Audacity issue 1

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Audacity ...a British Society of Audiology Publication issue 1 august 2013 .............................

10 Update on the BSA Annual Conference

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

68 Essay Competition deadline 31st October 2013


British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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Audacity is published by: The British Society of Audiology 80 Brighton Road, Reading, RG6 1PS, UK. E: W: Cover image is rodent cochlea with the bony shell removed to reveal the spiral organ. Courtesy of Dr David Furness, University of Keele.

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Editorial “Every great advance in science has issued from a new audacity of imagination.” John Dewey American psychologist, philosopher, educator, social critic and political activist

Welcome to the first edition of Audacity, the new publication for the membership of the British Society of Audiology.


udacity replaces BSA News – the newsletter and magazine that served the membership for 43 years. Times change and the BSA council recognised the need for an update to the membership publication with a requirement for it to appeal to the multiprofessional nature of the BSA. As a Trustee, I was given responsibility for overseeing the changes. I became editor– in-chief and a number of committed and truly enthusiastic colleagues from Manchester Royal Infirmary agreed to become fellow editors. We aim to deliver a publication that promotes learning and knowledge, reflects the clinical, academic and research age in which we live and explores new ideas. There will be three editions per year, available in printed copies and electronic pdfs. The long term plan will be to have an interactive electronic version only. Audacity has regular sections that should appeal to all members of the BSA. Within this first edition we are honoured to have three featured articles by renowned researchers in the field of auditory system regeneration. They introduce us to concepts that may be unfamiliar to many; however, their work may have a significant impact on how we deliver services in the future – if indeed there is a future need for audiologists! Regular features will provide updates from research and academic institutions in the UK and throughout the world. ‘Research round-up’ places a spotlight on new and interesting projects and in this issue we focus on work being carried out by the Ewing Auditory Research team

Martin O’Driscoll Editor-in-Chief On behalf of the editorial team E:

at the University of Manchester and we also join the University of Southampton’s Institute of Sound and Vibration Research (ISVR) in celebrating its 50th anniversary! To mark this event we have included extracts from key figures in audiology who reflect on their life and times at ISVR. Other regular features will focus on the delivery of clinical audiology and research in different countries – read the ‘Ear Globe’ section to discover Angela Mack’s enviable commute to work. Within ‘Ear Reach’, we highlight the important humanitarian work of the BSA and with our ‘Ear to the Ground’ we decant some of the ear-related stories in the media and social networks. For Twitter dinosaurs (like me) read Amanda Hall’s ‘A Guide to Twitter’ and open up a whole new world... Of course, Audacity is a work in progress and will need to evolve. No single issue could include all aspects of audiology although many of the apparently different fields can often interlink and overlap. Each edition may have a slightly different emphasis but our aim is that Audacity is a publication for the whole membership of the BSA. We welcome feedback and suggestions for articles or sections that you would like to see included. If you would like to be a guest editor for a particular section or be involved in the editorial team then please let us know. We would like to thank all who contributed to this first edition and we hope you enjoy reading every page.

from the editor

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Contents meet the editorial team...


Editorial Martin O’Driscoll


Chairman’s Message Kevin Munro


Conference Update David Furness


Martin O’Driscoll E:

SIG Segment information and updates from BSA Special Interest Groups Section Editor: Martin O’Driscoll / E:


Knowledge Learning Practice Impact information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG)

Rachel Booth E:

Section Editor: Rachel Booth / E:


Featured Articles expert writing about topical areas in audiology Section Editors: Martin O’Driscoll / E: Rachel Booth / E:


Research Round-up

Becki Gladdis E:

a spotlight on major ongoing research projects in the Audiology community worldwide. Section Editor: Rachel Hopkins / E:


Lunch & Learn a summary of the latest bite size online seminars for you to get your teeth into! Section Editor: Shahad Howe / E: Jenny Griffin E:



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welcome to

Audacity ....a British Society of Audiology Publication

meet the editorial team...

52 Ear to the Ground a guide to all things Ear-related in the media‌ Section Editor: Becki Gladdis / E:

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

Rachel Hopkins E:

60 Ear Reach find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved. Section Editor: Jenny Griffin / E:

Shahad Howe E:

67 Hearsay News from Regional Groups and BSA Members Section Editor: Danny Kearney / E:

71 Essentials Key information for the membership Section Editor: Danny Kearney / E:

Danny Kearney E: 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 for further information. Audacity is published in April, August and December. Contributions should preferably be emailed to: 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.



Julie Reading E:

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chairman’s message


Chairman’s Message BSA and you: let’s get engaged Politicians and journalists are apt to use the term ‘It is not a given’ when they mean we should not take something for granted. So let’s cut to the chase: do we take BSA for granted? Do we assume that BSA will always be part of the fabric of UK audiology? What if there was no BSA? What if no: 1. annual conference or ‘Lunch and Learn’ seminars? 2. Special Interest Groups? 3. bursaries or funding for applied research? Kevin J Munro 4. recommended procedures, clinical Chairman guidance or position statements? 5. International Journal of Audiology or Audacity 6. link with the International Society of Audiology or the European Federation of Audiology Societies? 7. learned society providing links between knowledge, learning, service and impact? 8. independent advice for stakeholders? By most measures, membership of BSA represents excellent value for money, and as the leading learned society that strives to promote Audiology, deserves to be listed on the CV of any professional ‘worth their salt’. Annual membership, including subscription to The International Journal of Audiology, is only £64. Attendance at the annual conference is only £89. And the hugely successful ‘Lunch and Learn’ seminars are free to all.The list goes on. Low membership fees, a competitively priced annual conference and free access to information are all part of the BSA vision to improve the lives of those with hearing and balance problems. But can we go on like this or is it an extravagance we can ill afford? Limited income is causing visible stress and slows our progress with, for example, the development of the new BSA website and NICE accreditation of the documents that are overseen by the Professional Practice Committee (see later).This is, in fact, not an issue for the delicate or fainthearted because it strikes at the very heart of how we define the BSA. Let me provide a rather crude analogy. Our top museums don’t charge for admission- a point of pride for new Labour when free admission was reintroduced in 2001. Yet the visitor profile

chairman’s message

of museums and art galleries has not benefited from free admission: the middle classes attend more frequently but the poor and excluded continue to be, well, poor and excluded. I recall Alan Bennett, the playwright, actor, screenwriter and author (Talking Heads, The History Boys etc.) arguing that public libraries are a sign of a civilised Society. And to an extent I agree, except this is a bit like the statistics showing an increase in attendance at museums and art galleries post 2001- it isn’t quite the full picture. A civilised Society looks after the poor and the needy but, unfortunately, the poor and needy are apparently rarely found in public libraries. Returning to the BSA, is it an extravagance that, for example, the: • most popular learning event (the Lunch and Learn seminars) is provided free of charge? • price differential for members and non members to attend annual conferences and other learning events is vanishingly small? • annual membership fee includes free subscription to The International Journal of Audiology? It is likely that we are divided on this issue and it is something that will require a thoughtful answer. On issues such as this, we really need to find better ways of engaging with you, the membership. There is a tendency for Council to provide information but not actively communicate. Although sometimes used interchangeably, they signify quite different things: to quote the American journalist, Sydney J Harris, ‘Information is giving out: communication is getting through’. Part of our current programme of modernisation must include more effective methods to engage with you. I have been engaging Trustees at recent Council meetings by posing questions such as: what transformative changes would you make to BSA, what would you do if you could be Chairman, and what will be your legacy? The challenge now for me, and this is not trivial, is to find ways to implement some of the excellent suggestions. A forthcoming opportunity for membership engagement is the ‘Innovation Forum’ that will take place at the 2013 annual conference. This will be a one hour event, supported by a professional facilitator, and devoted to the topic of ‘engagement’. I would like to invite and encourage you to sign up and participate in this

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chairman’s message


Discussing the first Action Plan at the June Council meeting

event. Numbers will be limited so watch out for more details which will be circulated shortly. The Innovation Forum will provide me with an opportunity to hear your views on improving internal and external engagement. Some of your views may be sufficiently inspirational that Council will incorporate them into our Action Plan. Discussing the first Action Plan at the June Council meeting We have changed the focus of Council meetings so that we have more time to review our progress, identify current issues and discuss the next steps. Our efforts are focused on four strategic areas: (i) provision of clinical guidance and recommended procedures, (ii) facilitating inter-disciplinary and inter-professional interactions, (iii) provision of independent and expert advice, and (iv) improving publicity, communications and engagement. Each of these four areas is overseen by a team of 5-6 individuals, coordinated by a Trustee whose role is to actively engage with the team and move the strategic area forward. At our most recent meeting, we had the opportunity to put some flesh on our Action Plan for 2013-14. Our overlapping strategic areas form the basis of our first Action Plan The idea behind the Action Plan is very simple: we identify our priorities for the coming 12 months so that we can move forward with purpose. Otherwise, it is all too easy to drift and drown on the day-to-day activities of running the Society. The Action Plan is a tool to help us work strategically and to use our time most efficiently. We will use it as a stepping stone until we are in a position to commit to longer-term plans. I am indebted to Huw Cooper, vice chair, who is responsible for bringing the different stands of our first

Action Plan together. A copy of the complete Action Plan appears as an appendix in the online version of this message at the In this first Action Plan, we have limited the overall number of actions and tried to avoid ones that are simply beyond our capacity (what Samuel Gorovitz and Alasdair MacIntyre called ‘necessary fallibility’ in their 1976 account of sources of errors in medicine). We have tried to group the actions under the different strategic areas but a precise categorisation is not the priority. Undoubtedly there will be a few trials and errors along the way but we will learn and we will revise. By making our plans transparent, a process that is long overdue, you will be able to use the plan as a checklist and monitor our progress. As the American architect and designer, Frank Lloyd Wright, once said, ‘A doctor can bury his mistakes but an architect can only advise his client to plant vines.’ Within the strategic area of Publicity, Communications and Engagement, our priorities are to overhaul the BSA website and BSA News. We will also be modernising our communication

Our overlapping strategic areas form the basis of our first Action Plan

chairman’s message

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The first Annual Monitoring event where we reviewed progress over the past 12 months and our plans for the future.

methods with a digital (but balanced) diet of blogs, Facebook and Twitter. Work on these actions is being coordinated by Helen Pryce and the Communications Group. John Day and the Advisory Group will be coordinating the actions that fall within the area of Expert Independent Advice. The priorities are to look for new opportunities to publicise the BSA as the ‘go to’ source of information. You will see from the appendix that developments over the next 12 months or so include the provision of media packs and press releases. Within the strategic area of Inter-disciplinary and Inter-professional Interactions, we will create a Learning Events Group to ensure we have a full and growing calendar of events.There are two key actions which can be grouped under the heading of ‘social responsibility’. One of these is for BSA to become much more involved in public engagement: the other is to support and promote global health in Audiology. Work on these actions is being coordinated by Heather Fortnum and the Networking Group. Paul Jones and the Professional Practice Committee are responsible for the final area which deals with Recommended Procedures and Clinical Guidance. A key development will be NICE accreditation which will enhance the quality, status, and consistency across all of our documents. It will also raise the profile of BSA and Audiology with links from NICE/NHS Evidence websites. This is a huge undertaking for BSA and the Professional Practice Committee in terms of effort and resources. The first Annual Monitoring event where we reviewed progress over the past 12 months and our plans for the future. Against the backdrop of the Action Plan, there are a range of developments at various stages of completion. A few examples include: 1. Formation of a ‘Cognition and Hearing’ Special Interest Group under the interim leadership of Piers Dawes. This new group has set an impressive list of short, medium and

chairman’s message

2. 3.



long terms goals. For example, they have agreement from the editor of International Journal of Audiology to publication a discussion paper on the topical, but controversial subject of listening effort- what is it and how should it be measured. ‘Cognition and Hearing’ will be the topic of the BSA Midlands Evening Meeting scheduled for 7 November 2013. The first Annual Monitoring of BSA activities took place in June with a written report and oral presentation from our various committees, working groups and Special Interest Groups. This was a useful exercise but we may modify the format for future years (perhaps splitting the reports over a number of Council meetings) because a lot of information was cover in a short space of time, with little opportunity for discussion and engagement. We are in discussion with several of the audiology professional organisations regarding how we might best collaborate over the coming few years. We are in the process of modernising the BSA logo and letterheads.

I would like to offer my warmest congratulations to the recent recipients of BSA awards and prizes to be presented at the annual conference in September: Professor Brian CJ Moore, Thomas Simm Littler Lecture; Dr Michael A Akeroyd, Thomas Simm Littler prize; Dr John Fitz Gerald, Ruth Spencer prize; Daniel Rowan, Denzil Brook Trophy; Marshall Chasin, Jos Millar Shield (for his article, ‘Setting Hearing Aids for Music’ in BSA News Issue 68, April 2013). Professor Mark Lutman has been awarded Honorary Life Membership. I would also like to take this opportunity to thank outgoing personnel and welcome the new faces: Dr Graham Frost’s term of office has come to an end after many years of outstanding and distinguished service: Dr Dolores Umapathy has resigned as a Trustee; Dr Ros Davis, former Chair of BSA, has resigned from her role as Chair of the Gatehouse Applied Research Fund and will be replaced by Dr Heather Fortnum; Paul James is the interim Chair of the Professional Practice Committee; Dr Michael A Akeroyd, Peter Bryom and Tracey Twomey will commence their 3-year term of office

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chairman’s message

9 as Trustees immediately following the Annual General Meeting in September. We are currently seeking nominations for one further Trustee position. There is a common fallacy that this needs to be someone relatively senior. This is entirely unfounded. If you are motivated and enthusiastic with a commitment to making a difference, then please consider standing as a Trustee. Keep abreast of the work of BSA by visiting our website: The general mail address for contacting the Society is: and you can contact Council at: Please share this message with non-members and encourage them to support BSA (go to ‘Joining the Society’ link on the website for a membership application). Also, take a moment to check that you are receiving emails from the BSA secretariat: we do not want to lose touch with you when we reduce our paper mailings in 2014. I hope this message continues to convey the determination of Council to move forward with purpose and that you are proud to be a member of BSA. I very much appreciate the comments, suggestions and messages of support. As always, I welcome your views and you can contact me at

My best wishes,

Comments or Contributions to


Kevin J Munro Manchester July 2013

Contact the Editorial Team at: References Gorovitz S, MacIntrye A. Toward a theory of medical fallibility. Journal of Medicine and Philosophy. 1976, 51-71.

chairman’s message

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BSA Annual Conference


Update on the Annual Conference Keele University, Sept 4 - 6, 2013

Dr David N Furness Keele University (on behalf of the organisers)

The Annual Conference at Keele is fast approaching. There will be themed sessions and plenary talks by Professor Ruth Bentler, Professor Adrian Davies, Professor Sue Hill, Dr Leonardo Manzari and Professor David McAlpine. The Ted Evans lecture will be given by Professor Robert Fettiplace and the Twilight Lecture by Dr Marcelo Rivolta. The Thomas Simm Littler lecture will be given by Professor Brian Moore. These wide range of talks cover research from the basic sciences through translational to clinical research. There are also opportunities to find out what the BSA can do for you and to influence its future directions. Special features of the conference: • **free** membership to participants who are currently non-members • registration fee of **less than £100**

BSA Annual Conference

• launch of Audacity, the **new** publication from BSA • presentations on tinnitus, hearing aids and balance disorders • dedicated session to welcome new (and new-at-heart) members with expert advice from experienced BSA members • ‘Innovation Forum’ where you have the opportunity to tell us what transformative changes you would make to BSA • presentations on the inner ear, the cortex and back again • clinical and sponsor workshops on current practices and developments • ample viewing time for over 100 posters • a **BSA Update** to bring you up to speed with new developments • keynote presentations on research studies and clinical activities • satellite activities, including the one-day APD event • full exhibition • social events Abstracts: Conference abstracts are published in The International Journal of Audiology. Abstract submission deadline has past and we currently have over 120 submitted. The abstracts will used for selecting oral presentations on the basis of the themes and quality (see the abstract submission form at Note that the main conference is followed by a Symposium on Auditory Processing Disorder which also promises to be a great event. The Annual Conference is an event not to missed – so we hope to see you at Keele in September.

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SIG segment


SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Group

BSA Auditory Processing Disorder (APD) Special Interest Group We are celebrating our 10th Anniversary! Established in 2003, under the thoughtful guidance of Tony Sirimanna, this dynamic group has raised the profile of APD nationally and internationally, and fostered collaboration between researchers and clinicians across different professions to promote good quality research and evidence-based care for those presenting with APD.

A popular APD Patient Awareness Day on 11th June 2013, arranged by Doris-Eva Bamiou and Tony Sirimanna, NHNN and GOSH, provided an opportunity for public consultation. The aim of this one-day ‘free and open’ event was to (1) update families and individuals with APD, and (2) obtain their feedback regarding clinical needs and research, which is invaluable for our future planning.

Over the past 3 years, we have published a peer reviewed Position Statement (2011), Practice Guidance Document (2011), plus a ‘White Paper’ (2013) with an international set of commentaries and collaborated with the American Academy of Audiology (AAA) to present a successful APD day as part of the AAA conference held in Boston in March, 2012. This one-day event, titled ‘Global Perspectives on (C)APD’, was co-chaired by Frank Musiek (USA) and Doris-Eva Bamiou (UK) and saw over 250 delegates engage with over 75 presentations on APD by international speakers from a wide range of disciplines.

To celebrate our 10th Anniversary, we are hosting an APD Satellite Day, titled ‘APD and other Childhood Neurodevelopmental Disorders’ as part to the BSA Annual Conference at Keele University, on Saturday 7th September 2013. The highly acclaimed keynote speakers include Dr Carol Miller (USA), Prof Dave Moore (USA) and Prof Stuart Rosen (UK). The registration cost for the day and accommodation, if required, are exceptionally affordable. The day is open to professionals of all disciplines and will be of interest to those working in areas such as APD, Dyslexia, Specific Language Impairment, ADHD and Autism. We look forward to seeing you there!

For more information visit the BSA website Report by: Nicci Campbell/Chair APD SIG members: Roshini Alles, Doris-Eva Bamiou, Nicci Campbell (Chair), David Canning (Past Chair), Sandra Duncan, Pauline Grant (Vice Chair), Dave Moore, Pam Murray, Stuart Rosen,Tony Sirimanna, Dilys Treharne, and Kelvin Wakeham, APD SIG Advisor: Prof Anne O’Hare (Paediatrician, University of Edinburgh)

SIG segment

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SIG segment

12 BSA Balance Interest Group The Balance Interest Group (BIG) have had another busy and productive year. I took over as chair of the group in January, from Paul Radomskij, and the whole group would like to thank him for his excellent leadership of BIG over the last few years. Protocols and guidance documents continue to be an important part of our work, and work has been ongoing on a new protocol on ‘Eye Movement Assessment’. This document should soon be circulated for wider consultation from the BSA membership. BIG will welcome any comments from members, and we hope that when the document is complete it will become a valuable resource for clinicians and trainees performing balance function testing. In the coming year we also hope to complete a protocol for positioning testing (this will be an extension of the Dix Hallpike protocol including testing for BPPV of all three canals), and a guidance document on the up and coming technique of o-VEMPs. An aim of BIG is to promote awareness amongst health professionals of vestibular disorders (both peripheral and

central) and their treatment. A number of the group have been doing this by giving talks to groups such as GPs, Elderly Care Physicians and Physiotherapists.This has included practical sessions for GPs on the testing and treatment of BPPV, raising awareness of this condition and in many cases allowing treatment to be carried out (more quickly) at the primary care level. Plans for the biennial BIG conference to be run in 2014 are soon to be discussed, and information about this event will then be circulated. Many of the group have continued with the educational aims of BIG by lecturing on the leading UK vestibular courses. Finally, one of many potential projects in the pipeline is to perform a nationwide survey of balance function testing and rehabilitation service provision. BIG welcomes new ideas or projects for the group to work on from those involved in the field, and would be keen to collaborate on research projects with other clinicians. Debbie Cane, Chair of BIG

BSA Paediatric Audiology Interest Group (PAIG) You will have seen the recent PAIG Lightening Update and the PAIG flyer and therefore be well informed already. Many of you will also be aware of the annual PAIG conference in Sheffield, which doubled its size this year and attracted many BSA members over the 2 days. The new paediatric tinnitus guidelines are under development. This is an exciting new area PAIG is focussing on and we hope you contribute to it by responding to the public consultation which we hope will happen in the first half of 2014. Please keep an eye out for it. Rosie Kentish (Clinical Psychologist) is leading this piece of work. David Canning who is taking over as chair in 2014 is heading a group to develop similar guidance for school entry hearing screening. Stuart Harris will lead the group taking forward the London

work on discharge criteria for children assessed with visual reinforcement audiometry. Following the May 2013 PAIG conference we are keen for people to consider re-using behavioural observational audiometry (BOA) for assessment of young children. We hope to introduce some practical workshops regionally for testing BOA but are still exploring ways to do this. If you practise BOA or you are a regional centre for this, we would very much like to hear from you. Please inform us through the BSA secretariat. We would like to support the development of local PAIG groups as the clinical equivalent to the strategic Children’s Hearing Services Working Groups (CHSWGs). If you are heading such a group or are part of one and have ideas how BSA-PAIG can support such a group by improving learning and putting knowledge into practice, please let us know.

There are more things we can do, but we need an active membership and that is you. So please feedback and let us know how you can support paediatric audiology and PAIG. Chair: Dr Sebastian Hendricks (Audiovestibular Physician & Paediatrician) Vice Chair: David Canning (Educational Audiologist)

SIG segment

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SIG segment

13 New BSA Special Interest Group for Cognition in Hearing With a growing awareness of the close relationship between hearing ability and cognitive skills there is a requirement for the field of Audiology to continually develop its understanding of the role of cognition in hearing. On May 16th, an exploratory meeting was held to establish a Special Interest Group (SIG) for clinicians and researchers interested in aspects of cognition in hearing. The SIG was created ‘to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment, and intervention’. Attendees at the exploratory meeting debated the aims of the SIG, defined the group’s short-, medium- and longterm goals, and agreed on an interim committee to guide the group forward whilst a permanent committee is formed. Short-term goals • Disseminate details of the exploratory meeting • Establish the SIG management committee • Launch a web page for the SIG • Engage with clinicians to establish issues of cognition in hearing relevant to clinical practice Medium-term goals • Discussion ‘white papers’ on hot-topics in cognition in hearing • Lunch and Learn seminars Long-term goals • Forums for interaction between clinicians and researchers • Forge links with the wider Psychological research community • Develop clinical guidelines • Contribute to education and training

A summary of the meeting was distributed to all individuals who expressed an interest in the SIG, chairs of other SIGs and the BSA council.The development of the SIG was outlined on a poster presented at the 2nd International Conference on Cognitive Hearing Science for Communication (16th –19th June, Linköping Sweden). For those who would like to learn more about the Cognition in Hearing SIG, a special event for clinicians and researchers will be held at the BSA Annual Conference (4th – 6th September, Keele), where there will also be a second chance to view the poster. Interim committee members: Piers Dawes (Chair), Research Fellow, University of Manchester. Ansar Ahmmet, Consultant Paediatric Audiovestibular Physician, Royal Preston Hospital. Sygal Amitay, Senior Investigator Scientist, MRC Institute of Hearing Research. Johanna Barry, Senior Research Scientist (NHS), MRC Institute of Hearing Research. Antje Heinrich, Senior Investigator Scientist, MRC Institute of Hearing Research. Helen Henshaw, Research Fellow, NIHR Nottingham Hearing Biomedical Research Unit. Scott Richards, Academic Support Officer, Aston University.

