Effects of cochlear synaptopathy on middle-ear muscle reflexes in unanesthetized mice

Noise-induced synaptic loss and its post-exposure recovery in CBA/CaJ vs. C57BL/6J mice

Acute noise-induced loss of synapses between inner hair cells (IHCs) and auditory nerve fibers (ANFs) has been documented in several strains of mice, but the extent of post-exposure recovery reportedly varies dramatically. If such inter-strain heterogeneity is real, it could be exploited to probe molecular pathways mediating neural remodeling in the adult cochlea. Here, we compared synaptopathy repair in CBA/CaJ vs. C57BL/6J, which are at opposite ends of the reported recovery spectrum. We evaluated C57BL/6J mice 0 h, 24 h, 2 wks or 8 wks after exposure for 2 h to octave-band noise (8-16 kHz) at either 90, 94 or 98 dB SPL, to compare with analogous post-exposure results in CBA/CaJ at 98 or 101 dB. We counted pre- and post-synaptic puncta in immunostained cochleas, using machine learning to classify paired (GluA2 and CtBP2) vs. orphan (CtBP2 only) puncta, and batch-processing to quantify immunostaining intensity. At 98 dB, both strains show ongoing loss of ribbons and synapses between 0 and 24 h, followed by partial recovery, however the extent and degree of these changes were greater in C57BL/6J. Much of the synaptic recovery is due to transient reduction in GluA2 intensity in synaptopathic regions. In contrast, CtBP2 intensity showed only transient increases (at 2 wks). Neurofilament staining revealed transient extension of ANF terminals in C57BL/6J, but not in CBA/CaJ, peaking at 24 h and reverting by 2 wks. Thus, although interstrain differences in synapse recovery are dominated by reversible changes in GluA2 receptor levels, the neurite extension seen in C57BL/6J suggests a qualitative difference in regenerative capacity.

Altered Fhod3 expression involved in progressive high-frequency hearing loss via dysregulation of actin polymerization stoichiometry in the cuticular plate

Age-related hearing loss (ARHL) is a common sensory impairment with complex underlying mechanisms. In our previous study, we performed a meta-analysis of genome-wide association studies (GWAS) in mice and identified a novel locus on chromosome 18 associated with ARHL specifically linked to a 32 kHz tone burst stimulus. Consequently, we investigated the role of Formin Homology 2 Domain Containing 3 (Fhod3), a newly discovered candidate gene for ARHL based on the GWAS results. We observed Fhod3 expression in auditory hair cells (HCs) primarily localized at the cuticular plate (CP). To understand the functional implications of Fhod3 in the cochlea, we generated Fhod3 overexpression mice (Pax2-Cre+/-; Fhod3Tg/+) (TG) and HC-specific conditional knockout mice (Atoh1-Cre+/-; Fhod3fl/fl) (KO). Audiological assessments in TG mice demonstrated progressive high-frequency hearing loss, characterized by predominant loss of outer hair cells, and a decreased phalloidin intensities of CP. Ultrastructural analysis revealed loss of the shortest row of stereocilia in the basal turn of the cochlea, and alterations in the cuticular plate surrounding stereocilia rootlets. Importantly, the hearing and HC phenotype in TG mice phenocopied that of the KO mice. These findings suggest that balanced expression of Fhod3 is critical for proper CP and stereocilia structure and function. Further investigation of Fhod3 related hearing impairment mechanisms may lend new insight towards the myriad mechanisms underlying ARHL, which in turn could facilitate the development of therapeutic strategies for ARHL.

Hidden hearing loss: Fifteen years at a glance

Hearing loss affects approximately 18% of the population worldwide. Hearing difficulties in noisy environments without accompanying audiometric threshold shifts likely affect an even larger percentage of the global population. One of the potential causes of hidden hearing loss is cochlear synaptopathy, the loss of synapses between inner hair cells (IHC) and auditory nerve fibers (ANF). These synapses are the most vulnerable structures in the cochlea to noise exposure or aging. The loss of synapses causes auditory deafferentation, i.e., the loss of auditory afferent information, whose downstream effect is the loss of information that is sent to higher-order auditory processing stages. Understanding the physiological and perceptual effects of this early auditory deafferentation might inform interventions to prevent later, more severe hearing loss. In the past decade, a large body of work has been devoted to better understand hidden hearing loss, including the causes of hidden hearing loss, their corresponding impact on the auditory pathway, and the use of auditory physiological measures for clinical diagnosis of auditory deafferentation. This review synthesizes the findings from studies in humans and animals to answer some of the key questions in the field, and it points to gaps in knowledge that warrant more investigation. Specifically, recent studies suggest that some electrophysiological measures have the potential to function as indicators of hidden hearing loss in humans, but more research is needed for these measures to be included as part of a clinical test battery.

Acoustic reflexes: should we be paying more attention?

OBJECTIVE

The clinical audiology test battery often involves playing physically simple sounds with questionable ecological value to the listener. In this technical report, we revisit how valid this approach is using an automated, involuntary auditory response; the acoustic reflex threshold (ART).

DESIGN

The ART was estimated four times in each individual in a quasi-random ordering of task conditions. The baseline condition (referred to as Neutral) measured the ART following a standard clinical practice. Three experimental conditions were then used in which a secondary task was performed whilst the reflex was measured: auditory attention, auditory distraction and visual distraction tasks.

STUDY SAMPLE

Thirty-eight participants (27 males) with a mean age of 23 years were tested. All participants were audiometrically healthy.

RESULTS

The ART was elevated when a visual task was performed at the same time as the measurements were taken. Performing an auditory task did not affect the ART.

CONCLUSIONS

These data indicate that simple audiometric measures widely used in the clinic, can be affected by central, non-auditory processes even in healthy, normal-hearing volunteers. The role of cognition and attention on auditory responses will become ever more important in the coming years.

Perceptual Consequences of Cochlear Deafferentation in Humans

Cochlear synaptopathy, a form of cochlear deafferentation, has been demonstrated in a number of animal species, including non-human primates. Both age and noise exposure contribute to synaptopathy in animal models, indicating that it may be a common type of auditory dysfunction in humans. Temporal bone and auditory physiological data suggest that age and occupational/military noise exposure also lead to synaptopathy in humans. The predicted perceptual consequences of synaptopathy include tinnitus, hyperacusis, and difficulty with speech-in-noise perception. However, confirming the perceptual impacts of this form of cochlear deafferentation presents a particular challenge because synaptopathy can only be confirmed through post-mortem temporal bone analysis and auditory perception is difficult to evaluate in animals. Animal data suggest that deafferentation leads to increased central gain, signs of tinnitus and abnormal loudness perception, and deficits in temporal processing and signal-in-noise detection. If equivalent changes occur in humans following deafferentation, this would be expected to increase the likelihood of developing tinnitus, hyperacusis, and difficulty with speech-in-noise perception. Physiological data from humans is consistent with the hypothesis that deafferentation is associated with increased central gain and a greater likelihood of tinnitus perception, while human data on the relationship between deafferentation and hyperacusis is extremely limited. Many human studies have investigated the relationship between physiological correlates of deafferentation and difficulty with speech-in-noise perception, with mixed findings. A non-linear relationship between deafferentation and speech perception may have contributed to the mixed results. When differences in sample characteristics and study measurements are considered, the findings may be more consistent.

Comprehensive behavioral and physiologic assessment of peripheral and central auditory function in individuals with mild traumatic brain injury

Auditory complaints are frequently reported by individuals with mild traumatic brain injury (mTBI) yet remain difficult to detect in the absence of clinically significant hearing loss. This highlights a growing need to identify sensitive indices of auditory-related mTBI pathophysiology beyond pure-tone thresholds for improved hearing healthcare diagnosis and treatment. Given the heterogeneity of mTBI etiology and the diverse peripheral and central processes required for normal auditory function, the present study sought to determine the audiologic assessments sensitive to mTBI pathophysiology at the group level using a well-rounded test battery of both peripheral and central auditory system function. This test battery included pure-tone detection thresholds, word understanding in quiet, sentence understanding in noise, distortion product otoacoustic emissions (DPOAEs), middle-ear muscle reflexes (MEMRs), and auditory evoked potentials (AEPs), including auditory brainstem responses (ABRs), middle latency responses (MLRs), and late latency responses (LLRs). Each participant also received magnetic resonance imaging (MRI). Compared to the control group, we found that individuals with mTBI had reduced DPOAE amplitudes that revealed a compound effect of age, elevated MEMR thresholds for an ipsilateral broadband noise elicitor, longer ABR Wave I latencies for click and 4 kHz tone burst elicitors, longer ABR Wave III latencies for 4 kHz tone bursts, larger MLR Na and Nb amplitudes, smaller MLR Pb amplitudes, longer MLR Pa latencies, and smaller LLR N1 amplitudes for older individuals with mTBI. Further, mTBI individuals with combined hearing difficulty and noise sensitivity had a greater number of deficits on thalamic and cortical AEP measures compared to those with only one/no self-reported auditory symptoms. This finding was corroborated with MRI, which revealed significant structural differences in the auditory cortical areas of mTBI participants who reported combined hearing difficulty and noise sensitivity, including an enlargement of left transverse temporal gyrus (TTG) and bilateral planum polare (PP). These findings highlight the need for continued investigations toward identifying individualized audiologic assessments and treatments that are sensitive to mTBI pathophysiology.

