Past, present, and future applications of the auditory middle latency response

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.

A Review of the Role of Auditory Evoked Potentials in Mild Traumatic Brain Injury Assessment

Around 75% to 90% of people who experience a traumatic brain injury (TBI) are classified as having a mild TBI (mTBI). The term mTBI is synonymous with concussion or mild head injury (MHI) and is characterized by symptoms of headache, nausea, dizziness, and blurred vision. Problems in cognitive abilities such as deficits in memory, processing speed, executive functioning, and attention are also considered symptoms of mTBI. Since these symptoms are subtle in nature and may not appear immediately following the injury, mTBI is often undetected on conventional neuropsychological tests. Current neuroimaging techniques may not be sensitive enough in identifying the array of microscopic neuroanatomical and subtle neurophysiological changes following mTBI. To this end, electrophysiological tests, such as auditory evoked potentials (AEPs), can be used as sensitive tools in tracking physiological changes underlying physical and cognitive symptoms associated with mTBI. The purpose of this review article is to examine the body of literature describing the application of AEPs in the assessment of mTBI and to explore various parameters of AEPs which may hold diagnostic value in predicting positive rehabilitative outcomes for people with mTBI.

Profiles of Types of Central Auditory Processing Disorders in Children With Learning Disabilities

This article will profile five interesting cases of children with learning disabilities and auditory processing problems. These children have met a rather stringent criteria in terms of being classified as learning disabled. All subjects had normal peripheral hearning and speech discrimination ability in quiet bilaterally, with the exeption of Case 2. Each received extensive educational, psychological, and speech and language evaluations in addition to our audiological work-up. However, we will focus only on the audiological evaluations. Following each case, we will discuss the possible correlations between the presumed etiology and the unique audiological pattern on the central test battery. These five cases represent various kinds of central auditory profiles, with associated etiological correlates, which provide a categorization system for these children.

Human Auditory Evoked Potentials in the Assessment of Brain Function During Major Cardiovascular Surgery

Focal neurologic and intellectual deficits or memory problems are relatively frequent after cardiac surgery. These complications have been associated with cerebral hypoperfusion, embolization, and inflammation that occur during or after surgery. Auditory evoked potentials, a neurophysiologic technique that evaluates the function of neural structures from the auditory nerve to the cortex, provide useful information about the functional status of the brain during major cardiovascular procedures. Skepticism regarding the presence of artifacts or difficulty in their interpretation has outweighed considerations of its potential utility and noninvasiveness. This paper reviews the evidence of their potential applications in several aspects of the management of cardiac surgery patients. The sensitivity of auditory evoked potentials to the effects of changes in brain temperature makes them useful for monitoring cerebral hypothermia and rewarming during cardiopulmonary bypass. The close relationship between evoked potential waveforms and specific anatomic structures facilitates the assessment of the functional integrity of the central nervous system in cardiac surgery patients. This feature may also be relevant in the management of critical patients under sedation and coma or in the evaluation of their prognosis during critical care. Their objectivity, reproducibility, and relative insensitivity to learning effects make auditory evoked potentials attractive for the cognitive assessment of cardiac surgery patients. From a clinical perspective, auditory evoked potentials represent an additional window for the study of underlying cerebral processes in healthy and diseased patients. From a research standpoint, this technology offers opportunities for a better understanding of the particular cerebral deficits associated with patients who are undergoing major cardiovascular procedures.

Lateralization and Binaural Interaction of Middle-Latency and Late-Brainstem Components of the Auditory Evoked Response

We used magnetoencephalography to examine lateralization and binaural interaction of the middle-latency and late-brainstem components of the auditory evoked response (the MLR and SN10, respectively). Click stimuli were presented either monaurally, or binaurally with left- or right-leading interaural time differences (ITDs). While early MLR components, including the N19 and P30, were larger for monaural stimuli presented contralaterally (by approximately 30 and 36 % in the left and right hemispheres, respectively), later components, including the N40 and P50, were larger ipsilaterally. In contrast, MLRs elicited by binaural clicks with left- or right-leading ITDs did not differ. Depending on filter settings, weak binaural interaction could be observed as early as the P13 but was clearly much larger for later components, beginning at the P30, indicating some degree of binaural linearity up to early stages of cortical processing. The SN10, an obscure late-brainstem component, was observed consistently in individuals and showed linear binaural additivity. The results indicate that while the MLR is lateralized in response to monaural stimuli-and not ITDs-this lateralization reverses from primarily contralateral to primarily ipsilateral as early as 40 ms post stimulus and is never as large as that seen with fMRI.

