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The role of Audiovestibular Medicine in the Third Millenium

The role of Audiovestibular Medicine in the Third Millenium. Ewa Raglan IAPA 2014 17 th International Congress in Audiological Medicine In connection with Hearing International Annual Meeting Bangkok, Thailand 5-7 th November 2014.

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The role of Audiovestibular Medicine in the Third Millenium

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  1. The role of Audiovestibular Medicine in the Third Millenium Ewa Raglan IAPA 2014 17th International Congress in Audiological Medicine In connection with Hearing International Annual Meeting Bangkok, Thailand 5-7th November 2014

  2. The role of Audiovestibular Medicine in the third Millenium • Neuro-Oto-Audiology Clinic in the Third Millennium • The role of IAPA and an ENT Physician practicing an Audiovestibular Medicine.

  3. Summary • Development of audiology in the past • What is audiovestibular medicine? • A brief history of audiovestibular medicine • Growth of the subject in the last few years • Areas of audiovestibular medicine (paediatric AVM – UNHS, adult AVM – scope of the problem) • Future developments • Stem cells, Transdifferentiation • Local drug delivery to inner ear, • Neuro-otology (diagnoses,( vestibular migraine) techniques, treatment options) • Auditory Medicine( new diagnoses – auditory neuropathy spectrum disorder, central auditory processing disorders, genetics of deafness) • MDT

  4. Audiology in the past, past discoveries are the basis for further developments……. • Contributors to the developments of the medical science including audiology, over the years : • Hippocrates,Plato,Galen,Vesalius,Fallopio,Eustachio….etc • Schwartz 1920,Fletcher 1926- constructors of audiometers • Wever & Brey 1934 – cochlear microphonics potentials • Bekesy 1947, -- automated audiometry • 1969 first hearing aids worn within the ear • 1969 William House – cochlear implantation in adults • 1970 Jewett -- evoked auditory potentials • 1970 Jerger -- classification of tympanometry • 1971 Portmann,Aran –transtympanicelectrocochleography • 1978 Kemp - OAE

  5. Audiovestibular medicine • Diagnosis • Management of patients with hearing loss, tinnitus, dizziness

  6. Audiovestibular medicine – UK history • As a result of: • Development of science of audiology • Necessity to respond to patients’ needs and clinical presentations • Need to provide time, space for ENT surgery

  7. Growth of the subject • Medical manpower • Scientific manpower • Developments in science • Developments in technology

  8. PROGRESS in Audiovestibular Medicine 1990’s 2004/5 2007/8 2014 Surgery vs. medicine Scientific discoveries 1970’s Development of technology Development of new diagnoses ENT surgery vs. AVM Development of services MDT 50 (+20) AVP 3 MMC (medical) training changes 3000 Technician in Audiology Audiologist MSC training changes Consultant Clinical Scientist

  9. Role of Audiovestibular Physician • Diagnosis,aetiology of hearing loss, tinnitus, imbalance in Isolated ear disease or multisystem disease • Provide specific medical management, holistic medical care • Ensure AVM input in service provision and rehabilitation via MDT • Initially: +hands-on testing, hearing aid provision • Now: diagnosis, management, procedures

  10. Training in the UK - AVP • In the 1970’s • entry: ENT(FRCS)/General Medicine(MRCP)+5years AVM • Currently • Medical Degree • Foundation training for all(FY1/FY2) • Core Medical/ or Paediatric Training • 2 years in CMT or ST1/ST2 or • 3 years in core paediatric training (ST1, ST2, ST3) • Specialty Training(ST3 – ST7) • 5 years in AVM + Diploma/ Degree in AVM • Assessments - CCT

  11. Audiologists • 1970 - Technicians (shortage, inconsistent quality, O levels + courses + practical training) Career progression on duration of years worked • 2000 – Audiologists BSc in Audiology - 10 schools (300/yr) MSc in Audiological sciences • 2010/12 - Modernisation of scientific careers Change of training (BSc, MSc, HSST, PhD - career progression path towards Consultant Audiological Scientist on merit (knowledge & skills)

  12. Modernising Scientific Careers:Career and Training Pathways

  13. Audiological Medicine – UK Speciality • 1970’s • Paediatric audiology • Neuro-otology (vestibular medicine) • Adult Auditory rehabilitation • Founders • Tony Martin, Bethan Davies, Ron Hinchcliffe, Dai Stevens, John Marshall and others

