the health, lifestyle and communication of these individuals and their families. Since its inception in 2014, the NWA Clinic and Outreach Programme has expanded significantly, with the team now comprising of two fulltime audiologists, four fulltime newborn hearing screeners and two schoolbased screeners. The screening personnel were recruited from the community and trained to perform hearing screening as well as educate the community on ear and hearing health. Services Comprehensive audiology services are available to the residents in the Elias Motsoaledi Local Municipal area of the Sekhukhune District with a total of 20,790 individuals accessing the services to date from a population of approximately 250,000. The diagnostic clinic, based at the Ndlovu Medical Centre, is fully equipped with state-of-the-art equipment to offer paediatric and adult assessments as well as management of hearing impairment (e.g. hearing aids, aural (re)habilitation, etc.). Since the inception of the programme, 4,648 individuals underwent diagnostic assessments and 203 were fitted with hearing aids. Hearing screening takes place at a variety of sites including preschools, primary

Johannes Lukhele conducting hearing screen in a primary school

Outreach service at old-age pension pay point with mobile Booth provided by Wits undergraduates.

Primary school learners receive health education and hearing screening.

schools, primary health care (PHC) clin-

the three PHC clinics, newborn hearing

ics, old-age pension pay points and com-

screening is conducted on a daily basis

munity centers. School-based screening

with an average coverage rate of 93%

is offered to all preschool learners on an

and a referral rate of 3.55%, making this

annual basis with a 95% coverage rate. At

is one of the most successful newborn

ear globe: audiology around the world

32 screening programmes in the country. A mobile diagnostic booth, acquired in August 2017, is used for outreach to the PHC clinic, community centers, outlying villages and commercial farming operations. Prevention of hearing impairment Primary and secondary prevention of hearing impairment is an integral component of the NWA programme. Health education is provided at PHC clinics for mothers and health care professionals, whilst learners, teachers and parents are targeted during screening at schools and parent meetings. At least five health promotion campaigns are offered annually. Research The NWA Clinic and Outreach Programme are utilized by two South African universities and one American university as a student training site. Volunteers and researchers are always welcome to join the programme. This

active research programme focuses on providing an evidence-based model for the inclusion of audiology services, as part of integrated health, child and community care in rural South Africa. Seven honours and four MA (Audiology) research studies have been completed and the research presented at national and international conferences (HEAL, ASHA, Coalition for Global Hearing Health). The first article related to the NWA Clinic and Outreach Programme was published in 2017 (Joubert, Sebothoma & Kgare, 2017). The NWA Clinic and Outreach Programme proves that sustainable audiology services can be successfully included as part of integrated health, child and community care in rural South Africa provided that adequate policy support and resources are available. As Nelson Mandela said: It always seems impossible until it is done.

References 1. Health Systems Trust. (2017). ISDS Site: Greater Sekhukhune District Municipality. Retrieved from: http://www.hst.or g.za/content/ isds-site-greater-sekhukhune-district-municipality. 2. Joubert, K., Sebothoma, B., & Kgare, K.S. (2017). Public awareness of audiology, hearing and hearing health in the Limpopo Province, South Africa. South African Journal of Communication Disorders 64(1), a557. https:// doi.org/10.4102/ sajcd.v64i1.557. 3. Mulwafu, W., Ensink, R., Kuper, H. & Fagan, J. (2017). Survey of ENT services in sub-Saharan Africa: Little progress between 2009 and 2015. Global Health Action, 10 (1): 1289736. doi: 10.1080/16549716.2017.1289736. 4. World Health Organisation. (2018). Addressing the rising prevalence of hearing loss. Geneva: World Health Organization.

Post-Master’s Doctor of Audiology (Au.D.) Program IN THE UNITED KINGDOM

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• Students can start the program at any time and complete it in 24 months. • It is taught by experts in the field from the United States and abroad. For more information, contact us at audinfo@nova.edu or 001-954-262-7765, or visit our website at nova.edu/aud. “The Au.D. has helped me to … advance my clinical skills and knowledge. It has given me the confidence to know I am improving my patients’ quality of life.” —Gareth Smith, Au.D. Nova Southeastern University admits students of any race, color, sexual orientation, gender, gender identity, military service, veteran status, and national or ethnic origin. • Nova Southeastern University is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate’s, baccalaureate, master’s, educational specialist, doctorate, and professional degrees. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of Nova Southeastern University. 05-023-18SAT

ear globe: audiology around the world

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ear globe: audiology around the world

Audiology in Chile Overview of neonatal hearing screening programme FACTFILE... Chile stretching along South America’s western edge sitting between the Pacific Ocean and the Andes mountains, its population is 18,197,209 million.

Author and Correspondence Enrica Pittaluga Paediatrician at Children’s Auditory Rehabilitation Center, Sotero del Río Hospital in Chile Founder and Principal of the first Rehabilitation Center for Deaf Children Consultant in the Health Ministry for National Cochlear Implant Program E: rehabilitacion.crai@gmail.com

Congenital hearing loss is a public health problem. It is estimated that 1-3/1000 live births have significant hearing impairment worldwide. It is a permanent condition and children with undetected hearing loss suffer delays in their speech and language development and cognitive skills as well as showing poor participation at school. The Joint Committee on Infant Hearing (JCIH) endorses early detection and intervention for infants with hearing loss through universal newborn hearing screening (UNHS), evaluation, and family-centered intervention1 . Although some countries have taken steps towards introducing UNHS, evidence from the literature suggests that hearing loss is still considered a low-priority health condition in most parts of Latin America2. In Chile, there are no accurate national figures for childhood hearing loss. Based on the national CASEM survey and some publications, hearing loss is the third leading cause of childhood disability3.The Chilean health system has two sectors, public and private. The public sector covers 70% of the popu-

lation through Regional Health Services. This includes coverage for the low and middle classes, the retired, the self-employed professionals and technicians. The private sector covers 17.5% of the population and around 10% is covered by other public agencies, such as Health Services for the Armed Forces. The Universal System of Explicit Entitlements (GES) was recently established, which guarantees access to treatment for 80 health problems within a specific period of time4. Considering the magnitude of the problem, a law was introduced in 2005: “Bilateral Neurosensory Hearing Loss in Premature Newborn” in the GES regime, aimed at a selected at-risk population, specifically babies under 32 weeks or under 1500g at birth5. These babies are guaranteed hearing screening prior to discharge from Neonatology, using Automated Brainstem Auditory Potentials (AABR), whether under public or private care. Cases that fail the AABR exam are guaranteed otorhinolaryngology investigations through a network of providers defined by the Ministry of Health. The possibility of extending coverage to all newborns was raised. A cost verification study conducted by the Department of Health Economics in Chile concluded that moving from a selective strategy focused on at-risk babies to a universal strategy was cost-effective6. Despite this argument, government funding was not obtained to recruit screeners. A second law was introduced in 2013 which guarantees treatment for children under 2 years with bilateral neurosensory hearing loss7. This was extended to cover children up to 4 years old in 2016. This law covers treatment with hearing aids or cochlear implant surgery only in cases diagnosed before 4 years of age and does not mention screening and diagnostic study. Equipment for hearing screening and diagnostic studies became available in various public institutions in 2015 using funds from the Ministry of Social Development.

ear globe: audiology around the world

Neonatal universal hearing screening programs have been initiated in various public health centers, either through local initiatives or with the support of Universities or Foundations. In 2017 a survey of 73 high- and medium-complexity maternity hospitals was conducted by the Ministry of Health. It showed that 60% of the units had implemented a universal hearing screening program with an average coverage of 81% but with a wide variability of coverage (between 21-99%). There are no records or audits of these programs; they are all individual experiences. Sótero del Río Hospital is a public health facility which has been running the Universal Detection Program and Early Intervention of Hearing8. The experiences in this hospital over the first 10 years of the program have been studied. The program integrates all the aspects involved with the problem: The early screening before discharge from maternity or neonatal units; the follow-up and diagnostic evaluation by specialists; the implementation of hearing aids or cochlear implant surgery when required and the integral rehabilitation of the patient. The program began in April 2005 and was financed by a health research project FONIS, (national health research fund) which allowed the purchase of screening equipment and supplies. Initially the professionals in charge of the screening were trained midwives but since 2012 they have been replaced by phonoaudiologists. As of 2008, the program has been financed by the hospital and the purchase of hearing aids with pediatric specifications was incorporated. Two protocols were used according to the presence of risk factors: •

Children without Risk Factors - Otoacoustic Emissions by Distortion Products (DPOA) followed by Automated Auditory Potentials (AABR) for children who failed the DPOA.

•

Children with Risk Factors (High Risk Population) - Automated Brainstem Auditory Potentials (AABR) were used.

Both exams were preferentially performed before hospital discharge with information given to the mother. To identify the population with risk factors, a protocolized survey was applied according to the recommendations suggested by the American

ear globe: audiology around the world

Academy of Pediatrics. All children who did not pass the auditory screening test were referred to the Otorhinolaryngology and Phonoaudiology service for study with impedance and auditory response evoked brainstem exam (BERA). If the BERA test was normal, it implied discharge from the program. If the BERA test was abnormal twice, they were evaluated by an otolaryngologist. During this period, 64,454 children from a total of 67,688 newborns were screened, giving coverage of 95.2% (range: 84.8%-99.7%). 14% of all live newborns (9021) corresponded to children with high risk factors according to the survey. The rate of fail from this group was 17.9% (n=1619/9021) versus the rate of 1.4% in the population without risk factors (n=785/55,433). 2404 newborns (3.7%) of the total population screened were sent to the diagnostic studies, of which 83.2% (range 54.7%-98%) attended. 81 patients with hearing loss were diagnosed, with incidence of 1.26/1,000 live births. 43/81 have bilateral sensorineural hearing loss at a moderate to profound level (0.67/1000) and 38 have conductive hearing loss (0.59/1000). The average age of diagnosis was 5 months (range 2-12m). In 2011, the Children’s Rehabilitation Center for hearing loss was created at the Hospital with a complete team of professionals (social worker, psychologist, occupational therapist, phonoaudiologist, otorhinolaryngologist, pediatric physician, educator and music therapist). The hearing aids and cochlear implants are funded by ministerial health programs. Although different programs have existed for several years with different laws and specifications, an isolated approach is not effective9, 10. We need a supervised national program that includes all the steps of the process (screening, diagnostics, treatment, rehabilitation and follow up). Our current priority is to have a Universal Hearing Screening Law, which we believe it would be the key to achieving a substantial change in our children´s outcomes. References 1.

Joint Committee on Infant Hearing. Year 2000 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics [Internet]. 2000;106(4):798–817. Available from: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2007-2333

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35 6.

Nazar M G, Goycoolea V M, Godoy S JM, Ried G E, Sierra G M. Evaluación auditiva neonatal universal: Revisión de 10.000 pacientes estudiados. Rev Otorrinolaringol y cirugía cabeza y cuello [Internet]. 2009;69(2):93–102. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-48162009000200003&lng=es&nrm=iso&tlng=es

Castillo Laborde C, Loayza S, Aravena M, Freile B, Castillo-Riquelme M. Costo-Efectividad del Screening Y Tratamiento De Hipoacusia Bilateral En Recién Nacidos (Rn) En Chile [Internet]. Vol. 16, Departamento de Economía de la Salud, División de Planificación Sanitaria, Subsecretaría de Salud Pública. 2013. 696-697 p. Available from: http:// linkinghub.elsevier.com/retrieve/pii/S1098301513040114

MINSAL. Guia Clínica AUGE: Tratamiento de Hipoacusia moderada en menores de 2 años. 2013.

Becerril-Montekio V, de Dios Reyes J, Manuel A. Sistema de salud de Chile. Salud Publica Mex. 2011;53(SUPPL. 2).

Pittaluga DE, Palacios FO, Carolina D. Tamizaje Auditivo Universal Introducción.

Neurosensorial H, Prematuro BDEL. HIPOACUSIA NEUROSENSORIAL BILATERAL DEL PREMATURO. 2005;

Ministerio de Salud. Guía práctica clínica: Implante coclear. 2008;23.

10. Ministerio de Salud de Chile. Guía Clínica 2010 Hipoacusia Neurosensorial Bilateral del Prematuro. 2010;39.

García Pedroza F, López Peñaloza Y, Poblano A (Instituto NDCH. Los trastornos auditivos como problema de salud pública en México. An Otorrinolaringol Mex. 2002;48(1):20–9.

Audiology in Nepal The Britain Nepal Otology Service (BRINOS) FACTFILE... Nepal, a landlocked country between India and China, containing eight of the 10 highest peaks in the world. Nepal Population: 30,430,267 million (2013 est.)

