Evoked potential assessment of auditory system integrity in infants

One child in 750 is born with a handicapping hearing impairment. The methods available to screen and evaluate infants at risk (auditory brainstem responses, middle latency responses, and cortical auditory evoked potentials) are reviewed, explained, and illustrated with case histories.     

Normal ipsilateral/contralateral asymmetries in infant multiple auditory steady-state responses to air- and bone-conduction stimuli

OBJECTIVES: Two-channel recordings of infants' air- and bone-conduction auditory brainstem responses to brief tones show ipsilateral and contralateral (to the stimulated ear) asymmetries which may be used to isolate which cochlea is the primary contributor to the response. The objective of this study was to determine whether similar ipsilateral/contralateral asymmetries are also present in the air- and bone-conduction "brainstem" (77 to 101 Hz) auditory steady-state responses (ASSRs) of infants. DESIGN: Two-channel ASSRs were recorded in infants (2 to 11 mo) and adults (18 to 40 yr) with normal hearing. Multiple stimuli (carrier frequencies: 500 to 4000 Hz; amplitude/frequency modulated) were presented using a B-71 oscillator on the temporal bone or an ER3-A insert earphone. Bone-conduction ASSR amplitudes, phase delays, and thresholds were obtained for the electroencephalographic (EEG) channels ipsilateral and contralateral to the oscillator temporal-bone placement. Bone-conduction ASSRs were also obtained to the stimulus presented to the opposite temporal bone (at 40 dB HL only). Air-conduction ASSR amplitudes and phase delays were obtained at 60 dB HL in each ear for the EEG channels ipsilateral and contralateral to the transducer. RESULTS: Infants showed more ipsilateral/contralateral asymmetries in both air- and bone-conduction ASSRs compared with adults. Mean bone-conduction ASSR thresholds in infants were 13 to 15 dB higher (i.e., poorer) in the contralateral EEG channel compared with the ipsilateral EEG channel for 500 to 4000 Hz. In adults, there were no large differences (i.e., within 1 dB) between ipsilateral and contralateral ASSR thresholds. Based on ipsilateral/ contralateral threshold differences in infants, interaural attenuation for bone-conducted stimuli was estimated to be at least 10 to 30 dB for most infants. In contrast, most adults showed little interaural attenuation for bone-conducted stimuli. ASSR amplitudes are larger and phase delays are shorter in the ipsilateral EEG channel. For infants, the difference in air-conduction ASSR amplitude between EEG channels was twice that observed for adults. Infants also had greater ASSR amplitude differences between EEG channels for bone-conduction stimuli compared with adults, but the difference was less than that seen for air-conduction stimuli. For air-conduction stimuli, infants had significantly longer phase delays in the contralateral EEG channel compared with the ipsilateral EEG channel. Adults showed no significant differences in air-conduction ASSR phase delay between EEG channels. For bone-conduction stimuli, both infants and adults had significantly longer phase delays in the contralateral EEG channel compared with the ipsilateral EEG channel; the differences in ASSR phase delays between EEG channels were much smaller in infants compared with adults and fewer adults had absent responses in the contralateral EEG channels compared with infants (12% versus 34%). When the transducers were switched to the opposite ear/mastoid, the infant and adult ipsilateral/contralateral asymmetries also switched. CONCLUSIONS: Ipsilateral/contralateral asymmetries in air- and bone-conduction ASSRs are clearly present more often and are larger in infants compared with adults. Our findings also suggest that most infants have at least 10 to 30 dB of interaural attenuation to bone-conducted stimuli. These asymmetries in the bone-conduction ASSR have potential as a clinical tool for isolating the cochlea that is contributing to the response in infants.     

Human electrophysiological examination of buildup of the precedence effect

Event-related potential correlates of the buildup of precedence effect were examined. Buildup is a type of precedence effect illusion in which perception changes (from hearing two clicks to hearing one click) during a click train. Buildup occurs faster for right-leading than left-leading clicks. Continuous click trains that changed leading sides every 15 clicks were presented. Event-related potential N1 amplitudes became smaller with click train for right-leading only. N1 latency decreased with click trains. Mismatch negativity was seen after lead-lag sides were changed. When the perceived change differed in location (left-to-right), mismatch negativity peaked earlier than when the perceived change differed in location and number of clicks (right-to-left). Results suggest that buildup relates to: N1 refractoriness, event-related potential 'lead domination' and mismatch negativity differences.     