BSA Adult Rehabilitation Interest Group (ARIG) Over the past year, we have worked on grant applications to undertake a survey to gather information about the needs of professionals with regard to adult rehabilitation. There may be a survey coming your way so watch this space! We are also hoping to contribute to the BSA website so do look out for new information in the Adult Rehabilitation section. You can expect to find information on general rehabilitation principles, as well as more specific tools and links

to useful sites. ARIG is committed to raising the profile of adult rehabilitation so that we can enable clinicians to use rehabilitation principles within every appointment. If you would like to be involved or have any suggestions please contact the BSA secretariat. Beth-Anne Culhane

SIG segment

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knowledge learning practice impact


Knowledge Learning Practice Impact BSA Professional Practice Committee Update The Professional Practice Committee (PPC) fulfills the British Society of Audiology’s role in establishing standards, qualifications and courses in audiology. We currently have 10 members, 2 co-opted members and 6 advisory panel members from a wide variety of backgrounds. We meet quarterly (although numerous emails are exchanged in the interim), and the minutes of these meetings are published on the BSA website. Our aim is to promote good professional practice in audiology, with particular focus on multi- and cross-disciplinary issues through: 1. the provision and dissemination of guidance on good practice that is demonstrably high in relevance, quality and impact 2. the support and, where appropriate, accreditation of educational courses that promote good practice 3. working in partnership with other groups interested in promoting good practice and with stakeholders in good practice. Dr Daniel Rowan, current past-chair, has been awarded the Denzil Brooks Trophy 2013 in recognition of outstanding contributions to promoting excellence in clinical practice through Chairmanship of the PPC, which has become the leading provider of clinical guidance in audiology nationally and internationally. Under his guidance, we began the process of updating all existing Recommended Procedures, and writing new ones to incorporate NHSP protocols. This work continues at pace and we have also begun work to gain NICE accreditation. We are an enthusiastic committee and passionate about what we do, which forms an integral part of the BSA and

knowledge learning practice impact

affects everyone practicing audiology. We take a real pride our work, which ensures that other professionals work to a high standard of which they can also be proud. This is not to say that we take all the credit! As a society of collaborative professionals, we can all justifiably give ourselves a firm pat on the back for the way we have met challenges head-on in recent years, such as 18weeks, NHSP, AQP and MSC (to name but a few). As the dust begins to settle, and we take in the changing landscape of the NHS and healthcare science, there is a need to reflect on where we have come from, and where we should aim to be in the future. To achieve this, perhaps now more than ever before, there is a need for unity, involvement and advocates; not just in the PPC, but in the BSA as a whole. The PPC will continue to unite with the Special Interest Groups to develop new guidance and achieve NICE accreditation on behalf of the BSA. Do keep an eye out for new documents. We are rewriting old ones to ensure they are up-to-date, evidence based and hopefully easier to read, and we are writing new ones to cover areas for which there has previously been no guidance. Gaining NICE accreditation will ensure all our processes for producing documents are robust and will strengthen the international reputation of the BSA as a source of very high standard guidance, policies and standards. The PPC cannot function without the continued involvement of BSA membership to help with consultations of our Recommended Procedures. We would like to express our sincerest gratitude to all those who take the time to help with these consultations, and would encourage more people to get involved. Every comment and opinion is welcome!

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knowledge learning practice impact

15 As far as advocacy is concerned, I personally believe that in the current climate we must all be advocates both for our individual professions and the united force we represent, to ensure our continued strength. We need Future Redesign Utilising Innovation,Technology, Collaboration And Knowledge Exchange (FRUITCAKE).

nometry, all coming your way very soon! More documents are in the pipeline and will be going out for consultation, so please keep an eye out for these too.

Look out for‌

Fiona Barker is representing the PPC at the BSA conference and asking us all to reflect on what counts in rehabilitative audiology. Are we measuring the right things or the things that are easy to measure? At the BAA conference, she will also be presenting a Cochrane review of intervention to improve hearing aid use.

Practice Guidance on hearing assessment for non-audiologists, Recommended Procedures for VRA and Tympa-

We hope to see you there!

There are so many ways to get involved, so go on, have a slice. It’s good for you.

Details for correspondence:


Paul James MSc Chief Audiologist NHS Clinical Leadership Fellow E: or or

BSA Learning and Events Group Update The newly formed Learning and Events Group (LEG) has recently superseded the Programmes Committee. The remit of the group is to develop and expand the range and variety of BSA organised events and deliver learning opportunities that meet the broad and diverse membership of the BSA. LEG will continue to co-ordinate events in the format of traditional lecture-style meetings that have been well received in the past and, in addition, will be looking to include events with different formats to increase accessibility and delegate interaction. One of the innovations that has been introduced over the last year, co-ordinated by Shahad Howe, is the BSA Lunch and Learn eSeminars.These are an exciting series of short on-line presentations designed to ease continuing professional development during this challenging period of time. They cover current topics of interest and clinically relevant

research findings, and have so far been diverse and interesting to Audiologists and related professionals. To date, the seminars have been a great success, with an average of 350 listeners every month, peaking to a high of 700,, which is highly impressive for a UK-only virtual seminar. Please see the Lunch and Learn pages on the BSA website for more details, including how to access previous and future seminars as well as how to contribute a seminar. Another novel development is the BSA Lightning Updates, which are five minute online snippets released every month to update members on difference aspects of the society.These are also co-ordinated by Shahad Howe.The Updates have included contributions from some of the BSA special interest groups, have introduced new features such as the launch of Audacity, as well as keeping members informed on upcoming events, such as the Annual Confer-

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16 ence. Each update comes with a corresponding flyer that can be displayed in departments for both members and non-members. The popular annual BSA Evening Meetings are to continue, but will now be run twice a year as the BSA Twilight Series. For many years the meetings have been based in London. To increase accessibility to members outside London, the next meeting will be held in Birmingham at The Queen Elizabeth Hospital on the 7th November. The programme for this national meeting, organised by Mel Ferguson, Roulla Katiri and Liz Arram has been designed to mesh with, and promote, the recently formed BSA Hearing and Cognition Special Interest Group. The meeting will bring together speakers to cover the role of cognition in hearing in the areas of basic science, translational research and clinical practice. The speakers include Professor Sophie Scott (University College London) who will bring a neuroscience perspective, Dr Helen Henshaw (NIHR Nottingham Hearing Biomedical Research Unit) who will discuss how interventions such as auditory and cognitive (working memory) training can bring real-world benefits to people with hearing loss, and the ever popular and dynamic Dr Doug Beck (Oticon USA) will provide an overview of the how cognition impacts on clinical issues. So like the proverbial box of chocolates, this meeting offers something for everyone.

In December, Jane Wild (Wrexham Maelor Hospital) and Helen Henshaw will be organising the first BSA Journal Club.The meeting will take place at the NIHR Nottingham Hearing Biomedical Research Unit, and will be on the hot topic of Adult Hearing Screening, which has recently piqued the interest of parliamentary members. This will provide an opportunity to bring together a range of hearing professionals to discuss and bring together a variety of views, which will be made available to the wider community through Audacity. And of course there is the Annual Conference that is being held at Keele University this year, organised by Dr Dave Furness. By the time this piece gets distributed, the conference and APD satellite meeting will be upon us. The Annual Conference has undergone some significant changes over the last few years, merging with the Annual and Experimental Short Papers meeting in a bid to enhance interactions between researchers and clinicians. This will remain the focus over the up and coming conferences. The aim is to ensure that everyone who attends, irrespective of their professional background, comes away from the conference having developed new and relevant knowledge that is relevant to them and that they can implement into their everyday work, be it research or clinical. So who is going to do the work on LEG? Mel Ferguson is leading the group, and is delighted that Roulla, Shahad and Liz have agreed to sit on this group and will continue with their great work in organising some of the key events for BSA. But to be able to continue to develop new ideas and, importantly, implement them, the Learning and Events Group would like to invite keen and enthusiastic members of BSA to join the group to put together a set of events that create real interest amongst the membership. If you are interested in getting involved in national Audiology learning events with this dynamic group, please email Mel Ferguson ( Furthermore, if you have any ideas of events that you would like to stage through the BSA, drop Mel a line. Don’t be shy!

Details for correspondence:


Mel Ferguson Learning and Events Group Lead E:

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Regeneration of the Auditory System: Fantasy or Reality? Forward Within this first issue of Audacity we have three featured articles by internationally renowned experts on exciting developments and challenges in the field of auditory regenerative medicine. Within the first article Dave Furness identifies the three main contributors to cochlear deafness and suggests how stem cell strategies could be used to restore hearing in cases of deafness arising from damage in all three. In the second article, Dr Milene Massucci-Bissoli and Dr Marcelo Rivolta give in more detail an account of their recent studies showing how embryonic stem cells can be generated which have the potential to be hair cells or spiral ganglion neurones.These can be grown in vitro and transplanted into the cochlea.To date this approach has been used to repair auditory nerve damage with some success. In the third article Professor Andy Forge and Dr Ruth Taylor explore in greater detail some of the natural repair mechanisms in the cochlea that are potentially available for restoring hearing, including a discussion about which cell types may be capable of provoking hair cell re-growth. Together these articles are an up-to-date evaluation of the field of regenerative medicine as applied to the auditory system and are of enormous interest to all clinicians and researchers working in audiology. Martin O’Driscoll, Editor

Auditory Regenerative Medicine an overview and some new perspectives Author Dr David N Furness Reader in Auditory Neuroscience

The aims of this article are to give a general review of the state of current auditory regenerative medicine, emphasising potential targets for enhancing regenerative potential in the cochlea, and both current and future prospects for cellular transplantation to prevent hearing loss or restore hearing in hearing impaired people. As the majority of readers will know, 30% of people over the age of 65 have hearing loss, rising to 50% by the age of 75. Globally around 275 million people suffer hearing impairment (statistics obtained from Action on Hearing Loss, and Brigande and Heller, 2009 [1]). There are several different causes of hearing loss: inherited disorders, noise damage, ototoxic agents and agerelated hearing loss.The latter often includes contribution from the other causes, but there are also specific genes associated with age-related hearing loss [2]. Damage to, or degeneration of, several parts of the cochlea can contribute to hearing loss, either independently or in combination. In the present article, the main tissues to be considered are the spiral ganglion, the organ of Corti and the cochlear lateral wall (Fig. 1). Each of these regions has a specific part to

play: the organ of Corti contains the sensory hair cells which are delicate, mechanically sensitive cells and which, via the complex architecture of the organ of Corti, detect the vibrations caused by sound along the basilar membrane. The spiral ganglion represents the outgoing nerve supply of the cochlea, contacting the hair cells and passing signals to the brain. The lateral wall is a homeostatic tissue, consisting of two compartments, the stria vascularis and the spiral ligament. It generates the endocochlear potential an electrical battery that increases the sensitivity of the hair cells, powers the cochlear amplifier and allows auditory thresholds to be substantially improved. Damage to any of these regions is deleterious to hearing. Loss of the hair cells, a common feature of ageing, means sound can no longer be detected. Because the hair cells in humans are terminally differentiated at birth, they can no longer undergo cell division, and unlike many other vertebrates, humans and other mammals cannot regenerate them naturally. Similarly loss of the spiral ganglion neurones results in hearing impairment because of loss of signal transmission to the brain. Again, these cells cannot naturally regenerate. Cochlear lateral wall degeneration can affect both the stria vascularis and the spiral ligament. The stria is known to atrophy with

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Figure 1. Cross section of the cochlear duct showing the organ of Corti containing sensory hair cells, the afferent auditory nerve fibres that pass to the spiral ganglion, and the cochlear lateral wall, comprised of the stria vascularis, and spiral ligament containing fibrocytes. The inset shows a lower power view, with the spiral ganglion highlighted in blue.

time, whilst degeneration of cells in the ligament, called fibrocytes, is also a feature of some models of hearing loss [3]. Degeneration of these homeostatic tissues can upset the delicate balance of ionic composition between the fluids of the cochlea, leading to failure of the endocochlear potential. A mouse model of fibrocyte degeneration, the CD/1 mouse, also suggests that hair cell and spiral ganglion cell loss are possible sequelae of the damage [4]. Interestingly, of all the cells in the cochlea, fibrocytes are mesenchymal and have the potential to proliferate and therefore regenerate naturally. This is evidenced by the fact that these cells can be cultured in vitro (Fig. 2). Fibrocyte culturing was first achieved in 1996 by Gratton et al.[5], but there has been little development of this potential resource except as a basic research tool.

Research on cochlear regeneration has tended to focus on replacing the hair cells. This has proved extremely difficult to do, although periodically there are reports of hair-cell regeneration in vivo, in particular by interfering with the signalling pathways involved in hair-cell development. Thus, in one study in guinea pigs, the transcription factor ATOH1 was deliberately up-regulated, resulting in the formation of new hair cells after damage had been induced in the organ of Corti [6]. In another study, inhibitors of the Notch signalling pathway were used, again after deliberate noise damage, to induce new hair cells [7].These studies reveal some interesting possibilities for therapeutic approaches. To transplant hair cells would also be very difficult. It is difficult

Figure 2. Cochlear fibrocytes in culture, labeled for three proteins that different fibrocyte types are known to express: caldesmon (left panel), sodium-potassium ATPase (centre panel) and glutamate transporter (right panel).

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19 to grow and maintain hair cells in vitro as a source of transplantable material. It is possible to culture the early postnatal mouse or rat cochlea (see e.g., Furness et al., 1989 [8]), but adult hair cells do not survive in vitro for more than a few hours, and to physically insert hair cells would be invasive and potentially damaging. Hair cells have also been derived and grown to some extent in vitro from embryonic tissue. Derived from embryonic otic neurospheres, again the big obstacle is actually transplanting such cells into the right location. The second target, the spiral ganglion, has received relatively little interest. However, very recently, a group in Sheffield has injected specialised neural stem cells into the chemically damaged spiral ganglion of gerbils and shown some recovery of hearing (Chen et al., 2012 [9] - see the article by Rivolta and colleagues, this issue, for more details). Replacing spiral ganglion neurones after they have gone missing could re-connect the cochlea to the brain and also could provide a substrate for a cochlear implant to be effective in some hearing loss conditions. The third target, the lateral wall, has received a modicum of attention, with some attempts, again after induced damage, to replace fibrocytes by injecting mesenchymal stem cells [10]. This again resulted in a modest recovery of hearing. The advantage of these cells is that they could be obtained from the patient’s own mesenchyme (e.g. bone marrow). Our own lab has also chosen fibrocyte regeneration as a target but with two major differences from previous studies. Firstly, we have decided to attempt to use fibrocyte cultures as a source of cells. We have successfully grown the cells in vitro and demonstrated that they express proteins characteristic of native fibrocytes. We will use this system to determine whether we can identify drug treatments or genetic controls that could enhance natural proliferation in the cochlea. We have also begun to evaluate a delivery strategy, e.g. by injecting these cells directly into the ligament of the isolated cochlea. We are currently trying to develop a biomimetic scaffold to grow the cells in for physical transplantation. Secondly, we are using the CD/1 mouse that loses its hearing by natural loss of fibrocytes [4], without needing to induce damage experimentally.This model is more like human patients suffering from age-related hearing loss than other models. In summary, the three main targets for stem-cell and transplantation therapy I have described are hair cells, spiral ganglion neurones and fibrocytes. Each has its pros and cons: hair cells would be difficult to grow and transplant; spiral ganglion neurones and fibrocytes can be grown in some form and trans-

planted, and will each be useful for a subset of hearing problems. In all cases, progress continues to be made and we can be hopeful that the future will hold treatments for a variety of currently intractable auditory disorders.

References 1. Brigande JV, Heller S. 2009. Quo vadis, hair cell regeneration? Nat Neurosci. 12(6):679-85. 2. Yamasoba T, Lin FR, Someya S, Kashio A, Sakamoto T, Kondo K. 2013. Current concepts in age-related hearing loss: Epidemiology and mechanistic pathways. Hear Res [Epub ahead of print]. 3. Minowa O, Ikeda K, Sugitani Y, Oshima T, Nakai S, Katori Y, Suzuki M, Furukawa. M, Kawase T, Zheng Y, Ogura M, Asada Y, Watanabe K, Yamanaka H, Gotoh S, Nishi-Takeshima M, Sugimoto T, Kikuchi T, Takasaka T, Noda T. 1999. Altered cochlear fibrocytes in a mouse model of DFN3 nonsyndromic deafness. Science 285(5432):1408-11. 4. Mahendrasingam S, Macdonald JA, Furness DN. 2011. Relative time course of degeneration of different cochlear structures in the CD/1 mouse model of accelerated aging. J Assoc Res Otolaryngol. 12(4):437-53. 5. Gratton MA, Schulte BA, Hazen-Martin DJ. 1996. Characterization and development of an inner ear type I fibrocyte cell culture. Hear Res 99(1-2):71-8. 6. Kawamoto K, Ishimoto S, Minoda R, Brough DE, Raphael Y. 2003. Math1 gene transfer generates new cochlear hair cells in mature guinea pigs in vivo. J Neurosci. 23(11):4395-400. 7. Mizutari K, Fujioka M, Hosoya M, Bramhall N, Okano HJ, Okano H, Edge AS. 2013. Notch inhibition induces cochlear hair cell regeneration and recovery of hearing after acoustic trauma. Neuron 77(1):58-69. 8. Furness DN, Richardson GP, Russell IJ. 1989. Stereociliary bundle morphology in organotypic cultures of the mouse cochlea. Hear Res 38(1-2):95-109. 9. Chen W, Jongkamonwiwat N, Abbas L, Eshtan SJ, Johnson SL, Kuhn S, Milo M,Thurlow JK, Andrews PW, Marcotti W, Moore HD, Rivolta MN. 2012, Restoration of auditory evoked responses by human ES-cell-derived otic progenitors. Nature 490(7419): 278-82. 10. Kamiya K, Fujinami Y, Hoya N, Okamoto Y, Kouike H, Komatsuzaki R, Kusano R, Nakagawa S, Satoh H, Fujii M, Matsunaga T. 2007. Mesenchymal stem cell transplantation accelerates hearing recovery through the repair of injured cochlear fibrocytes. Am J Pathol. 171(1):214-26.

Details for correspondence:


Dr David N Furness Reader in Auditory Neuroscience Theme Lead for Neuroscience and Human Metabolism Director of the Electron Microscope Unit Keele University E:

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Developing stem cells as a therapy for hearing loss:state of the art Authors Dr Milene Massucci-Bissoli Visiting Researcher Dr Marcelo N Rivolta Reader in Sensory Stem Cell Biology

Milene Massucci-Bissoli is a visiting researcher at the Centre for Stem Cell Biology, University of Sheffield and an ENT Research Fellow at the University of Sao Paulo, Brazil. Marcelo N. Rivolta is a medically-trained, Professor of Sensory Stem Cell Biology at the Centre for Stem Cell Biology, University of Sheffield where he leads a group working on regenerative treatments for hearing loss.

Take home message: The article introduces a few key concepts about regenerative strategies for the inner ear and summarizes the current advances achieved using stem cells in the quest for a treatment for hearing loss.

Introduction Disabling hearing loss affects over 5% of the world’s populations according to the World Health Organization.The loss of hair cells and auditory neurons, either by genetic or environmental factors, appears as a major cause of this condition. Unfortunately, mammalians hair cells and spiral ganglion neurons do not undergo spontaneous regeneration following injury. They are highly specialized and differentiated cells and are actively prevented from entering cell division, making hearing loss permanent once installed. Treatments currently available for deafness use either prostheses that amplify remaining hair cell activity, or direct stimulation of the auditory nerve as an alternative to cochlear physiology. It is important to point out that both of them rely on a functional auditory nerve and central pathways. Recent advances in the field had led to a series of possibilities to restore hearing after injury.To establish a cell-based treatment for sensorineural hearing loss, it is important to understand the delicate architecture of the cochlea and its relations with the cochlear nerve and how their development leads to the lack of regenerative capacity.

Cochlear structure and development The inner ear starts to develop 3 weeks after fertilization and, in the following 19 weeks, it will go through a series of cell division and selection that will lead to a functional and complex hearing and balance organ. The organ of Corti is composed of more than ten different types of supporting cells and two types of sensory cells.The supporting cells lie above the basilar membrane in a specific order. The sensory cells are the outer and inner hair cells and they are connected to the central nervous system via auditory neurons: each inner hair cell is connected to several type I auditory neurons while each type II auditory neuron is connected to a number of outer hair cells[1]. This complex structure is of crucial importance to transduce the mechanical energy of the sound into a neuro-electrical signal to the brain. Cells on the organ of Corti are in a state called mitotic arrest, which means that, once they reach maturity, they are not able to re-enter the cell cycle and therefore they are not able to proliferate.This is a very good mechanism to maintain its complex structure stable but on the other hand it prevents regeneration after injury. Moreover, no evidence has been found that would support the existence an endogenous progenitor in the inner ear capable of proliferating in case of injury, as it is found in other epithelia throughout the body. The commitment to a sensory cell fate, or even a supporting cell fate is set in the early stages of development[2] and so far these conditions are not possible to be recreated in the mature animal. Several signalling pathways, besides those controlling cell cycle, are involved in hair cell development and differentiation and they have been recently reviewed by Fritzsch et al [3] and Neves et al [4]. Models of regeneration – birds can do it Although mature hair cells achieve the state of mitotic arrest and are supposed not to divide anymore, this is not the case for avian hair cells. In 1988 two groups showed hair cell recovery after injury in birds[5,6], and avian inner ear has become a model to study how hair cells can be regenerated. Through many studies, it has been discovered that nonsensory supporting cells play a major role in the repopulation of lost hair cells. Two mechanisms have been postulated and apparently they coexist in the living animal. On the first mechanism, the supporting cell leaves its quiescent state, divides and gives origin to a new supporting cell and a new hair cell. The other mechanism is called transdifferentiation and in this case there is no supporting cell division[7].

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22 Hair cell regeneration in mammals – what has been done and what to achieve Although it is well established that no regeneration occurs after injury in the adult mammalian cochlea, this is not the case for the vestibular sensory epithelium. There is some evidence supporting regeneration of utricular hair cells via transdifferentiation of supporting cells[8] and, to a lesser extent, mitosis[9]. Moreover, mice adult utricular sensory epithelium are able to form multipotent cell aggregates or spheres after dissociation[10], an assay generally used to identify stem or progenitor cells. Regarding the cochlear epithelium, the potential to generate multipotent spheres has been found in neonatal mammals such as mice, rats and guinea pigs[11-13]. This ability decreases within a short period[14], and so it does a population of so-called slow cycling cells that may harbour progenitor properties.These cells are present in the neonatal murine cochlea but disappear in the mature animal[15]. Further efforts to identify cells with progenitor properties in the mammalian cochlea have drawn attention to a group of supporting cells that express Lgr5 and that are competent to differentiate into hair cells[16, 17]. Lgr5 is a marker of adult stem cells in the intestine, and is expressed by cells in the greater epithelial ridge, inner border cells, inner pillar cells, and the third row of Deiter’s cells at birth. Although the early postnatal Lgr5+ cells are competent to produce hair cells, this property also disappears with age, even when Lgr5 is retained by inner pillar cells and the third row of Deiter’s at least until postnatal day 60[17]. Given this situation, three strategies that may lead to hair cell replacement are currently being explored: conversion of supporting cells into hair cells using gene therapy, stimulation of supporting cell division to derivate hair cells and stem cellderived strategies[18]. The following discussion will focus on the third approach. Stem cell-derived strategies are based on the idea of transplanting a cell capable of repopulating lost cochlear cells without disturbing cochlear chambers balance. This cell should ideally be at a progenitor stage, committed to the hair cell fate but still not completely differentiated so it would integrate to the epithelium. A hair cell progenitor should be capable of generating hair cells

not only in vitro, but also once transplanted in vivo. Another important feature would be to have an expandable source that could be used to generate these progenitors in useful numbers. For these, embryonic stem cells (ESCs) are ideal tools. These pluripotent stem cells have large proliferative capacity and can be expanded in vitro almost indefinitely. Hair cell progenitors were first generated from mouse ESCs in 2003[19], and protocols for their production have been improved since[20, 21]. The success achieved with the mouse model has lead to search for such progenitors in a human system.The identification and isolation of human auditory stem cells from 9-week-old to 11-week-old fetal cochleae (hFASCs) generated the first human otic progenitor lines[22]. These cells can undergo in vitro differentiation on either auditory neurons or hair cells, nevertheless they are of very limited availability and other sources have been pursued. Substantial advances have been achieved by developing a differentiation protocol using human embryonic stem cells (hESCs), and it is now possible to generate human hair cell-like cells in vitro by the end of four weeks following a two phases protocol[23]. Although these cells are still immature and not fully differentiated, obtaining them has been an important landmark in the development of human hair cells in vitro. Using hESCs is very convenient due to their self-renewal properties, but their use as a therapeutical tool for a non-life threatening condition raises concerns given the potential need for immunosuppressive drugs. For this reason, patient-specific treatments have also been explored. Human mesenchymal stem cells (hMSC) have been exposed to culture media conditioned by human fetal auditory stem cells and they successfully expressed several genes found in the otic progenitor lineages[24]. Another cell type that could circumvent the problems of immune rejection are induced-pluripotent stem cells (iPSCs). Developed initially by Shinya Yamanaka and his group in 2006[25], they have the same properties of a embryonic stem cell but can be produced from a somatic cell (such as a fibroblast) by reprogramming their genetic make-up artificially expressing a small number of genes. Ongoing work with human iPSCs is showing very promising signs towards the generation of hair cells in vitro (unpublished data). Although in vitro experiments have been relatively successful, attempts to restore lost hair cells in vivo have proven extremely challenging. Despite retention and survival of transplanted progenitors[26], no relevant functional amelioration has been

“The field is in a position that we could only have dreamt a decade ago. The idea of using stem cells for the treatment of hearing loss has left the realm of science fiction and is becoming a clear, achievable goal in a not too distant future”. featured articles

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23 achieved. This is probably due to, at least in part, changes in organ of Corti structure after losing hair cells. Deiter’s and Pillar cells eventually die or change into a flattened epithelium, with tight adherent junctions which may make more difficult the incorporation of transplanted progenitors[18]. Auditory neurons regeneration – a step closer Despite the lack of a consistent alternative to replace lost hair cells so far, the situation regarding auditory neurons regeneration is promising. After ablation of auditory neurons, gerbils have received otic neural progenitors derived from hESCs and they have shown a remarkable improvement in auditory-evoked response thresholds.This study has used a differentiation protocol based on FGF induction of otic differentiation, and otic neural progenitors have been manually purified before expansion in vitro and transplantation[23]. This result opens the way to new experiments combining, for example, cochlear implants and transplantation of otic neural progenitors. Efficacy may need to be explored across different species before moving into clinical trials, and long-term safety is definitely an issue that needs to be addressed properly. There is one case of teratoma formation after partially differentiated murine iPSCs were transplanted into mice[27], which points to the need of a strictly committed progenitor and methods to verify and prevent the transplantation of undifferentiated cells.While we have reasons to be optimistic since the work performed on gerbils has not reported any tumoregenesis, we have to remain extremely cautious and wait until long-term follow-up studies are available. Future perspectives – things to be considered There are many questions to be answered by developmental and regenerative medicine before proposing a reliable cell-base treatment for hearing loss. Safety must be regarded as the first priority, but other issues like timing after injury, etiology of the disease, surgical approach and risks from delivering the cells must be extensively addressed as well. Some of these questions are being addressed already. Timing after injury is a crucial point, since patients will seek professional advice at different stages and there is evidence that the optimal time window for engraftment and survival of transplanted cells takes place in the early post-injury period [28]. Moreover the variability of the cellular environment along the cochlear and the possible variability between individuals resulting from genetic influences on the rate at which remodeling occurs after injury to the cochlear epithelium and its relations with auditory neurons may pose challenges to devising the appropriate regenerative therapy for a deaf patient[18]. The surgical approach must take into account what progenitors are being transplanted, i.e. epithelial or neural, and the combination with cochlear implants in case of neural progenitors. Other possibilities could include the use of a scaffold or hydrogel[29] to limit eventual spread of the transplanted cells thus reducing the possible risk of tumorigenesis.