Author Robin Youngs MD FRCS, Consultant ENT Surgeon Gloucestershire Hospitals NHS Foundation Trust

BRINOS was founded in 1988 by Neil Weir, Consultant Ear Nose and Throat Surgeon to the Royal Surrey County Hospital, Guildford, UK. It came about as a result of a meeting with the late Dr L. N. Prasad, who at that time was Senior ENT Surgeon

to the Bir Hospital in Kathmandu and Royal Ear Surgeon to the King and Queen of Nepal. Dr Prasad, at one time the only ENT and Eye surgeon in the country, was aware of the urgent need to tackle the prevalence of ear disease in Nepal, as a survey of disability conducted in 1981 (the year of the disabled), found deafness to be the largest single disability. He was urged by His Majesty’s Government to plan future provision of ear care throughout the country. His aim was to reach out to those people living far away from Kathmandu, yet, as the only modern ear surgeon with no funds for equipment, it was difficult for him to achieve his goal. Eventually, twice yearly ear surgery camps were established as a direct response to Dr Prasad’s vision. The programme came about as a result of discussions between Neil Weir and Arnold Boulter, who had represented the Swiss Red Cross in Nepal and had instituted a Commu-

ear globe: audiology around the world

36 nity Eye Care and Health Improvement Programme (CEHP). The vision of community ear care was born which culminated in early 2009 in the forming of a new NGO, named the â&#x20AC;&#x153;BRINOS Ear Health Community Service (BEHCS)â&#x20AC;?. Community Ear Care is a crucial component of ear care in low and middle-income countries (LMIC) and centres

Puran Tharu the first BRINOS Community Ear Worker

Dr Urmila Gurung undertaking middle ear surgery during a BRINOS Ear Camp

The new BRINOS Ear Care Centre in Nepalgunj

around the training and appointment of Community Ear Assistants (CEAs). These individuals have undergone basic training as a Community Medical Auxiliary, followed by intensive training in ear care undertaken by both Nepali and UK ENT doctors. The first CEA appointed was Mr. Puran Tharu, followed by five subsequent CEA appointments, who now cover the districts of Banke, Bardia, Surkhet and Dailekh. In the rural villages, liaison is between the CEAs and 1100 female community health volunteers. In the early years of BRINOS, ear camps were held both in the eastern and western ends of Nepal. For some time in the early 1990s, camps were held in Dharan where the British Military Hospital had been established. In more recent years, BRINOS has concentrated its work in the city of Nepalgunj, in the south western Terai, initially working with the FatehBal Eye Hospital, then with the Nepalgunj Medical College. The Ear Camps have been run in Nepal, twice-yearly since 1989 and three times a year since 2008. There have been a total of 62 ear Camps to date. Staff from the UK include at least two ENT surgeons along with an anaesthetist and sponsored nurses. It is at these camps that staff from Nepal, as full team members, enhance their surgical skills and assist in the delivery of primary ear care. The surgeons undertaking reconstructive ear surgery during BRINOS Ear Camps are a mix of Nepali and overseas (mainly UK) otologists. A strong desire of BRINOS has been to train as many Nepali surgeons as possible in the techniques of ear surgery. To their credit, many of the otologists practicing in Nepal today have taken part in BRINOS Ear Camps, both during their training and as equal colleagues. Patients for each ear camp are pre-selected through the Primary Ear Care programme. Just over 100 major ear operations are performed over a nine-day period, using three operating tables running simultaneously. Most operations are performed under local anaesthetic with the patients awake. The surgical results are closely audited and are comparable with those expected in the UK. Many cases of

ear globe: audiology around the world

deafness in developing countries are preventable, particularly chronic ear infections. With this vital fact in mind, BRINOS has developed, with its partner agencies, a sustainable Primary Ear Care Programme in the west of Nepal. This programme, established in March 2000, has become a model of deafness service provision in remote rural areas. The work of BRINOS has been hugely transformed by the building and opening of the BRINOS Ear Care Centre (BECC) which was formally opened by Neil Weir and Bimal Tandon (Chairman of BEHCS) in November 2016. This purpose-built facility contains a modern operating theatre complex and wards as well as facilities for examination and audiometry. The work of BRINOS has been seen as an example of a highly successful partnership, helping those in desperate need of assistance, whose lives would otherwise be stigmatised by deafness and ear disease. Part of its work is to act as an advocate for those suffering with these conditions, in order to convey the message that there are many ways to gain help. BRINOS received the prestigious BMJ Surgical Team of the Year and overall BMJ UK Medical Team of the Year in 2012 and its members are actively involved in research into the Quality of Life of those affected with ear disease, producing a number of significant journal publications.

For more information about BRINOS visit the website on www.brinos.org.uk

Further reading 1. Diagnostic otoscopy skills of community ear assistants in Western Nepal. R Youngs, N Weir, P Tharu, RB Bohara, D Bahadur. The Journal of Laryngology and Otology 2011;125:27-29 2. Quality of life of Nepali patients with ear disease before and after corrective surgery. E Maile, P Tharu, H Blanchford, R Youngs, R Edmonson. Tropical Medicine and International Health 2015;20:1041-1047

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clinical catch-up

Top Ten Qs: Audiological Counseling with a Question Prompt List (QPL). Although QPLs have wider potential applications, this article will be of particular interest to those like me who practice paediatric Audiology and specifically the diagnosis and habilitation of hearing impaired children. With experience perhaps comes a risk that the Audiologist has heard it all before, they might strive to provide answers before and in anticipation of questions that they think should be asked. This is even more likely when time is pressing and there is a lot of ground to cover in a limited clinical slot, more so when the technology has an off day. On reading this article I was reminded of parents of one child in our caseload who arrived at their first appointment post diagnosis, with a long list of well considered questions, relating to the next year of management and beyond. Indeed so impressive, that I requested that we used these questions as a guide for other parents and for training purposes. Well, I’ve never got round to putting that into practice. But help is at hand as this article describes an evidence-based approach using parent validated questions that has potential to be usefully and practically introduced into our clinics. It’s a useful tool in that it could help overcome the barriers to seeking answers, that despite our efforts at empathy we might not overcome to engage optimally with families. It looks practical in that it can be shared before the appointment – preparing and informing service users in advance obviously has merits and is being encouraged more widely in the NHS. Finally, given the risk of technology over-dominating our interventions and contact time with families in clinic, it’s refreshing to read an article that provides a focus on the valuable counseling elements to our everyday work. If you too find QPLs of interest, the references are worth looking at. John Day

Authors Kris English Kris English is a Professor Emeritus of Audiology at the University of Akron in Ohio, US, and is co-author of Counseling-Infused Audiologic Care (3rd ed). Molly Smeal Molly Smeal is a 4th year extern at Cleveland Clinic and will complete her Doctorate in Audiology in May 2019.

1. Ah, a new acronym! What is a QPL, and how is it used in audiology? We’re excited to share information about this counseling tool, because it’s just beginning to be used in audiology. Briefly, a Question Prompt List (QPL) is a set of questions designed for specific patient populations and their health conditions, usually provided in a handout before or during appointments to let patients know that all questions are welcome. QPLs have been in use for more than 20 years in specialty areas such as cancer, heart disease, osteoarthritis, hypertension, and palliative care.

clinical catch-up

However, the first QPL in audiology was just recently introduced, created to help pediatric audiologists engage with families regarding their child’s hearing loss and associated challenges (English et al., 2017). It’s called the Childhood Hearing Loss Question Prompt List (CHL QPL) a longer acronym than we first let on. 2. A list of questions, got it. How can this QPL advance clinical care? A QPL can serve as an invitation to discuss a range of issues, both information-based and adjustment-based. Families may arrive with a list of questions or concerns but then forget to mention them during the course of the appointment, or not feel comfortable disrupting the flow of the appointment. They may feel embarrassed to ask for repetitions or clarifications. They may have worries or doubts or fears, but not know how to broach them, or even assume the audiologist is not interested. However, when a QPL is incorporated into an appointment, we purposefully extend an invitation and dedicate time to address a family’s questions and concerns, rather than relying on memory or comfort levels. 3. A QPL sounds a lot like the familiar FAQ handout or website – but apparently they are different? Yes, in fact there are two differences, one superficial and one philosophical. The superficial difference is that, unlike a FAQ, a QPL does not include answers. FAQs have closed-set content and are not designed to be conversation starters. And realis-

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39 tically, answers to hearing loss questions can be found online, making audiologists rather irrelevant in this regard. The philosophical difference is the overt commitment to family-centered conversation rather audiologist-centered “information dumping.” To reduce the likelihood of dominating the appointment with our expertise and training, this kind of tool helps us balance the conversation, wherein we listen more, talk less, and share the “appointment space” with families who need all kinds of support. 4.

For these reasons, is this why you describe the CHL QPL as a counseling tool rather than a parent education tool? The CHL QPL is definitely a counseling tool, but with the clarification that audiological counseling includes both education and adjustment support. The two cannot be separated. Neuroscience has shown that people do not learn if they are upset or distressed; both “mindsets” must be heeded simultaneously (Clark & English, 2018). Our QPL is intentionally designed to help conversations flow between parent education and family adjustment concerns as needed (Figure 1). Any question can be considered a “door-opener” to other concerns, sometimes only semi-related to the original question.

5. Can you give an example of how the QPL could be used? Before or during an appointment the CHL QPL is offered to families for review, along with a description of its purpose: that is, to convey our commitment to their questions and to confirm that time will be made to address their top priorities. At some time in the appointment, if the parent hasn’t mentioned the CHL QPL, the audiologist must inquire about it: “You’ve had a look at our Question Prompt List, and now would be a good time to focus on it, if you are interested….” 6.

Wait, why did you say the audiologist must inquire? Isn’t that a little pushy? As worded, it does sound pushy but only to make a very important point: if we wait for parents to broach the CHL QPL, they probably won’t. A representative study (Yeh et al. 2014) reported 60 patients indicating interest and willingness to use their physician’s QPL prior the appointment, but for reasons not explained, the physician did not mention it – and thus neither did any patient. 7. That’s odd. Why would that happen? We have to understand, and be willing to disrupt, what Brown et al. (2014) call the “canonical organization” of an appointment. Parents may already feel intimidated or overwhelmed, and they can also easily get the strong impression that there are rules

(the “canon”) to appointment dynamics, wherein the clinician controls what is discussed and when. Bringing up unsolicited questions can seem “frowned upon” and “against the rules.” Brown et al. (2014) recommend, “To counter this unspoken rule … patients need to be encouraged to ask questions and not fear being ridiculed or embarrassed for not knowing…” (p. 112). And at the risk of being redundant, our goal with the CHL QPL is not only to help parents ask questions they don’t know the answers to, but also feel comfortable bringing up any topic that may be impacting the family’s adjustment to their child’s hearing loss. 8. Would you describe using a QPL as an evidence-based practice? Yes. The evidence reported in a recent systematic review (Sansoni et al., 2014) is compelling. To add more evidence to the literature, the CHL QPL is currently being evaluated at three sites (one in the UK, two in the US). 9. In the meantime, where can we find the CHL QPL? So glad you asked! The Childhood Hearing Loss QPL is available in English and Spanish and can be found at https://www. phonakpro.com/com/en/resources/counseling-tools/family-centered-care/fcc-children/family-centered-care-qpl.html. Translations in other languages are forthcoming, as well as the development of an app version, and QPLs for adult and adolescent patients. 10. Before you sign off, how can readers reach you? They may want to try the CHL QPL and report their experiences to you. That would be wonderful! Please send email to the first author at ke3@uakron.edu. Thank you for the opportunity to introduce the CHL QPL! References 1.

Brown J, Weston W, McWilliam C, Freeman T. & Stewart M. 2014. “The third component: Finding common ground.” In M. Stewart, J. Brown, & T. Freeman (Eds.), Patient-centered medicine: Transforming the clinical method (3rd ed.)(p. 107-141). Abington, UK: Radcliffe Medical Press.

Clark, JG & English K. 2018. Counseling-infused audiologic care (3rd ed.). Inkus Press/ amazon.com

English K, Walker E, Farah K, Munoz K, Scarinci N, DesGeorges J, Pelosi A, Aungst H, Madell J, Moeller MP, Marriage J, Flexer C, & Jones C. 2017. “Implementing family-centered care in early intervention for children with hearing loss: Engaging parents with a Question Prompt List.” Hearing Review, 24(11), 12-18.

Sansoni J, Grootemaat P, Duncan C, Samsa P, & Eagar K. (2014). “A systematic literature review on Question Prompt Lists in health care (Final Report).” Centre for Health Service Development, University of Wollongong.

