Consultant physicians working with patients - Royal College of ...

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2 Specialties Audiovestibular medicineAudiovestibular medicineDr Breege Mac Ardle FRCP FRCPCH Consultant in audiovestibular medicineDr Sebastian Hendricks FRCPCH MSc Consultant audiovestibular physicianand paediatricianDr Dolores Umapathy FRCP MSc Consultant in audiovestibular medicine1 Description of the specialtyAudiovestibular medicine (AVM) is the specialtyconcerned with prevention, investigation, diagnosis andmanagement of adults and children with disorders ofhearing, balance and tinnitus. 1 Some specialists alsoinclude developmental disorders of speech andlanguage. This is a small specialty with an unevendistribution across the UK. There is an unmet need thatis only partially met by other specialties.Audiovestibular physicians (AVPs) play a key role in themultidisciplinary team (MDT) involved withassessment and management of patients. Competenciesin general internal medicine, paediatrics and childhealth underpin the practice of AVM. Knowledgeof the pathophysiology of systemic, neurologicaland otological diseases and disorders that affectthe audiovestibular system throughout life isessential.Who are the patients?Hearing loss and dysequilibrium are widespread in theUK adult population and will increase with thechanging demographics: One third of those over 60 years have a hearing lossof 25 decibels or more. Symptoms of dizziness or imbalance areexperienced by 30% of the population by the age of65 years. 1 Balanceproblemsarethemostcommoncauseofpresentation to primary care in patients over 74years of age. 2 AVPs are involved in complex cases of hearing lossand assessments for cochlear implants. Many patients have other complex needs, eg 45% ofdeaf adults under the age of 60 have additionaldisabilities. 3 Tinnitus affects up to 20% of the population, with5% describing the complaint as troublesome, whilefor 1% it is severe enough to have a significant effecton their quality of life. 3Balance disorders are less common in children, affectingonly 8%, 4 but may be difficult to assess and manage. Approximately 1:1,000 children are born withbilateral permanent hearing impairment each year 5and 2:1,000 will have a unilateral hearingimpairment. 6 25%ofallchildrenuptotheageof4yearssufferfrom otitis media with effusion at any one time 7 and80% of children under 8 years of age haveexperienced temporary deafness due to glue ear. 8Current best management of this includes the use ofamplification rather than surgery. 9 Approximately 10% of children have some degree ofauditory processing disorder. 10 Approximately 6% of children have speech andlanguage disorders. 11Main disease patternsPermanent childhood hearing impairment can becongenital or acquired and syndromic ornon-syndromic and is often accompanied by othersymptoms and disabilities. AVPs are involved in themedical diagnosis (from newborn hearing screeningand beyond), aetiological investigation and(re)habilitation. Hundreds of conditions are involvedand it is important for families to fully understand theirchild’s problem(s). Other associated conditions arementioned earlier.Balance disorders including those of vestibular originprovide the bulk of most AVPs’ adult-patient load butpatients with complex, progressive, unknown orasymmetrical hearing problems and/or tinnitus are alsocommon. Conditions range from the common benignparoxysmal positional vertigo (BPPV) andmigraine-associated vertigo through to complexC○ Royal College of Physicians 2013 35
Consultant physicians working with patientsneurological problems and systemic disease: diabetes,autoimmune disorders, syndromic disorders andvascular disease. Those with chronic balance disordersfrom whatever cause suffer significant social,occupational, emotional and economic disability.They are best managed by a team that will includeexpert physiotherapy, AVP and counselling. AVPsinvestigate causation and with the MDT manageboth children and adults with auditory processingdifficulties.2 Organisation of the service and patternsof referralA typical serviceThere are areas of the country where there are no AVPsand the service of each consultant varies. There is notypical service.AVPs are involved across primary, secondary andtertiary care. Most are employed by acute trusts. Someconsultants work in a ‘hub and spoke’ network,delivering services to neighbouring trusts on a practicalor consultative basis.Some consultants cover the whole spectrum of serviceprovision in AVM, but others may specialise inpaediatrics or adults. Subspecialty areas includecochlear implantation, auditory processing disorders,developmental neuro-otology, disorders of speech andlanguage, cleft palate, adults with learning disability,and paediatric vestibular service. Delivery ispredominantly through an MDT, which is commonlyled by an AVP, audiologist, paediatrician or otologist.Practice is primarily outpatient based with inpatientconsultation for patients admitted in other specialties;rarely, patients are admitted for intensive diagnostic orrehabilitative work. Adults and children are seen inseparate clinics in all practices.Secondary audiovestibular services provide amultidisciplinary approach in dedicated facilities andmanage the vast majority of audiovestibular problemseffectively. Approximately 20% of adult patients and67% of child patients will see more than two healthprofessionals at any one visit, with the aim offormulating both an accurate diagnosis and a plan forrehabilitation or treatment. Appointments often includedetailed testing by audiologists and assessments byother professionals.Tertiary services for both adults and children arehospital based and include sophisticatedneuro-otological test facilities, cochlear implantprogrammes, bone-anchored hearing aid programmes,and specialised advice and assessment in services suchas cleft palate, dual sensory loss or falls clinics.Integrated multidisciplinary care is a key feature ofthese services.Sources of referralFigure 1 shows the sources of referral to AVM from theprimary, secondary and tertiary levels.Locality-based and/or regional servicesSome AVPs work in district general hospitals (DGHs)and others in specialist centres where the majority ofwork is tertiary. There is a disproportionateconcentration of services in London and the south east,with a few consultants in the north of England, one inScotland, one in Wales and large gaps in most otherparts of the country. Different AVPs provide a regional,supra-regional or national service.The implementation of the Newborn Hearing ScreeningProgramme (NHSP) had a significant effect onpaediatric AVM with increased clinical, diagnostic andmanagement demands for patients at a much youngerage. In many areas, AVPs are involved in thecoordination and implementation of various local andnational aspects of this programme, working closelywith audiologists and consultant communitypaediatricians.The long-term nature of some neuro-otological andother underlying systemic disorders means thatorganisation of transitional care services betweenpaediatric and adult services is essential.Community models of careThere are no structured AVM services for adults inprimary care, although some services for adults are nowprovided in a primary-care setting by generalpractitioners with a special interest (GPwSIs) in otology.Some AVPs have developed community-based servicesfor common problems and hub-and-spoke serviceswould support the provision of more rapid effectivecare for this group of patients.A significant proportion of paediatric audiologicalservices, including hearing surveillance programmes,are provided by second-tier community services.36 C○ Royal College of Physicians 2013
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