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11 Otoacoustic Emissions: Applications for Pediatric Audiology
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig . 11.1 A screenshot from a popular TEOAE recording system. The top row of panels show demographic information, test settings, and the
stimulus waveform as well as OAE (blue) and noise oor (red) levels. The right column shows information that collectively informs the user about test
quality. Bottom panels show OAE (blue) and noise oor (red) levels as a function of frequency. Just below the OAE response plots, information that
collectively informs the user about the test quality is displayed.
in combination with ABR, both TEOAEs and DPOAEs produced
similar results.19 Whether dierent OAE types are dierentially
sensitive to various cochlear pathologies is a question of current
interest. Extending this idea even further, eorts are under way
to examine whether the concurrent evaluation of TEOAEs and
DPOAEs could yield greater clinical information.
26
Pearl
Acoustic clicks, brief in duration but broad in their spectral
content, evoke a wide-band TEOAE response in the cochlea.
Therefore, click-evoked TEOAEs provide a rapid solution to
screening cochlear health across a wide frequency range.
DPOAEs, on the other hand, are produced by two simultaneously presented pure tones. Although DPOAE test times may
be slightly longer than those from TEOAEs, they provide more
frequency-specic information.
11.2.3 Stimulus Frequency Otoacoustic
Emissions
Evoked using a single pure tone, SFOAEs are generated at its
characteristic frequency on the basilar membrane. SFOAEs
are currently not in clinical use, presumably because of the
complexities of extracting the emission from the stimulus,
with the resulting OAE being at the same frequency as the
stimulus tone. However, techniques to improve their clinical
applicability are continually being finessed,
expect to see their incorporation into clinical instruments in
the near future. Work from various laboratories have already
demonstrated that SFOAEs can be recorded at extended high
frequencies and are sensitive to subtle changes in the cochlea.29
They have also been used to estimate tuning properties of the
normal hearing ears30 and in ears with auditory disorders.
Given the promise of frequency specificity and potential ability
to predict tuning properties, SFOAEs could hold great clinical
promise.
27, 28
and we can
31,32
121
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig . 11. 2 A screenshot from a popular DPOAE recording system. Three panels, from right to left, show stimulus levels, spectrum of the ear canal
recorded pressure, and OAE (red) and noise (blue-green) oor levels, respectively. The gray areas in the leftmost panel show expected ranges of OAE
and noise oor level.
11.2.4 Spontaneous Otoacoustic
Emissions
Spontaneous otoacoustic emissions (SOAEs) are tonal emissions
generated without the need for any stimulation of the cochlea,
although a click or similarly brief stimulus can be used to synchronize SOAEs and record them once the click-evoked OAE
has dissipated. SOAEs are typically considered to be a sign of
cochlear health,33 although they have, on occasion, been associated with localized cochlear damage.34 Human ears that have
recordable SOAEs typically have more than one (~ 4 on average),
with right ears and females having more SOAEs than left or male
ears. While SOAEs are extremely sensitive to any and all insults
to OHCs, their clinical potential may be limited because they are
often absent in otherwise clinically normal ears. As it relates
to pediatric applications, it should be noted that humans are
born with numerous SOAEs, which gradually decay with time.
Other OAE tests conducted on newborns and young children are
undoubtedly inuenced by the presence of these SOAEs.
11.3 Generation Mechanisms of
OAEs
Modern-day theoretical models of OAE generation espouse
two fundamentally dierent mechanisms for the generation
of dierent types of OAEs: reection and distortion.35 In some
ways, the origins of this dichotomy between the mechanisms of
OAE generation started with the description of “place-fixed” and
“wave-fixed” emissions.36 Distortion emissions are due to the
injection of energy into the basilar membrane or cochlear uid
vibrations as a consequence of the nonlinearities in the receptor
current produced during the stereociliary transduction process.
DPOAEs are thought to be dominated by distortion. Reection
emissions, on the other hand, are produced by coherent filtering
and reection of forward-moving energy in the cochlea due to
randomly distributed impedances on the basilar membrane.
