The Laryngoscope

© 2019 The American Laryngological,

Rhinological and Otological Society, Inc.

Effect of Anesthesia on Evoked Auditory Responses in Pediatric

Auditory Brainstem Implant Surgery

Kevin Wong, MD ; Ruwan Kiringoda, MD; Vivek V. Kanumuri, MD; Samuel R. Barber, MD;
Kevin Franck, PhD, MBA; Nita Sahani, MD; M. Christian Brown, PhD; Barbara S. Herrmann, PhD;
Daniel J. Lee, MD

Objective: Electrically evoked auditory brainstem responses (EABR) guide placement of the multichannel auditory
brainstem implant (ABI) array during surgery. EABRs are also recorded under anesthesia in nontumor pediatric ABI recipients
prior to device activation to confirm placement and guide device programming. We examine the influence of anesthesia on
evoked response morphology in pediatric ABI users by comparing intraoperative with postoperative EABR recordings.
Study Design: Retrospective review.
Methods: Seven children underwent ABI surgery by way of retrosigmoid craniotomy. General anesthesia included inhaled
sevoflurane induction and propofol maintenance during which EABRs were recorded to confirm accurate positioning of the ABI. A
mean of 7.7  2.8 weeks following surgery, the ABI was activated under general anesthesia or sedation (dexmedetomidine) and
EABR recordings were made. A qualitative analysis of intraoperative and postoperative waveform morphology was performed.
Results: Seven subjects (mean age 20.6 months) underwent nine ABI surgeries (seven primary, two revisions) and nine
activations. EABRs were observed in eight of nine postoperative recordings. In three cases, intraoperative EABRs during gen-
eral anesthesia were similar to postoperative EABRs with sedation. In one case, sevoflurane and propofol were used for intra-
and postoperative recordings, and waveforms were also similar. In four cases, amplitude and latency changes were observed
for intraoperative versus postoperative EABRs.
Conclusion: Similarity of EABR morphology in the anesthetized versus sedated condition suggests that anesthesia does
not have a large effect on far-field evoked potentials. Changes in EABR waveform morphology observed postoperatively may
be influenced by other factors such as movements of the surface array.
Key Words: Pediatric auditory brainstem implant, ABI, electrically evoked auditory brainstem response, EABR, anesthesia,
sevoflurane, propofol, dexmedetomidine.
Level of Evidence: 4
Laryngoscope, 00:1–7, 2019

INTRODUCTION or aplasia of the cochlea or cochlear nerve. Several North

The auditory brainstem implant (ABI) is a neuroprosthe-
tic device that electrically stimulates second-order auditory
neurons of the cochlear nucleus using a multichannel surface
array. The ABI was originally developed to provide sound sen-
sations in patients with neurofibromatosis type 2 (NF2) and
was approved by the U.S. Food and Drug Administration in
2000 for NF2 patients ages 12 and older.1 New indications
have included congenital deafness associated with hypoplasia
From the Department of Otolaryngology (K.W., R.K., V.V.K., S.R.B., K.F.,
M.C.B., D.J.L.); the Department of Audiology (K.F., B.S.H.); the Department of
Anesthesiology (N.S.), Massachusetts Eye and Ear, Boston, Massachusetts,
U.S.A.; and the Department of Otology and Laryngology (R.K., V.V.K., M.C.B.,
B.S.H., D.J.L.), Harvard Medical School (R.K., V.V.K., M.C.B., B.S.H., D.J.L.), Boston,
Massachusetts, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
March 28, 2019.
Presented at the April 26-30, 2017 Triological Society’s 120th Annual
Meeting, COSM, San Diego, California, U.S.A. First place in Otology/Neuro-
tology Scientific Poster Competition.
This study was supported by the Bertarelli Foundation and by The
National Institute on Deafness and Other Communication Disorders
(NIDCD) (grant DC01089). The authors have no other funding, financial
relationships, or conflicts of interest to disclose.
Send correspondence to Daniel J. Lee MD, Massachusetts Eye and
Ear, 243 Charles St., Boston, MA 02114. E-mail: daniel_lee@meei.
harvard.edu
DOI: 10.1002/lary.28008
American clinical trials have examined the safety and feasibil-
ity of ABI surgery in nontumor children who are deaf and are
not candidates for the cochlear implant.2–4 Auditory benefits
with the pediatric ABI range from environmental sound
awareness in most subjects to open-set speech perception in a
few cases.2,5–7
ABI surgery is challenging. The convexity of the cere-
bellum and the narrow surgical corridor of the foramen of
Luschka obscures direct visualization of the auditory
brainstem during either translabyrinthine8 or retrosigmoid
craniotomy.9 The surgical team relies on indirect anatomic
landmarks such as the choroid plexus and root entry zone of
the glossopharyngeal nerve to place the electrode paddle
into the lateral recess of the IVth ventricle. Despite this
blind surgical approach, image guidance has not yet been
developed for ABI placement, although recent data suggests
that computed tomography (CT) can resolve detailed posi-
tioning data of the ABI array.10 Consequently, electrophysi-
ologic measures are needed to confirm accurate placement of
the ABI array.
Intraoperative electrically evoked auditory brainstem
responses (EABRs) following ABI placement were first
described by Waring in 199911 and serve two key roles.
EABRs generated during electrical stimulation of the cochlear

