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The reliability of distortion-product otoacoustic emission (DPOAE) measurements and their relation to loudness measurements was examined in 16 normal-hearing subjects and 58 subjects with hearing loss. The level of the distortion product (Ld) was compared across two sessions and resulted in correlations that exceeded 0.90. The reliability of DPOAEs was less when parameters from nonlinear fits to the input/output (I/O) functions were compared across visits. Next, the relationship between DPOAE I/O parameters and the slope of the low-level portion of the categorical loudness scaling (CLS) function (soft slope) was assessed. Correlations of 0.65, 0.74, and 0.81 at 1, 2, and 4 kHz were observed between CLS soft slope and combined DPOAE parameters. Behavioral threshold had correlations of 0.82, 0.83, and 0.88 at 1, 2, and 4 kHz with CLS soft slope. Combining DPOAEs and behavioral threshold provided little additional information. Lastly, a multivariate approach utilizing the entire DPOAE I/O function was used to predict the CLS rating for each input level (dB SPL). Standard error of the estimate when using this method ranged from 2.4 to 3.0 categorical units (CU), suggesting that DPOAE I/O functions can predict CLS measures within the CU step size used in this study (5). [ABSTRACT FROM AUTHOR]

Standing waves can cause measurement errors when sound-pressure level (SPL) measurements are performed in a closed ear canal, e.g., during probe-microphone system calibration for distortion-product otoacoustic emission (DPOAE) testing. Alternative calibration methods, such as forward-pressure level (FPL), minimize the influence of standing waves by calculating the forward-going sound waves separate from the reflections that cause errors. Previous research compared test performance (Burke et al., 2010) and threshold prediction (Rogers et al., 2010) using SPL and multiple FPL calibration conditions, and surprisingly found no significant improvements when using FPL relative to SPL, except at 8 kHz. The present study examined the calibration data collected by Burke et al. and Rogers et al. from 155 human subjects in order to describe the frequency location and magnitude of standing-wave pressure minima to see if these errors might explain trends in test performance. Results indicate that while individual results varied widely, pressure variability was larger around 4 kHz and smaller at 8 kHz, consistent with the dimensions of the adult ear canal. The present data suggest that standing-wave errors are not responsible for the historically poor (8 kHz) or good (4 kHz) performance of DPOAE measures at specific test frequencies. [ABSTRACT FROM AUTHOR]

Slopes of forward-masked psychometric functions (FM PFs) were compared with distortion-product otoacoustic emission (DPOAE) input/output (I/O) parameters at 1 and 6 kHz to test the hypothesis that these measures provide similar estimates of cochlear compression. Implicit in this hypothesis is the assumption that both DPOAE I/O and FM PF slopes are functionally related to basilar-membrane (BM) response growth. FM PF-slope decreased with signal level, but this effect was reduced or reversed with increasing hearing loss; there was a trend of decreasing psychometric function (PF) slope with increasing frequency, consistent with greater compression at higher frequencies. DPOAE I/O functions at 6 kHz exhibited an increase in the breakpoint of a two-segment slope as a function of hearing loss with a concomitant decrease in the level of the distortion product (Ld). Results of the comparison between FM PF and DPOAE I/O parameters revealed only a weak correlation, suggesting that one or both of these measures may provide unreliable information about BM compression. [ABSTRACT FROM AUTHOR]

In contrast to clinical click-evoked otoacoustic emission (CEOAE) tests that are inaccurate above 4-5 kHz, a research procedure measured CEOAEs up to 16 kHz in 446 ears and predicted the presence/absence of a sensorineural hearing loss. The behavioral threshold test that served as a reference to evaluate CEOAE test accuracy used a yes-no task in a maximum-likelihood adaptive procedure. This test was highly efficient between 0.5 and 12.7 kHz: Thresholds measured in 2 min per frequency had a median standard deviation (SD) of 1.2-1.5 dB across subjects. CEOAE test performance was assessed by the area under the receiver operating characteristic curve (AUC). The mean AUC from 1 to 10 kHz was 0.90 (SD = 0.016). AUC decreased to 0.86 at 12.7 kHz and to 0.7 at 0.5 and 16 kHz, possibly due in part to insufficient stimulus levels. Between 1 and 12.7 kHz, the medians of the magnitude difference in CEOAEs and in behavioral thresholds were <4 dB. The improved CEOAE test performance above 4-5 kHz was due to retaining the portion of the CEOAE response with latencies as short as 0.3 ms. Results have potential clinical significance in predicting hearing status from at least 1 to 10 kHz using a single CEOAE response. [ABSTRACT FROM AUTHOR]

Abstract: A wideband (WB) aural acoustical test battery of middle-ear status, including acoustic-reflex thresholds (ARTs) and acoustic-transfer functions (ATFs, i.e., absorbance and admittance) was hypothesized to be more accurate than 1-kHz tympanometry in classifying ears that pass or refer on a newborn hearing screening (NHS) protocol based on otoacoustic emissions. Assessment of middle-ear status may improve NHS programs by identifying conductive dysfunction and cases in which auditory neuropathy exists. Ipsilateral ARTs were assessed with a stimulus including four broadband-noise or tonal activator pulses alternating with five clicks presented before, between and after the pulses. The reflex shift was defined as the difference between final and initial click responses. ARTs were measured using maximum likelihood both at low frequencies (0.8–2.8kHz) and high (2.8–8kHz). The median low-frequency ART was elevated by 24dB in NHS refers compared to passes. An optimal combination of ATF and ART tests performed better than either test alone in predicting NHS outcomes, and WB tests performed better than 1-kHz tympanometry. Medial olivocochlear efferent shifts in cochlear function may influence ARs, but their presence would also be consistent with normal conductive function. Baseline clinical and WB ARTs were also compared in ipsilateral and contralateral measurements in adults. [Copyright &y& Elsevier]

This study tested the hypothesis that suppression contributes to the difference between simultaneous masking (SM) and forward masking (FM). To obtain an alternative estimate of suppression, distortion-product otoacoustic emissions (DPOAEs) were measured in the presence of a suppressor tone. Psychophysical-masking and DPOAE-suppression measurements were made in 22 normal-hearing subjects for a 4000-Hz signal/f2 and two masker/suppressor frequencies: 2141 and 4281 Hz. Differences between SM and FM at the same masker level were used to provide a psychophysical estimate of suppression. The increase in L2 to maintain a constant output (Ld) provided a DPOAE estimate of suppression for a range of suppressor levels. The similarity of the psychophysical and DPOAE estimates for the two masker/suppressor frequencies suggests that the difference in amount of masking between SM and FM is at least partially due to suppression. [ABSTRACT FROM AUTHOR]

Distortion-product otoacoustic emission (DPOAE) input/output (I/O) functions were measured in 322 ears of 176 subjects at as many as 8 f2 frequencies per ear for a total of 1779 I/O functions. The f2 frequencies ranged from 0.7 to 8 kHz in half-octave steps. Behavioral thresholds (BTs) at the f2 frequencies ranged from -5 to 60 dB hearing loss (HL). Both linear-pressure and nonlinear, two-slope functions were fitted to the data. The two-slope function describes I/O compression as output-controlled self-suppression. Most I/O functions (96%) were better fitted by the two-slope method. DPOAE thresholds based on each method were used to predict BTs. Compared to estimates based on linear-pressure functions, individual BTs predicted from DPOAE thresholds based on the two-slope model had lower residual error and accounted for more variance. Another advantage of the two-slope method is that it provides an estimate of response growth rate (RGR) that is not tied to threshold. At all frequencies, the median low-level RGR (across I/O functions of the same f2 and BT) usually increased as BT increased, while high-level compression decreased. The observed characteristics of DPOAE I/O functions are consistent with the loss of cochlear compression that is typically associated with mild-to-moderate HL. [ABSTRACT FROM AUTHOR]

