91 The Auditory Brainstem Response - Are South Mrican ENT's Missing the Point? Antonia Sahli, Shamim Ebrahim .and Wayne J Wilson Department of Speech Pathology and Audiology, University of the Witwatersrand, South Africa ABSTRACT The use and misuse of the auditory brainstem response (ABR) test by hearing professionals is often related to the extent and nature of the training they have received. This study used a postal survey based questionnaire to investigate the levels of training in, knowledge about, and appropriateness of referral for, ABR testing in Ear, Nose and Throat (ENT) surgeons and registrars in Gauteng, South Africa. Thirty-seven actively practising ENT specialists and registrars were sampled using a convenience sampling technique. Overall, a poor level of training and knowledge in ABR and its related areas of audiology was identified. This was mirrored by a high demand for further education. Considering the prevalence of auditory disorders in South Africa, and the push towards primary care and early intervention, this study's results highlight the need for im- proved training in ABR for ENT surgeons and registrars. OPSOMMING Die gebruik en misbruik van die ouditiewe breinstamrespons (OBR) toets deur professionele individue gemoeid met gehoor, hang dikwels af van die aard en omvang van die opleiding wat hulle ontvang het. Hierdie studie het deur middel van 'n posvraelys, die vlakke van opleiding, kennis, en toepaslikheid van verwysings vir OBR-toetsing deur 'n groep Oor-, Neus- en Keelartse (ONK) in Gauteng, Suid-Afrika, ondersoek. Sewe en dertig praktiserende ONK -artse en kliniese assistente is deur middel van 'n gerieflikheidssteekproeftegniek geselekteer. 'n Algemene gebrek aan opleiding en'n lae vlak van kennis oor OBR en verwante terreine van oudiologie is gei"dentifiseer. Terselfdertyd is daar 'n uitgesproke behoefte aan verdere opleiding. In die lig van die hoe voorkoms van gehoorprobleme in Suid-Afrika en die voorkoming en vroee interuensie, dui die resultate van hierdie studie op 'n besliste behoefte aan verbeterde opleiding oor OBR onder Oor-, Neus-, en Keelartse. KEYWORDs: auditory brainstem response, Ear Nose and Throat Surgeons and Registrars, training, knowledge. / / INTRODUCTION The auditory brainstem r~sponse (ABR) has been the mainstay ofthe advanced audiological and ENT neuro-oto- logical test battery since its cl~nical introduction in the late 1970's (Hall, 1992; Ferraro & Durrant, 1994). It is a far- field, differentially averaged, electrophysiologically re- corded signal that represents the summed and averaged responses to repeated acoustic stimulation, of thousands of nerve fibres in the VIIIth cranial nerve, and the audi- tory brainstem, thalamus and thalamocortical radiations (Hall, 1992). Clinical advantages of ABR include the fact that it is relatively easy to record, objective, non-invasive, is inde- pendent of state of subject arousal, is generally drug re- sistant, and provides ear-specific information (Hall, 1992; Musiek, Borenstein, Hall & Schwaber, 1994). Furthermore, ABR results provide reproducible, sensitive and quantita- tive clinical information that can localise lesions within the auditory pathway even when the patient's history and physical examination are normal (Chiappa & Young, 1985). As a result of its many advantages, the ABR is now es- tablished as the best audiological and oto-neurological test of the functional integrity of1eighth cranial nerve and au- ditory brainstem (the so called "site of lesion" or "diagnos- tic" ABR). In this application, the ABR has proven to be more sensitive in detecting mass lesions than a computer- ised tomography scan (but less sensitive than an magnetic resonance imaging scan), and more sensitive than any test in detecting functional lesions of the VIIIth CN and audi- tory brainstem (Hall, 1992; Stanton & Cashman, 1997). As the ABR is an accepted test of VIIIth CN and audi- tory brainstem function, it has also been widely and suc- cessfully used as estimator of hearing thresholds (the so called "threshold" ABR). In this role the ABR is used to estimate hearing thresholds in difficult to test subjects such as high risk newborn infants, the mentally and physically handicapped and psychogenic hearing losses (Hall, 1992). The ABR is not without significant limitations however. Of primary concern is the fact that the ABR is NOT a test of hearing. The perceptual act of hearing requires, at the very least, neural activity to occur in the cortex. As the ABR is a test of the VIIIth CN and auditory brainstem only, it cannot be used to comment on cortical function. The ABR cannot, therefore, be seen to reflect the conscious act of hearing (Hall, 1992; Roush & Matkin, 1994). Other ABR limitations include the need for sufficient peripheral hearing to enable accurate VIIIth CN and