AUDITORY BRAINSTEM RESPONSE

AUDITORY BRAINSTEM RESPONSE

(ABR; Brainstem auditory evoked response - BAER)

• A surface-recorded averaged far-field measure that reflects the synchronous neural

activity generated by nuclei along the brainstem in response to an acoustic signal
• Clinical uses:
• To determine auditory sensitivity
• Neurologic diagnosis
• Intra-operative monitoring
• Waveforms of ABR first labeled with Roman numerals by Jewett and Williston (1971)
• Summed responses of the synchronous firing of large numbers of CN VIII and
auditory brainstem neurons
• By measuring amplitude and latencies of each of the five major waves of the ABR, one
can objectively estimate hearing levels, screen for retrocochlear pathology and monitor
the CN VIII intra-operatively
• Click or toneburst stimuli generate a response that travels the auditory pathway
• The response is measured using surface electrodes and plotted as five peaks and troughs
• The positive peaks are generated from multiple axonal pathways in the auditory brainstem

Waveform Analysis
• Morphology – pattern or overall shape of waves
• Latency – time interval between the exact moment of stimulus presentation and
the appearance of a change in the AER waveform
• Amplitude – voltage difference between the peak of and the following trough
• Inter-aural wave V latency difference – function of neural components; test used
to distinguish cochlear from retrocochlear pathologies
• Wave V –lowest intensity (in dBnHL) that wave V is recognizable and reproducible
correlates with subjective audiometric thresholds

Rule of 5’s
• Wave V 5.5 msec
• Amplitude 0.5 μvolts
• Interpeak Wave
I-V latency (adults) 4.5 msec
• Interpeak Wave
I-V latency (newborns) 5.0 msec
 Ratio of V:I amplitude ratio 5.0 volts

Wave Components (5)

Wave I - true action potentials (AP of the EcochG) - generated from distal portion of the VIIIth
nerve; specifically, CN VIII firing due to activity in the basal portion of the cochlea

Wave II – generated from the proximal CN VIII, as it enters the brainstem

Wave III
• Second-order neuron activity
• Peak comes from in or near the cochlear nucleus
 AUDITORY BRAINSTEM RESPONSE

• Trough arises from the trapezoid body

• Generated in the caudal portion of the auditory pons

Wave IV
• Often seen tagging along on Wave V
• Arises from pontine third-order neurons, mostly located in the superior olivary complex
• Contributions from cochlear nucleus and nucleus of the lateral lemniscus

Wave V
• Positive peak related to the termination of the lateral lemniscus as they enter
inferior colliculus
• Negative trough attributed to dendritic potentials within the inferior colliculus

Cochlear Microphonics
• An alternating current potential that mocks the stimulus; not to be confused
with stimulus artifact
• Arises from the outer hair cells
• Can be seen by alternating the polarity of the stimulus (rarefaction and condensation)

Otoscopy Prior to ABR

• Examination of the external ear and tympanic membrane for signs of
disease, malformation, or blockage
• ABR procedure requires placement of insert phones, visual inspection serves to
confirm that there is no contraindication to placing insert phones in the ear canal

Testing Environment
• Quiet room
• Electrical shielding (brass)
• Adjustable dim light for sedation
• Proper temperature
• Bed for sleeping

Artifact
• Electrical activity that is not part of the response
• Types of artifacts
• Electromagnetic – external source
• Electrophysiologic – patient
• Three (3) main approaches to minimize artifacts:
• Determine source of artifact and eliminate it
• Modify test parameters – filter settings, electrodes arrays, number of survey
• Artifact rejection

Test Instruction
• The clinician should never forget that there is a human being between the
stimulus transducer and the recording electrodes
• Explain the steps of the procedure properly and what is expected of patient
• Use simple language understandable by patient
 AUDITORY BRAINSTEM RESPONSE

Important Points Needing Clarification

• It is a routine clinical procedure used even with newborn infants
• Procedure does not pose any risk to patient
• Procedure is non-invasive and not painful
• No side effects for non-sedated ABR
• Results may not be immediately available
• Assessment can be stopped at any time upon patient request

State of Subject
• To avoid artifacts related to muscle responses to be able to obtain a reliable
waveform, the patient should either be:
• Relax
• Awake or asleep
• Sedated
• Under general anesthesia
• Comatose
• Effects of sedation on ABR waveforms:
• Mean ABR waveforms for the control and anesthesia group
• Dotted lines were added to facilitate comparisons of the major waves
between groups
• Non-sedated pediatric ABR: recording done during normal sleep periods or after feeding
• Sleep deprivation
• Record ABR immediately after feeding
• Bean bag “bed” to minimize movement
• Non-sedated Pediatric ABR: ABR recordings not affected by state of arousal
• Sedative should be prescribed by a physician and should be
administered/monitored throughout testing by a medical
personnel
• Most commonly used sedatives: diphenhydramine (Benadryl), chloral
hydrate; anesthetics, barbiturates, anxiolytics
• Disadvantages of Anesthesia for ABR Assessment in Children:
• Delayed diagnosis due to problems with scheduling time in the operating
room and the medical support team
• Ten-fold increase in cost associated with services in the operating room
• Medical risk of anesthesia and related procedures (e.g., intubation)