Auditory evoked magnetic fields in children with functional hearing loss

OBJECTIVES

Abnormal cortical responses in patients with functional hearing loss were evaluated by magnetoencephalography, which can better separate bihemispherical activity than electroencephalography.

METHODS

Auditory evoked fields in response to 1 kHz or 2 kHz tone bursts at 80 dB sound pressure level were measured by a helmet-shaped magnetoencephalography system in 22 patients with functional hearing loss (18 females, mean age 13.2 years) as well as 5 control subjects under 10 years old. Waveform, latency, and equivalent current dipole of N100m responses were used to evaluate activity in the bilateral auditory cortices.

RESULTS

Abnormal N100m of the contralateral response to the stimulated ear, either absence or delayed latency in comparison to normal adult subjects, was found in 6 of the 7 patients with functional hearing loss aged 9 years or younger, but in only 3 of the 15 patients aged 10 years or older. However, such abnormalities were also observed in younger control subjects.

CONCLUSION

Auditory evoked field may be applied to objectively evaluate cortical auditory function in patients with functional hearing loss, but the normal findings for young children have not yet been established.

A study of logon-evoked middle latency responses in female subjects with normal hearing

The middle latency response (MLR) to an acoustic stimulus occurs between 10 and 80 ms. The waveform is characterized by a series of peaks and troughs labeled N0, P0, Na, Pa, Nb and Pb. Certain acoustic stimuli may excite specific cochlear areas in contrast with clicks, that activate the cochlea between 1000 and 4000 Hz. The logon stimulus activates segmentar areas of the cochlea and has advantages over clicks when assessing low frequency areas of the cochlea (below 1 kHz). Aim: The aim of this paper was to study the MLR electrophysiologic response when activated by logon stimuli at 500, 1000 and 2000 Hz. Method- a prospective and descriptive study. 14 female volunteers had normal otology and conventional audiology results. The stimulus was monoaural and ipsilateral (Cz/A1-2). Results- the NaPa complex was readily identified compared to other complexes and was present in 100% of the tests done at 2000 Hz, and in 96.4% of the tests done at 500 and 1000 Hz. Conclusion-the logon stimulus at 500, 1000 and 2000 Hz elicits MLRs; the NaPa complex was the most frequent event and the 2000 Hz frequency elicited more responses than other frequencies.

Auditory Middle Latency Responses: a study of healthy children

Aim: To examine the components of auditory middle latency responses (AMLRs) in a sample of healthy children to establish their properties. Methods: Thirty-two children of both genders aged between 10 to 13 years, with no neurological disorders, were included in the study. Data were analyzed statistically by descriptive statistics (mean + SD) and by analysis of variance using the F test. AMLRs were investigated with toneburst stimuli at 50, 60 and 70 dB HL. Results and Conclusions: The mean latencies of the components were Na = 20.79 ms, Pa = 35.34 ms, Nb = 43.27 ms, and Pb = 53.36 ms, in 70 dB HL. The mean values for the NaPa amplitude ranged from 0.2 to 1.9 mV (M = 1.0 mV). The amplitude increased and latency decreased with increasing sound intensity. Inclination of the NaPa wave complex was present in some cases, which deserves attention in similar studies or in children with speech, language and auditory processing difficulties. Conclusion: This study provides additional information about AMLRs and may be a reference for others clinical and experimental studies in children.