audi- Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 92 Antonia Sahli, Shamim Ebrahim and Wayne J Wilson tory brainstem site of lesion evaluation (Hall, 1992), and the high frequency emphasis ofthe click stimulus and less than ideal error margin (± 20 dB) when using ABR to esti- mate hearing thresholds (Eggermont, 1984; Bachmann & Hall, 1997). v Whilst there is no doubt the ABR is a powerful compo- nent of the advanced audiological and otoneurological test battery, poor knowledge of the ABR's advantages and dis- advantages have lead to its serious misuse in many clini- cal settings by both audiologists and medical doctors (Ferraro & Durrant, 1994). In a retrospective record re- view study, Holland (1996) and Downs (1996) showed 13/ 15 Southern African hearing impaired children from 15 to 74 months old to have been successfully assessed using be- havioural audiometry after being initially assessed using ABR. They concluded the initial ABR assessment to have been unnecessary and to have delayed the initiation of ap- propriate aural rehabilitation in all 13 cases. Such misuse of ABR is often related to the extent and nature of professional training in auditory evoked potentials. As Ear, Nose and Throat (ENT) specialists are often the first medical professional to be consulted about an auditory pathology, and the most likely to refer a pa- tient for ABR testing, they are the medical professionals in the most need of up-to-date and accurate ABR training. In view of the under-utilisation of ABR technology in South Africa to date, and the fact that a substantial number of ENT specialists presently practising in South Africa were trained before the peak era of ABR technology, there is a likely demand for continued ABR education of South Afri- can ENTs. Without adequate training, underutilisation and inappropriate utilisation of ABR technology will continue (Donohoe, 1988). TABLE 1: Description of respondents (n=37) Demographic Factor Sample 1. Level of Training Registrar Consultant 2. University of Graduation Cape Town Medunsa Bloemfontein Pretoria Stellenbosch Witwatersrand Other 3. Years of Practice Less than 1 year 1-3 years 4-6 years 7-10 years 10 or more years By the year 2000, South Africa's population is projected to reach 47 million, the health of whom is expected to be managed within a primary health care framework (Afri- can National Congress, 1994). In view of the potential of ABR for early identification of auditoty pathologies and hearing loss both as a screening tool and a diagnostic tool, and the emphasis in the White Paper for the Transforma- tion of the Health System in South Africa (1997) on the appropriate use of health technology, the current knowl- edge and training of South African ENTs on ABR needs to be evaluated. METHODS AIM This study used a postal survey based questionnaire to investigate ENT surgeon's and registrar's levels of train- ing in; knowledge about; and appropriateness of referral for; auditory brains tern response testing specifically, and its place within audiological site of lesion and threshold testing generally, in Gauteng, South Africa. Specifically this study aimed to: 1 Determine the extent and nature of training received by ENTs in, and; 2 Explore ENTs' perceptions regarding the adequacy of their training in; ABR testing specifically, and audiological site of lesion and threshold testing generally, and to; 3 Evaluate the referral criteria employed by ENTs for, and; 4 Determine ENTs' views with regard to their need for further training in; ABR testing specifically. Total Percentage 7 19% 30 81% 1 3% , 2 5% I 1 3% i , 10 27% ! ; 2 5% I 20 54% \ 1 3% I 3 8% I 3 8% I 9 24% 7 19% 15 41% 4. Place of Employment Government Hospital 27 73% , (n=51)* Private Practice 16 43% University 8 21% , / / / 5. Predominant Patient Population Infants (0-18 months) 34 92% (n=139)* Paediatrics (19 months - 11 years) 34 92% Adolescents (12-17 years) 35 95% Adults (18 years+) 36 / 97% * n"# 37 as respondents could reply in more than one category. ' / The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) The Auditory Brainstem Response - Are South African ENTs Missing the Point? 