In summary, the field is in a position that we could only have dreamt a decade ago. The idea of using stem cells for the treatment of hearing loss has left the realm of science fiction and is becoming a clear, achievable goal in a not too distant future.

References 1. Van De Water,T.R., Historical Aspects of Inner Ear Anatomy and Biology that Underlie the Design of Hearing and Balance Prosthetic Devices. Anat Rec (Hoboken), 2012. 295(11): p. 1741-59. 2. Kelley, M.W., Regulation of cell fate in the sensory epithelia of the inner ear. Nat Rev Neurosci, 2006. 7(11): p. 837-49. 3. Fritzsch, B., et al., Evolution and development of the tetrapod auditory system: an organ of Corti-centric perspective. Evol Dev, 2013. 15(1): p. 63-79. 4. Neves, J., et al., Patterning and cell fate in the inner ear: a case for Notch in the chicken embryo. Dev Growth Differ, 2013. 55(1): p. 96-112. 5. Ryals, B.M. and E.W. Rubel, Hair cell regeneration after acoustic trauma in adult Coturnix quail. Science, 1988. 240(4860): p. 1774-6. 6. Corwin, J.T. and D.A. Cotanche, Regeneration of sensory hair cells after acoustic trauma. Science, 1988. 240(4860): p. 1772-4. 7. Shang, J., et al., Supporting cell division is not required for regeneration of auditory hair cells after ototoxic injury in vitro. J Assoc Res Otolaryngol, 2010. 11(2): p. 203-22. 8. Golub, J.S., et al., Hair cell replacement in adult mouse utricles after targeted ablation of hair cells with diphtheria toxin. J Neurosci, 2012. 32(43): p. 15093-105. 9. Kawamoto, K., et al., Spontaneous hair cell regeneration in the mouse utricle following gentamicin ototoxicity. Hear Res, 2009. 247(1): p. 17-26. 10. Li, H., H. Liu, and S. Heller, Pluripotent stem cells from the adult mouse inner ear. Nat Med, 2003. 9(10): p. 1293-9. 11. Lou, X., Y. Zhang, and C. Yuan, Multipotent stem cells from the young rat inner ear. Neurosci Lett, 2007. 416(1): p. 28-33. 12. Diensthuber, M., K. Oshima, and S. Heller, Stem/progenitor cells derived from the cochlear sensory epithelium give rise to spheres with distinct morphologies and features. J Assoc Res Otolaryngol, 2009. 10(2): p. 173-90. 13. Oiticica, J., et al., Retention of progenitor cell phenotype in otospheres from guinea pig and mouse cochlea. J Transl Med, 2010. 8: p. 119. 14. Oshima, K., et al., Differential distribution of stem cells in the auditory and vestibular organs of the inner ear. J Assoc Res Otolaryngol, 2007. 8(1): p. 18-31. 15. Taniguchi, M., et al., Identification of tympanic border cells as slow-cycling cells in the cochlea. PLoS One, 2012. 7(10): p. e48544.

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24 16. Chai, R., et al., Wnt signaling induces proliferation of sensory precursors in the postnatal mouse cochlea. Proc Natl Acad Sci U S A, 2012. 109(21): p. 8167-72.

23. Chen, W., et al., Restoration of auditory evoked responses by human ES-cell-derived otic progenitors. Nature, 2012. 490(7419): p. 278-82.

17. Shi, F., J.S. Kempfle, and A.S. Edge, Wnt-responsive Lgr5expressing stem cells are hair cell progenitors in the cochlea. J Neurosci, 2012. 32(28): p. 9639-48.

24. Boddy, S.L., et al., Inner ear progenitor cells can be generated in vitro from human bone marrow mesenchymal stem cells. Regen Med, 2012. 7(6): p. 757-67.

18. Taylor, R.R., D.J. Jagger, and A. Forge, Defining the cellular environment in the organ of Corti following extensive hair cell loss: a basis for future sensory cell replacement in the Cochlea. PLoS One, 2012. 7(1): p. e30577.

25. Takahashi, K. and S.Yamanaka, Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell, 2006. 126(4): p. 663-76.

19. Li, H., et al., Generation of hair cells by stepwise differentiation of embryonic stem cells. Proc Natl Acad Sci U S A, 2003. 100(23): p. 13495-500. 20. Oshima, K., et al., Mechanosensitive hair cell-like cells from embryonic and induced pluripotent stem cells. Cell, 2010. 141(4): p. 704-16. 21. Koehler, K.R., et al., Generation of inner ear sensory epithelia from pluripotent stem cells in 3D culture. Nature, 2013. 22. Chen, W., et al., Human fetal auditory stem cells can be expanded in vitro and differentiate into functional auditory neurons and hair cell-like cells. Stem Cells, 2009. 27(5): p. 1196-204.

26. Hildebrand, M.S., et al., Survival of partially differentiated mouse embryonic stem cells in the scala media of the guinea pig cochlea. J Assoc Res Otolaryngol, 2005. 6(4): p. 341-54. 27. Nishimura, K., et al., Fates of murine pluripotent stem cellderived neural progenitors following transplantation into mouse cochleae. Cell Transplant, 2012. 21(4): p. 763-71. 28. Lang, H., et al., Transplantation of mouse embryonic stem cells into the cochlea of an auditory-neuropathy animal model: effects of timing after injury. J Assoc Res Otolaryngol, 2008. 9(2): p. 225-40. 29. Nayagam, B.A., et al., Hydrogel limits stem cell dispersal in the deaf cochlea: implications for cochlear implants. J Neural Eng, 2012. 9(6): p. 065001.

Details for correspondence:


Dr Marcelo N. Rivolta Reader in Sensory Stem Cell Biology Centre for Stem Cell Biology Department of Biomedical Science The University of Sheffield, Western Bank, Sheffield, S10 2TN E:

Dr Milene Massucci-Bissoli Visiting Researcher Centre for Stem Cell Biology Department of Biomedical Science The University of Sheffield, Western Bank, Sheffield, S10 2TN

Infant sucking response, the hot debate. Is there a role for this in paediatric audiology?

In the next edition of Audacity

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Prospects and challenges for tissue regenerative strategies in the inner ear Authors Andrew Forge Professor of Auditory Cell Biology Dr Ruth Taylor UCL Ear Institute

The problem Loss of the sensory “hair” cells from the organ of Corti – the auditory epithelium of the cochlea - is the major cause of hearing loss. Death of hair cells from the vestibular sensory epithelia – the utricular and saccular maculae and the cristae of the semicircular canals - is a significant factor in balance dysfunction. In all non-mammalian vertebrates - birds, reptiles, amphibians and fish - when either auditory or vestibular hair cells die they are spontaneously replaced by new ones1. This leads to full functional recovery. Although an ability to regenerate hair cells in the vestibular sensory epithelia of mammals has been demonstrated2, this capacity is severely limited and in the mammalian cochlea there is no hair cell regeneration. Consequently the functional deficits (hearing loss or balance disequilibrium) are permanent. Furthermore in the mammalian cochlea, hair cell loss, which is often progressive, is often followed by progressive loss of the afferent neurones that synapse with the hair cells (although loss of innervation may be a primary consequence of some disorders). Since the effectiveness of cochlear implants is dependent upon the continued presence of some auditory nerves, neuronal loss can compromise their efficacy. Regenerative strategies aim to replace lost hair cells and/or neurones with new ones to help restore hearing (or balance dysfunction). Some fundamentals In the sensory tissues of all vertebrate inner ears, including the mammalian organ of Corti, each hair cell is surrounded by and separated from its neighbours by intervening supporting cells (Figure 1).These two cell types derive during development from a common precursor that itself derives from the same cell line as that which generates the auditory neurones3. During development, following several rounds of cell division (mitosis), some cells enter cell cycle arrest (division is inhibited) and differentiate as the afferent auditory neurones. Other cells undergo further division before entering mitotic arrest. These cells differentiate as hair or supporting cells. Cells which first begin to differentiate as hair cells inhibit their neighbours from doing the same. The inhibited cells become supporting cells. In a precursor that is beginning to differentiate as a hair cell a particular gene, Atoh1, is activated and switches on those genes that turn the precursor into a hair cell. As differentiation of these cells is initiated they activate the inhibitory pathway which determines that the cells contacting them become supporting cells. Hair cells also

produce certain “neurotrophins”, chemicals that attract neurites from the auditory nerve towards them so the sensory cells become innervated. [The continued production of neurotrophins by hair cells (and also by some supporting cells) in the mature organ of Corti is important for the survival of neurons throughout the life of an animal which is why loss of hair cells may be followed by loss of neurones]. In the organ of Corti, unlike other hair cell containing epithelia, during late stages of maturation, supporting cells acquire particular specialisations that bestow mechanical properties important to the unique micromechanics of the organ of Corti, and functions that maintain the physiological environment necessary for hair cell survival and activity. Mutations in genes that encode the supporting cell proteins involved in maintenance of the cochlear environment (homeostasis) are associated with loss of hair cells and consequent deafness; the physiological environment inside the cochlea, and hair cell survival, are compromised when cochlear homeostasis is impaired. Repair of sensory epithelia after hair cell loss In all mechanosensitive epithelia in all vertebrate classes including mammals, when a hair cell dies, the lesion in the epithelium is immediately closed by expansion of the supporting cells that surround it (Figure 2).This occurs sufficiently rapidly to maintain tissue integrity. In all non-mammalian vertebrates, hair cells are then spontaneously regenerated from supporting cells1. Some turn directly into hair cells (“transdifferentiation” or “phenotypic conversion”) which results in a reduction in supporting cell number. Other supporting cells are stimulated to return to the cycle of cell division and new hair cells and supporting cells arise from the daughter cells of those divisions to restore both cell types (“proliferative regeneration”). Cell division is switched off when the cell numbers have returned to normal. In neither the auditory nor vestibular organs of mammals do supporting cells proliferate; the limited regeneration of hair cells in the mammalian vestibular system occurs through phenotypic conversion. Regenerative strategies based on endogenous production of hair cells Two potential means of regenerating hair cells in mammals have been defined. One is to induce proliferation of supporting cells in the repaired epithelium after hair cell loss. Although there is some understanding of the factors that hold cells in the mature organ of Corti in cell cycle arrest, as yet this approach has not shown promise. The other strategy is to induce phenotypic conversion of supporting cells, either by transferring the gene encoding Atoh1into supporting cells or by blocking the pathway that prevents differentiation as a hair cell. Atoh1 has been

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26 shown to convert non-sensory cells into hair cells, and a clinically relevant means to introduce genes into a cell is to use a virus, genetically manipulated to remove its harmful activities but incorporating the gene of interest. One report in which a viral vector (carrier) of Atoh1 was injected into scala media of an animal suggested significant hair cell regeneration in the organ of Corti could be achieved4, but this finding has not been reproduced. The production of new hair cells following Atoh1 transfection of utricular maculae in which hair cell loss had been induced has also been reported5. Blocking the pathway that prevents hair cell differentiation can be achieved with pharmaceutical agents (“y-secretase inhibitors”), and in the utricular maculae from mice maintained in culture in a dish, following treatments that caused hair cell loss subsequent incubation with a y-secretase inhibitor led to considerable numbers of new hair cells by phenotypic conversion from the supporting cells6. Most recently it was reported7 that in mice that had been bi-laterally deafened by loud noise, local application of a potent y-secretase inhibitor to the cochlea via the round window produced some recovery in hair cell numbers and some functional recovery, as measured by reduced ABR threshold shifts in the treated ear compared with the untreated one. However, the levels of recovery were very small.

specialised cells. The concept is to produce “in a dish” large numbers of as yet unspecialised cells of the correct cell lineage to differentiate only as hair cells or only as neurones, then apply these to the inner ear where they will differentiate appropriately. Cells with characteristics of “stemness” have been isolated in extremely small numbers from the mature utricular maculae of young mice, but procedures have also been developed for guiding cells from the embryonic inner ear, embryonic stem (ES) cells, and induced pluripotent stem (iPS) cells (cells from a normal adult individual genetically manipulated to acquire properties of ES cells), from mice and from humans to differentiate as cells with neurone-like and hair cell-like morphological, molecular and physiological properties8,9. As yet the use of this technology to generate hair cells in a damaged cochlea has not been reported and it may be difficult to target hair cell precursors to the appropriate site (the organ of Corti) inside the cochlea of a living animal. Some success has been achieved, however, with regenerating neurones from stem cell-derived cells8. Most notably, in animals (gerbils) treated to ablate almost all the neurons, but with hair cells preserved (a potential model of auditory neuropathy), injection of the neuronal precursor-like cells into the central spindle of the cochlear spiral (the modiolus), accessed through the round window, resulted in the differentiation of cells that expressed proteins characteristic of Figure 1 The normal organ of Corti A. Section across the organ of Corti. Ihc=inner hair cell; ohc=outer hair cell; Dc=Deiters’ cell; op=outer pillar cell; ip=inner pillar cell. Deiters’ cells and pillar cells collectively are the supporting cells. Arrows indicate heads of supporting cells intervening between hair cells. B. Scanning electron micrograph (SEM) of the surface of the organ of Corti. One row of inner hair cells (ihc) and 3 rows of outer hair cells (ohc); ip indicates head of the inner pillar cell. Scale bar indicates 10µm.

auditory afferent nerves and which extended neurite-like projections towards the hair cells and towards the cochlear nucleus. Repeated ABR recordings indicated significant recovery of auditory thresholds. However, it is not yet known whether the apparently newly generated neurones survive and support function in the long term nor whether neurones derived from exogenous sources can re-establish the proper tonotopic relationship between the cochlea and cochlear nucleus. In addition the long term fate of the exogenously applied cell population within the cochlea needs to be assessed to determine whether the cells continue to proliferate or whether cell division shuts off.

Production of hair cells and neurones through application of exogenous cells. The production of regenerated hair cells or nerves from exogenous sources usually refers to the use of cells derived from stem cells. These are cells that are able continuously to divide to replace themselves (self-renewal) but can also give rise to cells committed to proceed along a differentiation pathway towards

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Challenges facing regenerative therapies in the cochlea. Each of the regenerative procedures outlined above will require a particular cellular environment in the organ of Corti to be effective. Phenotypic conversion assumes supporting cells retain some precursor-like characteristics. Cell division may require cells in a sufficiently undifferentiated state to become sensitive to factors promoting cell division. Stem cells not only will need to be targeted to and incorporated into the appropriate site but

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Figure 2 Organ of Corti after hair cell loss. A. SEM. All ohc are lost and their places filled by expansion of the heads of the supporting cells (the outer pillar cells (op) and the Deiters’ cells (DC). Inner hair cells are still present. B. Organ of Corti surface labelled to show the intercellular junctions between supporting cells after hair cell loss. Both ihc and ohc are missing. The labelling outlining the borders between adjacent supporting reveal the extensiveness of these junctions. C,D,F Sections through the organ of Corti to shopw progression of re-organisation after loss of hair cells. C. The supporting cells expand to close the lesion. D. Outer pillar cell (op) collapses and the Deiters’ cells (Dc) migrate across towards the inner pillar cells (ip). E. The columnar supporting cells are replaced by flat cells in a single layer across the basilar membrane. E. SEM. Cells from the outer side of the organ of Corti replace the strip of columnar sensory epithelium. Scale bars 10µm.

the physiological environment will need to be able to support the survival, differentiation and maintenance of the exogenously derived cells. It is therefore of importance to consider the cellular constitution of the organ of Corti after hair cell loss10. When supporting cells close the lesion created by hair cell death, they change shape and expand to fill the body of the epithelium (Figure 2A,B,C), but they retain most of their specialisations and do not differentiate towards a more immature status (Figure 2C).They also retain complex, extensive sealing junctions between each other (Figure 2B) that would be difficult to rupture to allow incorporation of an exogenous cell. Subsequent to this initial tissue repair, the organ of Corti becomes re-modelled (Figure 2D,E,F). Cells from the outer side of the sensory strip migrate across, and the columnar epithelial cells that constitute the sensory strip of the organ of Corti are replaced by thin, flat cells all across the basilar membrane. The supporting cells that once surrounded the hair cells, equivalent to those from which hair cells are regenerated in the inner ears of non-mammalian vertebrates, appear to die. There is evidence that this “flat” epithelium is refractile to manipulations aimed at phenotypic conversion. Furthermore the initiation of re-modelling does not

occur systematically along the organ of Corti but in random locations; segments of “flat” epithelium are interspersed between regions with recognisable columnar supporting cells (Figure 2D). The speed and extent of re-modelling is also influenced by genetic factors. In one mouse strain treated to induce loss of almost all outer hair cells within 48 hours, initiation of re-modelling occurs within 2 weeks, whereas in another strain treated the same way the repaired epithelium with columnar supporting cells may persist for several months before re-modelling begins. Re-modelling occurs in regions where all outer hair cells are lost, but often inner hair cells may still be present, but also there maybe loss of all inner hair cells and all outer hair cells without the initiation of re-modelling. Thus, there can be a mixture of cellular compositions along the organ of Corti in an individual cochlea and also variability between individuals subjected to similar damaging conditions. Studies of human temporal bones confirm similar variations amongst patients whose audiograms taken before death reveal severe to profound hearing loss. Strategies for hair cell regenerative therapies may need to be tailored according to pathology, and the potential variabilities

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28 may require the application of different therapies in different cochleae or even more than one type of therapy targeted to different regions in the same cochlea. Clinically this would be complicated by the inability to assess the cellular environment inside the cochlea of a deaf patient. Current audiological assessments can tell relatively little more than whether there is a significant hearing loss; the cellular nature of the sensory epithelium at the time of assessment cannot be discerned. Further difficulties may arise from the fact that the initial loss of hair cells may have been a secondary consequence of changes in cochlear homeostasis that may be persistent and thus compromise the survival of replacement hair cells, or in addition to hair cell loss other tissues necessary for hair cells to function may be damaged. There is evidence that noise, ageing and otototoxins may damage cochlear tissues other than the sensory epithelium, with consequent adverse effects on cochlear physiology and thus, hair cell survival. Restoration of these other tissues may be necessary for any replacement hair cells to survive and function. Concluding remarks. Currently the possibility to regenerate hair cells in the organ of Corti as a therapy for deafness seems a distant prospect. The normal organ of Corti is highly and precisely organised and its complete restoration after hair cell loss may be difficult to achieve. Scattered replacement of some hair cells may be more feasible and could help to improve the efficiency of a cochlear implant. Regenerated hair cells should produce the neurotrophins necessary for the survival of neurons and there is some experimental evidence that regenerated hair cells can attract neurites. If hair cells were regenerated on or close to the site of the original organ of Corti, neurites attracted from any neurons remaining after loss of hair cells would be brought closer to the implant electrodes than would otherwise be the case, thereby improving efficiency. A more likely prospect at present seems to be the possibility for direct restoration of the neurones themselves, perhaps derived from stem cells. This could have a significant benefit for the use of cochlear implants. There are also other possibilities for combining biological and technological interventions in various ways, for example the implant providing a means to introduce a biological component to the cochlea, and this may be the direction in which approaches to restoring hearing may progress. However, the possible problems to hair cell regeneration in the organ of Corti probably do not apply to the vestibular sensory epithelia.The supporting cells of the vestibular sensory epithelia are not specialised in the same way as those of the organ of Corti; hair cell loss does not provoke major changes in epithelial

architecture in vestibular organs; and there appears to be a limited capacity for spontaneous hair cell regeneration in those epithelia. It may be much more straightforward to apply any or all the different proposed regenerative strategies to the vestibular sensory tissues. Accomplishing this could also provide clues to the conditions necessary for successful hair cell regeneration in the organ of Corti.

References 1. Rubel, E. W., Furrer, S. A. & Stone, J. S. A brief history of hair cell regeneration research and speculations on the future. Hearing research 297, 42-51, doi:10.1016/j.heares.2012.12.0 14 (2013). 2. Forge, A., Li, L. & Nevill, G. Hair cell recovery in the vestibular sensory epithelia of mature guinea pigs. The Journal of comparative neurology 397, 69-88 (1998). 3. Kelley, M. W. Regulation of cell fate in the sensory epithelia of the inner ear. Nature reviews. Neuroscience 7, 837-849, doi:10.1038/nrn1987 (2006). 4. Izumikawa, M. et al. Auditory hair cell replacement and hearing improvement by Atoh1 gene therapy in deaf mammals. Nat Med 11, 271-276 (2005). 5. Staecker, H., Praetorius, M., Baker, K. & Brough, D. E.Vestibular hair cell regeneration and restoration of balance function induced by math1 gene transfer. Otol Neurotol 28, 223231 (2007). 6. Lin,V. et al. Inhibition of Notch activity promotes nonmitotic regeneration of hair cells in the adult mouse utricles. The Journal of neuroscience : the official journal of the Society for Neuroscience 31, 15329-15339, doi:10.1523/JNE ROCI.2057-11.2011 (2011). 7. Mizutari, K. et al. Notch inhibition induces cochlear hair cell regeneration and recovery of hearing after acoustic trauma. Neuron 77, 58-69, doi:10.1016/j.neuron.2012.10.032 (2013). 8. Chen, W. et al. Restoration of auditory evoked responses by human ES-cell-derived otic progenitors. Nature 490, 278-282, doi:10.1038/nature11415 (2012). 9. Oshima, K. et al. Mechanosensitive hair cell-like cells from embryonic and induced pluripotent stem cells. Cell 141, 704-716, doi:10.1016/j.cell.2010.03.035 (2010). 10. Taylor, R. R., Jagger, D. J. & Forge, A. Defining the cellular environment in the organ of Corti following extensive hair cell loss: a basis for future sensory cell replacement in the Cochlea. PloS one 7, e30577, doi:10.1371/journal.pone. 0030577 (2012).

Details for correspondence:


Andrew Forge Professor of Auditory Cell Biology UCL Ear Institute 332, Gray’s Inn Road London, WC1X 8EE

Dr Ruth Taylor UCL Ear Institute 332, Gray’s Inn Road London WC1X 8EE E:


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Vibration-Induced Nystagmus: A simple test for peripheral vestibular asymmetry Authors Peter West, MA, MSc, BM, BCh, FRCS, FRCP Consultant Audiovestibular Physician Austin Timoney MSc Pre-registration Clinical Scientist

Introduction Vibration (60-100 Hz) applied to either mastoid process may provoke nystagmus in patients with unilateral peripheral vestibular hypofunction.Testing for Vibration-Induced Nystagmus (VIN) allows many cases of peripheral vestibular imbalance to be identified in the out-patient clinic in under a minute without recourse to expensive, time consuming and (in the case of caloric testing) unpleasant investigations. The VIN test has been in routine use in the first author’s Audiovestibular Medicine clinics for two years, where it has proved an invaluable aid to rapid diagnosis. But, although it is supported by an international literature dating to the late 1990s, it remains largely unknown and unused in the UK. This article aims to encourage its adoption in all clinics where significant numbers of dizzy or balance disordered patients are seen, to facilitate efficient and cost-effective diagnosis as part of the routine vestibular examination and test battery.

Figure 1: Synapsys Vestibular Vibrator

skull vibration to be alarming and even unpleasant. It is therefore recommended that the vibrator be demonstrated on the back of the patient’s hand before it is applied to the mastoid, to encourage their cooperation.