Stimulus frequency otoacoustic emissions (SFOAEs) measured using a suppressor tone in human ears are analogous to two-tone suppression responses measured mechanically and neurally in mammalian cochleae. SFOAE suppression was measured in 24 normal-hearing adults at octave frequencies (fp=0.5–8.0 kHz) over a 40 dB range of probe levels (Lp). Suppressor frequencies (fs) ranged from -2.0 to 0.7 octaves re: fp, and suppressor levels ranged from just detectable suppression to full suppression. The lowest suppression thresholds occurred for “best” fs slightly higher than fp. SFOAE growth of suppression (GOS) had slopes close to one at frequencies much lower than best fs, and shallow slopes near best fs, which indicated compressive growth close to 0.3 dB/dB. Suppression tuning curves constructed from GOS functions were well defined at 1, 2, and 4 kHz, but less so at 0.5 and 8.0 kHz. Tuning was sharper at lower Lp with an equivalent rectangular bandwidth similar to that reported behaviorally for simultaneous masking. The tip-to-tail difference assessed cochlear gain, increasing with decreasing Lp and increasing fp at the lowest Lp from 32 to 45 dB for fp from 1 to 4 kHz. SFOAE suppression provides a noninvasive measure of the saturating nonlinearities associated with cochlear amplification on the basilar membrane. [ABSTRACT FROM AUTHOR]

It has been proposed that the clinical accuracy of distortion product otoacoustic emissions (DPOAEs) is affected by the interaction of distortion and reflection sources contributing to the response. This study evaluated changes in dichotomous-decision test performance and threshold-prediction accuracy when DPOAE source contribution was controlled. Data were obtained from 205 normal and impaired ears with L2 ranging from 0 to 80 dB SPL and f2=2 and 4 kHz. Data were collected for control conditions (no suppressor, f3) and with f3 presented at three levels that previously had been shown to reduce the reflection-source contribution. The results indicated that controlling source contribution with a suppressor did not improve diagnostic accuracy (as reflected by relative operating characteristic curve area) and frequently resulted in poorer test performance compared to control conditions. Likewise, correlations between DPOAE and behavioral thresholds were not strengthened when using the suppressors to control source contribution. While improvements in test accuracy were observed for a subset of subjects (normal ears with the smallest DPOAEs and impaired ears with the largest DPOAEs), the lack of improvement for the larger, unselected subject group suggests that DPOAEs should be recorded in the clinic without attempting to control the source contribution with a suppressor. [ABSTRACT FROM AUTHOR]

Distortion product otoacoustic emission (DPOAE) fine structure has been attributed to the interaction of two cochlear-source mechanisms (distortion and reflection sources). A suppressor presented near the 2f1-f2 frequency reduces the reflection-source contribution and, therefore, DPOAE fine structure. Optimal relationships between stimulus and suppressor conditions, however, have not been described. In this study, the relationship between suppressor level (L3) and stimulus level (L2) was evaluated to determine the L3 that was most effective at reducing fine structure. Subjects were initially screened to find individuals who produced DPOAE fine structure. A difference in the prevalence of fine structure in two frequency intervals was observed. At 2 kHz, 11 of 12 subjects exhibited fine structure, as compared to 5 of 22 subjects at 4 kHz. Only subjects demonstrating fine structure participated in subsequent measurements. DPOAE responses were evaluated in 1/3-octave intervals centered at 2 or 4 kHz, with 4 subjects contributing data at each interval. Multiple L3’s were evaluated for each L2, which ranged from 20 to 80 dB SPL. The results indicated that one or more L3’s at each L2 were roughly equally effective at reducing DPOAE fine structure. However, no single L3 was effective at all L2’s in every subject. [ABSTRACT FROM AUTHOR]

Presents information on a study regarding genetic hearing loss caused by mutations in the connexin 26 (Cx26) gene. Summary of the clinical trials; Characteristics of the Cx26 patients; Assessment on their hearing impairment.

Background: In listening environments with background noise that fluctuates in level, listeners with normal hearing can "glimpse" speech during dips in the noise, resulting in better speech recognition in fluctuating noise than in steady noise at the same overall level (referred to as masking release). Listeners with sensorineural hearing loss show less masking release. Amplification can improve masking release but not to the same extent that it does for listeners with normal hearing., Purpose: The purpose of this study was to compare masking release for listeners with sensorineural hearing loss obtained with an experimental hearing-aid signal-processing algorithm with instantaneous compression (referred to as a suppression hearing aid, SHA) to masking release obtained with fast compression. The suppression hearing aid mimics effects of normal cochlear suppression, i.e., the reduction in the response to one sound by the simultaneous presentation of another sound., Research Design: A within-participant design with repeated measures across test conditions was used., Study Sample: Participants included 29 adults with mild-to-moderate sensorineural hearing loss and 21 adults with normal hearing., Intervention: Participants with sensorineural hearing loss were fitted with simulators for SHA and a generic hearing aid (GHA) with fast (but not instantaneous) compression (5 ms attack and 50 ms release times) and no suppression. Gain was prescribed using either an experimental method based on categorical loudness scaling (CLS) or the Desired Sensation Level (DSL) algorithm version 5a, resulting in a total of four processing conditions: CLS-GHA, CLS-SHA, DSL-GHA, and DSL-SHA., Data Collection: All participants listened to consonant-vowel-consonant nonwords in the presence of temporally-modulated and steady noise. An adaptive-tracking procedure was used to determine the signal-to-noise ratio required to obtain 29% and 71% correct. Measurements were made with amplification for participants with sensorineural hearing loss and without amplification for participants with normal hearing., Analysis: Repeated-measures analysis of variance was used to determine the influence of within-participant factors of noise type and, for participants with sensorineural hearing loss, processing condition on masking release. Pearson correlational analysis was used to assess the effect of age on masking release for participants with sensorineural hearing loss., Results: Statistically significant masking release was observed for listeners with sensorineural hearing loss for 29% correct, but not for 71% correct. However, the amount of masking release was less than masking release for participants with normal hearing. There were no significant differences among the amplification conditions for participants with sensorineural hearing loss., Conclusions: The results suggest that amplification with either instantaneous or fast compression resulted in similar masking release for listeners with sensorineural hearing loss. However, the masking release was less for participants with hearing loss than it was for those with normal hearing., (American Academy of Audiology.)

Objectives: Recent animal studies suggest that noise-induced synaptopathy may underlie a phenomenon that has been labeled hidden hearing loss (HHL). Noise exposure preferentially damages low spontaneous-rate auditory nerve fibers, which are involved in the processing of moderate- to high-level sounds and are more resistant to masking by background noise. Therefore, the effect of synaptopathy may be more evident in suprathreshold measures of auditory function, especially in the presence of background noise. The purpose of this study was to develop a statistical model for estimating HHL in humans using thresholds in noise as the outcome variable and measures that reflect the integrity of sites along the auditory pathway as explanatory variables. Our working hypothesis is that HHL is evident in the portion of the variance observed in thresholds in noise that is not dependent on thresholds in quiet, because this residual variance retains statistical dependence on other measures of suprathreshold function., Design: Study participants included 13 adults with normal hearing (≤15 dB HL) and 20 adults with normal hearing at 1 kHz and sensorineural hearing loss at 4 kHz (>15 dB HL). Thresholds in noise were measured, and the residual of the correlation between thresholds in noise and thresholds in quiet, which we refer to as thresholds-in-noise residual, was used as the outcome measure for the model. Explanatory measures were as follows: (1) auditory brainstem response (ABR) waves I and V amplitudes; (2) electrocochleographic action potential and summating potential amplitudes; (3) distortion product otoacoustic emissions level; and (4) categorical loudness scaling. All measurements were made at two frequencies (1 and 4 kHz). ABR and electrocochleographic measurements were made at 80 and 100 dB peak equivalent sound pressure level, while wider ranges of levels were tested during distortion product otoacoustic emission and categorical loudness scaling measurements. A model relating the thresholds-in-noise residual and the explanatory measures was created using multiple linear regression analysis., Results: Predictions of thresholds-in-noise residual using the model accounted for 61% (p < 0.01) and 48% (p < 0.01) of the variance in the measured thresholds-in-noise residual at 1 and 4 kHz, respectively., Conclusions: Measures of thresholds in noise, the summating potential to action potential ratio, and ABR waves I and V amplitudes may be useful for the prediction of HHL in humans. With further development, our approach of quantifying HHL by the variance that remains in suprathreshold measures of auditory function after removing the variance due to thresholds in quiet, together with our statistical modeling, may provide a quantifiable and verifiable estimate of HHL in humans with normal hearing and with hearing loss. The current results are consistent with the view that inner hair cell and auditory nerve pathology may underlie suprathreshold auditory performance.