93 PROCEDURE Subject sampling procedure and selection criteria Subjects were sampled using a convenience sampling technique from the names of90 ENTs and ENT Registrars listed as members of the South African Society of Otorhi- nolaryngology, Head and Neck Surgery. In order to be eligible for inclusion in the survey, all sub- jects were requir~d to be either actively practising as quali- fied ENT Specialists or be ENT Registrars completing their training. Due to time and resource restraints, OI1ly sub- jects practising in Gauteng Province, South Africa, were selected. Description of subjects Of the 90 subjects who received questionnaires, 37 re- sponded yielding a response rate of 41 %. Moser and Kalton ' (1971) report that a 20-30% response rate is acceptable as a baseline of replies to mailed questionnaires, and in gen- eral, a response rate below 50% is not unusual for postal surveys. A description of the respondents is provided in Table 1. Questionnaire The questionnaire comprised of20 close ended multiple choice questions divided into five sections: demographic information (five questions); extent, nature and perceived adequacy of training in ABR and related audiological/oto- logical tests (six questions); nature of current ABR referral practises (seven questions); need and desire for additional information in various areas of ABR (two questions); and an additional comments section that allowed for open ended comments to be made. Data analysis Questionnaire responses were analysed using descrip- tive statistics. Responses to multiple choice questions were assessed for percentages of respondents choosing each re- sponse. Responses to the open ended comment question were subjectively assessed for themes common across mul- tiple respondents, or on individual comments considered to be of interest. General conclusions were then made. RESULTS The results are presented in accordance with the sub- aims formulated for the study: UNDERGRADUATE AND PROFESSIONAL TRAIN- ING Respondent's training in the field of ABR Of the 37 respondents, 19 (51%) had received formal training in the ABR. For these 19 respondents, 2 (11%) re- ceived the training during their undergraduate courses, 16 (84%) during their time as an ENT registrar, and 1 (5%) during their time as a qualified ENT surgeon. Three of the 19 (16%) had their training conducted by an audiologist and ENT, whilst the remaining 16 (84%) had their training conducted by an audiologist only. Many of the 19 respond- ents received their ABR training in multiple formats with 13 (68%) responses for formal lectures, 6 (31%) for work- shops, 4 (21%) for conferences, 5 (26%) for journal clubs, and 10 (53%) for self-reading of the literature. This train- ing was for more than 10 hours in 6 (32%) cases, between 5-10 hours in4 (21 %) cases, between 1-4 hours 8 (42%) cases, and was less than one hour in 1 (5%) case. TABLE 2: Numbers and percentages of respondents who had received training in other audiological and/or electrophysiological test~ (n=37). AydiologiC/Electrophysi~logical Test Total Percentage Visual Reinforcement Audiometry 8 22% , Conditioned Orienting Re~ponse Audiometry 3 8% , Play Audiometry I 7 19% Tangible Reinforcement' O~erant Conditioning Audiometry 2 6% Pure Tone Air and Bone Audiometry 33 92% Speech Audiometry 28 78% Site-of-Lesion Testing (e.g., Bekesy Audiometry) 10 28% Otoacoustic Emissions 11 31% i Electrocochleogra phy 6 17% Auditory Middle Latency Response 4 11% Auditory P300 Response 0 0% Auditory 40 Hz Response i 0 0% Die Suid-Afrikaanse Tydskrifvir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 94 Respondent's training in other audiological site of lesion and threshold tests Percentages of the 37 respondents who had received training in other audiological and/or electrophysiological tests are shown in table 2. PERCEIVED ADEQUACY OF TRAINING The respondents average perceived adequacy of train- ing in ABR anatomy and physiology, clinical applications, clinical limitations, interpretation, and referral criteria is shown in figure 1. Their perceived adequacy of training in audiology in general is shown in figure 2 with the five point scale from one-poor to five-excellent showing percentages of responses of 17% for one, 22% for two, 47% for three, 8% for four, and 6% for five. RESPONDENT'S CURRENT LEVEL OF REFERRAL FORABR Professional to whom respondents refer for ABR test- ing Thirty-five (94%) respondents indicated they refer to an audiologist for ABR testing. Two (3%) indicated they refer to an audiologist and neurologist, whilst 2 (3%) indicated they refer to a medical technologist. Reasons for ABR referral Fourteen (37%) respondents indicated they refer for ABR testing for threshold estimation, 9 (26%) for threshold di- agnosis (exact threshold identification), and 14 (37%) for site oflesion purposes. Confidence in ABR results The respondent's average confidence in the accuracy of ABR results for site of lesion purposes, for threshold esti- mation purposes, and for fitting of amplification, is shown in figure 3. .' • Anatomy and Physiology II Clinical applications III Clinical limitations e Interpretation o Referral Criteria FIGURE I: Average responses (O-very poor to 5-very good) for respondent's perceived adequacy of train- ing in ABR (n=19). Antonia Sahli, Shamim Ebrahim and Wayne J Wilson Access to ABR resources The respondent's level of access to ABR is shown in fig- ure 4 with the five point scale from one-low to five-high showing percentages of responses of 6% for one, 6% for two, 11 % for three, 25% for four, and 52% for five. l.. .1 (very poor) U12 03 C]4 05 (very good) FIGURE 2: Percentage of respondents in each cat- egory for perceived adequacy of training in audiol- ogy in general (n=37). o 2 3 o For fitting of Amplification III Site-of-Lesion Purposes .Threshold Purposes 4 FIGURE 3: Average responses (O-low to 5-high) for respondent's confidence in ABR results (n=37). I I 5(high) / ' FIGURE 4: Percentage of respondents in each cat- egory (I-low to 5-high) for level of access to ABR (n=37). . . The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) The Auditory Brainstem Response - Are South African ENTs Missing the Point? 