Asha - Bera

Relevant
Relevant Paper Short Latency Auditory Evoked Potentials Tutorial Paper 1987 / II - 335
Short Latency
Auditory Evoked Potentials
Audiologic Evaluation Working Group on

Auditory Evoked Potential Measurements
Introduction recorded, and their sensitivity to dysfunctions of the

peripheral and brainstem auditory systems make them
Background well-suited for clinical application. However, clinical
The Working Group on Auditory Evoked Poten- application of AEP measurements requires an under-
tial Measurements was constituted (a) to review evi- standing of some procedural and subject variables.
dence and elevate the degree of consensus existing The short latency potentials are small amplitude,
with respect to the procedural variables and instrumen- far field potentials; that is, they are recorded at some
tation in the application of auditory sensitivity and (b) distance from their sources. Sophisticated techniques
to provide a report that is highly specific in nature and are needed to measure these potentials because they
intended to be a state-of-the-science update about meth- are buried in a background of physical and physiologi-
odology. cal noise. Additionally, variables such as the subjects
In partial response to this mandate, the working age, gender, and core temperature and the status of the
group elected to develop a basic overview or tutorial outer, middle, and inner ears may predictably affect
focused on the short latency auditory evoked poten- these responses. The ways in which these factors in-
tials (AEPs). This class of AEPs encompasses the ar- fluence the measurement, analysis, and/or interpre-
eas of electrocochleography (ECochG) and auditory tation of the short latency potentials are discussed in
brainstem response (ABR) measurement. These poten- this report.
tials represent sensory or neural responses from lower The intent of this document is not to mandate a
levels of the auditory system. The term latency is used set of standards for the measurement and evaluation
to describe the time of occurrence of a given potential of short latency AEPs. Rather the objective is to present
that, for these potentials, generally falls within 10 ms a background of information that the working group
of stimulus onset. This restriction in scope was made believes to be requisite for a basic understanding of
in view of the voluminous literature that has developed these measures. The audiologist wishing to enter this
concerning the short latency potentials. Although area of clinical study is encouraged to take appropri-
rapid expansion of information continues, basic prin- ate courses and seek supervised clinical experiences.
ciples can be drawn from research and clinical experi- Additionally, several texts on this topic have appeared
ence with these potentials. that may be useful references (see Glattke, 1983; Hood
Scope & Berlin, 1986; Jacobson, 1985; Moore, 1983).
Short latency AEPs are popular for the The tutorial is divided into three major sections.
electrophysiologic assessment of otology and neuro- The first, InstrumentationBasic Principles, presents
logic impairment. The stability of these potentials over instrumentation for both the stimulus generation and
subject state, the relative ease with which they may be the recording and analysis methods that are common
to noninvasive ECochG and ABR measurement. The
second section, Electrocochleography, details the re-
Reference this material as: American Speech-Language- cording, stimulus, and subject variables relevant to this
Hearing Association. (1987). Short latency auditory evoked topic. These sections purposefully precede the specific
potentials. Rockville, MD: Author. treatment of the Measurement of Auditory Brainstem
Index terms: Audiology, electrocochleograpy, hearing as- Evoked Potentials (the last section) because the infor-
sessment, otoacoustic emissions, physiologic measures mation in the first two sections is basic to an under-
Document type: Tutorials
II - 336 / 1987 ASHA 2002 Desk Reference Volume 2 Audiology
standing of the brainstem potentials. The reader is a silver-silver chloride (Ag-AgCl) electrode, which has
urged strongly to read this document from beginning an even lower impedance but requires rechloriding on
to end because each section proceeds on the assump- a regular basis. Unlike electrodes made of silver or
tion that previous sections have been read and under- other pure metals or alloys, the Ag-AgCl electrode is
stood. reversible or nonpolarized. This means that it can be
used to record (or pass) direct current (dc) and thus
InstrumentationBasic Principles performs well at very low frequencies. Impedance is
also lowest when the electrode makes direct contact
An understanding of how evoked potentials (EPs) with body fluids, even just under the skins surface.
are recorded and analyzed requires the grasp of cer- Needle electrodes provide such contact but are not at-
tain principles of instrumentation. Some of these con- tractive for routine clinical work because the skin must
cepts are addressed in the sections that follow. be punctured.
Electrodes and Electrode Impedance Good electrical contact can be achieved using sur-
The human body is a field of ongoing electrical face electrodes. The skin must be cleansed thoroughly
activity. The sources of this activity may include muscle to remove dirt, oil, and superficial dead skin. An elec-
contractions, sensory end organ responses, and neu- trolyte gel, paste, or cream is applied to improve the
ral events from the central and peripheral nervous conductivity of the dead skin layer, give contact sta-
system. These electrical events are often conducted to bility, and effectively increase the electrode surface
the bodys surface in an attenuated form and may be area. Numerous techniques for achieving low imped-
recorded using appropriate methods and equipment. ances are found in texts in electroencephalography
However, it is difficult to measure the AEPs because (EEG; e.g., Binnie, Rowan, & Gutter, 1982).
they are small in amplitude and buried in a back- Interelectrode impedances, which are the impedances
ground of electrical noise. Added to these problems are between each possible pair of electrodes, should be
the electrically insulative characteristics of the skin, measured routinely and, as a rule, should not exceed
particularly the outermost layer, the corneum stratum 5 kohms.
or the dead skin layer. There also is a fundamental Analysis
difference between biological and physical electricity.
In physical systems, electrical current is mediated via The amplitude of surface-recorded AEPs is small
electrons, whereas in biological systems it is mediated in relation to the amplitude of background electro-
via ions, that is, atoms/molecules with a net positive physiological activity and electrical noise; therefore,
or negative valence. Applying an electrode, a metal it is necessary to improve the signal-to-noise ratio
conductor, to the skin constitutes a barrier over which (SNR). Routine EP evaluations have become possible
there can be no net charge transfer. Such an interface primarily through the advent and availability of rela-
opposes, or impedes, current flow. Impedance varies tively small and inexpensive digital computers that
with frequency: in the present context the impedance can efficiently perform signal averaging. Computer-
varies inversely with frequency because the electrode- ized signal averaging reduces the background noise
skin interface acts like a capacitor (Geddes, 1972). For and the variance in the sound-elicited potential. The
applications discussed in this tutorial, impedance is recorded signal, which is a continuous function of
generally assessed at one frequency within the range time, is represented as an ensemble of discrete samples
of approximately 101000 Hz. to the computer, as illustrated in Figure la. The sam-
pling of the signal is accomplished through a process
Electrode impedance is a product of the electrode known as analog-to-digital (A-D) conversion, wherein
material and surface area, the skin, muscle, or mucosa the amplitude of the signal at a given point in time is
to which it is interfaced and anything in between (e.g., translated into a binary value that can be manipulated
oil, dirt, fluid, etc.). Silver, gold, and platinum have by the computer.
lower impedances and half-cell potentials than most
other metals. The half-cell potential is a voltage that The accuracy with which a computer represents
results from the tendency for charge to build up on the fine structure, and therefore frequency content, is
each side of the electrode interface, much as the elec- determined, in part, by the number of sampled points
trode of a battery. The half-cell potential will be desta- on the waveform (see Figures la and 1b). This number
bilized by mechanical movement, so a large half-cell depends on the maximum sampling rate of the A-D
potential makes the recording of bioelectric potentials conversion process, which is inversely related to how
much more vulnerable to movement artifact. Silver is long each conversion takes. The amount of time re-
an especially useful material for constructing elec- quired for the A-D converter and computer to sample
trodes because it also can be plated with salt, forming each point is called the dwell time. The sampling rate
Relevant Paper Short Latency Auditory Evoked Potentials Tutorial 1987 / II - 337
Figure 1. (a) Digital sampling and reconstruction of an analog signal. (b) Reconstructed signal sampled at twice
the rate as in (a). From Instrumentation by A.C. Coats, 1983, in E.J. Moore (Ed.), Bases of auditory brainstem evoked
responses (p. 210211). New York: Grune & Stratton. Copyright 1983 by Grune & Stratton. Adapted by permission.
thus determines directly the temporal resolution of the Signal averaging is necessary because the AEPs
waveform. must be extracted from much larger background noise.
Amplitude resolution depends on the numeric Poor SNR is overcome by summing numerous digi-
precision of the A-D converter, which is specified by tized wave forms, each timed-locked to the stimulus.
the number of bits or places in the binary number rep- Synchronous events that are time-locked to the stimu-
resenting its full-scale range of sensitivity. For example, lus should have like phases and thus will summate
suppose a 4-bit A-D converter were used to measure and grow out of the noise background. Any events
the voltage of a common flashlight battery, and that that are not time-locked to the stimulus (i.e., most of
this A-D converter had a sensitivity of 5 V. The volt- the background noise) will have randomly varying
age of a flashlight battery is 1.5 V. Converted from bi- phases (from epoch to epoch) and will tend to cancel
nary to decimal, the numbers that are available to out, leaving only the time-locked signal (waveform).
represent the measured voltages fall within the range The improvement in SNR is proportional to the square
of 0 to 15 (i.e., from no bits set to all bits set), as shown root of the number of samples that are summed (aver-
in Table 1. The actual voltage of the battery does not aged) (Picton & Hink, 1974). Thus, increasing the num-
fall exactly at an integer value, but neither does 0 V. ber of samples by a factor of 4 will increase the SNR by
This A-D converter therefore could only approximate a factor of 4 = 2. One of the limiting factors for SNR
the actual binary equivalent of the voltage, and any improvement is the precision of the A-D conversion.
voltages falling between - 0.33 V and + 0.33 V would Eight-bit resolution appears to be adequate for most
be represented as 0.
Table 1. Amplitude resolution of a four-bit A-D con- invert (+) the signal at the amplifiers output. The
verter. amplified signal is the difference between the two in-
Binary Decimal Voltage puts; specifically this signal is the algebraic difference
between the two inputs at each instant in time. Any
signal common to both inputs therefore is canceled or
1111 15 + 5.00 rejected; this is known as common mode rejection
1110 14 + 4.33 (CMR). Each channel of recording requires one elec-
trode as a ground and two electrodes to pick up the
1101 13 + 3.67 desired potential. All three electrodes generally are
1100 12 + 3.00 placed on the head for EP recordings. Most myogenic
1011 11 + 2.33 artifacts and extraneous electrical noises will appear
at the two electrode sites with nearly equal amplitudes
1010 10 + 1.67 and phases because of their proximity and therefore
1001 9 + 1.00 will be rejected. Other signals will not be rejected and,
1000 8 + 0.33 indeed, may be enhanced, as illustrated by Figure 2.
Common mode signals may be larger than differential
0111 7 - 0.33 signals, depending on the electrode location relative
0110 6 - 1.00 to the location and orientation of the source of the de-
0101 5 - 1.67 sired potential. The details of electrode placement will
be discussed later within the context of specific test
0100 4 - 2.33 procedures.
0011 3 - 3.00 There are several specifications of the amplifier
0010 2 - 3.67 (sometimes referred to as a preamplifier) that are im-
0001 1 - 4.33 portant. One is amount of CMR, which usually is speci-
fied in decibels and is defined as the amount of
0000 0 - 5.00 amplitude reduction of common signals. Commer-
cially available bioelectric amplifiers are capable of
CMRs of 80120 dB, which is sufficient for EP measure-
evoked potential measurements. Current commercial
ments. It cannot always be assumed, however, that the
test instruments employ 812-bit converters.
amplifier is properly adjusted to permit this amount
Amplification of CMR, and an occasional check and perhaps read-
justment (as per the manufacturers recommendation)
The small amplitude of surface-recorded EPs ne-
are required. Although CMR is dependent on the bal-
cessitates the use of amplification prior to signal aver-
ance between electrodes, if electrode impedances are
aging. The objective is not only to amplify the recorded
less than 5 kohms, then concerns for balance are re-
potentials, but also to optimize the voltage sampling
duced because of the high input impedance of differ-
for the desired potential while rejecting unwanted sig-
ential amplifiers. The input impedance should be a
nals common to each of the amplifier inputs. This prin-
minimum of 1 Mohm, so as not to draw any signifi-
ciple is illustrated in Figure 2. The differential amplifier
cant amount of current from the electrodes.
has one input that inverts (-) and one that does not
The gain of the amplifier depends on the full-scale
voltage range of the A-D converter and minimum volt-
age input requirements. Typical gain values for
evoked response systems range from 10,000 to 500,000.
The objective is to present the A-D converter with a
signal whose voltage is nearly full scale. For example,
if an A-D converter were used with a 5 V range (i.e.,
10 V full scale) and the recorded signal (including
background noise) were 10 V (0.00001 V) peak to peak,
then a gain of approximately 100,000 (i.e., 10/0.00001)
would be needed.
Figure 2. Differential amplification. The high-fre-
All electrical circuits create some thermal noise,
quency signal is common mode (same amplitude and
and this noise may be amplified. Internal noise should
phase at the two inputs) and is rejected. In contrast,
be below 10 V peak-to-peak to maximize SNR im-
the low-frequency signal is of opposite phase and is
provement achieved by signal averaging. The ampli-
enhanced.
fier also should be able to withstand the accidental oc- and tend to make the recordings vulnerable to move-
currence of relatively high voltages across its inputs, ment artifacts. The front-end differential amplifier is
or overvoltaging, and it should be able to recover ex- dc coupled, so the filtering or ac coupling is done at a
pediently. A certain amount of mishandling of the am- later stage of amplification. Consequently, care must
plifier is inevitable in clinical situations. One example be exercised to minimize the presence of large dc or very
is removing the electrodes from the subject before dis- low frequency ac potentials at the amplifiers inputs.
connecting them and thereby turning the electrode This can be accomplished by using proper skin prepa-
leads into antennae for electrical noise from the lights ration, using large-surfaced and reversible electrodes
and wiring in the test area. The amplifier should be able to keep impedances low, and minimizing electrode
to take such abuse without electronic failure. movement.
Overvoltaging reflects amplifier saturation. Therefore, Low pass filtering is needed because high fre-
it is important that overvoltaging not occur during re- quency noise can be superimposed on the tracing and
sponse averaging because this form of nonlinear am- can obscure peak EP identification. The use of low
plification can affect the signal averaging process. pass filtering also is determined by the sampling rate
Techniques such as artifact rejection suspend averag- of the A-D converter. Consequently, there is an upper
ing during overvoltaging and the subsequent recovery frequency limit for the allowable spectrum of the sig-
period. Finally, baseline (dc) drift should be negligible nal being processed. If this frequency is exceeded, there
to ensure stability over long test sessions. is wraparound or aliasing of the signals spectrum, in
All of these specifications are readily met by mod- which frequencies above a certain frequency are rep-
ern bioelectric amplifiers. However, manufacturers of resented as lower frequencies in a predictable manner.
EP test equipment provide few protocols for checking Because there must be at least two sample points to
these parameters and typically do not give amplifier define a cycle of a waveform, the upper limit of permis-
specifications in their manuals. sible frequencies is one-half the sampling rate of the
A-D conversion (e.g., 5000 Hz if the sampling rate is
Filtering
10000 Hz). The highest permissible frequency is called
The spectra of most EPs are concentrated such that the Nyquist frequency (Nyquist, 1924). For example, a
much of the background noise can be removed via fil- complex tone made up of 3000 Hz and 6000 Hz will
tering. Filtering can be done before and/or after the appear to be made up of 3000 Hz and 4000 Hz compo-
signal averaging, but some prefiltering usually is in- nents if the sampling rate is 10000 Hz (Nyquist fre-
corporated in the (pre)amplification process, prior to quency is 5000 Hz). This occurs because 6000 Hz
averaging. Filtering must be applied judiciously and exceeds the Nyquist frequency and is represented at
with knowledge that it may distort the waveform of the its aliasing frequency of 4000 Hz (this is the difference
desired potential and may influence latency and am- between the sampling rate and the true frequency to
plitude measurements. Analog filtering introduces be analyzed or 10000 Hz minus 6000 Hz). In practice
phase shifts that become increasingly severe as the it is necessary to be even more conservative if the ac-
cutoff frequency of the filter approaches the lower fre- tual waveform is to be adequately reproduced, as is the
quency limits of the spectrum of the potential. Not all case in evoked response work. An upper limit of less
components of a recorded potential are optimally fil- than or equal to one-half the Nyquist frequency or one-
tered using the same filter settings and/or response fourth the sampling rate (in the above example, - 2500
characteristics of the filter. Conversely, not all poten- Hz) is more appropriate (Picton & Hink, 1974).
tials or components are affected in the same manner
Some high frequency noise is likely to remain, even
by a given filter response. In some recording amplifi-
with low-pass filtering. This may be treated via some
ers a single-stage (single-pole), passive (resistance-ca-
form of post filtering or smoothing, which is a form of
pacitance) filter is used that provides a rejection slope
low pass filtering. Many signal averaging systems pro-
of 6 dB/octave. Others may have two or more stages
vide some type of smoothing function. The most com-
and/or utilize one of various active filter circuits to
mon approach is the sliding average in which each
provide other response characteristics and/or higher
point is averaged with one or more adjacent points.
rejection slopes. The cutoff frequency generally is speci-
Care must be taken that the smoothing algorithm itself
fied at the half-power point of the filters response,
does not cause time delays or that such delays are cor-
which is the frequency at which the filters response
rectable. In general, digital filtering provides more pre-
is 3 dB down from its maximum response.
cise filter skirts and zero phase shift, minimizing the
It is desirable to high-pass filter, or ac couple, to problems associated with analog filtering and certain
eliminate very low frequency and dc potentials. These smoothing algorithms. Although digital filtering has
potentials cause drift in the baseline of the recording become more widely available, many instruments still
utilize a combination of analog filtering and digital which it is applied, however, may alter the acoustics
smoothing. of the earphone.
Artifact Rejection A particularly effective way to reduce stimulus
artifacts was described by Sohmer and Pratt (1976), in
Recording a well-defined response depends on the
which a tube is used to couple the earphone to the
initial SNR, the number of samples averaged, and the
subjects ear and thereby create an acoustic delay line.
extent to which the noise background is truly random.
There has been a growing interest in the use of certain
It is possible that an event will occur during averag-
types of insert earphones, which provide the advan-
ing that may not be canceled by a clinically practical
tage of the delay line effect (e.g., see Clemis, Ballad, &
number of samples. For example, an incidental swal-
Killion, 1986). There now are commercially available
low can create a large electromyogenic artifact that
insert earphones with output characteristics similar to
may not be averaged out. Signal averaging can provide
the Telephonics TDH-39 earphone. The transducer
substantial noise reduction, even with the occurrence
unit is positioned away from the ear, and the sound is
of such incidental fluctuations in the noise back-
directed through a flexible plastic tube that is coupled
ground; however, it generally is best to exclude unusu-
to the ear canal with an earplug. The delay imposed
ally large amplitude noise samples.
by the tube must be taken into account when determin-
Many artifacts encountered in EP recordings are ing absolute response latencies, in order to obtain val-
sufficiently large in relation to the desired potential that ues consistent with those obtained with conventional
they can be excluded on the basis of their amplitude. earphones. Latencies obtained with this type of insert
Most commercially available test systems include the earphone will be several tenths of a millisecond or
capability of specifying an acceptable input amplitude more longer than those observed from responses stimu-
window or adjusting the input sensitivity while test- lated via conventional earphones. Insert earphones
ing for samples exceeding full scale. Artifact rejection have the added advantages of increased comfort and
schemes are most effective in eliminating samples con- more interaural attenuation, reducing the need for
taining incidental voltage spikes but are relatively in- masking of the nontest ear.
effective in dealing with continuously high levels of
Interference from 60 Hz noise can be minimized
noise. Increasing the threshold for artifact rejection or
by choosing stimulus rates such that the interstimulus
reducing the amplifier gain merely admits more noise
interval equals an odd multiple of one-half the period
without improving the SNR because the SNR is essen-
of 60 Hz (i.e., 8.333 msec). For example, at 17 stimuli
tially unchanged.
per second, the interstimulus interval = 1/17 = 58.8 ms
Shielding and Related Issues ~ 7 x 8.333 ms. Similarly, stimulus artifact can be re-
The amplification required for the recording of the duced by presenting stimuli of alternating polarity/
short latency and other AEPs makes it easy to pick up phase or randomly varying phases. Some caution must
extraneous electrical noises via electrostatic and/or be exercised in applying this method in that, if there is
electromagnetic coupling. The former is exemplified by distortion in the stimulus artifact, cancellation will not
the reception of 60 Hz noise from a fluorescent light, be complete. Cancellation using alternating phases
and the latter is exemplified by reception of 60 Hz noise also can obscure potentials that may be desired. Fi-
induced in the amplifier circuit by radiation from a nally, some commercial instruments provide the pos-
power transformer, electrical machinery, or electrical sibility of zeroing the initial part of the response
wiring around the test room. Electromagnetic fields tracing in which the artifact is prominent. This can
also are created by earphones and similar transduc- minimize the effects of stimulus artifacts on response
ers, and are the most prominent source of stimulus scaling but does not eliminate artifacts or their effects
artifact. Precautions to minimize such artifacts include on the quality of the recorded responses.
the careful separation of the earphone wires from the Proper electrical wiring of the sound production
electrode wires, draping the electrode leads close to the and response recording systems is important, not only
subjects body, braiding and/or shielding electrode to minimize electrical artifacts but also to minimize
leads, and making the electrode leads as short as prac- electrical hazards (Pfeiffer, 1974). Evoked response test
tical. equipment should be evaluated for electrical safety in
Earphones can be electromagnetically shielded accordance with published standards (e.g., Joint Com-
using one or more layers of mu-metal (Elberling & mission on Accreditation of Hospitals, 1987). An EP
Salomon, 1973), a material that tends to encourage the system should never be used without an intact three-
cancellation of the magnetic field. It also provides elec- pronged, hospital-grade line plug, nor should it be
trostatic shielding if it is grounded. The manner in plugged into an electrical outlet not known to be free
of ground faults. The use of a three- to two-prong
adapter is unacceptable. The test instrument and out-