Loudness depends on both the intensity and spectrum of a sound. Listeners with normal hearing perceive a broadband sound as being louder than an equal-level narrowband sound because loudness grows nonlinearly with level and is then summed across frequency bands. This difference in loudness as a function of bandwidth is reduced in listeners with sensorineural hearing loss (SNHL). Suppression, the reduction in the cochlear response to one sound by the simultaneous presentation of another sound, is also reduced in listeners with SNHL. Hearing-aid gain that is based on loudness measurements with pure tones may fail to restore normal loudness growth for broadband sounds. This study investigated whether hearing-aid amplification that mimics suppression can improve loudness summation for listeners with SNHL. Estimates of loudness summation were obtained using measurements of categorical loudness scaling (CLS). Stimuli were bandpass-filtered noises centered at 2 kHz with bandwidths in the range of 0.1-6.4 kHz. Gain was selected to restore normal loudness based on CLS measurements with pure tones. Gain that accounts for both compression and suppression resulted in better restoration of loudness summation, compared to compression alone. However, restoration was imperfect, suggesting that additional refinements to the signal processing and gain-prescription algorithms are needed.

The purpose of this study was to investigate the combined effect of multiple suppressors. Distortion-product otoacoustic emission (DPOAE) measurements were made in normal-hearing participants. Primary tones had fixed frequencies (f2 = 4000 Hz; f1 / f2 = 1.22) and a range of levels. Suppressor tones were at three frequencies (fs = 2828, 4100, 4300 Hz) and range of levels. Decrement was defined as the attenuation in DPOAE level due to the presence of a suppressor. A measure of suppression called suppressive intensity was calculated by an equation previously shown to fit DPOAE suppression data. Suppressor pairs, which were the combination of two different frequencies, were presented at levels selected to have equal single-suppressor decrements. A hybrid model that represents a continuum between additive intensity and additive attenuation best described the results. The suppressor pair with the smallest frequency ratio produced decrements that were more consistent with additive intensity. The suppressor pair with the largest frequency ratio produced decrements at the highest level that were consistent with additive attenuation. Other suppressor-pair conditions produced decrements that were intermediate between these two alternative models. The hybrid model provides a useful framework for representing the observed range of interaction when two suppressors are combined.

The metric used to equate stimulus level [sound pressure level (SPL) or sensation level (SL)] between ears with normal hearing (NH) and ears with hearing loss (HL) in comparisons of auditory function can influence interpretation of results. When stimulus level is equated in dB SL, higher SPLs are presented to ears with HL due to their reduced sensitivity. As a result, it may be difficult to determine if differences between ears with NH and ears with HL are due to cochlear pathology or level-dependent changes in cochlear mechanics. To the extent that level-dependent changes in cochlear mechanics contribute to auditory brainstem response latencies, comparisons between normal and pathologic ears may depend on the stimulus levels at which comparisons are made. To test this hypothesis, wave V latencies were measured in 16 NH ears and 15 ears with mild-to-moderate HL. When stimulus levels were equated in SL, latencies were shorter in HL ears. However, latencies were similar for NH and HL ears when stimulus levels were equated in SPL. These observations demonstrate that the effect of stimulus level on wave V latency is large relative to the effect of HL, at least in cases of mild-to-moderate HL.

Objectives: Diagnosis of hearing loss and prescription of amplification for infants and young children require accurate estimates of ear- and frequency-specific behavioral thresholds based on auditory brainstem response (ABR) measurements. Although the overall relationship between ABR and behavioral thresholds has been demonstrated, the agreement is imperfect, and the accuracy of predictions of behavioral threshold based on ABR may depend on degree of hearing loss. Behavioral thresholds are lower than ABR thresholds, at least in part due to differences in calibration interacting with the effects of temporal integration, which are manifest in behavioral measurements but not ABR measurements and depend on behavioral threshold. Listeners with sensory hearing loss exhibit reduced or absent temporal integration, which could impact the relationship between ABR and behavioral thresholds as degree of hearing loss increases. The present study evaluated the relationship between ABR and behavioral thresholds in infants and children over a range of hearing thresholds, and tested an approach for adjusting the correction factor based on degree of hearing loss as estimated by ABR measurements., Design: A retrospective review of clinical records was completed for 309 ears of 177 children with hearing thresholds ranging from normal to profound hearing loss and for whom both ABR and behavioral thresholds were available. Children were required to have the same middle ear status at both evaluations. The relationship between ABR and behavioral thresholds was examined. Factors that potentially could affect the relationship between ABR and behavioral thresholds were analyzed, including degree of hearing loss observed on the ABR, behavioral test method (visual reinforcement, conditioned play, or conventional audiometry), the length of time between ABR and behavioral assessments, and clinician-reported reliability of the behavioral assessment. Predictive accuracy of a correction factor based on the difference between ABR and behavioral thresholds as a function of ABR threshold was compared to the predictive accuracy achieved by two other correction approaches in current clinical use., Results: As expected, ABR threshold was a significant predictor of behavioral threshold. The agreement between ABR and behavioral thresholds varied as a function of degree of hearing loss. The test method, length of time between assessments, and reported reliability of the behavioral test results were not related to the differences between ABR and behavioral thresholds. A correction factor based on the linear relationship between the differences in ABR and behavioral thresholds as a function of ABR threshold resulted in more accurately predicted behavioral thresholds than other correction factors in clinical use., Conclusions: ABR is a valid predictor of behavioral threshold in infants and children. A correction factor that accounts for the effect of degree of hearing loss on the differences between ABR and behavioral thresholds resulted in more accurate predictions of behavioral thresholds than methods that used a constant correction factor regardless of degree of hearing loss. These results are consistent with predictions based on previous research on temporal integration for listeners with hearing loss.

This study describes procedures for constructing equal-loudness contours (ELCs) in units of phons from categorical loudness scaling (CLS) data and characterizes the impact of hearing loss on these estimates of loudness. Additionally, this study developed a metric, level-dependent loudness loss, which uses CLS data to specify the deviation from normal loudness perception at various loudness levels and as function of frequency for an individual listener with hearing loss. CLS measurements were made in 87 participants with hearing loss and 61 participants with normal hearing. An assessment of the reliability of CLS measurements was conducted on a subset of the data. CLS measurements were reliable. There was a systematic increase in the slope of the low-level segment of the CLS functions with increase in the degree of hearing loss. ELCs derived from CLS measurements were similar to standardized ELCs (International Organization for Standardization, ISO 226:2003). The presence of hearing loss decreased the vertical spacing of the ELCs, reflecting loudness recruitment and reduced cochlear compression. Representing CLS data in phons may lead to wider acceptance of CLS measurements. Like the audiogram that specifies hearing loss at threshold, level-dependent loudness loss describes deficit for suprathreshold sounds. Such information may have implications for the fitting of hearing aids.