95 Referral of paediatric and difficult-to-test patients for ABR thresho(d testing PRIOR to other audiologi- cal testing Twenty-four (64%) respondents said they would refer neonates (0-3 months old), 26 (69%) infants (4-18 months old), 11 (31%) toddlers (19 months - 4 years old), 3 (8%) children (5-11 years old), 12 (33%) physically disabled pa- tients, and 29 (78%) mentally retarded clients, prior to any other audiological testing. Indication for ABR testing of various pathologies, signs and symptoms Table 3 shows respondent's responses as to the indica- tion for ABR testing of various patholoiies, signs and symp- toms. NEED FOR ADDITIONAL ABR INFORMATION Respondent's perceptions regarding the type of ABR information that is required Six (16%) of the 37 respondents reported they did not, and 31 (84%) reported they did require further ABR train- ing. Of the 31 respondents requesting further ABR train- ing, 22 (70%) requested training on referral criteria for ABR, 28 (90%) on interpretation of ABR results, 25 (80%) on the clinical limitations of ABR, 30 (97%) on the clinical appli- cations of ABR,and 21 (67%) on the anatomy and physiol- ogy of ABR. Twenty-three (73%) of these 31 respondents preferred this information to be presented in a workshop format, 4 (13%) preferred a conference format, and 11 (37%) preferred a lecture format. Twenty nine (94%) of these 31 respondents preferred this information to be presented by an audiologist, whilst 1 (3%) preferred a neurologist, and 1 (3%) a medical technologist. ADDITIONAL COMMENTS In the final item ofthe questionnaire, respondents were given the opportunity to express any further comments. This question was formulated as an open-ended item. The following are comments that were recorded verbatim: "In all cases I will prefer otoacoustic emission testing prior to ABR if available." "Unavailability of ABR in my region is the main reason for my low referral rate. For screening purposes, OAE's seem to be taking over." TABLE 3: Respondent's responses (n=37) as to the indication for ABR of various pathologies, signs and symptoms (* indicates moderate and ** indicates major literature support for ABR use), PATHOLOGY Total Percentage Otosclerosis 2 6% Ossicular Discontinuity 1 3% Cochlear Pathologies * 18 50% Presbycusis '" 3 8% , Tinnitus, Vertigo, Hearing Loss ** 30' 83% / I /. Recruitment * I 16 44% Poor Speech Discriminati6n ** 21 58% I I '!bne Decay ** I 20 56% I i Intra-axial Brainstem Le$ion~** 20 56% Extra-axial Brainstem Lesions ** 20 56% Demyelinating Lesions of the Brainstem ** 23 64% Cerebral Vascular Disease in the Acute Stages 19 53% Cerebral Vascular Disease in the Recovery Stages 9 25% Hydrocephalus * 10 28% Comatose Patients '" 19 53% Intra-Operative Monitoring of Neurological Status after Brain Injury * 16 44% Intensive Care Unit Monitoring * 20 56% Die Suid-Afrikaanse Tydskrifuir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 96 "ABR is LESS important in ENT than in general and otoneurology. Developments in audiology and radiology are surpassing its diagnostic ability. The high costs of ABR will serve to limit its use in battery testing in a managed care environment." "In my opinion, MRI scanning has replaced ABR for di- agnosis of pathology regarding intra-cranial tumours, CV disease, comatose patients, M.S. ABR is suitable for threshold testing in small children and malingerers." "Depending on costs and logistics a lot more patients could be referred for ABR." "Education is very necessary for the ENT specialist." "I have chosen an audiologist to now train me in ABR because I do not know how much information others have onABR." DISCUSSION This study used a postal survey based questionnaire to investigate ENT surgeon's and registrar's levels of train- ing in, knowledge about, and reasons for referral for, audi- tory brainstem response testing. Specifically the aims of the study were to; determine the extent and nature oftrain- ing received by ENTs in, and explore ENT's perceptions regarding the adequacy of their training in, ABR testing specifically and audiological site of lesion and threshold testing