Yeh J, Cheng J, Chung C, & Smith T. 2014. “Using a question prompt list as a communication aid in advanced cancer care.” Journal of Oncology Practice, 10(3), 3137-3141

clinical catch-up

Primary Care Audiology Services in Wales: An Update CD

Authors and Correspondence

Natalie Phillips Principal Clinical Scientist, ABMU HB, Neath Port Talbot Hospital, Port Talbot SA12 7BX. E: Natalie.Phillips@wales.nhs.uk

Primary care services are the majority of patients’ first contact with the NHS. Recently in Wales, primary care clusters were formed from groups of GP surgeries. The aims of the clusters are to allocate and forecast the appropriate resources for the population and to manage the future demand on primary care. Across the 7 health boards in Wales, there are 64 primary care clusters. The cluster populations have the necessary critical mass to support a service delivery model that includes a primary care audiology service. Due to shortages of GPs, population growth and an ageing demographic, there has been increasing demand on Primary Care services. Similarly, demand on secondary care services has also increased, resulting in longer waiting times for patients to receive specialist care. The Primary Care Audiology Service aims to address this increasing demand by redesigning audiology services within a primary care setting. It will offer an improved access for patients with audiology related symptoms, as patients will be seen by an Advanced Audiology Practitioner (AAP) rather than their GP or practice nurse.This is in-line with the Welsh Government’s plans for the workforce in primary care based on a prudent and value based healthcare system. Prudent Healthcare Values

Matthew Evans Principal Clinical Scientist, BCUHB, Ysbyty Glan Clwyd, Bodelwyddan, LL18 5UJ. E: Matthew.Evans2@wales.nhs.uk

Primary care audiology services aim to deliver the following: • • • • • • • • •

A skilled workforce (a “new breed” of advanced practitioner) Specialist care closer to home Co-produced clinical management decisions following prudent healthcare guidance Advice on hearing conservation Management of tinnitus Management of BPPV (in BCUHB) Aural care/wax removal Provision of first level hearing assessments and onward referral as needed Shorter clinical pathways involving fewer clinicians

There are currently 2 Health Boards in Wales operating a Primary Care Audiology Service: Abertawe Bro Morgannwg University Health Board In Abertawe Bro Morgannwg University Health Board (ABM UHB) there are 11 primary care clusters, each serving a population of approximately 50,000 people. The primary care audiology service in ABM UHB started in August 2016 in three clusters

clinical catch-up

41 and extended to a fourth cluster in July 2017; supporting a total of 18 GP surgeries. To support the service expansion, the ABM primary care team has increased from 3 AAP’s to 5, with each cluster having access to an AAP for 4 clinical sessions (equivalent to 0.5 WTE). Patients access the service via the GP telephone triage system. Those with symptoms identified as suitable (see table 1a) for the AAP are booked into the appropriate clinic. The appointment is 30 minutes and consists of a patient history, ear examination, hearing test and if required wax removal. Following the assessment, results are explained and management options discussed using co-production techniques. This enables the patient to have their hearing fully assessed to make an informed ongoing management choice, including ‘do nothing’ where appropriate. Table 1a: Primary Care Audiology Service Triage Criteria Suitable for AAP

Require GP opinion

• Over 16 years

• Under 16 years

• Hearing loss (any type)

• Ear pain

• Tinnitus (noises in ears/ head)

• Ear Infection/ discharge

• Blocked ears

• Non-ABMU Resident

• Interested in trying hearing aid(s)

to approximately 600 hours of GP time saved (based on a 10 minute GP consultation time). There are improvements across the audiology clinical pathways which include a reduction in secondary care ENT referrals between those GP surgeries offering the primary care audiology service and those which do not currently offer the service (see fig 2a). The main reason for the reduction in ENT referrals in GP surgeries with access to the AAP, is the ability to refer for MRI for cases with unilateral/asymmetric auditory symptoms. The efficacy of the clinical pathways has also improved by offering more services in the primary care setting which often eliminates the need for a hearing assessment to be conducted in a secondary care setting which reduces the length of wait and number of appointments required. For example, the hearing aid pathway (secondary care) has been reduced by up to eight weeks for the patient and saves approximately 1.5 hours of clinical time.

• Dizziness

• Would like ears checked Since the introduction of the service in August 2016, over 4,000 primary care patients have been seen by the ABM UHB primary care audiology service. Following a primary care audiology assessment, there are 5 main management outcomes that can occur (see Fig 1a; NB some patients do require multiple referrals). As shown in Fig 1a, 61% of patients have been discharged without needing further management or investigation. The remaining proportion of patients have been referred onwards with 20% referred to secondary care Audiology, 10% referred to ENT, 4% have required MRI investigations and only 5% have been referred back to the GP. The Primary Care Audiology Service is dealing with 95% of patients who would have likely been seen by GPs or Practice nurses. This equates

Surgeries without Audiology

Surgeries with Audiology *Arrows indicate start date of primary care audiology clinics Fig 2a. Impact on ENT referrals from Primary care since the start* of the Primary Care Audiology clinics.

Fig 1a. Management outcomes from primary care audiology appointments

Patient satisfaction questionnaires indicate patients are accessing the service easily and are very pleased with the outcome of their appointment. Patient experience questionnaires indicated patients were having a marked improvement in their ear and

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42 hearing problems after accessing the service. The outcomes as rated by the patients themselves have been measured using the patient enablement index. Results indicated 95% of patients understood their condition better following their consultation, 92% were more confident about their health and 94% felt they were better able to help themselves. The primary care audiology service in ABM UHB has been well received by patients and fellow health care professionals. Some of the positive feedback received from the service users includes: “Great to have my hearing test at the surgery when I thought I’d wait months for a hospital appointment”

sharing this information with surgeries and working towards improved rates for all. Since the introduction of the service in August 2016, over 9000 primary care patients have been booked to see an AAP. Following assessment, there are 5 main management outcomes that can occur (see Fig 2b; NB some patients do require multiple referrals). Since the start of 2018, 36% of the patients seen to date have been effectively managed by the AAP, with the majority managed at the initial appointment and only 7% referred to the GP.This data implies that the AAP can effectively manage people presenting with hearing, tinnitus and BPPV in primary care and only refer onwards for specialist care where necessary.

“Excellent service; I had my wax removed and a hearing test all in one appointment.” Betsi Cadwaladr University Health Board In Betsi Cadwaladr University Health Board (BCUHB) there are 14 primary care clusters, each serving a population of approximately 50,000 people. The primary care audiology service in BCUHB is divided into 3 regions. Service provision started in August 2016 with 3 area leads for each of the three regions. Currently there are 6 staff (5.5WTE) working in Primary Care Audiology, with services currently provided at 31 GP surgeries, and further expansion due in the coming months. Patients access the service via self referral, reception signposting, or are referred across by other Primary Care clinicians. Table 1b: Primary Care Audiology Service Triage Criteria Suitable for AAP

Require GP opinion

• Over 16 years

• Under 16 years

• Hearing loss (any type)

• Ear pain

• Tinnitus (noises in ears/ head)

• Ear Infection/ discharge

• Dizziness (likely BPPV)

• Routine Wax removal*

• Non-Routine Wax removal (perforated TM etc)

• Dizziness

• Ear Symptoms (aural pressure etc) *Routine wax removal services have been piloted in limited surgeries to contribute to development of a separate cluster funded wax removal pathway

The proportion of patients accessing the AAP directly is a key service performance indicator. As other Primary Care teams and the public become more aware of the Audiology service, the rates of self referral will increase. Data evaluated over the period August 2016 – August 2017 shows a steady decrease in the proportion of patients who saw their GP before seeing the AAP. In August 2017, only 34% of patients saw their GP before seeing the AAP. Furthermore, there are significant differences between different Practices. At some Practices as few as 10% of patients see their GP prior to an AAP appointment. We are

clinical catch-up

Fig 2b. Management outcomes from primary care audiology appointments (June-December 2017)

The number of referrals to Audiology has been slowly increasing over the last 5 years with a marked increase since the Primary Care Audiology service has been in place. This reflects the increased number of presentations for hearing, tinnitus and BPPV related issues. It was not expected that the presence of Audiology in Primary Care would have an impact on referral rates to ENT. It was proposed that Audiologists would be as effective as GPs at identifying those requiring onward referral. Pathways were developed with ENT and GP’s in line with current practice in primary care. There has been a steady referral rate to ENT over the last 5 years, with no significant increase since AAP’s have been in post. Service user experience has continued to be very positive. This is evaluated using a patient satisfaction survey handed out to all service users during set periods and completed anonymously. Two hundred and seventeen people have returned a completed survey to date. The responses show a high level of effectiveness and acceptance of the Audiology service in Primary care, with 98% of people reporting that their needs had been met by the AAP, 97% rating the service as either very good or excellent and 98% of people saying they would recommend the Audiology service to others.

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43 Some of the positive feedback received from the service users includes: “It met my needs in every aspect. It is an essential local service” “It is very convenient to be seen in my GP surgery” “Everything was explained in detail so that I would understand the process test and outcome/advice” The experience of Primary Care staff has also been collected. The data below shows a similar high regard for the Audiology service in Primary Care with 100% of clinicians responding that they feel that the service is of value to their patients at least to some extent and 98% reporting that they would like the service to continue in their practice. Conclusions The services in BCUHB and ABMU HB are run separately and use a different model, with both services still currently in the pilot phase. Both services are working to develop a Primary Care Audiology network across Wales to share best practice and ideas, which will help shape the development of Primary Care Audiology across Wales. In the short to medium term, both services have the potential to develop further by: • Expanding the service to other cluster networks • Offering the service to paediatric patients. Currently, the

service is for adults aged 16 years and over • Introducing non-medical prescribing management of non-complex dizziness, such as BPPV (in AMBU HB) In summary, the Primary Care Audiology Service across Wales has transitioned well over the past 2 years to form an integral part of a modern primary care service within GP practices, receiving positive feedback from both patients and health care professionals. This innovative service has enabled patients with ear, hearing and balance related symptoms to be seen by an advanced practitioner in a familiar environment close to home; this is not only of benefit to the patient, but the wider health care system. References 1. Action on Hearing Loss, Facts and Figures. Accessed on April 2018 2. https://www.actiononhearingloss.org.uk/about-us/our-research-and-evidence/facts-and-figures/ 3. Welsh Government (2015) ‘Our Plan for a Primary Care Service for Wales up to March 2018’, 4. Welsh Government (2015) ‘A Planned Primary Care Workforce for Wales Approach and development actions to be taken in support of the plan for a primary care service in Wales up to 2018’. 2018 5. Welsh Government (2016) ‘National Ears, Nose and Throat Implementation Plan’.

clinical catch-up

Are we aiming to screen hearing or to measure hearing levels in paediatric audiology clinics? CD

Authors and Correspondence

Josephine Marriage, BSc Speech Science, MSc Audiology, PhD, CAC, RHAD Clinical Scientist in Audiology, Director of Chear Ltd www.chears.co.uk Correspondence address: Chear Ltd 30 Fowlmere Road, Shepreth, Royston, Herts SG8 6QS E: josephine@chears.co.uk Co-authors Huw Thomas Carolina Leal

The HTS exam for clinical scientists in audiology gives the opportunity for examiners to visit different departments and observe and evaluate clinical practice from audiologists at an early stage in their career development. This has historically acted as an informal mechanism for peer review across departments. In the paediatric audiology section of the HTS the candidate is required to assess hearing in a child with a developmental age of between six and 24 months. This age group is chosen as it is assumed that visual reinforcement audiometry (VRA) testing will be the developmentally appropriate test of choice. The distraction test (DT) has been superseded as reported over 20 years ago by Adrian Davis et al(1997) as it is unfit for the purpose of assessing minimum response levels for each ear using air conduction and bone conduction. The DT is therefore not appropriate for clinical assessments in NHS audiology clinics in 2018 and training for DT has largely been removed from the audiology curriculum. The second age group that the HTS candidate is required to assess is between the age of 30 months and 42 months and is assumed to require conditioned play audiometry (CPA) testing, again with separate ear and bone conduction testing. A common observation by external HTS examiners is the tendency for the candidate to try to demonstrate normal hearing of 20 dB or less by making repeated presentations at this level during VRA or CRA testing. This draws into question the rationale of these paediatric audiology assessments. The use of a set level of presentation is appropriate practice in a screening test, for example, in school screening. However by the time a child has been referred to a paediatric audiology service there is

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either concern about their hearing levels or they have a risk factor for hearing loss identified through the surveillance program. Thus all children seen in NHS paediatric audiology clinics have a higher likelihood of hearing loss than children in the general population, on the basis of the previous screening, referral and surveillance systems. The assumption is therefore that children being referred to paediatric audiology services, whether in the community or hospital, will have a hearing loss unless proven otherwise at the time of testing. (This is not necessarily the same as in other countries which donâ&#x20AC;&#x2122;t have an integrated healthcare system, in which families can buy a hearing assessment for their child despite having no concerns about their speech and/or listening skills.) The purpose of testing in these clinics is therefore to evaluate the childâ&#x20AC;&#x2122;s current hearing levels and define their thresholds or minimum response levels (MRL) for each ear. This requires the use of an appropriate and valid protocol for testing. Conclusion With the demise of the HTS scheme and the introduction of centralised STP clinical examinations there is a continuing benefit for clinicians to be able to observe different departments and to share good practice across services. The need for peer review across different paediatric audiology sites has been recommended by the NDCS following review of paediatric audiology services in the UK (Listen Up, 2015). Continuous review of audiology practice and efficiency is necessary to make paediatric audiology services efficient and cost-effective in these days of reduced budgets. Service-leads should be able to observe and review practice in trainees and in established audiologists within the team, and should be reviewed

