Medicine in the Third Millenium Ewa Raglan IAPA 2014 17 th International Congress in Audiological Medicine In connection with Hearing International Annual Meeting Bangkok Thailand ID: 915755
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Slide1
The role of Audiovestibular Medicine in the Third Millenium
Ewa
Raglan
IAPA 2014
17
th
International Congress in
Audiological
Medicine
In connection with
Hearing International Annual Meeting
Bangkok, Thailand
5-7
th
November 2014
Slide2The role of Audiovestibular Medicine in the third Millenium
Neuro-
Oto
-Audiology Clinic in the Third Millennium
The role of IAPA and an ENT Physician practicing an
Audiovestibular
Medicine
.
Slide3Summary
Development of audiology in the past
What is
audiovestibular
medicine?
A brief history of
audiovestibular
medicine
Growth of the subject in the last few years
Areas of
audiovestibular
medicine (paediatric AVM – UNHS, adult AVM – scope of the problem)
Future developments
Stem cells,
Transdifferentiation
Local drug delivery to inner ear,
Neuro-otology (diagnoses
,( vestibular migraine)
techniques, treatment options
)
Auditory Medicine( new
diagnoses
– auditory neuropathy spectrum disorder, central auditory processing disorders, genetics of deafness)
MDT
Slide4Audiology in the past, past discoveries are the basis for further developments…….
Contributors to the developments of the medical science including audiology, over the years :
Hippocrates,Plato,Galen,Vesalius,Fallopio,Eustachio
….
etc
Schwartz 1920,Fletcher 1926- constructors of audiometers
Wever
&
Brey
1934
– cochlear
microphonics
potentials
Bekesy 1947, -- automated audiometry
1969 first hearing aids worn within the ear
1969 William House – cochlear implantation in adults
1970 Jewett -- evoked auditory potentials
1970
Jerger
-- classification of tympanometry
1971
Portmann,Aran
–
transtympanic
electrocochleography
1978 Kemp - OAE
Slide5Audiovestibular medicineDiagnosis
Management of patients with hearing loss, tinnitus, dizziness
Slide6Audiovestibular medicine – UK history
As a result of:
Development of science of audiology
Necessity to respond to patients’ needs and clinical presentations
Need to provide time, space for ENT surgery
Slide7Growth of the subjectMedical manpowerScientific manpower
Developments in science
Developments in technology
Slide8PROGRESS in Audiovestibular Medicine
1970’s
1990’s
2004/5
2007/8
2014
Surgery vs.
medicine
ENT surgery vs. AVM
Scientific discoveries
Development of technology
Development of new diagnoses
Development of services
AVP
MMC (medical)
training changes
Technician in Audiology
Audiologist
Consultant Clinical Scientist
MDT
3
50
(+20)
3000
MSC training changes
Slide9Role of Audiovestibular Physician
Diagnosis,aetiology
of hearing loss, tinnitus, imbalance in
Isolated ear disease or multisystem disease
Provide specific medical management, holistic medical care
Ensure AVM input in service provision and rehabilitation via MDT
Initially: +hands-on testing, hearing aid provision
Now: diagnosis, management, procedures
Slide10Training in the UK - AVP
In the 1970’s
entry: ENT(FRCS)/General Medicine(MRCP)+5years AVM
Currently
Medical Degree
Foundation training for all(FY1/FY2)
Core Medical/ or Paediatric Training
2 years in CMT or ST1/ST2 or
3 years in core paediatric training (ST1, ST2, ST3)
Specialty Training
(ST3 – ST7)
5 years in AVM + Diploma/ Degree in AVM
Assessments - CCT
Slide11Audiologists
1970 - Technicians
(shortage, inconsistent quality, O levels + courses + practical training)
Career progression on duration of years worked
2000 – Audiologists
BSc in Audiology - 10 schools (300/
yr
)
MSc in
Audiological
sciences
2010/12 - Modernisation of scientific careers
Change of training (BSc, MSc, HSST, PhD - career progression path towards Consultant
Audiological
Scientist on merit (knowledge & skills)
Slide12Modernising Scientific Careers:Career and Training Pathways
Slide13Audiological Medicine – UK Speciality
1970’s
Paediatric audiology
Neuro-otology (vestibular medicine)
Adult Auditory rehabilitation
Founders
Tony Martin, Bethan Davies, Ron
Hinchcliffe
, Dai Stevens, John Marshall and others
Slide14Audiological Medicine-IAPA
Set up in 1980 meeting in Poland
Slide15Development of new technology
Hearing aids - digital
Cochlear implants
Brainstem implants
BAHA( bone anchored hearing aids)
Vestibular implant
Emerging technologies of assessing vestibular mechanisms
