Soft Tissue Conduction: Review, Mechanisms, and Implications

A bone-conducted Tullio phenomenon-A bridge to understand skull vibration induced nystagmus in superior canal dehiscence

Nystagmus produced in response to air-conducted sound (ACS) stimulation-the Tullio phenomenon-is well known in patients with a semicircular canal (SCC) dehiscence (SCD). Here we consider the evidence that bone-conducted vibration (BCV) is also an effective stimulus for generating the Tullio phenomenon. We relate the clinical evidence based on clinical data extracted from literature to the recent evidence about the physical mechanism by which BCV may cause this nystagmus and the neural evidence confirming the likely mechanism. The hypothetical physical mechanism by which BCV activates SCC afferent neurons in SCD patients is that traveling waves are generated in the endolymph, initiated at the site of the dehiscence. We contend that the nystagmus and symptoms observed after cranial BCV in SCD patients is a variant of Skull Vibration Induced Nystagmus (SVIN) used to identify unilateral vestibular loss (uVL) with the major difference being that in uVL the nystagmus beats away from the affected ear whereas in Tullio to BCV the nystagmus beats usually toward the affected ear with the SCD. We suggest that the cause of this difference is a cycle-by-cycle activation of SCC afferents from the remaining ear, which are not canceled centrally by simultaneous afferent input from the opposite ear, because of its reduced or absent function in uVL. In the Tullio phenomenon, this cycle-by-cycle neural activation is complemented by fluid streaming and thus cupula deflection caused by the repeated compression of each cycle of the stimuli. In this way, the Tullio phenomenon to BCV is a version of skull vibration-induced nystagmus.

Ankle Audiometry: A Clinical Test for the Enhanced Hearing Sensitivity for Body Sounds in Superior Canal Dehiscence Syndrome

INTRODUCTION

The aim of this study was to develop a clinical test for body sounds' hypersensitivity in superior canal dehiscence syndrome (SCDS).

METHOD

Case-control study, 20 patients affected by SCDS and body sounds' hypersensitivity and 20 control matched subjects tested with a new test called ankle audiometry (AA). The AA consisted of a psychoacoustic hearing test in which the stimulus was substituted by a controlled bone vibration at 125, 250, 500, and 750 Hz, delivered at the medial malleolus by a steel spring-attached bone transducer prototype B250. For each subject, it was defined an index side (the other being non-index), the one with major symptoms in cases or best threshold for each tested frequency in controls. In 3 patients, the AA was measured before and after SCDS surgery.

RESULTS

The AA thresholds for index side were significantly lower in SCDS patients (115.6 ± 10.5 dB force level [FL]) than in control subjects (126.4 ± 8.56 dB FL). In particular, the largest difference was observed at 250 Hz (-16.5 dB). AA thresholds in patients were significantly lower at index side in comparison with non-index side (124.2 ± 11.4 dB FL). The response obtained with 250 Hz stimuli outperformed the other frequencies, in terms of diagnostic accuracy for SCDS. At specific thresholds' levels (120 dB FL), AA showed relevant sensitivity (90%) and specificity (80%) for SCDS. AA did not significantly correlate to other clinical markers of SCDS such as the bone and air conducted hearing thresholds and the vestibular evoked myogenic potentials. The AA thresholds were significantly modified by surgical intervention, passing from 119.2 ± 9.7 to 130.4 ± 9.4 dB FL in 3 patients, following their relief in body sounds' hypersensitivity.

CONCLUSION

AA showed interesting diagnostic features in SCDS with significantly lower hearing thresholds in SCDS patients when compared to healthy matched subjects. Moreover, AA could identify the affected or more affected side in SCDS patients, with a significant threshold elevation after SCDS surgery, corresponding in body sounds' hypersensitivity relief. Clinically, AA may represent a first objective measure of body sounds' hypersensitivity in SCDS and, accordingly, be an accessible screening test for SCDS in not tertiary audiological centers.

How Is the Cochlea Activated in Response to Soft Tissue Auditory Stimulation in the Occluded Ear?

Soft tissue conduction is an additional mode of auditory stimulation which can be initiated either by applying an external vibrator to skin sites not overlying skull bone such as the neck (so it is not bone conduction) or by intrinsic body vibrations resulting, for example, from the heartbeat and vocalization. The soft tissue vibrations thereby induced are conducted by the soft tissues to all parts of the body, including the walls of the external auditory canal. In order for soft tissue conduction to elicit hearing, the soft tissue vibrations which are induced must penetrate into the cochlea in order to excite the inner ear hair cells and auditory nerve fibers. This final stage can be achieved either by an osseous bone conduction mechanism, or, more likely, by the occlusion effect: the vibrations of the walls of the occluded canal induce air pressures in the canal which drive the tympanic membrane and middle ear ossicles and activate the inner ear, acting by means of a more air conduction-like mechanism. In fact, when the clinician applies his stethoscope to the body surface of his patient in order to detect heart sounds or pulmonary air flow, he is detecting soft tissue vibrations.

Occlusion Effect in Response to Stimulation by Soft Tissue Conduction-Implications

To gain insight into the broader implications of the occlusion effect (OE—difference between unoccluded and occluded external canal thresholds), the OE in response to pure tones at 0.5, 1.0, 2.0 and 4.0 kHz to two bone conduction sites (mastoid and forehead) and two soft tissue conduction (STC) sites (under the chin and at the neck) were assessed. The OE was present at the soft tissue sites and at the bone conduction sites, with no statistical difference between them. The OE was significantly greater at lower frequencies, and negligible at higher frequencies. It seems that the vibrations induced in the soft tissues (STC) during stimulation at the soft tissue sites are conducted not only to the inner ear and elicit hearing, but also reach the walls of the external canal and initiate air pressures in the occluded canal which drive the tympanic membrane and excite the inner ear, leading to hearing. Use of a stethoscope by the internist to hear intrinsic body sounds (heartbeat, blood flow) serves as a clear demonstration of STC and its relation to hearing.

