Absorbance Measurements From Normal-hearing Ears in the National Health and Nutrition Examination Survey, 2015-2016 and 2017-2020

OBJECTIVE

To summarize absorbance and impedance angles from normal-hearing ears within the 2015-2016 and 2017-2020 US National Health and Nutrition Examination Surveys (NHANES).

DESIGN

Two publicly available NHANES datasets were analyzed. Ears meeting criteria for normal hearing and valid absorbance and impedance angle measurements were identified. Measurements were summarized via descriptive statistics within categories of age cohort, race/ethnicity cohort, sex (male, female), and ear (left, right).

RESULTS

A total of 7029 ears from 4150 subjects, ages 6 to 80 years, met inclusion criteria. Differences between subgroups within all categories (age, race/ethnicity, sex, and ear) were fractions of the sample SDs. The largest differences occurred between age cohorts younger than 20 years.

CONCLUSIONS

The NHANES absorbance and impedance angle measurements are consistent with published literature. These results demonstrate that trained professionals, using the Titan instrument in a community setting inclusive of all demographics, produce comparable measurements to those in laboratory settings.

Measurements of ear-canal geometry from high-resolution CT scans of human adult ears

Description of the ear canal's geometry is essential for describing peripheral sound flow, yet physical measurements of the canal's geometry are lacking and recent measurements suggest that older-adult-canal areas are systematically larger than previously assumed. Methods to measure ear-canal geometry from multi-planar reconstructions of high-resolution CT images were developed and applied to 66 ears from 47 subjects, ages 18-90 years. The canal's termination, central axis, entrance, and first bend were identified based on objective definitions, and the canal's cross-sectional area was measured along its canal's central axis in 1-2 mm increments. In general, left and right ears from a given subject were far more similar than measurements across subjects, where areas varied by factors of 2-3 at many locations. The canal areas varied systematically with age cohort at the first-bend location, where canal-based measurement probes likely sit; young adults (18-30 years) had an average area of 44mm² whereas older adults (61-90 years) had a significantly larger average area of 69mm². Across all subjects ages 18-90, measured means ± standard deviations included: canals termination area at the tympanic annulus 56±8mm²; area at the canal's first bend 53±18mm²; area at the canal's entrance 97±24mm²; and canal length 31.4±3.1mm².

Measurements of ear-canal cross-sectional areas from live human ears with implications for wideband acoustic immittance measurements

Wideband acoustic immittance (WAI) measures are noninvasive diagnostic measurements that require an estimate of the ear canal's area at the measurement location. Yet, physical measurements of the area at WAI probe locations are lacking. Methods to measure ear-canal areas from silicone molds were developed and applied to 169 subjects, ages 18-75 years. The average areas at the canal's first bend and at 12 mm insertion depth, which are likely WAI probe locations, were 63.4 ± 13.5 and 61.6 ± 13.5 mm², respectively. These areas are substantially larger than those assumed by current FDA-approved WAI measurement devices as well as areas estimated with acoustical methods or measured on cadaver ears. Left and right ears from the same subject had similar areas. Sex, height, and weight were not significant factors in predicting area. Age cohort was a significant predictor of area, with area increasing with decade of life. A subset of areas from the youngest female subjects did not show an effect of race on area (White or Chinese). Areas were also measured as a function of insertion depth of 4.8-13.2 mm from the canal entrance; area was largest closest to the canal entrance and systematically decreased with insertion depth.

Intrasubject variability in power reflectance

BACKGROUND

Power reflectance measurements are an active area of research related to the development of noninvasive middle-ear assessment methods. There are limited data related to test-retest measures of power reflectance.

PURPOSE

This study investigates test-retest features of power reflectance, including comparisons of intrasubject versus intersubject variability and how ear-canal measurement location affects measurements.

RESEARCH DESIGN

Repeated measurements of power reflectance were made at about weekly intervals. The subjects returned for four to eight sessions. Measurements were made at three ear-canal locations: a deep insertion depth (with a foam plug flush at the entrance to the ear canal) and both 3 and 6 mm more lateral to this deep insertion.

STUDY SAMPLE

Repeated measurements on seven subjects are reported. All subjects were female, between 19 and 22 yr old, and enrolled at an undergraduate women's college.

DATA COLLECTION AND ANALYSIS

Measurements on both the right and left ears were made at three ear-canal locations during each of four to eight measurement sessions. Random-effects regression models were used for the analysis to account for repeated measures within subjects. The mean power reflectance for each position over all sessions was calculated for each subject.

RESULTS

The comparison of power reflectance from the left and right ears of an individual subject varied greatly over the seven subjects; the difference between the power reflectance measured on the left and that measured on the right was compared at 248 frequencies, and depending on the subject, the percentage of tested frequencies for which the left and right ears differed significantly ranged from 10% to 93% (some with left values greater than right values and others with the opposite pattern). Although the individual subjects showed left-right differences, the overall population generally did not show significant differences between the left and right ears. The mean power reflectance for each measurement position over all sessions depended on the location of the probe in the ear for frequencies of less than 1000 Hz. The standard deviation between subjects' mean power reflectance after controlling for ear (left or right) was found to be greater than the standard deviation within the individual subject's mean power reflectance. The intrasubject standard deviation in power reflectance was smallest at the deepest insertion depths.

