Transcript Knowledge - UEMS

DRAFT
UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS)
EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS)
Hearing and Balance in adults
Training Programme and Logbook
October 2012 / revised October 2013/August 2014
Subspecialty working group:
Kajsa-Mia Holgers
Ligija Kise
Ulf Schönsted-Madsen
Rene Dauman
Heikko Löppönen
Eva Raglan
Consensus curriculum
•
This document presents the contents of the hearing and balance and peadiatric
audiovestibular modules based on the curriculum for audiovestibular medicine,
specialty concerned with investigation, diagnosis and management of disorders of
balance, hearing ,tinnitus and auditory communication.
•
The aim of the curriculum is to define the core competencies including
knowledge , skills and attitudes for a specialist practicing that subject as applied to
adults and childrfen ( subdividing it into basic and advanced parts )
•
Basic section is to be used primarily within general ORL speciality training
curriculum and advanced section would constitute the curriculum for the
additional years of training.
•
Paediatric audiology although an integral part of audiovestibular medicine in
some countries ,is practiced separately in the others or in conjunction with
phoniatrics in some other countries.
Curriculum
• General internal medicine and neurosciences
form the basic foundations for Hearing and
Balance module. Modern care for hearing and
balance disorders requires the whole system
approach in which the “ ear “ problem is not
considered in isolation but as part of the
patient’s overall health.
• Multidisciplinary team
Curriculum
• This curriculum adapted from the Audiovestibular Medicine
Curriculum of the Royal College of Physicians of England
2010/2013, comprises two main fields of clinical practice, that
of Adult/ Child Hearing and Balance/Vestibular.
• In addition and common to all the fields are the background
knowledge, generic skills and experience in related medical
disciplines. Training in those specific areas can occur either
before or during specialist training.
• This training program is a guide for trainers and trainees, and
is endorsed by the International Association of
Audiovestibular Physicians.
CONTENT -logbook of training sections
1.
Background Knowledge
i.
ii.
iii.
2.
Basic Sciences
Preventive Medicine
Instrumentation
Generic skills
i.
ii.
iii.
3.
Clinical skills
Communication skills
Patient approach
Core Fields
i.
ii.
4.
Adult Hearing Section
Adult Balance Section
Practical procedures
i.
ii.
Adult hearing disorders
Adult balance disorders
CONTENT
5 Related medical disciplines
i.
ii.
iii.
iv.
v.
vi.
vii.
Otorhinolaryngology
Neurology
Ophthalmology
Psychology/ psychiatry
Genetics
Care of the elderly
Immunology and allergy
viii. Radiology
6. Pediatric Hearing Module
7.
Knowledge, skills
8. Pediatric Vestibular Module
9. Learning and teaching , training programs
7.
i.
Diploma in Audiovestibular medicine ( relevant modules)
ii.
Requirements of training posts
Assessments
1 BACKGROUND KNOWLEDGE
1a) BASIC SCIENCES
A sound and comprehensive knowledge of the basic sciences subserving the audiological and vestibular systems is essential to
practice.
Knowledge
Performance
Category
Anatomy, physiology, neurochemistry, pharmacology of the auditory and vestibular
systems, their central pathways, connections and related systems / organs.
B
Embryology.
B
Age related changes in postural control and responses to visuo-vestibular stimulation.
B
Psychology of hearing and balance including psychoacoustics.
A
Advances in molecular biology: repair / regeneration in relation to the cochlea and
vestibular system, stem cell research in relation to the ear, genetic manipulation etc.
Theoretical basis of auditory and vestibular tests.
BA
Principles of auditory and vestibular rehabilitation, knowledge of external support
agencies, voluntary bodies and policies inclusive of employment support
BA
Principles of instrumental rehabilitation including auditory nerve stimulation and
basic electroacoustic properties of the hearing aids.
Basics acoustics including physics of sound waves and room acoustics.
B A
Standards relating to acoustics, calibration and sound proofing.
A
BA
A
Date
Signature
Trainer
1 b) PREVENTIVE MEDICINE
Knowledge
Performance Date
Category
General principles of primary, secondary and tertiary prevention
B
Screening principles, methods and practice; including setting up a screening
programme, dealing with screen failures, monitoring and audit.
BA
Screening for hearing loss — newborn, school, industrial, elderly etc.
Timeline for the support of hearing disorders.
A
A
Noise and its effect on the audio-vestibular system, damaging noise levels, sources of
such noise and prevention of exposure including noise surveys, hearing conservation,
ear protection and international standards
BA
Ototoxicity; substances, drugs, industrial toxins that affect the audio-vestibular system
and their effects.
BA
Genetics affecting predisposition to ototoxic agents.
A
Epidemiology and prevention of hearing loss.
BA
Role of immunization and therapy in the prevention of hearing and balance disorders.
BA
Signature
Trainer
1 c) INSTRUMENTATION
Practice of hearing and balance specialist requires a comprehensive knowledge of auditory and vestibular
test equipment, amplification, including assistive listening devices.
Knowledge
Performance
Category
Principles, technology and limitations of auditory and vestibular test equipment .
BA
Principles, function of analogue, digital hearing aids, including body worn, post
aural, in the ear, in-the-canal, totally-in-the-canal, vibrotactile aids, bone-anchored
hearing aids , frequency compression ,frequency transposition aids, CROS
