”Those who are about to become deaf will first hear the gnats flying”, “Liezi? The earliest record of the symptoms of deafness and the association of deafness with tinnitus is found in Zhongni, and the “Divine Formula of Hua Tuo”, which appeared during the Han Dynasty in China, already prescribed several remedies for deafness, such as “treating deafness of kidney deficiency, treating deafness of wind, and treating deafness after illness”. Therefore, it is possible that the prototype of otorhinolaryngology, or the initial stage of its development, began with the internal pharmacological diagnosis and treatment of deafness. Today, more than two thousand years later, the inherited civilization has given it a new name – otolaryngology, which is like a blooming oddball, appearing the earliest but blooming the latest. In the long history of medical discourse, what is involved in internal otology seems to have always existed, but it has never been given the specialist status it deserves. Scholars at home and abroad have been working tirelessly to develop otolaryngology so that it can have its own definite disciplinary status in otorhinolaryngology, head and neck sciences, thus contributing to the development of otorhinolaryngology, head and neck sciences.
(1) The definition of otology and the scope of clinical practice covered by otology (Otological Medicine or Audiological Medicine) is an ancient and emerging discipline. In the author’s opinion, otology is a specialized medical field covering the inner ear and the related pathologies and abnormalities of the auditory central nervous system. Otologists need to have a good knowledge of general medicine, neurology, otology, neuroscience, pharmacology, engineering science and audiology. The otology program requires systematic training and continuing education for specialists, and solid training in basic research.
Otology is an inevitable product of the development and progress of otolaryngology. We know that otolaryngology has gone through the process of name changes such as pentacology, otolaryngology, otolaryngology, head and neck surgery, etc. Each name change means the in-depth and refinement of the development of the discipline and the development and perfection of subspecialties. In the author’s opinion, the current otorhinolaryngology head and neck surgery is forming the science of otorhinolaryngology head and neck. These sub-disciplines will become more and more clear with the development of medicine and the market demand.
The International Association of Physicians in Audiology (IAPA), founded in 1980, is currently the most recognized international professional society in the field of otolaryngology. The journal is published three times a year and covers various aspects of otology, such as audiology in children, auditory electrophysiology and the management of otologic diseases. The International Congress of Otology is held every one to two years, and the 15th Annual International Forum of Otology will be held in Krakow, Poland, in September 2010, with the theme of furthering the development of otology worldwide.
There are currently about ten names talking about such an event in otology: Neuro-oto-audiology; Otological Medicine; Audiological Medicine; Audiovestibular Medicine); ABC Medicine (ABC Medicine); Medical Audiology (Medical Audiology); Medical Otology (Medical Otology); (Medical) Neuro-otology (Medical); Otoneurology (Otoneurology). Internal otolaryngology (Medical ENT). In my opinion, the term “otolaryngology” should be able to express the scope of work involved in otolaryngology in China. In terms of English expression, whether Otological Medicine or Audiological Medicine can clearly express the connotation needs to be discussed and agreed upon by colleagues at home and abroad.
Otology was born early in the United Kingdom, and the personnel involved in otology consisted of three parts, consisting of otolaryngology head and neck physicians, audiologic pathologists and internal medicine physicians. Historically, audiologic technologists had limited training and basic audiology qualifications, worked in otolaryngology, were responsible for hearing tests and fitting analog hearing aids, and could not work on the diagnosis and treatment of disease. 2000 saw a change in audiology training with the establishment of a postgraduate specialty. Career paths also changed with the establishment of the Bachelor of Science degree in Audiology University. After successful completion of the 3-year B.Sc. program, audiologists can start working directly and, after a period of practical training, continue to develop career paths by pursuing the M.Sc. and D.Sc. degrees until they reach the level of consultant audiologist. However, in the current state of the world, there are no professional programs that cater to the training of otolaryngologists and no clearly defined training system for otolaryngologists in medical positions and qualifications.
At the 2007 IAPA meeting in Rand, Dr. Ewa Raglan of the University of London, UK, gave an overview of the various training models for otologists in Europe and determined that currently only the UK, Italy, Poland and Germany have separate training programs similar to the Auditory Vestibular Medcine (AVM) for otologists. These individuals are also required to undergo specialized training in otolaryngology before they are allowed to enter the field. The duration of specialized training in otolaryngology is typically 5 years, and the duration of training in audiovestibular medicine (or speech-language pathologist) is typically 2-3 years, after which one enters the specialized field. Although some countries have recognized the status of physicians specializing in auditory vestibular medicine, most countries still do not pay enough attention to the specialty of auditory vestibular medicine. The United Kingdom, where otology was first and most developed, has only a very small number of audiovestibular physicians, 46 in total, serving a population of 60 million. This shows that the number of otolaryngology medicine is far from meeting the needs of the huge patient population, and therefore, there is an urgent need to expand and grow.