CONCLUSIONS

All subjects had differences in power reflectance between their left and right ears at some frequencies; the percentage of frequencies at which differences occurred varied greatly across subjects. The intrasubject standard deviations were smallest for the deepest probe insertion depths, suggesting clinical measurements should be made with as deep an insertion as practically possible to minimize variability. This deep insertion will reduce both acoustic leaks and the effect of low-frequency ear-canal losses. The within-subject standard deviations were about half the magnitude of the overall standard deviations, quantifying the extent of intrasubject versus intersubject variability.

Distortion Product Otoacoustic Emissions and Intracranial Pressure During CSF Infusion Testing

BACKGROUND

A noninvasive method to monitor changes in intracranial pressure (ICP) is required for astronauts on long-duration spaceflight who are at risk of developing the Visual Impairment/Intracranial Pressure syndrome that has some, but not all of the features of idiopathic intracranial hypertension. We assessed the validity of distortion product otoacoustic emissions (DPOAEs) to detect changes in ICP.

METHODS

Subjects were eight patients undergoing medically necessary diagnostic cerebrospinal fluid (CSF) infusion testing for hydrocephalus. DPOAE measurements were obtained with an FDA-approved system at baseline and six controlled ICP levels in ∼3 mmHg increments in random order, with a range from 10.8 ± 2.9 mmHg (SD) at baseline to 32.3 ± 4.1 mmHg (SD) at level 6.

RESULTS

For f2 frequencies between 800 and 1700 Hz, when ICP was ≥ 12 mmHg above baseline ICP, DPOAE angles increased significantly and DPOAE magnitudes decreased significantly, but less robustly.

DISCUSSION

Significant changes in DPOAE angle and magnitude are seen when ICP is ≥ 12 mmHg above a subject's supine baseline ICP during CSF infusion testing. These results suggest that the changes in DPOAE angle and magnitude seen with change in ICP are physiologically based, and suggest that it should be possible to detect pathological ICP elevation using DPOAE measurements. To use DPOAE for noninvasive estimation of ICP during spaceflight will require baseline measurements in the head-up, supine, and head-down positions to obtain baseline DPOAE values at different ICP ranges. Williams MA, Malm J, Eklund A, Horton NJ, Voss SE. Distortion product otoacoustic emissions and intracranial pressure during CSF infusion testing. Aerosp Med Hum Perform. 2016; 87(10):844-851.

Intracranial pressure modulates distortion product otoacoustic emissions: a proof-of-principle study

BACKGROUND

There is an important need to develop a noninvasive method for assessing intracranial pressure (ICP). We report a novel approach for monitoring ICP using cochlear-derived distortion product otoacoustic emissions (DPOAEs), which are affected by ICP.

OBJECTIVE

We hypothesized that changes in ICP may be reflected by altered DPOAE responses via an associated change in perilymphatic pressure.

METHODS

We measured the ICP and DPOAEs (magnitude and phase angle) during opening and closing in 20 patients undergoing lumbar puncture.

RESULTS

We collected data on 18 patients and grouped them based on small (<4 mm Hg), medium (5-11 mm Hg), or large (≥15 mm Hg) ICP changes. A permutation test was applied in each group to determine whether changes in DPOAEs differed from zero when ICP changed. We report significant changes in the DPOAE magnitudes and angles, respectively, for the group with the largest ICP changes and no changes for the group with the smallest changes; the group with medium changes had variable DPOAE changes.

CONCLUSION

We report, for the first time, systematic changes in DPOAE magnitudes and phase in response to acute ICP changes. Future studies are warranted to further develop this new approach.

ABBREVIATIONS

DPOAE, distortion product otoacoustic emissionICP, intracranial pressureIIH, idiopathic intracranial hypertensionLP, lumbar punctureTBI, traumatic brain injury.

Effects of middle-ear disorders on power reflectance measured in cadaveric ear canals

OBJECTIVE

Reflectance measured in the ear canal offers a noninvasive method to monitor the acoustic properties of the middle ear, and few systematic measurements exist on the effects of various middle-ear disorders on the reflectance. This work uses a human cadaver-ear preparation and a mathematical middle-ear model to both measure and predict how power reflectance R is affected by the middle-ear disorders of static middle-ear pressures, middle-ear fluid, fixed stapes, disarticulated incudostapedial joint, and tympanic-membrane perforations.

DESIGN

R was calculated from ear-canal pressure measurements made on human-cadaver ears in the normal condition and five states: (1) positive and negative pressure in the middle-ear cavity, (2) fluid-filled middle ear, (3) stapes fixed with dental cement, (4) incudostapedial joint disarticulated, and (5) tympanic-membrane perforations. The middle-ear model of Kringlebotn (1988) was modified to represent the middle-ear disorders. Model predictions are compared with measurements.