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45 gives a clear signal to the child that they did not hear the previous signal, or did not respond. If a child feels that they are not being successful in the task they tend to turn to the parent, and the tester is likely to lose the cooperation of the child.

themselves as part of this process. We all have a role to play in incorporating and improving new practice within our service teams and using cases of inaccurate hearing assessment to upskill and evolve. Recommendations for Accurate Testing with for VRA & CRA 1. In clinical practice with young children, audiology professionals may decide on a lowest test level (e.g. 15 or 20 dB HL) which indicates satisfactory hearing levels within the normal hearing range. 2. The marking down of non-responses is crucial in order to fulfil the criteria of two positive responses out of three presentations which defines the minimum response level. The local protocol may specify that these should be two ascending thresholds and/or two responses at the same level or within 5 dB. When two clear responses have been observed with no non-responses at a given level , a minimum response level can be recorded (eg. MRL = 15 dB HL). 3. When no response is observed when the signal is presented at a given level, the protocol requires that the signal intensity must be increased. It is not valid testing to re-present at the same signal intensity. When the child does not respond at 20dB (even once) the signal must be increased in 5 or 10dB steps as specified in the protocol. This relies on every stimulus being physically recorded as either a response (tick) or non-response (cross). Increasing the signal level should occur as soon as a non-response is observed. 4. The protocol specifies that to confirm hearing, two responses must be observed at the same level, one of which may be while the signal is descending (usually in steps of 10 dB) and at least one of which is made when the signal level is ascending (usually in steps of 5 dB). If there are non-responses at that same level, the criterion of 2 positive responses out of 3 presentations is applied. 5. A physical record of a tick or cross for each stimulus presentation should be made and this should be filed in the patient notes as a full record of the assessment procedure for that appointment.

7. It is very important to have variable gaps between signals, varying between 2 and 5 seconds. These gaps need to be up to 5 seconds with no presentation to be equivalent to: signal presented (inaudible) 2 seconds, signal turned up 5 dB presented (inaudible) 2 seconds, signal turned up 5 dB signal presented (audible) child hears and responds (1 second). References Davis A, Bamford J, Wilson I, Ramkalawan T, Forshaw M, Wright S (1997) A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment. Health Technol Assess 1:1–177. www.ndcs.org.uk/ListenUp Item 3 on recommendations for Paediatric Audiology departments

www.thebsa.org.uk Our website allows for online registration for new members and renewal of membership for current members. You can Facebook and Tweet us – or reach us in more traditional ways.

We are there for you – on your ipad, notebook or computer, in a format that is quick and easy to access.

Some of the key elements of the website are: • The BSA Chair’s message • Online access to electronic versions of BSA publications • Easy and free access to BSA Policies and Procedures • Easy access to our very popular recorded Lunch & Learn and Lightning Updates • Direct access and updates on the work of the BSA Special Interest Groups • Information about conferences and events • Information about global outreach projects • Job adverts and information and links to organisations.

6. In conditioned play audiometry (CPA) the tester must alter the level of signal presentation without the child having any visual cues e.g. looking down at the warble tone generator in order to change the presentation level. Giving cues

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NOBODY SHOULD FACE

TINNITUS ALONE • 61% of people living with tinnitus feel isolated by their condition. • 95% of Tinnitus Support Group members said it reduced their feelings of isolation. • In 2018 we reached the major milestone of 100 Tinnitus Support Groups.

You can help us tackle loneliness and isolation Refer - tell your patients about their local support group. Advise - get involved with your local group, or talk to us about setting one up in your location. Donate - support our appeal at www.tinnitus.org.uk/tackling-isolation For more information about setting up a Tinnitus Support Group, or for details of your local group call 0114 250 9933 or visit www.tinnitus.org.uk/find-a-support-group Registered charity no: 1011145. Company limited by guarantee no: 2709302. Registered in England.

research round-up

47 In this edition we are showcasing the research of current STP students covering current hot topics such as cochlear implantation in pre-lingual adults and access to hearing loss help for individuals with dementia. We end the research round-up with a summary of the experiences of a two-part student conference hosted in both Leeds and Ghent.

Nystagmus duration after caloric irrigations CD

Author and Correspondence

Charlotte Skipper Audiology department, Clinic 10, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ The interstimulus interval in caloric testing is defined as the time between the offset of the first irrigation and the onset of the next irrigation (Beattie & Thompson, 1996). The British Society of Audiology (BSA) guidelines currently do not define an interstimulus interval as such, but recommended a minimum of seven minutes between the two onsets of consecutive irrigations (BSA, 2010). However, there is little evidence to support the use of seven minutes, and current guidance is based on a compromise due to differences in the literature and in interpretation of the previous guidelines (BSA, 2010). Studies suggest and employ a range of interstimulus intervals with different reasoning behind each recommendation, from three minutes (Beattie & Koester, 1992; Beattie & Thompson, 1996; Benitez et al., 1978 cited Beattie & Koester, 1992) to fifteen (Capps et al., 1973; Coats, 1986). In clinical practice, an interstimulus interval that is too short or too long may have implications on the comfort of the patient or the time taken in clinic to complete caloric testing. A short interval also has the potential to contaminate results of the next test if

nystagmus is still present. Due to the lack of evidence for interstimulus intervals that current guidelines base their recommendations on, the variation in methods and recommendations in previous studies, and differences in procedures used in these studies compared to modern techniques, further investigation is warranted. This study aimed to measure nystagmus duration after warm and cool water irrigations. Durations were also compared between warm and cool irrigations, and in relation to maximum slow phase velocity (SPV) to investigate if the maximum SPV measurement could predict duration of response. 52 patients attending the vestibular clinic at Addenbrooke’s Hospital, Cambridge underwent up to four caloric irrigations during routine vestibular assessment appointments. This provided data for 99

ears and 147 irrigations in total. Ordinarily, the videonystagmography (VNG) goggles record nystagmus (measured in degrees per second (°/s)) until after the period of maximal activity, usually around 2 minutes, at which point the recording is stopped and the cover lifted from the goggles. The nystagmus response is diminishing but has often not ended at this point. However, in this study, the cover on the goggles remained closed, and the recording continued until the clinician deemed any nystagmus to have stopped or reach a minimal level relative to the subject’s baseline (as measured prior to the irrigations with the subject in the caloric test condition (CTC)). The minimal level of nystagmus was defined as being within 2°/s of the subject’s baseline. The nystagmus duration and maximum SPV were then measured. The mean duration for all irrigations analysed together was 183.89 seconds

Figure 1: Histogram to show durations (in seconds) of nystagmus responses for all irrigations

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48 (standard deviation = 41.27; standard error = 3.40). The population mean can be estimated to lie within ± 6.67 seconds of the sample mean with 95% confidence. The minimum duration was 79.8 seconds and the maximum duration 300.2 seconds. Nystagmus became minimal after 264.77s in 97.5% of our sample. Figure 1 shows a histogram for the duration of nystagmus response in all irrigations. There was no significant difference between warm and cool irrigation durations, and Pearson’s correlation and linear regression analysis showed a weak correlation between duration and maximum SPV (r = .25). This study suggests that for an average patient undergoing caloric testing, their nystagmus will reach a minimal level at around three minutes after the start of the irrigation. In our sample, nystagmus became minimal in under 4.5 minutes in almost all patients, which is substantially less than the recommended seven minutes between irrigations. If 99.7% of our sample lie within three standard deviations of the mean, then very nearly all nystagmus would end at just over five minutes. The results from this study are representative of this, with the longest duration of nystagmus at 300.2 seconds. There was no significant difference between warm and cool irrigations, therefore these values apply to all irri-

gations in this study and interstimulus intervals do not need to be adjusted for irrigation temperature or maximum SPV. The limitations of the study included challenges in analysing the VNG traces on the software due to the low levels of nystagmus being measured, particularly when a CTC nystgamus was present in the opposite direction. Some of the traces were ‘noisy,’ for example due to blinking, which made analysis difficult. A larger sample size would also make the findings more robust, particularly as some of the units (ears) were not independent of each other. The results from this study give preliminary evidence for the support of a shorter interstimulus interval. This agrees with other studies who have recommended an interstimulus interval less than seven minutes (Beattie & Koester, 1992; Beattie & Thompson, 1996; Lightfoot, 2004), although it is thought that this study is one of the first in the literature to use VNG and water irrigation techniques, rather than the now less-commonly used electronystagmography and air irrigation techniques. The results from this study suggest that it may be possible to use a duration of five minutes for all patients between irrigation onsets. Further studies are required to build on this research and implement caloric guidelines, potentially leading to improved use

of time for both patients and clinicians. References Beattie, R.C. & Koester, C.K., 1992. Effects of interstimulus interval on slow phase velocity to ipsilateral warm air caloric stimulation in normal subjects. Journal of the American Academy of Audiology, 3, 297-302. Beattie, R.C. & Thompson, L.C., 1996. Effects of interstimulus interval and test-retest reliability on slow phase velocity to cool air calorics using normal subjects. Australian Journal of Audiology, 18, 13-22. Benitez, J.T., Bouchard, K.R. & Choe, Y.K., 1978. Air calorics: a technique and results. Annals of Otology, Rhinology and Laryngology, 87 (2), 216-23. British Society of Audiology (BSA), 2010. Recommended procedure: The caloric test. Available from http://www.thebsa. org.uk/resources/recommended-procedure-caloric-test/ Capps, M.J., Preciado, M.C., Paparella, M.M. & Hoppe, W.E., 1973. Evaluation of the air caloric test as a routine examination procedure. The Laryngoscope, 83 (7), 1013-21. Coats, A.C., 1986. ENG examination technique. Ear and Hearing, 7 (3), 143150. Lightfoot, G.R., 2004. The origin of order effects in the results of the bi-thermal caloric test. International Journal of Audiology, 43, 276-82.

The Identification of Benign Paroxysmal Positional Vertigo by Telephone Consultation CD

Author and Correspondence Bridget Akande STP Year 3 Trainee (Audiology) MSc Clinical Science (Neurosensory Sciences) Manchester University. Project supervisors: Dr Karolina Kluk de Kort, Mrs Susannah Goggins

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Background BPPV is the most common vestibular disorder experienced by patients in the world. It has a high recurrence rate approaching 50% depending on the age of the patient (Fife et al., 2008). Clinically, the Dix-Hallpike test is used as the gold standard to diagnose posterior canal BPPV, which involves bringing the patient into a clinical setting for a face-to-face appointment. The National Health Service (NHS) is currently under strain to optimise service provision for patients. One way this can potentially take place is by reducing appointment times by using telephone consultations instead. A literature review was completed, which found no studies conducted

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49 to assess the effectiveness of telephone consultations in diagnosing the presence of BPPV or other forms of dizziness. Thus, the present study aimed to investigate whether residual BPPV symptoms following treatment could be correctly identified by a telephone consultation. Method Design: Patients attended a BPPV screening appointment in the Audiology departments of Betsi Cadwaladr University Health Board. Those with a positive unilateral Dix-Hallpike test result were invited to take part in the study.Treatment was completed with the Epley manoeuvre, participants were asked to complete the Dizziness Handicap Inventory (DHI) and a follow-up appointment was agreed a minimum of one week later. Telephone consultations were administered a day before the patient’s follow-up appointment.The DHI was completed again, along with self-report of residual dizziness symptoms to identify whether BPPV was still present. Responses from the telephone consultation were compared to the results of the face-to-face follow-up appointments in which the Dix-Hallpike test was completed to assess the presence of BPPV clinically. Sample: Power analysis suggested a sample size of 44. During the study period, 18 patients were recruited, with 14 included in the final analysis as 4 did not complete both appointments.

The demographics of the sample were 10 females and 4 males with a mean age of 67±11 years. Results Table 1 shows the comparison of the two sets of results for this sample. Compared to the gold standard Dix-Hallpike test in the face-to-face appointment, the telephone consultation gave: • a low sensitivity of 33% (95% confidence interval (CI) 6.1-72.2) • high specificity of 82% (95% CI 52.3-94.8) Figure 1 shows mean DHI scores for those with (N=3) and without (N=11) BPPV detected on follow-up. DHI follow-up scores were lower in the group with successfully treated BPPV, however the group sizes were small and the pre-treatment DHI score was also lower in this group. Interestingly, DHI scores dropped even in patients with residual BPPV. More data is needed to investigate the relationship between treatment outcome and DHI scores. Conclusions The high specificity of the telephone consultation (82%) suggests that those who do not have residual BPPV are likely to be correctly identified by a telephone consultation. The low sensitivity (33%) suggests that telephone consultations are not sufficiently sensitive to identify those do who have residual BPPV following treatment. However a further avenue of study may be whether asymptomatic BPPV warrants treatment. Interpretation should be taken with caution, as the study was underpowered, but the results are supportive of further study. Further recommendations include: • To continue collecting data to the suggested sample size and reanalyse • To investigate the relationship between self-report of residual symptoms and DHI scores • To consider use of telephone consultation as a screen for BPPV follow-up appointments, i.e. not bringing back patients who report no residual dizziness

Figure 1: Mean DHI scores pre-treatment and on telephone consultation for patients with negative result (upper) and positive result (lower) on Dix-Hallpike at their follow up appointment.