Skin Preparation
• Disinfect skin with 70% alcohol
• Clean skin with scrub
• No oil, cosmetic, lotion, dead skin
• Place conductive electrode paste or gel on skin/electrode
• Check for electrode impedance
• Permitted should be less than 5000 ohms (Ω) or 5 KΩ
• Objectives of Electrode Placement
• Consistent and anatomically accurate placement
• Low inter-electrode impedance (< 5000 Ω)
• Balanced inter-electrode impedance (difference should be less than 2000 Ω)
• Secure and consistent attachment throughout the test
• Minimal discomfort and no risk to subject
 AUDITORY BRAINSTEM RESPONSE

Electrode Site (Electrode Array)

• Non inverting Electrode
• Vertex (Cz) or high midline forehead near Fz
• High forehead preferred than vertex:
 Eliminates problems associated with preparing the skin and
occurring electrodes
 Vertex electrodes site is neither technically operational and
clinically feasible
 Forehead site is most associated with larger wave I amplitude
• Inverting Electrode
• Mastoid or earlobe of the stimulus side
• Earlobes are preferable to mastoid site
 Wave I tends to be longer
 Less electromagnetic/myogenic artifact
 Wave V amplitude may be slightly reduced with this arrangement
• Ground electrode - low midline forehead

Bilateral Recording
• Two recording channels
• Separates Wave IV and V complex
• 0.1 or 0.2 msec delay than ipsilateral
• Wave I diminished in amplitude or absent
• Wave III more attenuated than Wave II
• Absolute wave III faster latency
• Wave I-III inter-peak latency shortened
• Wave I-V inter-peak latency higher
• Wave V latency increases at a rate of 0.1ms per decade of time

Advantages of Bilateral Recording

• Avoid electrode misrouting
• Ipsilateral recording shows a robust wave I while contralateral recording shows
robust wave IV & V
• Contralateral recording should not show wave I
• For bone conduction ABR (BC-ABR), the presence of wave I in both cochleae
are diagnostic of cochlear status

Transducer – Insert Phones

• Delayed latency of approximately 0.9 msec
• Advantages of inserts:
• Avoids canal collapse
• Suitable for any head size (including babies)
• Light weight
• Problem with Inserts
• Difficult calibration
 AUDITORY BRAINSTEM RESPONSE

Factors To Consider in ABR Measurement

A. Subjective Factors
1. Age
• Maturation of AER’s tend to proceed from the peripheral to the central auditory system
• Age effects
• ABR waveform is incomplete at birth
• Inter-wave latency values are initially prolonged
• After the first 18 - 24 months (ABR adult-like)
• Newborns and Infants
• Wave I (more prominent than later waves): proximity of recording electrodes
• Wave I Delay: external and middle ear factors; immature peripheral auditory system
• Delay I-V Interval: incomplete nerve fiber myelinization; reduced axonal
diameter and synaptic functioning
• Advancing Age
• Fewer 8th nerve fibers
• Atrophy of the spiral ganglion
• Degeneration of the ganglion cells within the ventral cochlear nucleus,
superior olivary complex and medial geniculate body

2. Gender
• Females - shorter latency values, larger amplitudes for later ABR waves
• Better hearing at high frequency
• Higher average body temperature
• Smaller head size and hair dimension
• Gender Issues
• Smaller head circumference foreshortening the brainstem pathway
• Earlier response latencies
• Average wave V latency for males 0.14 msec longer than females

3. Effect of Body Temperature

• Patient at risk - infection, coma, alcohol or anesthesia
• ABR latency increase with decrease in temperature
• Correction factor for I-V latency: 2.0 msec for every degree of body temperature below 37 0C
• Attention and state of arousal - no difference

4. Muscle Artifact
• ABR components can be completely obscured by excessive muscle artifact
• Artifact – electrical activity that is not part of the response
• Electromagnetic – external source
• Electrophysiologic – patient
• Approaches to Minimize Artifacts
• Determine source and eliminate
• Modify test parameters
• Filter settings
• Electrodes arrays
• Number of sweeps
• Artifact rejection
 AUDITORY BRAINSTEM RESPONSE

