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Author: admin, 25.06.2014. Category: Severe Tinnitus Symptoms

A review of OAE concepts, the application of screening versus diagnostic OAEs, as well as normative data to help clinicians in the interpretation of DPOAEs for the Interacoustics Titan DPOAE440 module.
Otoacoustic emissions (OAEs) were first reported by Kemp.1 In brief, as sound is introduced within a healthy (ie, normal hearing and functioning) cochlea, the stereocilia of the outer hair cells are stimulated.
OAEs may therefore be considered acoustic sounds that originate secondary to movement of the cochlea’s hair cells. However, OAEs are susceptible to noise, and may be compromised via excessive cerumen, and a variety of middle ear anomalies (otitis media, ossicular discontinuity, otosclerosis, perforated tympanic membrane, etc). Recently, Beck5 reported that acoustic reflex testing should be reconsidered and added to every hearing screening protocol—as the information ascertained from simple pure-tone screenings is insufficient to state “normal hearing ability.” Likewise, the importance of adding OAEs to the diagnostic test battery cannot be overstated.
In this article, we present multiple introductory OAE concepts, the separate and unique application of screening versus diagnostic OAEs, and we present normative distortion product data for the Interacoustics Titan. An “acceptable” TEOAE is usually 3 to 6 dB above the noise floor (referred to as the signal-to-noise ratio or SNR) and is reproducible.
For example, if f1 = 1000 Hz and f2 = 1200 Hz, then 2f1-f2 = 2(1000) – 1200 = 2000 – 1200 = 800 Hz. TEOAEs are recorded after and between click presentations, as mentioned earlier, while DPOAEs are recorded during cochlear activation. Similar (although not identical) to TEOAEs, DPOAEs are expected to be present if all pure-tone thresholds are better than 25 dB HL, and DPOAEs are expected to be absent when all pure-tone hearing thresholds are worse than 40 dB HL.
Similar to auditory brainstem response (ABR) and auditory steady state evoked response (ASSR), one must consider that each device (and the protocols selected within that device), each test environment, and each patient is unique. The Titan DPOAE440 employs a number of technologies to improve detection and reduce test time. While SNRs are commonly used as a means to judge whether a DPOAE is present or absent, the published literature advocates an objective approach to analysis by comparing a patient’s DPOAEs to an appropriate normative data set8,9 while performing diagnostic analysis.
Therefore, we have undertaken a small clinical study to collect DPOAEs across a pre-defined frequency range to provide an appropriate normative data set to be used with the Titan DPOAE440 module. Following confirmation of normal hearing thresholds and middle ear status, DPOAEs were recorded using the Titan DPOAE440 module.
Analysis of DPOAEs using normative data (as shown above) is enhanced by displaying the normative range on the DP-Gram.9 The following steps are recommended to make diagnostic inferences about DPOAE results. 1) Assess the noise floor and ensure it is sufficiently low for the correct analysis of the presence or absence of DPOAEs. As the clinical acceptance and utility of OAEs has evolved, DPOAEs have been identified as having significant diagnostic value. The Auditory Brainstem Response (ABR) test is an electrophysiological measurement that allows audiologists to predict hearing sensitivity based on responses (evoked potentials) from the central auditory nervous system. As in behavioral audiometry, bone conduction ABR uses a bone conduction transducer to deliver vibrations directly to the inner ear, bypassing the outer and middle ear structures.
A physical exam, using a ear microscope or endoscope, will evaluate the ear canal and tympanic membrane.
Acoustic Impedance Audiometry – Tests the Acoustic Reflex the contraction of a tiny ear muscle that responds to sounds at different volumes. A graphical computerized report of hearing function (Audiogram) and pressure within the middle ear and measurement of reflex movements of tiny muscles in the middle ear (Acoustic Impedance) are the basic tests for diagnosis of hearing disorders. Conductive Deafness – When deafness is caused by disease of the outer (external) ear, ear drum or mddle ear, it is referred to as a conductive deafness. Sensori neural Deafness – When deafness is caused by disease of the inner ear, nerveof hearing or brain centres, it is referred to as a Sensori neural Deafness. Ear Associates and Rehabilitation Services provide audiology services, evaluation, and diagnostic testing for adults and children of all ages.
This is the basic hearing test that is performed to determine the softest sounds a client can hear at different pitches, or frequencies. The hearing test results indicate if a client has normal hearing or a hearing loss ranging from mild to profound. This test is an objective means of assessing the integrity and function of the middle ear system. Acoustic reflex testing consists of subjecting the ear to a loud sound and determining if it causes a reflexive stiffening of the eardrum due to the tightening of the stapedius muscle in the middle ear. Additional follow-up or specialized diagnostic testing may be recommended for further evaluation.
Auditory Brainstem Response (ABR) is a widely used objective test to assess hearing sensitivity and auditory nerve function. ECochG measures the electrical potentials generated in the inner ear in response to stimulation by sound. Hearing loss in infants is now diagnosed more frequently due to the neonatal screening programs.