RESULTS

For a given disorder, the general trends of the measurements and model were similar. The changes from normal in R, induced by the simulated disorder, generally depend on frequency and the extent of the disorder (except for the disarticulation). Systematic changes in middle-ear static pressure (up to 6300 daPa) resulted in systematic increases in R. These affects were most pronounced for frequencies up to 1000 to 2000 Hz. Above about 2000 Hz there were some asymmetries in behavior between negative and positive pressures. Results with fluid in the middle-ear air space were highly dependent on the percentage of the air space that was filled. Changes in R were minimal when a smaller fraction of the air space was filled with fluid, and as the air space was filled with more saline, R increased at most frequencies. Fixation of the stapes generally resulted in a relatively small low-frequency increase in R. Disarticulation of the incus with the stapes led to a consistent low-frequency decrease in R with a distinctive minimum below 1000 Hz. Perforations of the tympanic membrane resulted in a decrease in R for frequencies up to about 2000 Hz; at these lower frequencies, smaller perforations led to larger changes from normal when compared with larger perforations.

CONCLUSIONS

These preliminary measurements help assess the utility of power reflectance as a diagnostic tool for middle-ear disorders. In particular, the measurements document (1) the frequency ranges for which the changes are largest and (2) the extent of the changes from normal for a spectrum of middle-ear disorders.

Non-ossicular signal transmission in human middle ears: Experimental assessment of the "acoustic route" with perforated tympanic membranes

Direct acoustic stimulation of the cochlea by the sound-pressure difference between the oval and round windows (called the "acoustic route") has been thought to contribute to hearing in some pathological conditions, along with the normally dominant "ossicular route." To determine the efficacy of this acoustic route and its constituent mechanisms in human ears, sound pressures were measured at three locations in cadaveric temporal bones [with intact and perforated tympanic membranes (TMs)]: (1) in the external ear canal lateral to the TM, P(TM); (2) in the tympanic cavity lateral to the oval window, P(OW); and (3) near the round window, P(RW). Sound transmission via the acoustic route is described by two concatenated processes: (1) coupling of sound pressure from ear canal to middle-ear cavity, H(P(CAV) ) identical withP(CAV)P(TM), where P(CAV) represents the middle-ear cavity pressure, and (2) sound-pressure difference between the windows, H(WPD) identical with(P(OW)-P(RW))P(CAV). Results show that: H(P(CAV) ) depends on perforation size but not perforation location; H(WPD) depends on neither perforation size nor location. The results (1) provide a description of the window pressures based on measurements, (2) refute the common otological view that TM perforation location affects the "relative phase of the pressures at the oval and round windows," and (3) show with an intact ossicular chain that acoustic-route transmission is substantially below ossicular-route transmission except for low frequencies with large perforations. Thus, hearing loss from TM perforations results primarily from reduction in sound coupling via the ossicular route. Some features of the frequency dependence of H(P(CAV) ) and H(WPD) can be interpreted in terms of a structure-based lumped-element acoustic model of the perforation and middle-ear cavities.

Determinants of hearing loss in perforations of the tympanic membrane

BACKGROUND

Although tympanic membrane perforations are common, there have been few systematic studies of the structural features determining the magnitude of the resulting conductive hearing loss. Our recent experimental and modeling studies predicted that the conductive hearing loss will increase with increasing perforation size, be independent of perforation location (contrary to popular otologic belief), and increase with decreasing size of the middle-ear and mastoid air space (an idea new to otology).

OBJECTIVE

To test our predictions regarding determinants of conductive hearing loss in tympanic membrane perforations against clinical data gathered from patients.

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary referral center.

INCLUSION CRITERIA

Patients with tympanic membrane perforations without other middle-ear disease.

MAIN OUTCOME MEASURES

Size and location of perforation; air-bone gap at 250, 500, 1,000, 2,000, and 4,000 Hz; and tympanometric estimate of volume of the middle-ear air spaces.

RESULTS

Isolated tympanic membrane perforations in 62 ears from 56 patients met inclusion criteria. Air-bone gaps were largest at the lower frequencies and decreased as frequency increased. Air-bone gaps increased with perforation size at each frequency. Ears with small middle-ear volumes, < or = 4.3 ml (n = 23), had significantly larger air-bone gaps than ears with large middle-ear volumes, > 4.3 ml (n = 39), except at 2,000 Hz. The mean air-bone gaps in ears with small volumes were 10 to 20 dB larger than in ears with large volumes. Perforations in anterior versus posterior quadrants showed no significant differences in air-bone gaps at any frequency, although anterior perforations had, on average, air-bone gaps that were smaller by 1 to 8 dB at lower frequencies.

CONCLUSION

The conductive hearing loss resulting from a tympanic membrane perforation is frequency-dependent, with the largest losses occurring at the lowest sound frequencies; increases as size of the perforation increases; varies inversely with volume of the middle-ear and mastoid air space (losses are larger in ears with small volumes); and does not vary appreciably with location of the perforation. Effects of location, if any, are small.

How does the sound pressure generated by circumaural, supra-aural, and insert earphones differ for adult and infant ears?

OBJECTIVE

To determine how the ear canal sound pressure levels generated by circumaural, supra-aural, and insert earphones differ when coupled to the normal adult and infant ear.