These rough impedances act as numerous reectors creating
many wavelets, a few of which sum coherently to form, ulti-
mately, the reected emission in the ear canal. TEOAEs, SFOAEs,
and to the greatest extent spontaneous OAEs are dominated by
reection emissions.
Pearl
Although clinical decisions are mostly based on OAE levels,
the phase behavior of OAEs holds tremendous future clinical
potential for evaluating cochlear health and tuning. The phase of
distortion emissions does not change as a function of frequency
under certain stimulus conditions (xed f2/f1 DPOAE recordings).
The phase of reection emissions (e.g., SFOAEs), on the other
hand, changes rapidly as a function of frequency.
122
11 Otoacoustic Emissions: Applications for Pediatric Audiology
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
11.4 Factors Aecting OAE
Measurements
The ear canal OAE is colored by both the forward and reverse
transmission of energy. In addition, many other physiologic
processes also aect OAEs and their measurement. The valid
and reliable measurement of OAEs depends on minimizing the
inuence of certain intrinsic and extrinsic factors. Here we
refer to factors aecting OAEs as intrinsic if they are inherent
to the patient and cannot be directly manipulated by the tester.
Extrinsic factors are those that may be controlled by the tester to
facilitate OAE recording.
11.4.1 Intrinsic Factors
The patient’s own biologic sounds, also referred to as physiologic noise, are a major source of nuisance for recording OAEs.
Because OAEs are very weak signals, any physiologic noise can
drastically contaminate the measured emission and artificially
elevate the OAE level. Examples of physiologic noise include
movement of the head, neck, limb or jaw, chewing, talking,
coughing, and swallowing. Although many clinical OAE systems
have algorithms to reject physiologic noise as artifacts, it is best
to minimize physiologic noise by instructing adult and older
children to sit quietly, and testing babies while they are asleep.
Individual ear canal acoustics are also known to inuence OAE
measurements, particularly at higher frequencies. When a stimulus is delivered to the ear canal, the incident stimulus waves and
reected waves from the eardrum interact, resulting in standing
waves that depend on the shape and size of the ear canal and the
insertion depth of the probe. Because of these standing waves,
the stimulus levels reaching the eardrum can vary by as much as
20 dB at frequencies above 2 kHz.
account for individual ear canal anatomy using calibrations that
correct for resonance peaks and nulls for the stimulus reaching
the eardrum. Several calibration methods for minimizing the
eects of standing waves to deliver appropriate sound levels at the
eardrum have been proposed and evaluated recently.
on these advances in calibration techniques, newer clinical OAE
systems are starting to employ in-ear calibrations that attempt to
correct the stimulus levels reaching the eardrum.
Since OAEs rely on both forward and reverse transmission of
the energy, outer and middle ear disorders can reduce OAEs in
two ways: (1) by attenuating the stimulus going into the cochlea,
thereby reducing the OAE produced, and (2) by attenuating the
OAE as it travels back from the cochlea. However, the extent to
which OAEs are aected depends on the disorder. OAEs are generally recordable in individuals with ventilation tubes or perforation of the tympanic membrane (TM). In cases of eustachian tube
dysfunction and excessive negative middle ear pressure, OAEs
may be reduced in amplitude.
pathologies, such as ossicular discontinuity, otosclerosis, or otitis
media with eusion, OAEs will likely not be measurable. All things
considered, a true picture of cochlear status may not be obtained
in the presence of concomitant middle ear pathology.
37,38
Therefore, it is important to
39,40,41
42,43,44
For more severe middle ear
3,45
Based
Therefore,
it is important to assess middle ear function using tympanometry
46
or reectance measurements
in conjunction with OAE testing
for appropriate clinical decision making.
OAEs can also be inuenced by eerent modulation of the
cochlea from the central auditory system through the medial
olivocochlear (MOC) reex. The MOC reex is a binaural, soundevoked reex that reduces OHC activity when activated. The MOC
nerve fibers synapse directly onto the OHCs and release inhibitory
neurotransmitters to reduce cochlear amplifier gain.
47,48,49
Since
OAEs reect the activity of the cochlear amplifier, OAEs serve as a
noninvasive tool for assessing the MOC system.