ABR: Auditory Brainstem Response (ABR) is a widely used objective test to assess hearing sensitivity and auditory nerve function. ASSR: Auditory Steady State Response (ASSR) is another test to evaluate infants who fail newborn screening in the hospital. OAE: Otoacoustic Emissions (OAE) are acoustic signals generated by the normal inner ear, either in the absence of acoustic stimulation (spontaneous emissions) or in response to acoustic stimulation. Visual Reinforcement Audiometry (VRA): VRA is used to test hearing of infants and toddlers between 6 months to 2 years. Conditioned Play Audiometry: Conditioning play audiometry (CPA) is used to test children between age of two (2) and four (4). Amplification with hearing aids or the use of masking devices can be considered in the treatment of tinnitus.

In response to stimulation, the outer hair cells change their shape to preferentially amplify and propagate particular sounds along the basilar membrane. These acoustic sounds from the cochlea can be measured from  the external auditory canal, given a clean and healthy external auditory canal, as well as a healthy and normal functioning middle ear. OAEs are highly sensitive and highly dependent on outer hair cell function, they do not require behavioral responses, and they offer immediate, ear-specific results.
The bottom line is, the audiogram is a diagnostic tool and it is relatively insensitive to multiple important aspects of hearing and listening. In clinical practice, the most common OAEs recorded are Transient Evoked Otoacoustic Emissions (TEOAEs) and Distortion Product Otoacoustic Emissions (DPOAEs). Importantly, Robinette, Cevette, & Probst7 indicate when all pure-tone hearing thresholds are better than 20 dB HL, TEOAEs are present 99% of the time. A DP-Gram from the Titan DPOAE440 module displaying the normal range, noise floor, and recorded DPOAEs. DPOAEs are typically recorded from 1000 to 6000 Hz, and can be recorded up to 10,000 Hz, too, but this varies by manufacturer.
Therefore, it is particularly important to have “normative data” gathered from the specific device used, so as to maximally interpret the data acquired on an individual.
The detection algorithm uses Bayesian weighted averaging to obtain faster and more reliable recordings in typical test situations with noisy patients. Automatic Gain Control (AGC) ensures that the correct stimulus level is being presented based on the ear canal volume, and the option of pressurized OAE testing allows for testing at tympanometric peak pressure, compensating for the effects of negative middle ear pressure, thereby reducing false refers. Normal-hearing young adults ages 18 to 25 years were recruited on a volunteer basis from Denmark.
Results from each subject were compiled into an Excel spreadsheet to calculate the mean, standard deviation, and percentiles.
However, to maximize the usefulness and accuracy of DPOAEs, development of, and comparison to, normative data is important.
The ABR involves the recording of microvolt electrical activity from surface electrodes in a quiet environment while a patient is sleeping. Comparison of bone conduction and air conduction ABR results can be used to distinguish between sensorineural and conductive hearing loss. Waves I and II result from the eighth nerve while later waves reflect postsynaptic activity in major brainstem auditory centers.
This hearing test is conducted by an audiologist while the client sits in a sound-treated booth. The test also determines if the loss is conductive, which means the problem is in the middle ear, or sensorineural, which means the problem is in the inner ear or nerve of hearing. It is used to determine ear drum mobility, eustachian tube function, acoustic reflex threshold, and ossicular chain integrity and mobility. Tympanometry aids assessment of the outer and middle ear system, including the eustachian tube. The tightening of stapes muscle is called as an acoustic reflex and the lowest intensity level at which this occurs is called as the acoustic reflex threshold.
Both Auditory Brainstem Response (ABR) and Electrocochleography (ECochG) testing provide diagnostic information to determine the cause of hearing loss, tinnitus, ear fullness, dizziness, and other conditions. A test sound is given to the ear and the responses from auditory neural activity are recorded using electrodes attached to the skin of the head with a sticky substance. As per the National Institute on Deafness and Other Communication disorders, approximately 12,000 new babies are diagnosed with a hearing loss. Electrodes are again stuck to the skin of the head and a test sound is delivered to the ears. OAE’s can be measured by presenting sound through a probe which is inserted in the outer ear canal. When VRA is used, a head turn response following an auditory stimulus is rewarded with an interesting visual event or reinforcer, such as an animated toy. When a patient with tinnitus obtains hearing aids, the tinnitus is frequently improved or eliminated when the devices are worn. The OAE itself is thought to have an amplitude that may vary from -10 dB SPL to +30 dB SPL in healthy ears.3 Therefore, OAEs can be used as a screening tool to determine if the cochlea is responding to sound in a typical fashion. Of importance, a normal audiogram (or a normal pure-tone screening result) does not and cannot indicate normal “hearing” or “normal listening” (particularly in noise and other challenging situations) ability. Kramer6 notes TEOAEs are recorded during the silent intervals between brief broad-spectrum transient clicks, which activate a wide portion of the basilar membrane. Of note, if a reproducible response is not evident at a SNR of 3 dB or more, it can be assumed the outer hair cells of that frequency region are not functioning normally.