“The VIN test is an excellent clinical screening tool for unilateral or asymmetrical peripheral vestibular weakness” Figure 2: Performing the VIN test

Equipment Whilst the first author initially experimented (with some success) with a battery powered “massager” purchased from Argos for £10, the VIN test should be performed using a powerful mains-powered vibrator, preferably offering frequency specific vibration. At Queen Alexandra Hospital, a Synapsys Vestibular Vibrator (Figure 1) provides vibration at frequencies of 60 and 100 Hz. As the induced nystagmus is of peripheral origin and may therefore be suppressed by optic fixation, eye movements should be examined with fixation removed using infra-red video-Frenzel’s goggles (which should, in any case, be in routine use in all vestibular clinics (1)). VIN may also be recorded as part of the vestibular test battery using Electronystagmography (ENG) or Videonystagmography (VNG) equipment. Method Although even a positive test will induce little or no subjective vertigo, some patients find the sudden application of vigorous

The patient is seated wearing video-Frenzel’s goggles with fixation removed and is instructed to look straight ahead with eyes open for the duration of the test. Vibration is applied at 60 and 100 Hz, with firm pressure, to each mastoid process in turn for 10 seconds. The exact position is said not to be critical but the first author has had most success with the vibrator held level with the external auditory meatus (Figure 2) or to the mastoid tip. Alternatively, the vibrator may be applied to the lower part of the sternocleidomastoid muscle (taking care to avoid the carotid body) but this position has been found to be less effective. Interpretation A strength of the VIN test is that any vibration-induced nystagmus will begin immediately, persist for the duration of vibration and cease instantly when the vibrator is switched off. Hamann and Schuster (1999) found no adaptation of the

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30 response over a 40 second period of vibration (2). A positive result is indicated by horizontal nystagmus beating in the same direction which ever mastoid is stimulated.This implies a unilateral or asymmetric vestibular weakness with the slow phase of the nystagmus generally towards the affected ear.The nystagmus has been classed as significant if the slow phase velocity exceeds 2.9 o/s (3). If there is no nystagmus, or if the direction of the nystagmus changes depending upon which mastoid is vibrated, the test is negative. The significance, if any, of a vertical or torsional nystagmus remains unclear and such nystagmus can probably be

been likened to a “vestibular Weber” test (6) and stimulates the labyrinth in a completely different way to that of caloric or rotation tests (3). Research evidence for the VIN test Good sensitivity and specificity relative to calorics and head-shaking. In one of the earliest reports, Michel et al. (2001) (7) vibrated the skull vertex and both right and left dorsal neck muscles, as well as both mastoids, in 300 patients with unilateral peripheral vestibular dysfunction. 85% had VIN with slow phase to the affected side at three of the five sites, as against 6% in healthy controls and none in controls below the age of 30. This

Figure 3: VNG traces of VIN (fixation removed). Left - 2 o/s spontaneous right-beating nystagmu

Centre - 8 o/s VIN with 100 Hz vibration applied to right mastoid

disregarded. Some research has suggested a correlation between vertical nystagmus and superior semicircular canal dehiscence (4). However, since subjects with no pathology can also exhibit vertical VIN, the link is tenuous and more research is needed in this area. Whilst many patients, in the authors’ experience, respond to vibration at both frequencies, some seem to respond better (or only) to 60 Hz and others to 100 Hz. There is no clear explanation for this. We therefore recommend that both frequencies be routinely used. (Figure 3) shows VNG traces obtained from a patient with an 83% left canal paresis on bithermal caloric testing. Spontaneous right-beating nystagmus of 2 o/s was enhanced to 8 o/s when 100 Hz vibration was applied to either mastoid, and to 10 o/s and 4 o/s when 60 Hz vibration was applied to right or left mastoid respectively. Pathophysiology The exact mechanism of VIN is unknown. Vibration at 60-100 Hz is propagated through the skull at approximately 100 m/s (5), therefore both labyrinths will be stimulated simultaneously. This frequency of vibration is too high to involve endolymph flow, so it is thought to act directly on the sensory cells of the labyrinth. Given that vertical VIN is seen in some cases of superior SCC dehiscence (4) and that 100 Hz vibration has been reported to affect subjective visual horizontal, it is possible that all six canals and even the utricle are stimulated. The VIN test has therefore

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Right - 8 o/s VIN with 100 Hz vibration applied to left mastoid

compared favourably with head shaking nystagmus which was present in only 34% of patients.The prevalence of VIN in central cases (10%) and in patients with vertigo of unknown origin (6%) was comparable to that of the controls. In a series of 28 patients with canal paresis on caloric testing persisting for six months following vestibular neuritis (with 25 normal control subjects), Nuti and Mandala (2005) (8) found that the 100 Hz VIN test identified a peripheral vestibular weakness with a sensitivity of 75% and specificity of 100%. (None of the controls had VIN.) The sensitivity increased as the canal paresis increased. Only one patient had VIN with slow phase not to the pathological side, so the test correctly identified the side of lesion with a specificity of 95%. (Unfortunately, a few patients with VIN when only one mastoid was stimulated were included in the calculations of sensitivity and specificity which weakens this study.) In a series of 99 patients with partial canal paresis, 131 with total canal paresis and 95 controls, Dumas et al (2011) (6) found VIN in 75% of patients with partial and 98% of patients with total paresis. Only 6% of controls had VIN (giving a specificity of 94%) and all of those were over the age of 70. Similarly, Koo et al (2011) (10) found the 100 Hz VIN test to correlate well with canal paresis in 74 patients with acute unilateral vestibular loss. 64 tested positive for VIN and in 98% of those, the slow phase was towards the side of lesion.VIN was superior to the head shaking test in identifying a canal paresis. In 2008, Park et al used 100 Hz mastoid vibration in 22 patients with unilateral vestibular neuritis and 24 with Meniere’s disease (11).

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31 21 of the 22 vestibular neuritis patients had a canal paresis greater than 25% and all of these showed VIN with the slow-phase towards the impaired ear. 8 out of 9 patients with Meniere’s disease who had a canal paresis above 25% also gave VIN with the slow phase to the pathological ear. In the other Meniere’s patients, the VIN was not necessarily localising.The amplitude of VIN significantly correlated with the magnitude of canal paresis for both vestibular neuritis and Meniere’s patients.The lateralisation value of VIN was far superior to that of head-shaking nystagmus. Test-retest reliability VIN has been shown by Park et al (2010) (9) to have excellent test-retest reliability both in terms of direction and maximum slow phase velocity. 52 patients with a range of vestibulopathies were tested in two separate sessions, 30 minutes apart.Vibration of 100 Hz was applied to both mastoids and sternocleidomastoid muscles. 43 patients (83%) gave VIN in the first session and 41 patients (79%) in the second session.The incidence of nystagmus changing direction between testing sessions at each stimulation site was 0 – 4%. Summary of research findings: • In identifying a peripheral vestibular weakness, the sensitivity and specificity of the VIN test is comparable to that of caloric testing (6,7,8). • The sensitivity of the VIN test increases with canal paresis (6,8,10). • There is a good correlation between canal paresis magnitude and VIN slow phase velocity (6,8). • The VIN test shows excellent test-retest reliability (9). • The lateralisation value of VIN is comparable to that of the caloric and superior to that of head-shaking nystagmus (7,8,10,11). Clinical Utility of VIN Test Whilst the VIN test may not give the same quantitative information, in many patients it allows a clinical diagnosis to be made (and treatment instituted) without the need for caloric testing which is time consuming, expensive and unpleasant for the patient. It is especially useful when the caloric test is not tolerated or is contraindicated, such as in patients with disease of the external auditory canal or middle ear. Unlike spontaneous or head-shaking nystagmus, a vibrationinduced nystagmus may persist for years, unaffected by central compensatory processes. The VIN test may therefore be used to monitor changing vestibular status, much more readily than the caloric test.

We conclude that the VIN test, when used as part of a thorough neuro-otological examination, is an excellent clinical screening tool for unilateral or asymmetrical peripheral vestibular weakness and we would encourage its widespread adoption in balance clinics.

References 1. West, P.D.B., Sheppard, Z. A. & King E.V. (2012) Comparison of techniques for identification of peripheral vestibular nystagmus. Journal of Laryngology & Otology, 126: 1209-1215 2. Hamann, K.F. & Schuster, E.M. (1999) Vibration induced nystagmus – A sign of unilateral vestibular deficit. Journal for Oto-rhino-laryngology and its Related Specialties 61: 74-9 3. Boniver, R. (2008) Vibration-induced nystagmus. B-ENT 4(8): 13-14 4. White, J.A., Hughes, G.B. & Ruggieri, P.N. (2007) Vibrationinduced nystagmus as an office procedure for the diagnosis of superior canal dehiscence. Otology & Neurotology 28: 911-916 5. Hood, J.D. (1962) Bone conduction: a review of the present position with especial reference to the contributions of Dr Georg Von Bekesy. Journal of the Acoustic Society of America 32: 1325-1332 6. Dumas, G., Karkas, A., Perrin, P., Chahine, K. & Schmerber, S. (2011) High-frequency skull vibration-induced nystagmus test in partial vestibular lesions. Otology & Neurotology 32(8): 12911301 7. Michel, J., Dumas, G., Lavieille, J.P. & Charachon, R. (2001) Diagnostic value of vibration-induced nystagmus obtained by combined vibratory stimulation applied to the neck muscles and skull of 300 vertiginous patients. Rev Laryngol Otol Rhinol (Bord) 122(2): 89-94 8. Nuti, D. & Mandala, M. (2005) Sensitivity and specificity of mastoid vibration test in detection of effects of vestibular neuritis. ACTA Otorhinolaryngologica Italica 25(5): 271–276 9. Park, H., Lee, Y., Park, M., Kim, J. & Shin, J. (2010) Test-retest reliability of vibration-induced nystagmus in peripheral dizzy patients. Journal of Vestibular Research 20(6): 427-431 10. Koo, J., Kim, J. & Hong, S. (2011) Vibration-induced nystagmus after acute peripheral vestibular loss: comparative study with other VOR tests in the yaw plane. Otology & Neurotology 32: 466-471 11. Park, H.J., Shin, J.E., Lim, Y.C. & Shin, H.A. (2008) Clinical significance of vibration-induced nystagmus. Audiology & Neurotology 13(3): 182-186

Details for Correspondence


Dr Peter West, FRCS, FRCP, Depart. of Audiovestibular Medicine, Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire. PO6 3LY

Austin Timoney MSc Pre-registration Clinical Scientist Queen Alexandra Hospital Portsmouth


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Update on CMV In the last issue an article ‘ Cytomegalovirus and Deafness’ by Jan Pearman highlighted the apparent lack of knowledge amongst professionals about congential cytomegalovirus (cCMV). Here Sally Wood from the Newborn Hearing Screening Programme writes to the editor in response. The featured article ‘Congenital CMV: current and future research in the UK’ updates us on the very latest research. A leaflet is included with this issue of Audacity from the UK registered charity CMV Action run by parents and volunteers. It works to raise public awareness and campaigns for better prevention measures within the NHS.

14 May 2013

Dear Editor I am sorry that your writer and her family had such a negative experience of newborn hearing screening and audiology services for her new granddaughter. (Cytomegalovirus and Deafness BSA News April 2013.) Newborn hearing screening protocols and guidance for the English programme are clear that all babies that fail the newborn screen in one or both ears must be referred for an immediate and detailed audiological assessment. They must have the opportunity to attend such an assessment within 4 weeks of completing the screen or by 44 weeks corrected age. Babies that pass the screen but are identified with congenital cytomegalovirus must be offered a targeted follow up at around 7-9 months of age and then appropriate ongoing audiological monitoring in line with the NHSP surveillance guidelines at The relationship between CMV and hearing loss has been known for many years. It is indeed disappointing that this family encountered so many professionals with so little knowledge of this condition. Yours sincerely

Sally Wood Newborn Hearing Screening Programme (England)

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Congenital CMV: current and future research in the UK Authors Dr Seilesh Kadambari BSc(Hons), MBBS, MRCPCH Clinical Research Fellow Prof Mike Sharland FRCPCH Consultant in Paediatric Infectious Diseases

Congenital CMV is the most common congenital infection and a leading cause of sensorineural hearing loss. We describe the current research studies being conducted in the UK that are looking at integrating screening for congenital CMV into the Newborn Hearing Screening Programme and developing more effective antiviral treatment.

A recent global review showed approximately 0.7% of children worldwide are born with congenital cytomegalovirus (cCMV) infection.1 Studies have shown that the 11% of babies with signs and symptoms from cCMV identified at birth are at highest risk of permanent neurological impairment including sensorineual hearing loss (SNHL), intellectual and developmental disabilities.2 A further 13% of children who are asymptomatic at birth, may develop later impairments, primarily SNHL. Over half of all hearing loss caused by congenital CMV occurs amongst babies who have no symptoms at birth. Congenital CMV accounts overall for approximately 20% of moderate to profound bilateral hearing loss.3 It is the most common nongenetic cause of SNHL and the only potentially treatable cause. CMV related hearing loss can be either unilateral or bilateral but can cause severe progressive loss. SNHL most frequently affects children under the age of 3, coinciding with the critical period for speech and language development. The SNHL caused by cCMV is often progressive, worsening through early childhood. Antiviral treatment has been shown in a Randomised Control Trial to prevent further hearing loss and improve developmental outcomes when started in the first month of life in babies born with central nervous system (CNS) disease.4 At present in the UK testing for cCMV only occurs after a baby is confirmed with hearing loss, and this typically occurs too late for treatment to be offered or effective.

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BEST study (The Benefits, feasibility and acceptability of Extended Screening Testing in newborn babies who are referred for further hearing assessment after their neonatal screen) Screening for cCMV in the UK is not currently performed. Detecting CMV using CMV DNA PCR on Dried Blood Spot (Guthrie) cards has been shown to be insensitive.5 Testing saliva using CMV PCR is nearly 100% sensitive for detection of the virus but there is currently no NHS clinical or laboratory framework to take saliva samples from every baby at birth and rapidly process them. Integrating saliva testing for cCMV into the routine newborn hearing test could potentially identify affected newborns that could be treated within the time during which treatment is known to work.This may reduce the overall burden of childhood deafness (and developmental disability), and overall costs to the NHS. The BEST study was funded by the charity Sparks ( Recruitment commenced in Newcastle in August 2010 and south west London in April 2011. Newborns being referred for further audiological evaluation after their initial Newborn Hearing Screen Programme (NHSP) were identified by hearing screeners and parents were contacted by a study co-ordinator. After obtaining verbal consent over the phone, study packs were posted to parents. The study pack contained a saliva swab, urine collection pack, instructions to take samples, consent form and standardised anxiety and ease of use questionnaires. During the first 12 months of the BEST study, of 14,389 newborns, 351 were “referred” for further hearing testing after their initial hearing screening and 248 families were approached with 152 (61%) agreeing to cCMV screening. Five were positive, all known in time to allow assessment for treatment within 28 days. Salivary samples were clearly easier for families with 95% (145) returning salivary samples, all of which were suitable for processing. Only 49% (74) of urine samples were returned of which 15% (11) were not processed as they had leaked in transit. 97% of parents preferred salivary sampling: 71% rated salivary samples ‘very easy’ to collect compared to only 18% for urine samples. Anxiety scores were not significantly different to reference mothers. However, only just over 45% of eligible participants were recruited into the study due to the inherent problems with postal recruitment. The BEST study has demonstrated that targeted screening for cCMV using saliva swabs is feasible and acceptable to parents. The study finished in March 2013 and the results will be published later this year.

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35 BEST 2 study (The Benefits of Extended Screening Testing for congenital CMV – Enhancing clinical Integration with the Newborn Hearing Screening Programme) BEST 2 aims to assess the feasibility of clinically integrating screening for cCMV into the NHSP. BEST 2 will build on the BEST study, but will now ask the newborn hearing screeners to take the saliva samples at the point of referring newborns to audiology after their initial hearing screen. We anticipate that an increased number of newborns with cCMV will be detected through BEST 2 thus enabling antiviral treatment to be started appropriately in the first month of life. Babies with congenital CMV, in whom SNHL is not confirmed would require regular monitoring in case they develop late onset hearing loss.6 We aim to commence recruitment into BEST 2 by October 2013 across south west London for a 12 month period. CASG 112 (A Phase III, randomised, placebo controlled, blinded investigation of six weeks vs six months of oral valganciclovir therapy in infants with symptomatic congenital cytomegalovirus infection) Intravenous ganciclovir therapy has been used to treat cCMV for the last twenty years.7 Only one phase III randomised trial by the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group (CASG 102 study) has been conducted to assess the outcome of ganciclovir treatment in symptomatic congenitally affected infants.4 The study showed that treatment prevented hearing deterioration at 6 months and 1 year of life in infants with CNS involvement. Moreover, infants were shown in a follow up study to have reduced developmental delay at 6 and 12 months of age compared to untreated infants.8 Ganciclovir therapy however has been shown to cause abnormalities in white cells, requires prolonged hospital admission and is associated with line related problems including sepsis and thrombosis.

transplant patients and as an off licence infection to treat cCMV disease in Europe. Valganciclovir is an oral syrup which can be administered by parents at home. To date no studies have looked at comparing the efficacy and safety of valganciclovir to ganciclovir in cCMV affected babies. A placebo-controlled, double blind, randomized study comparing 6 weeks versus 6 months of oral VGCV conducted by the Collaborative Antiviral Study Group (CASG 112) closed to recruitment in the UK and USA in June 2013 ( The primary objectives of the study were to compare hearing outcomes, safety profiles, assess neurological outcomes and monitor CMV viral loads in symptomatic neonates up to one month of life who received 6 weeks versus 6 months of VGCV. The results will be available from late 2013 and may be a significant advance in managing cCMV.

Valganciclovir is the oral prodrug of gancilcovir.Valganciclovir has been licenced by the US Food and Drug Administration to treat CMV disease in high risk heart or kidney

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36 CASG 403 (A Phase II randomised and controlled investigation of six weeks of oral valganciclovir therapy in infants and children with congenital cytomegalovirus infection and hearing loss) In the absence of any screening programme, the majority of CMV related SNHL is detected only when investigations are performed in a child identified with hearing loss in infancy or early childhood. No treatment studies have been conducted to assess the effectiveness of starting antiviral treatment to infants after the first month of life when the great majority are diagnosed. The CASG 403 study is aiming to open to recruitment across 17 sites in the UK and USA by the end of 2013 ( term=congenital+cmv&rank=7). The primary objective of the study will be to assess the hearing outcomes in infants aged between one month and 3 years with diagnosed cCMV and SNHL and who are randomised to receiving six weeks of valganciclovir therapy or placebo. The study will aim to recruit 54 participants and is planned to close to recruitment in 2017. CMV Action The congenital CMV parents group ( is run on a voluntary basis by the parents of children with cCMV. The association offers very helpful advice and support to families affected by cCMV. Our research group continue to work very closely with CMV Action to develop research studies to improve prevention, treatment and management strategies and promote awareness of this poorly understood condition.

References 1. Dollard SC, Grosse SD, Ross SD. New estimates of the prevalence of neurological and sensory sequalae and mortality associated with congenital cytomegalovirus infection. Rev Med Virol 2007; 17: 355-63 2. Kenneson A, Cannon MJ. Review and meta-analyses of the epidemiology of congenital cytomegalovirus (CMV) infection Rev Med Virol 2007; 17: 253-76 3. Grosse S, Ross DS, Dollard SC Congenital cytomegalovirus (CMV) infection as a cause of permanent bilateral hearing loss: a quantitative assessment. J Clin Virol 2008; 41: 57-62 4. Kimberlin DW, Lin CY, Sánchez PJ et al Effect of ganciclovir therapy on hearing in symptomatic congenital cytomegalovirus disease involving the central nervous system: a randomized, controlled trial. National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. 2003; Jul; 143(1):16-25 5. Boppana S, Ross S, Novak Z et al Dried Blood Spot Real-time Polymerase Chain Reaction Assays to Screen Newborns for Congenital Cytomegalovirus Infection JAMA. 2010; 303(14):1375-1382 6. Kadambari S, Williams EJ, Luck S et al Evidence based management guidelines for the detection and treatment of congenital CMV Early Hum Dev 2011; 87 (11): 723-8 7. Fan-Harvard P, NahataMC, BradyMC. Ganciclovir – a reviewof pharmacology, therapeutic efficacy and potential use for the treatment of congenital cytomegalovirus infections. J Clin Pharm Ther 1989;14:329–40. 8. Oliver SE, Cloud GA, Sanchez PJ. Neurodevelopmenatal outcomes following ganciclovir therapy in symptomatic congenital cytomegalovirus infections involving the central nervous system. J Clin Virol 2009;46(Suppl 4):S22–6.

Seilesh Kadambari is a clinical research fellow in the Paediatric Infectious Diseases Research Group at St George’s University of London. Seilesh’s research interests lie in the epidemiology of neonatal viral infections. Seilesh has helped coordinate congenital CMV studies in London since 2011. He has worked closely with the NHSP to prioritise integrating screening for CMV into the NHSP and improve care pathways. Seilesh was part of a collaboration that published the first evidence based guidelines to treat congenital CMV in the UK. Seilesh’s work includes laboratory studies to better understand molecular resistance patterns in cCMV infected infants treated with ganciclovir. Seilesh also works

closely with Public Health England on different studies to better understand the aetiology of neonatal viral infections in the U.K. Mike Sharland is a consultant in Paediatric Infectious Diseases at St George’s Hospital, and Professor of Paediatric Infectious Diseases at St George’s University of London. He heads the busy Paediatric Infectious Diseases Service for South London and has a long standing research interest in congenital CMV. Mike’s research interests focus on developing and optimising antimicrobial prescribing for children. He has published over 150 papers in this area.

Details for correspondence:


Dr S Kadambari BSc(Hons), MBBS, MRCPCH Clinical Research Fellow Paediatric Infectious Diseases Research Group Division of Clinical Sciences Jenner Wing, Level 2, Room 2.215E St George's University of London SW17 ORE E:

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Prof Mike Sharland FRCPCH Consultant in Paediatric Infectious Diseases St George's University of London SW17 ORE

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research round-up


Research Round-up the Ewing Auditory Research (EAR) team Research round-up places a spotlight on new and interesting projects happening across major hearing and balance research institutions around the world. This edition of Audacity focuses on work being carried out by the Ewing Auditory Research team led by Professor Kevin Munro at the University of Manchester.

Kevin J Munro Ewing Professor of Audiology

Who were the Ewings? It is almost 100 years since Sir Alexander and Lady Irene Ewing, from the University of Manchester, introduced the fundamental concepts of what we now call ‘paediatric audiology’. Their pioneering work has influenced professionals throughout the world. Irene R Ewing, received an OBE in the King’s birthday honours list in 1944 and Alexander GW Ewing was knighted in the 1959 New Year’s honours list.The Ewings recognised the importance of linking: i) research, ii) education and iii) practice, a characteristic we strive to emulate in our EAR Team today. I was delighted to be able to say a little about their work, in my capacity as Ewing Professor of Audiology, at a recent evening reception in the House of Lords.

Importance of early identification and intervention

Importance of early involvement of the family

Procedures for hearing assessment in infants

The Ewing legacy: the fundamental concepts of paediatric audiology

Who are the ‘EAR Team’? The audiology activities at the University of Manchester are extensive and cover the compete lifespan.This article provides an overview of the current research activity that is carried out by the researchers and PhD students with whom I work most closely and who share the same vision of improving the lives of adults and children who have a hearing disorder. Much of our work is carried out in the Ewing Auditory Research lab and, since I am the Ewing Professor of Audiology, we like to refer to ourselves, informally, as the ‘EAR Team’. In reality, the EAR Team is only one small part of the audiology research activity in Manchester although we do have an extensive network of collaborators including the Manchester Academic Health Science Centre, a partnership that

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unites NHS clinicians with researchers in order to provide patients and clinicians with rapid access to the latest research discoveries. We also collaborate with a wide range of researchers within the UK (e.g., Professor Deb Hall and Dr Heather Fortnum, Nottingham Hearing Biomedical Research Unit; Professor Mark Lutman, University of Southampton; Professor Adrian Davis, UCL) as well as overseas (e.g., Professor David Moore at the Cincinnati Children’s Hospital Medical Centre; Professor Suzanne Purdy at the University of Auckland; Professor Karen Cruickshanks, University of Wisconsin). What do we do? We have a wide range of teaching, research, clinical and administrative responsibilities with several of us involved

in many professional activities. Our research spans the continuum from: i) increasing our understanding of the normal and disordered auditory system, through to ii) translational projects that have the potential to transform audiology, and finally iii) applied clinical research. Although the currency of success in an academic environment is typically measured in terms of research outputs in highimpact, peer-reviewed journals, our work has had most real world impact when the findings have been incorporated into our education and training programmes for audiologists and related health care professions. More recently, we have been using the BSA ‘Lunch and Learn’ seminars to bring some of our work (e.g., placebo effects in hearing aid trials, population-

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39 based studies of hearing disability, auditory acclimatisation and adaptation to hearing aids etc) to the attention of busy health care professionals. For the same reason, we also publish regularly in national and international magazines and newsletters e.g., Newsletter of British Society of Hearing Aid Audiologists, Canadian Hearing Report, ENT and Audiology News, Audiology Online and The Hearing Journal, to name a few. Many of the EAR Team undertake clinical work and are able to take research findings into the clinic, as well as identify urgent clinical questions that we should address.

