Audacity Issue 5 by Audacity magazine

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Audacity ...a British Society of Audiology Publication issue 5 December 2014 ..................................

23 OAEs: they just keep coming back

54 Audiology in India

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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."

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

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BSA Annual Conference 2015 British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

Hearing and Balance - Research to Clinical Prac ce

Next Annual Conference with

Clinical, transla onal and basic science in one forum will take place at

Ca rdiff Unive rs i t y 2 - 4 September 2015

E T A D E

H T E

V A S

Knowledge │ Learning │ Practice │ Impact

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Editorial

am writing this on ‘Black Friday’ and when I think

about the hordes of shoppers, the gridlocked streets and the mad, desperate scramble for that bargain of

a lifetime, I consider myself fortunate to be indoors reading the final proof of the December issue of Audacity. Indeed, as I read the final proof I think the BSA is fortunate to have so many people who take time out of their busy lives to write something for Audacity. Much of this issue has links to the BSA successful conference in Keele in September organised by David Furness and his team. We present the prize-winning abstracts that show the diversity in basic, translational and clinical research that underpins our society. The recipient of the Chairman’s award, David Kemp writes an enjoyable and informative article on the journey that OAEs have taken in research and clinical practice and following her interesting presentation in Keele, Nicola Topass writes about her use of motivation to change behaviour and outcomes in balance rehabilitation. This issue also shines a spotlight on evoked potentials (Siobhan Brennan), children’s hearing screening (Adam Walker and Greg Nassar), adult hearing services in South Wales (Rhys Meredith), the strategy of managing hearing loss in the UK (Will Brassington), ototoxicity (Ghada Al-Malky), Audiology in India (Ashwini Rao) and academia and research at UCL (Debbie Vickers). Combine all the above with our regular media and Twitterarty updates written by Dion Jones and Amanda Hall and you will have plenty to keep you occupied when you take a well-earned break over the festive period.

The editorial team wish you a restful Christmas and a successful 2015

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

from the editor

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Contents 3

meet the editorial team...

Editorial Martin O’Driscoll

Chairman’s Message Kevin Munro

Conference Catch-up information and updates from conferences in audiology Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk

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

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

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

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

Research Round-up a spotlight on major ongoing research projects in the Audiology community worldwide. Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk Dion Jones E: dion.jones@cmft.nhs.uk

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

E: audacity@thebsa.org.uk

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

W: www.thebsa.org.uk

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welcome to

Audacity ....a British Society of Audiology Publication

meet the editorial team...

37 Lunch & Learn a summary of the latest bite size online seminars for you to get your teeth into! Section Editor: Shahad Howe / E: shahad.howe@cmft.nhs.uk

Ear to the Ground a guide to all things Ear-related in the mediaâ&#x20AC;Ś Section Editor: Dion Jones / E: dion.jones@cmft.nhs.uk Rachel Hopkins E: rachel.hopkins@cmft.nhs.uk

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

54 Ear Globe an opportunity to learn more about audiology around the world. Explore a different country in every issue! Section Editor: Julie Reading / E: Julie.reading@cmft.nhs.uk

58 Hearsay News from Regional Groups and BSA Members

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

Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

Essentials Key information for the membership Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

Danny Kearney E: danny.kearney@cmft.nhs.uk The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics. Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information. Audacity is published in April, August and December. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; The Editor, Audacity, 80 Brighton Road, Reading, RG6 1PS. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings.The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

W: www.thebsa.org.uk

E: audacity@thebsa.org.uk

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

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chairman’s message

Chairman’s Message - Autumn 2014 Dear members Our conference and AGM in Keele in September seem like yesterday, but time flies by and I am now nearly two months into the new role of Chairman. Therefore I must begin this message with a big thankyou and tribute to the previous chairman Kevin Munro, who is to be honest a hard act to follow. Kevin has led the society superbly for the last two years, during which time a number of challenging issues arose and were admirably dealt with by him. The complexity and history of the BSA is significant and it is remarkable how much activity there is in different aspects of the society. The achievements attained by the BSA over the last two years were outlined clearly in Kevin’s last chairman’s message and are substantial- we have certainly got a massive amount done and, in my view, moved our society on towards a more modern, relevant and responsive organisation. As we begin the next two years, I feel very lucky to be able to work with an enthusiastic, experienced and engaged team of trustees.The success of the BSA depends on the motivation and dedication of its members and our council. The recent appointment of Graham Sutton as treasurer and Liz Midgley as vice chair will be enormously helpful as they are reliable, experienced colleagues with plenty of common sense- just what we need. We are also about to recruit up to three new trustees - it is great to see ‘new blood’ willing to come forward and to contribute to the success of the society. Also, the leadership of the LEG (Learning and Events Group) by Mel Ferguson has been dynamic- we now have an active and varied programme of events throughout the year which confirms one of the BSA’s main purposes as a leading purveyor of scientific knowledge.The ‘twilight’ meetings which are now going to appear more often around the country are particularly popular and rightly so- a small number of talkers on a specific topic, close to home, with both a basic scientific and clinical perspective. This, combined with a superb new website and amazing magazine, Audacity, really puts the BSA in a hugely strong position and we will I hope build on these strengths in the coming years. In my view, one of the wonderful things about audiology is its variety and breadth; this should be reflected most visibly in our annual conference, which for the last few years has brought together the ‘old’ annual conference with the experimental short papers meeting. Enabling this varied mixture of people, with different backgrounds and interests (for example- from the most fascinating, detailed and intricate investigations of the function of cochlear hair cells through to the performance of digital hearing aids in noise) to come together into a successful event that really does stimulate as many people as possible while moving forward our shared knowledge and understanding, is certainly challenging, but also potentially so rewarding. All that we do clinically in the application of audiology to improving the lives of people with hearing loss, balance problems or tinnitus must be founded on sound scientific knowledge. The BSA should be the champion of

chairman’s message

this principle, and therefore we will be making every effort to make the 2015 conference in Cardiff a well attended, stimulating, respected ‘can’t miss’ event; the conference organising committee has begun the planning process and I hope very much that 2015 will see the ‘rebirth’ of our conference as the one event that anyone with an interest in audiology or hearing science considers essential to be at. Meanwhile, the harsh reality of the financial and political world we now inhabit was exemplified by the recent proposals by one CCG (Clinical Commissioning Group) in North Staffordshire to withdraw funding for hearing aids in that area for adults with mild or moderate hearing loss. Instinctively, the madness of this proposal seems obvious to anyone who has the slightest knowledge of the topic. The BSA, excellently represented by John Day (lead trustee for the BSA’s expert advisory role) has responded to this challenge with great speed and rigour, in close collaboration with key other players such as Action on Hearing loss. This matter is sadly not yet settled; despite the rejection of these plans by the local health committee, the drive to find savings and perception of hearing loss as an ‘easy target’ might still lead to the loss of this funding, which would be a historic rolling back of one of the key principles of the NHS. This issue has, however, provided clear evidence not only that the BSA can respond rapidly with accurate scientific evidence and advice, but also collaborate closely with our allies in the field on key issues; we should be proud of this, and long may it continue. Unfortunately, just today we heard that another CCG in a different part of the country (but covering a large area) is now also proposing a restriction on their funding for hearing aids for adults with mild losses; we may be seeing the first few battles in what may become a prolonged war, in which the key role of the BSA as the leading provider of scientific and clinical knowledge is going to become ever clearer. Only two months into the role, and I can begin to glimpse the size of this chairman’s job, but feel so positive about the way forward for the BSA; it has a bright future and I am genuinely excited about being part of its journey for a short while, in the company of great friends and colleagues who share a desire to do our best.

Huw cooper Chairman

Performance Design

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Conference Catch-up

British Society of Audiology Annual Conference 2014 The annual BSA conference took place at Keele University between the 1st and 3rd September 2014. A summary of the prizes awarded at the conference and the abstracts from the prize winning posters are given below; congratulations to all the prizewinners!

Above: Evening reception at Keele Hall Left: Posters being viewed by delegates

conditions they do not resemble native fibrocytes and have proved difficult to transplant successfully in vitro. We have developed methods of fibrocyte culture in injectable matrices of collagen I. Here we evaluate the morphology and ultrastructure of these cells.

D.N. Furness, M.Z. Israr, N.C. Matthews, A.H. Osborn, K. Riasat and S. Mahendrasingam, Institute for Science and Technology in Medicine, Keele University, Keele, UK.

We prepared gels in two ways. (i) 3mg/mL collagen I gels were made in standard 24 well plates and solidified. Cells grown in 2D cultures in T25 flasks were harvested and seeded at a density of 10,000-50,000 cells per cm2 onto the surface of the gels and grown for 1-4d. (ii) we developed a simple way of culturing cells in the collagen gel solidified within a pipette tip. Approximately 100 l of 3mg/mL final concentration collagen I gel solution was drawn up into a 1mL syringe through a cut down yellow pipette tip. This was followed by 50 l of cell suspension.The gels became solidified overnight and were kept for 1-2 d. Gels were then removed from the wells or extruded from the tips, fixed and prepared for either scanning or transmission electron microscopy, or for immunocytochemistry using our standard methods.

Lateral wall fibrocytes play an important role in maintaining cochlear fluids by recycling potassium from endolymph to perilymph. It is thought that fibrocyte degeneration may lead to hearing loss so replacing fibrocytes may prevent this (Mahendrasingam et al, 2011). Fibrocyte cultures are a source of potentially transplantable cells, but when grown in standard culture

Cells survived for at least 2d on all the gels. Immunocytochemistry showed that almost all expressed aquaporin, a marker characteristic primarily of native type III fibrocytes. However, some cells also expressed S-100 or Na,K,ATPase, characteristic of other fibrocyte types, suggesting a mixed phenotype. Scanning and transmission election microscopy revealed cell mor-

â&#x20AC;˘ Poster prize winners: Basic Research Sponsored by the BSA. Growing cochlear fibrocyte cultures on transplantable matrices

Conference Catch-up

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Conference Catch-up

phologies that were partially consistent with the suggestion that the cells were phenotypically type III, but they also had other features that were less reminiscent of native cochlear fibrocytes. These data suggest that it possible to grow viable fibrocyte cultures in gels that could be used for transplantation.The extrusible gels can be manipulated relatively easily from their pipette tip, providing a potentially ideal way of introducing them into the lateral wall under control, without damage to the culture cells themselves. Acknowledgements This research was funded by Action on Hearing Loss and the Freemasonsâ&#x20AC;&#x2122; Grand Charity. References Mahendrasingam S., Macdonald J.A. & Furness D.N. 2011. Relative time course of degeneration of different cochlear structures in the CD/1 mouse model of accelerated aging. J Assoc Res Otolaryngol 12, 437-453.

Translational Research Sponsored by Starkey Laboratories.

that the task could only done by listening to SNR, not level per se. Averaged across participants, the SNR JND was 3 dB. This value was corroborated using different participants in a fixedlevel task. JNDs were not correlated with hearing ability. To measure the subjective import of an increase in SNR, we presented paired examples of speech and noise: one at a reference SNR and the other at a variably higher SNR. In different experiments, participants were asked (1) to rate how many successive conversations they would tolerate given each example, (2) to rate the ease of listening of each example, (3) if they would be willing to go to the clinic for the given increase in SNR, and (4) if they would swap the reference SNR for the better SNR example (e.g., their current device for another). The results showed that the mean listening-ease ratings increased linearly with a change in SNR (experiments 1-2), but an SNR change of at least 6 dB was necessary to motivate participants to seek intervention (experiments 3-4). To probe individual variance, a questionnaire of general and hearing health was also administered to participants in the latter experiments. Overall, the results indicate not only the difference limen for SNR, but also how large a change in SNR is needed for it to be meaningful to someone. While an SNR increase less than 3 dB may have relevance to speech-recognition performance, it may not be enough of an SNR improvement to be reliably recognized and, furthermore, may be too little increase to motivate potential users. Acknowledgements Supported by intramural funding from the Medical Research Council (grant number U135097131) and the Chief Scientist Office of the Scottish Government.

Developing a perceptual benchmark for speech-intelligibility benefit D. McShefferty*, W. Whitmer* and M. Akeroyd* *MRC/CSO Institute of Hearing Research â&#x20AC;&#x201C; Scottish Section, Glasgow Royal Infirmary, UK. How large does a change in speech in noise need to be before for it to be meaningful to someone? We here attempt to answer this question using objective and subjective methods. First, we measured the just-noticeable difference (JND) in signal-tonoise ratio (SNR) to find the lower limits of perceptually relevant features (e.g., noise reduction). Second, we measured the minimum SNR change necessary to spur someone to seek out an intervention using different subjective-comparison paradigms. To measure an SNR JND, we used a variation on the classic level discrimination paradigm using equalised sentences in same-spectrum noise with various controls and roves to ensure

Conference Catch-up

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Conference Catch-up

10 Clinical Research Sponsored by the BSA. Attending to narrative and detecting mispronunciations with Auditory Processing Disorder (APD) H. Roebuck and J.G. Barry, MRC Institute of Hearing Research, University Park, Nottingham, UK. Recent research has suggested that Auditory Processing Disorder (APD) may reflect an underlying deficit in an ability to maintain attention (Moore et al, 2010). This suggestion was partly based on evidence of fluctuating threshold levels during psychophysical assessment of auditory processing. Tests of auditory processing are inherently boring and bear little relationship to everyday listening. In this study, we assess the hypothesis that APD is effectively a disorder of sustained attention using a story task designed to mimic everyday listening. The current sample consists of 27 children (8-10 years) with and without a referral for APD, or listening difficulties identified using the ECLIPS questionnaire (Barry and Moore, 2014) (n=13/14). The participants were asked to press a button when they heard a mispronounced word. To assess the role of language, mispronounced words were presented in both predictable and unpredictable contexts. Previous research has shown that children and adults are faster and more accurate at detecting mispronounced words presented in predictable contexts (Cole & Perfetti, 1980). If sustaining attention rather than underlying language difficulty is the primary difficulty for participants with APD we would predict a similar benefit for mispronunciations in predictable contexts, but fewer words would be detected. If however, underlying language deficits impact task performance, we would expect the difference in word context to disappear. Preliminary data suggests the listening difficulty group missed more mispronunciations (15.4 ± 1.9) than their typically developing counterparts (5 ± 1.8, p<0.001). Secondly, both groups detected more words in a predictable context (p=0.003), and identified these words more quickly than in the unpredictable context (p=0.001).Taken together, this suggests that the listening difficulty group derived some benefit from sentence context when detecting mispronunciations, but their attention could not be maintained throughout the duration of the task. The results appear to support the idea that problems with

Conference Catch-up

sustained attention contribute to listening difficulties during every day listening tasks, and are not limited to more artificial tasks designed to assess auditory processing. Acknowledgements Supported by the Medical Research Council and Nottingham University Hospitals NHS Trust. References Moore, D.R., Ferguson, M.A., Edmondson-Jones, A.M., Ratib, S., & Riley, A. (2010). The nature of auditory processing disorder in children. Pediatrics, 126, e382-390. Cole, R.A., & Perfetti, C.A. (1980). Listening for mispronunciations in a children's story:The use of context by children and adults. J Verb Learn Verb Beh, 19, 297-315. Barry, J.G. and Moore, D.R. (2014). Evaluation of Children’s Listening and Processing (ECLiPS) Manual edition 1.

Student Poster Sponsored by PC Werth.

An investigation into the relationships between hearing loss, hearing handicap, tinnitus handicap, and attention R. Lakshman*, N. Mohamad§, D. Hoare§, D.A. Hall§, School of Medicine, University of Nottingham*§, National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit§. One major complaint of tinnitus patients is the effect tinnitus has on their ability to concentrate and perform attentiondemanding tasks. However, whether and to what degree hearing loss or handicap has a confounding effect on the relationship between tinnitus handicap and cognitive function is unclear. To begin to interpret these relationships this study sought first to explore the correlation between puretone audiogram (PTA) average and self-reported hearing handicap. Essentially we wished to identify whether hearing loss was a sufficient predictor of hearing handicap to be included as a covariate when considering the relationship between tinnitus and attention for example. One-hundred and twenty-two participants completed PTA, the Hearing Handicap Inventor (HHI), the Tinnitus Handicap Inven-

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Conference Catch-up

11 tory (THI), and Subtest 7 of the Test of Everyday Attention (TEA) which provides a measure of sustained attention. PTA thresholds were measured at 0.5, 1, 2, and 4 kHz with averages calculated for across both ears, and individually (to determine better ear). There was a strong correlation between HHI scores and the average PTA across both ears (r = 0.72), and for the better ear only (r = 0.70) suggesting that either the audiogram data or the self-report questionnaire would provide a reliable account of the effect of hearing in a model. In contrast, correlations between the THI and hearing measures were weak (r = 0.39 for HHI, 0.13 for PTA average) clearly demonstrating that the THI is measuring a construct different to that of the hearing measures. THI score only weakly correlated with TEA scores (r = -0.18) suggesting tinnitus to have little effect on sustained attention in this instance. We have demonstrated the reliability of using either hearing loss or HHI score to represent the construct of hearing. Further work will demonstrate whether tinnitus has effects on other forms of attention or other cognitive function. Acknowledgements This is a summary of work supported by the University of Nottingham and the National Institute for Health Research.

