Survey on the State of Otoneurology in Spain | Acta Otorrinolaringológica Española

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] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Encuesta sobre la situación de la otoneurología en España" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1056 "Ancho" => 1620 "Tamanyo" => 77735 ] ] "descripcion" => array:1 [ "en" => "Rotation times of interns in otoneurology in 37 of the 40 hospitals that have an otorhinolaryngology training programme." ] ] ] "textoCompleto" => "IntroductionOtoneurology covers a broad range of common pathologies.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> It originated in Ear, Nose and Throat Neurology, and was formally recognised more than 50 years ago. It studies the vestibular system and its interactions with the central and peripheral nervous systems to maintain oculocephalic coordination, balance and spatial orientation. The first otoneurological society appeared in the United States in 1963, and since then, different training programmes have emerged which, in a non-standardised way, offer instruction in this field.In 1995, the American Council of Graduate Medical Education approved the sub-speciality of otology–otoneurology, with a common structure and content in all of its training programmes in the USA.<a class="elsevierStyleCrossRefs" href="#bib0090">2,3</a> Nevertheless, otoneurology, like other medical specialities, originated in Europe in the second half of the 19th century thanks to the development of large hospitals in the continent, such as Hospital de Salpêtrière in France, the Hospital General in Vienna or Guy's Hospital in London.This process is the logical outcome of increasing knowledge in the field of medical sciences. It was achieved thanks to pioneers who with few technical resources and much effort opened up the way for what are now different medical specialities and sub-specialities.<a class="elsevierStyleCrossRef" href="#bib0100">4</a>In the case of otoneurology, we have to underline the importance of Jean Pierre Flourens (1794–1867), who, surpassing the anatomical studies of the inner ear by Corti and Scarpa, and using the physiological observations of Purkinje, paid special attention to the physiology of the semicircular ducts, differentiating the vestibular and auditory functions of the inner ear.<a class="elsevierStyleCrossRefs" href="#bib0105">5,6</a>Friedrich Leopold Goltz (1834–1902) stands out too in this line of physiological research. He postulated that the hydrostatic pressure of the endolymph played a role in the stimulation of the ampullary nerves; this research was continued by his disciple Ernest Julius Richard Ewald (1885–1921), who, after exhaustive and meticulous work, established the well-known “Ewald's laws”, the basic pillars of vestibular physiology that, with few modifications, are still valid.<a class="elsevierStyleCrossRefs" href="#bib0110">6,7</a>Another of the outstanding researchers who contributed to the construction of what is now otoneurology was Josef Breuer (1842–1925), a clinician and researcher who introduced the concept of receptors that respond to the force of acceleration, located in the semicircular canals.<a class="elsevierStyleCrossRefs" href="#bib0100">4,6,7</a>All of the information about vestibular physiology made available before 1914 would be subsequently used by Robert Barany (1876–1936) to create the works that led him to win the Nobel Prize for Medicine in that year. His research led to the birth of modern otoneurology.<a class="elsevierStyleCrossRefs" href="#bib0110">6,7</a>Nevertheless, among all of the precursors and founders of otoneurology as a science, the figure of Prosper Ménière (1799–1862) stands out. His work “Mémoire sur des lésions de l’oreille interne donnant lieu â des symptômes de congestion cérébrale apoplectiforme”, which was presented to the Imperial Academy of Medicine, Paris, in January 1861, means that he can be considered to be the father of otoneurology. Ménière postulated that the disease which today bears his name originated in the inner ear and not in the brain, as was then believed.<a class="elsevierStyleCrossRefs" href="#bib0110">6–11</a>In our own country, Spain has 2 world-famous figures in the field of otoneurology, doctor Santiago Ramón y Cajal (1852–1934) and his disciple Dr. Rafael Lorente de No (1902–1990). Both had brilliant careers in the field of histological and physiological vestibular research, and their discoveries in this area played a fundamental role in attaining the current level of knowledge about vestibular physiology and its connections to the brain.The period in which otoneurology may be said to have developed into an independent discipline in Spain dates from the start of the 20th century, when brilliant ear, nose and throat specialists appeared and made major contributions to the field. These include Dr. Ricardo Botey (1855–1927), Dr. Antonio García-Tapia (1875–1950) and most especially Dr. Adolfo Azoy (1901–1988), who in 1948 published El Vértigo: Estudio Fisiopatológico, a work ahead of its time and the first book in Spanish to be completely devoted to this material.<a class="elsevierStyleCrossRefs" href="#bib0110">6,12</a>More recently, special mention should be made of Dr. Vicente Honrrubia (1934), whose clinical and research career mainly took place in the UCLA School of Medicine in the United States, as well as Dr. César Gavilán Alonso (1929–2004), Dr. Miguel Ciges Juan (1933) and Dr. Juan Bartual Pastor (1937) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0145">13</a> Dr. Bartual is the otorhinolaryngologist who has contributed the most to the development of otoneurology in Spain over the recent years. Due to his intense scientific and research work, as well as his organisation of many congresses in this field and active participation in the same, together with his fundamental books on the subject, he has been and will be an example for all specialists with a vocation for otoneurology.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>His legacy is now being continued by many of the neurologists he helped to train, ensuring that this speciality will remain in good health in the future.The Aim of This StudyThe overall aim of this study is to examine the current situation of otoneurology within the Spanish Sistema Nacional de Salud (SNS) (National Health System).MethodsThis is a descriptive and qualitative study. Information was obtained by means of a survey sent using the mailing list of the Sociedad Española de Otorrinolaringología (SEORL) to all the Heads of Department or otherwise, the Section Heads of SNS hospitals and centres that work with them.The survey was anonymous and contained 23 multiple-choice (<a class="elsevierStyleCrossRef" href="#sec0040">Appendix A</a>) questions, which for statistical purposes were transformed into 66 variables. It was sent out on 24 May 2013, and replies had to be sent in within 30 days.The questionnaire structure aimed to investigate specific aspects of the practice of otoneurology in Spain, with special emphasis on the following points:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Who practices it, and where (questions 1–6).</li><li class="elsevierStyleListItem" id="lsti0010">-How is it practiced (questions 7, 9, and 11).</li><li class="elsevierStyleListItem" id="lsti0015">-The resources it uses (questions 8, 10, 12, and 13).</li><li class="elsevierStyleListItem" id="lsti0020">-Teaching activity (questions 14–17).</li><li class="elsevierStyleListItem" id="lsti0025">-Scientific production (questions 18–23).</li></ul>The replies were received using Google Docs by an on-line link, which in turn transformed them into an Excel database. From here they were checked one by one and then sent to the SPSS v17 statistical programme for processing.All of the surveys that may have been duplicated were eliminated. The criterion for duplication was that 2 surveys were exactly the same and had been sent in at least 1min apart. This is because the same survey may have been sent in twice by accident. Neither were those surveys which contained less than 80% of the required information taken into account.A total of 115 questionnaires were received, of which 10 were eliminated, 2 due to the suspicion of duplication and 8 because they contained less than 80% of the requested information. Finally the information contained in 105 questionnaires was used.ResultsThe answers given by different types of hospitals, according to their size, were homogeneous (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). More than half of them (60) were university hospitals.