31,50,51,52,53
Although
the functional relevance of the MOC system in human hearing is
still being investigated, the activation of the MOC reex can be
problematic for clinical OAE measurements in a critical way. For
example, ambient noise in a typical hospital room can activate
the MOC reex contralaterally and reduce the OAE.54 The MOC-
induced reduction in OAE level may result in an abnormally high
false positive rate. Therefore, it may be useful for clinicians to
cover the nontest ear during OAE measurements to mitigate MOCinduced reduction in OAE levels of the test ear.
11.4.2 Extrinsic Factors
The test environment and measurement probe itself also
inuence OAE measurements. A proper test environment for
OAE measurements is necessary to ensure that the OAE signal
is recorded well above the noise oor. Typically, a noise oor
between –25 and –5 dB SPL is acceptable,55 with ambient noise
levels of the testing room not to exceed 50 A-weighted decibels
(dBA).56 In order to minimize ambient noise from the environment, OAE measurements should be made in a quiet place such as
a booth or a quiet room. Investigators have examined the eects
of test environment on TEOAEs in neonates and concluded that
testing newborns in a nonworking isolette within or outside the
newborn nursery can reduce the testing time, increase the sig-
nal-to-noise ratio, and ultimately improve screening eciency.57
Additionally, the fit of the probe tip in the ear canal should be
deep and snug to reduce noise levels in the ear canal. In two very
useful guides for clinicians, Kemp and colleagues discuss how to
evaluate probe fit and response quality using helpful illustrations
and examples.
Another intuitive yet important quality check is the integrity
of the OAE probe assembly, which is essential for accurate OAE
measurements. The probe should be inspected regularly for debris
and cleaned as needed. Otoscopy should be performed to verify
that the ear canal is clear of debris, wax, and vernix in babies to
prevent occlusion of the probe. A daily listening check can be used
to check globally that sound ports are clear. For a more thorough
diagnosis of the probe, calibration of the probe assembly should
be done regularly to ensure that appropriate stimulus levels are
being generated and that the microphone sensitivity has not
deteriorated over time. In absence of these quality checks of the
probe, the measurements made may not reect the true status of
the cochlea, as the OAE levels may be artificially elevated or not
recordable.
45,58
3,37
123
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
11.5 Pediatric Applications of OAEs
OAEs have certain advantages over traditional behavioral
and physiologic measures of hearing in pediatric populations
because they are objective, noninvasive, and easy to record and
do not require a long testing time. The most prominent appli-
cation of OAEs globally is the universal identification of hearing
loss in newborns, but OAEs can also be used for dierential
diagnosis, ototoxic monitoring, school screenings, and testing
dicult-to-test and special-needs populations. In fact, the use
of OAE screeners in pediatric primary care settings has also
been proposed for improving identification of hearing loss to
bridge the critical time gap between universal newborn hearing
screenings and school screenings.59 Current clinical and research
applications of OAEs are further discussed in detail in the subsequent paragraphs.
11.5.1 Newborn Hearing Screenings
Long before the discovery of OAEs,1 universal newborn hearing
screening (UNHS) was an idea recognized by many audiologists.
However, there was a lack of substantiated evidence on the
negative impact of hearing loss on speech and language development to justify the costs associated with universal newborn
hearing screenings. In 1969, Downs and Hemenway published a
study, based on hearing screening results for 17,000 neonates,
that reported an alarmingly high hearing loss incidence of 1 in
1000 newborns.60 This report led to the formation of the Joint
Commission on Infant Hearing (JCIH),61 which later called for
the universal identification of hearing loss in all newborns
using objective measures of auditory function such as auditory
brainstem response (ABR) and/or OAEs.62 Today, 90 to 95% of
newborns are screened for hearing loss in hospitals across parts
of the globe using OAEs, ABRs or both.
For well-baby nurseries, the JCIH recommends using either an
ABR or an OAE screener, and rescreening with the same technology in case of an initial failure.65 The screening protocols for babies
in the neonatal intensive care units (NICU) are stricter because
the risk of hearing loss is greater for NICU babies. The prevalence
of hearing loss is estimated to be 6.4 in every 100 NICU babies.66
Accordingly, the most recent JCIH position statement calls for
either ABR-only screeners or a combined ABR and OAE protocol for
NICU babies.65 This is because combined OAE and ABR screeners
can detect both cochlear and neural hearing losses. Further, there
is evidence that a two-stage screening protocol that includes both
OAEs and ABR is more sensitive in detecting hearing loss than an
ABR-only screener is.