Tinnitus

Changes in resting-state oscillatory power in anaesthetised guinea pigs with behaviourallytested tinnitus following unilateral noise trauma. V.L. Kowalkowski*§, B. Coomber*, M.N. Wallace*, K. Krumbholz*, MRC Institute of Hearing Research, UK, University of Nottingham, UK. Chronic tinnitus affects about one in ten people in the UK, and can be highly bothersome for some individuals. It is often associated with noise trauma or hearing loss.There are several theories for how the tinnitus percept is generated, such as the ‘thalamo-cortical dysrhythmia’, and ‘cortical-reorganisation’ models. In the former, deafferentation as a result of noise exposure leads to a slowing of spontaneous oscillatory activity between the auditory thalamus and cortex, as well as an increase in spontaneous high-frequency activity within auditory cortex.The increased spontaneous activity is thought to underlie the tinnitus percept. On the other hand, the latter model posits that tinnitus arises as a result of inhomogeneous (e.g., sloping) hearing loss, which deprives some areas of the hearing range of input, but leaves others intact.This is thought to create an imbalance of inhibitory and excitatory inputs to the intact areas, leading to expansion of their cortical representation, as well as increased spontaneous activity and tinnitus.

In this study, we measured spontaneous oscillatory activity from the auditory cortical surface of 12 anaesthetised guinea pigs. Six of the animals were unilaterally exposed to loud noise to induce tinnitus and then allowed to recover for 8-10 weeks. The presence of tinnitus was tested with pre-pulse inhibition of the Preyer startle reflex, and ABR measurements were used to show that the exposed animal’s hearing thresholds had recovered to within 20 dB of their baseline. Six of the animals were unexposed controls. Consistent with the ‘thalamo-cortical dysrhythmia’ model, some differences in the frequency composition of the spontaneous activity were observed between the exposed and control groups, with a relative increase in mid-frequency activity in the exposed animals. More striking, however, was a highly significant group-by-hemisphere interaction, which seems to accord with the ‘cortical reorganisation’ model in that spontaneous activity in the contralateral hemisphere was reduced in the exposed animals compared to the controls, whilst activity in the ipsilateral hemisphere was increased. The contralateral hemispheres receives predominant input from the exposed ear, whereas the ipsilateral hemisphere receives predominant input from the intact ear. Future work aims to investigate changes in resting-state activity in humans with tinnitus and hearing loss using electroencephalography. 'Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.'

•Other prizewinners: Andrew Reid - awarded Honorary Member of the Society in recognition of his long service to the BSA. Graham Sutton and Amanda Hall - awarded the Jos Miller Shield for Best Article in Audacity issue 2, with the title ‘Can the infant sucking response be used to evaluate hearing?’ Piers Dawes - awarded the Thomas Simm Littler Prize for his significant contribution to large scale population studies in hearing. Josephine Marriage - awarded the Ruth Spencer Prize for her contribution to paediatric audiology and research. David Kemp, Emeritus professor of Auditory Biophysics – given the Chairman’s Award. In addition, PC Werth have agreed to sponsor a new award next year in honour of Lawrence Werth.

Conference Catch-up

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SIG segment

SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Group

BSA Adult Rehabilitation (ARIG) Special Interest Group Lucy Handscomb, Chair, Adult Rehabilitation (ARIG) SIG E: l.handscomb@ucl.ac.uk

ARIG continues to promote rehabilitation options in adult audiology. Currently, our key priority is to engage with clinical and research colleagues identifying what is wanted and needed in terms of learning, support and information in this area. Priority area 1 - forming a network ARIG held its first open event at the BSA conference in September, and we were very pleased at how well this was received. Our discussion forum, entitled ‘Who Defines Rehabilitation?’ enabled delegates to participate in roundtable discussions on outcome measures, shared decision making and facilitating change. These topics prompted people to share their views and experiences and learn from each others’ expertise. We identified next step priorities for action and these will help to inform ARIG’s future work in these areas. In particular, the discussion forum has led to revisions on the proposed UK decision aid for hearing aids. Delegates commented that they enjoyed the opportunity to participate in discussion and to meet

SIG segment

others with similar interests and we hope that people will be able to build on the networks that were created at the workshop. We are most grateful to Huw Cooper for hosting this event. Local networks are re-forming and Hearing Therapists in the South west and west midlands have agreed to meet as a local ARIG group – this provides a route to CPD and ongoing support. Priority area 2 investigating the state of current practice Work is now underway on the construction of our BSAfunded survey of rehabilitation services. Having received ideas from members of our reference group, representatives from ARIG, BAA and BSHAA (who will be distributing the survey amongst members) have had a fruitful initial meeting with Dr Neil Coulson, an expert in online survey design at the University of Nottingham. At time of writing, a draft survey is being compiled which will be evaluated and refined before its launch. Our aim is to make the survey as informative and user- friendly as possible and we are hoping for a big response from BSA members. The higher the response rate, the more accurate a picture we will get of the current state aural rehabilitation. We are delighted to have Beth- Ann Culhane rejoining the ARIG core committee. Our next meeting is scheduled for December.

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SIG segment

13 BSA Auditory Processing Disorder (APD) Special Interest Group Pauline Grant, Chair, Auditory Processing Disorder (APD) SIG

The updated APD Position Statement and Management Guidelines for APD will be finalised by the end of this year and go out for peer review in early 2015. Thanks to Dave Moore & Nicci Campbell who are leading on these respectively. Both papers will be available on the website. In the meantime, the current documents remain on the APD pages and provide very good information and advice. Both documents have been referenced in the Canadian APD Statement and there is no doubt that the work of the APD SIG is helping to shape international thinking. Our new information leaflet for children is ready and will shortly be published on the website. Printed versions will also be available. Thanks to Dilys Treherne for her work on this. The adult version is imminent! We are delighted to report that the much anticipated ECLiPSE (Evaluation of Children’s Listening & Processing Skills) is now available. Johanna Barry and Dave Moore (MRC Institute of Hearing Research) have led this project. It will offer a valuable contribution to the clinical assessment of APD. More information can be found at: www.ihr.mrc.ac.uk/pages/studies/epic-q/index. This year we were delighted to welcome Professor Harvey Dillon, Director of the National Acoustic Laboratories in Sydney to one of our meetings. This has inspired us to establish more collaborative links internationally and so far, as well as Australia and the USA, we are in touch with APD professionals in Germany, Canada and New Zealand. It is interesting to note that the National Foundation for the Deaf in NZ view the perceived lack of APD services in their country as breaching the UN Convention on the Rights of Persons with Disabilities. Our last report explained that the focus of the APD SIG in 2015 would be “Getting the message out there”. We are doing our best! Coming up during the next few months:

• An Information Day for Professionals at Southampton University in November 2014. • A Family & Professional Information Day – with hands on experience of resources and technology - in London in March 2015. • A pilot ‘APD Road Show’ (under the auspices of the APD SIG) for health and education professionals. This will take place in the South West next Spring. We then hope to offer the Road Show across the country at minimal cost – reflecting our firm belief in the importance of a multi-disciplinary approach to the management of APD.

More information about APD and its members is available on the BSA website.

BSA Electrophysiology (EP) Special Interest Group Siobhán Brennan, Chair, Electrophysiology SIG

The second meeting of the BSA Electrophysiology SIG was held during the BSA conference at the University of Keele in September. New members were welcomed and it was exciting to discuss the potential of the SIG. Developments so far include: 1. The British Society of Audiology website now hosts some of the previous NHSP Guidance. The EP SIG plan to review some of these documents when it becomes appropriate including “Guidance for Auditory Brainstem Response testing in babies” and “Guidelines for the early audiological assessment and management of babies referred from the Newborn Hearing Screening Programme”. 2. Work has begun on a new guidance document on cortical responses being edited by Guy Lightfoot. This document is to include information on gathering these responses from a range of patient groups.

SIG segment

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SIG segment

14 3. Work has also begun on ABR guidance specific to testing in situations other than newborn assessment such as testing older children and testing in operating theatres. This work is being led by Michelle Foster and Raouf Chaudri. 4. Amanda Hall delivered an extensive update on current provision of training in electrophysiological techniques within the UK. One area for development will be the provision of a BSA workshop on cortical evoked responses to be held on January 19th 2015. Further information on this workshop can be gathered at www.thebsa.org.uk/events/event 5. Amanda is also collating information on pressing needs for auditory electrophysiological research.

For any further information please contact the group Chair, Siobhan Brennan, via email: siobhan.brennan@sth.nhs.uk

BSA Balance (BIG) Special Interest Group Debbie Cane, Chair, Balance Interest Group (BIG) SIG E: debbie.cane@ royalberkshire.nhs.uk

We are working on extending the BIG section of the BSA website. Our hope is to have a regular ‘interesting topic’ for discussion. This month has been anterior canal bppv. The group is encouraged to contribute via email, and the collated thoughts will be posted on the website. We also continue to encourage people to share interesting articles and complex case histories. Following obtaining patient consent and anonymising the history, the latter can be sent to me, and I will circulate to the group for comment. The hope is that, through sharing our knowledge and experiences, this will help in the management of these patients whilst extending our own knowledge. Any ideas for new sections of the website please let me know. Of course we have all heard patients talk about their ‘titinus’. I will end with a conversation heard recently in an audiology waiting room... please feel free to email me with any similar amusing comments or anecdotes and we will add this the website. An elderly lady, whilst waiting to be fitted with a hearing aid, was discussing (very loudly) about her dizziness to a rapt waiting room audience.. ‘So... its all very interesting... apparently I had some bits of chalk which had moved from my brain into my ear, and this has caused my dizziness. Its ok, though, because my GP has moved them back to my brain and I’m now completely fine.’ Another successful Epley!

It’s all change in the BIG steering committee! Two members Johanna Beyts and Jenny Townsend are both stepping down, and I would like to thanks them for all their hard work over many years of service. We are looking to replace them, and would be interested to hear from anyone who feels they have the requisite qualities. We need BSA members who have an interest in Balance (both clinical and research). Members should have the knowledge and experience to contribute to the guidance and education of professionals in all the disciplines involved in the testing and management of patients with vertigo, dizziness and imbalance. Commitment is 2/3 of our day long face to face meetings (currently at Reading), help in organizing the biennial conference and regular contributions throughout the year to ongoing projects such as protocol writing. At present our committee is quite audiology dominated, and so we would particularly welcome applications from other professions with the hope of making the committee as multidisciplinary as possible.

SIG segment

At the heart of BSA is the various committees and special interest groups that bring together people with overlapping interests and provide them with a common purpose. www.thebsa.org.uk

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SIG segment

15 BSA Cognition in Hearing Special Interest Group Piers Dawes, Chair of Cognition in Hearing SIG

www.thebsa.org.uk

E: pier.dawes@manchester.ac.uk

The aim of the special interest group for cognition in hearing is to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment and intervention. Since the last edition of Audacity, the SIG committee met during the annual BSA conference to discuss plans for 2014-2015 and update on the progress of SIG initiatives, such as the survey of clinicians. Over the summer and autumn, the SIG carried out a survey of clinicians to identify areas related to hearing and cognition of particular interest.The survey was designed and led by Clare Howard and Christian Fulgrabe. Survey results will be published in a future edition of Audacity and will be used to plan future SIG activities. If you are an audiologist and have not yet completed the survey, there may still be time to complete it!

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

We are there for you – on your ipad, notebook or computer, in a format that is quick and easy to access. Please go to https://www.surveymonkey.com/s/7XGJM5L Some of the key elements of the new website are:

Upcoming events for 2015 include

• The BSA Chairman’s message • Online access to electronic versions of BSA publications

• Journal clubs on hearing loss and dementia organised by Jane Wild and Sarah Bent, to take place in Manchester, Cardiff and Brighton during March-April • Discussion groups on topics related to cognition in hearing (details to be confirmed!) • A workshop on measurement of ‘listening effort’ and ‘listening fatigue’ at Manchester University during March/April organised by Ronan McGarrigle If you would like to join the SIG and be added to the mailing list, or suggest an activity for the SIG, please feel free to email me piers.dawes@manchester.ac.uk

• Easy and free access to BSA Policies and Procedures • Easy access to our very popular recorded Lunch & Learn and Lightning Updates • Direct access and updates on the work of the BSA Special Interest Groups • Information about conferences and events • Information about global outreach projects • Job adverts and information and links to organisations.

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

SIG segment

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

The BSA Events calendar for 2015 is shaping up rather nicely. The Balance Interest Group conference ‘Balance testing- Past, Present & Future’ held in November sets the scene for a couple of other SIG meetings in the coming year. The newly formed Electrophysiological SIG is organising a workshop on Cortical Evoked Potential Measurement in Children and Adults, which will be held in January. Following on from the successful APD satellite meeting at last year’s annual conference the APD SIG are organising an information day for families and professionals in March. Many of you, particularly those at audiology’s coalface, will be acutely aware of the rapidly changing landscape in Audiology. To capture some of the current hot topics, the LEG is organising a meeting on ‘What the future has in store for Audiology’ in February at Warrington. Key opinion leaders from the audiology profession and the third sector have been invited to speak. This will include insights into the North Staffs CCG situation and how Audiology needs to be prepared for similar future proposals. There will be plenty of opportunity for delegates to join in with a Q&A session and discussion groups on how to develop sustainable hearing services. No passive sitting and daydreaming or thumb twiddling at this event! The Twilight Series meetings will be held in April and October. The April meeting on Hearing and Comorbidities will be held in Wrexham, and as I write this we are looking to secure a leading international researcher to present at this meeting. The autumn meeting will be on Paediatric Habilitation and will be held in the North-East. We continue to extend the reach of BSA across the different regions with the newly formed journal clubs. The first two, held in Nottingham and at the BSA conference, on Adult Hearing Screening have spring-boarded the next set

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of three, which will be on Hearing and Dementia. These will be held in Brighton, Cardiff and Manchester around April.The papers have already been selected – take a look on the BSA website under Journal Clubs. Each journal club will invite a local expert on dementia to contribute, and we are planning on summarising the discussions in podcasts – another BSA first. The Lunch and Learn monthly eseminars have some excellent speakers lined up for the next six months including Alan Palmer, Harvey Dillon (delivering the one-hour Christmas special), Padraig Kitterick, Sven Mattys and De Wet Swanopoel. The guest list is just getting better! Lightning updates continue to bring forth news and updates from the SIGs and hot topics. You might never have thought that the words ‘BSA Annual Conference’ and ‘Hot Topic’ would ever appear in the same sentence, however there is a lot of debate about the Annual Conference and the format it should take, with diametrically opposed views in some cases. By the time this edition of Audacity is published an e-survey to obtain views will be out. Please fill it in – all views are valid and worthy. A small group of us are scoping the possible future formats of the conference and your views will help shape this. Whatever the outcome, the dates for the next Annual Conference to be held in Cardiff are the 2-4th September. Finally, we are working on the first BSA e-conference, which will take place next summer. The focus will be on Global Aspects of Audiology and we will be inviting some of the great and good across the world to speak. Remember to check the BSA website for up to date information on all events. So lots of activity – I feel quite inspired looking at this. Much of this is down to the members of LEG, which is probably one of the best professional groups I’ve sat on. So thanks to Roulla Katiri who has boundless enthusiasm when it comes to the Lunch and Learn eseminars, Jane Wild who is playing a blinder with the journal clubs and lightning updates and Chris Cartwright who as well as sourcing the vitals of the e-conference, has the best Little Black Book in Audiology.

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17 BSA Learning and Events Group Update Graham Frost, BSc, MSc, MIOA, MIET, RHAD Technical Consultant Chairman, PPC E: ppcadmin@thebsa.org.uk

At the September meeting of the BSA Professional Practice Committee, I took over the position of Chairman from Paul James and I would like to take this opportunity to thank Paul, on behalf of the BSA, for the significant contribution that he has made to the work of the PPC both during his term as Chairman and prior to that as a member of the Committee. I would also like to personally thank Paul for his support during this transition and I am delighted that he has agreed to remain on the Committee as immediate past chair. You will be aware that the PPC, in conjunction with the BSA, facilitates the development and promotion of good clinical audiological practice at all stages of care by providing and disseminating guidance on good practice. This is achieved through the provision of recommended procedures, guidelines, minimum training standards and training days. As a vital part of its continued drive for good practice, the PPC also liaises with other organisations and bodies who are similarly committed to this process, particularly those who are involved in audiology or a related discipline. Included in these is the British Standards Institute, BSI. The BSI is responsible for the publishing of our National Standards which are intended to “standardise” product specifications, including audiological equipment and instrumentation, reference data, for example reference equivalent hearing threshold SPL values, and procedures. In recent years processes have been established so that, whenever possible, National Standards are harmonised to ensure that standards published by individual countries are as far as possible technically equivalent. To facilitate this harmonisation the majority, if not all, of standards published by the BSI, including those relevant to audiology, are re-published documents which have been developed by either the International Elecrotechnical Commission (IEC) or the International Organisation for Standardisation (ISO) and are in most respects identical. Each of these organisations have member countries and, when a standard is to be developed or revised, the member countries are invited to nominate representatives to form a working group which will be responsible for the

drafting and development of that particular standard. Once established a working group will often become responsible for a number of similar standards, for example all the IEC 60118 series of standards, which cover hearing aids, are developed by the same working group. Member countries will in general each have their own National Committees, each responsible for an area of standardisation. This is particularly true for the BSI which has two principle technical committees responsible for audiology related standards. These are EPL/29 Electroacoustics, whose responsibilities include audiometric equipment and hearing aids, and EH/1, whose sub-committee EH1/1 is responsible for standards which include those relating to reference hearing threshold values. Something which is often overshadowed by its other activities is that the BSA PPC has BSI National Committee representation and that BSA members have the opportunity to actively participate in the development of new standards and revisions that they may potentially use. New standards, and revisions of current IEC and ISO standards, go through a number of draft stages and at certain times during this process the draft documents can be made available to BSA members for comment and vote. The PPC is currently considering ways by which BSA members can be informed when specific documents are available for comment, provided with easy access to them and establish a mechanism which will encourage the submission of appropriate comments and contributions. Comments can then be forwarded to our relevant National Committee who will in turn submit them to the appropriate IEC or ISO working group for consideration. The PPC hopes that by providing this resource you, and others in both your and allied professions, can benefit from your knowledge and experience through developing standards which are appropriate and reflect your needs as a professional. I hope that you will all take full advantage of this valuable opportunity. This is of course only one of the ways in which you as an individual can contribute to “making audiology better” and those of you who attended the PPC Symposium, at this year’s annual conference, will be fully aware that the PPC wishes to encourage greater involvement of BSA members in its activities. You will also I hope have seen the recent call for nominations for members of the PPC and if at any time you would like to contribute to its activities as a member, or in some other capacity, please contact the BSA Office (ppcadmin@thebsa.org.uk).