let to which it is connected should be checked by a
qualified electrician or electrical safety officer. The use
of faulty equipment, faulty wiring, or improper
grounding must be avoided.
Consideration must be given to the location of
evoked response testing, both with regard to electrical
and acoustical shielding. A metal sound isolation
chamber, designed especially for electromagnetic and
electrostatic shielding, is ideal but not essential in ev-
ery situation. The need depends on the electrical and
acoustical environment. Because testing is usually
done under earphones, a quiet office may prove ad-
equate for some applications (e.g., otoneurologic evalu-
ations involving only high level stimulation).
Outputting Data
The final determinant of the fidelity with which
the waveform of the EP is reproduced depends on the
manner in which the data are plotted. In the case of
digital plotters, wherein the X and Y coordinates are
changed in steps, the reproduction will be true to the
form of the digitized wave, except that there will always
be a slightly jagged character in the detail of the wave-
form due to the stepping action of the pen (somewhat
like the waveform shown in Figure lb). The smoothness
of the tracing will depend on the resolution associated
with the analysis, the rate at which the plotter works,
and instrument characteristics that are rarely under
user control.
The outputting of data via analog devices, such as
the X-Y plotter, requires digital-to-analog (D-A) con-
version of the data in the computers memory. Some of
the same considerations given to A-D conversions
apply to D-A conversion although, in practice, the de-
mands are much less in terms of dwell time and reso- Figure 3. (a.1) Acoustic output of an earphone
lution. (Telephonics TDH-39) in response to direct current
pulses applied to the earphone input, producing clicks
Sound Stimulation initiated by condensation (con.) or rarefaction (rar.)
Spectrum: Clicks Versus Tone Bursts. Temporally phases. (a.2) Spectrum of the acoustic output, that is the
concise stimuli result in synchronized neural dis- click (solid line), versus the electrical pulse (dashed line)
charges and robust EPs. Unfortunately, temporal driving the earphone. From Fundamentals of Sound
specificity of the stimulus is achieved at the expense Generation by J.D. Durrant, in E.J. Moore (Ed.), Basis
of frequency specificity. A click is a sound obtained by of auditory brainstem evoked responses (p. 31). New York:
applying a dc pulse to an earphone or loudspeaker Grune & Stratton. Copyright 1983 by Grune & Stratton.
(Figure 3a.1), and it provides an excellent stimulus for Adapted by permission. (b) Spectrum of a brief tone
eliciting the short latency potentials. Its abrupt onset burst, showing main central lobe sidebands.
and brief duration contribute to good synchronization,
minimize stimulus artifact, and provide a broad spec-
trum that stimulates many nerve fibers. However, the
When frequency specificity is desired, sinusoidal
frequency response of earphones may alter the spec-
pulses (tone pips or bursts) or band-pass filtered clicks
trum of a dc pulse (Figure 3a.2). The auditory system
may be used. Because such stimuli are transients, their
itself also filters the stimulus. Thus, there always are
spectra are characterized by energy spread around the
frequency limits imposed on the click-evoked poten-
nominal or center frequency (Figure 3b). Sinusoidal
tial (Durrant, 1983).
pulses produce short latency potentials whose laten- significantly affect the short latency potentials, but rates
cies vary as a function of frequency (for a given inten- of 20/second or more are often satisfactory for clinical
sity), reflecting somewhat the traveling wave purposes. Higher rates improve efficiency of data col-
propagation time in the cochlea (Naunton & Zerlin, lection but jeopardize the identification of a response
1976). Visual detection levels (VDLs) of the auditory or certain component waves of the EP, particularly in
nerve and brainstem potentials elicited by filtered some pathological cases. Because there are effects of
clicks and brief tone bursts correlate reasonably well increasing repetition rate specific to each of the short
with audiometric thresholds at frequencies at and latency potentials, further discussion will be reserved
above 500 Hz. This agreement adds credibility to the for later.
assumption that the appropriate frequency region of Stimulus Calibration. Calibration of the test stimu-
the cochlea is generating the response. lus is an integral part of evoked response evaluation.
There are some difficulties with the use of sinusoi- The intensity of a click is frequently reported in dBnHL,
dal pulses or filtered clicks. First, there may be a broad which is the number of decibels above the behavioral
excitation pattern in the cochlea at high stimulus lev- threshold of a group of normal listeners. (Note: this
els (Bekesy, 1960; Durrant, Gabriel, & Walter, 1981). measure has been referred to variably in the literature
This is true also for steady state sinusoids, gated sinu- as nHL, HL, nSL, or SL.) Although the nHL can serve
soids, and clicks. Second, there is still an intensity as a useful clinical reference, it does not provide a
dependent latency shift, just as in the case of broad- physical measurement of intensity that permits checks
band click stimulation, reflecting the basalward spread of stimulus output or comparisons across clinics. Cali-
of excitation at higher intensities (Folsom, 1984). Third, bration procedures are difficult because of the tran-
the shift in latency with frequency reflects, in part, a sient nature of the stimuli employed. Sound level
change in the rise time of the stimulus (e.g., longer at meters typically used for audiometric calibration re-
lower frequencies). Fourth, there is a greater chance of quire long duration signals for accurate measurement.
contamination from stimulus artifact with these longer Different techniques must be utilized to measure the
stimuli compared to the click. Finally, the amplitudes amplitude of brief stimuli.
of short latency EPs diminish and the waveform is less Although no standard calibration procedure ex-
sharply defined as the frequency of the stimulus de- ists for clicks and other transients, a popular approach
creases, especially below 1000 Hz. is to determine the peak equivalent sound pressure
Temporal Factors. There are various temporal pa- level (peSPL). This measurement is obtained by using
rameters associated with stimulation, particularly an oscilloscope to match the amplitude of a sine wave
with regard to the use of tone bursts. These include with the peak amplitude of the click stimulus. The
plateau duration, rise/fall duration, and the gating or amplitude of the long duration pure tone can then be
windowing function by which the amplitude envelope measured on a sound level meter. Stapells, Picton, and
of the sinusoid is shaped (e.g., rectangular, cosine, Smith (1982) showed that 0 dBnHL for clicks occurs at
logon, etc.). The short latency potentials are relatively approximately 30 dB peSPL. An alternative procedure
insensitive to the plateau duration of the stimulus be- is to use a sound level meter that can capture transients
cause they are largely onset responses. The rise-fall such as clicks.
duration, however, does affect these responses. Gen- Stimulus polarity does not affect the amplitude
erally speaking, the slower the rise time, the lower the spectrum (Figure 3a), but it can affect the short latency
amplitude and the longer the latency of the evoked potentials. Therefore, it is essential to measure the start-
response. The resulting changes in the EPs presum- ing phase of the signal to determine whether the stimu-
ably are the result of decreased synchronization of lus begins with condensation or rarefaction (Figure
discharges to stimulus onset, the concomitant decrease 3a.1). The phase of the stimulus can be examined by
in stimulus amplitude near the instant of onset, and connecting the output of a sound level meter to an os-
the narrower bandwidth of the stimulus as stimulus cilloscope and comparing the phase of the stimulus to
rise time is increased. The shape of the gating function a known pressure change (Cann & Knott, 1979).
also influences the stimulus spectrum, and some func-
tions result in greater concentration of energy than The spectrum of the stimulus should be measured
others in the main spectral lobe and lower energy in if the instrumentation is available. The temporal fea-
the sidebands (Harris, 1978; Nuttall, 1981). tures of the stimulus waveform also should be exam-
ined. The transient response of an earphone should be
Stimulus repetition rate is also an important pa- characterized by minimal ringing (i.e., minimal over-
rameter. The repetition rate of the stimulus must be shoots at the onset and offset of the stimulus). The
slow enough to prevent significant adaptation of the waveform should be scrutinized for changes that may
response. Repetition rates of 10/second or less do not occur over time, especially with an earphone that may
have been dropped or otherwise abused. To ensure necessarily imply solely sensorineural impairment; a
comparable acoustic stimuli to each ear, the two ear- moderate or more severe degree of mixed loss might be
phones should create stimuli of nearly identical wave involved. Conversely, due to the low frequency empha-
forms. Again, such observations can be made with the sis of the bone conduction click, a conductive lesion
aid of a sound level meter coupled to an oscilloscope. could be erroneously deduced when, in fact, there is a
If an oscilloscope is not available, then the signal av- precipitously sloping high frequency loss. However,
eraging system can be used (Weber, Seitz, & this problem can be vitiated with the use of
McCutcheon, 1981). tympanometry, acoustic reflexes, and the measure-
Finally, when determining hearing levels, the psy- ment of Wave I latency.
chophysical method for threshold measurement and There is one other problem with existing bone vi-
number and rate of stimulus presentations are impor- brators. Like the conventional earphone, the bone vi-
tant factors. The integrity of the hearing of the norma- brator is an electromagnetic device and therefore emits
tive group sample must be affirmed. All of these factors electromagnetic waves, causing stimulus artifact. The
should be documented and referenced in the hearing bone vibrator is actually a worse offender due to its
level specification until such time that a national stan- lower efficiency (i.e., a higher voltage driving signal is
dard is developed. For more in-depth discussions of necessary to obtain the same hearing level as that ob-
these and other aspects of stimulus calibration (e.g., tained using an earphone).
choice and effect of pulse duration for click stimula- Despite these limitations, most evoked response
tion), the reader is referred to chapters by Durrant audiometer manufacturers now offer bone conduction
(1983) and Gorga, Abbas, and Worthington (1985). options, and support has been expressed for the use of
Bone Conduction. In conventional audiometry the bone conduction in AEP testing (Berlin, Gondra, &
magnitude of conductive lesions is assessed by com- Casey, 1978; Mauldin & Jerger, 1979; Weber, 1983).
paring thresholds obtained via air versus bone conduc- Bone conduction testing can help in newborn screen-
tion stimuli. It is also possible to use this approach in ings and other audiologic applications but, clearly,
evaluations of AEPs (although conductive lesions care must be taken in the use and the interpretation of
manifest themselves in other ways, as discussed be- results obtained.
low).
The efforts to date to integrate bone conduction Electrocochleography
stimulation in testing the short latency potentials have Electrocochleography (ECochG) is a term that has
centered around the use of conventional audiometric been applied to a family of electrophysiologic tech-
bone vibrators with AEP test instruments (see niques directed specifically toward the recording of
Schwartz, Larson, & DeChicchis, 1985). Unfortunately, stimulus related potentials generated from the cochlea
even when the earphone and bone vibrator outputs are and eighth nerve. Attempts at clinical applications of
adjusted for equal sensation levels (for clicks), the bone ECochG date back almost as far as the discovery of the
conduction elicited response is delayed by 0.5 ms or cochlear potentials by Wever and Bray (1930), but prac-
more (Weber, 1983). Some investigators have attributed tical applications were not realized until the late
this delay to the poor high frequency response of the 1960s. However, work in this area decreased over the
bone vibrator (Mauldin & Jerger, 1979). The bone vi- next decade as the clinical interest in ABRs expanded.
brator tends to have a major spectral peak between 1 Recently, there has been renewed interest in ECochG
and 2 kHz with a substantial roll-off in the frequency in assessing and monitoring certain audiologic/oto-
response above about 1.62.5 kHz. Therefore, air and logic and neurologic disorders, in monitoring surgi-
bone conduction clicks have different spectra. This has cal procedures, and in supplementing ABR
been revealed by comparing the earphone output mea- measurements (Ferraro, 1986).
sured in a 6 cm3 cavity with the bone vibrator output
measured on an artificial mastoid, as well as measures The record of the potentials recorded via ECochG
rendered in terms of estimated hearing levels (Schwartz is called the electrocochleogram (ECochGm). Although
et al., 1985). the ECochGm consists of more than one electrical po-
tential (Figure 4), the most obvious and most easily
The output of the vibrator is around 40 dB below recorded component is the whole nerve action poten-
that of the earphones, even when both are driven to tial (AP) of the eighth nerve. The AP is characterized
saturating levels of output, just as in the case of pure by a series of one to three predominantly negative
tone audiometry. However, the realizable hearing lev- waves, the largest of which is known as N1 (Figure 4).
els (i.e., 4050 dB) permit only relatively mild conduc- The AP N1 component is the most salient feature of the
tive hearing losses to be quantified. Thus, the absence ECochGm (Coats, 1974).
of a click-evoked potential by bone conduction does not
the combination of stimulus parameters and record-