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nucleus are thought to indicate the ABI paddle position most
likely to activate auditory neurons. These electrophysiologic
data guide the surgical team and help maximize the number
of electrodes eliciting an auditory sensation.11 Continuous
intraoperative EABR monitoring following final placement
also ensures that the array did not shift during manipulation
of the harness when closing dura and soft tissue.8,9
At our center, pediatric ABI recipients undergo initial
device activation and EABR testing under sedation or gen-
eral anesthesia followed by awake activation the next day.
EABRs identify electrodes most likely to elicit auditory sen-
sation versus those likely to elicit side effects from neighbor-
ing nonauditory axons of passage.2,7 A change or absence in
postoperative EABRs (compared to intraoperative measure-
ments at the time of device placement) may 1) indicate
shifting of the ABI array position due to intracranial pulsa-
tions or brain growth and 2) predict modest or absent percep-
tual responses in the awake condition. Finally, monitoring of
nonauditory stimulation under anesthesia is essential in
children to eliminate electrodes associated with cardiovascu-
lar changes or noxious responses.
Given the importance of monitoring EABR changes
during and after ABI surgery to help guide initial device
mapping in children, it is critical to understand whether
electrophysiological measurements are influenced by exter-
nal perioperative factors such as the choice of anesthetic
agent. Anesthesia has shown to have a dose-dependent
effect on amplitude, threshold, and latency of sound-evoked
ABRs in frogs,12 mice,13 rats,14,15 and lizards.16 In humans,
specific anesthetic regimens have also been shown to have
an impact on EABRs.17 For example, in a study of 12 chil-
dren between the ages of 29 and 52 months, significant
delays in ABR latencies were observed for wave V and
interpeak intervals I to III, III to V, and I to V.
This study was undertaken because of the opportunity
to compare within a single ABI subject EABRs in the anes-
thetized intraoperative condition to the sedated postopera-
tive condition several months later. We hypothesize that
the variance in postoperative EABR morphology compared
to intraoperative measurements during ABI surgery cannot
be explained entirely by differences in anesthesia. The goal
of this study was to characterize the association of anes-
thetic approach with changes in postoperative EABRs in
pediatric ABI patients.
MATERIALS AND METHODS
This study was approved by the Human Studies Committee at
Massachusetts Eye and Ear (13-028H). All subjects were part of the
safety and feasibility trial for auditory brainstem implantation in
non-NF2 children approved by the Food and Drug Administration
(NCT01864291). Inclusion and exclusion criteria for this trial are
listed in Table I. Candidates who fulfilled these criteria underwent
retrosigmoid craniotomy and placement of either the Cochlear
Nucleus N24 ABI or Nucleus ABI541 (Cochlear Corporation, NSW,
Australia). Mean age at primary ABI surgery was 20.6  7.7 months
(Table II), and average age at initial clinic evaluation was 18 
8.1 months (standard deviation). The first four subjects were
implanted with the Cochlear Corporation, NSW, Australia ABI24,
and the last three were implanted with the Cochlear ABI541 after
production of the Nucleus ABI24 was discontinued. All surgeries
used a retrosigmoid craniotomy approach. Six subjects received an
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TABLE I.