generally; and evaluate the referral criteria em- ployed by ENT's for, and to determine ENT's views with regard to their need for further training in, ABR testing specifically. Thirty-seven actively practising ENT Special- ists and seven ENT Registrars from Gauteng Province, South Africa were sampled using a convenience sampling technique. Their questionnaire responses will now be dis- cussed in the order of the s.tudy's aims. UNDERGRADUATE AND PROFESSIONAL TRAINING With only 51% of the respondents having received any formal training in ABR, the precedent for poor ENT ABR knowledge was immediately set. The finding that the ma- jority (84%) of this 51 % received their training during their registrar period was not surprising considering the special- ist auditory nature of the ABR. The vast majority (87%) of respondents with ABR training were trained by an audi- ologist, whilst the remainder (13%) were trained by an ENT and audiologist. This shows that when formal ABR train- ing did occur, the professional of choice for ABR training, i.e., the audiologist, was involved. On closer examination of the 51% of respondents who had received formal ABR training, the quality of this train- ing seems questionable with the lecture (68%) and personal reading of literature (53%) methods being the dominant form of education. Audiology Curriculum Guidelines for Otolaryngologists recommend that students need to observe and participate in testing that they are involved in (Campbell, 1995). Whilst such recommendations promote the workshop method as being the ideal (Kimura, 1985; Caffarella, 1994), only 31 % of respondents withABR train- ing received it in this format. The fi.nding that only 53% of respondents with ABR training reported reading ABR lit- erature is also concerning considering the literature review is perceived as the most basic form of continuing education and a primary strategy for developing understanding and skills (Moll, 1974). Further effecting the quality of ENT ABR training is Antonia Sahli, Shamim Ebrahim and Wayne J Wilson the finding that only a minority of respondents (32%) re- ceived training that extended for a time period of greater than ten hours. Because ABR testing is continually evolv- ing technologically, continuing education programmes of less than 10 hours are unlikely to have kept the respond- ents up to date in the field (Kimura, 1985). Such brief durations of training commonly educate solely in terms of clinical applications, and run the risk of generating false senses of competence (Kimura, 1985). Whilst ABR training was generally poor, overall train- ing in audiology was somewhat improved, but was still far from ideal (table 2). Whilst the majority of respondents (as many as 92%) had received training in basic audiological procedures, only a minority of respondents (as few as 0%) had received training in all areas of diagnostic and thresh- old audiology. This result is concerning considering the well accepted fact that a test battery approach is vital in any assessment of hearing (Hecox & Jacobson, 1984; ASHA, 1989). With the increased recognition of ABR as an effective screening method for evaluating hearing in young infants, such incomplete knowledge of audiological test procedures also puts ENTs at risk of inappropriately referring for, or over-utilising, electrophysiological tests in lieu of classic behavioural methods. Such a problem would be consistent with literature reports of inappropriate referrals of chil- dren aged five to 74 months for immediate ABR testing when behavioural audiometry was the preferred first test of choice (Widen, 1990; Hodgson, 1994; Downs, 1996; Hol- land, 1996). A comprehensive knowledge of all audiological tests is required by ENTs because, in certain clinical appli- cations, these tests surpass ABR in terms of their diagnos- tic and threshold capabilities (Cornacchia, Viglian & Arpipini, 1982; Folsom, 1990; Hall, 1992). Overall, the "extent and nature of ABR training received by ENTs" results suggest that the current education of ENT's in terms of ABR specifically, and audiology gener- ally, is unsatisfactory and supports the many literature reports of a shortage of clinical training opportunities for those who are no longer attending academic institutions (Hall, 1992). PERCEIVED ADEQUACY OF TRAINING Whilst the "extent and nature of ABR training received by ENTs" results suggest that the current education ofE~T's in ABR is unsatisfactory, on average respondents who had received prior ABR training perceived this training to bk of a generally good standard (Figure 1). This was particul~rly true in the areas of clinical applications of ABR, less s6 in the anatomy and physiology, clinical limitations and refer- ral criteria of ABR, and not so for interpretation of ABR. Such results are useful in further