(contralateral routing of signal) and BICROS aids and implantable hearing aids
including middle ear , bone conduction and cochlear implants
BA
Hearing aid fitting formulae and real ear measurements .
The effects of various parts of hearing aid system (hooks, moulds, tubing etc) on
sound amplification.
A
A
Assistive devices available including the radio aid and FM soundfield systems,
alarm systems, loop systems .
BA
Methods of assessing benefit of amplification.
A
Date
Signature
Trainer
1.c) INSTRUMENTATION Continued
Skills: To be able to
Critically review audiometric and vestibular test results
Perform
ance
Category
BA
Determine the appropriateness / type of amplification (including cochlear
implant) through discussion with audiological colleagues, patients
BA
Discuss the current best technology with patients, their families, and other
professionals
B
Refer appropriately for amplification
B
To have practical experience of:
Perform
ance
Category
Selecting various hearing aids , devices including BAHA and cochlear implants
BA
Measuring benefit of amplification, inclusive of active middle ear and bone
conduction implants
Particles repositioning manoeuvres egg. Epley, Semont etc.
BA
Instructing the patient in appropriate exercises e.g. Cawthorne- Cooksey,
Brandt- Daroff, customised/ protocols for visual vertigo
BA
BA
Date
Signature
Trainer
Date
Signature
Trainer
2. GENERIC SKILLS
Aside from the generic skills required of all practicing doctors there are specific required generic skills These are an integral part of
training in all aspects of the work.
Clinical Skills: To be able to:
History
Performance Date
Category
BA
Take detailed history of auditory and vestibular disorders and associated problems including a developmental or
psychosocial history.
Examination
BA
Perform clinical examination, ENT, neuro-otological, oculomotor, neurological.
Select / interpret
BA
Audiological, vestibular , etiological tests appropriate to the patient’s presentation, age and additional difficulties.
Select/ interpret
BA
Appropriate multidisciplinary assessments including speech and language, psychometric or physiotherapy
assessment .
Integrate
BA
The history, examination, investigative findings , formulate a diagnosis and management plan.
Management strategies
BA
Select appropriate management strategies through multidisciplinary team discussion and discussion with the
patient and careers; e.g. hearing aids, tinnitus instruments, cognitive therapy, relaxation, pharmacological options,
physiotherapy, occupational therapy, educational strategies, surgical options - depending on the cause and impact
of the problem and the age and additional disabilities of the patient.
The impact of a management
BA
Assess the impact of a management strategy using appropriate outcome measures
Disability
BA
Assess disability accurately and judge occupational fitness e.g. use of machinery and fitness to drive
Identify additional medical problems which may be causative or may adversely affect rehabilitation e.g. visual defects,
neurological disease, endocrine disease, joint pathology, cardiac disease, developmental delay
BA
Identify psychological problems needing psychology/psychiatric referral.
BA
Identify syndromic and genetic causes of hearing and balance disorders.
Elicit sensitive information from the parent/patient relevant to management
BA
BA
Signature
Trainer
2. GENERIC SKILLS - Continued
2 b Communication Skills:
to be able to:
Performance
Category
Communicate effectively with patients of all ages, including the
children and elderly.
BA
o
with disorders of hearing
BA
o
with poor speech production due to deafness or other disorders
of speech and language
BA
o
with visual disorders including the deaf-blind
BA
o
with intellectual disability
BA
o
With those needing sign language or spoken language
interpretation
BA
Communicate effectively with colleagues within the
multidisciplinary team and with specialists in other disciplines
BA
Determine the communication abilities and needs of the
congenitally deaf and the deaf/blind patient and where needed use
finger spelling and some basic signs
BA
Counsel the patient/parent/ carer appropriately
BA
Date
Signature
Trainer
2.C Patient Approach
The specialist must recognize and understand:
The need for an empathetic, tactful and positive approach
Performance
Category
The impact of disorders of hearing and balance on the individual and their family
with regard to everyday function including employment, psychology and social
interaction
The impact of disorders of hearing on the development and maintenance of speech
and language and education
The combined effect of deafness or /and balance , dizziness disorders with other
difficulties, such as visual defects, learning disability etc.
The importance of holistic care
The importance of the history including family history & developmental history in
making a diagnosis.
The importance of a social, educational and psychological history in managing
individuals with audiovestibular impairment.
Referral routes of patients with hearing/ dizziness/balance problems egg
psychology, social services, neurology, cardiology, ophthalmology, physiotherapy,
occupational therapy.
The importance of education of significant others to aid rehabilitation .
The value of multidisciplinary team working both within and outside the clinic .
BA
The attitudes of those within the Deaf Community .
The use and value of complementary medical approaches to holistic management of
tinnitus and of otitis media with effusion .
The importance of patient confidentiality and informed consent.
The importance of effective multidisciplinary team work and communication with
colleagues both verbally and in writing .