Evaluation of Lifetime Noise Exposure History Reporting

PURPOSE

The purpose of this study is to critically evaluate lifetime noise exposure history (LNEH) reporting. First, two different approaches to evaluate the cumulative LNEH were compared. Second, individual LNEH was associated with the subjects' hearing status. Third, loudness estimates of exposure activities, by means of Jokitulppo- and Ferguson-based exposure levels, were compared with dosimeter sound-level measurements.

METHOD

One hundred one young adults completed the questionnaires, and a subgroup of 30 subjects underwent audiological assessment. Pure-tone audiometry, speech-in-noise intelligibility, distortion product otoacoustic emissions, auditory brainstem responses, and envelope following responses were included. Fifteen out of the 30 subjects took part in a noisy activity while wearing a dosimeter.

RESULTS

First, results demonstrate that the structured questionnaire yielded a greater amount of information pertaining to the diverse activities, surpassing the insights obtained from an open-ended questionnaire. Second, no significant correlations between audiological assessment and LNEH were found. Lastly, the results indicate that Ferguson-based exposure levels offer a more precise estimation of the actual exposure levels, in contrast to Jokitulppo-based estimates.

CONCLUSIONS

We propose several recommendations for determining the LNEH. First, it is vital to define accurate loudness categories and corresponding allocated levels, with a preference for the loudness levels proposed by Ferguson et al. (2019), as identified in this study. Second, a structured questionnaire regarding LNEH is recommended, discouraging open-ended questioning. Third, it is essential to include a separate category exclusively addressing work-related activities, encompassing various activities for more accurate surveying.

Evidence of cochlear neural degeneration in normal-hearing subjects with tinnitus

Tinnitus, reduced sound-level tolerance, and difficulties hearing in noisy environments are the most common complaints associated with sensorineural hearing loss in adult populations. This study aims to clarify if cochlear neural degeneration estimated in a large pool of participants with normal audiograms is associated with self-report of tinnitus using a test battery probing the different stages of the auditory processing from hair cell responses to the auditory reflexes of the brainstem. Self-report of chronic tinnitus was significantly associated with (1) reduced cochlear nerve responses, (2) weaker middle-ear muscle reflexes, (3) stronger medial olivocochlear efferent reflexes and (4) hyperactivity in the central auditory pathways. These results support the model of tinnitus generation whereby decreased neural activity from a damaged cochlea can elicit hyperactivity from decreased inhibition in the central nervous system.

Associations Between Physiological Correlates of Cochlear Synaptopathy and Tinnitus in a Veteran Population

PURPOSE

Animal models and human temporal bones indicate that noise exposure is a risk factor for cochlear synaptopathy, a possible etiology of tinnitus. Veterans are exposed to high levels of noise during military service. Therefore, synaptopathy may explain the high rates of noise-induced tinnitus among Veterans. Although synaptopathy cannot be directly evaluated in living humans, animal models indicate that several physiological measures are sensitive to synapse loss, including the auditory brainstem response (ABR), the middle ear muscle reflex (MEMR), and the envelope following response (EFR). The purpose of this study was to determine whether tinnitus is associated with reductions in physiological correlates of synaptopathy that parallel animal studies.

METHOD

Participants with normal audiograms were grouped according to Veteran status and tinnitus report (Veterans with tinnitus, Veterans without tinnitus, and non-Veteran controls). The effects of being a Veteran with tinnitus on ABR, MEMR, and EFR measurements were independently modeled using Bayesian regression analysis.

RESULTS

Modeled point estimates of MEMR and EFR magnitude showed reductions for Veterans with tinnitus compared with non-Veterans, with the most evident reduction observed for the EFR. Two different approaches were used to provide context for the Veteran tinnitus effect on the EFR by comparing to age-related reductions in EFR magnitude and synapse numbers observed in previous studies. These analyses suggested that EFR magnitude/synapse counts were reduced in Veterans with tinnitus by roughly the same amount as over 20 years of aging.

CONCLUSION

These findings suggest that cochlear synaptopathy may contribute to tinnitus perception in noise-exposed Veterans.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24347761.

A history of occupational noise exposure is associated with steep-slope audiograms and poorer self-reported hearing-aid outcomes

OBJECTIVE

To investigate the effects of previous occupational noise exposure in older adults with hearing loss on (1) audiometric configuration and acoustic reflex (AR) thresholds and (2) self-reported hearing abilities and hearing aid (HA) effectiveness.

DESIGN

A prospective observational study.

STUDY SAMPLE

The study included 1176 adults (≥60 years) with bilateral sensorineural hearing loss. Pure-tone audiometry, AR thresholds, and responses to the abbreviated version of the Speech, Spatial, and Qualities of Hearing Scale (SSQ12) and the International Outcome Inventory for Hearing Aids (IOI-HA) questionnaire were obtained, along with information about previous occupational noise exposure.

RESULTS

Greater occupational noise exposure was associated with a higher prevalence of steeply sloping audiograms in men and women and a 0.32 (95% CI: -0.57; -0.06) scale points lower mean SSQ12 total score among noise-exposed men. AR thresholds did not show a significant relation to noise-exposure status, but hearing thresholds at a given frequency were related to elevated AR thresholds at the same frequency.

CONCLUSIONS

A noise exposure history is linked to steeper audiograms in older adults with hearing loss as well as to poorer self-reported hearing abilities in noise-exposed men. More attention to older adults with previous noise exposure is warranted in hearing rehabilitation.

Abnormal outer hair cell efferent innervation in Hoxb1-dependent sensorineural hearing loss

Autosomal recessive mutation of HOXB1 and Hoxb1 causes sensorineural hearing loss in patients and mice, respectively, characterized by the presence of higher auditory thresholds; however, the origin of the defects along the auditory pathway is still unknown. In this study, we assessed whether the abnormal auditory threshold and malformation of the sensory auditory cells, the outer hair cells, described in Hoxb1null mutants depend on the absence of efferent motor innervation, or alternatively, is due to altered sensory auditory components. By using a whole series of conditional mutant mice, which inactivate Hoxb1 in either rhombomere 4-derived sensory cochlear neurons or efferent motor neurons, we found that the hearing phenotype is mainly reproduced when efferent motor neurons are specifically affected. Our data strongly suggest that the interactions between olivocochlear motor neurons and outer hair cells during a critical postnatal period are crucial for both hair cell survival and the establishment of the cochlear amplification of sound.

Altered Fhod3 Expression Involved in Progressive High-Frequency Hearing Loss via Dysregulation of Actin Polymerization Stoichiometry in The Cuticular Plate

Age-related hearing loss (ARHL) is a common sensory impairment with comlex underlying mechanisms. In our previous study, we performed a meta-analysis of genome-wide association studies (GWAS) in mice and identified a novel locus on chromosome 18 associated with ARHL specifically linked to a 32 kHz tone burst stimulus. Consequently, we investigated the role of Formin Homology 2 Domain Containing 3 (Fhod3), a newly discovered candidate gene for ARHL based on the GWAS results. We observed Fhod3 expression in auditory hair cells (HCs) and primarily localized at the cuticular plate (CP). To understand the functional implications of Fhod3 in the cochlea, we generated Fhod3 overexpression mice (Pax2-Cre+/-; Fhod3Tg/+) (TG) and HC-specific conditional knockout mice (Atoh1-Cre+/-; Fhod3fl/fl) (KO). Audiological assessments in TG mice demonstrated progressive high-frequency hearing loss, characterized by predominant loss of outer HCs and decrease phalloidin intensities of CP. Ultrastructural analysis revealed shortened stereocilia in the basal turn cochlea. Importantly, the hearing and HC phenotype in TG mice were replicated in KO mice. These findings indicate that Fhod3 plays a critical role in regulating actin dynamics in CP and stereocilia. Further investigation of Fhod3-related hearing impairment mechanisms may facilitate the development of therapeutic strategies for ARHL in humans.

