Alternate Binaural Loudness Balance Research Articles

Diagnosis and treatment strategies of 56 cases of middle ear myoclonus

Objective: To analyze the clinical characteristics and treatment of middle ear myoclonus. Methods: Fifty-six cases of middle ear myoclonus were enrolled in Shandong Provincial ENT Hospital, Shandong University from September 2019 to August 2021, including 23 males and 33 females. The age ranged from 6 to 75 years, with a median age of 35 years; Forty-seven cases were unilateral tinnitus, nine cases were bilateral tinnitus. The time of tinnitus ranged from 20 days to 8 years. The voice characteristics, inducing factors, nature (frequency) of tinnitus, tympanic membrane conditions during tinnitus, audiological related tests, including long-term acoustic tympanogram, stapedius acoustic reflex, pure tone auditory threshold, short increment sensitivity test, alternate binaural loudness balance test, loudness discomfort threshold, vestibular function examination, facial electromyography, and imaging examination were recorded. Oral carbamazepine and/or surgical treatment were used. The patients were followed up for 6-24 months and the tinnitus changes were observed. Results: Tinnitus was diverse, including stepping on snow liking sound, rhythmic drumming, white noise, and so on. The inducing factors included external sound, body position change, touching the skin around the face and ears, speaking, chewing and blinking, etc. Forty-four cases were induced by single factor and 9 cases were induced by two or more factors. There was no definite inducing factor in 1 case. One patient had tinnitus with epilepsy. One case of traumatic facial paralysis after facial nerve decompression could induce tinnitus on the affected side when the auricle moved. Tympanic membrane flutter with the same frequency as tinnitus was found in 12 cases by otoscopy, and the waveform with the same frequency as tinnitus was found by long-term tympanogram examination. There were 7 patients with no tympanic membrane activity by otoscopy, the 7 cases also with the same frequency of tinnitus by long-term tympanogram examination, but the change rate of the waveform was faster than that of the patients with tympanic membrane flutter. All patients with tinnitus had no change in hearing. One case of tinnitus complicated with epilepsy (a 6-year-old child) was treated with antiepileptic drug (topiramate) and tinnitus subsided. One case suffered from tinnitus after facial nerve decompression for traumatic facial paralysis was not given special treatment. Fifty-four cases were treated with oral drug (carbamazepine), of which 10 cases were completely controlled and 23 cases were relieved; 21 cases were invalid. Among the 21 patients with no effect of carbamazepine treatment, 8 patients were treated by surgery, 7 patients had no tinnitus after surgery, 1 patient received three times of operation, and the third operation was followed up for 6 months, no tinnitus occurred again. The other 13 cases refused the surgical treatment due to personal reasons. Conclusions: Middle ear myoclonus tinnitus and the inducing factors manifestate diversity. Oral carbamazepine and other sedative drugs are effective for some patients, and surgical treatment is feasible for those who are ineffective for medication.

