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

A Systematic Review: State of the Science on Diagnostics of Hidden Hearing Loss

Background/Objectives: A sizeable population of patients with normal pure-tone audiograms endorse a consistent difficulty of following conversations in noisy environments. Termed hidden hearing loss (HHL), this condition evades traditional diagnostic methods for hearing loss and thus is significantly under-diagnosed and untreated. This review sought to identify emerging methods of diagnosing HHL via measurement of its histopathologic correlate: cochlear synaptopathy, the loss of synapses in the auditory nerve pathway. Methods: A thorough literature search of multiple databases was conducted to identify studies with objective, electrophysiological measures of synaptopathy. The PRISMA protocol was employed to establish criteria for the selection of relevant literature. Results: A total of 21 studies were selected with diagnostic methods, including the auditory brainstem response (ABR), electrocochleography (EcochG), middle ear muscle reflex (MEMR), and frequency-following response (FFR). Measures that may indicate the presence of synaptopathy include a reduced wave I amplitude of ABR, reduced SP amplitude of EcochG, and abnormal MEMR, among other measurements. Behavioral measures were often performed alongside electrophysiological measures, the most common of which was the speech-in-noise assessment. Conclusions: ABR was the most common diagnostic method for assessing HHL. Though ABR, EcochG, and MEMR may be sensitive to measuring synaptopathy, more literature comparing these methods is necessary. A two-pronged approach combining behavioral and electrophysiological measures may prove useful as a criterion for diagnosing and estimating the extent of pathology in affected patients.

Age-Related Listening Performance Changes Across Adulthood

OBJECTIVES

This study compares auditory processing performance across different decades of adulthood, including young adults and middle-aged individuals with normal hearing and no spontaneous auditory complaints.

DESIGN

We assessed 80 participants with normal hearing, at least 10 years of education, and normal global cognition. The participants completed various auditory tests, including speech-in-noise, dichotic digits, duration, pitch pattern sequence, gap in noise, and masking level difference. In addition, we conducted working memory assessments and administered a questionnaire on self-perceived hearing difficulties.

RESULTS

Our findings revealed significant differences in auditory test performance across different age groups, except for the masking level difference. The youngest group outperformed all other age groups in the speech-in-noise test, while differences in dichotic listening and temporal resolution emerged from the age of 40 and in temporal ordering from the age of 50. Moreover, higher education levels and better working memory test scores were associated with better auditory performance as individuals aged. However, the influence of these factors varied across different auditory tests. It is interesting that we observed increased self-reported hearing difficulties with age, even in participants without spontaneous auditory complaints.

CONCLUSIONS

Our study highlights significant variations in auditory test performance, with noticeable changes occurring from age 30 and becoming more pronounced from age 40 onward. As individuals grow older, they tend to perceive more hearing difficulties. Furthermore, the impact of age on auditory processing performance is influenced by factors such as education and working memory.

Normal behavioral discrimination of envelope statistics in budgerigars with kainate-induced cochlear synaptopathy

Cochlear synaptopathy is a common pathology in humans associated with aging and potentially sound overexposure. Synaptopathy is widely expected to cause "hidden hearing loss," including difficulty perceiving speech in noise, but support for this hypothesis is controversial. Here in budgerigars (Melopsittacus undulatus), we evaluated the impact of long-term cochlear synaptopathy on behavioral discrimination of Gaussian noise (GN) and low-noise noise (LNN) signals processed to have a flatter envelope. Stimuli had center frequencies of 1-3kHz, 100-Hz bandwidth, and were presented at sensation levels (SLs) from 10 to 30dB. We reasoned that narrowband, low-SL stimuli of this type should minimize spread of excitation across auditory-nerve fibers, and hence might reveal synaptopathy-related defects if they exist. Cochlear synaptopathy was induced without hair-cell injury using kainic acid (KA). Behavioral threshold tracking experiments characterized the minimum stimulus duration above which animals could reliably discriminate between LNN and GN. Budgerigar thresholds for LNN-GN discrimination ranged from 40 to 60ms at 30dB SL, were similar across frequencies, and increased for lower SLs. Notably, animals with long-term 39-77% estimated synaptopathy performed similarly to controls, requiring on average a ∼7.5% shorter stimulus duration (-0.7±1.0dB; mean difference ±SE) for LNN-GN discrimination. Decision-variable correlation analyses of detailed behavioral response patterns showed that individual animals relied on envelope cues to discriminate LNN and GN, with lesser roles of FM and energy cues; no difference was found between KA-exposed and control groups. These results suggest that long-term cochlear synaptopathy does not impair discrimination of low-level signals with different envelope statistics.