64,67
Using visually reinforced behavioral responses from 4,911
infants, investigators have examined the sensitivity of OAE screeners to ABR in detecting newborn hearing loss. They concluded
that the sensitivity of DPOAEs and TEOAEs was similar to ABR in
detecting hearing loss. Furthermore, they found the sensitivity of
all three screening tests for detecting mild hearing loss was quite
poor but improved with the degree of hearing loss.
OAE screeners are preferred by some over ABR for ease of use and
minimal training required to use them,
have higher referral rates (8%) and consequently increased costs
63,64
19,68,69
19,68,70
OAE-only protocols
Although
associated with follow-up, compared to ABR-only (2%) and
combined OAE/ABR (0.5–1%) protocols.
71,72
Further discussion of
other important considerations for designing and implementing
a newborn hearing screening program is presented by Gravel et
71
al.
11.5.2 Preschool and School Screenings
The scre ening of toddlers, prescho olers, and school-aged children
is just as critical as screening newborns because the prevalence
of hearing loss in older children is 3.65 in 1,000, which is 2 to 3
times higher than in newborns.
born hearing screening, they may develop or acquire temporary
or permanent hearing loss due to various etiologies.77 Whether
temporary or permanent, postnatal hearing loss among children
can negatively impact their language development, academic
performance, social functioning, and psychosocial health.
Therefore, continued screening is necessary for proper iden-
tification and referral in Early Head Start programs , pediatric
clinics, and schools.
81,82,83,84
Current school screening protocols primarily rely on behavioral pure tone screening. However, pure tone screenings can be
time-consuming, and not all children can participate in behavioral
testing. OAEs, on the other hand, provide a faster, objective measurement that could be used to screen all children. To evaluate
the ecacy of OAEs in screening of preschool- and school-aged
children, Prieve et al76 conducted an evidence-based systematic
review and summarized the sensitivity and specificity of OAEs
compared to pure-tone audiometry. They concluded that although
pure-tone audiometry may be a better tool for identifying hearing
loss in children, OAEs are more viable for younger children such as
preschoolers and other dicult-to-test populations such as children with developmental disabilities, who cannot participate in
behavioral testing. It is important to note that OAEs reect only the
status of inner ear function and do not assess the entire auditory
system as behavioral tests of hearing do. In certain pathologies of
the auditory system, such as auditory neuropathy, OAEs can be
present, but ABR measurements and behavioral thresholds may
be aected.
OAEs are also inuenced by middle ear pathology such as
eustachian tube dysfunction (ETF) and otitis media with eusion
(OME) or glue ear. In preschoolers, abnormal OAE screening
results may often be a result of middle ear dysfunction rather
than inner ear pathology, because preschool-aged children have
a high prevalence of OME.
inferred from OAE testing, tympanometry should be utilized in
screenings. Per American Academy of Audiology (AAA) guidelines,
if a child fails an OAE screening, an immediate middle ear screening using tympanometry should be performed, and appropriate
referrals should be made.84 Once the OME and/or ETF has resolved,
a second screening using both tympanometry and OAEs should be
performed at approximately 8 weeks post initial screening.
73,74,75,7 6
Even if children pass new-
85,86
Since middle ear status cannot be
78,79,80
124
11 Otoacoustic Emissions: Applications for Pediatric Audiology
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
11.5.3 Ototoxicity Monitoring
Ototoxicity refers to damage to structures of the auditory and
vestibular system caused by radiation and drugs such as antineo-
plastic agents, nonsteroidal anti-inammatory drugs (NSAIDs),
loop diuretics, and antibiotics. In pediatric patients, ototoxic
drugs may be used to treat cancer, malaria, cystic fibrosis,
infections, and/or heart and pulmonary disease.
87,88,89,90
Previous
reports suggest that ototoxicity aects younger children (< 5
years) more severely than older children, with the risk for oto-
toxicity decreasing among teenagers (> 15 years).