Local field potentials and spiking activity in the primary auditory cortex in response to social calls

The mustached bat, Pteronotus parnellii, uses complex communication sounds ("calls") for social interactions. We recorded both event-related local field potentials (LFPs) and single/few-unit (SU) spike activity from the same electrode in the posterior region of the primary auditory cortex (AIp) during presentation of simple syllabic calls to awake bats. Temporal properties of the LFPs, which reflect activity within local neuronal clusters, and spike discharges from SUs were studied at 138 recording sites in six bats using seven variants each of 14 simple syllables presented at intensity levels of 40-90 dB SPL. There was no clear spatial selectivity to different call types within the AIp area. Rather, as shown previously, single units responded to multiple call types with similar values of the peak response rate in the peri-stimulus time histogram (PSTH). The LFPs and SUs, however, showed a rich temporal structure that was unique for each call type. Multidimensional scaling (MDS) of the averaged waveforms of call-evoked LFPs and PSTHs revealed that calls were better segregated in the two-dimensional space based on the LFP compared with the PSTH data. A representation within the "LFP-space" revealed that one of the dimensions correlated with the predominant and fundamental frequency of a call. The other dimension showed a high correlation with "harmonic complexity" ("fine" spectral structure of a call). We suggest that the temporal pattern of LFP and spiking activity reflects call-specific dynamics at any locus within the AIp area. This dynamic contributes to a distributed (population-based) representation of calls. Alternatively stated, the fundamental frequency and harmonic structure of calls, and not the recording location within the AIp, determines the temporal structure of the call-evoked LFP.

Accuracy of cortical evoked response audiometry in the identification of non-organic hearing loss

Cortical evoked response audiometry (CERA) has been used to identify the presence of a non-organic component in cases where compensation for hearing disability is claimed. This study aims at verifying the magnitude of discrepancy between thresholds estimated by CERA and by pure-tone audiometry (PTA). Results from 204 claimants (408 ears) with reliable PTA and CERA records showed mean discrepancy values between PTA and CERAT of less than 5 dB at high frequencies. Over 83.2% of claimants had a CERAT and PTA threshold discrepancy within 10 dB. Results suggested that while CERA threshold measurement could not accurately predict PTA in all cases, it could still be used as an objective guideline to rule out the presence of a non-organic component in hearing disability compensation claimants.

Amplitude--intensity functions for auditory middle latency responses in hearing-impaired subjects

Results from animal studies show that hearing loss can result in increased neural responsiveness within the central auditory system. This study employed auditory middle latency evoked responses to compare central auditory responsiveness in human males with and without hearing loss. Measurements of auditory middle latency responses (MLRs) recorded from 14 normal hearing males were compared with MLR measures from 14 males with high-frequency, sensorineural hearing loss. Sixteen toneburst stimuli (four frequencies x four intensities) were used. Slopes of the amplitude-intensity functions for the several components of the MLR were obtained for each subject at frequencies below, near, and above the audiometric edge. Analysis of variance (ANOVA) revealed a significant group effect for MLR component Pa-Na, with less steep slopes at all frequencies for the hearing-impaired group. The ANOVA also showed a trend towards a significant group effect for Pb-Nb. Two-sample t-tests performed for Pb-Nb for each of the four tonebursts showed a frequency-specific effect. For Pb-Nb there was a statistically greater mean slope for the hearing-impaired group at the toneburst frequency associated with the audiometric edge.

Middle latency auditory evoked potentials in epilepsy

Middle latency auditory evoked potentials (MLAEPs) have been recorded after cortical lesions and seizure surgery. We recorded interictal MLAEPs in 14 patients with well documented complex partial and secondary generalized seizures. Na and Pa potentials did not differ in latency between patients and controls, although both were longer among seizure patients. Pa and Na were significantly reduced in amplitude in complex partial seizure patients compared to controls. These findings accord with previous suggestions that MLAEPs may be generated subcortically but modulated by temporal lobe structures. MLAEPs may be of value in differentiating temporal and extratemporal epilepsy. They may also help clarify interictal cognitive or behavioral symptoms related to epilepsy or the effects of antiepileptic medication.