VEMP (vestibular evoked myogenic potentials)
HTT (Head thrust test)
VAT (vestibular-auto rotation test)
New range of motorised Barany chairs with
computerised analysis
Slide16Service Developments
MHAS/MCHAS – Modernisation of Hearing Aid Services for Adults and Children
Digital Sound Processing
Bone Anchored Hearing Aids programme
Cochlear Implant programme
Newborn
Hearing Screening
Programme
[NHSP]
New
services:auditory
disorders and paediatric vestibular services
Slide17Amplification-Hearing Aids
Slide18Amplification-Implantable Devices
Slide19Paediatric Audiology in the UKBeginning of the 20
th
Century
Ewing Foundation established first university based programme for teachers of the deaf and undertook research into childhood deafness
Ewing’s established
fundamental principles of paediatric audiology
Procedures for hearing assessment in pre-school children
Involvement of family in intervention programmes
Recognition of importance of early identification and intervention
Slide20Paediatric Audiology – Universal Neonatal Hearing Screening Programme (UK)
Established 10 years ago
Age of fitting hearing aids reduced from 18+ months to 2-3 months
Quality assurance programme – testing VRA (bone conduction/ insert phone 6-7months)
Real ear measurements for hearing aid fitting
Improvement of quality of testing and interpretation of ABRs (peer-review)
Families are told of diagnostic test outcome same day
Slide21Audiovestibular symptoms – Scope of the problem (UK)
Aged 55-75 years, 30% UK population bilateral hearing impairment
At 65 years, 30% population suffers dizziness/imbalance
At 55-75 years, 40% reporting hearing loss have associated tinnitus
Slide22Integrated Care PathwayDoH vision for improving services for patients with hearing impairment, tinnitus, dizziness, imbalance follows network model
Patients referred as quickly as possible to appropriate level of expertise
Requires teamwork within culture of continuous improvement and evaluation
Slide23Future (I)Auditory regenerative medicine/ Use of stem cells
To prevent hearing loss
To restore hearing
Local drug delivery for inner ear therapy
To avoid unwanted systemic drug effects
To protect inner and outer hair cells from damage (antioxidants, steroids, salicylates) in prevention of
oto
-toxic actions of aminoglycosides, chemotherapeutic agents, excessive noise, electrode-induced trauma
Slide24Future (II)Transdifferentiation
Differentiation of one cell type into another (in absence of mitotic event)
E.g. Non-sensory cells differentiate into sensory cells in response to transcription factor involved in hair cell differentiation (auditory and vestibular systems)
? Safety and efficacy of the technology as applied to the inner ear/application as therapeutic approach to restoration of hearing and balance
(
Stecker
et al, 2011)
Slide25Neuro-otologyDiscoveries of the last 30 years
New diagnoses
Vestibular
paroxysmia
Phobic postural vertigo
Superior canal dehiscence syndrome
Subtypes of BPPV
Vestibular Migraine
Slide26Neuro-otologyDiscoveries of the last 30 years
Development of new innovative techniques now in clinical use
Quantification of gain of VOR
Evaluation of the
otolith
function (
cVEMP
saccule
,
oVEMP
utricle)
Slide27Neuro-otologyDiscoveries of the last 30 years
New treatment options proven by clinical trials
Liberatory
maneouvres
(for subtypes of BPPV)
Corticosteroids for acute vestibular
neuronitis
Betahistamines
for Meniere’s disease
Carbamazepine for vestibular
paroxysmia
Aminopyridines
for down/upbeat nystagmus and episodic ataxia
Canal plugging in SCDS
Slide28Changes in the medical practice Increased subspecialisationChanging focus and scope
Appearance of other professionals
Increased incidence of some conditions
Technological developments
Economic issues(cost effectiveness ,preserving quality of care )
Slide29Multidisciplinary team approachWorking together to provide patients with best overall
care, but patient seen with a particular problem by a professional who is able to give him that care
eg
patient with
presbyacusis
seen by the audiologist, red flags escalated to the doctor.
Result- improvements of outcomes, and not substitution for a primary provider
.
Slide30Audiovestibular Multidisciplinary Team
( MDT)
ENT Specialist
Other members of MDT (specialists doctors and therapists)
Audiologist Scientist
Audiovestibular Physician
ENT Specialist
Slide31Thank you