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Starkey Audiology Series STARKEY AUDIOLOGY SERIES DIAGNOSIS AND MANAGEMENT OF PEDIATRIC AUDITORY NEUROPATHY Deborah Hayes, Ph.D. Chair, Audiology, Speech Pathology and Language Services The Children’s Hospital - Colorado Auditory neuropathy (AN) is a complex auditory resonance imaging (MRI) evidence of auditory nerve disorder, which results in a distinct pattern of abnormality. For an excellent review of auditory audiometric test results and a wide range of neuropathy, see Yvonne Sininger and Arnold Starr symptoms and auditory complaints. The range of (editors): Auditory Neuropathy A New Perspective functional auditory abilities in individuals with AN on Hearing Disorders. is vast and may include normal hearing sensitivity and limited auditory complaints, fluctuating hearing Although the scientific and professional community sensitivity and difficulty understanding speech, have made significant progress in understanding the especially in noise, or profound hearing loss and nature and variable consequences of AN, optimal inability to understand even amplified speech in clinical management options for individuals with quiet despite evidence of normal cochlear outer hair this disorder remain elusive, especially for infants cell function. and very young children. For infants with “typical” sensory hearing loss who are identified through Early reports of auditory neuropathy described newborn hearing screening, excellent and detailed the paradox of individuals with normal pure-tone guidelines for identification, diagnosis, and early audiograms but absent or severely abnormal intervention are widely accepted (Joint Committee auditory brainstem responses (ABR). In some cases, on Infant Hearing, 2007). These guidelines do not individuals demonstrated pure-tone audiograms with address, however, some of the specific challenges mild to moderately-elevated detection thresholds, in providing families with appropriate management absent/abnormal ABRs, and absent middle options for infants with AN. For example, early ear muscle (acoustic) reflexes. The addition of amplification fitting is a recommended option otoacoustic emissions (OAEs) to the audiometric test for infants with “typical” sensory hearing loss, battery as well as improved techniques for recording and fitting protocols can be based on the infant’s the inner-ear pre-neural cochlear microphonic (CM) frequency-specific hearing thresholds as estimated from the ABR helped clarify the puzzling physiology by electrophysiological measures such as ABR of this disorder. Individuals with auditory neuropathy to frequency-specific signals or auditory steady commonly demonstrate presence of OAEs and/ state response (ASSR). In contrast, neither ABR nor or CM ~ responses generated by the cochlear ASSR provide accurate predictions of frequency- outer hair cells. Given normal cochlear outer hair specific hearing thresholds in individuals with AN. In cell function and absent or abnormal auditory newborns and very young infants with AN, there are nerve conduction, the site of dysfunction could currently no audiometric measures, either behavioral be localized to inner hair cells, or inner hair cells- or physiologic, which predict audibility or degree auditory nerve fiber synapse, or the auditory nerve of auditory deficit the baby will experience. The itself. There is only limited evidence of inner hair uncertainty and ambiguity about the developmental cell abnormality in humans, but compelling genetic impact of AN for an infant is frustrating and anxiety- evidence of inner hair cell-auditory nerve fiber provoking for parents and professionals alike. synaptic dysfunction, and unequivocal magnetic Starkey Audiology Series | Volume 1, Issue 2 | 2009 To address the unique needs of infants and young limited or mild effects (complaints of difficulty children with AN, an international panel of experts “hearing” in noisy listening conditions) to profound in audiology, hearing science, medical genetics, effects (inability to “hear” in any listening condition, neonatology, and neurology gathered in Como, functionally “deaf”). Finally, the term “spectrum” Italy, in June 2008 to discuss and debate issues was felt to expand the concept of this disorder relevant to identification and management of infants to include sites of lesion other than the auditory and young children with AN. The panel developed nerve. In practice, especially when communicating a set of guidelines addressing terminology, with families, using the shortened term, “auditory diagnostic criteria, recommended comprehensive neuropathy” would appear appropriate to avoid assessments, recommended audiological test confusion with other childhood conditions that battery, recommended amplification strategies, present on a spectrum. special considerations