Effect of click rate on the latency of auditory brain stem responses in humans

Auditory Neural Responses and Communicative Functioning in Children With Microcephaly Related to Congenital Zika Syndrome

OBJECTIVES

Children with microcephaly exhibit neurodevelopmental delays and compromised communicative functioning, yielding challenges for clinical assessment and informed intervention. This study characterized auditory neural function and communication abilities in children with microcephaly due to congenital Zika syndrome (CZS).

DESIGN

Click-evoked auditory brainstem responses (ABR) at fast and slow stimulation rates and natural speech-evoked cortical auditory evoked potentials (CAEP) were recorded in 25 Brazilian children with microcephaly related to CZS ( M age: 5.93 ± 0.62 years) and a comparison group of 25 healthy children ( M age: 5.59 ± 0.80 years) matched on age, sex, ethnicity, and socioeconomic status. Communication abilities in daily life were evaluated using caregiver reports on Vineland Adaptive Behavior Scales-3.

RESULTS

Caregivers of children with microcephaly reported significantly lower than typical adaptive functioning in the communication and socialization domains. ABR wave I latency did not differ significantly between the groups, suggesting comparable peripheral auditory function. ABR wave V absolute latency and waves I-V interwave latency were significantly shorter in the microcephaly group for both ears and rates. CAEP analyses identified reduced N2 amplitudes in children with microcephaly as well as limited evidence of speech sound differentiation, evidenced mainly by the N2 response latency. Conversely, in the comparison group, speech sound differences were observed for both the P1 and N2 latencies. Exploratory analyses in the microcephaly group indicated that more adaptive communication was associated with greater speech sound differences in the P1 and N2 amplitudes. The trimester of virus exposure did not have an effect on the ABRs or CAEPs.

CONCLUSIONS

Microcephaly related to CZS is associated with alterations in subcortical and cortical auditory neural function. Reduced ABR latencies differ from previous reports, possibly due to the older age of this cohort and careful assessment of peripheral auditory function. Cortical speech sound detection and differentiation are present but reduced in children with microcephaly. Associations between communication performance in daily life and CAEPs highlight the value of auditory evoked potentials in assessing clinical populations with significant neurodevelopmental disabilities.

Midlife Speech Perception Deficits: Impact of Extended High-Frequency Hearing, Peripheral Neural Function, and Cognitive Abilities

OBJECTIVES

The objectives of the present study were to investigate the effects of age-related changes in extended high-frequency (EHF) hearing, peripheral neural function, working memory, and executive function on speech perception deficits in middle-aged individuals with clinically normal hearing.

DESIGN

We administered a comprehensive assessment battery to 37 participants spanning the age range of 20 to 56 years. This battery encompassed various evaluations, including standard and EHF pure-tone audiometry, ranging from 0.25 to 16 kHz. In addition, we conducted auditory brainstem response assessments with varying stimulation rates and levels, a spatial release from masking (SRM) task, and cognitive evaluations that involved the Trail Making test (TMT) for assessing executive function and the Abbreviated Reading Span test (ARST) for measuring working memory.

RESULTS

The results indicated a decline in hearing sensitivities at EHFs and an increase in completion times for the TMT with age. In addition, as age increased, there was a corresponding decrease in the amount of SRM. The declines in SRM were associated with age-related declines in hearing sensitivity at EHFs and TMT performance. While we observed an age-related decline in wave I responses, this decline was primarily driven by age-related reductions in EHF thresholds. In addition, the results obtained using the ARST did not show an age-related decline. Neither the auditory brainstem response results nor ARST scores were correlated with the amount of SRM.

CONCLUSIONS

These findings suggest that speech perception deficits in middle age are primarily linked to declines in EHF hearing and executive function, rather than cochlear synaptopathy or working memory.

Temporal Envelope Coding of the Human Auditory Nerve Inferred from Electrocochleography: Comparison with Envelope Following Responses

Neural coding of the slow amplitude fluctuations of sound (i.e., temporal envelope) is thought to be essential for speech understanding; however, such coding by the human auditory nerve is poorly understood. Here, neural coding of the temporal envelope by the human auditory nerve is inferred from measurements of the compound action potential in response to an amplitude modulated carrier (CAPENV) for modulation frequencies ranging from 20 to 1000 Hz. The envelope following response (EFR) was measured simultaneously with CAPENV from active electrodes placed on the high forehead and tympanic membrane, respectively. Results support the hypothesis that phase locking to higher modulation frequencies (> 80 Hz) will be stronger for CAPENV, compared to EFR, consistent with the upper-frequency limits of phase locking for auditory nerve fibers compared to auditory brainstem/cortex neurons. Future work is needed to determine the extent to which (1) CAPENV is a useful tool for studying how temporal processing of the auditory nerve is affected by aging, hearing loss, and noise-induced cochlear synaptopathy and (2) CAPENV reveals the relationship between auditory nerve temporal processing and perception of the temporal envelope.

Audiologic characterization using clinical physiological measures: Normative data from macaque monkeys

Clinical auditory physiological measures (e.g., auditory brainstem responses, ABRs, and distortion product otoacoustic emissions, DPOAEs) provide diagnostic specificity for differentially diagnosing overt hearing impairments, but they remain limited in their ability to detect specific sites of lesion and subtle levels of cochlear damage. Studies in animal models may hold the key to improve differential diagnosis due to the ability to induce tightly controlled and histologically verifiable subclinical cochlear pathologies. Here, we present a normative set of traditional and clinically novel physiological measures using ABRs and DPOAEs measured in a large cohort of male macaque monkeys. Given the high similarities between macaque and human auditory anatomy, physiology, and susceptibility to hearing damage, this normative data set will serve as a crucial baseline to investigate novel physiological measures to improve diagnostics. DPOAE amplitudes were robust at f2 = 1.22, L1/L2 = 65/55, increased with frequency up to 10 kHz, and exhibited high test re-test reliability. DPOAE thresholds were lowest from 2-10 kHz and highest < 2 kHz. ABRs with a standard clinical electrode montage (vertex-to-mastoid, VM) produced Waves I-IV with a less frequently observed Wave-I, and lower thresholds. ABRs with a vertex-to-tympanic membrane (VT) electrode montage produced a more robust Wave-I, but absent Waves II-IV and higher thresholds. Further study with the VM montage revealed amplitudes that increased with stimulus level and were largest in response to click stimuli, with Wave-II showing the largest ABR amplitude, followed by -IV and -I, with high inter- and intra-subject variability. ABR wave latencies decreased with stimulus level and frequency. When stimulus presentation rate increased or stimuli were presented in close temporal proximity, ABR amplitude decreased, and latency increased. These findings expand upon existing literature of normative clinical physiological data in nonhuman primates and lay the groundwork for future studies investigating the effects of noise-induced pathologies in macaques.