91,92,93
Because
the early years of life are critical for language development, the
impact of hearing loss is much greater among young children,
and thus the need for monitoring is crucial.
Ototoxicity monitoring protocols typically rely on high-frequency audiometry (HFA); however, HFA in very sick or young
c
hildren may not be possible. OAEs, on the other hand, are
an excellent tool for ototoxicity monitoring in pediatrics.
Previous evidence has demonstrated that standard DPOAEs and
TEOAEs are more sensitive to ototoxicity-related changes than
conventional audiometry (up to 8 kHz) and just as sensitive as
HFA (> 8 kHz).
94,95,96,97,98
Emerging evidence now suggests that
high-frequency DPOAEs may be even more sensitive than HFA.99
Unfortunately, high-frequency OAE measurements have not been
fully incorporated into clinical protocols just yet. Furthermore,
additional research is needed on determining the criteria for ototoxicity-related changes in OAEs before monitoring protocols for
high-frequency OAEs can be standardized. Current consensus is
that standard DPOAEs and TEOAEs should be obtained in children
before, during, and every 6 months after exposure,
100
especially
because some ototoxic therapies can have long-lasting impact on
cochlear structures, particularly in children.
93,101
11.5.4 Dierential Diagnosis
Combining subjective and objective tests of hearing is essential
for accurate diagnosis of auditory impairments, especially for
young children. OAEs lend well to the quick and noninvasive
cross-check of behavioral findings and dierentially diagnosing
the site of lesion. As discussed previously, OAEs reect the status
of OHC activity and will be reduce d or absent when a considerable
amount of OHC loss is present. However, not all pathologies of the
auditory system are coupled to OHC loss, and consequently (re)
habilitation in those cases may not be as clear. To ensure proper
(re)habilitation, it is essential to verify behavioral thresholds and
determine the site of lesion, utilizing a test battery approach that
includes OAEs.
For most clinical applications, OAEs are described as being
absent or present. This dichotomy is useful when a hearing loss
is suspected or to cross-check audiometric findings when behavioral responses are unreliable. However, the concept of using OAEs
to predict thresholds objectively and noninvasively is intriguing.
There have been many attempts to establish correlations between
behavioral thresholds and OAEs using various predictive models,
IO functions, and calibration techniques,
research in clinical populations is ongoing.
OAEs are also used in the diagnosis of auditory neuropathy
spectrum disorder (ANSD), also sometimes referred to as auditory
23,24,102,103,104
although
neuropathy/dyssynchrony. The site of lesion in ANSD is beyond
OHCs and thought to be pre- or post-synaptic dysfunction of inner
hair cells and aerent auditory neurons.
105,106
Therefore, telltale
audiologic findings of ANSD are the presence of robust OAEs
despite an abnormal auditory brainstem response (ABR),
although OAEs may disappear over time.
109
105,106,107,108
Another auditory impairment that presents similar symptoms
to ANSD is characterized by central deficits in auditory processing and is therefore referred to as (central) auditory processing
disorders, or (C)APD. Children with APD often perform poorly in
settings where speech signals are degraded, but they have normal
hearing on audiometric tests.
110
Not only does OAE testing in APD
rule out the possibility of OHC dysfunction, but combining OAE
and ABR findings can dierentially diagnose APD from ANSD.
Some evidence suggests that children with APD may have an
unusually higher functioning cochlea than typically developing
children,31 akin to premature cochlea.
111
Assays of the eerent
auditory system using OAEs suggest that there may be some dys-
function in eerent control in APD children; however, additional
research is needed to probe the cochlear functioning in children
with APD.
112
11.6 OAE Interpretations and
Clinical Norms
As has just been described, OAEs have many applications in
the pediatric population. Each of these applications leverages a
particular distinctive property of OAEs, some related to methodology and others to the underlying physiology. For example, in
various screening applications, the major attraction is the ease
of measurement of OAEs. In contrast, in dierentially diagnosing
ANSD or monitoring the toxic eects of pharmacological agents,
the central role of OHCs in the generation of OAEs as well as
the vulnerability of OHCs to particular pharmacological agents
become paramount. Each application is most eective when it
is approached in a nuanced manner with particular attention to
unique test configuration, signal processing, and interpretation.