ing site and method, the SP may be of either positive or
negative polarity. When elicited by a transient stimu-
lus such as a click, the SP appears as a transient de-
flection on which the AP is superimposed and forms a
shoulder on the leading edge of the AP waveform, as
shown in Figure 4 (Coats, 1981). For a more extensive
treatment of these potentials, the reader is referred to
Dallos (1973) and to Durrant and Lovrinic (1984).
Recording Techniques: Electrode Type and Mon-
tage
There are two general recording techniques avail-
able for ECochG. One method involves inserting a
needle electrode through the tympanic membrane (TM)
to rest on the cochlear promontory. The invasive na-
ture of this approach has limited its applications in the
United States. Because of this, the use of transtympanic
ECochG will not be considered directly in this discus-
sion. (Extra)tympanic techniques utilize recording elec-
trodes located on the lateral surface of the TM or in the
ear canal. Cullen, Ellis, Berlin, and Lousteau (1972) first
described an extratympanic, surface recording method
using a silver ball electrode wrapped in a saline-
soaked cotton pledget and placed against the TM. This
technique provided good results with minimal dis-
comfort to the subject, although the subject was re-
quired to lie down, and the stimulus had to be
presented via sound field. A recently designed
extratympanic electrode (Stypulkowski & Staller, 1987)
has rekindled interest in this approach to ECochG as
it largely obviates problems with older designs.
Coats (1974) introduced an electrode assembly
Figure 4. Component potentials of the (human) that is self-retaining, although the point of recording
electrocochleogram recorded from the ear canal us- was moved away from the eardrum and onto the floor
ing condensation (C) and rarefaction (R) click stimuli: of the ear canal. This electrode is illustrated in Figure
N1, major component of the whole-nerve action po- 5. A light, flexible but springy clip is used to hold a
tential (AP); CM, cochlear microphonic; SP, summat- silver ball electrode against the canal wall. This elec-
ing potential. The CM and SP can be selectively trode can be used under earphones, provides good
enhanced by manipulating the R and C responses, as recordings, and visual detection levels (VDLs) in many
indicated. Ear-canal negative (-EC) potentials are subjects approximate the behavioral threshold of the
plotted as downward deflections. (Based on data stimulus (see Figure 6).
from Coats, 1981.)
Inherent problems with this type of ear canal elec-
trode are the difficulty of controlling placement and the
The stimulus related potentials generated by the relatively high electrode impedances. Impedances typi-
hair cells (i.e., prior to excitation of the auditory nerve) cally are in excess of 20 kohms (Durrant, 1986). With
are the cochlear microphonic (CM) and the summat- modern preamplifiers and their very high input imped-
ing potential (SP). The CM has a similar waveform to ances, the magnitude of the electrode impedance is not
the stimulus. For example. if a tone burst is presented, as much of concern as is the balance between each
a sinusoidal voltage is recorded. The recorded poten- branch of the circuit formed in connecting the differ-
tial, however, often is asymmetrical, with its zero axis ential amplifier to the patient. The balance between
offset from the baseline. This is due to the presence of electrode pairs is generally poor, and this degrades
the SP. The SP can be isolated via low-pass filtering or CMR and noise suppression. Higher impedances also
phase cancellation of the CM (Figure 4). Depending on create more noise artifact.
Figure 5. An electrode assembly for recording from

the ear canal: (A) silver ball electrode supported by
retainer made of acetate; (B) assembly held by forceps
as required for insertion; (C) placement in the ear
canal. From On Electrocochleographic Electrode De-
sign by A.C. Coats, 1974, Journal of the Acoustical So-
ciety of America, 56, p. 79. Copyright 1974 by the
American Institute of Physics. Reprinted by permis- Figure 6. Combined electrocochleogram and brainstem
sion. potential recording at different sensation levels of the
click stimulus. Recording montage: ear-canal electrode
connected to the noninverting input of the differential
Other ear canal electrode designs have been de- amplifier, surface electrode placed on the forehead at
scribed that are placed closer to the entrance to the ear midhairline connected to the inverting input; surfacer
canal (e.g., Whitaker & Lewis, 1984; Yanz & Dodds, electrode over the zygomatic process connected to
1985). Also, an earplug electrode of this general type ground. By virtue of this recording montage, both ear-
compares favorably with the Coats electrode, when the canal negative potentials and forehead/vertex positive
latter is inserted near the entrance to the ear canal potentials are plotted as downward deflections. From
(Ferraro, Murphy, & Ruth, 1986). These more recent Combined ECochG-ABR Versus Conventional ABR Re-
designs have substantially reduced the impedance cordings by J.D. Durrant, 1986, Seminars in Hearing
problem due to their effectively large surface areas. The (Electrocochleography), 7, p. 292. Copyright 1986 by
amplitude of the recorded potential, however, is re- Thieme Medical Publishers. Reprinted by permission.
duced for less deep electrode placements (Coats, 1974).
These electrodes do appear to provide useful record-
ings of the AP and the SP. The earplug electrode as-
It will be recalled that in differential recordings a
sembly is similar to tubal insert earphones. Thus, the
second electrode, sometimes called the reference elec-
response is much less susceptible to stimulus artifact,
trode, is required, along with a ground electrode. Two
compared to responses obtained with other types of ear
possible placements for the reference electrode are the
canal electrodes used in conjunction with the conven-
ipsilateral earlobe and mastoid. Some of the desired
tional earphone.
potential, however, will be canceled by the differential
amplifier because neither the ipsilateral earlobe nor the Stimulus Variables
ipsilateral mastoid is totally inactive. Preferable sites Intensity. Compound APs grow in proportion to
for the reference electrode are the nasion (just above the the amplitude of the stimulus, as shown in Figure 7.
bridge of the nose) or contralateral earlobe/mastoid, AP latency also depends on the intensity of the stimu-
which are relatively inactive for the ECochGm. Durrant lus. The latency of the AP is defined as the delay be-
(1977, 1986) also suggested recording between the ear tween the onset of the stimulus and the occurrence of
canal and the vertex or forehead to provide simulta- the N1 response peak. The graph of latency versus
neous pickup of the eighth nerve and brainstem com- stimulus level is called the latency-intensity function
ponents, as illustrated by Figure 6. Although this (Figure 7). These data demonstrate that as the stimu-
works well in some cases, in other cases the AP may lus intensity decreases, latency systematically in-
not be picked up much better in the ear canal than on creases.
the earlobe or mastoid and in still others the AP can be
overwhelmingly large (thereby interfering with the The latency-intensity shift of the AP is demon-
resolution of the brainstem components). Nevertheless, strated further by the ECochGm shown in Figure 8a.
this approach may help to enhance the eighth nerve The basis of this phenomenon is evident from the re-
component (Wave I) of the ABR (Durrant, 1986; cordings presented in Figure 8b. The latter ECochGms
Eggermont, Don, & Brackmann, 1980). Alternatively, were obtained in the presence of different high pass
a two-channel system can be used to record simulta- noise maskers. The subtraction of the response ob-
neously from ear canal and surface electrodes and thus tained with a masker of lower frequency cutoff from
separately monitor eighth nerve and brainstem re- that obtained with a masker of higher frequency cutoff
sponses (Coats & Martin, 1977). yields the contribution largely of neurons innervating
the cochlear region between the places marked by the
Another form of noninvasive ECochG is that of cutoff frequencies (Teas, Eldridge, & Davis, 1962). The
recording via a scalp/surface electrode placed on the high level response is dominated primarily by the con-
earlobe or mastoid. Even prior to the appearance of the tributions of fibers located near the base (high fre-
classic paper by Jewett, Romano, and Williston (1970) quency region) of the cochlea, whereas the
describing ABRs, Sohmer and Feinmesser (1967) de- contributions from lower frequency regions tend to
scribed ECochG using essentially the same electrode cancel one another (Eggermont, 1976a). The low level
placements. The differences between these studies responses shown in Figure 8a have latencies corre-
were the polarity reference and the presumed sources sponding to responses generated by bands centered
of the responses. Jewett and his associates considered around 2000 Hz, which is consistent with the greater
the vertex to be active, and Sohmer and Feinmesser con- sensitivity of the 2000 Hz region near threshold. The
sidered the earlobe to be active. Both are really active, latency-intensity shift, therefore, is primarily a reflec-
but the earlobe (or mastoid) is more active for the AP, tion of the time required for the traveling wave to
and the vertex is more active for the brainstem compo- propagate to the corresponding place along the basi-
nents. Indeed, it is well established that the ECochGm lar membrane. As discussed earlier, the click has a
forms the initial part of the ABR as illustrated by Fig-
ure 6.
Comparisons among tympanic membrane (TM),
ear canal, and surface ECochG recordings have re-
cently appeared in the literature (Ferraro & Ferguson,
in press; Ferraro et al, 1986; Stypulkowski & Staller,
1987; Ruth, Lambert, & Ferraro, in press; Ruth, Mills,
& Ferraro, in press). As expected, recordings from the
TM yield the largest, most sensitive and reliable re-
sponses among the three approaches. Although it is
possible to record the AP or even the CM (Sohmer &
Pratt, 1976) from the earlobe or mastoid, recordings
from these sites suffer from substantial reduction in
sensitivity compared to ear canal recording techniques
(Ferraro et al., 1986). Reliable recordings of the SP from
sites as remote as the earlobe/mastoid have yet to be
demonstrated.
Figure 7. AP latency-intensity function and corre-
sponding ECochG tracings (recorded via an ear-ca-
nal electrode).
Figure 8. (a) Wide-band click-evoked APs. From Electrocochleography by J.J. Eggermont, 1976, in W.D. Keidel
and W.D. Neff (Eds.) Handbook of sensory physiology, vol. 3: Auditory system: clinical and special topics (p. 650). Ber-
lin, Springer-Verlag. Copyright 1976 by Springer-Verlag, Berlin-Heidelberg-New York. Adapted by permis-
sion. (b) Derived narrow-band responses with click stimulus presented at 90 dB peSPL. From Analysis of
Compound Action Potential Responses to Tone Bursts in the Human and Guinea Pig Cochlea by J.J. Eggermont,
1976, Journal of the Acoustical Society of America, 60, p. 1135. Copyrighted 1976 by the American Institute of Physics.
Adapted by permission. Both sets of recordings are from the promontory via a transtympanic electrode.
broad spectrum but the same mechanism is involved transtympanic recordings is characterized by approxi-
even with more frequency specific stimuli such as tone mately proportionate growth with stimulus intensity,
bursts. Because more basalward fibers will be recruited similar to the CM (when the input-output function is
as the level of the stimulus is increased, the latencies plotted in log-log coordinates) but without much evi-
become shorter. The important point is that different dence of saturation.
populations of neurons dominate the AP at different Spectral and/or Temporal Variables. The effects of
levels and frequencies of stimulation. stimulus spectrum and/or temporal characteristics on
Both the CM and SP have very short latencies and the short latency potentials were discussed in general
no significant dependence of latency on intensity of terms earlier, but there are some matters of specific
stimulation. The CM magnitude, if represented in loga- interest with regard to the elicitation of the ECochGm.
rithmic units, grows in direct proportion to sound pres- One relevant variable is stimulus phase. As illustrated
sure in decibels, usually with a slope of unity. As by Figure 4, the CM is phase sensitive, whereas the SP
shown in Figure 9, its output saturates at high levels is not, and the AP is only slightly phase sensitive
of stimulation and even decreases with continued in- (Coats, 1981). Also, the use of tone bursts that typically
creases in intensity (Dallos, 1973). outlast the click requires particular care in ECochG
The behavior of the SP is more complex overall because of possible contamination from electromag-
than that of the CM (Dallos, 1973). Generally, only a netic radiation from the earphone. Again, acoustic
negative SP is seen in normal hearing human subjects delays or electromagnetic shielding can be used to
(Eggermont, 1976b). The SP input-output function from minimize stimulus artifacts.
Figure 9. CM input-output function (based on mean

data from a sample of normal hearing subjects).
Stimulus was a 1-kHz tone burst of 5 ms duration; re-
cordings from needle electrode in the floor of the ear
canal, proximal to the ear drum. (Figure modified and
redrawn from Elberling & Solomon, 1973.)
Figure 10. Effects of stimulus rate in clicks per sec-

Stimulus repetition rate is an important factor in ond (CPS); for reference, the interstimulus intervals
recording the ECochGm, particularly the AP. As illus- (ISI) have been computed for each rate tested (*, arti-
trated by Figure 10, the amplitude of the AP decreases fact). The click stimulus was presented at 80 dB SL.
and latency increases with increasing rate. In contrast, AP as well as brainstem potentials (I-V) were re-
the SP and CM (although not evident in Figure 10) do corded via electrodes placed in the ear canal and at
not seem to exhibit temporal interactions of any con- vertex. From Combined ECochG-ABR Versus Con-
sequence and maintain essentially constant ampli- ventional ABR Recordings by J.D. Durrant, 1986,
tudes regardless of repetition rate. Indeed, one Seminars in Hearing (Electrocochleography), p. 300.
technique employed by some to emphasize the SP is to Copyright 1986 by Thieme Medical Publishers.
increase the repetition rate until the AP is maximally Adapted by permission.
depressed (Coats, 1981; Gibson, Moffat, & Ramsden,
1977). This method requires repetition rates on the or-
der of 100/second, but even at such high repetition
rates the AP contribution to the recorded response will tentials of the ECochGm are recorded in a quasi near-
not be entirely eliminated because the effect of increas- field manner (Davis, 1976); consequently, the
ing repetition rate is not one of pure adaptation ECochGm is strongest in the vicinity of electrodes near-
(Durrant, 1986; Harris & Dallos, 1979). The repetition est to generators of the cochlear and eighth nerve po-
of the stimulus itself causes a certain amount of syn- tentials. Recording on the side of the head opposite the
chronization of neural discharges, which can occur ear stimulated thus yields a substantially attenuated
even at frequencies of several hundred hertz. Other- response. Second, due to the substantial transcranial
wise, the AP would completely adapt, rather than ac- attenuation of sound, the amplitude of a response elic-
commodating to the repetitious stimulus. ited by crossover stimulation will be greatly reduced,
Masking. Fundamentally, the problem of selec- with a concomitant latency shift, compared to that ob-
tively testing one ear is the same for ECochG as it is for tained with direct stimulation of that ear.
conventional audiometry. The problem, however, is far Subject Variables
less acute in ECochG, and masking is not used rou-
Normal Variability. Considerable variability in the
tinely. Masking is unnecessary for most applications
amplitude of the ECochGm is typically observed. Even
of ECochG for two reasons. First, the component po-
with transtympanic recordings, in which the recorded
signal is usually an order of magnitude higher than leagues have applied the surface technique in a vari-
that obtained via extratympanic methods, AP ampli- ety of cases (Sohmer & Feinmesser, 1973, 1974; Sohmer,
tudes vary by as much as 20:1 (see data of Eggermont, Feinmesser, & Bauberger-Tell, 1972). Currently, the
1976b). Although the extratympanic ECochGm is in- most popular clinical application of ECochG is in the
herently vulnerable to variance in electrode placement, identification, assessment, and monitoring of
its variance actually does not appear to be greater than Menieres disease or endolymphatic hydrops. The pri-
that experienced with the transtympanic method and mary impetus for this was the work of Coats (1981),
is comparable to that obtained with surface recordings following the observations of Eggermont (1976b) and
from the mastoid (Durrant, 1986). The main difficulty Gibson et al. (1977) that the SP amplitude is altered in
with extratympanic methods is a poor SNR that is a many cases. Although the rationale for this finding has
result of a reduction in signal amplitude without yet to be fully explained, it is well documented that the
changes in noise amplitude. Naturally, the more re- ECochGm of many Menieres patients is characterized
mote the site of recording, the poorer is the SNR. by an enlarged SP, especially in comparison to the AP
The variability of latency is much less than that of component (Coats, 1981, 1986; Eggermont, 1976b;
amplitude and is relatively independent of recording Ferraro, Arenberg, & Hassanein, 1985; Gibson et al.,
technique. Standard deviations are typically less than 1977; Staller, 1986). This finding is illustrated in Fig-
0.2 ms for the AP recorded from normal hearing sub- ure 11, which demonstrates the relation between the
jects (Durrant, 1986). SP and AP amplitudes for groups of subjects present-
ing with retrocochlear impairment, cochlear impair-
Age and Gender. The effects of age and gender on ment, and Menieres disease.
ECochG have not been studied extensively. Gender dif-
ferences appear to arise at levels of the system beyond Originally, it had been hoped that the ECochGm
the eighth nerve (McClelland & McCrae, 1979). The waveform, as well as the input-output and latency-
only known effects of age are during early development intensity functions, would conform to distinct patterns
(Fria & Doyle, 1984; Starr, Amlie, Martin & Sanders, in cases of different pathologies of the auditory system.
1977). In newborns, particularly premature infants, As summarized in Figure 12, this goal was partially
there is a slight delay in the AP that progressively de- realized utilizing the transtympanic method (e.g.,
creases with maturity. This decrease may reflect matu- Aran, 1978). Here it can be seen that cochlear, conduc-
ration of the peripheral system and/or resolution of tive, and normal patterns are fairly distinguishable.
conductive hearing loss that may be associated with To some extent, similar patterns have been demon-
the presence of fluid in the neonatal ear. strated using noninvasive techniques as well (e.g.,
Berlin & Gondra, 1976). Some exemplary latency-in-
Clinical Applications of Electrocochleography tensity data are shown in Figure 13. However, the fre-
Clinically, AEPs have been used in otoneurologic quent inability to track the AP down to low levels of
diagnoses and hearing threshold predictions. ECochG stimulation limits the extent to which either the la-
has been used in both of these areas, although the early tency-intensity function or the input-output amplitude
work involved primarily transtympanic measure- function can be described. Also, the residual noise in
ments. The discussion here will focus on the clinical the noninvasive recordings generally precludes accu-
utility of extratympanic methods. rate typing of the ECochG waveform. These factors
have reduced the clinical value of noninvasive
Hearing Threshold Prediction. Ear canal ECochG
ECochG, although it appears that many of them can
has not proven particularly useful for threshold esti-
be overcome by recording from the TM (Stypulkowski
mation and does not provide as reliable determinations
& Staller, 1987).
of threshold estimates as the transtympanic technique
(Probst, 1983). It is difficult to record the AP reliably Finally, perhaps the most neglected area of
below about 30 dB relative to the individuals behav- ECochG is the use of the CM. One discouraging aspect
ioral threshold (Cullen et al., 1972). These findings is the considerable difficulty of eliminating stimulus
concur with data reported for the early components of artifact to a degree that one is confident that only CM
the ABR. For some purposes, the gap between AP is being recorded. Sohmer and Pratts (1976) sound
threshold and behavioral threshold might be accept- delivery system, discussed earlier, was designed spe-
able, but the ABR can be recorded reliably near the be- cifically for circumventing this problem; they have de-
havioral threshold and thus has replaced scribed successful recordings of the CM using surface
extratympanic ECochG for threshold estimation. electrodes. Despite the support given by some authori-
ties (e.g., Beagley, 1974; Hoke & Lutkenhoner, 1981),
Otoneurologic Applications. The clinical utilities
the value of CM measurement as a clinical tool has yet
in the area of otoneurologic or differential diagnoses
to be established.
also have been limited for ECochG. Sohmer and his col-
Figure 11. Scatterplots of SP versus AP amplitudes for three groups of pathologic ears. The curves represent
best-fit estimates of 2 standard deviations for responses obtained from normal ears. Recordings from ear canal.
From The Summating Potential and Menieres Disease by A.C. Coats, 1981, Archives of Otolaryngology, 107, p.
205. Copyright 1981 by the American Medical Association. Reprinted by permission.
Measurement of Auditory Brainstem

