Audacity Issue 7 by Audacity magazine

Audacity ...a British Society of Audiology Publication

issue 7 November 2015 ...................................

17 The ear is connected to the...

Hear the World Foundation: Better Hearing for...

46 Previously unresolved problems in hearing rehabilitation...

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Editorial Key events coming in 2016 • 29th February - It’s a leap year

you ?

• 25th to 27th April - The relaunched BSA annual conference • 5th to 21st August - The Rio Olympic Games • 8th November - US Presidential elections • 25th November - The Audacity Editorial Team step down

New Editor in Chief ?

Yes, that’s correct, a key event of 2016 will be the

If this exciting opportunity interests you either send

handing over of Audacity to a new editorial team in

me an email or contact Laura Turton, BSA Operations

November. The campaign to find that new editorial

Manager: laura@thebsa.org.uk

team starts today! Enjoy the 7th edition of Audacity – just think what you We are proud of the work we have done to transform

could do with it….

BSA News into Audacity but change should happen to keep the publication evolving. If you read Audacity and want to make a contribution, have fresh ideas or think it is missing something then you could be part of the next editorial team. If you work as part of a dynamic clinical or academic department, why not join together to take it on. The current editors are all based at Manchester Royal Infirmary and we found this helpful with communication and organising face to face meetings, it also gave students and trainees an opportunity to be involved directly in the publication which looks good on their CVs. Sharing the work makes editing very manageable and the design team at Pinpoint Scotland are excellent. The current editors and the BSA operations manager would be very willing to help in the transition period. We will be handing over a successful publication with well - established design and print teams in place which means that you can concentrate on ideas and fun!

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

editorial

Contents meet the editorial team...

Editorial

Chairman’s Message

SIG Segment

Martin O’Driscoll

Huw Cooper

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

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

Knowledge Learning Practice Impact

information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG) Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk Rachel Booth E: rachel.booth@cmft.nhs.uk

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Wireless hearing technologies: from babies to boomers CD

Author and Correspondence Dr Imran Mulla, BSc, MRes, PhD Consultant Research Audiologist, The Ear Foundation, Nottingham, UK Audiology Lead for Education, Sensory Support Services, Bolton, UK

Introduction Wireless technologies can provide a much needed option for people with hearing loss to access a wider range of listening environments and devices that many of their hearing peers would have daily access to. Connectivity to everyday devices like phones, tablets, laptops, televisions and hands free systems can significantly improve the overall quality of life a hearing technology user can expect compared to the use of their hearing device on its own. Furthermore, the ability to connect to a range of wireless microphone transmitters provides enhanced access to speech, improving signal to noise ratios (SNR) for all hearing technology users regardless of their age. The article will initially provide a summary of the different types of devices available. Thereafter, the potential benefits that have been noted with the use of wireless devices for different age groups will be summarised. The aim is to give the reader an appreciation of the potential for maximising listening opportunities for their clients. Types of devices Proprietary wireless options are now available for nearly every hearing technology manufacturers’ devices (including cochlear implants, bone conductions aids and hearing aids). These proprietary devices enable connectivity to everyday technologies via wireless protocols and act as a hub between the hearing device and the connected device (e.g. smartphone). Examples of these devices in clinic include GN Resound and Cochlear’s phone clip, Oticon Medical’s ConnectLine streamer and Phonak and Advanced Bionics’s ComPilot streamer. One of the major innovations in wireless hearing devices over the past few years is the range of Remote Microphone (RM) transmitters now available. Traditionally RM transmitters would carry the signal using FM frequencies, however in recent years the first real shift in the transmission protocol has occurred. Higher frequencies (e.g.

2.4GHz) have now been adopted that improve clarity, connectivity and overcome interference. RM transmitters improve the signal to noise ratio (SNR) by reducing the distance between the speaker and the microphone. The microphone transmits the speech signal over a wireless channel directly to the receiver attached/integrated to a hearing instrument. This helps to overcome the challenges of distance, reverberation (room echoes) and noise present in the surrounding environment, making the speech signal louder and clearer for the individual wearing the receiver. Improved SNR is essential in ensuring the listener can access speech. The better the SNR the more improved speech comprehension will be. RM transmitters primarily improve access to live speech, mainly one main speaker, for example; parent speaking to child, teacher speaking to student, spouse speaking to spouse etc. Some RMs can be used in group situations also as a conference mic.

The figure below summarises some of the current RM options:

Remote Microphone Options

Proprietary

Universal

Ear Level Receivers via DAI (Euro 3 pin)

Telecoil neckloop

Streamer neckloop

Integrated Receivers

Figure 1: summary of the current Remote Microphone (RM) options available to hearing technology users.

The range of RM options available and the rapid advancements in this area of hearing technology can make the selection process overwhelming for both clinicians and clients.The list below briefly highlights some device options to consider: • Universal: these are dedicated transmitter + receiver options like Comfort Audio, Phonak Roger and traditional FM devices that can work with most hearing devices and are generally of two types; o Ear level receivers: these are commonly used in school settings where a 3 pin receiver is attached

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16 o

usually via an ‘FM shoe’ connected to the hearing device. Telecoil neckloop: a more commonly chosen option by older users worn around the neck and activated through the telecoil option in the hearing device.

• Proprietary: these are manufacturer specific devices that only work with certain hearing technologies; o Streamer neckloop: RM transmitters connect to the streamer neckloop which sends the signal to the hearing device. The streamer neckloops are multifunctioning connecting to a multiple range of devices, making this a useful option for young people and adults who might want improved listening and connectivity to smartphones, mp3s etc. o Integrated receivers: these hearing devices have receivers fully integrated within them, therefore not requiring any intermediary device. With the reduced size this can be an ideal option for preschool and school-aged children in home settings, especially as the improved SNR will help with language learning for younger children.

Clinical research Pre-school Given that children have a systematic progression in language acquisition, they are more susceptible to environmentally acoustic challenges. In general, research has consistently highlighted that younger children with normal levels of hearing experience greater difficulty discriminating speech in noise than adults (for example see Neuman et al., 2010). Furthermore, despite well-fitted hearing technologies, adults with hearing loss have greater difficulty processing speech compared to normal hearing listeners (see for example Glyde et al. 2012). The combined effects of hearing loss and young age for preschool children with hearing loss would expectedly increase the difficulties in accessing speech for this population. Mulla and McCracken (2014) explored the use of FM systems with pre-school children. The overall study highlighted subjective quantitative benefits identified through usage diaries and objective quantitative benefits identified through word counts

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as analysed by the Language Environment Analysis (LENA) tool. Qualitative analysis emphasised the wide ranging benefits parents and users of the technologies observed over a longitudinal period including improvements in access to speech, listening, communication, wellbeing and ownership of hearing technologies. Devices such as the current Mini Mic for use with GN Resound/Danalogic hearing aids and Cochlear’s cochlear implants and bone conduction aids are ideal transmitters to be used with these children. A recent trial of the GN Mini Mic with pre-school children at home and in nursery with a Manchester Clinic (audiologist Zarina Naeem: zarina.naeem@cmft. nhs.uk), identified positive outcomes with the use of the Mini Mic transmitter for this age group. Currently Claire Sunderland, a specialist Teacher of the Deaf, is exploring the use of the Mini Mic with Cochlear’s N6 cochlear implant as part of her Master’s dissertation at Mary Hare school. Young people and young adults (11-21 years of age) The use of FM/RM microphone transmitters is widely established in primary school settings. However once children get into secondary school the use of RM transmitters presents its very own challenges making it difficult for young people to make good use of their RM devices. The Ear Foundation (2014) conducted research with teenagers on their experiences of FM use. Many of the teenagers highlighted the benefits of an improved SNR, however they expressed frustration around mainstream teachers not being able to manage the technology effectively. Improving SNRs through the use of transmitter technology for this age group is important as research has highlighted the ability to access and combine speech cues does not fully mature until closer to adulthood (Brown et al., 2010). Recent research (Mulla et al., 2015) looking into the use of the Oticon Medical ConnectLine wireless streamers and transmitters with users of bone conduction aids highlighted multiple benefits of wireless technology for this particular age group. As the older children had their own smart phones, the streamers were with them all day as a connection to their phone to take and receive calls and listen to mp3/video files directly. Other uses, important to the young people, included connecting with Playstation and Xbox consoles allowing their hearing devices to become gaming headsets. Overall the teenagers highlighted the

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17 significant impact the streamers and the transmitter connected to the streamer had on their daily activities. A unique benefit of this particular transmitter was that it had two way control of the power allowing for it to be switched on and off by the listener via the streamer. This handed control of the listening to the young person allowing them to decide when they wanted to listen to the tutor or work supervisor and when they wanted to switch them off (e.g. if they were speaking with another student). This overcame one of the main frustrations young people have commented on when using transmitter technology. An important observation when using streaming technology was the personal benefits the teenagers cited on using the device, which resulted in immediate ‘buy in’ from the young

person. Once this ‘buy in’ was established the young people were then able to focus in on the benefits of the transmitter resulting in improved compliance. This emphasises the importance of working closely with the young person to ensure they are getting the best of their technologies rather than focussing on ‘selling’ the best technologies to them which many times can result in non-compliance. Older Adults: The ability to process speech in noise has shown to decline from the age of 50-60 (Cameron et al. 2011). This ‘bell shaped curve’ of speech processing ability with age highlights, just as SNRs need to be improved for younger children, older adults should also benefit from the use of transmitters to improve access to speech. The Ear Foundation has dedicated Sound Advice sessions available for adults to come in and try a range of different wireless devices (both universal and proprietary) and to decide what device they feel meets their needs best. This service includes the option of a trial period where the adults can return and/or trial a different device. Athalye et al. (in prep) followed a group of users who had purchased a Comfort Audio system, seven with a telecoil neck loop and three with ear level receivers, to explore their experiences of using the system. The overall feedback was positive with users explaining the considerable benefit the system provided in situations where their hearing aids alone were not sufficient. These included situations like conversations in a cafe, in meetings and lectures, walking outdoors with a partner and conversations in the car.

Conclusion The above summarised the different devices available for users of hearing technologies and the potential benefits these can provide, regardless of age and hearing technology type. The fitting of wireless devices cannot be expected to be a ‘one size fits all’. A patient centred approach taking into consideration the needs of each individual will help to ascertain the best device options to consider. Just like with any technology some will find the process of getting used to their device longer than others. The important aspect is to ensure each client is adequately informed of the device options out there and is given enough information and support to maximise these opportunities. The question remains whether this much needed service should be provided within departments (whilst generating income) or should more services like the one setup by the Ear Foundation be available in all regions?

References 1. Athalye S, Archbold S and Mulla I (in press). Perspectives of FM/RM usage in Adults: A qualitative study. 2. Brown D, Cameron S, Martin J, Watson C and Dillon H (2010) The North American Listening in Spatialized Noise—Sentences Test (NA LiSN-S): Normative Data and Test-Retest Reliability Studies for Adolescents and Young Adults. Journal of the American Academy of Audiology, 21, 629-641. 3. Glyde H, Cameron S, Dillon H, Hickson L and Seeto M (2012). The Effects of Hearing Impairment and Ageing on Spatial Processing. Ear and Hearing, 34, 15-28. 4. Mulla I and McCracken W (2014). FM for Pre-Schoolers with Hearing Loss. Seminars in Hearing, 35, 206-216. 5. Mulla I, Archbold S, Harbor D and Ng ZY (2015) Oral presentation: Teenagers’ Use of Wireless Technologies with Bone Conduction Hearing Implant/Devices. Osseo 2015 5th International Congress on Bone Conduction Hearing and Related Technologies. Fairmont Chateau, Lake Louise, Alberta, Canada 6. Neuman A, Wroblewski M, Hajicek J and Rubinstein A (2010). Combined Effects of Noise and Reverberation on Speech Recognition Performance of Normal-Hearing Children and Adults. Ear & Hearing, 31, 336–344. 7. The Ear Foundation (2014) FM Technology: Teenagers Views. Available from: http://www.earfoundation.org. uk/research/current-research/fm-technology-teenagers-views (last accessed: 30/09/2015).

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The ear is connected to the CD

Author and Correspondence Andrew Causon Trainee Clinical Scientist Central Manchester University Hospitals NHS Foundation Trust E: Andrew.causon@cmft.nhs.uk

Take home message: Our overall health could have stronger ties to our hearing than we first thought. Understanding the effect of biological factors on hearing could help improve the treatment of hearing disorders.

“Hearing is due to the ear, isn’t it?”. That’s what most patients would ask you, the hearing professional, as you explain that hearing is a construct of auditory system function; which includes the outer ear, the brain and a lot of anatomy in between.You’ve studied it for years and you’ve worked the job for even longer, but have you actually got hearing all figured out? Detailed knowledge of the auditory pathway distinguishes the professionals from service users but there may be other variables at play outside of the auditory system affecting hearing performance outcomes which are still unknown to the professionals. Audiologists have short term factors related to hearing pinned down. A distracted, tired or just uninterested patient could have notably different outcomes from one appointment to the next. But are there any other biological factors which could have an effect on audiometric thresholds or speech reception tests and are these factors operating in the short or long term? This type of reasoning is nothing new for people who study the central nervous system. There is a lot of research and thinking which shows that a pathology located anatomically far away from the brain can still have effects on brain function even though there’s a blood-brain barrier in place. This is not some rare disease which affects 0.1% of the population. This Mouse ear is sickness behaviour

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which almost anyone who gets the flu exhibits1. Influenza is primarily a respiratory tract infection but through mechanisms which are still not completely confirmed, it affects the brain: sufferers feel lethargic, they’re not hungry and they just need care and attention - especially if it’s man-flu! The infection hasn’t gotten more serious or spread to the brain. What has happened is that proteins similar to those found in the site of infection have been replicated in the brain. It’s called de novo synthesis of brain-borne cytokines, and it’s been systematically proven in various mouse and rat experiments2. The phenomenon is thought to have evolutionary benefits in fighting the pathology: if you feel bad you stay home and rest and you don’t eat lots of sugars, which bacteria love. Sickness behaviour is just one example of how well connected various systems in the body are and how working on just ears doesn’t necessarily mean that the auditory system is working independently of the rest of the body. The inner ear: an extension of the brain The cochlea is very similar to the brain. It has neuronal and supporting cells, a very restricted blood supply and blood-labyrinthine barrier3, and contains neuro-immune cells called microglia4; which are mostly found in the brain. These features made researchers at the University of Southampton wonder whether the cochlea would behave like the brain in response to systemic inflammatory triggers (such as the aforementioned example of the flu). The concept is relevant because studies of the neuropathological brain, such as in Alzheimer’s dementia, identified brain responses which greatly differ from the healthy brain. A person who doesn’t have neurodegeneration would undergo brain-borne cytokine synthesis when they have the flu but this would eventually resolve and return to a base level5–7. People with neurodegeneration exhibited hyper-responses in the brain, resulting in increased quantities of cytokines, more severe clinical symptoms and a very slow return to base level. The result is that clinical symptoms were more severe and there was also the possibility of further damage to brain tissue. The inner ear undergoes neurodegenerative change during hearing loss8. Could it be that when the cochlea is not at its healthiest it is more susceptible to systemic triggers? This would be relevant for our Audiology patients with chronic systemic inflammation. Biological factors in hearing preservation The theory can be extended to hearing preservation after cochlear implantation; which was the interest of my PhD research. Residual hearing is the limited acoustic hearing a patient is capable of before cochlear implantation. Its preservation is beneficial to patients as it grants access to temporal cues and low frequency spectral information which isn’t coded as well by the one or two apical electrodes of the cochlear implant9. The preservation of low frequency residual hearing is becoming