Experimental drugs for the prevention or treatment of sensorineural hearing loss

INTRODUCTION

Sensorineural hearing loss results in irreversible loss of inner ear hair cells and spiral ganglion neurons. Reduced sound detection and speech discrimination can span all ages, and sensorineural hearing rehabilitation is limited to amplification with hearing aids or cochlear implants. Recent insights into experimental drug treatments for inner ear regeneration and otoprotection have paved the way for clinical trials in order to restore a more physiological hearing experience. Paired with the development of innovative minimally invasive approaches for drug delivery to the inner ear, new, emerging treatments for hearing protection and restoration are within reach.

AREAS COVERED

This expert opinion provides an overview of the latest experimental drug therapies to protect from and to restore sensorineural hearing loss.

EXPERT OPINION

The degree and type of cellular damage to the cochlea, the responsiveness of remaining, endogenous cells to regenerative treatments, and the duration of drug availability within cochlear fluids will determine the success of hearing protection or restoration.

Wideband Acoustic Reflex Measurement

Acoustic reflex thresholds (ART) obtained using pure-tone probe stimuli as part of a traditional immittance test battery can be used to evaluate site of lesion and provide a cross-check with behavioral results. ARTs obtained as part of a wideband acoustic immittance (WAI) test battery using a click as the probe stimulus can be used in the same way with the added benefit that they may provide lower ARTs than those obtained using a pure-tone probe. Another benefit of the WAI ART test is that it can be completed without requiring a hermetic seal or pressurizing the ear canal. A new adaptive method of obtaining ARTs using WAI techniques may cut test time in half, thus making this an attractive option for future clinical use. More advanced uses of WAI ART tests include the measurement of AR growth functions. These may be used to investigate the possible effects of synaptopathy related to high levels of noise exposure and possible auditory deficits related to ototoxicity.

The middle ear muscle reflex: Current and future role in assessing noise-induced cochlear damage

The middle ear muscle reflex (MEMR) in humans is a bilateral contraction of the middle ear stapedial muscle in response to moderate-to-high intensity acoustic stimuli. Clinically, MEMR thresholds have been used for differential diagnosis of otopathologies for decades. More recently, changes in MEMR amplitude or threshold have been proposed as an assessment for noise-induced synaptopathy, a subclinical form of cochlear damage characterized by suprathreshold hearing problems that occur as a function of inner hair cell (IHC) synaptic loss, including hearing-in-noise deficits, tinnitus, and hyperacusis. In animal models, changes in wideband MEMR immittance have been correlated with noise-induced synaptopathy; however, studies in humans have shown more varied results. The discrepancies observed across studies could reflect the heterogeneity of synaptopathy in humans more than the effects of parametric differences or relative sensitivity of the measurement. Whereas the etiology and degree of synaptopathy can be carefully controlled in animal models, synaptopathy in humans likely stems from multiple etiologies and thus can vary greatly across the population. Here, we explore the evolving research evidence of the MEMR response in relation to subclinical noise-induced cochlear damage and the MEMR as an early correlate of suprathreshold deficits.

Binaural temporal coding and the middle ear muscle reflex in audiometrically normal young adults

Noise exposure may damage the synapses that connect inner hair cells with auditory nerve fibers, before outer hair cells are lost. In humans, this cochlear synaptopathy (CS) is thought to decrease the fidelity of peripheral auditory temporal coding. In the current study, the primary hypothesis was that higher middle ear muscle reflex (MEMR) thresholds, as a proxy measure of CS, would be associated with smaller values of the binaural intelligibility level difference (BILD). The BILD, which is a measure of binaural temporal coding, is defined here as the difference in thresholds between the diotic and the antiphasic versions of the digits in noise (DIN) test. This DIN BILD may control for factors unrelated to binaural temporal coding such as linguistic, central auditory, and cognitive factors. Fifty-six audiometrically normal adults (34 females) aged 18 - 30 were tested. The test battery included standard pure tone audiometry, tympanometry, MEMR using a 2 kHz elicitor and 226 Hz and 1 kHz probes, the Noise Exposure Structured Interview, forward digit span test, extended high frequency (EHF) audiometry, and diotic and antiphasic DIN tests. The study protocol was pre-registered prior to data collection. MEMR thresholds did not predict the DIN BILD. Secondary analyses showed no association between MEMR thresholds and the individual diotic and antiphasic DIN thresholds. Greater lifetime noise exposure was non-significantly associated with higher MEMR thresholds, larger DIN BILD values, and lower (better) antiphasic DIN thresholds, but not with diotic DIN thresholds, nor with EHF thresholds. EHF thresholds were associated with neither MEMR thresholds nor any of the DIN outcomes, including the DIN BILD. Results provide no evidence that young, audiometrically normal people incur CS with impacts on binaural temporal processing.

Categorization of tinnitus listeners with a focus on cochlear synaptopathy

Tinnitus is a complex and not yet fully understood phenomenon. Often the treatments provided are effective only for subgroups of sufferers. We are presently not able to predict benefit with the currently available diagnostic tools and analysis methods. Being able to identify and specifically treat sub-categories of tinnitus would help develop and implement more targeted treatments with higher success rate. In this study we use a clustering analysis based on 17 predictors to cluster an audiologically homogeneous group of normal hearing participants, both with and without tinnitus. The predictors have been chosen to be either tinnitus-specific measures or measures that are thought to be connected to cochlear synaptopathy. Our aim was to identify a subgroup of participants with characteristics consistent with the current hypothesized impact of cochlear synaptopathy. Our results show that this approach can separate the listeners into different clusters. But not in all cases could the tinnitus sufferers be separated from the control group. Another challenge is the use of categorical measures which seem to dominate the importance analysis of the factors. The study showed that data-driven clustering of a homogeneous listener group based on a mixed set of experimental outcome measures is a promising tool for tinnitus sub-typing, with the caveat that sample sizes might need to be sufficiently high, and higher than in the present study, to keep a meaningful sample size after clustering.

Cross-species experiments reveal widespread cochlear neural damage in normal hearing

Animal models suggest that cochlear afferent nerve endings may be more vulnerable than sensory hair cells to damage from acoustic overexposure and aging. Because neural degeneration without hair-cell loss cannot be detected in standard clinical audiometry, whether such damage occurs in humans is hotly debated. Here, we address this debate through co-ordinated experiments in at-risk humans and a wild-type chinchilla model. Cochlear neuropathy leads to large and sustained reductions of the wideband middle-ear muscle reflex in chinchillas. Analogously, human wideband reflex measures revealed distinct damage patterns in middle age, and in young individuals with histories of high acoustic exposure. Analysis of an independent large public dataset and additional measurements using clinical equipment corroborated the patterns revealed by our targeted cross-species experiments. Taken together, our results suggest that cochlear neural damage is widespread even in populations with clinically normal hearing.

Cross-species experiments on chinchillas and at-risk humans suggest cochlear synaptopathy from noise exposure and aging are widespread even among individuals with clinically normal hearing status.

Evaluation of hidden hearing loss in normal-hearing firearm users

Some noise exposures resulting in temporary threshold shift (TTS) result in cochlear synaptopathy. The purpose of this retrospective study was to evaluate a human population that might be at risk for noise-induced cochlear synaptopathy (i.e., "hidden hearing loss"). Participants were firearm users who were (1) at-risk for prior audiometric noise-induced threshold shifts, given their history of firearm use, (2) likely to have experienced complete threshold recovery if any prior TTS had occurred, based on this study's normal-hearing inclusion criteria, and (3) not at-risk for significant age-related synaptopathic loss, based on this study's young-adult inclusion criteria. 70 participants (age 18-25 yr) were enrolled, including 33 firearm users experimental (EXP), and 37 non-firearm users control (CNTRL). All participants were required to exhibit audiometric thresholds ≤20 dB HL bilaterally, from 0.25 to 8 kHz. The study was designed to test the hypothesis that EXP participants would exhibit a reduced cochlear nerve response compared to CNTRL participants, despite normal-hearing sensitivity in both groups. No statistically significant group differences in auditory performance were detected between the CNTRL and EXP participants on standard audiom to etry, extended high-frequency audiometry, Words-in-Noise performance, distortion product otoacoustic emission, middle ear muscle reflex, or auditory brainstem response. Importantly, 91% of EXP participants reported that they wore hearing protection either "all the time" or "almost all the time" while using firearms. The data suggest that consistent use of hearing protection during firearm use can effectively protect cochlear and neural measures of auditory function, including suprathreshold responses. The current results do not exclude the possibility that neural pathology may be evident in firearm users with less consistent hearing protection use. However, firearm users with less consistent hearing protection use are also more likely to exhibit threshold elevation, among other cochlear deficits, thereby confounding the isolation of any potentially selective neural deficits. Taken together, it seems most likely that firearm users who consistently and correctly use hearing protection will exhibit preserved measures of cochlear and neural function, while firearm users who inconsistently and incorrectly use hearing protection are most likely to exhibit cochlear injury, rather than evidence of selective neural injury in the absence of cochlear injury.

