Mismatch Negativity in the Neurophysiologic/Behavioral Evalu- Ation of Auditory Processing Deficits: a Case Study

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Mismatch Negativity in the Neurophysiologic/Behavioral Evalu- Ation of Auditory Processing Deficits: a Case Study Mismatch Negativity in the Neurophysiologic/Behavioral Evalu- ation of Auditory Processing Deficits: A Case Study Nina Kraus, Therese McGee, Jeanane Ferre, Jo-Ann Hoeppner, Thomas Carrell, Anu Sharma, Trent Nicol Abstract & Szabo, 1993; Lenhardt, 1981; Starr, McPherson, Patterson, Luxford, Shannon, Sininger, Tonokawa, & The subject of this case report is an Ibyea~ld Waring, 1991; Worthington & Peters, 1980). Reports of woman with grossly abnormal auditory brain stem young patients with Brainstem Auditory Processing response (ABR), normal peripheral hearing, and specific behavioral auditory processing deficits. Syndrome (BAPS) have focused on babies and toddlers Auditory middle latency responses (MLRs) and with absent ABR, but only mdd-to-moderate loss of cortical potentials NI, P2, and P300 were intact. hearing sensitivity (Kraus, Ozdamar, Stein, & Reed, The mismatch negativity (MMN) was normal in 1984). Although it has been speculated and partially response to certain synthesized speech stimuli documented that these patients show deficits in auditory and impaired to others-consistent with her processing, the specific nature of these deficits is poorly behavioral discrimination of these stimuli. Behav understood. Little is known about how these individuals ioral tests of auditory processing were consistent function in "real life" or how these deficits will affect with auditory brain stem dysfunction. A neurop them over time. sychological evaluation revealed normal intellectual The awareness that such patients exist has resulted and academic performance. The subject was in her first year of college at the time of the in the identification of an increased number of such evaluation. This case study is important because: patients in hearing/otology clinics. Starr et al. (1991) (1) Although there have been saveral reports of reported a case of severely impaired auditory absentdabnormal ABR with preserved peripheral temporal processing in which ABR was abnormal. hearing and deficits in auditory processing, little The patient was totally unable to understand speech is known about the specific nature of the auditory despite normal hearing sensitivity. It would be deficits experienced by these individuals. Such valuable to learn the communication capabilities of information may be valuable to the clinical other patients with abnormal ABR but preserved management of patients with this constellation peripheral hearing. Additional reports of the status of findings. (2) Of interest is the information that of such patients would be valuable from a prognostic the mismatch negativity (MMN) cortical eventire- standpoint and could aid in making appropriate lated potential can bring to the evaluation of patients with auditory processing deficits. The recommendations for treatment and counseling. MMN reflects central auditory processing of small The subject of this case report is an 18-year-old acoustic differences and may provide an objective woman with subclinical hydrocephalus, a grossly measure of auditory discrimination. (3) From a abnormal ABR, normal peripheral hearing, and theoretical standpoint, a patient with neural specific deficits in auditory processing, as revealed deficits affecting specific components of the by behavioral tests. Other evoked potentials measured auditory pathway provides insight into the included auditory middle latency responses (MLRs) relationship between evoked potentials and physC and cortical potentials N1, P2, the mismatch nega- ological mechanisms of auditory processing. How do various components of the auditory pathway tivity (MMN), and P300. The patient also underwent contribute to speech discrimination? How might a battery of conventional behavioral tests of auditory evoked potentials reflect the processes underlying processing in which the primary signal was altered the neural coding of specific features of speech through electronic filtering, was presented in com- stimuli such as timing and spectral cues? petition with speech or noise, or required binaural processing. Additional behavioral testing included There have been several reports of absent/abnormal psychoacoustic discrimination of pairs of well-defined ABR with normal peripheral hearing and deficits in synthesized speech stimuli, which were the same auditory processing (Berlin, Hood, Cecola, Jackson, stimuli used to elicit the cortical potentials. The patient also underwent a neuropsychological evalu- Departments of Communication Sciences and Disorders [N.K. ation of intellectual and academic function. T.M., J.F., T.C., A.S., T.N.], Neurobiology and Physiology [N.K.], and Otolaryngology-Head and Neck Surgery [N.K.], One of the principal objectives for presenting this Northwestern University and the Evaluation Center for case is to illustrate what the MMN may bring to Learning [J.A.H.]