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Opinions on referral guidelines from audiology to ent

But we are still not treating children early enough, and we are hardly reaching adults at all! Opening up referral routes Whilst there is a way to go before NICE guidance fully meets the needs of all patients who would clinically benefit from cochlear implantation, we as professionals need to use the existing mechanisms already open to us more effectively.

We can significantly improve patient outcomes by early referral, efficient assessment and timely treatment. The National Service Specification, for instance, has opened up referral opportunities beyond the original ENT consultant only, to now include general practitioners GPsNHS and private audiology services, and paediatricians. This is already tried and tested in some centres, and has led to a significant increase in referrals.

Ear, Nose & Throat (ENT) and Audiology Service

Age at implant can be improved further The most common age at implant for children on our programme went down from three years of age in 2006 to one year of age in 2009.

This may be attributed to the introduction of the Universal Newborn Hearing Screening programme in 2006. Whilst a significant proportion of our paediatric referrals are for later onset opinions on referral guidelines from audiology to ent losses or immigrant populations who have failed to receive care earlier abroad, there remain many young babies and children who are referred late for a whole host of reasons, including management of complex medical conditions or additional difficulties.

Paediatric challenges Hearing impaired babies and children can present challenges which frustratingly disrupt a smooth and timely assessment pathway, including difficulties in testing, recurrent middle ear conditions and hearing aid intolerance. The result is that babies and young children can still wait too long for diagnosis, correct hearing aid management, treatment of middle ear conditions and referral to a CI centre.

Furthermore, evidence has shown a 10 year gap between an adult becoming aware of their hearing difficulties, and their seeking help. There is also a paucity of information available for adults. Areas for improvement Two key areas for improvement are identified: What are we doing? To provide more accessible information for prospective patients, we have developed a DVD which covers the whole process from assessment, through surgery to long-term support.

We continue to promote early referral for paediatrics, with Refer Me Early leaflets which explain our support for very young babies.

Reducing inappropriate ENT referrals

For adults, we have developed a simple leaflet on auditory implantation, aimed at GP and ENT waiting rooms and we are introducing training for GPs. Contact us at naip. What can you do? As referring professionals, there is much you can do to help your implant programme ensure your patients are assessed and treated in a timely fashion.

Our referral guidelines are available at www. Acceptability, benefit and costs of early screening for hearing disability: Cochlear Implants in the United Kingdom: Cochlear Implants International 2013;14 S1: Declaration of Competing Interests: At what point should the referral be made?

Babies and young children: Although we may not see them until they are four to six months of age, we will work with local services in the interim to provide support and advice.


Early fitting of hearing aids remains essential. Ideally, they will attend their first CI assessment with hearing aids set to optimum levels, well-fitting ear-moulds and where possible, clear middle ears.

However, do not delay referral if challenges arise in reaching this point, or contact your local CI centre for local arrangements. Information required The referral should comprise appropriate medical history, unaided hearing test results including 2 and 4kHz where possibleand evidence of hearing aid trial.

What are the NICE criteria for cochlear implantation? Speech, language and listening skills which are below appropriate for age, developmental stage and cognitive ability. Valid hearing aid trial A valid hearing aid trial consists of regular use of optimally fitted hearing aids with well-fitting ear moulds for a specific period of time.

NICE guidance stipulates a three month minimum trial, where appropriate. The duration of the trial can be flexed if clinically appropriate. We can accept referrals whilst the trial is ongoing.

Outpatient Clinics

Referrals are encouraged where severe to profound functional deafness is suspected. An audiogram does not always reflect the difficulty a patient may have in hearing. We will need evidence of reliable and consistent hearing levels on at least two occasions prior to implantation, so the level and accuracy of local hearing tests can really help to minimise the number of visits required to the CI centre.

Measure the level of sensorineural hearing in the absence of a conductive overlay wherever possible. Treat middle ear congestion and infection proactively and without delay. Middle ear suction can cause temporary threshold shift and thus over-estimate hearing loss. Any ABR assessment undertaken immediately following suction should be interpreted with caution. CI cannot proceed until this has been fully supported, due not least to the possibility of rejection and non-compliance following surgery.