DESIGN

The ratio between the sound pressure generated in an adult ear and an infant ear was calculated for three types of earphones: a circumaural earphone (Natus Medical, ALGO with Flexicoupler), a supra-aural earphone (Telephonics, TDH-49 with MXAR cushion), and an insert earphone placed in the ear canal (Etymoup and down arrow tic Research, ER-3A). The calculations are based on (1) previously published measurements of ear canal impedances in adult and infant (ages 1, 3, 6, 12, and 24 months) ears (Keefe et al., 1993, Acoustic Society of America, 94:2617-2638), (2) measurements of the Thévenin equivalent for each earphone configuration, and (3) acoustic models of the ear canal and external ear.

RESULTS

Sound-pressure levels depend on the ear canal location at which they are measured. For pressures at the earphone: (1) Circumaural and supra-aural earphones produce changes between infant and adult ears that are less than 3 dB at all frequencies, and (2) insert earphones produce infant pressures that are up to 15 dB greater than adult pressures. For pressures at the tympanic membrane: (1) Circumaural and supra-aural earphones produce infant pressures that are within 2 dB of adult ears at frequencies below 2000 Hz and that are 5 to 7 dB smaller in infant ears than adult ears above 2000 Hz, and (2) insert earphones produce pressures that are 5 to 8 dB larger in infant ears than adult ears across all audiometric frequencies.

CONCLUSIONS

Sound pressures generated by all earphone types (circumaural, supra-aural, and insert) depend on the dimensions of the ear canal and on the impedance of the ear at the tympanic membrane (e.g., infant versus adult). Specific conclusions depend on the location along the ear canal at which the changes between adult and infant ears are referenced (i.e., the earphone output location or the tympanic membrane). With circumaural and supra-aural earphones, the relatively large volume of air within the cuff of the earphone dominates the acoustic load that these earphones must drive, and differences in sound pressure generated in infant and adult ears are generally smaller than those with the insert earphone in which the changes in ear canal dimensions and impedance at the tympanic membrane have a bigger effect on the load the earphone must drive.

Posture-induced changes in distortion-product otoacoustic emissions and the potential for noninvasive monitoring of changes in intracranial pressure

INTRODUCTION

Intracranial pressure (ICP) monitoring is currently an invasive procedure that requires access to the intracranial space through an opening in the skull. Noninvasive monitoring of ICP via the auditory system is theoretically possible because changes in ICP transfer to the inner ear through connections between the cerebral spinal fluid and the cochlear fluids. In particular, low-frequency distortion-product otoacoustic emissions (DPOAEs), measured noninvasively in the external ear canal, have magnitudes that depend on ICP. Postural changes in healthy humans cause systematic changes in ICP. Here, we quantify the effects of postural changes, and presumably ICP changes, on DPOAE magnitudes.

METHODS

DPOAE magnitudes were measured on seven normal-hearing, healthy subjects at four postural positions on a tilting table (angles 90 degrees , 0 degrees , - 30 degrees , and - 45 degrees to the horizontal). At these positions, it is expected that ICP varied from about 0 (90 degrees ) to 22 mm Hg ( - 45 degrees ). DPOAE magnitudes were measured for a set of frequencies 750 < f2 < 4000, with f2/f1 = 1.2.

RESULTS

For the low-frequency range of 750 <or=f2<or= 1500, the differences in DPOAE magnitude between upright and - 45 degrees were highly significant (all p < 0.01), and above 1500 Hz there were minimal differences between magnitudes at 90 degrees versus - 45 degrees. There were no significant differences in the DPOAE magnitudes with subjects at 90 degrees and 0 degrees postures.

CONCLUSIONS

Changes in ICP can be detected using the auditory-based measurement of DPOAEs. In particular, changes are largest at low frequencies. Although this approach does not allow for absolute measurement of ICP, it appears that measurement of DPOAEs may be a useful means of noninvasively monitoring ICP.

How does the sound pressure generated by circumaural, supra-aural, and insert earphones differ for adult and infant ears?

OBJECTIVE

To determine how the ear canal sound pressure levels generated by circumaural, supra-aural, and insert earphones differ when coupled to the normal adult and infant ear.

DESIGN

The ratio between the sound pressure generated in an adult ear and an infant ear was calculated for three types of earphones: a circumaural earphone (Natus Medical, ALGO with Flexicoupler), a supra-aural earphone (Telephonics, TDH-49 with MXAR cushion), and an insert earphone placed in the ear canal (Etymoup and down arrow tic Research, ER-3A). The calculations are based on (1) previously published measurements of ear canal impedances in adult and infant (ages 1, 3, 6, 12, and 24 months) ears (Keefe et al., 1993, Acoustic Society of America, 94:2617-2638), (2) measurements of the Thévenin equivalent for each earphone configuration, and (3) acoustic models of the ear canal and external ear.

RESULTS

Sound-pressure levels depend on the ear canal location at which they are measured. For pressures at the earphone: (1) Circumaural and supra-aural earphones produce changes between infant and adult ears that are less than 3 dB at all frequencies, and (2) insert earphones produce infant pressures that are up to 15 dB greater than adult pressures. For pressures at the tympanic membrane: (1) Circumaural and supra-aural earphones produce infant pressures that are within 2 dB of adult ears at frequencies below 2000 Hz and that are 5 to 7 dB smaller in infant ears than adult ears above 2000 Hz, and (2) insert earphones produce pressures that are 5 to 8 dB larger in infant ears than adult ears across all audiometric frequencies.

