Biomedicine: 2012; 32(4): 576 - $82 Comparison of hearing ability between blind and normal sighted subjects based on brain stem evoked response audiometry and pure tone audiometry *M. Anbarasi and **B. Vishwanatha Rao Department of Physiology, Chennai Medical College Hospital & Research Centre, Irungalur, Thiruchirapalli - 621 105, Tamilnadu, India. **Department of Physiology, Madras Medical College, Chennai ~ 600 003, Tamilnadu, India. (Received 16% April,2012; Revised 18% October, 2012; Accepted 25" October, 2012) Corresponding Author Dr. M. Anbarasi, Email: anbarasi.physio@gmail.com, dr_anbarasi@yahoo.com Tel: 0431 3058668 (office) Cell: +919790542244 Abstract Background & Objectives: Human brain is capable of adaptive plastic changes from one sensory modality to another. This study is done to test the concept of cross-modal plasticity by doing two different hearing tests - Pure tone Audiometry (PTA) and Brainstem Evoked Re- sponse Audiometry (BERA) on blind subjects and comparing the results with that of normal sighted subjects. Methods: This is a comparative, cross-sectional study done in Madras Medical College, Chen- nai. The study group comprised of 30 blind subjects (15 male and 15 female) and the control group included 30 age and sex matched normal sighted subjects. Both the groups were sub- jected to PTA and BERA and their hearing was assessed. Results: The pure tone audiometry results showed no significant difference between the two groups. In BERA, the absolute latency for wave V of BERA was significantly shorter in male blind subjects compared to the control group (right ear ~ 5.47 Vs 5.66; p - 0.004 & left ear - 5.43 Vs 5.62; p value -0.02), Conclusion: The shorter absolute latency of wave V indicates the evidence of enhanced hearing ability and hence cross-modal plasticity in blind people. Key Words: Cross-modal plasticity, Brainstem evoked response audiometry, Pure tone audi- ‘ometry Introduction there are subjective evidences in favour of a notion that humans with congenital loss of cone sensory system become better at making dis- criminations with the remaining sensory systems. Blind people are known to be better than the normal sighted people at orienting themselves by sound, The younger the age of onset of blindness, the more plasticity the visual cortex seems to have. Con- genitally blind subjects were reported by Strelow sere biomedicineonline.org & Brabyn in 1982(1) to show sensitivity in auditory perception, enabling them to use echoes to perceive spatial positions of objects. PET scanning also dem- onstrates that tactile and auditory stimuli increases metabolic activity in the visual cortex in blind in- dividuals. Thus, there is a compensatory adapta- tion of the auditory system in the congenitally (or carly) blind, presumably because of reorganization of the neocortex(2).This hypothesis is supported by recent neuroimaging studies of blind individuals demonstrating that both auditory localization tasks Biomedicine - Vol 32; No.d: 2012377 'M. Anbarasi and B. Vishwanatha Rao et a: Brain stem evoked response audiometry in lind and normat and Braille reading (3, 4, 5) activate regions of cor- tex normally involved in visual processing, These results indicate that the amount of cortex devoted to a particular sensory system and organization of cortical areas is determined to a greater extent by Peripheral innervation and activity pattems gener- ated with use. There ate multiple complex mecha- nisms at the molecular level that may lead on to the different plastic changes in sensory deprivation de- pending on the peripheral inputs. The present study is aimed at evaluating the extent to which the infiu- ence of peripheral auditory system and its prelimi- nary pathway structures can sculpt the architecture and functions of the entire sensory system in the students with congenital and early onset blindness who have undergone rehabilitation by Braille train- ing and various auditory aids of training. Here we are analyzing and comparing the various parameters of the wave pattems of brainstem auditory evoked Potentials of students with congenital or early on- set of blindness with that of the same age and sex matched normal sighted subjects Materials and Methods This comparative, cross-sectional study is done in the research laboratory of Institute of Physiology & Experimental Medicine and Upgraded Institute of Otorhinolaryngology, Madras Medical Col- lege, Chennai. The study was done after getting Institutional Ethical Committee approval (Ref: L.Dis.No.3798/P&D3/Bthics/Dean/GGH/O8 dated 15.02.08). The study group consisted of 