. Evanston, IL. the evaluation of a patient with auditory processing 0196/0202/93/1404-0223$3.00/0 0 Ear & Hearing 0 Copyright 01993 by Williams & Wilkins Printed in the USA. 223 224 Ear 6 Hearing, Vol. 14 No. 4 1993 deficits. The MMN is a neurophysiological reflection However, the patient reported particular difficulty of sensory processing within auditory cortex for hearing in the presence of background noise and which important clinical applications are envisioned perceived her hearing problem as frustrating and (Naatanen, 1992, review; Naatanen, Gaillard, & debilitating. Despite the behavioral and electrophysi- Mantysalo, 1978; Kraus, McGee, Micco, Sharma, ological deficits described below, this patient was Carrell, & Nicol, 1993a; Kraus, McGee, Sharma, succeeding academically and was in her freshman Carrell, & Nicol, 1992; Kraus, Micco, Koch, McGee, year of college at the time of testing. Carrell, Sharma, Wiet, & Weingarten, 1993b; Korpila- Magnetic resonance imaging, performed subsequent hti, Ek, & Lang, 1992). The MMN is a passively- to evoked potentials testing, revealed moderate elicited, objective measure that does not require diffuse enlargement of the ventricular system (sub- attention or a behavioral response to the stimuli. It clinical hydrocephalus) and no midline shift of is elicited by a physically deviant stimulus occurring structures, and was otherwise normal. The results in sequence with a series of homogeneous, standard of a recent neurological evaluation, her first, were stimuli. The MMN is a neuronal response to minimal unremarkable. changes in acoustic parameters such as frequency, intensity, location, and duration (Naatanen, 1992; Naatanen, Paavilainen, Alho, Reinikainen, & Sams, Evoked Potentials 1987; Paavilainen, Karlsson, Reinikainen, & With respect to generating systems, the ABR reflects Naatanen, 1989; Sams, Aulanko, Aaltonen, & the activity of the VIIIth nerve and brain stem Naatanen, 1990; Sams, Paavilainen, Alho, & Naatben, auditory pathways (Hecox & Galambos, 1974; Mdler 1985) and can be elicited by speech stimuli (Aaltonen, & Jannetta, 1985; Picton, 1986; Starr & Don, 1988). Niemi, Nyrke, & Tuhkanenen, 1987; Kraus et al, The MLR reflects the activity of primary and 1993a,b; Sams et al, 1990; Sharma, Kraus, McGee, nonprimary divisions of the auditory thalamo-cortical Carrell, & Nicol, 1993). In addition to reflecting the pathways with contributions from the mesencephalic processing of stimulus features such as frequency, reticular formation (Kraus & McGee, 1992, review). intensity, and duration, the MMN is a response to The N1 /P2 complex has a complex generating system stimulus change. Therefore, it may be a significant involving sensory and motor processes (Davis, 1939; neurophysiological tool because it is stimulus change Naatanen & Picton, 1987; Picton, Hillyard, Krausz, that fundamentally characterizes the acoustics of & Galambos, 1974). The generating system for the human speech. Current models of speech perception MMN is largely modality dependent (Ritter, Simson, place special emphasis on the importance of patterns & Vaughan, 1983), with major sources originating of stimulus change over time as the primary means from the supratemporal plane (Alho, Paavilainen, of conveying linguistic information (Gordon, 1988; Reinikainen, Sams, & Naatanen, 1986; Cskpe, Karmos, Kewley-Port, 1983; Remez, Rubin, Pisoni, & Carrell, & Molnir, 1987; Giard, Perrin, Pernier, & Bouchet, 1981; Van Tasell, Soli, Kirby, & Widen, 1987). 1990; Hari, 1990; Kaukoranta, Sams, Hari, Another principal objective in presenting this case Hamalainen, & Naatanen, 1989; Naatanen & Picton, is to highlight the benefit of combining electrophysi- 1987; Sams, Kaukoranta, Hamalainen, & Naatanen, ological and behavioral measures in assessing patients 1991). The P300 generating system is diffuse (Sutton, with central auditory deficits. The combined approach 1965; Donchin, 1981; Polich & Starr, 1984), involving taken in the assessment of this patient reveals numerous multisensory cortical and subcortical struc- information relevant to the treatment and prognosis tures (Buchwald, 1989; Halgren, Stapleton, Smith, & of other individuals with a similar constellation of Altafullah, 1986; Harrison, Buchwald, Kaga, Woolf, symptoms. From a theoretical standpoint, results & Butcher, 1988; Knight, Hillyard, Woods, & Neville, from a patient with specific neural deficits of the 1980; Knight, Scabini, Woods, & Clayworth, 1989; auditory pathway can provide insight into the McCarthy, Wood, Williamson, & Spencer, 1989). relationship between evoked potentials, physiological ABR. ABR recordings were obtained from Cz, mechanisms of auditory processing, and the neural referenced to
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