Second is the degree of synchronization of the activity of those neural elements.

Thus, larger
amplitudes may represent better synchronized activation of fewer elements rather than
activation of larger numbers of neural elements. Amplitude measures should be very sensitive to
the loss of desynchronization of eighth-nerve activity resulting from compression by an eighthnerve tumor. The standard amplitude measure of ABR component peaks parallel those for
latency measures discussed earlier.
WAVE V AMPLITUDE
Description
Similar to the simple wave V latency measure is the simple wave V amplitude measure. The
amplitude is typically determined by the difference in magnitude between the peak of wave V
and the succeeding trough (fig.13.2). The amplitude is then compared with those in a distribution
of non-tumor, normal-hearing individuals to determine whether the amplitude is abnormally
small. Over the years, many studies examined ABR amplitude measures in retrocochlear disease.
A special case of an amplitude measure is the absence of wave V, which often occurs when
tumors are fairly large or the retrocochlear disease is extensive.
Limitations
In general, amplitude measures are successful in detecting large tumors that cause large
reductions in wave V amplitudes. However, the overall conclusion is that because of the high
variability of the simple wave V amplitude measure, it has power sensitivity to tumors than do
latency measure. There are several reason for the variable nature of simple amplitude measure
in general.
1. ABR electrical fields are weak. The magnitude of the electrical activity recorded at the
surface is very small, usually less than one microvolt (1 uV), because it originates from
auditory brainstem structures that are deep in the skull. The amplitude or strength of an
electrical field recorded at the surface of the head depends on to the distance and
orientation of the neural generators to the recording electrodes. Thus, individual variations
in the neuroanatomy and anatomy, for examples, head size, skull thickness, and skin
impedance, may affect amplitudes. In contrast, latencies are less affected by most of
these individual variables.
2. ABRs have poor signal-to-noise-ratios (S/Ns). Because the activity recorded at the surface
is very small, ABRs have poor S/Ns that is, low evoked potential amplitudes relative to the
amplitude of the physiologic background noise. Averaging a fixed numbers of sweep does
not guarantee that the residual noise in the average will be low enough for an accurate
measure of the true amplitude of the response peak. Clinically, traces with poor S/Ns have
produced major problems in identification of near-threshold responses and in reliable
measurements of the components of the ABR for otoneurologic or neurologic diagnosis.
Even after averaging, considerable residual noise may add to the response peaks and alter
their amplitudes. Thus, the uncertainties, inaccuracies, and failures that have occurred
both in research and clinical applications of the ABRs may be attributed, to a large degree,
to the influence of the variable residual background noise on ABR measures, particularly
wave V amplitude. As discussed in previous chapters, there are several techniques to
improve the S/N, such as filtering and averaging responses in the time domain. However,
even with these techniques, the amount of residual noise in the ABR average is usually not
controlled. In addition, the variable amount of residual noise in the average leads to
variable peak amplitudes even when stimulus conditions are identical.
3. Both the peak and trough must be identified. Amplitude measures typically require
identification of both the peak and the succeeding trough; latency measures require
identification of only the peak. While identification of the peak can be difficult at times,
trough identification can be equally problematic. Even when there is low residual noise in
the average, identifying the peak and trough can be difficult because of great variations in

waveform morphology. Therefore, amplitude measures are inherently more variable than
latency measures because an additional component, a trough, must also be identified.

