On the differential diagnosis of Ménière's disease using low-frequency acoustic biasing of the 2f1-f2 DPOAE

Impact of endolymphatic hydrops on DPOAE in subjects with normal to mild hearing loss

Objective

The increased endolymph volume affects a shift in the organ of Corti and basilar membrane in ears with endolymphatic hydrops (EH), which might affect distortion-product otoacoustic emissions (DPOAE) by altering the operating point of the outer hair cells. We investigated how changes in DPOAE are related to the distribution site of EH.

Study Design

Prospective study.

Methods

Among 403 patients with hearing or vestibular symptoms who underwent contrast-enhanced magnetic resonance imaging (MRI) for the diagnosis of EH and subsequent DPOAE testing, subjects whose hearing levels on pure tone audiometry were ≤35 dB at all frequencies were included in this study. In patients with EH on MRI, the presence and amplitude of DPOAE were evaluated between groups with hearing levels of ≤25 dB at all frequencies versus hearing levels of >25 dB at one or more frequencies.

Results

There were no differences in the distribution of EH between groups. The amplitude of DPOAE had no clear correlation with the presence of EH. However, in both groups, there was a significantly higher probability of the presence of a DPOAE response from 1001 to 6006 Hz in cases with EH in the cochlea.

Conclusion

Among patients whose hearing levels were ≤35 dB at all frequencies, better responses on DPOAE testing were found in subjects with EH in the cochlea. Alteration of DPOAEs in the early stages of hearing impairment could indicate morphological changes in the inner ear with altered basilar membrane compliance due to EH.

Level of Evidence

4.

Measuring Distortion-Product Otoacoustic Emission With a Single Loudspeaker in the Ear: Stimulus Design and Signal Processing Techniques

The distortion-product otoacoustic emission (DPOAE) is a backward propagating wave generated inside the cochlea during the wave amplification process. The DPOAE signal can be detected rapidly under relatively noisy conditions. In recent years, the earphone industry demonstrated interest in adopting DPOAE as an add-on feature to make their product “intelligent” of inner-ear status. However, a technical challenge remains to be tackled—the loudspeaker in an earphone generates its own cubic distortion at the same frequency as DPOAE. Unfortunately, the intensity of loudspeaker distortion is typically comparable to that of the DPOAE, if not higher. In this research, we propose two strategies, namely compensation and cancellation, to enable DPOAE measurement with a single loudspeaker. The compensation strategy exploits the part of the growth function of the loudspeaker distortion which is almost linear, and thus suppresses the distortion it generates while retaining a larger portion of DPOAE in the residual signal. The cancellation strategy utilizes a one-dimensional Volterra filter to remove the cubic distortion from the loudspeaker. Testing on normal-hearing ears shows that the compensation strategy improved the DPOAE-to-interference ratio by approximately 7 dB, resulting in a cross-correlation of 0.62 between the residual DPOAE level and the true DPOAE level. Meanwhile, the cancellation strategy directly recovered both the magnitude and the phase of DPOAE, reducing the magnitude estimation error from 15.5 dB to 3.9 dB in the mean-square sense. These pilot results suggest that the cancellation strategy may be suitable for further testing with more subjects.

On the Relationship Between Menière's Disease and Endolymphatic Hydrops

: The relationship between Menière's disease and endolymphatic hydrops is ambiguous. On the one hand, the existence of cases of endolymphatic hydrops lacking the classic symptoms of Menière's disease has prompted the assertion that endolymphatic hydrops alone is insufficient to cause symptoms and drives the hypothesis that endolymphatic hydrops is a mere epiphenomenon. Yet, on the other hand, there is considerable evidence suggesting a relationship between the mechanical pressure effects of endolymphatic hydrops and resultant disordered auditory physiology and symptomatology. A critical appraisal of this topic is undertaken, including a review of key histopathologic data chiefly responsible for the epiphenomenon hypothesis. Overall, a case is made that A) the preponderance of available evidence suggests endolymphatic hydrops is likely responsible for some of the auditory symptoms of Menière's disease, particularly those that can be modulated by mechanical manipulation of the basilar membrane and cochlear microphonic; B) Menière's disease can be reasonably considered part of a larger spectrum of hydropic inner ear disease that also includes some cases that lack vertigo. C) The relationship with endolymphatic hydrops sufficiently robust to consider its presence a hallmark defining feature of Menière's disease and a sensible target for diagnostic detection.