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Fifty-nine of the hospitals that answered the survey have an otoneurology unit, although only they are only recognised as such within the organisational chart of the hospital in 34 of these. Of the university hospitals, 68% have a unit.When the hospitals with no otoneurology were asked whether they considered one to be necessary, in 70% of cases (33 of the 45 hospitals that do not have an otoneurology unit), it was considered to be either necessary or very necessary (24 and 9 hospitals, respectively). The need for an otoneurology unit increased proportionally to hospital size; thus 30% of the hospitals with 200 or fewer beds did not consider one to be necessary, while this percentage fell to 5% in hospitals with more than 800 beds.Of the 12 hospitals that do not have a unit and do not consider one to be necessary, 11 have fewer than 400 beds.Regarding the number of specialists who work in the otoneurology surgery, 2 specialists do so in the majority of hospitals (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The larger the hospital, the higher the number of specialists who work there.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The majority of the work involved in this sub-speciality covers vestibular pathology and hearing loss in adults, while only half of the hospitals work in the field of paediatric hearing loss (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Of the equipment used, videonystagmography is the most common vestibular examination instrument in the hospitals that answered the survey. It is followed, in order of frequency, by cervical myogenic evoked vestibular potentials, dynamic posturography and static posturography (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Other resources, such as Semont's manoeuvre, electrocochleograph or the self-rotating vestibular test, are used in very few hospitals (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia>Instrumental vestibular rehabilitation is only used in 30 hospitals, i.e., in only half of those which have an otoneurology unit. A dynamic platform is used for this in 20 hospitals, while 12 use a static platform. Only 7 hospitals use Semont's manoeuvre (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). It should be underlined that only 7 hospitals have a rehabilitator, while 5 have a physiotherapist.<elsevierMultimedia ident="fig0035"></elsevierMultimedia>The time spent with each patient is most often from 5 to 20min, while the duration mentioned most frequently in different hospitals is from 11 to 15min (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<elsevierMultimedia ident="fig0040"></elsevierMultimedia>In almost half of the hospitals, assistance is provided by a technical assistant, and in a quarter of them, by an auxiliary nurse; there are practically no psychologists or psychiatrists within the unit, as the unit has the aid of a psychiatrist in only 2 hospitals, while 2 are aided by a psychologist.Respecting teaching work in the field of otoneurology, 40 of the hospitals which answered the survey train interns in otorhinolaryngology. The time spent in the unit by interns is shown in <a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>. In 10 hospitals, the interns do not rotate through otoneurology, as rotation there is simply through otology–otoneurology. Of these 40 hospitals, 32 (80%) have an otoneurology unit.<elsevierMultimedia ident="fig0045"></elsevierMultimedia>Finally, the data on scientific production with the field of otoneurology are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>. In half or more of the hospitals that answered the survey, no papers or publications have been presented in Spain in the last 3 years. An even higher percentage of the hospitals answered in the negative when they were asked about international studies. On the other hand, only 11% of the hospitals had mentored a doctoral thesis or undertaken research work in connection with otoneurology during the last 3 years<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionThe most important qualities in a survey are reliability and validity. Reliability measures the capacity of an instrument to supply consistent measurements, i.e., results that are similar when it is used by different researchers or by the same researcher for the same subjects. Validity refers to the capacity of a questionnaire to measure the material for which it was designed.<a class="elsevierStyleCrossRef" href="#bib0150">14</a>In our case and due to the nature of the survey, it is to be expected that the resulting data will be valid; nevertheless, its reliability would have to be studied by using a specially designed additional test or other instruments parallel to the survey. The data obtained in this survey have therefore to be accepted with caution.Nevertheless, and in spite of the fact that this is a qualitative study, some data indicate that the information obtained by it should be taken into account.Firstly, a large number of replies were received. According to the National Catalogue of Hospitals for the year 2013,<a class="elsevierStyleCrossRef" href="#bib0155">15</a> in December 2012 there were 255 hospitals in the SNS; in this survey, we received valid replies from 105 hospitals, so that we can conclude that replies were received from approximately 40% of SNS hospitals.On the other hand, in 2012 there were 68 hospitals accredited for teaching interns in otorhinolaryngology,<a class="elsevierStyleCrossRef" href="#bib0160">16</a> of which 40 took our survey. This means that information was obtained from 59% of the hospitals which teach otorhinolaryngology at postgraduate level.We therefore consider the information obtained and presented here to be relevant. We would like to underline the following points:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">•More than half of the hospitals which answered the survey (59 hospitals) have an otoneurology unit, although only half of them are recognised within the hospital organisational chart.</li><li class="elsevierStyleListItem" id="lsti0035">•The majority of hospitals without an otoneurology unit believe one to be necessary (72% of the hospitals which have no otoneurology unit consider one to be necessary or very necessary).</li><li class="elsevierStyleListItem" id="lsti0040">•The item of technical equipment used the most in these units is, outstandingly, the videonystagmograph.</li><li class="elsevierStyleListItem" id="lsti0045">•Only half of the hospitals with the potential capacity to offer instrumental vestibular rehabilitation do so.</li><li class="elsevierStyleListItem" id="lsti0050">•In more than 30% of the hospitals, the average time spent with patients who consult is from 11 to 15min.</li><li class="elsevierStyleListItem" id="lsti0055">•The time spent by interns in otoneurology is usually from 1 to 3 months.</li><li class="elsevierStyleListItem" id="lsti0060">•80% of the hospitals with a training programme for interns in otorhinolaryngology have an otoneurology unit.</li><li class="elsevierStyleListItem" id="lsti0065">•There is generally very little scientific production, and it is concentrated in a very small number of specific hospitals.</li></ul>Based on the analysis of this information, we are able to confirm that otoneurology is a consolidated sub-speciality in our country. This was to be expected, given the high prevalence and in many cases the complexity of the pathology they cover, as these lead to its being studied in units with accumulated experience in diseases of this type.In fact, the creation of units specifically for this field was generally considered to be highly recommendable. Debate is still required on where they should be and the minimum human and material resources that they would require. Although these criteria are necessary, they are yet to be determined. These questions will have to be analysed in the future by the Otoneurology Commission.We believe that in the centres where certain members of staff work exclusively in this field, this should be recognised within the organisational chart of the ear, nose and throat service or section, as well as the chart of the hospital itself. This would ensure they receive proper support to allow them to work in the best possible way; this support runs from granting the necessary time for them to see otoneurological patients (at least 30min for their first visit and 15min for check-ups), to a minimum supply of technical and human resources.One of the most frequent problems is probably the lack of sufficient staff and time to attend to a complex and growing group of patients. This eventually finds expression in the incapacity to perform other parallel activities, such as keeping proper records of information, designing personalised programmes for vestibular rehabilitation or offering clinical check-ups for patients. In turn, this situation probably also leads to the lack of scientific work or research projects, both of which, as was shown, should be encouraged.On the other hand, in spite of the fact that in all of the teaching hospitals the interns rotate through the otoneurology unit (or the otology-otoneurology unit in those hospitals where both fields are covered without distinction), the time they spend seems to us to be insufficient, given that the majority only spend 3 months here during their whole internship. This period is clearly very short if the prevalence and complexity of this pathology is taken into account, as well as the large number of instrumental