Objective: Accurate ear-canal acoustic measurements, such as wideband acoustic admittance, absorbance, and otoacoustic emissions, require that the measurement probe be tightly sealed in the ear canal. Air leaks can compromise the validity of the measurements, interfere with calibrations, and increase variability. There are no established procedures for determining the presence of air leaks or criteria for what size leak would affect the accuracy of ear-canal acoustic measurements. The purpose of this study was to determine ways to quantify the effects of air leaks and to develop objective criteria to detect their presence., Design: Air leaks were simulated by modifying the foam tips that are used with the measurement probe through insertion of thin plastic tubing. To analyze the effect of air leaks, acoustic measurements were taken with both modified and unmodified foam tips in brass-tube cavities and human ear canals. Measurements were initially made in cavities to determine the range of critical leaks. Subsequently, data were collected in ears of 21 adults with normal hearing and normal middle-ear function. Four acoustic metrics were used for predicting the presence of air leaks and for quantifying these leaks: (1) low-frequency admittance phase (averaged over 0.1-0.2 kHz), (2) low-frequency absorbance, (3) the ratio of compliance volume to physical volume (CV/PV), and (4) the air-leak resonance frequency. The outcome variable in this analysis was the absorbance change (Δabsorbance), which was calculated in eight frequency bands., Results: The trends were similar for both the brass cavities and the ear canals. ΔAbsorbance generally increased with air-leak size and was largest for the lower frequency bands (0.1-0.2 and 0.2-0.5 kHz). Air-leak effects were observed in frequencies up to 10 kHz, but their effects above 1 kHz were unpredictable. These high-frequency air leaks were larger in brass cavities than in ear canals. Each of the four predictor variables exhibited consistent dependence on air-leak size. Low-frequency admittance phase and CV/PV decreased, while low-frequency absorbance and the air-leak resonance frequency increased., Conclusion: The effect of air leaks can be significant when their equivalent diameter exceeds 0.01 in. The observed effects were greatest at low frequencies where air leaks caused absorbance to increase. Recommended criteria for detecting air leaks include the following: when the frequency range of interest extends as low as 0.1 kHz, low-frequency absorbance should be ≤0.20 and low-frequency admittance phase ≥61 degrees. For frequency ranges as low as 0.2 kHz, low-frequency absorbance should be ≤0.29 and low-frequency admittance phase ≥44 degrees.

Objective: Cochlear reflectance (CR) is the cochlear contribution to ear-canal reflectance. CR is equivalent to an otoacoustic emission (OAE) deconvolved by forward pressure in the ear canal. Similar to other OAE measures, CR level is related to cochlear status. When measured using wideband noise stimuli, potential advantages of CR over other types of OAEs include (1) the capability to cover a wider frequency range more efficiently by requiring fewer measurements, (2) minimal influence on the recorded emission from the measurement system and middle ear, (3) lack of entrainment of spontaneous OAEs, and (4) easier interpretation because of the existence of an equivalent linear model, which validates the application of linear systems theory. The purposes of this study were to evaluate the reliability, assess the accuracy in a clinical screening paradigm, and determine the relation of CR to audiometric thresholds. Thus, this study represents an initial assessment of the clinical utility of CR., Design: Data were collected from 32 normal-hearing and 58 hearing-impaired participants. A wideband noise stimulus presented at seven stimulus levels (10 to 70 dB SPL, 10 dB steps) was used to elicit the CR. Reliability of CR was assessed using Cronbach's α, standard error of measurement, and absolute differences between CR data from three separate test sessions. Test performance was evaluated using clinical decision theory. The ability of CR to predict audiometric thresholds was evaluated using regression analysis., Results: CR repeatability across test sessions was similar to that of other clinical measurements. However, both the accuracy with which CR distinguished normal-hearing from hearing-impaired ears and the accuracy with which CR predicted audiometric thresholds were less than those reported in previous studies using distortion-product OAE measurements., Conclusions: CR measurements are repeatable between test sessions, can be used to predict auditory status, and are related to audiometric thresholds. However, under current conditions, CR does not perform as well as other OAE measurements. Further developments in CR measurement and analysis methods may improve performance. CR has theoretical advantages for cochlear modeling, which may lead to improved interpretation of cochlear status.

Because frequency components interact nonlinearly with each other inside the cochlea, the loudness growth of tones is relatively simple in comparison to the loudness growth of complex sounds. The term suppression refers to a reduction in the response growth of one tone in the presence of a second tone. Suppression is a salient feature of normal cochlear processing and contributes to psychophysical masking. Suppression is evident in many measurements of cochlear function in subjects with normal hearing, including distortion-product otoacoustic emissions (DPOAEs). Suppression is also evident, to a lesser extent, in subjects with mild-to-moderate hearing loss. This paper describes a hearing-aid signal-processing strategy that aims to restore both loudness growth and two-tone suppression in hearing-impaired listeners. The prescription of gain for this strategy is based on measurements of loudness by a method known as categorical loudness scaling. The proposed signal-processing strategy reproduces measured DPOAE suppression tuning curves and generalizes to any number of frequency components. The restoration of both normal suppression and normal loudness has the potential to improve hearing-aid performance and user satisfaction.

Objectives: Distortion-product otoacoustic emissions (DPOAEs) collected after sound pressure level (SPL) calibration are susceptible to standing waves that affect measurements at the plane of the probe microphone due to overlap of incident and reflected waves. These standing-wave effects can be as large as 20 dB, and may affect frequencies both above and below 4 kHz. It has been shown that forward pressure level (FPL) calibration minimizes standing-wave effects by isolating the forward-propagating component of the stimulus. Yet, previous work has failed to demonstrate more than a small difference in test performance and behavioral-threshold prediction with DPOAEs after SPL and FPL calibration. One potential limitation in prior studies is that measurements were restricted to octave and interoctave frequencies; as a consequence, data were not necessarily collected at the standing-wave null frequency. In the present study, DPOAE responses were measured with f2 set to each participant's standing-wave frequency in an effort to increase the possibility that differences in test performance and threshold prediction would be observed for SPL and FPL calibration methods., Design: Data were collected from 42 normal-hearing participants and 93 participants with hearing loss. DPOAEs were measured with f2 set to 4 kHz and at each participant's notch frequency after SPL and FPL calibration. DPOAE input/output functions were obtained from -10 to 80 dB in 5 dB steps for each calibration/stimulus condition. Test performance was evaluated using clinical decision theory. Both area under receiver operating characteristic curves for all stimulus levels and cumulative distributions when L2 = 50 dB (a level at which the best performance was observed regardless of calibration method) were used to evaluate the accuracy with which auditory status was determined. A bootstrap procedure was used to evaluate the significance of the differences in test performance between SPL and FPL calibrations. DPOAE predictions of behavioral threshold were evaluated by correlating actual behavioral thresholds and predicted thresholds using a multiple linear regression model., Results: First, larger DPOAE levels were measured after SPL calibration than after FPL calibration, which demonstrated the expected impact of standing waves. Second, for both FPL and SPL calibration, test performance was best for moderate stimulus levels. Third, differences in test performance between calibration methods were evident at low- and high-stimulus levels. Fourth, there were small but statistically significant improvements in test performance after FPL calibration for clinically relevant conditions. Fifth, calibration method had no effect on threshold prediction., Conclusions: Standing waves after SPL calibration have an impact on DPOAE levels. Although the effect of calibration method on test performance was small, test performance was better after FPL calibration than after SPL calibration. There was no effect of calibration method on predictions of behavioral threshold.

The aim of this study is to further explore the relationship between distortion-product otoacoustic emission (DPOAE) measurements and categorical loudness scaling (CLS) measurements using multiple linear regression (MLR) analysis. Recently, Thorson et al. [J. Acoust. Soc. Am. 131, 1282-1295 (2012)] obtained predictions of CLS loudness ratings from DPOAE input/output (I/O) functions using MLR analysis. The present study extends that work by (1) considering two different (and potentially improved) MLR models, one for predicting loudness rating at specified input level and the other for predicting the input level for each loudness category and (2) validating the new models' predictions using an independent set of data. Strong correlations were obtained between predicted and measured data during the validation process with overall root-mean-square errors in the range 10.43-16.78 dB for the prediction of CLS input level, supporting the view that DPOAE I/O measurements can predict CLS loudness ratings and input levels, and thus may be useful for fitting hearing aids.

