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The Pathophysiology of Auditory Neuropathy Spectrum Disorders…for Dr. Jie Wang Beijing Symposium Sept 2011. - PowerPoint PPT Presentation
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The Pathophysiology of Auditory Neuropathy Spectrum Disorders…for Dr. Jie Wang Beijing Symposium Sept 2011
Charles I. Berlin PhD Research Professor Otolaryngology Head and Neck Surgery University of South Florida and Clinical Coordinator of the All Childrens Hospital Center for Auditory Neuropathy Spectrum Disorders, St. Petersburg [email protected]
All slides and teaching material will be posted online at:
•www.kresgelab.com
How different is Auditory Neuropathy/Dys-synchrony from “regular hearing loss”?
• What do they sound like? (Simulations of filtered speech from Berlin, CI, Ed. Hair Cells and Hearing Aids, Singular Press, 1996 and The Auditory Tour, U of Wisconsin http://www.neurophys.wisc.edu/ftp/pub/aud-tour/windows/index.html; and F. G. Zeng et al. http://www.ucihs.uci.edu/com/hesp/newversion/procSim/simulations.htm.)
• What are the underlying physiologic differences?• How is it diagnosed and what difference does it make…
shouldn’t we still rely on the audiogram to provide guidelines for treatment and management? Anectdotal Evidence says the audiogram can be very misleding.
A brief review of how the diagnosis of AN/AD is made?• Absent or abnormal ABR or Electrocochleography. • Normal, or at one time normal, otoacoustic emissions, in the
presence of…• ABSENT or Elevated Middle Ear Muscle Reflexes.• Other signs…
Using physiology to IDENTIFY patients with auditory dys-synchrony/neuropathy
• Our first patient was thought to have a peripheral (cochlear) hearing loss after a space-occupying lesion was ruled out.
• History:• Female, 47 years old• Hearing loss first documented at 11 years, possibly
congenital• Problems understanding many words and hearing in
background noise
Pure-Tone Audiogram
Middle Ear MeasuresMiddle Ear Measures
• Tympanograms
• Ipsilateral reflexes
• Contralateral reflexes
• Non-acoustic reflexes
• Normal
• Absent
• Absent
• Present
Speech AudiometrySpeech Audiometry
• Word recognition in quiet:• Right ear: 12% at 85 dB HL• Left ear: 20% at 80 dB HL
• Word and sentence recognition in noise: 0% at signal-noise ratio of +10 dB
Auditory Brainstem Auditory Brainstem ResponseResponse
• No synchronous neural discharge
• Cochlear microphonic present and reversed with polarity reversals
Masking Level DifferenceMasking Level Difference (MLD)(MLD)
• No masking level differences at 250 or 500 No masking level differences at 250 or 500 Hz.Hz.
• Normal MLDs for these stimuli are 10-12 Normal MLDs for these stimuli are 10-12 dB.dB.
• MLDs take advantage of the ability to MLDs take advantage of the ability to process phase differences at the level of process phase differences at the level of the brainstem and are sensitive to auditory the brainstem and are sensitive to auditory nerve and lower brainstem problems.nerve and lower brainstem problems.
RadiologyRadiology
CT Scan with contrast: – Normal internal auditory
canals
Magnetic Resonance Imaging:– No tumors at the
cerebellar pontine angle– No intracranial neoplasm
Initial Management Plan
• With negative results of radiology and an apparent cochlear disorder, trial of hearing aids was recommended.
• Low-frequency emphasis hearing aids were fit with an earmold that allowed natural use of HF information (in the range of her normal hearing).
• She tried the hearing aids for several weeks but reported no benefit.
• She used lipreading and occasional notes to communicate.
When OAEs arrived…
OAEs are normal suggesting normal outer hair cell function and helping to explain why hearing aids didn’t help.
Cochlear Hearing Loss Cochlear Hearing Loss (Patient MS)(Patient MS)
Auditory Neuropathy PatientAuditory Neuropathy Patient
To avoid missing these patients, or confusing them with CAPD patients, we recommend the following triage with each new patient as follows:
• Tympanometry• Middle Ear Muscle Reflexes• Otoacoustic Emissions.• See blank Chart …
Construct Desk Chart for Triage or sorting.