References Fife T.D., et al. 2008. Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review) - Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70, 2067-2074.

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Opinions on the barriers and facilitators for patients with dementia in care homes accessing help for hearing loss; exploration of the permeability and organisation of services CD

Author and Correspondence

Pam Kaur STP Year 3 Trainee (Audiology) MSc Clinical Science (Neurosensory Sciences), Royal United Hospital, Bath Background The world’s population is living longer and the ageing process may be accompanied by various health related illnesses and disabilities (Kirkwood, 2017; Larry, 2008;Turjamaa et al, 2014); dementia and hearing loss being just two of these. An untreated hearing loss has been shown to impact a person’s cognitive ability and intellectual function (Arlinger et al, 2009; Lin et al, 2013). Furthermore, it may lead to problems with social isolation, depression and reduced quality of life (Fratiglioni et al, 2000; Panza et al, 2015; Qi & Jianguo, 2010; Tae Su & Jong Woo, 2013). Evidence shows the use of hearing aids can protect against further cognitive decline in patients who have dementia (Lin et al, 2013, Amieva et al, 2015, Dawes et al, 2015; Desjardins, 2016; Wahl & Heyl, 2003). This research explored the barriers and facilitators for patients with dementia in care homes when accessing help for hearing loss. For people with dementia gaining access for audiology services may not be a straightforward process. They may not

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identify a hearing problem themselves or understand how to obtain help. In England, approximately 283,000 people with dementia live in care homes (Alzheimer’s Society, 2015). Evidence shows using health services requires considerable effort; people need to employ a range of resources and for this reason those living in a nursing or residential home may be disadvantaged in their access to these services (Robbins et al, 2013; Gordon et al, 2014; Hopper et al, 2016). Often the responsibility of gaining access is placed on relatives or care staff. This study differs from previous work as it aims to obtain a better understanding of the current access to audiology services specifically for dementia patients in care homes in Bath (UK). The ease of access and utilising services is sometimes referred to as the ‘permeability’ of a system or service. As well as permeability, this study considers the organisation of the service; whether the arrangement of the service has any impact on the ease of access. A highly permeable service requires less effort from the user and is most comfortable for people to use (Dixon-Woods et al, 2006). Methods Viewpoints were sought from people involved in providing the service: audiologists and those accessing it on behalf of the patient, relatives of patients and care home staff. Grounded theory approach was used to study the participants’ thoughts on the current system, including the barriers and facilitators they may have encountered. This study focused on the audiology service in Bath, UK and would hopefully serve as a pilot study for research on a larger scale.

One-to-one interviews were conducted; data collection and analysis were not discrete steps but happened alongside each other. Constant comparisons were made between the emerging data and like findings were grouped and re-grouped to form categories then broader themes, eventually the core category emerged. Results A total of eight participants were recruited and the main findings from this study are that access to audiology services requires a substantial amount of effort from its users and this supports previous research around healthcare, and the core category that emerged is ‘who is responsible?’. This was tightly linked to all other themes identified in this study and was present throughout all interviews. The issue surrounding responsibility covers a range of tasks including: identifying a problem in order to seek help, help seeking itself, making system changes, providing staff training and raising awareness of services.There appears to be a great deal of uncertainty surrounding who is accountable for the various tasks involved in accessing help for this particular group of patients. Discussion & Recommendations The study supports previous research that accessing healthcare for dementia patients in care homes is challenging but despite the vast amount of evidence supporting hearing health for these patients, little progress seems to have been made for easing this access. Carrying out the study on a larger scale covering a greater geographical area would be beneficial to see if any differences in services impacts the access to audiology or whether the postcode lot-

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51 tery plays a part. Furthermore, a larger geographical area will allow inclusion of a greater range of ethnic backgrounds to see if perceptions surrounding dementia and hearing health vary amongst populations or are influenced by cultural norms. Including GPs and healthcare managers may help shed some light on capacity and funding issues that may exist. References 1. Alzheimer’s Society (2015), Dementia 2015: Aiming higher to transform lives. [www] Available from: https:// www.alzheimers.org.uk/download/ downloads/id/2700/dementia_2015_ aiming_higher_to_transform_lives. pdf [Accessed 05/02/18] 2. Amieva, H., et al (2015), ‘Self-Reported Hearing Loss, Hearing Aids, and Cognitive Decline in Elderly Adults: A 25-Year Study’, Journal of the American Geriatrics Society, no. 10, p. 2099. 3. Arlinger, S., et al (2009), ‘The emergence of cognitive hearing science’, Scandinavian Journal of Psychology, vol.50, pp. 371–384. 4. Dawes, P. et al (2015), ‘Hearing loss and cognition: the role of hearing aids, social isolation and depression’, PLOS ONE, vol. 10., no. 3, p.1. 5. Desjardins, J.L. (2016), ‘Analysis of Per-

formance on Cognitive Test Measures Before, During, and After 6 Months of Hearing Aid Use: A Single-Subject Experimental Design’, American Journal of Audiology, vol. 25, no. 2, pp. 127-141. 6. Dixon-Woods, M, et al (2006), ‘Conducting a critical interpretative synthesis of the literature on access to healthcare by vulnerable groups’, BMC Medical Research Methodology, vol. 6, Iss. 1, p35. 7. Fratiglioni, L., et al (2000), ‘Influence of social network on occurrence of dementia: a community-based longitudinal study’, Lancet, vol. 355, no. 9212, p. 1315-9. 8. Gordon, A.L., et al (2014), ‘Health status of UK care home residents: a cohort study’, Age and Ageing, no. 1, p.97. 9. Hopper, T., et al (2016), ‘Hearing loss and Cognitive Communication Test Performance of Long-Term Care Residents with Demenetia: Effects of Amplification’, Journal of Speech, Language & Hearing Research, vol. 59, no. 6, pp. 1533-1542. 10. Kirkwood, T.L. (2017), ‘Why and how are we living longer?’, Experimental Physiology, no. 9, p. 1067. 11. Larry, S.T. (2008), ‘Is Living Longer Living Better?’, Journal of Applied Philosophy, no. 3, p. 193.

12. Lin, F.R., et al (2013), ‘Hearing loss and cognitive decline in older adults’, JAMA, The Journal Of the American Medical Association, vol. 173, no. 4, pp 293-299. 13. Panza, F., et al(2015), ‘Age-related hearing impairment -- a risk factor and frailty’, Nature Reviews Neurology, vol. 11, no. 3, pp. 166-175. 14. Qi, H. et al (2010), ‘Age-related hearing loss or presbycusis’, European Archives of Oto-Rhino-Laryngology, vol. 267, no. 8, pp. 1179-1191. 15. Robbins, I., et al (2013), ‘Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study’, BMJ Open, vol.3, no. 7. 16. Tae Su, K. et al (2013), ‘Evaluation of Age-Related Hearing Loss’, Korean Journal of Audiology, vol. 17, no. 2, pp. 50-53. 17. Turjamaa, R., et al (2014), ‘Living longer at home: a qualitative study of older clients’ and practical nurses’ perceptions of home care’, Journal of Clinical Nursing, no. 21-22, p. 3206. 18. Wahl, H.W. et al(2003), ‘Connections between vision, hearing and cognitive function in old age’, Generations, vol. 27, pp. 39-45.

Investigating the Sensory Impairment Service to describe what it means to adults with hearing loss, and the components considered most helpful. CD

Author Patricia Ward STP Year 3 Trainee (Audiology) MSc Clinical Science (Neurosensory Sciences), Aston University Dr Helen Pryce Lead investigator (Project supervisor)

Background Hearing loss is known to affect many people in the UK, with the number expected to continue to increase. Negative impacts of hearing loss are well documented in the research literature, so systems and services that support people and potentially reduce those impacts are an important area for research. The value of services such as local authority Sensory Impairment Services (SIS), is poorly covered in the literature with few

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52 examples of this area being explored. In one example the impact of attendance at a Sensory Support Centre on the lives of people with sensory impairment was investigated (Smith et al., 2016). The centre provides access to assistive equipment and specialist assessment to people with sensory impairment including hearing loss, with the study finding that this and the support provided enabled people to increase their level of independence at home, while improving self-esteem and safety (Smith et al., 2016). Clients valued that their needs were addressed with sensitivity, and the empathetic way the service was delivered (Smith et al., 2016). This study aimed to describe what one local authority’s SIS means to its service users (clients) and staff, and detail service components considered most helpful. The degree of agreement between the SIS Technical Officer (TO) and the participants was explored. The SIS provides information and advice regarding assistive equipment and can provide some equipment on a long-term loan basis making it free-of-charge to the clients. Benefits of assistive equipment and free provision have been demonstrated in the literature (including by Hartley et al., 2010; and Southall et al., 2006), as has the involvement of professionals to match individuals to equipment and provide advice on its use (Hartley et al., 2010; and Walling & Dixon, 2012). Method This study was a qualitative ethnography inspired descriptive study using some of the inductive procedures associated with grounded theory. Ethical approval was granted by Aston University Life and Health Sciences Research Ethics Committee. Purposive, convenience sampling (non-probability) was used to identify participants that were attending the SIS on two days when the research took place. Initial open-ended interviews were conducted with the TO and five participants who had full environmental assessments of need.Two spouses of participants also took part in the interviews, which took place immediately after the assessment.

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Written informed consent was taken on the day. Second interviews were conducted 6 to 8 weeks later. Participant 4 did not participate in the second interview due to illness, and the spouse of Participant 5 chose not to take part. Interviews were audio-recorded and transcribed verbatim, then the data was coded and analysed using thematic analysis. Line-by-line coding was used, allowing the identification of initial categories that were combined to identify refined categories and themes: six themes from the initial interviews and three from the second. Each theme had several categories with helpful aspects of SIS including provision of advice and equipment, personal and professional qualities of the TO, and benefits of assistive equipment.

Using some grounded theory procedures to produce a descriptive account has been an appropriate method. Limitations included the small sample size meaning that data saturation was not possible, so the data did not provide enough depth for theoretical analysis, so a full grounded theory could not be used. The small sample is also not likely to represent the views of the entire hearing-impaired population. This study could be repeated with a larger sample to allow this. Future research could look at multiple local authorities’ services to see if there is agreement with these findings. References 1.

Golding, M. & Mitchell, P (2010) Use

Results The interview with the TO revealed:

of Hearing Aids and Assistive Listening Devices in an Older Australian Population. Journal of the American Academy of

• Most clients find out about SIS from NHS Audiology, or by word-of-mouth. • SIS identifies equipment that meets individual needs through demonstration and trial, and either equip them free-of-charge or signpost to the cheapest method of purchase.

Hartley, D., Rochtchina, E., Newall, P.

Audiology. 21(10), pp. 642-653 2.

Smith, A., Shepherd, A., Jepson, R. & Mackay, S. (2016) The impact of a support centre for people with sensory impairment living in rural Scotland. Primary Health Care Research & Development. 17, pp. 138–148.

• TO thinks the most helpful aspects are allowing people to try equipment before buying, and the clients knowing SIS is always there to provide ongoing support.

Discussion A large amount of agreement was seen between the TO and participants, and a moderate amount between this study and published literature. All participants found being able to try the equipment and experience improvements from it helpful but expressed that they would have found a way to have it even if it wasn’t free because of the positive impact from it. They highlighted the personal and professional qualities of the TO e.g. knowledgeable, experienced, helpful, open, easy to talk to and understanding their problems and how to help them. They valued the personal service they felt they were receiving from somebody qualified to advise them.

Southall, K., Gagné, J.P. & Leroux, T. (2006) Factors that influence the use of assistance technologies by older adults who have a hearing loss. International Journal of Audiology. 45(4), pp. 252-259. Walling, A.D. & Dickson, G.M. (2012) Hearing Loss in Older Adults. American Family Physician. 85(12), pp. 1150-1156.

