BERA (ABR) and Its Variants

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

BERA (ABR) Agenda

Agenda: Click Air Conduction ABR Toneburst Air Conduction ABR Click Bone Conduction ABR Stacked Auditory Brainstem Response CHAMP Cochlear Hydrops Analysis Masking Procedure BioMAP Biological Marker of Auditory Processing

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Click Air Conduction ABR

Click air conduction ABR is a good starting point Gives you good general information about waveform
morphology and general idea of patients hearing level

If you use click air conduction ABR in isolation: Cannot infer hearing loss configuration Do not have adequate information for a hearing aid fitting. high frequency hearing loss.

The click air conduction ABR can miss both low and

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Example of Electrode Montage

Electrode Montage 1) Non-Inverting Cz or high forehead - sometimes if an

infant has a large soft spot it is difficult to get low impedance.

2) Inverting A1 and A2 - use the earlobe instead of the

mastoid, so that if bone conduction is needed you will have less placement difficulties with oscillator.

3) Inverting C7 (nape) for infants using C7 instead of

A1 and A2 can help increase amplitude of wave V, however you will decrease detection of wave I.

4) Ground - usually center of forehead

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Example of Click Parameters

EQUIPMENT PARAMETERS Two Channel Recording

Cz to A1 or C7 Cz to A2 or C7

Hi Filter (Low Pass)- 1500 Hz (3000) Lo Filter (High Pass) - 30 Hz (100)

20 MS Window
Rate 13.3 Gain 100,000 (150,000) Points (Sampling Rate) 256 (512) Rarefaction Click (Alternating to rule out cochlear microphonic)
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Click Air Conduction ABR

Threshold Search ABR Start at a moderate level - 60 dB nHL If wave V is present, decrease to 30 dB nHL If present, decrease to 20 dB nHL. This is within normal limits. If not present at 30 dB, bracket at 40 or 50 dB depending on
latency of response.

If no response at 60 dB, increase to 80 dB. 20 dB or below is within normal limits

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Click Air Conduction ABR

High Intensity Infant ABR

Perform ABR at 75 dB nHL to evaluate waveform morphology

Wave Morphology - Infants may have a larger Wave I than Wave V Evaluate Wave I to V Interpeak Latency Change polarities to look for cochlear microphonic (used as a diagnostic tool in auditory neuropathy/dys-synchrony)

High Intensity Adult ABR

pathology

Perform ABR at high intensity to evaluate for retrocochlear

Latency (interaural and absolute) Change stimulus rate to evaluate neural synchrony

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Click Air Conduction ABR

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Toneburst Air Conduction ABR

Provides frequency specific information Can diagnose low and high frequency hearing loss. May take several attempts to replicate a wave Toneburst Stimuli

Blackman ramping - (commonly used)

Toneburst ABR is needed to determine if the infant has a

high frequency hearing loss (such as infants given ototoxic medications).

Helps determine the configuration of the hearing loss which

assists in selecting proper amplification device.

Electrode Montage

Can use the same as click air conduction ABR

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Toneburst Air Conduction ABR

500 Hz

Response is a broad rounded peak about 4 to 8 ms longer

than the click

Cyclical stimulus ringing sometimes occurs - this is not a

response.

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Click Bone Conduction ABR

The click bone conduction ABR provides a
differential diagnosis of the type of hearing loss (sensorineural vs. conductive vs. mixed)

Provides the information you need to better

counsel and make your next step toward intervention/habilitation.

One way to diagnose hearing loss in patients

with craniofacial anomalies (aural atresia)

Indicator of middle ear dysfunction in infants.

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Click Bone Conduction ABR

Electrode Montage and Transducer Placement Same as click air conduction ABR Always use earlobe instead of mastoid placement. Bone oscillator headbands are often too big for infants.
Hand-held placement can be used. Firmly hold the oscillator to the infants mastoid with 1 index finger. Push the oscillator on the mastoid until you could almost push the childs head away from you.

Transducer placement should be consistent to reduce

variability. Never use 2 fingers to hold it as this can dampen the output.

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Click Bone Conduction ABR

EQUIPMENT PARAMETERS

One Channel Recording using electrode switching in Biologic system.

Channel 1, input 1: (CZ) Channel 1, input 2: (Left earlobe) Common/ground: (Right earlobe)

Two Channel Recording

Cz to A1 Cz to A2

Alternating Click - minimizes artifact Perform Biologic Calibration to determine what correction factors are needed. Always replicate your waveforms

More information

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Click Bone Conduction ABR

Threshold Search ABR
Start at a moderate level - 30 dB nHL. If you start too
high the infant may wake up

Do not exceed 50 dB nHL. You will overdrive the

oscillator.