Optimizing Parameters for Using the Parallel Auditory Brainstem Response to Quickly Estimate Hearing Thresholds

OBJECTIVES

Timely assessments are critical to providing early intervention and better hearing and spoken language outcomes for children with hearing loss. To facilitate faster diagnostic hearing assessments in infants, the authors developed the parallel auditory brainstem response (pABR), which presents randomly timed trains of tone pips at five frequencies to each ear simultaneously. The pABR yields high-quality waveforms that are similar to the standard, single-frequency serial ABR but in a fraction of the recording time. While well-documented for standard ABRs, it is yet unknown how presentation rate and level interact to affect responses collected in parallel. Furthermore, the stimuli are yet to be calibrated to perceptual thresholds. Therefore, this study aimed to determine the optimal range of parameters for the pABR and to establish the normative stimulus level correction values for the ABR stimuli.

DESIGN

Two experiments were completed, each with a group of 20 adults (18-35 years old) with normal-hearing thresholds (≤20 dB HL) from 250 to 8000 Hz. First, pABR electroencephalographic (EEG) responses were recorded for six stimulation rates and two intensities. The changes in component wave V amplitude and latency were analyzed, as well as the time required for all responses to reach a criterion signal-to-noise ratio of 0 dB. Second, behavioral thresholds were measured for pure tones and for the pABR stimuli at each rate to determine the correction factors that relate the stimulus level in dB peSPL to perceptual thresholds in dB nHL.

RESULTS

The pABR showed some adaptation with increased stimulation rate. A wide range of rates yielded robust responses in under 15 minutes, but 40 Hz was the optimal singular presentation rate. Extending the analysis window to include later components of the response offered further time-saving advantages for the temporally broader responses to low-frequency tone pips. The perceptual thresholds to pABR stimuli changed subtly with rate, giving a relatively similar set of correction factors to convert the level of the pABR stimuli from dB peSPL to dB nHL.

CONCLUSIONS

The optimal stimulation rate for the pABR is 40 Hz but using multiple rates may prove useful. Perceptual thresholds that subtly change across rate allow for a testing paradigm that easily transitions between rates, which may be useful for quickly estimating thresholds for different configurations of hearing loss. These optimized parameters facilitate expediency and effectiveness of the pABR to estimate hearing thresholds in a clinical setting.

Active Middle Ear Implant Evoked Auditory Brainstem Response Intensity-Latency Characteristics

Objective

To analyze intensity-latency functions of intraoperative auditory evoked brainstem responses (ABRs) to stimulation by the Vibrant Soundbridge (VSB) active middle ear implant with respect to coupling efficiency, VSB evoked ABR thresholds, and coupling modality [oval window (OW) placement vs. Incus placement and vs. round window (RW) placement].

Study Design

Exploratory study.

Setting

Bi-centric study at tertiary referral centers.

Patients

Twenty-four patients (10 female, 14 male, mean age: 58 years) who received a VSB.

Outcome Measures

Wave-V intensity-latency functions of intraoperative VSB evoked ABRs using a modified audio processor programmed to preoperative bone conduction thresholds for stimulation. Threshold level correction to coupling efficiency and ABR thresholds. Individual plots and exponential function fits.

Results

After ABR threshold level correction, the latency functions could be aligned. A large variance of latencies was observed at individual threshold level. Wave-V latency was longest in the Incus placement subgroup (9.73 ms, SD: 1.04) as compared to OW placement subgroup (9.47 ms, SD: 1.05), with the shortest latency in the RW placement subgroup (8.99 ms, SD: 0.68). For increasing stimulation levels, the variance decreased with intensity-latency function slopes converging toward a steady-state (saturation) latency caused by saturation of audio processor (stimulation) gain. Latency saturation was reached at a stimulation level of 50 dB nHL for the OW placement subgroup, 35 dB nHL for the Incus placement subgroup, and 30 dB nHL for the RW placement subgroup. The latency and saturation results indicated decreased dynamic range for RW placement, i.e., reverse stimulation.

Conclusions

VSB evoked ABR wave-V intensity-latency function slopes were similar to acoustic stimulation at high stimulation levels with a shift toward longer latencies caused by audio processor signal delay. Saturation of latencies occurred for higher stimulation levels due to saturation of audio processor gain. Thus, the analysis of VSB evoked intensity-latency functions appears to allow for the objective assessment of a patient's individual dynamic range. This can further improve diagnostics as well as intraoperative and postoperative quality control.

Sound level context modulates neural activity in the human brainstem

Optimal perception requires adaptation to sounds in the environment. Adaptation involves representing the acoustic stimulation history in neural response patterns, for example, by altering response magnitude or latency as sound-level context changes. Neurons in the auditory brainstem of rodents are sensitive to acoustic stimulation history and sound-level context (often referred to as sensitivity to stimulus statistics), but the degree to which the human brainstem exhibits such neural adaptation is unclear. In six electroencephalography experiments with over 125 participants, we demonstrate that the response latency of the human brainstem is sensitive to the history of acoustic stimulation over a few tens of milliseconds. We further show that human brainstem responses adapt to sound-level context in, at least, the last 44 ms, but that neural sensitivity to sound-level context decreases when the time window over which acoustic stimuli need to be integrated becomes wider. Our study thus provides evidence of adaptation to sound-level context in the human brainstem and of the timescale over which sound-level information affects neural responses to sound. The research delivers an important link to studies on neural adaptation in non-human animals.

Exposing distinct subcortical components of the auditory brainstem response evoked by continuous naturalistic speech

Speech processing is built upon encoding by the auditory nerve and brainstem, yet we know very little about how these processes unfold in specific subcortical structures. These structures are deep and respond quickly, making them difficult to study during ongoing speech. Recent techniques have begun to address this problem, but yield temporally broad responses with consequently ambiguous neural origins. Here, we describe a method that pairs re-synthesized ‘peaky’ speech with deconvolution analysis of electroencephalography recordings. We show that in adults with normal hearing the method quickly yields robust responses whose component waves reflect activity from distinct subcortical structures spanning auditory nerve to rostral brainstem. We further demonstrate the versatility of peaky speech by simultaneously measuring bilateral and ear-specific responses across different frequency bands and discuss the important practical considerations such as talker choice. The peaky speech method holds promise as a tool for investigating speech encoding and processing, and for clinical applications.

