ABR Short

AUDITORY ELECTROPHYSIOLOGY
Mohd Normani Zakaria,

PhD
Head / Senior Lecturer
Audiology Program,
USM
mdnorman@usm.my
0136779774
Central Auditory Nervous System
• Diagram of the CANS

Introduction
• In Audiology, auditory electrophysiology is
about measuring Auditory evoked potential
(AEP)
• AEP is an electrical signal recorded from a
human’s head (at specific locations) following a
presentation of a repetitive stimulus
• Following sound stimulation, the action
potentials generated are able to travel from
deep part of brain to the electrodes (attached
on the head) via a complex media consisting of
fluids, brain tissues, bone and skin
Introduction…
• Auditory electrophysiology is about
measuring an Auditory evoked potential
(AEP)
• AEP is an electrical signal recorded from a
human’s head (at specific locations)
following a presentation of a repetitive
stimulus
• AEP testing is an objective test and serves
many diagnostic functions
Introduction…
• Types of stimulus to record AEP:
Clicks (3 types, 0.1 ms duration)
Condensation Rarefaction Alternating

Introduction…
Pure tones (2 types, 1.5 – 6 ms duration)
Tone Burst Tone Pip

Introduction…
Pure tones (2 types, 1.5 – 6 ms duration)
Tone Burst Tone Pip

Introduction…
Others
/da/ stimulus Chirp

Introduction…
• Classification of AEP:
Early Latency Responses (0 - 10 ms)
Electrocochleography (EcochG)
Auditory Brainstem Response (ABR)
Auditory Middle Latency Response (AMLR)
(10 – 80 ms)
Late Latency Response (LLR) or Cortical
Evoked Response Audiometry (CERA) (50 -
800 ms)
AUDITORY BRAINSTEM RESPONSE
Introduction…
• Auditory Brainstem Response (ABR) is an
early AEP and is defined as an evoked
electrical response occurring within 10ms
after the stimulus onset following repetitive
auditory stimulations
• Simultaneous firing of auditory nerve fibers
(“neural synchrony”) is required to evoke
the ABR
Introduction…
• It measures electrical activities (compound
action potentials) within the auditory
brainstem (up to Inferior Colliculus)
• Also known as Brainstem Auditory Evoked
Response (BAER), Brainstem Auditory
Evoked Potential (BAEP) and Brainstem
Evoked Response (BSER)
ABR Generators
• Consists of 5 to 7 positive peaks (I to VII)
• Each positive peak of ABR represents a
specific area within the auditory brainstem:
Wave I: Distal portion of eighth nerve
Wave II: Proximal portion of eighth nerve
Wave III: Cochlear Nucleus
Wave IV: Superior Olivary Complex
Wave V: Lateral Lemniscus & Inferior
Colliculus
ABR Generators…
ABR Generators
ABR Recording
• 4 stages:
Identifying the purpose of performing ABR
Skin preparation/electrode application
Setting up the test parameters and
protocols
The measurement starts and the test
parameters are manipulated to obtain the
required ABR waveforms
A typical electrode placement for ABR recording
ABR Interpretation…
• ABR waveform is interpreted in terms of:
Morphology (shape or pattern)
Latencies
Amplitudes (less important)
• Latencies:
Absolute latency (e.g. wave I)
Interpeak latency (e.g. wave I – V)
Interaural latency difference (between ears)
• Intensity levels are often expressed in dBnHL
ABR Interpretation
• For instance, at 80 dBnHL, the normal
absolute latencies are around:
Wave I: 1.5 ms
Wave II: 2.8 ms
Wave III:3.5 ms
Wave IV: 4.2 ms
Wave V: 5.5 ms
• Wave V is the most robust component of ABR
and used in hearing threshold estimation
Factors Influencing ABR Results
• Factors that can affect ABR results:
Subject issues (age, gender, condition,
state of arousal and body temperature)
Sedatives/anesthetic agents
Examiner’s competency
Stimulus parameters
Acquisition parameters
Clinical Applications of ABR
• For objective hearing threshold estimation
in “special” patients (e.g. infants, difficult-
to-test children, non-organic hearing loss
cases etc.)
• For differential diagnosis (e.g. cochlear vs.
retrocochlear pathology)
• Newborn hearing screening (i.e. AABR)
• For intra-operative monitoring
• For medico-legal reasons
ABR in Threshold Estimation…
• Click stimulus produces the most robust
ABR and agrees well with PTA (by 5-10
dB) at 2000 – 4000 Hz region
• That is, although it is a broadband
stimulus, when produced by most
headphones and earphones, it has the
greatest energy around 3000 Hz
• Therefore, only “1 point audiogram”
• Spectral energy of
clicks by TDH-39
headphone and ER-3A
earphone (note the
peak around 3 kHz)
• ABR obtained
with a click
stimulus at
different intensity
levels for a
normal subject
• Note the
threshold is at 16
dB
• Tone bursts are the better option but they give
less neural synchrony (smaller response)
• As a result, big discrepancies are found
between ABR threshold and PTA (ABR > PTA
by up to 20-25 dB), especially for lower
frequencies
• At higher frequencies (e.g. 2 and 4 kHz), ABR
agrees well with PTA (within 5-10 dB)
• Some clinics apply “correction factors” to
account for the disagreements
ABR in Type of Loss Estimation
• Each equipment should have its own
normative data
• Estimation of type of loss can be done by:
By plotting latency-intensity function
graph
Performing bone conduction ABR
Inspecting ABR waveforms at one specific
intensity level (e.g. 80 dBnHL)
ABR in Type of Loss Estimation…
Latency-intensity function of wave V in a patient with CHL