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19 ment is needed.There could be rationale to deliver these drugs increasingly important as greater numbers of people are bepost-operatively. Monitoring inflammatory state could indicate ing implanted with significant degrees of residual hearing, using the best time for it. Electro-Acoustic Stimulation (EAS) or hybrid cochlear implants. EAS implants are greatly dependent on acoustic hearing for For audiologists who do not work with cochlear implant pathe perception of low frequency sounds because the electrode tients, this article is a call to remember that the auditory sysarray is shorter than conventional cochlear implants and mostly tem is but one part of a combination of systems which work encodes mid and high frequency sounds. Also, surgeons are intogether to form the healthy human body. As we keep working creasingly using hearing preservation as a marker of how atrautowards a more stratified (personalised) approach to patient matic the surgery was. The growing popularity of EAS and the care, individual biological factors such benefits of atraumaticity therefore as inflammatory state may become push us to find new ways to reduce Remember that the more important players in achieving the variability in hearing preservaauditory system is but one the best outcomes possible. tion amongst patients.

part of a combination of

Acknowledgements: I followed patients from the Unisystems which work This work was carried out with Dr versity of Southampton Auditory Implant Service and from the Mantogether to form the healthy Carl Verschuur, Director of the University of Southampton Auditory Implant chester Auditory Implant Centre human body. Service and Dr Tracey Newman, Assobefore, during and after cochlear ciate Professor in Clinicial Neurosciimplantation. Since I was investigatence, both at the University of Southampton. ing whether systemic inflammatory state could have an impact on hearing outcomes, I drew blood samples at each audiolReferences ogy appointment in order to establish a marker of systemic 1. Hart B. Biological basis of the behavior of sick animals. inflammatory state from their serum. We were then able to Neurosci Biobehav Rev. 1988;12(2):123-137. compare changes in pro-inflammatory serum markers with 2. Van Dam A, Brouns M, Louisse S, Berkenbosch F. Appearroutine hearing outcomes measured in the clinic. The results ance of interleukin-1 in macrophages and in ramified miof the analysis were extremely encouraging; with changes in croglia in the brain of endotoxin-treated rats: A pathway one of four pro-inflammatory markers significantly correlating for the induction of non-specific symptoms of sickness?”. with the hearing preservation scores and BKB in noise scores. Brain Res. 1992;588(2):291-296. It’s good that not all the serum markers were particularly high 3. Raphael Y, Altschuler R. Structure and innervation of and that they didn’t all correlate with hearing outcomes bethe cochlea. Brain Res Bull. 2003;60(5-6):397-422. cause this showed that the patients were not particularly sick doi:10.1016/S0361-9230(03)00047-9. during the day of sampling. The correlation is therefore more 4. Okano T, Nakagawa T, Kita T, et al. Bone marrow-derived likely to suggest that the serum is mirroring inflammation in the cells expressing Iba1 are constitutively present as resident cochlea. Additionally, the pro-inflammatory marker which gave tissue macrophages in the mouse cochlea. J Neurosci Res. a significant correlation is known as IFN-gamma. This cytokine 2008;86(8):1758-1767. doi:10.1002/jnr.21625. is known to attract and activate microglia, the same neuro-in5. Perry V, Newman T a, Cunningham C. The impact of flammatory cells which are believed to be implicated in hysystemic infection on the progression of neurodegenper-inflammatory responses in neurodegenerative disease. The erative disease. Nat Rev Neurosci. 2003;4(2):103-112. results support the reasoning that cochlear inflammation needs doi:10.1038/nrn1032. to be kept low for better hearing outcomes. 6. Holmes C, Cunningham C, Zotova E, et al. Systemic inflammation and disease progression in Alzheimer Cochlear inflammatory state has long been a suspected cause disease. Neurology. 2009;73(10):768-774. doi:10.1212/ of problems in hearing preservation and this is why surgeons WNL.0b013e3181b6bb95. often use corticosteroids such as dexamethasone during im7. Perry V, Holmes C. Microglial priming in neurodegenplantation. It was previously suspected that the inflammation erative disease. Nat Rev Neurol. 2014;10(4):217-224. is solely caused by the surgical procedure involved in inserting doi:10.1038/nrneurol.2014.38. the array but this research implies that the inflammatory state 8. Morest DK, Kim J, Bohne B a. Neuronal and transneuof the rest of the body could also play a role in determining ronal degeneration of auditory axons in the brainstem cochlear inflammatory state. after cochlear lesions in the chinchilla: cochleotopic and non-cochleotopic patterns. Hear Res. 1997;103(1-2):151What does this all mean in the real world? It’s time to think 168. doi:10.1016/S0378-5955(96)00172-4. about the way we’re timing cochlear implant surgeries and the 9. Büchner A, Schüssler M, Battmer R-D, Stöver T, Lesincandidacy of some patients with systemic inflammation. Moniski-Schiedat A, Lenarz T. Impact of low-frequency hearing. toring a patient’s inflammatory state may become more comAudiol Neurotol. 2009;14(Suppl 1):8-13. mon and could be used to decide if additional steroid treat-

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Hearing Maps – Documenting a child’s speech comprehension in noise CD

Author and Correspondence Carmel Capewell PhD BPS Chartered Psychologist School of Education, The University of Northampton. E: carmel.capewell@northampton.ac.uk

Take home message: Young children have valuable information to contribute about how their hearing loss impacts their daily lives and the actions that they, and adults, can take to mitigate it. Hearing Maps potentially provide empirical evidence of function in daily life to assist professionals to better support children with hearing loss.

Introduction Otitis Media (OM) or Glue Ear is very common in children under five years old, but most cases resolve within three months and require no treatment. It is estimated that 80% of children under the age of 7 years will have at least one episode of OM but its behavioural and educational implications are largely unknown by educationalists (Higson and Haggard, 2005).There is very little known about how it impacts a specific child on a day-to-day basis. It is more common in children with specific developmental syndromes, such as Down’s Syndrome, and those with cleft-palate. Despite policies in Education and Health (Department for Education and Department of Health, 2014) suggesting that children and parents take an active role in providing information about factors which could impact a child’s education or health care, there are currently few situations in which they are provided with such opportunities. Both professionals and parents recognise this is the result of time pressures and lack of resources to implement such strategies. Often the role of young children in particular is restricted to providing information in response to specific questions or in situations, such as pressing a button as part of a hearing test. Current NICE Guidelines for the treatment of OM suggest a period of three months, variously described as ‘watchful waiting’ or ‘active observation’ to monitor a child’s hearing loss associat-

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ed with OM prior to taking action. Most parents and children are doing the ‘waiting’ with no clear understanding what role they play in the ‘observation’. This can lead to feelings of frustration and impotence in the parents, particularly if they have a child who has recurring ear infections or clearly is not hearing on a regular or intermittent, basis. The potential message for the child is that his/her hearing loss is not important. Children with OM are usually aware of the differences when they can and can not understand what is said to them. The usual pathway for parents and children, is for referral to an ENT Consultant by the GP. An audiogram is used to identify the hearing loss associated with OM and to monitor if this is at or above 25dB loss in one or both ears. The ear drums are examined to identify if there is evidence of the presence of liquid in the middle ear cavity. In some cases, the parents and/ or child may be asked about whether they feel the hearing loss affects daily life. However, this last measure is not collected in a structured or systematic way in which comparisons could be made within a specific child’s environment or to collate comparison data for other children impacted by OM. Anecdotally, ENT surgeons comment that two children could have the same audiogram results and tympanogram profile, but whereas one child appears to be performing well in school and developing positive social interactions, the other does not.This suggests that it may be worthwhile exploring the child’s environment and encouraging parent and child to identify what helps and hinders their understanding of speech in their daily life. Development of Hearing Maps The aim of the research described here is to develop a tool for the active participation of children (3-7 years of age) and the adults around them to document each child’s understanding of speech in their daily life. This could then be provided in a diagrammatic format to GPs, ENT doctors and Audiologists to evaluate the extent to which a child can understand and follow speech in his/her daily life. It could also enable the child and adults around him/her to make adjustments to improve his/her hearing environment. The long-term aim is to develop an app which can be used by adults and children to gather and collate their experience. The research described here relates to a small-scale feasibility study involving six children (aged 3-7 years, two girls and

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21 four boys who had a diagnosis of OM by an ENT consultant and no other developmental or health conditions). The focus of this study was to construct questions and tasks which young children could complete. As OM-prone children often have difficulty with pragmatic language skills (Vernon-Feagans, Miccio and Yont, 2003) the wording of the criteria and explanation of the task required a number of iterations. Additionally the task needed to be engaging to children of this age range. Initial ideas for the task were developed through consultation with the Young People’s Advisory Group (YPAG) at Nottingham Hospital whose assistance was invaluable. Initially adults were not asked to contribute their perspective of the situation, but it became apparent that there were times when the child was not aware that they had not heard and that the adult with whom they were interacting needed to take action to gain their attention. For a more complete understanding of the child’s ability to distinguish specific voices and interpret speech in noise, adult comments were included. In this research the data was initially collected by completing a table which was filled in by child, adult or both. Each child was given a choice of a brightly coloured scrap book, asked to choose a pseudonym and select a colour to represent the level of understanding of speech in each situation. This was done to indicate to the child that his/her opinion was of importance and he/she was the expert and that there was not a right/

wrong answer. I explained and worked through examples with each child and a parent to check for understanding and engagement. Each child was asked to select a range of activities from their daily life where they would need to hear and understand what others were saying to them. No instructions were given on the number of activities but they were asked to collect the data over a two week period. Figure 1 provides an example of a page from one child’s (Unheroable, boy aged 7 years) data. The table required the date and in some instances the time of the activity. The child described the location and the people present. The colour was selected by the child to indicate one of the three choices of hearing ability. In this case green indicates that the child “can understand all/most of what is said” to him; purple that he could “understand some of what was said” to him; and orange that he could “understand little/none of what was said” to him. Child and adult comments were used to gain additional insight into the rationale for the choice of colour and to qualify the environmental factors which were enablers and disablers for the child to understand speech. A three point scale was selected as being easiest for the child to differentiate and to keep the task achievable. Analysing Hearing Maps The data is collated into a Hearing Map which summarises

Figure 1: Unheroable’s Page

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22 the extent to which an individual child understands what is said to him/her. Figure 2, Rosey’s Hearing Map provides an example. Rosey, aged 6 years, identified that 25% of the time she could understand little or none of what was said to her. This may be useful in a diagnostic context when health care professionals are trying to assess what action could be beneficial for an individual child, particularly when combined with existing measures. Further analysis in this feasibility study of the descriptive comments by adults and children provided insight into enablers/disablers to the child’s ability to understand speech in their daily noisy environments. Figure 3 shows that the most common aspect which contributed to a lack of understanding was ‘other people talking’ which was seen as the reason in 53% of the cases. The speaker’s position, either behind the child or where they could not see the speaker’s mouth was cited for 14% of cases as causing difficulty. Competing loud noises or being outside led to difficulties 11% of the time with the same percentage meaning the child did not tune into another voice when he/ she was involved in another activity. Conclusions For many children with OM and their parents the only contact that they may have with an audiologist is the child having a hearing test as part of the ENT consultation process. Very few children with OM have contact with specialist Teachers of the Deaf. This may mean that they are given very little, if any advice regarding ways to support their child’s hearing loss.

Figure 2: Rosey’s Hearing Map

Figure 3: Situations when there is a difficulty understanding what is said

Even when advice and fact sheets are available they may not be read by parents and the adults who interact with a child with OM. By raising awareness of the actions and situations that were and were not supportive to a child’s understanding of speech the parents and children in this study took actions so that the child could be better placed to understand what was said to them. As one mother reported when developing her son’s Hearing Map, “I now have a happier and more confident child who is taking action to ensure that he can hear what is said to him. I am less frustrated as I am more aware of specific things I can do when speaking with competing noises.” From the findings of this feasibility study I am looking to develop a larger scale trial to gather more data from children, including those with Down’s Syndrome and cleft palate who have high levels of OM, to gain greater insight into how better to support children with hearing loss from OM. I would like to apply the

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findings to the development of an app for recording the data so that it can contribute to discussions with health care and educational professionals supporting children with OM. References: 1. Higson, J. and Haggard, M. (2005) Parent versus professional views on the developmental impact of multi-faceted condition at school age: otitis media with effusion (‘glue ear’). British Journal of Educational Psychology, 75(4), 623-643. 2. Department for Education and Department of Health (2014) Special Educational Needs and Disability Code of Practice: 0-25 years. Crown Copyright www.gov.uk/ government/publications/send-code-of-practice-0-25 (Accessed 15 September 2015). 3. Vernon-Feagans, L., Miccio, A. and Yont, K. (2003) Speech, Language, Pragmatics and Attention. In Rosenfeld, R and Bluestone, C. (eds.) Evidence-based Otitis Media. 2nd ed. Hamilton: B C Decker, pp.360-382.

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National Acoustic Laboratories An Update CD

Author and Correspondence Author and Correspondence

Fabrice Bardy PhD Research Electrophysiologist National Acoustic Laboratories Level 5 Australian Hearing Hub 16 University Avenue Macquarie University NSW 2109 E: fabrice.bardy@nal.gov.au

The Australian Hearing Hub

National Acoustic Laboratories (NAL) is a world leader in hearing loss assessment, prevention and rehabilitation. With the benefit of wide collaboration, the knowledge gained and solutions developed are disseminated internationally. Central auditory processing disorder NAL has conducted an investigation into the efficacy of dichotic listening tests, which are used extensively as an assessment tool for central auditory processing disorder (CAPD). By presenting different sounds to each ear, these tasks are said to measure the ability of the auditory pathways to transmit signals from each ear to the brain for language processing. However, NAL questioned the possibility that higher-order cognitive abilities might be impacting on test results. To test this, NAL developed the Dichotic Digits difference Test (DDdT), an assessment tool which can be used to differentiate between children with cognitive deficits and children with genuine dichotic deficits. Our studies

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found that over 60% of the variance in traditional dichotic testing could be attributed to cognitive factors - such as memory, attention and intelligence that do not involve the perception of dichotic stimuli. Furthermore, the DDdT “dichotic advantage” score was able to identify children who show difficulties when dichotic cues are present compared to when there are not, thus suggesting that these children have genuine dichotic deficits. This is important as clinicians need to correctly identify true auditory processing deficits in order to offer appropriate management or remediation options for their clients. The DDdT is currently being developed for clinical use for those who offer a CAPD service such as Australian Hearing. Know your Noise NAL, supported by funding from the Office of Hearing Services and in conjunction with the HEARing Co-operative Research Centre (CRC), has recognized that young Australians are at potential risk of noise injury from

regular participation in ‘noisy’ non-work and leisure activities. NAL previously established an on-line NOISE database <noisedb.nal.gov.au> listing measured noise exposures from typical nonwork and leisure activities. In order to reach out to this at-risk audience, NAL developed the Know Your Noise website knowyournoise.nal.gov.au, which invites individuals to assess their hearing and find out if their hearing habits are placing them at risk of developing noise-injury. The site was launched November 2014 and in the first six months around 4,000 individuals completed the online hearing test. A further 2,000 visitors used the site’s interactive ‘Noise Risk Calculator’ to determine their personal level of noise risk. This site will be updated on a regular basis to ensure it remains a vital and relevant resource to help people better understand the risks associated with leisure noise exposure. The NAL Dynamic Conversational Test A new test of speech comprehension,