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The Newborn Audiogram: We're not there yet CD

Author and Correspondence Dr SiobhĂĄn Brennan Lead Clinical Scientist (Audiology) Regional Department of Neurotology, Sheffield Teaching Hospitals E: siobhan.brennan@sth.nhs.uk

Take home message Work continues to develop newborn hearing assessment methods and there are exciting opportunities to improve both the quantity and quality of the information we gather in the newborn period.

Since the movement of responsibility for quality of diagnostic assessments following the newborn hearing screen away from NHSP there remains a need for our collective focus not only on quality but also development in this area. It is tempting to suppose that because effective and well established guidelines exist there remains little need to further evolve. However despite ABR having been used to assess hearing for over 40 years significant limitations continue to exist. 'So what alternatives are there?' Alternative 1: Optimising the Toneburst ABR The challenges of recording such small responses from newborns who, despite our best efforts may not be as settled as we need them to be, are being addressed in many different ways depending on the equipment that is available. It is a common belief that the lower the artefact rejection levels, the better for improving the signal-to-noise ratio. However taking a less rigid

approach and utilising a facility called Bayesian averaging has been found to improve response detection in the most challenging test conditions (Lightfoot & Stevens 2014). It is possibly surprising, but many countries do not use bone-conduction with ABR in neonates as routine. It is the authorâ&#x20AC;&#x2122;s view that the use of boneconducted stimuli is currently the best way to differentiate between conductive and sensori-neural hearing loss in neonates. If this is not identified in the post screen assessment it may be several years before single ear bone-conduction thresholds become available due to the challenges in using masking in early paediatric behavioural assessment. There are however situations such as the presence of large bilateral conductive losses where bone-conduction ABR is limited in the information it can provide due to the required high levels of masking noise causing cross-masking. Alternative promising solutions have

been investigated such as using latency differences between different types of loss (Baldwin & Watkin 2014) and 2 channel ABR. In the case of 2 channel ABR the ABR waveforms from both ears are recorded simultaneously and compared. Differences in the response may indicate which ear is responding to the stimuli such as the presence or absence of wave I and relative amplitude and latencies of wave V (Janssen 2008). There are certainly challenges in this technique. Using the standard UK ABR neonatal protocols a wave I is difficult to record and a separate protocol would be required. The amplitude of wave I is often smaller than wave III and V and not a part of the waveform we are frequently looking for in the neonatal testing session, so the usual level of uncertainty is likely to be increased for this technique. Additionally, the majority of the data on comparisons between ipsilateral and contralateral ABR is to click stimuli as opposed to more frequency specific stimuli. When 2 channel testing suggests that it is the contralateral cochlea generating the response, we must still resort to masking to evaluate the ipsilateral cochlear reserve. Another area where the majority of ABR research focuses on the use of clicks as opposed to frequency specific stimuli is the impact of Otoxicity. There is little work investigating ABR threshold assessment to very high frequency tone pips, particularly in newborns. Corrections for this are therefore not

When chirps are available there is both ample evidence and guidance to support their use. featured articles

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19 Figure 1. Narrow-band CE-Chirps速 frequency spread and time waveforms with kind permission from Interacoustics.

currently available in eSP, the database used by the Newborn Hearing Screening Programme. Considering how frequently referrals are received by paediatric audiology services following the administration of potentially ototoxic medication this work could be enormously beneficial. Alternative 2: Chirps An alternative to the click stimulus is the broad-band chirp, and an alternative to the tone-burst is the narrow-band chirp (Figure 1). The chirp is a stimulus that compensates for the travelling wave on the basilar membrane by presenting the low frequencies incrementally a short time before the high frequency parts of the stimulus. The compensation for the travelling wave is often considered the primary advantage of this type of stimulus. Developments of chirp stimuli are also taking in to account other cochlear mechanisms including upward spread of excitation and differences in cochlear-neural delay with stimulus intensity (Elberling & Don 2010). Chirps have now been available on commercial devices for over 5 years and corrections for narrow band CE-Chirps are on the eSP database. The use of chirp stimuli have been found repeatedly to increase the amplitude of the ABR in a wide range of groups including neonates following the hearing screen (Ferm et al

2013). The work in adults to date in developing the chirp stimulus would certainly suggest that further advantages of chirp stimuli over tone-bursts and clicks in newborns are likely. The majority of the literature on the use of chirps for ABR in newborns applies to the CE-Chirp速. eSP and the Masking Calculator (2013) refer to the CEChirp速. While chirps are not currently available on all equipment used in the UK to assess hearing in newborns, when they are available there is both ample evidence and guidance to support their use. Alternative 3: ASSR The chirp stimulus is also increasingly being used as the stimulus of choice to evoke ASSR (Venail et al 2014) due to similar increases in amplitude as observed in ABR. Some of the challenges of ASSR are similar to the challenges found in recording ABRs such as recording reliable responses at 500Hz and the potential for misinterpreting noise for a genuine auditory response. Issues specific to the post-screen diagnostic assessment such as aspects of maturation that may affect the ASSR differently to ABR continue to be studied. ASSR thresholds in the first 6 weeks of life have been found to have greater variability than ABR (Rance et al

2006). While in the UK we currently attempt to carry out ABRs as soon as possible after the hearing screen after full term it has been suggested that for reliable confirmation of normal hearing in infants using ASSR the optimum window is 4-12 weeks (Swanepoel 2011).The use of ASSR at any stage post newborn screen in the UK currently remains underutilised. Some of the challenges unique to ASSR are being extensively investigated. The faster recording of multiple frequencies is generally assumed to be their greatest asset. Interactions have been observed between responses to different frequencies in some conditions so studies are looking at maximising efficiency (Hatton & Stapells 2011). In terms of achieving multiple frequencies for the purposes of hearing aid management the ASSR remains more efficient than ABR. The current advice in the English NHSP ASSR Guidance is to use it in conjunction with ABR. The current guidance does not currently include advice regarding masking required for use with ASSR. Using findings from studies in this area (Small et al 2014) it is likely that the next version of these guidelines will include information on appropriate masking for ASSR.

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20 Conclusions There are currently good opportunities to improve both the amount and accuracy of information gained in the post newborn hearing assessment appointments. Since the closure of the NHSP Clinical Group the new British Society of Audiology Electrophysiology Special Interest Group aims to provide continued review and development of electrophysiological protocols within the UK. Acknowledgement: I would like to thank Guy Lightfoot and Jessica Arrue Ramos for their assistance in writing this article

References 1. Lightfoot G1, Stevens J. (2014) Effects of artefact rejection and Bayesian weighted averaging on the efficiency of recording the newborn ABR. Ear Hear. 2014 MarApr;35(2):213-20 2. Baldwin & Watkin (2014) Predicting the type of hearing loss using click

auditory brainstem response in babies referred from newborn hearing screening. Ear Hear 35(1):1-9. NHSP Clinical Group (2013) Guidance for Auditory Brainstem Response testing in babies Version 2.1 http://hearing.screening.nhs.uk/ Janssen (2008) BC Early Hearing Program Diagnostic Auditory Brainstem Response https://www.phsa.ca/NR/rdonlyres/ B8B8FF59-6474-4E66-8B925F1EA30916FD/40120/zDiagnostic ABRTrainingManualSept292008.pdf Elberling & Don (2010) A direct approach for the design of chirp stimuli used for the recording of auditory brainstem responses.J Acoust Soc Am. 128(5):2955-64 Ferm, Lightfoot, Stevens (2013) Comparison of ABR response amplitude, test time, and estimation of hearing threshold using frequency specific chirp and tone pip stimuli in newborns. Int J Audiol 52(6):419-23. Venail, Artaud, Blanchet, Uziel, Mondain. (2014) Refining the

audiological assessment in children using narrow-band CE-Chirpevoked auditory steady state responses. Int J Audiol. 18:1-8. 8. Rance, Tomlin, Rickards (2006) Comparison of auditory steadystate responses and tone-burst auditory brainstem responses in normal babies. Ear Hear 27(6):751762 9. Swanepeol (2011) Clinical Status of the Auditory Steady- State Response in Infants http://www.dspace.up.ac.za/bitstrea m/handle/2263/19043/Swanepoel_ Clinical%282011%29.pdf?sequence =1 10. Hatton & Stapells (2011) The efficiency of the single- versus multiple-stimulus auditory steady state responses in infants. Ear Hear. 32(3):349-57 11. Small, Smyth, Leon (2014) Effective masking levels for 500 and 2000 Hz bone conduction auditory steady state responses in infants and adults with normal hearing. Ear Hear. 35(1):63-71

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David Kemp receives 2014 Chairman’s Award He moved to the National Throat Nose and Ear Hospital in 1971, working initially on psychoacoustic tests of auditory ability in children. 1977 was a key turning point with his discovery of otoacoustic emissions (OAEs) from within the human auditory system, and the subsequent publication appeared in the Journal of the Acoustical Society of America the following year. In 1980, he formed a research team at UCL to investigate OAEs and to develop their practical application. David Kemp is first and foremost a scientist. He rose through the ranks of Senior Lecturer, Reader and then, in 1989, to Professor of Auditory Biophysics. In 2004, he was a co-founder of the UCL Centre for Auditory Research, now the UCL Ear Institute. He was elected Fellow of the Royal Society of London in 2004 and his contribution has been recognised in a number of ways including ‘Order of Merit’ from ARO as well as the BSA TS Littler Prize. The recipient of the BSA Chairman’s Award for 2014 is David Kemp, Emeritus Professor of Auditory Biophysics at the UCL Ear Institute. The award is made at the personal discretion of the BSA Chairman and is an opportunity for the Chairman to recognise a unique and substantial contribution to audiology and hearing science. David Thomas Kemp was born in Liverpool in 1945, son of Thomas Kemp, an evangelist and song writer. He obtained his BSc in Physics and PhD in Radio Physics from Kings College, University of London. His first peer-reviewed publications were on geophysics and his first research post was with the Central Electricity Generating Board.

He founded Otodynamics Ltd in 1988, which still designs, develops and supplies OAE screening instruments internationally. On two occasions, he has received the UK National ‘Queens’ Award for innovation and industrial success’. The BSA Chairman’s award was made in recognition of David Kemp’s outstanding contribution to hearing science and audiology; in particular, his studies on the existence, characterisation and clinical application of otoacoustic emissions. Kevin J Munro, Sept 2014

In recognition of receiving the Chairman’s award, we have asked David Kemp to share his thoughts. In his interesting and enjoyable article we learn about the journey OAEs have taken in research and clinical practice since their discovery, his opinions on how they have challenged and contributed to our understanding of the cochlea and their role in our audiology of the future. Congratulations David from the Audacity editorial team on your award – and for the use of the word ‘audacity’ in your article!

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OAEs: they just keep coming back! David Kemp Emeritus Professor of Auditory Biophysics UCL Ear Institute

Having been unable to attend the BSA conference in September to receive the BSA Chairman’s Award personally from Kevin Munro, I could hardly refuse an invitation to respond in ‘Audacity’. I’ve always had the greatest respect for the BSA. So many of its first members were buzzing around the RNTNE at Gray’s Inn Road at the time I arrived to switch my career from physics to auditory science in the early 1970’s. Working in the same Nuffield Centre basement corridor as Ron Hinchcliffe, John Knight, Peggy Chalmers and Larry Fisch - I couldn’t fail to see the BSA as the centre of gravity the audiological world. I learnt so much from its members and its meetings. Now, after a long career in hearing research, it’s a great honour to be acknowledged by the BSA in this way.

and audiology, meeting outright denial in some quarters and unfounded expectations in others. But key researchers did begin testing the claim including auditory physiologist Ted Evans who approached the topic from the conventional view, fellow physicist Pat Wilson, who I suspect was already only months away from coming to a similar conclusion to me, and William Rutten (Lieden) who was the first to publish experimental confirmation of the ‘cochlear echo’. As a newcomer to biology, my own part in this verification process was modest and I want to acknowledge some colleagues from that time who were a great help. Ade Pye (anatomist) who showed me around the cochlea as if it was her own home. Rudolph Chum (now Focus Research) who was so much better than I at constructing the electronic instruments I needed. Stewart Anderson (former BSA Treasurer) who introduced me to auditory physiology and worked with me to show that monkeys had OAEs too.

Careers in research typically lurch from achievement to failure to achievement and so on, each event seeming very important at the time but then fading as new challenges are met. That’s largely been my experience. But I’ve also experienced that unusual phenomenon when a piece of work takes on a life of its own not because the work is technically different from ones other work but because the results happen to have major repercussions for the subject as a whole. That’s the way it was with ‘otoacoustic emissions’. They raised profound questions about the cochlea- and they keep coming back to raise more questions. I am often asked “How and why were OAEs discovered?” and “What is your perspective on OAEs now and for the future?”. To the first question I have to restrain myself from giving a blow by blow account of that fascinating time. But in the latter case I find it hard to give an answer. The way I see it OAEs shouldn’t be separated from the much broader subject of cochlear biophysics and physiology. Only when we fully understand how the cochlea works will it be possible to explain the incredible complexity of OAEs and to find their ultimate applications in audiology.

I would never had the audacity to challenge established auditory theory in 1978 had I not seen and measured a physical phenomena well within my own professional expertise to interpret. My outrageous claim that ‘ears made sounds’ ricocheted around the academic labyrinths of auditory physiology

Unique view of inside the organ of corti, the outer and inner cell stereocilia and the curled back tectorial membrane. Photo courtesy of Andrew Forge, UCL Ear Institute.

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24 but were OAEs relevant to cochlear theory? The lack of any conventional explanation pointed to a gaping hole in the received wisdom about how the cochlea functioned. That first flurry of experiments answered the burning questions of the day. For example “Was otoacoustic emission due to a twitching middle ear muscle?”. No it wasn’t. “Did OAEs provide the explanation of tinnitus?”. No they didn’t. “Could OAEs be discounted as an epiphenomenon of no relevance to how the ear operated?”. Well, yes OAEs clearly played no function in hearing (in common with CM, AP and ABR signals) -but they did emanate from the cochlea and they did allow us to detect very small cochlear hearing losses non-invasively. That solved a big problem for infant screening. It had just been established that 50% of hearing impaired infants had no risk factors and were not being detected until 2-3 years of age. ABR technology had not developed sufficiently for mass screening at that timeand OAEs promised to fill that gap. But were OAEs relevant to cochlear theory? The lack of any conventional explanation pointed to a gaping hole in the received wisdom about how the cochlea functioned. An ill-defined ‘active process’ was cited as the missing element. As lab techniques for measuring minute sound vibrations inside the cochlea improved experiments by e.g. Johnstone, Patuzzi and others revealed a cochlea that was many times more tuned, responsive and complex than was conventionally believed. And as cell biology and single unit recording techniques advanced the enigmatic outer hair cells revealed their ‘party trick’ of dancing in response to even threshold sounds; a dance without which hearing thresholds would be 40-60dB higher. By the mid 1980s a new consensus was emerging. It seemed as though there was an ‘amplifier’ inside the cochlea created by the action of ‘outer hair cell motility’ on the basilar membrane, an action which enhanced the stimulus driven travelling wave and increased the energy reaching the inner hair cells. OAEs were to be seen as an ad hoc leakage of that amplifier energy. Hallowell Davis, a giant in auditory research at the time, gave his blessing to the concept of the ‘cochlear amplifier’ in his 1983

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Hearing Research paper. Although little more than a conjecture, the majority accepted the cochlear amplifier concept. It heralded the future integration of OAEs, hair cell physiology, and cochlear biophysics into a unified theory of ‘everything cochlear’. A complete understanding of the cochlea and sensory hearing loss was sure to emerge from the explosion of physiological and biophysical research that all these new techniques encouraged. But it didn’t turn out quite like that. Back in the nursery and clinic of course theory mattered little compared to practical applications. Mark Lutman and Adrian Davis at IHR explored the potential of TEOAEs for infant screening with their POEMS device. In my lab at the RNTNE/ILO brilliant work by Peter Bray, Dave Brass, Siobhan Ryan and Ru Chum created a PC based ‘OAE’ instrument design ( the ILO88) which was robust enough to be manufactured for wider use. Side-stepping the massive inertia that existed (and still exists) within the mainstream audiological equipment industry from 1988 we began supplying these machines to interested (or rather ‘excited’) labs and clinics around the world. The availability of a ready made OAE instrument hugely accelerated clinical research and allowed their routine use. Universal newborn hearing screening began to take off in the USA with these machines. I strongly believe that, if at all possible, researchers should try to ‘publish’ their work in tangible (i.e. useable) form as well as in a paper. I was very lucky in that both MRC and the Hearing Research Trust showed foresight and helped fund the ‘publication’ of OAEs in hardware such as the ILO88. More commonly industry is expected to make that decision and foot the bill.The problem is that stable industries have to be risk averse. They lack flexibility and insightful expertise. Promising research can easily fall into the gap between state and commercial funding. Politically correct university-industrial collaborations can be more focused on supporting central overheads than feeding individual initiatives. Although I now run a hearing test instrument company, I haven’t found a complete solution to the problem of translating technology developed for research into useful instruments for wider use. It is still difficult and happens lamentably slowly. OAE instruments today still largely rely on techniques developed for research in the 1980s. Lab research can actually be easier to fund, at least in the UK. The possibility of detecting frequency specific threshold-level activity in the cochlea without electrodes or surgery (which OAEs offer) gave rise to a vast range of basic and clinical research in the 1990s - with many discoveries. For example OAEs showed us that noise literally deadens the ears to sound; OAEs revealed that left and right ears ‘talk’ to each other neutrally through the midbrain ( the cochlear reflex), and OAEs showed that (rarely) sensory deafness can coexist with normal cochlear sensitivity making amplification suspect (auditory neuropathy). Despite all this the clinical application OAE bandwagon began to lose some momentum in the 1990s. Audiology was hooked

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

on ‘threshold’ and this tended to colour people’s expectations of OAE technology. If OAEs couldn’t actually determine

threshold then what possible use were they in the clinic? Some researchers tried to squeeze threshold estimates out of OAEs but with very limited success. A ‘DP-gram’ is not an audiogram. It is telling us something different - but what? The cochlear research roller coaster was also beginning to judder in the 1990s as its simplistic ‘cochlear amplifier’ conceptual undercarriage proved to be not quite up to the job.Theoretical modellers (key players in the evolution of auditory hypotheses) just couldn’t reconcile their mathematical simulations of ‘active’ cochlear responsiveness, or OAEs, to real world measurements by physiologists, cell biologists and anatomists.