Test Normal Outer Hair Cell
Inner Hair cell/nerve fibers
Conductive
Tymps/Reflectance
A
Reflexes PRESENT 95 DB OR <
Emissions 6 dB S/N ormore
ABR Normal latency-intensity
Construct Desk Chart for Triage or sorting.
Test Normal Outer Hair Cell
Inner Hair cell/nerve fibers
Conductive
Tymps/Reflectance
a a B and c
Reflexes Normal levels
Elevated or absent
Absent or elevated
Emissions absent Present or one time present
Absent or reduced
ABR Normal untilthreshold
Absent desynchronized
Shifted to right
At present, how do we test outer vs. inner hair cells?• Outer Hair Cells can be tested
with two procedures:• 1. Otoacoustic Emissions.• 2. Cochlear microphonics
using insert earphones and reversing the polarity of the click at least once at the end of a completed average. (Berlin, Hood, et al. 1998)
• Inner Hair Cells can be tested with FIVE procedures:• EcochG• ABR (remember to separate
CM from AP). CLIP the TUBE to rule out induction artifacts !!
• Summating Potentials.• Cochlear Microphonics• MIDDLE EAR MUSCLE
REFLEXES. If these are absent or elevated above 95dB HL, in the presence of normal emissions, it warrants further careful investigation. (Berlin, Hood et al. 2005)
Insert versus supra-aural earphones
CM
neural components do not.
AN/AD patient - all CM, no neural response
ABR and Cochlear Microphonics (CM - electrical responses generated in part by the outer hair cells)
Normal ABR to condensation and rarefaction clicks; CM inverts -
A Normal ABR on the Left, a Potential Trap or Misdiagnosis of Central Brain Disorder on the Right
Reverse the Click Polarity and What Looked Like an ABR is Revealed as a Cochlear Microphonic
A review of the underlying physiology• The normal human ear in motion.• The paradox of the human threshold detection vs. the 65 dB
dynamic range of the inner hair cell.• Outer hair cell function vs. Inner Hair Cell Function (Spoendlin,
Brownell, Ruggero, Jont Allen)
HOW DO THE OUTER HAIR CELLS APPEAR TO OVERCOME THIS PARADOX?
Hair Cell in Action from Jonathan Lear Ashmore and/or Bogota Colombia Laboratory.
Displacement of the Chinchilla Basilar Membrane Relative to the Stapes Adapted from Ruggero in Berlin, 1996
Idealized Gain Function of a Hearing Aid Which Would Do Somewhat the Same Thing in the Intensity Domain and Whose Compression Knee Begins at 40 dB Input Adapted from Berlin, 1996
Siblings with AN/AD
• Tympanometry normal• Reflexes absent
• Emissions Present• ABR…• Management…
• Video of Patient before implantation.
• Video after cochlear implantation, done at the mother’s insistence…
ABR from subjects with “corner audiograms” and Otoferlin mutations affecting inner hair cells.
Temporal Bone of Premature, Amatuzzi et al. June 2001 Arch Otolaryngology
Temporal Bone of Premature, Courtesy of Mass. Eye and Ear Published in June 2001 Arch Otolaryngology
Normal nerve fiber count insidethe habenula perforata,
Temporal Bone of Premature, Courtesy of Mass. Eye and Ear Published in June 2001 Arch Otolaryngology
Note missing Inner Hair cell, Normal nerve fiber count insidethe habenula perforata,
Temporal Bone of Premature, Courtesy of Mass. Eye and Ear Published in June 2001 Arch Otolaryngology
Note missing Inner Hair cell, Normal nerve fiber count insidethe habenula perforata, and normal outer hair cells which would lead to and normal outer hair cells which would lead to normal emissions and NO ABRnormal emissions and NO ABR
A Normal ear; B selective OHC loss; C combined IHC andOHC loss; D–F complete IHC loss with scattered or no OHC loss.