for cochlear implantation, recommended habilitation for communication Diagnostic Criteria. development, screening newborns for auditory Auditory neuropathy is characterized by evidence neuropathy, monitoring infants with “transient” of cochlear hair cell (sensory) function and absence/ auditory neuropathy, and counseling families abnormality of auditory nerve function. Therefore, of infants with this disorder. Some of the more the (minimum) test battery needed to diagnose AN challenging issues that the panel addressed are requires tests of cochlear hair cell (sensory) function summarized below. and auditory nerve function is as follows: 1. Tests of cochlear hair cell (sensory) function: Terminology. a. Otoacoustic emissions: Standard screening or The term “auditory neuropathy” was coined diagnostic protocol using Transient-evoked by Starr et al (1996) to describe perplexing OAEs (TEOAEs) or Distortion Product OAEs auditory symptoms exhibited by a group of (DPOAEs), and/or 10 patients from various clinical sites; seven of b. Cochlear microphonics: Click-evoked ABR these patients exhibited generalized peripheral using insert earphones and separate polarity neuropathy. Other terms for this disorder have recordings to responses of positive vs. been proposed including auditory neuropathy/ negative stimulus. auditory dys-synchrony, auditory neuropathy type 2. Test of auditory nerve function: I (pre-synaptic) and type II (post-synaptic), and a. Click-evoked ABR to high-level stimuli (80-90 auditory nerve disorder. The panel considered these dB nHL). multiple designations as well as those proposed at the conference and concluded that “auditory Special Considerations in Diagnosing Infants with neuropathy spectrum disorder” was the preferred Auditory Neuropathy usage. Three principles drove this consensus. First, When using these test procedures in newborns and despite potentially inexact usage, the term “auditory very young infants, recording conditions must be neuropathy” has gained widespread acceptance optimum to obtain valid, artifact-free, unambiguous and usage, both in the professional literature and test results. Infants should be quietly sleeping in among parent/consumer organizations. Renaming either natural or sedated sleep to avoid movement the disorder could lead to confusion for patients artifact or “noisy” recordings. Caution should be and other professionals whereas retaining current used in interpretation of results when these tests terminology would provide continuity for the are used in infants below 36 weeks gestational age. scientific community. Second, the expression of this Repeated measures, over several weeks or months, disorder in everyday listening and communication are recommended to determine the reliability behaviors encompasses a spectrum ranging from of test results. Because “transient” AN has been 2 Starkey Audiology Series | Volume 1, Issue 2 | 2009 reported in a percentage of infants, particularly (e.g., Word Intelligibility by Picture Identification, those with hyperbilirubinemia, hypoxia, ischemia, WIPI) or open-set tests should be employed. and central nervous system immaturity and low birth Standardized taped materials are preferable to weight, frequent monitoring by the AN test battery live-voice presentation to obtain consistency of is recommended to establish the stability of test stimuli across test sessions. results. 4. Otoacoustic emissions utilizing either TEOAEs and/or DPOAEs. Although initially present, OAEs Recommended Audiological Test Battery. Because may disappear in individuals with AN. the developmental effects of AN cannot be 5. Cortical evoked potentials to speech or speech- predicted by electrophysiological audiologic tests, like signals are not yet a standard clinical measure behavioral evaluation of infants with this diagnosis for infants or toddlers. However, these measures is of paramount importance. The recommended show promise as objective clinical tools for test battery permits assessment of middle ear status predicting speech-recognition performance in as well as functional hearing abilities and auditory young children with AN. development using behavioral response to pure tones, speech reception, and speech recognition. In Recommended Amplification Strategies. concert with JCIH recommendations (2007), the test For infants with “typical” sensory hearing loss, battery includes: hearing aid fitting can proceed in the earliest 1. Otoscopic examination and acoustic immittance months of life based on electrophysiological measures of middle ear function; as with any estimates (e.g., ABR, ASSR) of hearing sensitivity. infant, infants with AN may develop middle For infants with AN, however, electrophysiological ear dysfunction and otitis media with effusion methods do not
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