To use an easy example, the very highest frequencies, representing the function of the cochlear base, are of interest in monitoring ototoxicity during platinum compound therapy. In contrast,
much lower frequencies would be of interest in screening auditory function in the school-aged population. Thus, it is beyond
the scope of this chapter to outline the recommended recording,
analysis, and interpretation parameters for each application of
OAEs in the pediatric population. Instead we choose to orient
the reader to some universal attributes of OAEs related to their
recording, analysis, and reporting.
11.6.1 Indicators of Data Quality
We find it useful to think of a variety of data displayed in TEOAE
and DPOAE measurement systems as markers of data quality, as
opposed to indicators of cochlear health. Various items recorded
and reported by clinical OAE software that would fall in this
category include, in the case of TEOAEs, wave reproducibility,
probe or stimulus stability, and ratio between accepted and
125
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
rejected responses to clicks. Similarly, in the case of DPOAEs,
stimulus levels and the ratio between acquired or accepted
versus rejected buers portray the quality of the recording. See
Fi g . 11.1 and Fig. 11. 2 for a host of these markers in reported
exemplars of clinical OAE measurement and reporting software. Perhaps the most important of these markers, common
to both DPOAEs and TEOAEs, is the noise oor. Factors that
can inuence the noise oor have been discussed previously.
Without an acceptably low noise oor, the OAE data become
uninterpretable.
It is of considerable importance to have a good sense of the
expected and usual frequency-dependent noise levels for any
given OAE system used in a given clinical environment. When the
noise oor falls in the vicinity of this expectation, the clinician
can interpret the results of the test with confidence. Unusually
high noise oors can indicate environmental, instrumentation, or
physical noise generated by the patient. An unusually low noise
oor can be indicative of a malfunctioning microphone or another
component of the recording and digitizing circuit. Modern-day
OAE software allows the storage of expected noise levels at each
test frequency for a given setup. These levels are then displayed on
the results screen, providing confidence or raising concern about
the quality of the test, depending on the proximity of the mea-
sured noise oor to the expected. Recording software typically
rejects or ignores data buers that are noisy, thereby limiting cor-
ruption. The greater the prevalence of noisy samples, the longer
signal averaging has to be performed to attain predetermined,
and sometimes user-determined, noise levels and signal-to-noise
ratios. Failure to reach these levels could essentially “time out”
data recording at a certain frequency. In other words, the total
averaging time in the case of DPOAEs and the number of samples
rejected are themselves markers of data quality. Once all quality
markers, and especially the noise oor, are found to be satisfactory, OAE levels or other properties can be evaluated to ascertain
cochlear health.
11.6.2 Indicators of Cochlear Health
Given that the current gamut of clinically reported OAE properties is limited to OAE levels, this discussion can be rather succinc t.
OAE levels measured suciently above the noise oor indicate
good cochlear health. Unfortunately, with that statement we
could essentially describe almost all there is to interpreting OAE
results today. This does seem rather limited and disjointed from
the pronouncements earlier in this chapter about the integral
relationship between cochlear mechanics and OAEs. One could
easily argue that OAEs are generally underutilized in the clinic
today—a topic discussed subsequently. However, given this
limited application, the parameters of what OAE levels can and
cannot tell us can be outlined.
First, for screening applications, recording software, often
adjustable by the audiologist, sets the pass/refer criteria. Typically,
this algorithm considers the noise oor (acceptable or not) and
signal-to-noise ratio or OAE level (acceptable or not) in each test
frequency or band to arrive at a pass/refer decision for that band
or test frequency. An overall recommendation is made by simply
counting the proportion of frequency bands in which a certain
outcome was achieved. Thus, a pass in three or four out of the
ve bands or frequencies tested would result in the reporting of
fi
an overall pass.