Evoked Potentials
The ABR consists of a series of 57 waves, as il-
lustrated in Figure 14. Two labeling systems have been
used, one attributable to Sohmer, Feinmesser, and
Szabo (1974) and the other to Jewett and Williston
(1971), with the latter scheme now being used more
widely. The potentials comprising the ABR arise from
the auditory nerve, as well as brainstem structures
(Jewett, 1970). The simplest view of the genesis of the
ABR is that each wave arises from a single anatomical
site. However, this view overlooks the complexity of
the neural pathways, including bilateral representa-
tion, decussation of nerve fibers at various levels, path-
ways that do not involve synapses at every nucleus,
neurons with multiple synapses within a structure, and
secondary and tertiary firings of neurons. In humans,
Wave II is now believed to arise from the central end of
the eighth nerve (Moller & Jannetta, 1982). Only waves
Figure 12. (a) Typical input-output and latency-inten-
beyond II are now believed to represent brainstem level
sity functions for subjects with normal hearing (A)
activity. Waves I and II arise from structures ipsilat-
and conductive (B), recruiting high-frequency (C),
eral to the side of stimulation. Later waves may come
and recruiting flat (D) hearing loss. (b) Correspond-
from structures that receive ipsilateral, contralateral,
ing ECochG wave forms (transtympanic recordings).
or bilateral inputs from the auditory periphery (Achor
From Contributions of Electrocochleography to Di-
& Starr, 1980a, 1980b; Buchwald & Huang, 1975;
agnosis in Infancy. An 8-Year Survey by J.M. Aran,
Moller, Jannetta, Bennett, & Moller, 1981; Wada &
1978, in S.E. Gerber & G.T. Mencher (Eds.), Early di-
Starr, 1983a, 1983b, 1983c).
agnosis of hearing loss, p. 218219. New York: Grune
& Stratton. Copyright 1978 by Grune & Stratton. Because Wave I represents the initial response of
Adapted by permission. the auditory nervous system, the later waves tend to
mimic its behavior, especially its dependence on stimu-
Figure 13. AP latency-intensity functions for group of patients with mild-to-moderate conductive (a) and slop-
ing sensorineural hearing loss (b). Measurements made from recordings from the surface of the eardrum. From
Clinical Application of Recording Human VIIIth Nerve Action Potentials From the Tympanic Membrane by
C.I. Berlin, J.K. Cullen, M.S. Ellis, R.J. Lousteau, W.M. Warbrough, and G.D. Lyons, 1974, Transactions of the
American Academy of Ophthalmology and Otolaryngology, 78, p. 404406. Copyright 1974 by C.V. Mosby Com-
pany. Adapted by permission.
lus parameters and the status of the middle and inner

ears (Davis, 1976). Nevertheless, there is some degree
of independence between the brainstem and periph-
eral nerve components.
Basic ABR Measures
The two parameters of the ABR waveform that
usually are measured are amplitude and latency.
Amplitude typically is measured between a positive
peak and the following negative peak or trough (Fig-
ure 15). Peak-to-peak measures are favored because
they avoid the difficulty of determining the baseline of
the potential.
Figure 14. Auditory brainstem responseJewett Waves There are several latency measures of interest. The
IVII. Onset of click (clk.) stimulus as indicated. Record- most basic is absolute latency, which is defined as the
ing montage: surface electrodes at vertex (connected to time difference between stimulus onset and the peak
the noninverting input of the recording amplifier), mas- of the wave (Figure 15). Interwave latencies (or
toid (inverting input), and nasion (ground); therefore, interpeak intervals) are the differences between abso-
following the most widely adopted convention, vertex- lute latencies of two peaks, such as I-V, I-III, and III-V
positive (+ Cz) potentials are plotted as upward deflec- (Figure 15). In evaluating ABR latencies, emphasis
tions. Peak identifiers in parentheses: terminology from usually is placed on the vertex-positive peaks of the
Sohmer and Feinmesser (1967) who used the earlobe for waveform.
the noninverting input and the bridge of the nose for the
inverting input.
Stimulus Parameters
Intensity. Latency-intensity functions for major
components of the click-evoked ABR are shown in Fig-
ure 16. The latencies increase as stimulus intensity de-
creases, roughly in parallel with latency changes in
the AP (Wave I). The amplitudes of the waves decrease
as the intensity decreases. In addition, as intensity
decreases the waves prior to Wave V diminish and ul-
timately vanish, whereas Wave V often remains dis-
cernible down to levels approximating the behavioral
thresholds for the same stimulus.
The primary basis for the latency-intensity shift
described above is revealed by data from Don and
Eggermont (1978), who used the subtractive masking
method. This method was developed originally to in-
dicate the regions of the cochlea that contribute to the
click-evoked AP (Teas et al., 1962). As shown in Fig-
ure 17, different high pass noises are used to obtain
masked click-evoked ABRs. The ABR obtained with a
lower masker frequency cutoff is subtracted from the
response obtained with a higher masker frequency
cutoff. The high level unmasked response is domi- Figure 16. ABR latency-intensity functions and cor-
nated by contributions from fibers at the basal end of responding ABR wave forms.
the cochlea. The latency-intensity shift then appears
to reflect the time required for the wave to propagate to
the place on the basilar membrane dominating the re-
Spectrum: Clicks Versus Tone Pips. Clicks are the
sponse. However, if one assumes that this technique
most commonly used stimuli for eliciting the ABR. The
results in the masking of basal cochlear regions, then
abrupt onset and broad spectrum of a click result in
upward spread of excitation cannot entirely account
synchronous excitation of a broad population of neu-
for changes in latency for individual derived bands
rons. The click is usually the most effective stimulus
(see Figure 6 of Eggermont & Don, 1980).
and can provide high frequency information (Coats &
Figure 17. (a) Broad-band click-elicited ABRs. (b)

Derived narrow-band responses. From Analysis of
the Click-Evoked Brainstem Potentials in Man Using
High-Pass Noise Masking by M. Don and J.J.
Eggermont, 1978, Journal of the Acoustical Society of
Figure 15. Basic amplitude and latency measures of America, 63, p. 1087. Copyright 1978 by the American
the ABR. Institute of Physics. Adapted by permission.
Martin, 1977; Don, Eggermont, & Brackmann, 1979; ABRs with slightly shorter latencies and better reso-
Gorga, Worthington, Reiland, Beauchaine & Goldgar, lution of the peaks in the IVN complex. However, some
1985; Jerger & Mauldin, 1978; Moller & Blegvad, 1976). subjects may show the opposite trends or no signifi-
Tone pips, filtered clicks, or the subtractive masking cant differences between polarities. When polarity ef-
(derived band) technique must be used for more fre- fects are observed, they rarely amount to more than a
quency specific information (Stapells, Picton, Perez- 0.10.2 ms difference in latency in normal hearing,
Abalo, Read, & Smith, 1985). neurologically intact subjects, but the presence of a
The same concerns that are evident for the use of sloping high frequency hearing loss can cause more
frequency specific stimuli to elicit the AP are present dramatic effects (Coats & Martin, 1977). Phase effects
also for the ABR. Tone pips are transient stimuli, so seem to depend on the low frequency content of the
there is a spread of energy around the central frequency. stimulus (Moller, 1986), although Salt and Thornton
Second, with increasing intensity the basal fibers pro- (1983) reach slightly different conclusions regarding
gressively dominate the response, regardless of stimu- the sources of the phase effects.
lus frequency (Folsom, 1984). This problem exists for Phase effects are not very great in most subjects. As a
conventional pure tone audiometry as well. Third, the consequence, many examiners prefer to use stimuli of
effective rise time may become progressively longer as alternating polarity, which help to minimize stimulus ar-
the frequency decreases. This may reduce synchrony tifact and the CM, both of which can obscure Wave I. This
in the apical end of the cochlea, making it more diffi- approach can reduce or eliminate the need for electromag-
cult to measure. However, the ABR can be elicited with netic shielding of the earphone. Still, it is generally pref-
stimuli as low as 500 Hz with appropriate filter set- erable to keep the phases separate to avoid distorting the
tings and sampling epochs (Stapells & Picton, 1981; ABR waveform. This is particularly important in subjects
Suzuki, Hirai, & Horiuchi, 1977). Good agreement has who have substantially different responses to rarefaction
been reported between tone burst ABR and behavioral and condensation stimuli. If necessary, the alternating
thresholds at corresponding audiometric frequencies condition can be derived by combining responses for each
(Suzuki & Yamane, 1982). stimulus polarity in the computers memory. No infor-
The spectrum of the stimulus is influenced by the
stimulus plateau and rise/fall durations, as well as by
the gating function by which the sound is turned on
and off. The brainstem components, like the AP, are
relatively insensitive to the stimulus duration (Gorga,
Beauchaine, Reiland, Worthington, & Javel, 1984) but
quite dependent on the rise/fall times (Kodera, Marsh,
Suzuki, & Suzuki, 1983). Response amplitudes de-
crease and latencies increase as rise time increases.
Wave V is the least affected in terms of amplitude dec-
rements with increasing stimulus rise/fall times
(Hecox, Squires, & Galambos, 1976).
Various gating functions can be used to minimize
spectral splatter of tone bursts (Harris, 1978; Nuttall,
1981). Another approach is to use either notch-band
(or stop-band) noise to mask all but the frequency re-
gion of the main spectral lobe of the stimulus (Picton,
Ouellette, Hamel, & Smith, 1979; Stapells et al., 1985)
or the subtractive masking paradigm. The VDL of the
ABR can then be determined for each frequency band
of interest. These methods may be more technically
demanding and time consuming than the use of un-
masked tone bursts or filtered clicks. Figure 18. Effects of click polarity (i.e., starting phase)
on the ABR: C = condensation; R = rarefaction. From
Polarity. Polarity or starting phase of the stimu-
Reconstruction of the Audiogram Using Brainstem
lus can affect the latencies of the waves and the de-
Responses and High-Pass Noise Masking by M. Don,
tailed morphology of the ABR waveform. Different
J.J. Eggermont, and D.E. Brackman, 1979. Annals of
polarities/phases may differentially affect the ampli-
Otology, Rhinology, and Laryngology, 88 (Suppl. 57), p.
tudes, latencies, and/or resolution of some peaks (Fig-
6. Copyright 1979 by Annals Publishing Company.
ure 18). For example, the rarefaction phase may elicit
Reprinted by permission.
mation is lost because rarefaction, condensation, and