4. Phase cancellation of neural elements can be significant. The biphasic nature of the
electrical neural activity means that, depending on the relative timing of activation, some
neural elements can phase cancel the activity of others. In addition, a condition that
causes a loss of phase-canceling neural activity could result in an increase in peak
amplitude. We mentioned earlier that, with broadband stimuli (e.g. clicks), phase
cancellations of field activity from more apical regions of the cochlea occur, so that the
resulting peaks in the response largely reflect activity from the most basal regions. In
addition, it has been demonstrated that the large amplitudes variations in the standard
ABR to click stimuli are mainly the result of irregularities in cochlear response time (the
degree of synchronization across the cochlea). Therefore, because of the variable amount
of synchronization and conduction time, but also differences in response times (transport
and filter build-up times) of the different parts of the cochlea that dominate and determine
the latency of wave I and V. It has been demonstrated that there is diferential cochlear
representation of waves I and V. Thus, it is not surprising that the I-V delay of standard
ABRs is affected by stimulus level and amount and configuration of hearing loss. The
effects of level, particularly for levels above 60 to 70 dB nHL, and hearing loss on the I-V
delay appear to be relatively small. Nonetheless, the differential cochlear representation of
waves I and V may, in some cases, confound the interpretation of the measured I-V delay.
True neural conduction time can be estimated with waves I and V only when both waves
represent activity initiated from the same place-specific region of the cochlear. A high-pass
masking technique to obtain derived-band ABRs initiated from place-specific areas of the
cochlea is discussed in detail later in this chapter. The I-V delay in the derivedband ABR
from a place-specific region of the cochlea is largely independent of stimulus intensity and
cochlear hearing loss, as well as frequency place in the cochlea. Because this true
interpeak delay from cochlear place-specific ABRs is relatively independent of stimulus
level and hearing loss, it avoids the problems of conductive and sensory hearing loss. Note
that the I-V delay from either standard or cochlear place-specific ABRs is gender
dependent, and reference norms for each gender must be stablished.
The fourth problem with the I-V standard ABR measure is that the intra-aural delay is
compared to a distribution of values obtained from non-tumor individuals. As with the
simple delay measure, the prolonged interpeak delay caused by a tumor may not exceed
the diagnostic criterion value if a patient normally has relatively short interpeak intervals.
Thus, false negatives will occur, resulting in decreased sensitivity. Similarly, non-tumor
individuals with normally long I-V intervals that exceed the diagnostic criterion will be
diagnosed as having a tumor, leading to false positives and decreased specificity. To
address these problems, the following measure has been suggested.
INTERAURAL COMPARISON OF INTERPEAK DELAYS
Description
This is the same interpeak I-V delay described in the third measure noted earlier, except the
interpeak reference is the patient`s nonsuspected ear rather than the average of a group of
normal-hearing individuals without tumors. Note that, even though the computed difference uses
patient`s nonsuspected ear, the determination of whether the difference is abnormal is still
based on a distribution of the differences observed between ears for non-tumor individuals.
Normally, the I-V delay is similar for both ears. This measure circumvents the problem with a
patient who normally has relatively short interpeak intervals. In these patients, the I-V delay from

the tumor ear may be within normal population limits but abnormally long with respect to the
nonsuspected ear. Moreover, non-tumor patients with normally long I-V delays will be correctly
identified because the inter-ear comparison will be normal. Thus, this I-V delay inter-ear
comparison has the potential of achieving better sensitivity and specificity than comparison with
the distribution of I-V delays from a population of non-tumors ears.

Limitations
The problems with this measure are the same as for the first three noted earlier for the interpeak
I-V delay. In addition, the problem of an abnormal reference ear noted with the IT5 measure also
applies. That is, in the rare cases involving bilateral tumors (i.e. NF2 patients), the I-V delay may
be prolonged on both sides, and the interaural interpeak measure may not detected either
tumor. Also this measure requires good identification of wave I peak latencies in responses from
not only one but both ears. As mentioned earlier, wave I peaks are often difficult to identify when
the patients have mid-to high-frequency hearing losses.
MISCELLANEOUS LATENCY MEASURES
Other latency measures, such as latency-intensity functions, have also been examined. We have
deliberately omitted a detailed review of these measures because they are less widely used,
have not proven to be as effective as some of the latency measures discussed earlier. And are
greatly affected by hearing loss. In fact, Bauch et al. (1996) claim that the best latency measures
for detecting a tumor are the IT5 and the I-V delay.
GENERAL SUMMARY OF LATENCY MEASURES
The main problem with all of these latency measures is that they often fail to detected small
(menor o igual 1.0 cm) acoustic tumors. ABR latencies are typically used in clinical applications
because they are robust and fairly easy to measure. By definition, a robust measure tends to be
insensitive to small perturbations. Thus, it is not too surprising that robust latency measures are
insensitive small neural perturbations caused by small tumors. A more detailed explanation of
this insensitivity to small tumors is presented later in the chapter.
AMPLITUDE MEASURES
Peak amplitudes of components in an ABR depend on two equally important aspects of neural
activity. First is the number of neural elements activated by the sound stimulus.