The importance of sharing information with patients and their careers
The existence of national guidelines and their values and limitations.
BA
BA
The value of voluntary agencies in supporting the patient with hearing and balance
disorders and their family/careers.
BA
BA
BA
BA
BA
BA
BA
BA
BA
BA
BA
BA
Date
Signature
Trainer
3. CORE FIELDS
3.i.
Adult “ Hearing” module ( inclusive of adolescents, younger , older adults and elderly)
3.i.i
Clinical Topics - Knowledge Base
Tinnitus
Performance
Category
Etiological and triggering factors
Current pathophysiological theories about tinnitus generation
Prevalence of tinnitus and its natural history of habituation.
Audiometric and etiological investigations
Psychological effects on the patient and how these can be managed
BA
BA
BA
BA
BA
Management of patients with tinnitus including instrumentation
BA
Sudden hearing loss
Performance
Category
Presentation and causes.
Audiological and etiological investigations
The psychological impact of sudden hearing loss, particularly if
permanent and bilateral.
Current evidence based management of acute presentation
Management including indications for surgery, amplification,
communication strategies and hearing tactics
BA
BA
BA
BA
BA
Date
Date
Signature
Trainer
Signature
Trainer
Clinical Topics - Knowledge Base - Continued
Unilateral hearing loss, progressive or fluctuating
unilateral or bilateral hearing loss.
Performance Date
Category
Presentation and causes
BA
Audiometric and etiological investigations
BA
Identification of site of lesion
BA
Impact on the patient and significant others
BA
Current evidence based pharmacological,audiological
rehabilitative or / and surgical management
BA
Signature
Trainer
Clinical Topics - Knowledge Base - Continued
Dysacuses, auditory processing disorders (APD) and auditory
neuropathy/dysynchrony (AN/AD)
Performance
Category
Presentation and causes of dysacuses, APD and AN/AD
A
Investigation and management of dysacuses and their causes
A
Methods of testing the function of the different parts of the central
auditory pathway
A
The rehabilitative approaches available for APD and AN/AD
A
The psychosocial effects of these hearing difficulties
A
Intellectually disabled adult
Performance
Category
Audiological or neuro-otological problems that may be associated with
intellectual handicap and the specific effects that such problems may
have
A
Presentation, diagnosis, investigation and management of hearing
problems in adults with learning difficulties
A
Rehabilitative approaches available for such patients
A
Issues concerning ‘consent’ in these patients
A
Date
Date
Signature
Trainer
Signature
Trainer
Clinical Topics - Knowledge Base - Continued
Congenitally deaf adult
Performance Date
Category
Causes of congenital deafness/hearing impairment
Effects on speech & language and communication
Impact on individuals and significant others, including psychosocial
effects
Associated symptoms such as tinnitus or balance difficulties
Alternative communication systems
Deaf culture and the local support facilities for deaf people
Hearing aids and environmental aids
Rapid advances in the research of genetic deafness and its impact on
patient management
BA
BA
BA
Hearing problems in the elderly
Performance
Category
Causes of hearing impairment in the elderly.
Effects of the general ageing process on the auditory system
General medical problems or other impairments which might affect
rehabilitation e.g. Loss of tactile sensitivity, joint mobility, blindness,
poor memory
BA
BA
BA
Associated problems such as balance disturbance and falls
Psychosocial issues including feelings of isolation and avoidance
Rehabilitative approaches in the elderly ( inclusive of auditory and
vestibular)
External support agencies, voluntary bodies and policies e.g. Social
workers
BA
BA
BA
Signature
Trainer
BA
A
A
BA
A
BA
Date
Signature
Trainer
3b. Adult “ Balance “ Module
Background Knowledge Specific to the Field
Performance
Category
The anatomy and physiology of the vestibular system, its central
connections and interactions with the visual and oculomotor
systems.
An understanding of vestibular test equipment, investigative
techniques, selection of appropriate set of investigations and
interpretation of results
Clinical presentation of various conditions presenting with dizziness/
unbalance
BA
BA
BA
BA
Differentiation of peripheral from central vestibular causes of vertigo
and definition of site of lesion within CNS
Assessment of impact of the balance disorder on the individual
Factors likely to affect rehabilitation
BA
BA
Date
Signature
Trainer
Adult Balance - Clinical Topics - Knowledge Base
Acute vertigo
Performance
Category
Causes, presentation and natural history of acute vertigo
BA
Associated eye movement abnormalities
BA
Audiovestibular and etiological investigations
BA
Management options, including rehabilitation, dietary manipulation,
pharmacological and surgical
BA
Recurrent disequilibrium
Performance
Category
The sensorimotor physiology involved in balance maintenance
Causes of peripheral and central vestibular disorders with remitting and
relapsing courses
BA
BA
Factors hindering vestibular compensation including pathology in other
stabilizing sensory and motor effector systems
BA
The psychological impact of recurrent disequilibrium
Vestibular tests and etiological investigation
Management options including pharmacological, physical rehabilitation and
psychological /psychiatric interventions
BA
BA
BA
Date
Date
Signature
Trainer
Signature
Trainer
Adult Balance - Clinical Topics - Knowledge Base
Chronic imbalance
Performance
Category
The range of central vestibular disorders causing chronic imbalance
A