5. State of Arousal and Drug Effects – see notes above

B. Stimulus Factors
1. Stimulus Type and Frequency
• Brief duration clicks (100 msec) abrupt onset
• Most commonly used stimulus for ABR
• Higher frequencies responsible for generating ABR on the 1000-4000 Hz region of
the cochlea
• Response to cochlear activation in the higher frequency regions has already occurred by
the time the traveling wave has covered the distance from the base to the apex
• Leading “front” of the traveling wave is more gradual when it reaches the apical region
and consequently not as effective in producing synchronous firing of many fibers
• Frequency specificity of stimuli is indirectly related to duration
• Direct relationship between duration of the response and duration of the stimulus
• The most obvious for generating an ABR reflecting hearing sensitivity at a specific
frequency is to use brief tone stimulation (toneburst)
• Methods to Evoke Frequency Specific ABR:
• Masking frequency regions that are not intended to be part of the stimulus
• High pass noise
• Noise with a notch in the region of the desired frequency
• Masking with pure tone
• Response to a stimulus at a specific frequency or with a defined frequency region
is derived from two other region
• Use of a tonal stimulus with carefully selected onset characteristic
• Toneburst ABR

2. Duration
• Sum of the rise time, plateau, and fall time
• Click short duration of 100 milliseconds
• Toneburst with 2-1-2 paradigm
• With very brief stimuli, energy tends to be distributed over more frequencies,
whereas stimuli with longer duration are spectrally constrained

3. Latency
• ABR latency decreases and amplitude increases with greater stimulus intensity
• Physiological Bases: post-synaptic excitation potentials reach threshold faster for
higher intensity levels and therefore synaptic transmission time decreases

4. Intensity
• Intensity starts at 75 to 90 dB
• If there is no waveform noted at these levels, increase intensity levels
• If there is no waveform noted at highest intensity levels, condensation and
rarefaction polarities should be done
• If there are waveforms noted, decrease by increments of 10 dB and increase with
5 dB increments (wave V thresholding)
 AUDITORY BRAINSTEM RESPONSE

5. Stimulus Rate
• ABR latency increases and amplitude decreases as rate increases
• Physiological Bases: rate effect is a cumulative neural fatigue & adaptation and
incomplete recovery involving hair cell-cochlear nerve junction and also subsequent
synaptic transmission
• Fast Stimulation Rate: latency increased; early waves become obscured
• Suggestions:
• Slow stimulation rate for clear Wave I, III & V (e.g. 11.1/sec)
• Fast stimulation rate to measure Wave V (e.g. 27.7/sec)

6. Polarity
• Rarefaction: initial diaphragm outward movement; better wave III amplitude
• Condensation: initial inward diaphragm movement; better wave V amplitude
• Alternating: use at high intensities; switching back and forth of the two initial
modes; overwrite stimulus artifacts

7. Mode of presentation

8. Type of transducer
• Insert phones (ER3A) used for air conduction ABR testing
• Stimulus artifact is essentially eliminated by the time delay introduced by the tubing
• Travel time delay (0.9 msec) must be considered
• Tubing length change - stimulus delay must be altered
• Temporal waveform of stimulus
• Extra deflections are not observed from insert phones
• Prevents collapse of ear canals
• Insert cushion reduces concern about possible cross-over of the stimulus from
the test ear to the non-test ear
• Sound attenuating properties
• Ensures proper transducer placement
• Comfortable

• Bone oscillator used for bone conduction ABR testing

• Used for atresia of the external ear
• Wave V latency delays of 0.5 msec
• Acoustic input is 40 dB less than the corresponding earphone output at
equal attenuator settings
• Bone Oscillator
• High frequency response than ear phone
• Generated by more spiral ganglion region of cochlea; longer latency
• Under-utilization
• Maximum effective intensity level of about 55 dB HL for bone
conduction stimulation
• Electromagnetic energy radiating from bone can cause serious
stimulus artifacts
• Conductive hearing impairment is usually greatest for audiometric
frequencies in the region of 1000 Hz and whereas click would ABR
is dependent on stimulus energy mostly in the 1000-4000 Hz
region
 AUDITORY BRAINSTEM RESPONSE

• Masking dilemma and the need for contralateral masking

• Sound field: speakers placed at a distance of 0.5 meter with time delay (0.0015 msec)
• Masking
• dB or greater difference between the intensity of the click stimulus presented to
the test ear and the BC threshold between 1kHz and 4KHz in the non-test ear
• Interaural latency difference >1.5msec 0.4msec/10dB of intensity change

C. Acquisition factors
1. Electrodes – see notes above
2. Amplification – see notes above
3. Filtering – see notes above
4. Analysis time
• Period after presentation of stimuli in which the ABR waves normally appears
• Major ABR components are observed within 5.5-6.0 msec period after
stimulus presentation
• High intensity level
• Reasonably slow rate
• Conventional supra-aural earphones
• Subject normal audiologically & neurologically
• Prolonged ABR latency values:
• Insert phones
• Severe conductive hearing loss
• Immature CNS in the newborn
• Threshold level stimulus intensity
• Severe auditory dysfunction

5. Improving Signal to Noise Ratio (SNR)

SNR = Signal Amplitude/Noise
Amplitude
 Increase in signal amplitude
 Decrease in noise amplitude
 Greater number of sweeps

6. Amplifier
• Device that increases the strength of a signal
• Gain ratio of the voltage of the signal at the output of the amplifier to the
voltage delivered the input
• ABR gain x 100,000
• Gain of 10 (20 dB)
• Gain of 100,000 (100 dB)