combined responses each can be examined.
Repetition Rate of Stimuli
The amplitudes and latencies of the ABR compo-
nents are dependent on stimulus repetition rate (see
Picton, Stapells, & Campbell, 1981, for a review). As
the stimulus rate is increased, the latencies of all the
waves are prolonged and the amplitudes of the early
waves are decreased. Rates of 10/second or less are
necessary for maximal definition of all the waves; the
interstimulus interval at this rate is sufficiently long
to prevent any significant adaptation of the response
for high level stimuli. There is no evidence to suggest
that high rates adversely affect the response for low
level stimuli. As illustrated in Figure 19, faster rates
prolong the latencies of all the waves progressively, so
that Wave I is delayed approximately 0.1 ms and Wave
V is delayed approximately 0.3 ms between rates of 10
and 50/second (Fowler & Noffsinger, 1983). High
rates also decrease the amplitudes of waves prior to
Wave V. Waves II and IV are affected the most, followed
by Waves I and III. Although rates of 10/second have
been proposed to enhance differential diagnoses based
on the ABR exam, research findings are not conclusive
(Campbell & Abbas, 1987; Fowler & Noffsinger, 1983).
Low rates are advisable when a full complement of
waves is necessary, such as in the case of otoneurologic
evaluations. For other purposes, such as threshold test-
Figure 19. Effect of stimulus (click) repetition rate on
ing, rates of 2540/second are acceptable because the
the ABR.
amplitude of Wave V is minimally reduced. This im-
proves the efficiency of ABR measurements because
more averages can be taken in the same period of time. mined by increasing the level of masking in the nontest
Masking ear until the crossover response is eliminated.
There is considerable debate as to whether mask- Monaural Versus Binaural Stimulation
ing is ever needed. First, at least for clicks, there ap- Binaurally stimulated brainstem responses are
pears to be greater transcranial attenuation than larger than monaurally elicited responses by almost
encountered in pure-tone audiometry (Finitzo-Hieber, twofold (Dobie & Norton, 1980). Binaural stimulation
Hecox, & Cone, 1979). Further, additional transcranial can be used for screenings or in applications in which
attenuation can be realized through the use of insert it is adequate to know that the peripheral auditory
earphones (Clemis et al., 1986). Second, in terms of mechanism is intact in at least one ear or that there is
determining the possibility of retrocochlear pathology, brainstem level function (e.g., in comatose patients).
a response to crossover stimuli would be so delayed Monaural stimuli are recommended for most neuro-
as to raise as much suspicion as an absent response. logic diagnostic purposes and for the estimation of
In the audiologic-oriented (sensitivity) evaluation, thresholds separately for the ears.
however, similar considerations for masking must be The difference between the monaural and binau-
given as in behavioral audiometry. Contralateral mask- ral responses also forms the basis for measurement of
ing is required whenever the stimuli are sufficiently the so-called binaural interaction potential (Figure 20).
intense as to produce crossover responses. A crossover The left and right monaural responses are added (form-
response will be of smaller amplitude and longer la- ing a predicted binaural response), and the binaural
tency, compared to an ipsilateral response, due to the response is subtracted from this sum (Dobie & Berlin,
much lower intensity of the stimulus reaching the con- 1979; Dobie & Norton, 1980). This difference potential
tralateral ear. Ideally, each clinic should determine ef- is associated with Waves V-VII and is attributed to
fective masking levels for its own equipment and neurons that are shared by the left and right brainstem
stimuli. The appropriate amount of masking is deter-
auditory pathways. The clinical utility of this compo- 1978). Whether the waves are traced as positive (as in
nent has not been established and is hampered by the Figure 14) or negative deflections (as in Figure 6) is a
low amplitude of the binaural interaction potential matter of how the electrodes are connected to the am-
and its sharp dependence on waveform morphology plifier. Although no site on the head is totally inactive
of the monaural responses (Fowler & Swanson, 1988). for the ABR (Terkildsen, Osterhammel, & Huis int Veld,
1974), a cephalic reference site is preferred as it pro-
Recording Parameters
vides for superior noise suppression because the
Recording techniques are selected to enhance the amount and nature of the noise to both differential
SNR of the auditory nerve and brainstem potentials, amplifier inputs will be similar (compared to a
which typically are less than 1 V in amplitude and are noncephalic reference, such as the neck). Because the
buried in 10 or more V of noise. The following factors earlobe/mastoid site is active for the eighth nerve po-
can influence the detectability and quality of the ABR: tential, the AP is recorded primarily as a large nega-
(a) electrode configuration, (b) amplification (includ- tive wave but combines with the brainstem potentials
ing differential amplification), (c) filtering, (d) response via amplifier inversion to form a peak of the same ap-
averaging, and (e) artifact rejection. parent polarity as the brainstem components, as illus-
Electrode Montage. Early studies of the ABR and trated in Figure 21. Although different electrode
its clinical utility relied mainly on recordings from elec- placements may enhance various components of the
trodes placed on the vertex and the earlobe/mastoid ABR, small differences in placement will have little
of the stimulated ear with a ground on the nasion, fore- effect (Martin & Moore, 1977).
head, or opposite earlobe or mastoid. The placement EP test systems with two or more channels permit
of electrodes on the forehead at hairline and the ipsi- simultaneous recording from multiple montages. For
lateral mastoid or earlobe (with the ground electrode clinical purposes, a contralateral recording montage
typically placed on the contralateral mastoid) cur- is frequently used. The vertex/forehead inputs are tied
rently is popular. This montage avoids problems of together and electrodes from each earlobe/mastoid are
affixing electrodes to skin with hair and yields simi- connected individually to each channel. As shown in
lar, although not identical, results to the vertex-to- Figure 22, Wave I is absent or substantially attenuated
mastoid montage (Beattie, Beguwala, Mills, & Boyd, in the contralateral recording, although the negative
1986). An electrode on the vertex or forehead picks up deflection following Wave I may remain prominent at
the primary brainstem waves as positive potentials high intensities. The amplitude differences diminish
relative to ground, and these sites provide optimal for later waves and slight latency differences may be
pickup of the ABR (van Olphen, Rodenburg, & Verway, seen, with respect to the ipsilaterally recorded ABR
(e.g., see data of Creel, Garber, King, & Witkop, 1980).
Wave V recorded contralaterally may be as much as
0.2 ms later than the ipsilaterally recorded Wave V.
One application of contralateral recordings is in cases
in which the IVN complex is fused in the ipsilateral
recording (Figure 22); Waves IV and V are generally
separated in the contralateral recording (Stockard,
Stockard, & Sharbrough, 1978).
Differential effects of brainstem level pathology on
the ABRs recorded contra- versus ipsilaterally have
been suggested (Hashimoto, Ishiyama, & Tozuka,
1979), but some caution is needed in interpreting the
responses recorded under these conditions. Such re-
cordings do not provide independent views of the two
sides of the brainstem. At most, some degree of
sidedness seems probable only for Waves I-III, repre-
senting activity from the eighth nerve and, most likely,
the cochlear nuclei (Durrant, Shelhamer, Fria, & Ronis,
1981). Centrally, the generators of the responses are too
close together to be resolved easily in far-field record-
Figure 20. Binaural (BIN) versus monaural ABRs (L ings. Another use of two-channel recordings is to take
and R) and the derivation (i.e., BIN - [L + R]) of the the difference between channels (see Figure 21). This
binaural interaction component (BIC, demarked by method gives the transverse derivation, which yields
Peaks A and B). the same results as recording differentially between
Figure 21. Derivation of the ipsilaterally recorded ABR (i.e., recorded between vertex and ipsilateral mastoid.
Simulated from two-channel recording with the contralateral recording taken as an estimate of vertex pickup
and the transverse derivation taken as an estimate of the mastoid pickup.)
earlobes/mastoids. Although it emphasizes the pickup falling outside the spectrum of the ABR. For normal
of auditory nerve and low brainstem potentials subjects, the potentials elicited by high intensity
(Durrant, Shelhamer, Fria & Ronis, 1981), this deriva- stimuli are composed of frequencies between 50 and
tion is not a substitute for ECochG because it actually 1000 Hz (Kevanishvili & Aponchenko, 1979), but, as
does little to improve the SNR for Wave I, which is the the intensity of the eliciting stimuli decreases, the po-
primary problem with recording Wave I (Durrant, tentials may be composed of lower frequency compo-
1986). nents (Elberling, 1979a). Raising the cutoff of an analog
Filter Bandwidth. The filter bandwidth for the ABR high pass filter stabilizes the baseline but also de-
is selected to prevent aliasing effects on the recorded creases the latencies of the component waves and re-
signal and to reject physical and physiological noise duces their amplitudes (see analog data in Figure 23).
Abnormal responses may also be composed of lower
frequencies than are normal responses, so there is no
one filter setting equally applicable in all situations.
Current practices suggest that the high pass filter cut-
off (i.e., 3 dB down point) should not exceed 100 Hz
for single stage passive filters (i.e., 6 dB/octave rolloffs).
The cutoff should be lowered when using filters with
steeper slopes, when measuring responses from in-
fants, and when low frequency stimuli are used. The
cutoff also should be lowered and the sampling epoch
extended to 20 ms when recording responses to low
frequency stimuli because the low frequency content
of the ABR is relatively greater than in the case of high
frequency stimuli or clicks (Suzuki & Horiuchi, 1977).
Reducing the low pass cutoff of an analog filter
smoothes the responses but may increase their laten-
cies (see analog data in Figure 23). As a consequence,
cutoff frequencies below 1600 Hz are seldom used,
with 3000 Hz representing a typical cutoff frequency.
Because analog filters cause phase distortion and,
therefore, bias latency values, there is growing inter-
est in the use of zero phase shift digital filtering. These
filters achieve narrower bandwidths without the tem-
poral distortion of analog filters (Boston & Ainslie,
Figure 22. Ipsilateral (I) versus contralateral (C) re- 1980; Domico & Kavanaugh, 1986). Because the filter-
cordings of the ABR.
Figure 23. Effects of analog (X) versus digital (O) filtering on the ABR. Analog filter settings are for a Grass
recording amplifier (i.e., half-voltage cutoffs of a passive filter with initial settings of 303000 Hz). From Ef-
fects of Analog and Digital Filtering on Brainstem Auditory Evoked Potentials by J.R. Boston and P.J. Ainslie,
1980, Electroencephalography and Clinical Neurophysiology, 48, p. 362. Copyright 1980 by Elsevier Scientific Pub-
lishers. Reprinted by permission.
ing is much sharper, better SNRs can be obtained with els, it may be useful to increase the number of sweeps
less waveform distortion (although this depends on the because the amplitude of the ABR decreases with de-
specific filter function used). A comparison of the ef- creasing intensity. The exact number of sweeps is per-
fects of analog versus digital filtering is shown in Fig- haps less important than is the reproducibility of the
ure 23. averaged responses for identical stimulus conditions.
Few commercially available systems provide the There should be essentially no reproducibility between
capability of digital band-pass filtering, although most responses obtained under stimulus versus
provide some form of digital smoothing. Thus, analog nonstimulus conditions. It is advisable to repeat each
filtering with active filter networks and 12 dB/octave condition at least once and occasionally to include
rolloffs are prevalent among manufactured equipment. nonstimulus or control conditions at intervals
Despite the criticisms above, it should be recognized throughout the test session, particularly in noisy cases.
that adequate ABRs can be measured with appropri- In most instances, it is the examiners pattern recogni-
ate analog filter settings. If more than one set of filter tion ability that is ultimately responsible for judging
conditions is used routinely, however, then separate the response. The repeatability of events is easier to
norms should be collected for each. The discussion judge than is the occurrence of isolated events. Addi-
above emphasizes the fact that response wave forms tionally, comparisons of tracings across stimulus con-
can be altered by the filter response, and thus, the use ditions can be helpful. For example, the peaks of the
of very narrow filter bandwidths is not recommended. ABR are expected to shift in a fairly predictable man-
ner as intensity changes (see Figures 16 and 17a).
Sampling Variables. The number of sweeps of the
signal that must be averaged to produce a repeatable Sampling rate is important because it determines
ABR is determined by various factors (e.g., stimulus the temporal resolution of the waveform and, together
intensity, subject state, and auditory sensitivity). For with the number of points sampled, the duration of the
example, when working at relatively low stimulus lev- recorded epoch. Throughout the intensity range, the
click-elicited ABR is generally contained within a time sus females for neurologic diagnostic purposes. Be-
window of 10 ms (see Figures 14 and 16). With this cause there is considerable overlap between the dis-
window and 256 data points, there will be 40 s tem- tributions of ABR latencies for the two sexes, however,
poral resolution (dwell time), which is more than suf- any allowance for gender must be applied judiciously.
ficient, although windows up to 20 ms (80 s resolution As adult subjects age, amplitudes of the waves may
with 256 data points) are also adequate for ABR work. decrease and reproducibility of responses may dete-
These longer time windows are necessary for evalua- riorate. The consensus of experimental evidence shows
tions of ABR thresholds, especially for low frequency that absolute latencies of Waves I, III, and V are 0.1 to
stimuli, because of the long latencies of Wave V under 0.2 ms longer for subjects aged 50 years and older than
these conditions. In general, longer windows are rec- for those aged 2030 years. Data regarding the influ-
ommended for audiological evaluations so that the ence of age on interwave latency are inconclusive but
desired response can fall within the time frame of the also suggest that there may be an age-related prolon-
analysis. gation of 0.1 to 0.2 ms for the I-V interpeak interval
Subject/Nonpathologic Variables (Chu, 1985; Rosenhall, Bjorkman, Pederson, & Kall,
1985). Age-related changes may be confounded by the
Subject State. The ABR is relatively unaffected by
presence of sensory hearing loss. Age and hearing loss
changes in subject state, including natural and sedated
appear to have opposite effects on interwave latency
sleep (Amadeo & Shagass, 1973; Sohmer, Gafni, &
and similar but nonadditive effects on absolute la-
Chisin, 1978) and attention (Picton & Hillyard, 1974).
tency. When the threshold at 4000 Hz is 50 dB HL or
As a consequence, ABRs of sedated subjects can be
less, the main determinant of Wave V latency is age.
compared to norms established in unsedated subjects
When the hearing loss at 4000 Hz exceeds 50 dB HL,
(Stockard, Stockard, & Sharbrough, 1978). For young
both age and hearing loss contribute to latency prolon-
children, and older children and adults who cannot
gations, but the major factor is hearing loss (Hyde,
relax, sedation should be available after clearance by
1985). Thus, it is desirable to have comparative data
the patients physician. Immediate accessibility to
for adults over the age of 50 years who have no more
emergency medical care is necessary to deal with any
than a mild cochlear hearing loss at 4000 Hz (Brewer,
untoward side effects.
1987). For elderly adults whose threshold at 4000 Hz
Anesthesia does not alter substantially the laten- exceeds the mild hearing loss range, the effects of ag-
cies or amplitudes of the potentials unless the core tem-
perature of the body is lowered below 33 degrees
Centigrade, in which case the latency of Wave V will
be prolonged. Reduced temperature prolongs the ab-
solute and relative latencies of all the waves (Stockard,
Sharbrough, & Tinker, 1978). Alcohol also can increase
the latency of Wave V, apparently due to an induced
decrease in core temperature (Squires, Chu, & Starr,
1978).
Age and Gender. Maturational changes during
early life are reflected in age-related changes in the ABR.
The data presented in Figure 24, based on data from
newborns (Cevette, 1984), show maturational changes
in Waves III and V through the 18th month. As a con-
sequence, ABR evaluations in premature infants and
newborns require the use of age-adjusted norms and
necessitate the use of a wider analysis window (e.g., Figure 24. ABR Wave V latencies and I-V interpeak
1520 ms) than is typically used for adults (e.g., 10 ms). latencies at indicated nHLs versus conceptual age.
Throughout childhood the ABR changes little, but Conceptual ages in months (too) are actually 44 weeks
in adolescence, males begin to develop longer Wave V (wk) + the indicated number of months. Horizontal
latencies than females, which by adulthood amounts bars above each data point demark latencies that are
to an average intersex difference of approximately 0.2 2 standard deviations (sd) above the means (N = 580
ms (Rowe, 1978). Additionally, females display newborns). From Auditory Brainstem Response Test-
slightly larger Wave V amplitudes than do males ing in the Intensive Care Unit by M.J. Cevette, 1984,
(Jerger & Hall, 1980). Thus, separate norms are sug- Seminars in Hearing, 5, p. 62. Copyright 1984 by
gested for the interpretation of the ABR in males ver- Thieme Medical Publishers. Adapted by permission.
ing and hearing loss on absolute latency should be