Pathology in the stabilizing sensory systems which give rise to
multisensory imbalance
A
Pharmacotherapeutic agents causing chronic imbalance
A
Etiological and vestibular investigations
A
Management options
A
Blackouts/drop attacks
Performance
Category
The mechanisms of epilepsy, pseudo-epilepsy, syncope, vasovagal attacks,
and blackouts, and to
know the etiological factors involved
A
The investigation protocol and type of abnormalities found for each of
the above
A
The pharmacotherapeutic options available to treat each cause
A
The law regarding black-outs and syncope and fitness to drive
A
Date
Signature
Trainer
Date
Signature
Trainer
Falls in the elderly
Performance
Category
The effects of ageing and neurological disorder on the postural and righting
reflexes
The causes of black-outs and drop attacks including cardio- and
cerebrovascular pathology
The musculo-skeletal disorders impairing maintenance of the upright posture
and locomotion
Audiovestibular and etiological investigations
The pharmacological and physiotherapeutic management options
A
A
A
A
A
Date
Signature
Trainer
5. PRACTICAL PROCEDURES
a.– specialist in adult hearing disorders
Knowledge:
Theoretical basis of audiological testing (See Basic Sciences section )
Indications for the various audiological tests
Values, limitations and practical difficulties of audiological testing
Performance
Category
Date
Signature
Trainer
a. PRACTICAL PROCEDURES – specialist in adult hearing disorders - Continued
Skills
Performance
Category
Select appropriately and interpret correctly all the following
audiological tests.
BA
Practical experience of all the following tests. Competency in performing
particular tests will depend on the specific clinical practice of the country.
A
o
Psychoacoustic tests of hearing and auditory function:
o
Pure tone audiometry (air conduction, bone conduction with or without
masking)
A
o
Behavioral and conditioning techniques for soundfield and ear specific
audiometry in learning disabled adults
A
o
Speech perception tests including speech in noise
A
o
Tests of auditory processing
A
o
Objective tests of auditory function
o
Acoustic immitance measures and middle ear reflex measures
A
o
Otoacoustic emissions (transient, distortion product, spontaneous, contralateral suppression)
A
o
Evoked responses (electro-cochleography, auditory brainstem responses,
middle latencies,
cortical responses, auditory steady state responses etc)
A
Date
Signature
Trainer
b. PRACTICAL PROCEDURES- Specialist in adult balance / vestibular disorders
Knowledge:
Performance
Category
Theoretical basis of vestibular testing( see Basic Sciences section )
BA
Indications for vestibular testing
BA
Values, limitations and practical difficulties of vestibular testing in adults.
A
Skills:
Performance
Category
To be able to select appropriately and interpret correctly
all the following vestibular tests in adults.
BA
To have practical experience of all the following tests. Competency in
performing particular tests will depend on the specific clinical practice of the
country
o
Dix-Hallpike testing
o
Video-nystagmography
o
Caloric irrigations
A
o
o
o
A
A
A
BA
Posturography , Head trust test , Visual Dynamic Acuity
ENG/EOG recordings during visuo-vestibular stimulation
Vestibular evoked myogenic potentials (VEMPs, cervical and ocular)
To be able to integrate the results of audiological,
vestibular and aetiological tests to formulate a diagnosis
and a management plan
BA
A
A
Date
Signature
Trainer
Date
Signature
Trainer
6. RELATED MEDICAL DISCIPLINES
6 a OTORHINOLARYNGOLOGY(requirement in relation to training program of
specialist in audiovestibular disorders)
Performance Date
Objectives:
Category
Signature
Trainer
To gain a detailed knowledge of pathology and management of otological
conditions
To observe audiology related ENT surgery such as
• grommet insertion,
• mastoidectomy,
• tympanoplasty,
• cochlear implantation,
• bone anchored hearing aids
• vestibular schwannoma.
To be experienced and competent in use of ENT referral criteria
To gain knowledge of rhinological, oropharyngeal, upper airway and other head
& neck conditions that may affect the audiovestibular system and speech.
Knowledge:
Embryology, anatomy, physiology of the ear and head & neck
Pathology, appropriate investigations (including imaging) and management of
congenital, acquired and other conditions of the ear including indications, risks,
outcomes and complications of surgery
Head and neck conditions that may produce aural symptoms including
conductive hearing loss, and their appropriate management
Performance Date
Category
Signature
Trainer
a, OTORHINOLARYNGOLOCY - Continued
Skills: To be able to:
Performance Date
Category
Signature
Trainer
Performance Date
Category
Signature
Trainer
Take a full otological/ENT history relevant to the audiovestibular
system and speech.
Perform an accurate and comprehensive examination of the ear, nose,
oral cavity, pharynx and head & neck including use of otoscope,
operating microscope, head mirror
Identify and treat causes of otalgia, external and middle ear
dysfunction .
Perform intratympanic injections of medications
To be competent at:
Removal of wax and debris from the external auditory canal using
appropriate instruments, syringing or suction either under direct vision
or using the operating microscope as appropriate
b. NEUROLOGY
Objectives
Performance
Category
Date
Signature
Trainer
To make an accurate neurological assessment of a patient
To know when to refer a patient to a neurologist or a neurosurgeon
Knowledge
Performance
Category
Date
Signature
Trainer
Causes of central audiological and vestibular disorders
Neurological disorders with neuro-otological manifestations
Investigation protocols for the above disorders
