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Pediatric Whitepaper Pediatric Whitepaper January 2010 Electrophysiological Threshold Estimation and Infant Hearing Instrument Fitting Merethe Lindgaard Fuglholt, M.A. Oticon A/S, Pediatric Audiology Abstract These matters complicate the application of This paper addresses the use of hearing thresh- correction factors to the ABR thresholds (nHL) in olds derived from auditory brainstem response the estimation of behavioral thresholds (eHL). (ABR) testing when fitting hearing instruments to Finally, the application of the real-ear-to-coupler infants. Stimulus calibration and the difference difference (RECD) to estimated behavioral thresh- between the electrophysiologic hearing thresh- olds is addressed. This is done to compensate old (nHL) and a behavioral threshold (HL) will be for individual ear canal acoustics in infant hear- addressed. ing instrument fittings. Introduction Tone Burst ABR Universal Newborn Hearing Screening (UNHS) Behavioral pure-tone audiometry is suitable for Another factor worth considering when hand- acoustics for correcting the audiogram as programs continue to be implemented world- ear-specific testing using insert earphones or ling ABR data is that calibration of the equip- recommended by current best practice guide- wide. Detecting hearing loss early allows audi- own earmolds in children aged six months and ment may vary from clinic to clinic (Bagatto et lines (AAA, 2003; JCIH, 2007). To ensure that ologists to support communication develop- older. For infants younger than five to six al., 2005). Despite the standardized protocols the amplification levels are appropriate for the ment by fitting hearing instruments to infants months of age, electrophysiological methods currently available (IEC 60645-3, 2007; ISO 389-6, infant in question the RECD can be used. early. But these instruments must be adjusted have proven to be acceptable (JCIH, 2007; 2007; ISO 389-9, 2009), ABR thresholds may appropriately to give the pre-lingual listener full ASHA, 2004). One such method is the tone- not be comparable between clinics, as the ref- and consistent access to sound, with no risk of burst evoked ABR. This widely accepted clinical erence threshold may differ. discomfort for loud sounds. This requires an method is effective for estimating frequency- accurate assessment of their hearing. specific hearing thresholds in infants (Gorga et Producing accurate gain prescriptions from ABR al., 2006; Stapells, 2000). thresholds requires addressing any sources of Tone Burst ABR variance to arrive at the best estimate of the A proper diagnostic assessment includes, at Arriving at an Accurate Gain Prescription pure-tone audiogram. This paper examines the very least, obtaining ear-specific thresholds Prescriptive formulas for fitting infants and some of the sources that can result in incorrect for air-conducted stimuli in the 500 to 4000 Hz young children, i.e. NAL-NL1, DSL m[i/o] v5.0a, threshold estimations. This paper also address- audiometric frequency region. This region con- utilize behavioral thresholds to calculate the es the incorporation of individual ear canal tains the frequncies important for speech recog- gain prescription. Because of the inherent dis- nition. When combined with the type and con- crepancies between ABR and behavioral thresh- figuration patterns of the hearing loss, these olds it is essential to use frequency-specific thresholds provide detailed specifications for a correction factors to estimate behavioral hear- Newborn ready for screening with ABR fitting. ing levels. 2 3 Attention to Stimulus Calibration Standardised methods for calibrating audiome- are standardized in ISO 389-6 for various trans- ters are available and used in most clinics ducers (earphones, bone vibrators and loud- (ANSI S3.6-2004; ISO 389-x). This ensures that speakers) and for different acoustic calibration peak-peak 2 thresholds obtained at different clinics will be couplers (ear simulators) . amplitude 1000 Hz pure tone almost equivalent. Unfortunately, the same consistent use of a standardized method for The reference values specify the acoustical calibration of the ABR system does not take peak-to-peak equivalent sound pressure level, place. Consequently the reference threshold dB peSPL of short duration signals at the nor- cannot unequivocally be considered a gold mal-hearing threshold (0 dB nHL), when the FIG. 1. Adopted from IEC 60645-3, Fig. 2b. The level of a 1000 Hz pure tone (for click calibration) is adjusted to give the same peak-to-peak amplitude as the short duration stimulus (e.g. a click, left). In this condition, the dB peSPL of the short duration stimulus equals the dB SPL standard, making the comparison of ABR signals are presented with alternating polarity of the tone. thresholds from different clinics problematic at a rate of 20/s. The peak-to-peak equivalent Note 1: When alternating polarity is used it is still the peak-to-peak amplitude of the single stimulus that is used to define the dB peSPL. (Poulsen & Legarth, 2008). New ISO and IEC sound pressure level, dB peSPL, is defined in Note 2: For tone-burst calibration the