No Reduction in the 226-Hz Probe Tone Acoustic Reflex Amplitude Following Severe Inner Hair Cell Loss in Chinchillas

The relationship between the middle ear acoustic reflex (AR) and inner hair cell (IHC) loss is currently unknown. Given that IHC are believed to convey nearly all acoustic information to the central auditory nervous system, it has been assumed that loss of IHC would significantly impact the AR. To evaluate this relationship, we assessed the presence and amplitude of the AR in chinchillas before and after treatment with carboplatin, an anticancer drug that reliably and selectively destroys IHC in this species. Baseline measures of hearing sensitivity, including auditory brainstem response (ABR) thresholds and distortion product otoacoustic emissions (DPOAE), were assessed and then re-evaluated following carboplatin treatment. Post-carboplatin ABR thresholds and DPOAE were found to be unchanged or slightly elevated; results were consistent with published reports. Our main hypothesis was that loss of IHC would abolish the reflex or significantly reduce its amplitude. Contrary to our hypothesis, the ipsilateral 226-Hz AR continued to be reliably elicited following carboplatin treatment. Post-mortem histological analysis confirmed significant IHC loss (65-85 %), but no measurable loss of outer hair cells (OHCs). Given that loss of IHC alone does not significantly reduce the 226-Hz AR, our results suggest that few IHC are needed to maintain the 226-Hz AR response. These results suggest additional studies are needed to better understand the role of IHC in the reflex arc, present opportunities to further study the reflex pathway, and could change how we use the clinical AR as a potential diagnostic tool for IHC dysfunction, including those related to IHC synaptopathy.

Hidden hearing loss: current concepts

PURPOSE OF REVIEW

The purpose of this review is to offer a concise summary of current knowledge regarding hidden hearing loss (HHL) and to describe the variety of mechanisms that contribute to its development. We will also discuss the various diagnostic tools that are available as well as future directions.

RECENT FINDINGS

Hidden hearing loss often also called cochlear synaptopathy affects afferent synapses of the inner hair cells. This description is in contrast to traditional models of hearing loss, which predominantly affects auditory hair cells. In HHL, the synapses of nerve fibres with a slow spontaneous firing rate, which are crucial for locating sound in background noise, are severely impaired. In addition, recent research suggests that HHL may also be related to cochlear nerve demyelination. Noise exposure causes loss of myelin sheath thickness. Auditory brainstem response, envelope-following response and middle-ear muscle reflex are promising diagnostic tests, but they have yet to be validated in humans.

SUMMARY

Establishing diagnostic tools for cochlear synaptopathy in humans is important to better understand this patient population, predict the long-term outcomes and allow patients to take the necessary protective precautions.

The hunt for hidden hearing loss in humans: From preclinical studies to effective interventions

Many individuals experience hearing problems that are hidden under a normal audiogram. This not only impacts on individual sufferers, but also on clinicians who can offer little in the way of support. Animal studies using invasive methodologies have developed solid evidence for a range of pathologies underlying this hidden hearing loss (HHL), including cochlear synaptopathy, auditory nerve demyelination, elevated central gain, and neural mal-adaptation. Despite progress in pre-clinical models, evidence supporting the existence of HHL in humans remains inconclusive, and clinicians lack any non-invasive biomarkers sensitive to HHL, as well as a standardized protocol to manage hearing problems in the absence of elevated hearing thresholds. Here, we review animal models of HHL as well as the ongoing research for tools with which to diagnose and manage hearing difficulties associated with HHL. We also discuss new research opportunities facilitated by recent methodological tools that may overcome a series of barriers that have hampered meaningful progress in diagnosing and treating of HHL.

Dopaminergic and cholinergic innervation in the mouse cochlea after noise-induced or age-related synaptopathy

Cochlear synaptopathy, the loss of or damage to connections between auditory-nerve fibers (ANFs) and inner hair cells (IHCs), is a prominent pathology in noise-induced and age-related hearing loss. Here, we investigated if degeneration of the olivocochlear (OC) efferent innervation is also a major aspect of the synaptopathic ear, by quantifying the volume and spatial organization of its cholinergic and dopaminergic components, using antibodies to vesicular acetylcholine transporter (VAT) and tyrosine hydroxylase (TH), respectively. CBA/CaJ male mice were examined 1 day to 8 months after a synaptopathic noise exposure, and compared to unexposed age-matched controls and unexposed aged mice at 24-28 months. In normal ears, cholinergic lateral (L)OC terminals were denser in the apical half of the cochlea and on the modiolar side of the inner hair cells (IHCs), where ANFs of low-spontaneous rate are typically found, while dopaminergic terminals were more common in the basal third of the cochlea and, re the IHC axes, were offset towards the habenula with respect to cholinergic terminals. The noise had only small and transient effects on the density of LOC innervation, its spatial organization around the IHC axes, or the extent to which TH and VAT signal were colocalized. The synaptopathic noise also had relatively small and transient effects on cholinergic innervation density in the outer hair cell (OHC) area, which normally peaks in the 16 kHz region and falls monotonically towards higher and lower frequencies. In contrast, in the aged ears, there was massive degeneration of OHC efferents, especially in the apical half of the cochlea, where there was also significant loss of OHCs. In the IHC area, there was significant loss of cholinergic terminals in both apical and basal regions and of dopaminergic innervation in the basal half. Furthermore, the cholinergic terminals in the aged ears spread from their normal clustering near the IHC basolateral pole, where the ANF synapses are found, to positions up and down the IHC somata and regions of the neuropil closer to the habenula. This apparent migration was most striking in the apex, where the hair cell pathology was greatest, and may be a harbinger of impending hair cell death.

Effect of Occupational Noise Exposure on Cognition and Suprathreshold Auditory Skills in Normal-Hearing Individuals

OBJECTIVES

Adverse effects of noise exposure on hearing and cognition are well documented in the literature. Recently, it has becoming increasingly evident that noise exposure deteriorates suprathreshold auditory skills, even though the hearing sensitivity is intact. This condition is termed as cochlear synaptopathy or hidden hearing loss, which is apparent in animal models. However, equivocal findings are reported in humans. This study aimed at assessing the working memory, attention abilities, and suprathreshold hearing abilities in normal-hearing individuals with and without occupational noise exposure. We also explored the relationship between cognitive measures and suprathreshold auditory measures.

DESIGN

The study participants were divided into two groups. All the participants had normal-hearing thresholds. The control group consisted of 25 individuals with no occupational noise exposure, whereas the noise exposure group had 25 individuals exposed to occupational noise of 85 dBA for a minimum period of 1 year. Working memory was assessed using auditory digit span (forward and backward), operation span, and reading span. The Erikson flanker test was used to evaluate attention abilities. The suprathreshold hearing was assessed in terms of gap detection thresholds and sentence identification in noise.

RESULTS

The results showed that the noise exposure group performed poorly compared to the control group on all auditory and cognitive tasks except the reading span.

CONCLUSION

The results of the study suggest that occupational noise exposure may hamper the cognitive skills and suprathreshold hearing abilities of the individual despite having normal peripheral hearing.

