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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 30  |  Issue : 1  |  Page : 38-42

Assessing the applications of cortical auditory evoked potentials as a biomarker in children with hearing aids


ENT Department, Audiology Unit, Cairo University, Cairo, Egypt

Date of Submission01-Jan-2013
Date of Acceptance19-Feb-2013
Date of Web Publication17-Feb-2014

Correspondence Address:
Hoda Mahmoud Weheiba
MD, Audiologist in Electricity Hospital
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1012-5574.127200

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  Abstract 

Background
Cortical auditory evoked potentials (CAEPs) are noninvasive measures used to quantify central auditory system function in humans. More specifically, the P1-N1-P2 CAEP has a unique role in identifying a central auditory system that has benefited from amplification or implantation. P1 reflects the maturation of the auditory system in general as it has developed over time.
Objective
The objective of this study was to assess the CAEP in children with hearing aids versus age-matched controls, and to compare the pattern of P1 CAEP in patients with hearing aids versus those with cochlear implants.
Materials and methods
Twenty hearing-impaired children (using their own binaural digital hearing aids) were compared with 20 age-matched and sex-matched children with normal hearing. In both groups, P1 CAEP latency and waveform morphology were recorded by free-field auditory stimulation using tone bursts at 500 and 2000 Hz at 100 dB sound pressure level. Finally, P1 CAEP was compared between patients using hearing aids and 20 children with cochlear implants.
Results
We have assessed the use of P1 latency and CAEP waveform morphology in a total of 20 children with hearing aids as a biomarker for the development of the central auditory pathway in patients with hearing loss. Children using hearing aids exhibited an exponential decay in P1 latencies, indicating an overall delay in maturation when compared with that in children with normal hearing. There was no statistically significant difference as regards P1 latencies and amplitudes between cochlear implant and hearing aid users, who showed statistically significantly higher mean values compared with the normal group.
Conclusion
Children's auditory systems develop comparatively as long as they are receiving appropriate amplification, whether this is through a cochlear implant or through the use of hearing aids. The P1 CAEP test can be applied as a tool in the diagnosis of central processing disorders in children with hearing impairments fitted with cochlear implants or hearing aids. This information will be useful when monitoring a child's progress with his hearing device and in auditory training.

Keywords: P1 Cortical auditory evoked potential, free-field auditory responses, hearing aids, hearing impaired children, tone bursts


How to cite this article:
Mostafa IZ, Shabana MI, El Shennawy AM, Weheiba HM. Assessing the applications of cortical auditory evoked potentials as a biomarker in children with hearing aids. Egypt J Otolaryngol 2014;30:38-42

How to cite this URL:
Mostafa IZ, Shabana MI, El Shennawy AM, Weheiba HM. Assessing the applications of cortical auditory evoked potentials as a biomarker in children with hearing aids. Egypt J Otolaryngol [serial online] 2014 [cited 2020 Apr 7];30:38-42. Available from: http://www.ejo.eg.net/text.asp?2014/30/1/38/127200


  Introduction Top


Cortical auditory evoked potentials (CAEPs) are noninvasive measures used to quantify central auditory system function in humans. More specifically, the P1-N1-P2 CAEP has a unique role in identifying a central auditory system that has benefited from amplification or implantation. P1 reflects the maturation of the auditory system in general as it has developed over time [1].

CAEPs are not widely used as a clinical test, especially in very young children, because of the difficulty in recording. Indeed, the use of tone bursts through hearing aids or cochlear implants, as in CAEP, offers the possibility to evaluate many more frequencies and louder intensities compared with other tests on the basis of a click as a stimulus [2].

On using P1 to assess patients, it may be difficult to make sufficiently audible sounds when testing patients with severe to profound hearing loss, and therefore, no P1 response to stimuli is observed. Moreover, Nash et al. [1] performed P1 testing before cochlear implant or hearing aid fitting in children with severe to profound hearing loss and revealed no response to auditory stimulation.

By measuring the central auditory system responses to amplified sound we can learn more about the effects of hearing loss and amplification on the central auditory system and, in turn, improve our understanding of the science underlying auditory rehabilitation [3].