Well OAEs have come back again to challenge our

understanding of the cochlea. Then slowly the underling complexity of OAE generation began to be understood. Starting with Ann Brown, then with major contributions from George Zwieg (who by the way jointly ‘invented’ quarks) and Chris Shera and many others, a way forward seemed to emerge. Cochlear echoes were reflections of the amplified travelling wave due to tiny irregularities in cochlea construction. Each healthy outer hair cell could generate a distortion product. But despite the precision with which DPOAEs

could be measured in the ear canal, they weren’t emitted from precisely defined frequency-specific places as was supposed. Rather DPOAEs leaked back from a broad region of the cochlea which changed depending on how you stimulated. Often DPOAEs came from two regions at once relying on different mechanisms for their escape. No wonder OAEs were difficult to interpret! They were a jumble of disparate information from the cochlea; unique, but impossible to decode . Richard Knight’s ‘wave and place fixed’ DPOAE cochlear maps of 2001, proved a valuable tool for visualising and interpreting this complexity. His maps have stood the test of time and are increasingly used to communicate research findings on OAE complexity. Revelations about the origins of OAE complexity re-enthused the OAE research community. “If only we could tease apart the different component of OAEs there would be untold dividends in terms of clinical applications”. That is a good line for a grant application. Unfortunately the argument depends on OAE complexity being the single major obstacle denying us crystal clear understanding of the cochlea and hearing loss - which is not the case. Looking back, OAEs were completely unexpected in 1978 largely because ideas about the way the cochlea functioned were too simplistic. Everyone happily accepted experiments that confirmed what the text books told them and dutifully challenged experiments that contradicted expectations- until OAEs came along to put a spanner in the works. That’s human nature, if not good science. Well OAEs have come back again to challenge our understanding of the cochlea. In June this year I attended a high level workshop called ‘The Mechanics of Hearing’, the twelfth in a triennial series- which are all published. A major part of the workshop’s business is ‘cochlear mechanics’. Cochlear mechanics has the high aim of uniting known physiological knowledge of the cochlea with a

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26 physical/mathematical model of how sound vibration is captured, manipulated and transduced in the cochlea. OAEs play a small part in this ambitious task both as the challenge to model OAEs’ complex behaviour, and as a test of the validity of any model. OAEs must emerge from any realistic model of how the cochlea responds to sound.

where OAEs come from or why? Several papers (e.g. by Ren, Seigel, Stagner and Martin) have reported paradoxical behaviours of OAEs that just don’t fit with the rational model developed by Chris Shera and others over the last decade. Instead the behaviours support other as yet unconfirmed modes of stimulus energy flow in the cochlea.

OAEs can help do that

It is noteworthy that in a heated debate at the Workshop a majority of participants wanted to ban further discussion of the ‘cochlear amplifier’ as too simplistic a concept and no longer productive. Their new vision that the cochlea (and its unknowns) is so complex that the 1980’s concept of a von Bekesey cochlear with its travelling wave being enhanced by a ‘cochlear amplifier’, is no longer relevant to the debate.

and so will come back in a new form to play a key role in the ‘new-audiology’ that is emerging. Well the take home message from this workshop is that we are still some way off being able to create such a realistic model, and that is not for lack of good physics or maths. The problem is we just don’t know enough or understand enough about the individual structures in cochlea and their behaviour when stimulated. As a consequence we aren’t able to fully interpret OAEsalthough that’s not a priority in this context. There is however good reason for optimism. The technologies for ‘seeing’ and ‘feeling’ the responses of the various elements of the cochlea as they respond to sound stimulations are advancing by leaps and bounds - approaching the sensitivity of OAE technology. Who would have thought 10 years ago that it would be possible to image individual hair cell and reticular lamina motion optically through the bone of the cochlea; or to record the near-threshold motions of each element of a living organ of Corti in 3D; or to visualise noise-induced neural damage in an ear with completely recovered OAEs, ABR and hearing thresholds? Who would have anticipated that 53 years after von Bekesy received his Nobel Prize for ‘explaining’ frequency analysis by the cochlea’s travelling wave that several new proposals for how stimulus energy flows in the cochlea would be on the table? And if stimulus energy flow isn’t always indicated by the motion of the basilar membrane how do we know

So are we back at square one in being able to ‘read OAEs’ for clinical purposes? Absolutely not. We have just escaped the perennial trap of being too content with our simplistic ideas and knowledge about the cochlea (again). OAEs are NOT well understood.The cochlea is NOT well understood.The full clinical potential of OAEs won’t be achieved until we understand the cochlea a lot better. That understanding is limited by the technology and concepts we apply to researching the cochlea in its entirety. Thirty five years ago OAEs allowed audiologists, biophysicists and psychophysicists to take part in cutting edge cochlear research that previously could be done only in high tech physiology laboratories, for example that of Ted Evans and his team at Keele, and more recently by Nigel Cooper. The present explosion of newer technologies applicable to basic cochlear research should be coinciding with a great increase in basic cochlear physiology and biophysics research and funding. I fear that isn’t happening. Expertise and funding for hearing research is being spread over a much wider range than ever before, including really important topics like genetics, oto-protectants and central processing. Cochlear physiology and biophysics are at risk of being neglected. But most hearing loss affects the cochlea and if you really want to know how the cochlea is working and how it is changing - you really have to be able to observe it in real time as it responds to sounds and as it is affected by therapies. OAEs can help do that and so will come back in a new form to play a key role in the ‘new-audiology’ that is emerging.

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Motivational approach to behaviour change in vestibular rehabilitation to improve clinic attendance CD

Author and Correspondence Dr. Nicola Topass, AuD Team Leader Balance Service Audiology Department Royal Surrey County Hospital Guildford GU27XX E: Nicola.topass@nhs.net

Take home message The conclusion is that a motivational approach to vestibular rehabilitation delivery appears to be related with improved clinic attendance and thus indirectly improved program adherence.

The Line Please mark on the lines below the most suitable answer 1. How important is it for you to improve your balance/dizzness symptoms right now? 0 10 2. How much do you believe in your ability to actively participate in the balance rehabilitation program? 0 10

Figure 1. The Line translated into a version suitable for vestibular rehabilitation patients

The Box 1. Please state what you believe are the benefits of not receiving balance therapy and the situation remaining the same.

2. Please state what you believe to be the negatives in your life due to the current way you are managing your balance/dizziness difficulties.

4. Please state what you believe to be the benefits of participating in balance therapy and finding new ways to manage your balance/dizziness difficulties.

3. Please state what you believe to be the downside of participating in balance therapy and changing your current way of managing your balance/dizziness difficulties.

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An important part of learning a new behaviour is for the patient to identify and acknowledge the value of the new behaviour (Konle-Parker, 2001). Behaviour change has been an area of much research in psychology and it was in 1977 that Janis and Mann first conceptualised the decisional ‘balance sheet’. There was further work in this area and in 1983 Miller first introduced motivational interviewing (Tonnesen, 2012). Motivational interviewing is a directive counselling technique which has been developed to help patients to explore and resolve ambivalence related to behaviour change (Emmons & Rollnick, 2001). Motivational interviewing as a technique was used in other areas of health care, but it was the Ida institute who translated the work for motivational interviewing into a format suitable for hearing aid audiology patients and clinicians. The motivational interviewing operational model involved tools known as the ‘Line’, the ‘Box’ and the ‘Circle’. These tools were developed for hearing aid patients, but it was conceptualised that these tools would translate well to vestibular rehabilitation patients. These tools were thus modified for the vestibular rehabilitation population and are further discussed below. The ‘Line’ employs open ended questioning that is directed at identifying the patient’s belief about two key areas. The first is the patient’s belief in the importance of the ‘behaviour change’ and the second is around the patient’s belief in his or her own ability to change their behaviour.

Figure 2. The ‘Box’ modified for the vestibular rehabilitation population.

The important feature of the technique is to use the ‘number’ the patient gives as a starting point for an open ended dialogue about any ambivalence the patient may have toward their vestibular rehabilitation

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29 late cancellation rate was 15.4% (A late cancellation is made within 1 week of the appointment).

The Circle Which statement applies to you most at present? Only choose one

Tick as appropriate

I am not ready for treatment of my dizziness/balance problem at the moment I have been thinking that I might need help with my dizziness/balance problems I have started seeking information about treatment for dizziness/balance problems I am ready to do balance exercises if they are recommended I am comfortable with the idea of doing balance exercises and accepting my altered abilities I am no longer doing my exercises I am living well with my balance problem and the changes I have made to my lifestyle to accommocate my new balance abilities Figure 3. The ‘Circle’ modified for vestibular rehabilitation patients.

treatment. For example, “I see that you have marked importance as ‘8’. So why would it be ‘8’ rather than ‘7’ or ‘9’?”. The ‘Box’ is a decisional matrix that is a balance sheet with lists for and against behaviour change.The important feature of the ‘Box’ is that it starts with the patient identifying reasons to remain at ‘the status quo’ and ends with the patient identifying the reasons for behaviour change. The patient needs to be their own motivator for behaviour change for the technique to be most effective. The ‘Circle’ is related to identifying the patient’s ‘readiness’ for change. It is based on the work of Prochaska and DiClemente and their spiral model of change. It includes five stages: Precontemplation, Contemplation, Preparation, Action and Maintenance.The circle is used in clinic to identify those patients who are ready for treatment and those who are not ready for treatment.

This study’s aim was to compare how the use of a motivational approach to behaviour change would improve patient clinic attendance and thus therapy adherence. Vestibular rehabilitation is the recommended primary treatment for stable vestibular lesions (Shepard et al, 1995). The prognosis for uncompensated peripheral vestibular lesions is generally very good with the percentage of patients who dramatically or completely improve set at 90% (Shepard et al, 1995). Adherence to vestibular rehabilitation programs can however prove to be difficult as is the case in many chronic health conditions. A review of our clinic attendance was compiled to determine the efficacy of the customised vestibular rehabilitation program.The review entailed an audit of the patient database and the data was reviewed in terms of: attendance, did not attends (DNA’s); and cancellation history for the six month period from September 2012 to February 2013. The percentage of DNA’s was 12.6% and the

A review of current literature revealed that patient motivation may be a key element to the high DNA rate for this particular speciality, thus a motivational approach to the patient pathway was introduced.This motivational approach was employed on two levels. The first was a change to the patient pathway. All new patients would need to attend an introductory educational group session which would explain the vestibular rehabilitation in terms of: current research, time commitment and the possible prognosis for therapy. The patient would then ‘opt in’ or ‘opt out’ of the therapy program. The second level would be the employment of motivational interviewing techniques in the individual therapy sessions. This was the employment of the ‘Line’, the ‘Box’ and the ‘Circle’. The patient is sent a questionnaire with the ‘Line’, the ‘Box’ and the ‘Circle’ and requested to complete the form for the first individual therapy session. The patient is only sent this information if they have opted for therapy and have attended the introductory session. The clinician would then work with the patient through the answers that they provided on the questionnaire. The changes were implemented and the data was reviewed again for the period 9 September 2013- February 2014. The same time of year was utilised to minimise the effect of extraneous variables. The percentage of DNA’s was then 4.7% (previously 12.6%) and the patient late appointment cancellation rate was 4.7% (previously 15.4%). The conclusion is that a motivational approach to vestibular rehabilitation delivery appears to be related with improved clinic attendance and thus indirectly improved program adherence. Further re-

An important part of learning a new behaviour is for the patient to identify and acknowledge the value of the new behaviour (Konle-Parker, 2001). featured articles

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30 The Opt-in method ‘Opt-Out’

ENT

Discharged to GP

Group introductory Session - 6 people - 45 mins

Audiology diagnostic

‘Opt-In’

1st VR appointment 90 mins

Figure 4. The new patient pathway employing motivational approach for ‘opt-in’ to treatment.

search is needed as in this study the effect of the program change and the clinic change has not been separated. It was also not identified how many patients opted out by not attending the first introductory group session. The study was limited as it was conducted as an audit of normal clinical care and there were thus many variables that were not controlled. Further research is required to assess patient satisfaction with vestibular rehabilitation with and without motivational interviewing. Further research is also required to identify the objective outcome

of vestibular rehabilitation with and without motivational interviewing. Acknowledgements Supported by Community Health Psychology, Farnham Road Hospital, UK. References 1. Emmons, K. & Rollnick, S. (2001) Motivational interviewing in health care settings opportunities and limitations. American Journal of Preventive Medicine, 20(1), 68-74. 2. Konkle-Parker, DJ. (2001) A motiva-

tional intervention to improve adherence to treatment of chronic disease. Journal of American Academy of Nurse Practitioners, 13(2), 61-68. 3. Shepard, N., Telian, S., & Michigan, AA. (1995) Programmatic vestibular rehabilitation. Otolaryngology -Head and Neck Surgery , 112, 173-182. 4. Tønnesen, H. (2012) Engage in the process of change: Facts and methods. WHO-CC Clinical Health Promotion Center Bispebjerg University Hospital Copenhagen, Denmark Health Sciences Lund University, Sweden.

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research round-up

The University College London, Ear Institute CD

Author and Correspondence Deborah Vickers, BSc, MA, PhD Principal Investigator Correspondence: UCL Ear Institute, 332-336 Gray’s Inn Road, London. WC1X 8EE E: d.vickers@ucl.ac.uk

The UCL Ear Institute will be celebrating its 10th birthday in 2015. It was created out of a vision of a group of hearing researchers who were dispersed around UCL and believed that their work would be more effective, and have greater impact, if they worked together with common purpose under one roof. Following a successful bid for funding to the Wellcome Trust (led by Professors Andy Forge and David Kemp) a building was constructed directly adjacent to the Royal National Throat Nose and Ear Hospital - in order to increase the opportunity for enhanced clinical interactions – and the Ear Institute was

formally opened in January 2005. As of today, the Ear Institute houses 22 Principal Investigators, 31 post-doctoral researchers and over 30 PhD students, employing their combined research interests and expertise in order to better understand hearing and fight deafness. Given that deafness is the most common sensory disability – in the developed and developing world alike – the Ear Institute’s mission is to ensure that basic science translates to tangible benefits for the widest range of people suffering from communication disorders brought on by deafness. Through these combined research efforts we can increase awareness of the prevalence of deafness (1 in 7 adults) and the extent of the difficulties associated with it, including social isolation, self-efficacy, problems with ‘cocktail party listening’ and tinnitus (5 million sufferers in the UK alone). The researchers at the Ear Institute operate within four research units but much of our strength as a research centre comes from the strong collaborative links between units. Two of the units have a biological focus (Neurophysiology and Computation and Cell and Molecular Biology) and two are

Child with cochlear implants undergoing spatial listening testing in the AB-York Crescent of Sound.

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33 cells and auditory nerve fibres progress our understanding of acoustic coding in normal hearing, and explore the opportunity for restoring or enhancing function in disease.