What are the current research projects? Below, we have summarised 13 of our projects (written in a ‘relaxed magazine format’, as instructed by the new editor!) and provided suggested reading for anyone wishing to obtain further information about any of the studies. Details are also available on our website: Opportunities for individuals to join (or collaborate) with the EAR Team arise from time-to-time: contact if you are interested. We think the Ewing legacy is in safe hands.

1. Why yellow hearing aids are best (or are they)? BASIC e.g., plasticity after hearing loss or intervention

TRANSLATIONAL e.g., acclimatisation to devices, prevalence of hearing disablility

APPLIED e.g., benefits of frequency conpression dead regions

Our activities span from basic through to applied hearing research Like most research groups, we now appreciate the benefit of involving patients in our research plans and we do this is a number of ways including our Children Hearing Research Group and Adult Hearing Research Group. We also have a strong programme of public engagement. Recently, Hannah Brotherton, one of our newest PhD students won ‘I’m a scientist… get me out of here!’ a two-week science engagement event with 13-14 year olds, supported by the Wellcome Trust. We have recently started to write articles for ‘The Conversation’, an online newspaper written by academics but for the lay public. We are frequently asked for advice and, this year, have contributed to articles on BBC Online and The Daily Mail. Even when not invited, we sometimes feel provoked into offering our views: see, for example, our online response (Perpetuating the low and slow uptake of adult hearing services) to an article in the British Medical Journal (BMJ 2013;346:f1501).

The expectation of the doctor/scientist and the expectation of the patient/participant can affect the outcome of a wide range of medical treatments. This is termed the ‘placebo’ effect. Medical trials incorporate controls for placebo effects, though trials of hearing technology usually do not. Our research: We took two identical hearing aids, put one in a yellow-coloured case, and told the research participants that the yellow one was the very latest technology. The participants preferred the yellow hearing aid and performed better with it on a variety of listening tests.This is an example of the well-known phenomenon called the placebo effect. We have repeated the study and obtained similar results. These findings demonstrate that the placebo effect can have a powerful impact on the outcome of hearing aid trials. The implication of this is that one should interpret the findings of hearing aid trials with a ‘pinch of salt’ when treatments have not been blinded since the results may have

been biased, perhaps even subconsciously, by the participant or/and the investigator. The findings have been presented at a variety of national and international conferences. We are currently pursuing funding to extend this work so that we can investigate how to minimise the role of expectations in clinical trials and how it can affect the outcome of interventions in clinical practice. Interested in reading more on this topic? Dawes P, Powell S, Munro KJ. The placebo effect and the influence of participant expectation on outcome of hearing aid trials. Ear and Hearing 2011; 32: 767-774. This work was carried out by Piers Dawes, Rachel Hopkins, Kevin J Munro and Sam Powell with support from Starkey UK.

2. Fitting babies with hearing aids: progress means new challenges Permanent hearing loss in infants is common and its impact on the child is vast. >70% of children with hearing loss fail to achieve the government benchmark of 5 GCSEs at A* to C. In order to identify and assess hearing loss early, a hearing screen has been available to all new born babies in England since 2006. However, early identification alone will not lead to a better outcome. We now provide hearing instruments to infants at a few months of age but there is an urgent need for procedures that will guide the appropriateness of the prescription and when to expedite trials of alternative devices such as cochlear implants. This is the important clinical challenge we are seeking to address in this project.

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40 3. Understanding risks for age-related hearing loss: UK Biobank

Our research: Previous studies have demonstrated that a procedure known as cortical auditory evoked potentials (CAEPs) can be successfully recorded in infants who wear hearing instruments. It involves attaching 3-4 recording leads to the head and recording the electrical activity generated by the brain in response to speech and other sounds. CAEPs have the real potential to tailor treatment to the individual and improve quality of life. Before embarking on a large scale trial, we are undertaking an essential underpinning study, on 100 normal hearing infants and 10 infants with hearing loss, to answer questions related to the natural changes that occur in the brain in response to sound as the infant grows, the ability to consistently detect a CAEP, as well as investigating the feasibility and acceptability of making these measurements in the clinical setting. More information is available at: Interested in reading more on this topic? Munro KJ, Purdy SC, Ahmed S, Begum R, Dillon H. Obligatory cortical auditory evoked potential waveform detection and differentiation using a commercially available clinical system: HEARLab. Ear and Hearing, 2011; 32: 782-786. This project is a collaboration between the University of Manchester and Central Manchester University Hospitals NHS Trust. It is funded by a CMFT strategic research grant (Early intervention of permanent childhood hearing impairment: progress means new challenges). The investigators include: Rachel Booth, Iain Bruce, Martin O’Driscoll, Kevin J Munro, Ruth Nassar and Kai Uus.

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Hearing loss is a very common problem, with almost everyone experiencing some hearing loss as they grow older.There are currently 10 million adults with hearing loss in the UK, and this number will increase in coming years. Hearing loss impairs communication, so there is a significant impact on social, emotional and physical well-being. Hearing loss is on track to be in the top ten highest burdens of disease in the UK by 2030. However, there is recent evidence that hearing loss may be avoided or minimised.

Piers Dawes, Research Fellow

‘We are the first group in the world to obtain data from UK Biobank’ Interested in reading more on this topic? Dawes P, Fortnum H, Moore DR, Elmsley R, Cruickshanks KJ, Davis AC, EdmonsonJones M, Norman P, Lutman M, Munro KJ. Hearing and vision in middle age: A population snapshot of 40-69 year-olds in the UK. Ear and Hearing 2013 (Under Review).

Our research: Using the UK Biobank resource with data from over 500,000 UK adults, our work will provide unique insight into the prevalence of hearing problems as well as understanding the risk factors for hearing disability, including noise exposure, cardiovascular disease, diet, exercise, smoking, alcohol intake, medications and brain function. We will also examine how hearing loss, visual impairment and dual sensory impairment affect quality of life. This research will lay the foundation for future work exploring interactions between genetics and environmental risk factors for hearing loss. With a wide range of data included and the very large sample size, the UK Biobank provides a unique resource for doing this important research. Our ultimate aim is to identify ways of preventing hearing loss and improving quality of life for older adults. We have presented this work at conferences in the UK and EU. More information about this study can be found on the UK Biobank website via this link: ing-and-sight-loss-study-underway/

This work is being carried out by Piers Dawes and Kevin J Munro in collaboration with leading scientists in the UK and US: Professor David Moore at Cincinnati Children’s Hospital Medical Centre, Dr Heather Fortnum, Dr Abby McCormack and Mark Edmondson-Jones at the NIHR Nottingham Hearing Biomedical Research Unit; Professor Adrian Davis, Royal Free Hampstead NHS Trust, London; Professor Mark Lutman, University of Southampton and Dr Karen Cruickshanks, University of Wisconsin.

4. Plasticity: re-wiring the auditory brain Contrary to the age-old myth, a leopard really can change its spots. The brain has an extraordinary ability to modify the way it works, to re-wire itself, following changes in the body or in the environment. It is most plastic during childhood,

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41 which is why babies can learn to walk and talk all on their own, and kids can soak new information up like sponges. But the brain remains surprisingly plastic even into adulthood. It is this lifelong ability to change and adapt which is associated with recovery after a stroke or sensory deprivation, or learning to use a prosthetic limb or hearing devices after deafness. Our Research: Our present work is involved in characterising the way in which the adult auditory brain re-wires itself following deafness. We take people who have gone deaf suddenly in one ear, and study the ways in which the brain learns to make best use of the hearing from their one good ear. So far our work has revealed the timecourse of changes, which is important for deciphering the way in which the rewiring works.This will ultimately shed light on ways to alleviate various hearing problems like tinnitus, and also help people learn to use their hearing devices most effectively. This work has been presented at a variety of international conferences, including the international ERA Study Group, New Orleans. Interested in reading more on this topic? Maslin MRD, Munro KJ, El-Deredy W. Evidence for multiple mechanisms of cortical plasticity: a study of humans with late-onset profound unilateral deafness. Clinical Neurophysiology 2013; 124: 1414-142 (and see accompanying editorial 1267-8).

This project is being carried out by Mike Maslin, Kevin J Munro and Chris Plack. It leads on from Mike Maslin’s MRC-funded PhD.

5. Do adults need time to acclimatise to their hearing aids? We know that the adult brain changes over time when there is an injury or if we provide a period of training. There is also irrefutable evidence that using a hearing instrument, especially cochlear implants, can cause changes in the brain. However, it is less clear if this happens routinely when adults are provided with a hearing aid. Our research: We have been investigating auditory acclimatisation in a number of studies using a relatively large number of adults fitted with hearing aids for the first time. We have used a variety of techniques to identify changes over time ranging from listening in noise to recording changes in EEG activity using electrodes attached to the scalp. So far, we have found little evidence to suggest that the changes over time are sufficiently robust and meaningful to be of importance in clinical practice. A raft of studies has been accepted for publication in a variety of journals including Ear and Hearing, Journal of the Acoustical Society of America and Neuroreport. Interested in reading more about this topic? Dawes P, Munro KJ, Kalluri S, Edwards B. Acclimatisation to hearing aids. Ear and Hearing 2013 (In Press).

Michael Maslin, Post-doctoral Researcher

‘Working with our NHS colleagues to research on the auditory pathway will allow us to personalise audiological management’

This work is being carried out by Piers Dawes, Brent Edwards, Sridhar Kalluri and Kevin J Munro. It is funded by the Starkey Hearing Research Center, USA.

instrument users, and failure to adjust to the device may result in reduced benefit or non-use. Failure to tune out background sounds may also result in reduced performance in background noise. It may also be possible to optimize rehabilitation strategies based on individual differences in ‘attentional tuning’. Our research: We hypothesize that acclimatization to hearing aids involves a process of learning to ‘tune out’ newly audible unwanted sounds (for example, buzzing strip lighting or a droning refrigerator motor), which new hearing aid users find annoying and distracting. The main benefits of understanding attentional tuning will be in facilitating strategies to boost adaptation and regular use of hearing instruments, as well as increasing benefit. This would be of direct benefit to hearing instrument users, device aid manufacturers and society as a whole. This work is being carried out by Piers Dawes, Kathryn Hopkins and Kevin J Munro. It is funded by a grant from the Industry Research Consortium (IRC; Attentional tuning and acclimatization to hearing aids).

7. Transforming infant hearing services Every week in the UK, another 20-25 children are born deaf and this can be confirmed soon after birth. The first days, months and years of a child’s life have a tremendous impact on development: theirs, society’s and the world’s. However, formal behavioural assessment of a child’s hearing cannot normally take place until they are able to turn their head in response to sound (at around 8 months of age). There is an urgent clinical need to remove the unacceptable time delay

6. Why so many annoying sounds? The problem The experience of ‘annoying sounds’ is a frequent complaint among new hearing

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42 between confirmation of deafness and obtaining reliable behavioural hearing assessment data. Our research: The mission of our world-leading paediatric deafness team is to improve the lives of deaf children, and their families, via early and accurate diagnosis, improved hearing devices and more effective treatment. We are about to embark on a study that will investigate a new hearing assessment technique for use with very young children. This involves tracking eye movements in response to sound in order to reveal whether this can provide reliable information about hearing. The purpose of this research study is to provide confidence that the eye tracking technique is a viable approach to hearing assessment in individual infants. In this initial study, the only one of its kind within the UK, we will use the eye tracking technique with 100 infants with normal hearing. This project is a collaboration between the University of Manchester and Central Manchester University Hospitals NHS Trust. This work is being carried out by Rachel Booth, Iain Bruce, Thea Cameron-Faulkner, Kevin J Munro, Martin O’Driscoll, Andrew Stewart and Kai Uus

8. Hearing loss and broken pianos Background We set out to find out how common cochlear dead regions are and how best to programme hearing devices when a person is identified with one. These dead regions are often compared to a piano with broken stings: pressing hard on the broken keys may cause adjacent strings to vibrate. A dead region occurs when inner hair cells and/or neurons are functioning

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so poorly that a tone producing peak vibration in this region is detected by offfrequency listening. A cochlear dead region may impact on patient counselling, selection of gain-frequency response, and hearing aid benefit. Our research: We have conducted a number of research projects on the topic of cochlear dead regions in adults and in children.The findings will help inform audiologists about the need to diagnose dead regions, how to programme the hearing instruments and how to counsel people with dead regions. It will ensure that patients who need hearing instruments receive the best treatment possible and reduce unnecessary appointments for reassessments. Most of this work has been published in peer-reviewed journals but we have also collaborated with industrial partners and disseimated the findings via their publications e.g., Phonak Focus. Interested in reading more about this topic? Malicka A, Munro KJ, Baer T, Baker RJ, Moore, BCJ. The effect of low-pass filtering on identification of nonsense syllables in quiet by school-age children with and without cochlear dead regions. Ear and Hearing 2013 (In Press). This work is being carried out by Karolina Kluk, Kath Lewis, Kevin J Munro and Anna Pepler. The project is funded by a grant from the National Institute of Heath Research (PB-PG-0408-15055; Cochlear dead regions in hearing-impaired adults: prevalence and benefit from hearing aids).

9. Eyes, ears and accents Have you ever wondered how you “tune in” to someone’s accent? Humans have the remarkable ability to understand different speakers and accents, but it is not fully understood how this rapid perceptual adaptation takes place. We are carrying out research to understand how we adapt to hearing unfamiliar foreign or regional accents, and whether visual speech information (seeing a speaker as well as hearing them) helps people to adapt.

Our research: We use eyetracking (a way of measuring people’s eye movements) to investigate how older and younger adults combine visual and auditory speech information when adapting to a new accent. We also carry out neuropsychological tests to examine the role of cognition (such as memory, attention and linguistic processes) in understanding accented speech. The findings will help us to understand why some older people have difficulty understanding speech in difficult listening conditions, and may identify ways to help overcome this. Interested in reading more about this topic? Janse, E. and Adank, P. Predicting foreignaccent adaptation in older adults. Quarterly Journal of Experimental Psychology, 2012; 65: 1563-1585. This work is being carried out by Briony Banks, Patti Adank, Emma Gowen and Kevin J Munro. Briony Banks is a PhD student funded by BBSRC (Audio-visual plasticity in spoken language comprehension in aging).

10. Listening effort in the young adults and child Have you ever wondered how difficult it is for hearing-impaired individuals to understand speech in noise? Noisy environments are ubiquitous e.g. cafeteria, classroom, bus etc. With even a mild hearing loss, the ability to detect speech in these settings is seriously hindered. As a result, people with a hearing loss often report an exhausting need for sustained

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43 mental effort to listen in these environments.

patients. However, the characteristics of central gain still remain unclear.

Our research: Using a wide range of psychophysiological techniques (e.g., measuring skin conductance, electrical activity in the brain, pupil dilation) we aim to uncover a sensitive and reliable measure of this listening effort in young adults and children. If successful, such a measure could be used clinically when assessing hearing disability and assessing the benefit of interventions. We are hoping to undertake a similar research study in older adults too.

Our research: We aim to characterise the gain mechanism, investigating the origin, time scale of changes and if it is frequency specific, following different periods of earplug deprivation. Changes in the central gain mechanism will be investigated using the acoustic reflex threshold (ART) and auditory brainstem response (ABR). If we can understand more about this mechanism, it may become possible to deliver therapeutic strategies aimed at reducing the central gain, and potentially inform treatment decisions for symptoms such as tinnitus.

Interested in reading more about this topic? Howard CS and Munro KJ, Plack CJ. Listening effort at signal-to-noise ratios that are typical of school classrooms. International Journal of Audiology 2010; 49: 928-932. This work is being carried out by Piers Dawes, Ronan McGarrigle, Kevin J Munro and Andrew Stewart. Ronan McGarrigle is a PhD student within the School of Psychological Sciences.

11. To gain is to lose Imagine a car sat at the traffic lights, it is not moving and remains stationary, yet you can hear the engine humming and working away.This analogy can be used to describe the auditory system. Even when sound is not present, spontaneous neural activity can still be recorded from the auditory pathway. However, an increase in central gain, a mechanism that modulates the neural sensitivity within the auditory system can result in this spontaneous activity become hyperactive. This could potentially explain tinnitus, the perception of a noise/ringing in the ears or head without an external reference, in some

Interested reading more on this topic? Munro KJ, Merrett JF. Brainstem plasticity and modified loudness following shortterm use of hearing aids. Journal of the Acoustical Society of America, 2013; 113: 343-349. This work is being carried out by Hannah Brotherton, Chris Plack, Kevin J Munro and Roland Schaette UCL. Hannah Brotherton is a PhD student within the School of Psychological Sciences.

Our research: We have conducted a number of research projects on hearing aids that use non-linear frequency compression. In the present study, we are investigating the benefit of listening to speech with these hearing instruments when they are first fitted and after a period of adjustment/acclimatisation (with and without auditory training). The findings will have implications for the use of frequency compression and auditory training in auditory rehabilitation. Interested in reading more on this topic? Ellis RJ, Munro KJ. Benefit and predictors of outcome from frequency compression in experienced adult hearing aid users with moderate-to-severe sensorineural hearing loss. Ear and Hearing 2013 (In Press). This project is being carried out by Richard Baker, AnnMarie Dickinson, Kevin J Munro and Catherine Siciliano in collaboration with colleagues at Phonak AG, Switzerland. The project is funded by Phonak AG as a threeyear CASE industrial award (Plasticity, perceptual learning and real-world benefit with frequency-compression instruments: the role of auditory training).

13. Understanding and improving benefit from hearing aids: the Eriksholm “hearing aid use� study

12. Squashing sounds to make them audible If you have difficulty detecting highpitched sounds then this can prevent you from hearing some important speech sounds, even when you wear a hearing aid. A potential solution is to squash the high-pitched sounds down to a lower frequency to help make these speech sounds audible.

Background Although hearing loss causes huge difficulties with communication, only one in six people who could benefit from a hearing aid actually use one. Of those who do use hearing aids, another one in six does not receive substantial benefit from their hearing aid. Our research: We are part of a large multi-centre research project led by researchers at the Eriksholm Research Centre in Denmark ( The aims of this study are i) to explore the definition and determinants of optimal hearing aid use from the perspectives of hearing aid users and audiologists and contrast the two, ii)

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44 investigate the determinants of hearing aid use and iii) develop and evaluate a tool for hearing aid use goal setting and assessment for audiologists and to use together with hearing aid users. Interested in reading more on this topic? Laplante-Lévesque A, Jensen LD, Dawes P, & Nielsen C. Optimal Hearing Aid Use: Focus Groups With Hearing Aid Clients and Audiologists. Ear & Hearing, 2013; 34: 193–202.

This project is being carried out by Piers Dawes, in collaboration with Ariane Laplante-Levesque, Lisbeth Jensen, Claus Nielsen and colleagues at the Eriksholm Research Centre, Denmark. Acknowledgements Many of the projects listed above have been facilitated by the Manchester Biomedical Research Centre. Kevin J Munro, The University of Manchester, and Central Manchester University Hospitals NHS Trust, Manchester Academic Health Science Centre

Assessing risk factors for hearing disability and tinnitus using the UK Biobank resource Authors Abby McCormack Mark Edmondson-Jones Heather Fortnum

The UK Biobank study is a population survey of genetic, environmental and lifestyle causes of diseases of middle and older age (Allen et al. 2012). It was set up to support a diverse range of research into factors affecting older age with the ultimate aim of improving the prevention, diagnosis and treatment of illness, and the promotion of health throughout society. More than 500,000 people aged 40 to 69 years were recruited during 2006-2010. Recruitment was carried out through National Health Service registers and aimed to be inclusive and as representative as possible of the UK population. A total of 9.2 million invitations were sent and a response rate of 5.47% was achieved to give a final sample size of 503,325 participants. The assessment involved a single visit to one of 22 assessment centres located in England, Scotland and Wales, and took approximately 90 minutes to complete.

A touchscreen questionnaire was used to collect information on a wide range of markers such as demographics, lifestyle, occupation, family history, psychological state, hearing, and much more. In addition cognitive tests and a speech-in-noise test (based on the digit triplet test used by Action on Hearing Loss, and others) were also performed on a large subset of participants. The UK Biobank study contains information that allows an assess-

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ment of hearing, cognitive function and psychological state in a large number of volunteers in this age group.Together with demographic and biological data, the questionnaire and test results provide extremely rich epidemiological data on hearing status and tinnitus. UK Biobank data became available in 2012 offering a major opportunity to address a range of issues in translational

hearing research, and we have begun to do this. The questionnaire included the following hearing-related questions: • "Do you have any difficulty with your hearing?" • "Do you find it difficult to follow a conversation if there is background noise (such as TV, radio, children playing)?" • “Do you get or have you had noises

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• • • •

(such as ringing or buzzing) in your head or in one or both ears that lasts for more than five minutes at a time?" "How much do these noises worry, annoy or upset you when they are at their worst?" "Do you use a hearing aid most of the time?" "Do you have a cochlear implant?" “Have you ever worked in a noisy place where you had to shout to be heard?" "Have you ever listened to music for more than 3 hours per week at a volume which you would need to shout to be heard or, if wearing headphones, someone else would need to shout for you to hear them?"

Analysis shows that, according to the hearing test, a total of 10.7% of adults aged 40-70 had a significant hearing disability whereas only 2.0% in this age range used a hearing aid. Increasing age was associated with higher risk of hearing disability, and hearing aid usage accelerated with age. Those from a low socioeconomic background and those with a history of work-related noise exposure were also more likely to have a hearing disability. Music related noise exposure

Only 20% of people who would benefit from a hearing aid are actually wearing one, and tinnitus is related to an increased risk of depressive and anxiety symptoms. Early psychosocial intervention could prevent the development of chronic tinnitus and the associated distress. greater than 5 years was associated with a small but significant increased risk of hearing problems. Ethnicities at highest risk of hearing disability were Bangladeshi,

Black African, Pakistani, Black Other and Asian Other. Prevalence of tinnitus for this population was 17%, with 4% reporting tinnitus as moderate or severe. The prevalence of tinnitus was higher for males than for females (18% vs 14%), with a clearly increasing trend with age for both sexes, i.e. the older a person is the more likely they are to have tinnitus. With this resource we are also exploring the association of psychological state with tinnitus severity. Those with tinnitus had greater number of depressive and anxiety symptoms. Clinicians treating people for anxiety/depression should bear in mind that tinnitus may be a contributing factor, and there are audiological interventions (such as noise masker, hearing aid) that might be helpful for these patients. Likewise, clinicians treating tinnitus patients should also consider treatment for anxiety and depression. It is possible that early psychosocial intervention in patients at risk may prevent development of chronic tinnitus and the related psychological distress. Of importance is the ability to prevent emerging tinnitus from becoming severe and persistent tinnitus. Previous research has also suggested that personality can be a

The opportunities with this dataset are endless. We endeavour to make the most of this large nationally representative database of UK adults aged 40 to 69 to further understand prevalence and risk factors associated with hearing disability and tinnitus.

factor in the perceived severity of tinnitus. After controlling for age, sex, hearing difficulty and SES, we found that neuroticism was a novel predictor of tinnitus. Individuals with tinnitus and higher levels of neuroticism are more likely to experience bothersome tinnitus, possibly as a reflection of greater sensitivity to intrusive experiences. Further analysis of UK Biobank will also explore the relationship between hearing difficulty and/or tinnitus and lifestyle factors such as diet, exercise, smoking and alcohol intake. We would also welcome suggestions from readers on anything else that would be interesting to explore. References Allen, N., Sudlow, C., Downey, P., Peakman,T., Danesh, J., Elliott, P., Gallacher, J., Green, J., Matthews, P., Pell, J., Sprosen, T., Collins, R. (2012). UK Biobank: Current status and what it means for epidemiology. Health Policy and Technology, 1, 123-126. Website list:

Abby McCormack BA (Hons) Psychology MSc Health Psychology PhD Psychology

Address for correspondence: Abby McCormack; Research Fellow NIHR Nottingham Hearing Biomedical Research Unit Ropewalk House 113 The Ropewalk Nottingham NG1 5DU E:

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ISVR at 50 The University of Southampton’s Institute of Sound and Vibration Research (ISVR) is celebrating its 50th anniversary. Founded in 1963 by Professor E Richards, it is recognised as a centre of excellence for research, teaching and consultancy in acoustics, noise and vibration. In recognition of the event past figures in the history of ISVR have written reflections of their time. Here we publish extracts from key figures in Audiology. Full versions of these and others can be found at

Early Days in ISVR Audiology cers, Ron Hinchcliffe, John Knight and Chris Rice.