30 blind students (15 male and 15 female) who were totally blind (either congenitally or early-onset blindness) recruited from “The Blind students’ association, Chennai”. The age of the study group subjects is chosen between 17 — 23 years. All the blind stue dents were either Undergraduate or Postgraduate students in various disciplines. The mode of train- ing for these students since their schoo! hood pe- riod was Braille Method and training by auditory stimulation using audio casseites. Control group consisted of 30 normal sighted subjects (15 girls and 15 boys) who were studying MBBS with age ‘group ranging from 17 ~23 years (studying I ~ II] www biomedicineonline.org year MBBS) Students with combined blindness and deafness, blindness associated with mental retarda- tion known auditory pathology, known history of Diabetes Mellitus, Long duration of Anemia and ‘those under long term medications that affect hear- ing were excluded from study. Methodology History regarding the general details like name, age and address of the subjects, their educational status with mode of training, cause and duration of blind ness, family history of blindness, auditory problems and diabetes mellitus etc. were elicited in the study group subjects. Similar history stated as above was also elicited in normal sighted subjects except for history about blindness. Instead, these subjects were enquired about any visual problems like re- fractory errors or any other eye-related problems, Clinical examination and Specific ENT Exami- nation for both study and control groups: Regular anthropometric measurements (height and weight) were taken in both groups. General exami- nations of the subjects of both groups were done. Systemic examinations including cardiovascular system, Respiratory system and Central Nervous system including Cranial Nerve examinations were done. Both the groups of subjects were subjected for specific ENT examinations, The ENT examination includes external ear examination, tuning fork tests like Rhine’s test and Weber's test, otoscopic exami- nation of tympanic membrane, presence of any ob- struction by wax and examination of throat and nose. If there is any presence of obstruction by wax, it is promptly dissolved by appropriate treatment before subjecting them for Pure fone Audiometry, Pure Tone Audiometry: Both the group of subjects were subjected for Pure tone Audiometry to know the hearing threshold of the subjects of both groups and also to rule out any extemal or middle ear pathology. Biomedicine - Vol 32: Nod: 2012M. Ambarasi and B. Vskwanatha Rao eal: Brainstem evoked response audiometry in Blind and normal Brainstem Evoked Response Audiometry (BERA) (6,7): Both the group of subjects were subjected to BERA. ‘The apparatus set up for measuring BERA are set as per the “Recommended standards for the clini- cal practice of Evoked Potentials” introduced in Guideline 9A: Guidelines on Evoked Potential, by American Society of Clinical Neurophysiology (8) “The apparatus for BERA used in our study is RMS EMG EP MARK Il, The electrical montage used for testing are L: Cz—A1,R:Cz—A2, Ground: Fz. The nature of the stimulus tothe test ear is a broad band click of 100 micro seconds duration with the inten- sity of 90 dB at a stimulus rate of 11.1 clicks pet second, The analysis time was set as 10 millisec- ‘onds and included 1500 trials with two repetitions. The contralateral ear was masked with white noise of 50 - 60 dB. The absolute latencies of the waves 1, IIT and V and the inter-peak latencies like I -V, 111 and II -V were documented. The amplitude ratio of wave Vi is also noted, Statistical Analysis: ‘One-way ANOVA and Student's T test were used to analyze the results statistically. P value of < 0.05 is considered to be statistically significant. Results Table I shows the comparison of basic data like age, height and weight. One way ANOVA analysis showed no significant differences in age but there are highly significant differences in height and weight between the two groups. Table 2, Chart 1 and Chart 2 shows pure tone aver- age obtained by PTA, the absolute and inter-peak wave latencies and amplitude ratio of wave Vil of BERA for the right ear and the left ear. There '5 no statistically significant difference in pure tone average, On analyzing the BERA waveforms, the absolute wave latency for wave V were found to f= significantly shortened in the male study group Sempared to the control group in both ears (p=0.004 ees biomedicinconline.org for the right ear and p=0.02 for the left ear). Simi- larly the amplitude ratio ofthe left ear also