# Global Audiology/Europe/France

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# General Information

The French Republic comprises metropolitan France in Western Europe and several overseas regions and territories. Metropolitan France is bounded by the North Sea, Channel, Atlantic Ocean and Mediterranean Sea. Paris is the capital; other major urban areas include Lyon, Marseille–Aix-en-Provence, Lille, Toulouse, Bordeaux, Nice, Nantes, Montpellier, Strasbourg, Rennes, Grenoble, and Rouen. France was for many centuries a center of art, science, and philosophy. Historically, the French Revolution in 1789 led to the Declaration of the Rights of Man and of the Citizen. France is a founding and leading member of the European Union. It hosts the world's fifth-largest number of UNESCO World Heritage sites. France is the prime tourist destination in the world, with popular sites including the Eiffel Tower, Château de Versailles, Louvre Museum, castles of the Loire Valley, French Riviera, and Normandy. The French way of life is internationally recognized for its gastronomic tradition, wine and champagne. France is also known for its strong social security system, protecting people against the financial consequences of illness, maternity, old age, and unemployment.
| Country name | France |
| Current population | 68 million |
| Gross Domestic Product (GDP) | 3,130 billion dollars (2024) |
| Currency | Euro |
| Official language(s) | French |

# History of Audiology

The French Society of Audiology (SFA) is an affiliated member of the European Federation of Audiology Societies (EFAS) and the International Society of Audiology (ISA). The SFA uses the BIAP classification of hearing loss. In France, aural care is provided by 3 types of professional: ENT doctors, audioprosthetists, and speech therapists. Schooling for the deaf took more than two centuries to develop before being officialized in the late 18th century. France played a crucial role in its history at two key moments, with the creation of the School of the Abbé de l'Épée in the late 18th century and the preparation of international congresses in the late 19th century. The otolaryngology profession was formed in the late 1860s, when otologists and laryngologists realized that they were using the same type of lighting. The union took place very early in France. In 1875, the first ENT journal appeared in France, the "Annals of Ear and Larynx Diseases, (otoscopy, laryngoscopy, rhinoscopy)". A French Society of Otology and Laryngology was created in 1882, one of the very first, if not the first, French specialty societies. The history of medical treatment of the deaf in France and the history of the emergence of modern otology merge, at least during the first decades of the 19th century. Laryngology experienced exponential growth in just a few years in the early second half of the century, with the use of the laryngology mirror and artificial light, whereas otology was constituted over several centuries. However, the study of ear diseases only took on a scientific basis when it came to founded on an anatomo-clinical concept, the beginning of which precisely coincided with the creation in France of institutions for the deaf, in the aftermath of the French Revolution. The National Institution of the Deaf, in the Rue Saint-Jacques in Paris, and its doctors, above all Itard and Menière, left a strong imprint on both the history of audiology and the beginnings of modern otology.

## Notable milestones

* In 1861, French physician Prosper Menière described an inner ear condition that now bears his name and is well-known for its association with the clinical triad of recurrent rotatory vertigo, fluctuating sensorineural hearing loss and tinnitus.
* André Djourno and Charles Eyriès invented the original cochlear implant in 1957, and are credited with the first direct electrical stimulation of the auditory system in a deaf human subject aimed at restoring useful hearing.
* Prof. Portman, in Bordeaux, described an innovative otosclerosis surgery technique in the mid-20th century.
* Alain Uziel conducted pioneer studies of auditory brainstem response maturation in newborns and infants in the early 80's.
* Lionel Collet, Evelyne Veuillet and their group described a non-invasive testing method of the medial olivocochlear system in humans, based on contralateral suppression of otoacoustic emissions in the earlyn 90's.
* Rémy Pujol and Jean-Luc Puel described glutamate-mediated excitotoxicity in the postsynaptic terminal as a mechanism of noise-induced cochlear synaptopathy.
* Paul Avan and his group showed that distortion-product otoacoustic emission phase shift in response to body tilt is unstable in subjects with symptomatic Menière disease compared to asymptomatic patients, providing audiologists with a new diagnostic tool.
* Christine Petit, brought auditory neuroscience into the molecular era through her pioneering work on the genetics of human deafness deciphering the underlying functions of the genes concerned and focusing in particular on the key functions of auditory sensory cells., including mechanoelectrical transduction. Her identification of a score of deafness-related genes launched the molecular diagnosis of hereditary deafness. In parallel, she elucidated the pathogenic mechanisms involved in many forms of deafness, thereby paving the way for the development of treatments for hearing loss.