Subject Criteria for Pediatric Auditory Brainstem Implant.
Inclusion Criteria
1. Prelinguistic hearing loss with:
 MRI  CT evidence of one of the following:
• Cochlear nerve deficiency
• Cochlear aplasia or severe hypoplasia
• Severe inner ear malformation
• Postmeningitis ossification
 When a cochlea is present or patent with a normally appearing
cochlear nerve, lack of significant benefit from CI despite consistent
use (>6 months)
• No or limited speech perception ability (limited to pattern
perception on closed set testing materials using the CI)
• Lack of progress in auditory skills development
2. Postlinguistic hearing loss (<18 years of age) with both:
 No benefit from CI without possibility for revision or contralateral implant
• Postmeningitis ossification
• Bilateral temporal bone fractures with cochlear nerve
avulsion
• Failed revision CI without benefit
 Previous open set speech perception and auditory-oral
language skills
3. Ability to tolerate general anesthesia
4. Receipt of the appropriate meningitis vaccinations
5. No or limited cognitive/developmental delays, which would be
expected to interfere with the child’s ability to cooperate in
testing and/or programming of the device or in developing
speech and oral language
Exclusion Criteria
1. Pre- or postlinguistic child currently making significant progress
with CI
2. MRI evidence of one of the following:
 Normal cochlea and cochlear nerves or NF2
 Brainstem or cortical anomaly that makes implantation
unfeasible
3. Clear surgical reason for poor CI performance that can be
remediated with revision
4. Intractable seizures or progressive, deteriorating neurological
disorder
5. Lack of potential for spoken language development
6. Unable to participate in behavioral testing and mapping with
their CI
CI = cochlear implant; CT = computed tomography; MRI = magnetic
resonance imaging; NF2 = neurofibromatosis type 2.
ABI on the right side and one on the left side. Subject one (S01)
underwent revision surgery for device failure after impact from a
mechanical fall, and another subject (S02) underwent surgery for
spontaneous device failure approximately 1 year following initial
implantation. Inhalation induction with sevoflurane and propofol for
maintenance was utilized for all nine intraoperative EABR record-
ings (Table III).
Following ABI array placement, intraoperative EABRs were
obtained, and the array position was adjusted to optimize evoked
response measurements. The method for eliciting intraoperative
EABRs was similar to that previously described.18 Briefly, EABRs
were recorded using an Xltek Protektor IOM system (Natus Inc.,
Pleasanton, CA) triggered by manufacturer stimulating software.
Bipolar electrical stimulation used single biphasic pulses (100 or
150 μs phase duration, 8 μs interphase gap) delivered to the ABI
array through a processor and coil. The most frequent electrode
pairs stimulated were either at the corners of the electrode paddle,
that is, electrodes 2 and 8, or crossing the paddle, that is, electrodes
11 and 12 (Fig. 1). The number of stimulated electrode pairs vary
between subjects for several reasons, including the amount of time
available for recording intra- and postoperatively, the number of
electrode pairs with responses, and the morphology of those
responses. Even with EABR guidance during placement of the
array, the physical orientation of implanted electrodes also varies
across subjects. Between two and 10 electrode pairs were tested per
Wong et al.: Anesthesia and EABRs in Pediatric ABI Users
 TABLE II.
Subject Characteristics.
S01 S02 S03 S04 S05 S06 S07