Cochlear synaptopathy and hidden hearing loss: a scoping review

PURPOSE

To identify the pathophysiological definitions adopted by studies investigating "cochlear synaptopathy" (CS) and "hidden hearing loss" (HHL).

RESEARCH STRATEGIES

The combination of keywords "Auditory Synaptopathy" or "Neuronal Synaptopathy" or "Hidden Hearing Loss" with "etiology" or "causality" or "diagnosis" was used in the databases EMBASE, Pubmed (MEDLINE), CINAHL (EBSCO), and Web of Science.

SELECTION CRITERIA

Studies that investigated CS or HHL in humans using behavioral and/or electrophysiological procedures were included.

DATA ANALYSIS

Data analysis and extraction were performed with regard to terminology, definitions, and population.

RESULTS

49 articles were included. Of these, 61.2% used the CS terminology, 34.7% used both terms, and 4.1% used HHL. The most-studied conditions were exposure to noise and tinnitus.

CONCLUSION

CS terminology was used in most studies, referring to the pathophysiological process of deafferentiation between the cochlear nerve fibers and inner hair cells.

Systemic cisplatin increases the number of patients showing positive off-frequency masking audiometry

OBJECTIVE

The study aimed to evaluate the effect of systemic cisplatin administration on off-frequency masking audiometry.

METHODS

Among 26 patients receiving systemic cisplatin, 48 ears were included in the analysis. All patients underwent pure-tone audiometry with ipsilateral narrow-band masking noise (off-frequency masking audiometry). In the off-frequency masking audiometry, 70 dBHL band-pass noise (center frequency 1000 Hz, 1/3 octave bandwidth) was administered to the tested ear. The acquired thresholds were compared to those of standard pure-tone audiometry, and threshold elevations greater than 10 dB were regarded as significant. The number of patients showing abnormal threshold elevation was compared between before and after the cisplatin administration.

RESULTS

Before cisplatin administration, 91.7, 93.8, 97.9, and 93.8% of ears showed normal off-frequency masking audiometry outcomes at 125, 250, 6000, and 8000 Hz, respectively. After cisplatin administration, a higher number of patients showed abnormal off-frequency masking audiometry outcomes. This change was more prominent with increasing doses of cisplatin. After the cisplatin administration of 100∼200 mg/m2, the prevalence of patients with normal off-frequency masking audiometry outcomes was 77.3, 70.5, 90.9, and 88.6% at 125, 250, 6000, and 8000 Hz, respectively. At 250 Hz, the change was statistically significant (p = 0.01, chi-squared test).

Noise-induced hearing disorders: Clinical and investigational tools

A series of articles discussing advanced diagnostics that can be used to assess noise injury and associated noise-induced hearing disorders (NIHD) was developed under the umbrella of the United States Department of Defense Hearing Center of Excellence Pharmaceutical Interventions for Hearing Loss working group. The overarching goals of the current series were to provide insight into (1) well-established and more recently developed metrics that are sensitive for detection of cochlear pathology or diagnosis of NIHD, and (2) the tools that are available for characterizing individual noise hazard as personal exposure will vary based on distance to the sound source and placement of hearing protection devices. In addition to discussing the utility of advanced diagnostics in patient care settings, the current articles discuss the selection of outcomes and end points that can be considered for use in clinical trials investigating hearing loss prevention and hearing rehabilitation.

Development of an audiological assessment and diagnostic model for high occupational noise exposure

PURPOSE

To explore the diagnostic auditory indicators of high noise exposure and combine them into a diagnostic model of high noise exposure and possible development of hidden hearing loss (HHL).

METHODS

We recruited 101 young adult subjects and divided them according to noise exposure history into high-risk and low-risk groups. All subjects completed demographic characteristic collection (including age, noise exposure, self-reported hearing status, and headset use) and related hearing examination.

RESULTS

The 8 kHz (P = 0.039) and 10 kHz (P = 0.005) distortion product otoacoustic emission amplitudes (DPOAE) (DPs) in the high-risk group were lower than those in the low-risk group. The amplitudes of the summating potential (SP) (P = 0.017) and action potential (AP) (P = 0.012) of the electrocochleography (ECochG) in the high-risk group were smaller than those in the low-risk group. The auditory brainstem response (ABR) wave III amplitude in the high-risk group was higher than that in the low-risk group. When SNR = - 7.5 dB (P = 0.030) and - 5 dB (P = 0.000), the high-risk group had a lower speech discrimination score than that of the low-risk group. The 10 kHz DPOAE DP, ABR wave III amplitude and speech discrimination score under noise with SNR = - 5 dB were combined to construct a combination diagnostic indicator. The area under the ROC curve was 0.804 (95% CI 0.713-0.876), the sensitivity was 80.39%, and the specificity was 68.00%.