# Incidence and Prevalence of Hearing Loss

| Hearing loss: do you have some hearing troubles? If yes, which ones? | Number of people | % of the total population |
| Deafness | 182,000 | 0.3% |
| Hard of hearing | 1,062,000 | 1.7% |
| Single-sided deafness | 974,000 | 1.5% |
| Other hearing loss but neither hard of hearing, nor deaf | 3,153,000 | 0,05 |
| Other hearing trouble (tinnitus, buzzing, ringing in the ears...) | 2,012,000 | 3.2% |
| At least one hear impairment | 7,056,000 | 11.2% |
Disabling hearing loss prevalence is estimated today to range between 8.6% and 11.2% of the overall French population. The 2015 Eurotrak data released by the EHIMA (European Hearing Instrument Manufacturers Association) are based on a qualitative survey in a representative sample of 14,824 French people. Hearing-loss prevalence was around 9.3% of the general population (11.4% for people older than 18), and this estimate has been steady since 2009 (2009: 10.4%; 2012: 9.4%).

# Audiology education including programs offering degrees in audiology

In France, audiology education programs are delivered to speech therapists, hearing aid practitioners and ENT doctors. Medical audiology and otoneurology are taught by professors of ENT and/or physiology. In 2019, the French National Council of Universities (CNU) set up a of Rehabilitation and Readaptation section (n°91) promoting research and teaching at an academic level in various fields including aural rehabilitation and speech therapy.
The pioneer of speech and language therapy in France is Suzanne Borel-Maisonny. The status of speech and language therapist in France has been officially recognized since 1964, with a full 3-year university course since 1966. To have the right to exercise, speech therapists must have the CCO (Certificat de Capacité d’Orthophoniste) diploma, delivered by one of the 21 university departments of speech and language pathology in France. The full course increased to 4 years in 1986 and to 5 years in 2013. Since 2013, French speech therapists graduate with a Master’s degree. Within the 3,158 hours of theoretical courses, 225 hours, for 16 ECTS (European Credit Transfer System) credits, focus on pediatric and adult audiology. Other parts of the training concern speech, language, voice and cognition in all aspects of communication, and swallowing.
The text defining and governing the profession of audioprosthetist in France dates from January 3, 1967 (Law n° 67-4) in the Public Health Code. Under the terms of article L4361-1 of the Code: "Anyone who fits hearing aids for the hearing impaired is considered as exercising the profession of audioprosthetist."
The French State Diploma course lasts for 3 years. Training includes theoretical courses (860 hours) and especially practical work, with 1,715 hours of hospital internship, in an institution and in community hearing-aid practice. To date there are nine schools in France, all dependent on a local university (usually Medicine or pharmacy). Each school is part of the National Education system, and has a limited number of places, with a numerus clausus since 2015. Following the European Bachelor’s-Master’s-Doctorate reform, a Master's degree in Sensory and Motor Neuroprostheses was created in 2005.
Given the importance of technical and scientific developments in this field in recent years, proposals have made since 2018 to expand the duration of studies from three to five years. Before this, practitioners did not have a specific status and often carried out their activity in addition to another: pharmacist, orthopedist, radioelectrician, etc. This explains their dual status: health professional, but also retailer registered with the Chamber of Commerce and Industry - an exception among the health professions in France.

# Audiological services (public vs. private), scope of practice

In 2019, there were 3,023 ENT doctors in France (73% male; mean age, 53 years; 44% private practice, 27% public and university hospitals, 29% mixed) (Sante Gouv France). Almost 97% of speech therapists are women. The mean age is 43 years. Speech and language therapists come under the Public Health Code. In 2016, the definition of speech and language therapy was updated in the Code. The list of acts covers rehabilitation and preservation of voice, speech and language, speech development and lipreading education, including in case of cochlear implants or other devices for the hearing rehabilitation. In 2018, there were 25,607 speech therapists exercising in France (private or private/public: 20,787; public/semi-public: 4,820).
A very large majority of hearing aid practitioners work in the private sector, while a few work in the public sector, mainly in university hospital centers for the cochlear implant fitting or for audiometric testing. 60% of French hearing care professionals are self-employed or under franchise; 40% are employees (30% branch operators working for hearing aid retailers, 10% working in a non-profit center). There are currently around 4,478 hearing aid professionals working in France. This number was 1,422 in 2000, which represents 3-fold increase in about 20 years. This increase follows increase in the elderly population and consequent market progression.
The audiological services covered by French National Health Insurance include:
* Neonatal hearing screening for deafness is mandatory under French law.(Legifrance-Neonatal)
* Hearing aids: Audiological care for all degrees of hearing loss is fully covered up to the age of 20. Eligibility criteria for total coverage of hearing aids have been updated. (Legifrance-Hearing aids). The only exception, speech-in-noise audiometry, is now an eligibility criterion for full insurance cover for category-1 hearing aids. Hearing-aid fitting sessions are not chargeable.
* Deafness and disabled worker status. The recognition as a disabled worker is granted as of moderate hearing loss, and entitles the person to financial assistance.
* Cochlear implants are among the list of medical devices with full national health insurance cover. Indications are for bilateral severe to profound hearing loss, and single-sided deafness with disabling tinnitus. Bilateral implants are covered for adults and children.
Cochlear implant fitting is fully covered and is performed by a doctor or, under medical supervision, by an audioprosthetist, a speech therapist or an electrophysiology technician. Since 2021, France’s national health authority has authorized remote monitoring and fitting procedures.(Legifrance-Cochlear implants)
* Speech-therapy sessions are covered by public (60%) and private (40%) insurance.
* Remote speech therapy is allowed for up to 20% of activity.