Objective evidence of temporal processing deficits in older adults

The older listener's ability to understand speech in challenging environments may be affected by impaired temporal processing. This review summarizes objective evidence of degraded temporal processing from studies that have used the auditory brainstem response, auditory steady-state response, the envelope- or frequency-following response, cortical auditory-evoked potentials, and neural tracking of continuous speech. Studies have revealed delayed latencies and reduced amplitudes/phase locking in subcortical responses in older vs. younger listeners, in contrast to enhanced amplitudes of cortical responses in older listeners. Reconstruction accuracy of responses to continuous speech (e.g., cortical envelope tracking) shows over-representation in older listeners. Hearing loss is a factor in many of these studies, even though the listeners would be considered to have clinically normal hearing thresholds. Overall, the ability to draw definitive conclusions regarding these studies is limited by the use of multiple stimulus conditions, small sample sizes, and lack of replication. Nevertheless, these objective measures suggest a need to incorporate new clinical measures to provide a more comprehensive assessment of the listener's speech understanding ability, but more work is needed to determine the most efficacious measure for clinical use.

The Effects of Random Stimulation Rate on Measurements of Auditory Brainstem Response

Electroencephalography (EEG) signal is an electrophysiological recording from electrodes placed on the scalp to reflect the electrical activities of the brain. Auditory brainstem response (ABR) is one type of EEG signals in response to an auditory stimulus, and it has been widely used to evaluate the potential disorders of the auditory function within the brain. Currently, the ABR measurements in the clinic usually adopt a fixed stimulation rate (FSR) technique in which the late evoked response could contaminate the ABR signals and deteriorate the waveform differentiation after averaging, thus compromising the overall auditory function assessment task. To resolve this issue, this study proposed a random stimulation rate (RSR) method by integrating a random interval between two adjacent stimuli. The results showed that the proposed RSR method was consistently repeatable and reliable in multiple trials of repeated measurements, and there was a large amplitude of successive late evoked response that would contaminate the ABR signals for conventional FSR methods. The ABR waveforms of the RSR method showed better wave I–V morphology across different stimulation rates and stimulus levels, and the improved ABR morphology played an important role in early diagnoses of auditory pathway abnormities. The correlation coefficients as functions of averaging time showed that the ABR waveform of the RSR method stabilizes significantly faster, and therefore, it could be used to speed up current ABR measurements with more reliable testing results. The study suggests that the proposed method would potentially aid the adequate reconstruction of ABR signals towards a more effective means of hearing loss screening, brain function diagnoses, and potential brain–computer interface.

Adaptation and spectral enhancement at auditory temporal perceptual boundaries - Measurements via temporal precision of auditory brainstem responses

In human and animal auditory perception the perceived quality of sound streams changes depending on the duration of inter-sound intervals (ISIs). Here, we studied whether adaptation and the precision of temporal coding in the auditory periphery reproduce general perceptual boundaries in the time domain near 20, 100, and 400 ms ISIs, the physiological origin of which are unknown. In four experiments, we recorded auditory brainstem responses with five wave peaks (P1 –P5) in response to acoustic models of communication calls of house mice, who perceived these calls with the mentioned boundaries. The newly introduced measure of average standard deviations of wave latencies of individual animals indicate the waves’ temporal precision (latency jitter) mostly in the range of 30–100 μs, very similar to latency jitter of single neurons. Adaptation effects of response latencies and latency jitter were measured for ISIs of 10–1000 ms. Adaptation decreased with increasing ISI duration following exponential or linear (on a logarithmic scale) functions in the range of up to about 200 ms ISIs. Adaptation effects were specific for each processing level in the auditory system. The perceptual boundaries near 20–30 and 100 ms ISIs were reflected in significant adaptation of latencies together with increases of latency jitter at P2-P5 for ISIs < ~30 ms and at P5 for ISIs < ~100 ms, respectively. Adaptation effects occurred when frequencies in a sound stream were within the same critical band. Ongoing low-frequency components/formants in a sound enhanced (decrease of latencies) coding of high-frequency components/formants when the frequencies concerned different critical bands. The results are discussed in the context of coding multi-harmonic sounds and stop-consonants-vowel pairs in the auditory brainstem. Furthermore, latency data at P1 (cochlea level) offer a reasonable value for the base-to-apex cochlear travel time in the mouse (0.342 ms) that has not been determined experimentally.

Comparison of maximum length sequence and randomized stimulation and averaging methods on the bottlenose dolphin auditory brainstem response

The purpose of the present study was to compare auditory brainstem responses (ABRs) using two approaches that allow the use of high stimulation rates, but with different temporal variability in the interstimulus interval: maximum length sequences (MLS) and iterative randomized stimulation and averaging (I-RSA). ABRs were obtained to click stimuli in six bottlenose dolphins (Tursiops truncatus). In experiment 1, click level was held constant and click rate varied from 25 to 1250 Hz. For MLS, interstimulus intervals varied by a factor of 6 at each rate, while for I-RSA the interstimulus intervals varied by ± 0.5 ms regardless of rate. In experiment 2, stimulus rates ranged from 100 to 1000 Hz and click level varied from 105 to 135 dB re: 1 μPa. For experiment 1, MLS and I-RSA showed similar decreases in ABR peak amplitudes and increases in ABR peak latencies and interwave intervals with increasing rate. For experiment 2, there was an increase in peak latency and a decrease in peak amplitude with decreasing click level; however, the effects of click level were reduced at higher rates. The results indicate that the greater jitter for MLS compared to I-RSA does not substantially affect the dolphin ABR.

Musical Experience, Sensorineural Auditory Processing, and Reading Subskills in Adults

Developmental research suggests that sensorineural auditory processing, reading subskills (e.g., phonological awareness and rapid naming), and musical experience are related during early periods of reading development. Interestingly, recent work suggests that these relations may extend into adulthood, with indices of sensorineural auditory processing relating to global reading ability. However, it is largely unknown whether sensorineural auditory processing relates to specific reading subskills, such as phonological awareness and rapid naming, as well as musical experience in mature readers. To address this question, we recorded electrophysiological responses to a repeating click (auditory stimulus) in a sample of adult readers. We then investigated relations between electrophysiological responses to sound, reading subskills, and musical experience in this same set of adult readers. Analyses suggest that sensorineural auditory processing, reading subskills, and musical experience are related in adulthood, with faster neural conduction times and greater musical experience associated with stronger rapid-naming skills. These results are similar to the developmental findings that suggest reading subskills are related to sensorineural auditory processing and musical experience in children.