Simultaneous measurement of auditory brain stem response (ABR) and otoacoustic emission (OAE) delays may provide insights into effects of level, frequency, and stimulus rise-time on cochlear delay. Tone-burst-evoked ABRs and OAEs (TBOAEs) were measured simultaneously in normal-hearing human subjects. Stimuli included a wide range of frequencies (0.5-8 kHz), levels (20-90 dB SPL), and tone-burst rise times. ABR latencies have orderly dependence on these three parameters, similar to previously reported data by Gorga et al. [J. Speech Hear. Res. 31, 87-97 (1988)]. Level dependence of ABR and TBOAE latencies was similar across a wide range of stimulus conditions. At mid-frequencies, frequency dependence of ABR and TBOAE latencies were similar. The dependence of ABR latency on both rise time and level was significant; however, the interaction was not significant, suggesting independent effects. Comparison between ABR and TBOAE latencies reveals that the ratio of TBOAE latency to ABR forward latency (the level-dependent component of ABR total latency) is close to one below 1.5 kHz, but greater than two above 1.5 kHz. Despite the fact that the current experiment was designed to test compatibility with models of reverse-wave propagation, existing models do not completely explain the current data.

Objective: This study tested the hypothesis that wideband aural absorbance predicts conductive hearing loss (CHL) in children medically classified as having otitis media with effusion., Design: Absorbance was measured in the ear canal over frequencies from 0.25 to 8 kHz at ambient pressure or as a swept tympanogram. CHL was defined using criterion air-bone gaps of 20, 25, and 30 dB at octaves from 0.25 to 4 kHz. A likelihood-ratio predictor of CHL was constructed across frequency for ambient absorbance, and across frequency and pressure for absorbance tympanometry. Performance was evaluated at individual frequencies and for any frequency at which a CHL was present., Study Sample: Absorbance and conventional 0.226-kHz tympanograms were measured in children of age three to eight years with CHL and with normal hearing., Results: Absorbance was smaller at frequencies above 0.7 kHz in the CHL group than the control group. Based on the area under the receiver operating characteristic curve, wideband absorbance in ambient and tympanometric tests were significantly better predictors of CHL than tympanometric width, the best 0.226-kHz predictor. Accuracies of ambient and tympanometric wideband absorbance did not differ., Conclusions: Absorbance accurately predicted CHL in children and was more accurate than conventional 0.226-kHz tympanometry.

Growth of distortion-product otoacoustic emission suppression was measured in 65 subjects with mild-to-moderate sensorineural hearing loss (HI). Measurements were made at four probe frequencies (f(2)) and up to five L(2) levels. Eleven suppressor frequencies (f(3)) were used for each f(2), L(2) combination. These data were compared to data from normal-hearing (NH) subjects (Gorga et al., 2011a). In both NH and HI subjects, growth of suppression depended on the relation between f(2) and f(3), such that the slope was close to one when f(3) ≈ f(2), steeper than one when f(3) < f(2), and shallower than one when f(3) > f(2). Differences in growth of suppression between NH and HI subjects were not observed for fixed f(2), L(2) combinations, however large differences were observed in suppressor "threshold" when compared at the same probe sensation level (dB SL). Smaller group differences were observed when compared at the same probe sound-pressure level (dB SPL). Therefore, the extent of these differences depended on how probe level (L(2)) was specified. When the results from NH and HI subjects are compared with each other and with psychophysical studies of masking, differences are observed that have implications for the remediation of mild-to-moderate hearing loss.

Distortion-product otoacoustic emission (DPOAE) suppression tuning curves (STCs) were measured in 65 hearing-impaired (HI) subjects at f(2) frequencies of 2.0, 2.8, 4.0, and 5.6 kHz and L(2) levels relative to sensation level (SL) from 10 dB to as much as 50 dB. Best frequency, cochlear-amplifier gain (tip-to-tail difference, T-T), and tuning (Q(ERB)) were estimated from STCs. As with normal-hearing (NH) subjects, T-T differences and Q(ERB) decreased as L(2) increased. T-T differences and Q(ERB) were reduced in HI ears (compared to normal) for conditions in which L(2) was fixed relative to behavioral threshold (dB SL). When STCs were compared with L(2) at constant sound pressure levels (dB SPL), differences between NH and HI subjects were reduced. The large effect of level and small effect of hearing loss were both confirmed by statistical analyses. Therefore, the magnitude of the differences in DPOAE STCs between NH and HI subjects is mainly dependent on the manner in which level (L(2)) is specified. Although this conclusion may appear to be at odds with previous, invasive measures of cochlear-response gain and tuning, the apparent inconsistency may be resolved when the manner of specifying stimulus level is taken into account.

Objectives: To determine whether an "optimal" distortion product otoacoustic emission (DPOAE) protocol that (1) used optimal stimulus levels and primary-frequency ratios for each f2, (2) simultaneously measured 2f2 - f1 and 2f1 - f2 distortion products, (3) controlled source contribution, (4) implemented improved calibration techniques, (5) accounted for the influence of middle ear reflectance, and (6) applied multivariate analyses to DPOAE data results in improved accuracy in differentiating between normal-hearing and hearing-impaired ears, compared with a standard clinical protocol., Design: Data were collected for f2 frequencies ranging from 0.75 to 8 kHz in 28 normal-hearing and 78 hearing-impaired subjects. The protocol included a control condition incorporating standard stimulus levels and primary-frequency ratios calibrated with a standard SPL method and three experimental conditions using optimized stimuli calibrated with an alternative forward pressure level method. The experimental conditions differed with respect to the level of the reflection-source suppressor tone and included conditions referred to as the null suppressor (i.e., no suppressor tone presented), low-level suppressor (i.e., suppressor tone presented at 58 dB SPL), and high-level suppressor (i.e., suppressor tone presented at 68 dB SPL) conditions. The area under receiver operating characteristic (A(ROC)) curves and sensitivities for fixed specificities (and vice versa) were estimated to evaluate test performance in each condition., Results: A(ROC) analyses indicated (1) improved test performance in all conditions using multivariate analyses, (2) improved performance in the null suppressor and low suppressor experimental conditions compared with the control condition, and (3) poorer performance below 4 kHz with the high-level suppressor. As expected from A(ROC), sensitivities for fixed specificities and specificities for fixed sensitivities were highest for the null suppressor and low suppressor conditions and lowest for standard clinical procedures. The influence of 2f2 - f1 and reflectance on test performance were negligible., Conclusions: Predictions of auditory status based on DPOAE measurements in clinical protocols may be improved by the inclusion of (1) optimized stimuli, (2) alternative calibration techniques, (3) low-level suppressors, and (4) multivariate analyses.

Distortion-product otoacoustic emission (DPOAE) suppression data as a function of suppressor level (L(3)) for f(2) frequencies from 0.5 to 8 kHz and L(2) levels from 10 to 60 dB sensation level were used to construct suppression tuning curves (STCs). DPOAE levels in the presence of suppressors were converted into decrement versus L(3) functions, and the L(3) levels resulting in 3 dB decrements were derived by transformed linear regression. These L(3) levels were plotted as a function of f(3) to construct STCs. When f(3) is represented on an octave scale, STCs were similar in shape across f(2) frequency. These STCs were analyzed to provide estimates of gain (tip-to-tail difference) and tuning (Q(ERB)). Both gain and tuning decreased as L(2) increased, regardless of f(2), but the trend with f(2) was not monotonic. A roughly linear relation was observed between gain and tuning at each frequency, such that gain increased by 4-16 dB (mean ≈ 5 dB) for every unit increase in Q(ERB), although the pattern varied with frequency. These findings suggest consistent nonlinear processing across a wide frequency range in humans, although the nonlinear operation range is frequency dependent.

Distortion-product otoacoustic emissions (DPOAEs) were used to describe suppression growth in normal-hearing humans. Data were collected at eight f(2) frequencies ranging from 0.5 to 8 kHz for L(2) levels ranging from 10 to 60 dB sensation level. For each f(2) and L(2) combination, suppression was measured for nine or eleven suppressor frequencies (f(3)) whose levels varied from -20 to 85 dB sound pressure level (SPL). Suppression grew nearly linearly when f(3) ≈ f(2), grew more rapidly for f(3) < f(2), and grew more slowly for f(3) > f(2). These results are consistent with physiological and mechanical data from lower animals, as well as previous DPOAE data from humans, although no previous DPOAE study has described suppression growth for as wide a range of frequencies and levels. These trends were evident for all f(2) and L(2) combinations; however, some exceptions were noted. Specifically, suppression growth rate was less steep as a function of f(3) for f(2) frequencies ≤ 1 kHz. Thus, despite the qualitative similarities across frequency, there were quantitative differences related to f(2), suggesting that there may be subtle differences in suppression for frequencies above 1 kHz compared to frequencies below 1 kHz.