showed significant difference in male study group (p=0.04). Discussion With plenty of information regarding the concept of cross modal plasticity in blind people, we intend to hypothesize in the present study that learning to attend to non-visual inputs probably strengthens the remaining active synapses following visual depri vation, and thereby, increasing eross-modal acti tion of lower tier auditory areas when performing highly demanding non-visual tasks like Braille ‘Training and Auditory input training. Age: There is no statistically significant difference (p= 0.36) in the age groups of the study and con- trol group making them well comparable. Norihiro Sadato et al. (9), in their study found out that the age dependency of the fimetional reorganization of cortex were more prominently seen in blind sub- jects who lost their sight before 16 years of age ‘when compared to those who became blind after 16 years of age. In our study, we selected only con- genitally and early blind students as subjects with mean age of 19.62 years, since this age group is the ‘optimum age, up to which the blind students would have maximally been trained in their schools and colleges using auditory training and Braille method of training Duration of Blindness and Cross Modal Plasticity Though the average duration of blindness was slightly higher in males, it was not statistically significant, Also, in all the subjects, blindness was attributable to peripheral damage of the visual system and there were no additional neurological problems. Kujala Tet al(10), have demonstrated in their results, plastic changes in neural populations involved in processing of auditory space following early loss of vision. Animal research by Volgyi et al., 1993(11) had documented that the compen: tory effect was much greater if deprivation occurred Biomedicine - Vol 32; No.d: 2012 ee379 M-Anbarasi and B. Vishwanath Rao eal Bran stem evoked reponse audiometry in blind and normat Table. 1 Comparison of Age, height and weight of subjects of both groups Female Female ate One Parameter Pvaue blind contra contol__way ANOVA ASC) a gn 472 92 ee Hejgm(oms) 1504359 15953224 I@.07!38 168.3891 e262 gore Ween 398463 saBasa sodere _sa7set41 _Feinat aor “pale = 0.00, highly sigan Mean Table2, Pure ton audiometry and BER rests of both groupe Patan Fw SLE a Rightcar Leftear Rightcar Leflear Rightewr Lear Righewr Lele PTA 18:24 188223190123 190421191427 185221 a01004 Ingery Abela latencies = jal Weve 1.66402 161602 1.66002 1.64201 160002 1.60002 1@Od 17000 Wavelll 363402 3.66:02 36802 367302 366109 370801 370103 3.78002 Wave $4602 551402 sassna sasio2 $43502* Sarsos” 62402 56102 “Tater peakaiencin E Wael 197602 205403 2002 2034024 2004 20702 iosiad 7AOTIAS WoelIL-V 193403 18402 170403 181802 186103 1.78601 191403 asap WavelV 340103 39m03 34103 390103 392404 38402 390403 a9m03 ony 5.1487 1.8741.7 2,993.4 2.44423 70.5479 2.60425 2.63414 2,0641.4 ratio V/L Values are Means Female lin; FC Female contol; MB ~ Male Hind, MC Male contol, PTA Pare one average ‘Wave V of male group (vale right eat - 0.008 early in Tife. In our study, we have selected the sub- jects of the study group such that their average du- ration of blindness would be optimum to produce the plasticity changes, if any, Duration of Peripheral Training ‘The mean duration of peripheral training was sig- nificantly higher in males (p = 0.005) which may be because of eurlier rehabilitation training given to males. Activation of the new functional connec- tions of blind subjects is strongly task-related and training ~induced (12). Diana M. Kahn & Leah Krubitzer, 2002 (4) have postulated that the amount wwnbiomedicineonline.org Feftear- 0.002) hight signin, of cortical reorganization is greatly modified by Peripheral innervations and activity pattems gener- ated with use. William F.Ganong in his “Review of Medical Physiology"(26) says that “Synapses are dynamic structures, increasing and decreasing in their complexity and number with use and experi- ence, The amount of blood flow and expression of ‘molecules essential for the cortical development also depends on the activity of the particular neu- rons”, The explanation of the cortical representa- tion occurring in blind appears to be that, cortical connections of sensory units to the cortex have ex- tensive convergence and divergence with connec- tions that can become weak with disuse and strong Biomedicine - Vol 32; Not: 2012M-Anbarast and B. Viswanathe Reo ea: Brin stom evoked response aniometry in bind and normal 580 CChart.1 Pure tone average and BERA results from right ear of both groups % a wre # a Ae ae (Ze Mc |B 64 i i] von et : se eee A waar We WE SETS ER De EAT cl nr | 205 Z ve we > oR wFB gi mFC bee] aad mee a8 Ze =MC i: | 4 4 2 = i | PTA Wave! Wavelll ‘WaveV Wave = Wave Wave AR Vi | im tev eV FB—Female Blind; FC Female contol, MB ~ Male bling: MC Je contol PTA Pure tne average; AR Wil ~ Amplitude ratio Vi with use, studies suggest that cortical reorganization occurs in areas above the cortical relay areas that were BERA Waveforms of Study And ControlGroups: tested. In our study, there were significantly lower latencies of wave V of BERA (p value = 0,004 in TLR Nagendra and K.VNaveen et al.