identifying the areas of ABR knowledge that the ENTs themselves perceive as be- ing their most inadequate. Whilst those ENTs who have received formal ABR train- ing perceived it to be of a generally high standard, on aver- age, the majority of all ENT respondents (86O/~felt their overall adequacy of training in audiology in general was av- erage to very poor (Figure 2). This perception/was supported by the low numbers of responses given -(as low as 0%) for actual training received in many ~f the audiological tests listed in table 2. Such poor perceived and actual training in audiology does not provide a good platform for training in more advanced audiological procedures such as ABR. The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) The Auditory Brainstem Response -Are South Mrican ENTs Missing the Point? 97 RESPONDENT'S CURRENT LEVEL OF REFERRAL FORABR All respondents indicated that they refer for ABR test- ing, with the overwhelming majority (97%) referring to an audiologist. Considering the poor level of knowledge of ABR amongst the ENTs surveyed, the fact that they are all re- ferring for ABRs is concerning. The concurrent finding that these referrals ~re to audiologists predominantly is reas- suring, however, as it provides a safety net for the filtering of unnecessary referrals. Reasons for referring for ABR, and confidence in ABR results, were less promising with 63% of the respondents stating that they refer for threshold estimation or thresh- old diagnosis purposes, compared to only 37% for site-of- lesion testing. Similarly, respondent's confidence in ABR results was, on average, higher for threshold assessments than for site of lesion assessments (Figure 3). These find- ings do not comply with the literature that states the ABR is at its most sensitive and specific when used as a site of lesion tool in an audiologicallotoneurological test battery, and is less sensitive and specific when used as a threshold estimation tool (Hall, 1992; Stanton and Cashman, 1997) where the ABR's subcortical properties and poor accuracy in estimating hearing thresholds prevent it from being a true test of hearing (Weber, 1994). The poor confidence, on average, in ABR as a useful tool in hearing aid fitting was consistent with the literature (Kileny, 1982; Gorga, Beuchaine & Reiland, 1987; Seitz & Kisiel, 1990). Following on from the skewed preference for ABR use as a thresholding tool, was the 69% of respondents who indicated that they would immediately refer an infant (4- 18 months) for ABR testing without obtaining prior behav- ioural measurements. This data conflicts with abundant literature on infant paediatric audiological testing which asserts that it is in the neonatal (0-3 months) population that the clinical applications of ABR measurements are especially salient (ASHA, 1989; Folsom, 1990; Joint Com- mittee on Infant Hearing, 1991; Sininger, Abdala & Cone- Wesson; 1997), whilst behavioural audiometry is preferred for,children who are old enough to be conditioned (gener- ally over four months old) (ASHA, 1991). The numbers of respondents who would immediately refer toddlers (19 months to 4 years) (31 %), children (5 to 11 years) (8%), and • J the mentally and the physically retarded (78%) for ABR assessment were more in lib.e with relevant ABR guide- lines (Silman & Silverman, ]991; Hall, 1992; Hood, 1995), but still demonstrated an oveteagerness for immediate ABR referral. ; /' In agreement with the poor ABR knowledge levels shown previously was the respondents poor responses to appro- priate and non-appropriate indicators for ABR referral (ta- ble 3), despite the literature coverage of this area being extensive (Hall, 1992; Musiek et aI., 1994; Hood, 1995; Stanton & Cashman, 1997). The major ABR indicators (listed as tinnitus, vertigo and hearing loss) and contraindicators (listed as otoschlerosis, ossicular discon- tinuity and cerebrovascular disease) were well identified (as high as 83%), but many respondents missed (as low as 8%) other, less obvious, direct and indirectABR indicators (listed as poor speech discrimination, tone decay, intra and extra-axial brainstem lesions, and demylinating lesions of the brainstem, cochlear pathologies, presbyacusis, recruit- ment, hydrocephalus, comatose patients, intra-operative monitoring after brain injury, and ICU monitoring). Whilst the respondents showed evidence of poor ABR knowledge and training, most (88%) (figure 4) also reported having an average to high access to ABR. Such accessibil- ity reinforces the need for appropriate education to pre- vent the underutilisation of, and inappropriate referral for, ABR testing. Overall, the "respondent's current level of referral for ABR" results were consistent with the "extent and nature of ABR training received by ENTs" results and further suggest a need to