CARLOS POTENCIANO REYES, MD (1940 - 2020) Little-Known but Significant Pioneer

Consultants and more senior co-resident physicians at the Philippine General Hospital (PGH) would call him “Caloy.” Hardly would I hear anybody (including our ENT department secretary) address him as Dr. Reyes. This was not because he was not a respected faculty member. Rather, he was everybody’s friend and he probably preferred to be addressed by his nickname.
 Dr. Carlos P. Reyes was a tall, friendly guy, easily recognizable while walking through the short PGH corridor stretching from the old ENT Ward (Ward 3) to the old ENT operating room (OR) called Floor 15, later designated as the PGH Nursing Office. He would almost always be holding either an expensive photography camera, electronic gadget, ENT OR instrument, or car magazines – suggesting his varied interests aside from having good knowledge of Otolaryngology, particularly Otology. He would usually stop and chat with an acquaintance about his new medical or non-medical interests.
 I first met Dr. Caloy when I was the first year resident assigned to the Otology section. He would call me “Ging” while presenting the ear patients at the outpatient department (OPD) Ear Clinic, only to learn later that he would address all unfamiliar persons by that name. He was kind, helpful and very understanding. Equipped with ample information in Otology he gathered from postgraduate studies abroad, he would selflessly share these with the residents in order to sharpen our diagnostic acumen. He would instruct us to rely on concise yet complete clinical examination, involving audiologic evaluation tools and meager radiologic information in considering differential diagnoses. He was quite willing to assist us in our learning processes, particularly on how to distinguish middle ear from inner ear disorders, and cochlear versus retrocochlear diseases. Since we did not have any audiologist at that time, he admonished us to carry out the needed audiometric evaluations on our ear patients ourselves in order to learn both the techniques of the procedures and their limitations. Hence, after the OPD clinic we would not only perform routine pure tone and speech audiometric tests but also special examinations like the Bekesy test, short increment sensitivity index (SISI) test, alternate binaural loudness balance (ABLB) test and the test for tone decay. We would then discuss the test results during our next ear clinic and we would listen and be amazed at how Dr. Caloy would integrate the information and arrive at the complex diagnosis.
 Dr. Caloy was our mentor at the time when refinements in tympanoplasty and mastoidectomy aroused the excitement and imagination of budding otologists worldwide. Whereas canal down mastoidectomy was the usual norm to safely remove common mastoid pathology like cholesteatoma, Dr. Caloy introduced the concept of intact canal wall mastoidectomy that avoids or mitigates recurrent postoperative cleaning of the mastoid bone. The period was also the dawn of neuro-otology when Dr. William House popularized the transmastoid approach for acoustic neuroma and the endolymphatic mastoid shunt as treatment for Meniere’s disease. In order to teach us the anatomical and surgical principles of performing these procedures, Dr. Caloy set up the first temporal bone dissection laboratory in the country at the mezzanine above the ENT conference room. He would offer the course to all ENT residents-in-training and consultants nationwide. He practically revolutionized the method of otologic surgery by requiring ENT surgeons to practice doing ear surgery in the temporal bone dissection lab prior to performing ear surgeries in the operating room. In addition, he advocated the use of the operating microscope and dental drills in place of the old bone gouges, chisels and bone ronguers. His ideas were later adopted by other ENT training institutions as we see today. The requirement that every ENT resident must undergo temporal bone dissection in the course of his training obviously stemmed from the efforts of Dr. Caloy. Many senior ENT consultants who are still with us today were former students of Dr. Caloy in his temporal bone lab
 Unfortunately, before finishing my residency training, Dr Caloy expeditiously left the PGH ENT department for unknown reasons. He then set up his private clinic in Quezon City and later joined the ENT department of University of Santo Tomas.
 Reflecting on the significant yet probably unknown achievements of Dr. Caloy toward the advancement of otology and neuro-otology in our country, I realize how blessed I was to be one of his students during that brief period when he was still with us at UP-PGH.
 With our profound gratitude Sir, we will always remember you.

Detecting the recruitment phenomenon in adults using 80-Hz auditory steady-state response

ObjectivesThe ASSR is used widely as an objective measurement of hearing in clinical settings because of its high frequency specificity. The recruitment phenomenon is generally detected using subjective evaluations which require direct communication with the patient. If the recruitment phenomenon can be detected with ASSR, it would facilitate diagnosis in patients with developmental disorders and infants. Subjects and methodsWe examined 2 groups of subjects: 10 subjects with unilateral hearing impairment in whom the recruitment phenomenon was detected by the alternate binaural loudness balance test and 12 normal subjects. We compared the relationships between the ASSR response and the stimulus sound pressure level in the 2 groups using the 80-Hz ASSR. ResultsThe amplitude of ASSR was significantly higher in the impaired ear in hearing-impaired subjects compared to a normal ear in normal subjects. The latency of ASSR was significantly shorter in the impaired ear in hearing-impaired subjects than in the normal ear in the normal subjects. ConclusionThis study showed that the recruitment phenomenon caused the higher amplitude and the shorter latency observed in hearing-impaired subjects in the 80-Hz auditory steady-state response (ASSR) in comparison with normal subjects.

Correlations Between the Degree of Endolymphatic Hydrops and Symptoms and Audiological Test Results in Patients With Menière's Disease: A Reevaluation.