Objective: To further examine the reliability of categorical loudness scaling (CLS) for individual loudness categories and for the slope of the CLS functions. And, to evaluate the relationship between CLS and audiometric threshold., Design: CLS functions were obtained in 74 subjects, 58 with hearing loss and 16 with normal hearing. CLS functions were measured at three frequencies (1, 2, and 4 kHz) in two separate sessions separated by as little as 1 wk and as much as 6 mo. Reliability of mean and median levels within each loudness category was assessed using SDs and correlation coefficients. Lines were fit to the CLS functions, and slopes of the lines were used to assess reliability and the relation between CLS and audiometric threshold., Results: Similar reliability for CLS measurements was observed in both normal-hearing and hearing-impaired subjects at all frequencies. Across both groups of subjects, correlations describing the reliability of mean stimulus level within category exceeded 0.92 at all frequencies. In addition, SDs of the mean stimulus-level difference between visits ranged from 6.6 to 7.8 dB, depending on frequency. The correlation between the slope of a straight line fitted to the entire CLS function and audiometric threshold collapsed across frequencies was 0.72. Two line segments were then fit to the CLS function: one segment was fit to the soft portion of the CLS function (categorical units < or =20) and the other segment to the loud portion (categorical unit >20). Slopes of the line fit to the entire CLS function and of the line fit to the soft portion of the CLS function were both reliable across sessions. The slope of the line fit to the soft portion increased as audiometric threshold increased, with the correlations greater than 0.86 at all frequencies. No relationship was observed between slope of the line fit to the loud portion of the CLS function and audiometric threshold. Iso-loudness contours were constructed from the CLS data and used to determine the gain that would be needed to produce "normal" loudness percepts for hearing-impaired individuals., Conclusions: Within-subject CLS measurements were reliable across sessions both for individual loudness categories and for slope of the CLS functions. In addition, the slope of the low-level portion of the CLS function varied in a predictable manner with audiometric threshold, with slope increasing as audiometric threshold increased. Finally, gain as a function of input level needed to provide loudness percepts for individuals with hearing loss equal to the loudness percepts of normal-hearing individuals can be estimated from audiometric threshold. This finding supports the assumption that audiometric threshold and response growth (loudness) are both determined by the same underlying cochlear mechanisms.

Objectives: Distortion-product otoacoustic emission (DPOAE) stimulus calibrations are typically performed in sound pressure level (SPL) before DPOAE measurements. These calibrations may yield unpredictable DPOAE response levels, presumably because of the presence of standing waves in the ear canal. Forward pressure level (FPL) has been proposed as an alternative method for stimulus calibration because it avoids complications due to standing waves. DPOAE thresholds after four FPL calibrations and one SPL calibration were compared with behavioral thresholds to determine which calibration results in data that yield the highest correlations between the two threshold estimates., Design: Fifty-two subjects with normal hearing and 103 subjects with hearing loss participated in this study, with ages ranging from 11 to 75 yr. These were the same individuals whose data were used to address the influence of calibration method on test performance in an accompanying article. DPOAE input/output (I/O) functions were obtained at f2 frequencies of 2, 3, 4, 6, and 8 kHz with the primary frequency ratio fixed at f2/f1 approximately 1.22. L(1) was set according to the equation L(1) = 0.4 L(2) + 39 with L(2) levels ranging from -20 to 70 dB SPL and FPL in 5-dB steps. I/O functions were obtained at each frequency for each of the five stimulus calibrations: SPL, daily FPL at room temperature, daily FPL at body temperature, reference FPL at room temperature, and reference FPL at body temperature. DPOAE thresholds were estimated using two methods. In the first method, DPOAE threshold was taken as the lowest L(2) for which DPOAE level is 3 dB or greater than the noise floor (signal- to-noise ratio > or =3 dB). In a second method, a linear regression method first described by Boege & Janssen (2002) and later adapted by Gorga et al. (2003), all DPOAE levels in each I/O function are converted to linear pressure and extrapolated to 0 microPa, at which the L(2) is taken as threshold. Correlations of DPOAE thresholds with behavioral thresholds were obtained for each frequency, calibration method, and threshold-prediction method., Results: Correlations were greatest for frequencies of 3 to 6 kHz and lowest for 8 kHz, consistent with previous frequency effects. Calibration method made little difference in correlations between DPOAE and behavioral thresholds at any frequency. A small difference was noted in correlations for the two threshold prediction methods, with the linear regression method yielding slightly higher correlations at all frequencies., Conclusions: Little difference in threshold correlations was observed among the five calibration methods used to calibrate the stimuli before DPOAE measurements. These results were not anticipated, given the known effects of standing waves on ear-canal estimates of SPL at the plane of the probe. In addition, there was no effect of temperature (body versus room) or timing (daily versus reference) for FPL calibrations. It may be important to note that differences between SPL and FPL calibrations should not be seen if a standing wave does not occur at the plane of the probe at or near the frequency being tested. The frequencies (2 to 8 kHz) were chosen because it was expected that effects from standing waves would occur between these frequencies because of the typical lengths of ear canals for the age group tested. Because measurements were taken at only five discrete frequencies in the interval, it is possible that standing waves were present but did not affect the specific test frequencies. In total, these results suggest that SPL calibrations may be adequate when attempting to predict pure-tone thresholds from DPOAEs, despite the fact that they are known to be susceptible to errors associated with standing waves.

Objective: Calibration errors in distortion-product otoacoustic emission (DPOAE) measurements because of standing waves cause unpredictable changes in stimulus and DPOAE response level. The purpose of this study was to assess the extent to which these errors affect DPOAE test performance. Standard calibration procedures use sound pressure level (SPL) to determine specified levels. Forward pressure level (FPL) is an alternate calibration method that is less susceptible to standing waves. However, FPL derivation requires prior cavity measurements, which have associated variability. In an attempt to address this variability, four FPL methods were compared with SPL: a reference calibration derived from 25 measurements before all data collection and a daily calibration measurement, both of which were made at body and room temperature., Design: Data were collected from 52 normal-hearing and 103 hearing-impaired subjects. DPOAEs were measured for f2 frequencies ranging from 2 to 8 kHz in half-octave steps, with L2 ranging from -20 to 70 dB SPL (5-dB steps). At each f2, DPOAEs were measured in five calibration conditions: SPL, daily FPL at body temperature (daily body), daily FPL at room temperature (daily room), reference FPL at body temperature (ref body), and reference FPL at room temperature (ref room). Data were used to construct receiver operating characteristic (ROC) curves for each f2, calibration method, and L2. From these curves, areas under the ROC curve (AROC) were estimated., Results: The results of this study are summarized by the following observations: (1) DPOAE test performance was sensitive to stimulus level, regardless of calibration method, with the best test performance observed for moderate stimulus level conditions. (2) An effect of frequency was observed for all calibration methods, with the best test performance at 6 kHz and the worst performance at 8 kHz. (3) At clinically applicable stimulus levels, little difference in test performance among calibration methods was noted across frequencies, except at 8 kHz. At 8 kHz, FPL-based calibration methods provided superior performance compared with the standard SPL calibration. (4) A difference between FPL calibration methods was observed at 8 kHz, with the best test performance occurring for daily calibrations at body temperature., Conclusions: With the exception of 8 kHz, there was little difference in test performance across calibration methods. At 8 kHz, AROCs and specificities for fixed sensitivities indicate that FPL-based calibration methods provide superior performance compared with the standard SPL calibration for clinically relevant levels. Temperature may have an impact on FPL calculations relative to DPOAE test performance. Although the differences in AROC among calibration procedures were not statistically significant, the present results indicate that standing wave errors may impact DPOAE test performance and can be reduced by using FPL, although the largest effects were restricted to 8 kHz.