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25 developed at NAL, has been extended to include more natural conversations between multiple talkers, and a reverberant background environment with competing conversations. In comparison to traditional speech tests, this new dynamic speech test taps into the mental processes we use when engaging in real-life conversations. Results obtained on normally hearing listeners suggest that in real conversations there might be a range of in built compensatory cues and redundancies that are sufficient to maintain the flow of information, despite the requirement to switch attention between talkers. Real-life effects of hearing loss In collaboration with the Hearing and Deafness Centre at LinkĂśping University, a large epidemiology data set of more than 100,000 individuals from the UK has been analysed to investigate the effect of hearing loss on depression and cognition. People with poorer functional hearing reported higher levels of both depressive episodes and depressive symptoms, with the relationship between hearing and depression being stronger for depressive symptoms and for younger participants (in their 40s). Poor functional hearing was also independently associated with poor episodic long-term memory, visuospatial working memory, and verbal reasoning, with the effect being strongest for long-term memory. Binaural beamformer Listening in noisy environments remains one of the biggest challenges for people with hearing problems. In collaboration with the HEARing CRC, a super-directional signal processing algorithm (beamformer) was developed, implemented in hearing protectors and hearing aid prototypes, and tested. A novel feature of the technology produces a super-directional output signal while preserving the localisation cues. Preservation of location cues is critical for speech communication in group conversations. In the laboratory, the beamformer has been shown to improve speech understanding in noise, improve comfort in prolonged exposure to noise and improve the ease of listening

generally. Work to support possible commercialisation of the technology in hearing aids, cochlear implants, and assistive listening devices is in progress. Child outcomes study The Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study, conducted by NAL and its collaborators within the HEARing CRC, has provided population-based, world-first evidence for the benefits of early intervention resulting from universal newborn hearing screening. The LOCHI study has shown that children who received early fitting of hearing aids or cochlear implantation combined with early educational intervention have achieved good language outcomes at five years of age. However, it has also revealed that many children displayed weaknesses in pre-reading skills. Of those who have now completed their evaluations at nine years of age, many continued to exhibit deficits. These results suggest that additional intervention targeting specific skills is needed. NAL has commenced research into strategies for providing early support for the development of pre-reading skills with a new cohort using a tablet-based application devised by NAL. A parent-led program for training pre-reading skills has been implemented and is currently on trial with families in Victoria (funded by Victorian Deaf Education Institute). Objective detection of auditory processing deficits NAL research investigated how the auditory system copes with rapidly presented sounds, similar to speech sounds, using brainwave recordings from the scalp.The results add to the basic knowledge of the auditory system and open the door for applications such as earlier detection of speech and language impairment, temporal processing issues and dyslexia without the need to rely on a behavioural tests. A related project investigated whether spatial processing disorder (SPD), which reduces a childâ&#x20AC;&#x2122;s ability to understand speech in noise,

3D Speaker Array

can be detected through brainwave recordings. Such a method would enable remediation to be implemented before the disorder causes children to fall behind at school. Evaluating infants objectively The HEARLab system developed by NAL for the measurement of cortical responses to sounds has been further extended with new software modules. A second module, aimed at measuring brainstem responses is being prepared for European Union certification. A third module, the cortical automatic threshold estimator has been developed to allow automatic estimation of cortical thresholds of infants and adults who are difficult to test behaviourally. Clinical performance evaluation of the module is underway. Investigations, in conjunction with overseas collaborators, were carried out to

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26 determine whether HEARLab can be used with cochlear implants. As children are getting implanted earlier in life – which is important for their language development as shown by the LOCHI study – an appropriate adjustment of the implant is essential even when these children are too young to be able to provide reliable behavioural feedback. Measuring speech discrimination in infants Novel tests of speech discrimination by infants with hearing loss have been developed as part of a project funded by NHMRC and in collaboration with Macquarie and Melbourne Universities. The tests include objective measurements using a new experimental module im-

plemented in the HEARLab system and behavioural measurements using a visual reinforcement paradigm. The study will investigate the relationship between early speech discrimination and acquisition of language. If successful, the new tests will be translated into clinical tools to enable early referral and evaluation for cochlear implant candidacy in infants who do not benefit from hearing aids sufficiently for speech acquisition. This will enable them to reap the maximal benefit from early intervention. Neural effects of noise exposure Recent studies have shown that noise exposure may affect auditory nerve fibres that encode high-level sounds, which participate to a great extent

in challenging daily activities such as speech perception in noise. However, typical audiometric testing in clinical practice only evaluates the auditory system at levels near threshold. Some people may therefore be suffering from specific hearing problems without being diagnosed. Within the Early Indicators of Noise Injury (EINI) project, we are developing different neurophysiology strategies to evaluate the integrity of the auditory system at supra-threshold levels. These strategies might enable us to diagnose what is nowadays called “hidden hearing loss”. For further details on NAL publications go to: www.nal.gov.au

Previously unresolved problems in hearing rehabilitation; the Donders Hearing & Implants approach CD

Authors J. van Opstal1 M. Agterber1,2 L. Mens2 E. Mylanus2 M. van Wanrooij1 A. Snik2 Radboud University Nijmegen, Department of Biophysics

Radboud University Nijmegen Medical Center, Department of Otorhinolaryngology and Donders Institute for Brain, Cognition and Behaviour

Correspondence Ad Snik Department of Otorhinolaryngology PO Box 9101 6500 HB Nijmegen The Netherlands E: ad.snik@radboudumc.nl

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Introduction Hearing impairment affects communication and, consequently, it has a significant impact on the subject’s activities and feelings of well being. For young children, hearing impairment has a direct effect on their cognitive and socio-emotional development. Hearing technology has improved over the last decades because of the introduction of digital sound processing and growing knowledge in the field of biomaterials. Amongst improving conventional hearing solutions, this enabled the clinical application of implantable hearing devices and created new amplification options for patients with previously unresolved hearing problems. For more than 25 years now, application of auditory implants is one of the major research topics of the Nijmegen ENT clinic; auditory implants comprise cochlear implants (CI), middle ear implants (MEI) and implantable bone-conduction devices (iBCDs). Research focus has been on safety and stability issues as well as on the effectiveness of these new treatment options. Apart from studying these technologies and attempts to optimize their applications, we also studied the effects of new sound processing algorithms, bilateral applications and combination of different stimulation modes. This research was carried out in close cooperation with the department of Biophysics. In May 2011, the clinical and academic research activities were bundled in a new institute, named “Donders Hearing and Implants”. The aim of this institute was to broaden the research activities and to initiate new projects in the field of rehabilitation of hearing impairment using innovative technologies. Studies that are performed can be subdivided in fundamental, translational and applied/clinical research including behavioural studies.This report presents an overview of our translational research and will touch upon clinical projects and behavioural studies.

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27 Spatial hearing and hearing impairment Typically, when asked, hearing impaired subjects have two complaints, that is, problems with speech recognition in noisy places and poor acoustic â&#x20AC;&#x2DC;controlâ&#x20AC;&#x2122; over their environment. In either case, hearing with two ears plays an important role. Therefore, one of our study topics concerns the ability of hearing device users to effectively use the available binaural cues for directional hearing, which is so crucial in complex listening situations. With our experimental set-up (Figure 1), we are able to unravel which binaural and/or monaural cues are being used for the localization of sounds, by varying systematically stimulus conditions like bandwidth, sound level, stimulus duration and, of course, direction. During the measurements we ensure that the participants can only rely on acoustic information when localizing sounds. Therefore, measurements are performed in the dark while head movements are recorded (Figures 1 and 2). Recently, we studied mainly vertical localisation, which relies on perception of high pitched cues caused by pinna reflections. It is known that the pinna continues to grow, even in the elderly. We tested if the growth of the pinna lowers the characteristic filtering frequencies, possibly to compensate for the high frequency hearing loss that occurs with aging (Otte et al., 2013). As expected, a significant effect of pinna size on vertical localisation was found, however, it was not large enough to compensate the age-related high frequency hearing loss. In other words, vertical localisation deteriorated in the elderly despite growing ears. Agterberg et al (2014) studied directional hearing in patients with single sided (total) deafness (SSD). Such patients might have learned in daily practise to use monaural cues, caused by the head shadow, for directional hearing in the horizontal plane: relatively soft sounds might be interpreted as sounds generated at the deaf side and louder sounds at the hearing side.

Roving the amplitude of each stimulus in the laboratory will minimize the beneficial use of this cue. However, despite roving, several SSD patients localized sounds reasonably well. Interestingly, pinna effects proved to play a role. The pinna affects the spectrum of sounds in the high frequency range, depending on the angle of incidence . As mentioned above this is the most important cue for vertical localization. Obviously, several SSD patients have learned to use such spectral cues effectively for horizontal localisation (Agterberg et al., 2014). Indeed, when moulding the pinna, affecting its filtering effect, both vertical and horizontal localisation deteriorated to chance levels. Ongoing research aims at a possible disturbance of monaural localization abilities by any amplification device (CROS device) in SSD patients. Another reseach topic in this field is the binaural benefit of bilaterally, sequentially placed CIs in bilaterally deaf children. A cohort-control study has been carried out; this project started in 2006, comprising 30 children (Sparreboom et al., 2014a). A steady improvement in binaural benefit was found regarding speech recognition in noise but also in horizontal localization. Measurements showed that interaural level difference cues seem to be the dominant cue and that improvements extended over many years. Variation between children was found which was associated with (in)consistent use of both CIs. Experiments in deaf adults with bilateral CIs are ongoing, aiming at the effect of processing and coding strategies on horizontal localisation, as well as in hearing impaired adults with a CI in one ear and a conventional hearing aid in the other ear. Differences in sound processing as incorporated in commercially available hearing aids were found to disrupt speech understanding in spatially challenging situations (Veugen, 2015). As a result, the industry partner in this study will make an improved speech processing strategy available world-wide in the beginning of next year.This work is continued in the EU project HealthPAC.

Figure 1. The set-up for horizontal and vertical sound localisation. The subject is sitting in the dark in a vertical arc of loudspeakers that can be rotated to any position. Head movements are recorded

Figure 2. The (electromagnetic magnetic) registration system to measure head movements attached to spectacles

research round-up

28 In challenging listening situations with signals masked by several competing sounds, how can we single out and listen to a specific speaker? The putative solution to this problem, ‘binaural scene analysis’, is what enables listeners to show the socalled ‘cocktail-party’ phenomenon. Scene analysis assumes that not only bottom-up perception is import, but also top-down processing. Although studied extensively in listeners using psychophysical tests, little is known about the neural mechanisms underlying segregation of auditory objects from complex backgrounds, and how hearing impairment influences this. A new lab with 128 loudspeakers was build to create dynamic sound environments. First measurement, part of the EU project ‘iCARE’ are underway.

es than visual stimuli (as was found in the PET study). However, no multisensory enhancement was observed, as the audiovisual NIRS signal resembled the auditory response. NIRS results in the post-lingually deaf CI users strongly resembled those of the normal-hearing subjects (van de Rijt et al., 2015). Recently, the EEG and NIRS equipment were updated comprising now 72 and 48 measuring channels, respectively. This allows for studying the rapid changes in auditory information processing, that are crucial for speech understanding and spatial hearing (EU-iCARE project).

The auditory brain Functional neuroimaging techniques allow for investigation of central auditory processing by assessing auditory cortical activity. As scanning techniques using magnetic fields are to be avoided, positron emission tomography (PET), elecFigure 3. Typical NIRS recordings, measuring the change in oxy- (red) and deoxyhemoglobin (blue) concentrations. Stimuli were sentences (duration 20 s) presented either visually only (V; left), auditory only (A; middle) or audiovisual troencephalography (EEG) and (AV; right), represented by the grey patch. Optodes were placed at the presumed position of the auditory cortex functional near-infrared spectroscopy (NIRS) can be applied. Especially the latter two techniques In the study mentioned above in children with sequentially imallow for measurements in a comfortable and natural environplanted bilateral CIs, we also recorded the EEG. At the brainment, they can be utilized in children, are portable, easy to stem and cortical level, obvious intra-aural differences were handle, and have a relatively low cost and can be used in CI seen in the recordings (see Figure 4 for the cortical responses). patients. We use such techniques to provide an objective measThe length of the time period between first and second imure in the efficacy of cochlear implantation. plantation played a part, see figure (Sparreboom et al., 2014b). With increasing use of the two CIs, interaural differences deHearing performance varies across CI users, especially in late creased. In the long run, obvious differences in cortical potenimplanted prelingually hearing impaired subjects. It has been tials between the ears were still found in several children and hypothesized that cross-modal reorganisation of the auditoproved to be associated with differences in bilateral device use. ry cortex by visual functions plays a role. Using PET scanning, This study is ongoing. we studied such patients, applying auditory only and combined audio-visual stimulation. Increased cortical activity in temporal Clinical research and occipital regions was found compared to in normal listenAmplification options for conductive and mixed hearing loss ers. The suggestion is that part of the understimulated auditory A great deal of our clinical work focused on stability and effeccortex is stimulated by other sensory input, referred to as cross tiveness of implantable devices such as the percutaneous iBCD modal stimulation. However, no change in activation was found and MEI with the actuator directly coupled to the cochlea. when comparing pre and post implantation scans. Statistical Stability of several types of titanium BCD implants (different analysis showed that the hypothesis about cross-activation by shapes, different surface treatments) has been evaluated (e.g. e.g. visual stimuli could not be confirmed in our study (StraatNelissen et al., 2016). In principle, the MEI is a competitor for man, 2015). iBCD. Gain and maximum output of all the amplification options for conductive/mixed hearing loss have been studied in Using NIRS, we also measured how activity in the auditory detail, what has lead to a categorization of these options and a cortex is influenced by auditory and visual speech. Figure 3 new fitting procedure (Snik, 2015). Stability and MRI compatipresents a typical example. Results from 33 normal-hearing bility were also taken into account. subjects were compared to that of 5 postlingually deafened CI users assessing multisensory integration in the auditory corDevelopment of deaf children with cochlear implants tex. Although considerable inter-individual variability in NIRS This line of research aims at the relation between speech recresponse amplitude was found, consistent effects of stimulus ognition with a CI and long-term development of cognitive mode were found. Auditory stimulation evoked larger respons-

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29 functions. First results are most encouraging; a statistically significant relation was observed between the ability to understand speech in demanding situations and long-term verbal cognition. The intermediate factor was hypothesized to be â&#x20AC;&#x2DC;informal learningâ&#x20AC;&#x2122; (de Raeve et al., 2015). Effects on the socio-emotional development and the development of academic abilities were found as well (Langereis & Vermeulen, 2015). Owing to the success of cochlear implantation, more and more children with multiple handicaps are being referred. Research has focussed on benefit in general as well as in subgroups of children with additional handicaps (e.g. children with CMV, CHARGE syndrome, Waardenburg syndrome). The aim was to find predictors of success, helpful for counselling the parents and to guide the rehabilitation process. These studies are ongoing.