CONCLUSIONS

Sound pressures generated by all earphone types (circumaural, supra-aural, and insert) depend on the dimensions of the ear canal and on the impedance of the ear at the tympanic membrane (e.g., infant versus adult). Specific conclusions depend on the location along the ear canal at which the changes between adult and infant ears are referenced (i.e., the earphone output location or the tympanic membrane). With circumaural and supra-aural earphones, the relatively large volume of air within the cuff of the earphone dominates the acoustic load that these earphones must drive, and differences in sound pressure generated in infant and adult ears are generally smaller than those with the insert earphone in which the changes in ear canal dimensions and impedance at the tympanic membrane have a bigger effect on the load the earphone must drive.

Acoustics of the human middle-ear air space

The impedance of the middle-ear air space was measured on three human cadaver ears with complete mastoid air-cell systems. Below 500 Hz, the impedance is approximately compliance-like, and at higher frequencies (500-6000 Hz) the impedance magnitude has several (five to nine) extrema. Mechanisms for these extrema are identified and described through circuit models of the middle-ear air space. The measurements demonstrate that the middle-ear air space impedance can affect the middle-ear impedance at the tympanic membrane by as much as 10 dB at frequencies greater than 1000 Hz. Thus, variations in the middle-ear air space impedance that result from variations in anatomy of the middle-ear air space can contribute to inter-ear variations in both impedance measurements and otoacoustic emissions, when measured at the tympanic membrane.

Simultaneous measurement of middle-ear input impedance and forward/reverse transmission in cat

Reported here is a technique for measuring forward and reverse middle-ear transmission that exploits distortion-product otoacoustic emissions (DPOAEs) to drive the middle ear "in reverse" without opening the inner ear. The technique allows measurement of DPOAEs, middle-ear input impedance, and forward and reverse middle-ear transfer functions in the same animal. Intermodulation distortion in the cochlea generates a DPOAE at frequency 2f1-f2 measurable in both ear-canal pressure and the velocity of the stapes. The forward transfer function is computed from stapes velocities and corresponding ear-canal pressures measured at the two primary frequencies; the reverse transfer function is computed from velocity and pressure measurements at the DPOAE frequency. Middle-ear input impedance is computed from ear-canal pressure measurements and the measured Thévenin equivalent of the sound-delivery system. The technique was applied to measure middle-ear characteristics in anesthetized cats with widely opened middle-ear cavities (0.2-10 kHz). Stapes velocity was measured at the incudo-stapedial joint. Results on five animals are reported and compared with a published middle-ear model. The measured forward transfer functions and input impedances generally agree with previous measurements, and all measurements agree qualitatively with model predictions. The reverse transfer function is shown to depend on the acoustic load in the ear canal, and the measurements are used to compute the round-trip middle-ear gain and delay. Finally, the measurements are used to estimate the parameters of a two-port transfer-matrix description of the cat middle ear.

Middle-ear function with tympanic-membrane perforations. II. A simple model

A quantitative model of the human middle ear with a tympanic-membrane (TM) perforation is developed. The model is constrained by several types of acoustic measurements made on human cadaver ears, which indicate that perforation-induced changes in transmission result primarily from changes in driving pressure across the TM and that perforation-induced change in the structure of the TM and its coupling to the ossicles contributes a substantially smaller component. The model represents the effect of a perforation on the pressure difference across the TM by inclusion of a path for sound coupling through the perforation from the ear canal to the middle-ear cavity. The model implies that hearing loss with perforations depends primarily on three quantities: the perforation diameter, sound frequency, and the volume of air in the middle-ear cavity. For the conditions that produce the largest hearing loss (low frequency and large perforation), the model yields a simple dependence of loss on frequency, perforation diameter, and middle-ear cavity volume. Predictions from this model may be useful to clinicians in determining whether, in particular cases, hearing losses are explainable by the observed perforations or if additional pathology must be involved.

Middle-ear function with tympanic-membrane perforations. I. Measurements and mechanisms

Sound transmission through ears with tympanic-membrane (TM) perforations is not well understood. Here, measurements on human-cadaver ears are reported that describe sound transmission through the middle ear with experimentally produced perforations, which range from 0.5 to 5.0 mm in diameter. Three response variables were measured with acoustic stimulation at the TM: stapes velocity, middle-ear cavity sound pressure, and acoustic impedance at the TM. The stapes-velocity measurements show that perforations cause frequency-dependent losses; at low frequencies losses are largest and increase as perforation size increases. Measurements of middle-ear cavity pressure coupled with the stapes-velocity measurements indicate that the dominant mechanism for loss with TM perforations is reduction in pressure difference across the TM; changes in TM-to-ossicular coupling generally contribute less than 5 dB to the loss. Measurements of middle-ear input impedance indicate that for low frequencies, the input impedance with a perforation approximates the impedance of the middle-ear cavity; as the perforation size increases, the similarity to the cavity's impedance extends to higher frequencies. The collection of results suggests that the effects of perforations can be represented by the path for air-volume flow from the ear canal to the middle-ear cavity. The quantitative description of perforation-induced losses may help clinicians determine, in an ear with a perforation, whether poor hearing results only from the perforation or whether other pathology should be expected.