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53 Table 1: Themes and categories from the initial interviews. Theme

Categories

Indicative quotes from interviews

7. SIS is definitely helpful

• TO’s specific qualities • • Face-to-face discussion • Feeling benefit • BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 • Equipment • Signposting to future equipment • Saving money • • Being supported • Being informed • Happy clients

British Society of Audiology Organisational Membership

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8. Assistive equipment

• Benefitsww • Positive impact on life • Problems

“I think it was a help to me and I think it would be a help to a lot of, a lot of other people.” Feeling “you’ve got somewhere to turn to, and you’ve got support, and you’ve spoken to them and you’ve got confidence” “We wouldn’t have known what was available. We wouldn’t have known how they would have suited us. So it’s, it’s that sort of interface from which we’ve gained quite a lot, yeah.”

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• Describing impact of TV loop system: “Well, well……., instead of erm……., either [daughter] was suffering, or I was suffering. You know, straining to hear. Now I can just relax Benefits of organisational membership include: and hear it. So, great! Mmm.” • Discounted opportunities to network through attending, sponsoring or exhibiting at BSA events, including 9. Free equipment is not essential • More important than being free • Pt2 illustrated this by explaining, “I’m 90, so anything I can twilight lectures, journal clubs and special • conferences, Benefits of free provision do to improve my life, for whatever I’ve got left, I’m going It maximises opportunities Benefits of organisational membership include: forCURRENT MEMBER group workshops SA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 Page interest 1 ert.V1.qxp_Layout 1 30/03/2017 12:14 Page 1 • Being free more important for some people. do it.” opportunities departmental staff to be on •to Discounted to network through attending, Benefits of 1organisational membership include: • Profile recognition onPage the BSA website and within the TESTIMONIALS dvert.V1.qxp_Layout 1 30/03/2017 12:14 Page sponsoring or exhibiting at BSA events, including BSA_A5_Landscape_Membership_Advert.V1.qxp_Layout 1 30/03/2017 12:14 1 BSA Council or Committee, conferences, twilight lectures, journal clubs and special Audacity magazine • Discounted opportunities to network through attending, It maximises opportunities for as they don’t need to be interest group workshops “ sponsoring or exhibiting at BSA events, including departmental staff to be on • Receive a 30% reduction on advertising within the• Profile recognition on personal the BSA website and withinto thedo this. members conferences, twilight lectures, journal clubs and special BSA Council or Committee, Audacity magazine Audacity magazine It maximises opportunities for as they don’t need to be interest group workshops • Receive a 30% reduction on advertising within the Professor Michael Akeroyd, departmental staff to bewith on benefits including: personal members to do this. • All employees get full membership • Profile recognition on the BSA website and within the ” Audacity magazine

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British Society of Audiology CURRENT MEMBER Organisational Membership TESTIMONIALS

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British Society of Audiology Audiology “ yof of Audiology British Society of Audiology Organisational Membership Online access to the International Journal of Audiology alMembership Membership Organisational Membership British Society of Audiology Access to the members’ only area of” the BSA website BSA Council or Committee, as they don’t need to be personal members to do this.

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Director, Medical Research All employees get full Council membershipInstitute with benefits of including: Hearing Online access to the International Journal of Audiology Research

Professor Michael Akeroyd, Audacity magazine • Director, Medical Research • Receive a 30% reduction on advertising within the Council Institute of Hearing Research Audacity magazine Access to the members’ only area of the BSA website Organisational Membership Professor Michael Akeroyd, Benefits of organisational membership include: 25% discount to all BSA events • All employees get full membership with benefits including: 25% discount to all BSA events As a department that covers enefits of organisational membership include: Director, Medical Research As a department that covers Access to Special Interest Groups all areas of Audiology, having • Discounted opportunities to network through attending, Benefits of organisational membership include: CURRENT MEMBER CouncilInterest Institute of Hearing Access tomembership Special Groups Benefits opportunities of organisational membership include: Online access to the International Journal of Audiology Discounted to network through attending, Benefits ofattending, organisational include: of Audiology, having access to the SIGs will help allforareas • Discounted opportunities network through Opportunity to apply up to £5,000 in research grants sponsoring or exhibiting BSAattoevents, including TESTIMONIALS Research sponsoringat or exhibiting BSA events, including sponsoring or exhibiting at BSA events, including Access to the members’ only area BSA website • Discounted opportunities to network conferences, through attending, conferences, twilight journal of clubsthe and special service development and • lectures, Discounted opportunities to network through attending, Opportunity Audacity membership magazine access to the SIGs will help It maximises opportunities for to apply for up to £5,000 in research grants twilightinterest lectures, journal clubs and special group workshops “ departmental staff to be on conferences, lectures, clubs25% and special knowledge management. sponsoringtwilight or exhibiting at journal BSA events, including • Profile recognitionevents on the BSA website and within It maximises sponsoring orthe exhibiting at BSA events, includingopportunities for discount to all BSA BSA Council or Committee, interest group workshops service development and It maximises opportunitiesAudacity for Audacity magazine As a department that covers as they don’t need to bemembership magazine nterest group workshops conferences, twilight lectures, journal clubs and special Available Membership Packages departmental staff to be on conferences, lectures, journal clubs and special From Head of Service at • Receive a 30% reduction on advertising within the twilight personal members to do this. Access to Special Interest Groups departmental staff to bethe on for of Audiology, having all areas ” • Profile recognition on the BSA website and within Audacity magazine knowledge management. It maximises opportunities It maximises opportunities for NHS Tayside Audiology and interest group workshops Professor Michael Akeroyd, Profile recognition on the BSA website and within the interest group workshops BSA Council or Committee, • All employees get full membership with benefits including: • Departmental / Small Company includes all employees Director, Medical Research orinCommittee, Opportunity to apply forBSA updepartmental toCouncil £5,000 research grants Balance Services Kings Cross Audacity magazine access to the SIGs will help staff to be onInstitute departmental staff to be on Council of Hearing Online access to the International Journal of Audiology Audacity magazine and registered peopleFrom within the department as they don’t need to be • Profile recognition on the BSA website and within the Research •they Profile recognition on the BSA website and within the Hospital Head of Service at Access to the members’ only area of the BSA website as don’t need to be service development and BSA Council or Committee, Audacity membership magazine BSA Council or Committee, • Receive a 30% reduction on advertising within the 25% discount to all BSA events Packages start from £1,000 for up to 20 employees. Audacity magazine Receive a 30% reduction on advertising within the As a department that covers personal members to do this. Audacity magazine NHS Tayside Audiology and personal members to do “this. Interest Groups as they don’t need to be all areas of Audiology, having knowledge management. as they don’t need to be Audacity magazine Access to Special • Departmental Opportunity to apply for up to £5,000 in research grants Audacity magazine access to the SIGs will help/ Small Company includes all employees • Receive a 30% reduction on advertising within the Speak with your today andKings join at www.thebsa.org.uk • personal Receive a 30% reduction on advertising withinMichael the Balance Services Cross Professor Akeroyd, members to do this. service development and membership magazine personal members to do this.employer • All employees get full Audacity membership with benefits including: Professor Michael Akeroyd, From Head of Service at knowledge management. and registered within the department Audacity magazine All employees get full membership with benefits including: Audacity magazine Director, Medical Research ”people Speak with your employer today and Hospital Available Membership Packages From Head of Service at Director, Medical Research NHS Tayside Audiology and Professor Michael Akeroyd, Telephone: 0118 9660622 Email: bsa@thebsa.org.uk Website: www.thebsa.org.uk Professor Michael Akeroyd, NHS Tayside Audiology and Council Institute of Hearing Online access to the International Journal of Audiology • Departmental / Small Company includes employees • Online All employees get full membership with benefits including: • Departmental / Small Company includes all all employees Packages start from £1,000 for up to 20 employees. • All employees get full membership with benefits including: Balance Services Kings Cross Institute of Hearing access to the International Journal of Audiology and registeredCouncil Balance join at www.thebsa.org.uk Medical Research peopleDirector, within the department Research Hospital ResearchServices Kings Cross Director, Medical andAccess registered people within the fordepartment Packages start from £1,000 up to 20 of employees. to the members’ only area the BSA website Research Hospital Council Institute of Hearing Online to the International Journal Audiology Council Institute of Hearing Access to access the members’ only area of the BSAof website Online access to the International Journal of Audiology Speak with your employer today and join at www.thebsa.org.uk Packages start from to £1,000 for events up to 20 employees. discount all BSA Research Access to the members’ only area of25% the BSA website 25% discount to all BSA events Asof a the department that covers Research Access tothat thecovers members’ only area BSA website Telephone: 0118 9660622 Email: bsa@thebsa.org.uk Website: www.thebsa.org.uk As a department Access Specialemployer Interest Groups withto your today andthat join www.thebsa.org.uk 25%to discount all BSA eventsSpeak Access Specialto Interest Groups 25% discount to covers all at BSA events all areas of Audiology, having of Audiology, having all areas As a department As a department that covers Telephone: 0118 9660622 Email: Website: www.thebsa.org.uk Opportunity to apply for up to £5,000 in research grants access tobsa@thebsa.org.uk the SIGs will help Access totoSpecial Interest Opportunity apply for up to Groups £5,000 in research grants access to the will help Access to Special Interest Groups ofSIGs Audiology, having all areas all areas of Audiology, having service www.thebsa.org.uk development and membership magazine Telephone: 0118 9660622 Email: Website: service development and Opportunity to apply for up to £5,000Audacity in research grants bsa@thebsa.org.uk access to the SIGs will help Audacity membership magazine Opportunity to apply for up to £5,000 in research grants access to the SIGs will help knowledge management. knowledge management.and service development service development and Audacity membership magazine Audacity membership magazine From Head of Service at knowledge management. knowledge management. 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research round-up

Investigating Outcomes of Cochlear Implants in Congenitally, Pre- and Peri-lingually Deafened Adults CD

Author and Correspondence

additional measures are needed(3). In order to develop appropriate outcome measures of cochlear implantation for these patients it is important to understand the types of outcomes that these patients report.Therefore this study aimed to investigate the outcomes of cochlear implants in congenitally, pre- and peri- lingually deafened adults through qualitative interviews. Method

Participant

Katie Bentley STP Year 3 Trainee (Audiology) MSc Clinical Science (Neurosensory Sciences), Manchester University Dr Sarah Bent Lead investigator (Project supervisor) Glan Clwyd Hospital, Bodelwyddan, Denbighshire, LL18 5UJ

Background Longer duration of deafness has been associated with limited effectiveness of cochlear implantation(1). Hence, congenitally, pre- and peri- lingually deafened adults have previously been considered as unsuitable candidates for CI(1)(3). In those who have been implanted, it has sometimes proven difficult to demonstrate benefit using objective measures of speech perception(2)(3). as is typically done in clinic. Subjective benefits (such as improvements in quality of life (QOL) often exceed speech perception abilities(4) and patients have been known to report satisfaction from their CI even when there is limited measurable clinical benefit(5). At the North Wales Cochlear Implant Programme (NWCIP), we have also found patients to report anecdotal benefit despite poor performance on speech testing. Although QOL instruments measure subjective benefit they may still fail to capture important aspects of quality of life relevant to this population. It has been argued that current outcome measures do not accurately reflect or demonstrate the benefit these patients receive from cochlear implantation and

research round-up

Age at onset of Deafness

Age at Implantation

No. of Years Experience with CI

APDIP score

Birth progressive

4y 5m

18 month

6y 5m

<3 years

5y 4m

Birth

1y 7m

<2 years

5y 5m

Birth

1y 8m

<2 years

3y 5m

Birth progressive

6 years

3y 7m

<5 years

1y 11m

Ten congenitally, pre- and peri- lingually deafened patients who were implanted as adults took part in semi-structured interviews (see table 1 for participant demographics) to explore their experiences with their cochlear implant and the outcomes they report from cochlear implantation. All interviews were video recorded and the recordings transcribed. Transcripts were reviewed and analysed using a thematic analysis approach.

research round-up

55 3 core themes and 10 sub-themes emerged from analysis of the interview transcripts (see figure 1). Results Participants reported a range of outcomes within the themes of perception of sound, social interaction and participation, and impact on psychosocial wellbeing. Figure 1 presents a summary of the key themes and sub-themes in which patients reported outcomes. Quotes

itive experiences were possibly more likely to respond to the invitation to take part in the study and hence the results may be skewed. Additionally, considering the APDIP scores of the participants were fairly low (See Table 1 – this scale is a measure of pre-operative concern), this study sample consisted mainly of patients with more residual hearing and a history of good hearing aid use. It could be argued that including patients with a wider range of hearing history would alter the findings towards less positive outcomes. Despite the limitations of the study, the outcomes discussed by participants and the themes identified in this study are consistent with existing research and validated measures (2)(7). Conclusions Patients who were congenitally, pre- and peri- lingually deafened report a variety of outcomes following cochlear implantation with regards to general improvements in hearing, hearing environmental sounds, television, music and radio, social interaction, work life, confidence, independence, reduced psychological burden and ease of life. This highlights that these are issues of importance to these patients and therefore should be considered when measuring outcomes of cochlear implantation in this population. The findings of this study could be used to aid future development of appropriate outcome measures which accurately demonstrate benefit of cochlear implantation in congenitally, pre- and peri- lingually deafened adults. To increase the reliability and validity of the findings it would be beneficial to conduct this study with a larger sample with a broader range of APDIP scores which is more representative of the congenital, pre- and peri- lingually deafened population. References