# Professional and Regulatory Bodies
##### Services offered by otolaryngologists/otologists

ENT doctors conduct physical examination and all the audiometric tests for diagnosis of hearing loss and auditory disorder. They also performing objective assessment to determine the origin and degree of hearing loss. Associated disorders such as tinnitus, hyperacusis and vestibular impairment are also diagnosed by physicians. Surgical and fitting indications are carried by otologists.

##### Services provided by speech therapists

Speech and language therapist focuses on all dimensions of language, as a means of expression, interaction and access to symbolization requiring linguistic, cognitive and psycho-affective competencies. Speech and language therapy plays a major role throughout the follow-up of deaf or hearing-impaired persons, from early diagnosis of deafness, after newborn hearing screening, to inform and accompany the parents in their communication with their baby.
As the child grows up, the speech and language therapist proposes a specific rehabilitation program to develop the child's language, while respecting the family’s choice of the modalities of communication of the child. When deafness occurs in adulthood, the speech and language therapist proposes compensation strategies to maintain natural spontaneous communication, such as speechreading or enhancement of top-down processes.

##### Services offered by audioprosthetists

By Article L4361-1 Amended by Law n ° 2005-102 of February 11, 2005 - art. 81 February 12, 2005 “Anyone who fits hearing aids in the hearing-impaired is considered to be exercising the profession of audioprosthetist. Fitting includes the choice, adaptation, delivery and immediate and long-term efficacy control of the hearing aid and prosthetic education of the hearing-impaired person. Delivery of each hearing aid is subject to mandatory prior medical prescription for wearing a device, after otological examination, pure-tone and speech audiometry."(Legifrance-Audioprosthetists).
The audioprosthetist, following the medical prescription, performs data collection from patient and family, audiologic testing and choice of rehabilitation, adaptation, immediate efficacy control, device delivery and prosthetic education, and personalized audioprosthetist’ s follow-up. The audiologic testing can include:
* Anatomic and otoscopic work-up for hearing-aid fitting.
* Air and bone conduction pure-tone threshold audiometry.
* Supra-threshold audiometry to identify MCL (Most Comfortable Level), UCL (UnComfortable Levels), and LGOB (Loudness Growth in ½ Octave Bands).
* Speech audiometry in silence.
* Speech audiometry in noise (see SFA/SFORL guidelines).
* Other audiometric tests (spatial localization, dichotic listening, TEN test, tinnitus assessment, etc.).
* Assessment of the patient’s needs, functional impairment and disability, on validated questionnaires.
All these examinations are conducted according to current standards (as laid out in Decree n° 85-590 of June 10, 1985), in premises with ≥15m3 working volume, with residual continuous equivalent acoustic level (Leq A) over 1 hour not exceeding 40 dB(A) (a current reflection is in progress to lower it to 30 dB (A)), and with <0.5 sec reverberation time at 500 Hz. After explaining the assessment results to the patient, a mold is taken of the outer ear canal, and a standardized price estimate is drawn up.
Adaptation of one or more hearing aids for mandatory prior trials (Decree of November 14, 2018: Hearing aids) lasting at least 30 days (with possible prolongation). During the trial period, adjustments according to anatomic conditions, explanations on use, handling and upkeep, and progressive settings: free field, with Hearing instrument test box measurements, in-vivo measurements, and daily-living simulation tests.
Intensive monitoring throughout the first year, to optimize settings and adaptation, followed by regular monitoring during the next 3 years. An adaptation report is sent to the prescriber within 7 days of invoicing: patient motivation, type of hearing aid, audiometry, pure-tone and speech audiometric gain, daily number of hours of use.