Auditory brainstem and middle latency responses to 1 khz tones in noise-masked normally-hearing and sensorineurally hearing-impaired adults

The present study provides comparative evaluation of the ABR and MLR to 1 kHz brief tones in two groups of hearing-impaired subjects (noise-masked normally-hearing; and sensorineurally hearing-impaired adults), as well as a normally-hearing control group. Tones were presented at intensities from threshold to 80-90 dB nHL. The results of this study show that: (1) the ABR and MLR to these low-frequency (1 kHz) tones are equally accurate in estimating hearing threshold, (2) at supra-threshold levels, there are differences in the ABRs and MLRs for subjects with decreased hearing sensitivity resulting from cochlear pathology, compared to those obtained from adults with simulated hearing loss due to broadband masking, and (3) supra-threshold stimuli produce differential effects on the latency and amplitude characteristics of the ABR and MLR in listeners with true sensorineural hearing impairments. Possible physiologic explanations are offered for this differential pattern of results.     

听性稳态反应应用于婴幼儿听力评估的现状

刺激速率为70～110 Hz的听性稳态反应(auditory steady-state response, ASSR)(亦称为80 Hz)最近倍受听力学工作者特别是小儿听力学工作者的关注,设备制造商也正在推销其产品.本文回顾了ASSR的技术、应用基础,并总结了其应用于婴幼儿听力评估的现状.文中斜体字为基本原则.详细的ASSR方法学、正常值以及一些ASSR研究结果请参阅Picton(2003)的综述.ASSR并不是一个新发现的听觉反应,1960年Geisler就从人类头颅上记录到了该反应;以后研究者又记录到了短声、正弦调制波以及方波调制波所诱发的反应.Galambos等在1981年发表的有关40 Hz事件相关电位将ASSR引入听力领域.不同刺激速率的ASSR的产生部位是不同的,40 Hz的ASSR产生于皮层和脑干,而80 Hz的ASSR主要来源于脑干,而且很有可能它就是ABR的波Ⅴ,只是与ABR的刺激和记录方法不同而已.ASSR的重要特征之一就是在频域内分析的方法,通过计算位相相关性或刺激速率值处的信噪比,再根据统计学分析来判定反应的引出与否,这种客观性使ASSR显著优于ABR.ASSR的刺激信号最早是象ABR一样的短纯音信号,以后主要用调幅调制声,有时也加入10%～20%的调频调制,目前大多数设备都采用这一信号,最近一种新ASSR设备的缺省设置是5～8 ms的短音.ASSR的另一个重要特征是能够同时记录多个刺激声信号所产生的反应,这种多频刺激的方法能够同时记录双耳八个频率(每耳四个频率)的反应.研究证明只要各个信号的频率相距一个倍频程以上,强度在75 dB SPL以下,多个刺激声之间的干扰就很小或没有.