studies which future specialists have to learn.Following this first step to discover the current state of things within the field of otoneurology, the Otoneurology Commission of the SEORL intends, with the support of all the specialists who work in this field, to establish general guidelines for specific aspects. These include the minimum conditions that a unit must have to be considered as such, obtaining formal recognition of the speciality, recommending minimum times for seeing these patients to the administration, recommending the training time that interns should spend on otoneurology, and continuing to seek ways of increasing scientific production within this field.ConclusionsThis survey confirms that otoneurology is a consolidate sub-speciality in our country. In fact, the majority of hospitals that lack an otoneurology unit consider one to be necessary.Specific aspects in connection with planning the work of otoneurology in the future have yet to be determined. These include setting minimum times for patient visits, deciding on the criteria for hospitals which should have a unit, or stipulating the minimum human and material resources which such units must have.It is also recommendable to improve teaching structure and promote scientific production.We hope that the information included in this study will be used as the starting point in undertaking these important tasks.Conflict of InterestsThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres588187" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec603954" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres588186" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec603955" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "The Aim of This Study" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Methods" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of Interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-15" "fechaAceptado" => "2014-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec603954" "palabras" => array:4 [ 0 => "Otoneurology" 1 => "Neurotology" 2 => "Neurotology trends" 3 => "Neurotology organisation and administration" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec603955" "palabras" => array:4 [ 0 => "Otoneurología" 1 => "Neurotología" 2 => "Tendencia en neurotología" 3 => "Organización y administración en neurotología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Otoneurology is a sub-specialty of otolaryngology–neurology, which has experienced extraordinary progress in the last 50 years and is currently fully consolidated in our environment.Through this study, prepared by the Otoneurology Commission of the Spanish Society of Otorhinolaryngology (SEORL), we have attempted to design an approach to provide information on what the current situation regarding the exercise in Spain is, trying to determine who practice it and where, what resources are available and what the teaching and scientific productions are.The results obtained are generally satisfactory and reflect the strength of the exercise of otoneurology. The number of centres with otoneurology units is significant and the majority of centres that lack such a unit consider it necessary. However, there are aspects to be established, related to minimum requirements for its performance in satisfactory conditions, as well as determining future guidelines to ensure improved teaching and increased scientific production." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La otoneurología es una subespecialidad de la otorrinolaringología-neurología que ha experimentado avances extraordinarios en los últimos 50 años y que en este momento se encuentra plenamente consolidada en nuestro medio.Mediante este trabajo, elaborado por la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología (SEORL), se ha querido hacer una aproximación que aporte información sobre cuál es la situación actual en cuanto a su ejercicio en España, tratando de determinar quién la practica y dónde, con qué medios se cuenta y cuál es la actividad docente y la producción científica.Los resultados obtenidos, en general, son satisfactorios y reflejan la solidez del ejercicio de la otoneurología. El número de centros que cuentan con Unidad de Otoneurología es significativo, y la mayor parte de centros que carecen de unidad la consideran necesaria. No obstante, quedan por establecer aspectos relacionados con los requerimientos mínimos para su ejercicio en condiciones satisfactorias, así como establecer las directrices futuras que garanticen la mejora en la docencia y el incremento en la producción científica." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "Member of the Otoneurology Commission of the SEORL-PCF." "identificador" => "fn1" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Alemán-López O, Pérez-Garríguez H, Pérez-Vásquez P, Arán-González I, Martin-Sanz E. Encuesta sobre la situación de la otoneurología en España. Acta Otorrinolaringol Esp. 2015;66:309–315." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:12 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 783 "Ancho" => 600 "Tamanyo" => 73610 ] ] "descripcion" => array:1 [ "en" => "Dr. Juan Bartual Pastor (1937)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1008 "Ancho" => 1609 "Tamanyo" => 73843 ] ] "descripcion" => array:1 [ "en" => "Distribution of hospitals according to number of beds." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1040 "Ancho" => 1601 "Tamanyo" => 78295 ] ] "descripcion" => array:1 [ "en" => "Distribution of the number of specialists in otoneurology." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 989 "Ancho" => 1626 "Tamanyo" => 91765 ] ] "descripcion" => array:1 [ "en" => "Clinical activities within the field of otoneurology." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 992 "Ancho" => 1619 "Tamanyo" => 105623 ] ] "descripcion" => array:1 [ "en" => "Distribution of technical resources per hospital. C.M.V.E.P.: cervical myogenic vestibular evoked potentials; O.M.V.E.P.: ocular myogenic vestibular evoked potentials; V.H.I.T.: Video Head Impulse Testing." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 849 "Ancho" => 1608 "Tamanyo" => 87923 ] ] "descripcion" => array:1 [ "en" => "Technical resources that are used less. Ecog: electrocochleograph; V.A.T.: vestibular autorotating test." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 945 "Ancho" => 1612 "Tamanyo" => 111864 ] ] "descripcion" => array:1 [ "en" => "Technical resources used in rehabilitation. V.A.T.: vestibular autorotating test." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1030 "Ancho" => 1626 "Tamanyo" => 90620 ] ] "descripcion" => array:1 [ "en" => "Time spent in an otoneurological visit (first visit)." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1056 "Ancho" => 1620 "Tamanyo" => 77735 ] ] "descripcion" => array:1 [ "en" => "Rotation times of interns in otoneurology in 37 of the 40 hospitals that have an otorhinolaryngology training programme." ] ] 9 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Communications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">National communicationsNumber of hospitals \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">International communicationsNumber of hospitals \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Publications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">National publicationsNumber of hospitals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">International publicationsNumber of hospitals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab960485.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Publications and Communications in Connection With Otoneurology in the Last 3 Years." ] ] 10 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Doctoral theses \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of hospitals \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Research projects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Number of hospitals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab960486.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Doctoral Theses and Research Projects in Connection With Otoneurology in the Last 3 Years." ] ] 11 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 80927 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in auditory and vestibular medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.A. Hamid" 1 => "D.R. 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Lambert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MAO.0b013e3182713b9b" "Revista" => array:6 [ "tituloSerie" => "Otol Neurotol" "fecha" => "2013" "volumen" => "34" "paginaInicial" => "1" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23111406" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0100" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The history and future of neuro-otology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.W. Baloh" 1 => "M. Halmagyi" 2 => "D. 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Survey on the State of Otoneurology in Spain