Pharmacological treatments and side-effects of common neurological
disorders with neuro-otological manifestations
Skills: To be able to:
Take a complete neurological history and perform competently a full
neurological examination
Recognise neuro-otological manifestations of neurological disorders
and select appropriate investigations
Performance
Category
Date
Signature
Trainer
c. OPHTHALMOLOGY
Objectives:
Performance
Category
Date
Signature
Trainer
Date
Signature
Trainer
To know how to screen a patient for ophthalmological and oculomotor
disorders
To know when to refer a patient with such symptoms
Knowledge:
Performance
Category
Ophthalmological disorders with associated audiological and neuro-otological
manifestations
Eye movement disorders
Impact of visual disorders on balance and the confounding effect upon
vestibular test procedures
Impact of visual problems on communication for the hearing impaired
Management of common visual problems
Causes, impact and management (including the role of voluntary bodies) of dual
sensory impairment
Skills: To be able to:
Take a history of ophthalmological symptoms from a patient
Make an accurate assessment of a strabismus, latent nystagmus, saccades,
smooth pursuit, spontaneous and optokinetic nystagmus
Perform a full ophthalmological examination and correctly recognise optic field
defects, papilloedema, conjunctivitis, choroiditis, iritis, retinitis and disordered
eye movements
Recognise relevant and common visual disorders i.e. Altered visual acuity.
strabismus, benign intracranial hypertension, glaucoma, presby- and hypermetropia
Performance Date
Category
Signature
Trainer
d. PSYCHOLOGY/PSYCHIATRY
Objectives:
Performance
Category
Date
Signature
Trainer
Performance
Category
Date
Signature
Trainer
Performance
Category
Date
Signature
Trainer
To understand the psychological difficulties and psychiatric disorders
associated with deafness and hearing impairment and the presentation
of these disorders in the deaf patient
To understand the psychological difficulties and psychiatric disorders
associated with tinnitus, dysacuses, vertigo and imbalance
To obtain an adequate psychological profile, to recognise manageable
conditions and refer appropriately
To acquire appropriate counseling skills
Knowledge:
Psychiatric disorders with audiological and vestibular manifestations
How psychotropic medication may influence audiovestibular disorders
Psychological/psychiatric morbidity of neuro-otological disorders,
tinnitus, dysacusis and sudden hearing loss
Pathogenesis and presentation of non-organic hearing loss.
Psychological morbidity of hearing impairment including dual sensory
impairment
Presentation of psychological problems and psychiatric disorder in the
congenitally deaf patient
Skills: To be able to:
Identify behavioural disturbances and psychiatric disorder from the
clinical presentation
Discuss psychological/psychiatric disorder appropriately with patient
e. GENETICS
Objectives:
Performance
Category
Date
Signature
Trainer
To obtain an understanding of genetics in audiovestibular disorders
and the role of the clinical geneticist
Knowledge:
Performance
Category
Date
Signature
Trainer
Inheritance patterns of hearing loss.
Genetics of and available tests for conditions associated with
audiovestibular disorders.
The psychological impact of genetic disorders.
Skills: To be able to:
Elicit and record correctly a detailed family tree.
Interpret correctly a diagnostic DNA report together with its
implications
Performance
Category
Date
Signature
Trainer
f. CARE OF THE ELDERLY
Objectives:
Performance
Category
Date
Signature
Trainer
Performance
Category
Date
Signature
Trainer
To obtain an overview and understanding of the medical conditions
affecting the elderly including falls, multi-system disease, cognitive and
visual impairment
Knowledge:
Common causes of falls and imbalance in the elderly.
The effect of ageing on cognition and memory
The impact of multi-system disease and its pharmacological management
Roles of other members of the multi-disciplinary teams caring for the
elderly.
g. IMMUNOLOGY & ALLERGY
Objectives
Performance
Category
Date
Signature
Trainer
To understand the effect of disordered immunity and allergy on the
audiovestibular system
Knowledge:
The pathophysiology, presentation, diagnosis, management and
prognosis of auto-immune diseases that affect the audiovestibular
system
The pathophysiology, presentation, diagnosis and management of
allergy affecting audiovestibular function, in particular allergic rhinitis
Immune deficiency disorders affecting the audiovestibular system - their
pathophysiology, diagnosis and management
Performance Date
Category
Signature
Trainer
h. RADIOLOGY
Objectives
To appreciate the value of imaging in the diagnosis and management of
audiovestibular disorders
Ability to select and request optimal imaging technique and views for
specific disorders
Knowledge
The congenital and acquired abnormalities of the petrous temporal bone
and central nervous system that can be identified by radiological imaging
techniques, such as CT scan, MRI scan, fMRl scan and PET scans.
Performance
Category
Date
Signature
Trainer
PAEDIATRIC AUDIOLOGICAL MEDICINE
• Fundamental to practice in this field is a sound knowledge of
developmental pediatrics, otorhinolaryngology, pediatric
neurology, pediatric ophthalmology, child
psychology/psychiatry and genetics as detailed in Section 5
• As well as background knowledge in Basic Sciences,
Preventive Medicine and Instrumentation (Section 1).
• Generic skills, as they apply to a pediatric practice, outlined in
section 2 underpin practice in this area. Training in child
protection is essential.