Discrimination reversal conditioning of an eyeblink response is impaired by NMDA receptor blockade

In the present study we examined the effects of the specific NMDA receptor antagonist CPP on discrimination reversal learning in rabbits. We report two primary findings. First, the institution of NMDA receptor blockade had no effect on a learned discrimination. Second, after stimulus reversal, CPP treatment impaired acquisition of the discrimination reversal. This impairment manifested itself early in training as a retardation in acquisition of a CR to the new CS+ and late in training as an inability to suppress responsiveness to the new CS-. Given the comparability of the present results with previously published results for phenytoin-treated rabbits, we suggest that the effects of phenytoin on learning in this paradigm is at least in part mediated by its effects on NMDA receptors. We further suggest that these findings emphasize the need to better define the role of NMDA receptor activation and hippocampally-mediated circuits in a variety of associative learning paradigms.

How do tympanic-membrane perforations affect human middle-ear sound transmission?

Although tympanic-membrane (TM) perforations are common sequelae of middle-ear disease, the hearing losses they cause have not been accurately determined, largely because additional pathological conditions occur in these ears. Our measurements of acoustic transmission before and after making controlled perforations in cadaver ears show that perforations cause frequency-dependent loss that: (1) is largest at low frequencies; (2) increases as perforation size increases; and (3) does not depend on perforation location. The dominant loss mechanism is the reduction in sound-pressure difference across the TM. Measurements of middle-ear air-space sound pressures show that transmission via direct acoustic stimulation of the oval and round windows is generally negligible. A quantitative model predicts the influence of middle-ear air-space volume on loss; with larger volumes, loss is smaller.

Acoustic responses of the human middle ear

Measurements on human cadaver ears are reported that describe sound transmission through the middle ear. Four response variables were measured with acoustic stimulation at the tympanic membrane: stapes velocity, middle-ear cavity sound pressure, acoustic impedance at the tympanic membrane and acoustic impedance of the middle-ear cavity. Measurements of stapes velocity at different locations on the stapes suggest that stapes motion is predominantly 'piston-like', for frequencies up to at least 2000 Hz. The measurements are generally consistent with constraints of existing models. The measurements are used (1) to show how the cavity pressure and the impedance at the tympanic membrane are related, (2) to develop a measurement-based middle-ear cavity model, which shows that the middle-ear cavity has only small effects on the motion of the tympanic membrane and stapes in the normal ear, although it may play a more prominent role in pathological ears, and (3) to show that inter-ear variations in the impedance at the tympanic membrane and the stapes velocity are not well correlated.

Middle ear pathology can affect the ear-canal sound pressure generated by audiologic earphones

OBJECTIVE

To determine how the ear-canal sound pressures generated by earphones differ between normal and pathologic middle ears.

DESIGN

Measurements of ear-canal sound pressures generated by the Etymtic Research ER-3A insert earphone in normal ears (N = 12) were compared with the pressures generated in abnormal ears with mastoidectomy bowls (N = 15), tympanostomy tubes (N = 5), and tympanic-membrane perforations (N = 5). Similar measurements were made with the Telephonics TDH-49 supra-aural earphone in normal ears (N = 10) and abnormal ears with mastoidectomy bowls (N = 10), tympanostomy tubes (N = 4), and tympanic-membrane perforations (N = 5).

RESULTS

With the insert earphone, the sound pressures generated in the mastoid-bowl ears were all smaller than the pressures generated in normal ears; from 250 to 1000 Hz the difference in pressure level was nearly frequency independent and ranged from -3 to -15 dB; from 1000 to 4000 Hz the reduction in level increased with frequency and ranged from -5 dB to -35 dB. In the ears with tympanostomy tubes and perforations the sound pressures were always smaller than in normal ears at frequencies below 1000 Hz; the largest differences occurred below 500 Hz and ranged from -5 to -25 dB. With the supra-aural earphone, the sound pressures in ears with the three pathologic conditions were more variable than those with the insert earphone. Generally, sound pressures in the ears with mastoid bowls were lower than those in normal ears for frequencies below about 500 Hz; above about 500 Hz the pressures showed sharp minima and maxima that were not seen in the normal ears. The ears with tympanostomy tubes and tympanic-membrane perforations also showed reduced ear-canal pressures at the lower frequencies, but at higher frequencies these ear-canal pressures were generally similar to the pressures measured in the normal ears.

CONCLUSIONS

When the middle ear is not normal, ear-canal sound pressures can differ by up to 35 dB from the normal-ear value. Because the pressure level generally is decreased in the pathologic conditions that were studied, the measured hearing loss would exaggerate substantially the actual loss in ear sensitivity. The variations depend on the earphone, the middle ear pathology, and frequency. Uncontrolled variations in ear-canal pressure, whether caused by a poor earphone-to-ear connection or by abnormal middle ear impedance, could be corrected with audiometers that measure sound pressures during hearing tests.