Utricular Sensitivity during Hydrodynamic Displacements of the Macula

To explore the effects of cochlear hair cell displacement, researchers have previously monitored functional and mechanical responses during low-frequency (LF) acoustic stimulation of the cochlea. The induced changes are believed to result from modulation of the conductance of mechano-electrical transduction (MET) channels on cochlear hair cells, along with receptor potential modulation. It is less clear how, or if, vestibular hair cell displacement affects vestibular function. Here, we have used LF (<20 Hz) hydrodynamic modulation of the utricular macula position, whilst recording functional and mechanical responses, to investigate the effects of utricular macula displacement. Measured responses included the Utricular Microphonic (UM), the vestibular short-latency evoked potential (VsEP), and laser Doppler vibrometry recordings of macular position. Over 1 cycle of the LF bias, the UM amplitude and waveform were cyclically modulated, with Boltzmann analysis suggesting a cyclic modulation of the vestibular MET gating. The VsEP amplitude was cyclically modulated throughout the LF bias, demonstrating a relative increase (~20-50 %; re baseline) and decrease (~10-20 %; re baseline), which is believed to be related to the MET conductance and vestibular hair cell sensitivity. The relationship between macular displacement and changes in UM and VsEP responses was consistent within and across animals. These results suggest that the sensory structures underlying the VsEP, often thought to be a cranial jerk-sensitive response, are at least partially sensitive to LF (and possibly static) pressures or motion. Furthermore, these results highlight the possibility that some of the vestibular dysfunction related to endolymphatic hydrops may be due to altered vestibular transduction following mechanical (or morphological) changes in the labyrinth.

Transient-evoked otoacoustic emission signals predicting outcomes of acute sensorineural hearing loss in patients with Ménière's disease

Background: Fluctuating hearing loss is characteristic of Ménière's disease (MD) during acute episodes. However, no reliable audiometric hallmarks are available for counselling the hearing recovery possibility.Aims/objectives: To find parameters for predicting MD hearing outcomes.Material and methods: We applied machine learning techniques to analyse transient-evoked otoacoustic emission (TEOAE) signals recorded from patients with MD. Thirty unilateral MD patients were recruited prospectively after onset of acute cochleo-vestibular symptoms. Serial TEOAE and pure-tone audiogram (PTA) data were recorded longitudinally. Denoised TEOAE signals were projected onto the three most prominent principal directions through a linear transformation. Binary classification was performed using a support vector machine (SVM). TEOAE signal parameters, including signal energy and group delay, were compared between improved (PTA improvement: ≥15 dB) and nonimproved groups using Welch's t-test.Results: Signal energy did not differ (p = .64) but a significant difference in 1-kHz (p = .045) group delay was recorded between improved and nonimproved groups. The SVM achieved a cross-validated accuracy of >80% in predicting hearing outcomes.Conclusions and significance: This study revealed that baseline TEOAE parameters obtained during acute MD episodes, when processed through machine learning technology, may provide information on outer hair cell function to predict hearing recovery.

Early Detection of Endolymphatic Hydrops using the Auditory Nerve Overlapped Waveform (ANOW)

Endolymphatic hydrops is associated with low-frequency sensorineural hearing loss, with a large body of research dedicated to examining its putative causal role in low-frequency hearing loss. Investigations have been thwarted by the fact that hearing loss is measured in intact ears, but gold standard assessments of endolymphatic hydrops are made postmortem only; and that no objective low-frequency hearing measure has existed. Yet the association of endolymphatic hydrops with low-frequency hearing loss is so strong that it has been established as one of the important defining features for Ménière's disease, rendering it critical to detect endolymphatic hydrops early, regardless of whether it serves a causal role or is the result of other disease mechanisms. We surgically induced endolymphatic hydrops in guinea pigs and employed our recently developed objective neural measure of low-frequency hearing, the Auditory Nerve Overlapped Waveform (ANOW). Hearing loss and endolymphatic hydrops were assessed at various time points after surgery. The ANOW detected low-frequency hearing loss as early as the first day after surgery, well before endolymphatic hydrops was found histologically. The ANOW detected low-frequency hearing loss with perfect sensitivity and specificity in all ears after endolymphatic hydrops developed, where there was a strong linear relationship between degree of endolymphatic hydrops and severity of low-frequency hearing loss. Further, histological data demonstrated that endolymphatic hydrops is seen first in the high-frequency cochlear base, though the ANOW demonstrated that dysfunction begins in the low-frequency apical cochlear half. The results lay the groundwork for future investigations of the causal role of endolymphatic hydrops in low-frequency hearing loss.