Dr Ross Coles: c1971

My part in ISVR’s story started with an attachment from the Royal Naval Medical Service to work at the Medical Research Council’s Wernher Research Unit on Deafness at King’s College Hospital, London. This was directed by T S (Tom) Littler, who with William Burns and Douglas Robinson coordinated the

‘the formation in 1965 of the Audiology and Human Factors Group’ national governmental study of the effects of noise on hearing, with supportive research by the Unit’s three scientific offi-

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Chris Rice left the Unit in 1964 to join the newly-formed ISVR, and a little earlier I had been re-appointed to the Royal Naval Medical School (now the Institute of Naval Medicine) at Alverstoke near Gosport, Hants to continue work on gunfire noise-induced hearing loss. Gradually that became more collaborative with Chris Rice and others at ISVR. In

‘negotiated with the Department of Health to introduce audiological scientists into the forthcoming Hospital Scientific Service’ exchange, I became increasingly involved with ISVR’s studies on industrial noise and on hearing and its various disorders, including clinical diagnostics. That in turn led to the formation in 1965 of the Audiology and Human Factors Group, jointly chaired by myself and Chris Rice. My own personal interest changed, from studies of impulse noise towards diagnos-

tic audiology including use of the newlydeveloping techniques of tympanometry and acoustic reflex testing together with cortical and brainstem evoked response audiometry. We succeeded in obtaining a large programme grant from the Medical Research Council, covering the period 1968 to 1973, later renewed for 1973 to 1978, and in 1970 I took voluntary retirement from the Royal Navy, to join ISVR full-time. In addition we obtained research grants from the Science Research Council, Wates Foundation and Department of Health, together with a clinical services contract with the Wessex Regional Hospital Board. Thus was built a strong team, including Ian Acton, Martyn Hyde, Mark Lutman, Andreas Markides, Alan Martin, Barry McCormick, Vilija Priede, Susan Snashall, Dai Stephens, Roger Thornton and John Walker. We then negotiated with the Department of Health to introduce audiological scientists into the forthcoming Hospital Scientific Service. Given the green light, we set up ISVR’s annual MSc course in audiology, which began in 1972. In 1978 I left ISVR to take up the post of deputy director of the newly-formed MRC Institute of Hearing Research at Nottingham, handing over my ISVR commitments to my successor, Alan Martin.

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47 Early audiological research in the ISVR was in the upstairs front bedroom at 60 University road. Ross Coles and Vilija Priede were downstairs in the clinic, Chris Rice was in the back bedroom with an impressive array of equipment and Sue Banham, our secretary, occupied the other front bedroom. Prof Roger Thornton

My early research experiences were due, as was my degree in electronics, to Eric Zepler. Eric had interviewed me for my first degree and had then resigned, written his book on the end-game in chess, got bored and returned as a Research Fellow in the new ISVR. Naturally he looked to his old department for PhD students and, in 1965, he became my Ph.D. supervisor. Initially we did work on the sonic boom as there was still the debate about whether overland supersonic flight would be permitted. I

This meant that I studied the physiological reactions to impulsive, short-duration sounds and this involved both animal (Periplaneta Americana – the very large American cockroach, which has external hair cells that provide a very good hearing system) and human recordings. I remember Sue Banham panicking after she came into my room when one of the cockroaches had escaped. I heard the door slam and saw the papers, which she had brought me, still in midair continuing their descent! Later David Parker and I worked on developing a technique to measure the travelling wave velocity along the basilar

‘one of the cockroaches had escaped’ membrane ( the real centre of the hearing system). In turn this led to an objective test for Ménière’s disease and a way of evaluating the effectiveness of drug treatments. In 1972, on the new M.Sc. course, set up by Ross Coles, I lectured on Anatomy, Psychoacoustics, Electroacoustics, Computation, Electrophysiological Audiometry and Statistics. There is nothing like having to teach a subject that makes you really understand it! Later, I began work with neurologists on an experimental spinal cord stimulation system as a treatment for Multiple Sclerosis but in 1978, like Ross Coles, I moved to the new Institute of Hearing Research (IHR) and became the Director of the Southampton Section of the IHR.

ISVR Audiology: research, teaching and clinical

Dr Alan Martin in his ISVR days

I joined the Audiology Group in the ISVR as a Post Doctoral Research Fellow in 1971, working with Dr Ross Coles. I became a Lecturer in Audiology in 1978 and a Senior Lecturer in 1985. I retired in 1999 to realise my dream of sailing off to the Mediterranean with my wife Janie.

One of the primary philosophies of the ISVR at the time, and the basis of its success, was to concentrate on the tripod of “research, teaching and service to the community”. In the case of audiology, research involved disorders of hearing and balance and their rehabilitation; teaching was the MSc course in audiology, along with a number of annual short courses and the supervision of research students, although Professor Mark Lutman extended this to an undergraduate course in later years; and service to the community was primarily the Audiology Clinic which was funded by and provided diagnostic and rehabilitation services to the Wessex Regional Health Authority. This was later extended by Denise

Cafarelli-Dees to become the very successful South of England Cochlear Implant Centre, now the University of Southampton Auditory Implant Service, directed by Julie Brinton. Research Research in the early years involved studies in Industrial Audiology and the development of the Hearing Conservation Unit, which was concerned with the prevention of occupational noise-induced hearing loss. A separate project investigating the effect of gunfire noise on earmuff attenuation involved the somewhat grizzly process of instrumenting the ears of cadavers in the

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48 mortuary of Southampton General Hospital. Apart from the technical difficulties with condenser microphones, as everything was so cold, we had to check that the Chapel of Rest, which was right next door to the mortuary, did not have any mourners in it when we fired the starting pistol! This work was awarded the annual award of merit of the American Occupational Medicine

Association in 1980.

formed MRC Institute of Hearing Research.

Teaching The MSc course in audiology was set up in 1972 by Dr Ross Coles to educate and train Audiological Scientists to work in the NHS. The course gradually expanded and I took over as course organiser in 1978 when Ross became Deputy Director of the newly

One of the pleasures of running the course was the dinner party Janie and I held every year for them at home. This became a traditional and enjoyable event. Many graduates come back to support and celebrate their time at the ISVR at various functions.

Audiology into the 21st century

Prof Mark Lutman

I returned to the ISVR at the end of 1995 to join the Hearing and Balance Centre as Professor of Audiology, after 16 years working as a Scientist at the Medical Research Council’s Institute of Hearing Research.The Hearing and Balance Centre at that time was funded mainly by a recurrent grant from the Regional Health Authority, which essentially paid the salaries of most of the staff, under the leadership of Kevin Munro.Teaching activities were predominantly associated with the MSc in Audiology led by Alan Martin, which typically had 5-10 students per cohort. There was also the growing cochlear implant programme led by Mr Norman Haake FRCS. Unbeknown to anyone at the time, all of this was to change radically. First, changes in government policy meant that it was no longer appropriate for the Regional Health Authority to fund clinical activity directly or to support teaching and research in the same way, so the main grant that funded most of the staff was withdrawn in stages. This posed a huge challenge to substitute alternative funding

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and maintain a viable unit. In the event, the Hearing and Balance Centre grew substantially, rather than contracting, as a consequence of three developments.

to be a large Enterprise Unit in the University occupying separate premises under the joint leadership of Julie Brinton and Julie Eyles, still with strong links to the ISVR.

The most notable change was in teaching where the sizes of MSc cohorts were increased, reaching a peak of about 30; then a new 4-year BSc in Audiology was developed in response to government initiative, led by Gary Farrell, with the first cohort of 31 students commencing in 2003. This changed the atmosphere not just in the Hearing and Balance Centre but in ISVR generally, as the number of undergraduates more than doubled and the proportion of female students increased greatly. The BSc established itself as an excellent programme, but alas governments change their minds and the BSc has had to change to a 3-year programme that conforms to a more generic template for Healthcare Scientists. The last cohort of the 4-year programme will complete their studies in 2014. Government decisions have also threatened the MSc in Audiology for similar a reason: the desire for more generically trained healthcare scientists. Postgraduate trainees funded by the NHS will no longer undertake the MSc in Audiology and ISVR will have to place greater dependence on international students for it to be sustainable.

The third major change was to have a much stronger focus on research, with increasing numbers of PhD students and research grant income. In more recent years this has been led by Stefan Bleeck. Reflecting back over the past 18 years, the Hearing and Balance Centre has changed almost out of recognition. From a small group of audiologists and related professionals who carried out clinical work, taught small numbers of postgraduate students and undertook small-scale research projects, it has evolved into two entities: a large auditory implant centre that implants more than 100 devices per year for NHS patients and a flourishing academic unit providing a mix of teaching at undergraduate and postgraduate levels, with attendant grant-funded research.

Secondly, the cochlear implant programme expanded rapidly as cochlear implants for severely and profoundly deaf adults and children became a more mainstream clinical provision within the NHS, with two new surgeons joining the team in 1997: Peter Ashcroft and Mike Pringle. It has now grown

What is the legacy of audiology at ISVR over the past 50 years? There has certainly been ground breaking research that has influenced understanding of hearing and hearing impairment around the world.The Auditory Implant Service has radically improved the lives of many patients and particularly it has given opportunity for numerous children to reach their potential that would not have occurred otherwise. However, the most profound legacy probably stems from the training of audiologists that have become leaders in their profession all around the world, with knock-on effects for their own trainees and patients.

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lunch and learn


Feast upon the BSA Lunch and Learn eSeminars

In collaboration with

What’s it about?

How do you get it?

The BSA Lunch and Learn eSeminars are an exciting series of on-line presentations, first released in October 2012.They are an easily accessible and effective way to enable continuing professional development in a period where ever-increasing time constraints are placed on clinicians.They aim to cover current topics of interest and clinically relevant research findings in Audiology and related professions, and are free of charge to all BSA members and non-members.

The seminars are provided on-line in collaboration with Phonak iLearn. Each seminar goes live on the first Monday of every month and can be accessed by the emailed link, via the BAA or Audiology Northwest England Facebook pages, or archived at and You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

The seminars include a pre-recorded introduction and 20 minute presentation, designed to be viewed in a lunch time but which could practically be watched anytime. Feedback has shown that several departments have been watching them projected on a large screen as a group stimulating some interesting discussions. Listeners then have email access to the speaker for comments or questions for two weeks following the release of the presentation.

If you are not a BSA member and would like regular email updates, please email us to add your name to the mailing list.

‘easily accessible and effective way to enable continuing professional development’

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Live presentations


Speakers from across the UK have recorded seminars including Bob Carlyon from MRC-Cognition and Brain Sciences Unit in Cambridge and David Furness from Keele University. There have also been a few international contributions, such as Kris English from the University of Akron and Karen Gordon from the University of Toronto. Seminar topics have been diverse and exciting. They have included both paediatric and adult audiology; and ranged from cell transplantation therapy to hearing aids, tinnitus to evoked responses, and counselling techniques to cortex reorganisation.

The seminars so far have been a great success, with an average of 350 listeners every month and with a peak of 700! This is highly impressive for a UK only virtual seminar and illustrates the worth of time-effective CPD. We are always looking for new speakers so if you would like to contribute then please do not hesitate to contact us. Recording is very straightforward, can be completed remotely and takes less than half an hour of your time. Listeners really do appreciate your time and contribution; this is clear from the number who tune in every month.

These are just a few of the topics we have covered and links for these are well as all the other recorded seminars are available on the BSA and Phonak websites. Future links will be added as they are released so please keep checking for new presentations. ‘5 August 2013 Hearing disability and vision impairment in UK adults: prevalence, co-occurrence and correlates’ Dr Piers Dawes, The University of Manchester

7 September 2013 ‘A pilot study of hearing aids and combination devices in the management of tinnitus’ Danny Kearney, Manchester Royal Infirmary

If you would like to contribute a seminar, have any queries or would like regular email updates, please email:

CD lunch and learn

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak



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Patient conversations: What We Say Matters This short communication is based on the on-line BSA Lunch and Learn seminar by Kris English, PhD, 13th May 2013. The recording is available at

Much of audiologic counselling focuses on listening, and indeed it is the first step. For instance, suppose we hear a patient say, “I’d be embarrassed to be seen at work with hearing aids” or “Everyone says hearing aids are a big hassle”. If we are careful listeners, we may hear an expression of fear. Depending on the patient, it might be fear of the unknown, failure, stigma, unfamiliar technology, or even fear of losing face (“I’ve been denying a hearing problem for years, I can hardly admit it now”). When we do hear fear or other emotion-based concerns, we have a choice: to ignore it like the proverbial elephant in the room (Figure 1), try to persuade the patient to feel otherwise, or address the concern openly. Does our decision matter? A good question! Surely our approach to patient communication requires as much scrutiny as our testing techniques and treatment outcomes. In fact, for more than 40 years, the study of communication in medical settings and its outcomes has flourished. For example, Adams and colleagues (2012) recently asked, what happens when a physician avoids or addresses emotion expressed by their patients? To find out, they audio-recorded 79 physician-patient encounters, and identified 190 instances of patient emotional expression. They coded physicians’ responses as (1) a response that focused away from emotion (directing attention to information or fixing a problem, or changing the topic altogether), (2) neutral responses, or (3) responses that focused toward emotion. They also documented the consequences of those responses. It should surprise no one that when physicians focused comments away from emotion, patient outcomes were not productive. Subsequent conversations reflected distance and even antagonism between patient and provider. What are the chances that the patient will adhere to any recommendations? According to Thom et al. (2004) and Zolnierek and DiMatteo (2009), the chances are pretty slim. Patient adherence rates to medical recommendations are directly related to trust levels, and in these situations, physicians did not prove themselves trustworthy (“I told you something personal but got no reaction. Why should I listen to you when you didn’t listen to me?”). However, neutral comments and comments focused toward emotion allowed for additional opportunity to

Figure 1. Patients may never use the word “fear,” but we need to realize that it is “in the room” with us like the proverbial elephant, and presents itself as resistance, as a “no” to our recommendations.

communicate further, which then developed into a positive relationship with the provider. Either directly or indirectly, patients will reveal their doubts and fears. If we focus away from those emotions, patients will withdraw from us and perhaps even feel betrayed. The relationship developing from this point will be unproductive. If we focus toward the emotion, or at the minimum give the patient additional opportunity to clarify and expand, our patients are more likely to believe that we, and our recommendations, can be trusted (Clark & English, 2014). The final decision to adhere is up to the patient; however, the audiologist’s influence on those decisions can be positive, is measurable, and is learnable. References Adams K. et al. (2012). Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotions in hospital admission encounters. Patient Education and Counselling, 89, 44-50. Clark JG, & English, K. (2014). Counseling-infused audiologic care. Boston: Allyn & Bacon. Thom D. et al. (2004). Measuring patients’ trust in physicians when assessing quality of care. Health Affairs, 23(4), 24-132. Zolnierek K.B., & DiMatteo M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47, 826–834.

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ear to the ground


Ear to the ground for all things ear-related in the media The internet means we all have a wealth of information from around the world competing for our attention 24 hours a day. With a swipe of a finger or the click of a mouse the world wide web is available at work, home and even on the move. There are already hundreds of dedicated health websites online and social media means we are constantly asked to 'like', 'subscribe', 'add' or 'click' on something new. It can feel as if you are being drowned in a sea of news, data, criticism, advice and piano playing cats. But there's no need to worry because help is at hand. Here we examine useful websites to follow to pick up the latest ear related news, features and viral trends.

Website: Average Estimated Web Hits: 2.5 Million Unique Monthly Visitors

Science Daily is an American news website for topical science articles. It features articles on a wide variety of science topics. Articles are selected from news releases submitted by universities and other research institutions. Users can subscribe to a free daily newsletter distributed by email, which contains links to all articles for the day and a short introduction to each article, as well as following it on Social Media Sites. ScienceDaily: May 2013 Blind People Have the Potential to Use Their 'Inner Bat' to Locate Objects This research started to ask the question can blind people use echoes from an object to work out its location. The researches wanted to find out what factors help or restrict the ability to use echoes to look at real world solutions and aids for blind and those with difficulties seeing in certain environments. The results showed that both sighted and blind people with good hearing showed the potential to use echoes to locate objects. Key to good performance was hearing above 2000Hz. The next step will be for researchers to develop training programmes and assistive devices to use these new findings. Rowan et al Identification of the lateral position of a virtual object based on echoes by humans. Hearing Research, 2013; 300: 56

Website: Average Estimated Web Hits: 1 Million Monthly Visitors

The Conversation is an independent source of news and views, sourced from the academic and research community and delivered direct to the public. Professional editors work with university and research institute experts to unlock their knowledge for use by the wider public theconversation: Oct 2012 Tone deaf people struggle to hear emotional subtext Tone deaf? Then you might also struggle to hear emotional messages such as sadness or annoyance in speech. So says a study reported on ‘’. The study found that tone deaf participants were significantly worse at detecting the emotional subtext in the spoken phrases. In a separate questionnaire, the tone deaf subjects said that they struggled with this problem in their daily lives, reporting that facial cues, body language and the pace of speech were more useful in determining hidden meaning in speech. The findings suggest music and language, usually thought to be controlled by two different parts of the brain, may in fact be more closely related. This has caused excitement in other researchers and the finds are compatible with the theory proposed by Charles Darwin that in human evolution song must have existed before language.

ear to the ground

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AutoFit could save an Audiology Department up to ÂŁ1,000 per month*

Delivering audiology solutions in a changing market.

Offering reliability, efficiency, quality and patient satisfaction - Siemens can be your partner of choice. IMPACT Pro has a less than 1% warranty failure rate, a robust housing design matched with ease of use and AutoFit which provides a high quality and highly efficient fitting with REM, saving up to 15 minutes per binaural fit* . The result. Patient satisfaction.

Find out more by visiting or contact your Account Manager for a demonstration quoting reference JN6586. * Reference - Can AutoFit REMs improve workflow? Sarah Hinchcliffe, Ipswich NHS Trust (2012)

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54 Website: Average Estimated Web Hits: 4,500 Unique Monthly Visitors

New Scientist website covers recent developments in science and technology for a general audience. The magazine covers current developments, news, and commentary from the scientific community. It also prints speculative articles, ranging from the technical to the philosophical. There is a readers' letters section which discusses recent articles, and discussion on the website. (Available to buy as a monthly subscription online/tablet and hard-copy)

Website: Babies can hear syllables in the womb, says research

In February the BBC reported on research that is reported to show that babies can decipher features of speech 3 months before birth.The evidence comes from detailed brain scans of 12 infants born prematurely. At just 28 weeks' gestation, the babies appeared to discriminate between different syllables like "ga" and "ba" as well as male and female voices.The researches claim that the findings also apply to babies in the womb at that gestation and that their experiences in the ‘outside world’ would not affect the results. . We already know that babies are able to hear noises in the womb - the ear and the auditory part of the brain that allow this are formed by around 23 weeks' gestation. This latest research perhaps supports the idea that babies develop language skills while still in the womb in response to their parents' voices. But it is still debated whether humans are born with an innate ability to process speech or whether this is something acquired through learning after birth. The authors of the study say environmental factors are undoubtedly important, but based on their findings they believe linguistic processes are innate.

we already know that babies are able to hear noises in the womb

next edition a focus on charity websites..

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Twitterarty Often Twitter is considered to be a way to keep up to date with breaking news, follow your favourite celebs and be in touch with friends. But it can also be used to follow experts, institutions and organisations within Audiology, acoustics, science, health and academia. In each issue of Audacity Twitterarty will look at different themes and groups of tweeters showing how Twitter can be used to keep up to date in professional affairs, learn about new research and policies and enter debate. In this first issue we start with a guide to Twitter and focus on academics who tweet. Happy Tweeting!

A Guide to Twitter By @HallAmandJ

Figure caption: This tweet was posted on Twitter by NHS Choices in 2011 following the publication of the study by Lin and colleagues examining the association between hearing loss and dementia. Not only did this notify all @NHSChoices followers about the recent publication of this study but it provided a link to an expert critical appraisal of the research as well as the reference to the journal article. Not bad in only 140 characters.

So what is Twitter? Twitter is an electronic newsfeed, a form of social media, in which people post short messages to the world. Anybody can access these messages, but people who subscribe or follow these sources receive their tweets automatically in a Twitter feed, example shown below. By selecting a number of sources to follow it is as if you have your own personally designed magazine in which you choose the topics and who authors them. Each individual newsfeed or tweet has to be 140 characters or less, which mainly ensures all posts are succinct and to the point.

As well as receiving tweets from others, you can post your own news to your followers.This can be a way of disseminating your own views, news and information, or that of your service or business, to others. You can engage in conversation with other tweeters by responding to tweets they’ve posted but remember that these could potentially be viewed by everyone. Why is it useful? Twitter is a powerful way of keeping up to date with current news and information about topics and people you’re interested in. It’s also a way of having conversations and engaging in discussion with a wide range of people who you might not normally come into contact with. It can be used socially but professionally it’s a useful way of discovering newly published research and topical articles often with links or references to find out more. How to start using Twitter? First create a user name and profile at or using a Twitter app. All twitter names start with @ but the rest is up to you. Some people use a pseudonym but if you’re planning to tweet for work you might prefer to use your real name so people know who you are. Once you have an account you’re ready to start following other Tweeters and to start tweeting. When you start, it may feel a bit like shouting into an empty room as only your followers will automatically see what you’re tweeting. Saying

ear to the ground

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56 that, a word of caution - remember that Twitter is a public forum and your tweets could potentially be seen by the whole world. Don’t tweet anything on Twitter that you wouldn’t be happy to stand on top of the roof top and shout out to the world.

@NHSChoices Official site of the NHS @bmj_latest BMJ Medical Journal @TheKingsFund The Kings Fund, an independent charity working to improve health and health care in England

As well as text you can also include links to other websites or documents in your tweets. There are websites that you can use to shorten weblinks so they fit into one tweet e.g.

However the most interesting tweets and conversations are often from individuals who post opinion rather than the official view of an organisation.

Academics who tweet Hashtags Tweeters often embed key words preceded with a hash #, known as hashtags, as a way of relating a tweet to a particular topic. For example many audiologist tweeters use the hashtag #AudPeeps or #Audiology to label their tweet as an Audiology related tweet or of interest to Audiologists. Hashtags are not predefined or compulsory but they are a useful way of categorising tweets and for searching on a particular topic. Using hash tags will ensure that your tweets get a wider audience than just your followers.

@muirgray Sir Muir Gray, Director of Better Value Healthcare; previous director of UK National Screening Committee. Tweets about public health and health care systems. Worth following to keep up to date on his views on reconfiguring and improving delivery of a range of health services.

Hashtags can be used at scientific conferences to provide ongoing commentary on presentations in real time for those unable to attend. Tweets from the recent Cognitive Hearing Science Conference in Sweden were posted using the hashtag #chscom2013.

@deevybee Dorothy Bishop, Professor of Developmental Neuropsychology, Oxford University. Tweets about language research, autism, genetics and research methods amongst other things. Often tweets about topics of relevance to paediatric audiology.

@david_colquhoun Professor of Pharmacology and Science Blogger. Tweets and blogs regularly on science with a particular emphasis on “investigating dubious and dishonest science”

Also look out for @bengoldacre Ben Goldacre, author of Bad Science and Bad Pharma. Tweets regularly about topics such as evidence based medicine, clinical trials and the pharmaceutical industry. Includes updates on the campaign for pharmaceutical companies to release all their clinical trials data into the public domain. Who to follow? The list of people to follow is endless. There are many audiologist tweeters out there as well as health organisations, hearing aid companies, charities, academics and researchers. You can use the search facility to find people who might be on twitter; and of course the British Society of Audiology has a twitter feed (@BSAudiology1). A good tip is to find someone who you’re interested in or who has similar interests to you and have a look at who they’re following. Most official organisations and journals have a twitter feed such as:

ear to the ground

@cebmblog Carl Henegan, Director for the Centre of Evidence Based Medicine, Oxford. Tweets about evidence based medicine and health research, often with links to articles of interest around healthcare treatments and interventions. @trishgreenhalgh Trisha Greenhalgh, Professor of Primary Health Care and author of the “How to read a paper” series. Tweets about topics including sociology of health and applied health research.


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Audiology in Western Australia (WA)

FACTFILE... Population: 2.4 million Total area: 2.6 million km2 Capital: Perth Population aged 65+: 285,200 Population with hearing impairment (estimated): 518,400 Prevalence of hearing impairment in adults aged 70+: 74%

Author Angela Mack, Implant and Balance Centre Manager, Ear Science Institute Australia, Subiaco, WA

Angela has almost 30 years experience in Audiology and was awarded an MSc by Manchester University in 1999. She gained experience in several departments throughout the North-West before becoming Head of Service at Royal Bolton Hospital in 1995. During her career Angela has been actively involved in the education, training and assessment of Audiologists and Assistant Practitioners. She went on secondments to NHS Improvement and MRC and worked closely with departments across England to improve services. In November 2011 she took the brave decision to move to Perth, Western Australia (WA). For 12 months she worked at Australian Hearing as a Senior Audiologist, and then moved to the Ear Science Institute Australia (ESIA) as the Implant and Balance Centre Manager.