Accuracy of averaged auditory brainstem response amplitude and latency estimates

OBJECTIVE

The aims were to 1) establish which of the four algorithms for estimating residual noise level and signal-to-noise ratio (SNR) in auditory brainstem responses (ABRs) perform better in terms of post-average wave-V peak latency and amplitude errors and 2) determine whether SNR or noise floor is a better stop criterion where the outcome measure is peak latency or amplitude.

DESIGN

The performance of the algorithms was evaluated by numerical simulations using an ABR template combined with electroencephalographic (EEG) recordings obtained without sound stimulus. The suitability of a fixed SNR versus a fixed noise floor stop criterion was assessed when variations in the wave-V waveform shape reflecting inter-subject variation was introduced.

STUDY SAMPLE

Over 100 hours of raw EEG noise was recorded from 17 adult subjects, under different conditions (e.g. sleep or movement).

RESULTS

ABR feature accuracy was similar for the four algorithms. However, it was shown that a fixed noise floor leads to higher ABR wave-V amplitude accuracy; conversely, a fixed SNR yields higher wave-V latency accuracy.

CONCLUSION

Similar performance suggests the use of the less computationally complex algorithms. Different stop criteria are recommended if the ABR peak latency or the amplitude is the outcome measure of interest.

Auditory neuropathy in a patient with hemochromatosis

OBJECTIVE

To evaluate the auditory function of an individual with genetically confirmed hemochromatosis.

METHODS

A 57 year old male with mildly impaired sound detection thresholds underwent a range of behavioural, electroacoustic and electrophysiologic assessments. These included the recording of otoacoustic emissions and auditory brainstem responses, measurement of monaural temporal resolution and evaluation of binaural speech processing. Findings for this patient were subsequently compared with those of 80 healthy controls with similar audiometric thresholds.

RESULTS

The patient showed the three cardinal features of auditory neuropathy, presenting with evidence of normal cochlear outer hair cell function, disrupted neural activity in the auditory nerve/brainstem and impaired temporal processing. His functional hearing ability (speech perception) was significantly affected and suggested a reduced capacity to use localization cues to segregate signals in the presence of background noise.

CONCLUSION

We present the first case of an individual with hemochromatosis and auditory neuropathy. The findings for this patient highlight the need for careful evaluation of auditory function in individuals with the disorder.

Neonate Auditory Brainstem Responses to CE-Chirp and CE-Chirp Octave Band Stimuli II: Versus Adult Auditory Brainstem Responses

OBJECTIVES

The purpose of the study was to examine the differences in auditory brainstem response (ABR) latency and amplitude indices to the CE-Chirp stimuli in neonates versus young adults as a function of stimulus level, rate, polarity, frequency and gender.

DESIGN

Participants were 168 healthy neonates and 20 normal-hearing young adults. ABRs were obtained to air- and bone-conducted CE-Chirps and air-conducted CE-Chirp octave band stimuli. The effects of stimulus level, rate, and polarity were examined with air-conducted CE-Chirps. The effect of stimulus level was also examined with bone-conducted CE-Chirps and CE-Chirp octave band stimuli. The effect of gender was examined across all stimulus manipulations.

RESULTS

In general, ABR wave V amplitudes were significantly larger (p < 0.0001) and latencies were significantly shorter (p < 0.0001) for adults versus neonates for all air-conducted CE-Chirp stimuli with all stimulus manipulations. For bone-conducted CE-Chirps, infants had significantly shorter wave V latencies than adults at 15 dB nHL and 45 dB nHL (p = 0.02). Adult wave V amplitude was significantly larger for bone-conducted CE-Chirps only at 30 dB nHL (p = 0.02). The effect of gender was not statistically significant across all measures (p > 0.05).

CONCLUSIONS

Significant differences in ABR latencies and amplitudes exist between newborns and young adults using CE-Chirp stimuli. These differences are consistent with differences to traditional click and tone burst stimuli and reflect maturational differences as a function of age. These findings continue to emphasize the importance of interpreting ABR results using age-based normative data.

Intertrial auditory neural stability supports beat synchronization in preschoolers

The ability to synchronize motor movements along with an auditory beat places stringent demands on the temporal processing and sensorimotor integration capabilities of the nervous system. Links between millisecond-level precision of auditory processing and the consistency of sensorimotor beat synchronization implicate fine auditory neural timing as a mechanism for forming stable internal representations of, and behavioral reactions to, sound. Here, for the first time, we demonstrate a systematic relationship between consistency of beat synchronization and trial-by-trial stability of subcortical speech processing in preschoolers (ages 3 and 4 years old). We conclude that beat synchronization might provide a useful window into millisecond-level neural precision for encoding sound in early childhood, when speech processing is especially important for language acquisition and development.

Interaural stimulation timing in single sided deaf cochlear implant users

The interaural time difference (ITD) is an important cue for the localization of sounds. ITD changes as little as 10 μs can be detected by the human auditory system. By provision of one ear with a cochlear implant (CI) ITD are altered due to the partial replacement of the peripheral auditory system. A hearing aid (HA), in contrast, does not replace but adds a processing delay component to the peripheral auditory system extending ITD. The aim of the present study was to quantify interaural stimulation timing between these different modalities to estimate the need for central auditory temporal compensation in single sided deaf CI users or bimodal CI/HA users. For this purpose, wave V latencies of auditory brainstem responses evoked either acoustically (ABR) or electrically via the CI (EABR) have been measured. The sum of delays consisting of CI signal processing measured in the MED-EL OPUS2 audio processor and EABR wave V latencies evoked on different intracochlear sites allowed an estimation of the entire CI channel-specific delay for MED-EL MAESTRO CI systems. We compared these values with ABR wave V latencies measured in the contralateral normal hearing or HA provided ear in different frequency bands. The results showed that EABR wave V latencies were consistently shorter than those evoked acoustically in the unaided normal hearing ear. Thus, artificial delays within the audio processor can be implemented to adjust interaural stimulation timing. The currently implemented group delays in the MED-EL CI system turned out to be reasonably similar to those of the unaided ear. For adjustment of CI and contralateral HA, in contrast, an adjustable additional across-frequency delay in the range of 1-11 ms implemented in the CI would be required. Especially for bimodal CI/HA users the adjustment of interaural stimulation timing may induce improved binaural hearing, reduced need for central auditory temporal compensation and increased acceptance of the CI/HA provision.