Objectives: To determine whether new stimulus parameters, which have been shown to produce large distortion-product otoacoustic emission (DPOAE) levels in a group of normal-hearing listeners (Neely et al. 2005; Johnson et al. 2006), result in more accurate identification of auditory status and more accurate predictions of behavioral threshold than traditional stimulus conditions., Design: DPOAE input/output (I/O) functions for eight f2 frequencies ranging from 0.7 to 8 kHz were recorded from 96 ears with normal hearing and 226 ears with sensorineural hearing losses ranging from mild to profound. The primary-level differences and primary-frequency ratios were set according to the stimulus relations developed by Johnson et al. (2006). The accuracy of the dichotomous decision task (area under the relative operating characteristic curve [AROC]) for these new stimulus conditions was evaluated as a function of L2 and was compared with previous reports in the literature where traditional stimuli were used (Stover et al. 1996). Here, traditional stimuli are defined as L1 = L2 + 10 and f2/f1 = 1.22 for all L2 and f2 values. In addition to I/O functions, DPgrams with L2 = 55-dB sound pressure level (SPL) and f2 ranging from 0.7 to 8 kHz were recorded for each subject using the traditional stimuli. This provided a direct within-subject comparison of AROC for moderate-level stimuli when the new and traditional stimuli were used. Finally, the accuracy with which DPOAE thresholds predicted behavioral thresholds was evaluated in relation to previous reports in the literature for two definitions of DPOAE threshold, one where the entire I/O function was used to make the prediction and a second where the lowest L2 producing a signal to noise ratio > or =3 dB was used., Results: There was no evidence that the new stimuli improved the accuracy with which auditory status was identified from DPOAE responses. With both the new and traditional stimuli, moderate stimulus levels (L2 = 40- to 55-dB SPL) resulted in the most accurate identification of auditory status. When L2 = 55-dB SPL, the new stimuli produced AROC values that were equivalent to those observed with traditional stimuli. The new stimuli resulted in more accurate prediction of behavioral threshold for several f2 values when using the entire I/O function, although the effect was small. Furthermore, using the entire I/O function to predict behavioral threshold results in more accurate predictions of behavioral threshold than using the signal to noise ratio definition, although this approach can be applied to a smaller percentage of ears., Conclusions: The new stimuli that had been shown previously to produce large DPOAE levels in normal-hearing listeners (Neely et al. 2005; Johnson et al. 2006) do not result in more accurate identification of auditory status and have only a small positive effect on the prediction of behavioral threshold.

Objective: Universal newborn hearing screening (UNHS) test outcomes can be influenced by conditions affecting the sound conduction pathway, including ear canal and/or middle ear function. The purpose of this study was to evaluate the test performance of wideband (WB) acoustic transfer functions and 1-kHz tympanometry in terms of their ability to predict the status of the sound conduction pathway for ears that passed or were referred in a UNHS program., Design: A distortion-product otoacoustic emission (DPOAE) test was used to determine the UNHS status of 455 infant ears (375 passed and 80 referred). WB and 1-kHz tests were performed immediately after the infant's first DPOAE test (day 1). Of the 80 infants referred on day 1, 67 infants were evaluated again after a second UNHS DPOAE test the next day (day 2). WB data were acquired under ambient and tympanometric (pressurized) ear canal conditions. Clinical decision theory analysis was used to assess the test performance of WB and 1-kHz tests in terms of their ability to classify ears that passed or were referred, using DPOAE UNHS test outcomes as the "gold standard." Specifically, performance was assessed using previously published measurement criteria and a maximum-likelihood procedure for 1-kHz tympanometry and WB measurements, respectively., Results: For measurements from day 1, the highest area under the receiver operating characteristic curve was 0.87 for an ambient WB test predictor. The highest area under the receiver operating characteristic curve among several variables derived from 1-kHz tympanometry was 0.75. In general, ears that passed the DPOAE UNHS test had higher energy absorbance compared with those that were referred, indicating that infants who passed the DPOAE UNHS had a more acoustically efficient conductive pathway., Conclusions: Results showed that (1) WB tests had better performance in classifying UNHS DPOAE outcomes than 1-kHz tympanometry; (2) WB tests provide data to suggest that many UNHS referrals are a consequence of transient conditions affecting the sound conduction pathway; (3) WB data reveal changes in sound conduction during the first 2 days of life; and (4) because WB measurements used in the present study are objective and quick it may be feasible to consider implementing such measurements in conjunction with UNHS programs.

Objectives: Current protocols presumably use criteria that are chosen on the basis of the sensitivity and specificity rates they produce. Such an approach emphasizes test performance but does not include societal implications of the benefit of early identification. The purpose of the present analysis was to evaluate an approach to selecting criteria for use in Universal Newborn Hearing Screening (UNHS) programs that uses benefit-cost ratio (BCR) to demonstrate an alternative method to audiologists, administrators, and others involved in UNHS protocol decisions., Design: Existing data from more than 1200 ears were used to analyze BCR as a function of Distortion Product Otoacoustic Emission (DPOAE) level. These data were selected because both audiometric and DPOAE data were available on every ear. Although these data were not obtained in newborns, this compromise was necessary because audiometric outcomes (especially in infants with congenital hearing loss) in neonates are either lacking or limited in number. As such, it is important to note that the characteristics of responses from the group of subjects that formed the bases of the present analyses are different from those for neonates. This limits the extent to which actual criterion levels can be selected but should not affect the general approach of using BCR as a framework for considering UNHS criteria. Estimates of the prevalence of congenital hearing loss identified through UNHS in 37 states and U.S. territories in 2004 were used to calculate BCR. A range of estimates for the lifetime monetary benefits and yearly costs for UNHS were used, based on data available in the literature. Still, exact benefits and costs are difficult to know. Both one-step (DPOAE alone) and two-step (DPOAE followed by automated auditory brainstem response, AABR) screening paradigms were considered in the calculation of BCR. The influence of middle ear effusion was simulated by incorporating a range of expected DPOAE level reductions into an additional BCR analyses, Results: Our calculations indicate that for a range of proposed benefit and cost estimates, the monetary benefits of both one-step (DPOAE alone) and two-step (DPOAE followed by AABR) NHS programs outweigh programmatic costs. Our calculations indicate that BCR is robust in that it can be applied regardless of the values that are assigned to benefit and cost. Maximum BCR was identified and remained stable regardless of these values; however, it was recognized that the use of maximum BCR could result in reduced test sensitivity and may not be optimal for use in UNHS programs. The inclusion of secondary AABR screening increases BCR but does not alter the DPOAE criterion level at which maximum BCR occurs. The model of middle ear effusion reduces overall DPOAE level, subsequently lowering the DPOAE criterion level at which maximum BCR was obtained, Conclusion: BCR is one of several alternative methods for choosing UNHS criteria, in which the evaluation of costs and benefits allows clinical and societal considerations to be incorporated into the pass/refer decision in a meaningful way. Although some of the benefits of early identification of hearing impairment cannot be estimated through a monetary analysis, such as improved psychosocial development and quality of life, this article provides an alternative to audiologists and administrators for selecting UNHS protocols that includes consideration of societal implications of UNHS screening criteria. BCR suggests that UNHS is a worthwhile investment for society as benefits always outweigh costs, at least for the estimations included in this article. Although the use of screening criteria that maximize BCR results in lower test sensitivity compared with other criteria, BCR may be used to select criteria that result in increased test sensitivity and still provide a high, although not maximal, BCR. Using BCR analysis provides a framework in which the societal implications of NHS protocols are considered and emphasizes the value of UNHS.