4. Nelissen RC, Stalfors J, de Wolf MJ, Flynn MC, Wigren S, Eeg-Olofsson M, Green K, Rothera MP, Mylanus EA, Hol MK. Long-term stability, survival, and tolerability of a novel osseointegrated implant for bone conduction hearing: 3-year data from a multicenter, randomized, controlled, clinical investigation. Otol Neurotol. 2014;35(8):1486-91. 5. Otte RJ, Agterberg MJ, Van Wanrooij MM, Snik AF, Van Opstal AJ. Age-related hearing loss and ear morphology affect vertical but not horizontal sound-localization performance. J Assoc Res Otolaryngol. 2013; (2):261-73. 6. van de Rijt LPH, Snik AFM, Mylanus EAM, Yin Hu H, Straatman LV, van Opstal AJ. Auditory cortex activation to audiovisual speech in normal-hearing and cochlear implant users with functional near-infrared spectroscopy. 2015. Under review. 7. Snik AFM. Auditory implants (2015). www:/snikimplants.nl 8. Sparreboom M, Langereis MC, Snik AF, Mylanus EA. Longterm outcomes on spatial hearing, speech recognition and receptive vocabulary after sequential bilateral cochlear implantation in children. Res Dev Disabil. 2014a;36C:328-337. 9. Sparreboom M, Beynon AJ, Snik AF, Mylanus EA. Auditory cortical maturation in children with sequential bilateral cochlear implants. Otol Neurotol. 2014b;35(1):35-42. 10. Straatman LV. Multisensory brain metabolic activity in prelingually deaf adults varies with speech recognition after cochlear implantation. In: Cochlear implantation in the prelingually deaf. PhD thesis, Radboud University Nijmegen, 2015 11. Veugen LCE, Chalupper J, Snik AF, van Opstal AJ, Mens LHM. Matching Automatic Gain Control Across Devices in Bimodal Cochlear Implant Users. 2015. Under review.

Figure 4. Development of the cortical auditory evoked potential elicited by the first and second CI at 6, 12 and 24 months after the second cochlear implantation. The results shown are of a child with a relatively long interval between first and second implantation. The amplitude and morphology of the second implanted ear are less pronounced

Acknowledgement References: 1. Agterberg MJ, Hol MK, Van Wanrooij MM, Van Opstal AJ, Snik AF. Single-sided deafness and directional hearing: contribution of spectral cues and high-frequency hearing loss in the hearing ear. Front Neurosci. 2014;8:188. 2. De Raeve L, Vermeulen A, Snik AFM. Verbal Cognition in Deaf Children Using Cochlear Implants: Effect of Unilateral and Bilateral Stimulation. Audiol Neurootol. 2015;20:261-6. 3. Langereis M, Vermeulen A. School performance and wellbeing of children with CI in different communicative-educational environments. Int J Pediatr Otorhinolaryngol. 2015;79(6):834-9.

The authors wish to thank all the master students and PhD students who participated in the studies as well as Anja Roye, Margreet Langereis, Anneke Vermeulen, Marloes Sparreboom, Myrthe Hol and Andy Beynon for their contributions. Studies have been supported by grants from Cochlear Europe, Advanced Bionics, Phonak, William Demand fund and EU grants (iCARE, HealthPAC) .

research round-up

Manchester Audiology Bursting with Excitement CD

Author and Correspondence Author and Correspondence

Dr Kai Uus, MD, PhD Reader in Audiology, Head of Audiology & Deafness Teaching University of Manchester E: kai.uus@manchester.ac.uk

Manchester audiology is unique and special: unique because of the range of education, research, service provision and service development and special because of the leading role in each of those areas. Previous articles in this newsletter have focussed on our research and clinical activities; therefore, the purpose of this article is to summarise our educational programmes. I am writing this in the middle of September, just before the beginning of the new academic year. It is a very apt moment to take stock of how things are and what’s to come. In 2019 we shall be celebrating the 100th anniversary of the appointment of Irene Goldsack (later Ewing) as Lecturer in Deaf Education in Manchester. Today University of Manchester Audiology and Deafness group is the UK leader of audiology and deaf education training. The group currently provides an undergraduate programme, four post-graduate programmes and two clinical competency programmes. We also continue to offer a range of Continuing Professional Development (CPD) courses which we are constantly updating and expanding

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on. This year we are re-launching a new and improved version of our flagship CPD module: Effective Amplification for Infants and Children. While the DoH programme of Modernisation Scientific Careers has meant modifications to existing pre-registration undergraduate and postgraduate programmes, a significant development for the clinical profession is the provision of the Higher Specialist Scientist Training (HSST) Programme. This is an exciting addition to the already outstanding portfolio of education and training programmes and, for the first time, provides a higher qualification at post-registration level that will provide audiology leaders for the future. As readers may already know, HSST is part of the Department of Health Modernising Scientific Careers framework. Through a HSST programme reflecting the standards of training undertaken by doctors to train as Medical Consultants, selected Clinical Scientists will bring high-level scientific and clinical leadership as Consultant Clinical Scientists. The consortium based on Manchester Academy for Healthcare Scientist Education (MAHSE) won the DoH tender to be the only provider of the highest training programme in all 19 Healthcare Science disciplines. The consortium comprises the University of Manchester, Manchester Metropolitan University, University of Liverpool, Aston University and Kings College London. The aim of the consortium, led by MAHSE, is to generate a dramatic and sustained step change in the influencing and promoting Healthcare Science services and Healthcare Science research in the UK. University of Manchester will be responsible for the HSST programme in Audiological Science. It is a privilege for Manchester to train clinical scientists at the doctoral level. It will be an exciting challenge to engage and inspire

the trainees with already high levels of pre-existing expertise and clinical experience. The programme will be using blended learning with a distinct emphasis on clinically-integrated structured independent learning, peer learning and community of practice approach. Because our trainees are busy clinicians working across the country, face-to-face on-campus sessions will be kept to the minimum and designed to be highly interactive (e.g. advanced communication role-plays, genomics boot camp, flipped classroom blunder cases of children with complex medical needs etc). Opportunities will be provided to go beyond the prescribed curriculum and attend ‘Esteem Lectures’ by world-leading experts in the field to hear about the cutting-edge research carried out in Manchester. The whole programme will also have a meaningful service-user involvement ranging from the sharing of patient perspectives to assessing and evaluating both the trainees as well as the teaching staff. An essential part of the HSST programme is designing, conducting and presenting of a doctoral thesis leading to Doctor of Clinical Science (D Clin Sci) degree. The 2015 launch of the HSST Audiological Science Programme (and the first cohort to graduate in 2020) is a longterm investment in the best quality highest level audiology training in the United Kingdom which will not only raise the profile and reputation of audiology but, more importantly, will, in the long run, also improve services for the patients and their families. In order to maintain and improve high-quality provision, our group has had success in recruiting many excellent new members of staff: Dr Michael Stone who has just finished a long stint in Professor Brian Moore’s Auditory Perception Group at the University of

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31 Cambridge; Dr Ann-Marie Dickinson who has a strong background in clinical audiology with expertise in non-implantable hearing devices, Dr Rebecca Millman an expert in neuroimaging; Dr Siobhan Brennan who is highly regarded for her expertise in electrophysiology and work with adults with learning difficulties. And after years of not having had an in-house vestibular expert, we are over the moon about Debbie Cane bringing some much needed balance into our group. In addition to these our group has recently welcomed two world leading experts who have joined us part time: Prof David Moore (Director of the Communication Sciences Research Center at Cincinnati Children’s Hospital and a Professor of Otolaryngology at the University of Cincinnati) and Prof Cynthia Morton (Professor of Genetics, Harvard Medical School) and both of them are excited to contribute to the HSST programme.

teaching-related Awards. Prof Wendy McCracken was awarded the Higher Education Academy National Teaching Fellowship; Prof McCracken together with Helen Chilton won an Outstanding Contribution to Widening Participation Award. Sheila Fidler’s work has earned her three awards: Learning through Research Award; Social Entrepreneurship Award and Curriculum Innovation in

Social Responsibility Award; and last, but by no means the least, Prof Kevin Munro won the Lecturer of the Year 2015 as voted by the students of the Faculty of Medical and Human Sciences. Congratulations to all!

Happy New Academic Year to everyone!

List of pre-registration programmes taught in the A&D: • • • •

BSc in Healthcare Science (Audiology) [Prog Dir Dr Richard Baker] MSc in Clinical Science (Neurosensory Sciences) [Prog Dir Dr Kai Uus] MSc Audiology [Prog Dir Sheila Fidler] Certificate of Clinical Competence UK & Irish Certificate of Clinical Competence in Audiology (ICCCA) [Prog Dir Bridget Skelly] • PG Dip/MSc in Deaf Education [Prog Dir Prof Wendy McCracken]

List of post-registration programmes taught in the A&D: • MSc in Advanced Audiological Studies [Prog Dir Sheila Fidler] • D in Clinical Science (Audiological Science) [Prog Dir Dr Kai Uus]

And finally I want to take this opportunity to celebrate the success of my colleagues for wining a variety of

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ear reach

Battling waiting lists in Africa:

Donating hearing aids alone is not doing the trick

Author and Correspondence

Steen Frentz Laursen Vice President Group Communication GN Resound E: info@gn.com W: www.gn.com Proper fitting is a must if donated hearing aids are to make any sustainable difference for the users

On WHO’s agenda

“For ten years my hearing impairment continued to get worse, and I nearly lost all hope - I used to try to avoid people because of the embarrassment.”

“In developing countries, children with hearing loss and deafness rarely receive any schooling. Adults with hearing loss also have a much higher unemployment rate. Among those who are employed, a higher percentage of people with hearing loss are in the lower grades of employment compared with the general workforce. Improving access to education and vocational rehabilitation services, and raising awareness especially among employers, would decrease unemployment rates among adults with hearing loss. In addition to the economic impact of hearing loss at an individual level, hearing loss substantially affects social and economic development in communities and countries.” Source: World Health Organization – Deafness and hearing loss – February 2014

58-year old Bongani Jeffrey Malekane suffered from a sensorineural hearing loss for more than 10 years. His hearing impairment got progressively worse year-by-year, but he was unable to get a hearing aid due to lack of public funding.

Trained audiologists are a scarce resource and in high demand in this part of the world.

Bongani’s case is far from unique among impoverished people in South Africa, where he lives. One problem is that hearing aids are expensive instruments. But should public funding or donations of hearing aids be available, proper fitting is still a huge obstacle across Africa.

Killing those two birds – the lack of hearing aids and professional fitting – with one stone was exactly the goal of a new program that GN Store Nord set up in 2013. GN Store Nord is the Danish company behind the hearing aid brands ReSound, Beltone and Interton.

The company has a dedicated Corporate Social Responsibility policy, where one of five focus areas is to “engage in social activities supporting and helping underprivileged people in their everyday life e.g. by donation of hearing aids.” “The focus of this project has been to ensure sustainable help is given – not just handing out hearing aids. That is how this project differs from most charity initia-

ear reach

34 tives, the longevity of the project and the attention to ensuring hearing aid use and follow-up and thereby real end-user benefit. Rather than charity we wanted to help local communities help themselves,” says Charlotte Thunberg Jespersen, Director Global Audiology at GN ReSound and member of the board of the GN Store Nord Foundation. A structured program Since donations alone would not do the trick, GN set up a structured program, where professional fitting was an integral element. “Early identification and the provision of amplification would be worthless without access to follow-up and without the provision of practical items needed to make use of the hearing aids. Rather than inject as many hearing aids as possible into the communities, our focus has been to ensure long-term sustainability e.g. by training local audiologists and providing batteries and ear molds,” says Charlotte Thunberg Jespersen. In early 2013, GN launched the program under the auspices of the Clinton Global Initiative, which was established by President Bill Clinton to convene global leaders to create and implement innovative solutions to the world’s most pressing challenges.

“Now I’m happy again because to really live you have got to be able to communicate,” said Bongani at that event. Empowering local audiologists Setting up the program required extensive planning, work and resources. The infrastructure in South Africa is challenging – both in terms of basic transportation and technology. The hearing impaired don’t just come by when audiologists are at hand, and flexibility from all involved parties is needed. The ambition is to clear the waiting lists by supplying the needed hearing aids and equipment in order to perform the fitting, thus empowering the local audiologist to help those who would not otherwise be considered eligible for rehabilitation. Though the government each year invests a lot in the provision of hearing aids to hearing impaired citizens, they don’t have sufficient budgets to supply everyone with rehabilitation, and many will therefore end up on the waiting lists. Often prioritisation of the waiting patients will favour the younger patients, and the elderly population or more mature adults could be waiting for years. These patients would not be likely to receive the help they needed if it was not for this program.

Initially, GN donated 6,600 hearing aids to two provinces, Gauteng and KwaZulu-Natal. On January 15, 2013, the program was officially launched at the Chris Hani Baragwanath Hospital in the Soweto township of Johannesburg. An on-stage live demonstration of a hearing aid fitting was carried out to give an impression of the work that local audiologists would be performing when using the donated hearing aids. One of the patients who was fitted at the launch was Bongani Jeffrey Malekane. With his new hearing aids, GN Resound Metrix Power Behind-theear, Bongani was able to begin living a normal life, keep a job and enjoy social activities.

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Training of local audiologists in South Africa

Local anchoring is essential GN’s current local partner – Impact Hearing – is instrumental in making the program successful, and GN also entered into partnership with key personnel at each of the public health departments of Gauteng and KwaZulu-Natal. Alone in the KwaZulu-Natal province there was a waiting list for hearing aids of more than 2,000 people, and some people had been on the waiting list for over four years. In the Gauteng province, the waiting list consisted of around 1,800 people. GN’s program does not replace any public offering, but is an opportunity to those most impoverished. Prior to the launch of the program, two of GN’s senior audiologists trained 65 local audiologists from 41 health facilities across Gauteng and KwaZulu-Natal, making them capable of fitting the hearing aids professionally. The on-site training of South African audiologists has enabled them to make the proper selection and perform the best fitting for each patient. This can improve the end user benefits and the motivation to wear the hearing aids, and enjoy situations from which they had previously been excluded as a result of their hearing impairment.

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35 Improving lives Testimonials from patients fitted with hearing aids in June 2014 at Groote Schuur Hospital, South Africa: Darlene Van Der Marie: “I am very happy I can hear again. God bless you for giving me my hearing back.” Mona: “Really I’m so happy and pleased, now I don’t need to ask my kids ‘what are you saying?’. Thanks very much. May god bless you people.” Pulmathee: “Thank you so much, greatly appreciated. I am now in touch with the outside world and the quality of my life has improved greatly.”

Throughout the duration of the donation program, GN will continue to send audiologists free of charge to train local audiologists in South Africa to ensure a high level of user satisfaction. Today, GN has expanded the program to include all nine provinces in South Africa. Currently, approximately 100 hearing impaired Africans each month receive hearing aids in this program. Numerous public hospitals are part of the initiative, and GN provides local staff with training in IT and audiology to offer an increasing number of fittings to hearing impaired on their waiting lists. GN aims at donating 2,000 hearing aids per

year until 2020. Moving into Zimbabwe The next step is to expand north into Zimbabwe. A former GN employee – a professional audiologist who was crucial in establishing GN’s first program in South Africa – has set up a clinic in Harare in Zimbabwe, where they are seeing patients free of charge on a caseby-case basis. In 2015, they will expand the free service and encourage applications from parents of hearing impaired children. They will offer free new born hearing screenings with an aim to catch more children at an early age and provide the early intervention, which is cru-

cial for speech development. The free hearing aids will be provided by GN, but the crucial factor for success is still local anchoring – and empowerment to help people help themselves. “With the access to hearing, children helped through this project can attend normal schools giving them access to education. Literacy moves them away from certain poverty in adulthood and empowers them to be able to provide for themselves and their families. For adults, access to amplification and specialist help can mean a return to the job market,” says Charlotte Thunberg Jespersen.