7. Common Mode Rejection

• CMR ratio is more than 10,000 activity detected similarly by both electrodes such
as electrical interference, is more than 10,000x smaller than the amplitude of
activity detected by the non-inverting electrode
• CMR ratio of 10,000 = 80 db
• Differential amplifier
 AUDITORY BRAINSTEM RESPONSE

8. Filter
• Filters reject electrical energy at certain frequencies and pass energy at
other frequencies.
• Imbalance detection of a signal in the presence of background electrical noise
(EEG neuromuscular activity)
• Band pass filter (High pass = 30 Hz; Low pass = 30,000 Hz)

9. Amplifier
• Current instrumentation: 512 sample points that make a resolution for 10 ms
analysis time of 0.02 ms

Parameter Selection

Parameter Click ABR Set Up Toneburst ABR Set Up

Time Window 10.66ms 21.33ms
High Cut Filter 1500Hz 1500-3000Hz
Low Cut Filter 100Hz 30-100Hz
Transducer Insert phone Insert phone
Type 100usec click Toneburst 2 rise and fall cycle
Polarity Condensation/rarefaction Condensation
Rate 27.7/s 27.7, 39.1/sec
Presentation Level 75 dBnHL 75, 55, 35, 15 dBnHL
No. of Sweeps 2000 2000 (may be variable)
Masking White noise White noise
Masking level 20-30dB below testing level 20-30dB below testing level

ABR Applications
 Hearing screening
 Site of lesion testing - identification of neurological abnormalities of the 8th nerve
and brainstem pathways
 Threshold (sensitivity) estimation - estimation of hearing sensitivity based on presence
of responses at various intensity levels
 Intra-operative monitoring

ABR Thresholding Using Clicks

• Threshold is based on presence of a recognizable and reproducible wave V in the
lowest intensity level
• Approximately 10 to 20 dB of behavioral thresholds
• Frequency tested is higher frequency: Lower frequency loss may not be picked up and
will have normal ABR

Need for Frequency-Specific ABR

• Clicks are useful for neural testing and determining neural synchrony, but not
threshold testing
• One cannot be sure what frequency range is being tested when using a broad-band
(e.g., click) stimulus
 AUDITORY BRAINSTEM RESPONSE

 The frequency range being tested with a broad-band stimulus is only known
with normal hearing or a flat hearing loss at all frequencies
• Pure-tone audiometry is completed at multiple frequencies, not just one frequency
• Must use frequency specific stimuli:
 Tonebursts at multiple frequencies
 Amplitude and/or frequency modulated tones
 Chirps – octave band

Vanderbilt ABR Protocol (Linda Hood, PhD)

 Combination of clicks and tonebursts
 Addresses neural integrity and sensitivity
 Tonebursts at several frequencies
 Include bone conduction - to define “type” of hearing loss
 ABR Toneburst Parameters
 Stimulus type Toneburst
 Duration 2 cycle rise/2 cycle fall
 Polarity Condensation or Rarefaction
 Intensity 75, 55, 35, 15 dBnHL
 Presentation rate 27.7, 39.1/sec
 Timebase 20, 25 msec
 Number of channels Two (Cz-A1, Cz-A2)
 Filter band 30-1500 Hz, 100-3000 Hz
 Number of sweeps Variable: 2000
 Subject state Quiet, asleep, sedated

 Toneburst Characteristics
 500 Hz toneburst
 Duration of one cycle = 2 ms
 2-0-2 envelope = 4ms-0ms-4ms
 1000 Hz toneburst
 Duration of one cycle = 1 ms
 2-0-2 envelope = 2ms-0ms-2ms
 2000 Hz toneburst
 Duration of one cycle = 0.5 ms
 2-0-2 envelope = 1ms-0ms-1ms
 4000 Hz toneburst
 Duration of one cycle = 0.25 ms
 4-0-4 envelope = 1ms-0ms-1ms

Protocol for Neural Integrity (Vanderbilt University - Linda Hood, PhD)

• Stimuli: Clicks at 75 dB nHL
 If no response, increase intensity
• If ABR is obtained, conduct two runs with condensation clicks and at least one run
with rarefaction clicks at a single intensity level. Then, proceed to tonebursts
• If only a cochlear microphonic (CM) is present, conduct control run
• If CM only is observed in both ears AND no other testing is needed
• Track CM to threshold (optional) and ABR testing is then completed
 AUDITORY BRAINSTEM RESPONSE

Protocol for Hearing Threshold Estimation (Vanderbilt - Linda Hood, PhD)