A system with potential for middle-ear screening and diagnostic testing was developed for the measurement of wideband energy absorbance (EA) in the ear canal as a function of air pressure, and tested on adults with normal hearing. Using a click stimulus, the EA was measured at 60 frequencies between 0.226 and 8 kHz. Ambient-pressure results were similar to past studies. To perform tympanometry, air pressure in the ear canal was controlled automatically to sweep between -300 and 200 daPa (ascending/descending directions) using sweep speeds of approximately 75, 100, 200, and 400 daPas. Thus, the measurement time for wideband tympanometry ranged from 1.5 to 7 s and was suitable for clinical applications. A bandpass tympanogram, calculated for each ear by frequency averaging EA from 0.38 to 2 kHz, had a single-peak shape; however, its tympanometric peak pressure (TPP) shifted as a function of sweep speed and direction. EA estimated at the TPP was similar across different sweep speeds, but was higher below 2 kHz than EA measured at ambient pressure. Future studies of EA on normal ears of a different age group or on impaired ears may be compared with the adult normal baseline obtained in this study.

The goal of this study was to determine the extent to which the variability seen in distortion product otoacoustic emissions (DPOAEs), among ears with normal hearing, could be accounted for. Several factors were selected for investigation, including behavioral threshold, differences in middle-ear transmission characteristics either in the forward or the reverse direction, and differences in contributions from the distortion and reflection sources. These variables were assessed after optimizing stimulus parameters for individual ears at each frequency. A multiple-linear regression was performed to identify whether the selected variables, either individually or in combination, explained significant portions of variability in DPOAE responses. Behavioral threshold at the f(2) frequency and behavioral threshold squared at that same frequency explained the largest amount of variability in DPOAE level, compared to the other variables. The combined model explained a small, but significant, amount of variance in DPOAE level at five frequencies. A large amount of residual variability remained, even at frequencies where the model accounted for significant amounts of variance.

Distortion product otoacoustic emission suppression (quantified as decrements) was measured for f(2)=500 and 4000 Hz, for a range of primary levels (L(2)), suppressor frequencies (f(3)), and suppressor levels (L(3)) in 19 normal-hearing subjects. Slopes of decrement-versus-L(3) functions were similar at both f(2) frequencies, and decreased as f(3) increased. Suppression tuning curves, constructed from decrement functions, were used to estimate (1) suppression for on- and low-frequency suppressors, (2) tip-to-tail differences, (3) Q(ERB), and (4) best frequency. Compression, estimated from the slope of functions relating suppression "threshold" to L(2) for off-frequency suppressors, was similar for 500 and 4000 Hz. Tip-to-tail differences, Q(ERB), and best frequency decreased as L(2) increased for both frequencies. However, tip-to-tail difference (an estimate of cochlear-amplifier gain) was 20 dB greater at 4000 Hz, compared to 500 Hz. Q(ERB) decreased to a greater extent with L(2) when f(2)=4000 Hz, but, on an octave scale, best frequency shifted more with level when f(2)=500 Hz. These data indicate that, at both frequencies, cochlear processing is nonlinear. Response growth and compression are similar at the two frequencies, but gain is greater at 4000 Hz and spread of excitation is greater at 500 Hz.

In 2004, Sininger and Cone-Wesson examined asymmetries in the signal-to-noise ratio (SNR) of otoacoustic emissions (OAE) in infants, reporting that distortion-product (DP)OAE SNR was larger in the left ear, whereas transient-evoked (TE)OAE SNR was larger in the right. They proposed that cochlear and brainstem asymmetries facilitate development of brain-hemispheric specialization for sound processing. Similarly, in 2006 Sininger and Cone-Wesson described ear asymmetries mainly favoring the right ear in infant auditory brainstem responses (ABRs). The present study analyzed 2640 infant responses to further explore these effects. Ear differences in OAE SNR, signal, and noise were evaluated separately and across frequencies (1.5, 2, 3, and 4 kHz), and ABR asymmetries were compared with cochlear asymmetries. Analyses of ear-canal reflectance and admittance showed that asymmetries in middle-ear functioning did not explain cochlear and brainstem asymmetries. Current results are consistent with earlier studies showing right-ear dominance for TEOAE and ABR. Noise levels were higher in the right ear for OAEs and ABRs, causing ear asymmetries in SNR to differ from those in signal level. No left-ear dominance for DPOAE signal was observed. These results do not support a theory that ear asymmetries in cochlear processing mimic hemispheric brain specialization for auditory processing.

Low- and high-frequency cochlear nonlinearity was studied by measuring distortion product otoacoustic emission input/output (DPOAE I/O) functions at 0.5 and 4 kHz in 103 normal-hearing subjects. Behavioral thresholds at both f2's were used to set L2 in dB SL for each subject. Primary levels were optimized by determining the L1 resulting in the largest L(dp) for each L2 for each subject and both f2's. DPOAE I/O functions were measured using L2 inputs from -10 dB SL (0.5 kHz) or -20 dB SL (4 kHz) to 65 dB SL (both frequencies). Mean DPOAE I/O functions, averaged across subjects, differed between the two frequencies, even when threshold was taken into account. The slopes of the I/O functions were similar at 0.5 and 4 kHz for high-level inputs, with maximum compression ratios of about 4:1. At both frequencies, the maximum slope near DPOAE threshold was approximately 1, which occurred at lower levels at 4 kHz, compared to 0.5 kHz. These results suggest that there is a wider dynamic range and perhaps greater cochlear-amplifier gain at 4 kHz, compared to 0.5 kHz. Caution is indicated, however, because of uncertainties in the interpretation of slope and because the confounding influence of differences in noise level could not be completely controlled.

Design: A retrospective medical record review of evoked potential and audiometric data were used to determine the accuracy with which click-evoked and tone burst-evoked auditory brain stem response (ABR) thresholds predict pure-tone audiometric thresholds., Methods: The medical records were reviewed of a consecutive group of patients who were referred for ABR testing for audiometric purposes over the past 4 yrs. ABR thresholds were measured for clicks and for several tone bursts, including a single-cycle, Blackman-windowed, 250-Hz tone burst, which has a broad spectrum with little energy above 600 Hz. Typically, the ABR data were collected because the patients were unable to provide reliable estimates of hearing sensitivity, based on behavioral test techniques, due to developmental level. Data were included only if subsequently obtained behavioral audiometric data were available to which the ABR data could be compared. Almost invariably, the behavioral data were collected after the ABR results were obtained. Because of this, data were included on only those ears for which middle ear tests (tympanometry, otoscopic examination, pure-tone air- and bone-conduction thresholds) indicated that middle ear status was similar at the times of both tests. With these inclusion criteria, data were available on 140 ears of 77 subjects., Results: Correlation was 0.94 between click-evoked ABR thresholds and the average pure-tone threshold at 2 and 4 kHz. Correlations exceeded 0.92 between ABR thresholds for the 250-Hz tone burst and low-frequency behavioral thresholds (250 Hz, 500 Hz, and the average pure-tone thresholds at 250 and 500 Hz). Similar or higher correlations were observed when ABR thresholds at other frequencies were compared with the pure-tone thresholds at corresponding frequencies. Differences between ABR and behavioral threshold depended on behavioral threshold, with ABR thresholds overestimating behavioral threshold in cases of normal hearing and underestimating behavioral threshold in cases of hearing loss., Conclusions: These results suggest that ABR thresholds can be used to predict pure-tone behavioral thresholds for a wide range of frequencies. Although controversial, the data reviewed in this paper suggest that click-evoked ABR thresholds result in reasonable predictions of the average behavioral thresholds at 2 and 4 kHz. However, there were cases for which click-evoked ABR thresholds underestimated hearing loss at these frequencies. There are several other reasons why click-evoked ABR measurements were made, including that they (1) generally result in well-formed responses, (2) assist in determining whether auditory neuropathy exists, and (3) can be obtained in a relatively brief amount of time. Low-frequency thresholds were predicted well by ABR thresholds to a single-cycle, 250-Hz tone burst. In combination, click-evoked and low-frequency tone burst-evoked ABR threshold measurements might be used to quickly provide important clinical information for both ends of the audiogram. These measurements could be supplemented by ABR threshold measurements at other frequencies, if time permits. However, it may be possible to plan initial intervention strategies based on data for these two stimuli.