Cutting edge technology being demonstrated to students

more translational in focus (Human Function and Audiology and Medicine and Clinical Trials). Biological research at the Ear Institute spans discipline boundaries, from genetics of deafness to neuro-computational models of spatial listening, and from synaptic physiology of the inner ear to animal models of behaviour. Researchers in the Neurophysiology and Computation Research Unit assess neural coding in health and disease along the entire auditory pathway, from the peripheral nerve to the auditory cortex employing a wide range of sophisticated techniques, including in vivo and in vitro electrophysiology, optogenetics, patch-clamp recording, small-animal imaging, and computer modelling of auditory neural processing of spatial cues, pitch and speech coding. Disease models include tinnitus and noise-induced hearing loss as well as a range of central auditory deficits associated with complex human conditions such as auditory processing disorders. Developing lines of research include a cochlear implant programme in small animals and investigations into the implications of inner-ear regeneration on central auditory processing. The Cell and Molecular Biology Research Unit is fundamental to the success of the Ear Institute. Comprising seven principal investigators, whose research spans an extraordinary range of techniques and species. Fundamental discovery science in fruitflies, birds and mammals provide a means of understanding molecular pathways in the development and homeostasis of the auditory system, its response to damage and its capacity for repair. Mouse models of deafness, from genetics to the impact of implantation on inner ear homeostasis, have great translational power, informing studies of human hearing loss and therapeutic interventions. Investigations into the properties of hair

The Human Function and Audiology Research Unit conduct research with normal hearing and hearing-impaired adults and children. Often the research is exploratory and laboratory based and a range of populations and approaches is employed. The themes are natural progressions from the topics investigated in the more biologically focused research units.The group aims to understand normal development and the typical ageing process in the auditory system; from birth and across the lifespan, and to understand how this is affected by disorders in hearing, auditory processing, tinnitus, device intervention and rehabilitation. We not only explore speech perception and psychoacoustic abilities but also look at long-term impact on education and quality of life.The group uses objective measures and develops new more sophisticated assessments to carefully assess perception of carefully controlled acoustic stimuli, speech and music. Much of the research work with young children focusses on how perception changes with developmental age and how different listening environments can impact upon the cues that young children use. Individual characteristics that can affect perception are explored, such as home language, auditory processing abilities, developmental age, other complex needs and hearing status. Research programmes investigating hearing in adults not only investigate the perceptual impact of hearing-impairment and auditory processing difficulties but also how it interacts with other conditions such as dementia, as well as how other conditions can be associated with hearing difficulties - a good example of this being the hearing loss experienced by someone suffering a stroke.The interventions explored range from counselling, training and rehabilitation, to device-based interventions and optimisation, and the use of assistive listening devices such as sound-field amplification systems in classrooms, and FM systems to assist listening in those with processing disorders or following a stroke. The majority of the Instituteâ&#x20AC;&#x2122;s undergraduate and postgraduate student research projects are conducted in this group and our students are very successful at being awarded poster and presentation prizes at the British Society of Audiology Conference and the British Academy of Audiology Conference; in the 2013 conferences three of our students were prize winners. We also encourage and support our students to write or contribute to published papers as authors; approximately 15-20% of student research projects result in publication. The final research unit at the Ear Institute is the Medicine and Clinical Trials group. This group predominantly conducts hospital-based research and, through the ENT clinical trials programme is able effectively to conduct world leading clinical intervention research. This unit has strong links with the UCL

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34 value that all individuals have is what make it an effective team for delivering improvements for people with hearing difficulties in the UK and across the world. Many of the researchers and PhD students are funded by grants from UK research councils and charities such as Action on Hearing Loss whose invaluable funding allow us to conduct such ground-breaking research. The worldrenowned reputation of the Ear Institute is acknowledged by multiple international research collaborations the high success rate that we have in obtaining European, International and UK-based grant funding. A key measure of our success will be the impact we have on the lives of people with hearing loss and their families. To this end, an important aspect of our work is to liaise closely with clinicians, hearing-impaired individuals and their families to inform them of our work and ensure that we are taking our research directions from those who are most likely to benefit from our findings. We see this group as a crucial part of our team, helping us to ensure that our vision of taking research from the laboratory to the patient is effectively realised in a timely fashion.

Scanning electron micrograph of the organ of Corti spiral from a gerbil viewed from the top.

Partners, Academic Health Science partnership linking UCL to many of the key hospitals in London ensuring a true two-way collaboration between academia and health-care provision. Applied research in this arena seeks to improve directly the lives of hearing-impaired people. A recent grant funded by Action on Hearing Loss (together with York University) examined â&#x20AC;&#x153;Which children should be considered as candidates for cochlear implantsâ&#x20AC;?, and may lead to changes in the candidacy criteria for bilateral cochlear implants in children. The Ear Institute is working as part of a National Team led by the Ear Foundation to compile evidence on candidacy for cochlear implants in both adults and children that will be used as evidence to request that the NICE guidance on cochlear implants is reviewed. Research conducted into tinnitus is a prime example of how the different research units can work on a topic from the lab to the clinic. Work funded by the British Tinnitus Association has helped to develop our knowledge of tinnitus mechanisms in the central auditory pathways. Together with research projects assessing potential therapies for tinnitus and in seeking to understand tinnitus in individuals using cochlear implants, we are developing an understanding of the interventions that are most effective in alleviating this often distressing and debilitating condition. The multi-disciplinary nature of our research programme is the Ear Instituteâ&#x20AC;&#x2122;s biggest strength. The underlying mutual respect between researchers in different areas of expertise and the

research round-up

Finally, this research round-up would not be complete without highlighting how important it is to the Ear Institute to pass our legacy to the up-and-coming clinicians of the future. We pride ourselves on ensuring that the undergraduate and postgraduate students that train at the Ear Institute on Audiological and ENT courses are taught by top researchers and clinicians in the field ensuring best practice and that research advances are rapidly translated into every day clinical practice. To keep up-to-date on the research news at the Ear Institute look out for our Newsletters (http://www.ucl.ac.uk/ear/news01)

References 1. Greenberg D, Meerton L, Graham J, and Vickers D. (under review) Perceptual Changes to Tinnitus Sound Characteristics for Adult Cochlear Implant Recipients. Audiology and Neurotology 2. Lovett R E, Vickers D A, Summerfield A Q (2014). Bilateral Cochlear Implantation for Hearing-Impaired Children: Criterion of Candidacy Derived from an Observational Study. Ear Hear [Epub ahead of print] 3. McKenna L, Handscomb L, Hoare D, Hall D (2014) A scientific cognitive behavioral model of tinnitus: novel conceptualizations of tinnitus distress, Frontiers in Neurology 5; 196 4. Schaette R. (2014) Tinnitus in men, mice (as well as other rodents), and machines. Hearing Research. 311: 63-71

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Asking questions Whether we are clinicians or scientists or just curious human beings, asking questions (also known as research) is fundamental to what we do. Consider a life where you never question anything. How fulfilling would that be? That’s a grand introduction to something you might consider to be fairly unimportant – an opportunity to apply for £5000 to start you on the road to answering that crucially important clinical or scientific question. Yes it’s the BSA Applied Research Fund. You may think that £5000 doesn’t buy much these days in terms of research and maybe that it isn’t worth the effort of applying for such a trivial amount but there are 23 BSA members who would disagree. They are the 23 people who, since 2008, have been awarded grants ranging from £1428 to £5000 and totalling more than £80,000. Examples of what up to £5000 can fund include: • a systematic review to summarise evidence and highlight research gaps (e.g. Watchful waiting and tinnitus: a systematic review and meta-analysis, £3201) • an assessment of service provision (e.g. The influence of advances in hearing aid technology on models of service delivery for hearing impaired adults in the NHS, £4908) • an evaluation of diagnostic/investigative tools (e.g. Repeatability of neck and lower limb sound induced vestibular evoked myogenic potentials, £3000) • a survey of available service (e.g. Consensus on hearing-aid fitting candidature for mild hearing loss, with and without tinnitus: Delphi review, £1428) • clinically-related psychophysics (e.g. Perceptual consequences of plasticity in binaural systems: evidence from adults with unilateral deafness, £4561)

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

• an analysis of existing datasets (e.g. Evaluating candidate genes identified by whole exome sequencing in a cohort of familial otosclerosis patients, £4967.50) • a pilot study to feed into the design of a larger project and an application for further funding (e.g. What is important to parents of children with glue ear? £4960) Who can apply? The principal investigator must be a full or student member of the BSA at the time of application. Collaborative projects between clinicians and scientists are actively encouraged. What can be funded? Applied research areas relevant to hearing, tinnitus and/or balance Top-up for an otherwise part-, self-, or un-funded PhD What can’t be funded? Indirect research costs. Publication costs, conference attendance or training meetings. (although you must present the work by poster or talk at a BSA conference and one registration fee will be covered in addition to the requested value of the grant). When can I apply? Two award rounds per year. Closing dates are advertised each year and are close to the last Friday in May and the last Friday in November. How do you decide what to fund? Grants are scored and funded on the basis of • scientific quality [including both rationale (i.e., "what is the problem" or "why do I want to do this") and method ("what will I do")] • roles and relevant expertise of the research team • full details & justifications of costs; value

for money • importance to applied research in hearing, tinnitus, and/or balance; relevance to key areas How much can I apply for? Currently the total fund available amounts to £20,000 per year and each application can be up to £5000. What are my chances of success? You will succeed if you have a good research question, with robust methodology and a good team. Without that your application will not be funded even if you are the only applicant! Having said that, the chances are pretty good, maybe 1 in 4. Can I get any help and support? If required, each successful applicant will be offered a mentor. How do I apply? Go to the BSA website to download an application pack, including the application form and guidance http://www.thebsa.org.uk/bsa-appliedresearch-grant/ or contact the BSA office on bsa@thebsa.org.uk.

Who is on the panel? Dr Heather Fortnum (Chair) (heather.fortnum@nottingham.ac.uk) Dr Michael Akeroyd (Representing MRC) Dr Ros Davies (BSA member) Prof Dave Furness (BSA member) Dr Amanda Hall (BSA member)

If you have any questions, please contact Heather Fortnum or any member of the review panel.

research round-up

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lunch and learn

Lunch and Learn CD

Facilitators and Correspondence

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

Roulla katiri Chief Audiologist, Mater Misericordiae University Hospital Dublin

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

E: rkatiri@mater.ie

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 2014 APD: Learning from History › Dr Wayne Wilson, PhD MAudSA CCP School of Health and Rehabilitation Sciences, The University of Queensland, Australia.

September 2014 Ototoxicity as a preventable cause of inner ear diseaseIs the Audiology profession doing enough to actually achieve this? › Dr Ghada Al-Malky, PhD Senior Lecturer & BSc Audiology Course Director, The UCL Ear Institute, London

October 2014 Speech recognition and spatialisation in complex listening environments: effects of hearing aids and processing › Professor Todd Ricketts Vanderbilt Bill Wilkerson Center for Otolaryngology, Nashville, USA

November 2014 Fitting Hearing Aids for Different Languages › Dr Marshall Chasin Director of Auditory Research at the Musicians’ Clinics of Canada, Toronto

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

Christmas Special Issues in diagnosing and treating auditory processing disorders › Professor Harvey Dillon, PhD Director, National Acoustic Laboratories Australian Hearing Hub, Macquarie University

January 2015 Hearing-assistive devices in single-sided deafness: which device and what benefits? › Pádraig Kitterick, Nottingham Hearing Biomedical Research Unit

February 2015 Health initiatives to increase access to hearing screening in underserved communities › De Wet Swanopoel, Department of Speech-Language Pathology and Audiology , University of Pretoria, South Africa

March 2015 Vestibular assessment and VEMPs › Jas Sandhu, Department of ENT, Sheffield University Teaching Hospitals

April 2015 Psychology and cognition › Professor Sven Mattys, Department of Psychology, University of York

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Ototoxicity as a preventable cause of inner ear disease - Is the Audiology profession doing enough to actually achieve this?

This short communication is based on the on-line BSA Lunch and Learn seminar by Dr Ghada Al-Malky, 1 Sept 2014 The recording is available at www.thebsa.org.uk

This presentation was made to shed some light on ototoxicity, which is a common cause of inner ear damage due to exposure to drugs or chemicals. It included outcomes of research that was undertaken in collaboration between the Ear Institute, UCL and Great Ormond Street Hospital (GOSH) where we addressed the following questions: 1. How prevalent is ototoxicity in a group of patients with Cystic Fibrosis (CF), who we already knew were exposed to repeat courses of ototoxic aminoglycosides yet are rarely assessed audiologically for this problem. 2. Does ototoxic hearing loss cause significant worsening of the Quality of Life (QoL) of children with cancer compared to

the same group of children without ototoxicity? 3. Are we, as audiological professionals, contributing enough to trying to decrease this preventable cause of inner ear damage? We already know that ototoxic medications can be either cochleotoxic or vestibulotoxic and they can either cause permanent or reversible damage. We also know that the commonest permanent ototoxic drug groups are chemotherapeutics, such as cisplatin/carboplatin, and aminoglycoside antibiotics. Patients with CF are repeatedly exposed to extensive aminoglycosides to combat pseudomonas chest infections but previous research had shown that the prevalence of ototoxicity was variable (0-50%) and less common in children (0-6%). Our research using standard and extended-high frequency audiometry and DPOAEs showed a higher prevalence of ototoxicity in children with CF (15/70, 24%), which was closer to the average prevalence in adults. Figure 1 shows audiometric outcomes, which showed two clear groups of patients, ototoxic versus non-ototoxic. More detail can be found in Al-Malky et al, 2011 and 2014 [1,2]. We also assessed risk factors that may increase susceptibility to aminoglycoside ototoxicity and found that increased age, cumulative exposure, poorer lung function and specific types of aminoglycosides were identified. We also looked for genetic susceptibility with the mtDNA A1555G mutation in the 12S rRNA gene and found two cases. Interestingly,

-10

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lunch and learn

9.0 10.0 11.8 12.5 14.0 16.0

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Figure 1: Audiometric outcomes of the right and left ears of 70 children with CF with variable levels of exposure to ototoxic aminoglycosides. Two clear groups are identified, one with normal hearing thresholds (non-ototoxic group) and another with evidence of high frequency sensorineural hearing loss typical of ototoxicity (ototoxic group). EHF PTA: Extended-high frequency audiometry.

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39 has now been established at GOSH with a view of rolling this out into all CF units in the UK.

Figure 2. Outcomes of the HUI3 questionnaire for both groups of children with cancer. Eight attributes are assessed. The Hearing and Cognition attributes were significantly worse in the ototoxic group in addition to a significantly poorer overall multi- attribute utilities score (p<0.05).

Communication and independence Emotional wellbeing Peer comparisons Acceptance

Figure 3: Outcomes of the PAQL questionnaire for both groups of children with cancer. All four subscales of the questionnaire were significantly worse in the ototoxic group (p<0.05).

one of these children had normal hearing despite having the mutation and confirmed history of exposure to aminoglycosides. This questioned the previously reported 100% penetrance of this mutation when associated with

aminoglycoside exposure. For more information see Al-Malky et al, 2014 [3]. This part of the research highlighted the importance of regularly monitoring this group of patients through setting up of an ototoxicity monitoring service, which

The second research question looked at whether ototoxicity adds to already deteriorated QoL of children with cancer. We assessed 78 children with cancer, 37 with no evidence of ototoxicity and 41 with ototoxicity.Two parent proxy questionnaires were used; a generic Health Utilities Index Mark3 (HUI3) and a disease-specific Paediatric Audiology Quality of Life (PAQL) questionnaire were used. Both tools showed a significantly worse overall QoL for the children with ototoxicity. Hearing loss will affect the children’s cognitive function, communication, education, peer acceptance, self esteem and overall well-being. Monitoring for early detection of ototoxicity with the aim to allow clinicians to make informed choices to prevent further damage should therefore be made. Figures 2 and 3 show the significant deterioration of the QoL measures in the ototoxic group. The third research question was addressed using an online survey, which was sent to audiologists, oncologists and CF clinicians all over the UK. The survey assessed whether ototoxicity monitoring was undertaken or not and if it was, it assessed details of this service including criteria for referral and change in management, methods and rate of audiological monitoring, whether counseling was provided and by whom. Responses were obtained from 133 Audiology, 78 Oncology and 33 CF Clinicians. It was encouraging to see that 60-70% of all three groups said that they did monitor for ototoxicity. However, variations in this service identified shortcomings. The indications for ototoxicity monitoring were commonly ‘presence of symptoms’ which is managing side effects rather than monitoring. Results highlighted possible underutilization of the audiologists’ skills in counseling, accurate identification and management of hearing loss due to ototoxicity. A deficiency in communication between audiologists and clinicians seemed to exist. Most of

lunch and learn

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40 the monitoring usually didn’t continue post-treatment so late onset loss was likely to be missed. Minimal differences between monitoring and conventional audiological test batteries precluded the early detection of ototoxicity. In conclusion, the absence of a UK-wide agreed ototoxicity monitoring protocol as the ASHA (1994) or AAA (2009) [4,5] protocols has led to an inconsistent monitoring service across centers in the UK. It was recommended that Audiology professionals should take the lead to develop: • UK clinical guidelines for minimum standards of monitoring & care • Professional education programmes to increase awareness and standardisation of monitoring practice. Overall all this research has highlighted that there is still a clear need to translate

lunch and learn

the extensive research on ototoxicity to actually reach the patient groups that really need it and that as an audiology profession we are best placed to take the lead in implementing these changes. If you are interested to read more about this research please see my PhD thesis at:http://www.ucl.ac.uk/ear/courses /faculty/al-malky or contact me if you are interesting in collaborating. References 1. Al-Malky G, Suri R, Dawson SJ, Sirimanna T, Kemp D. Aminoglycoside antibiotics cochleotoxicity in paediatric cystic fibrosis (CF) patients: A study using extended high-frequency audiometry and distortion product otoacoustic emissions. Int J Audiol. 2011 Feb;50(2):112-22. 2. Al-Malky G, Dawson SJ, Sirimanna T, Bagkeris E, Suri R. High-frequency audiometry reveals high prevalence of aminoglycoside ototoxicity in

children with cystic fibrosis. J Cyst Fibros. 2014 Aug 12. Al-Malky G, Suri R, Sirimanna T, Dawson SJ. Normal hearing in a child with the m.1555A>G mutation despite repeated exposure to aminoglycosides. Has the penetrance of this pharmacogenetic interaction been overestimated? Int J Pediatr Otorhinolaryngol. 2014 Jun;78(6):969-73. ASHA. (1994).Guidelines for the audiologic management of individuals receiving cochleotoxic drug therapy. ASHA, 36 (Suppl. 12), 11– 19. American Academy of Audiology's Position Statement and Practice Guidelines on Ototoxicity Monitoring at: http://www.audiology.org/publications-resources/document-libr ar y/ototoxicity-monitor ing (accessed 10/2014)

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ear to the ground

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

In this edition of Ear to the Ground, Amanda Hall's #twitterarty piece focusses on campaigns by charities and others promoting Audiology, as well as resources for professionals shared online and people's experiences and opinions. The Bits and Pieces section in this issue has plenty of tidbits from within the media, including some interesting outdated treatments for ailments including hearing loss, memories of those in WW1 with hearing loss and the experiences of singer Katie Melua and former transport minister Stephen Norris.