Acoustic mechanisms that determine the ear-canal sound pressures generated by earphones

In clinical measurements of hearing sensitivity, a given earphone is assumed to produce essentially the same sound-pressure level in all ears. However, recent measurements [Voss et al., Ear and Hearing (in press)] show that with some middle-ear pathologies, ear-canal sound pressures can deviate by as much as 35 dB from the normal-ear value; the deviations depend on the earphone, the middle-ear pathology, and frequency. These pressure variations cause errors in the results of hearing tests. Models developed here identify acoustic mechanisms that cause pressure variations in certain pathological conditions. The models combine measurement-based Thévenin equivalents for insert and supra-aural earphones with lumped-element models for both the normal ear and ears with pathologies that alter the ear's impedance (mastoid bowl, tympanostomy tube, tympanic-membrane perforation, and a "high-impedance" ear). Comparison of the earphones' Thévenin impedances to the ear's input impedance with these middle-ear conditions shows that neither class of earphone acts as an ideal pressure source; with some middle-ear pathologies, the ear's input impedance deviates substantially from normal and thereby causes abnormal ear-canal pressure levels. In general, for the three conditions that make the ear's impedance magnitude lower than normal, the model predicts a reduced ear-canal pressure (as much as 35 dB), with a greater pressure reduction with an insert earphone than with a supra-aural earphone. In contrast, the model predicts that ear-canal pressure levels increase only a few dB when the ear has an increased impedance magnitude; the compliance of the air-space between the tympanic membrane and the earphone determines an upper limit on the effect of the middle-ear's impedance increase. Acoustic leaks at the earphone-to-ear connection can also cause uncontrolled pressure variations during hearing tests. From measurements at the supra-aural earphone-to-ear connection, we conclude that it is unusual for the connection between the earphone cushion and the pinna to seal effectively for frequencies below 250 Hz. The models developed here explain the measured pressure variations with several pathologic ears. Understanding these mechanisms should inform the design of more accurate audiometric systems which might include a microphone that monitors the ear-canal pressure and corrects deviations from normal.

A memory clinic in a department of old-age psychiatry: Its role in clinical and academic research

Memory clinics are specialist outpatient services offering assessment and evaluation in clinical practice. Memory clinics have been criticized for being preoccupied with research. We analysed the outcomes of 405 referrals to a memory clinic, providing a framework for discussion of the contributions of research to clinical practice. Of the 80% of referrals receiving a formal diagnosis, one-third were recruited on to treatment studies, contributing to clinical research. The remaining two-thirds of patients referred were followed up by specialized care services, and findings from assessment procedures were used to contribute towards academic research. These findings are discussed with reference to the role of research for a memory clinic in clinical practice. The benefits of clinical research are noted, in relation to the percentage of patients involved. The nature of academic research is clarified; it is a dual process, with findings both aiding clinical research and contributing to the body of knowledge about dementia as a possible disease process. It is concluded that memory clinics, as specialized outpatient services, are concerned with research as well as clinical practice, and it is essentially this research which enables clinical practice to develop.

Toynbee Memorial Lecture 1997. Middle ear mechanics in normal, diseased and reconstructed ears

A review of the structure-function relationships in normal, diseased and reconstructed middle ears is presented. Variables used to describe the system are sound pressure, volume velocity and acoustic impedance. We discuss the following: (1) Sound can be transmitted from the ear canal to the cochlea via two mechanisms: the tympanoossicular system (ossicular coupling) and direct acoustic stimulation of the oval and round windows (acoustic coupling). In the normal ear, middle-ear pressure gain, which is the result of ossicular coupling, is frequency-dependent and smaller than generally believed. Acoustic coupling is negligibly small in normal ears, but can play a significant role in some diseased and reconstructed ears. (2) The severity of conductive hearing loss due to middle-ear disease or after tympanoplasty surgery can be predicted by the degree to which ossicular coupling, acoustic coupling, and stapes-cochlear input impedance are compromised. Such analyses are used to explain the air-bone gaps associated with lesions such as ossicular interruption, ossicular fixation and tympanic membrane perforation. (3) With type IV and V tympanoplasty, hearing is determined solely by acoustic coupling. A quantitative analysis of structure-function relationships can both explain the wide range of observed post-operative hearing results and suggest surgical guidelines in order to optimize the post-operative results. (4) In tympanoplasty types I, II and III, the hearing result depends on the efficacy of the reconstructed tympanic membrane, the efficacy of the reconstructed ossicular chain and adequacy of middle-ear aeration. Currently, our knowledge of the mechanics of these three factors is incomplete. The mechanics of mastoidectomy and stapedectomy are also discussed.

Phenytoin blocks the reversal of a classically conditioned discriminative eyeblink response in rabbits

PURPOSE

Cognitive deficits associated with chronic treatment with phenytoin (PHT) have been reported. PHT blocks transfer from a signaled appetitive bar press to an active avoidance response in rats. We investigated the effects of PHT and the prodrug fosphenytoin in rabbits required to learn a discrimination and reversal of a classical eyeblink conditioning paradigm.