7.Background Knowledge- Pediatric Hearing Module
7 a. Normal child development including normal
speech and language development
The impact of deafness on speech and language development
When and to whom to refer children with hearing difficulties and
additional problems e.g. psychology, education, neurology, endocrinology,
cardiology, ophthalmology etc.
Country specific statutory educational provision for children with special
educational needs, including hearing loss, speech & language disorders,
balance disorders and learning disability.
Principles and practice of screening for hearing loss see also preventive
medicine 3b
Value of multidisciplinary working
Existence of national/international guidelines and their value and
limitations.
Performance
category
A
BA
A
A
BA
A
Date
Signature
Trainer
7 b. Clinical Topics - Knowledge Base
Congenital and prelingual Deafness:
Performance
category
Signs, symptoms and presentation
BA
Etiology of hearing disorders including involvement of other systems
A
Etiological investigations
A
Impact of deafness on speech and language development, education,
social and emotional development of the child
BA
Management of a deaf child including alternative modes of
communication and educational needs
A
Psychological and cultural issues surrounding deafness, its diagnosis and
management.
A
Date
Signature
Trainer
7.c. Progressive, Sudden or Late Onset Deafness
To be able to detect, investigate, diagnose and manage progressive or sudden deafness in
children
Knowledge
The signs, symptoms, aetiology and management
BA
The psychological sequelae
BA
The impact of progressive, sudden or late onset hearing loss on speech and
communication skills, education and school performance
A
The changing educational needs of the child
A
The appropriate audiovestibular and aetiological investigations
A
When to refer for further medical opinions and to other allied healthcare
professionals
Local and national guidelines covering the identification, management and
investigation of progressive or sudden hearing loss
A
The indications, benefits , limitations and side effects of any medication used for
progressive or sudden hearing loss
BA
A
7.d Fluctuating Deafness, Including Otitis Media with Effusion
To be able to detect, investigate, diagnose and manage fluctuating deafness, including otitis
media with effusion, in children
Performance date
To demonstrate knowledge of::
The signs and symptoms
BA
The aetiology including otopathology and its pathogenesis, immunology and
allergy
BA
The impact of otitis media with effusion on emerging speech / language skills/
behaviour, balance and its management
B
The impact on education, emotional and social development
BA
Evidence based and appropriate audiovestibular and aetiological investigations
BA
Current best evidence for medical, audiological and surgical management of
fluctuating deafness, including local and national guidelines
BA
The indications, benefits, limitations and side effects of medication that can be
used for fluctuating deafness
BA
When to refer for further medical opinions and to other allied professionals
A
Trainer
7.e. Non-Organic Hearing Difficulties
To be able to detect, investigate, diagnose and manage non-organic hearing difficulties in
children
Knowledge
Performance date
The developmental/history profile of children presenting with non organic
hearing difficulties
B A
The factors in presentation which are commonly seen in non-organic hearing
difficulties
BA
Correct management of non-organic hearing difficulties
When to refer for further medical opinions and to other allied professionals
Local child protection pathways
Skills
A
A
BA
:
Take an accurate history and carry out an accurate audiovestibular, development
and general examination; to include a clear profile of psychological and
educational achievements
BA
trainer
7.f. Auditory Processing Disorders (APD)
To be able to suspect, diagnose and manage auditory processing problems in children
Knowledge
Performance date
The signs and symptoms of APD and how it can affect the child’s educational progress
and behaviour
The conditions that may cause or be associated or co-existent with APD
A
Central neural processing of information presented through auditory and other
domains, including interactions and influence of higher level processes such as
attention, concentration and long and short-term memory (i.e. information storage and
retrieval)
The importance of multidisciplinary assessment of children with suspected APD
A
The indications, application, difficulties and interpretation of audiological test batteries
for APD
Methods of habilitation of children with APD
A
A
A
A
trfainer
7.g Auditory Neuropathy Spectrum Disorder (ANSD)
To be able to suspect, diagnose and manage auditory neuropathy spectrum disorder in
children
Performance
Knowledge
The presentation, natural history and diagnosis of ANSD
Diagnostic tests for ANSD
How ASND can affect the child’s language development and educational progress
How to use tests to investigate the site of the lesion with regard to predicting the
outcome of interventions such as cochlear implantation
A
A
A
A
The conditions that may cause or be associated with ANSD
Methods of rehabilitation of children with ANSD including the value of cochlear
implant
The educational needs of children with ANSD
A
A
A
date
Trainer
7.hTinnitus, Dysacusis and Hyperacusis in Children
To be able to suspect, diagnose and manage tinnitus, dysacusis and hyperacusis in
children
Performance Date
Knowledge
How tinnitus, dysacusis and hyperacusis may present in children
The prevalence of tinnitus, dysacusis and hyperacusis and the natural history of
habituation
The different conditions which can cause or trigger tinnitus, dysacusis or hyperacusis