Is this all we can use OAEs for? The answer is a resounding no,
even when data are limited to OAE levels only. The amount of clinical information available from an OAE test is critically dependent
on t
he density of data available. Since OAE test results are typically
reported as DPOAE or TEOAE levels as a function of frequency,
the frequency range of the recordings as well as, in the case of
DPOAEs, the number of data points in the measurement range
determine the richness of clinical information available from the
test. The frequency range simply determines the extent of the
cochlea examined. The data density determines how accurately
an area of malfunction in the cochlea can be pinpointed. Both data
density and measurement frequency range become especially
important in applications such as monitoring chemotoxicity,
where a particular portion of the cochlea (the base in this case) is
known to be more vulnerable.
Rather than simply making a present-versus–absent decision, is
it possible to make a more nuanced judgement about the degree
of degradation of cochlear health based on how far OAE levels
in a particular ear deviate from a set of norms? Theoretically,
the answer to this question is yes. However, we are yet to have
normative data sets that will allow us to do so reliably, especially
in pediatric populations. For adult ears, large normative data sets
22,113
exist.
These data, however, demonstrate a large variance in OAE
levels in normal ears, creating a substantial overlap between OAE
Table 11.1 Expected DPOAE levels at various frequencies for term-born and 4.5-week-old infants compared with adults
Age
Term 15.8 (5.8) 13.6 (5.5) 9.5 (5.9) 9.5 (6.4) 9.6 (5.8) 5.8 (6.8) 5.9 (6.6)
4.5 wks 15.8 (7.1) 14.2 (5.6) 10.5 (9.1) 13.3 (15) 15 (6.4) 9.7 (7.5) —
Adult 9.9 (4.6) 6 (6) 5.6 (5.8) 5.9 (5.9) 5.1 (5) -0.3 (6.5) -4.1 (7.7)
Term 118 48, 70 70, 48
4.5 wks 18 9, 9 7, 11
Adult 48
Data are presented from a group of 48 normal-hearing adults between 18 and 35 years of age for comparison.
in the bottom half of the table along with the sex and ear distribution.
1,500 2,000 3,000 4,500 6,000 8,000 9,000
N Sex (F, M) Ear (L, R)
F2 Frequency (Hz)
Subject Characteristics
115
The number of subjects in each group is displayed
126
11 Otoacoustic Emissions: Applications for Pediatric Audiology
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
into linear pressure units (micropascals, µPa). Now a regression
line is fi tted to the converted IO function and extrapolated down
toward lower stimulus levels till the fi tted line crosses 0 µPa. The
stimulus level at which this crossing happens is taken to be the
related to the hearing threshold at that frequency. While all this
seems rather awkward and time consuming, the actual computational manipulations can be easily incorporated into an algorithm
and the audiologist simply presented with an estimated hearing
threshold. Such an application, validated rigorously, would fi nd
instant popularity in the pediatric audiologic practices.
Fig . 11. 3 Average DPOAE levels as a function of frequency for ve
age groups.
the gure legend along with the age ranges included. The error bars
represent ±1 standard deviation.
16
The number of subjects in each age group are shown in
levels recorded from those and other mildly impaired ears. The situation is even worse in the case of pediatric populations, because
both TEOAE
114
and DPOAE16 levels change considerably in the fi rst
months and years of life. In Table 11.1 we have compiled data from
Abdala et al
115
to give readers a general idea of how DPOAE levels
might change at various frequencies from birth through the fi rst
month of life and how these levels compare with DPOAE levels in
young adult years. Similarly, we have presented data from Abdala
and Dhar16 (Fig. 11.3) demonstrating dramatic and frequency-de-
pendent changes in DPOAE levels from premature infants to young
adults. Most scholars working in this fi eld would agree that the
bulk of this volatility can be attributed to changes in the outer and
middle ears in early life. These changes in the outer and middle
ears impact OAEs especially because stimuli have to travel inward
function. However, in the case of OAEs, the measured quantity has
to travel outward through the middle and outer ears again, thereby
multiplying the in uence of the conductive auditory pathway on
the recorded OAEs. The volatility of OAE levels in the early years of
life make it di cult to extract clear insights about cochlear health
from OAE levels alone. New ideas about recording and interpreting
OAEs, discussed in subsequent paragraphs, might remove this limitation in the coming years. But before that futuristic discussion,
we have to engage in the most favorite audiological pastime—predicting hearing thresholds using another test.