# Ongoing audiology research

Within the French Society of Audiology (SFA), several working groups have been created in recent years around clinical research themes as diverse as the standardization of audioprosthetic reporting, telemedicine in audiology, recommendations for the practice of speech audiometry in noise in adults, the care pathway for presbycusis, or speech audiometry in children.
Numerous basic research projects in the field of audiology are conducted by units of the Institut National de la Santé et de la Recherche Médicale (INSERM) a national institute for health and medical research and the Centre National de la Recherche Scientifique (CNRS) throughout France.
The Hearing Institute, an Institut Pasteur center dedicated to hearing, was created on the initiative of the Fondation Pour l'Audition and the Institut Pasteur, and was inaugurated on February 27, 2020, in the presence of the French Prime Minister, Édouard Philippe. (Institute de l'Audition). It is a joint research unit of the Institut Pasteur and INSERM, with scientific staff from the Institut Pasteur, INSERM and CNRS.
The Hearing Institute includes a Center for Research and Innovation in Human Audiology (or CERIAH) which develops innovative diagnostic methods under the direction of Pr. Paul Avan and Pr. Hung Thai-Van. It will work in collaboration with the ENT departments of the Paris Hospitals Board (APHP: Necker-Enfants Malades, Pitié-Salpêtrière, etc.) and those of the regional university hospitals (Lyon, Clermont-Ferrand, Bordeaux, Lille, etc.) and with other hearing health professionals, particularly hearing aid practitioners. The Paris city council is a partner in the project, particularly with regard to the acquisition and installation of the premises. Pr. Christine Petit, director of the joint research unit on hearing genetics and physiology at the Institut Pasteur and INSERM, member of the French and US Academy of Sciences and US Academy of Medicine and professor at the Collège de France, is the founding Director of the Institut de l'Audition, home to 10 research teams. The teams are in charge of conducting interdisciplinary and integrative fundamental and translational auditory neuroscience research projects. This research aims to contribute to elucidating the modes of processing acoustic information from the periphery to the hearing centers of the brain, and the foundations of auditory cognition under normal and pathological conditions. This is in order to provide the knowledge base and the continuum of scientific and clinical expertise which are essential for the development of new diagnostic tools and new therapeutic solutions.

# Challenges, Opportunities and Notes

In 2019, the International Society of Audiology (ISA) confided the organization of the XXXVIIth World Congress of Audiology to the French Society of Audiology. This event had previously been hosted in France on two occasions: in 1955 under the presidency of Pr. André Aubin, one of the founding members of the ISA, and in 1974 under the presidency of Pr. Paul Pialoux. The congress took place in the Fall of 2024 in Paris.

# Audiology Charities

Created in 2015, the Fondation Pour l’Audition is a non-profit public-interest foundation for Hearing. (Fondation Pour l’Audition). The foundation’s ambition is to bring talents together in a three-fold mission: supporting research and innovation to offer new hope; mobilizing public opinion to protect hearing health through prevention and awareness initiatives; and improving the lives of people with hearing loss.
The Fondation Pour l’Audition aims to accelerate research and scientific innovation in hearing sciences by supporting research teams through calls for proposals, fellowships, studentships and scientific prizes. (Fondation Pour l’Audition).
When creating the Institut de l’Audition, an Institut Pasteur Research Centre directed by Pr. Christine Petit, was to dedicate reserach into auditory neurosciences, which includes 10 research teams involved in basic and translational research. The Institute hosts a Centre for Research and Innovation in Human Audiology (CERIAH), directed by Pr. Paul Avan, for the development of innovative auditory diagnostic and evaluation tools. (Institut de l’Audition). It also aims at developing authentic treatments for human hearing loss at both peripheral and central levels.
A French clinical research network in audiology, headed by Pr. Françoise Denoyelle, promotes follow-up of cohorts, using a unique clinical data hub, and the development of clinical trials and therapies for hearing loss. The first 2 centers to join the network are the Centers for Research in Audiology at the Necker and Pitié hospitals of the AP-HP Parisian hospital system.
In partnership with the University of Pretoria and the University of Montpellier, the Fondation Pour l’Audition has developed an innovative validated French-language hearing screening app called Höra, based on the antiphasic digits-in-noise test used by the World Health Organization. Höra is available for free at the French Apple and Google Play Stores.
In 2019, the Fondation Pour l’Audition and the French National Federation of Speech Therapists created the first free web platform in French, "Orthophonie & Surdité", helping speech therapists to care for hearing-impaired people at all ages and to network with their colleagues thanks to a professional directory. (Orthophonie & Surdité)