considered.
Pathologic Variables
Conductive Hearing Loss. Conductive hearing
losses cause sound energy to be attenuated through the
outer or middle ear. Such losses will prolong the la-
tencies of all the waves of the ABR due to the effective
lowering of the stimulus level. The evaluation of the
ABR is easier and the interpretation more precise if
conductive lesions are identified or resolved before the
ABR is measured. Thus, otoscopic examination, immit-
Figure 25. Example of the effects of conductive pa-
tance testing, and air and bone conduction audiom-
thology on latencies of ABR Waves I, III, and V.
etry are valuable for a thorough ABR examination if
Stippled area represents 2 standard deviations of
the purpose is for neurologic diagnosis.
latencies for normal hearing subjects.
Conductive hearing losses prolong the latencies
of the waves without greatly affecting the I-V interpeak
latency value and cause essentially the same degree of is dependent on the severity and configuration of the
latency shift at all stimulus levels (Fria, 1980; loss, as well as the frequency composition of the stimu-
Mendelson, Salamy, Lenoir, & McKean, 1979). Thus, lus. Although broad band in nature, the spectrum of
the latency-intensity function for a subject with a con- the click is shaped primarily by the response charac-
ductive hearing loss is shifted along the intensity axis teristics of the earphone. A TDH-49 earphone, for ex-
by essentially the amount of the conductive hearing ample, has a resonance peak at about 40006000 Hz,
loss (Figure 25). In addition, the waves prior to Wave which boosts the energy in that frequency range by
V may be lost, as is generally the case with low level about 10 dB. This resonance peak, the band-pass char-
stimuli. There also are exceptions to the parallel shift acteristics of the outer and middle ear, and the fact that
of the latency-intensity function, for instance in cases the cochlea produces more synchronous responses at
of conductive losses that are not flat across frequency. the basal end, lead to ABR latencies that depend on
In these cases, the latency-intensity function may be the status of high frequency neurons, at least for click
altered because the configuration of the hearing loss stimulation.
produces shifts in the cochlear region that dominate Wave V latencies in subjects with cochlear hear-
the response (Gorga, Reiland, & Beauchaine, 1985). ing losses are essentially equivalent to those collected
Some ostensible conductive hearing losses can at the same nHL in normal hearing subjects (Selters &
arise from nonpathologic problems that can be avoided. Brackmann, 1977) as long as these stimuli are at least
The most common causes are ear canal collapse un- 20 dB above the threshold at 4000 Hz, the configura-
der earphones and slippage of the earphones during tion of the hearing loss is not steeply sloping, and the
the testing. Collapsing ear canals can be dealt with loss is no greater than mild to moderate in severity.
most accurately and effectively with the use of insert Latency-intensity functions for these subjects also con-
earphones. Alternative procedures may include using verge on those of normal hearing subjects at high in-
an open earmold, an earphone with a circumaural tensity levels, as shown for one subject in Figure 26.
cushion, or holding the earphone near (but not against) (In this case the hearing loss was fairly flat in configu-
the ear. Such procedures may affect the stimulus spec- ration and of a moderate degree.) Hearing losses con-
trum and, accordingly, the response latencies. Al- fined to the low frequencies have no appreciable effect
though this may compromise the judgment of normalcy on Wave V latencies.
of the absolute latencies, reasonably accurate evalua- Precipitously sloping high frequency losses of
tions of interwave latencies and interaural differences moderate severity, however, cause increased latencies
can be made by testing both ears in the same manner. (Bauch & Olsen, 1986; Coats & Martin, 1977; Gorga,
Earphone slippage can be detected by repeating the Reiland, & Beauchaine, 1985; Gorga, Worthington,
first test condition. If the latencies of the waves are Reiland, Beauchaine, & Goldgar, 1985). Presumably
longer on the final response, the earphone has prob- this is because of both the added time for the traveling
ably slipped from its proper placement over the ear wave to reach more normal regions of the cochlea and
(Noffsinger & Fowler, 1983). the reduction in stimulus intensity at the effective
Cochlear Hearing Loss. The ABR may be greatly stimulating frequencies of the resonant peak of the
influenced by cochlear hearing loss. The overall effect earphone. Additionally, it should be recognized that
the effects of high frequency hearing loss may not be
identical for all components of the ABR (Coats & Mar- brainstem lesions. Otoneurologically oriented evalu-
tin, 1977; Fowler & Noffsinger, 1983; Keith & Greville, ations of the ABR are the focus of this section. Several
1987). Clearly, for neurologic diagnostic purposes, the variables preclude the specification of a precise proce-
pure tone audiogram would be useful for accurate in- dure or method to analyze the ABR. First, the ABR must
terpretation of the ABR evaluation. be interpreted in the context of other available infor-
Several methods have been proposed to account mation, such as history, results of audiologic evalua-
for the latency delay introduced by cochlear hearing tion, and findings of physical examination. Second,
losses when attempting to screen for retrocochlear le- the auditory system is complex, and each wave of the
sions. One method is to identify Wave I through the ABR has multiple generators. Third, lesions vary in
normal electrode configuration or by placement of the their size and location. Finally, different pathologies
reference electrode in the ear canal. Then it can be de- that cause lesions at the same level may have similar
termined if the I-V interpeak latency difference is within effects on the ABR (e.g., acoustic tumor and vascular
normal limits. For cochlear hearing losses, the I-V compression of the eighth nerve). The consequence of
interpeak latency difference may be normal or slightly these factors is that there is no one ABR pattern that is
shorter than normal (Coats & Martin, 1977). Neverthe- uniquely characteristic of a given pathology, for ex-
less, the I-III interpeak latency interval can be pro- ample, acoustic tumor versus vascular compression of
longed slightly in cochlear hearing losses (with the eighth nerve or multiple sclerosis versus brainstem
concomitant shortening of the III-V interval), even infarct. This is true for any audiologic test that is used
when the I-V interpeak latency difference is within nor- to indicate site of lesion. There is, however, a general
mal limits (Fowler & Noffsinger, 1983). relationship between level of lesion and the effects of
the lesion on the ABR.
Various corrections for Wave V latency have been
suggested to take into account degree of peripheral loss The presence of a peripheral hearing loss may
(Hyde & Blair, 1981; Selters & Brackmann, 1977). Al- confound the interpretation of wave forms in precisely
ternatively, reference data can be collected on persons those patients for whom the results of the ABR evalu-
with different degrees and configurations of cochlear ation are most important. If hearing is symmetrical and
hearing loss. Finally, tone pip stimuli or ipsilateral nearly normal (assuming no other symptoms of neu-
masking can be used to limit the response to equiva- rologic consequence), suspicion of a retrocochlear pa-
lent response areas in normal and cochlear-impaired thology is low in comparison to the case in which there
subjects (Eggermont & Don, 1980; Kileny, Schlagheck, is a unilateral hearing loss and asymmetrical scores
& Spak, 1986). Because of insufficient data comparing on other auditory tests. The latter case, however, is one
these methods, there is no clear method of choice at this in which there may be poor waveform morphology and
time. prolonged wave latencies because of the peripheral
hearing loss. There are reports of ABR abnormalities
Diagnostic Interpretation of the ABR Evaluation in 95% or more cases with acoustic neuromas (e.g.,
There are two general uses of the ABR: threshold Selters & Brackmann, 1977). However, a false positive
estimation and identification of auditory nerve and rate of as high as 30% can occur in cases with asym-
metrical hearing losses (Clemis & Mitchell, 1977).
Thus, a complete audiologic work-up in conjunction
with the diagnostic ABR evaluation may provide more
information than either evaluation alone. Accuracy,
however, depends on the combined sensitivities and
specificities of each test and their intercorrelation. For
an extensive treatment of these factors and test perfor-
mance, the reader is referred to a series of papers by
Turner and his associates (Turner, Frazer, & Shepard,
1984; Turner & Nielsen, 1984; Turner, Shepard, &
Frazer, 1984).
Although it is not our purpose to prescribe specific
parameters for ABR evaluations, some generally use-
ful approaches to the evaluation may serve as points
of reference. For neurological diagnostic purposes,
Figure 26. Example of the effects of cochlear pathol- stimuli generally are presented at a sufficiently high
ogy on latencies of ABR Waves I, III, and V as shown intensity to elicit the potentials at or near their short-
by circles. Stippled area represents 2 standard de- est latencies. That is, click stimuli should be presented
viations of latencies for normal-hearing subjects.
at least 20 dB above the patients threshold at 4000 Hz reason, the terms transmission time or central conduc-
and/or at least at 95 dB peSPL (or approximately 60 tion time are often applied to interpeak intervals. Of
65 dB nHL). More than one intensity level often is nec- primary interest are the intervals between Waves I and
essary to identify clearly individual waves and to III, I and V, and III and V. These measures have the ad-
assist in the interpretation of anomalies in the re- vantage of separating a Wave V delay into its more
sponses. peripheral (I-III) and more central (Ill-V) components.
The fact that the population of neurons dominat- Prolongation of these intervals beyond the norms is
ing the ABR changes across intensity has several clini- generally suggestive of retrocochlear pathology (Fig-
cal implications. First, for neurological applications, ure 27a). Conductive and cochlear hearing losses do
Wave V latency norms should be based on the abso- not substantially affect the transmission time from
lute intensity of the stimulus and not on the subjective Waves I to V, although prolonged I-V intervals may be
threshold (e.g., sensation level) or perceived loudness observed in cases of notched cochlear hearing loss
of the stimulus. Second, in cases of high frequency (Keith & Greville, 1987). Thus, caution must be exer-
cochlear hearing losses, the response latencies may be cised in interpreting interpeak intervals in these cases
prolonged because neurons originating from more as well as in cases of unilateral or asymmetrical co-
apical regions will dominate the response. In other chlear losses because cochlear losses can delay Wave
words, there will be a delay, attributable to the propa- III without a concomitant delay in Wave V (Fowler &
gation characteristics of the traveling wave (Coats & Noffsinger, 1983) or shorten the I-V interval. A greater
Martin, 1977; Gorga, Reiland, & Beauchaine, 1985; problem in cases of substantial hearing loss and the
Gorga, Worthington, Reiland, Beauchaine, & Goldgar, major limitation in the use of the I-III and I-V intervals
1985). If, and only if, there is sufficient integrity of the is that Wave I may be resolved inadequately or may be
basal region of the cochlea and there is sufficient stimu- undetectable. In these cases, the application of
lus intensity, then this effect can be overcome. Third, it ECochG for resolving Wave I may be beneficial
is the intensity of the stimulus actually reaching the (Eggermont et al, 1980).
cochlea that is important. For example, increases in Interaural Latency Differences. Interaural latency
intensity can be used to compensate for any conduc- comparisons are applied primarily to absolute Wave
tive loss that may be present. V latencies (Clemis & McGee, 1979; Selters &
The criteria for determining the normalcy of the Brackmann, 1977). Normal variability of the interaural
ABR can be based on several characteristics of the re- latency difference suggests that it generally should be
sponse including: (a) absolute latencies, (b) interwave less than 0.30.4 ms. (See Figure 27a for an example of
latency differences, (c) interaural latency differences, an abnormal interaural latency difference.) The pri-
(d) absolute and relative amplitudes, (e) reproducibil- mary advantage of this measure is that it can be made
ity of wave forms, (f) waveform templates with cross- in the absence of Wave I. Another advantage is that
correlation analysis, and (g) the judgment of presence small retrocochlear disorders can be detected by small
versus absence of wave components. Of these, latency- latency differences between ears, even when both (ab-
based measures typically are used and are considered solute) latencies may fall within normal limits. Each
to be more reliable than amplitude-based measures. As subject is his/her own control. The major disadvan-
in any procedure, it is necessary to develop confidence tage is that unilateral or asymmetrical peripheral hear-
limits in order to account for the variance in the distri- ing losses may create latency differences between ears,
bution of scores of normal subjects. which can lead to false positive results. Here,
interaural differences in the interpeak intervals may
Absolute Latencies. Comparing the wave latencies be helpful.
to the range of normal values is the most basic method
for evaluating an ABR and yet it is the most vulner- Amplitudes. Norms for absolute amplitudes also
able. These latencies may be affected by various patho- can be developed and used for evaluative purposes.
logic (e.g., peripheral hearing loss) and non pathologic The major limitation is that amplitudes are highly vari-
factors (e.g., age). Still, absolute latencies are the single able (Thornton, 1975). This variability is due prima-
most used parameter of the ABR evaluation and are rily to the residual noise in the recording but also may
particularly critical for interpreting findings in cases reflect variables associated with electrode placement
of bilateral impairment when there is no normal ear and variability in the potentials themselves.
for comparison. An alternative to absolute amplitude measures is
Interwave Latency Differences. Presumably, the use of relative amplitudes, particularly the ratio
interpeak intervals (see Figure 15) somewhat reflect the between Wave V (or IV/V) and Wave I amplitudes
time necessary for a nerve impulse to travel from one (Starr & Achor, 1975). This method has the potential
generator site to another (Starr & Achor, 1975). For this advantage of controlling for sources of variability com-
mon to both waves. In practice the V:I ratio does not
establishment of a template response from a group of

normal hearing subjects and comparison of the ABR
from individual patients to the template. Such a tem-
plate can be formed by averaging the response from the
normal group, and the comparison can be quantified
by computing the correlation coefficient between the
template and the individual ABR. This approach is
plagued with difficulties if the SNR in the ABR under
evaluation is not held constant. It requires sophisti-
cated equipment and programming for analyses, and
there may be a need to develop appropriate templates
Figure 27. ABRs recorded from patients with surgi- for patients of different ages, genders, and types of
cally confirmed acoustic tumors. The top waveform hearing loss. Despite the limitations, the potential
in each panel is from a normal ear. The lower advantages of these techniques are obvious and new
waveform in (a) shows the prolonged I-V interval algorithms are being evaluated (e.g. Arnold, 1985; Don,
from a patient with an acoustic neuroma. The Elberling, & Waring, 1984; Elberling & Don, 1987).
lower waveform in (b) shows an absence of waves Absence of Waves. The absence of waves follow-
beyond Wave II from a patient with a meningioma ing Wave I is a strong indication of retrocochlear pa-
in the cerebello-pontine angle. thology (Figure 27b). On the other hand, the absence
of waves prior to V can result from cochlear pathology,
advancing age, high physiological noise levels, or
improve precision of measurement beyond that of the some stimulus parameters. An absence of waves fol-
absolute measures, primarily due to the variability of lowing III is a strong indication of pathology affecting
Wave I amplitude (Durrant, 1986). Also, this measure the rostral pons and midbrain. Waves II and IV tend to
only provides relative information about the integrity be demonstrated less reliably and are of less diagnos-
of the generators of Waves I and V and is not a mea- tic significance than Waves I, III, and V. The assign-
sure of the overall amplitude of the ABR. The effects of ment of wave numbers to the peaks of the ABR may be
stimulus parameters (e.g., see Emerson, Brooks, Parker, confounded by what appear to be extra or double
& Chiappa, 1982) and electrode placement must be peaked components. The interpretation of ABR find-
considered. The final and most obvious problem lies ings can be improved by using multiple trials at differ-
in the need for both waves to be present, although ent stimulus levels, different stimulus polarities, and
Wave I can be difficult to measure in many cases pre- two channel recordings.
senting with hearing loss.
Reproducibility of Waveforms. The comparison of ABRs and ABR Testing in Infants and
one tracing of the ABR with another gives a qualita- Children
tive determination of whether or not the two traces are ABRs from infants differ substantially from those
similar. In earlier discussions, this method was sug- obtained from adults. Maturation of the auditory sys-
gested as a means of judging the presence of a response. tem is not complete at birth. Consequently, the ABR
Such a comparison also can be done to assess undergoes significant changes early in life. Neverthe-
interaural differences in wave morphology. Even in the less, ABRs have been used in screening of preterm and
absence of clear interaural differences in latency mea- other high-risk neonates to identify the presence of
sures, different appearing waveforms for the two ears hearing loss and to determine the need for interven-
of stimulation could be suggestive of pathologic in- tion. Additionally, there has been interest in using the
volvement. Although this method lacks objectivity and ABR as a basis for estimating hearing levels in patients
suffers from a lack of control over fluctuating noise who do not yield adequate behavioral data (e.g., due
levels, obvious and consistent waveform differences to severe mental retardation). Certain factors that must
between ears cannot be ignored. Asymmetrical hear- be considered in the application of ABR testing to a
ing loss also can cause interaural differences in the pediatric population are discussed below.
ABR waveforms.
ABR Maturation
Waveform Templates. Another approach to ABR
evaluation is the use of a template for the normal re- ABRs in infants are different from those observed
sponse (Elberling, 1979b). The potential advantage of in adults (Fria, 1980; Starr et al., 1977). As shown in
automated scoring procedures is to increase objectiv- Figure 28, waveform morphology and response laten-
ity in ABR interpretation. This method requires the cies undergo a variety of changes as a function of age.
A summary of age-related latency changes is shown