(2) The huge patient demand is the source of motivation for the development of endo-auricular medicine. The results of the second national sample survey of disabled people in 2006 showed that there were 27.8 million patients with hearing disabilities in China. Among them, there are 20.04 million people with simple hearing disability, accounting for 24.2% of the total number of people with disabilities (82.96 million); 7.76 million people with multiple disabilities have hearing disability, i.e. 57.4% of people with multiple disabilities have hearing disability (the total number of people with multiple disabilities is 13.52 million. Among the 27.8 million people with hearing disabilities, 15.57% and 11.01% of them have Grade 1 and Grade 2 hearing disabilities respectively, which is 26.58% in total. According to this projection, there are about 7.39 million people with complete hearing loss (the second sample survey criteria are divided into primary, secondary, tertiary and quaternary according to the hearing loss; that is, the average hearing threshold of four frequencies of the better ear are: ≥ 91 dB HL; 81-90 dB HL; 61-80 dB HL; 41-60 dB HL). Due to the aging of the population and other reasons, the number of elderly people with hearing disabilities in China has increased significantly, and according to incomplete estimates, about 20-50% of people have significant hearing loss when they enter old age. In the epidemiological study of hearing loss conducted by WHO, the prevalence of hearing loss among the elderly aged 60 and above was 58.1%, of which 33.1% were mild, 17.8% were moderate, 5.9% were severe and 1.3% were very severe; the prevalence of hearing disability was 25%. The National Health Survey of the United States showed that the prevalence of hearing loss within 10 years was 11.0% to 12.7% for Caucasians and 5.9% to 8.5% for Blacks, with a higher prevalence among Caucasians than Blacks, with no statistical difference within races1. The National Auditory Study conducted in the United Kingdom showed that there were 8.6 million people with hearing loss across the Commonwealth, accounting for about 17% of all people with disabilities. Additional studies of hearing loss have shown that men are more susceptible than women, with the risk rate for men being four times higher than for women, and studies of the relationship between education and income and hearing loss have shown a negative correlation with prevalence2 .
In addition to deafness, tinnitus is also a common ear disorder in the population with a prevalence of 3% to 30.3%. Tinnitus is positively correlated with self-reported or measured hearing loss, with those with poor hearing being more likely to have tinnitus, and the more severe the hearing loss (especially in high frequencies) the more pronounced the tinnitus. Tinnitus is more common in the elderly population, and 35% of them experience discomfort throughout the day. In severe cases, it can have a significant impact on their lives and work, and is therefore a problem that otologists must actively address.
Vertigo is another common disorder in otology. The prevalence of dizziness and vertigo (with or without balance dysfunction) is 5-10%, and its prevalence reaches 40% in people over 40 years old. The prevalence of unsteadiness (falling) is 25% in people over 65 years of age. Vestibular disorders can directly cause unsteadiness, especially in patients with multiple sensory dysfunctions. Migraine (10%) has a higher prevalence than Meniere’s disease (1%). The prevalence of vertigo and movement disorders in migraine is 30-50%, and it is sometimes difficult to distinguish dizziness associated with migraine from primary inner ear disease. Current studies around the world generally support that vertigo tends to increase with age, more in women than in men, with no significant differences by race. Many studies have also shown that vestibular system disorders are the main cause of vertigo, with peripheral vestibular dysfunction being the main cause. Although vertigo is a common symptom and most people can adapt to it, it is also of great concern because it requires bed rest during attacks and can cause discomfort and fear, and in some people it can take more than a month to recover, seriously affecting the quality of life.
The above epidemiological studies on hearing loss, tinnitus and vertigo show that otolaryngologists are faced with a large patient population. Some European countries with an early start in otology, including the United Kingdom, Germany, Italy, Poland, Sweden and Finland, have a ratio of otolaryngologists to their population base, typically 1:100,000 or even 1:1 million. As an emerging subdiscipline, the number of its practitioners is far from meeting the needs and needs to be expanded and grown. In China, in June 2008, the General Hospital of the People’s Liberation Army for Otolaryngology, Head and Neck Surgery formally established an otolaryngology ward with a special echelon and personnel, establishing a model of otolaryngology development adapted to our national conditions, and there are also some large general hospitals in China that have otolaryngology departments with personnel specializing in otolaryngology, but no subspecialty has been established yet. Therefore, for a country with a large population like ours, the establishment and development of the discipline of otolaryngology is even more urgent, and the huge patient demand is the source of motivation for the development of otolaryngology.