• Stimuli: Condensation polarity tone bursts
• Test order: 2000, 500, 1000, and 4000 Hz
 If OAEs present at all frequencies
 If no OAE energy is present above 2000 Hz, the order should be 2000, 500,
4000, and 1000 Hz
• Stimuli: Condensation polarity tonebursts
• Intensity: Start at 75 dBnHL and increase or decrease intensity in 20 dB steps
replicating at each level
• Once the threshold range has been bracketed, step size should be decreased to 10 dB
• Lower intensity until wave V disappears or is observed within a normal range
 Each frequency assessed in each ear and alternated between frequencies.
(e.g., 2000 Hz in the right then the left ear)
 If insertion of an earphone would result in awakening a sleeping baby,
may complete the testing in one ear prior to testing the opposite ear.
• BC thresholds should be obtained when:
• Air conduction thresholds are not normal during an initial evaluation
• OAEs, tympanograms, or reflexes are abnormal
• For subsequent visits, there is reason to believe there has been a sensory change
• Stimuli: Toneburst stimuli
• Methods: Same protocol as for AC tonebursts
• Oscillator placement

Toneburst ABR & Hearing Loss Estimation

FREQUENCY dB nHL CORRECTION* eHL

500 Hz 30 20 10
1000 Hz 30 15 15
2000 Hz 50 10 40
4000 Hz 40 5 35
* Correction for eHL (estimated hearing level) based on Ontario data

Audiologic and Neurologic Diagnosis

• Site of the lesion testing
• Must examine carefully the following parameters
• Wave morphology & reproducibility
• Latencies
• Amplitudes

Mechanisms Underlying Peak Latencies and Amplitudes

• Place of generation along the cochlea (determined by CF)
• Stimulus level
• Degree of hearing loss
• Patient characteristics: age, gender, body temperature

Small Wave I:V Amplitude Ratio

• Seen in babies
 AUDITORY BRAINSTEM RESPONSE

• May be secondary to immature neurologic development reflected by

reduced synchronization of neural firing and incomplete myelinization
• ABR adult-like at approximately 18 months

Mechanical and Physiological Processing That Determine Peak Latencies

• Cochlear transport time: It is determined by passive basilar membrane properties
specifically the stiffness gradient & mass loading
• Cochlear Filter Buildup time: Sharpness of tuning at cochlea & CF of the BM location
or auditory nerve fiber
• Synaptic delay between IHCs and auditory nerve fibers
• Neural conduction time and any intervening synaptic delays from cochlear nerve to the
point in brainstem pathway responsible for the peak activity

Factors That Determine Amplitude

• Number of neural elements that are activated synchronously
 The number of neural elements
 Degree of synchrony
 Most avoid using amplitudes due to variability and that is because of the
residual noise left in the average

Problems Associated With Amplitude

• Do not appear to be normally distributed
• Highly susceptible to myogenic activity and noise level
• Difficult to replicate
• Easily influenced by minor alterations in recording techniques

Diagnostic Indices Used in Assessing Neurotologic ABR’s

• Waveform morphology
• Absolute latencies (usually waves I and V)
• Inter-peak latency intervals (I-III, III-V & I-V)
• Inter-aural latency differences (ILD)
• Wave V (ILD-V or IT-5)
• Wave I-V (ILD I-V or IT-I-V)
• Change in wave V latency with increasing stimulus rate
• Wave V/I amplitude ratio
• Latency-Intensity function: a graph is created for wave V as a function of intensity
• Comparison of wave V latency for rarefaction versus condensation clicks
• Comparison of inter-aural wave V latency

Absolute and Interpeak/Interwave Latencies

• Ideally in a clinical practice, normative data for absolute and inter-peak latencies should
be established for each evoked potential system since they are dependent upon stimulus
and recording parameters employed
 AUDITORY BRAINSTEM RESPONSE

UST Normative Values

WAVE -2SD +2SD

I 1.4 1.8
III 3.5 3.9
V 5.4 5.8
I-III 1.6 2.4
I-V 3.4 4.2
III-V 1.4 2.2

What is regarded as abnormal?

• Using > 2 standard deviations (95% confidence interval) as criterion for abnormality
• However, the use of 2.5 SD as an alternative criterion is also supported and these can
be calculated from the published norms

Peripheral Auditory Assessment

 Non-organic hearing impairment
 Comatose persons
 Severe bilateral conductive hearing loss presenting the masking dilemma
 Evaluation for Meniere’s disease
 Suggested retro-cochlear pathology

Effect of Conductive Hearing Loss

• Prolongation of all peaks
• Interpeak latencies are within normal limits
• Reduction in the level of the signal arriving at the cochlea
• Amount that the latency-intensity function for click stimuli is offset from the normal
latency- intensity function is consistent with the amount of conductive hearing loss in the
high frequencies
• Otitis Media
• Wave I prolonged
• Prolonged history of OME: Hall & Grose
• Wave III and wave V were significantly prolonged
• Inter-peak waves I-III and I-V intervals were also prolonged

