Vestibular Testing: Patient Perceptions, Morbidity, and Opportunity Costs.

OBJECTIVE: To characterize patient tolerance and nonmonetary cost burdens of vestibular testing. Rigorously acquired data are essential for patient counseling and to determine if proposed additions/modifications to current protocols improve quality, experience, and efficiencies of care. STUDY DESIGN: Prospective observational study. SETTING: Tertiary center. PATIENTS: 130 adults (67% women, mean age 55 yr), referred to audiology clinic for vestibular testing. INTERVENTION(S): Surveys administered to patients and audiologists immediately and 1 week following videonystagmography (VNG) with caloric and/or rotary chair (RC) testing. MAIN OUTCOME MEASURE(S): Symptoms, visual analog scale ratings of dizziness, distress, and nausea during testing; test completion; and opportunity costs (time, missed work). RESULTS: Seventy-five patients (58%) experienced undesirable symptoms during testing, including nausea (50%), vomiting (5%), and headaches (12%). Distress and nausea ratings during testing were low (<3/10), with RC ratings lower than VNG. Nineteen patients (15%) discontinued testing early, rating distress and nausea two to three times higher than those who completed testing (p < 0.05). Greater dizziness was associated with younger age and female sex, not migraine and total eye speed. Women had increased distress. Test times were 71 [23] and 26 [13] minutes for VNG with calorics and RC, respectively. Testing required 48% to miss work (range 2-120 h) and 78% obtained assistance to/from testing. Posttest symptoms included drowsiness/fatigue (44%), nausea (31%), and headache (33%). CONCLUSIONS: This work provides baseline patient tolerance data for vestibular testing. While eliciting distress ratings comparable to other in-office otolaryngology procedures, there are high frequencies of undesirable symptoms, posttest morbidity, and opportunity costs.

Clinical test performance of distortion-product otoacoustic emissions using new stimulus conditions.

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.

Distortion-product otoacoustic emission input/output characteristics in normal-hearing and hearing-impaired human ears.

Distortion-product otoacoustic emission (DPOAE) input/output (I/O) functions were measured in 322 ears of 176 subjects at as many as 8 f(2) frequencies per ear for a total of 1779 I/O functions. The f(2) frequencies ranged from 0.7 to 8 kHz in half-octave steps. Behavioral thresholds (BTs) at the f(2) 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 f(2) 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.

Low-frequency and high-frequency distortion product otoacoustic emission suppression in humans.

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.

Low-frequency and high-frequency cochlear nonlinearity in humans.

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.

Distortion product otoacoustic emissions: cochlear-source contributions and clinical test performance.

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 L(2) ranging from 0 to 80 dB SPL and f(2)=2 and 4 kHz. Data were collected for control conditions (no suppressor, f(3)) and with f(3) 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.

A validation and potential clinical application of multivariate analyses of distortion-product otoacoustic emission data.

OBJECTIVE: To test the generalizability of multivariate analyses of distortion-product otoacoustic emission (DPOAE) data. Previously published multivariate solutions were applied to a new set of data to determine if test-performance improvements, evident in previous reports, are retained. An additional objective was to provide an alternative approach for making multivariate dichotomous decisions of hearing status in the clinic, based on DPOAE measurements. DESIGN: DPOAE level and noise were obtained in 345 ears of 187 subjects. Approximately one third of the subjects had normal hearing, whereas the remainder had hearing loss, ranging from 25 to more than 120 dB HL. DPOAE data were collected at each of nine frequencies. After data collection, clinical decision theory, in combination with univariate (DPOAE level and signal-to-noise ratio [SNR]) and multivariate (logistic regression) analyses, was used to construct relative operating characteristic (ROC) curves and to generate ROC curve areas. In addition, test performance was assessed by fixing the false-alarm rate and comparing different approaches to analyses in terms of their failure rates as a function of magnitude of hearing loss. The DPOAE test results were compared with either single-frequency or multifrequency gold standards. The multivariate solutions were taken from previously published work (Dorn et al., 1999; Gorga, et al., 1999). RESULTS: DPOAE level and SNR resulted in roughly equivalent test performance (ROC curve areas and failure rates among ears with hearing loss), although DPOAE level performed better for frequencies above 1 kHz, and SNR performed better for frequencies at 0.75 and 1 kHz. Multivariate analyses resulted in better test performance for nearly all conditions, compared with the univariate approaches that used either DPOAE level or SNR. The improvements in test performance were greatest for the frequencies at which the univariate analyses performed poorest (0.75 kHz, 1 kHz, and 8 kHz). Less difference was observed between univariate and multivariate approaches when multifrequency gold standards were used; however, even for the multifrequency cases, multivariate analyses generally resulted in better performance. An approach that might facilitate the interpretation of multifrequency DPOAE measurements in the clinic is described. CONCLUSIONS: Previously described multivariate analyses were robust in that they improved test performance when applied to an entirely new set of DPOAE data. This, in turn, suggests that the previously described multivariate solutions may have clinical utility in that they are expected to improve test performance at no additional cost in terms of data-acquisition or data-analysis time. In addition to demonstrating that these solutions generalized to new data, an alternative approach to interpreting multifrequency DPOAE measurements is provided that includes the advantages of using multivariate analyses. This new metric may be useful when DPOAEs are used for screening purposes.