Behavioral Pure-Tone Threshold Shifts Caused by Tympanic Membrane Electrodes

OBJECTIVE

To determine whether tympanic membrane (TM) electrodes induce behavioral pure-tone threshold shifts.

DESIGN

Pure-tone thresholds (250 to 8000 Hz) were measured twice in test (n = 18) and control (n = 10) groups. TM electrodes were placed between first and second threshold measurements in the test group, whereas the control group did not receive electrodes. Pure-tone threshold shifts were compared between groups. The effect of TM electrode contact location on threshold shifts was evaluated in the test group.

RESULTS

TM electrodes significantly increased average low-frequency thresholds, 7.5 dB at 250 Hz and 4.2 dB at 500 Hz, and shifts were as large as 25 dB in individual ears. Also, threshold shifts did not appear to vary at any frequency with TM electrode contact location.

CONCLUSIONS

Low-frequency threshold shifts occur when using TM electrodes and insert earphones. These findings are relevant to interpreting electrocochleographic responses to low-frequency stimuli.

Assessment Tools for Use in Patients with Ménière Disease: An Update

A number of electrophysiological tests have been proposed for the initial diagnostic assessment or for the follow-up phase of patients affected by Ménière disease. The most common are: (i) vestibular evoked myogenic potentials (VEMPs); (ii) electrocochleography (ECochG); and (iii) otoacoustic emissions (OAEs). This paper presents the latest clinical developments with these 3 testing modalities. The PubMed, Embase, and Cinahl databases were searched from 2006 to December 2016. Full-text articles were obtained in cases where the title, abstract, or key words suggested that the study may be eligible for this review. The medical subject heading (MeSH) terms included the following: Ménière, hearing threshold, vestibule, otoacoustic emissions, inner ear, ECochG, VEMPs. There were 368 identified papers, out of which 87 were eligible for inclusion. Overall the data in the literature are still limited and the recommended procedures have not reached an international consensus. From the available data, one can conclude that none of the electrophysiological tests could be considered as pathognomonic, for the diagnosis of Ménière disease: presently, the tests could be mostly used in a supportive role to the clinical diagnosis. Hopefully, in the future, improved technology in electrophysiological testing could contribute to the development of better strategies for the diagnosis of Ménière disease.

An analysis of cochlear response harmonics: Contribution of neural excitation

In this report an analysis of cochlear response harmonics is developed to derive a mathematical function to estimate the gross mechanics involved in the in vivo transfer of acoustic sound into neural excitation (f(Tr)). In a simulation it is shown that the harmonic distortion from a nonlinear system can be used to estimate the nonlinearity, supporting the next phase of the experiment: Applying the harmonic analysis to physiologic measurements to derive estimates of the unknown, in vivo f(Tr). From gerbil ears, estimates of f(Tr) were derived from cochlear response measurements made with an electrode at the round window niche from 85 Hz tone bursts. Estimates of f(Tr) before and after inducing auditory neuropathy-loss of auditory nerve responses with preserved hair cell responses from neurotoxic treatment with ouabain-showed that the neural excitation from low-frequency tones contributes to the magnitude of f(Tr) but not the sigmoidal, saturating, nonlinear morphology.