A heartwarming experience Unlike in South Africa, there are no public funds for hearing aids in Zimbabwe, which means that hearing aids are out of the question for people who have been diagnosed with hearing loss. Donations of hearing aids are therefore much needed, and highly appreciated. Here is a heartwarming experience from Jenny Nesgaard, audiologist and former GN employee, who has set up a clinic in Harare in Zimbabwe: “A father came in with his four year old son who was diagnosed as deaf and dumb. The child was recommended hearing aids three years ago, but they could not afford it, so he was unaided and has not developed any speech. The father’s employer heard about this young son and an older nine year-old son with the same diagnosis. She offered to pay half of the testing costs for the youngest son, as she could not believe two children would be born deaf and mentally handicapped in the same family. We saw the youngest child earlier in the year, and his hearing loss was profound. We fitted him with a set of Alera 960 devices, but warned the father that since no speech testing could be performed, we could not guarantee his ability to discriminate speech sounds. They returned for a follow up and the youngest boy is speaking! Just a few words, but it is light years more than he could perform just a few months earlier. At the follow up visit the older boy came along, and we found out he is in the deaf schooling system, but amplification was never attempted for him either so he also got himself a pair of hearing aids. Such great dedication from their father to use one of his two monthly days off (he works in another town all month and is only home two days) to invest in his children. And how amazing to be able to help and offer such life changes free of charge. We will see them back in a few months, can’t wait to see how things are going!”

ear reach

Phonak CROS II Improved speech understanding thanks to binaural beamforming

With the introduction of Phonak CROS II, a binaural adaptive beamformer is available in a Contralateral Routing of Signal (CROS) system, for the first time. The binaural beamformer creates a narrower beam that allows a listener to focus on a particular voice when in a noisy situation. The result is improved speech understanding. Phonak ran a study aimed to investigate speech understanding differences in difficult listening situations with two CROS generations from Phonak. The newer Phonak CROS II, provided more benefit when compared to the Phonak CROS, which has a monaural adaptive beamformer. The conclusion was the study clearly demonstrated that the binaural adaptive beamformer of Phonak CROS II outperforms the monaural adaptive beamformer of

Phonak CROS and CROS II. With the binaural adaptive beamformer of CROS II, subjects showed a benefit objectively and subjectively when in a ‘speech in loud noise’ situation. Thanks to Binaural VoiceStream Technology™ and StereoZoom, people with SSD will benefit from significant improvements in speech understanding compared to using a monaural adaptive beamformer (SPiN). In summary, the proven performance of Phonak CROS II should improve life quality for people with SSD. To read and download the full study, please visit www.phonaknhs.co.uk

ear reach

Hear the World Foundation:

Better Hearing for a Better Future

Author and Correspondence Elena Torresani Head of Hear the World Initiative

The Hear the World Foundation was established in 2006 as an initiative of the Sonova Group, the leading manufacturer of innovative hearing care solutions. The Group operates through its core business brands Phonak, Unitron, Advanced Bionics and Connect Hearing. The Hear the World Foundation advocates for equal opportunities and improved quality of life for people with hearing loss around the world. The vision of the Hear the World Foundation is a world in which:

Professional follow-up speech therapy as a key element.

• Each person has the chance to experience good hearing, • Wearing a hearing aid is no longer a taboo, • Hearing is cherished and protected, and • People with impaired hearing enjoy equal opportunities. Since 2006, the foundation has been involved in over 60 projects on all five continents and has given thousands of people with hearing loss the chance to enjoy a better life. Hearing loss – a neglected issue Hearing loss is still a neglected issue, even though the figures speak volumes: more than 15 percent of the adult population is affected by hearing loss, and around half of these cases could have been avoided by taking preventive measures. Some 665,000 children with significant hearing loss are born every year . One of the biggest challenges is that 80 percent of people with hearing loss live in low- to middle-income countries and often do not have any access to audiological or medical care. In low-income countries, for example, only one in 40 people with hearing loss wears a hearing aid . This has serious consequences: children with untreated hearing loss, particularly those living in these regions, have hardly any future prospects. After all, children who cannot hear very well have difficulty learning to speak, which reduces their chances of receiving an education and developing at an appropriate rate for their age.

people with hearing loss to enable them to enjoy a better quality of life. The foundation also aims to draw attention to and raise awareness of the issue of hearing loss by carrying out studies and campaigns. Support is provided via financial resources, the provision of hearing systems and the deployment of one of the foundation’s own teams. Sonova bears all of the foundation’s administration costs to ensure that 100 percent of all donations go directly to the projects.

Foundation goals Against this backdrop, the Hear the World Foundation’s goal is to actively support and promote projects that provide help for

Every year we receive a large number of applications for support. An essential criterion for selecting and implementing projects is sustainability. The quality of audiological care

Using state-of-the-art devices for diagnostics.

ear reach

The ABC Hearing Clinic and Training Center in Lilongwe, Malawi.

provided is a crucial element of sustainability, and attention is paid to the potential for: • High quality evidence-based practice • Long-term capacity-building • Outcome-monitoring The first audiology clinic for Malawi The Hear the World Foundation funds some services directly, but most often works through existing NGOs. In Malawi for example, since 2010, the Hear the World Foundation has provided support for the building and equipping of the ABC Hearing Clinic and Training Center in Lilongwe, the first purpose-built audiology facility in the country.The ABC Hearing Clinic and Training Center program has three key elements: Service,Training and Outreach. Since 2010, the Hear the World Foundation has been a major donor in each of these areas of operation; ensuring a robust and rapid development of the project. The facility is led by the Australian Audiologists Peter and Rebecca Bartlett. Its long-term sustainability depends upon

Children from Haiti thank Hear the World for its support

ear reach

Prof. John Bamford, Member of the Hear the World Foundation Advisory Board with Chiko, one of the students at ABC Hearing Clinic and Training Center in front of the Hear the World Foundation’s Trailer for outreach missions.

training Malawian audiologists. This is why the ABC Hearing Clinic and Training Center has trained six graduates as audiology assistants. These graduates are now the backbone of audiology services and outreach provided by ABC Hearing Clinic and Training Center. Hundreds of Malawians every month are now receiving audiology care in their own language.To provide longterm leadership, the Hear the World Foundation is providing further funding for two graduates to undertake an Audiology MSc at the University of Manchester in the UK. The Hear the World ambassadors Hear the World is supported by more than 90 celebrity ambassadors, all of whom have had their photographs taken by musician and photographer Bryan Adams in the Hear the World Pose: with one hand behind the ear to symbolize conscious hearing. Sting, Annie Lennox, Julianne Moore, Ben Kingsley, and Kate Moss are just some of the many celebrities featured in these impressive photos. They all contribute toward raising public awareness of the importance of good hearing and the consequences of hearing loss.

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Sting, Jude Law, Elle McPherson, Jerry Hall and Bryan Adams, 5 of the more than 90 celebrity ambassadors supporting the Hear the World Foundation

Further information can be found at www.hearthe-world.com. Become a fan of Hear the World at www.facebook.com/CanYouHearTheWorld

Are you looking for the ideal Christmas gift idea?

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Photographed by Bryan Adams

Featuring exclusive portraits of stars such as Tina Turner, Anastacia, Rosamund Pike and many more. The limited edition 2016 Hear the World calendar combines aesthetic appeal with helping a good cause. The calendar, which is priced at 33Eur, is available from www.hear-the-world.com. All proceeds from the calendar sales go to the Hear the World Foundation.

ear reach

ear globe: audiology around the world

Audiology in Jordan FACTFILE... Population: 6.8 million Total Area: 89,342 km2 Capital: Amman Offical Language: Arabic Average life expectancy: 74 yrs

Author and Correspondence Hala Mousa AlOmari

Assistant Professor Head of Department of Hearing and Speech Science University of Jordan 11942 Amman Jordan E: halaomari@gmail.com

Biography Hala AlOmari is the Head of the Audiology and Speech Pathology Department and Assistant Professor at The

About the Hashemite Kingdom of Jordan The Hashemite Kingdom of Jordan is located at the heart of the Middle East with a population of approximately 7 million. Jordan has been perpetually populated since the dawn of civilization and its rich history is showcased in ruins such as Petra, and Greco-Roman Jerash. Furthermore, Jordan enjoys peace and stability in a region plagued by unrest. Coupled with a culture of hospitality, Jordan identifies as a location for tourism, investment and healthcare. Competitive labor costs and high education standards in healthcare enhance this position. Accordingly, the World Bank ranked Jordan first regionally and fifth internationally for top medical tourism destinations in 2012 (JIC, JIC.gov.jo ).In fact, Jordan is considered a pivotal centre for audiology patients from neighbouring countries such as Iraq, Libya and Palestine.

University of Jordan. She is a qualified audiologist who completed her BSc in Audiology at the Applied University of Science in Jordan and obtained her Master of Science degree from the University of Southampton, UK. She worked as a lecturer at the University of Jordan for two years, and then pursued her PhD in Audiology at the University of Southampton. Her thesis was titled â&#x20AC;&#x153;Binaural Hearing with Bilateral Bone Conduction Stimulationâ&#x20AC;?. Map of the Hashemite Kingdom of Jordan

ear globe: audiology around the world

41 Development of Audiology in Jordan Nearly thirty years ago, the first audiology department in Jordan was initiated by the military medical unit,The Royal Medical Services.The field of Audiology has since grown into numerous government centres providing comprehensive audiology services, from hearing testing and hearing aid fitting, to balance testing and later, cochlear implant provision. In addition to The Royal Medical Services, government centres offering audiological services today include Ministry of Health hospitals, Jordan University Hospital, and King Abdullah Hospital. The private sector also has a considerable share of the field with stateof-the-art audiology clinics that follow international guidelines. The first cochlear implant (CI) in Jordan was carried out in 2003 by a Jordanian team in collaboration with international specialists, paving the way for public and private facilities to follow suit and ultimately leading to a surge in CI implantations nationally. Since 2003, over 500 operations have been performed through government funding in three medical institutions: The Royal Medical Services, Prince Hamzah Bin Al Hussein Hospital and King Abdullah I University Hospital. Non- governmental audiology centres include Queen Alia Foundation for Hearing and Speech which was founded with a humanitarian mandate of providing free services to all who are hearing impaired, as well as providing practical training for audiology and speech and language pathology students. The Holy Land Institute of the Deaf, established in 1962, is another example of a non-governmental organization that extends assistance to vulnerable deaf and deaf blind children in Jordan and the Middle East. In 1982, the institute established the Department of Hearing Aids, Earmoulds, Audiology and Resources (HEAR). HEAR offers much-needed audiology services to the poorer sector of society and provides training for audiology technicians, often employing earmould technicians who may have previously accessed the service themselves.

Prevalence of Hearing Loss in Jordan There are limited studies investigating the prevalence of hearing loss in Jordan. A major study conducted by Attias et al (2006) looked into the prevalence of congenital and early-onset hearing loss in Jordanian and Israeli infants.The findings showed a large contrast between the two countries in terms of the prevalence and severity of hearing loss, showing higher prevalence and more severe hearing losses amongst Jordanian infants. The prevalence of sensorineural hearing loss amongst newborn Jordanian infants was 1.14% and 10 of every 1000 newborn infants (1%) were found to have bilateral sensorineural hearing loss. Differences in prevalence rates were linked to higher rates of consanguinity and reduced application of preventative perinatal treatments for hyperbilirubinemia and bacterial meningitis in Jordan. Hearing screening for New Born Infants Three years ago, the Health Ministry mandated a new hearing screening programme for newborns, citing the importance of early detection of hearing loss and early intervention. The Royal Medical Services have also adopted the neonatal hearing screening programme. However, screening is still optional in the private sector, sadly implying that there may continue to be some undetected cases of hearing loss in infancy. Audiology Services Patients requiring audiological assessment are generally referred to the audiology department by E.N.T. specialists or paediatricians. Currently, hearing tests are not covered by insurance on a national level. However, civil servants and military personnel, veterans and dependents are covered by the Health Ministry and Royal Medical services respectively. Hearing aids Hearing aids are funded by the Royal Medical Services through tenders chosen annually. They supply around 3,500 hearing

ÂŠ http://www.alhussein.jo/en/life-pictures/advocacy-and-initiatives#/17 Crown Prince Hussein follows up on hearing disability initiative â&#x20AC;&#x2DC;Hearing Without Bordersâ&#x20AC;&#x2122;

ear globe: audiology around the world

42 diology graduates. Unfortunately, the University later discontinued the audiology programme but students interested in hearing and speech can still pursue studies at three of the main Jordanian universities: University of Jordan, Jordan University of Science and Technology, and Al-Ahliyya Amman University. It is worth mentioning that current programmes offer a joint Bachelor’s degree for both audiology and speech sciences. Graduates select their specialisations after they graduate and obtain a license to practice audiology from the Ministry of Health before undergoing a theoretical and practical examination.

Dr Daniel Rowan with faculty staff and students from the University of Jordan.

aids every year. Currently army personnel and their dependents (up to 18 years old) receive hearing aids free of charge. Dependents aged over 18 years are covered for 50% of the hearing aid price ($176). Bilateral hearing aids are only provided for minors. Health insurance policies do not cover hearing aids and consider them an elective treatment. Therefore, those requiring hearing aids who are not provided for by the Royal Medical Services apply for funding from the Ministry of Health, Higher Council, charity organisations or the United Nations agencies who may contribute a portion of the hearing aid price. The remainder of the cost is paid by the patient, unless they have insufficient income, in which case they can apply to other organisations for additional assistance. Typical hearing aid costs range between $282 and $2820. Cochlear Implants Similarly to hearing aids, cochlear implants (CIs) are not covered by insurance. An initiative by H.R.H. Crown Prince Hussein Bin Abdullah called “Hearing Without Borders” was launched in 2013 with the aim to provide CIs to children in need. The initiative provides funding for CI implantation and post implant support for speech and language therapy and training. CIs are provided unilaterally due to their high cost in order to benefit more children. Hearing Conservation Under the Ministry of Labour laws, all factories must provide their employees with ear protection and there are frequent health and safety checks to ensure that noise levels do not exceed the maximum permissible international levels. Furthermore, employees working in noisy environments have their hearing tested bi-annually. Education and training as an Audiologist The Applied Science University was the first to introduce an undergraduate audiology programme in the region in the early nineties. I was privileged to be amongst the first batch of au-

ear globe: audiology around the world

We were privileged to welcome Dr Daniel Rowan from the University of Southampton to the University of Jordan last year where he spoke to our students about the latest advances in Audiology. Dr Rowan inspired our students with exciting prospects for their future careers in Audiology. Professional Organisation The Advanced Arab Academy of Audiovestibulogy (4A), established in 2012, is a non-profit organisation dedicated to promoting quality of hearing and balance services and increasing public awareness of hearing and balance disorders and their treatment. It holds an annual conference which attracts scientists from all over the world. Summary Jordan deserved its recognition by the World Bank as a regional medical treatment hub. However, non-mandatory hearing screenings, non-universal coverage of hearing aids and limitations posed by insurers are not in line with the audiology standards of more developed nations. This doesn’t mean that the field will never catch up. In fact the collective national experience grows with every screening, treatment, and CI implantation and already far outweighs the expected capabilities of a small and resource poor nation. The development of Audiology in Jordan continues and though the road may be long and weary, Jordan is known for punching above its weight.

