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Auditory Evoked Potentials

MAUD 203

Discovery of the Auditory Brainstem

Response
In 1970 and 1971, Don

Jewett and several colleagues

at the University of California
San Francisco published
classic papers describing how
brain activity was consistently
and noninvasively recorded in
humans in response to sounds.
The stimulus sounds were
very brief or transient sounds
like clicking sounds and short
portions of tones.

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Discovery of the Auditory Brainstem

Response
The tiny electrical response

from the brain is less than one

millionth of a volt.
The response is detected with
tiny metal discs connected to
wires attached to the scalp on
the top of the head or on the
forehead and also near the
ear.
The response was first
referred to as Jewett bumps.
Since 1979, it has been called
the auditory brainstem
response (ABR).

Invaluable beacause:
Highly consistent recordings
and almost identical from one
person to the next.
Response could be activated by
very rapid sounds
The ABR was clearly visible

when elicited with different

types of stimulation, including
clicking sounds and short bursts
of tones.

Sleep, sedation, or anesthesia

had no effect on the ABR, so

babies did not need to be
awake during testing.

Central Auditory Nervous System

Auditory Stimulation of the
cochlea produces an electrical
neural response at the level of
implicated structures

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Central Auditory Nervous System

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Anatomy and physiology

The ABR reflects activity of many auditory nerve fibers and

of pathways within the auditory brainstem.

The summed electrical activity from a sizable group of nerve
fibers firing together is picked up with detectors (electrodes)
located as far away as the scalp on the forehead and near the
ear.
Electrical responses to sound in the auditory nerve fibers and
in the brain stem must pass through brain tissue and the skull
to each the electrodes on the skin.

In summary
The ABR
Series of peaks and valleys which are referred to

as waves.
Waves represent activity in one or more regions
of the auditory system.
Major waves are waves I, III, and V.

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Anatomy and Physiology

Wave I arises from activity in

auditory nerve fibers,

particularly fibers in the distal
end of the auditory nerve
near the cochlea.
Wave III is produced by
combined activity from two
or three pathways in the pons
portion of the brain stem.
Wave V, the most prominent
wave, is generated in the
rostral midbrain portion of
the auditory brainstem.

Pediatric Clinical Applications of ABR

By the early 1980s,

audiologists at major
medical centers were
beginning to acquire
instrumentation allowing
them to record the
auditory brain stem
response for pediatric
hearing assessment and to
screen newborn infants for
hearing loss.

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Pediatric Clinical Applications of ABR

Early Identification and Diagnosis

of Hearing Loss in Infants
Automated ABR was first used in
the mid 80s

Adult Clinical Applications of ABR

Availability of equipment for

recording ABR in the clinic

contributed to exploration of
various uses in adult
populations as well as in
children.
In the late 1970s,
investigators from around the
world demonstrated that the
ABR was valuable for
assessment of patients with
various serious neurological
disorders and for detection of
tumors affecting the auditory
nerve.

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Clinical Applications

Screening

Threshold search
Neuro-Diagnostic

ABR Measurement: Stimulation

Transducer:
Insert earphones
Bone vibrator
Common stimuli for eliciting the ABR are:
Clicking sounds
Tone bursts

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ABR Measurement: Detection

Neural response is

extracted from other

general neural activity at
the scalp by:
Averaging
Filters
Common mode rejection

Why is ABR important in Hearing

Assessment of Children?
The Joint Committee on Infant Hearing (JCIH) guidelines

strongly recommend reliance on three objective techniques

for hearing assessment of infants and young children from
birth to 6 months:
Acoustic immittance measurements
Otoacoustic emissions
ABR

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AABR Screening
Average test time 2-5 minutes per ear.
Screening intensity: 35 dBnHL
Average screening time per baby is 20 minutes
Screening stimulus is the click

What Does an AABR PASS Look Like?

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What Does an AABR PASS Mean?

A PASS result indicates that
the babys hearing system is
responding normally, at the time
of the screening (to level of the
lower brainstem).
The infant likely has normal
hearing or hearing no poorer
than 30-35 dB, which is a level
required for speech and language
development.

What Does an AABR REFER Look

Like?

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What Does an AABR REFER Mean?

Further investigation is needed.
AABR rescreening and/or
Referral for diagnostic ABR

Any Benefits to AABR compared to OAE?

ABR screening is less sensitive to
middle ear debris than OAE
screening, resulting in lower referral
rates for diagnostic testing.