不对称型的听力图、不同频率所产生的反应幅度的不同以及多频刺激方式所导致的各个频率反应幅度整体的下降延长了这种方法的测试时间,使其不如理想中的那么省时,但仍比单一刺激方式快2～3倍.80 Hz ASSR通常采用的是正弦调幅调制纯音,因为其特有的频率特异性而被认为是优于短纯音ABR的一个方面,但是声信号的频率特异性只是其中的一方面,还应考虑到耳蜗基底膜的部位特异性以及神经反应的特异性.研究证明ASSR的频率特异性与短纯音ABR是非常接近的.ASSR技术以飞快的速度发展,十年前还没有商用的设备,五年前只有两家,而目前至少有六种不同的设备.随着设备的增加,各个设备之间标准化的问题突显出来.有些设备有很浑厚的研究背景,而有些则没有,使用者应该根据设备的性能及临床资料而加以选择.关于80 Hz ASSR与行为听力测试相关性的研究很多,多为感音神经性聋成人或较大儿童,结果表明至少在该人群中ASSR的阈值能够很好地预测行为听力阈值.许多ABR与ASSR的比较研究声称ASSR比ABR能够更好地评估残余听力,也就是当受试者听力损失很重、ABR不能引出时,仍能够引出ASSR.尽管这一现象客观存在,但是还有一些其他需要考虑的影响因素,如:①所比较的信号在某一特定频率上的能量是不相等的,众所周知短声的能量分布频率范围很宽,其最大输出强度较ASSR信号小;②ASSR在高强度会有伪迹或非听性反应;③ASSR的长时强声刺激会导致耳蜗损害.因此需慎重对待这一问题.目前还没有关于传导性聋或混合性聋气导ASSR的研究,模拟传导性聋的研究表明气导ASSR阈值远高于行为听阈,而且ASSR骨气导差过大.骨导ASSR的研究显示听力正常婴幼儿各个频率的ASSR的阈值与成人显著不同.正常听力婴幼儿的短纯音ABR阈值以及诊断标准已经确立,而ASSR在这一方面的研究则显得不足,而且不同研究所采用的刺激(单频与多频)及记录(不同信噪比、噪声标准以及记录时间)方法不同,使这一形势更加恶化.综合不同调幅调制纯音ASSR的研究结果,正常听力婴幼儿在500、1 000、2 000及4 000 Hz的平均阈值分别为41、43、35和32 dB HL,如果转换为dB SPL则与短纯音ABR非常相似.如果以均值的90%～95%为可信区间,取二倍标准差,则诊断标准在500 Hz为60 dB HL,1 000、2 000及4 000 Hz为50 dB HL.关于感音神经性聋儿童ASSR的研究有很多,这种研究比较理想的方法应该将婴幼儿的ASSR阈值与行为听阈或短纯音ABR阈值相比较.遗憾的是多数研究都是短声ABR与ASSR的比较.总结以上工作发现,首先样本数量还很少,其次多数有方法学的缺陷,加之不同研究所采用的刺激和记录方法不同,临床资料就更加减少.最后还没有不同类型听力损失的婴幼儿ASSR的研究.总而言之,尽管ASSR在婴幼儿听力评估方面很有前途,但目前单独以此作为听力诊断的电生理方法还为时过早,还必须结合短纯音ABR,因为只有短纯音ABR才具有充足的基础、临床研究和明确的诊断标准,因而也是目前婴幼儿听力诊断电生理方法的金标准.根据上述回顾,ASSR在婴幼儿听力诊断的现状总结如下:①新的刺激及记录方法通常都没有经过同行审阅的临床科研为依据,特别是缺乏听力障碍婴幼儿的数据;②不同设备采用不同的刺激和记录方法,且缺少专业人员的评估;③不同的方法或设备层出不穷,缺乏标准化;④刺激声信号的校准问题以及ASSR与行为听力之间的关系问题还没有解决,各种设备采用不同的刺激和记录方法更加恶化了这一状况;⑤极重度聋者的ABR和ASSR的关系还有待于进一步研究;⑥听力损失儿童的ASSR与行为听力测试的关系的研究还很少,而且现有的大多数研究没有能够将ASSR与听力诊断的金标准--行为听力和/或短纯音ABR进行比较;⑦六个月以下婴幼儿的ASSR 研究还很少;⑧传导性聋或混合性聋成人和婴幼儿的研究还很少;⑨成人的骨导ASSR研究很少,还没有婴幼儿骨导ASSR的研究报道,也没有病理状态下成人或婴幼儿的骨导ASSR研究(极重度聋除外).如果上述问题得不到解决,ASSR技术就不能称为成熟.因为对于一个结果,无法准确地判定该阈值是正常还是升高.短纯音ABR的研究虽然尚需完善,但它已有非常多的研究背景和临床数据,能够提供气导和骨导听阈,是当前婴幼儿(特别是6个月以下儿童)听阈确定的首选方法.因此目前ASSR还需与短纯音ABR或行为听力测试结合使用. 80 Hz ASSR除了用于阈值的评估外,也可以用于阈上功能的评估,如单词识别或助听器效果的预估.结果 表明在正常或异常听力成人以言语调制声为信号,其识别阈与ASSR有显著相关性,它反映了较低水平的听觉处理能力.     