Effect of Cochlear Hearing Loss on ABR

• Normal wave V latencies have been observed at 70 to 90 dB nHL in patient’s with
Meniere’s disease and hearing losses of up to 60 dB HL
• Wave V latency and morphology are affected by greater degrees of peripheral hearing losses
• Normal ABRs were noted in all whose PTA were:
• Normal up to 2kHz or better than 35 dB HL at 3k &4k Hz
• When 4k Hz > 50 dBHL, wave I absent
• When 2-4kHz = 50-70 dBHL, ABR abnormal
• Sharply sloping (>HF loss), wave V delays
• Normal ABR if rising audiogram
• Latency-Intensity Function in Cochlear Loss:
• Latency intensity function is steeper
 AUDITORY BRAINSTEM RESPONSE

• As wave V latency increases at faster than normal rates at moderate intensities

• As intensity increases, response amplitudes increases more rapidly in
cochlear hearing loss patients
• High frequency hearing loss
• Show a reduced I-V IPL interval as wave I is more prolonged than wave V
• Waves I-V have been reported to decrease with increased cochlear hearing loss
• Greater shift in the latency of wave I than either wave III or V
• Reduced I-III & I-V interval
• More basal cochlear generation pattern of Wave I

Abnormal Absolute Latency Pattern

• Delay in wave I - most common absolute latency abnormality plus an equivalent delay
in subsequent wave components peripheral auditory dysfunction
• Slightly increased wave I latency - high frequency sensory deficit
• Substantial wave I delay - conductive or mixed defects

Unrecognizable Wave I
• Some normal persons show no ABR Wave I
• Characteristic effect of high frequency hearing loss on the ABR is poor Wave I or absence
of Wave I
• Retrograde neural degeneration
• Interference with blood supply
• Extremely distal site of lesion
• What to do for small or indistinct wave I
• Increase intensity
• Decrease rate
• Verify ipsilateral electrode site
• Use earlobe versus mastoid electrode
• Use an ear canal electrode (TIPtrode)
• Use tympanic membrane (TM) or transtympanic (TT) electrode
• Change stimulus polarity to rarefaction
• Horizontal electrode array
• Use clicks versus toneburst
• Lower high pass filter
• Increase number of sweeps
• Obtain audiogram (High frequency HL)

Effect of Retrocochlear (CN VIII) Hearing Loss on ABR

• Slows the conduction velocity of nerve impulses
• Desynchronization of the firing rate of neurons
• Selective action of a tumor on high and slow frequency fibers of the auditory nerve
maybe responsible for ABR nerve delay
• Changes in vascular supply in the IAM and lower brainstem
• Prolongation of absolute latency
• Inter-wave V latency intervals
• Degradation of the waveforms
• Absence of waves
• Wave V is prolonged at all intensities
 AUDITORY BRAINSTEM RESPONSE

Interaural Wave V Latency Difference

• Interaural wave V latency difference (normal value): 0.2 to 0.4 msec (average: 0.3 msec)
• Most sensitive indicator of retrocochlear lesion (more than 0.3 msec)
• Wave I-V interval most powerful latency measure in the detection of otoneurological deficits
• Repetition rate - neural refractory period
• Correction Factor: Reduce 0.1 msec for every 10 dB increase in hearing loss above 50 dBHL
at 4KHz

Waveform Morphology for Retrocochlear Lesions

Abnormal ABR waveform patterns in cases of retrocochlear pathology

• Interpeak I-V prolongation
• Interpeak I-III prolongation
• Interpeak III-V prolongation
• Abnormal latency & poor morphology
• Absent wave V
• Only early waves (I and II) present
• Absent response

Multiple Sclerosis – nerve demyelination

• Bilateral, high frequency, sensorineural loss
• Prolonged inter-peak latencies
• Low amplitude especially wave V
• Poor morphology
• Poor test repeatability
• Total absence of one or more components after Wave I & II
• Absence or prolonged Wave I

Infants – Immaturity
• Three vertex/ forehead (+) peaks
• Absolute and inter-peak latencies of these waves are longer than adults
• Absolute and relative amplitudes are markedly different from those of the adults

Decreased Waveform Latencies Seen In:

• Myelinization
• Cochlear maturation
• Resolution of middle ear abnormalities
• Increased synaptic efficiency
• Firing synchrony

Writing ABR Results

1. Findings
• Wave morphology & reproducibility
• Absolute & inter-peak latencies
• Amplitude ratio of waves I and V
• Inter-aural wave V latency difference
• Estimated hearing threshold
 AUDITORY BRAINSTEM RESPONSE

2. Conclusion
• Degree and possible type of hearing loss
• Site of lesion for neurotologic diagnosis
• Recommendation, if any

Appendix: CAS Protocol for ABR Testing

Environment
The test should be conducted in a relatively quiet and electrically shielded room. Uses of RF
equipment are not allowed within the test area.