From Amatuzzi. Liberman and Northrop JARO 2011
Alternatively, Starr et al. show this type of pathophysiology
Comparing a normal cochlea (right) to one with Auditory Neuropathy
From Starr et al. MPZ Gene paper
My patients are mostly adults,
Does this happen much in adults?See Brian CJ Moore and Chris Turner and their work on Dead Zones and see for example:Dead regions and noisiness of pure tones. Huss M, Moore BC.Int J Audiol. 2005 Oct;44(10):599-611.3 A clinical perspective on cochlear dead regions: intelligibility of speech and subjective hearing aid benefit. Preminger JE, Carpenter R, Ziegler CH.J Am Acad Audiol. 2005 Sep;16(8):600-13;
Patient who acquired AN/AD• History of normal hearing until she was beaten
unconscious by an abusive boyfriend• Claimed subsequently to be totally deaf to speech
and pure tones• Tympanometry normal• Emissions normal• Initially diagnosed from emissions alone as
“hysterical” or “malingering”• BUT Reflexes (done only by us) ABSENT
Rt Lt
Nr Nr
Nr Nr
SRT
Disc
Reflexes?:
Emissions?:
ABR?:
Movie of a patient I (CB) initially mis-diagnosed as having CAPD• ..\Teaching Material and papers\Ali's Film
AN/AD versus and central auditory processing disorders
Case Study
- Male, first seen at age 13 years
- Difficulty in school
- Doesn’t hear instructions
- Doesn’t pay attention
- Sometimes “off in own world”
- In regular classroom, “C student”
Audiogram and DPOAEs: First Test
DPOAE
Noise Level
Speech Audiometry
• Word recognition in quiet:• Right ear: 84% at 40 dB SL• Left ear: 8% at 40 dB SL, 48% at 60 dB HL
• Word and sentence recognition in noise: 0% at signal-noise ratio of +10 dB
Middle Ear Measures
• Tympanograms: Normal
• Ipsilateral reflexes: Absent
• Contralateral reflexes: Absent
• Non-acoustic reflexes: Present
Auditory Evoked Potentials
Cochlear microphonics
Audiogram and OAEs: Second Test
Radiological and neurological evaluations
• CT Scan with contrast and MRI:CT Scan with contrast and MRI: Normal
• Neurological evaluationNeurological evaluation – Dx of Charcot-Marie-Tooth syndrome
• A group of genetically determined polyneuropathies with distal muscle weakness, atrophy and sensory nerve involvement; demyelinating
• ManagementManagement– Lipreading, preferential seating, visual information,
note-taking service, real-time closed captioning,
AN/AD versus CAPD
• AN/AD:AN/AD:– Synchrony disorder, possible pre-neural site
• Inner hair cells, synapse, VIIIth nerve– ABR, MEMR absent– Cochlear implants beneficial
• Central APD:Central APD:– More diffuse in nature
• Peripheral neural synchrony usually normal (VIIIth n.)– ABR, MEMR usually normal or near normal– Cochlear implants not useful
AN/AD: Otoacoustic Emissions
Cochlear Hair Cell Loss
Phenotyping AN/AD: Variable Characteristics and Time Courses
• OnsetOnset– Congenital, later onset, acquired
• ProgressionProgression• Progressive worsening (loss of peripheral auditory integrity; component of other
progressive peripheral neuropathy)• Stays the same• Partial recovery of auditory ability (improved pure tones and sound awareness
despite continued dys-synchrony)
• Genetic patternsGenetic patterns• Dominant, recessive, non-syndromic, syndromic, mitochondrial
• Auditory sensitivity and ability to utilize speech informationAuditory sensitivity and ability to utilize speech information
Kresge Lab AN/AD Database• Total confirmed patients with AN/AD = 225
– Based on present OAEs and/or CM and absent/abnormal ABR
• Age– 0-24 months 67– 25-48 months 42– 4-6 years 36– 7-12 years 38– 13-18 years 5– 19-30 years 13– >30 years 16– Unknown 8
• 46% female; 54% male
Tests Results: Hair Cell Function
- Normal otoacoustic emissions (despite abnormal pure tone thresholds)
- Present cochlear microphonics
- - Absent middle ear muscle reflexesAbsent middle ear muscle reflexes- Absent auditory brainstem responses- Absent auditory brainstem responses- No suppression of otoacoustic emissions- No suppression of otoacoustic emissions- No masking level differences- No masking level differences- Variable audiograms- Variable audiograms- iNORDINATELY Poor speech recognition in noise- iNORDINATELY Poor speech recognition in noise
Most cases in the Australian and Brazilian literature are Inner Hair cell based
• Inner Hair Cell Based (Kirsty Gardner Berry and Prof WPR Gibson)• Temporal Bones Amatuzzi, Liberman and Northrop 2011.