Temporary and Permanent Auditory Effects Associated with Occupational Coexposure to Low Levels of Noise and Solvents

This study aimed to assess temporary and permanent auditory effects associated with occupational coexposure to low levels of noise and solvents. Cross-sectional study with 25 printing industry workers simultaneously exposed to low noise (<80 dBA TWA) and low levels of solvents. The control group consisted of 29 industry workers without the selected exposures. Participants answered a questionnaire and underwent auditory tests. Auditory fatigue was measured by comparing the acoustic reflex threshold before and after the workday. Workers coexposed to solvents and noise showed significantly worse results in auditory tests in comparison with the participants in the control group. Auditory brainstem response results showed differences in III−V interpeak intervals (p = 0.046 in right ear; p = 0.039 in left ear). Mean dichotic digits scores (exposed = 89.5 ± 13.33; controls = 96.40 ± 4.46) were only different in the left ear (p = 0.054). The comparison of pre and postacoustic reflex testing indicated mean differences (p = 0.032) between the exposed (4.58 ± 6.8) and controls (0 ± 4.62) groups. This study provides evidence of a possible temporary effect (hearing fatigue) at the level of the acoustic reflex of the stapedius muscle. The permanent effects were identified mainly at the level of the high brainstem and in the auditory ability of binaural integration.

Clinical and investigational tools for monitoring noise-induced hyperacusis

Hyperacusis is a recognized perceptual consequence of acoustic overexposure that can lead to debilitating psychosocial effects. Despite the profound impact of hyperacusis on quality of life, clinicians and researchers lack objective biomarkers and standardized protocols for its assessment. Outcomes of conventional audiologic tests are highly variable in the hyperacusis population and do not adequately capture the multifaceted nature of the condition on an individual level. This presents challenges for the differential diagnosis of hyperacusis, its clinical surveillance, and evaluation of new treatment options. Multiple behavioral and objective assays are emerging as contenders for inclusion in hyperacusis assessment protocols but most still await rigorous validation. There remains a pressing need to develop tools to quantify common nonauditory symptoms, including annoyance, fear, and pain. This review describes the current literature on clinical and investigational tools that have been used to diagnose and monitor hyperacusis, as well as those that hold promise for inclusion in future trials.

The Relative and Combined Effects of Noise Exposure and Aging on Auditory Peripheral Neural Deafferentation: A Narrative Review

Animal studies have shown that noise exposure and aging cause a reduction in the number of synapses between low and medium spontaneous rate auditory nerve fibers and inner hair cells before outer hair cell deterioration. This noise-induced and age-related cochlear synaptopathy (CS) is hypothesized to compromise speech recognition at moderate-to-high suprathreshold levels in humans. This paper evaluates the evidence on the relative and combined effects of noise exposure and aging on CS, in both animals and humans, using histopathological and proxy measures. In animal studies, noise exposure seems to result in a higher proportion of CS (up to 70% synapse loss) compared to aging (up to 48% synapse loss). Following noise exposure, older animals, depending on their species, seem to either exhibit significant or little further synapse loss compared to their younger counterparts. In humans, temporal bone studies suggest a possible age- and noise-related auditory nerve fiber loss. Based on the animal data obtained from different species, we predict that noise exposure may accelerate age-related CS to at least some extent in humans. In animals, noise-induced and age-related CS in separation have been consistently associated with a decreased amplitude of wave 1 of the auditory brainstem response, reduced middle ear muscle reflex strength, and degraded temporal processing as demonstrated by lower amplitudes of the envelope following response. In humans, the individual effects of noise exposure and aging do not seem to translate clearly into deficits in electrophysiological, middle ear muscle reflex, and behavioral measures of CS. Moreover, the evidence on the combined effects of noise exposure and aging on peripheral neural deafferentation in humans using electrophysiological and behavioral measures is even more sparse and inconclusive. Further research is necessary to establish the individual and combined effects of CS in humans using temporal bone, objective, and behavioral measures.

Animal-to-Human Translation Difficulties and Problems With Proposed Coding-in-Noise Deficits in Noise-Induced Synaptopathy and Hidden Hearing Loss

Noise induced synaptopathy (NIS) and hidden hearing loss (NIHHL) have been hot topic in hearing research since a massive synaptic loss was identified in CBA mice after a brief noise exposure that did not cause permanent threshold shift (PTS) in 2009. Based upon the amount of synaptic loss and the bias of it to synapses with a group of auditory nerve fibers (ANFs) with low spontaneous rate (LSR), coding-in-noise deficit (CIND) has been speculated as the major difficult of hearing in subjects with NIS and NIHHL. This speculation is based upon the idea that the coding of sound at high level against background noise relies mainly on the LSR ANFs. However, the translation from animal data to humans for NIS remains to be justified due to the difference in noise exposure between laboratory animals and human subjects in real life, the lack of morphological data and reliable functional methods to quantify or estimate the loss of the afferent synapses by noise. Moreover, there is no clear, robust data revealing the CIND even in animals with the synaptic loss but no PTS. In humans, both positive and negative reports are available. The difficulty in verifying CINDs has led a re-examination of the hypothesis that CIND is the major deficit associated with NIS and NIHHL, and the theoretical basis of this idea on the role of LSR ANFs. This review summarized the current status of research in NIS and NIHHL, with focus on the translational difficulty from animal data to human clinicals, the technical difficulties in quantifying NIS in humans, and the problems with the SR theory on signal coding. Temporal fluctuation profile model was discussed as a potential alternative for signal coding at high sound level against background noise, in association with the mechanisms of efferent control on the cochlea gain.

Optimizing non-invasive functional markers for cochlear deafferentation based on electrocochleography and auditory brainstem responses

Accumulating evidence suggests that cochlear deafferentation may contribute to suprathreshold deficits observed with or without elevated hearing thresholds, and can lead to accelerated age-related hearing loss. Currently there are no clinical diagnostic tools to detect human cochlear deafferentation in vivo. Preclinical studies using a combination of electrophysiological and post-mortem histological methods clearly demonstrate cochlear deafferentation including myelination loss, mitochondrial damages in spiral ganglion neurons (SGNs), and synaptic loss between inner hair cells and SGNs. Since clinical diagnosis of human cochlear deafferentation cannot include post-mortem histological quantification, various attempts based on functional measurements have been made to detect cochlear deafferentation. So far, those efforts have led to inconclusive results. Two major obstacles to the development of in vivo clinical diagnostics include a lack of standardized methods to validate new approaches and characterize the normative range of repeated measurements. In this overview, we examine strategies from previous studies to detect cochlear deafferentation from electrocochleography and auditory brainstem responses. We then summarize possible approaches to improve these non-invasive functional methods for detecting cochlear deafferentation with a focus on cochlear synaptopathy. We identify conceptual approaches that should be tested to associate unique electrophysiological features with cochlear deafferentation.

The Impacts of Noise Exposure on the Middle Ear Muscle Reflex in a Veteran Population

PURPOSE

Human studies of noise-induced cochlear synaptopathy using physiological indicators identified in animal models (auditory brainstem response [ABR] Wave I amplitude, envelope following response [EFR], and middle ear muscle reflex [MEMR]) have yielded mixed findings. Differences in the population studied may have contributed to the differing results. For example, due to differences in the intensity level of the noise exposure, noise-induced synaptopathy may be easier to detect in a military Veteran population than in populations with recreational noise exposure. We previously demonstrated a reduction in ABR Wave I amplitude and EFR magnitude for young Veterans with normal audiograms reporting high levels of noise exposure compared to non-Veteran controls. In this article, we expand on the previous analysis in the same population to determine if MEMR magnitude is similarly reduced.

METHOD

Contralateral MEMR growth functions were obtained in 92 young Veterans and non-Veterans with normal audiograms, and the relationship between noise exposure history and MEMR magnitude was assessed. Associations between MEMR magnitude and distortion product otoacoustic emission, EFR, and ABR measurements collected in the same sample were also evaluated.

RESULTS

The results of the statistical analysis, although not conventionally statistically significant, suggest a reduction in mean MEMR magnitude for Veterans reporting high noise exposure compared with non-Veteran controls. In addition, the MEMR appears relatively insensitive to subclinical outer hair cell dysfunction, as measured by distortion product otoacoustic emissions, and is not well correlated with ABR and EFR measurements.

CONCLUSIONS

When combined with our previous ABR and EFR findings in the same population, these results suggest that noise-induced synaptopathy occurs in humans. In addition, the findings indicate that the MEMR may be a good candidate for noninvasive diagnosis of cochlear synaptopathy/deafferentation and that the MEMR may reflect the integrity of different neural populations than the ABR and EFR.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.18665645.