Encuesta sobre la situación de la otoneurología en España

Oscar Alemán-Lópeza,◊,

Corresponding author

osal.888@gmail.com

Corresponding author.

, Hermino Pérez-Garríguezb,◊, Paz Pérez-Vásquezc,◊, Ismael Arán-Gonzálezd,◊, Eduardo Martin-Sanze,◊

a Servicio de Otorrinolaringología, Hospital General Universitario de Alicante, Alicante, Spain

b Servicio de Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain

c Servicio de Otorrinolaringología, Hospital de Cabueñes, Gijón, Asturias, Spain

d Servicio de Otorrinolaringología, Complejo Hospitalario de Pontevedra, Pontevedra, Spain

e Servicio de Otorrinolaringología, Hospital Universitario de Getafe, Getafe, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Otoneurology covers a broad range of common pathologies&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> It originated in Ear&#44; Nose and Throat Neurology&#44; and was formally recognised more than 50 years ago&#46; It studies the vestibular system and its interactions with the central and peripheral nervous systems to maintain oculocephalic coordination&#44; balance and spatial orientation&#46; The first otoneurological society appeared in the United States in 1963&#44; and since then&#44; different training programmes have emerged which&#44; in a non-standardised way&#44; offer instruction in this field&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1995&#44; the American Council of Graduate Medical Education approved the sub-speciality of otology&#8211;otoneurology&#44; with a common structure and content in all of its training programmes in the USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3</span></a> Nevertheless&#44; otoneurology&#44; like other medical specialities&#44; originated in Europe in the second half of the 19th century thanks to the development of large hospitals in the continent&#44; such as Hospital de Salp&#234;tri&#232;re in France&#44; the Hospital General in Vienna or Guy&#39;s Hospital in London&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This process is the logical outcome of increasing knowledge in the field of medical sciences&#46; It was achieved thanks to pioneers who with few technical resources and much effort opened up the way for what are now different medical specialities and sub-specialities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the case of otoneurology&#44; we have to underline the importance of Jean Pierre Flourens &#40;1794&#8211;1867&#41;&#44; who&#44; surpassing the anatomical studies of the inner ear by Corti and Scarpa&#44; and using the physiological observations of Purkinje&#44; paid special attention to the physiology of the semicircular ducts&#44; differentiating the vestibular and auditory functions of the inner ear&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Friedrich Leopold Goltz &#40;1834&#8211;1902&#41; stands out too in this line of physiological research&#46; He postulated that the hydrostatic pressure of the endolymph played a role in the stimulation of the ampullary nerves&#59; this research was continued by his disciple Ernest Julius Richard Ewald &#40;1885&#8211;1921&#41;&#44; who&#44; after exhaustive and meticulous work&#44; established the well-known &#8220;Ewald&#39;s laws&#8221;&#44; the basic pillars of vestibular physiology that&#44; with few modifications&#44; are still valid&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Another of the outstanding researchers who contributed to the construction of what is now otoneurology was Josef Breuer &#40;1842&#8211;1925&#41;&#44; a clinician and researcher who introduced the concept of receptors that respond to the force of acceleration&#44; located in the semicircular canals&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">All of the information about vestibular physiology made available before 1914 would be subsequently used by Robert Barany &#40;1876&#8211;1936&#41; to create the works that led him to win the Nobel Prize for Medicine in that year&#46; His research led to the birth of modern otoneurology&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Nevertheless&#44; among all of the precursors and founders of otoneurology as a science&#44; the figure of Prosper M&#233;ni&#232;re &#40;1799&#8211;1862&#41; stands out&#46; His work &#8220;<span class="elsevierStyleItalic">M&#233;moire sur des l&#233;sions de l&#8217;oreille interne donnant lieu &#226; des sympt&#244;mes de congestion c&#233;r&#233;brale apoplectiforme&#8221;</span>&#44; which was presented to the Imperial Academy of Medicine&#44; Paris&#44; in January 1861&#44; means that he can be considered to be the father of otoneurology&#46; M&#233;ni&#232;re postulated that the disease which today bears his name originated in the inner ear and not in the brain&#44; as was then believed&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#8211;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In our own country&#44; Spain has 2 world-famous figures in the field of otoneurology&#44; doctor Santiago Ram&#243;n y Cajal &#40;1852&#8211;1934&#41; and his disciple Dr&#46; Rafael Lorente de No &#40;1902&#8211;1990&#41;&#46; Both had brilliant careers in the field of histological and physiological vestibular research&#44; and their discoveries in this area played a fundamental role in attaining the current level of knowledge about vestibular physiology and its connections to the brain&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The period in which otoneurology may be said to have developed into an independent discipline in Spain dates from the start of the 20th century&#44; when brilliant ear&#44; nose and throat specialists appeared and made major contributions to the field&#46; These include Dr&#46; Ricardo Botey &#40;1855&#8211;1927&#41;&#44; Dr&#46; Antonio Garc&#237;a-Tapia &#40;1875&#8211;1950&#41; and most especially Dr&#46; Adolfo Azoy &#40;1901&#8211;1988&#41;&#44; who in 1948 published <span class="elsevierStyleItalic">El V&#233;rtigo&#58; Estudio Fisiopatol&#243;gico</span>&#44; a work ahead of its time and the first book in Spanish to be completely devoted to this material&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">More recently&#44; special mention should be made of Dr&#46; Vicente Honrrubia &#40;1934&#41;&#44; whose clinical and research career mainly took place in the UCLA School of Medicine in the United States&#44; as well as Dr&#46; C&#233;sar Gavil&#225;n Alonso &#40;1929&#8211;2004&#41;&#44; Dr&#46; Miguel Ciges Juan &#40;1933&#41; and Dr&#46; Juan Bartual Pastor &#40;1937&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> Dr&#46; Bartual is the otorhinolaryngologist who has contributed the most to the development of otoneurology in Spain over the recent years&#46; Due to his intense scientific and research work&#44; as well as his organisation of many congresses in this field and active participation in the same&#44; together with his fundamental books on the subject&#44; he has been and will be an example for all specialists with a vocation for otoneurology&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">His legacy is now being continued by many of the neurologists he helped to train&#44; ensuring that this speciality will remain in good health in the future&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The Aim of This Study</span><p id="par0065" class="elsevierStylePara elsevierViewall">The overall aim of this study is to examine the current situation of otoneurology within the Spanish Sistema Nacional de Salud &#40;SNS&#41; &#40;<span class="elsevierStyleItalic">National Health System</span>&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">This