This study was performed to reevaluate the diagnostic significance of clinically well-accepted audiological tests in indicating endolymphatic hydrops (EH) in Menière's disease (MD). Retrospective case review. Hospital. Fifty patients (52 affected ears) diagnosed with MD were enrolled. Diagnostic. To analyze the correlations between endolymphatic hydrops and results of audiological test including the pure-tone audiometry threshold, suprathreshold function tests, electrocochleogram, and glycerol test. Three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging demonstrated EH in either the vestibule or cochlea to various degrees in all of the MD patients, 24 hours after intratympanic gadolinium chelate injection. Both vestibular and cochlear EH were significantly correlated with PTA threshold. However, EH was not associated with alternate binaural loudness balance or the tone decay test, although a correlation was observed with the short-increment sensitivity index. There was also a correlation between vestibular EH, but not cochlear EH, and the negative summating potential/action potential (-SP/AP) ratio. Neither vestibular EH nor cochlear EH was correlated with the glycerol test results. In addition, the frequency of vertigo attacks, the existence of tinnitus, and aural fullness did not correlate with EH. Disrupted ionic homeostasis in the inner ear, but not the EH, may contribute to changes in the -SP/AP ratio. The relevance of glycerol test in identifying EH through detection of hearing changes needs further investigation in the future.

일 대 다 모델을 지원하는 자동 ABLB 청력 검사 시스템

ABLB (alternate binaural loudness balance) test is one of the medical assessments to diagnose detailed lesion of sensory-neural hearing loss based on a recruitment phenomenon. However, current ABLB audiometry takes an operational model, so called face-to-face model, in which model one audiometrist can assess only one subject at a time. As a result, this face-to-face model leads to expensive audiometrist's labor cost and lengthy wait when there exist many subjects. As a solution, this paper suggests an ABLB audiometry system supporting one-to-many model in which model an audiometrist enables to assess several subjects concurrently. By providing such capabilities as real-time transfer of assessment result, video monitoring of subject and video chat, this solution can provide same effect as face-to-face model but overcome weakness of the existing face-to-face model.

자동 ABLB 검사 소프트웨어 개발

ABLB(양측 귀 교대 평형) 검사는 누가현상에 기초한 감각신경성 난청의 세부 병변을 감별하기 위한 검사중 하나이다. 본 논문은 자동 ABLB 검사 소프트웨어를 기술한다. 이 소프트웨어는 ABLB 검사 주파수 및 검사 시작음을 자동으로 결정한다. 또한 검사 음에 대한 피검자의 반응을 분석하여 다음 검사를 결정하는 알고리즘을 지원한다. 또, 피검자의 ABLB 검사 제어 및 모니터링을 위한 인터페이스를 제공하고 검사 결과를 Ladder Diagram으로 나타낸다. 디지털 오실로스코프를 이용하여 ABLB 검사 음이 정확하게 출력되는지 확인하였다. ABLB(Alternate Binaural Loudness Balance) test is one of the medical assessments to diagnose detailed lesion of sensory-neural hearing loss based on a recruitment phenomenon. This paper describes an Auto ABLB test software. This software automatically decides test frequency and intensity of first test tone. And it supports an automatic algorithm that analyses the subject's reponses in the current step and then decides intensity of tone provided in next step. Also, this software supports an interface to control and monitor subject's ABLB test. The assessment result is represented by a ladder diagram. The output of this software has been verified using a digital oscilloscope.

Acoustic reflex threshold and loudness in patients with unilateral hearing losses

The relationship between the acoustic reflex threshold (ART) and loudness was examined in patients with unilateral hearing losses and subjects with simulated hearing losses using a masking method. Significant differences in the ART between the two ears of patients with unilateral hearing losses were correlated with differences in loudness at the level of the ART with differences in loudness determined by the alternate binaural loudness balance test. A similar relationship of ART and the sensation of loudness was also observed in ears with simulated hearing losses. The results obtained in the present study suggest a positive relationship between the ART and loudness, and provide some support for the assumption that a common neuronal information pathway plays an important role both in producing the loudness and eliciting the acoustic reflex.