Predicting synapse counts in living humans by combining computational models with auditory physiology

Aging, noise exposure, and ototoxic medications lead to cochlear synapse loss in animal models. As cochlear function is highly conserved across mammalian species, synaptopathy likely occurs in humans as well. Synaptopathy is predicted to result in perceptual deficits including tinnitus, hyperacusis, and difficulty understanding speech-in-noise. The lack of a method for diagnosing synaptopathy in living humans hinders studies designed to determine if noise-induced synaptopathy occurs in humans, identify the perceptual consequences of synaptopathy, or test potential drug treatments. Several physiological measures are sensitive to synaptopathy in animal models including auditory brainstem response (ABR) wave I amplitude. However, it is unclear how to translate these measures to synaptopathy diagnosis in humans. This work demonstrates how a human computational model of the auditory periphery, which can predict ABR waveforms and distortion product otoacoustic emissions (DPOAEs), can be used to predict synaptic loss in individual human participants based on their measured DPOAE levels and ABR wave I amplitudes. Lower predicted synapse numbers were associated with advancing age, higher noise exposure history, increased likelihood of tinnitus, and poorer speech-in-noise perception. These findings demonstrate the utility of this modeling approach in predicting synapse counts from physiological data in individual human subjects.

Effect of Titrated Exposure to Non-Traumatic Noise on Unvoiced Speech Recognition in Human Listeners with Normal Audiological Profiles

Non-traumatic noise exposure has been shown in animal models to impact the processing of envelope cues. However, evidence in human studies has been conflicting, possibly because the measures have not been specifically parameterized based on listeners' exposure profiles. The current study examined young dental-school students, whose exposure to high-frequency non-traumatic dental-drill noise during their course of study is systematic and precisely quantifiable. Twenty-five dental students and twenty-seven non-dental participants were recruited. The listeners were asked to recognize unvoiced sentences that were processed to contain only envelope cues useful for recognition and have been filtered to frequency regions inside or outside the dental noise spectrum. The sentences were presented either in quiet or in one of the noise maskers, including a steady-state noise, a 16-Hz or 32-Hz temporally modulated noise, or a spectrally modulated noise. The dental students showed no difference from the control group in demographic information, audiological screening outcomes, extended high-frequency thresholds, or unvoiced speech in quiet, but consistently performed more poorly for unvoiced speech recognition in modulated noise. The group difference in noise depended on the filtering conditions. The dental group's degraded performances were observed in temporally modulated noise for high-pass filtered condition only and in spectrally modulated noise for low-pass filtered condition only. The current findings provide the most direct evidence to date of a link between non-traumatic noise exposure and supra-threshold envelope processing issues in human listeners despite the normal audiological profiles.

Current topics in hearing research: Deafferentation and threshold independent hearing loss

Hearing research findings in recent years have begun to change how we think about hearing loss and how we consider the risk of auditory damage from noise exposure. These findings include evidence of noise-induced cochlear damage in the absence of corresponding permanent threshold elevation or evidence of hair cell loss. Animal studies in several species have shown that noise exposures that produce robust but only temporary threshold shifts can permanently damage inner hair cell synaptic ribbons. This type of synaptic degeneration has also been shown to occur as a result of aging in animals and humans. The emergence of these data has motivated a number of clinical studies aimed at identifying the perceptual correlates associated with synaptopathy. The deficits believed to arise from synaptopathy include poorer hearing in background noise, tinnitus and hyperacusis (loudness intolerance). However, the findings from human studies have been mixed. Key questions remain as to whether synaptopathy reliably produces suprathreshold perceptual deficits or whether it serves as an early indicator of auditory damage with suprathreshold deficits emerging later as a function of further cochlear damage. Here, we provide an overview of both human and animal studies that explore the relationship among inner hair cell damage, including loss of afferent synapses, auditory thresholds, and suprathreshold measures of hearing.

Endolymphatic Hydrops is a Marker of Synaptopathy Following Traumatic Noise Exposure

After acoustic trauma, there can be loss of synaptic connections between inner hair cells and auditory neurons in the cochlea, which may lead to hearing abnormalities including speech-in-noise difficulties, tinnitus, and hyperacusis. We have previously studied mice with blast-induced cochlear synaptopathy and found that they also developed a build-up of endolymph, termed endolymphatic hydrops. In this study, we used optical coherence tomography to measure endolymph volume in live CBA/CaJ mice exposed to various noise intensities. We quantified the number of synaptic ribbons and postsynaptic densities under the inner hair cells 1 week after noise exposure to determine if they correlated with acute changes in endolymph volume measured in the hours after the noise exposure. After 2 h of noise at an intensity of 95 dB SPL or below, both endolymph volume and synaptic counts remained normal. After exposure to 2 h of 100 dB SPL noise, mice developed endolymphatic hydrops and had reduced synaptic counts in the basal and middle regions of the cochlea. Furthermore, round-window application of hypertonic saline reduced the degree of endolymphatic hydrops that developed after 100 dB SPL noise exposure and partially prevented the reduction in synaptic counts in the cochlear base. Taken together, these results indicate that endolymphatic hydrops correlates with noise-induced cochlear synaptopathy, suggesting that these two pathologic findings have a common mechanistic basis.

A Time-Course-Based Estimation of the Human Medial Olivocochlear Reflex Function Using Clicks

The auditory efferent system, especially the medial olivocochlear reflex (MOCR), is implicated in both typical auditory processing and in auditory disorders in animal models. Despite the significant strides in both basic and translational research on the MOCR, its clinical applicability remains under-utilized in humans due to the lack of a recommended clinical method. Conventional tests employ broadband noise in one ear while monitoring change in otoacoustic emissions (OAEs) in the other ear to index efferent activity. These methods, (1) can only assay the contralateral MOCR pathway and (2) are unable to extract the kinetics of the reflexes. We have developed a method that re-purposes the same OAE-evoking click-train to also concurrently elicit bilateral MOCR activity. Data from click-train presentations at 80 dB peSPL at 62.5 Hz in 13 young normal-hearing adults demonstrate the feasibility of our method. Mean MOCR magnitude (1.7 dB) and activation time-constant (0.2 s) are consistent with prior MOCR reports. The data also suggest several advantages of this method including, (1) the ability to monitor MEMR, (2) obtain both magnitude and kinetics (time constants) of the MOCR, (3) visual and statistical confirmation of MOCR activation.

Wideband Acoustic Reflex Growth in Adults With Cystic Fibrosis

Purpose Individuals with cystic fibrosis (CF) are often treated with intravenous (IV) aminoglycoside (AG) antibiotics to manage life-threatening bacterial infections. Preclinical animal data suggest that, in addition to damaging cochlear hair cells, this class of antibiotics may cause cochlear synaptopathy and/or damage to higher auditory structures. The acoustic reflex growth function (ARGF) is a noninvasive, objective measure of neural function in the auditory system. A shallow ARGF (small reflex-induced changes in middle ear function with increasing elicitor level) has been associated with synaptopathy due to noise exposure in rodent and human studies. In this study, the ARGF was obtained in CF patients with normal hearing, some of whom have been treated with IV AGs, and a control group without CF. The hypothesis was that patients with IV-AG exposure would have a shallow ARGF due to cochlear synaptopathy caused by ototoxicity. Method Wideband ARGFs were examined in four groups of normal-hearing participants: a control group of 29 individuals without CF; and in 57 individuals with CF grouped by lifetime IV-AG exposure: 15 participants with no exposure, 21 with low exposure, and 21 with high exposure. Procedures included pure-tone audiometry, clinical immittance, wideband acoustic immittance battery, including ARGFs, and transient evoked otoacoustic emissions. Results CF subjects with normal pure-tone thresholds and either high or low lifetime IV-AG exposure had enhanced ARGFs compared to controls and CF participants without IV-AG exposure. The groups did not differ in transient evoked otoacoustic emission signal-to-noise ratio. Conclusion These results diverge from the shallow ARGF pattern observed in studies of noise-induced cochlear synaptopathy and are suggestive of a central mechanism of auditory dysfunction in patients with AG-induced ototoxicity.

Olivocochlear Changes Associated With Aging Predominantly Affect the Medial Olivocochlear System

Age-related hearing loss (ARHL) is a public health problem that has been associated with negative health outcomes ranging from increased frailty to an elevated risk of developing dementia. Significant gaps remain in our knowledge of the underlying central neural mechanisms, especially those related to the efferent auditory pathways. Thus, the aim of this study was to quantify and compare age-related alterations in the cholinergic olivocochlear efferent auditory neurons. We assessed, in young-adult and aged CBA mice, the number of cholinergic olivocochlear neurons, auditory brainstem response (ABR) thresholds in silence and in presence of background noise, and the expression of excitatory and inhibitory proteins in the ventral nucleus of the trapezoid body (VNTB) and in the lateral superior olive (LSO). In association with aging, we found a significant decrease in the number of medial olivocochlear (MOC) cholinergic neurons together with changes in the ratio of excitatory and inhibitory proteins in the VNTB. Furthermore, in old mice we identified a correlation between the number of MOC neurons and ABR thresholds in the presence of background noise. In contrast, the alterations observed in the lateral olivocochlear (LOC) system were less significant. The decrease in the number of LOC cells associated with aging was 2.7-fold lower than in MOC and in the absence of changes in the expression of excitatory and inhibitory proteins in the LSO. These differences suggest that aging alters the medial and lateral olivocochlear efferent pathways in a differential manner and that the changes observed may account for some of the symptoms seen in ARHL.