The influence of cochlear spectral processing on the timing and amplitude of the speech-evoked auditory brain stem response

The speech-evoked auditory brain stem response (speech ABR) is widely considered to provide an index of the quality of neural temporal encoding in the central auditory pathway. The aim of the present study was to evaluate the extent to which the speech ABR is shaped by spectral processing in the cochlea. High-pass noise masking was used to record speech ABRs from delimited octave-wide frequency bands between 0.5 and 8 kHz in normal-hearing young adults. The latency of the frequency-delimited responses decreased from the lowest to the highest frequency band by up to 3.6 ms. The observed frequency-latency function was compatible with model predictions based on wave V of the click ABR. The frequency-delimited speech ABR amplitude was largest in the 2- to 4-kHz frequency band and decreased toward both higher and lower frequency bands despite the predominance of low-frequency energy in the speech stimulus. We argue that the frequency dependence of speech ABR latency and amplitude results from the decrease in cochlear filter width with decreasing frequency. The results suggest that the amplitude and latency of the speech ABR may reflect interindividual differences in cochlear, as well as central, processing. The high-pass noise-masking technique provides a useful tool for differentiating between peripheral and central effects on the speech ABR. It can be used for further elucidating the neural basis of the perceptual speech deficits that have been associated with individual differences in speech ABR characteristics.

Auditory brainstem and middle latency responses recorded at fast rates with randomized stimulation

Randomized stimulation and averaging (RSA) allows auditory evoked potentials (AEPs) to be recorded at high stimulation rates. This method does not perform deconvolution and must therefore deal with interference derived from overlapping transient evoked responses. This paper analyzes the effects of this interference on auditory brainstem responses (ABRs) and middle latency responses (MLRs) recorded at rates of up to 300 and 125 Hz, respectively, with randomized stimulation sequences of a jitter both greater and shorter than the dominant period of the ABR/MLR components. Additionally, this paper presents an advanced approach for RSA [iterative-randomized stimulation and averaging (I-RSA)], which includes the removal of the interference associated with overlapping responses through an iterative process in the time domain. Experimental results show that (a) RSA can be efficiently used in the recording of AEPs when the jitter of the stimulation sequence is greater than the dominant period of the AEP components, and (b) I-RSA maintains all the advantages of RSA and is not constrained by the restriction of a minimum jitter. The significance of the results of this study is discussed.

Optimizing Stimulus Repetition Rate for Recording Ocular Vestibular Evoked Myogenic Potential Elicited by Air-Conduction Tone Bursts of 500 Hz

Amidst several publications reporting the effects of stimulus-related parameters on ocular vestibular evoked myogenic potential (oVEMP), the effect of the repetition rate on oVEMP responses has largely gone unexplored. Studies have used a repetition rate of ~5.1 Hz mainly due to a presumption that oVEMP, like cervical VEMP, should produce best responses for ~5 Hz, although there is paucity of experimental evidence to support this hypothesis. 52 healthy individuals in the age range of 17-35 years underwent air-conduction oVEMP elicited by 500 Hz tone-bursts using seven different repetition rates (3.1, 5.1, 10.1, 15.1, 20.1, 25.1 and 30.1 Hz). The results revealed a tendency for prolongation of latencies and reduction in amplitude with increasing repetition rate. However, significantly longer latencies were observed only for 20.1 Hz and larger amplitudes for 3.1 and 5.1 Hz (P<0.05). There was no significant difference between the rates of 3.1 Hz and 5.1 Hz. However 3.1 Hz produced poorer signal-to-noise ratio and required considerably longer time and thereby had lesser efficiency than 5.1 Hz (P<0.05). This would also result in higher fatigue and irritation levels considering the physical act of maintaining a supero-medial gaze. Thus the use of 5.1 Hz is recommended for clinical recording of oVEMP.

Brainstem auditory evoked responses in children living at high altitude in the andes mountains

OBJECTIVES

This neurophysiological study compared brainstem auditory evoked responses (BAER) in children living at high elevations (2800 to 3000 meters) in the Andes Mountains of Ecuador with a reference group of children living at sea level in the U.S.

METHODS

BAER absolute latencies of waves I through V; interpeak latencies I-III, III-V, and I-V; amplitudes of waves I and V; and the V/I amplitude ratio were measured by scalp electrodes at acoustic click stimulus rates of 10 and 50 pulses per second (pps).

RESULTS

Statistical analysis showed that the high-altitude group had significantly longer absolute and interpeak BAER latencies than the sea-level reference group at both the 10 and 50 pps stimulus rates for most wave peaks. The amplitudes of waves I and V were significantly reduced for the high-altitude group at 10 and 50 pps, suggesting blood O2 saturation effects.

CONCLUSIONS

The BAER of children in the high-altitude group suggested physiological anomalies in auditory neural conduction and summation compared with the sea-level group. The results further suggest that small physiological effects of altitude on BAER, especially at elevations near 3000 meters and higher, should be taken into consideration in the evaluation of brainstem auditory function.

Unstable representation of sound: a biological marker of dyslexia

Learning to read proceeds smoothly for most children, yet others struggle to translate verbal language into its written form. Poor readers often have a host of auditory, linguistic, and attention deficits, including abnormal neural representation of speech and inconsistent performance on psychoacoustic tasks. We hypothesize that this constellation of deficits associated with reading disorders arises from the human auditory system failing to respond to sound in a consistent manner, and that this inconsistency impinges upon the ability to relate phonology and orthography during reading. In support of this hypothesis, we show that poor readers have significantly more variable auditory brainstem responses to speech than do good readers, independent of resting neurophysiological noise levels. Thus, neural variability may be an underlying biological contributor to well established behavioral and neural deficits found in poor readers.