Decrease in 10 dB steps Perform your own clinic norms, typically 20 dB nHL and
below is within normal limits

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Sample of Bone Conduction ABR Response

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A Brief Introduction to Stacked ABR and Cochlear Hydrops Analysis Masking Procedure (CHAMP)

Prepared for Bio-logic Systems Corp. by

Manuel Don, Ph.D. / Betty Kwong, M.S. Electrophysiology Department House Ear Institute, Los Angeles, CA

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Normal Internal Auditory Canal (IAC)

Facial Nerve Sup. Vest. Nerve

Standard ABR
High-frequency

Acoustic Nerve
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Inf. Vest. Nerve

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Medium or Large Tumor in IAC

Facial Nerve Sup. Vest. Nerve

Abnormal Standard ABR

Tumor

Acoustic Nerve
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Inf. Vest. Nerve

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Small Tumor in IAC Facial Nerve Sup. Vest. Nerve

Abnormal Standard ABR

Acoustic Nerve
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Inf. Vest. Nerve

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Small Tumor in IAC

Facial Nerve Sup. Vest. Nerve

Normal Standard ABR Inf. Vest. Nerve

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Acoustic Nerve

Normal IAC
Facial Nerve Sup. Vest. Nerve

Stacked
ABR

Acoustic Nerve
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Inf. Vest. Nerve

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Normal IAC
Facial Nerve Sup. Vest. Nerve

Stacked ABR 1

3 5 4
Inf. Vest. Nerve
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Acoustic Nerve

Diagnostic Test: If you add the activity from each of the five areas, is the amplitude normal?
Activity from area 1

Activity from area 2

+
+ +

Activity from area 3 Activity from area 4 Activity from area 5

1 2 3 4 5

Normal Amplitude

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Medium or Large Tumor in IAC

Abnormal Stacked ABR 1 2 3 4 5
Normal Tumor

Tumor

Acoustic Nerve
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Small Tumor in IAC

Abnormal Stacked ABR
1 2 3 4 5
Normal Tumor

Acoustic Nerve
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Small Tumor in IAC Missed by Standard ABR Facial Nerve Sup. Vest. Nerve

Normal Standard ABR Inf. Vest. Nerve

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Acoustic Nerve

Small Tumor in IAC

Abnormal Stacked ABR 1 2 3 4 5 Normal Tumor Acoustic Nerve
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Stacked ABR Measure

Requirements
1. An auditory signal that stimulates essentially all frequency regions of the cochlea 2. A method for separating the responses from different frequency regions of the cochlea 3. A procedure for summing responses to approximate total neural activity =>

Proposed Methods
Wide-band Click

=>

The Derived-band ABR Technique

=>

The Stacking Technique

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TDH-49

Click 0.5 1.0 2.2. 0 0 4.0 8.0

High-pass Masking Noise (8.0, 4.0, 2.0, 1.0, and 0.5 kHz)

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Base 8

Frequency kHz 4 2

Apex 0.5

Click Alone and High Pass Noise Responses

Click Alone Unmasked

M M M

8.0 kHz

4.0 kHz

M M M

M M M

M M M M M M
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2.0 kHz

1.0 kHz

0.5 kHz

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CONCLUSION

The Stacked ABR appears to have better sensitivity and specificity than the standard ABR for small ( < 1 cm) tumors. In other words, the Stacked ABR is better at : 1. detecting small tumors, and 2. decreasing the number of misdiagnosed non-tumor patients (i.e., decreasing the number of false-positives referred for MRI).
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Endolymphatic Hydrops

Alters Basilar Membrane Parameters (e.g., stiffness, fluid column height, etc.)

Changes how cochlea processes auditory stimuli

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In Menieres disease, we think that:

Cochlear hydrops alters the response properties of the basilar
membrane.

Low frequency masking noise is less effective for masking activity

in higher frequency regions.

Thus, we observe undermasking in the high pass responses.