The untold stories of deaf people in WW1 In a blog on the BBC website, See Hear producer William Mager chronicles the stories of some of the deaf people who contributed in World War 1. He also describes how the sentry systems set up across Britain led to the random shooting of many deaf people who could not hear the calls for them to stop. Finally, there are some comments by filmmaker Julian Peedle-Calloo, who recently made a 30 minute drama for BSLZone about a a deaf man who wants to fight, but is shunned by both the Army and his neighbours. Read his comments, and the rest of the blog at http://www.bbc.co.uk/news/blogs-ouch-29846154

The perils of the cotton bud Audiology Community –rejoice! Writer Anna Mangan published a piece in the Daily Express detailing her own experience of visiting a GP due to fears over her hearing. She was told that impacted wax was likely the cause of this deterioration, and that use of cotton buds is likely to have contributed to the wax build up. My favourite quote of the month comes from Michael Wareing in this article – “I would advise against putting anything smaller than your elbow in your ear”. The use of olive oil, syringing and microsuction are discussed, although the article does incorrectly imply that microsuction is only available privately. The piece is available at http://www.express.co.uk/life-style/health/498459/Earwax-hearing-loss

£3m Miners’ Claims A short article in the Daily Mail reported on a fourfold increase in claims by miners relating to noise induced hearing loss over the past two years. A Freedom of Information request to the Department of Energy and Climate Change revealed that in this time period £3 million has been paid out in successful claims. The Department is responsible for the welfare of workers from 1947 until the sector was privatised in 1994. The full report can be read at http://www.dailymail.co.uk/money/news/article-2798485/governmentpayments-miners-suffered-hearing-loss-result-work-jumps-fourfold-3-million-past-two-years.html.

ear to the ground

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43 Dear Virginia... A letter written in the "Dear Virginia" column tells a familiar story to many clinicians of a gentleman whose partner is struggling with her hearing but refusing to accept it. The article is interesting as Virginia's answer includes many of the morsels of advice that would be given in clinic, which are followed by suggestions from readers. These give a more personal insight into approaches that families and friends take before seeking professional help. Read the article at http://www.independent.co.uk/life-style/health-and-families/features/readerdilemma-my-partner-is-deaf-but-wont-admit-it-9778176.html?origin=internalSearch.

Silent Movie The Guardian published a review recently of a film which was played at Cannes and London film festivals. The Tribe, by Miroslav Slaboshpytskiy, is a Ukranian story of a student’s introduction to Kiev’s teenage gang and crime underworld. What makes the film interesting is that all of the dialogue in the film is in sign language, without any sub-titles for a non-signing audience. The reviewer opens an interesting debate – sign is a language like any other, why is this any different to watching any other foreign film without subtitles? He postulates that could be a way of highlightsing the alienation of the Deaf community. Read the review at http://www.theguardian.com/film/2014/oct/17/the-tribe-review-deaf-mutemiroslav-slaboshpytskiy.

Right Royal hearing aids The Telegraph report on the first sighting of Prince Phillip wearing hearing aids. A thin tube is seen in a zoomed in picture of the Prince's ear, with speculation as to whether he has RITE hearing aids or conventional open fit BTEs. It is refreshing to see that there is an emphasis on the availability of both devices on the NHS. The commentary provided by the editor of Majesty magazine suggests that Prince Phillip has been struggling in group conversations for a while, and that his hearing aids may improve his quality of life. The article can be read at http://www.telegraph.co.uk/news/uknews/prince-philip/11192748/Duke-of-Edinburgh-seen-wearinghearing-aids-for-first-time.html.

Former Transport Minister in call to action over hearing loss Former Conservative Transport minister Stephen Norris wrote a piece in the Sunday Express discussing his hearing loss, and calling for donations to Action on Hearing Loss (AoHL) to fund hearing research. The article begins with Mr Norris’ history of hearing difficulties, and in large parts successfully conveys the contradictions seen in Adult services throughout the country. It is clear from what he writes that, though he is cognitively aware of his moderate hearing loss, he has not emotionally accepted it. It is unsurprising, then, that the call for donations to AoHL is focussed on their stem cell research to cure deafness. The article is a great advert for AoHL and the fantastic work that they do. However, there is a danger of feeding the notion of hearing loss as a disability to be embarrassed about. The article can be read at http://www.express.co.uk/life-style/health/510905/Transport-minister-wecan-find-a-cure-for-being-deaf.

ear to the ground

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44 App-y Days The Daily Mail published an article online recently, detailing an app developed in America that works as a real-time speech to text translator. The app, called Transcence, is able to pick up multiple voices in group conversations, and provide a running text for the person who is struggling to follow the conversation. Each person’s smartphone microphone is used to send speech information to the speaker, meaning that everyone in the group needs a smartphone, which may be a disadvantage for some families. However, for a majority of people, this technology may be a useful solution to a problem that is frequently brought up in the Audiology clinic. The article explains that the app can be purchased for around $150 per year and can be read at http://www.dailymail.co.uk/sciencetech/article-2794087/the-app-lets-deaf-people-hear-software-turnssmartphone-real-time-speech-translator.html.

Tudor fox fat deafness cure In an article detailing “the A-Z of history’s weirdest cures”, the Daily Mail list an old wives’ tale thought to cure deafness. It is suggested that the Tudors mixed fox fat with hare’s gall bladder and put the mixture in patients’ ears to reduce wax build up. Fortunately, the article does clarify that this treatment is more likely to push wax deeper into the ear canal and lead to further complications. Read the other interesting ailment cures at http://www.dailymail.co.uk/health/article-2754591/A-Zhistorys-weirdest-cures-crystal-meth-urine-frogs-butter.html.

Katie Melua’s spid-ear surprise Singer Katie Melua posted a video on her instagram page in October of a live spider that was removed from her ear. She believes that the spider found its way into an old in-the-ear headphone and moved into her ear canal when she put the headphone in. She went to the doctor a week later as she heard a rustling in her ear, and the spider was microsuctioned out alive. The story is widely reported by the press – the BBC website’s account, which includes a link to Melua’s Instagram page, can be seen at http://www.bbc.co.uk/news/entertainment-arts-29878047.

Youtube Sensation A video that was taken two years ago but only recently posted on Youtube has gone viral through social media and received coverage on the Mirror’s website. The clip shows an Australian baby with moderate-to-severe hearing loss being fitted with a hearing aid for the first time, with the kind of reaction every paediatric Audiologist hopes for. Lachlan Lever stops crying immediately after the hearing aid is switched on and breaks into a grin on hearing his Mum’s voice. See the video at http://www.mirror.co.uk/news/world-news/listen-heartwarming-moment-deaf-baby4174017.

Don’t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

ear to the ground

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Twitterarty @HallAmandJ introduces you to the audiology Twitter community

Campaigning against North Staffs proposal to decommission hearing aids The proposal by North Staffs CCG generated many tweets on the subject. The charity Action on Hearing Loss led a campaign against the proposal and tweeted regular updates with links to current information. ActionOnHearingLoss @ActionOnHearing . Jul 28 Help us keep hearing aids free on the NHS by joining our online protest! #goo.gl/PGzP9u

ActionOnHearingLoss @ActionOnHearing . Sep 18 Over 400 members of the audiology community sign open letter condemning proposed #NorthStaffs #NHS hearing aid cuts ow.ly/BFMZR ActionOnHearingLoss @ActionOnHearing . Sep 22 'Influential health body rejects hearing aid cuts' - good news for our #NorthStaffs #NHS Hearing Aid Cuts campaign ow.ly/BLEcT

BritishSocAudiology @BSAudiology1 . Oct 6 Read the BSA's update on the North Staffs proposal to decommission #hearingaid services #AudPeeps #Audiology buff.ly/1vGDbzF

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.

The charity SENSE responds to the recent Care Act.. Sense - deafblind @Sensetweets . Oct 23 Threshold for social "far too high" - @SueBrownSense response to the Care Act regulations published today: sense.org.uk/content/sense... Sense - deafblind retweeted Richard Kramer @RichardKSense . Oct 23 Letter in today's @guardian on the need for a more integrated approach to health & social care theguardian.com/society/2014/o...

The CEO of Action on Hearing Loss in conversation with Norman Lamb... Norman Lamb @normanlamb . Oct 5 Interesting conversation with @pbreckell @actiononhearingloss on importance of acknoledgement, support and prevention of hearing loss #idconf Paul Breckell @pbreckell . Oct 5 thank you @normanlamb for your time today talking about the importance of hearing loss @ActionOnHearing

A conference around the future of subtitling in broadcasting â&#x20AC;Ś UKCouncilonDeafness @UKDeafCouncil . Oct 10 The Future of Subtitling - TV and Broadcasting - eepurl.com/5stRH

Campaigning NDCS campaigning for continued quality assurance of paediatric audiology servicesâ&#x20AC;Ś NDCS @NDCS_UK . Oct 17 #Gov plans to stop assessing quality of childrens #audiology services! Join our campaign & tell your MP to #ListenUp! bit.ly/1ywt4mo

The Future of Subtitling - TB and Broadcasting Conference Action on Hearing Loss, Sense and UKCoD are organising a one day conference to discuss the challenges and solutions for the future of television subtitles. Subtitles were first developed 35 years ago...

ear to the ground

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46 Resources and events for patients and professionals

British Tinnitus @British Tinnitus Do you know any children with tinnitus? We have three new leaflets for young people to help them understand and... fb.me/1MvFO1oDT

Sense - deafblind @Sensetweets . Sep 23 Route map for professional on supporting MSI CYP in the new #SEN system: goo.gl/Bh8Esl

Join us on Twitter @BSAudiology1

MSI CYP: multi-sensory impairment children and young people; SEN special educational needs Hearing Link @HearingLink . Sep 21 Living with #hearingloss in #Hampshire? We can support you. Book today for our Self Management Prog. ow.ly/BG8tU Meniere's Society @MenieresSociety . Sep 14 This week is Balance Awareness Week. Thanks to everyone who's getting involved. Find out more menieres.org.uk #balanceaware The Ear Foundation @EarFoundation . Oct 16 Our new report on the cost of adult deafness launched with @LilianGreenwood at the House of Commons download it bit.ly/1wbWHWQ

Experiences and discussion Tweets can link to a diverse range of blogs and articles relating to hearing and balance issuesâ&#x20AC;Ś. British Deaf News @BritishDeafNews . Oct 22 "Marvel's New Superhero with Cochlear Implans Sparks Divided Response from Deaf Community" bit.ly/1CWcwBg

Follow us on Twitter to keep up to date with BSA courses, meetings and conferences. Hearing Link @HearingLink . Oct 4 "My hearing aid is now a part of me..." Read Margaret's story: ow.ly/CcccC Ian Noon @iannoon ICYMI: my blog for @NDCS_UK asking if using the term 'deaf' might not always be in deaf children's best interests... wp.me/p4lh3f-dv ICYMI: in case you missed it

Why not give twitter a try. A good place to start is by following the British Society of Audiology @BSAudiology1

ear to the ground

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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clinical catch-up

Age, Hearing Loss and New Hearing Aid Fittings â&#x20AC;&#x201C; Some Facts and Figures from South Wales CD

Author and Correspondence Rhys Meredith, Consultant Clinical Scientist, ABMUHB, Singleton Hospital, Swansea

New hearing aid patients (n) Mean age (S.D.) Median Figure 1: Age groups for Bridgend, Swansea and Wales as a proportion of the overall population

Auditbase has been used in Wales to record patient demographics and test results since 2002. A large amount of information is available for audit and service development. The present report uses these data to investigate trends and make comparisons between services and the findings of previous research. Some questions which are addressed;

Bridgend

Swansea

8831

13257

70.4 (13.6) 70.1 (14.0) 72.3

72.2

Table 1: Age statistics for new hearing aid fittings

Throughout this period the mean age of first hearing aid remained close to 70 years (median 72) in both clinics.

1. Is the age of 1st fitting changing? 2. What is the average hearing level at hearing aid fitting and is this changing? 3. Are there any gender or socio-economic effects? Anonymised data was collected from the databases from two NHS Audiology departments in South Wales. The services operated independently until they merged in 2012 and served the Swansea and Bridgend areas, which have populations of 140,000 and 240,000 respectively. The combined population amounts to 9% of the total population of Wales and has an age distribution which is consistent with that of Wales as a whole (figure 1). Age of 1st Hearing Aid fitting A total of 20,088 new adult patients were fitted with hearing aids in the Bridgend and Swansea clinics between 2003-2013, (11 years). The age distributions, mean and median ages of the two departments were remarkably similar (table 1 and figure 2).

Figure 2: Age distributions for patients at 1st hearing aid fitting

Figure 3: Four frequency average BEHL and WEHL by age group at first hearing aid fitting (data Bridgend Clinic)

clinical catch-up

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48 Hearing Thresholds A method of extracting audiometric data from Auditbase was devised which used a combination of Crystal Reports and an Excel spreadsheet. Data was analysed using SPSS ver20. Mean air conduction (AC) thresholds were produced for four frequencies (0.5, 1, 2 and 4kHz) for the better and worse hearing ears (BEHL, WEHL)(see figure 3). The results showed that the four frequency mean hearing levels were close to 40dBHL and 50dBHL for the better and worse ears respectively. The mean AC thresholds obtained in the two clinics were very similar. (see figure 4)

Figure 4: Mean Air Conduction hearing thresholds at the time of the 1st hearing aid fitting for all patients between 2003-2013

The 4 frequency mean hearing levels for females were only 1-2 dB poorer than for males and the threshold distributions were very similar (see figure 5). There were significant differences in the AC thresholds between males and females for individual frequencies. Females tended to have poorer hearing for low frequencies whilst males had poorer hearing at 4kHz (see figure 6). The 4 frequency mean AC Hearing thresholds of patients obtaining a hearing aid for the first time was shown to be gradually and consistently improving over the 11 years of data collection. In comparison to 2003, the mean 4 frequency average was approximately 5dB better in 2013. When the audiometric data was analysed by age category, the results showed an interesting age effect. As would be predicted, high frequencies were poorer in older patients, but it was also found that the mean low frequency threshold tended to be worse in patients under the age of 60 years. The unexpected result is probably quite easily explained. Older patients generally obtain hearing aids for progressive, high frequency, age related hearing loss (presbyacusis), whereas a higher

clinical catch-up

Figure 5. Gender comparison of the four frequency mean hearing levels for the better and worse hearing ears.

Figure 6 BEHL at new hearing aid fitting by gender. The same pattern of differences was found for the worse hearing ears

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49 proportion of younger patients obtain hearing aids because of conductive hearing losses. Socio-Economic effects The Welsh Index of Multiple Deprivation (WIMD) provides a measure of social deprivation by area. Swansea has seven postal districts.The age and hearing levels of new hearing aid patients from the district with the highest WIMD score “SA3” (least deprived) was compared to the lowest “SA1” (most deprived). The mean age of first hearing aid fitting for persons from the more deprived area was approximately 6 years lower than those from the more affluent area. However this was expected as the age distribution of the more deprived area was considerably younger. After controlling for age it could be shown that for patients aged over 40 years, the mean hearing levels of those from the deprived area were significantly poorer than their counterparts from the more affluent area. Discussion The present report does not include data relating to hearing aid uptake in the private sector. According to Stephens et al (2001), approximately, 80-85% of people who possess a hearing aid in the UK obtained them via the NHS with a further 5% possessing both NHS and private hearing aids.This was consistent with the findings of Stevenson and Dawfrey (1980) and Davis et al (2007). The results in this report were based on 11 years of data from two separate audiology clinics in South Wales. The clinics serve relatively similar demographic pop-

ulations, but had until recently been managed independently. The mean age of patients at the time of their first hearing aid fitting appears to be consistently 70 years (median 72), in this part of South Wales. This compares closely with the 69.9 years reported by Meredith et al (2010), which used data collected from 22,000 new patients in 2008 from all NHS audiology services in Wales. Davis et al (2000) stated that the median age of new hearing aid fittings in the UK had risen from 70 years in the early 1980s to 74 years in 1999. It would appear that in Wales at least, the average age is a couple of years lower. Between 2003 and 2013 there was no change in the average age of patients at the time of new hearing aid fitting. However thresholds at fitting improved by approximately 5dB over the 11 year period. Interestingly, although the mean 4 frequency hearing thresholds of males and females were very similar, there was a clear gender difference for AC thresholds for individual frequencies with males having worse hearing in high frequencies and females worse for low frequencies. This is consistent with the epidemiological results reported by Davis (1995). Other findings from the analysis of audiometric data showed differences in hearing levels and hearing loss configuration between age groups. As would be expected older patients have the poorest high frequency and 4 frequency average hearing thresholds but younger patients obtaining a hearing aid for the first time are shown to have worse hearing in the low frequencies compared to older age

groups.This is almost certainly due to the high proportion of younger hearing aid patients having conductive hearing losses. Finally the comparison of patients from relatively affluent and deprived areas provided some cause for concern. After controlling for age, patients from the more deprived area were found to have significantly poorer hearing at the time they accessed a hearing aid for the first time. Davis (1995) showed that hearing tends to be poorer for lower socio economic groups. These results imply that those in more deprived areas may take longer to access hearing aid services than their more affluent counterparts.