Abnormal nerves seen on MRI (trans-IAM view)
Should be 4 separate nerves:1. Facial2. Superior Vestibular.3. Inferior Vestibular.4. Auditory. Sometimes only 1, 2 or 3 can be
seen because they haven’t developed properly.
Pattern of results for 5 Babies with a Compromised VIIIth nerve
Baby 1 - Right CI 2 - Right CI 3 - Right CI 4 - Left CI 5 - Right CI
Cochlear Mondini dysplasia Displastic basal turn, not dilineated.
Modiolus not demonstrated
Normal Normal
VIIIth nerve
VIIIth nerve hypoplastic/
absent
VIIIth nerve hypoplastic/ absent
VIIIth nerve hypoplastic/
absent
Absent Thin nerve
ECochG 8kHz
Pre-op TTEABR
ImpEABRMP1+2
Rt TT EABR
50µV
1
323
50µV
2
410
50µV
3
256
50µV
4
439
50µV
5
1024
Rt TT EABR
50µV
1
314
50µV
2
663
50µV
3
484
50µV
4
621
50µV
5
416
50µV
6
577
Rt TT EABR
20µV
1
306
20µV
2
327
20µV
3
332(5)
20µV
4
326(5)
20µV
5
377(9)
20µV
6
334(3)
20µV
7
399(12)
Lt TT EABR
50µV
1
1024(13)
50µV
2
946(15)
50µV
3
1024(18)
50µV
4
362(5)
Lt TT EABR
50µV
1
571
50µV
2
481
Misc Re MP1+2 Response MP1+2
Rt 8kHz ECochG
ECochG 100dB
10ms 10µV 70 dBnHL
1
128
ECochG 90dB
10ms 10µV 60 dBnHL
2
128
ECochG 80dB
10ms 10µV 50 dBnHL
3
128
ECochG 70dB
10ms 10µV 40 dBnHL
4
128
ECochG 60dB
10ms 10µV 30 dBnHL
5
128
Rt 8kHz ECochG
ECochG 110dB
10ms 20µV 80 dBnHL
1
31
ECochG 100dB
10ms 20µV 70 dBnHL
2
28
ECochG 90dB
10ms 20µV 60 dBnHL
3
36
ECochG 80dB
10ms 10µV 50 dBnHL
4
35ECochG 70dB
10ms 5µV 40 dBnHL
5
54
ECochG 60dB
10ms 1µV 30 dBnHL
6
64ECochG 50dB
10ms 2µV 20 dBnHL
7
64
Rt 8kHz ECochG
ECochG 110dB
10ms 2µV 80 dBnHL
1
128
Lt 8kHz ECochG
ECochG 110dB
10ms 2µV 80 dBnHL
1
256
ECochG 100dB
10ms 2µV 70 dBnHL
2
128
Lt 8kHz ECochG
ECochG 110dB
10ms 2µV 80 dBnHL
1
256
ECochG 100dB
10ms 2µV 70 dBnHL
2
128
Acknowledgements:
Drs. Linda J. Hood and Thierry Morlet for slides and data collection.Drs. Kirsty Gardner-Berry and Professor WPR Gibson and Halit Sanli For access to their data.Collaborators include Harriet Berlin, Li Li MD, and the staff of the LSUHSC Audiology and Otolaryngology Departments. Donors include the Marriott, Oberkotter and Hearing Research Foundations , NIDCD and BMDR-1549.Technical Assistance by Benjamin Russell Au.D. is especially appreciated,