is a descriptive and qualitative study&#46; Information was obtained by means of a survey sent using the mailing list of the Sociedad Espa&#241;ola de Otorrinolaringolog&#237;a &#40;SEORL&#41; to all the Heads of Department or otherwise&#44; the Section Heads of SNS hospitals and centres that work with them&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The survey was anonymous and contained 23 multiple-choice &#40;<a class="elsevierStyleCrossRef" href="#sec0040">Appendix A</a>&#41; questions&#44; which for statistical purposes were transformed into 66 variables&#46; It was sent out on 24 May 2013&#44; and replies had to be sent in within 30 days&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The questionnaire structure aimed to investigate specific aspects of the practice of otoneurology in Spain&#44; with special emphasis on the following points&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Who practices it&#44; and where &#40;questions 1&#8211;6&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">How is it practiced &#40;questions 7&#44; 9&#44; and 11&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">The resources it uses &#40;questions 8&#44; 10&#44; 12&#44; and 13&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Teaching activity &#40;questions 14&#8211;17&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Scientific production &#40;questions 18&#8211;23&#41;&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">The replies were received using Google Docs by an on-line link&#44; which in turn transformed them into an Excel database&#46; From here they were checked one by one and then sent to the SPSS v17 statistical programme for processing&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">All of the surveys that may have been duplicated were eliminated&#46; The criterion for duplication was that 2 surveys were exactly the same and had been sent in at least 1<span class="elsevierStyleHsp" style=""></span>min apart&#46; This is because the same survey may have been sent in twice by accident&#46; Neither were those surveys which contained less than 80&#37; of the required information taken into account&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A total of 115 questionnaires were received&#44; of which 10 were eliminated&#44; 2 due to the suspicion of duplication and 8 because they contained less than 80&#37; of the requested information&#46; Finally the information contained in 105 questionnaires was used&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">The answers given by different types of hospitals&#44; according to their size&#44; were homogeneous &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; More than half of them &#40;60&#41; were university hospitals&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Fifty-nine of the hospitals that answered the survey have an otoneurology unit&#44; although only they are only recognised as such within the organisational chart of the hospital in 34 of these&#46; Of the university hospitals&#44; 68&#37; have a unit&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">When the hospitals with no otoneurology were asked whether they considered one to be necessary&#44; in 70&#37; of cases &#40;33 of the 45 hospitals that do not have an otoneurology unit&#41;&#44; it was considered to be either necessary or very necessary &#40;24 and 9 hospitals&#44; respectively&#41;&#46; The need for an otoneurology unit increased proportionally to hospital size&#59; thus 30&#37; of the hospitals with 200 or fewer beds did not consider one to be necessary&#44; while this percentage fell to 5&#37; in hospitals with more than 800 beds&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Of the 12 hospitals that do not have a unit and do not consider one to be necessary&#44; 11 have fewer than 400 beds&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding the number of specialists who work in the otoneurology surgery&#44; 2 specialists do so in the majority of hospitals &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The larger the hospital&#44; the higher the number of specialists who work there&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The majority of the work involved in this sub-speciality covers vestibular pathology and hearing loss in adults&#44; while only half of the hospitals work in the field of paediatric hearing loss &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Of the equipment used&#44; videonystagmography is the most common vestibular examination instrument in the hospitals that answered the survey&#46; It is followed&#44; in order of frequency&#44; by cervical myogenic evoked vestibular potentials&#44; dynamic posturography and static posturography &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Other resources&#44; such as Semont&#39;s manoeuvre&#44; electrocochleograph or the self-rotating vestibular test&#44; are used in very few hospitals &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Instrumental vestibular rehabilitation is only used in 30 hospitals&#44; i&#46;e&#46;&#44; in only half of those which have an otoneurology unit&#46; A dynamic platform is used for this in 20 hospitals&#44; while 12 use a static platform&#46; Only 7 hospitals use Semont&#39;s manoeuvre &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; It should be underlined that only 7 hospitals have a rehabilitator&#44; while 5 have a physiotherapist&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The time spent with each patient is most often from 5 to 20<span class="elsevierStyleHsp" style=""></span>min&#44; while the duration mentioned most frequently in different hospitals is from 11 to 15<span class="elsevierStyleHsp" style=""></span>min &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">In almost half of the hospitals&#44; assistance is provided by a technical assistant&#44; and in a quarter of them&#44; by an auxiliary nurse&#59; there are practically no psychologists or psychiatrists within the unit&#44; as the unit has the aid of a psychiatrist in only 2 hospitals&#44; while 2 are aided by a psychologist&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Respecting teaching work in the field of otoneurology&#44; 40 of the hospitals which answered the survey train interns in otorhinolaryngology&#46; The time spent in the unit by interns is shown in <a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#46; In 10 hospitals&#44; the interns do not rotate through otoneurology&#44; as rotation there is simply through otology&#8211;otoneurology&#46; Of these 40 hospitals&#44; 32 &#40;80&#37;&#41; have an otoneurology unit&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Finally&#44; the data on scientific production with the field of otoneurology are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; In half or more of the hospitals that answered the survey&#44; no papers or publications have been presented in Spain in the last 3 years&#46; An even higher percentage of the hospitals answered in the negative when they were asked about international studies&#46; On the other hand&#44; only 11&#37; of the hospitals had mentored a doctoral thesis or undertaken research work in connection with otoneurology during the last 3 years</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">The most important qualities in a survey are reliability and validity&#46; Reliability measures the capacity of an instrument to supply consistent measurements&#44; i&#46;e&#46;&#44; results that are similar when it is used by different researchers or by the same researcher for the same subjects&#46; Validity refers to the