Loudness adaptation accompanying ribbon synapse and auditory nerve disorders

Abnormal auditory adaptation is a standard clinical tool for diagnosing auditory nerve disorders due to acoustic neuromas. In the present study we investigated auditory adaptation in auditory neuropathy owing to disordered function of inner hair cell ribbon synapses (temperature-sensitive auditory neuropathy) or auditory nerve fibres. Subjects were tested when afebrile for (i) psychophysical loudness adaptation to comfortably-loud sustained tones; and (ii) physiological adaptation of auditory brainstem responses to clicks as a function of their position in brief 20-click stimulus trains (#1, 2, 3 … 20). Results were compared with normal hearing listeners and other forms of hearing impairment. Subjects with ribbon synapse disorder had abnormally increased magnitude of loudness adaptation to both low (250 Hz) and high (8000 Hz) frequency tones. Subjects with auditory nerve disorders had normal loudness adaptation to low frequency tones; all but one had abnormal adaptation to high frequency tones. Adaptation was both more rapid and of greater magnitude in ribbon synapse than in auditory nerve disorders. Auditory brainstem response measures of adaptation in ribbon synapse disorder showed Wave V to the first click in the train to be abnormal both in latency and amplitude, and these abnormalities increased in magnitude or Wave V was absent to subsequent clicks. In contrast, auditory brainstem responses in four of the five subjects with neural disorders were absent to every click in the train. The fifth subject had normal latency and abnormally reduced amplitude of Wave V to the first click and abnormal or absent responses to subsequent clicks. Thus, dysfunction of both synaptic transmission and auditory neural function can be associated with abnormal loudness adaptation and the magnitude of the adaptation is significantly greater with ribbon synapse than neural disorders.

Recording of auditory brainstem response at high stimulation rates using randomized stimulation and averaging

The recording of auditory brainstem response (ABR) at high stimulation rates is of great interest in audiology. It allows a more accurate diagnosis of certain pathologies at an early stage and the study of different mechanisms of adaptation. This paper proposes a methodology, which we will refer to as randomized stimulation and averaging (RSA) that allows the recording of ABR at high stimulation rates using jittered stimuli. The proposed method has been compared with quasi-periodic sequence deconvolution (QSD) and conventional (CONV) stimulation methodologies. Experimental results show that RSA provides a quality in ABR recordings similar to that of QSD and CONV. Compared with CONV, RSA presents the advantage of being able to record ABR at rates higher than 100 Hz. Compared with QSD, the formulation of RSA is simpler and allows more flexibility on the design of the pseudorandom sequence. The feasibility of the RSA methodology is validated by an analysis of the morphology, amplitudes, and latencies of the most important waves in ABR recorded at high stimulation rates from eight normal hearing subjects.

Assistive listening devices drive neuroplasticity in children with dyslexia

Children with dyslexia often exhibit increased variability in sensory and cognitive aspects of hearing relative to typically developing peers. Assistive listening devices (classroom FM systems) may reduce auditory processing variability by enhancing acoustic clarity and attention. We assessed the impact of classroom FM system use for 1 year on auditory neurophysiology and reading skills in children with dyslexia. FM system use reduced the variability of subcortical responses to sound, and this improvement was linked to concomitant increases in reading and phonological awareness. Moreover, response consistency before FM system use predicted gains in phonological awareness. A matched control group of children with dyslexia attending the same schools who did not use the FM system did not show these effects. Assistive listening devices can improve the neural representation of speech and impact reading-related skills by enhancing acoustic clarity and attention, reducing variability in auditory processing.

Frequency-dependent effects of background noise on subcortical response timing

The addition of background noise to an auditory signal delays brainstem response timing. This effect has been extensively documented using manual peak selection. Peak picking, however, is impractical for large-scale studies of spectrotemporally complex stimuli, and leaves open the question of whether noise-induced delays are frequency-dependent or occur across the frequency spectrum. Here we use an automated, objective method to examine phase shifts between auditory brainstem responses to a speech sound (/da/) presented with and without background noise. We predicted that shifts in neural response timing would also be reflected in frequency-specific phase shifts. Our results indicate that the addition of background noise causes phase shifts across the subcortical response spectrum (70-1000 Hz). However, this noise-induced delay is not uniform such that some frequency bands show greater shifts than others: low-frequency phase shifts (300-500 Hz) are largest during the response to the consonant-vowel formant transition (/d/), while high-frequency shifts (720-1000 Hz) predominate during the response to the steady-state vowel (/a/). Most importantly, phase shifts occurring in specific frequency bands correlate strongly with shifts in the latencies of the predominant peaks in the auditory brainstem response, while phase shifts in other frequency bands do not. This finding confirms the validity of phase shift detection as an objective measure of timing differences and reveals that this method detects noise-induced shifts in timing that may not be captured by traditional peak latency measurements.

Brainstem correlates of temporal auditory processing in children with specific language impairment

Deficits in identification and discrimination of sounds with short inter-stimulus intervals or short formant transitions in children with specific language impairment (SLI) have been taken to reflect an underlying temporal auditory processing deficit. Using the sustained frequency following response (FFR) and the onset auditory brainstem responses (ABR) we evaluated if children with SLI show abnormalities at the brainstem level consistent with a temporal processing deficit. To this end, the neural encoding of tonal sweeps, as reflected in the FFR, for different rates of frequency change, and the effects of reducing inter-stimulus interval on the ABR components were evaluated in 10 4-11-year-old SLI children and their age-matched controls. Results for the SLI group showed degraded FFR phase-locked neural activity that failed to faithfully track the frequency change presented in the tonal sweeps, particularly at the faster sweep rates. SLI children also showed longer latencies for waves III and V of the ABR and a greater prolongation of wave III at high stimulus rates (>30/sec), suggesting greater susceptibility to neural adaptation. These results taken together appear to suggest a disruption in the temporal pattern of phase-locked neural activity necessary to encode rapid frequency change and an increased susceptibility to desynchronizing factors related to faster rates of stimulus presentation in children with SLI.