Likewise, when all pure-tone hearing thresholds are greater than 40 dB HL, TEOAEs are always absent. Because the cochlea is non-linear, distortion occurs—that is, some sounds generated within the cochlea were not externally presented.
The DPOAE reflects the status of the cochlea at the representative cubic difference tone, not the primary tones (although the primary tones also must be perceived in order to create the DP). The rest of this article will address our collection and analysis of normative data for the Interacoustics Titan DPOAE440 module.
The use of a reliability criteria and a DP tolerance setting reduces the detection of false-positive OAEs. The f2 frequencies measured covered the range from 500 to 8000 Hz, three frequencies per octave, as well as 9000 and 10,000 Hz (primary tone intensity levels used for f1=65 dB SPL, and f2=55 dB SPL). In this article, we identified multiple types of OAEs, reviewed methods used to gather normative data, and produced tables to help interpret DPOAEs obtained using the Interacoustics Titan DPOAE440 module.

Otoacoustic emissions and audiometric outcomes across cochlear and retrocochlear pathology. ABR is a critical part of the pediatric audiologic battery because it provides an accurate and reliable prediction of hearing loss in children too young or developmentally unable to fully participate in behavioral testing.
Click stimuli evoke responses in the frequency range from 100-8000 Hz, which is too broad to estimate hearing sensitivity.
Wave V, the component most analyzed in clinical applications, originates from the inferior colliculus. Tympanometry is useful in distinguishing between types of conductive deafnes – due to middle effusions, disruption or fixation of the small chain of bones, negative middle ear pressure in the middle ear. The results of the tests are evaluated to determine the most appropriate treatment options.
This test does not require any participation from the patient and is very easy to administer.
Tympanometry is administered by placing a soft probe in the patient’s ear and varying the pressure levels causing the eardrum to move. Acoustic reflex test results give the clinician valuable information regarding the severity of your hearing loss and the possible cause of your hearing loss.
While testing an infant, we look for the lowest intensity at which a repeatable waveform can be produced. Emissions generated by the outer hair cells of the healthy cochlea are reflected back through the middle ear to the outer canal. Testing for dysfunction of the auditory system can be performed with extensive audiometric testing including a diagnostic audiogram, immittance, OAEs and ABR testing. Giving the person suffering with tinnitus a break from the noise and providing a sense of control over this problem can be very relieving.
Typical latencies (from click presentation to OAE recording) are perhaps 5 to 15 milliseconds.
In general, DPOAEs appear 5 to 6 dB above the noise floor; that is, the SNR should be 5 to 6 dB, and it is essentially the amplitude of the DPOAE that determines a successful DPOAE. Note, the total data set for males was 19 as one data set was corrupted and could not be used). Artifact-free averaging was conducted at each f2 frequency for 20 seconds to allow the noise at each frequency to reach sufficiently low levels.
Tables 1-3 display the normative data for male ears (n=19), female ears (n=20), and males and females combined (N=39) between 500 and 8000 Hz.
Utilizing air-conducted, bone-conducted, and frequency-specific stimuli, the ABR test produces information on degree, type and configuration of hearing loss and this information can be used to fit a patient with hearing aids. Click stimuli presented at high levels (80-90 dB nHL) are used to distinguish between cochlear and neural dysfunction. Audiometric testing is also used to monitor a previously identified hearing loss issue to assess treatment results. Acoustic immittance testing is of great importance in the evaluation of adults and children with ear issues.
The ABR test is a non-invasive procedure and does not require active cooperation from the patient.
The resulting sound is picked up by the probe microphone and processed by a special software and hardware. Shorter latencies are attributed to higher frequency regions of the cochlea, such as the basal region. Testing was conducted for 5 minutes per ear across the frequency range and results were continuously displayed and stored in a DP-Gram for further analysis. Emissions test is conducted in a quiet room and requires no participation from the patient.
A test assistant is used during the test to help the child focus on the visual reinforcer following the acoustic stimulus. Counseling and recommendations are then made to help the patient achieve alleviation of this annoying symptom. The device comes with headphones which deliver precisely designed music embedded with a pleasant acoustic neural stimulus. Longer latencies are attributed to lower frequencies and therefore represent the apical end of the cochlea.
Our evaluation includes state of the art diagnostic testing with ABR, ASSR, Immittance and OAE testing. After the child understands the task, softer sounds are presented to find the lowest level at which a response is obtained.
Otoscopy, 226 Hz tympanometry, and 1 kHz ipsilateral reflex measurements were obtained using Titan IMP440 impedance module to confirm normal middle ear status. ABR, ASSR and OAE tests provide information about the integrity of specific sites within the auditory system.
Behavioral tests like Visual Reinforcement Audiometry and Conditioned Play Audiometry tests provide a direct measure of hearing. It is therefore very important to follow the infant or child with serial tests over time until we achieve behavioral test results. The ultimate goal is to determine if the child has sufficient hearing for age appropriate speech and language development.

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