capacity of a questionnaire to measure the material for which it was designed&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In our case and due to the nature of the survey&#44; it is to be expected that the resulting data will be valid&#59; nevertheless&#44; its reliability would have to be studied by using a specially designed additional test or other instruments parallel to the survey&#46; The data obtained in this survey have therefore to be accepted with caution&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Nevertheless&#44; and in spite of the fact that this is a qualitative study&#44; some data indicate that the information obtained by it should be taken into account&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Firstly&#44; a large number of replies were received&#46; According to the National Catalogue of Hospitals for the year 2013&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> in December 2012 there were 255 hospitals in the SNS&#59; in this survey&#44; we received valid replies from 105 hospitals&#44; so that we can conclude that replies were received from approximately 40&#37; of SNS hospitals&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">On the other hand&#44; in 2012 there were 68 hospitals accredited for teaching interns in otorhinolaryngology&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> of which 40 took our survey&#46; This means that information was obtained from 59&#37; of the hospitals which teach otorhinolaryngology at postgraduate level&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">We therefore consider the information obtained and presented here to be relevant&#46; We would like to underline the following points&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">More than half of the hospitals which answered the survey &#40;59 hospitals&#41; have an otoneurology unit&#44; although only half of them are recognised within the hospital organisational chart&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">The majority of hospitals without an otoneurology unit believe one to be necessary &#40;72&#37; of the hospitals which have no otoneurology unit consider one to be necessary or very necessary&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">The item of technical equipment used the most in these units is&#44; outstandingly&#44; the videonystagmograph&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Only half of the hospitals with the potential capacity to offer instrumental vestibular rehabilitation do so&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">In more than 30&#37; of the hospitals&#44; the average time spent with patients who consult is from 11 to 15<span class="elsevierStyleHsp" style=""></span>min&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">The time spent by interns in otoneurology is usually from 1 to 3 months&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">80&#37; of the hospitals with a training programme for interns in otorhinolaryngology have an otoneurology unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">There is generally very little scientific production&#44; and it is concentrated in a very small number of specific hospitals&#46;</p></li></ul></p><p id="par0255" class="elsevierStylePara elsevierViewall">Based on the analysis of this information&#44; we are able to confirm that otoneurology is a consolidated sub-speciality in our country&#46; This was to be expected&#44; given the high prevalence and in many cases the complexity of the pathology they cover&#44; as these lead to its being studied in units with accumulated experience in diseases of this type&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">In fact&#44; the creation of units specifically for this field was generally considered to be highly recommendable&#46; Debate is still required on where they should be and the minimum human and material resources that they would require&#46; Although these criteria are necessary&#44; they are yet to be determined&#46; These questions will have to be analysed in the future by the Otoneurology Commission&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">We believe that in the centres where certain members of staff work exclusively in this field&#44; this should be recognised within the organisational chart of the ear&#44; nose and throat service or section&#44; as well as the chart of the hospital itself&#46; This would ensure they receive proper support to allow them to work in the best possible way&#59; this support runs from granting the necessary time for them to see otoneurological patients &#40;at least 30<span class="elsevierStyleHsp" style=""></span>min for their first visit and 15<span class="elsevierStyleHsp" style=""></span>min for check-ups&#41;&#44; to a minimum supply of technical and human resources&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">One of the most frequent problems is probably the lack of sufficient staff and time to attend to a complex and growing group of patients&#46; This eventually finds expression in the incapacity to perform other parallel activities&#44; such as keeping proper records of information&#44; designing personalised programmes for vestibular rehabilitation or offering clinical check-ups for patients&#46; In turn&#44; this situation probably also leads to the lack of scientific work or research projects&#44; both of which&#44; as was shown&#44; should be encouraged&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">On the other hand&#44; in spite of the fact that in all of the teaching hospitals the interns rotate through the otoneurology unit &#40;or the otology-otoneurology unit in those hospitals where both fields are covered without distinction&#41;&#44; the time they spend seems to us to be insufficient&#44; given that the majority only spend 3 months here during their whole internship&#46; This period is clearly very short if the prevalence and complexity of this pathology is taken into account&#44; as well as the large number of instrumental studies which future specialists have to learn&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Following this first step to discover the current state of things within the field of otoneurology&#44; the Otoneurology Commission of the SEORL intends&#44; with the support of all the specialists who work in this field&#44; to establish general guidelines for specific aspects&#46; These include the minimum conditions that a unit must have to be considered as such&#44; obtaining formal recognition of the speciality&#44; recommending minimum times for seeing these patients to the administration&#44; recommending the training time that interns should spend on otoneurology&#44; and continuing to seek ways of increasing scientific production within this field&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0285" class="elsevierStylePara elsevierViewall">This survey confirms that otoneurology is a consolidate sub-speciality in our country&#46; In fact&#44; the majority of hospitals that lack an otoneurology unit consider one to be necessary&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Specific aspects in connection with planning the work of otoneurology in the future have yet to be determined&#46; These include setting minimum times for patient visits&#44; deciding on the criteria for hospitals which should have a unit&#44; or stipulating the minimum human and material resources which such units must have&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">It is also recommendable to improve teaching structure and promote scientific production&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">We hope that the information included in this study will be used as the starting point in undertaking these important tasks&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of Interests</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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            1 => "Neurotolog&#237;a"