Stimulus rate and subcortical auditory processing of speech

Many sounds in the environment, including speech, are temporally dynamic. The auditory brainstem is exquisitely sensitive to temporal features of the incoming acoustic stream, and by varying the speed of presentation of these auditory signals it is possible to investigate the precision with which temporal cues are represented at a subcortical level. Therefore, to determine the effects of stimulation rate on the auditory brainstem response (ABR), we recorded evoked responses to both a click and a consonant-vowel speech syllable (/da/) presented at three rates (15.4, 10.9 and 6.9 Hz). We hypothesized that stimulus rate affects the onset to speech-evoked responses to a greater extent than click-evoked responses and that subcomponents of the speech- ABR are distinctively affected. While the click response was invariant with changes in stimulus rate, timing of the onset response to /da/ varied systematically, increasing in peak latency as presentation rate increased. Contrasts between the click- and speech-evoked onset responses likely reflect acoustic differences, where the speech stimulus onset is more gradual, has more delineated spectral information, and is more susceptible to backward masking by the subsequent formant transition. The frequency-following response (FFR) was also rate dependent, with response magnitude of the higher frequencies (>400 Hz), but not the frequencies corresponding to the fundamental frequency, diminishing with increasing rate. The selective impact of rate on high-frequency components of the FFR implicates the involvement of distinct underlying neural mechanisms for high- versus low-frequency components of the response. Furthermore, the different rate sensitivities of the speech-evoked onset response and subcomponents of the FFR support the involvement of different neural streams for these two responses. Taken together, these differential effects of rate on the ABR components likely reflect distinct aspects of auditory function such that varying rate of presentation of complex stimuli may be expected to elicit unique patterns of abnormality, depending on the clinical population.

Brainstem auditory evoked potentials--a review and modified studies in healthy subjects

The authors review the brainstem auditory evoked potential (BAEP), and present studies on 40 healthy subjects. In addition to the conventional click evoked BAEP, three modified BAEP examinations were performed. The modified BAEP tests include a 1,000 Hz tone-burst BAEP, and more rapid rate binaural click and 1,000 Hz tone-burst BAEPs-each of the last two studies performed at four diminishing moderate intensities. In addition to the usual parameters, the authors examined the Wave V to Vn interpeak latency, and stimulus intensity versus Wave V latency and amplitude functions in the rapid rate binaural studies. Studies were also repeated on healthy subjects in a dependant head position in an attempt to increase intracranial pressure. Discussion centers on the BAEP, its current utility in medicine, unique neurophysiology, and literature support that the above modifications could increase the practicality of the test in patients at risk with intracranial lesions and perhaps improve the feasibility for real-time continuous or frequent monitoring in the future.

Influence of cochlear traveling wave and neural adaptation on auditory brainstem responses

The present study investigates the relationship between evoked responses to transient broadband chirps and responses to the same chirps when embedded in longer-duration stimuli. It examines to what extent the responses to the composite stimuli can be explained by a linear superposition of the responses to the single components, as a function of stimulus level. In the first experiment, a single rising chirp was temporally and spectrally embedded in two steady-state tones. In the second experiment, the stimulus consisted of a continuous alternating train of chirps: each rising chirp was followed by the temporally reversed (falling) chirp. In both experiments, the transitions between stimulus components were continuous. For stimulation levels up to approximately 70 dB SPL, the responses to the embedded chirp corresponded to the responses to the single chirp. At high stimulus levels (80-100 dB SPL), disparities occurred between the responses, reflecting a nonlinearity in the processing when neural activity is integrated across frequency. In the third experiment, the effect of within-train rate on wave-V response was investigated. The response to the chirp presented at a within-train rate of 95 Hz exhibited the same amplitude as that to the chirp presented in the traditional single-stimulus paradigm at a rate of 13 Hz. For a corresponding experiment with bandlimited chirps of 4 ms duration, where the within-train rate was 250 Hz, a clear reduction of the response amplitude was observed. This nonlinearity in terms of temporal processing most likely reflects effects of short-term adaptation. Overall, the results of the present study further demonstrate the importance of cochlear processing for the formation of brainstem potentials. The data may provide constraints on future models of peripheral processing in the human auditory system. The findings might also be useful for the development of effective stimulation paradigms in clinical applications.

The use of QSD (q-sequence deconvolution) to recover superposed, transient evoked-responses

OBJECTIVE

We describe q-sequence deconvolution (QSD), a new data acquisition/analysis method for evoked-responses that solves the problem of waveform distortion at high stimulus repetition-rates, due to response overlap. QSD can increase the sensitivity of clinically useful evoked-responses because it is well known that high stimulus repetition-rates are better for detecting pathophysiology.

METHODS

QSD is applicable to a variety of experimental conditions. Because some QSD-parameters must be chosen by the experimenter, the underlying principles and assumptions of the method are described in detail. The theoretical and mathematical bases of the QSD method are also described, including some equivalent computational formulations.

RESULTS

QSD was applied to recordings of the human auditory brainstem response (ABR) at stimulus repetition-rates that overlapped the responses. The transient ABR was recovered at all rates tested (highest 160/s), and showed systematic changes with stimulus repetition-rate within a single subject.

CONCLUSIONS

QSD offers a new method of recovering brain evoked-response activity having a duration longer than the time between stimuli.

SIGNIFICANCE

The use of this new technique for analysis of evoked responses will permit examination of brain activation patterns across a broad range of stimulus repetition-rates, some never before studied. Such studies will improve the sensitivity of evoked-responses for the detection of brain pathophysiology. New measures of brain activity may be discovered using QSD. The method also permits the recovery of the transient brain waveforms that overlap to form 'steady-state' waveforms. An additional benefit of the QSD method is that repetition-rate can be isolated as a variable, independent of other stimulus characteristics, even if the response is a nonlinear function of rate.

The combined effects of forward masking by noise and high click rate on monaural and binaural human auditory nerve and brainstem potentials

OBJECTIVE

To study effects of forward masking and rapid stimulation on human monaurally- and binaurally-evoked brainstem potentials and suggest their relation to synaptic fatigue and recovery and to neuronal action potential refractoriness.

METHODS

Auditory brainstem evoked potentials (ABEPs) were recorded from 12 normally- and symmetrically hearing adults, in response to each click (50 dB nHL, condensation and rarefaction) in a train of nine, with an inter-click interval of 11 ms, that followed a white noise burst of 100 ms duration (50 dB nHL). Sequences of white noise and click train were repeated at a rate of 2.89 s(-1). The interval between noise and first click in the train was 2, 11, 22, 44, 66 or 88 ms in different runs. ABEPs were averaged (8000 repetitions) using a dwell time of 25 micros/address/channel. The binaural interaction components (BICs) of ABEPs were derived and the single, centrally located equivalent dipoles of ABEP waves I and V and of the BIC major wave were estimated.

RESULTS

The latencies of dipoles I and V of ABEP, their inter-dipole interval and the dipole magnitude of component V were significantly affected by the interval between noise and clicks and by the serial position of the click in the train. The latency and dipole magnitude of the major BIC component were significantly affected by the interval between noise and clicks. Interval from noise and the click's serial position in the train interacted to affect dipole V latency, dipole V magnitude, BIC latencies and the V-I inter-dipole latency difference. Most of the effects were fully apparent by the first few clicks in the train, and the trend (increase or decrease) was affected by the interval between noise and clicks.