(3) Systematic curriculum is a key element in the training of otologists. In June 2008, the International Symposium of the International Association of Physicians in Audiology (IAPA) International Curriculum was held at the Institute of Child Health, University College London, which focused on the study of otology and its subspecialties. The workshop focused on the development of a training curriculum for otology. This meeting was the first time that the authors of this paper participated as Chinese delegates, making it an international joint meeting of British, American, European and Asian otologists. The conference was a forum for national delegates to discuss training programs adopted in different countries and to identify the levels of knowledge, skills and competencies required of otologists in order to develop an international curriculum model tailored to local needs. are as follows.
1. The background knowledge that must be acquired is an important element of the systematic teaching curriculum in otology: it includes knowledge of basic medicine, preventive medicine and knowledge of scientific instruments and equipment.
1.1. Basic medical knowledge includes detailed anatomical, physiological, neurochemical and pharmacological knowledge of the auditory and vestibular systems and their central pathways, connections and related systems or organs; knowledge of the embryological development of the above systems, organs, etc.; auditory psychology and balance, including psychoacoustics; sound insulation law requirements; relevant standards of acoustics, audiology and correction; sound, wave and motion physics; basic acoustics, including room acoustics; basic hearing aids including room acoustics; basic electroacoustic properties of hearing aids; recent advances in molecular biology, recent advances in repair and regeneration concerning the cochlea and vestibular system, recent advances in stem cell research concerning the ear and genetic manipulation, etc.
1.2. Knowledge of preventive medicine is required: general principles of primary, secondary and tertiary prevention; screening principles, methods, establishment of regional screening programs, handling of screening failures, monitoring and auditing; screening for hearing loss – newborns, students, industrial workers and the elderly, etc.; noise and its effects on the auditory-vestibular system, destructive noise levels, such noise sources and their prevention, including noise measurement, auditory protection, ear protection and international standards; ototoxicity, substances and drugs affecting the auditory-vestibular system and their effects, including industrial toxins; genetics of causative agents affecting ototoxicity; epidemiology of hearing loss and its prevention; the role of immunization and therapy in the prevention of hearing disorders and balance disorders.
1.3. Knowledge of scientific instruments and equipment means that the practice of audiology should have a comprehensive knowledge of auditory and vestibular testing equipment and amplification of hearing aids for adults and children, including: principles, techniques, and limitations of auditory and vestibular testing equipment; analog and digital hearing aids, including body-peep hearing aids, behind-the-ear hearing aids, in-the-ear hearing aids, in-canal hearing aids, total in-canal hearing aids, vibrotactile hearing aids, and bone-anchored hearing aids (BAHA), frequency-shifted hearing aids, CROS and BICROS hearing aids, and implantable hearing aids, including cochlear implants; hearing aid fitting and true ear testing for children and adults; “canal systems” (hooks, molds, catheters, etc.) and their effect on sound amplification; available assistive devices, including radios, FM sound field systems, alarm systems, and loop systems; gain assessment methods for sound amplification in children and adults; and the ability to critically review audiometric and vestibular test reports; determine appropriate amplification rates and forms of amplification (including cochlear implants) through discussions with audiology colleagues, patients, and parents (if the patient is a child); discuss with patients, their families, and other professionals the best current technology; and the appropriate application of amplification rates.
2. Specialized special skills are an important part of the training of audiologists in internal medicine, and these special skills include the following.
2.1. Clinical skills specific to otology, including: obtaining a true, relevant and detailed history, including psychosocial development, from the patient or his or her companion; performing a relevant and detailed clinical examination, including otorhinolaryngologic, neuro-otologic, oculomotor, neurologic, developmental (in children) and comprehensive general examinations; selecting and resolving the appropriate patient profile, age and audiologic Select and analyze appropriate interdisciplinary assessments, including speech and language assessments, psychometric assessments; synthesize the history, examination, and test findings into a diagnostic and treatment plan; select appropriate treatment strategies such as hearing aids, tinnitus devices, cognitive therapy, relaxation therapy, pharmacological options, physical therapy, occupational therapy, and educational strategies through interdisciplinary team discussions and discussions with the patient and their caregivers. physical therapy, occupational therapy, educational strategies, surgical options; evaluate the effectiveness of the treatment strategies used; accurately evaluate the disability and make an assessment of occupational suitability, e.g., for operating machines or driving; identify other medical problems that may contribute to or interfere with recovery, e.g., visual deficits, neurological disorders, endocrine disorders, joint pathology, cardiac disease, developmental delays, etc.; identify Psychological problems requiring psychological/psychiatric treatment; clarify the syndromic causes and genetic etiology of hearing impairment and balance disorders.