Effects of hypobaric hypoxia on the middle-latency and steady-state auditory evoked potentials

The aim of the present paper was the investigation of middle-latency responses (MLRs) and steady-state responses (SSRs) during and after a 30-min exposure to hypobaric hypoxia (5182 m above sea level). The test was performed in a hypobaric chamber on 8 male audiologically normal volunteers. The auditory stimulus (500-Hz tone burst), delivered at rates of 10 and 40/s for MLRs and SSRs, respectively, was recalibrated in the hypobaric condition because of the reduced air density. Absolute latencies of waves Na and Pa and their interpeak amplitude were the MLR parameters investigated; for the SSRs, the first positive wave (P1) absolute latency and the interpeak amplitude between P1 and the first negative wave (N1) were considered. The results showed an absence of statistically significant modification of the MLRs. On the contrary, the SSRs showed a significant (p < 0.025) latency increase during hypoxia, with an immediate recovery upon return to ground level. No significant changes of SSR amplitudes were observed. One possible data interpretation is related to the higher stimulation rate adopted for the SSRs; a second possibility could be a different electrogenesis between MLRs and SSRs.

Normative data for 40-Hz event-related potentials to 500-Hz tonal stimuli in young and elderly subjects

Recordings of 40-Hz event-related potentials (ERPs) were obtained in 81 young subjects (18-40 years) and in 20 elderly subjects (60-77 years) with hearing normal for their age. The stimuli were 500-Hz logons. The first negative peak (N1) of the response was analyzed. With increasing intensity the amplitude of the responses increased and the latency decreased for all subjects. The 40-Hz ERP was obtained within 10 dB of the behavioral threshold for more than 80% of the population under study. The N1 was prolonged in latency and enhanced in amplitude in the older subjects. No differences were found between young and elderly subjects regarding binaural interaction, or in responses elicited by ipsi- and contralateral stimulation. From the clinical point of view, the 40-Hz ERP recordings of young and elderly subjects are similar.

Neuroaudiologic Correlates to Anatomical Changes of the Brain

1. There appears to be a relationship among the improved overall behavior of this patient, anatomical changes in the brain, and enhanced performance of both psychophysical and electrophysiological central auditory tests.2. The right-sided peripheral hearing loss was one of the primary indicators for further diagnostic workup, but probably is unrelated to the lesion that was later discovered.3. In demonstrating structural as well as functional improvement, this case demonstrates the plasticity of the young human brain.

The effects of anterior temporal lobectomy (ATL) on the middle-latency auditory evoked potential (MLAEP)

The anatomical and physiological origins of the middle-latency auditory evoked potential (MLAEP) are not well understood. The present investigation was conducted to determine whether the MLAEP derives its origins in part from the anterior temporal lobe. Twelve subjects with intractable seizures were evaluated with the MLAEP pre and post excision of the anterior-mesial temporal lobe (ATL) unilaterally. In our study, component Pa latency was unaffected by the ATL. The Na latency and the Na/Pa amplitude showed significant increases after ATL. The results we interpreted as being consistent with currently held beliefs regarding the origins of Pa. The changes in Na latency and Na/Pa amplitude are hypothesized to reflect a loss of the modulating influence of the cortex on the subcortical generators of Na.

Auditory steady-state responses in the rabbit

The authors have studied auditory brainstem (ABRs), middle latency (MLRs) and steady-state potentials (SSRs) in 15 adult male rabbits weighing between 2.5 and 3 kg in order to verify if SSRs are due to a mere superimposition of ABRs and MLRs or to a resonance phenomenon. Ten of them were awake while 5 were studied under urethane anesthesia. Acoustic stimuli consisted in 0.1-ms square-wave pulses delivered at presentation rates ranging between 1 and 80/s at a stimulus intensity of 80 dB p.e. SPL. Our data show that reliable auditory SSRs can be obtained in the rabbit at a presentation rate of 30 stimuli/s, probably due to the superimposition of ABRs and MLR Pb waves which show an interwave interval of about 35 ms. The nonlinear aspects which can be detected are probably due to the effect of decreasing interstimulus intervals on the duration and amplitude of the Pb wave. It can then be concluded that SSRs in the rabbit are due more to a superimposition of ABR and MLR waves than to a resonance phenomenon.