CONCLUSIONS

The changes in latency and magnitude of ABEP and BIC components with advancing position in the click train and the interactions of click position in the train with the intervals from noise indicate an interaction of fatigue and recovery, compatible with synaptic depletion and replenishing, respectively. With the 2 ms interval between noise and the first click in the train, neuronal action potential refractoriness may also be involved.

Click-evoked ABR at high stimulus repetition rates for neonatal hearing screening

A new, fast screening algorithm based on auditory brainstem response (ABR) recorded at a high click repetition rate is proposed. Response detection is carried out in the frequency domain by a statistical test procedure which includes the fundamental frequency and the harmonics below 800 Hz. First, the method was tested in 25 young adults. ABRs were recorded in the repetition rate range 20/s to 400/s. With a mean response detection time of 31 s, a click repetition rate of 140/s was found to be the optimum rate among the adult group. The method was then tested using a group of 114 neonates in whom the repetition rate range 60/s to 200/s was examined. At the repetition rate 90/s, which was found to be the optimum rate in neonates, the mean detection time was 24.6 s. In addition to the fast ABR detection, the proposed screening algorithm also allows simultaneous hearing screening of both ears using a one-channel data recording.

The cumulative effect of high click rate on monaural and binaural processing in the human auditory brainstem

OBJECTIVE

The objective of the present study was to compare the effects of high stimulus rate and click position in the train on monaurally and binaurally evoked activities in the human auditory brainstem and suggest their possible physiological mechanism.

METHODS

Auditory brainstem evoked potentials (ABEPs) were recorded from 15 normally and symmetrically hearing adults from 3 channels, in response to 50dB nHL, alternating polarity clicks, presented at a rate of 21/s as well as separately to each click in a train of 10 with an interstimulus interval of 11ms. Click trains were presented at a rate of 5.13/s. The binaural interaction components (BICs) of ABEPs were derived by subtracting the response to binaural clicks from the algebraic sum of monaural responses. Single, centrally located equivalent dipoles were estimated as concise measures of the surface-summated activity of ABEPs and BICs generators.

RESULTS

A significant effect of click position in the train on equivalent dipole latency of ABEP component V and on equivalent dipole magnitude of III were found. Latency was prolonged and amplitude was increased the later the click's position in the train. A significant effect of click position in the train on equivalent dipole latencies of all components of BICs was found. Latencies were prolonged if the click's position occurred later in the train, with most of the latency shift achieved by the third click in the train for the first major BIC and by the seventh click for other BIC components. No significant effects on equivalent dipole magnitudes of BICs were found. No significant effect of click position in the train on orientation of any of the equivalent dipoles of ABEP or BIC was found.

CONCLUSIONS

The progressive prolongation of latency of ABEP and BIC components with advancing position in the train may be attributed to cumulatively decreased synaptic efficacy at high stimulus rates, resulting in prolonged synaptic delays along the auditory pathway. The paradoxic enhancement of ABEP dipole III magnitude with advancing click position in the train may reflect higher sensitivity of inhibitory brainstem neurons to increased stimulus rate, resulting in disinhibition. The absence of significant effects on BIC dipole magnitudes may reflect the amplifying effect of divergence in the ascending auditory pathway, as has been observed for the monaurally evoked ABEP components from the upper pons.

Functional development of the auditory brainstem in the tammar wallaby (Macropus eugenii): the superior olivary complex and its relationship with the auditory brainstem response (ABR)

Twenty pouch-young tammar wallabies (Macropus eugenii) were used to determine the generator of the auditory brainstem response (ABR) during development through ABR and focal superior olivary complex (SO) recordings. A click response from the SO in the wallaby was recorded from postnatal day (PND) 112 when the ABR was only a positive-negative deflection. Before PND 120, the SO response did not contribute to the ABR as it occurred outside the ABR time-span. After PND 140, the SO response was correlated with multiple waves of the ABR with its dominant component corresponding to the ABR P3 wave. The latency, threshold, and amplitude of the SO response developed to the adult-like level at PND 140, while the rate-following ability in the SO response reached the adult level at PND 160. Presumably this was due to more complicated mechanisms underlying the auditory adaptation. The adaptation of the SO response was directly proportional to the stimulus rate and intensity as well as developmental status. Developmental comparison between the ABR and the focal responses from four auditory brainstem nuclei indicated that each ABR component may have a dominant contributor from the auditory brainstem, but there was no simple and exclusive association between the ABR component and the auditory brainstem nuclei.

The effects of high stimulus rate on the electrocochleogram in normal-hearing subjects

The use of high stimulus rates has the potential to improve the electrocochleogram's (ECochG) sensitivity and specificity in endolymphatic hydrops and Menière's disease, but is currently hindered by the absence of an acceptable normative database. In response, this study recorded click-evoked ECochG tracings from 51 normal-hearing subjects (102 ears), between 18 and 60 years of age, at 7.1, 51.1, 101.1 and 151.1 clicks/s using a tympanic membrane electrode. As stimulus rate increased, various statistically significant (p < 0.05) changes were observed. In general, summating potential (SP) latency and amplitude and action potential (AP) latency increased, SP/AP amplitude ratio and waveform width increased but then plateaued, and AP amplitude fluctuated. While providing the largest contribution to a high-stimulus-rate ECochG normative database published to date, potential clinical limitations were identified and a possible solution proposed.

The varieties of auditory neuropathy

Auditory neuropathy (AN) was initially described as impairment of auditory neural function, with preserved cochlear hair cell function. In this report, 67 patients with audiological and neurophysiological criteria for hearing loss due to auditory neuropathy are described. Reviewing this large body of patients, AN appears to consist of a number of varieties, with different etiologies and sites affected. All varieties share a relatively spared receptor function, and an impaired neural response, with diminished ability to follow fast temporal changes in the stimulus, but different varieties in this general scheme can be distinguished. Analyses of the clinical features indicate that auditory neuropathies vary in several measures including age of onset, presence of peripheral neuropathy, etiology, and behavioral and physiological measures of auditory function. The sites affected along the peripheral auditory pathway may include dysfunction of the outer hair cells, the synapse between hair cell and auditory nerve, and the auditory nerve fibers, with myelin as well as axonal impairments contributing to the disorder.