The patient population
Audiovestibular physicians lead the investigation, diagnosis and management of the medical aspects of disorders of hearing and balance in children and adults. Hearing loss affects 11 million people in the UK. The epidemiology of hearing and balance problems is well described (opens PDF, 1.64MB). It affects people of all ages, including:
- at least 50% of adults in the UK experience hearing or balance disorders during their lifetime
- one in 1,000 children is born with a permanent hearing loss which affects learning and development
- 40% of people aged 65 and over have a hearing loss that impairs communication
- dizziness and/or imbalance is the most common reason for a visit to a doctor by patients over 65, and are major risk factors predisposing to falls among older people.
Dizziness is prevalent in 8–18% of children. An increasing older population, as well as more premature babies surviving with complex needs, will lead to a greater number of people requiring care for hearing and balance disorders in the future. With the correct diagnosis some auditory and many vestibular disorders are treatable, leading to improved quality of life.
Despite the prevalence of hearing and balance disorders in the general population and their impact on function and quality of life, the provision of medical care for these problems has remained a low priority for the NHS. Currently, the distribution of audiovestibular physicians is patchy throughout England, with clustering of audiovestibular physicians in specialised centres in London and Manchester, and some areas having no service at all. As a result, many audiovestibular physicians take referrals from other regions. If there is no audiovestibular physician or adequately staffed multidisciplinary team available in their locality, many patients presenting with hearing and balance symptoms may not be seen by a service with the appropriate medical expertise. This could lead to limited or delayed diagnosis and treatment of relevant medical conditions, in addition to inappropriate, unnecessary and expensive investigations, and additional referrals.
Prevention of disease
The cost of hearing and balance disorders to the individual and the economy is evidenced here (opens PDF, 1.64MB):
- the cost of falls on NHS and social services (£981 million in 1999)
- early retirement
- loss of time from work
- repeated medical attendances
- costly unnecessary investigations.
Recent estimates suggest that in 2013, the UK economy lost £24.8 billion in potential economic output due to lower employment rates for those with hearing loss.
Primary prevention includes limiting noise-induced hearing loss and ototoxic audiovestibular pathologies. This can be achieved by identifying noise as a cause of hearing loss and counselling the patient appropriately, and by educating patients and health professionals about the use of ototoxic drugs and instigating appropriate monitoring. Also important is the continuing vigilance of audiovestibular physicians in identifying possible aetiologies of audiovestibular pathologies that can be treated. This can be achieved through education of the population and of other health professionals, in addition to effective information about available patient care pathways, to ensure that the patient is promptly put on the right pathway. In addition, the prevention of illnesses that cause deafness, eg vaccination for meningitis prophylaxis, is an important part of primary prevention.
Secondary prevention includes screening for hearing loss in newborn and school-age children, in addition to monitoring hearing and balance function in patients receiving ototoxic drugs or going through dialysis. Many disorders of hearing and balance are chronic; accordingly, the tertiary prevention mainly includes effective rehabilitation. Appropriate self-care is an important part of this rehabilitation; engaging with and educating patients about self-care is critical.
Planning effective services
Encouraging the development of patient care pathways, in conjunction with primary and secondary care providers, will ensure that audiovestibular physicians are providing specialist care for the most complex cases. One-stop clinics are desired by patients and are already provided in specialist hospitals (eg tertiary referrals for hearing and balance disorders, auditory processing disorders, aetiological investigations of hearing loss, tinnitus/hyperacusis, patients with complex needs / learning disability, assessment for implants and patients with dual-/multisensory problems). Such clinics need to be implemented nationally and require effective administrative, technical and professional support.
More straightforward cases can be managed in primary/secondary care by GPs, audiologists, local teachers of deaf and hearing impaired children, and local speech and language therapists.
The need for specialist and supraspecialist services for adults and children with hearing and balance problems, which target the more complex cases, is such that specialist commissioning should be developed.
Consultants in audiovestibular medicine have played key roles in setting standards for the medical and audiological care of patients with hearing and balance problems in the UK (tinnitus (opens PDF, 372KB), adult balance services (opens PDF, 270KB), children’s hearing (opens PDF, 455KB)). Audiovestibular consultants also provide standards and guidelines for the field, and there is continuous work on developing and regularly reviewing these. The BAAP guideline process has recently been granted National Institute of Health and Care Excellence (NICE) accreditation. Adherence to published clinical standards and the development of national and local guidelines are reviewed by audit. The yearly national audit meeting provides specialty-specific national audits, and supports and promotes audit to inform and improve practice.
Many audiovestibular consultants provide a single-handed service; thus the development of regional specialty groups, which provide peer review and audit as well as education, is a necessity to support continuing review of activity and outcomes.
The provision of medical care for hearing and balance disorders is patchy throughout the UK with no service provision in some areas due to insufficient numbers of medical and non-medical personnel, limited availability of test facilities (for diagnosis) and poor access nationally to the range of treatment and rehabilitation options. An RCP working party report (opens PDF, 1.6MB) from 2007 recommended 1:250,000 population served by each whole-time equivalent audiovestibular consultant, but at present there is less than one audiovestibular physician per million population in England.
If there is no audiovestibular physician or adequately staffed multidisciplinary team available in their locality, patients presenting with hearing and balance symptoms may not be seen by a service with the appropriate medical expertise. This could lead to limited or delayed diagnosis and treatment of relevant medical conditions in addition to inappropriate, unnecessary and expensive investigations and additional referrals. The US National Institute of Health reports that a patient with peripheral vestibular pathology (ie vestibular neuritis or ‘labyrinthitis’) sees an average of 4.5 physicians before receiving a correct diagnosis. A similar finding is reported from specialist balance centres in the UK where audiovestibular physicians practice.
The role of audiovestibular physicians is likely to change with the predicted changes in team structure, for example with the recent development of the Higher Specialist Scientific Training. With enhanced training and knowledge, particularly of audiologists, there will be a greater demand for the medical aspects of hearing and balance disorders as awareness of the complexity of these conditions increases. Expansion of audiovestibular services is required to improve quality of care for patients with prompt identification of the underlying pathology, comorbidities, additional needs and appropriate medical management leading to reduced morbidity and improved quality of life.