2.2. The ability to communicate effectively with patients of all ages, including the elderly, younger children and their parents, and special patients such as: hearing impairment; low speech production due to deafness or other speech and language disorders; visual impairment, including deaf-blindness; intellectual disability; and the need for a sign language or spoken language interpreter; to clearly explain test results, treatment options, and prognosis for auditory vestibular problems to all patients and their companions. The patient and his or her caregivers are informed and make appropriate decisions (if competent to do so) by clearly explaining test results, treatment options, and the prognosis for vestibular problems.
The ability to work effectively with an interdisciplinary team is essential to the development of the otolaryngologist.
Physicians practicing otology need to work closely with audiologists, audiologists, speech and language therapists, psychologists, physical therapists, and otolaryngologic surgeons.
Otologists working primarily with children also collaborate with teachers of deaf children, educational audiologists, play therapists, and pediatricians. Broader team members also include health visitors, nurses, social workers, general practitioners, occupational therapists, and others. It is also important to connect with other medical practitioners, which often include otologists, pediatricians, geneticists, neurologists, psychiatrists, ophthalmologists, and geriatricians. Audiology internal medicine needs to be able to work effectively within an interdisciplinary team to obtain the best treatment options; gain knowledge of the various skills within the interdisciplinary team; and maintain appropriate contacts with other professionals in the hospital and in the community.
Since interdisciplinary collaboration is not possible in most hospitals and is not universal, otolaryngologists also need their own training in the following specific disciplines in order to be able to work alone and achieve satisfactory consultation and treatment, including
(1) Otolaryngology, with adequate knowledge of pathology and treatment of otologic conditions; familiarity and understanding of hearing-related otolaryngologic surgery, such as, tympanic tube placement, mastoidectomy, tympanoplasty, cochlear implantation, bone-anchored hearing aid surgery, and vestibular nerve sheath tumor surgery; proficiency in the use of otolaryngologic reference standards; knowledge of nasal, oropharyngeal, and other head, neck, and throat procedures that may affect the vestibular system and speech. knowledge of the upper respiratory tract and other head and neck disorders that may affect the vestibular system and speech.
(2) Developmental pediatrics, knowledge and understanding of child developmental characteristics and disease features, development of an appropriate and fully feasible child/family-centered approach, ability to assess the child as a whole; understanding of the different roles of the various members of the interdisciplinary child health team.
(3) Neuroscience, to provide accurate neurological assessment of the patient; to know when to refer the patient to a neurologist or neurosurgeon for a systematic evaluation and consultation, and to be able to determine in the first instance whether the disorder is neurological or otologic, and thus determine the treatment plan.
(4) Ophthalmology, to know how to screen patients with ophthalmology or ocular motility disorders, to know when to talk to patients about these symptoms, and to understand and determine the correlation between ophthalmology and otology-related organ disorders.
(5) Psychology/Psychiatry to know the psychological and psychiatric disorders associated with deafness and hearing loss and how these disorders manifest in deaf patients; to know the psychological and psychiatric disorders associated with tinnitus, hearing loss, vertigo, and imbalance; to have a thorough understanding of psychology, identify treatable conditions, and give appropriate referrals; and to have appropriate counseling skills.
(6) Child and adolescent psychiatry/psychology with a thorough understanding of child and adolescent psychiatric and behavioral disorders to be able to consult with a medical professional and to have an appropriate perspective on the child and his or her family; and an understanding of the role of the treating psychologist in the evaluation and treatment of children.
(7) Geriatrics and Nursing with a comprehensive understanding of medical disorders affecting the elderly, including falls, multisystem disorders, cognitive impairment, and visual impairment. Knowledge of the special features of geriatric care and provide helpful guidance and counseling.
(8) Immunology and allergic reactions, to understand the effects of dysregulated immunity and allergic reactions on the auditory vestibular system.