in Figure 24. Wave I latencies reach adult values by 6
24 weeks, whereas latencies of Waves III and V do not
attain adult values until approximately 18 months. For
preterm infants, latencies of all components are pro-
longed compared to term infants. At about 2730
weeks gestational age (GA) a low amplitude ABR of
long latency can be recorded. Over the coming weeks,
latency rapidly decreases until 35 weeks GA and then
diminishes more gradually until term (3840 weeks
GA). Furthermore, during the first 18 months of life, the
Wave I-V interpeak interval systematically decreases
(Salamy & McKean, 1976). In preterm infants this
interwave latency can be as much as 78 ms (i.e., at 30
weeks GA) and decreases to roughly 5.2 ms at term, in
contrast to the approximate 4.0 ms of the mature re-
sponse.
The ABR also exhibits maturational changes in
terms of amplitudes of individual components
(Salamy, Fenn, & Bronshvag, 1979). Waves I and III
increase in amplitude until approximately 6 months
of chronologic age (CA), then decrease slightly until
adulthood. Wave V amplitude increases to a peak value
at between 24 and 60 months CA, and then decreases
slightly until adulthood.
Typically, the click-evoked ABR Wave V thresh-
old shows little or no age-dependent effects, at least for
children as young as 33 weeks conceptional age
(Gorga, Reiland, Beauchaine, Worthington, & Jesteadt,
1987). When frequency-specific stimuli have been
used, maturational effects vary with frequency. In gen-
eral, it has been shown that when ABRs are restricted
to the basal region of the cochlea, they exhibit the great-
est age-related differences in threshold and latencies
(Klein, 1984; Teas, Klein, & Kramer, 1982). When the Figure 28. ABR from subjects of different ages, as in-
responses are restricted to apical portions of the co- dicated. From The Auditory Brainstem Response:
chlea, through the use of masking or frequency-specific Background and Clinical Applications by T.J. Fria,
stimuli, the ABRs from infants are similar to ABRs from 1980, in Postnatal development of human brainstem
adults in terms of both VDLs and Wave V latencies life by A. Salamy and C.M. McKean, 1976, Electroen-
(Folsom & Wynne, 1986; Klein, 1984). Consequently, cephalography and Clinical Neurophysiology, 40, p. 421.
interpretation of ABR studies in infants must be made Copyright 1976 by Elsevier Scientific Publishers.
in light of the stimuli used to elicit responses. The time- Adapted by permission.
table for development of mature Wave V latencies,
when using mid- or low-frequency stimuli, is signifi- responses are within the normal range for his/her age.
cantly shorter than when using click stimuli (Teas et If only click stimuli are used, response detection thresh-
al., 1982). olds are relatively stable across age.
Clinical Application The relationship between ABR and behavioral
Failure to account for age-related differences in thresholds permits accurate predictions of hearing
infant responses can result in substantial errors in loss. This feature is useful because it allows assessment
hearing level estimation (up to 30 dB), particularly if of difficult-to-test patients who may be unable to pro-
stimuli are high-frequency tone pips (Klein, 1984). For vide voluntary responses to sound. As a consequence,
example, if adult norms (for either latency or detection hearing loss can be identified expediently permitting
threshold) are used, an infant might appear to deviate timely (re)habilitative intervention. It should be recog-
substantially from the norm when, in fact, the infants nized that there are certain cases when the ABR may
not accurately reflect auditory sensitivity, although Other Auditory Evoked Potentials
these cases are extremely rare (Murray, Javel & Watson,
The focus of this tutorial has been on the ECochGm
1985; Worthington & Peters, 1980). The interpretive
and ABR, which are the earliest segments of the elec-
accuracy of the ABR evaluation can be enhanced when
tric response of the brain to sound. The entire AEP may
it is combined with other data, such as acoustic immit-
last several hundred milliseconds or longer (Figure
tance measures, behavioral audiological measures,
29). Estimates of hearing sensitivity, using
and case history information.
electrophysiologic measures, have not been limited to
Although it is beyond the scope of this writing to the short latency responses. For example, responses in
delve into the details of strategies and protocols for the 1050 ms epoch, known as the middle latency re-
ABR evaluations directed toward auditory assess- sponses (MLRs), are recorded easily with minor para-
ment, a brief overview of the typical procedure can be metric and procedural changes from the ABR recording
given. An intensity series usually is conducted. Wave and are reportedly useful for obtaining near threshold
V is tracked down to the VDL, which is generally within information for low frequency stimuli (Mendel & Wolf,
10 dB of the behavioral threshold, at least for the higher 1983). The 40-Hz event-related or steady-state poten-
frequencies (Gorga, Reiland, & Beauchaine, 1985; tial has been reported to be useful for estimating low
Jerger & Mauldin, 1978). The latency-intensity function frequency sensitivity as well (Galambos, Makeig, &
also can be useful in such assessments (Coats & Mar- Talmachoff, 1981) although response variability as a
tin, 1977, Gorga, Reiland, & Beauchaine, 1985; Gorga, function of sleep state is problematic. Late or long la-
Worthington, Reiland, Beauchaine, & Goldgar, 1985), tency cortical EPs have a long history of clinical appli-
but the VDL is relied on most heavily for threshold es- cation (see Reneau & Hnatiow, 1975). Although the
timation. This procedure usually is repeated for each late responses can provide reasonably good estimates
ear, using stimuli of different frequencies, although of hearing thresholds, they are vulnerable to subject
such evaluations may be initiated with the click. state variables, such as level of arousal or even state of
Sedation attention (Schwent, Hillyard, & Galambos, 1976) and
are not currently used to estimate threshold. The corti-
Infants and young children up to 7 years of age cal potentials have been of interest because of their pre-
(or older, if uncooperative) typically require some form sumed relationship to the perceptual attributes of
of sedation in order to improve the SNR and to permit sound and interhemispheric differences and because
sufficient time to complete the test. Natural sleep is typi- of their various neurologic and psychiatric applica-
cally sufficient for infants up to 6 months of age, al- tions.
though it is usually safe to sedate younger children
(Fria, 1980). The MLRs and later responses are beyond the
scope of this writing, but it is important to recognize
The most common sedative used is chloral hy- that there may be useful information from activity re-
drate, although others (e.g., secobarbital and a cock- corded beyond the time window discussed in this tu-
tail of Demerol, phenergan, and thorazine) are often torial. Additionally, there are other phenomena and
used. Medical supervision of the administration of the applications related to the short latency potentials that
sedative and availability of medical personnel for were not covered in this document. These topics and
emergency intervention is required. The evaluation their kernel references include: the frequency follow-
must be carefully coordinated with the childs parents ing response and the SN-10 response (Davis, 1976),
or guardians so that the child will be appropriately hearing aid selection based on ABR measures
sedated at the time of the test. For example, it might be (Beauchaine, Gorga, Reiland & Larson, 1986; Gorga,
useful to deny a child his/her nap during the day of Beauchaine, & Reiland, 1987; Hecox, 1983), ABR moni-
the test. ABR testing must be carried out efficiently toring during surgery (Grundy, Janetta, Procopio, Lina,
because sedation wears off quickly. It is also important Boston, & Doyle, 1981; Moller & Janetta, 1983), and the
to remember that these sedatives differ from anesthe- use of ABR evaluation to assist in outcome prediction
sia, so that unnecessary stimulation (e.g., excessive or for the comatose patient and as a part of the assess-
abrupt body movement) should be avoided. Finally, in ment of brain death (Brewer & Resnick, 1984; Hall,
some cases where no sedation of any form is success- Mackey- Hargadine, & Kim, 1985; Hall & Tucker, 1986;
ful, general anesthesia may be the only recourse. In Seales, Rossiter, & Weinstein, 1979).
electing to test under general anesthesia, the risk-ben-
efit equation should be evaluated carefully. Guidelines The intent of this tutorial was to provide an over-
for the use of sedation and general anesthesia in pedi- view for clinicians of the short latency AEPs. The in-
atric patients have been formulated by the American fluence of instrumental, stimulus, and subject variables
Academy of Pediatrics (1985). were reviewed in the context of their effects on the clini-
cal application of AEPs. Both the strengths and limi-
Figure 29. Auditory evoked potential analyzed on logarithmic time-base to reveal the component potentials with
approximately equal weighting and categorized in arbitrary but commonly used time windows of short- (SLR),
middle- (MLR), and long- (LLR) latency responses. (Figure modified and redrawn from Michelini et al., 1982.)
tations of ECochG and ABR measures for threshold Bauch, C.D., & Olsen, W.O. (1986). The effect of 20004000
determination and otoneurologic diagnosis were dis- Hz hearing sensitivity on ABR results. Ear and Hearing,
cussed. The applications of these techniques are within 7, 314317.
the scope of practice of clinical audiologists, both from Beagley, H.A. (1974). Can we use the cochlear microphonic in
traditional and contemporary perspectives. This tuto- electrocochleography? Revue de Laryngologie, 95, 531536.
rial is intended to serve as a helpful tool for those clini- Beattie, R.C., Beguwala, F.E., Mills, D.M., & Boyd, R.L.
cal audiologists using these techniques and to prepare (1986). Latency and amplitude effects of electrode place-
ment on the early auditory evoked response. Journal of
them for future developments in this field.
Speech and Hearing Disorders, 51, 6370.
Beauchaine, K.A., Gorga, M.P., Reiland, J.K., & Larson, L.L.
References (1986). The application of auditory brainstem response
Achor, L J., & Starr, A. (1980a). Auditory brainstem re- measurements to the selection of hearing aids: Preliminary
sponses in the cat I: Intracranial and extracranial record- data. Journal of Speech and Hearing Research, 29, 120128.
ings. Electroencephalography and Clinical Neurophysiology, Bekesy, G. von (1960). Experiments in hearing. New York:
48, 154173. McGraw-Hill.
Achor, L.J., & Starr, A. (1980b). Auditory brainstem re- Berlin, C.I., Cullen, J.K., Ellis, M.S., Lousteau, R.J.,
sponses in the cat II: Effects of lesions. Yarbrough, W.M., & Lyons, G.D. (1974). Clinical appli-
Electroencephalography and Clinical Neurophysiology, 48, cation of recording human VIIIth nerve action poten-
174190. tials from the tympanic membrane. Transactions of the
Amadeo, M., & Shagass, C. (1973). Brief latency click- American Academy of Ophthalmology and Otolaryngology,
evoked potentials during waking and sleep in man. Psy- 78, 401410.
chophysiology, 10, 244250. Berlin, C.I., & Gorga, M.I. (1976). Extratympanic clinical
American Academy of Pediatrics. (1985). Guidelines for the electrocochleography with clicks. In R.J. Ruben, C.
elective use of conscious sedation, deep sedation, and Elberling, & G. Salomon (Eds.), Electrocochleography (pp.
general anesthesia in pediatric patients. Pediatrics, 76, 457469). Baltimore: University Park Press.
317321. Berlin, C.I, Gondra, M.I., & Casey, D. (1978). Bone conduc-
Aran, J.M. (1978). Contributions of electrocochleography tion electrocochleography: Clinical applications. Laryn-
to diagnosis in infancy. An 8 year survey. In S.E. Gerber goscope, 88, 756763.
& G.T. Mencher (Eds.), Early diagnosis of hearing loss (pp. Binnie, C.D., Rowan, A.J., & Gutter, T. (1982). A manual of
215242). New York: Grune & Stratton. electroencephalographic technology. Cambridge, England:
Arnold, S.A. (1985). Objective versus visual detection of the Cambridge University Press.
auditory brainstem response. Ear and Hearing, 6, 144150.
Boston, J.R., & Ainslie, P.J. (1980). Effects of analog and Davis, H. (1976). Principles of electric response audiometry.
digital filtering on brainstem auditory evoked poten- Annals of Otology, Rhinology, and Otolaryngology, 85
tials. Electroencephalography and Clinical Neurophysiology, (Suppl. 28), 196.
48, 361364. Dobie, R.A., & Berlin, C.I. (1979). Binaural interaction in
Brewer, C.C. (1987). Electrophysiologic measures. In H.G. brainstem-evoked responses. Archives of Otolaryngology,
Mueller, & V.C. Geoffrey (Eds.), Communication disorders 105, 391398.
in aging (pp. 334380). Washington, DC: Gallaudet Uni- Dobie, R.A., & Norton, S.J. (1980). Binaural interaction in
versity Press. human auditory evoked potentials. Electroen-
Brewer, C.C., & Resnick, D.M. (1984). The value of BAEP in cephalography and Clinical Neurophysiology, 49, 303313.
assessment of the comatose patient. In R.H. Nodar & Domico, W.D., & Kavanaugh, K.T. (1986). Analog and zero
C. Barber (Eds.), Evoked potentials II (pp. 578581). Bos- phase-shift digital filtering of the auditory brainstem
ton: Butterworth Publishers. response waveform. Ear and Hearing, 7, 377382.
Buchwald, J.S., & Huang, C.M. (1975). Far-field acoustic re- Don, M., & Eggermont, J.J. (1978). Analysis of the click-
sponse: Origins in the cat. Science, 189, 382384. evoked brainstem potentials in man using high-pass
Campbell, K.C.M., & Abbas, P.J. (1987). The effect of stimu- noise masking. Journal of the Acoustical Society of America,
lus repetition on the auditory brainstem response in 63, 10841092.
tumor and nontumor patients. Journal of Speech and Hear- Don, M., Eggermont, J.J., & Brackmann, D.E. (1979). Re-
ing Research, 30, 494502. construction of the audiogram using brainstem re-
Cann, J, & Knott, J. (1979). Polarity of acoustic click stimuli sponses and high-pass noise masking. Annals of Otology,
for eliciting brainstem auditory evoked responses: A Rhinology, and Laryngology, 88 (Suppl. 57), 120.
proposed standard. American Journal of Don, M., Elberling, C., & Waring, M. (1984). Objective detec-
Electroencephalography and Technology, 19, 125132. tion of averaged auditory brainstem responses. Scan-
Cevette, M.J. (1984). Auditory brainstem response testing dinavian Audiology, 13, 219228.
in the intensive care unit. Seminars in Hearing, 5, 5768. Durrant, J.D. (1977). Study of a combined noninvasive
Chu, N.S. (1985). Age related changes in the brainstem ECochG and BSER recording technique. Journal of the
auditory evoked potentials. Electroencephalography and Acoustical Society of America, 62, S87.
Clinical Neurophysiology, 62, 431436. Durrant, J.D. (1983). Fundamentals of sound generation.
Clemis, J.D., Ballad, W.J., & Killion, M.C. (1986). Clinical use In E.J. Moore (Ed.), Bases of auditory brainstem evoked re-
of an insert earphone. Annals of Otology, Rhinology, and sponses (pp. 1549). New York: Grune & Stratton.
Laryngology, 95, 520524. Durrant, J.D. (1986). Combined ECochG-ABR versus con-
Clemis, J.D., & McGee, T. (1979). Brainstem electric re- ventional ABR recordings. Seminars in Hearing
sponse audiometry in the differential diagnosis of acous- (Electrocochleography), 7, 289305.
tic tumors. Laryngoscope, 89, 3142. Durrant, J.D., Gabriel, S., & Walter, M. (1981). Psycho-
Clemis, J.D., & Mitchell, C. (1977). Electrocochleography physical tuning functions for brief stimuli: Preliminary
and brainstem responses used in the diagnosis of acous- report. American Journal of Otolaryngology, 2, 108113.
tic tumors. Journal of Otolaryngology, 6, 447459. Durrant, J.D., & Lovrinic, J.H. (1984). Bases of hearing sci-
Coats, A.C. (1974). On electrocochleographic electrode design. ence (2nd ed.) Baltimore: Williams & Wilkins.
Journal of the Acoustical Society of America, 56, 708711. Durrant, J.D., Shelhamer, M., Fria, T.J., & Ronis, M.L. (1981).
Coats, A.C. (1981). The summating potential and Menieres Examination of the sidedness of the brainstem auditory evoked
disease. Archives of Otolaryngology, 107, 199208. potential. Paper presented at the biennial symposium of
Coats, A.C. (1983). Instrumentation. In E.J. Moore (Ed.), the international response audiometry study group,
Bases of auditory brainstem evoked responses (pp. 197220). Bergamo, Italy.
New York: Grune & Stratton. Eggermont, J.J. (1976a). Analysis of compound action po-
Coats, A.C. (1986). Electrocochleography: Recording tech- tential responses to tone bursts in the human and guinea
niques and clinical applications. Seminars in Hearing pig cochlea. Journal of the Acoustical Society of America,
(Electrocochleography), 7, 247266. 60, 11321139.
Coats, A.C., & Martin, J.L. (1977). Human auditory nerve Eggermont, J.J. (1976b). Electrocochleography. In W.D.
action potentials and brainstem evoked responses. Ar- Keidel, & W.D. Neff (Eds.), Handbook of sensory physiol-
chives of Otolaryngology, 103, 605622. ogy, Vol. V/3: Auditory system-Clinical and special topics
Creel, D., Garber, S.R., King, R.A., & Witkop, C.J. Jr. (1980). (pp. 625705). Berlin: Springer-Verlag.
Auditory brainstem anomalies in human albinos. Sci- Eggermont, J.J., & Don, M. (1980). Analysis of the click-
ence, 209, 12531255. evoked brainstem potentials in humans using high-pass
Cullen, J.K. Jr., Ellis, M.S., Berlin, C.I. & Lousteau. R.J. (1972). noise masking. II. Effect of click intensity. Journal of the
Human acoustic nerve action potential recordings from Acoustical Society of America, 68, 16711675.
the tympanic membrane without anesthesia. Acta Eggermont, J.J., Don, M., & Brackmann, D.E. (1980).
Otolaryngologica, 74, 1522. Electrocochleography and auditory brainstem electric re-
Dallos, P. (1973). The auditory periphery. New York: Aca- sponses in patients with pontine angle tumors. Annals of
demic. Otology, Rhinology, and Laryngology, 89 (Suppl. 75), 119.
Eggermont, J.J., Odenthal, D.W., Schmidt, P.H., & Spoor, Fria, T.J., & Doyle, W.J. (1984). Maturation of the auditory
A. (1974). Electrocochleography: Basic principles and brainstem response (ABR): Additional perspectives. Ear
clinical application. Acta Otolaryngologica (Suppl. 316), 1 and Hearing, 5, 361365.
84. Galambos, R., Makeig, S., & Talmachoff, P.J. (1981). A 40-
Elberling, C. (1979a). Auditory electrophysiology: Spectral Hz auditory potential recorded from the human scalp.
analysis of cochlear and brainstem evoked potentials. Proceedings of the National Academy of Science, 78, 2643
Scandinavian Audiology, 8, 5764. 2647.
Elberling, C. (1979b). Auditory electrophysiology: The use Geddes, L.A. (1972). Electrodes and the measurement of bio-
of templates and cross correlation functions in the analy- electric events. New York: Wiley-Interscience.
sis of brainstem potentials. Scandinavian Audiology, 8, Gibson, W.P.R., Moffat, D.A., & Ramsden, R.T. (1977). Clini-
187190. cal electrocochleography in the diagnosis and manage-
Elberling, C., & Don, M. (1987). Threshold characteristics ment of Menieres disorder. Audiology, 16, 389401.
of the human auditory brainstem response. Journal of Glattke, T.J. (1983). Short latency auditory evoked potentials.
the Acoustical Society of America, 81, 115121. Baltimore: University Park Press.
Elberling, C., & Salomon, G. (1973). Cochlear microphonics Gorga, M.P., Abbas, P.J., & Worthington, D.W. (1985).