Age at time of 18 months 11 months 15 months 30 months 20 months 16 months 34 months

primary surgery
Gender Male Female Female Male Female Female Male
Birth history Preterm Term Term Term Term Term Term
Oligohyd- CHARGE Hyperbilir- Meconium CHARGE
ramnios syndrome ubinemia aspiration syndrome
Family history of None None None None None None Maternal
hearing loss grandparent
Newborn Absent ABR Absent ABR Absent ABR Absent ABR Absent ABR in Absent ABR Absent ABR
screening one ear; inconsistent
results in other ear
Prior intervention None None None None Failed left cochlear Failed hearing None
implant trial aid trial

ABR = acoustic auditory brainstem response; S = subject.

subject (Table III). Responses were recorded using the electrode
montage described by Waring15 (vertex (+) to nape (−) with the gro-
und electrode at the hairline). Average hospital stay was 2.9 
0.9 days.
The mean time of postoperative EABR evaluations was 7.7 
2.8 weeks (range: 6 to 12 weeks) after surgery. All subjects had EABR
testing under light sedation or general anesthesia approximately 1 to
2 days prior to awake device activation. Intramuscular dexmedetomi-
dine was used in six sedated evaluations (66.7%, 6 of 9) and general
anesthesia with sevoflurane/propofol induction was used in three
evaluations (33.3%, 3 of 9). One sedated evaluation was converted from
dexmedetomidine to general anesthesia with sevoflurane after the
initial sedation techniques failed. EABR responses were obtained for
all postoperative evaluations, except one in which technical equipment
problems prevented recording. Methods were similar to intraoperative
recordings except for the use of a custom-programmed evoked poten-
tial system14 (instead of the Xltek; Natus Inc.). The same electrode
pairs were stimulated using bipolar stimulation paradigm as previ-
ously described.
RESULTS
Subject Characteristics
Patient demographics, operative events, and anes-
thetic agent(s) used during ABI surgery and at initial acti-
vation are summarized in Table II. On high-resolution
magnetic resonance imaging with parasagittal sequences,
the most common structural anomalies were cochlear nerve
(vestibulocochlear nerve VIII) aplasia (100%, 7 of 7) with
bilateral cochlear hypoplasia (85.7%, 6 of 7). One subject
also had bilateral cochlear aplasia (14.3%, 1 of 7). Two sub-
jects had CHARGE syndrome, and one subject had a family
history of hearing loss.2 One subject had a failed cochlear
implant trial, and another subject had a failed trial with
hearing aids.
Intraoperative and Activation EABRs
In total, seven children underwent nine ABI surgeries
(7 primary, 2 revisions) and nine activations. EABRs were
obtained in all surgeries and all but one postoperative record-
ing. For all surgeries, intraoperative EABRs were used to
adjust array position until the maximum number of responses
with adequate waveform morphologies was achieved. Evoked
responses associated with the final position of the ABI array
were used for this study. Overall waveform morphology was
similar to that seen in adult NF2 patients, with waves often
identified as N1, P1, and P3, as well as later positive waves
between 6 and 8 ms.18 The presence or absence of positive
waves after 15 ms could not be assessed because the recording
response window was 0 to 20 ms. Occasionally, some stimula-
tion pairs elicited a large and sharp waveform around 4 ms
(e.g., Fig. 2C). We term this waveform a myogenic response
because in some cases it was associated with an increase in
the activity on cranial nerves VII and/or X, as observed with
intraoperative monitoring and accompanied by visible twitch-
ing of the face or throat muscles, respectively.
Intraoperative and Postoperative EABR
Comparison
Figure 2 compares example waveforms of EABR record-
ings for single subjects during ABI surgery and at activation.
Recordings from two subjects are shown in which the wave-
forms are generally the same in both conditions (Fig. 2A),
and recordings from three other subjects are shown in which
the waveforms are different (Fig. 2B, 2C). Waveforms from
recordings during ABI surgery and at activation for each sub-
ject were qualitatively compared across four dimensions:
general waveform morphology (number and shape of waves),
overall waveform amplitude, the presence or absence of a
myogenic-like response, and general wave latency. Overall,
waveform morphology was similar during ABI surgery and
at activation in half of the eight subjects (Table III). Of those
that were similar, three patients (S01, S02, S02R) under-
went EABR testing under sedation, and one was done under
general anesthesia. Changes in myogenic responses were
seen in only two subjects, and those changes were minimal
(S01, S02). Latencies were similar when no waveform mor-
phology changes were observed and were consistent with
the change in recording equipment.
Four of the subjects had major changes in waveform
morphology at ABI activation (Table III). The majority of
these patients underwent general anesthesia as opposed to
a single patient who was sedated at the time of initial device

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4
TABLE III.

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Summary of Anesthesia/Sedation Used and EABR Comparisons.
S01 S01R S02 S02R S03 S04 S05 S06 S07