            2 => "Tendencia en neurotolog&#237;a"
            3 => "Organizaci&#243;n y administraci&#243;n en neurotolog&#237;a"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Otoneurology is a sub-specialty of otolaryngology&#8211;neurology&#44; which has experienced extraordinary progress in the last 50 years and is currently fully consolidated in our environment&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Through this study&#44; prepared by the Otoneurology Commission of the Spanish Society of Otorhinolaryngology &#40;SEORL&#41;&#44; we have attempted to design an approach to provide information on what the current situation regarding the exercise in Spain is&#44; trying to determine who practice it and where&#44; what resources are available and what the teaching and scientific productions are&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The results obtained are generally satisfactory and reflect the strength of the exercise of otoneurology&#46; The number of centres with otoneurology units is significant and the majority of centres that lack such a unit consider it necessary&#46; However&#44; there are aspects to be established&#44; related to minimum requirements for its performance in satisfactory conditions&#44; as well as determining future guidelines to ensure improved teaching and increased scientific production&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La otoneurolog&#237;a es una subespecialidad de la otorrinolaringolog&#237;a-neurolog&#237;a que ha experimentado avances extraordinarios en los &#250;ltimos 50 a&#241;os y que en este momento se encuentra plenamente consolidada en nuestro medio&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mediante este trabajo&#44; elaborado por la Comisi&#243;n de Otoneurolog&#237;a de la Sociedad Espa&#241;ola de Otorrinolaringolog&#237;a &#40;SEORL&#41;&#44; se ha querido hacer una aproximaci&#243;n que aporte informaci&#243;n sobre cu&#225;l es la situaci&#243;n actual en cuanto a su ejercicio en Espa&#241;a&#44; tratando de determinar qui&#233;n la practica y d&#243;nde&#44; con qu&#233; medios se cuenta y cu&#225;l es la actividad docente y la producci&#243;n cient&#237;fica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los resultados obtenidos&#44; en general&#44; son satisfactorios y reflejan la solidez del ejercicio de la otoneurolog&#237;a&#46; El n&#250;mero de centros que cuentan con Unidad de Otoneurolog&#237;a es significativo&#44; y la mayor parte de centros que carecen de unidad la consideran necesaria&#46; No obstante&#44; quedan por establecer aspectos relacionados con los requerimientos m&#237;nimos para su ejercicio en condiciones satisfactorias&#44; as&#237; como establecer las directrices futuras que garanticen la mejora en la docencia y el incremento en la producci&#243;n cient&#237;fica&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:3 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Member of the Otoneurology Commission of the SEORL-PCF&#46;</p>"
        "identificador" => "fn1"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alem&#225;n-L&#243;pez O&#44; P&#233;rez-Garr&#237;guez H&#44; P&#233;rez-V&#225;squez P&#44; Ar&#225;n-Gonz&#225;lez I&#44; Martin-Sanz E&#46; Encuesta sobre la situaci&#243;n de la otoneurolog&#237;a en Espa&#241;a&#46; Acta Otorrinolaringol Esp&#46; 2015&#59;66&#58;309&#8211;315&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0315" class="elsevierStylePara elsevierViewall">The following are the Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0045"
          ]
        ]
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Dr&#46; Juan Bartual Pastor &#40;1937&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Distribution of hospitals according to number of beds&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the number of specialists in otoneurology&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical activities within the field of otoneurology&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of technical resources per hospital&#46; C&#46;M&#46;V&#46;E&#46;P&#46;&#58; cervical myogenic vestibular evoked potentials&#59; O&#46;M&#46;V&#46;E&#46;P&#46;&#58; ocular myogenic vestibular evoked potentials&#59; V&#46;H&#46;I&#46;T&#46;&#58; Video Head Impulse Testing&#46;</p>"
        ]
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        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr6.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Technical resources that are used less&#46; Ecog&#58; electrocochleograph&#59; V&#46;A&#46;T&#46;&#58; vestibular autorotating test&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Technical resources used in rehabilitation&#46; V&#46;A&#46;T&#46;&#58; vestibular autorotating test&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr8.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Time spent in an otoneurological visit &#40;first visit&#41;&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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            "Tamanyo" => 77735
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Rotation times of interns in otoneurology in 37 of the 40 hospitals that have an otorhinolaryngology training programme&#46;</p>"
        ]
      ]
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Communications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">National communicationsNumber of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">International communicationsNumber of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#8211;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#62;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Publications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">National publicationsNumber of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">International publicationsNumber of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&#8211;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#62;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Publications and Communications in Connection With Otoneurology in the Last 3 Years&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Doctoral theses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Research projects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Number of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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          "identificador" => "bibs0005"
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            0 => array:3 [
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              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advances in auditory and vestibular medicine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;A&#46; Hamid"
                            1 => "D&#46;R&#46; Trune"
                            2 => "M&#46;B&#46; Dutia"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Audiol Med"
                        "fecha" => "2009"
                        "volumen" => "7"
                        "paginaInicial" => "180"
                        "paginaFinal" => "188"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20711412"
                            "web" => "Medline"
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2014.12.001

