A MULTIPLE TEST BATTERY APPROACH DURING THE ASSESSMENT OF THE AUDITORY NERVOUS SYSTEM OF PATIENTS WI

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A MULTIPLE TEST BATTERY APPROACH DURING THE
ASSESSMENT OF THE AUDITORY NERVOUS SYSTEM OF
PATIENTS WITH MULTIPLE SCLEROSIS (MS)
by RENé HORNBY
M. COMMUNICATION PATHOLOGY UNIVERSITY OF
PRETORIA SUPERVISOR PROF. S.R.
HUGO CO-SUPERVISOR DR. D. SCHMULIAN
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OVERVIEW OF MS

• Degenerative neurological disease (fluctuate,
  progressive) MRI
• Parkinsons, Alzheimer, Charcot-Marie-Tooth,
  Neurofibrosis
• CNS (white matter) - Cerebrum
• - Spinal cord
• Areas of concern Cerebral hemispheres
• (Periventricular)
• Brainstem
• Cerebellum
• Spinal cord

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OVERVIEW OF MS(continued)

• MS
• most common demyelinating disease

• INFLAMMATORY DISEASE
• myelin of white matter pathways of CNS

• MULTIPLE scattered areas are involved

• SCLEROSIS hardened patches of nerve
  (plaques)

• NERVE FIBRE electrical cord

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OVERVIEW OF MS(continued)

• Etiology Unknown (combination
• genetic, infectious immunologic factor)
• Patients 20 40 years
• 21 (FemaleMale)
• Higher prevalence (colder, caucasians)
• Diagnosis Clinical (Neurologist)
• Course 4 types
• Most common relapsing-remitting
• Silent demyelinating lesions

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OVERVIEW OF MS(continued)

• FACTS CONCERNING MS HEARING
• HI initial symptom/prominent complaint
• Sudden onset of HL in MS 1
• Incidence of peripheral HL 1 86
• Large-scale statistics on incidence of HL
  (spesifically due to MS) not available
• Mild degree
• More unilateral than bilateral
• High frequency sensorineural
• Tinnitis less than 10
• 40 of MS with normal audiogram report difficulty
  hearing
• Abnormal ABR with subjectively normal hearing is
  common
• OAEs normal
• Several ABR abnormalities

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CURRENT STUDY(Subjects)

• 25 subjects diagnosed with MS
• All 4 types of courses
• 17 Female 8 Male
• 31 49 years old
• Variables Presbycusis
• Otoxicity
• Middle-ear diseases and/or surgery
• Head and/or ear trauma
• Normal tympanograms
• No conductive/mixed hearing loss

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CURRENT STUDY(Methodology)

• Group 1 (15 subjects with no exposure to noise)
• Group 2 (10 subjects with exposure to sudden or
  continuous noise)
• Purpose Determine whether a multiple test
  battery can effectively describe the auditory
  deficits of patients with MS.
• Battery of audiological tests Subjective
  Objective measurements

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SELF-ASSESSMENT QUESTIONNAIRE
Figure 4.1 Initial MS-related symptoms
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SELF-ASSESSMENT QUESTIONNAIRE (continued)
Figure 4.2 Auditory-vestibular symptoms
reported during the current study
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SELF-ASSESSMENT QUESTIONNAIRE (continued)
 

• TINNITUS
• Group 1 - 4 subjects
• Group 2 - 2 subjects
• HEARING DIFFICULTIES
• Group 1 - 3 subjects
• Group 2 - 3 subjects

• CONCLUSION
• Patients with MS, not complaining of tinnitus
  and/or hearing difficulties should not be
  excluded from further audiological assessment
  silent lesions mild unilateral hearing losses
  may occur

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SELF-ASSESSMENT QUESTIONNAIRE(continued)

• Quality of life comparing hearing difficulties
  with other MS-related problems

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HEARING SENSITIVITY

• GROUP 1 (30 ears)
• 21 ears normal thresholds (0 20 dBHL 125
  8000 Hz)
• 2 subjects displayed bilateral hearing losses
• 5 subjects displayed unilateral hearing losses
• Configurations high Hz hearing losses 5 ears
• notches 2 ears
• sloping 1 ear
• dome-shaped 1 ear
• Degree of hearing loss - Mild (20 40 dB)
• Moderate (40 55 dB)

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HEARING SENSITIVITY(continued)

• GROUP 2 (20 ears)
• 5 ears normal thresholds (0 20 dBHL 125
  8000 Hz)
• 6 subjects displayed bilateral hearing losses
• 3 subjects displayed unilateral hearing losses
• Configurations high Hz hearing losses 11
  ears
• notches 1 ear
• dome-shaped 1 ear
• rising 1 ear
• other 1 ear
• Degree of hearing loss - Mild (20 40 dB)
• Moderate (40 55 dB)