Summary of Sedation/Anesthesia and EABR

Intraoperative Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane & Sevoflurane &
anesthesia propofol propofol propofol propofol propofol propofol propofol propofol propofol
EABR (intra-op) Present Present Present Present Present Present Present Present Present
Postoperative Dexmedetomidine Dexmedetomidine Dexmedetomidine Dexmedetomidine Sevoflurane & Dexmedetomidine Dexmedetomidine Sevoflurane & Sevoflurane &
anesthesia propofol convert to propofol propofol
sevoflurane
EABR (postop) Present Not available* Present Present Present Present Present Present Present
Comparison of Intraoperative and Postoperative EABR
Number 4 0* 13 7 7 12 4 12 9
of electrode
pairs compared
Waveform Similar for 2 Similar for 10 Similar for 4 Similar for 5 Major changes Major morphology Major changes Major morphology
morphology electrode pairs electrode pairs electrode pairs electrode pairs on 6 electrode changes on all on 2 electrode changes on 8
pairs 4 electrode pairs pairs, slight electrode pairs
changes on
others
Waveform Postop response All postop All but 1 postop All postop All postop All postop 4 postop 1 intra-op
amplitude larger amplitude responses response responses responses responses responses response absent
for 1 pair smaller in larger in slightly larger in larger in smaller in larger in postop
amplitude amplitude amplitude amplitude amplitude amplitude
Myogenic 1 pair with 4 pairs with No myogenic No myogenic in No myogenic No myogenic in No myogenic No myogenic
myogenic only in myogenic in in either either intra- or in either either intra- or in either in either intra- or
postoperative intra- and intra- or postop pairs intra- or postop pairs intra- or postop pairs
response postop postop postop pairs postop pairs
responses.
1 pair with
myogenic only
in postop
response
Latency Minimal Minimal Minimal Minimal Morphology Morphology Minimal Morphology
differences differences differences differences changes changes differences changes
prevent prevent prevent
comparison comparison comparison

*Technical difficulties in postoperative recording prevented comparison.

EABR = electrically evoked auditory brainstem responses; intraop = intraoperative; postop = postoperative; R = revision; S = subject.

Wong et al.: Anesthesia and EABRs in Pediatric ABI Users


Fig. 1. Schematic of Cochlear Corporation, NSW, Australia 21-channel
ABI surface array. Example bipolar stimulation pairs used for electri-
cally evoked ABI recordings. Electrode pair 2/8 (dark gray) illustrates a
pair from the lateral superior quadrant. Electrode pair 17/18 traverses
the electrode array at the medial aspect of brainstem. ABI = auditory
brainstem implant.
activation. EABR waveform amplitudes were larger in five
subjects (S01, S02R, S03, S04, S06) and smaller in two sub-
jects (S02, S05) at activation compared to recordings during
ABI surgery.
DISCUSSION
This is the first study to record and compare EABRs
from pediatric ABI patients in the intraoperative, anesthe-
tized condition and the sedated/anesthetized, postoperative
condition. We found EABRs were largely unchanged in the
two conditions for some subjects, suggesting that anesthesia
does not have a large effect on waveform morphology. Other
subjects had different EABRs in the postoperative condition,
and the interpretation in those cases is less clear.
EABRs for ABIs
The use of intraoperative EABRs to guide ABI electrode
placement was first described for adult patients by Waring
in 1995.19 Positive peaks at mean latencies of 0.4 ms and
1.45 ms and/or the presence of a three-wave response within
the first 25 ms of stimulus onset were thought to indicate
stimulation of the cochlear nucleus.19–21 Similar waveforms
were seen in pediatric patients in the present study and by
O’Driscoll et al.22 As found in the present study, almost all
previous studies of EABRs from ABI stimulation report vari-
ability from subject to subject and for different electrode
pairs within a single subject.
There is a correlation between the presence of EABRs
and sound perception in awake ABI users,18,22 and these
measures are predictive of auditory sensation at those elec-
trodes.22 Although an increase in the number of “auditory”
electrodes are associated with those contacts that evoke
EABR waveforms, the absence of EABRs is not necessarily a
predictor for lack of sound perception in either adults or
pediatric patients.
Anesthesia and EABRs
A number of studies have shown that anesthesia can
influence the sound-evoked ABR in animals.13–17 Van Looij
et al. investigated the impact of anesthesia on ABR record-
ings in mice and found that ABR peak latencies, interpeak
latencies, and thresholds were all significantly increased in
anesthetized mice compared to the awake condition.13 Dif-
ferent anesthetic agents can have different and sometimes
contradictory effects. For example, ABR recordings in
guinea pigs after anesthetic induction with isoflurane show
a dose-dependent decrease in waveform amplitudes but with
increased latency. An anesthetic effect on the cochlea does
not appear to cause these effects because cochlear responses
from awake guinea pigs are not affected by anesthesia as
long as cochlear temperature is normal.23 Thus, the
observed changes are likely caused by anesthetic effects on
the ABR generators and their pathways in the central ner-
vous system. In humans, a dose-dependent relationship has
also been shown between anesthesia and ABRs. These
results show that undesired increases in ABR latency may