Because P1 latency varies as a function of chronological age, it can be used to infer the maturational status of auditory pathways in children. Of particular interest are children with significant hearing loss. P1 latency is considered to be a measure of central auditory development in patients who receive intervention in the form of hearing aids or cochlear implants. Sharma et al. [4] have described the use of P1 latency and CAEP waveform morphology as biomarkers for the development of the central auditory pathway in patients with hearing loss who receive intervention in the form of conventional hearing aids or cochlear implants.

P1 latency can provide the clinician with an objective tool to evaluate whether acoustic amplification in hearing-impaired patients has provided sufficient stimulation for normal development of the central auditory pathway. This tool when combined with traditional audiological and speech language assessment can give information on whether to provide the patient with a cochlear implant after an appropriate hearing aid trial [5],[6].

Many researchers worldwide have suggested that there is a need for further research examining the clinical feasibility of P1 latency as an objective tool to evaluate the normal development of function of central auditory pathways in children with hearing impairment [7],[8],[9]; Golding et al., 2008 [10]; and [11],[12],[13]. Thus, there is a great need for objective assessment of central auditory development in children after implantation or hearing aid fitting.


  Materials and methods Top


A total of 20 hearing aid users and 20 normal hearing children of both sexes (24 male and 16 female) were included in the present study. The study was conducted at the Audiology Unit, Kasr El Einy Hospitals, Cairo University. At the time of testing, the ages of the patients ranged from 3 to 16 years. The hearing level of the hearing aid group ranged from severe to profound hearing loss. Children with hearing aids were further compared with 35 children with cochlear implants with severe to profound hearing loss, who were implanted between the ages of 3 and 7 years. All children were submitted to full history taking, otological examination, basic audiological evaluation, and aided warble tone response threshold measurements in sound field using a two-channel audiometer (GSI model 1761, Egypt) for hearing aid and cochlear implant children only. Immittance was measured using GSI 33, Egypt (Grason Stadler middle ear analyzer version II) and the P1 CAEP test was performed using Amplaid model MK12, Egypt.

Participants were comfortably seated in a sound-treated room and CAEPs were recorded for each participant by hearing aid amplification or cochlear implantation. One-channel recordings were obtained using an ipsilateral electrode montage. The active (noninverting) electrode was placed on the vertex (Cz), whereas the reference (inverting) electrode, M1/M2, was placed on the right or left mastoid in hearing aid patients and normal participants, and on the contralateral mastoid to the implanted side in the patients with cochlear implants (to minimize the stimulus artifact); the ground electrode was placed on the forehead (Fz). Electrode impedance was kept below 5 Ω.

P1 obligatory cortical auditory responses were recorded in response to tone bursts at 500 and 2000 Hz, applied through a loudspeaker connected to an amplifier to increase its output, placed at an angle of 90° to the side of the patient at a 1-m distance. The stimuli were presented at a rate of 1/s and at a level of 100 dB sound pressure level. It was confirmed with each child that this was at a loud but comfortable listening level.

Responses were recorded using filter settings of 0.1-50 Hz. The time window was taken as 500 ms. At least two runs of 200 response sweeps were collected for each participant. P1 morphology was evaluated and waveforms were judged replicable on the basis of visual inspection of the recordings. P1 was defined as the first robust positivity in the waveform in the latency range from 40 to 300 ms with waveform repeatability. Latency and amplitude values were determined for P1.

Statistical analysis

Normative values were estimated and upper and lower 95% confidence limits were estimated using the linear regression model and were represented by continuous lines. Quantitative (numerical) data were presented as mean and SD values. Student's t-test was used in testing significance for the comparison between the means of two groups. The analysis of variance test was used to compare the means of more than two groups. Qualitative (categorical) data were presented as numbers and percentages. The c2 -test was used for comparison between qualitative data. Pearson's correlation coefficient (r) was used to determine significant correlations between the different quantitative variables. The significance level was set at P less than 0.05 and P less than 0.01 was highly significant.

Results and discussion of the P1 cortical auditory evoked potential test

Seventy-five children of both sexes were examined in this study. Their ages ranged between 3 and 16 years, with a mean age of 5.8 ± 2.8 years. They were 44 male and 31 female children.