References 1. Davis A. Hearing in Adults. London Whurr: 1995. 2. Davis A, Smith P, Lovell E, Ferguson M, Lutman M, Gatehouse S et al. Adult Hearing Screening; what would be an efficient and effective hearing screen for ability to benefit from amplification? In XXV International Congress of Audiology, The Hague; 2000. P22. 3. Meredith R, Manchaiah VKC and Stephens, SDG. Estimating NHS Hearing Aid Uptake in Wales Using AuditBase. BSA News Issue 62, 2010. 4. Stephens D, Lewis P, Davis A, Gianopoulos I, Vetter N. Hearing aid possession in the population: lessons from a small country. Audiology 2001; 40: 104-111. 5. Stevenson J and Dafrey L, A study of private hearing aid users in London. Br J Audiol 1980; 14:105-114.

Lightning Updates

The BSA Lightning Updates are 5 minute online snippets released every month updating members on different aspects of the society. This may include the various special interest groups, as well as introducing new features such as the launch of the new website. They are also a way for members to keep informed on upcoming events such as the conference. www.thebsa.org.uk/lightning/

clinical catch-up

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The Role of the School Entry Hearing Screen in Identifying Childhood Hearing Impairment in Reception Age Children CD

Authors and Correspondence Adam Walker, Clinical Scientist (Audiology)

Group 1998) of NHSP leads to a high degree of confidence that children screened do not have a ‘significant’ high frequency hearing loss. As a result, pro-

Greg Nassar, Clinical Scientist (Audiology)

Central Manchester University Hospitals NHS Foundation Trust Trafford General Hospital E: trafford.paedaudiology@nhs.net

Introduction Prior to the national implementation of the newborn hearing screening programme (NHSP) in 2006, screening for childhood hearing loss was achieved via the eight month distraction test and the school entry hearing screen (SEHS). Shortcomings of the distraction test led to this being phased out in favour of a more reliable screening method, hence the implementation of NHSP (Davis et al 1997). Despite the introduction and subsequent move away from the eight month distraction test no guidance has followed relating to the SEHS. Therefore, as stated by Bristow et al (2007) “the SEHS has evolved as a responsibility of local NHS services” and hence is not governed by any specific national standards. The high sensitivity (over 90%) and specificity (approximately 95%) (Wessex Universal Neonatal Hearing Screening Trial

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fessionals tend to rely on parental or professional concern as a means of referral, with less emphasis appearing to be placed on subsequent wide-spread screening. As highlighted by Kennedy et al (2005), the number of undiagnosed hearing losses in the school population will be fewer following the implementation of NHSP, which may potentially reduce the perceived importance of the screen. Watkin and Baldwin (2011) found that 3.65/1000 children were identified with some degree of permanent hearing loss by the time they reached school age. However, only 0.9/1000 of these children were identified through NHSP.This therefore leaves a large proportion of children with known permanent hearing loss that were ‘missed’ by NHSP. In the Trafford area, School Nurses are trained, by the Audiology department, to perform a hearing screen in reception age children (typically four or five year olds) in the school setting. A ‘pass’ on the screening test is deemed to be minimal response levels of 25dB HL across the frequency range of 500Hz – 4kHz in

both ears, with any levels of 30dB HL or greater in either ear deemed to be a ‘fail’. If a child fails the screening test, or if there are significant parental concerns for a child passing the screen, then the School Nurse seeks parental consent for a referral into the audiology service. Methods A retrospective audit of the outcome of new patient assessments for all children referred via the school age hearing screen was undertaken for the 12months from February 2011 until February 2012. The outcome of the initial assessment was audited and categorized into one of the following groups: 1. Normal hearing bilaterally and discharged. 2. Temporary conductive hearing loss in at least one ear of <40dB. 3. Temporary conductive hearing loss in at least one ear of >40dB. 4. Sensorineural hearing loss not suffi-

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51 cient to require intervention (hearing aid/s) at present. 5. Sensorineural hearing loss requiring intervention (hearing aid/s). Children from Group 2 were placed on a watchful waiting pathway and were subsequently reviewed after 3months. Children from Group 3 were offered immediate hearing aids and appropriate review, if parents declined hearing aids then these children were placed on a 3 month watchful waiting pathway. Following the 3 month review, children from groups 2 and 3 with persistent conductive hearing loss were offered hearing aids or ENT intervention. Results Of 2343 children who underwent the SEHS a total of 176 children (7.5%) children were referred into Audiology from the school screen. As shown in Table 1, of those 176 children 88 (50%) had normal hearing in both ears and were subsequently discharged. 66 children (37.5%) were found to have a conductive hearing impairment with evidence of middle ear congestion and underwent a watchful wait period of 3 months. A further 13 children (7.4%) had a conductive hearing loss significant enough to warrant immediate intervention and were referred to ENT at the parents’ request. A total of 9 children (5.1%) were found to have some degree of sensorineural hearing loss. (see Table 2) 5 of these children opted for no intervention from hearing aids at the current time, 3 of the remaining children were issued with bilateral hearing aids and 1

Group

child was issued with a CROS (contralateral routing of signal) aid.

hearing loss may be persistent and remain unresolved without intervention.

Of the 5 children opting for no intervention, 2 children had a mild mid-frequency cookie-bite hearing loss, one child had a severe unilateral loss, one child had a unilateral low-frequency loss and the remaining child had a mild, bilateral high frequency loss. 3 of the 4 children issued with hearing aids had a bilateral, moderate high frequency hearing loss. The child fitted with the CROS aid had a severe to profound unilateral sensorineural hearing loss.

Of the 176 children referred to audiology, 9 (5%) were identified as having a sensorineural hearing loss, of these children 4 (2%) required no intervention from hearing aids, whilst hearing aids were fitted to the remaining 5 (3%) children.Therefore, of all the children undergoing the SEHS, 0.2% were identified as having a sensorineural hearing loss requiring no intervention and 0.2% were fitted with hearing aids.

Standard aetiological investigations were offered to the parents of all 9 children identified with sensorineural hearing loss. 4 families decided to proceed with investigations at this time, in 3 cases the hearing loss was deemed to be idiopathic and in the remaining case (patient 1) was attributed to CMV. Discussion Half of the children referred from the school hearing screen required further intervention (i.e immediate referral to ENT or hearing aid fitting) or monitoring (i.e watchful wait or permanent hearing loss requiring no intervention).Therefore, at the time of the school screen, 88 reception age children in the Trafford area had some degree of hearing loss that was potentially affecting their ability to hear well in the classroom. Further investigation is required in the monitoring group to analyse the time between initial referral and eventual discharge or intervention, as in some cases the ‘temporary’

Type and Degree of Hearing Loss

Number of Children

In 7 out of the 9 cases of sensorineural hearing loss, these children passed the newborn hearing screen in both ears (NHSP data were not available for two cases), see Table 2 for details. This may obviously be indicative of a late-onset hearing loss. However it may be that although the children passed the newborn hearing screen, they did in fact have the hearing loss from birth. The newborn hearing screening programme is designed to identify ‘significant’ hearing loss. Although some of these children were seen in audiology for a full threshold ABR test the NHSP ABR protocol at that time still advised the use of a click stimulus with a dial discharge level of 40dBHL. This means that children with a mild high frequency loss may have had a clear response at this discharge level. Therefore, with the exception of the 2 children with severe unilateral hearing loss, all of the remaining children identified with SNHL in this report had the ‘potential’ to obtain bilateral clear re-

Percentage of total referrals (%)

Normal hearing bilaterally

88 / 176

Mild conductive loss

66 / 176

37.5

Moderate conductive loss

13 / 176

7.4

Sensorineural loss with no intervention

5 / 176

2.8

Sensorineural loss with intervention

4 / 176

2.3

Table 1 – To show the number and proportion of children in each of the 5 groups

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52 Patient Number

OAE1 Right

OAE1 Left

Pass

OAE2 Right

OAE2 Left

Risk Factors

Current Hearing Loss

Pass

None

Severe-profound unilateral snhl (right)

Pass

None

Mild bilateral high frequency snhl

aABR Right

Pass

aABR Left

Fail

Pass

No Data

Pass

No Data

Pass

No Data

rABR Right

rABR Left

Pass

FH*

Moderate bilateral high frequency snhl

Pass

None

Moderate-Severe Unilateral snhl (right)

None

Mild bilateral cookie bite snhl

FH*

Moderate bilateral high frequency snhl

NICU

Mild bilateral high frequency snhl

None

Moderate low frequency unilateral snhl (right)

None

Mild bilateral cookie bite snhl

No Data No Data

Table 2 – To show the NHSP results of all 9 children in the study (rABR = referred for ABR following Newborn Hearing Screen referral) *Family history identified subsequently

sponses on the newborn screen (as they had either normal or mildly elevated high frequency thresholds). Our findings are similar to recent findings by Sandwell and West Birmingham Hospitals NHS Trust (presented at the 2012 NHSP Conference by Gill Atty) in which 66% of children referred to audiology from the SEHS were found to have normal hearing, 33% were found to have some degree of temporary conductive hearing loss and 1% had a permanent hearing loss. Aetiological investigations in our cohort revealed an idiopathic loss in 4 children and CMV in the remaining 1 child, however.This was a small sample number and is most likely not representative of the wider population of children with permanent hearing loss. These results represent the intake of one school year, equating to 2343 children. Given that 176 children were referred to audiology this equates to 75 in 1000

clinical catch-up

children failing the school entry hearing screen, and 3.8 in 1000 children with a permanent hearing loss identified at the point of the school entry hearing screen. This figure is similar to that found by Watkin and Baldwin (2011) who found that 3.65 in 1000 children had permanent hearing loss at the time of the school entry hearing screen.

It is therefore hypothesised that subsequent school entry hearing tests for following years will yield similar patterns of results and therefore the importance of a school entry hearing screen cannot be under-estimated; both as a source of identification of congestion related hearing impairment and also back-up for the newborn hearing screen. Clearly, it is not sufficient to simply rely on parental or professional concerns as a means of detecting permanent hearing loss in children that passed the newborn hearing screen. A screening test for all children of reception age would a further ‘failsafe’ to the system.

References 1. Davis A, Bamford J, Wilson I, Ramkalawan T, Forshaw M, Wright S. A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment. Health Technol Assess 1997;1(10). 2. United Kingdom school-entry hearing screening: current practice K Bristow,1 H Fortnum, 2 S Fonseca, 3 J Bamford, 4 Arch Dis Child 2008;93:232–235. 3. Wessex Universal Neonatal Hearing Screening Trial Group. Controlled trial of universal neonatal screening for early identification of permanent childhood hearing impairment. Lancet 1998;352:1957–64 4. Kennedy C, McCann DC, Campbell MJ, et al. Universal newborn screening for permanent childhood hearing impairment: an 8-year follow-up of a controlled trial. Lancet 2005;366:660– 2. 5. Identifying deafness in early childhood: requirements after the newborn hearing screen P M Watkin, M Baldwin Arch Dis Child 2011;96:62–66.

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Audiology in India

FACTFILE... Population: 1.27 million Total area: 3.29 million km2 Capital: New Delhi Prevalence of hearing impairment: 6.3% (WHO estimate)

Author and Correspondence Ashwini Rao P. N.

Junior Clinical Specialist Cochlear Medical Device Company India Private Limited Mumbai India

west, and an arc of mountains including the Himalayas in the north. It is the third largest country in Asia and seventh in the world, with a population of over a billion people. Approximately 70% of the population live in rural areas. India is comprised of 29 states and seven territories, and each has at least one official language. While the national language is Hindi, there are around 22 official languages and nearly 400 living languages spoken in various parts of the country.

E: arao@cochlear.com

Biography Ashwini became a qualified Audiologist in 2009 on achieving her Bachelor’s degree in Speech & Hearing. After successful completion of her specialised Master’s degree in Audiology from the All India Institute of Speech & Hearing, she began an important role within the global corporation, Cochlear. During her professional development as a Clinical Specialist, she has helped to ensure standardized service delivery at numerous cochlear implant clinics and hospital setups across South India. Ashwini has maintained her passion for research and keeping up to date with the evidence base alongside her responsibilities in clinical practice.

India is situated in the southern part of Asia and borders the Indian Ocean, Arabian Sea and the Bay of Bengal. India has a diverse geomorphology which can be divided into four main regions: upland plains (including the Deccan Plateau) in the south, flat rolling plains along the Ganges river, deserts in the

ear globe: audiology around the world

“The National Rural Health Mission (NRHM) was launched in 2005 with the aim to provide universal access to quality healthcare” History of Audiology in India Audiology is a young profession in India, arising just over 45 years ago. Within this short period of time, the profession of Audiology has grown exponentially in both the public and private sectors. The profession has seen significant developments in education and training, quality of services, coverage of services, number of specialist services available, and public awareness. In 1965, All India Institute of Speech and Hearing (AIISH) was established in Mysore as an autonomous institute for provision of audiological services to adults and children with hearing impairment and communication disorders.The institute is a popular training centre for both domestic and international students wishing to pursue a career in Audiology. I consider

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55 “the Assistance to Disabled Persons (ADIP) scheme was introduced to widen access to amplification and ensure that low income is not a barrier to treatment” peripheral and central hearing pathways, in addition to the specialist services of tinnitus counselling and vestibular assessment and management, in both children and adults. Diagnostic services are delivered through behavioural, psychoacoustic, and electrophysiological measures. Adult rehabilitation involves assessment, selection, verification and servicing of individual amplification devices and ear moulds. Amplification devices available include conventional digital hearing aids, boneanchored devices, implantable devices (cochlear and brainstem implants) and assistive listening devices. The availability of modern digital hearing aids of all styles, makes and models in India has improved following liberalization of import policies. Leh - the mighty Himalayas in the backdrop

myself fortunate to have completed my Bachelor’s degree in Speech and Hearing and Master’s degree in Audiology from the premier institute in India. Following the opening of AIISH, more training programmes were introduced at various levels (including diploma, undergraduate, postgraduate and PhD programmes) to facilitate manpower development in the field of Audiology. Currently, there are around 20 universities which provide Speech Pathology & Audiology programmes accredited by the Rehabilitation Council of India (RCI). The RCI is a statutory body under the Ministry of Social justice and Empowerment. Professionals registered as an Audiologist under RCI after degree completion are eligible to practice anywhere across the country. Services in India Audiology services in India are delivered in a variety of settings, including: Government hospitals, private clinics, rehabilitation centres, University-based speech and hearing institutes, and ENT clinics. Audiologists are involved in the screening, assessment and management of hearing disorders affecting the

Localisation set up in Psychoacoustic Lab, All India Institute of Speech & Hearing, Mysore

Following the enactment of the Persons with Disabilities (Equal opportunities, Protection of Rights and Full Participation) Act in 1995, the Assistance to Disabled Persons (ADIP) scheme was introduced to widen access to amplification and ensure that low income is not a barrier to treatment. Under this scheme, body-worn aids are provided either free of charge or subsidised by 50%, depending on income, with funding from the Ministry of Social Justice and Empowerment. Those with incomes exceeding Rs.10,000 per month are required to pay the full price for a hearing aid issued from either the public or private sector.The number of private clinics far exceeds that of state audiology departments and most services are located in urban areas. The National Rural Health Mission (NRHM) was launched in 2005 with the aim to provide universal access to quality healthcare and this has resulted in rural camps being set up to provide audiological services to those in remote locations. Newborn Hearing Screening Challenges of implementing universal newborn hearing screening in India include the large population and high birth rate, as well as the large number of births occurring in homes in rural areas. In 2006, the Ministry of Health and Family Welfare launched the pilot phase of the National Programme in Prevention and Control of Deafness (NPPCD) with an objective of early identification, diagnosis and treatment of hearing loss. A two-part protocol, including both institutionbased and community-based screening, was designed to overcome the challenges faced in introducing universal newborn screening. Institution-based screening involves OAE testing on every child born in hospital, a re-test at 1 month old for those who fail and ABR testing at a tertiary centre following the second fail. All other babies are screened in the community, typically using a questionnaire and behavioural observation audiometry at approximately six weeks of age.

ear globe: audiology around the world

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Trekking the Kuduremukh in the Western Ghats, India during National Service Scheme (community service) activity

Those that fail are referred for OAE testing and later ABR testing if there is a second fail. Despite the recommended protocol, practice remains variable between districts and hospitals, and newborn hearing screening is not mandatory. Surveys have suggested that whilst most University-based speech and hearing institutes conduct a newborn hearing screening programme, the proportion of medical colleges (public teaching hospitals) offering such programmes is much lower.