Determining the upper limits of stimulation for auditory steady-state response measurements.

OBJECTIVE: To determine the maximum stimulus levels at which a measured auditory steady-state response (ASSR) can be assumed to be a reliable measure of auditory thresholds. DESIGN: ASSR thresholds were measured at octave frequencies from 500 to 4000 Hz in 10 subjects with profound hearing loss. These subjects provided no behavioral responses to sound at the limits of pure-tone audiometers and at the limits of the stimulus levels produced by the ASSR device. Subjects were divided into two groups of five, with repeated measures obtained within the same session in one group and repeated measures obtained in a separate session on a different day in the other group. RESULTS: ASSR thresholds were observed in all 10 subjects at each of four frequencies and in both trials. On average, these ASSR thresholds were observed at 100 dB HL (SD = 5 dB). Because these responses were at least 18 to 22 dB below the limits of the equipment where all subjects had no behavioral responses, it is reasonable to conclude that the ASSRs were not generated by the auditory system. CONCLUSIONS: An artifact or distortion may be present in the recording of ASSRs at high levels. These data bring into question the view that there is a wider dynamic range for ASSR measurements compared with auditory brain stem response measurements, at least with current implementation.

Distortion product otoacoustic emission suppression tuning curves in normal-hearing and hearing-impaired human ears.

Distortion product otoacoustic emission (DPOAE) suppression measurements were made in 20 subjects with normal hearing and 21 subjects with mild-to-moderate hearing loss. The probe consisted of two primary tones (f2, f1), with f2 held constant at 4 kHz and f2/f1 = 1.22. Primary levels (L1, L2) were set according to the equation L1 = 0.4 L2 + 39 dB [Kummer et al., J. Acoust. Soc. Am. 103, 3431-3444 (1998)], with L2 ranging from 20 to 70 dB SPL (normal-hearing subjects) and 50-70 dB SPL (subjects with hearing loss). Responses elicited by the probe were suppressed by a third tone (f3), varying in frequency from 1 octave below to 1/2 octave above f2. Suppressor level (L3) varied from 5 to 85 dB SPL. Responses in the presence of the suppressor were subtracted from the unsuppressed condition in order to convert the data into decrements (amount of suppression). The slopes of the decrement versus L3 functions were less steep for lower frequency suppressors and more steep for higher frequency suppressors in impaired ears. Suppression tuning curves, constructed by selecting the L3 that resulted in 3 dB of suppression as a function of f3, resulted in tuning curves that were similar in appearance for normal and impaired ears. Although variable, Q10 and Q(ERB) were slightly larger in impaired ears regardless of whether the comparisons were made at equivalent SPL or equivalent sensation levels (SL). Larger tip-to-tail differences were observed in ears with normal hearing when compared at either the same SPL or the same SL, with a much larger effect at similar SL. These results are consistent with the view that subjects with normal hearing and mild-to-moderate hearing loss have similar tuning around a frequency for which the hearing loss exists, but reduced cochlear-amplifier gain.