Comparison between hearing aid and normal hearing groups

All of the children using hearing aids showed considerable improvements in the aided versus unaided condition for the behavioral measures, which suggests that the brain processes speech stimuli in a more effective manner when hearing-impaired individuals use their personal hearing aids [Figure 1] and [Figure 2].
Figure 1:

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Figure 2:

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This could be explained by central auditory system neural reorganization or plasticity and the acclimatization effect related to hearing aid use [14]. Changes were also expected for cortical responses in the frequency region of 2000 Hz on the basis of previous evidence for high-frequency cortical reorganization in humans with acquired hearing loss [15],[16]. These results identified whether the two different stimuli can reliably give rise to different cortical responses, presumably arising from activity in different cortical locations and/or at different time points [3].

[Figure 3].[Figure 4],[Figure 5] and [Figure 6] show that most latencies of individuals with cochlear implants and hearing aids were outside the 95% confidence limit for age-matched normal-hearing children. This was more evident in P1 latencies than in amplitude measures especially at 500 Hz, at which most children with cochlear implants and hearing aids had amplitudes within the range of normal. There was a highly statistically significant difference between the hearing aid group and the normal hearing group as regards history of consanguinity, denoting that the two groups are not matched as regards consanguinity (16 of 20 in hearing aid group, only six of 20 in normal hearing group showed positive consanguinity). There was no statistically significant difference in age at onset of deafness, etiology of hearing loss, age at hearing aid fitting, sex, social class, and residency, as well as P1 wave latencies and amplitudes in the hearing aid group. There was no statistically significant difference in P1 wave latency and amplitude at 500 and 2000 Hz in the hearing aid group - that is, there was no effect of frequency on P1 wave test results.
Figure 3:

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Figure 4:

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Figure 5:

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Figure 6:

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The findings of the present study demonstrated significant differences in all latency measurements recorded for either children with cochlear implants or children with hearing aids versus normal hearing controls when evoked with either 500 or 2000 Hz tone burst stimuli. There was no statistically significant difference as regards P1 latencies and amplitudes between the cochlear implant and heating aid users in the present study, who showed a statistically significantly higher mean value compared with the normal group. This supports our hypothesis that the evoked responses in age-matched children with hearing impairment, who received a hearing instrument during the sensitive period of cortical development, would be identical, whether they are receiving amplification from a cochlear implant or a hearing aid. This strengthens the finding that children's auditory systems develop comparatively as long as they are receiving appropriate amplification, whether through a cochlear implant or through the use of hearing aids.

However, future research is needed to support this emerging theory suggested by this preliminary study comparing directly the CAEP waveforms of age-matched children using different types of hearing instruments (cochlear implant or hearing aid) for the same duration. This study was carried out determine whether children who receive appropriate amplification during the sensitive period of maximal cortical plasticity will have comparable waveforms despite the type of hearing instrument used.

Collectively, these preliminary findings suggest that P1 CAEP might be a useful clinical tool for assessing hearing aid benefit in the younger hearing-impaired population and may be of assistance to audiologists in initially fitting and adjusting these instruments. Additional research is needed, however, before P1 CAEP can be used in the clinic to assess the neural representation of amplified sound.

Clinical implications of the P1 cortical auditory evoked potential test

The P1 CAEP test can be applied as a tool in the diagnosis of central processing disorders in children with hearing impairments fitted with cochlear implants or hearing aids. This information will be useful when monitoring a child's progress with his/her device and in auditory training. Absence of CAEPs while wearing high-powered hearing aids facilitates an early decision about cochlear implant candidacy. Decreases in P1 latency can objectively determine whether a child is receiving adequate amplification from his/her hearing instrument. Therefore, this would assist in the difficult decision making process of whether an implant is required in difficult-to-test populations, such as infants. If latency measurements do not decrease to within the age-appropriate range during the hearing aid trial, this would suggest that they are not receiving sufficient stimulation and a cochlear implant should be considered [17]; Sharma, Dorman et al., 2002a [18]; Sharma, Dorman et al., 2002b. Likewise, the presence of robust CAEPs to moderate-level speech sounds (65 dB sound pressure level) can lead to the decision to continue with bilateral hearing aids rather than a referral for cochlear implant candidacy evaluation [19].