Latency-intensity function of wave V in a patient with SNHL

(cochlear loss < 50 dB)
• Air and bone conduction
ABR of a patient with
conductive loss
• As shown, ABR air
conduction threshold =
65 dBnHL & bone
conduction threshold =
0 dBnHL
ABR recorded at 80 dBnHL in A) Normal hearing, B) CHL, C) Sensory
loss (PTA < 50 dBnHL) and D) Neural loss (Acoustic Neuroma)
• Findings in patients with conductive

hearing loss (at 80 dBnHL):
Morphology is normal (all peaks maybe
present)
All absolute latencies are delayed
Normal interpeak latencies
• Findings in patients with sensori (cochlear)

hearing loss (PTA < 50 dBnHL) (at 80
dBnHL):
Abnormal morphology
Normal absolute latencies
• Findings in patients with sensori (cochlear)
hearing loss (PTA > 50 dBnHL) (at 80
dBnHL):
Abnormal morphology (depends on PTA
threshold, can be a flat response)
Delayed absolute latencies
• For neural loss, ABR findings are dependent on
which site that is compromised
• Common pathologies affecting neural parts are
acoustic neuroma and auditory neuropathy
• Typical findings in patients with auditory
neuropathy:
Severely abnormal ABR morphology (can be flat
at maximum intensity level)
Normal OAE and cochlear microphonic of ECochG
ABR threshold is worse than PTA
PTA, TEOAE & ABR in Auditory Neuropathy
• ABR has been shown to be sensitive in
detecting acoustic neuroma:
Nearly 100 % of cases for tumor > 1 cm
(Bauch et al., 1983; Josey et al., 1980)
For a small tumor, sensitivity ranges from
63 to 93 % (Dornhoffer et al., 1994)
• A new stacked ABR improves the detection
rate for a small tumor (up to about 95%
sensitivity)
• For acoustic neuroma, “within ear” and
“between ears” comparisons can be used:
• “Within ear” comparisons (at 80 dBnHL):
Abnormal morphology
Normal absolute latency of wave I
Delayed absolute latency of wave V
Delayed interpeak latency of I-V or I-III (but
normal for III-V)
• Interpeak latency
for tumor
detection
• “Between ears” comparison (at 80 dBnHL):
Comparing wave V absolute latency
between tumor ear and non-tumor ear
(positive if >0.2 ms)
Comparing interpeak latency (I-V or I-III)
between tumor ear and non-tumor ear
(positive if >0.2 ms)
These methods work well if the non-tumor
ear is normal
• ABR in a patient with

acoustic neuroma
• Note the prolonged
wave V absolute
latency in the
affected side
• Difference = 0.9 ms
ABR results of a patient with multiple sclerosis (involving
brainstem and medulla in both ears)
ABR in Neonatal Hearing Screening
• A screening version of ABR, known as
Automatic ABR (AABR) is available for
hearing screening (only pass/refer result is
displayed)
• It may be used for first screening or
subsequent screenings (in conjunction with
OAE)
• AABR is faster than conventional AABR and
requires about 8-10 minutes to complete
(hearing is screened at 30-40 dB nHL at
fast stimulus rates)
ABR in Neonatal Hearing Screening…
• Compared to OAE, AABR

Requires electrode application
Requires a longer testing time
More expensive BUT
Is less affected by vernix in ear canal
(reducing false positive)
Can give information beyond cochlea (e.g.
auditory neuropathy)
ABR in Intra-operative Monitoring
• An Audiologist can actually assist ENT
surgeons during surgery by using AEP
• ABR has been used commonly during
operations to monitor auditory nerve and
brainstem (to prevent injuries to these
areas)
• Normally, the combination of ECochG &
ABR is recommended, as the ABR tends to
be noisy and has low amplitudes
ABR in Intra-operative Monitoring…
ABR in acoustic neuroma surgery (note the preserved

auditory nerve)
ECochG and ABR in
acoustic neuroma
surgery
ABR in Intra-operative monitoring…
ABR in acoustic neuroma surgery (note the preserved

auditory nerve)
ABR for Medico-Legal Reasons
• Since ABR is an objective test, it can be
used to confirm hearing status for medico-
legal cases such as worker’s compensation
cases, testifying in court and so on
• ABR is performed to verify the claimed
PTA and if there is any discrepancy, ABR
result is more trustable (in this case,
performing other objective tests are also
encouraged)
Reference
• Katz J. (2002) Handbook of Clinical

Audiology, Lippincott Williams & Wilkins,
Philadelphia.
• Hall J.W. (2007) New Handbook of
Auditory Evoked Potentials, Pearson
Education, Inc.
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AUDITORY ELECTROPHYSIOLOGY

Mohd Normani Zakaria,

• Diagram of the CANS

Condensation Rarefaction Alternating

Tone Burst Tone Pip

Tone Burst Tone Pip

/da/ stimulus Chirp

Latency-intensity function of wave V in a patient with CHL

Latency-intensity function of wave V in a patient with SNHL

• Findings in patients with conductive

• Findings in patients with sensori (cochlear)

• ABR in a patient with

• Compared to OAE, AABR

ABR in acoustic neuroma surgery (note the preserved

ABR in acoustic neuroma surgery (note the preserved

• Katz J. (2002) Handbook of Clinical

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