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Click Alone (Unmasked) and High Pass Noise (HPN) Responses

ABR to Click Alone (unmasked)

Unmasked 8.0 kHz

ABR to Click + 8 kHz HPN

ABR 4.0 kHz

2.0 kHz 1.0 kHz

to Click + 4 kHz HPN

ABR to Click + 2 kHz HPN ABR to Click + 1 kHz HPN to Click + 0.5 kHz HPN

0.5 kHz ABR 0 2 4 6 8 10 12 14 ms

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Undermasking in Menieres Disease

Menieres disease

non-Menieres disease

Unmasked 8.0 kHz 4.0 kHz 2.0 kHz 1.0 kHz 0.5 kHz

Unmasked 8.0 kHz 4.0 kHz 2.0 kHz 1.0 kHz 0.5 kHz

8 10 12 14 ms

8 10 12 14 ms

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Wave V Latency Delay (500 Hz HP Click Alone)

Menieres disease

non-Menieres disease

Unmasked 8.0 kHz 4.0 kHz 2.0 kHz 1.0 kHz 0.5 kHz

Unmasked 8.0 kHz 4.0 kHz 2.0 kHz 1.0 kHz 0.5 kHz

10 12 14 ms

8 10 12 14 ms ms

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Wave V Latency Delay (500 Hz HP Click Alone)

100 90
Normal - typical wave V (N = 35)

0 10
Normal - undermasked wave V (N = 3) Menieres (N = 20)

80 70
% Sensitivity

20 30 40 50 60 70 80 90
100 100

60 50 40 30 20 10 0 -1 0 1 2 3 4 5 6 7

Wave V Latency Delay (500 Hz HP - Click Alone) in ms

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IMPORTANT!
Do not confuse the Stacked ABR method with this method for evaluating Menieres disease. The Stacked ABR is for small tumor detection and is not used for Menieres disease assessment. Stacked ABR uses the sum of the aligned derived-band (subtracted) ABRs while the Menieres test uses only the high-passed noise masked responses to clicks.

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Staff Acknowledgements
Department of Electrophysiology
Manuel Don, Ph.D. Betty Kwong, M.S., CCC-A Erin Maloff, M.S., CCC-A Michael Waring, Ph.D.

Department of Clinical Studies

Ann Masuda, M.S., CCC-A Chiemi Tanaka, M.A., CCC-A

Department of Histopathology
Fred Linthicum, M.D.

Physicians at the House Ear Clinic

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Support
NIH/NIDCD 1R43 DC04141 Raviv (PI) NIH/NIDCD 2R44 DC04141 Raviv (PI) NIH/NIDCD R01 DC03592 Don (PI)

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References
Don M, Masuda A, Nelson RA, and Brackmann DE (1997). Successful Detection of Small Acoustic Tumors Using the Stacked Derived Band ABR method. Am J Otolaryngol.; 18: 608-621.

Don M and Kwong B (2002). Auditory Brainstem Response: Differential Diagnosis. In: Katz J, Eds. Handbook of Clinical Audiology, Fifth Edition. Pennsylvania: Lippincott Williams & Wilkins Publishing; pp. 274-297.
Don M (2002). Auditory brainstem response testing in acoustic neuroma diagnosis. Current Opinion in Otolaryngology & Head and Neck Surgery 10:376-381. Don M, Kwong B, Tanaka C, Brackmann DE, Nelson RA (2005) The Stacked ABR: A Sensitive and Specific Screening Tool for Detecting Small Acoustic Tumors (Audiology & Neurotology 10: 274-290) Don M, Kwong B, Tanaka C (2005) A Diagnostic Test for Menieres Disease and cochlear Hydrops: Impaired High-pass Noise Masking ABRs. (Otology & Neurotology 26: 711-722.)
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All Slides on Stacked & CHAMP are from House Ear Institute

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Who developed BioMAP?

The Auditory Neuroscience Laboratory at Northwestern University was founded in 1990 by Nina Kraus, Ph.D.

Together with her colleagues, staff and graduate students, Dr. Kraus has been investigating neural encoding of complex sounds such as speech and music in normal listeners and a variety of clinical populations.

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What is BioMAP?
Biological Marker of Auditory Processing

An electrophysiologic response, measured at the level of the brainstem, that mimics

characteristics of the speech

stimulus /da/ used to evoke it.

BioMAP data collection is very

similar to a standard click ABR.
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For what population is BioMAP used?

Studies on children from 8-12 years old have shown that the BioMAP response is abnormal in approximately 30% of children who have been diagnosed with various learning problems such as:
Dyslexia Central Auditory Processing Disorder (CAPD) Specific Language Impairment Learning Disability (LD)
ADHD
Auditory perception & Neural encoding deficits

LD

SLI

Dyslexia

Attention Deficit Hyperactivity Disorder (ADHD)

CAPD

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For what population is BioMAP used?

The 30% of the children with known Learning Problems who also have abnormal BioMAP responses tend to be:
Behavioral Manifestations poorest readers - WRAT (Wide Range Achievement Test) poorest spellers - WRAT poorest auditory processing - Woodcock Johnson poor fine-grained speech syllable discrimination excessive backward masking slower speed of processing - Woodcock Johnson Cortical Consequences (revealed in challenging listening situations) abnormal cortical response in noise (P1/N1/P2) fine-grained stimulus differences not encoded (MMN)

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BioMAP Theory
What is the physiological event upon which BioMAP was developed? The Brainstem response reflects the acoustic characteristics of speech

with remarkable fidelity.