pure tone frequency should correspond to the tone burst itself. standards (IEC 60645-3, 2007; ISO 389-6, 2007; fig. 1. ISO 389-9, 2009) have been made readily avail- able to facilitate a uniform calibration of short Thus the stimulus levels of the tone bursts, and duration signals. the obtained thresholds, can be given equally well in either dB peSPL or dB nHL. Calibration reference values, i.e. peRETSPL1, for clicks and tone-bursts specified in IEC 60645-3, 1 peRETSPL: Peak-to-peak reference equivalent sound pressure level in dB re. 20 μPa. 2 According to ISO 389-6, calibration of the insert earphones (ER-3A and ER-2) should be performed with the 711-occluded ear simulator (IEC 60318-4). Preparation of baby for ABR testing 4 5 Discrepancies between Behavioral Pure-tone and ABR Evoked Thresholds Behavioral measures of hearing level have a Stimulus Duration and response detection criteria, to name but a Compensation in the Pediatric Fitting complex relationship to electrophysiological Another reason for discrepancies between the few (Elberling & Don, 2007). Besides the vari- For infants and young children with sen- measures. Both measures evaluate auditory outcomes of the two measures of auditory ous procedural variables, analyses of empirical sorineural hearing loss, ABR thresholds have sensitivity, but the thresholds are determined thresholds is the duration of the stimuli. Pure data (Stapells et al., 1995) and clinical practice been demonstrated to be from 5 to 30 dB high- on different premises (Elberling & Don, 1987; tones used for behavioral audiometry are long- are involved when attempting to derive correction er than their behavioral thresholds (Stapells, 2007). As discussed in the introduction, tone- lasting compared to the brief tone bursts used factors that compensate for the discrepancy 2000; Bagatto et al., 2005). This discrepancy burst ABR offers an objective means of assess- for ABR. Temporal integration has less effect for between ABR and behavioral thresholds must be compensated for when fitting infants. ing hearing levels. These can be used to predict shorter signals, which will yield higher thresh- (Ontario IHP, 2008). The consequence of failing to compensate for the pure-tone audiogram and, in turn, to pre- olds in the dB peSPL-scale compared to the dB this is likely to be over (or under) amplification, scribe the gain. SPL-scale (Zwislocki, 1960; Elberling & Don, which could have a substantial impact on the 1987). Moreover, higher stimulus levels reduce infant’s hearing and language development. Auditory Perception and Auditory Evoked the effect of temporal integration. With sen- Potentials sorineural hearing loss, tone bursts are pre- The inherent discrepancies between the results sented at higher levels, which in turn yield of behavioral and electrophysiological methods higher ABR thresholds (Elberling & Don, 1987). are partly due to the assessment of different parts of the auditory system. While behavioral Correction Factors thresholds reflect a perceptive response in rela- There are many variables besides those tion to the function of the entire auditory sys- described above, which affect the relationship tem, auditory-evoked potentials elicit electro- between ABR thresholds and behavioral hear- physiological information up to the level of the ing levels. The level at which an ABR is detect- brainstem (Elberling & Don, 1987; 2007). able depends on several factors: EEG noise lev- Baby in natural sleep for ABR testing els, filter bandwidths, averaging parameters, 6 7 Application of Correction Factors dB HL The best possible approximation of a true It is important to distinguish between the ABR General ABR-to-behavioral correction factors are -10 behavioral threshold can be achieved by apply- thresholds in nHL and the estimated behav- available in some fitting software such as 0 ing a frequency-specific correction factor to the ioral threshold in eHL. Often the clinician DSL v5.0a and Oticon’s fitting software, Genie 10 ABR threshold (Bagatto et al., 2005). This only obtaining the ABR thresholds will not be the (table 1). These offer a solution for the audiol- 20 30 applies to thresholds referenced in nHL. Some same as the one fitting the hearing device. This ogist when the hearing thresholds supplied to 40 ABR systems have correction factors pre- stresses the need for terminology that clearly them are not corrected (see the appendix for 50 embedded into the derivation of thresholds. In indicates whether correction factors have more information about the application in 60 this case the thresholds are referenced in the indeed been applied to the ABR threshold or Genie). 70 HL-scale and should be regarded as similar to not. Implementing standardized terminology 80 the thresholds referenced in the ‘eHL’-scale indicating whether a behavioral correction has 90 FIG 2. The purple squares 100 represent the nHL values, (see Terminology). been applied as the estimated HL, eHL, or if 110 while the green dia- not, as the normalized HL, nHL, could be the 120 monds represent the eHL Terminology solution to this problem (Bagatto et al., 2005).
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