Preparation
1. Obtain a medical history

2. Check external ear status

3. Electrodes placement
Active: Vertex
Input1: High forehead
Input2: L earlobe
Ground or Common: R earlobe

4. Skin preparation and impedance measurement.

 Reduce the skin impedance first by wiping the site with cotton wet with
alcohol then with skin preparation gel to abrade the skin lightly.
 Apply electrode gel or paste to the electrode.
 Attach the electrode firmly onto each site.
 Measure the impedance. The impedance should be below 5kΩ at each site
and the difference between the two sides should be not more than 2kΩ,
 If the impedance at any electrode exceeds the preset limit, double check
the electrode wire and leads for any problem. If problem persist, repeat
skin preparation.
 Check impedance periodically throughout the test

5. Subject positioning
 Reduce electrical interference of the testing environment. Irrelevant
electrical appliances should be disconnected or switched off. Also ask client
(and caretaker) to switch off mobile phones, etc.
 The client should be lying comfortably on a bed or a couch. The neck should
be well supported so that the neck muscles are relaxed.
 AUDITORY BRAINSTEM RESPONSE

6. Insert phone positioning

 Place the insert phone in position making sure that it snugly fits the meatus.
Make sure the correct insert phone is on the corresponding ear and that the
size corresponds to that of the ear canal.
 Check electrode impedance again to ensure that there were no
electrodes displaced.

7. Bone conductor positioning

 The bone conductor should be placed supero-posterior to the pinna of the
individual ear on the temporal bone or very high mastoid. For infants,
using fabric or Velcro may be necessary to keep the vibrator in place.

8. Electrode connection to the amplifier.

 Connect the electrodes as described earlier in the “electrode placement.”
 To ensure client safety, always connect the ground electrode first.

9. Client instruction
The test procedure and goals should be clearly explained to the client (or guardian)
before electrode placement. Ensure that the client understands that recording leads will
be attached to his/her head from which the signal from the auditory nerve will be
recorded. Once the electrodes are in place, the client should lie down comfortably on
the bed with a pair of insert phones on. Client will then hear a clicking noise one ear at a
time. Client has to relax, keep still and if possible, go to sleep. Any neck and mouth
movements should be avoided.

Parameters

Parameter Click ABR Set Up Toneburst ABR Set Up

Time Window 10.66ms 21.33ms
High Cut Filter 1500Hz 1500-3000Hz
Low Cut Filter 100Hz 30-100Hz
Transducer Insert phone Insert phone
Type 100usec click Toneburst 2 rise and fall cycle
Polarity Condensation/rarefaction Condensation
Rate 27.7/s 27.7, 39.1/sec
Presentation Level 75 dBnHL 75, 55, 35, 15 dBnHL
No. of Sweeps 2000 2000 (may be variable)
Masking White noise White noise
Masking level 20-30dB below testing level 20-30dB below testing level

Procedure
Neurologic Evaluation
1. Start with clicks at 75dBnHL in the better ear.
 AUDITORY BRAINSTEM RESPONSE

a. If all waveform components cannot be identified after 2000 sweeps, conduct

two runs with condensation clicks and at least one run with rarefaction clicks.
b. If only cochlear microphonic is present, conduct control run. If CM only
is observed in both ears, no other testing is needed.
c. It may be necessary to test the better ear again to ensure responses are
obtained in both ears at the same stimulus levels in order to measure inter-
aural wave V latency difference.

Estimating Auditory Sensitivity

1. Complete the neurologic evaluation
2. Start at 75dBnHL in the better ear.
3. Using condensation polarity tonebursts, test at 2000Hz, 500Hz, 1000Hz, and 4000Hz
in order.
4. If wave V cannot be identified after 2000 sweeps at this level, increase the stimulus in
20dB steps until a clear response is obtained or the maximum output of the equipment
is reached.
5. If wave V can be identified, decrease the level in 20dB steps until wave V disappears.
6. Repeat the procedure on the worse ear.
7. Proceed to bone conduction testing using the same procedure, if applicable.

Helpful Hints
- Ensure that all mobile phones and other unnecessary equipment, which may cause
electrical interference, are switched off prior to testing.
- Avoid using fluorescent bulbs in the testing area.

For pediatric clients, it may be necessary to sedate the child to obtain reliable results. In this case,
necessary referral to a doctor should be made for sedative drug prescription. Sedation of a client
should always be under the supervision and observation of a trained nurse or physician.

BONE CONDUCTION ABR (BC-ABR)

• There are complex underlying mechanisms and technical difficulties that influence the
clinical assessment of BC thresholds
• Transmission of sound to the cochlea by the bones of the skull
 Distortional
 Inertial
 Osseotympanic

The vibration of the bones of the skull elicits auditory sensation

• Sound needs to be strong to cause bones to vibrate
• The oscillator needs to be applied to the skull
• An impedance mismatch between the air and bone is greater than the air and
cochlear fluid
 AUDITORY BRAINSTEM RESPONSE

• An airborne sound must exceed the air conduction threshold by at least 50-60dB
before the BC threshold is reached