(9) Radiology, evaluate the significance and value of cranial MRI and CT imaging in the diagnosis and treatment of disorders of the auditory vestibular system. Be able to select and use imaging techniques and views for specific diseases to understand the pathophysiologic changes characteristic of the disease and the possible etiology. To communicate adequately with radiologists to achieve maximum detection of imaging features in patients with auditory vestibular disorders.
(iv) Opportunities and challenges for the development of endoacoustics in China Both in China and internationally, there is no doubt that the development of endoacoustics is in line with the current trend, the needs of a large patient population, and the inevitable trend in the development of audiology. However, the development of otology in China and the establishment of a development model and implementation system for otology that is suitable for China and in line with international practice is a daunting systemic project that faces many opportunities and challenges.
Opportunity 1: At present, there is an imbalance in the development of endo-auricular science in various countries, and endo-auricular science is an emerging discipline, so it is worthwhile to intervene early and thus reflect the contribution of Chinese scholars. In the process of developing endo-auricular science, we should have in-depth exchanges with scholars in Europe and the United States, who have developed earlier in the world, and express the opinions and views of our scholars, and jointly develop training plans and programs that meet the actual conditions of many countries, so as to achieve the goal of synchronous development and common progress with our international counterparts.
Opportunity 2: China’s large population base, the large number of patients and the lack of specialist physicians make the development of otolaryngology have huge development space and market demand opportunities. Most domestic otolaryngologists have undergone systematic training as otolaryngology residents and chief residents, and their basic knowledge is still good. Therefore, if they can add 2-3 years of training in audiology to this foundation, it is relatively easy to transform into an otolaryngologist. However, it must be noted that the practitioner must have sufficient knowledge base and love to gradually grow into a qualified otolaryngologist.
Opportunity 3: The subspecialty division of otolaryngology provides a good opportunity for the development of otolaryngology. As explained earlier, the subspecialty division of otolaryngology, head and neck science is becoming more and more detailed and mature. In otology, there are already otologic surgery and otolaryngology; in rhinology, there is rhinosurgery and the formation of rhinology; in pharyngology, there are already voice medicine and upper airway medicine; in head and neck science, there is already head and neck surgery and the formation of head and neck tumor internal chemotherapy. The division of subspecialties makes otolaryngologists to choose their own subspecialty career after 5-8 years of medical practice, and thus become specialists in specialized diseases. This process of subspecialty division will provide many opportunities for emerging specialties. Medical professionals who wish to pursue different subspecialties will be able to plan and choose at a young age, thus creating an academic climate in which subspecialties can flourish.
Despite the above-mentioned tempting opportunities, the challenges are not negligible and are very serious. According to the statistics at the end of 2007, the number of health institutions in China was 315,000, including 19,900 hospitals, 40,000 health centers, 24,000 community health service centers (stations), and 3,007 maternal and child health centers (institutes and stations). There are about 6 million medical workers in the country, serving 1.3-1.4 billion people nationwide, or 1/216. 23,000 otolaryngology, head and neck surgeons are among them, serving 1.3-1.4 billion people nationwide, meaning that there is one otolaryngologist for every 56,000 people, while the maximum estimate of specialists who can be called otologists and audiologists nationwide is not more than 1,000, to serve a national population of 1.3-1.4 billion, meaning that there may be only 1 otolaryngologist or audiology specialist for every 1.3 million people. Even so, there is no specific career position and access developed to define otologists. Just like the first author of this article who went through 10 years of training as an otolaryngologist and another 10 years of accumulating basic research on the mechanisms of deafness, transitioned to start a specialized otology ward and began working full-time as an otolaryngologist. However, how to train the younger generation? How to establish a clinical team? How to determine the title promotion and specialty direction? How to define the scope of work with otolaryngology-head and neck surgeons and audiologic technologists? Should we just let nature take its course and mix them up, so that everyone can just come and do otolaryngology treatment? In small and medium-sized hospitals where subspecialties have not yet been formed, how to implement and develop them, etc. A series of problems need to be solved one by one, and need to be gradually standardized, and need to gain the recognition and support of peers. These serious problems cannot be solved overnight, but require the efforts of several generations and the gradual development of the discipline as a whole.
Therefore, the author calls on colleagues who are interested in a lifelong career in deafness diagnosis, treatment, prevention and control to join the development of otolaryngology, to start from the smallest detail, to become professionals dedicated to this discipline, and to work tirelessly to contribute to the development of otolaryngology. The road may be winding, but the future is bright!