Discussion Semi-structured interviews were chosen for this study as they elicit discussion of issues that are most pertinent to participants(6). Hence, the themes and sub-themes identified in this study are likely the issues most important to the patients in this study and should be considered in the development of outcome measures for this population. Although the aim of the project was to explore the types of outcomes these patients report and not to demonstrate the extent of benefit they achieve from cochlear implantation, the experiences and outcomes reported by participants were generally positive. This is an encouraging finding as the participants were encouraged to discuss both positive and negative experiences. It is important to note that the study sample was likely influenced by response bias. That is, those who have had more pos-

1. UK Cochlear Implant Study Group. (2004). Ear & Hearing, 2, pp. 310–335. 2. Jeffs, E et al. (2015). Cochlear Implants International, 16(6), pp. 312-320. 3. Craddock, L. et al. (2016). Cochlear Implants International, 17(sup1), pp. 26-30. 4. Peasgood, A et al. (2003). Cochlear Implants International, 4(4), pp. 171-190. 5. Most, T et al. (2010). American Journal of Otolaryngology– Head and Neck Medicine and Surgery, 31, pp. 418-423. 6. Barbour, R. (2008). Introducing Qualitative Research: A Student Guide to the Craft of Doing Qualitative Research. London: Sage 7. Hinderink,, J et al. (2000). Otolaryngology – Head and Neck Surgery, 123(6), pp. 756-765.

research round-up

IPAB 2018: An international student experience for audiology undergraduates CD

Authors Shavez Abid, Nina Brown, Edilia Cassandra, Faizal Karolia, Ajmal Mohammed, Ibrahim Musa, Griet De Smet, Karolien Van der Kelen, Melina Willems and Ted Killan University of Leeds and Artevelde University College, Ghent

As part of a wider collaboration, the Audiological Science and Education Group at the University of Leeds and the Audiology team at Artevelde University College, Ghent each hosted a week-long conference between the 19 and 23 March 2018 - the Intensive Programme of Audiology across Borders (IPAB 2018). The main aim of these conferences was for audiology undergraduate students to share in an international experience, where they could learn about audiological education and prac-

research round-up

tice across Europe. IPAB 2018 also provided opportunity for extra-curricular learning, including finding out about new technologies, advanced aspects of audiology and latest research developments. University of Leeds’ students were supported to attend the IPAB in Ghent, or act as hosts for the Leeds IPAB. In both cases, they were joined by students attending from Belgium, Denmark, Germany, Spain, Sweden and Turkey. Both conferences followed a similar format that encouraged students to share their perspectives on audiology. This included student-led presentations or discussion groups that explored how aspects of audiology differed across all countries represented. Particular differences noted were related to funding and the models of service delivery (medical vs social). Students were also encouraged to socialise together, with student hosts both in Ghent and Leeds providing a range of fun activities. The night-out in Leeds Student Union was a particular highlight, and it was interesting to note that students from Belgium took hearing protection a lot more seriously than their Leeds counterparts!

Other highlights across both conferences included learning about 3D printing applications in audiology and cutting-edge hearing aid technology. Students in Ghent were able to visit a cochlear implant (CI) manufacturing site whilst students at Leeds visited Yorkshire Auditory Implant Service and listened to CI users’ experiences. Research presentations included an overview of a project exploring the music listening experiences of people with hearing loss and descriptions of soundscapes in care homes for the elderly. Both the IPAB in Ghent and Leeds were described as fantastic experiences by students. In addition to visiting a country and experiencing its sights, sounds (even if too loud) and tastes (Belgian waffles), all students really valued the opportunity to share audiological experiences with peers from other parts of Europe. One student described the experience as “making the sometimes small world of audiology feel much bigger!” Planning has already started for Ghent and Leeds IPAB 2019. Further information will be available shortly at http://globalizationinhealthcareahs.be/ipab/.

Contrast.™

Separating speech from the noise. Reducing listening effort.

rom NE W fos! Now t n Siva t r ac t o n co n N H S to t he

Signia Contrast: Photo Copyright Sivantos

New Signia Contrast now on NHS Contract! Sivantos is delighted to announce that our new NHS product family, Signia Contrast, has been successfully awarded onto the NHS Supply Chain National Framework and is now available. Signia Contrast will be available alongside the existing Siemens Teneo™ models and introduces new innovations and features which will bring lasting benefits to patients enabling resocialisation and reduced listening effort thereby improving general well-being. Signia Contrast: • 32 channels – for highest quality fittings & adjustment options • 32 channel directionality – high resolution directionality for superior speech understanding in noise • NEW e2e™ 3.0 with true binaural processing – transfer of audio data between hearing aids • NEW Narrow Directionality, SpeechMaster, SpeechFocus & Spatial Configurator – for more precise hearing in all directions and improved communication in difficult situations • NEW Wireless CROS/BiCROS – wireless solution for patients with unaidable hearing loss on one side • NEW Tinnitus ocean wave therapy and notch therapy – for a greater range of tinnitus therapy options

• NEW HD Music program – delivering outstanding quality when listening to recorded music • NEW eWindscreen™ binaural – eliminates wind noise for more comfortable listening outdoors • NEW Telecare - innovative telehealth option for NHS Audiology providing audiologist/patient communication, auditory training on patient’s smartphone • NEW Colour options – 11 colour options for greater patient choice • ATEX 1 certified

For more information or to book your Contrast demonstration and to receive a Contrast marketing pack, please contact your Sivantos NHS Audiologist.

1. ATEX is the name commonly given to the European directive for using electronic devices such as hearing aids in potentially explosive atmospheres – Directive 2014/34/EU.

ear to the ground

Ear to the ground

for all things ear-related in the media Hearing Loss through Noise Exposure at a Younger Age may ‘Open the Door’ to Dementia in Later Life. Researchers from Ohio State University have recently discovered that subtle hearing deficits at a young age can lead to changes in cognitive behaviour often noted in older subjects. This incidental finding was discovered during a study involving participants between the age of 18 and 41 years. Each participant had their brain activity monitored using functional MRI while listening to sentences varying in complexity. They were screened for hearing prior to taking part in the study and the decision made to include subjects with a very mild hearing loss, as this was considered to have little impact on the overall study outcome. The incidental finding reported was as a direct result of this inclusion. Subjects with a subtle hearing deficit had increased activity in the Right frontal brain hemisphere as well as the Left, while those with normal hearing had activity only in the Left hemisphere as expected. Activity in the Right frontal brain activity is normally seen in older patients as a result of the ageing process. Concern was raised by researchers about the possibility of earlier cognitive decline, due to increased use of cognitive resources at an earlier age. For further information and full article: https://www.sciencedaily.com/releases/2018/05/180522123246.htm

Social Media Study: A ‘Buzz about Tinnitus’ The recently published study looked at the social media habit of tinnitus sufferers in an attempt to understand how they use this form of communication and how tinnitus information and support can be best provided. Results found that tinnitus sufferers access a wide variety of information for advice and assistance but Youtube and Twitter proved the most popular.The most popular twitter accounts were those publishing evidence based research and attracted 69% of the Twitter followers. YouTube was mainly used for accessing information regarding sound therapy and support. The findings of this study highlight the importance of tinnitus-related conversations in social media and could be viewed as a useful tool for patients to access a support network and to assist clinicians in tinnitus counselling. For further information: The Hearing Journal: May 2018 - Volume 71 - Issue 5 - p 20,21,22,23

Smokers up to 60 per cent more likely to lose their hearing Japanese researchers claim to have found a strong link between smoking and hearing loss. They looked at the health records over 8 years of 50,000 Japanese workers which included an annual hearing test. Results indicated that the workers who smoked were 60% more likely to develop a hearing loss mainly affecting the higher frequencies. These workers were also exposed to occupational noise but the researchers accounted for this in their final analysis. As a new area of study, further work is required to support claims made but initial results do indicate a deleterious effect on hearing health through use of cigarettes. Study published this year in the journal Nicotine and Tobacco Research. For further information and full article: https://www.independent.co.uk/news/health/smoking-cigarettes-health-hearing-loss-study-japan-tokyo-tobacco-research-a8256856.html

ear to the ground

59 Did You Know about World Hearing Day? March 3rd 2018 was ‘World Hearing Day’. The theme this year was ‘Hear the Future…..and prepare for it’.The driver behind this initiative is the World Health Organisation along with other European organisations focused on helping people with hearing impairment. The aim of this day was to raise public awareness of the need for prompt identification and treatment of hearing loss. An estimated 52 million people in Europe live with hearing loss. A 25 year longitudinal study conducted in France followed the lives of 3,777 people aged 65 years and over.The findings indicated that a person with an untreated hearing loss can have reduced social interaction with others, leading to more isolation and increased dependency. On the other hand, if hearing loss is addressed through the use of hearing aids, a person’s independence is similar to someone with normal hearing. A link to the article reference is below. https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glx250/4783130?redirectedFrom=fulltext https://www.hear-it.org/hearing-care-and-hearing-aids-keep-you-independent

Tinnitus in Children We know that 10% of the adult population can be affected by tinnitus but 3% of children can also experience it. There is more information concerning tinnitus in children circulating in the media and the British Tinnitus Association have been working with parents and teachers to produce support material. This short video clip found on the BBC website highlights the story of a 10 year old boy whose tinnitus was found to be noisier than a fire alarm and how he learned to cope with it. http://www.bbc.co.uk/news/av/uk-england-nottinghamshire-42973475/boy-s-tinnitus-noisier-than-a-fire-alarm

Is the London Underground Damaging Commuters Hearing? This was an interesting study conducted by the University College London looking at the noise levels commuters are subject to on various journeys using the London Underground. The researchers found that noise levels were comparable to being at ‘a rock concert’. Using a sound level meter they measured levels up to 105 decibels with peaks of up to 109 decibels.There was variation between underground journeys, with the Victoria line being on average the loudest, but parts of the Northern and Jubilee line were considered so loud that if in a workplace environment, ear protection would be required. The findings suggested that for long term commuters, accumulative noise exposure may increase their risk of hearing damage and tinnitus. http://www.bbc.co.uk/news/uk-england-london-42791299

Practical and sensible advice for tinnitus sufferers. Article recently published by the Guardian aimed at giving practical advice to anyone suffering with tinnitus from management of ear wax through to use of sound therapy and hearing aids. Highlighted the NICE review of tinnitus looking at all aspect of diagnosis and management (due to be published in May 2020). https://www.theguardian.com/lifeandstyle/2018/feb/12/seven-ways-to-deal-with-tinnitus

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CMYK / .eps

Don’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.

ear to the ground

60 With July 2018 being the 70th Anniversary of the National Health Service in the UK, twitter was flooded with comments from people that have benefitted from the NHS over the years, using the handle #NHS70.

Twitterarty

In this edition of Twitterarty, we take a look at just some of the tweets about #audpeeps, Audiology & ENT services and other support that people of all ages have received. There have been so many that we do not have room for a featured profile, but it is good to hear these voices – what are ears if not attached to real people! Roz Gray @RGray46 ´ Jul 5 Special shout out to the Audiology department at the Royal Berkshire Hospital in Reading for looking after my son for the past 13 years!! Thank you!! #NHS70

Sarah Bent @HearingDementia, updates on and attempts to demystify the audiology Twitter community known as #audpeeps

Léah Belle @leahbelleee ´ Jul 5 Without them I would have never heard the hum of a fridge, hear people talking to me from behand or even have two ears...so amazed by the opportunities I’ve had thanks to hearing aids and the confidence I’ve been given due to prosthetics. #NHS70 thank you. Jack Kirby @jdk653 ´ Jul 5 Making an exception to ignoring trending hashtags and emoji because hearing aids and audiology from @MFTnhs enable me to have a better quality of #nhs70 life every single day. And has helped me, family and friends with much else besides. Thank you.