References Attias, J., et al. “The prevalence of congenital and early-onset hearing loss in Jordanian and Israeli infants: La Incidencia de hipoacusias congénitas y de inicio temprano en niños jordanos e israelíes.” International journal of audiology 45.9 (2006): 528-536.

Website list 1. http://www.alhussein.jo/en/initiatives/hearing-without-borders 2. http://www.queenaliafoundation.jo/ 3. http://www.holyland-deaf.org/ 4. http://www.jic.gov.jo 5. http://4aacademy.net/site/default.aspx

lunch and learn

Lunch and Learn CD

Facilitators and Correspondence

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

BSA Lunch and Learn eSeminars

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

Recent bites

Coming up on the menu

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

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

August 2015 Summer Special

The Past, Present and Future: Early Hearing Detection and Intervention. › Professor Christine Yoshinaga-Itano,

November 2015

Tinnitus in children: Practice Guidance › Dr Veronica Kennedy,

September 2015

Paediatric Vestibular Assessment. › Dr Devin McCaslin,

December 2015 Christmas Special To be confirmed

October 2015

Patient Centred Care. › Dr Caitlin Grenness and Dr Carly Meyer,

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

Look out for the new quarterly ‘Research Roundup’ A series of e-presentations showcasing the latest research from UK research institutes.

Coming soon from the BSA!

lunch and learn

Attention, listeners! Cognitive load impairs hearing and listening This short communication is based on the on-line BSA Lunch and Learn seminar by Professor Sven Mattys, 12/04/2015. The recording is available on www.thebsa.org.uk How good is an audiometric test at predicting a pilot’s ability to understand spoken instructions while monitoring flight instruments? Even leaving aside background noise and other forms of signal degradation, we know that listening is not performed by an “encapsulated module” that reliably takes in an auditory signal, extracts its component phonemes and maps them onto long-term word representations. Listening requires attention. But so does monitoring flight instruments… Under the assumption that humans have limited cognitive resources at their disposal and that these resources are shared across mental activities, listening accuracy must necessarily trade off with the demands of any concurrent tasks. And indeed, attending to a speaker while ignoring another voice is harder when asked to simultaneously hold several digits in working memory compared to a single one. Likewise, listeners fail to detect a tone more often when instructed to simultaneously perform a complex rather than simple visual task. This last example, referred to as inattentional deafness, is intriguing because it suggests not only that cognitive resources are shared across the auditory and visual modalities, but also that a shortage of resources can have consequences on a task as

Listening under cognitive load

lunch and learn

basic as sound detection. We recently found that the just-noticeable duration difference between two tones increased by approximately 50 ms when listeners were asked to simultaneously detect a red square in a 10-by-10 array of coloured shapes (a hard task) compared to performing the same task in a 2-by-2 array (an easier task). These and other findings indicate that listening is not impervious to cognition. What remains unanswered, though, is whether cognitive load truly impairs our ability to perceive or instead simply changes the way we listen.To find out, we measured brain activity during an auditory syllable discrimination task performed simultaneously with an easy vs. a hard visual task. We focused on two brain regions. The first region was the primary auditory cortex (or PAC), a cluster of auditory areas associated with the encoding of primary dimensions of sound, such as pitch and loudness, and the posterior superior temporal sulcus and gyrus (the pSTS and pSTG) and posterior middle temporal gyrus (the pMTG), areas associated with the encoding of acoustic-phonetic details. The second region was the dorso-lateral pre-frontal (DLPF) cortex, which is thought to regulate the voluntary control of attention and executive functions. The results showed weaker activation in the auditory cortex (mostly pSTS, pSTG and pMTG) during the hard visual task than during the easy one, but no difference in the prefrontal cortex. Thus, the detrimental effect of cognitive load is manifested as early as at the sound-encoding stage.

lunch and learn

45 psycholinguistics, hearing science and clinical practice can meet.

What these findings suggest is that hearing is deeply entrenched in cognition. Hence, our understanding of how we hear, perceive and listen can only benefit from a model of how such activities interface with attention and memory. For instance, an individual’s ability to cope with speech in noise shows a positive correlation with his or her capacity to hold materials in working memory. In that account, working memory enables a listener to hold onto patches of intelligible speech until later fragments can be used to disambiguate them; memory as a binding element. Given the wide individual differences in working memory capacity, it is tempting to conclude that how well one deals with speech in noise could be partly explained by how effective one’s working memory is.This kind of hypothesis lies at the core of cognitive hearing science.

References 1. Arlinger, S. , Lunner, T. , Lyxell, B., & Pichora-Fuller M.K. (2009) .The emergence of cognitive hearing science. Scandinavian Journal of Psychology, 50, 371-384. 2. Francis, A. L. (2010). Improved segregation of simultaneous talkers differentially affects perceptual and cognitive capacity demands for recognizing speech in competing speech. Attention, Perception, & Psychophysics, 72, 501-516. 3. Macdonald, J. S., & Lavie, N. (2011). Visual perceptual load induces inattentional deafness. Attention, Perception, & Psychophysics, 73, 1780-1789. 4. Mattys, S. L., Davis, M. H., Bradlow, A. R., & Scott, S. K. (2012). Speech recognition in adverse conditions: A review. Language and Cognitive Processes, 27, 953-978. 5. Mattys, S. L. & Palmer, S. D. (2015). Divided attention disrupts perceptual encoding during speech recognition. Journal of the acoustical Society of America, 137, 14671473. 6. Tun, P. A., McCoy, S., & Wingfield, A. (2009). Aging, hearing acuity, and the attentional costs of effortful listening. Psychology and aging, 24, 761-766.

So, how good is an audiometric test at predicting a pilot’s ability to understand spoken instructions while monitoring flight instruments? Probably not very. At least not on its own. Now, consider the same audiometric test performed under divided attention (e.g., monitoring a CCTV camera) and a normalised measure of the difference between the two conditions. Put simply, such a measure would be an index of the difference between hearing and listening. This is exactly the space where

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lunch and learn

ear to the ground

Ear to the ground

for all things ear-related in the media This issue of Ear to the Ground takes a looks at some of the lighter topics surrounding hearing and balance that have made their way into the media in recent times. There are even appearances by two sportsmen and a TV presenter! We also consider recent advances in research that have been reported on popular news websites. Amanda Hall’s #Twitterarty article covers the twitter debate hosted by North East Essex CCG on their proposals to follow North Staffordshire’s lead in denying access to NHS hearing aids for patients with mild hearing losses. The debate covered several different arguments, some of which transcend Audiology to ask bigger questions about the future direction of the NHS in this country.

Hair cell repairs go viral?

BBC News website reported recently on a study published in Science Translational Medicine which demonstrated that a genetically modified virus could infect mutated inner hair cells, correcting the mutations. The mouse study found that by repairing the TCM1 gene profoundly deaf mice saw improvements in their hearing thresholds from 115 dBHL to 85 dBHL over 60 days. The article concludes that human trials are still a fair way into the future but offers some hope for cautious optimism. It is also reassuring, from a professional point of view, to read the article explaining that noise induced damage will not be treatable this way because NIHL is caused by outer hair cell damage. The article is available at http://www.bbc.co.uk/news/health-33442820

Golfer recovers from vertigo to finish round

The Telegraph is among several media outlets to report on the story of Jason Day, who collapsed during his second round of golf at the US Open, but went on to finish his round. He was also able to play two rounds to come close to winning the tournament over the subsequent two days. Reading between the lines of the article, it appears that Day suffered an episode of central decompensation following vestibular neuritis in 2010. He was prescribed anti-emetics which allowed him to continue. Initial reports suggested that Day experienced BPPV, but following testing at a US clinic, this was ruled out as a cause for his episode. You can read Day’s comments on the Telegraph website http://www.telegraph.co.uk/sport/golf/ theopen/11735113/Jason-Day-will-not-be-deterred-at-The-Open-by-last-months-collapse.html

ear to the ground

47 Auditory Brain Training

An interesting article in New Scientist considered the effects of auditory brain training on improving intelligibility and listening ability. As explained in the articles there are many products on the market which claim to hold hearing loss at bay with brain training exercises, and the author decided to try one of them out. She was tested by ABR and speech in noise testing before and after a 40 brain training protocol, and the results were fairly interesting. Following training the author reports an improvement of 1.25 dB speech-to-noise ratio, and a decreased latency of 0.26 milliseconds in her ABR. She is fairly balanced in her opinions, explaining that she didn’t find a significant difference in her perceived hearing ability, but did feel more confident. The article is available at the New Scientist website, but unfortunately a subscription is required: https://www.newscientist.com/article/mg22730301-100-train-your-brain-for-better-hearing/?

Baseball player out with dizziness

Across the Pond, the New York Post report that baseball player Stephen Drew’s season is over after being hit by a ball which has caused concussion and may have caused a recurrence of a previous vestibular pathology. Drew has previously suffered vestibular damage secondary to trauma in 2013, and clinicians appear to suggest that further trauma has resulted in his current symptoms. Comments from Drew and his coach show disappointment, but the player’s welfare takes precedent, and both men are accepting of this. They are both grateful that MRI scans have ruled out more sinister pathologies. Read the report at http://nypost.com/2015/09/30/stephen-drews-season-likely-over-but-it-couldve-been-worse

“Have more sympathy” – Titchmarsh

Former Garden Force favourite Alan Titchmarsh used his article in the Telegraph to sympathise with adults with hearing loss. The article is not particularly well informed, and it is clear that Mr Titchmarsh has many of the pre-conceptions described in the survey reported in the above article. However, the point he is trying to make is to improve communication skills, which is to be commended. It is interesting to hear the views given to us in clinic so articulately delivered. In a nutshell, “I feel for others with hearing loss, but I’m fine. It’s just wax!” Read the article at http://www.telegraph.co.uk/goodlife/11825797/We-need-to-have-more-sympathy-for-those-with-hearing-loss.html

NHS AQP Providers “preferred” by patients

An article in the Independent in May highlights research which has demonstrated that since the introduction of the Any Qualified Provider (AQP) initiative, the majority of patients have opted for NHS services over free private providers. It is important to stress that these data are not Audiology specific, rather they cover the full range of services available via AQP. Further data from the research suggest that of 427 AQP schemes, only 165 are in fact offering a choice between NHS and private care. A spokesperson for Unison is quoted as describing AQP as “a waste of money” as the report suggests that patients choose the NHS. The full article can be read at http://www.independent.co.uk/life-style/health-and-families/health-news/most-patientsturning-down-the-chance-of-free-private-treatment-on-the-nhs-says-research-10221590.html

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48 Drugs for hearing loss and tinnitus

An article in the Mirror newspaper states that drugs will be available to treat tinnitus and hearing loss by 2020. They highlight a new report by Action on Hearing Loss, suggesting that with five drugs in the final stages of testing and several more in development, it is likely that 2020 will herald a new era in treating these conditions. The drugs that are in the pipeline aim to mitigate noise induced hearing loss, counter the ototoxic effects of certain chemotherapeutic agents and alleviate some types of tinnitus. The article can be read at http://www.mirror.co.uk/lifestyle/health/drugs-treat-tinnitus-hearing-problems-5527073

The social cost of hearing loss

The New York Times posted an article on their website interviewing a routine adult patient after they were first fitted with hearing aids. What is striking about the article is how the human element is added to the statistics that we all know so well; the time between a patient developing hearing loss and seeking help, the social cost of hearing loss to an individual, and the impact on friends and family. The article goes on to discuss a large scale survey which dates back to 1999, and it is interesting to see that overall attitudes have not changed significantly despite the leap forward Audiology has made technologically. The article can be read at http://well.blogs.nytimes.com/2015/09/28/hearing-loss-costs-far-more-than-ability-to-hear/?_r=1

Usher’s Case Update

In the last issue of Audacity, we reported on a video of a lady with Usher’s Syndrome who had her cochlear implants switched on and was delighted with the response. We are sad to bring the follow on piece, which describes the tour that Joanne Milne has been taking to build up a visual memory bank as her sight diminishes. The BBC’s Inside Out programme followed Joanne’s journey, and can be viewed on the iPlayer. Alternatively, excerpts of Joanne’s words were published in a BBC article. Which you can read at http://www.bbc.co.uk/news/uk-england-tyne-34339499

Call for Manx mobile trial A BBC article has added weight to a recruitment drive for a study on the Isle of Man which aims to evaluate the efficacy of altered signal processing in mobile phones to compensate for sensorineural hearing loss. The trial, run by Goshawk Communications, asks users to try the new processing and report back on any differences. According to Goshawk’s Matthew Turner, the devices combine ordinary telephone use with “audiology software”. The article, along with contact details for anybody who wants more information, Are available at http://www.bbc.co.uk/news/world-europe-isle-of-man-34648502

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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.

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Twitterarty @HallAmandJ introduces you to the audiology Twitter community

On October 7th, North East Essex CCG ran a one hour twitter chat to discuss proposed changes to hearing aid provision, using the hash tag #NEEchat. A selection of tweets from the chat is shown below (not necessarily in the order posted). NHS North East Essex @NEECCG Lets have conversation re plans restrict hearing aids minimal hearing loss We must find savings if not this what?

This edition of Twitterarty looks at recent twitter feeds of some of the charities and organisations supporting people with hearing loss, tinnitus and balance problems. We focus on tweets relating to campaigns as well as those promoting events and resources for patients and professionals.

Jason Smalley@bostonshirede . Oct 7 @Maxhickman5Max @NEECCG 37dB? Average? 1point? Worst ear? Better ear? Air condition? Bone conduction? #neechat Balance Course 2016@AdvBalance2016 . Oct 7 @NEECCG mild hearing loss on an audiogram does not necessarily equate to mild need. Don’t make this about the audio #NEEchat Kathleen @kathleenlhill . Oct 7 @cpmStarkiller @NEECCG please listen to patient’s difficulties and ignore scores. We speak in words not beeps.

The issue of service rationalisation as well as finances were raised...

There was some involvement from people with hearing loss in the discussions… Shona Hudson @shonajhudson . Oct 7 #NEEchat all I know is my hearing loss has a huge impact on my life & without access to treatment I would be lost Peter Byrom @audiophono001 . Oct 11 #NEEchat As an audiologist with a mild hearing loss I have to say I would be lost without my hearing aids

…although the extent of involvement was questioned Gareth @garethlsmith . Oct 7 Given this is not a massively popular medium in the target pop, how else is @NEECCG engaging with users & evidence #neechat

The proposed changes were clarified and implementation was discussed

Brit Acad Audiology @BAAudiology . Oct 7 @AdrienneBean9 @NEECCG #NEEchat service chagne does not have to be service rationing for the unlucky few in an area. Gareth @garethlsmith . Oct 7 #neechat denying the service, u are forcing people with a need to go privately, is that not back-door privatisation NHS North East Essex @NEECCG #neechat This is not about privatisation. This is about making difficult decisions in difficult times @bostonshirede #NEEchat Max Hickman @Maxhickman5Max . Oct 7 As a local GP I think we have to prioritise services. We are having to make some very difficult decisions #NEEchat Adrienne Bean @AdrienneBean9 . Oct 7 @Maxhickman5Max #neechat yess and I bet there are cases where you wish you didnt have to charge for a perscription too.....but ppl pay yes?