Thresholds determined using the monotic and dichotic multiple auditory steady-state response technique in normal-hearing subjects

Auditory steady-state responses (ASSRs) were elicited by presenting single or multiple, 77-105 Hz amplitude-modulated 0.5, 1, 2, and 4 kHz tones to one or both ears. Objectives of this study were to (i) replicate and extend previous multiple ASSR studies in a quiet double-walled sound booth, and (ii) discover differences (if any) between thresholds assessed in monotic and dichotic conditions, which ranged between 15 and 22dB SPL. The present study's behavioural and ASSR thresholds are 0-10 dB lower (better) than results of previous monotic studies. Further, there are no significant differences in ASSR thresholds between dichotic and monotic stimulus conditions. Therefore, dichotic multiple AM tone stimulation does not produce a change in the ASSR that affects threshold estimation in a clinically significant manner. Thus, at least for detecting normal hearing, the dichotic multiple ASSR technique is a feasible method for estimating hearing thresholds that would substantially reduce recording time compared to conventional single-stimulus techniques.     

The effects of decreased audibility produced by high-pass noise masking on N1 and the mismatch negativity to speech sounds /ba/and/da.

This study investigated the effects of decreased audibility produced by high-pass noise masking on the cortical event-related potentials (ERPs) N1 and mismatch negativity (MMN) to the speech sounds /ba/ and /da/, presented at 65 dB SPL. ERPs were recorded while normal listeners (N = 11) ignored the stimuli and read a book. Broadband masking noise was simultaneously presented at an intensity sufficient to mask the response to the speech sounds, and subsequently high-pass filtered. The conditions were QUIET (no noise); high-pass cutoff frequencies of 4000, 2000, 1000, 500, and 250 Hz; and broadband noise. Behavioral measures of discrimination of the speech sounds (d' and reaction time) were obtained separately from the ERPs for each listener and condition. As the cutoff frequency of the high-pass masker was lowered, ERP latencies increased and amplitudes decreased. The cutoff frequency where changes first occurred differed for N1 and MMN. N1 showed small systematic changes across frequency beginning with the 4000-Hz high-pass noise. MMN and behavioral measures showed large changes that occurred at approximately 1000 Hz. These results indicate that decreased audibility, resulting from the masking, affects N1 and the MMN in a differential manner. N1 reflects the presence of audible stimulus energy, being present in all conditions where stimuli were audible, whether or not they were discriminable. The MMN is present only for those conditions where stimuli were behaviorally discriminable. These studies of cortical ERPs in high-pass noise studies provide insight into the changes in brain processes and behavioral performance that occur when audibility is reduced, as in hearing loss.     

Auditory brainstem and middle latency responses to 1 kHz tones in noise-masked normally-hearing and sensorineurally hearing-impaired adults

The present study provides comparative evaluation of the ABR and MLR to 1 kHz brief tones in two groups of hearing-impaired subjects (noise-masked normally-hearing; and sensorineurally hearing-impaired adults), as well as a normally-hearing control group. Tones were presented at intensities from threshold to 80–90 dB nHL. The results of this study show that: (1) the ABR and MLR to these low-frequency (1 kHz) tones are equally accurate in estimating hearing threshold, (2) at supra-threshold levels, there are differences in the ABRs and MLRs for subjects with decreased hearing sensitivity resulting from cochlear pathology, compared to those obtained from adults with simulated hearing loss due to broadband masking, and (3) supra-threshold stimuli produce differential effects on the latency and amplitude characteristics of the ABR and MLR in listeners with true sensorineural hearing impairments. Possible physiologic explanations are offered for this differential pattern of results.     

Inconsistency of auditory middle latency and steady-state responses in infants

Auditory middle latency and steady-state responses (MLR/SSRs) were recorded in normal infants (aged 3 weeks to 28 months) and adults. SSR amplitudes were maximum using stimulus presentation rates near 40 Hz in adults. By contrast, the infant data showed no consistent amplitude maximum across the rates tested (9-59 Hz). With the exception of the brain-stem response wave V to MLR Na deflection, MLR components in infants' responses to 10.85 Hz clicks did not show any consistent pattern. To investigate the hypothesis that the 40 Hz SSR is derived from overlapping of the 10 Hz MLR components, 43.4 Hz SSRs were synthesized from the responses recorded at 10.85 Hz and compared with those recorded at 43.4 Hz. The predictive accuracy of the synthesized 43.4 Hz SSRs was significantly better in adults than in infants. The results of these studies indicate the presence of large age-related differences in the auditory MLR and SSR, and in the relationship between the two responses.