METHODS

Before drug treatment was started, rabbits were trained to produce a discriminated eyeblink response. PHT (n = 7) was administered centrally or the prodrug fosphenytoin (n = 2) was given systemically. Control animals were similarly treated centrally with either saline (n = 3) or no drug treatment (n = 13). Rabbits were then challenged with a stimulus reversal while being maintained on the respective drug.

RESULTS

On the first day of reversal training, control animals typically displayed high response rates to both tones, followed by a reduction in responsiveness to the new conditioned stimulus (CS-) in the ensuing days. In contrast, PHT-treated animals failed to suppress responsiveness to the new CS-.

CONCLUSIONS

The response patterns observed are similar to those observed in rabbits with hippocampal ablations, leading us to suggest that the adverse effects of phenytoin may be due to actions in the hippocampus.

Analysis of middle ear mechanics and application to diseased and reconstructed ears

OBJECTIVE

To review current concepts of the mechanical processes of the human middle ear, and to apply them to practical issues in clinical otology and tympanoplasty surgery.

BACKGROUND

The wide range of conductive hearing losses associated with middle ear pathology and reconstruction cannot be adequately explained by simple models of middle ear function.

METHODS

Variables used to describe the system are sound pressure, volume velocity, and acoustic impedance. The relationship between specific middle ear structures and these variables is described such that inferences can be drawn regarding sound conduction in the normal, diseased, and reconstructed middle ear.

RESULTS AND CONCLUSIONS

Sound can be transmitted from the car canal to the cochlea via two mechanisms: the tympano-ossicular system (ossicular coupling) and direct acoustic stimulation of the oval and round windows (acoustic coupling). Acoustic coupling is negligibly small in normal ears, but can play a significant role in some diseased and reconstructed ears. In the normal ear, middle ear pressure gain (which is the result of ossicular coupling) is frequency-dependent and less than generally believed. The severity of conductive hearing loss due to middle-ear disease or after tympanoplasty surgery can be predicted by the degree to which ossicular coupling, acoustic coupling, and stapescochlear input impedance are altered. Hearing after type IV and V tympanoplasty is determined solely by acoustic coupling. The difference in magnitude between the oval- and round-window pressures is more important than the difference in phase in determining cochlear input. In tympanoplasty types I, II, and III, adequate middle-ear and round-window aeration is necessary and the tympanic membrane-ossicular configuration may be less crucial.

Is the pressure difference between the oval and round windows the effective acoustic stimulus for the cochlea?

The assumption that the pressure difference between the cochlear windows is the stimulus that produces cochlear responses is tested experimentally in the ears of anesthetized cats. Cochlear potential is used as a measure of cochlear response. The sound pressures at the oval and round windows are individually controlled with both pressures at the same frequency and amplitude. When the angle difference between the two pressures is varied over one cycle, cochlear-potential magnitude varies by about 40 dB, with a sharp minimum occurring with the angle difference near zero. A linear model of the response to the two input pressures estimates a complex common-mode gain C and a complex difference-mode gain D; magnitude of D is about 35 dB greater than magnitude of C over the frequency range that was tested (75 to 1000 Hz). Thus, except for conditions that make the common-mode input much larger than the difference-mode input, the pressure difference between the oval and round windows is, to a good approximation, the effective acoustic stimulus for the cochlea.

Measurement of acoustic impedance and reflectance in the human ear canal

The pressure reflectance R (omega) is the transfer function which may be defined for a linear one-port network by the ratio of the reflected complex pressure divided by the incident complex pressure. The reflectance is a function that is closely related to the impedance of the 1-port. The energy reflectance R (omega) is defined as magnitude of [R]2. It represents the ratio of reflected to incident energy. In the human ear canal the energy reflectance is important because it is a measure of the inefficiency of the middle ear and cochlea, and because of the insight provided by its simple frequency domain interpretation. One may characterize the ear canal impedance by use of the pressure reflectance and its magnitude, sidestepping the difficult problems of (a) the unknown canal length from the measurement point to the eardrum, (b) the complicated geometry of the drum, and (c) the cross-sectional area changes in the canal as a function of distance. Reported here are acoustic impedance measurements, looking into the ear canal, measured on ten young adults with normal hearing (ages 18-24). The measurement point in the canal was approximately 0.85 cm from the entrance of the canal. From these measurements, the pressure reflectance in the canal is computed and impedance and reflectance measurements from 0.1 to 15.0 kHz are compared among ears. The average reflectance and the standard deviation of the reflectance for the ten subjects have been determined. The impedance and reflectance of two common ear simulators, the Brüel & Kjaer 4157 and the Industrial Research Products DB-100 (Zwislocki) coupler are also measured and compared to the average human measurements. All measurements are made using controls that assure a uniform accuracy in the acoustic calibration across subjects. This is done by the use of two standard acoustic resistors whose impedances are known. From the experimental results, it is concluded that there is significant subject variability in the magnitude of the reflectance for the ten ear canals. This variability is believed to be due to cochlear and middle ear impedance differences. An attempt was made at modeling the reflectance but, as discussed in the paper, several problems presently stand in the way of these models. Such models would be useful for acoustic virtual-reality systems and for active noise control earphones.