improve ENT knowledge of ABR specifically, and audiology generally. NEED FOR ADDITIONAL ABR INFORMATION The respondents showed an overwhelming desire (84%) for additional information and gave strong indications of the areas they want covered and the way the information should be presented. According to the majority of ENTs surveyed in this study, ABR education in the ENT popula- tion needs to be: - Primarily in the areas of interpretation, clinicallimita- tions and clinical applications of ABR, then in referral criteria, and then the anatomy and physiology underly- ing the technique. - Presented in practical workshops rather than confer- ences and lectures. - Presented by audiologists. ADDITIONAL COMMENTS These verbatim responses indicated that some respond- ents in the study felt that both oto-acoustic emissions as well as magnetic resonance imaging were transcending ABR in terms of their diagnostic abilities in both audiology and otoneurology. However, in direct contrast to this, other re- spondents also indicated that because of its high cost and inaccessibility, ABR is not sufficiently employed. Lastly, the need for further training was also highlighted. Respond~ ents thus again, appeared willing and motivated to increase their knowledge with regard to ABR. This has implications for the provision of future education. CONCLUSIONS Overall, a poor level of training and knowledge in ABR and its related areas of audiology, was identified in the sur- veyed ENT specialists and registrars in Gauteng. This find- ing was mirrored by a high demand amongst the respond- ents for further education in ABR technology, preferably in a workshop format run by a qualified audiologist. This demonstrated willingness amongst ENTs to further their working knowledge of ABR places the responsibility for this education back on the South African audiology com- munity. The South African audiology community needs to be more active in its attempts to make a larger contribu- tion to the audiological education of its ENT allies, both at undergraduate and postgraduate levels. The ABR remains essential to the modern practice of hearing medicine. Its proliferation in the last 20 years, and the often limited expertise of its users, has seen the ABR become both over and underutilised in the clini~al setting. Considering the prevalence of auditory disorders in South Africa, it is hoped that this study's results will heighten the need for improved awareness of ABR in ENT surgeons Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 98 and registrars. An improved awareness will motivate in- creased training in ABR, the enforcement of correct refer- ral guidelines, and further research into ABR and related areas. Such endeavours are likely to lead to a refined use of ABR in South Mrica, which in turn should result in im- provements in the provision of hearing health care to the population at large. Limitations of this study include the relatively small and restricted ENT population sampled. These limitations pre- vent this study's results from being generalised beyond the ENT surgeon and registrar population practising in Gauteng, South Mrica. Note: The questionnaire used in this study is available on request from the corresponding author; Wayne Wilson, Department of Speech Pathology and Audiology, Univer- sity of the Witwatersrand, Private Bag 3, WITS, 2050, South Africa. Email: 053wayne@muse.wits.ac.za. REFERENCES African National Congress. (1994). A National Health Plan for South Africa. Johannesburg: African National Congress. American Speech, Language and Hearing Association. (1989). Guidelines for audiological screening of newborn infants who are at risk for hearing impairment. ASHA, 31,89-92. American Speech-Language-Hearing Association. (1991). Guide- lines for the audiological assessment of birth through 36 months of age. ASHA, 33 (suppl.5), 37-43. Bach~ann, K.R. & Hall, J.W. (1997). Paediatric auditory bramstem response assessment: The cross-check principle twenty years later. Seminars in Hearing, 19,41-60. Caffarella, RS. (1994). Planning Programs for Adult Learner.s. San Fransisco: Jossey-Bass Inc. Campbell, KC. (1995). Audiology curriculum guidelines for otolaryngologists. American Journal of Audiology, 4, 35-36. Chiappa, KH. & Young, RR. (1985). Evoked Responses: Over- used, Underused, or Misused? Archives Neurology, 42,76-79. Cornacchia, L., Viglian, E. & Arpipini, A. (1982). A comparison between brainstem evoked response audiometry and behav- ioural audiometry in 270 Infants and Children. Audioloay 21 359-363.' b' , Donohoe, C.D. (1988). Application of the brainstem auditory evoked response in clinical neurologic practice. In Owen, J.H. & Donohoe, C.D. (Eds.), Clinical Atlas of Auditory Evoked Potentials. New York: Grune and Stratton. Downs, D. (1996). A retrospective study