Comparison of the intrasubject repeatability of auditory brain stem and middle latency responses elicited in young children

The auditory brain stem response (ABR) and middle latency response (MLR) were studied in 48 young children (96 ears). The responses were elicited using low intensity stimuli (30-dB nHL clicks) and simultaneously were recorded on a dual time base. Both the ABR and MLR were elicited in 70 ears. In 12 ears, just one response was recorded (ABR in eight ears and the MLR in four ears). In 14 ears, neither response was recorded. Test-retest analysis on the same subject demonstrated that the ABR was more repeatable and easier to identify than the MLR. The test-retest difference was determined for the amplitude and latency of the ABR and MLR waveforms. The test-retest latency difference for wave Pa was found to be 3.6 times larger than for wave V. The normalized test-retest amplitude difference for P phi-Na, Na-Pa, and Pa-Nb was found to be two to three times larger than for wave V. These data support the conclusion that the ABR, rather than the MLR, should be used to measure hearing in young children. The authors also advocate using minimal high pass (HP) filtering when recording the ABR in a sedated or sleeping child. Muscle artifact was not found to be a problem. The authors suggest the use of minimal HP filtering so that phase-shift distortion is minimized and a larger response amplitude can be recorded.

40-Hz auditory event-related potential in normal adults

40-Hz event-related potentials (AERP) in response to 0.5-, 1-, 2- and 4-kHz tone pips were studied in 45 subjects (18 males and 27 females) in order to assess their reliability and threshold in normal adults and to study the effects of stimulus frequency and intensity on their latency and amplitude. In all subjects well-formed and reproducible 40-Hz AERP were detected, thus showing a good reliability of 40-Hz AERP to tone pips. The response was always detectable within 15 dB nHL intensity level and showed a sequence of positive (P1, P2 and P3) and negative (N1, N2 and N3) waves. It has also been observed that the latency of the first component following the acoustic stimulus decreased at increasing stimulus frequency and intensity, while the amplitude of the whole response increased upon increasing stimulus intensity. It can be suggested that the 40-Hz AERP to tone pips may represent a useful tool in assessing auditory threshold in the low-frequency range.

Development of the middle latency response in an animal model and its relation to the human response

Although the clinical use of the middle latency response (MLR) in adults is fairly straightforward, its use is complicated by maturational changes that continue throughout the first decade of life. In order to telescope the time period of this long developmental course, we have approached the study of MLR maturation using the gerbil as an animal model. The course of MLR obtained over the temporal lobe development was characterized in the Mongolian gerbil ranging in age from 10 days to 3 months of life. The adult gerbil MLR consists of two positive peaks (A and C) at 11 and 25 ms, respectively, and a negative component (B) at 16 ms. These components emerge in a systematic fashion as a function of age. The present work supports a strong age effect of increased MLR detectability in the gerbil, similar to findings reported for humans. Wave A was infrequently detected in young animals, but when present, it occurred at adult latencies. The latency of waves B and C decreased systematically with age. The amplitude of all components increased with age, similar to findings in humans. The fact that adult-like thresholds were obtained shortly after birth indicates that when present, MLRs may be a good index of hearing threshold. Effects of stimulating across a wide range of intensities were described. The gerbil model appears appropriate for the study of development of the central auditory system function.

Scalp potentials of normal and hearing-impaired subjects in response to sinusoidally amplitude-modulated tones

None of the current electrical audiometric procedures, alone or in combination, has yet achieved the precision of conventional audiometric testing that is used to assess hearing in verbally capable children and adults. The reason for this, in part, lies in the use of stimuli which have a wide frequency content. We have measured scalp potentials which follow the envelopes of sinusoidally amplitude-modulated tones: a frequency-specific stimulus. In normal subjects such amplitude-modulation following responses (AMFRs) appear to be generated by two sources. One source has a latency of about 30 ms, generates large responses and is only observed at modulations below 55 Hz, while the other source has a latency of 7-9 ms, generates smaller responses, and is only observed at modulations from 100-350 Hz. The latencies of these two sources are consistent with origins in the cortex and midbrain, respectively. We examined AMFRs to low frequency (50 Hz) modulations as a possible audiometric tool. In normal subjects, the amplitude of the AMFR increased as a function of intensity, decreased as a function of carrier frequency, and could be evoked across the whole audiometric range (250-8000 Hz). In hearing-impaired subjects, the AMFR amplitudes as a function of carrier frequency accurately reflected the pattern of hearing loss on a frequency-by-frequency basis. In most subjects, the threshold for evoking the AMFR was within 0-25 dB of hearing threshold. It therefore appears that the AMFR may be a potentially useful tool to assess hearing in those unable to undergo conventional audiometric testing.