10/2/2017. The Outer Ear THE EXTERNAL AUDITORY MEATUS

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1 AUDITORY ANATOMY AND HIDDEN CLINICAL VARIABLES Presented by Lawrence R. Wierzbowski AuD DABNM FASNM IONM-P Neurophysiologist & Audiologist Avatrode LLC No Conflict of Interest AUDITORY SYSTEM ANATOMY The Ear AUDITORY SYSTEM ANATOMY The Ear Outer Middle Inner 1

2 Pinna The Outer Ear THE EXTERNAL AUDITORY MEATUS Outer Ear Two-thirds bone one-third cartilage Length ~ 2.5 cm Resonant frequency ~ 2.7K Hz Isthmus = junction of cartilaginous and bony canal. 2

3 EXTERNAL AUDITORY MEATUS CONDUCTIVE HEARING LOSS Cerumen Subha et al. AUDITORY BRAINSTEM RESPONSE LATENCY-INTENSITY SERIES 3

4 THE MIDDLE EAR Tympanic Membrane Tympanic Cavity Ossicles Eustachian Tube TYMPANIC MEMBRANE 4

5 MIDDLE EAR ANATOMY Ossicular Discontinuity Photo curtesy of Jeffery M. Driben MD CONDUCTIVE HEARING LOSS TYMPANIC CAVITY THE INNER EAR Semicircular Canals Vestibule Cochlea 5

6 ANATOMY OF THE COCHLEA COCHLEAR PHYSIOLOGY Cochlea uncoiled for demonstration purposes. COCHLEAR ANATOMY Basilar Membrane, Organ of Corti & Inner and Outer Hair Cells 6

7 SENSORINEURAL HEARING LOSS BAER MORPHOLOGY Right BAEP BAER terminology The auditory brainstem response (BAER) test gives information about the cochlea, auditory nerve and brainstem pathways. This test is also referred to as AEP ABR BAEP BAER = BAEP = ABR All are the SAME test The Auditory Nerve & Brainstem Auditory Pathways 7

8 The Auditory Nerve Sensory cells that transform the motion of the basilar membrane into nerve impulses of auditory nerve fibers are the hair cells along the basilar membrane in the organ of Corti. (Moller, Aage. Auditory Physiology) Basilar Membrane The pseudo-resonant and structural characteristics of the basilar membrane determine the frequency at which it is most sensitive. Oghalai JS. The cochlear amplifier: augmentation of the traveling wave within the inner ear. Current Opinion in Otolaryngology & Head & Neck Surgery. 12(5):

9 The Organ of Corti The organ of Corti is located in the cochlea Mechanosensory cells, known as hair cells Inner Hair Cells Stereocilia Outer Hair Cells Stereocilia» Electromotility Brownell WE, Bader CR, Bertrand D, de Ribaupierre Y ( ). "Evoked mechanical responses of isolated cochlear outer hair cells". Science. 227 (4683): Lim, D. (1986). Functional structure of the organ of Corti: a review. Hearing Research, 22, Stereocilia and Electro-Mechanical Transduction The deflection of stereocilia causes stretch-sensitive ion channels to open. Stereocilia bathe in endolymph, which is rich in potassium Stereocilia shearing in one direction causes channels to open: potassium (K+) enters the hair cell, enabling depolarization. Calcium (Ca2+), also enters the cell. Used with permission <animation by S. Blatrix, from "Journey into the World of Hearing" ( by R. Pujol et al., NeurOreille, Montpellier> Excitatory synaptic junctions Excitatory synaptic junctions connect hair cells to the afferent (ascending) nerve fibers and to the auditory part of the eighth cranial nerve. Moller, Aage. Auditory Physiology 9

10 The Auditory Nerve There are approximately 30,000 nerve fibers in the human auditory nerve. Approximately 95% of afferent fibers for the auditory nerve innervate inner hair cells, the remaining afferent fibers (only 5%) terminate on outer hair cells (Spoendlin, 1970). Auditory Pathways The University of Sydney Page 29 Central Auditory Pathways The fibers of the cochlear nerve originate from nerve cell bodies in the spiral ganglion. After entering the medulla, the cochlear nerve fibers proceed to the cochlear nucleus. Dorsal (DCN) Ventral (VCN Anterior Ventral (AVCN) Posterior Ventral (PVCN) 10

11 Central Auditory Pathways Pattern for fibers leaving CN ~80% of the CN fibers decussate (Contralateral) Three main paths exiting the CN: Dorsal Acoustic Stria Intermediate Stria Trapazoid Body Central Auditory Pathways Superior Olivary Complex in the Pons Neural convergence & divergence continues Lateral Lemniscus tract, extends from Superior Olive to Inferior Colliculus Auditory Brainstem Response Criteria for BAER Interpretation Absolute Latency Interpeak Latency Amplitude I-V Amp Ratio Morphology Wave Peak Latency Norms Adult I = 1.57 msec V= 5.76 msec Adapted from Schwartz and Berry 11