Drive to work

Audiology services in Australia Audiology services are generally split into diagnostic and rehabilitation services. Audiologists tend to choose their path very early in their career. Hearing aid services A voucher system operates for the provision of hearing aids to pensioners, disabled people, children and young adults (up to 26 years). These clients can apply to the Office of Hearing Services (OHS) for a voucher, which they can take to a registered provider in exchange for hearing assessment, hearing aids and rehabilitation services.The voucher is valid for a three year period before clients have to apply for another one. Clients can choose their provider, but they need to inform OHS if they wish their voucher to be transferred to an alternative provider. Patients are given an aid of similar quality to those provided by the NHS, but they can choose to pay extra for a more sophisticated device (top-up), which can vary from a few hundred to several thousand dollars in cost. At one time Australian Hearing provided all the government services, but now vouchers can be taken to any

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58 don’t think the UK residents realise how lucky they are. Hearing and support services are provided by many different organisations in a competitive market and can be fragmented and difficult to access. Neonatal Screening I have had limited involvement in neonatal screening which varies across Australia. It’s such a big country, even larger than Europe. In Western Australia, screening is offered to all babies but as some private hospitals charge a fee, not all parents take up the opportunity. Moves are being made to make screening free to all in the hope of achieving 100% coverage.

Chilling with the locals

registered Audiologist. Australian Hearing only see voucher clients and have no purely private hearing aid clients. I was shocked at the sheer amount of paperwork and evidence required to claim for work completed in the voucher system. Australian Hearing also see all the community service obligation (CSO) clients which are generally the more complex cases. Children, the frail and elderly, people with learning disabilities, people with dual sensory impairment and the profoundly deaf fall into this category and are provided with higher level products free of charge, although they still have the option to top-up. The system is very complex and it took me a while to understand, however I now believe it is based on the same basic common sense principles as the NHS. The paperwork includes rules that need to be followed to protect clients and the OHS from poor or immoral practices. For example, there is a minimal hearing loss requirement if aids are to be funded, but exceptions can be made if troublesome tinnitus is present. I often felt that I spent more time proving I had done something than actually doing it. Fortunately, my caseload was mainly complex and I was not under pressure to sell top-up devices. It is worth noting that clients not eligible for vouchers would attend private clinics and be required to pay high prices for hearing services, with very little being covered by health insurance. I have met so many people that are managing without aids, because they are not able to find the money to purchase one. Another shock for me was the empty stock cupboards - aids, receivers, etc. are ordered for the individual client and departments carry no reserve stock. When a product fails and cannot be repaired by the technician it is sent back to the manufacturer. Being in Perth, the most isolated city in the world, everything has to go “over east” and will take the mandatory 10 days. If the clients really can’t manage without their aid a loan device is set up for them, but they are generally old and of inferior technology. The Australians just accept this, without complaint. I

ear globe: audiology around the world

Working in remote locations and with indigenous communities Whilst with Australian hearing I sometimes worked in remote and idyllic locations. Southern parts of WA have some lush coastal countryside and an abundance of vineyards. What more could you want? I must admit doing an afternoon clinic after a 6 hour drive or 4am flight was hard work, but we did get to stay at each location for the week. Driving home through the woods at dusk was fraught with danger; mobs of kangaroos have no road sense. I had the amazing opportunity to work with the indigenous communities. Australian Hearing provide hearing and screening services to the Aboriginal people, often living in very isolated and harsh conditions. This usually involved a two hour flight followed by a 3-4 hour drive through red dust, dirt tracks through the red sandy landscape. We had to have 4x4 training and carry water, first aid kit, a radio and two spare tyres. These communities have a high incidence of poor general health and ear disease and much is being done to try to address this. As health care workers we were made welcome and got an opportunity to see and understand aboriginal culture first hand. I must admit, I was afraid of the almost wild dogs and the accommodation was not five star, but I found this so rewarding and “what an adventure”. Meeting some more of the locals

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59 awesome supervisor and embraced this opportunity to expand my knowledge and learn new things. Ear Science Institute Australia (ESIA) I am now working at ESIA, which is a not for profit organisation, employing a bright and motivated group of individuals from around the world. I am managing the implant and balance services and to be honest it’s not so different to my role in the UK. The organisation is committed to research and training and has a high profile school hearing conservation programme, named “cheers for ears”. It is so good to work in an organisation with staff employed purely to do Audiological research rather than trying to “fit it in between patients”. We have an annual formal educational dinner Drive home from work for GP’s and lots of other training events. The fundraising side of things is new for me, but so much fun. We host a charity ball each year, and this year we raised the equivalent of over £500,000, the Getting recognition as a qualified Audiologist to work in generosity of the donors is just unbelievable. Australia The amount of work to achieve this should not be Final thoughts underestimated. The Australian standards are very similar to Australians are so friendly, they work hard and long hours too American ones, so there was lots to learn. My employer, (many unpaid), but when you clock off you feel like you’re on Australian Hearing, suggested that I first register with the holiday. I earn more money, but boy is it an expensive place to Australian College of Audiology (ACAud) as this would allow me live. I will never tire of the sun setting over the Indian Ocean or to practice as an Audiometrist, doing audiometry and basic the drive to work along the coast road. I am getting used to the hearing aid work. I was able to enrol on the course from the UK over use of acronyms and extended vowels; I needed to change and was awarded the certificate based on accredited prior my Manchester “u” to an “ar” to be understood. Clients can spend learning alone. I was also required to keep a log book/diary for a fortune and travel for days to attend appointments with 12 months. specialists. I have found the general standard of audiology care to be very high and I have met some amazing audiologists. I clearly needed to be a full member of the Audiological Society of Australia (ASA) if I wanted to practice as an Audiologist. Did I make the right choice? I miss the Bolton staff, but I made Audiologists in Australia have a Masters Degree and are then the right decision, for sure. required to complete a 50 week internship programme. It took several months to pull together, requiring lots of assistance from Manchester University, sufficient evidence regarding my qualifications to be permitted to sit the aptitude test, and a three hour examination of equivalent level to the Australian Masters Websites Degree. The examination should not be taken lightly. I sat it in Office of Hearing Services April 2012 when only two of the 16 candidates passed; I had Australian College of Audiology worked hard and was thankful to be one of them. I only had the Audiological Society of Australia BAAT part II practical assessment and had not done the Australian Hearing Certificate in Clinical Competence (CCC), so I had to complete Ear Science Institute Australia the ASA internship programme. I was lucky enough to have an


Angela Mack, MSc Aud, M.Aud.SA. (CCP) Implant and Balance Centre Manger, Ear Science Institute Australia, Subiaco, WA E:

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Charity and humanitarian work EarAid Nepal 2013,Chainpur Female patient doing pure-tone audiometry

‘Swa swa sunena.’ At least one of us could have been heard intoning this oft-repeated Nepalese audiometric phrase in the bazaar when lost for words or maybe even in our sleep. Understandable considering that in seven days of ear camp 595 patients were seen (118 ear surgeries, 254 audiological assessments, 75 hearing aid fittings, and 460 dental appointments). If not for New Year holiday and the sad occasion of a local funeral following a festivity related fatal accident, there would have been even more. International Nepal Fellowship ( with Ear Aid Nepal ( organise these camps twice yearly under the leadership of Mike Smith, Hereford ENT consultant. Sustainability for this type of patient service including followup is the focus of the soon-to-be built ear training hospital in Pokhara.The camps are staffed not only by the visiting UK team like ourselves, comprised of ENT surgeons, anaesthetists, audiologists, scrub nurses and dentists; but also by a delightful Nepali team of managers, nurses, orderlies, drivers, engineers, and interpreters working for INF. Armed with donated earmoulds, hearing aids and hearing aid fitting kit from our baggage as well as EarAid Nepal’s audiometric and insta-mold kit; we traveled to rural western Nepal. Camps are located in the west because there are even

ear reach

‘so pleased to see him smile and turn to her voice’ fewer resources than in the east of this country where the annual per capita income is about £130. Notably, an estimated 2/3 of world-wide hearing loss is found in developing countries where at least half of it is preventable. From the western airport of Nepalgunj we drove 13 hours (18 counting the wait for 4 punctured tyres) in Land Rovers, from sea level, in the Terai region, eventually reaching an altitude of 2500 meters and back down again to a mountain valley village. Imagine if you can, Alpine hair pin curves combined with Manila-style driving, stalled by occasional goat herders and police check points. Enjoying a steady diet of daal bhat, samosa and roti throughout our week and a daily commute by foot through the village bazaar and across a high suspension foot bridge, we set up clinic in the dusty bare cement rooms of Chainpur, Bajhang District Hospital in a mountain valley of the western Himalaya.

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61 children being unaccustomed to representational play. Surgical intervention offered at the camp excellently addressed the needs of the prevalent outer and middle ear disease diagnosed in the majority of patients secondary to poverty, poor hygiene and diet. (We rarely encountered the classic NIHL, presbycusis and tinnitus to which we've become so accustomed in the UK.) However, it of course couldn’t help the dozen or so children and young people we saw with permanent sensorineural deafness. With the help of the visiting social worker, we tried to help make connections to the few service resources available, though none were local. When it came to hearing aid fittings, the lack of accessible ear mould manufacture meant custom earmoulds were limited to Insta-fit materials, and therefore donated earmoulds were carefully fit and adapted if needed to suit our purposes before a suitable donated hearing aid could be verified in a coupler. Being resourceful clinicians working with resourceful patients we were able to overcome many of these obstacles in the very short time we had.

‘new bone conduction hearing aid enabled her to understand them talking normally for the first time in many years’

Sayar*, with his new hearing aid'

The challenges of working there alongside the highlights of successes were analogous to our clinic window. From it we could view breath-taking snow-capped peaks , but also dealt with fly swarms, generator noise, or smoke from burning surgical rubbish. Challenges Testing in ambient noise that was almost never less than 55 dB was only one of several challenges. Our gestures and learned Nepali instructional phrases were useful, but didn’t go far toward establishing an initial notion of communicative ability that is so important to our rehabilitation-oriented profession. Even with interpreters we were hard-pressed to get across sufficiently the notion of threshold search for quietest levels, masking, or expectations/satisfaction with hearing aid fit. Using manipulatable tools such as Ida Institute’s ‘My World’ paediatric counseling tool, sometimes helped to get at the bigger picture of communicative difficulties, but here too we were limited by

Highlights Apparently profuse thank yous are not prevalent in Nepali culture, but undoubtedly we each saw the essence of gratitude in the smiles and ‘Namaste’ greetings when hearing aids were fitted or in the queue of 118 post-op patients on the last day. One family who had traveled 16 hours on the night bus, were surprised and all a chatter when they realised their Auntie Manahra’s* new bone conduction hearing aid enabled her to understand them talking normally for the first time in many years. A middle-aged mystery man (shaman) Sayar*, though of very sober demeanour, chose a smiley face icon to express his pleasure at receiving his hearing aid. The mother of 10 year old Charda* with cerebral palsy and severe sensorineural hearing loss was so pleased to see him smile and turn to her voice with his new hearing aid, and was encouraged to know that her careful work with him has been useful. Even our hotel host Parem* had two family members with bandaged ears at the end of the week and a grateful ‘Namaste’ salutation on our departure.

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Two little girls, recovering post-operatively

Being able to eventually catch up with the sheer volume of patients, and to contribute to better organisation of kit for smoother future running of camps were gratifying accomplishments. Finding a stock earmould that fit was always a pleasing outcome, especially if the recipient was happy with the odd glitter or novelty motif! All of us agreed that another highlight was the simple pleasure of being able to wash hands with soap and running water in the one clean washroom of the hospital which was in the surgical scrub room loo. Our last half day included a team trek upriver across a 200 meter long suspension foot bridge at a giddy height and a refreshing dip in the melted Himalayan snows of the river. Along the way we encountered many helpful and kind, colourfully dressed Nepalis leading their bell-adorned donkeys along steep goat tracks; and in each small village or homestead we noticed bandaged ears and hearing aids from the previous week’s work. After leaving camp, some team members had the opportunity to experience other parts of Asia such as trekking round the Annapurna circuit or spending several days in the 40 degree heat of Delhi.


Next Steps Ear camp will return to Nepal in November on its usual rotation. And next year they will set up in a village two hours further north along the road as it is built up the valley. All the team members seemed keen to return in future if commitments allow. Certainly we will stay involved with development projects from the UK end, contributing to sustainability, gathering information and equipment resources. On the top of our list presently is to add to the current kit with a hand held warbler, OAE kit, small earmoulds, and batteries. Most importantly we have taken back with us not only the profound sense of having been able to give something back, but our own personal reflections on renewal, adaptability, sustainability, respect toward the people we served and gratitude toward the many individuals who supported and encouraged us in making the journey.

We are always looking for new and exciting articles, for the ear reach section, if you are interested in submitting please contact: Jenny Griffin – E:

Joy Rosenberg (Clinical scientist, Mary Hare Training services; recipient of BSA’s TSL travel bursary) Jenny Griffin (Audiologist, Manchester Royal Infirmary) David Blakeman (Trainee clinical scientist, Brighton and Sussex University Hospitals)

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Humanitarian Audiology: how the BSA can help

Elizabeth looking thoughtful

Author Huw Cooper Consultant Clinical Scientist (Audiology)

Here in the UK we have the great fortune of having not only arguably the best health service in the world but also a very well developed, high quality and generally well-resourced Audiology system. However, for much of the rest of the world, particularly in developing countries where overall resources available for healthcare are tiny in comparison, the picture is very different; ear care and Audiology is often very limited by both the funding available for it and the skills and training of the staff on the ground. For example, in Zambia, a country of 13 million people, there is only one audiologist. In Sierra Leone, a country of six million people, there are none. In these countries there may also be huge problems with the prevalence of ear problems, hearing loss and deafness amongst both children and the adult population, with a great deal of unmet need for both ENT treatment and audiological provision. There are a number of organisations that are doing amazing work in various parts of the world and the BSA has a strong commitment to supporting humanitarian Audiology of all kinds;

indeed, many members of the society have given up their time to travel to distant places to help out and contribute, always finding the experience enormously rewarding and important. The table below summarises some of the organisations known to the BSA that are involved; anyone who is interested should have a good read of the websites, which give an insight into the varied and high quality projects that are going on. Some of the countries where this work takes place have suffered from multiple problems that make our life in this country seem exceptionally comfortable and safe. For example, All Ears Cambodia provides a unique medical service in a beautiful country that has been torn by years of warfare and where there is intractable poverty. By running outreach clinics in very difficult circumstances and ear health care education, the charity helps large numbers of Cambodians every ear. British audiologists can help by sending old hearing aids or other equipment that is no longer useful here but will be put to good use over there (see the charity’s website for more details). Similarly, the International Nepal Fellowship is a Christian mission serving Nepali people; as well as helping large numbers of vulnerable people including those with varied disabilities, leprosy, TB and health problems, they support Ear Camps in remote areas of the country, often in very difficult conditions a very long way from what we are used to here in Britain. An article about a recent trip to Nepal by Joy Rosenburg (supported by a BSA bursary) and others is also featured in this edition of Audacity, and gives a fascinating in-depth description of the experience.

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64 Tanzanear is a UK charity dedicated to helping deaf people in Tanzania lead richer and more fulfilling lives. Working closely with the Tanzania Society for the Deaf, they provide enormous help to the Buguruni School for the Deaf and also work with Umivita, a small organisation run by young deaf adults, which provides advocacy and support services to deaf people in Dar es Salaam.

Laura Finegold with the team in Gambia

The Aud-m-ed Trust carries out a wide range of activities around the world, and as the name indicates, their work encompasses audiology, medical audiology and education in Audiology. Although a small charity based in the UK, their achievements are many: a family centred workshop for teachers of deaf children has been set up in Ghana; a technician has been brought from Ghana for training in the UK; journals/books/equipment have been sent to Kenya, Ghana, Malawi, Jordan and Russia; hearing aids have been sent to Kenya and Iraq; a basic audiology unit set up in Nepal; and a survey and rehabilitation project is running in China.

Soundseekers (formerly known as the Commonwealth Society for the Deaf) will be familiar to many British audiologists and have been dedicated for many years to helping deaf and hearing-impaired people across the developing world. Sound Seekers used to be known mainly for providing mobile hearing health-care clinics (HARK! vehicles) but are now trying to work more deeply in fewer countries, including tele-audiology and targeted paediatric screening projects, and providing continuing professional development to in-country audiologists. Soundseekers have recently moved into a new office at the UCL Ear Institute in London, so are in the ’heart of the action’ when it comes to ear and hearing research and Audiology. Below is a call to all audiologists who are looking for an exciting opportunity to work in another part of the world and make a real difference – please read!

The BSA will continue to support the organisations described here, and promoting humanitarian audiology around the world is a key objective in the society’s Action Plan for the future.






Tanzania x.htm

Schools for deaf children; deaf advocacy

All ears Cambodia


Ear healthcare and audiology

Aud-m-ed trust

Ghana, other countries in Africa and around the world

International Nepal Fellowship


Running ear camps


Cameroon, Gambia, Ghana, Kenya, Malawi, Sierra Leone, Tanzania, Zambia

Long-term audiological support - provisions of training and equipment

ear reach

Raising awareness, training, providing equipment, funding research

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65 ‘Calling all would-be humanitarian Audiologists’

Sound Seekers is a small, London-based charity with projects in eight developing countries, all in sub-Saharan Africa. Our work is dedicated to improving quality of life for deaf and hearing-impaired people, in particular by assisting Ministries of Health to establish or develop audiology infrastructure and capacity. In the countries where Sound Seekers works, audiology services are few and far between, and where they do exist they usually lack the necessary equipment and qualified staff. Our works aims to address these gaps through providing training opportunities and audiological equipment. The number of fully qualified Audiologists in poor countries is pitiful. In Zambia, a country of 13 million people, there is only one. In Sierra Leone, a country of six million people, there are none. In several countries that we support, the only fully qualified Audiologists are working in the private sector. Although Sound Seekers supports candidates from developing countries to follow courses in audiology, at the moment we are limited to sponsoring participation in a one-year diploma in Clinical Audiology. Those who complete this course usually return to their home countries and are expected to hit the ground running and establish an audiology service from scratch.

This is where you come in! 1. 2. 3. 4.

Are you looking for a challenge and can you spare at least two weeks*? Do you enjoy coaching and mentoring? Would you like to use your skills in a resource-poor setting, where little is known about what an Audiologist is or does? Are you keen to visit a new country and work with some fabulous people?

… then we would like to hear from you! Sound Seekers is looking for audiology professionals to go to our project countries for a minimum of two weeks, to support staff on the ground that have received basic training in audiology and need help to establish or develop their service. If you are available immediately or in six months, please do email Emily Bell on and include a copy of your CV**. *but the longer the better! **If we can work out a suitable placement for you, Sound Seekers will help you raise funds towards your trip.


Huw Cooper Consultant Clinical Scientist (Audiology) E:

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Hearsay News from Regional Groups and BSA Members Sheila Fidler (Senior Clinical Lecturer, Dept of Human Communication and Deafness, University of Manchester)

Northwest BSA Evening Meeting The evening of Wednesday 24th April saw the second North West Regional Meeting hosted by the University of Manchester. The evening was kindly sponsored by Interacoustics who were represented at the meeting by their Regional Manager Anum Saleemi. Attendees came from across the Northwest and included private hearing aid dispensers, NHS Audiologists, Clinical Scientists, BSc, MSc and PhD students. Professor Kevin Munro introduced the evening, explaining that the purpose of the meeting was to forge better links between clinicians and academic institutions. Prof Munro then asked attendees to identify three research questions they felt were significant in their clinical setting. All questions were then

displayed and attendees were asked to rank them in order of importance.The aim of this exercise was to ensure that research undertaken by the Division of Human Communication and Deafness at the University of Manchester is useful and addresses important clinical needs. Following this Dr Piers Dawes presented a study exploring Auditory Acclimatisation undertaken with his colleagues Dr Michael Maslin and Prof Munro from the School of Psychological Sciences at the University of Manchester. The study tested for acclimatisation effects in new unilateral and bilateral hearing aid users. More than 70 adult hearing aid users from around Manchester were tested longitudinally from the point at which they were first fitted. The new hearing aid users participated in a battery of tests which included perceptual measures, electrophysiological measures and reports of real life benefit. Changes over time were compared to those of a control group of long-term hearing aid users. The expected changes over time were not observed so they decided to ask new hearing aid users to report their experience of 'getting used to' hearing aids in a focus group session. Participants did not mention any improvement in aided listening over time that might be consistent with an acclimatisation effect. However, participants did describe various challenges including managing practical matters such as, learning to clean and maintain the hearing aid, and discovering benefits and limitations of hearing aid use. They concluded that becoming accustomed to hearing aids is a challenging, multi-factorial process with both psychological and practical difficulties alongside the demands of adjusting to the amplification. If a hearing aid user has difficulty with any one of these challenges, they will not adjust to the hearing aid or obtain optimal benefit from it. The task for the audiologist is to help the new hearing aid user overcome these multiple challenges.

Next Meeting The date and time for the next meeting are yet to be confirmed but Prof Munro will be providing an update on the research questions of clinical importance and Tracey Adams, Audiological Support Specialist for Cochlear, will be presenting on patient and public engagement. We look forward to seeing you there. Š David Boardman


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Essay Competition Dear BSA Members, This new Essay Prize (worth £250) has been established by the British Association of Audiovestibular Physicians (BAAP) in honour of the late Professor Dafydd (Dai) Stephens one of our founder members. Dai trained initially in Psychiatry before changing specialities. He was a consultant at the Royal National Throat Nose and Ear Hospital and later Professor at the University of Cardiff.

Professor Dafydd Stephens

It has been decided that the prize should be open to any member of BAAP, IAPA, BSA or ENT-UK: all organisations with which Dai was involved. Candidates will present an essay of between two and three thousand words (excluding references) on a topic decided annually by the BAAP Executive Committee. The topic will reflect some aspect or aspects of Dai’s highly diverse interests.

THE TOPIC CHOSEN FOR THIS YEAR IS: “How is the history of medicine relevant to current audiovestibular rehabilitation?” Entries should be received by the BAAP Honorary Secretary (, copied to before the 31st October. The prize winner will be notified by the end of December. The successful candidate will be expected to give a short (10 minutes plus 5 for questions) account of their work at the BAAP Conference in March 2014.

Best wishes and good luck! Peter West (Hon Secretary, BAAP)


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The value of joining the BSA Ms Charlotte Turtle (BSA New Members Representative) As a Masters degree student I joined the British Society of Audiology after being encouraged to do so by my course tutor. At that time I had little idea of the role of the BSA, but I soon learnt of the rewards, and so chose to continue my membership once I had graduated. I have recently taken up the role of helping to encourage others to do the same so that they can also benefit.

About the BSA The main role of the BSA is to improve the lives of children and adults with hearing and balance problems. It does this through enhancing audiological practice by supporting multidisciplinary research. It is the largest audiology society in Europe, and the membership consists of a wide range people with an interest in this field.

Student membership Being a member of the BSA as a student offers exceedingly good value. For just £10 there are great opportunities to engage with the national and international world of Audiology and hearing research.The website which is currently being redesigned acts as an invaluable resource of recommended procedures and policies which are regularly reviewed and updated.

Full membership When working in the field of Audiology the BSA continues to support my learning, and offers opportunities for professional development and networking.The International Journal of Audiology arrives through the letterbox monthly, together with news of BSA meetings and the annual conference. This ensures everyone involved in audiology can be kept up to date and can continue developing throughout their career.

By becoming a BSA member, aside from supporting the invaluable work of the BSA, you will benefit from: • • • • • • • • • • • •

A monthly edition of the International Journal of Audiology (IJA) Discounted rate for BSA short paper meetings (clinical & experimental) Access to Special Interest Group (SIG) open meetings Lightening updates Lunch and Learn short lunchtime presentations online The annual conference Website including recommended policies and procedures and members area Audacity Interim mailings – career opportunities adverts, meeting info & flyers Free NDCS membership Access to competitions Access to applications for awards and financial support for research


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70 COMET– a call to engage in this new initiative to standardise patient outcome measures

A Conference report by Prof Deborah Hall, Director, NIHR Nottingham Hearing Biomedical Research Unit, Nottingham.


The COMET initiative

How do we know whether a particular clinical intervention is effective for patients? This is an important question for both clinical practice and research, but you may be surprised to find that the answer is far from straightforward. One of the main problems is that there are many different outcome measures to choose from, and so they get used very inconsistently across audiology centres and across research studies. Our recent survey of NHS tinnitus clinics across England is one good example. Only 38% of audiology staff reported using a standard outcome tool within their own department (Hoare et al., 2012). Across departments we also saw a lot of variability. Some ‘tinnitus’ outcome tools asked about hearing ability, others focussed on tinnitus-related emotional distress, while others considered general psychological wellbeing.

COMET stands for ‘Core Outcome Measures in Effectiveness Trials’. The COMET Initiative started in the North West of England and brings together people interested in the development and application of agreed standardised sets of outcomes, known as core outcome sets. These sets represent the minimum that should be measured and reported in all clinical trials of a specific condition, and are also suitable for use in clinical audit or research other than randomised trials. The existence or use of a core outcome set does not imply that outcomes in a particular trial should be restricted to those in the relevant core outcome set. Rather, there is an expectation that the core outcomes will be collected and reported, making it easier for the results of trials to be compared, contrasted and combined as appropriate; while researchers continue to explore other outcomes as well. COMET aims to collate and stimulate relevant resources, both applied and methodological, to facilitate exchange of ideas and information, and to foster methodological research in this area.