# External links

* French Society of Audiology
* French Society of Otorhinolaryngology-Head and Neck Surgery
* CFORL, Association of ENT Teachers
* SNORL, French ENT Society
* ACFOS, Action Connaissance Formation pour la Surdité
* AFREPA, Francophone Association of Multidisciplinary Teams in Tinnitus
* BIAP,International Bureau of Audiophonology
* JNA, Association French national day of hearing
* FNO, Speech-Therapist Federation
* Plateforme Orthophonie et Surdité/on-line resources for speech therapists
* GEORRIC, Cochlear implant rehabilitation and adjustment study and optimization group
* UNADREO, National Union for development of Research and Evaluation in Speech Therapy
* SURO, Academic Society of Research in Speech Therapy
* CNA, National College of Audioprosthetists
* SDA, French Audioprosthetists Society
* ARIA, International Audiology Research Association

# References

* ↑ Djourno, A., & Eyries, C. (1957). Prothèse auditive par excitation électrique à distance du nerf sensoriel à l’aide d’un bobinage inclus à demeure. Presse Médicale, 65(63), 1417-1417. PMID 13484817
* ↑ Portmann, M., & Claverie, G. (1958). Stapedio‐vestibular osteotomy in otosclerosis. The Laryngoscope, 68(4), 797-804. DOI: 10.1288/00005537-195804000-00011
* ↑ Uziel, A., Marot, M., & Germain, M. (1980). Evoked potentials of the auditory nerve and the brainstem in the newborn and the child. Revue de Laryngologie-Otologie-Rhinologie, 101(1-2), 54-71. PMID: 7384664
* ↑ Collet, L., Kemp, D. T., Veuillet, E., Duclaux, R., Moulin, A., & Morgon, A. (1990). Effect of contralateral auditory stimuli on active cochlear micro-mechanical properties in human subjects. Hearing Research, 43(2-3), 251-261. PMID: 2312416 DOI: 10.1016/0378-5955(90)90232-e
* ↑ Pujol, R., & Puel, J. L. (1999). Excitotoxicity, synaptic repair, and functional recovery in the mammalian cochlea: a review of recent findings. Annals of the New York Academy of Sciences, 884(1), 249-254. PMID: 10842598 DOI: 10.1111/j.1749-6632.1999.tb08646.x
* ↑ Avan, P., Giraudet, F., Chauveau, B., Gilain, L., & Mom, T. (2011). Unstable distortion-product otoacoustic emission phase in Menière’s disease. Hearing Research 277(1-2): 88-95. PMID: 21426928 DOI: 10.1016/j.heares.2011.03.006
* ↑ Petit, C. (1996). Genes responsible for human hereditary deafness: symphony of a thousand. Nature Genetics. 14(4):385-391. doi: 10.1038/ng1296-385. PMID: 8944017.
* ↑ Verpy, E., Weil, D., Leibovici, M., Goodyear, R.J., Hamard, G., Houdon, C., Lefèvre, G.M., Hardelin, J.P., Richardson, G.P., Avan, P., & Petit, C. (2008). Stereocilin-deficient mice reveal the origin of cochlear waveform distortions. Nature. 456(7219):255-258. doi: 10.1038/nature07380. Epub 2008 Oct 8.
* ↑ Caberlotto, E., Michel, V., Foucher, I., Bahloul, A., Goodyear, R.J., Pepermans, E., Michalski, N., Perfettini, I., Alegria-Prévot, O., Chardenoux, S., Do Cruzeiro, M., Hardelin, J.P., Richardson, G.P., Avan, P., Weil, D., & Petit, C. (2011). Usher type 1G protein sans is a critical component of the tip-link complex, a structure controlling actin polymerization in stereocilia. PNAS. 108(14):5825-5830. doi: 10.1073/pnas.1017114108. Epub 2011 Mar 21. PMID: 21436032; PMCID: PMC3078398.
* ↑ de Kervasdoué, J., & Hartmann, L. (2016). Economic impact of hearing loss in France and developed countries. (No. hal-02105131 https://api.semanticscholar.org/CorpusID:160007140
| | | | Contributors to the original text |
| Stéphanie Borel | Morgan Potier | Hung Thai-Van | Contributors to the original text |