The attraction of predicting behavioral hearing thresholds from
another measure, especially an objective physiologic measure, has
been ever present in audiology. Stapedial re ex thresholds and
all manner of variations of brainstem evoked responses are just a
few examples of our collective adventures in this domain. Relating
TEOAE or DPOAE levels extracted from a DP-gram to behavioral
116
hearing thresholds has not been successful.
However, DPOAE IO
functions have been used reasonably successfully to predict hearing thresholds.
23,24
While OAE IO measurements are yet to be rou-
tinely incorporated in clinical systems, it is useful to discuss brie y
how the process of predicting hearing thresholds works. DPOAE
IO functions are obtained at specifi c frequencies by varying the
levels of the two stimulus tones while maintaining a prescribed
relationship between them. This results in an estimate of DPOAE
level (in dB SPL) as a function of stimulus level, which is converted
11.7 The Future of OAEs
We started the chapter enthusiastically about the immense
potential of OAEs to inform us about cochlear health. However,
as the chapter developed, we found rather limited clinical use
of OAEs, especially so in the pediatric population. While the
specialty applications of monitoring chemotoxicity and di er-
entially diagnosing auditory neuropathy spectrum disorders are
important, we believe that the true potential of OAEs as a tool
in pediatric audiology will become apparent in the next decade.
Here we list some promising developments that are expected to
mature into validated clinical methods and applications.
1. Calibration: Calibration methods for OAE tests will make it pos-
sible to adjust for individual ear canal acoustics,39 potentially
eliminating some of the variability in pediatric OAE recordings
across di erent ages.
2. Speed: DPOAE and TEOAE recordings will be obtained at much
greater speed using either swept tones
sweep pairs presented simultaneously.
117
or multiple tone or
118
3. Component separation: Many signal-processing techniques are
being polished to e ectively isolate di erent OAE components
varying in latency or phase properties. These various OAE com-
ponents are thought to represent di erent cochlear mechanisms,
often operating at di erent cochlear locations.
components or di erent OAE types, when used in conjunction,
may provide greater insight into cochlear health.
119
These di erent
26
4. Investigating cochlear tuning: OAE phase gradient and latency
measures are showing promise in being a noninvasive probe into
cochlear tuning.
120
5. Investigating cochlear development: OAE phase gradients may
also reveal subtle maturational trends in the newborn and infant
121
cochlea.
6. Investigating cochlear mechanical control: Modulation of OAEs
by sound-, attention-, or learning-evoked e erent activity is
likely to provide great insight into top-down control of cochlear
mechanics and also enable the clinical evaluation of the integ-
rity of the auditory e erent neural network.
7. Investigating loudness perception: Estimates of categorical loud-
ness perception using otoacoustic emissions
122,123
124
may play a role in
understanding conditions such as hyperacusis as well as fi tting
hearing aids.
11.8 Conclusion
Ending chapters on a topic that is still evolving rapidly is di cult,
not only because the next big discovery that might altogether
change clinical practice may be just around the corner, but also
127
II Diagnosing Hearing Disorders in Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
because a publication boundless in scope but severely limited in
length allows only the outline of an essence and ignores important details. Citations used as examples are a direct outcome of
such length limitations. However, our attempt has been to draw
a horizon with many doors for the reader to explore deeper
tunnels in various topics related to the science and clinical
application of OAEs. Like any powerful physiologic measure,
OAEs should be handled with care, as artifacts—both environmental and instrumental—easily masquerade as biologic signals.
However, when the quality markers of a recording are satisfied,
OAEs tell a true story about OHC health colored by the passage
of sound through the outer and middle ears. They will tell even
more in the future as we continue to understand their source in
the cochlea and their journey out into the ear canal.
Discussion Questions
1. Which type of hair cells in the cochlea produce OAEs?
2. Which two types of evoked OAEs are most commonly
employed in clinical applications?
3. What biologic factors might lead to the instability of TEOAEs
and DPOAE levels in early life?
4. Describe aspects of OAE test results that can be used as markers of data quality and others that are more direct markers of
c
ochlear function.
5. Discuss some promising areas of research that are likely to
lead to new pediatric clinical applications of OAEs.
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