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HEARING SENSITIVITY(continued)

• CONCLUSION
• Patients with MS displaying normal puretone
  thresholds should not be excluded from further
  site-of-lesion measurements

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DISTORTION PRODUCTOTOACOUSTIC EMISSIONS (DPOAEs)

• GROUP 1 (30 ears)
• 20 ears normal DPOAEs (500 8000 Hz)
• 3 subjects bilateral abnormal DPOAEs
• 4 subjects unilateral abnormal DPOAEs
• Configurations of DPgrams corresponded with the
  audiometric configurations

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DISTORTION PRODUCTOTOACOUSTIC EMISSIONS
(DPOAEs)(continued)

• GROUP 2 (20 ears)
• 5 ears normal DPOAEs (500 8000 Hz)
• 7 subjects bilateral abnormal DPOAEs
• 1 subject unilateral abnormal DPOAEs
• Configurations of DPgrams corresponded with the
  audiometric configurations

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DISTORTION PRODUCTOTOACOUSTIC EMISSIONS
(DPOAEs)(continued)
Figure 4.4 Results of puretone audiometry and
DPOAEs of both groups
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DISTORTION PRODUCTOTOACOUSTIC EMISSIONS
(DPOAEs)(continued)

• CONCLUSION
• DPOAEs were useful in diagnosing existing
  cochlear damage, subtle cochlear involvement and
  a tool for differential diagnosis
• DPOAEs must be used in conjunction with ABRs

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AUDITORY BRAINSTEM RESPONSE (ABR) using both
rarefaction (R) condensation (C)click
polarities consecutively

• Rationale for using both polarities
• Criteria for classification of abnormalities
• Absent wave I, III or V
• Poor repeatability of wave I, III or V
• Prolonged absolute latencies of wave I, III or V
• Prolonged interpeak latencies of waves I, III or
  V
• Abnormal interaural wave V latency difference
• Abnormal amplitude ratios of wave V/I
• See table 3.12 for possible reasons of abnormal
  ABRs (handout)

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AUDITORY BRAINSTEM RESPONSE (ABR) using both
rarefaction (R) condensation (C)click
polarities consecutively(continued)
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AUDITORY BRAINSTEM RESPONSE (ABR) using both
rarefaction (R) condensation (C)click
polarities consecutively(continued)

• SUMMARY OF RESULTS
• Both Groups
• 68 abnormal ABR using R clicks
• 84 abnormal ABR using C clicks
• More bilateral than unilateral abnormalities

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R vs C CLICK POLARITY (during ABR)

• More discrepancies were present (in the same ear)
  after reversing the click polarity
• Both Groups (50 ears)
• Absent waves 10 ears
• Poor repeatability 12 ears
• Prolonged AL 4 ears
• Prolonged IPL 12 ears
• See examples (handout)

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R vs C CLICK POLARITY (during ABR)(continued)

• CONCLUSION
• Although R click polarity is the most often used
  during ABRs, the higher percentage of
  abnormalities found as well as the discrepancies
  observed, substantiates the implementation of C
  click polarity

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IN CONCLUSION

• Only 2 subjects passed the battery of test
  procedures (Group 1)
• 23 subjects failed the test battery and displayed
  auditory involvement of either cochlear and/or
  neural nature with/without corresponding hearing
  complaints and related symptoms

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IN CONCLUSION

• Silent lesions 3 subjects no symptoms or
  complaints, abnormal ABR
• 6 Subjects displayed auditory brainstem
  involvement with normal puretone thresholds
  cochlear function (complained of communication
  difficulties)
• 5 Subjects displayed neural involvement
  possible sensory involvement (influence of CNS on
  cochlear biomechanical system)

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IN CONCLUSION

• Group 1 displayed a higher incidence of reported
  hearing difficulty, auditory-vestibular symptoms
  and communication difficulties
• Group 2 displayed more impaired puretone
  thresholds and abnormal DPOAEs, indicating
  cochlear involvement
• All subjects had abnormal ABRs when using C
  click polarity, indicating additional neural
  involvement

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IN CONCLUSION

• The abnormal DPOAEs found in Group 1 may indicate
  that the perception that MS affects only the
  brainstem structures (Starr et al. 2001) is not
  entirely accurate
• All test procedures contributed to a better
  understanding of the degree nature of auditory
  involvement

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IN CONCLUSION

• Multiple test battery must be cost effective
• Multiple test battery must be used to monitor MS
  as it progresses

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REFERENCES

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  auditory evoked potential evidence of eight
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• Emerson, R.G. et al., 1982. Effects of click
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  in normal subjects and patients Unexpected
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