A
A
Current pathophysiological theories about tinnitus, dysacusis and hyperacusis
generation
The psychological effects of tinnitus, dysacusis and hyperacusis on the child and
family and how these can be managed
The possible effects of tinnitus, dysacusis or hyperacusis on education
How to manage a child with tinnitus, dysacusis or hyperacusis in the context of the
multi-disciplinary team
A
A
A
A
A
Trainer
7.h Children with Complex Medical or Developmental Problems and Others who are “Difficult
to Assess”
To be able to carry out an accurate assessment of those children
To be able to suspect and investigate additional medical and developmental problems in children with a
diagnosis of deafness
To be able to diagnose and manage deafness in these children
Knowledge
Performance date
The signs and symptoms of hearing loss in children with complex medical
problems including visual impairment
A
Possible psychological /educational issues for children with additional difficulties
and hearing loss, particularly in relation to their special needs, and their
immediate and long term management
A
The impact of additional medical and developmental problems for the deaf child
and family
A
Methods of assessing benefit and problems with amplification
A
Possible psychological /cultural issues surrounding deafness, particularly in
relation to the child’s additional difficulties, and their immediate and long term
management
A
trainer
7.i Children with Speech and Language Problems (ST6 & ST7)
To be able to identify speech/language disorder/delay in children and participate in joint
assessment with a specialist speech and language therapist
To perform appropriate medical investigation of children who present with speech and
language disorders.
Knowledge
Performance Date
:
The signs, symptoms and pathologies associated with speech, language and
communication disorder/delay in children
A
The difference between delayed and disordered speech development
A
The difference between delayed and disordered language development
A
The association of developmental disorders of speech and language with other
developmental and processing disorders
A
The educational needs of children with speech and language disorder/delay and
statutory assessment of educational needs
A
The specialist provision and range of educational provision for children with
speech language and communication disorders
A
Trainer
7.j Transition and Transfer of Adolescents
To be able to manage a young person with audiovestibular problems through the
process of transition and transfer
Performance date
Knowledge
The process of transition
The needs of deaf teenagers and their approach to their need for care
The need to provide a seamless transfer of care from the paediatric to the adult
services for children with long-standing disorders of hearing and balance
BA
A
A
The needs of the learning disabled child during transition and transfer into adult
services
A
Skills
Discuss the young person’s hearing or balance difficulties with them and enable
them to make decisions regarding their future care through transition
A
Provide a supportive and informative clinical atmosphere in which the young
person can raise sensitive issues about their audiovestibular problems, and
associated issues, in their own right
Offer and explain the value of additional investigation into the aetiology of their
hearing and balance problems, if appropriate
Facilitate seamless and appropriate transfer to adult services at the right time for
the young person
Communicate effectively with the adult services about transfer of care
A
A
A
Trainer
8. a Skills / Patient approach
With regard to the above stated clinical categories a specialist in pediatric audiological medicine, in addition to the
generic skills outlined in Section 4, needs to be able to recognise:
The needs of the deaf adolescent during transition and
transfer
Performance
category
The cultural issues and parental views with regards to deafness and its management
A
The anxiety and stress caused by suspected deafness and the possible natural reactions
surrounding the diagnosis, in particular the grief reaction
A
The anxiety and stress caused by progressive or sudden deafness and the possible natural
reactions surrounding the diagnosis for both the child and parents
A
The effect of audiological and aetiological uncertainty following identification of
significant deafness in the newborn period especially with the diagnosis of an/ad
A
The importance of sensitivity to parents’ and patient’s response to a ‘non-organic’
diagnosis
A
Undertake an accurate and reliable audiological, neuro-otological,
developmental and general clinical examination of a child at all ages
A
Date
Signature
Trainer
7.k Practical Procedures in Paediatric Audiological Medicine
To gain a comprehensive knowledge of audiological testing in children
To gain practical skills in testing children.
To gain a critical appreciation of the value and limitations of audiological tests in children
Performance
Knowledge
To demonstrate knowledge of::
The anatomy and physiology of the ear and auditory pathways including central connections
BA
The theoretical basis of audiological testing including physics, acoustics and psychoacoustics
A
The normal development of behavioural responses to sound in children
BA
The indications for the various audiological tests in children
A
The values, limitations and practical difficulties of audiological testing in children
A
Skills
date
trainer
7.l Practical Procedures specific to pediatric assessments ( Skills)
Select appropriately and interpret correctly in the context of the clinical picture, all the audiological tests
mentioned below