Envelope following response measurements in young veterans are consistent with noise-induced cochlear synaptopathy

Animal studies have demonstrated that noise exposure can lead to the loss of the synapses between the inner hair cells and their afferent auditory nerve fiber targets without impacting auditory thresholds. Although several non-invasive physiological measures appear to be sensitive to cochlear synaptopathy in animal models, including auditory brainstem response (ABR) wave I amplitude, the envelope following response (EFR), and the middle ear muscle reflex (MEMR), human studies of these measures in samples that are expected to vary in terms of the degree of noise-induced synaptopathy have resulted in mixed findings. One possible explanation for the differing results is that synaptopathy risk is lower for recreational noise exposure than for occupational or military noise exposure. The goal of this analysis was to determine if EFR magnitude and ABR wave I amplitude are reduced among young Veterans with a history of military noise exposure compared with non-Veteran controls with minimal noise exposure. EFRs and ABRs were obtained in a sample of young (19-35 years) Veterans and non-Veterans with normal audiograms and robust distortion product otoacoustic emissions (DPOAEs). The statistical analysis is consistent with a reduction in mean EFR magnitude and ABR wave I amplitude (at 90 dB peSPL) for Veterans with a significant history of noise exposure compared with non-Veteran controls. These findings are in agreement with previous ABR wave I amplitude findings in young Veterans and are consistent with animal models of noise-induced cochlear synaptopathy.

Middle Ear Muscle Reflex and Word Recognition in "Normal-Hearing" Adults: Evidence for Cochlear Synaptopathy?

OBJECTIVES

Permanent threshold elevation after noise exposure, ototoxic drugs, or aging is caused by loss of sensory cells; however, animal studies show that hair cell loss is often preceded by degeneration of synapses between sensory cells and auditory nerve fibers. The silencing of these neurons, especially those with high thresholds and low spontaneous rates, degrades auditory processing and may contribute to difficulties in understanding speech in noise. Although cochlear synaptopathy can be diagnosed in animals by measuring suprathreshold auditory brainstem responses, its diagnosis in humans remains a challenge. In mice, cochlear synaptopathy is also correlated with measures of middle ear muscle (MEM) reflex strength, possibly because the missing high-threshold neurons are important drivers of this reflex. The authors hypothesized that measures of the MEM reflex might be better than other assays of peripheral function in predicting difficulties hearing in difficult listening environments in human subjects.

DESIGN

The authors recruited 165 normal-hearing healthy subjects, between 18 and 63 years of age, with no history of ear or hearing problems, no history of neurologic disorders, and unremarkable otoscopic examinations. Word recognition in quiet and in difficult listening situations was measured in four ways: using isolated words from the Northwestern University auditory test number six corpus with either (a) 0 dB signal to noise, (b) 45% time compression with reverberation, or (c) 65% time compression with reverberation, and (d) with a modified version of the QuickSIN. Audiometric thresholds were assessed at standard and extended high frequencies. Outer hair cell function was assessed by distortion product otoacoustic emissions (DPOAEs). Middle ear function and reflexes were assessed using three methods: the acoustic reflex threshold as measured clinically, wideband tympanometry as measured clinically, and a custom wideband method that uses a pair of click probes flanking an ipsilateral noise elicitor. Other aspects of peripheral auditory function were assessed by measuring click-evoked gross potentials, that is, summating potential (SP) and action potential (AP) from ear canal electrodes.

RESULTS

After adjusting for age and sex, word recognition scores were uncorrelated with audiometric or DPOAE thresholds, at either standard or extended high frequencies. MEM reflex thresholds were significantly correlated with scores on isolated word recognition, but not with the modified version of the QuickSIN. The highest pairwise correlations were seen using the custom assay. AP measures were correlated with some of the word scores, but not as highly as seen for the MEM custom assay, and only if amplitude was measured from SP peak to AP peak, rather than baseline to AP peak. The highest pairwise correlations with word scores, on all four tests, were seen with the SP/AP ratio, followed closely by SP itself. When all predictor variables were combined in a stepwise multivariate regression, SP/AP dominated models for all four word score outcomes. MEM measures only enhanced the adjusted r values for the 45% time compression test. The only other predictors that enhanced model performance (and only for two outcome measures) were measures of interaural threshold asymmetry.

CONCLUSIONS

Results suggest that, among normal-hearing subjects, there is a significant peripheral contribution to diminished hearing performance in difficult listening environments that is not captured by either threshold audiometry or DPOAEs. The significant univariate correlations between word scores and either SP/AP, SP, MEM reflex thresholds, or AP amplitudes (in that order) are consistent with a type of primary neural degeneration. However, interpretation is clouded by uncertainty as to the mix of pre- and postsynaptic contributions to the click-evoked SP. None of the assays presented here has the sensitivity to diagnose neural degeneration on a case-by-case basis; however, these tests may be useful in longitudinal studies to track accumulation of neural degeneration in individual subjects.

The Role of the Clinically Obtained Acoustic Reflex as a Research Tool for Subclinical Hearing Pathologies

The acoustic reflex (AR) shows promise as an objective test for the presence of cochlear synaptopathy in rodents. The AR has also been shown to be reduced in humans with tinnitus compared to those without. The aim of the present study was twofold: (a) to determine if AR strength (quantified as both threshold and growth) varied with lifetime noise exposure, and thus provided an estimate of the degree of synaptopathy and (b) to identify which factors should be considered when using the AR as a quantitative measure rather than just present/absent responses. AR thresholds and growth functions were measured using ipsilateral and contralateral, broadband and tonal elicitors in adults with normal hearing and varying levels of lifetime noise exposure. Only the clinical standard 226 Hz probe tone was used. AR threshold and growth were not related to lifetime noise exposure, suggesting that routine clinical AR measures are not a sensitive measure when investigating the effects of noise exposure in audiometrically normal listeners. Our secondary, exploratory analyses revealed that AR threshold and growth were significantly related to middle-ear compliance. Listeners with higher middle-ear compliance (though still in the clinically normal range) showed lower AR thresholds and steeper AR growth functions. Furthermore, there was a difference in middle-ear compliance between the sexes, with males showing higher middle-ear compliance values than females. Therefore, it may be necessary to factor middle-ear compliance values into any analysis that uses the AR as an estimate of auditory function.

Effects of age on electrophysiological measures of cochlear synaptopathy in humans

Age-related cochlear synaptopathy (CS) has been shown to occur in rodents with minimal noise exposure, and has been hypothesized to play a crucial role in age-related hearing declines in humans. Because CS affects mainly low-spontaneous rate auditory nerve fibers, differential electrophysiological measures such as the ratio of the amplitude of wave I of the auditory brainstem response (ABR) at high to low click levels (WIH/WIL), and the difference between frequency following response (FFR) levels to shallow and deep amplitude modulated tones (FFRS-FFRD), have been proposed as CS markers. However, age-related audiometric threshold shifts, particularly prominent at high frequencies, may confound the interpretation of these measures in cross-sectional studies of age-related CS. To address this issue, we measured WIH/WIL and FFRS-FFRD using highpass masking (HP) noise to eliminate the contribution of high-frequency cochlear regions to the responses in a cross-sectional sample of 102 subjects (34 young, 34 middle-aged, 34 older). WIH/WIL in the presence of the HP noise did not decrease as a function of age. However, in the absence of HP noise, WIH/WIL showed credible age-related decreases even after partialing out the effects of audiometric threshold shifts. No credible age-related decreases of FFRS-FFRD were found. Overall, the results do not provide evidence of age-related CS in the low-frequency region where the responses were restricted by the HP noise, but are consistent with the presence of age-related CS in higher frequency regions.