orunnecessary and neces- sary .use of auditory brainstem response testing in paediatric heartng assessment. Paper presented at the Pan African Fed- eration of Oto-Rhino-Laryngological Societies 3rd Scientific Meeting, 27 October - 01 November 1996 Du;ban South Af- rica. ' , Eggermont, J.J. (1984). The inadequacy of click-evoked and brain stem responses in audiological application. Annuals of the New York Academy of Science, 388, 707-709. Ferraro, ~.A. & Durrant, J.D. (1994). Auditory evoked potentials: OvervIew and basic principles. In Katz, J. (Ed.), Handbook of Clinical Audiology (4th ed.). Baltimore: Williams and Wilkins. Antonia Sahli, Shamim Ebrahim and Wayne J Wilson Fol~om, R~. (1990) .. Identification of hearing loss in infants us- mg audItory bramstem response: Strategies and progra choices. Seminars in Hearing, 11, 333-341. m Gorga, M.P., Beuchaine, KA. & Reiland, J.K (1987). Compari_ so~ o~ onset and steady state. responses of hearing aids: Im- phcatlOns for use of the ABR m the selection of hearing aid Journal of Speech and Hearing Research, 30, 130-136. s. Hall, J.W (1992). Handbook of Auditory Evoked Responses. Bos- ton: Allyn and Bacon. Hecox K & Jacobson, J.T. (1984). Auditory evoked potentials. In Northern, J.L. (Ed.), Hearing Disorders. 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Social Inves- tigation. (2nd ed.). London: Heinemann. Musiek, F.E., Borenstein, S.P., Hall, J.W & Schwaber, M.K. (1994). Aud~tory brains~em response: Neurodiagnosis and intra-op- eratlve apphcatlons. In Katz, J. (Ed.), Handbook of Clinical Audiology (4th ed) .. Baltimore: Williams and Wilkins. Roush, R, & Matkin, N.D. (1994). Infants and Toddlers with Hearing Loss: Family Centred Assessment and Intervention. Baltimore: York Press Inc. Seitz, M.R & Kisiel, D.L. (1990). Hearing aid assessment and the auditory brainstem response. In Sandlin, R. (Ed). Hand- . ?ook of Hearing Aid Amplification. Boston: College Hill Press. Smmger, Y.S., Abdala, C. & Cone-Wesson, B. (1997). Auditory thresho~d sensit~vity of the human neonate as measured by the audItory bramstem response. Hearing Research 104 27- 38. ' , Silman, S. & Silverman, C.A.(1991). Auditory Diagnosis: Princi- ples and Applications. New York: Academic Press. Stanton, S.G. & Cashman, M.Z. (1997). ABR: A comparison of different strategies for detection of cerebellopontine angle tumours. Scandinavian Audiology, 25, 109-119. , Weber, B.A. (1994). Auditory brainstem response: Threshold es- timation and auditory screening. In Katz, J (Ed.). Handbook of Clinical Audiology (4th ed.). Baltimore: Williams and Wilkins. . White ~aper for the Transformation of the Health System in South Afnca. Government Gazette No 1108 of 1997. Pretoria: 'Gov- ernment Printers. ", Widen, J.E. (1990). Behavioral screening of high-risk infant~ us- ing visual reinforcement audiometry. Seminars in Hea~ing 11, 343-348. I ' The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) INFORMATION FOR CONTRIBUTORS 1. Nature of publication The South African Journal of Communication Disorders pub- lishes reports and papers concerned with research, and criti- cally evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disor- ders, service provision, training and policy. The South African Journal of Communication Disorders will not accept material which has been published elsewhere or that is currently under review by other publications. 2. Manuscript style and requirements • Articles must be accompanied by a covering letter provid- ing the author's address, telephone and fax numbers and e- mail address. • Articles must be typed on A4 pages in double spacing and in a font size of 12. • Three print-outs of the article must be submitted. • ONE exact copy of the article on disk must be submitted. 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REFERENCES • References must be cited in the text by surname of the au- thor and the date, e.g., Van Riper (1971). • Where there are more than two authors, after the first oc- currence, et al. may be used from the start. , • The names of all authors must appear in the Reference List;' which must be listed in strict alphabetical order in triple spacing at the end of the article. • All references must be included in the List, including sec- ondary sources, (APA Pub. Man. 1983, p. 13.) ,. Only acceptable abbreviations of journals may be used, (see DSH ABSTRACTS, October; or The World List of Sci~ntific Periodicals). • The number of references should not exceed much more than 30, ·unless specifically warranted. EXAMPLES Locke, J.L. (1983). Clinical Psychology: The explanation and treatment of speech sound disorders. J. Speech hear. Disord., 48 339-341. Penrod, J.P. (1985). Speech discrimination testing. In J. Katz (Ed.), Handbook of clinical audiology (3"d ed.). 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