BC ABR Underutilization
• Maximum effective intensity level of about 55 dBHL for bone conduction stimulation
• Electromagnetic energy radiating from bone can cause serious stimulus artifacts
• Conductive hearing impairment is usually greatest for audiometric frequencies in
the region of 1000 Hz
• Masking dilemma and the need for contralateral masking (>35 dB)

Indications
• Otologic evidence of middle ear disorder (e.g. congenital aural atresia)
• Audiologic evidence of middle ear dysfunction
• 2007 JCIH guidelines for infants and young children
• Masking dilemma

Criteria for Obtaining BC ABR

• If any of the air-conduction thresholds were not within the normal range
• If OAEs, immittance, or reflexes are abnormal
• For subsequent visits, if there is a reason to believe there has been a sensory change

Why BC ABR?
• Latency-intensity function unreliable for diagnosis of conductive versus
sensorineural hearing loss
• Assessment of air-bone gap which may influence management
• Determines the extent of cochlear reserve

BC ABR
• Wave V latency delays of 0.5 ms
• Acoustic input is 40 dB less than the corresponding earphone output at equal
attenuator settings
• Bone Oscillator
 High frequency response than ear phone
 Generated by more spiral ganglion region of cochlea; longer latency

Technical Considerations
• Transducer
 B71 recommended
 Match impedance (10 versus 300 W)
 Placement and attachment
• Stimulus artifact solutions
 Placement
 Alternating stimulus polarity used
• Dynamic range restrictions limit upper levels
 AUDITORY BRAINSTEM RESPONSE

Bone Oscillator Placement

• Superoposterior placement B recommended

• Easier to maintain position, better quality responses,
less variable latencies
• Within 2.5 cm of, but not touching pinna
• Attach with velcro or elastic band
• Coupling force of 400 to 500 g recommended (latencies
significantly longer and amplitudes smaller at lower
force levels)

Handheld Transducer Attachment

 Problem = signal damping; pressure variations
 Signal damping can be reduced by using a single finger in the center of the oscillator

Procedural Considerations
• Responses are small so electrical noise must be minimized (good electrode
condition, braid cables, eliminate noise sources, etc)
• Ambient noise can mask low level response at 500 Hz
• Stimulus artifact from transducers can mimic cochlear microphonic, so keep
electrodes away
• 2000 averages, 2-3 recordings near threshold, superimpose traces, use adequate
display gain, record baseline (no stimulus) trace
• Two-channel recording is mandatory, and both ipsilateral and contralateral channels
will be evaluated and plotted

Montage for Two-Channel Recording

• The electrodes were placed as follows: reference electrodes in the right (A2) and left
(A1) earlobes, and active (Fz) and ground (Fpz) electrodes in the forehead.
• Bone oscillator placed in the skull above the A1 electrode (if left ear was tested) and
the A2 electrode (if right ear was tested)
• The vibrator fixed with a force of 400±25 g

Protocols
• BC two channel recordings (compare IPSI vs CONTRA)
• Test BC ABR at these levels
 500Hz: min 20dBnHL max 40dBnHL
 2kHz: min 30dBnHL max 60dBnHL
• Any threshold determination requires replication of responses at the “threshold”
level and replications of “no response” waveforms at the level below any elevated
threshold
 AUDITORY BRAINSTEM RESPONSE

Masking
• Masking is usually not necessary since it should be easy to differentiate a
response caused by cross-over
• Wave I is absent in a normal contralateral recording
• Wave V is delayed or absent if the response is due to the stimulus crossing
the head to the contralateral ear. The stimulus intensity will be diminished
by the crossover

Wave V
• The higher positive vertex, followed by a long negative deflection
• Threshold was determined by the lower intensity in which wave V was identified.
• Recording was carried out at least twice in each intensity level, in order to
verify reproducibility of responses
• More difficult to detect wave V at 500 Hz compared to 2000 Hz
• 500 Hz is essential to establish the presence of conductive factors, since this frequency
is the most affected by the presence of fluids in the middle ear

BC ABR
• Not used to provide a specific estimate of the air-bone gap
• It provides estimation of the presence or absence of a sensorineural component
• Indicate whether the sensorineural component is in the mild or moderate range or
is greater

Assessment Should Aim to Answer the Following Questions

1. Is an ear’s AC threshold normal or elevated? Is the other ear’s AC threshold normal
or elevated?
 Testing each ear at the minimum level required
 Involve a threshold search. If the baby wakes up at the end of this, clinician is
still able to state whether one or both ears’ thresholds are normal/elevated
2. If elevated, is the elevation conductive in nature or is there a SN component?
 BC testing the ear(s) with AC elevation(s) at the minimum BC level
 If the infant wakes up at the end of this stage, the clinician is able to state
that the elevation in AC threshold is conductive in nature or has a
sensorineural
3. If elevated, what are the specific thresholds (AC and/or BC)?
 Detailed determination of AC (and BC) thresholds
 AC thresholds for each required frequency are required for subsequent
interventions, including amplification (when chosen by the family)
when sensorineural hearing loss is present