ABR measurements are sensitive to

neural auditory disorders (i.e.,
auditory neuropathy), which can often
be found in babies of a specialty-care
nursery.
Sensitivity (99%) / Specificity (96%)

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Maturation of Auditory System

Begins at the periphery
Adult like at birth - cochlea
Cortical regions may not mature until adolescence
Rapid maturation process within the 1st year of life

(morphology and latency)

Decreased latencies of waves III and V believed to be due to
decreased neural conduction time caused by completion of the
myelination in the proximal to distal direction in the CNS
Premature babies: reliability of click evoked stimulus improves
between 24 and 32 weeks GA; replicable wave V at age ~28wks
(=> unreliable AABR)

Age Normative Data

Because there are such pronounced changes
in ABR latencies during the first 2 years, it
is recommended that age specific normative
latency data be applied on a weekly basis
during the preterm period, biweekly during
the 3 month period from term, and at
monthly intervals until 18 to 24 months

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ABR Maturation

Waves I and III/V complex

dominate at birth
Morphology and latencies mature
by about 1 year of age

Estimating Auditory Thresholds

Currently, evidence based test

protocols permit accurate

estimating hearing thresholds
for different audiometric test
frequencies even in infants
within days after birth.
To objectively estimate auditory
thresholds in infants and young
children, the ABR is repeatedly
recorded at progressively lower
stimulus intensity levels for click
stimuli and for tone burst
stimuli at different frequencies.

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Estimating Auditory Thresholds

Three major changes in the
waveforms as stimulus
intensity level is decreased:
Latency of the waves

increases as stimulus intensity

level decreases
Amplitude of the waves
decreases as stimulus
intensity level decreases
Only wave V remains at the
lowest intensity level at which
an ABR is still present

Estimating Auditory Thresholds

A patients auditory threshold corresponds to the intensity

level where ABR wave V disappears.

Hearing threshold assessed by behavioral testing is about 10
dB lower than the minimum intensity level producing an ABR
wave V.
ABR threshold is measured for tone burst stimulation at
different frequencies such as 500 Hz, 1000, 2000 Hz, and/or
4000 Hz.

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Electrode Montage
3 or 4 electrodes depending

on 1 or 2 channels
For each recording: 3

electrodes:
Active (+) also non-inverting
Reference (-) also inverting
Common (ground)

Common mode rejection

Voltage is different between the active and reference

electrode
Voltage related to noise is similar at both electrodes and the
response voltage has the greatest difference
Both response are added
Common components are cancelled (biological or
environment)
Poor interelectrode impedance is a very important factor for
common mode rejection

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Time window
Latency of wave V:
Increased as the intensity of the stimulus decreases
Increased as we decrease in frequency (tone burst)
Increased for newborns (immature system)
Conductive hearing loss will shift all the latencies equally

25 msec for newborns

15 sec for children aged 1yr

Filter Settings
Filter band through which the physiologic

response is recorded from the electrodes

Set up to pass the signal of interest
Eliminating Physiologic noise
Unrelated muscle potentials
General physiological activity

Eliminating external noise

60 Hz, 50 Hz
Other equipment in the environment

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Click
Rapid onset
Short duration
Broad frequency spectrum
Can be generated in the cochlea from any good hearing

region, correlating best with high frequencies (1-4kHz)

Potentially may underestimate hearing thresholds when the
hearing loss is restricted to certain frequencies
Used in :
Screening
Neurodiagnostic testing

ABR Threshold Limitations- only using

clicks

The lowest click sound

producing waves on the ABR
tells you about hearing in the
1000 4000 Hz range on the
audiogram.
In the previous slide, the
lowest level that waves could
be seen was 45 dB.
You could expect symbols on
the audiogram to fall within
the 35 50 dB range in the
highlighted frequency range.

FREQUENCY IN HERTZ (Hz)

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HEARING LEVEL (dB HL)

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ABR Threshold Limitations- only using clicks

FREQUENCY IN HERTZ (Hz)

PROBLEM: Child should be in sleep

state. Older children require
sedation.

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Your child could have a FLAT

hearing loss.

Your child could have a RISING

hearing loss.

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PROBLEM: You do not have full

knowledge of what is happening at
frequencies outside of this range.

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HEARING LEVEL (dB HL)

Your child could have a SLOPING

hearing loss.