  14. Audiological Medicine-IAPA • Set up in 1980 meeting in Poland

  15. Development of new technology • Hearing aids - digital • Cochlear implants • Brainstem implants • BAHA( bone anchored hearing aids) • Vestibular implant Emerging technologies of assessing vestibular mechanisms • VEMP (vestibular evoked myogenic potentials) • HTT (Head thrust test) • VAT (vestibular-auto rotation test) • New range of motorised Barany chairs with computerised analysis

  16. Service Developments • MHAS/MCHAS – Modernisation of Hearing Aid Services for Adults and Children • Digital Sound Processing • Bone Anchored Hearing Aids programme • Cochlear Implant programme • Newborn Hearing Screening Programme • [NHSP] • New services:auditory disorders and paediatric vestibular services

  17. Amplification-Hearing Aids

  18. Amplification-Implantable Devices

  19. Paediatric Audiology in the UK • Beginning of the 20th Century • Ewing Foundation established first university based programme for teachers of the deaf and undertook research into childhood deafness • Ewing’s established fundamental principles of paediatric audiology • Procedures for hearing assessment in pre-school children • Involvement of family in intervention programmes • Recognition of importance of early identification and intervention

  20. Paediatric Audiology – Universal Neonatal Hearing Screening Programme (UK) • Established 10 years ago • Age of fitting hearing aids reduced from 18+ months to 2-3 months • Quality assurance programme – testing VRA (bone conduction/ insert phone 6-7months) • Real ear measurements for hearing aid fitting • Improvement of quality of testing and interpretation of ABRs (peer-review) • Families are told of diagnostic test outcome same day

  21. Audiovestibular symptoms – Scope of the problem (UK) • Aged 55-75 years, 30% UK population bilateral hearing impairment • At 65 years, 30% population suffers dizziness/imbalance • At 55-75 years, 40% reporting hearing loss have associated tinnitus

  22. Integrated Care Pathway • DoH vision for improving services for patients with hearing impairment, tinnitus, dizziness, imbalance follows network model • Patients referred as quickly as possible to appropriate level of expertise • Requires teamwork within culture of continuous improvement and evaluation

  23. Future (I) • Auditory regenerative medicine/ Use of stem cells • To prevent hearing loss • To restore hearing • Local drug delivery for inner ear therapy • To avoid unwanted systemic drug effects • To protect inner and outer hair cells from damage (antioxidants, steroids, salicylates) in prevention of oto-toxic actions of aminoglycosides, chemotherapeutic agents, excessive noise, electrode-induced trauma

  24. Future (II) • Transdifferentiation • Differentiation of one cell type into another (in absence of mitotic event) • E.g. Non-sensory cells differentiate into sensory cells in response to transcription factor involved in hair cell differentiation (auditory and vestibular systems) • ? Safety and efficacy of the technology as applied to the inner ear/application as therapeutic approach to restoration of hearing and balance (Stecker et al, 2011)

  25. Neuro-otologyDiscoveries of the last 30 years • New diagnoses • Vestibular paroxysmia • Phobic postural vertigo • Superior canal dehiscence syndrome • Subtypes of BPPV • Vestibular Migraine

  26. Neuro-otologyDiscoveries of the last 30 years • Development of new innovative techniques now in clinical use • Quantification of gain of VOR • Evaluation of the otolith function (cVEMPsaccule, oVEMP utricle)

  27. Neuro-otologyDiscoveries of the last 30 years • New treatment options proven by clinical trials • Liberatorymaneouvres (for subtypes of BPPV) • Corticosteroids for acute vestibular neuronitis • Betahistamines for Meniere’s disease • Carbamazepine for vestibular paroxysmia • Aminopyridines for down/upbeat nystagmus and episodic ataxia • Canal plugging in SCDS

  28. Changes in the medical practice • Increased subspecialisation • Changing focus and scope • Appearance of other professionals • Increased incidence of some conditions • Technological developments • Economic issues(cost effectiveness ,preserving quality of care )

  29. Multidisciplinary team approach • Working together to provide patients with best overall care, but patient seen with a particular problem by a professional who is able to give him that care eg patient with presbyacusis seen by the audiologist, red flags escalated to the doctor. • Result- improvements of outcomes, and not substitution for a primary provider.

  30. Audiovestibular Multidisciplinary Team( MDT) Audiovestibular Physician Audiologist Scientist ENT Specialist Other members of MDT (specialists doctors and therapists) ENT Specialist

  31. Thank you

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