Hearing at threshold intensities: by slow mechanical traveling waves or by fast cochlear fluid pressure waves

The three modes of auditory stimulation (air, bone and soft tissue conduction) at threshold intensities are thought to share a common excitation mechanism: the stimuli induce passive displacements of the basilar membrane propagating from the base to the apex (slow mechanical traveling wave), which activate the outer hair cells, producing active displacements, which sum with the passive displacements. However, theoretical analyses and modeling of cochlear mechanics provide indications that the slow mechanical basilar membrane traveling wave may not be able to excite the cochlea at threshold intensities with the frequency discrimination observed. These analyses are complemented by several independent lines of research results supporting the notion that cochlear excitation at threshold may not involve a passive traveling wave, and the fast cochlear fluid pressures may directly activate the outer hair cells: opening of the sealed inner ear in patients undergoing cochlear implantation is not accompanied by threshold elevations to low frequency stimulation which would be expected to result from opening the cochlea, reducing cochlear impedance, altering hydrodynamics. The magnitude of the passive displacements at threshold is negligible. Isolated outer hair cells in fluid display tuned mechanical motility to fluid pressures which likely act on stretch sensitive ion channels in the walls of the cells. Vibrations delivered to soft tissue body sites elicit hearing. Thus, based on theoretical and experimental evidence, the common mechanism eliciting hearing during threshold stimulation by air, bone and soft tissue conduction may involve the fast-cochlear fluid pressures which directly activate the outer hair cells.

Theoretical investigation of the low frequency fundamental mechanism of the objective occlusion effect induced by bone-conducted stimulation

The objective occlusion effect induced by bone-conducted stimulation refers to the low frequency acoustic pressure increase that results from occluding the ear canal opening. This phenomenon is commonly interpreted as follows: the bone-conducted sound "leaks" through the earcanal opening and is "trapped" by the occlusion device. This instinctive interpretation misrepresents the fundamental mechanism of the occlusion effect related to the earcanal impedance increase and already highlighted by existing electro-acoustic models. However, these models simplify the earcanal wall vibration (i.e., the origin of the phenomenon) to a volume velocity source which, in the authors' opinion, (i) hinders an exhaustive comprehension of the vibro-acoustic behavior of the system, (ii) hides the influence of the earcanal wall vibration distribution, and (iii) could blur the interpretation of the occlusion effect. This paper analyzes, illustrates, and interprets the vibro-acoustic behavior of the open and occluded earcanal using an improved finite element model of an outer ear in conjunction with an associated electro-acoustic model developed in this work. The two models are very complementary to dissect physical phenomena and to highlight the influence of the earcanal wall vibration distribution, characterized here by its curvilinear centroid position, on the occlusion effect.

Audiogram in Response to Stimulation Delivered to Fluid Applied to the External Meatus

Background and Objectives

Hearing can be elicited in response to vibratory stimuli delivered to fluid in the external auditory meatus. To obtain a complete audiogram in subjects with normal hearing in response to pure tone vibratory stimuli delivered to fluid applied to the external meatus.

Subjects and Methods

Pure tone vibratory stimuli in the audiometric range from 0.25 to 6.0 kHz were delivered to fluid applied to the external meatus of eight participants with normal hearing (15 dB or better) using a rod attached to a standard clinical bone vibrator. The fluid thresholds obtained were compared to the air conduction (AC), bone conduction (BC; mastoid), and soft tissue conduction (STC; neck) thresholds in the same subjects.

Results

Fluid stimulation thresholds were obtained at every frequency in each subject. The fluid and STC (neck) audiograms sloped down at higher frequencies, while the AC and BC audiograms were flat. It is likely that the fluid stimulation audiograms did not involve AC mechanisms or even, possibly, osseous BC mechanisms.

Conclusions

The thresholds elicited in response to the fluid in the meatus likely reflect a form of STC and may result from excitation of the inner ear by the vibrations induced in the fluid. The sloping fluid audiograms may reflect transmission pathways that are less effective at higher frequencies.

Implications for Bone Conduction Mechanisms from Thresholds of Post Radical Mastoidectomy and Subtotal Petrosectomy Patients

OBJECTIVES

To assess bone conduction (BC) thresholds following radical mastoidectomy and subtotal petrosectomy, in which the tympanic membrane and the ossicular chain, responsible for osseous BC mechanisms, are surgically removed. The removal of the tympanic membrane and the ossicular chain would reduce the contributions to BC threshold of the following four osseous BC mechanisms: the occlusion effect of the external ear, middle ear ossicular chain inertia, inner ear fluid inertia, and distortion (compression-expansion) of the walls of the inner ear.

MATERIALS AND METHODS

BC thresholds were determined in 64 patients who underwent radical mastoidectomy and in 248 patients who underwent subtotal petrosectomy.

RESULTS

BC thresholds were normal (≤15 dB HL, i.e., better) in 19 (30%) radical mastoidectomy patients and in 19 (8%) subtotal petrosectomy patients at each of the frequencies assessed (0.5, 1.0, 2.0, and 4.0 kHz).

CONCLUSION

Normal BC thresholds seen in many patients following mastoidectomy and petrosectomy may be induced by a non-osseous mechanism, and the onset ("threshold") of the classical osseous BC mechanisms may be somewhat higher.