recorded from the ear canal in man. Acta Otolaryngologica, Stimulus calibration in ABR measure-ments. In J.T.
75, 489495. Jacobson (Ed.), The auditory brainstem response (pp. 49
Emerson, R.G., Brooks, E.B., Parker, S.W., & Chiappa, K.H. 62). San Diego, CA: College-Hill.
(1982). Effects of click polarity on brainstem auditory Gorga, M.P., Beauchaine, K.A., & Reiland, J.K. (1987). Com-
evoked potentials in normal subjects and patients: Un- parison of onset and steady-state responses of hearing
expected sensitivity of Wave V. Annals of the New York aids. Implications for use of the auditory brainstem re-
Academy of Science, 288, 710721. sponse in the selection of hearing aids. Journal of Speech
Ferraro, J.A. (Ed.). (1986). Seminars in Hearing and Hearing Research, 30, 130136.
(Electrocochleography), 7, 241337. Gorga, M.P., Beauchaine, K.A., Reiland, J.K., Worthington,
Ferraro, J.A., Arenberg, I.K., & Hassanein, R.S. (1985). D.W., & Javel, E. (1984). The effects of stimulus duration
Electrocochleography and symptoms of inner ear dys- on ABR and behavioral thresholds. Journal of the Acous-
function. Archives of Otolaryngology, 111, 7174. tical Society of America, 76, 616619.
Ferraro, J.A., & Ferguson, R. (in press). Tympanic ECochG Gorga, M.P., Reiland, J.K., & Beauchaine, K.A. (1985). Au-
and conventional ABR: A combined approach for the ditory brainstem responses in a case of high-frequency
identification of Wave I and the I-V interwave interval. conductive hearing loss. Journal of Speech and Hearing Dis-
American Journal of Otology. orders, 50, 346350.
Ferraro, J.A., Murphy, G.B., & Ruth, R.A. (1986). A com- Gorga, M.P., Reiland, J.K., Beauchaine, K.A., Worthington,
parative study of primary electrodes used in D.W., & Jesteadt, W. (1987). Auditory brainstem re-
extratympanic electrocochleography. Seminars in Hear- sponses from graduates of an intensive care nursery:
ing, 7, 279287. Normal patterns of response. Journal of Hearing Research,
Finitzo-Hieber, T., Hecox, K., & Cone, B. (1979). Brainstem 30, 311318.
auditory evoked potentials in patients with congenital Gorga, M.P., Worthington, D.W., Reiland, J.K., Beauchaine,
atresia. Laryngoscope, 89, 11511158. K.A., & Goldgar, D.E. (1985). Some comparisons be-
Folsom, R.C. (1984). Frequency specificity of human audi- tween auditory brainstem response thresholds, laten-
tory brainstem responses as revealed by pure-tone cies, and the pure-tone audiogram. Ear and Hearing, 6,
masking profiles. Journal of the Acoustical Society of 105112.
America, 66, 919914. Grundy, B.L., Janetta, P.J., Procopio, P., Lina, A., Boston,
Folsom, R.C., & Wynne, M.K. (1986). Auditory brainstem J.R., & Doyle, E. (1981). Intraoperative monitoring of
responses from human adults and infants: Restriction brainstem auditory evoked potentials. Journal of Neuro-
of frequency contribution by notched-noise masking. surgery, 57, 674681.
Journal of the Acoustical Society of America, 80, 10571064. Hall, J.W. III, Mackey-Hargadine, J.R., & Kim, E.E. (1985).
Fowler, C.G., & Noffsinger, D. (1983). The effects of stimu- Auditory brainstem response in the determination of
lus repetition rate and frequency on the auditory brain death. Archives of Otolaryngology, 111, 613620.
brainstem response in normal, cochlear-impaired, and Hall, J.W. III, & Tucker, D.A. (1986). Sensory evoked re-
VIII nerve/brainstem-impaired subjects. Journal of sponses in the intensive care unit. Ear and Hearing, 7, 220
Speech and Hearing Research, 26, 560567. 232.
Fowler, C.G., & Swanson, M.R. (1988). Binaural and monau- Harris, D.M., & Dallos, P.J. (1979). Forward masking of
ral phasic differences in the auditory brainstem response. auditory nerve fiber responses. Journal of Neurophysiol-
Manuscript submitted for publication. ogy, 42, 10831107.
Fria, T.J. (1980). The auditory brainstem response: Back- Harris, F.J. (1978). On the use of windows for harmonious
ground and clinical applications. Monographs in Contem- analysis with the discrete Fourier Transform. Proceed-
porary Audiology, 2, 144. ings of the IEEE, 66, 5183.
Hashimoto, I., Ishiyama, Y., & Tozuka, G. (1979). Bilater- Martin, M., & Moore, E. (1977). Scalp distribution of early
ally recorded brainstem auditory evoked responses. (010 msec) auditory evoked responses. Archives of Oto-
Their asymmetric abnormalities and lesions of the laryngology, 103, 326328.
brainstem. Archives of Neurology, 36, 161167. Mauldin, L. & Jerger, J. (1979). Auditory brainstem evoked
Hecox, K.E. (1983). Role of auditory brainstem responses in responses to bone-conducted signals. Archives of Oto-
the selection of hearing aids. Ear and Hearing, 4, 5155. laryngology, 105, 656661.
Hecox, K., Squires, N., & Galambos, R. (1976). Brainstem McClelland, R.J., & McCrea, R.S. (1979). Intersubject viabil-
auditory evoked responses in man. I. Effect of stimulus ity of the auditory-evoked brainstem potentials. Audi-
rise-fall time and duration. Journal of the Acoustical Soci- ology, 18, 462471.
ety of America, 60, 11871192. Mendel, M.I., & Wolf, K.E. (1983). Clinical applications of
Hoke, M., & Lutkenhoner, B. (1981). Electrophysiological the middle latency responses. Audiology: A Journal for
findings in patients with sudden deafness: A survey. In Continuing Education, 8, 141155.
Advances in otorhinolaryngology (pp. 8399). Basel: S. Mendelson, T., Salamy, A, Lenoir, M., & McKean, C. (1979).
Karger. Brainstem evoked potential findings in children with
Hood, L.J., & Berlin, C.I. (1986). Auditory evoked potentials. otitis media. Electroencephalography and Clinical Neuro-
Austin, TX: Pro-Ed. physiology, 105, 1720.
Hyde, M.L. (1985). The effect of cochlear lesions on the Michelini, S., Arslan, E.. Prosser, S., & Pedrielli, F. (1982).
ABR. In J.T. Jacobson (Ed.), The auditory brainstem re- Logarithmic display of auditory evoked potentials. Jour-
sponse (pp. 133146). San Diego, CA: College Hill Press. nal of Biomedical Engineering, 4, 6264.
Hyde, M.L., & Blair, R.L. (1981). The auditory brainstem Moller, A.R. (1986). Effect of click spectrum and polarity
response in neuro-otology: Perspectives and problems. on round window N1N2 response in the rat. Audiology,
Journal of Otolaryngology, 10, 117125. 25, 2943.
Jacobson, J.D. (Ed.) (1985). The auditory brainstem response. Moller, A.R., & Jannetta, P.J. (1982). Comparison between
San Diego, CA: College-Hill Press. intracranially recorded potentials from the human au-
Jerger, J., & Hall, J. (1980). Effects of age and sex on audi- ditory nerve and scalp recorded auditory brainstem re-
tory brainstem response. Archives of Otolaryngology, 106, sponses (ABR). Scandinavian Audiology, 11, 3340.
387391. Moller, A.R., & Jannetta, P.J. (1983). Monitoring auditory
Jerger, J., & Mauldin, L. (1978). Prediction of sensorineural functions during cranial nerve microvascular decom-
hearing level from the brainstem evoked response. pression operations by direct monitoring from the
Archives of Otolaryngology, 104, 454461. eighth nerve. Journal of Neurosurgery, 59, 493499.
Jewett, D.L. (1970). Volume-conducted potentials in re- Moller, A.R., Jannetta, P.J., Bennett, M., & Moller, M.B.
sponse to auditory stimuli as detected by averaging in (1981). Intracranially recorded responses from the hu-
the cat. Electroencephalography and Clinical Neurophysiol- man auditory nerve: New insights into the origin of
ogy, 28, 609618. brainstem evoked potentials (BSEP). Electroenceph-
Jewett, D.L., Romano, M.N., & Williston, J.S. (1970). Human alography and Clinical Neurophysiology, 52, 1827.
auditory evoked potentials: Possible brainstem compo- Moller, K., & Blegvad, B. (1976). Brainstem responses in
nents detected on the scalp. Science, 167, 15171518. patients with sensorineural hearing loss. Scandinavian
Jewett, D.L., & Williston, J.S. (1971). Auditory evoked far fields Audiology, 5, 115127.
averaged from the scalp of humans. Brain, 94, 681696. Moore, E.J. (Ed.). (1983). Bases of auditory brainstem evoked
Joint Commission on Accreditation of Hospitals. (1987). responses. New York: Grune & Stratton.
Standard PI.9: Patient care equipment. Accreditation Murray, A.D., Javel, E., & Watson, C.S. (1985). Prognostic
Manual for Hospitals, 199200. validity of auditory brainstem evoked response screen-
Keith, W.J. & Greville, K.A. (1987). Effects of audiometric ing in newborn infants. American Journal of Otolaryn-
configuration on the auditory brainstem response. Ear gology, 6, 120131.
and Hearing, 8, 4955. Naunton, R.F., & Zerlin, S.S. (1976). Basis and some diag-
Kevanishvili, Z., & Aphonchenko, V. (1979). Frequency nostic implications of electrocochleography. Laryngo-
composition of brainstem auditory evoked potentials. scope, 86, 475482.
Scandinavian Audiology, 8, 5155. Noffsinger, D., & Fowler, C.G. (1983). Brainstem auditory
Kileny, P., Schlagheck, G., & Spak, C. (1986). Site of lesion evoked potentials: Applications in clinical audiology. Bul-
ABR testing with tonal stimuli. Paper presented at the letin of the Los Angeles Neurological Societies, 47, 4354.
annual convention of the American Speech-Language- Nuttall, A.H. (1981). Some windows with very good
Hearing Association, Detroit. sidelobe behavior. IEEE Transactions on Acoustics, Speech
Klein, A.J. (1984). Frequency and age-dependent auditory and Signal Processing, 29, 8491.
evoked thresholds in infants. Hearing Research, 16, 291297. Nyquist, H. (1924). Certain factors affecting telegraph
Kodera, K., Marsh, R.R., Suzuki, M., & Suzuki, J. (1983). Por- speed. Bell System Technical Journal, 3 (2), 324346.
tions of tone pips contributing to frequency-selective Pfeiffer, R.R. (1974). Consideration of the acoustic stimu-
auditory brainstem responses. Audiology, 22, 209218. lus. In W.D. Keidel, & W.D. Neff (Eds.), Handbook of sen-
sory physiology, Vol. V/l: Auditory system-Anatomy and
physiology (ear) (pp. 938). Berlin: Springer-Verlag.
Picton, T.W., & Hillyard, S.A. (1974). Human auditory Sohmer, H, & Feinmesser, M. (1973). Routine use of
evoked potentials. II. Effects of attention. electrocochleography (cochlear audiometry) on human
Electroencephalography and Clinical Neurophysiology, 36, subjects. Audiology, 12, 167173.
191200. Sohmer, H., & Feinmesser, M. (1974). Electrocochleography
Picton, T.W., & Hink, R.F. (1974). Evoked potentials: How? in clinical-audio logical diagnosis. Archives of Otolaryn
What? Why? American Journal of EEG Technology, 14, 944. gology, 206, 91102.
Picton, T.W., Ouellette, J., Hamel, G., & Smith, A.D. (1979). Sohmer, H, Feinmesser, M., & Bauberger-Tell, L. (1972).
Brainstem evoked potentials to tonepips in notched Routine use of cochlear audiometry in infants with un-
noise. Journal of Otolaryngology, 8, 289314. certain diagnosis. Annals of Otology, Rhinology, and Laryn-
Picton, T.W., Stapells, D.R., & Campbell, K.B. (1981). Audi- gology, 81, 7275.
tory evoked potentials from the human cochlea and Sohmer, H., Feinmesser, M., & Szabo, G. (1974).
brainstem. Journal of Otolaryngology, 10 (Suppl. 9), 141. Electrocochleographic (auditory nerve and brainstem
Probst, R. (1983). Electrocochleography: Using extratym- auditory nuclei) responses to sound stimuli in patients
panic or transtympanic methods? ORL-Journal of Otorhi- with brain damage. Electroencephalography and Clinical
nolaryngology and Related Specialties, 45, 322329. Neurophysiology, 37, 663669.
Reneau, J.P., & Hnatiow, G.Z. (1975). Evoked response audi- Sohmer, H., Gafni, M., & Chisin, R. (1978). Auditory nerve
ometry. Baltimore: University Park Press. and brainstem responses: Comparison in awake and
Rosenhall, U., Bjorkman, G., Pederson, K., & Kall, H. (1985). unconscious subjects. Archives of Neurology, 35, 228230.
Brainstem auditory evoked potentials in different age Sohmer, H., & Pratt, H. (1976). Recording of the cochlear
groups. Electroencephalography and Clinical Neurophysi- microphonic potential with surface electrodes.
ology, 62, 426430. Electroencephalography and Clinical Neurophysiology, 40,
Rowe, M.J. (1978). Normal variability of the brainstem 253260.
auditory evoked response in young and old adult sub- Squires, K.C., Chu, N., & Starr, A. (1978). Acute effects of
jects. Electroencephalography and Clinical Neurophysiology, alcohol on auditory brainstem potentials. Science, 201,
44, 459470. 174176.
Ruth, R.A., Lambert, R.R., & Ferraro, J.A. (in press). Staller, S. (1986). Electrocochleography in the diagnosis and
Electrocochleography: Methods and clinical applica- management of Menieres disease. Seminars in Hearing
tions. American Journal of Otology. (Electrocochleography), 7, 267277.
Ruth, R.A., Mills, J.A., & Ferraro, J.A. (in press). The use of Stapells, D.R., & Picton, T.W. (1981). Technical aspects of
disposable ear canal electrodes in auditory brainstem brainstem evoked potential audiometry using tones. Ear
response testing. American Journal of Otology. and Hearing, 2, 2029.
Salamy, A., Fenn, E., & Bronshvag, M. (1979). Ontogenesis Stapells, D.R., Picton, T.W., Perez-Abalo, M., Read, D., &
of human auditory brainstem evoked potential ampli- Smith, A. (1985). Frequency specificity in evoked poten-
tude. Developmental Psychology, 12, 519526. tial audiometry. In J.T. Jacobson (Ed.), The auditory
Salamy, A., & McKean, C. M. (1976). Postnatal development brainstem response (pp. 147177). San Diego, CA: Col-
of human brainstem potentials during the first year of lege-Hill.
life. Electroencephalography and Clinical Neurophysiology, Stapells, D.R., Picton, T.W., & Smith, A.D. (1982). Normal
40, 418426. hearing thresholds for clicks. Journal of the Acoustical
Salt, A.N., & Thornton, A.R. (1983). The effects of stimulus Society of America, 72, 7479.
rise-time and polarity on the auditory brainstem re- Starr, A., & Achor, L.J. (1975). Auditory brainstem responses
sponses. Scandinavian Audiology, 13, 119127. in neurological disease. Archives of Neurology, 32, 761
Schwartz, D.M., Larson, V.D., & DeChicchis, A.R. (1985). 768.
Spectral characteristics of air and bone conduction trans- Starr, A., Amlie, R.N., Martin, W.H., & Sanders, S. (1977).
ducers used to record the auditory brainstem response, Development of auditory function in newborn infants
Ear and Hearing, 6, 274277. revealed by auditory brainstem potentials. Pediatrics, 60,
Schwent, V.L., Hillyard, S.A., & Galambos, R. (1976). Selec- 831839.
tive attention and the auditory vertex potential. I. Ef- Stockard, J.J., Sharbrough, F.W., & Tinker, J.A. (1978). Ef-
fects of stimulus delivery rate. Electroencephalography and fects of hypothermia on the human brainstem auditory
Clinical Neurophysiology, 40, 604614. response. Annals of Neurology, 3, 368370.
Seales, D.M., Rossiter, V.S., & Weinstein, M.D. (1979). Stockard, J.J., Stockard, J.E., & Sharbrough, F.W. (1978).
Brainstem auditory evoked responses in patients coma- Nonpathologic factors influencing brainstem auditory
tose as a result of blunt head trauma. Journal of Trauma, evoked potentials. American Journal of Electroenceph-
19, 347353. alogram Technology, 18, 177209.
Selters, W.A., & Brackmann, D.E. (1977). Acoustic tumor Stypulkowski, P.H., & Staller, S.J. (1987). Clinical evalua-
detection with brainstem electric response audiometry. tion of a new ECochG recording electrode. Ear and Hear-
Archives of Otolaryngology, 103, 181187. ing, 8, 304310.
Sohmer, H., & Feinmesser, M. (1967). Cochlear action po- Suzuki, T., Hirai, Y., & Horiuchi, K. (1977). Auditory
tentials recorded from the external ear in man. Annals brainstem responses to pure tone stimuli. Scandinavian
of Otology, Rhinology, and Laryngology, 76, 427435. Audiology, 6, 5156.
Suzuki, T., & Horiuchi, K. (1977). Effect of high-pass filter Wada, S.I., & Starr, A. (1983b). Generation of auditory
on auditory brainstem responses to tone pips. Scandi- brainstem responses (ABRs). II. Effects of surgical sec-
navian Audiology, 6, 123126. tion of the trapezoid body on the ABR in guinea pigs
Suzuki, J.I., & Yamane, H. (1982). The choice of stimulus in and cat. Electroencephalography and Clinical Neurophysi-
the auditory brainstem response test for neurological ology, 56, 340351.
and audiological examinations. Annals of the New York Wada, S.I., & Starr, A. (1983c). Generation of the auditory
Academy of Sciences, 388, 731736. brainstem responses (ABRs). III. Effects of lesions of the
Teas, D.C., Eldridge, D.H., & Davis, H. (1962). Cochlear re- superior olive, lateral lemniscus and inferior colliculus
sponses to acoustic transients and interpretation of the on the ABR in guinea pig. Electroencephalography and
whole nerve action potentials. Journal of the Acoustical Clinical Neurophysiology, 56, 352366.
Society of America, 34, 14381459. Weber, B.A. (1983). Masking and bone conduction testing
Teas, D.C., Klein, A.J., & Kramer, S.K. (1982). An analysis in brainstem response audiometry. Seminars in Hearing,
of auditory brainstem responses in infants. Hearing Re- 4, 343352.
search, 7, 1954. Weber, B.A., Seitz, M.R., & McCutcheon, M.J. (1981). Quan-
Terkildsen, K., Osterhammel, P., & Huis int Veld, F. (1974). tifying click stimuli in auditory brainstem response au-
Far field electrocochleography: Electrode positions. diometry. Ear and Hearing, 2, 1519.
Scandinavian Audiology, 3, 123129. Wever, E G., & Bray, C.W. (1930). Action currents in the
Thornton, A.R.D. (1975). Statistical properties of surface- auditory nerve in response to acoustic stimulation. Pro-
recorded electrocochleographic responses. Scandinavian ceedings of the National Academy of Sciences of the United
Audiology, 4, 91102. States of America, 16, 344350.
Turner, R.G., Frazer, G.J., & Shepard, N.T. (1984). Formu- Whitaker, S.R., & Lewis, A.E. (1984). The clinical usefulness
lating and evaluating audiological test protocols. Ear and of extratympanic electrocochleography. Paper presented at
Hearing, 5, 321330. the Midwinter Meeting of the Association for Research
Turner, R.G., & Nielsen, D.W. (1984). Application of clini- in Otolaryngology, St. Petersburg Beach, FL.
cal decision analysis to audiological tests. Ear and Hear- Worthington, D.W., & Peters, J.F. (1980). Quantifiable hear-
ing, 5, 125133. ing and no ABR: Paradox or error? Ear and Hearing, 1,
Turner, R.G., Shepard, N.T., & Frazer, G.J. (1984). Clinical 281285.
performance of audiological and related diagnostic tests. Yanz, J.L., & Dodds, H.J. (1985). An ear-canal electrode for
Ear and Hearing, 5, 187194. the measurement of the human auditory brainstem re-
van Olphen, A.F., Rodenburg, M., & Verway, C. (1978). Dis- sponse. Ear and Hearing, 6, 98104.
tribution of brainstem responses to acoustic stimuli over
the human scalp. Audiology, 17, 511578.
Wada, S.I., & Starr, A. (1983a). Generation of auditory
brainstem responses (ABRs). I. Effects of injection of a
local anesthetic (procaine HCL) into the trapezoid body
of guinea pigs and cat. Electroencephalography and Clini-
cal Neurophysiology, 56, 326339.

Asha - Bera

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Asha - Bera

Caricato da

Copyright:

Formati disponibili

Relevant

Audiologic Evaluation Working Group on

Introduction recorded, and their sensitivity to dysfunctions of the

adapter is unacceptable. The test instrument and out-

the combination of stimulus parameters and record-

Figure 5. An electrode assembly for recording from

Figure 9. CM input-output function (based on mean

Figure 10. Effects of stimulus rate in clicks per sec-

Measurement of Auditory Brainstem

lus parameters and the status of the middle and inner

Figure 17. (a) Broad-band click-elicited ABRs. (b)

mation is lost because rarefaction, condensation, and

ing and hearing loss on absolute latency should be

establishment of a template response from a group of

A summary of age-related latency changes is shown

Potrebbero piacerti anche