Abnormal fast fluctuations of electrocochleography and otoacoustic emissions in Menière's disease

The responses of cochlear hair cells to sound stimuli depend on the resting position of their stereocilia bundles, which is sensitive to the chemical and mechanical environment. Cochlear hydrops, a hallmark of Menière's disease (MD), which is likely to come with disruption of this environment, results in hearing symptoms and electrophysiological signs, such as excessive changes in the cochlear summating potential (SP) and in the postural shifts of distortion-product otoacoustic emissions (DPOAEs). Here, SP from the basal part of the cochlea and DPOAEs from the apical part of the cochlea were recorded concomitantly in 73 patients with a definite MD, near an attack (n = 40) or between attacks with no clinical symptoms (n = 33), to compare their sensitivities to posture and evaluate their stability. The phase of the 2f1-f2 DPOAEs was monitored during body tilt, with stimuli f1 = 1 kHz and f2 = 1.2 kHz at 72 dB SPL. Extratympanic electrocochleography was performed in response to 95-dBnHL clicks. The normal limits of the DPOAE phase shift with body tilt, [-18°, +38°], and of the SP to action-potential (AP) ratio, <0.40, were exceeded in 75% and 60% of patients, respectively, near an attack. In these patients, but not in the asymptomatic ones, both tests reveal fluctuating cochlear responses from one data sample to the next. They emphasize how hydrops hinders normal hair-cell operation and may generate fast fluctuations in inner-ear functioning. If these fluctuations also occur on shorter time scales, it might explain the imperfect diagnostic sensitivity of SP and DPOAE tests, as averaging procedures would tend to level out transient fluctuations characteristic of hydrops.

Multiple indices of the 'bounce' phenomenon obtained from the same human ears

Loud low-frequency sounds can induce temporary oscillatory changes in cochlear sensitivity, which have been termed the 'bounce' phenomenon. The origin of these sensitivity changes has been attributed to slow fluctuations in cochlear homeostasis, causing changes in the operating points of the outer hair cell mechano-electrical and electro-mechanical transducers. Here, we acquired three objective and subjective measures resulting in a comprehensive dataset of the bounce phenomenon in each of 22 normal-hearing human subjects. We analysed the level and phase of cubic and quadratic distortion product otoacoustic emissions and the auditory thresholds before and after presentation of a low-frequency stimulus (30 Hz sine wave, 120 dB SPL, 90 s) as a function of time. In addition, the perceived loudness of temporary, tinnitus-like sensations occurring in all subjects after cessation of the low-frequency stimulus was tracked over time. The majority of the subjects (70 %) showed a significant, biphasic change of quadratic, but not cubic, distortion product otoacoustic emissions of about 3-4 dB. Eighty-six percent of the tested subjects showed significant alterations of hearing thresholds after low-frequency stimulation. Four different types of threshold changes were observed, namely monophasic desensitisations (the majority of cases), monophasic sensitisations, biphasic alterations with initial sensitisation and biphasic alterations with initial desensitisation. The similar duration of the three bounce phenomenon measures indicates a common origin. The current findings are consistent with the hypothesis that slow oscillations of homeostatic control mechanisms and associated operating point shifts within the cochlea are the source of the bounce phenomenon.

Changes in cochlear function during acute endolymphatic hydrops development in guinea pigs

Previous studies have injected artificial endolymph into scala media in anaesthetized guinea pigs as an acute model of endolymphatic hydrops. Here, we have injected artificial endolymph into scala media in guinea pigs at rates of 40-80 nl/min, whilst monitoring Compound Action Potential (CAP) thresholds, the Summating Potential (SP)/CAP ratio, Cochlear Microphonic (CM) distortion, low-frequency modulated Distortion Product Otoacoustic Emissions (DPOAEs), and the Endocochlear Potential (EP). We found that abrupt recovery of CAP thresholds, SP/CAP ratio, and CM and DPOAE asymmetric distortion could occur several times during a single injection of less than 3 μl, suggesting that endolymph pressure could periodically decrease while the injection was ongoing. Larger volumes are thought to produce a rupture of the membranous labyrinth, however, our results suggest that multiple injections, each larger than 3 μl and within 40 min of each other, cause multiple pressure-related changes, which are difficult to be explained on the basis of a simple labyrinth rupture. We have also examined the morphological changes of the temporal bones ex vivo using X-ray micro-tomography. Both the functional changes and the micro-CT images suggest ruptures of the membranous labyrinth may not always be responsible for abrupt changes in inner ear function. Our results provide a new insight into the changes in cochlear function occurring during acute hydrops development, which compares well to the clinical findings observed in Ménière's Disease. We suggest that hydrops development may be a continual process, yet cause discontinuous functional changes due to mechanisms other than a simple rupture of the membranous labyrinth.