Identify inaccurate, artefactual or spurious results, understand why these might have occurred and suggest remedial or alternative action.

Perform competently:

Distraction testing on normal and ‘difficult to test’ children

Behavioural observation of hearing responses in an infant

Clinical speech perception tests

Have performed under supervision:

Visual reinforcement audiometry

Conditioning techniques for soundfield and ear specific audiometry

Pure tone audiometry (air conduction, bone conduction with or without masking)

Acoustic immitance measures

Otoacoustic emissions (transient evoked, spontaneous, distortion product and contralateral suppression)



Middle ear reflex measures
Speech audiometry including speech in noise
Auditory brainstem responses (ABR)
Have observed:

Tests of auditory processing

Evoked responses (electro-cochleography, middle latencies, cortical responses)

ASSR (Auditory Steady State Responses) if possible
8 Paediatric Vestibular Medicine
8.1. Imbalance in Children
objectives
Performance date
Knowledge
The sensori-motor physiology maintaining balance
BA
The development of postural control in childhood
The association between sensorineural hearing loss and abnormal
vestibular function
BA
A
The ways in which a child may express their symptoms of imbalance
The causes of imbalance in a child including neurological, musculoskeletal, developmental and vestibular causes
A
A
The impact of imbalance on a child particularly with regard to
education and social integration
A
Techniques available to investigate balance disorders in children of
different ages
A
Diagnostic investigations to establish aetiology and how to interpret
the results in the light of age related changes
A
The treatment options and vestibular habilitation/rehabilitation
approaches for children
A
When to refer to a paediatrician, paediatric neurologist,
ENT surgeon, geneticist, physiotherapist or occupational
therapist for an opinion
A
trainer
8 2. Dizziness in Children
To differentiate between vertigo and other causes of dizziness or ‘funny turns’ in children
To determine the cause of episodes of dizziness in children
To instigate and interpret an appropriate set of investigations and define a management plan
To assess the impact of the attack on the individual and family and manage appropriately
Assessment Methods
GMP
The various otological, neurological, general medical and psychological causes of acute and recurrent dizziness and ‘funny
turns’ in children and how to differentiate between them
A
1
The different causes and pathomechanisms of acute and recurrent attacks of vertigo/dizziness in a child
A
1
The ways in which a child may express their symptoms of dizziness in sign, gesture and spoken language and how parents
may interpret these symptoms second hand when the child has inadequate vocabulary to describe the episode
A
1,3
The impact of recurrent vertigo/dizziness on a child particularly with regard to education and social integration
A
1
The eye movement abnormalities that may be associated with vestibular disorders
A
1
Appropriate audiovestibular tests and aetiological investigations for acute and recurrent vertigo/dizziness
A
1
The techniques available to investigate vestibular disorders, which are suitable for children of different ages
A
1
The age related changes in balance function and how this is expressed in investigative results.
A
The treatment options and vestibular rehabilitation approaches for children
A
1
The life style changes and pharmacological options available to treat acute and recurrent vertigo including the role of diet
and the place of prophylaxis in patients with migraine, and specific treatment of episodic ataxia type 2
A
1
When to refer the patient to a paediatrician, paediatric neurologist, cardiologist, ENT surgeon, geneticist, occupational
therapist or psychologist for advice on management
A
1
The natural history of acute and recurrent vertigo in children
CbD, Dip., mini-CEX
1
Knowledge
8.3. Practical Procedures in Paediatric Vestibular Medicine
To gain a comprehensive knowledge of vestibular testing in children
To gain practical skills in testing children
To gain a critical appreciation of the value and difficulties of vestibular tests in children
Knowledge
Performance date
The anatomy and physiology of the vestibular system and the central vestibular pathways
BA
The theoretical basis of vestibular testing
The indications, value, limitations and practical difficulties of vestibular testing in children
B
A
Age-related changes in postural control and responses to visuo-vestibular stimulation
B
To demonstrate the ability to:
Select appropriately and interpret correctly all the vestibular tests listed below in children
A
Adopt a flexible approach to testing and be prepared to adapt strategies in order to obtain the
information required
Integrate the results of history and examination with audiological, vestibular and aetiological tests to
formulate a diagnosis and a management plan
Explain the results of testing to patient and parents
Identify spurious results and those due to immaturity, lack of concentration or poor testing technique
and know how to obtain optimal testing conditions (troubleshooting)
Be able to perform competently and independently:

Hallpike testing

Examination of eye movements using nystagmoscopy or Frenzel’s glasses

Halmagyi head thrust testing
Have performed under supervision

Caloric irrigations

ENG/EOG recordings during visuo-vestibular stimulation including rotational tests

Posturography
Have observed (where possible)

Vestibular evoked myogenic potentials (VEMPs)
A
A
A
A
B
A
A
A
A
A
trainer
Training programs
Diploma / MSc in Audiovestibular Medicine ( UCL)
SYLLABUS( Diploma)
• Module 1 – Audiovestibular Physics
– Module 1.1
Physics and Acoustics.
– Module 1.2
Statistics and Research Methodology.
• Module 2 – Anatomy and Physiology.
• Module 3 – Audiovestibular Diagnosis.
• Module 4 – Clinical Disciplines Allied to Audio vestibular Medicine
– Module 4.1
Pathology, Speech and Language, Genetics &
Radiology.
– Module 4.2
Evidence based Medicine, Immunology,
Ophthalmology, Psychology/Psychiatry.
• Module 5 - Vestibular Medicine.
• Module 6 - Clinical Auditory Medicine – Children and Adults.
Training programs
Requirements of the training posts
• At institutions with appropriate standard of clinical governance.
• Training posts must provide the necessary clinical exposure.
• Training posts must provide the evidence that required supervision and
assessments can be achieved.
• The sequence of training should ensure appropriate progression in
experience and responsibility.
• The trainees have access to all facilities required to gain practical
competencies.
• Training should take place in a range of district general hospitals ,teaching
hospitals , community clinics.
• Trainee has an educational and clinical supervisors.
• Learning through observation, clinical practice, attendance at regional
training days, presentations, national audit meetings, attendance at
lectures, tutorials, journal reviews, additional courses, research projects.
ASSESSMENT METHODS
Principles
• It is expected that trainees will undergo regular assessment of
competencies in the various areas of the curriculum covered according to
the training requirement of the individual country.
• The integrated assessment system should comprise both work based
assessments and knowledge based assessments ( Diploma or similar
course)
• Workplace assessments should take place throughout the training
program to allow trainee to continually gather evidence of learning and to
provide trainee with formative feedback.
Assessments methods
•
•
•
•
•
•
•
Workplace based assessments
MSF
multisource feedback
Mini-Cex mini-clinical evaluation exercise
CBD
case based discussion
DOPS
direct observation of practical skills
PS
patient survey
TO
teaching observation
Assessments methods
• MSF communication, leadership, team working, reliability
• Mini-CEX competence in practical skills, essential good clinical care
• CbD competence in clinical reasoning, decision making, application of
medical knowledge to patient care.
• PS behaviour of the doctor, effectiveness of the consultation,
assessment of interpersonal skills, communication skills, professionalism.
Reference:
• Specialty Training Curriculum for Audiovestibular Medicine May
2010/2013. Joint Royal College of Physicians Training Board
http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/AudiologicalMedicine.aspx
• Diploma/ MSc in Audiovestibular Medicine , UCL, London