NHS North East Essex @NEECCG . Oct 7 We are not stopping the hearing assessment. We would not consider restricting aids above 38 db @AudioWorldnews @pbreckell #NEEchat

Sue Falkingham @swimto40 . Oct 7 #NEEchat to save significant money you would need to stop referring those with mild loss so put screening in primary care. h/a sml cost

Sue Falkingham @swimto40 . Oct 7 @NEECCG #NEEchat could be said that identifying a loss and doing nothing is causing harm. Telling someone there is a problem and doing 0

Gareth @garethlsmith . Oct 7 Needs and outcome based assessment, not rationing is required #neechat

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50 The evidence was challenged... Paul Breckell @pbreckell . Oct 7 @NEECCG @AudioWorldnews #neechat providing hearing aids early helps compliance later if hearing loss deteriorates Adrienne Bean @AdrienneBean9 . Oct 7 #NEEchat As an aud/logist I gave away 100’s of h/aids to ple who didnt want them and didnt wear them until their loss was significant @neeccg

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Gareth @garethlsmith . Oct 7 NNE GP, from experience much of the opinion in primary care on HAs is outdated, how are you assessing the recent evidence? #neechat Fiona Barker @Fi_BGB . Oct 7 #NEECCG don’t know where idea came from that NHS is fitting hearing aids to people that don’t need them! #AudPeeps #NEEchat

Possible consquences of the proposed changes... Gianluca Trombetta @j0hnlucas . Oct 7 The great problem is low adoption. this will make more people believe they can cope without hearing aids #hearinglosshour #neechat Gianluca Trombetta @j0hnlucas . Oct 7 Stating that hearing aids for moderate loss are not needed is terribly harmful because people will believe it #neechat #hearinglosshour

Ideas to save money rather than cut services were discussed..... Laura Brookes @nhs_laura . Oct 7 I’d be interested to know what cost saving initiatives patients & staff would like to see? #NEEchat NHS needs to ensure sustainable services Shona Hudson @shonajhudson . Oct 7 @HearingLossHour @j0hnlucas @AdrienneBean9 does follow up have to be a fully trained audio every time is there not an in-between option Gianluca Trombetta @j0hnlucas . Oct 7 @shonajhudson @HearingLossHour @AdrienneBean9 I believe that with the right tools, users can do most of the work #hearinglosshour #neechat HearingLossFriendly @HearingLossHouse . Oct 7 I would think any hearing aid dispenser could do follow up. What do others think? #hearinglosshour #NEEchat Adrienne Bean @AdrienneBean9 . Oct 7 @j0hnlucas @shonajhudson @HearingLossHour #neechat Amen to that statement. to think differently thats all it needs!!!!#hearinglosshour #neechat Gianluca Trombetta @j0hnlucas . Oct 7 At least NHS could give away hearing aids for free and let private audiologists maintain them for a small fee #hearinglosshour #NEEchat Adrienne Bean @AdrienneBean9 . Oct 7 @j0hnlucas #neechat why should they be free when glasses arent?

You can find a summary of the consultation on the NEE website:

http://www.neessexccg.nhs.uk/Have%20Your%20Say/ Consultations%20and%20Surveys/Current%20Consultations. html

ear to the ground

Follow us on Twitter to keep up to date with BSA courses, meetings and conferences. Find out about relevant events and conferences worldwide; as well as all the latest news from the world of audiology. Get involved by sharing meeting photos and contributing to regular discussion points and surveys.

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51 Top 10 research questions for mild to moderate hearing loss in adults Despite being a leading Global Burden of Disease (WHO, 2008) and one of six priority health areas for the National Institute for Health Research (NIHR), there is significantly less money spent on research into hearing loss (£47 per Disability Adjusted Life Years or DALYs) than for other NIHR health priorities (AoHL, 2011 such as sight loss (£100 per DALYs) and Diabetes (£399 per DALYs).

Stage 2: Checking uncertainties These unanswered questions were then grouped into themes and turned into research questions using PICO format (Population, Intervention, Comparison, Outcome), and checked against the literature to ensure they hadn’t already been answered by research. Unanswered questions were deemed ‘true uncertainties’ and were taken forward to Stage 3.

“Hearing loss continues to be an area in which there is low and highly variable take-up of available interventions and little systematic data for outcomes” (Murray et al, 2013).

Stage 3: Interim prioritisation A second survey was launched in July 2015, where people with direct or indirect experience of mild to moderate hearing loss were asked to rank 87 ‘true uncertainties’ in terms of how important it was that these questions were answered by future research (from not a priority, to very high priority).

The James Lind Alliance (JLA), a non-profit making initiative funded by the National Institute for Health Research (NIHR), aims to bring patients, carers, family members and healthcare professionals together to identify and prioritise research questions. In summer 2014, a JLA Priority Setting Partnership was formed to prioritise patient and clinician priorities for future research into mild to moderate hearing loss in adults. The JLA PSP was co-ordinated by the NIHR Nottingham Hearing Biomedical Research Unit. Key partners include the user organisation Hearing Link, patient representatives, the British Society of Audiology (BSA), the British Academy of Audiology (BAA), the British Society for Hearing Aid Audiologists (BSHAA), Action on Hearing Loss, and Cochrane UK. The JLA method promotes four key stages: Stage 1: Gathering uncertainties An initial survey was launched in November 2014 which asked people with direct or indirect experience of mild to moderate hearing loss to submit any unanswered questions they had about the prevention, diagnosis or treatment of mild to moderate hearing loss.

Stage 4: Final consensus workshop The final consensus workshop used a nominal group technique, which enabled the three groups of attendees to have equal input into the prioritisation process. The day has been expertly captured by Sarah Chapman (Cochrane UK knowledge broker, PSP steering group member and hearing aid user) in an Evidently Cochrane blog: http://www.evidentlycochrane.net/top-10-prioritiesfor-research-on-mild-moderatehearing-loss Top 10 research priorities for mild to moderate hearing loss in adults 1. What adverse effects are associated with not treating mild to moderate hearing loss in adults? 2. Does the early fitting of hearing aid(s) result in increased patient benefit and/or improved cost-effectiveness of the service? 3. Does the early fitting of hearing aids slow the rate of cognitive decline? 4. What are the reasons for low hearing aid uptake, use and adherence? 5. Can new technologies replace hearing aids?

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52 6.

Can stem cell therapy offer a cure for mild to moderate hearing loss in adults? 7. Does the early identification, diagnosis and treatment of mild to moderate hearing loss prevent further deterioration of hearing? 8. Could new developments to digital hearing aids offer improved speech perception in noisy environments? 9. How realistic are hearing tests for assessing the everyday hearing abilities of adults with mild to moderate hearing loss? 10. Could the use of real-world sounds to help program hearing aids in clinic (rather than tones or beeps) improve hearing aid effectiveness?

A final prioritisation workshop was held on 3rd September 2015, where the top 10 research priorities were agreed by patients, their family & friends and clinicians. Helen Henshaw, Senior Research Fellow at the NIHR Nottingham Hearing Biomedical Research Unit and PSP coordinator says, “It’s been an absolute pleasure to coordinate the mild to moderate hearing loss PSP, working alongside such passionate and engaged patients and clinicians.” “The James Lind Alliance method has enabled us to reach the top 10 research priorities for mild to moderate hearing loss through an inclusive process that enabled equal participation from individuals with hearing loss, their family and friends, and clinicians. This not only ensures that the research agenda is shaped by those individuals whom know the most about mild to moderate hearing loss, but also ensures that the limited funding available for hearing research may be best put to use in future.” The top 10 priority research questions are soon to be published in The Lancet. All 87 ‘true uncertainties’ will also be uploaded to the UK Database of Uncertainties about the Effects of Treatments (UK DUETs: http://www.library.nhs.uk/duets) to ensure that they are made widely available to Researchers, Research Funders and Commissioners. However, the PSP doesn’t end here… researchers at the NIHR Nottingham Hearing Biomedical Research Unit plan to conduct collaborative research projects to answer some of these priority questions. Furthermore, the analysis and publication of treatment uncertainties that did not make it to the final prioritisation stage of the process will help ensure that all submitted questions have the opportunity to be addressed by

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future research. For more details about the PSP please visit the mild to moderate hearing loss PSP website: http://www.hearinglink.org/ james-lind-alliance-priority-setting-partnership or the James Lind Alliance website: http://www.jla.nihr.ac.uk/top-tens/mildto-moderate-hearing-loss The JLA Steering Group comprised: Linda Sharkey (Hearing Link), David Crowe (James Lind Alliance), Robin Wickes (patient representative), Jean Straus (patient representative), Gemma Twitchen & Louise Hart (Action on Hearing Loss), Sue Falkingham (BAA), Barry Downes (BSHAA), Helen Pryce (BSA), Sarah Chapman (UK Cochrane Centre), Natalie Bohm (ENT UK), Melanie Ferguson (NIHR Nottingham Hearing Biomedical Research Unit). More information on the Steering Group can be found on the Hearing Link website on the JLA page http://www.hearinglink.org/jla-psp/who-is-involved References Action on Hearing Loss. Hearing Matters. 2011: pp. 1-84. Murray CJ, Richards MA, Newton JN, Fenton KA, Anderson HR, Atkinson C, et al. UK health performance: findings of the Global Burden of Disease Study 2010.The Lancet; 2013. Henshaw, H., Sharkey, L., Crowe, D. & Ferguson, M. A. (in press). Consensus on the top 10 research priorities for mild to moderate hearing loss in adults. The Lancet. The National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit is a partnership between University of Nottingham, Nottingham University Hospitals Trust and Medical Research Council Institute of Hearing Research. This project was funded by the Nottingham Hospitals Charity and the NIHR Nottingham Hearing Biomedical Research Unit. The authors declare no conflicts of interest.

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The Cutting Edge of Science in Cardiff BSA Basic Auditory Science Conference

With the change in timing of the Annual Conference to April 2016, the opportunity was taken to organise an autumn meeting of many of the UK’s hearing scientists titled “BSA Basic Auditory Science – The Cutting Edge”.This was held at the University of Cardiff on September 3 and 4, organized by Professor John Culling of the School of Psychology.

Across the two days there were 23 talks, almost 50 posters, and about 100 delegates from the UK and Europe. The furthest distance travelled was between Dr Massimo Grassi (Padova) and Dr Gaston Hilkhuysen (Marseille), each well over 1000 km; the closest was under 500m from Cardiff University.

Overall it was a success. Many thanks to Professor John Culling and his team for all the organization, and to everyone who attended for the excellent science.

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23 Infant

Plasticity following short-term unilateral hearing loss

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

DEAFinitely Inclusive Sport

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

68 Essay Competition deadline 2013 31st October

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During the first lunch break there was the Annual General Meeting of BSA. Unfortunately it was only sparsely attended, perhaps in part because it was during lunch, but the formal business of the Society was conducted and approved. The conference dinner was held in the University’s Aberdare Hall, and after that there was a first for BSA, an evening poster session with drinks, to my own surprise and glee, welsh cakes. The idea is to encourage discussion of science in an informal setting. It worked (of course!) and the poster session was well attended even late into the evening. Across both days the setting was informal, the science excellent and the interactions stimulating. The BSA’s mis-

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Across both days the setting was informal, the science excellent and the interactions stimulating.

As at every BSA meeting there was a welcome mix of presenters: some were entirely new to any BSA meeting, some had been before but were giving their first talk, some were very experienced. There was an audience test on one particular phenomena, and a new word to add to our scientific vocabularies – “subitizing”, being the ability to identify the number of items immediately without needing to actually count them – thank you to Kate Roberts from Warwick!

sion is to advance knowledge, learning, practice and impact in hearing and balance. This meeting met that: every new result presented, new insight obtained, new experimental idea thought of was an advance in the scientific knowledge of hearing. Some of the science could influence clinical practice relatively quickly, for instance, Jacques Grange and John Culling (Cardiff) convincingly demonstrated from data and models that directly facing a talker is not what a listener with a cochlear-implanted listener should do, its instead really much better to face slightly away.

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44 A trip to Bangladesh

of the outer hair position on top in a 'near live' UCL Ear Institute." "Tectorial membrane courtesy of Andrew Forge, Photo cell steriocilia.

Michael A Akeroyd, MRC Institute of Hearing Research & Professor of Hearing Sciences, University of Nottingham

A range of auditory science topics were presented and discussed, from the representation of sound location in the auditory cortex of ferrets to the benefits of head-shadow for cochlear-implant users. Others included zinc finger proteins, the effects of salicylate, otitis media, working memory, audiovisual integration, temporal fine structure, just-noticeable differences, neural networks, smartphone apps, mice, guinea pigs, chinchillas, speech, noises, clicks, pulse-spreading harmonic complexes and Zwicker tones on the way.

47 The Dichotic Hearing Test - a brief history

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Comments or Contributions to

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

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Summary on the BSA Annual General Meeting Prof Dave Furness, BSA Secretary

The AGM was held in Cardiff at the Basic Sciences Meeting on 3rd September 2015. Present on behalf of council were Dr Huw Cooper (Chairman), Mrs Liz Midgley (Vice Chairman), Prof Dave Furness (Secretary), Mr Graham Sutton (Treasurer) with a quorum (minimum 30 members), which included 17 members sending in a proxy vote, and non-members in attendance. After asking for Declarations of interest, of which there were none, the minutes of the previous meeting were approved without amendments, proposed by John Day and seconded by Adrian Reece. There were no matters arising, and the meeting continued with the Secretary’s report and Financial Report of the Treasurer. The complete Annual Report is available in the members’ area of the BSA website. The accounts were approved in the meeting; proposed by Michael Akeroyd and seconded by Peter West. Edwin Smith (Chartered Accountant) was then reappointed as auditor. This was approved by the meeting; proposed by Peter West and seconded by Liz Midgley. New trustees co-opted during the year were David Greenburg, Nicci Campbell, Siobhan Brennan

and Gareth Smith. Finally, the meeting was concluded with Chairman’s remarks. Dr Huw Cooper thanked the staff, the Trustees and Officers for their contribution to the BSA during the last year and discussed the vast changes in the BSA’s work and structure within the last 12 months. He welcomed Laura Turton as Operations Manager for her work so far in increasing the effectiveness of the BSA. He acknowledged the benefits of the professional support the BSA has already gained from transferring the services over to Fitwise. The other change in the last 12 months has been the decision to move the annual conference from September to April. He acknowledged the change in date has been met with a mixed response but that there would be a new format including a heavy involvement from the BSA’s Special Interest Groups and plans are well underway. The Annual Conference still aims to bring together interdisciplinary working and collaboration. The Learning Events Group have run a full programme of events for the last 12 months including Journal Clubs, Lunch & Learn webinars and Twilight meetings and there has been a huge improvement in the programme, which is driven by this excellent committee. The advisory role, where the BSA can provide unbiased scientific advice, led by trustee John Day has developed further with the main focus being the rationing of hearing aids in the NHS and the BSA has collaborated with other partners in this matter. He remarked he is looking forward to the next 12 months and the work of the BSA over this time. Under any other business, Ian Winter enquired as to the BSA support for a September Basic Science meeting in future years. It was agreed that this would be considered as part of the Learning Events Group.

Your new secretariat and conference organiser Neil Watt, Managing Director Fitwise Management Ltd

employee owned company based in Scotland. Throughout our 20 year history, we have become one of the most respected and admired names in the field of healthcare association and conference management. We have built up a sound knowledge of the audiology field, which combined with our expertise in association and event management makes us ideally placed to help BSA achieve its future goals.