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Tone Burst
Advantage of being frequency specific
Estimates pure tone threshold
Helps in the Hearing amplification decision making process

Used in:
Threshold estimation testing

Preferred setting is 2-0-2

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Polarity
Onset phase of the stimulus
Rarefaction:

Use rarefaction then

condensation with clicks
and look for cochlear
microphonic:
Audiotory neurpathy

Starts by an inward movement of the diaphragm

=> negative onset pressure in the ear canal
=> initial upward movement of the basilar membrane

Leads to an enhancement of the ABR amplitude (wave I & V)

Condensation : opposing process
Alternating:
Usually used with tone bursts as it helps in cancelling the stimulus
artifact

Testing environment
Preamplifiers should be as far as possible from electrical

interference
monitor,
Transformers
Transducer (advantage of ER-3A)
Cell phones
Fluorescent light
Use a designated unshared plug

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Preparing you patient

Make sure the child is sleeping during the session (and not

before)
Make sure you have good impedance:
5 kOhms , and interimpedance +/- 2
Sedation may be needed for older children (4months +) or
for difficult to test children
Chloral hydrate widely used in clinics performing ABR under
sedation.
Prepare everything before you start. Try not to move the
baby after you start testing
ER-3A is the transducer of choice for AC

Criteria for present response

Response:
Repeatable
Look like a typical response
Follow the typical pattern of intensity change:
Decreased intensity= latency is longer
Decreased intensity = amplitude is smaller
Absolute latencies should follow appropriate normative data
Amplitude should be larger than background noise

Threshold :
Lowest intensity where response is present
no response at intensity below where threshold is determined
Absent response must be low in amplitude (eliminating the chance of

a buried response)

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ABR Latency Analysis

Calculations:
Latency of a wave is the
time interval from the
presentation of the
stimulus to the occurrence
of a wave.
Amplitude is calculated as
the size of the wave in
microVolts (mV) from its
peak to the valley that
occurs before or after the
peak.

Threshold Estimation
Close agreement between ABR and Pure tone threshold, but

they are not the same!

Studies with normal hearing infants:

20 dB nHL or lower : 52 and 98% had toneburst at 500 and

2000 Hz
92% of children with normal hearing had 500 Hz threshold at
30 dB n HL or lower
500 Hz
2000 Hz
30-40 dB nHL

20-30 dB nHL

Tone bursts ABR are agreed to be within 5-10 dB from

audiometric thresholds

Closer agreement when hearing loss is moderate or more, it is

not a 1 to 1 relationship!

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Decrease intensity level to

Reach Threshold

Compare Wave V Latency/ABR Threshold

with Norms (> 18 months of age)
ABR CLICK-EVOKED RESULTS

WAVE V LATENCY (ms)

ABR THRESHOLD (dB HL)

ABR TONE-BURST AUDIOGRAM

FREQUENCY (Hz)

INTENSITY (dB nHL)

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ABR Threshold Testing: Wave V LatencyIntensity Functions

ABR Threshold Testing: Wave V LatencyIntensity Functions

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ABR Threshold Testing: Wave V LatencyIntensity Functions

ABR Threshold Determination: Normal

Judge morphology
& latencies here

WAVE V LATENCY (ms)

CLICK-EVOKED ABR

Determine lowest
Repeatable wave here`
0

6 7

WAVE V LATENCY (ms)

Plot Wave V latencies

here

INTENSITY (dB nHL)

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CASE 3: Severe-Profound SNHL

FREQUENCY IN HERTZ (Hz)

-10

L: 100 dB

L: 95 dB

HEARING LEVEL IN dBHL (re: ANSI S3.6 1989)

L: 103 dB

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WAVE V LATENCY (ms)

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Bone Conduction ABR

A detected hearing loss in AC warrants further investigation with

BC ABR
Greater interaural attenuation compared to adults or older
children
Usually with conductive hearing loss there is a complete shift of all
the waves
Best placement: supero-posterior high on mastoid
Headband is used to attach the bone vibrator
As far as possible from electrode
Handheld (one finger pressing) is an option , but constant pressure
should be maintained
2 channels with recording of the contralateral waves is
recommended (expect to see large ipsi wave V)

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Tips
Add waveforms to improve waveform quality, repeat at

threshold levels
Take very special care of reusable electrodes or use disposable
ones
Braid electrodes
Place electrodes low on mastoid
Use vertex for non inverting electrode to get larger wave
If possible use 4 electrodes
Use masking when using high intensity stimulus level
Use an external amplifier

Clinically invaluable but

ABR is essential for describing both

the degree and type of hearing loss

in infants and young children.
ABR findings lead directly to early
intervention for hearing loss.
Early intervention of hearing loss in
children (before 6 months after
birth) is critical to increase the
chances of normal development of
speech, language, and effective
communication.

Not a hearing test:

ABR does not reflect activity of all
types of neurons in the auditory
system.
ABR primarily reflects activity of
the nerve fibers, not the many
collections of nerve cell bodies
within the auditory system.
With Wave I as an exception, there
is not a one-to-one relation
between a single auditory structure
and a single ABR wave.
ABR provides no information on
auditory structures above the level
of the brainstem.

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