CONCLUSIONS

We expect that high noise exposure can be detected early with this combined diagnostic indicator to prevent HHL or sensorineural hearing loss (SNHL).

TRIAL REGISTRATION NUMBER/DATE OF REGISTRATION

ChiCTR2200057989, 2022/3/25.

A Systematic Review and Meta-Analysis of Extended High-Frequency Hearing Thresholds in Tinnitus With a Normal Audiogram

OBJECTIVES

Current evidence supports the growing application of extended high-frequency (EHF: 9 to 20 kHz) audiometry in hearing research, which likely results from the high vulnerability of this frequency region to damage induced by known auditory risk factors. The present systematic review and meta-analysis were performed to investigate whether adults with a normal audiogram and tinnitus show increased EHF hearing thresholds relative to control peers.

DESIGN

A comprehensive search was undertaken on electronic databases consisting of PubMed, ScienceDirect, Wiley, and Google Scholar using combined keywords: "tinnitus," "extended high frequency," "normal audiogram," and "hidden hearing loss."

RESULTS

From 261 articles found by searching databases, nine studies met the inclusion criteria for the meta-analysis. A significant difference was observed between tinnitus and control groups in the effect size analysis of hearing thresholds at 10, 12.5, 14, 16, and 18 kHz ( p ≤ 0.001), and the I-square heterogeneity analysis was below 50% in all studies ( p ≥ 0.131). Visual inspection by the Funnel plot and Egger's regression test ( p ≥ 0.211) also exhibited no publication bias in the meta-analyses.

CONCLUSIONS

Our findings are in support of the idea that in most cases, tinnitus is associated with some degree of cochlear mechanical dysfunction, which may not be detected by conventional audiometry alone. This finding underscores the significance of EHF audiometry in clinical practice, which may help both early identification of individuals susceptible to developing tinnitus and reduce the number of new cases through preventive counseling programs.

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.

Possible Existence of Cochlear Synaptopathy in Patients Completely Recovered from Idiopathic Sudden Sensorineural Hearing Loss

Cochlear synaptopathy refers to a subclinical hearing pathology which could potentially explain hearing difficulties within the normal hearing threshold; it is also called “hidden hearing loss”. We hypothesized that a temporary threshold shift in sudden sensorineural hearing loss (ISSNHL) also affects the function in the synapse. The aim of the study was to evaluate the presence of cochlear synaptopathy in patients who had completely recovered from unilateral SSNHL Nineteen patients who had completely recovered from ISSNHL from January 2018 to June 2021 were assessed. Complete recovery was established by pure tone audiometry (PTA) 3 months after treatment, according to the American Academy of Otolaryngology–Head and Neck Surgery criteria. Subjects completed the pure tone audiometry, speech audiometry and auditory brain stem response (ABR) test, and completed a questionnaire regarding hearing loss after hearing recovery. The ABR amplitudes of wave I and wave V, and the ratio of wave I/V of both ears (recovered side and healthy side) were assessed. A visual analog scale (VAS) and a hidden hearing loss questionnaire were used to evaluate subjective hearing difficulty. The ABR waves I of the recovered ears had a significantly lower amplitude (p = 0.002) than those of the healthy side, whereas there was no difference in wave V (p = 0.985) or in the ratio of wave I/V (p = 0.107). Some patients still felt mild hearing difficulty although their PTA results were normal, but there was no clear relationship between the VAS score, wave I amplitude and speech recognition scores. The present findings point to the possible existence of cochlear synaptopathy in ears that have completely recovered from unilateral sudden sensorineural hearing loss. We suggest that the causes of cochlear synaptopathy and of idiopathic sudden hearing loss may have something in common.

Animal models of hidden hearing loss: Does auditory-nerve-fiber loss cause real-world listening difficulties?