12 Neural Generators of BAEP Wave I: Distal portion of VIII nerve Wave II Proximal portion of VIII nerve 12

13 Wave II Proximal portion of VIII nerve Wave IV Superior Olivary Complex & multiple brainstem origins Wave V Lateral Lemniscus termination at Inferior Colliculus in Pons/Midbrain 13

14 Practical ABR Monitoring: Part 1 Stimulating Transducers and Recording Electrodes The University of Sydney Page 40 ABR Stimulus Transducer Types Electromagnetic earphones Small electromagnetic earphones Archaic and rarely used Artifact prone Regular electromagnetic earphones Contraindicated -would obstruct the surgical site (TDH 39) 14

15 ABR Stimulus Transducer Types ER-3A Insert Earphone Examine the ear canal for obstruction and cerumen Roll the foam tip into the smallest diameter possible Pull the top of the ear gently up and back ***Interaural attenuation*** best with deep placement Interaural Attenuation: TDH-39 Interaural attenuation with headphones is ~60 db If stimulus is 90 db then ~30 db would stimulate the contra cochlea Masking needed Data from product insert The University of Sydney Page 44 Interaural Attenuation: ER-3A Interaural attenuation is significantly higher with foam insert earphones Deeply placed ear tips maximize interaural attenuation Need for masking minimized Data from product insert The University of Sydney Page 45 15

16 IONM ABR Click Stimulus A broad band click Stimulates a wide range of frequency regions along the cochlear partition Mainly 1K-4K Hz 100 µsec pulse width IONM Auditory Short Latency Recommendations ASNM 2008 Development of the Chirp stimulus for the recording of ABRs Claus Elberling ABR Stimulus Click Polarity Rarefaction Graphics from ACNS Guidelines 2008 Condensation Alternating Reduced cochlear microphonic artifact Less resolution with severe high frequency hearing loss (Coats and Martin 1977) 2017 Lawrence Wierzbowski IONM ABR Chirp Stimulus In Development Aligns the stimulus along the cochlea - stacking the response Low frequency stim starts before the higher frequency stimulus components Reordered frequency stim components result in increased Wave V amplitude 16

17 Stimulus Repetition Rate /sec Optimal stimulus repetition rate depends on pt s age and hearing loss Aage R. Møller Chapter 6, Intraoperative Neurophysiologic Monitoring Retrocochlear hearing loss shows greater amplitude decrease with higher repetition rates Commonly used IONM repetition rates 10.1to 20.1 pps and up to pps Avoid multiples of 60 Hz 2017 Lawrence Wierzbowski Stimulus Intensity db nhl = Decibels above the average hearing threshold of a group of normal hearing young adults. (Handbook of Clinical Audiology Jack Katz 1985) Intensity must be adequately high so that ABR amplitude is sufficient for interpretation 65 db to 90 db nhl depending on pre-existing hearing loss. Recording Parameters ABR IONM system bandpass Filters are devices that pass frequencies within a certain range and rejects (attenuates) frequencies outside that range. Typical ABR IONM bandpass 100 Hz to 1500 Hz Can vary from to 10 Hz to 3000 Hz 17

18 Analysis Time An analysis time of 15 ms is optimal for ABR intraoperative monitoring. Retrocochlear lesions present with delayed latency Number of Trials Averaged Two or more waveforms superimposed to show replicability - as many trials as needed to achieve this. Modern ABR machines need fewer trials than the older 1K to 4K recommendation Stimulus Artifact Insert earphones minimize stimulus artifact Electrode Placement Vertex Cz Position (10-20 system) Earlobes (Mastoid usually contraindicated as in the surgical site) A1 (left) A2 (right) Montage Channels Vertex-ipsilateral earlobe Cz-A1 Vertex-contra earlobe Cz-A2 Lawrence Wierzbowski

19 ABR is usually one of many modalities. Translabyrinthine Approach CN VII CN V AICA CN VIII CN IX CN VII Mastoid Segment CN X The University of Sydney Page 56 Once surgery starts there is no way to correct or adjust electrode placements on the head. 19

20 Bundle, twist, and tape to minimize EM noise, manage positioning and organize for amplifier and stimulus connections. Minimizing Electromagnetic Artifact in ABR The University of Sydney Used with Permission of Brett Netherton, MS FASNM CNIM Page 60 20

21 Know the final patient position and the location of ALL other equipment Prior to your setup. The University of Sydney Page 61 Surgical approach can alter your electrode locations Middle Fossa Retrosigmoid Translabyrinthine From ATLAS OF SKULL BASE SURGERY & NEUROTOLOGY. Thieme Created by: Robert Jackler (surgeon) and Christine Gralapp (artist) Auditory Anatomy and Hidden Clinical Variables Thank You 21

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