“in spite of the big strides made in improving the quality of audiology services in the past few decades, much still needs to be done”

Paediatric Audiology Services The majority of audiologists working in India are involved in the audiological assessment and management of children as well as adults. A survey of paediatric audiology services in India suggests that the majority of audiologists testing children’s hearing are equipped and trained to perform electrophysiological tests such as ABR and ASSR, as well as behavioural tests. Early identification of hearing loss through newborn hearing screening necessitates high quality early intervention programmes and availability of hearing aids to paediatric populations. State funding for paediatric hearing aid provision is also based on family income under the ADIP scheme. Binaural behind-the-ear aids are provided to school-age children up to a cost of Rs.8,000 per aid per ear. These may be replaced with a new model every two years. Families paying into a state insurance scheme will receive reimbursement for the cost of hearing aids. Until recently, cochlear implantation was only available to

ear globe: audiology around the world

children whose families could afford to pay the high costs of surgery and intensive speech therapy. However, some state governments are now taking the initiative to provide free cochlear implantation and financial support for auditory-verbal habilitation (AVH) to children selected by regional and state level technical committees. Furthermore, some private hospitals receive funding from corporate houses to provide cochlear implantation to children from lowincome families. Despite these schemes, only a small percentage of those born with profound hearing loss will receive an implant due to cost limitations. An ongoing project in India is to develop a low-priced indigenous cochlear implant in order to reduce the cost of cochlear implantation and improve accessibility.

Professional associations The Indian Speech and Hearing Association (ISHA), established in 1967, is a professional and scientific association of over 2500 members. Members comprise of speech-language pathologists, audiologists, and research scientists. ISHA’s objectives are to promote high educational, clinical and research standards in the fields of audiology and speech therapy; encourage and support research projects; enable continued professional development; and stimulate exchange of information and networking. India has another association for professionals working within the field of cochlear implants. Cochlear Implant Group of India (CIGI) is an association of surgeons, audiologists and auditoryverbal therapists. Cochlear implant manufacturers are able to join as associate members. CIGI plays an important role in standardizing techniques and protocols for cochlear implantation and also facilitates research in the area. Both organisations have annual conferences where professionals meet and discuss basic scientific research, translational research and clinical practice. As an Audiologist in India India is a highly diverse nation which allows for a variety of potential career paths for a qualified Audiologist. Working as a specialist in the field of cochlear implants is particularly fascinating. I like the fact that current technology is advancing at such a rapid pace and I am constantly learning something new with every step in my career. Looking towards the future, I feel there is a need to gear Audiology training programmes to meet the specific needs of the multi-lingual and multi-cultural population. Furthermore, in spite of the big strides made in improving the quality of audiology services in the past few decades, much still needs to be done. In particular, we must aim to provide equality of services across different regions and communities, and retain the professionals trained and invested in here to continue to provide high quality services.

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Conference Report Balance Testing - Past, Present & Future: 7th November 2014 Ear Institute, UCL In the region of 60 delegates attended our biennial conference at the Ear Institute, London on a somewhat wet November day. It was interesting to note the multidisciplinary line up of speakers and delegates, highlighting the wide array of health care professionals involved in the testing, diagnosis and rehabilitation of patients with dizziness.

Debbie Cane (MSc CS , Senior Clinical Scientist, Chair of BSA Balance Interest Group)

Dr Diago Kaski (Neurology) started the day speaking about the many different causes of balance problems and the importance of an accurate diagnosis using the increasingly wide range of diagnostic tests that we have available to us. Dr Andrew Wilkinson (Clinical Scientist in Audiology) then presented the result of his vestibular service provision questionnaire in his talk entitled ‘Postcode lottery for dizzy patients?’ This showed lots of excellent services around the country, but did highlight the variation in service provision. Dr Jas Sandhu (ENT and Scientist) continued the morning on the diagnostic theme with some of the more recent high tech test techniques available to aid in diagnosis, such as the video head thrust and vestibular evoked myogenic potential (VEMP). Dr Veronica Kennedy (AV Physician) then showed that how for children, high tech testing is often not required. She suggested that a great deal of information can be obtained with the use of skilfully performed quick and simple clinical bedside tests made more interesting with some ‘pocket money’ toys. Many of us made a mental note to visit IKEA to buy her recommended finger puppets and flashing toys to aid our testing! Finally we moved from the clinical side to research with Professor Andrew Forge (Ear Institute) who ended the morning with a fascinating presentation on the feasibility of vestibular hair cell regeneration. All these talks were highly informative and were followed by much debate on each topic which could have gone long into the night. Hopefully some of these debates will continue by email and at future meetings.There was then a break to reflect upon all the information from the morning and of course for lunch. Delegates were also invited to attend the BIG AGM, to look at the posters and manufacturers’ stalls with the latest diagnostic equipment. A “hands-on” afternoon then followed, starting with a lecture, case histories and practical demonstration on bedside clinical testing given by Dr Peter West (AV Physician). Delegates were then invited to attend two from three practical workshops on vestibular rehabilitation, VEMPs and bedside testing. Mid-way through the afternoon there was a further chance to look at the manufacturers’ equipment. Finally we had the poster prize presentation. This was a tough decision to make, with all posters being informative and well composed. Jenny Townsend, Rebecca Anderson and Vignapti Patel took first prize with their poster on normative data for gaze, body positional and head shaking evoked nystagmus. This was closely followed by second prize for Drs Jas Sandhu and Peter Rea for their work on BPPV, ocular and cervical VEMPs. Overall it was an excellent day. It was great to have a chance to talk to so many people passionate about our field, and to focus on our shared goal in improving care for dizzy patients.The Balance Interest Group Committee would like to thank all the speakers who presented or gave workshops, the manufacturers, and of course the delegates for attending. We hope that everyone found the day as enjoyable and informative as we did, and we look forward to organizing another conference in two years’ time.

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BSA Journal Club BSA Journal Club The first in the new series of Journal Clubs, on the topic of Adult Hearing Screening, took place in Nottingham in July (see article in Audacity Issue 4) and was repeated at the BSA annual Conference in Keele in September. Both events were a great success. BSA plan to organise two Journal Club topics every year, and for each topic there will be three Journal Clubs at three different locations across the UK. One cluster of Journal clubs will take place in March / April and the second cluster in September / October.

The Next Journal Clubs The next topic will be Dementia and Hearing and three journal clubs will be taking place during March and April 2015. The papers for discussion will cover three areas: • Hearing loss and dementia • Hearing Aids and cognition • Hearing assessment and dementia Keep an eye on the BSA events pages for further information about locations and exact dates. Future Journal Clubs The second topic for September / October 2015 will be Mild to Moderate Hearing Loss.

Twilight Meeting Update 24th Oct 2014 It is with great excitement that the Learning Events Group is ready to announce our next two scheduled BSA Twilight Series Meetings. These prestigious gatherings are historically known as the London Evening Meetings which have recently started rotating around the country in order to make them more accessible to all our colleagues. They are purposefully designed to cover a large variety of up and coming interesting topics. The Twilights are aiming to expand our knowledge on the most basic aspects, like basic research outcomes, give us ideas on how to implement research findings in everyday clinical practice and how we can positively impact our work as clinicians, researchers or simply interested audiology learners!! The ever popular Twilight Meetings see lots of healthy discussions and networking as well as expansion of our everyday work toolkits as clinicians or researchers.

Save the Dates!

Do not miss the next Twilight Meeting!

Springtime Twilight: Thursday 23rd April 2015 at 5pm, North West Region, Wrexham Medical Institute, Technology Park Centre, Croesnewydd Road, Wrexham, LL13 7YP New Perspectives on Dual Impairments: Hearing Loss & Dementia, Hearing Loss & Diabetes, Hearing Loss & Corrected Vision.

Autumn Twilight Thursday 5th November 2015 at 5pm, North East Region, Middlesbrough New Perspectives on Paediatric Habilitation: Early Habilitation, Long-term successes and challenges, auditory verbal therapy.

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The Importance of the ILC-UK Commission on Hearing Loss

William Brassington MSc President – British Academy of Audiology Commissioner – ILC-UK Commission on Hearing Loss E: william.brassington@nuh.nhs.uk

As Audiologists we are all too familiar with the challenges individuals with hearing impairment face on a daily basis.The complexity of managing hearing loss is of course well recognized in our profession, as is the profound impact that hearing loss can have on an individual’s life. Far too often in recent years we have observed attempts to draw analogy between the management of hearing loss and the management of visual impairment.The two conditions are of course associated with ageing however the management of these conditions is not comparable.The resolution of ones visual impairment may well be achieved with prescription lenses but successful management of hearing loss goes far beyond the prescription of hearing aids. Individuals with hearing loss face barriers in life every day. Communication is a given for most of us, but for individuals with hearing loss as their ability to communicate is diminished their ability to carry on a normal life often ceases with devastating effects on the individual and those around them.There is strong evidence linking deafness to mental health and with suicide rates being significantly higher in patients with mental health issues, the need to identify and address hearing loss at an early stage cannot be stressed enough. Despite these facts there remains a degree of apathy that surrounds hearing impairment. As clinicians we observe this every day as patients continually deny their hearing impairment for one reason or another. Is this their fear of appearing stupid or getting old? Regularly we hear and observe the mockery of people with hearing impairment; it’s clear that most people don’t appreciate the challenges faced by hearing impaired people and the societal impact of failing to address the future issues hearing loss will present in the UK. Hearing loss is all too often ignored in the hierarchy of needs of older people or accepted as an inevitable part of the ageing process. Data from Action on Hearing Loss (AOHL) suggests, there are currently around 10 million people in the UK with hearing impairment and this is set to rise to around 14.5 million by 2031. Of the 10 million hearing impaired its estimated around 4 million would benefit from hearing aids yet nationally there are only around 2 million hearing aid users. We may therefore ask ourselves, what is preventing people accessing hearing aids and how will we address the growing global disease burden of hearing impairment? Some of you may have come across the International Longevity Centre-UK (ILCUK). For those who haven’t it is an independent, non-partisan think tank dedicated to addressing issues of longevity, ageing and population change. They develop ideas, undertake research and create a forum for debate. Much of their work is directed at the highest levels within government and the civil service and earlier this year, supported by Boots Hearing Care Ltd they set up an independent Commission on Hearing Loss, chaired by Baroness Sally Greengross supported by invited commissioners to include MP’s and representatives from all health sectors. The purpose of the commission was to explore the wide-reaching implications of hearing loss and how to address them. Despite such large numbers with hearing loss and the significant implications of it, public awareness is low and this is reflected in

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61 public policy, which has failed to develop a coherent strategy in the face of this rising problem. The terms of reference for the Commission on Hearing Loss were set out to consider the extent of the challenges posed by hearing loss in the UK and how it could be tackled. Commissioners were asked to consider a number of critical questions as part of a series of oral evidence sessions: • How and to what extent can hearing loss impact on a person’s quality of life? • What are the wider implications of hearing loss with regard to social isolation, loneliness and exclusion, employment and extending working life, equal access to health and social care? • What are the current barriers which prevent early detection and support of hearing loss? • How can we support people to recognise their hearing loss earlier and come forward for help? • How can we de-stigmatise hearing loss and the use of hearing aids? • How can public and private health and social care providers improve early detection and hearing services? Over a two-month period the Commission held open evidence sessions and called for written evidence from leading experts, patient representatives and numerous associated professionals in the House of Lords. The evidence collected from the oral sessions and written submissions was extensive and can be downloaded as a separate document from the ILC-UK website.

it’s clear that most people don’t appreciate the challenges faced by hearing impaired people The ILC-UK Commission on Hearing Loss was subsequently published in July 2014. The report provides a comprehensive insight into the challenges presented with managing hearing loss in the UK. Giving an oversight of the barriers individuals face in accessing timely hearing care, the challenges services face in the process of commissioning hearing services, the lack of public awareness around hearing loss and the long term societal costs of failing to address these issues the report makes the following key recommendations: Early identification It takes 10 years on average for someone to realise that they are suffering from hearing loss and to then seek help.This is not good enough – during those 10 years someone’s hearing will continue to deteriorate adversely affecting their quality of life and reducing their ability to adjust in future.

Recommendation - Introduction of nationwide screening programme including guidance on piloting and assessment of patients with dementia is addressed. Referral While the GP has an undoubtedly crucial role to play as the first point-of call for many people who are seeking information or think they might have hearing loss, the GP referral route may also act as a barrier, which prevents more people from receiving full hearing services. One study suggested that 45% of people who go to the GP for a hearing aid are not referred on for treatment. Recommendation - Opening access-a review of current access and pilots to look at more innovative approaches to improve access. Strategic planning on hearing loss There are significant funding pressures on NHS services which could lead to a reduction in non-acute services such as hearing services unless the case is made that improved integration and quality of services for people with hearing loss will improve communication and quality of life, as well as reducing costs in the long term. Recommendation - A long-term strategic plan based on cost benefit analysis, the commission recommends publication of the Action Plan on Hearing Loss. Preparing a society that is ready for hearing loss The challenges of managing hearing loss in a society that is unprepared to do so remains a major issue. Awareness of hearing loss and strategies to manage it must be improved to ensure seamless integration for hearing impaired people in the future. Recommendation - Improving awareness of hearing loss through improved education of health and social care providers, employers and public campaigns. The full report provides many other recommendations and is a useful reference for many of us facing challenging conversations centered around the cost of providing hearing services. Hearing impairment in the UK is a major issue and if we are to tackle this in the future we must change the topic of conversation away from looking at the costs of providing hearing services and over to the costs of not providing hearing services. Full report: ILC-UK Commission on Hearing Loss and Submitted evidence can be downloaded from www.ilcuk.org.uk Take Home Message The ILC-UK Commission on Hearing Loss provides a comprehensive insight into the challenges presented with managing hearing loss in the UK.

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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 Michael Akeroyd Mr Peter Byrom Mrs Christine Cameron Mrs Nicci Campbell Mr Chris Cartwright Mr John Day Dr Heather Fortnum (RFSCo)

Dr Martin O’Driscoll (Audacity) Dr Helen Pryce Miss Tracey Twomey Council Advisors Miss Debbie Cane (BIG) Mr David Canning (PAIG) Prof. Adrian Davis (IJA) Dr Piers Dawes (Cognition & Hearing) Dr Melanie Ferguson (LEG) Ms Pauline Grant (APD) Ms Lucy Handscomb (ARIG) Mr Graham Frost (PPC) Miss Charlotte Turtle (New Members) Dr Peter West (IJA) Ms Siobhan Brennan (Electrophysiology SIG) Mrs Kathryn Lewis (BSA North Branch)

BSA Meeting Dates for 2015 Tuesday 17th March - Birmingham Tuesday 16th June - Birmingham Thursday 3rd September - Cardiff (TBC) Tuesday 8th December - Birmingham (TBC) Council from 11.00am to 4.30pm

Housekeeping Meetings Dates Tuesday 24th February Tuesday 19th May Tuesday11th August Thursday 17th November The above meetings will be held at the BSA Admin Office

Professional Practice Committee Meeting Dates 2015 Monday 2nd March Monday 1st June Monday 7th September Monday 23rd November (All dates to be confirmed) Hearing and Balance UK Meeting Dates 2015 Wednesday 25th February Wednesday 3rd June Wednesday 14th October

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

For further information, please contact BSA Admin Office Tel: 0118 966 0622 Fax: 0118 935 1915 Email: bsa@thebsa.org.uk Web: www.thebsa.org.uk

Unityâ&#x201E;˘ 3. Maximum efficiency â&#x20AC;&#x201C; Minimum size. For precise diagnostics and effortless fitting. www.siemens.co.uk/hearing The all new Unity 3 is a PC controlled diagnostic fitting system which combines small size and light weight with ease of use.

The new Unity 3 test box operates stand alone and independently from the fitting module, saving you money and space.

Building on the success of Unity 2, the new Unity 3 remains a powerful, robust, reliable and flexible fitting system. Unity 3 introduces new innovations and is extremely portable making it suitable for hearing instrument fittings in the clinic, in the home or for remote clinic use.

Unity 3 includes AutoFit (available in Connexx 7.3) for seemless, accurate and efficient Real Ear Measurements with no need to toggle between different fitting tools.

Unity 3 features include new binaural measurements which reduce testing times by half. New smart headsets which have their own calibration data stored on-board means calibration and maintenance is made easy. In fact, just opt into the Siemens replacement headset scheme and you will never be without your equipment. The result â&#x20AC;&#x201C; no service downtime.

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Life sounds brilliant.

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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) Evette Coopey Jamie Griffiths Danielle Biggin

David Gamble Paul Whitmarsh Tony Rumble

Sandra Sharratt Dave Marshall Jon Lusher-Seaman

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Mary Hare) Martina Farren Claire Sunderland

Dawn Bevington

Wendy Martin

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (TJ Audiology) Raj Arman

Anjula Manota

Anna Hughes

BSA Certificate in Industrial Audiometry (Audio-Training) Garnett Newman Jacqueline Mason Mohammed Ali Kirn Saini Janet Cripps Paula Kelly

Penny Draycott Bryce Finnegan Rajan Bhandari Imran Zafar Shalini Singh

Khalid Hussain Amir Javed Adil Saddique Jaseem Ramzan Tracy Hanvey

BSA Certificate in Industrial Audiometry (Albacare) Andrea McGrellis Abigail McNeish Heather Donald Jill Hamilton Barbara Ewart Beverley Thompson Mark Anthony Adaza Angela MacLeod Dermott Docherty Dorothy Muirhead

Elena Ramsay Anne Day Linda Townsley Donna Andrews Doreen Hand Sandra Warnock Catrona Lowey Lynsey Benton Margaret Torrance Marie Brannigan

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.

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Sarah-Louise Hardie Diane Callaghan Catherine Lowry Jacklynn Bell Valerie Stinson Dondie Sy Montiague Brian Kilpatrick Veronica Munro Malcolm Hodgson

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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 SUPPORTS

www.thebsa.org.uk

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