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Year/Month	Html	Pdf	Total

2023 March	1	1	2
2022 December	0	1	1
2022 September	0	1	1
2022 June	0	1	1
2022 February	0	1	1
2021 November	1	1	2
2021 August	0	1	1
2021 March	0	2	2
2021 January	0	2	2
2020 December	0	2	2
2020 October	0	1	1
2020 August	0	1	1
2020 June	0	1	1
2020 May	0	1	1
2020 April	0	2	2
2020 March	14	7	21
2020 February	18	5	23
2020 January	28	11	39
2019 December	32	13	45
2019 November	20	6	26
2019 October	20	4	24
2019 September	17	7	24
2019 August	13	13	26
2019 July	35	17	52
2019 June	67	16	83
2019 May	167	25	192
2019 April	88	26	114
2019 March	8	8	16
2019 February	22	9	31
2019 January	12	13	25
2018 December	8	5	13
2018 November	14	6	20
2018 October	13	7	20
2018 May	0	2	2
2018 April	2	3	5
2018 March	15	2	17
2018 February	10	1	11
2018 January	8	2	10
2017 December	8	1	9
2017 November	11	6	17
2017 October	16	4	20
2017 September	13	1	14
2017 August	12	2	14
2017 July	17	2	19
2017 June	35	10	45
2017 May	24	10	34
2017 April	23	11	34
2017 March	21	32	53
2017 February	18	4	22
2017 January	17	0	17
2016 December	20	11	31
2016 November	26	10	36
2016 October	26	5	31
2016 September	34	5	39
2016 August	37	5	42
2016 July	21	3	24
2016 June	30	15	45
2016 May	35	23	58
2016 April	33	12	45
2016 March	42	11	53
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2016 January	70	27	97
2015 December	32	14	46

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