Recruitment detection--a comparison of category loudness scaling and classical supra-threshold audiometry

The assessment and localization of hearing impairments require reliable and valid recruitment indicators. Although many diagnostic tests are available, which of these tests are most important is still the subject of controversy. To compare the efficacy of various diagnostic audiometric tests, 51 subjects with monaural sensorineural hearing loss were submitted to the following tests at 500 and 2000 Hz: category loudness scaling of narrowband noise bursts, alternate binaural loudness balance (ABLB), intensity difference limen test, SISI test, fixed frequency Békésy audiometry, and contralateral determination of the acoustic reflex threshold for pure tones. Using the findings of the ABLB test as reference, the results of the present study revealed that category loudness scaling and acoustic reflex audiometry are reliable quantitative recruitment indicators. This holds for the intensity difference limen test to a lesser extend as well. However, the recruitment selectivity of the SISI test and Békésy audiometry turned out to be considerably poorer. Category loudness scaling has proven to be a valuable element in the conventional recruitment test battery particularly for patients with symmetrical hearing loss. Therefore, category loudness scaling, ABLB test (when feasible), acoustic reflex measurement, and to a lesser extend the intensity difference limen test should be given the highest priority when selecting appropriate diagnostic audiometric tests. The efficacy of the SISI test and Békésy audiometry should be comprehensively reevaluated on the basis of expanded data. Until such material is available and a final judgement of the clinical value is possible, both these tests should be used and interpreted carefully.

Intensity resolution and loudness in high-pass noise

Intensity resolution and loudness growth for a 1000-Hz tone were studied in the presence of high-pass noise (cutoff: 1800 Hz). Intensity resolution was measured for gated and continuous standards using a three-interval forced-choice (3-IFC) adaptive procedure. Loudness matches were obtained using an adaptive, alternate binaural loudness balance procedure. Three subjects listened in three conditions (1) quiet; (2) high-pass noise with a spectrum level of 32 dB SPL; and (3) high-pass noise with a spectrum level of 42 dB SPL. Noise levels were selected so that detection thresholds were minimally affected at the test frequency; however, for frequencies in the noise passband, thresholds were shifted to either 50 or 60 dB SPL, depending on the spectrum level of the noise. On average, loudness growth and intensity resolution were unaltered by the presence of the noise for tonal levels below 40 dB SPL; above 40 dB SPL the following was generally true: (1) intensity resolution for gated standards was well described by Weber's law except at the highest levels where the Weber fraction decreased; (2) intensity resolution for continuous standards showed a "near-miss" to Weber's law, but just-noticeable differences (jnd's) were slightly larger than those in quiet for the same SPL; (3) loudness was reduced. A comparison of jnd's for equally loud tones showed that loudness is less dependent on excitation spread than the jnd. That is, jnd's in the threshold-shifted ear were larger than the ones in quiet when the comparison was made for tones judged to be equally loud.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Factors Relating to the Positive Glycerol Test for Ménière’s Disease

In order to investigate the clinical factors relating to positive glycerol tests, 51 patients with Ménière's disease were subjected to a complete battery of audiometric examinations, including the short increment sensitivity index, Bekesy, alternate binaural loudness balance, speech discrimination and pure-tone audiometry tests, both before and after glycerol ingestion. The correlation between positive glycerol tests and vestibular response, cochlear symptoms, age at onset and disease duration was investigated. High ratios of positive tests were obtained in the following categories of patients with Ménière's disease: elderly patients with vertiginous attacks; patients with high-level hearing loss; nystagmus patients, and patients with fluctuating hearing loss.

Diagnostic vetting of individuals with asymmetric sensorineural hearing impairments.

Audiological and vestibular tests were administered conjointly in a neurological or general ORL clinic to exclude cerebellopontine angle (CPA) tumours. This study aimed to assess the efficiency of various tests in achieving that exclusion with the minimum of unnecessary investigations. All patients received the full battery of auditory brainstem responses, acoustic reflex thresholds and decay, alternate binaural loudness balance and ENG and caloric testing. All patients who did not have normal auditory brainstem responses proceeded to high resolution CT scanning. One hundred and fifteen patients were investigated and four acoustic neuromas were diagnosed. The efficiency of these tests in a general ORL clinic is very much poorer than often suggested, due largely to the number of occasions on which the tests cannot be done, and to the very small proportion of the test population who have CPA tumours.

Magnitude estimation of loudness. II: Loudness perception in presbycusic listeners.