Fig. 2. Examples of EABRs recorded during auditory brainstem implant surgery and at activation. An illustration of waveform morphology
changes noted in Table III. Each bracketed pair of waveforms contains the intraoperative waveform (top) and the postoperative waveform (bot-
tom) from the same electrode pair for a given subject. (A) Example waveforms from two different subjects and electrode pairs illustrating simi-
lar intraoperative and postoperative EABR morphology. (B) Example waveforms from two other subjects illustrating major changes in
waveform morphology and amplitude between intraoperative and postoperative EABR recordings. (C) Example waveforms from another sub-
ject illustrating major changes in waveform morphology primarily due to the addition of a myogenic wave (black arrow) in the postoperative
recording. In all recordings, stimulus time begins at time 0 on the time scale (x-axis), and the amplitude scale (2 μV/division) is shown on the
y-axis for each plot. EABR = electrically evoked auditory brainstem. [Color figure can be viewed in the online issue, which is available at www.
laryngoscope.com.]

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occur in anesthetized children compared to the awake
condition.24
In our study, we found that EABR morphology from
subjects in anesthetized versus sedated states can be similar.
One explanation may be that nonquantitative comparisons of
ABR waveform morphology fail to detect small changes.
Although the same subject was tested in both conditions, the
change in recording equipment required by our experiments
was a complicating factor. Secondly, although unlikely, a lack
of EABR change could be explained by the fact that the anes-
thetics used in our study might not have the same effects as
anesthetics used in previous studies of the ABR. The choice of
inhaled sevoflurane induction and propofol maintenance was
made based on several considerations. Patients for neurosur-
gical procedures such as ABI surgery are at a greater risk for
elevated intracranial pressure due to hypoxia and hypercap-
nia, and care should be taken during anesthetic induction to
avoid this. Induction can be achieved intravenously with
thiopentone or propofol as well as through inhalation by
facemask. In our subjects, induction was by inhalation of a
volatile anesthetic agent such as sevoflurane and nitrous
oxide, with a loading dose of propofol 2 mg/kg followed by an
infusion of propofol at 200 mcg/kg/min. An intravenous infu-
sion of propofol with sevoflurane allows for a motionless
patient and uninterrupted and proper/accurate neuromonitor-
ing, which are crucial during brainstem manipulation. Induc-
tion with sevoflurane followed by continuous infusion of
propofol for maintenance was used for all surgical procedures
in our study. Finally, another possibility for lack of EABR
change is that the sedative used also has an anesthesia-like
effect on the EABR; thus, changes might have occurred if test-
ing occurred in the awake child. Intramuscular dexme-
detomidine was used for six sedated activations, whereas
general anesthesia with sevoflurane induction and propofol
was used for three activations. A dichotomy exists between
agents used for general anesthesia (sevoflurane and propofol)
and sedation (dexmedetomidine).24,25 General anesthetics
cause complete loss of consciousness as well as analgesia,
amnesia, and muscle paralysis. In contrast, sedatives are pri-
marily used for light-to-moderate sedation with intact con-
sciousness. Some sedatives such as dexmedetomidine also
have analgesic properties.
Cases Where EABR Morphology Changed
Following ABI Surgery
EABR waveforms from several subjects varied from
intraoperative measures during ABI surgery to activation
under anesthesia in two conditions. Changes in some
EABR recordings from children have been previously
reported.22 Anesthetics used during ABI placement and
postoperatively at activation were no different from those
in the subjects with no changes in EABR. One explanation
is that a small change in the three-dimensional orienta-
tion of the ABI array could result in changes in electrically
evoked responses. A change in the position of the device
has been shown to dramatically change auditory out-
comes.26 Future studies at our center will test this hypoth-
esis and build on our recent work that correlates
perception with detailed positioning data of ABI arrays on
CT in both adults and children.10 Finally, another possible
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explanation for changes seen on EABR following device
placement could be a change in the size and orientation of
the electrical field due to tissue changes after healing.
Limitations
Our study has several limitations. First, we report
observations from a small cohort of pediatric ABI users, and
therefore this study has limited power. Currently, pediatric
ABI surgery is performed at only a few centers worldwide.
Nevertheless, the consistency of our results increases the
strength of our conclusion regarding the effects of anesthetic
agents on electrically evoked responses. Another limitation
is the retrospective nature of this study, which does not
allow for controlling variables such as type of anesthetic
agent used.
Acknowledgment
Supported by the Bertarelli Foundation and by NIDCD
grant DC01089
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