Frances Stickley @FrancesStickley ´ Jul 5 Happy Birthday #NHS70 Thank you for keeping my baby alive. Thank you for the out of hours, non-obligatory boxing day phone calls, midnight ambulances, extra sandwiches and hearing aids. You’re the reason I’m proud of my country Mrs Gardner @mrsgardner ´ Jul 4 Thanks for all the operations, vaccinations, therapy, scans, general glueing us all back together and above all for my hearing aids @NHSEngland. Much love for our wonderfull NHS at 70 #NHS70 #HappyBrithdayNHS David Chriscole @DevillishAccord ´ Jul 5 #NHS70 Many Happy Returns. Without the NHS I would have to spend £££s on my hearing aids and supplies of batteries and tubes. It’s a comfort knowing the NHS is there when we need it the most. THANK YOU! Let’s make sure your’re still here in another 70. Victoria Ni @torinielsen ´ Jul 5 Without the wonderful care of this service as a premature baby, I wouldn’t be here today And being deaf, I wouldn’t have been able to hear as I do without their ongoing care and being supplied with hearing aids for free. Thank you #NHS70

#NHS70Birthday

Liam O’Dell @lifeofathinker ´ Jul 5 Finally, on a personal note: thank you to all those working in deaf services. I have the NHS to thank for my free hearing aids which are such an important part of my life. Thanks to all the audiologists (including my own), Teachers of the Deaf and more! #NHS70Brithday #NHS70 Katherine Birkett @Kitty_B_Good ´ Jul 6 Replying to @paulsinha I thank the NHS for my autism diagnosis, all the care given 21 years ago when I had major surgery to reshape my jaws (1 shortened, 1 lengthened), my hysterectomy, my glue ear surgery in childhood, my hearing aids (losing my hearing) and my diabetes care. #NHS70 @anne_hegerty

ear to the ground

Susan Ing @arohaamour ´ Jul 5 Replying to @NHSMillion A lot. Trying to help my mum with a mystery condition, helping her with other things like thyriod & blood problems. Helping me with my hearing aids and tinnitus & other problems. Ultimately for always being there when we need you #NHS70

Genevra Charsley @FlandersBTour ´ Jul 5 #NHS70 Under 10yrs of age I had 12 operations on my ear being born with a closed ear & half deaf. I had Meningitis, & in my early 30’s I had a paraesophageal hernia. Each time the #NHS were there...Thank You for being there & caring

Lindsey Dryden @Lindsey_Dryden ´ Jul 5 Happy birthday, beautiful #NHS Thank you for looking after me + everyone I know in the UK, being there at our scariest moments, being accessible to all regardless of wealth, and for your complex care w/ the intricacies of my hearing loss + accompanying chronic illness #NHS70 Ant Fitzpatrick @AntFitz90 ´ Jul 5 3 years ago my son was born deaf and without the NHS we would never have afforded the cochlear implant surgery he had. He now hears well enough to develop his speech normally. We are forever in your debt. Thank you #NHS70

ear to the ground

61 Julie Twaddell @Julie_Twaddell ´ Jul 5 Happy #NHS70 ! Without the NHS, my niece would still be deaf. With a double cochlear implant, she hears beautifully. She loves talking, she loves music and dancing, and with support, she loves school. (She also loved meeting Santa when he arrived in a helicopter).

Sam J.S @SamSmithPFC ´ Jul 5 #NHS70 Cheers NHS for helping me out when I cut the top of my right ear off and for taking care of my various family members who’ve come through your doors over the years! Imelda Sankson @Imeldaoneill We are eternally in the debt of the @NHSEngland @ RMCH_Ward78 for giving our son his first access to sound and breaking down barriers @theoshope4sound Happy 70th & thank you #nhs70 #NHS70manchester #NHS70Birthday.

Camilla Ackley @camillaackley ´ Jul 6 HB to the NHS! They saved my mother’s life, kept her alive through a 2wk coma and have continued to supported her through her post-meningitis recovery learning how to hear w cochlear implants and walk again. My brothers & I could never have affored any of this ourselves. #NHS70 kerry @kerryl7x ´ Jul 5 @nottmhospitals thank you to you. 70 years of the nhs and without you my son wouldn’t have had his cochlear implants. Plus the countless other times we’ve used your amazing services. Keep up the good work #amazing #NHS70 #cochlearimplant #Thank You CFR Smiley @cfr_smiley ´ Jul 5 Happy Birthday to #NHS70 ! I’ve been so privileged to be looked after by a series of wonderful audiologists and ENT specialists for 40 years! You gave me a cochlear implant and in doing so gave me the ability to give something back to you as a YAS CFR. Thank you Katie Edwards @KatieEdwards_11 ´ Jul 4 #HappyBirthdayNHS You’ve been absolutely amazing Mend my broken bones, gave me 2 Cochlear Implants, save me from suspecd septicaemia & meningitis & so on!! From paramedics, doctors, nurses, HCAs, volunteers and everyone in between - Thank You #SaveOurNHS #NHS70 grace amanda @gracielk_amanda ´ Jul 5 Thank-you #NHS70 for saving my dad’s hearing by reconstructing his ears 50 years ago and again just this week with a cochlear implant. He fulfilled his dream of being a professional stage actor and couldn’t have done it without you

Helen Burness @HBurness ´ Jul 5 Happy 70th Birthday @HNS. Thank you for the expert care you give our unique daughter. This tweet is for all her wonderful support team including: GP, paediatrician, respiratory/cardiology/urology/opthalmology/audiology/ENT consultants, OT, physio & SLT therapists! #NHS70 Emma Friedmann @emmafriedmann ´ Jul 5 @Leic_hopsital @LPTnhs #NHS70Leicester Thank you for saving my life and my son’s life on numerous occasions and providing excellent services #A&E #nicu #CancerTreatment #Neurology #OccupationalTherapy #LAS #LD #CAHMS #Genetics #audiology #physiotherapy #NHS70 Duncan Geddes @geddesduncan ´ Jul 5 Shout out to the NHS for sorting my ear out as a baby, and sorry for ruining it with horrible noisy music ever since. #NHS70

nae @wrayominay ´ Jul 5 without the nhs i wouldn’t be able to hear!! so much appreciation for all the staff do for us; my cochlear implants and i are eternally grateful. #NHS70

Shoulda Woulda Coulda @bling_pot ´ Jul 5 Saved my life at 16 Meningitis B. Choose me to part of cochlear programme before being on NHS. Restored my hearing as an implantee. Saved my life 3 years ago after being rushed in with severe heart failure Gave me the streghth to fight, my heart % now normal! I YOU #NHS70 Charlotte Cutts @ccuttsgames ´ Jul 5 Without the NHS, I would have hearing loss from all my ear infections going untreated, my sister would have struggled to learn to speak, my mother’s autoimmune illness would have gone untreated and my dad wouldn’t be able to walk #NHS70 Kate E Horstead @KateEHorstead ´ Jul 5 The NHS saved mum’s life from non-Hodgkins lymphoma (twice), stopped my dad’s cancer (more than twice), recovered the hearing in my left ear, & did its best with its mental health resources when we were teetering. We love to moan but what would we do without you #NHS70

Magical Minty @magicalminty_cf ´ Jun 29 Hearing tests are part of life with #cysticfibrosis due to strong doses of IV aminogylcoside #antibiotics. Annual #audiology test #cfaware. another #NHS team contributing to care #nhs70 #weloveour NHS

Susan Wokoma @susan_wokoma ´ Jul 5 Thank u for saving my little sister from cancer twice, for giving my Dad dignity in his last weeks & for taking out a watch battery from my ear when I wanted to wear it a an earring but it wouldn’t stay in place so I stuffed it into my ear canal (I was 5) #LoveTheNHS #NHS70

ear to the ground

62 Melanie Perry @melperry1910 ´ Jun 28 Fantastic service from @HywelDdaHB Audiology team at Prince Philip Hospital. I can hear my voice again, #NHS70. Diolch Neil Barnes @neilbarnes101 ´ Jul 5 35 years of hearing aids, consultations, tests, fittings and batteries. Even the tubing. Plus one removed appendix. and a fiancee! Thanks NHS #NHS70.

With the final words and a challenge for 2018 from the lead for NHS70 in England, Dr Tiernan. Antony Tiernan @AntonyTiernan ´ Jul 26 Do you work in the NHS? Can you spare 1 hour in 2018? Pls sign up to give a school talk and help inspire children and young people to work in the NHS nhs70.nhs.uk/get-involved/t... #NHS70 #teamNHS

Imogen @Imogenrachael ´ Jul 5 Thanks to the NHS and everyone at ENT and paediatric audiology at the Royal Berkshire Hospital, I received (FREE) surgery to reconstruct my perforated ear drums which enabled me to take up the violin aged 9 and ... Well the rest is history! Thank you will never be enough #NHS70 Jess @JessMcNulty ´ Jul 5 Happy 70th Brithday to the NHS, thanks for helping me out through all my clumsiness, supporting my family and friends through their cancer treatments, and giving my uncle his hearing aids #NHS70 Isabelle O’Carroll @IsabelleOC ´ Jul 5 Bono’s throat doctor is also the person who performed my six-hour face and brain-saving ear surgery, removing BAD THINGS and a sheet of muscle from my temple to create a new eardrum #NHS70 Harriet Dunn @HatiRose ´ Jul 5 Where I’ve had to great privilege to meet so many amazing people, and @RoyalLpoolHosps broadgreen hospital orthopaedics, orthotics, physio and audiology - so grateful for everyone whose had an impact on my life, you’re all life changing people who work so hard #NHS70

Antony Tiernan @AntonyTiernan ´ 15h 7 simple ways to support the NHS in its 70th year... 1. Volunteer 2. Take care of yourself 3. Pledge to use services wisely 4. Get involved in research 5. Work for the NHS 6. Give blood or join the Organ Donor Register 7. Support NHS charities nhs70.nhs.uk/support #NHS70

VMD @Salford7er ´ Jun 15 Incredible cleft lip&palate service @RMC Hosp with lots of audiology @SalfordCCG. 1st class care from all involved. #thankyouNHS @theipaper @olyduff #NHS70 #nhs

The final image should surely be of baby Alex, whose video of his new hearing aids and his wonderful smile has had over 800,000 views. Alder Hey Children’s Hospital @AlderHey ´ Jul 23 Baby Alex was born with Bilateral Moderate Sensorineural hearing loss, making him almost deaf This is the amazing moment he is fitted with his new hearing aids and hears his mummy’s voice clearly for the first time #amazing #toocute #audiology #technology #lovealderhey

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ear to the ground

FOR PROFESSIONALS

First for iPhone. First for Android™

In a recent clinical study,

The only cochlear implant sound processor offering direct smartphone connectivity and control Each patient is unique and their hearing solution should be too. With its exclusive wireless technology, the Nucleus 7 Sound Processor gives your patients more options to connect to the people they love and the things they love to do. ®

of users found it more convenient to control the Nucleus 7 Sound Processor with Nucleus Smart App compared with using a remote control.

Our smallest and lightest behind-the-ear hearing solution, the Nucleus 7 Sound Processor, combines comfort and wearability with proven hearing performance. 1

Find out how the Nucleus 7 Sound Processor can benefit your patients at:

www.cochlear.com/nucleus7 Follow us on:

References 1. Cochlear Limited. D1190805. CP1000 Processor Size Comparison. 2017, Mar; Data on file. 2. Cochlear Limited. D1296247. CLTD 5620 Clinical Evaluation of Nucleus 7 Cochlear Implant System. 2017, Sep; Data on file. Please seek advice from your medical practitioner or health professional about treatments for hearing loss. They will be able to advise on a suitable solution for the hearing loss condition. All products should be used only as directed by your medical practitioner or health professional. Not all products are available in all countries. Please contact your local Cochlear representative. For further information, precaution and warnings, please consider to read instructions for use. Cochlear, Hear now. And always, HearYourWay, Nucleus, True Wireless and the elliptical logo are either trademarks or registered trademarks of Cochlear Limited. The Nucleus 7 Sound Processor is compatible with iPhone X, iPhone 8 Plus, iPhone 8, iPhone 7 Plus, iPhone 7, iPhone 6s Plus, iPhone 6s, iPhone 6 Plus, iPhone 6, iPhone SE, iPhone 5s, iPhone 5c, iPhone 5, iPad Pro (12.9-inch), iPad Pro (9.7-inch), iPad Air 2, iPad Air, iPad mini 4, iPad mini 3, iPad mini 2, iPad mini, iPad (4th generation) and iPod touch (6th generation) using iOS 10.0 or later. Apple, the Apple logo, Made for iPad logo, Made for iPhone logo, Made for iPod logo, iPhone, iPad Pro, iPad Air, iPad mini, iPad and iPod touch are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. To use the Nucleus Smart App for Android, your device will need to run Android 5.0 (Lollipop) or later and support Bluetooth 4.0 and later. For a list of verified devices visit http://www.nucleussmartapp.com/android. Android, Google Play and the Google Play logo are trademarks of Google LLC. The Android robot is reproduced or modified from work created and shared by Google and used according to terms described in the Creative Commons 3.0 Attribution License. Information accurate as of May 2018. © Cochlear Limited 2018. D1440186 ISS1 JUN18

CONFERENCE 2018 The virtual audiology conference

Last year's BSA eConference was a huge success.

Global Connections

The BSA are delighted to announce that their 2nd eConference will be held in late 2018. More details will follow soon.

www.thebsa.org.uk

VIRTUAL EVENT @BSAudiology1 The British Society of Audiology