An award winning company with over 20 years of Healthcare expertise I am delighted that Fitwise Management Ltd (Fitwise) is now providing secretariat and conference services to the British Society of Audiology. Fitwise is a highly experienced and fast-growing

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Fitwise works with many leading medical, scientific and nursing associations providing them with a full range of secretari-

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55 www.thebsa.org.uk

at services. We are delighted to be supporting BSA with: PA/ secretarial, general administration, membership management, bookkeeping, and marketing, to facilitate the smooth running of your Society. Fitwise also specialises in healthcare conference and event management. From initial concept to final debrief our event experts will work closely with BSA to make your conference memorable, engaging and successful. A dedicated team of experienced Marketing and Conference Sales Specialists will develop a comprehensive and exciting campaign aimed at identifying new audiences and optimising delegate, sponsors and exhibitor numbers.

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.

What Sets Us Apart? • Our people: We are an employee owned organisation which means that are staff are more committed, dedicated and focused on delivering an outstanding service to our clients. • We are much more than just a professional conference organiser. At our heart we are a full service association management company with an infrastructure of expert teams in Events, Sales, Marketing, Finance and Administration services. • We are an award winning company with over 20 years of Healthcare expertise. Our most recent accolade is a Gold Investors in People award. • We are highly innovative and are experts in the latest conference technologies to ensure your event is a completely engaging experience from before it starts to after if finishes. • We have extensive experience of organising conferences and events of various sizes and complexity at a UK and international level. For more information on Fitwise please visit us at: www. fitwise.co.uk / @fitwise_mgt

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 new website are: • The BSA Chairman’s message • Online access to electronic versions of BSA publications

British • Easy and Society free access toof BSAAudiology Policies and Procedures

| PRACTICE | IMPACT •KNOWLEDGE Easy access |toLEARNING 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 projects British Society ofoutreach Audiology

• Job adverts and information and links to organisations. KNOWLEDGE | LEARNING | PRACTICE | IMPACT

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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essentials

Essentials Council Members / Meeting Dates Officers Dr Huw Cooper – Chairman Mrs Elizabeth Midgley – Vice Chairperson Prof. Kevin Munro – Immediate Past Chairman Prof David Furness – Secretary Dr Graham Sutton – Treasurer Elected Trustees

Dr David Greenburg Dr Helen Pryce Dr Gareth Smith Council Advisors Dr Piers Dawes (Cognition & Hearing) Dr Melanie Ferguson (Learning Events) Mr Graham Frost (Professional Practice Committee)

Dr Michael Akeroyd

Ms Pauline Grant (Auditory Processing Disorder)

Ms Siobhan Brennan

Ms Lucy Handscomb (Adult Rehabilitation)

Dr Nicci Campbell

Ms Katy Morgan (Balance Interest Group)

Mr Chris Cartwright

Miss Charlotte Turtle (New Members)

Mr John Day

Dr Peter West (IJA)

BSA COUNCIL MEETNGS

BSA HOUSEKEEPING MEETINGS

8th December 2015 - Birmingham

17th November 2015 - Birmingham

15th March 2016 - Birmingham

9th February 2016 - Birmingham

21st June 2016 - Birmingham

17th May 2016 - Birmingham

20th September 2016 - (or at the Basic Science meeting)

16th August 2016 - Birmingham

6th December 2016 - (so to avoid Christmas) - Bristol

15th November 2016 - Bristol

Council (3rd Tuesday of the month) – all Trustees and (Advisors when requested / required) All Council Meetings are planned to run from 10.30am - 4.30pm, unless otherwise advised nearer the meeting

Housekeeping (3rd Tuesday of the month) – For Officers All Housekeeping meetings are planned for 11am - 2pm, unless otherwise advised nearer the meeting

PROFESSIONAL PRACTICE COMMITTEE MEETING DATES 2016 Monday 14th March • Monday 6th June • Monday 5th September • Monday 14th November For further information, please contact BSA Admin Office British Society of Audiology Fax: 01506 811477 Blackburn House Email: bsa@thebsa.org.uk Redhouse Road Web: www.thebsa.org.uk Seafield, Bathgate, EH47 7AQ Tel: 0118 966 0622

Meeting dates and venues may be liable to change and new dates for 2016 will be released imminently.

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

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Audio-Training) Lindsay Freeman

Oksana Munro

Charles Belletty

Dean Carey

Sue Harris

Sam Light

Thomas Starkey

Jonathan Simcox

Tracy Bennett

Marcel Khan

Kathleen Bagshaw

Mechelle Pease

Sean Busby-Little

Sarah Busby-Little

Charlotte Hawes

Martin Reader

Miles Cowler

BSA Certificate in Industrial Audiometry (Audio-Training) Georgina Jones

Sarah Hobill

Michele Williams

Tina Charles

Jennifer Roberts

Justin Roberts

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

Previous digital versions of

Audacity are available at:

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Audacity ...a British Society of Audiology Publication

issue 4 August 2014 ................................

Audacity ...a British Society of Audiology Publication

...a British Society of Audiology Publication

SPECIAL FOCUS

Hearing aid provision in the NHS

Online access

Psychoacoustics and beyond

Audacity issue 6 May 2015 ..........................

issue 5 December 2014 ..................................

Auditory training can improve cognition and communication....

OAEs: they just keep coming back

w ne

bsa

website

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explores new ideas

A trip to Bangladesh

Audiology in India

resources

audacity@thebsa.org.uk

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Under Pressure: NHS Audiology across the UK.

The Role of the School Entry Hearing Screen....

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

audacity@thebsa.org.uk

................................. www.thebsa.org.uk

"Tectorial membrane in a 'near live' position on top of the outer hair cell steriocilia. Photo courtesy of Andrew Forge, UCL Ear Institute."

60 New website for the BSA www.thebsa.org.uk

47 The Dichotic Hearing Test - a brief history

Facebook “f ” Logo

CMYK / .eps

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Audacity May 15 (Conflicted copy from Caroline iMac on 2015-05-21).indd 1

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CMYK / .eps

audacity@thebsa.org.uk .................................

21/05/2015 12:49

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Essentials Sponsor Members The partnership with Sponsor members of the British Society of Audiology (BSA) is of fundamental importance to the Society. As the largest multidisciplinary society concerned with hearing and balance in the UK, the BSA seeks to include commercial colleagues and organisations in its mission to promote knowledge, research and clinical practice in these areas. Being a Sponsor member places an organisation in close dialogue with senior members of the BSA, supporting meetings and publications. The outworking of this are yearly meetings between the Officers of the BSA and the Sponsor members to share information and perspectives on the strategic direction of the BSA. Sponsor members have direct input to the Programmes Committee, and their input is especially valued in the organisation of meetings and supporting exhibitions, these being a crucial element of successful events. ACOUSTIC METROLOGY LIMITED Manufacturers of VRA systems. Repair service of Audiometers, tympanometers and acoustics instruments. E: info@a-met.com W: www.a-met.com

INDUSTRIAL ACOUSTICS COMPANY LTD World leader in the design, supply and installation of high performance, state-of-the-art of Audiometric Rooms. E: info@iac-acoustics.com W: www.industrialacoustics.com/uk

SIEMENS HEARING INSTRUMENTS LIMITED Leader in the provision of digital hearing systems to the NHS and private hearing aids dispensers. E: info-hearingaids.shi.ukhealthcare@ siemens.com

AMPLIVOX LIMITED Amplivox provides a range of audiological products and services that combine innovation and reliability E: n.court@amplivox.ltd.uk W: www.amplivox.ltd.uk

OTICON LIMITED Oticon designs and manufactures both hearing solutions for adults, and specialized paediatric instruments. E: info@oticon.co.uk W: www.oticon.co.uk

SPECSAVERS Specsavers is largest provider of the free NHS digital hearing aids and 60% of its 17.3m customers in the UK are from the NHS. W: www.specsavers.co.uk

AUDITDATA LIMITED Auditdata provides office management systems for hearing clinics, innovative audiometry fitting systems, and hearing instrument testing. E: uksupport@auditdata.com W: www.auditdata.com

OTODYNAMICS LIMITED Otodynamics Ltd. pioneered OAE screening 25 years ago and sells a wide range of OAE screening and diagnostic instruments and makes in-house research and development its top priority E: sales@otodynamics.com W: www.otodynamics.com

STARKEY LABORATORIES LIMITED Provides information throughout the world about hearing loss, hearing aids and different types of hearing professionals. E: sales@starkey.co.uk W: www.starkey.co.uk

BIOSENSE MEDICAL LIMITED Biosense Medical supply specialist equipment for use in Audiology, Vestibular and Balance, Neurophysiology, Pressure Measurement, Human Movement and Biomechanics W: www.biosensemedical.com

PHONAK UK Phonak offers latest product information, an interactive content about hearing and a specific children section W: www.phonak.com

THE TINNITUS CLINIC The Tinnitus Clinic is the leading provider of the latest evidence-based tinnitus treatments in the UK. W: www.thetinnitusclinic.co.uk

ECKEL INDUSTRIES OF EUROPE LIMITED Eckel supply, design and install hemi (semi) and anechoic chambers. Further applications offered include Audiology Rooms and Suites. E: general@eckeleurope.co.uk W: www.eckeleurope.co.uk

PURETONE Limited Manufacturers of quality digital and analogue hearing aids, tinnitus management systems. E: info@puretone.net W: www.puretone.net

P C WERTH LIMITED PC Werth supplies calibrate and service the UKâ&#x20AC;&#x2122;s leading range of instruments for every diagnostic and audiology need. E: sales@pcwerth.co.uk W: www.pcwerth.co.uk

GUYMARK UK LIMITED Guymark is a distributor of GSI audiological equipment, Vivosonic ABR equipment and Micromedical Technologies balance equipment E: sales@guymark.com W: www.guymark.com

GN RESOUND LIMITED ReSound is part of GN ReSound Group, one of the worldâ&#x20AC;&#x2122;s largest providers of hearing instruments and diagnostic audiological instrumentation E: iinfo@gnresound.co.uk W: www.gnresound.co.uk

THANK YOU FOR THE VALUABLE SUPPORT

www.thebsa.org.uk

essentials

Essentials Audacity Advertising rates THE BSA ADVERTISING RATES : 2016 The following rates will come in to force on 1st June 2015 and will be in place for 12 months. The British Society of Audiology provides different methods of advertising opportunities which are listed below.

Website Advertising (up to 2mths) Jobs listing x 1 Each additional job advertised (50% discount) Commercial courses/events Non-commercial external events/courses

Cost (£) £ 448 £ 224 £ 283 £ 52

Website Advertising (up to 12mths) Commercial courses/events Non-commercial external events/courses

£ 1,132 £ 208

Mailshot to BSA members (per email) Job listings £ 256 Each additional job advertised (50% discount) £ 128 Commercial courses/events £ 211 Non - commercial courses/events £ 64

COMBINED ADVERT (Website for 1mth + one email) - 15% discount Jobs listing £ 598 Each additional job advertised (50% discount) £ 176 Commercial courses/events £ 419 Non-commercial external events/courses £ 98

Mailing/Special Single A4 sheet (flyer provided by the customer) £ 1,107 Single A4 sheet (B/W printed by BSA) £ 1,597

Audacity Magazine: (per issue) - sponsors receive around 35% discount 1/2 Page (sponsors) colour £ 335 1/2 Page (non-sponsors) colour £ 510 Full A4 Page (sponsors) colour £ 561 Full A4 Page (non-sponsors) colour £ 870 Full page colour inside front cover or back cover (non-sponsor) £ 952

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Full page colour inside front back cover (sponsor) £ 221 Technology Update per issue £ 237 Single A4 sheet (flyer provided by the customer) £ 664 Single A4 sheet (B/W printed by BSA) £ 922

Audacity Magazine - Special Rates (annually in both publications) - 15% discount Full page colour 2 issues (sponsors) 1/2 page colour 2 issues (sponsors) Full page colour 2 issues (non-sponsors) 1/2 page colour 2 issues (non-sponsors)

£ 954 £ 570 £ 1,749 £ 867

Premium advertising packages Full page in Audacity (one issue) + Web listing (2mths) + Bulk Email (one email) £ 1,416 1/2 page in Audacity (one issue) + Web listing (2mths) + Bulk Email (one email) £ 1,025 Full page colour in Audacity [unlimited words] (one issue) + Web listing (2 mths) £ 1,231 1/2 page colour in Audacity [unlimited words] (one issue) + Web listing (2mths) £ 798 1/4 page colour [200 words] (one issue) + Web listing (2mths) £ 608

2016 - AUDACITY PUBLICATION SCHEDULE Advertisements (copy date deadline)

Audacity (dispatch date)

1st April 2016 3rd October 2016

27th May 2016 28th November 2016

For further information please contact the BSA Admin Office by: Email: bsa@thebsa.org.uk or Tel: 0118 966 0622

company corner

61 Sivantos launches New Siemens Teneo™ at this year’s BAA Conference, Harrogate

Sivantos continues to support NHS Audiology Providers with the launch of the new Siemens Teneo hearing aids. Siemens Teneo, which includes Teneo R+ (RIC), Teneo S/S+ (mini BTE), Teneo M/M+ (Moderate BTE) and Teneo HP/HP+ (High Power BTE), will be launched on Thursday 26th November at the annual BAA conference which takes place at the Harrogate International Centre. Teneo, the successor of Octiv, includes new technology which will ensure Teneo continues to deliver exceptional sound quality and patient satisfaction. All Teneo models feature 24 channel processing and 24 channel automatic directionality providing superior sound resolution for improved listening in difficult acoustic environments due to greater frequency specific noise management and directivity patterns. All Teneo models also include our new automatic acclimatisation fitting option which offers a more comfortable initial fitting for patients, with gradual gain increases selected in Connexx over a selected time period. The new easyTek™ audio streamer is available for all Teneo+ models, operating straight out of the box with no programming required for straight forward connection to Bluetooth® devices. “We are delighted to be launching our new Siemens Teneo products to NHS customers at this year’s BAA”, says Wendy Davies, National Sales and Audiology Manager for Sivantos Limited. “It is important to us that we keep our NHS products on new technology platforms which provide tangible hearing benefits for patients with continually improving outcomes. Teneo offers enhanced noise management and directionality which will help patients communicate in tough listening situations, one of our core defining principles as a manufacturer of hearing aids.”

For more information please contact your Sivantos Account Manager. Sivantos Limited Platinum House Sussex Manor Business Park Gatwick Road, Crawley West Sussex RH10 9NH T: 01293 423700 www.bestsound-technology.co.uk Contact for journalists: Mark Laben UK Product & Marketing Manager E: Mark.laben@sivantos.com T: 01293423725

Sivantos Limited formerly Siemens Hearing Instruments Ltd (Crawley, West Sussex) provides a comprehensive range of digital hearing instruments and software, patient management systems and audiology equipment to the National Health Service, independent retail dispensers and national chains in the UK. It is the UK operation of Sivantos Group, which is one of the world’s leading manufacturers of hearing instruments, With 5,000 employees. Sivantos’ international sales organization supplies products to hearing aid specialists and sales organizations in more than 120 countries. Particular emphasis is placed on product development. The owners of Sivantos are the anchor investors EQT together with the Strüngmann family and Siemens as co-investors. Sivantos Limited is a Trademark Licensee of Siemens AG. Further information can be found under www.sivantos.co.uk

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Audacity ....a British Society of Audiology Publication

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