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Nash A, Sharma A, Dorman M. Clinical applications of the P1 central auditory evoked potential (CAEP) biomarker. A sound foundation through early amplification. Proceedings of a Fourth International Conference. Chicago, IL; 2007 in April, 12.  Back to cited text no. 1
    
2.Burdo S, Razza S, Di Berardino F, Tognola G. Auditory cortical responses in patients with cochlear implants. Acta Otorhinolaryngol Ital 2006; 26:69-77.  Back to cited text no. 2
    
3.Billings CJ, Tremblay KL, Souza PE, Binns MA. Effects of hearing aid amplification and stimulus intensity on cortical auditory evoked potentials. Audiol Neurootol 2007; 12:234-246.  Back to cited text no. 3
    
4.Sharma A, Martin K, Roland P, Bauer P, Sweeney MH, Gilley P, Dorman M. P1 latency as a biomarker for central auditory development in children with hearing impairment. J Am Acad Audiol 2005; 16:564-573.  Back to cited text no. 4
    
5.Purdy S, Gardner-Berry K. Auditory evoked potentials and cochlear implants: research findings and clinical applications in children. Persp on Hear and Hear Dis in Child 2009; 19:14-21.  Back to cited text no. 5
    
6.Cunningham J, Nicol T, Zecker S, Kraus N. Speech-evoked neurophysiologic responses in children with learning problems: development and behavioral correlates of perception. Ear Hear 2000; 21:554-568.  Back to cited text no. 6
    
7.Purdy SC, Kelly AS, Thorne PR. Auditory evoked potentials as measures of plasticity in humans. Audiol Nerur-Otol 2001; 6:211-215.  Back to cited text no. 7
    
8.Tremblay KL. Beyond the ear: physiological perspectives on auditory rehabilitation. Semin Hear 2005; 26:127-136.  Back to cited text no. 8
    
9.Sharma A, Dorman MF. Central auditory development in children with cochlear implants: clinical implications. Adv Otorhinolaryngol 2006; 64: 66-88.  Back to cited text no. 9
    
10.Golding M, Dillon H, Seymour J and Carter L. (2008): The application of Cortical Auditory Evoked Potential (CAEP) recordings in infant hearing aid fitting. In: Proceedings of the 53rd EUHA International Congress of Hearing Aid Acousticians, 15-17 October 2008, Leipzig.  Back to cited text no. 10
    
11.Ching TYC, Chaogang W, Cao K, Zhang V, Dillon H, Lu Y, et al. Use of aided cortical responses and everyday functional performance for paediatric cochlear implant candidacy. Proceedings of the 7 th Asia Pacific Symposium on Cochlear Implants and Related Sciences - APSCI. Monduzzi Editore International, Medimond; 30, June, 2010.  Back to cited text no. 11
    
12.Eggermont JJ, Ponton CW, Don M, Waring MD, Kwong B. Maturational delays in cortical evoked potentials in cochlear implant users. Acta Otolaryngol 1997; 117:161-163.  Back to cited text no. 12
    
13.Ponton C, Eggermont JJ, Khosla D, Kwong B, Don M. Maturation of human central auditory system activity: Separating auditory evoked potentials by dipole source modeling. Clin Neurophysiol 2002; 113:407-420.  Back to cited text no. 13
    
14.Scot J. Effects of auditory training on hearing aid acclimatization (A). J Acoust Soc Am 2006; 120:3349-3349.  Back to cited text no. 14
    
15.Dietrich V, Nieschalk M, Stoll W, Rajan R, Pantev C. Cortical reorganization in patients with high frequency cochlear hearing loss. Hear Res 2001; 158:95-101.  Back to cited text no. 15
    
16.Thai-Van H, Micheyl C, Moore BCJ, Collet L. Enhanced frequency discrimination near the hearing loss cut-off: a consequence of central auditory plasticity induced by cochlear damage? Brain 2003; 126: 2235-2245.  Back to cited text no. 16
    
17.Sharma A, Dorman MF, Spahr AJ. A sensitive period for the development of the central auditory system in children with cochlear implants: implications for age of implantation. Ear Hear 2002b; 23:532-539.  Back to cited text no. 17
    
18.Sharma A, Dorman M and Spahr A (2002a): Rapid development of cortical auditory evoked potentials after early cochlear implantation. Neuroreport. Jul 19; 13:1365-8.  Back to cited text no. 18
    
19.Sharma A, Dorman M. The clinical use of P1 latency as a biomarker for assessment of central auditory development in children with hearing impairment. Audiol Today 2005; 3:18-19.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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