Afferent innervation of the cochlea by the auditory nerve declines during aging and potentially after sound overexposure, producing the common pathology known as cochlear synaptopathy. Auditory-nerve-fiber loss is difficult to detect with the clinical audiogram and has been proposed to cause 'hidden hearing loss' including impaired speech-in-noise perception. While evidence that auditory-nerve-fiber loss causes hidden hearing loss in humans is controversial, behavioral animal models hold promise to rigorously test this hypothesis because neural lesions can be induced and histologically validated. Here, we review recent animal behavioral studies on the impact of auditory-nerve-fiber loss on perception in a range of species. We first consider studies of tinnitus and hyperacusis inferred from acoustic startle reflexes, followed by a review of operant-conditioning studies of the audiogram, temporal integration for tones of varying duration, temporal resolution of gaps in noise, and tone-in-noise detection. Studies quantifying the audiogram show that tone-in-quiet sensitivity is unaffected by auditory-nerve-fiber loss unless neural lesions exceed 80%, at which point large deficits are possible. Changes in other aspects of perception, which were typically investigated for moderate-to-severe auditory-nerve-fiber loss of 50-70%, appear heterogeneous across studies and might be small compared to impairment caused by hair-cell pathologies. Future studies should pursue recent findings that behavioral sensitivity to brief tones and silent gaps in noise may be particularly vulnerable to auditory-nerve-fiber loss. Furthermore, aspects of auditory perception linked to central inhibition and fine neural response timing, such as modulation masking release and spatial hearing, may be productive directions for further animal behavioral research.

Three psychophysical metrics of auditory temporal integration in macaques

The relationship between sound duration and detection threshold has long been thought to reflect temporal integration. Reports of species differences in this relationship are equivocal: some meta-analyses report no species differences, whereas others report substantial differences, particularly between humans and their close phylogenetic relatives, macaques. This renders translational work in macaques problematic. To reevaluate this difference, tone detection performance was measured in macaques using a go/no-go reaction time (RT) task at various tone durations and in the presence of broadband noise (BBN). Detection thresholds, RTs, and the dynamic range (DR) of the psychometric function decreased as the tone duration increased. The threshold by duration trends suggest macaques integrate at a similar rate to humans. The RT trends also resemble human data and are the first reported in animals. Whereas the BBN did not affect how the threshold or RT changed with the duration, it substantially reduced the DR at short durations. A probabilistic Poisson model replicated the effects of duration on threshold and DR and required integration from multiple simulated auditory nerve fibers to explain the performance at shorter durations. These data suggest that, contrary to previous studies, macaques are uniquely well-suited to model human temporal integration and form the baseline for future neurophysiological studies.

Normal Tone-In-Noise Sensitivity in Trained Budgerigars despite Substantial Auditory-Nerve Injury: No Evidence of Hidden Hearing Loss

Loss of auditory-nerve (AN) afferent cochlear innervation is a prevalent human condition that does not affect audiometric thresholds and therefore remains largely undetectable with standard clinical tests. AN loss is widely expected to cause hearing difficulties in noise, known as "hidden hearing loss," but support for this hypothesis is controversial. Here, we used operant conditioning procedures to examine the perceptual impact of AN loss on behavioral tone-in-noise (TIN) sensitivity in the budgerigar (Melopsittacus undulatus; of either sex), an avian animal model with complex hearing abilities similar to humans. Bilateral kainic acid (KA) infusions depressed compound AN responses by 40-70% without impacting otoacoustic emissions or behavioral tone sensitivity in quiet. Surprisingly, animals with AN damage showed normal thresholds for tone detection in noise (0.1 ± 1.0 dB compared to control animals; mean difference ± SE), even under a challenging roving-level condition with random stimulus variation across trials. Furthermore, decision-variable correlations (DVCs) showed no difference for AN-damaged animals in their use of energy and envelope cues to perform the task. These results show that AN damage has less impact on TIN detection than generally expected, even under a difficult roving-level condition known to impact TIN detection in individuals with sensorineural hearing loss (SNHL). Perceptual deficits could emerge for different perceptual tasks or with greater AN loss but are potentially minor compared with those caused by SNHL.SIGNIFICANCE STATEMENT Loss of auditory-nerve (AN) cochlear innervation is a common problem in humans that does not affect audiometric thresholds on a clinical hearing test. AN loss is widely expected to cause hearing problems in noise, known as "hidden hearing loss," but existing studies are controversial. Here, using an avian animal model with complex hearing abilities similar to humans, we examined for the first time the impact of an experimentally induced AN lesion on behavioral tone sensitivity in noise. Surprisingly, AN-lesioned animals showed no difference in hearing performance in noise or detection strategy compared with controls. These results show that perceptual deficits from AN damage are smaller than generally expected, and potentially minor compared with those caused by sensorineural hearing loss (SNHL).

Noise-Induced Hearing Loss and its Prevention: Current Issues in Mammalian Hearing

Noise-induced hearing loss (NIHL) has been well investigated across diverse mammalian species and the potential for prevention of NIHL is of broad interest. To most efficiently develop novel therapeutic interventions, a good understanding of the current state of knowledge regarding mechanisms of injury is essential. The overarching goals of this review are to 1) concisely summarize the current state of knowledge, and 2) provide opinions on the most significant future trends and developments.