The solution to which many other clinical specialities and research methodologists are now turning is to develop an agreed standardised set of outcomes which should be measured and reported whenever one is interested in evaluating the efficacy or effectiveness of a treatment.The process of defining what should be measured is one that clinicians and patients should both be involved in. Indeed, as the NHS embraces the notion of a patient-centred healthcare service, one might argue that patient viewpoint should have a greater weighting over that of the clinician. Whatever the exact process, the final ‘product’ is a minimum set of condition-specific domains. We don’t yet have any standardised sets of outcomes for the different audiological conditions (i.e. hearing, balance and tinnitus-related problems). However, a starting point for hearing loss might consider the domains that have been recently proposed for conducting a comprehensive, multidisciplinary assessment of hearing loss (World Health Organization International Classification of Functioning Disability and Health).


COMET held its 3rd meeting in Manchester on 20-21 June 2013. Several of the tinnitus team from the NIHR Nottingham Hearing Biomedical Research Unit attended, with about 200 other delegates from the UK and overseas.The initiative is funded by the Medical Research Council and the European Commission (FP7 award). The COMET message is growing and becoming broadly influential. For example, the aims of the organisation are already endorsed by National Institute for Health Research (NIHR) and the Association of Medical Research Charities (AMRC). As yet, audiology and hearing sciences don’t seem to have been very engaged. I worry that maybe we’re all missing out on something that sounds rather exciting and innovative. If you’re interested in getting involved in projects to identify core outcome sets for hearing loss and/or tinnitus, please contact me, I’d very much like to hear from you –

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Essentials Calibration Services ACOUSTIC METROLOGY LIMITED AML is UKAS accredited and ISO9001 approved for the calibration of Audiometers both on site and at our laboratory in Glasgow. AML provide on site calibration and Medical Equipment Safety Testing to BS EN 62353:2008 for all audiometric equipment and an all makes repair service at our Laboratory. AML are approved calibration and repair partners with Interacoustics UK Ltd and Biosense Medical Ltd. Contact: Jennifer White, Acoustic Metrology Limited, Technical Centre, 46 Eastmuir Street, Glasgow G32 0HS. Tel: 0845 465 0141 or 0141 764 0069, Fax: 0141 778 4612. Email: Website:

AMPLIVOX Amplivox provide an economical and comprehensive calibration and repair facility for Amplivox screening, diagnostic and clinical audiometers as well as the Amplivox Otowave hand held tympanometer. The Service is to EN ISO 9001. For a quotation please contact the Sales Department, Amplivox Limited, 29-30 Station Approach, Kidlington, Oxon OX5 1JD. Tel: 01865 842411, Fax: 01865 841853. Email: Website:

CAMPBELL ASSOCIATES LIMITED CA offer UKAS and traceable calibration of measurement microphones (sensitivity, frequency response and capacitance) as well as sound calibrators (single and multi-frequency), and sound level meters (including frequency filters if required). Also, traceable calibration of ear simulators and audiometric couplers. For a competitive quotation and current turnaround times please Email: Campbell Associates Limited Sonitus House, 5b Chelmsford Road Industrial Estate, Great Dunmow, Essex, CM6 1HD. Tel: 01371 871030 Website:

GN OTOMETRICS (UK) Whilst manufacturing the widest range of audiology and balance assessment systems, we also provide comprehensive technical support for both our equipment and most other makes of equipment in these categories. This includes Calibration, Fault Repair and PAT Testing. Our UK Service team are both ISO9001 accredited and HIMSA Certified. Please contact us for more information and a quotation on Email: We are based in the heart of the country at Building A, Slade Farm, Kirtlington Business Centre, Portway, Kirtlington, Oxon OX5 3JA. Tel: 0870 9000 675, Fax: 01869 343190. Website:

GUYMARK UK LIMITED Now UKAS Accredited for the Calibration of Audiometers. The Guymark repair and calibration service covers all audiological equipment including sound field installations. Contact: Guymark UK Veronica House, Old Bush Street, Brietley Hill, West Midlands. Tel: 01384 890600, Fax: 01384 890609. Email: Website:

OTODYNAMICS LIMITED Otodynamics provides a service for the calibration and repair of its Echoport and Otoport precision instruments. Each system is calibrated using measuring equipment traceable to national standards. Otodynamics is certified to ISO 9001:2008 and ISO 13485. Contact: Otodynamics Limited 36-38 Beaconsfield Road, Hatfield, Herts. AL10 8BB. Tel: 01707 267540. Email: Website:

P C WERTH LIMITED As one of the UK’s leading audiometric companies we provide calibration, servicing and PAT Testing for a wide range of audiometric instruments and SLM including Maico, Kamplex, Interacoustics, Otovation and Audioscan equipment. We are an ISO-accredited repair and calibration laboratory offering in-house and on-site services via our highly trained and experienced technicians. We offer cost effective solutions to ensure your valuable instrumentation remains at peak effectiveness, performance and compliance. For more information contact: P C Werth Limited Audiology House, 45 Nightingale Lane, London SW12 8SP. Tel: 020 8772 2700, Fax: 020 8772 2701. Email: Website:

PURETONE LIMITED All make repair and calibration service of audiometers and tympanometers. Puretone are certified to ISO 9001:2008 and ISO13485:2003. Contact: Puretone Limited 9-10 Henley Business Park, Trident Close, Medway City Estate, Rochester, Kent. ME2 4FR. Tel: 01634-719427, Fax: 01634-719450. Email: Website:


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Essentials Council Members Officers

Council Advisors

Professor Kevin Munro – Chairman Dr Huw Cooper – Vice Chairman Dr David Baguley – Immediate Past Chairman Dr David Furness – Secretary (ESP) Mr Andrew Reid – Treasurer

Ms Charlotte Turtle (Student representative) Dr Nicci Campbell (Auditory Processing Disorders Group) Professor Adrian Davis (IJA) Dr Ros Davies (Chairman - Research Committee) Dr Martin O’Driscoll (Audacity Editor) Ms Lucy Handscomb (ARIG) Dr Sebastian Hendricks (Chairman - Paediatric Audiology Interest Group) Mr Paul James (Interim Chairman - PPC) Ms Debbie Cane (Balance Interest Group) Ms Mel Ferguson (Co-Ordinator Learning & Events Group – formerly

Elected Trustees Mr John Day Dr Heather Fortnum Mr Graham Frost Dr Sebastian Hendricks Dr Martin O’Driscoll Ms Helen Pryce Dr Nick Thyer Dr Dolores Umapathy

Programmes Committee)

Mr Jason Smalley (Web Administrator) Dr Peter West (IJA Representative)

Council and Learning & Events Group Meeting Dates for 2013 Tuesday 19th March - Ewing Seminar Room, University of Manchester Tuesday 11th June - Ewing Seminar Room, University of Manchester Wednesday 3rd September - Annual Conference, Keele Tuesday 10th December - Ewing Seminar Room, University of Manchester Programmes – 9.30 – 10.30am followed by Council from 11.00am to 4.30pm Housekeeping Meetings Monday 20th May Thursday 22nd August Thursday 24th October The above meetings will be held at the Secretariat in Reading or by teleconference. Venues to be confirmed Professional Practice Committee Meeting Dates for 2013 Monday 4th March Monday 3rd June Monday 23rd September Monday 25th November Hearing and Balance UK Meeting Dates for 2013 Wednesday 5th June Wednesday 16th October

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

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Essentials useful names & addresses ACTION ON HEARING LOSS

(formerly Royal National Institute for Deaf People (RNID)) 19-23 Featherstone Street London EC1Y 8SL Tel: 020 7296 8000 Textphone: 020 7296 8001 Fax: 020 7296 8199 RNID Helpline: 0808 808 0123 Textphone: 0808 808 9000 Monday to Friday 09.30am to 5pm) Tinnitus Helpline (Mon to Fri 9am to 5pm) Tel. 0808 808 6666 (freephone) Textphone: 0808 808 0007 Library: Librarian – Alex Stagg 330/332 Gray’s Inn Road London WC1X 8EE Tel: 020 7915 1553 (voice and textphone) Fax: 020 7915 1443 Email: ASSOCIATION OF INDEPENDENT HEARING HEALTHCARE PROFESSIONALS (AIHHP)

Membership Secretary – Shona Jackson House of Hearing 51 Bank Street Galashiels TD1 1EP Tel: 01896 755474 Email: BRITISH ACADEMY OF AUDIOLOGY

President – Adam Beckman Blackburn House Redhouse Road Seafield West Lothian EH47 7AQ Tel: 01625 290046 Fax: 01506 811477 Website: bid SERVICES

Deaf Cultural Centre Ladywood Road Birmingham B16 8SZ Tel: 0121 246 6100 Minicom: 0121 246 6101 Fax: 0121 246 6189 Email: Website: BRITISH ASSOCIATION OF AUDIOLOGICAL PHYSICIANS

Honorary Secretary - Dr Peter West Audiology Dept. Queen Alexandra Hospital Cosham Portsmouth PO6 3LY


The Royal College of Surgeons of England Administrative Manager – Nechama Lewis 35/43 Lincoln’s Inn Fields London WC2A 3PE Tel: 020 7611 1732 Fax: 020 7404 4200 Email: Website: BRITISH ASSOCIATION OF EDUCATIONAL AUDIOLOGISTS

(BAEA) Chairman – Peter Keen 4 Durnford Close Chilbolton Hampshire SO20 6AP Tel: 01264 860571 Email: BRITISH ASSOCIATION OF PAEDIATRICIANS IN AUDIOLOGY (BAPA)

Previously known as British Association of Community Doctors in Audiology (BACDA) Secretariat: Mrs Pam Williams 23 Stokesay Road Sale Cheshire M33 6QN Tel: 0161 962 8915 Fax: 0161 291 9398


Chairman - Mr Lawrence Werth c/o P C Werth Limited Audiology House 45 Nightingale Lane London SW12 8SP Tel: 0208 772 2700 Email: Website: BRITISH SOCIETY OF HEARING AID AUDIOLOGISTS

Secretary – Mrs Jill Humphreys 9 Lukins Drive Great Dunmow Essex CM6 1XQ Tel/Fax: 01371 876623 Email: Website: BRITISH STANDARDS INSTITUTION

389 Chiswick High Road London W4 4AL Tel: 020 8996 9000 Fax: 020 8996 7400 Email: BRITISH TINNITUS ASSOCIATION

Unit 5 Acorn Business Park Woodseats Close Sheffield S8 0TB Tel: Freephone 0800 018 0527 Email:


President – Gary Anderson Executive Officer – BATOD - Paul Simpson 21 Keating Close Rochester Medway Kent ME1 1EQ Tel & Fax: 0845 6435181 Email: Website: BRITISH COCHLEAR IMPLANT GROUP


Head Office Coventry Point – 10th Floor Market Way Coventry CV1 1EA Email: Website:


The Faculty of Deaf Education and Learning Support 1-10 Keeley Street Covent Garden London WC2B 4BA Tel: 020 7492 2725/6 (voice) 020 7492 2746 (minicom) 020 7492 2745 (fax) Email: DEAFNESS RESEARCH UK

330-332 Gray’s Inn Road London WC1X 8EE Tel: 020 7164 2290 Fax: 020 7278 0404 Website: DEPARTMENT OF HEALTH

For general information Dept. of Health Health Care (Administrative Division) Wellington House 135-155 Waterloo Road London SE1 8UG Tel: 020 7972 2000


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74 For technical matters Dept of Health Medical Devices Directorate 14 Russell Square London WC1B 5EP Tel: 020 7636 6811 Hearing Aids - informal guidance: Policy Division Dept of Health Tel: 020 7972 4120


The Grange Wycombe Road Saunderton Princes Risborough Bucks HP27 9NS Tel: 01844 348 100 (voice and minicom) Fax: 01844 348 101 Email: Website: INSTITUTE OF ACOUSTICS

Contact for the supply of hearing aids NHS Hearing Aids NHS Supplies, North West Division Headquarters - 80 Lightfoot Street Chester CH2 3AD Tel: 01244 586715 Fax: 01244 505050 Customer services and orders Lister Road Runcorn Cheshire WA7 1SW Tel: 01928 858532 Fax: 01928 580053 Scottish Healthcare Supplies Trinity Park House South Trinity Road Edinburgh EH5 3SH Tel: 0131 551 8590 (helpline) Fax: 0131 552 6535

Chief Executive – Mr Allan Chesney St Peter’s House 45-49 Victoria Street St Albans Herts AL1 3WZ Tel: 01727 848195 Fax: 01727 850553 Email: Website: MIDLANDS COCHLEAR IMPLANT PROGRAMME

Children’s Service: Aston University Day Hospital Aston University Birmingham B4 7ET Tel: 0121 204 3830 Fax: 0121 204 3840 Adult Service: Queen Elizabeth Hospital Audiology Centre University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Medical Centre Birmingham B15 2TH


Marjorie Sherman House 83 Sherwin Road Lenton Nottingham NG7 2FB Tel: 0115 942 1985 Fax: 0115 924 9054 Email: Website:


University Park Nottingham NG7 2RD Tel: 0115 922 3431

OR Level 1A City Tower Piccadilly Plaza Manchester M1 4BD NATIONAL PHYSICAL LABORATORY

Hampton Road Teddington Middlesex TW11 0LW Customer Services: +44 20 8943 8631 Email: Website: ROYAL COLLEGE OF SPEECH AND LANGUAGE THERAPISTS

2 White Hart Yard London SE1 1NX Tel: 0207 378 1200 Email: Website: SCOTTISH SENSORY CENTRE

Moray House School of Education University of Edinburgh Holyrood Road Edinburgh EH8 8AQ Tel: 0131 651 6501 Textphone: 0131 651 6067 Fax: 0131 651 6502 Website: SENSE

101 Pentonville Road London N1 9LG Tel: 0845 127 0060 Fax: 0845 127 0061 Textphone: 0845 127 0062 Email: Website: SOUNDSEEKERS

Contact BSA’s Secretariat for details

Honorary Secretary – Mr Paul Tomlinson P.O. Box 50 Amersham Bucks HP6 6XB Fax: 01305 262591 Website:

Chairman – Dr John Fincham BA PhD 34 Buckingham Palace Road London SW1W 0RE Tel: 020 7233 5700 Fax: 020 7233 5800 Email: Website:




Secretariat - 80 Brighton Road Reading RG6 1PS Tel: 0118 966 0002 Fax: 0118 935 1915

15 Dufferin Street London EC1Y 8UR Switchboard: 020 7490 8656 (voice and textphone) Fax: 020 7251 5020 Email: NDCS Freephone Helpline (Mon- Fri 9.30am-5pm; Sat. 9.30 a.m. - midday): 0808 800 8880 (voice and textphone) Website:

Beckett Street Leeds LS9 7LN Tel: 0113 244 4343 Senior Curator – Jim Garretts Librarian – Alan Humphries Email: Website:



27-28 The Waterfront Eastbourne East Sussex BN23 5UZ Tel: 0300 111 1113 SMS: 07526 123255 Fax: 01323 471260 Email: Website:




MidCity Place 71 High Holborn London WC1V 6NA NICE reception: 0845 003 7780 NICE enquiries: 0845 003 7781 NICE press office: 0845 003 7782 NICE publications: 0845 003 7783 Email: Website:

Mr A D Wallis Cirrus Research plc Acoustic House Bridlington Hunmanby North Yorkshire or: Mr B F Berry National Physical Laboratory Teddington Middlesex TW11 0LW

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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 P.O. Box 94 Middlesbrough Cleveland TS7 8XP Tel: 01642 325382 Fax: 01642 271555 Email: ADVANCED BIONICS UK LIMITED Grain House Mill Court Great Shelford Cambridge CB2 5LD Tel: 01223 847888 Fax: 01223 847898 AMPLIVOX LIMITED 29-30 Station Approach Kidlington Oxford OX5 1JD Tel: 01865 842411 Fax: 01865 841853 Email: Website: AUDITDATA LIMITED Centurion House London Road Staines Middx TW18 4AX Email: Website: BIOSENSE MEDICAL LIMITED 10–11 Eckersley Road Chelmsford CM1 1SL Tel: 0845 2266442 Fax: 0845 2263457 Email: Website: (please note revised website address) BROOK HENDERSON GROUP 37-43 Blagrave Street Reading RG1 1PZ Tel: 0118 900 8050 ECKEL INDUSTRIES OF EUROPE LIMITED Half Moon Street Bagshot Surrey GU19 5AL Tel: 01276 471199 Fax: 01276 453333

Email: Website: or GUYMARK UK LIMITED Veronica House Old Bush Street Brierley Hill West Midlands DY5 1UB Tel: 01384 410848 Fax: 01384 410898 Email: Website: INDUSTRIAL ACOUSTICS COMPANY LTD IAC House Moorside Road Winchester Hants SO23 7US Tel: 01962 873000 Fax: 01962 873111 Email: Website: OTICON LIMITED P.O. Box 20 Hamilton Lanarkshire ML3 7QE Tel: 01698 283363 Fax: 01698 284308 Email: Website: OTODYNAMICS LIMITED 30-38 Beaconsfield Road Hatfield Herts AL10 8BB Tel: 01707 267540 Fax: 01707 262327 Email: Website: PHONAK UK Cygnet Court Lakeside Drive Warrington WA1 1PP Tel: 01925 623600 Fax: 01925 245700 Website: PURETONE Limited 9-10 Henley Business Park Trident Close Medway City Estate

Rochester Kent ME2 4FR Tel: 01634 719427 Fax: 01634 719450 Email: Websiite: GN RESOUND LIMITED Building A Kirtlington Business Centre Portway Kirtlington Oxon OX5 3JA Tel: 01869 352800 Email: Website: SIEMENS HEARING INSTRUMENTS LIMITED Alexandra House Newton Road Manor Royal Crawley West Sussex RH10 9TT SPECSAVERS La Villiaze St Andrews Guernsey GY6 8YP STARKEY LABORATORIES LIMITED William F Austin House Bramhall Technology Park Pepper Road Hazel Grove Stockport SK7 5BX Tel: 0161 483 2200 Freephone 0500 262 131 Fax: 0161 483 9833 Email: THE TINNITUS CLINIC 121 Harley Street London W1G 6AX Tel: 0203 326 1777 Website: P C WERTH LIMITED Audiology House 45 Nightingale Lane London SW12 8SP Tel: 020 8772 2700 Fax: 020 8772 2701 Website: Email:


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Essentials Application for Membership FULL Members Name Bowcott, Ms S L Burke, Mr P Chilvers, Miss K L Griffiths-Brown, Miss A Richards, Mr S H

Address Southmead Hospital, Bristol Hidden Hearing, Co Meath Worcester Royal Hospital Shrewsbury and Telford Hospitals NHS Trust Aston University

Membership No. 4669 4670 4672 4671 4675

STUDENT Members Name Ashburne, Miss J Bartram, Miss E Bull, Dr K Card, Miss R Edwards, Mr S Hill, Miss K A Leadbetter, Miss G A Maqsood, Miss T U Ramsay, Mrs J Sahota, Mr H

Address Anglia Ruskin University University of Manchester Southampton University University of Southampton Aston University University of Bristol Sunderland University DeMontfort University Queen Margaret University University of Manchester

Membership No. 4661 4674 4662 4667 4668 4663 4665 4664 4673 4666

RETIRED Membership Name Varghese, Dr C M

Address Bolton

Membership No. 1990

STUDENT Members re-grading to full Name Downey, Mrs H R Scott, Mr S Willis, Miss E J

Address Royal Surrey County Hospital University of Southampton Plymouth NHS Trust

Membership No. 4147 4256 4413

AFFILIATED Members Name Walker, Ms F


Address Sound-Seekers, 34 Buckingham Palace Road, London

Membership No. 6014

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Essentials Membership and Advertising Fees (with effect from 1st June 2013 to 31st May 2014)


Direct Debit

FULL/ASSOCIATE MEMBERS UNITED KINGDOM FULL/ASSOCIATE MEMBERS OVERSEAS: Full/Associate including Airmail (excluding Europe) Full/Associate including Airmail (Europe) Full/Associate Surface Mail (excluding Europe)



£97 £87 £87

£92 £82 £82

STUDENT MEMBERS UNITED KINGDOM STUDENT MEMBERS OVERSEAS Student including Airmail (excluding Europe) Student including Airmail (Europe) Student Surface Mail (excluding Europe)



£43 £33 £33

£38 £28 £28

£40 £26

£40 £26

£68 £58 £58

£68 £58 £58

£54 £44 £44

£54 £44 £44

RETIRED/REDUCED RATE MEMBERS UNITED KINGDOM (with Journal) RETIRED/REDUCED RATE MEMBERS UNITED KINGDOM (without Journal) RETIRED/REDUCED RATE MEMBERS OVERSEAS (with Journal) Retired/Reduced including airmail (excluding Europe) Retired/Reduced including airmail (Europe) Retired/Reduced Surface Mail (excluding Europe) RETIRED/REDUCED RATE MEMBERS OVERSEAS (without Journal) Retired/Reduced including airmail (excluding Europe) Retired/Reduced including airmail (Europe) Retired/Reduced Surface Mail (excluding Europe)

No mailings will be sent after the 1 September 2013 if full payment of subscription has not been received. The BSA Financial Year runs from 1st June to 31st May. Subscription rates are subject to change in June each year. Members will be notified of any changes in the BSA’s April Mailing. • If you wish to pay by direct debit, a Direct Debit Mandate form can be downloaded from the BSA website or obtained from the BSA Secretariat • It is worth remembering that your subscription can be claimed back against income tax if you are in employment • The International Journal of Audiology is sent under separate cover direct from the publisher. EXHIBITION FEES (charges below are a guideline only and will vary depending upon the venue) Sponsors Non-sponsors

£220 per two metre stand per day (minimum) £440 per two metre stand per day (minimum)

NB: An additional charge of £20 will be added to cover administration costs


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1. Scheduled Mailing Print and Mail a single-sided A4 sheet in monochrome Print and Mail a single-sided A4 sheet in monochrome plus advertising on BSA Website

£370 + VAT £432 + VAT

2. Special Mailing If the Scheduled Mailing dates are unsuitable BSA can offer a Special Mailing which would be despatched from the BSA Office within 7 working days from receipt of the advert electronically. Print and Mail a single-sided A4 sheet in monochrome Print and Mail a single-sided A4 sheet in monochrome plus advertising on BSA Website

£770 + VAT £825 + VAT

3. Website Advertising only (career opportunities and meetings)

£400 + VAT

4. Mailing only – Insert supplied by Client: i. Scheduled Mailing Mail a single A4 sheet Mail a single A4 sheet plus advertising on BSA website ii. Special Mailing Mail a single A4 sheet Mail a single A4 sheet plus advertising on BSA website

£285 + VAT £345 + VAT £800 + VAT £860 + VAT

5. Advertising of Meetings/Events on the BSA Website – External Events Calendar: Please ensure an Order Number and Invoice Address is supplied when booking a mailing etc. Bulk email to consented members

£42 + VAT £58 + VAT

6. Equipment or services advertised in Audacity Full A4 page Sponsors Non-Sponsors Black and white Colour

£155 £460

£265 £920

Half A4 page Sponsors Non-Sponsors £115 £285

£230 £575

The Society reserves the right to refuse to circulate advertisements without having to state a reason Enquiries and advertising copy should be sent to the Secretariat: British Society of Audiology, 80 Brighton Road, Reading RG6 1PS. Tel: 0118 966 0622, Fax: 0118 935 1915 Email: Website: (An answering service operates when the office is closed).


BSA Summer 13 tweaked CE_Layout 1 16/08/2013 15:54 Page 79


ReSound Up

with Mini Microphone

Ř +HDULQJ DLGV with built in digital receiver Ř 0LQL 0LFURSKRQH with built in digital transmitter Ř &OLQLFDOO\ SURYHQ HTXLYDOHQW WR )0 To find out more email or visit


BSA Summer 13 tweaked CE_Layout 1 16/08/2013 15:54 Page 80

Introducing a revolution Wideband Tympanometry

WBT adds even more power to the Titan from Interacoustics

Wideband Tympanometry (WBT) from Interacoustics explores middle ear diagnostics from a whole new perspective. With WBT, the 226Hz probe tone is replaced by a broadband click measuring frequencies from 226 Hz to 8000 Hz. Differential Diagnostics will significantly improve from: s¬¬-ULTIPLE¬TYMPS¬IN¬ONE¬SWEEP¬ s¬¬7IDEBAND¬ AVERAGED ¬ tympanogram s¬¬!BSORBANCE¬MEASUREMENTS with age specific norm data s¬¬!¬NEW¬DIMENSION¬IN¬TESTING¬¬¬ middle ear pathologies s¬¬ $¬PEAKS¬OF¬INSIGHTFUL diagnostic data Experience the change at


For further information please contact:

Interacoustics UK Tel: +44 (0)1698 208205 | Fax: 01698 429509 | |

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