(13), showed right ear and 0.02 in left ear) in blind males when that there were no statistically significant differ- compared to normal sighted males which contra- ences in the wave V of BERA and wave ‘Na’ of the dicts the pattern seen in the aforementioned stud- Mid Latency Response, indicating that brainstem ies. Studies in anophthalmic mice (15) indicate that and diencephalic areas which are known generators auditory and somatic activation of visual cortex of these waves appeared unchanged in the blind, may be the result of subcortical rerouting of con- Neimeyer and Starling, 1981(14) also showed — nections. In these animals, the lateral geniculate lower peak latencies of NI wave of Long Latency nucleus receives novel input from the Inferior col- Response in the congenitally blind subjects. These liculus and cuneate nucleus. Inferior colliculus ww biomedicineonline.org Biomedicine - Vol 32; Not: 2012ssi Me Aes ond. Vsowanatha Rao et a: Brain stem evoked response audiometry in blind and normal probably influences cochlear signal processing There are evidences for reciprocal connectivity between either inferior colliculus or superior olive or cochlear nucleus. This imparts significance that inferior colliculus can be described as an acousti- comotor nucleus having widespread connections with the spinal cord, the cerebellum, the somato- sensory and vocalization systems. These facts about inferior colliculus suggest that it is one of the most important site of auditory processing and also a po- tential site for the occurrence of synaptic and neu- ronal plasticity. It is well known that Inferior col- liculus is the major generator of wave V(16). Thus we can convey from our study that the cross modal plasticity as explained by the shorter absolute la- tency of wave V in blind males compared to normal sighted males starts well from the level of Inferior colliculus which contradicts the concepts stated by previous studies namely Nagendra et al. (13), and Neimeyer and Starling et al (14). The eross-modal plasticity observed at the lower tier of the auditory training may be due to enhanced peripheral activ- ity (auditory training) by the blind students start- ing early in their lives which can be well correlated with their duration of blindness. The fact that en- hanced cross modal plasticity is observed only in blind males may be attributed to the significantly longer duration of peripheral training in males. This is in favour of the cross modal plasticity observed with enhanced utility. Conelusion The cross-modal plasticity observed in the present study is probably at the level of Inferior Colliculus (generator of wave V) as seen by a shorter abso- lute latency of wave V of BERA in blind subjects which contradicts the previous studies. The cross- ‘modal plasticity seen with male blind subjects can be related to their significantly enhanced duration peripheral activity in the form of early rehabilita- tion training. With this datum, in future, sensory Substitution prostheses can be developed using these additional neural resources to perform tasks that partially compensate for the loss of vision, Though we have related the cross-modal plasticity www biomedicineonline.org observed in our study to enhanced peripheral activ- ity, the role of visual deprivation per se is not ruled out, In order to prove / disprove the role of visual deprivation on cross-modal plasticity, it is ideal to perform these investigations also on untrained blind Population with the same duration of blindness in addition and compare the results with the trained blind population and normal sighted population. If ‘we could compare the results from evoked potential studies with that of Positron Emission Tomographic (PET) study of auditory localization or functional MRI study of parietal and occipital cortices, it will be fruitful to relate confidently the role of visual ar- as in cross-modal plasticity References 1. 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