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Speech Source vs. Filter Characteristics

source + filter = speech sound
Together the source and filter combine to create a spectrally and temporally complex waveform.

Source

Filter

vocal folds

vocal folds
Formants (F1, F2, F3) resonance of vocal tract

Fundamental frequency (F0) + harmonics

Frequency:
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frequencies depend on position of lips, tongue

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BioMAP Theory
Brainstem Comparison response to speech can be viewed in the same ways. Stimulus/Response

time domain
0 10 20 30
Time (ms)

frequency domain
60

40

50

250

500

750
Frequency (Hz)

1000

1250

1500

stimulus response

(filtered to mimic low-pass characteristic of the midbrain)

a very nice match!

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Courtesy of Auditory Neuroscience Laboratory, Northwestern University. Nina Kraus, Director.
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da
~ 120 Hz ~ 120 Hz

lll V l

Neural Event
A
0 10

~ 120 Hz

~ 120 Hz

C
20

D
30

O F
40 50

E
Time (ms)

modified from Kraus and Nicol, TRENDS in Neurosciences, 2005

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Courtesy of Auditory Neuroscience Laboratory, Northwestern University. Nina Kraus, Director.
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What happens to the BioMAP response after auditory training?

The BioMAP response IMPROVES with auditory training as do other behavioral measures. So, the post-training BioMAP response can be

used as an objective test to verify the benefit of auditory training. EVIDENCE BASED PRACTICE!!

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What characteristics of the BioMAP response are used in the analysis?

The abnormal BioMAP children have reduced amplitudes
LP NL

F1

High Frequencies

Hz

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Courtesy of Auditory Neuroscience Lab Northwestern University, Nina Kraus, Director
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What characteristics of the BioMAP response are used in the analysis?

Wave V Latency
0.2

amplitude (V)

The abnormal BioMAP children have delayed latencies and shallow slope

0 -0.2 -0.4 -0.6 -0.8 6 NL LD+ LD7

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V-A Slope

Wave A Latency
8 time (ms) 9 10
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How is the BioMAP test performed?

Child awake sitting quietly in comfortable chair

Watching favorite video; eyes open is OK

Soundtrack of video played on low volume; audible to left ear

BioMAP stimulus /da/ delivered into right ear; insert phone

One channel of ABR is collected Test takes about 20 minutes

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How is the BioMAP test performed?

Electrode setup:
One channel recording Cz = Channel 1, Input 1 Right Ear = plugged into ground on Nav Pro Left Ear = Channel 1, Input 2 (true ground in this recording)

Electrode switching = ON
With electrode switching on the right ear will be used as the inverting electrode when the stimulus is in the right ear.

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How is the BioMAP test performed?

Collection process: Collect 3 identical trials of 2000 sweeps Average the 3 trials together Mark V and A, using normative wave template as a guide
V

TEMPLATE
C

AVERAGE
A

TRIAL 1 TRIAL 2 TRAIL 3

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How is the BioMAP test analyzed?

Once the V and A on the response are labeled, the computer does the rest of the analysis.

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BioMAP Report

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Courtesy of Auditory Neuroscience Lab Northwestern University, Nina Kraus, Director
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Recent developments
A recently completed study at Northwestern

University has shown that the norms for children age 5 are identical to the norms previously collected on children in the 8-12 year old range.

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Recent developments
So the norms currently available for BioMAP can be used for children from 5-12 years of age. 3-4 year olds show

some0.2 differences that are still being investigated.

V

Amplitude (V)

0.1 0
C

-0.1 -0.2 -0.3 0

A

3yo 4yo
D
E F O

5yo 8-12yo

10

20

30

40

50

60

Time (ms)
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BioMAP Theory
SUMMARY Neural representation of speech in the brainstem
Brainstem response reflects the acoustic characteristics of speech with remarkable fidelity.
Measures of latency and FFT amplitude can be assessed. Normal perception depends on accurate timing of brainstem neurons.
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Quick Summary
BioMAP is an ABR to a speech stimulus.

30% of kids with auditory-based learning problems aged 8-12 years have poor BioMAP responses, confirming a physiologic basis for at least some of their learning problems.
These kids are the ones that show improved test scores on behavioral tests after intensive auditory training. These kids also typically show an improved BioMAP response after auditory training.
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References

Bio-logic:
www.natus.com BioMAP:
http://www.communication.northwestern.edu/brainvolts/list/

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