Circadian vulnerability of cisplatin-induced ototoxicity in the cochlea

The chemotherapeutic agent cisplatin is renowned for its ototoxic effects. While hair cells in the cochlea are established targets of cisplatin, less is known regarding the afferent synapse, which is an essential component in the faithful temporal transmission of sound. The glutamate aspartate transporter (GLAST) shields the auditory synapse from excessive glutamate release, and its loss of function increases the vulnerability to noise, salicylate, and aminoglycosides. Until now, the involvement of GLAST in cisplatin-mediated ototoxicity remains unknown. Here, we test in mice lacking GLAST the effects of a low-dose cisplatin known not to cause any detectable change in hearing thresholds. When administered at nighttime, a mild hearing loss in GLAST KO mice was found but not at daytime, revealing a potential circadian regulation of the vulnerability to cisplatin-mediated ototoxicity. We show that the auditory synapse of GLAST KO mice is more vulnerable to cisplatin administration during the active phase (nighttime) when compared to WT mice and treatment during the inactive phase (daytime). This effect was not related to the abundance of platinum compounds in the cochlea, rather cisplatin had a dose-dependent impact on cochlear clock rhythms only after treatment at nighttime suggesting that cisplatin can modulate the molecular clock. Our findings suggest that the current protocols of cisplatin administration in humans during daytime may cause a yet undetectable damage to the auditory synapse, more so in already damaged ears, and severely impact auditory sensitivity in cancer survivors.

Long-term moderate noise exposure enhances the medial olivocochlear reflex

OBJECTIVE

To investigate the effects of long-term moderate noise on hearing functions, MOCR, and MEMR.

METHODS

Mice were exposed to the moderate noise (11.2 - 22.4 kHz, 80 dB SPL, 6 h/day, 4 weeks). Subsequently, the hearing functions, including threshold and input-output roles of ABR (auditory brainstem response) and cubic (2f₁-f₂) DPOAEs (distortion product otoacoustic emissions) were evaluated. Also, MEMR and MOCR were assessed shortly after or at four weeks following the termination of exposure to the noise.

RESULTS

The mice's acoustic suppression reflex was strengthened, hearing functions and MEMR were unaffected four weeks after the moderate noise. For primary tones of 16, 20 and 24 kHz, the strengths of contralateral and ipsilateral suppression in the noise group were about double those recorded in the control group. In order to further determine whether the functional changes of the afferent or efferent nerves increased the strengths of acoustic suppression, the mouse's left ear was inserted the earplug, and then exposed the moderate noise for four weeks. The strengths of contralateral suppression at 16, 20 and 24 kHz were increased for the noise + earplug than for the control group and were indistinguishable between the noise + earplug and the noise group. While no significant changes were found in the strengths of ipsilateral suppression at all frequencies for the noise + earplug group compared with the control group. Under ketamine/xylazine anesthesia, the broadband suppressor noise did not stimulate the MEMR by 20 min post-induction at all frequencies in three groups.

CONCLUSION

Our data demonstrated that the long-term moderate noise-exposure strengthened mice's MOCR by changing its afferent nerves, and unaffected cochlear hair cells and type I spiral ganglion neurons.

The ongoing search for cochlear synaptopathy in humans: Masked thresholds for brief tones in Threshold Equalizing Noise

This study aimed to advance towards a clinical diagnostic method for detection of cochlear synaptopathy with the hypothesis that synaptopathy should be manifested in elevated masked thresholds for brief tones. This hypothesis was tested in tinnitus sufferers, as they are thought to have some degree of synaptopathy. Near-normal-hearing tinnitus sufferers and their matched controls were asked to detect pure tones with durations of 5, 10, 100, and 200 ms presented in low- and high-level Threshold Equalizing Noise. In addition, lifetime noise exposure was estimated for all participants. Contrary to the hypothesis, there was no significant difference in masked thresholds for brief tones between tinnitus sufferers and their matched controls. Masked thresholds were also not related to lifetime noise exposure. There are two possible explanations of the results: 1) the participants in our study did not have cochlear synaptopathy, or 2) synaptopathy does not lead to elevated masked thresholds for brief tones. This study adds a new approach to the growing list of behavioral methods that attempted to detect potential signs of cochlear synaptopathy in humans.

No Effect of Interstimulus Interval on Acoustic Reflex Thresholds

The acoustic reflex (AR), a longstanding component of the audiological test battery, has received renewed attention in the context of noise-induced cochlear synaptopathy—the destruction of synapses between inner hair cells and auditory nerve fibers. Noninvasive proxy measures of synaptopathy are widely sought, and AR thresholds (ARTs) correlate closely with synaptic survival in rodents. However, measurement in humans at high stimulus frequencies—likely important when testing for noise-induced pathology—can be challenging; reflexes at 4 kHz are frequently absent or occur only at high stimulus levels, even in young people with clinically normal audiograms. This phenomenon may partly reflect differences across stimulus frequency in the temporal characteristics of the response; later onset of the response, earlier onset of adaptation, and higher rate of adaptation have been observed at 4 kHz than at 1 kHz. One temporal aspect of the response that has received little attention is the interstimulus interval (ISI); inadequate duration of ISI might lead to incomplete recovery of the response between successive presentations and consequent response fatigue. This research aimed to test for effects of ISI on ARTs in normally hearing young humans, measured at 1 and 4 kHz. Contrary to our hypotheses, increasing ISIs from 2.5 to 8.5 s did not reduce ART level, nor raise ART reliability. Results confirm that clinically measured ARTs—including those at 4 kHz—can exhibit excellent reliability and that relatively short (2.5 s) ISIs are adequate for the measurement of sensitive and reliable ARTs.

Hidden Hearing Loss: A Disorder with Multiple Etiologies and Mechanisms

Hidden hearing loss (HHL), a recently described auditory disorder, has been proposed to affect auditory neural processing and hearing acuity in subjects with normal audiometric thresholds, particularly in noisy environments. In contrast to central auditory processing disorders, HHL is caused by defects in the cochlea, the peripheral auditory organ. Noise exposure, aging, ototoxic drugs, and peripheral neuropathies are some of the known risk factors for HHL. Our knowledge of the causes and mechanisms of HHL are based primarily on animal models. However, recent clinical studies have also shed light on the etiology and prevalence of this cochlear disorder and how it may affect auditory perception in humans. Here, we review the current knowledge regarding the causes and cellular mechanisms of HHL, summarize information on available noninvasive tests for differential diagnosis, and discuss potential therapeutic approaches for treatment of HHL.

The chinchilla animal model for hearing science and noise-induced hearing loss

The chinchilla animal model for noise-induced hearing loss has an extensive history spanning more than 50 years. Many behavioral, anatomical, and physiological characteristics of the chinchilla make it a valuable animal model for hearing science. These include similarities with human hearing frequency and intensity sensitivity, the ability to be trained behaviorally with acoustic stimuli relevant to human hearing, a docile nature that allows many physiological measures to be made in an awake state, physiological robustness that allows for data to be collected from all levels of the auditory system, and the ability to model various types of conductive and sensorineural hearing losses that mimic pathologies observed in humans. Given these attributes, chinchillas have been used repeatedly to study anatomical, physiological, and behavioral effects of continuous and impulse noise exposures that produce either temporary or permanent threshold shifts. Based on the mechanistic insights from noise-exposure studies, chinchillas have also been used in pre-clinical drug studies for the prevention and rescue of noise-induced hearing loss. This review paper highlights the role of the chinchilla model in hearing science, its important contributions, and its advantages and limitations.

Auditory brainstem response demonstrates that reduced peripheral auditory input is associated with self-report of tinnitus

Tinnitus is one of the predicted perceptual consequences of cochlear synaptopathy, a type of age-, noise-, or drug-induced auditory damage that has been demonstrated in animal models to cause homeostatic changes in central auditory gain. Although synaptopathy has been observed in human temporal bones, assessment of this condition in living humans is limited to indirect non-invasive measures such as the auditory brainstem response (ABR). In animal models, synaptopathy is associated with a reduction in ABR wave I amplitude at suprathreshold stimulus levels. Several human studies have explored the relationship between wave I amplitude and tinnitus, with conflicting results. This study investigates the hypothesis that reduced peripheral auditory input due to synaptic/neuronal loss is associated with tinnitus. Wave I amplitude data from 193 individuals [43 with tinnitus (22%), 150 without tinnitus (78%)], who participated in up to 3 out of 4 different studies, were included in a logistic regression analysis to estimate the relationship between wave I amplitude and tinnitus at a variety of stimulus levels and frequencies. Statistical adjustment for sex and distortion product otoacoustic emissions (DPOAEs) was included. The results suggest that smaller wave I amplitudes and/or lower DPOAE levels are associated with an increased probability of tinnitus.