Because clinical methods most commonly used for assessing loudness are indirect measures that require one normal or near normal ear, loudness perception has not been studied thoroughly in listeners with symmetrical hearing loss. In this investigation, loudness perception was studied in three groups of listeners: normal listeners, listeners with asymmetrical sensorineural hearing loss, and individuals with bilaterally symmetrical hearing impairment due to presbycusis. In Experiment 1, a Magnitude Estimation of Loudness (ME) technique was compared to Alternate Binaural Loudness Balance ( ABLB ) results for subjects with asymmetrical hearing impairment. Results indicate that ME and ABLB measurements produce similar evidence of abnormally rapid growth of loudness in asymmetrically impaired listeners. In Experiment 2, loudness growth in individuals with normal hearing or with presbycusic hearing impairment was determined from ME measurements. Although presbycusic subjects tended to have steeper loudness functions than normal subjects, the differences did not reach statistical significance except at 6000 Hz, suggesting that, as a group, presbycusic listeners display little, if any, recruitment of loudness.

Acoustic Neuromas: Diagnostic Efficiency of Various Test Combinations

In the majority of diagnostic tests usually used in the search for acoustic tumors, there is a large difference in the outcome between patients with and without tumors. Because of a possible coherence between the tests applied, a statistical analysis of this connection was performed with the aid of a logistic model. The best single investigation used to differentiate between patients with and without tumors was tomography of the internal acoustic meatus. This examination was used in combination with the differential caloric test and the alternate binaural loudness balance recruitment test to differentiate completely between patients with and without tumors. Results of other examinations did not contribute significantly to the differentiation between patients with and without tumors. This factor did not render the other examinations superfluous because the analysis was valuable only in patients with a hearing level better or equal to 80 dB. By applying the other tests, information was obtained on pressure conditions in the internal acoustic meatus and possible difficulties at surgery, as well as information about the size of the tumor.

Response factors in the choice of reference ear in ABLB.

Response patterns and the limits of loudness judgement accuracy were explored in a clinical presentation of the alternate binaural loudness balance (ABLB) procedure, and compared across the two methodological alternatives of using the better or poorer ear as reference ear. It was found: 1) that in the range of judgement uncertainty, responses were strongly influenced by stimulus presentation order; 2) that the magnitude of the range of uncertainty was similar across both methodologies. A suggested clinical procedure which controls for these effects is presented as an Appendix.

A computer-controlled binaural balance test.

The commonly used ABLB procedure (Alternate Binaural Loudness Balance) is strongly influenced by two psychological factors: the consistency of the referred side and the increase in intensity in equal stages on this side. To avoid this influence, side and intensity have to be randomized. The test has therefore been subjected to computer control and the results are continuously checked as to their significance. 26 patients with suspected inner-ear disturbance showed a significant relative recruitment; by contrast, in not one of 14 normal-hearing persons was the result positive. This test takes no longer than the conventional procedure.

Cross-modal matching of loudness and brightness as a recruitment test for hearing-impaired children.

Normal 5-year-olds have been reported to be able, in a simple game situation, to match brightness to loudness in the same way as a control group of adults. This study investigated supplanting the normal ear in an alternate binaural loudness balance test (ABLB) with the visual modality, as a recruitment test designed especially for bilaterally hearing-impaired children. The results of normal 10-year-olds, with simulated hearing losses, suggest that category scaling was adopted naturally as a simplifying strategy in preference to ratio scaling (absolute judgements). No proportional increase in the matching function slope was evident, despite the amount of recruitment measured with an ABLB. The instructions needed to combat this strategy render the test unfeasible with hearing-impaired children.

Auditory test results in 500 cases of acoustic neuroma.

Auditory test results in the first 53 causes of this series of 500 acoustic neuromas were reported in 1964. Subsequent studies involving larger numbers of patients detailed new results based on these additional cases. Five hundred cases of surgically confirmed acoustic neuromas were analyzed. Pure-tone loss configurations, speech discrimination, auditory adaptation as measured by the modified tone decay test, Bekesy audiometry, short increment sensitivity index test, and alternate binaural loudness balance test data were evaluated. The results of this investigation in general confirm previous studies, although percentage figures for positive tests differed in the large series. Acoustic reflex results were reported for those patients evaluated more recently. Slightly more than half of the cases had inconsistent audiometric results in one or more aspects. Inconsistencies to the tests were examined in detail. Consistent responses to the tests appear to be related to the size of the lesion. The full battery of audiologic tests is of importance in the differential diagnosis of acoustic neuromas.

Loudness balance procedures for the measurement of recruitment

COLES and PRIEDE have recommended that in the alternate binaural loudness balance test use of the normal ear as the reference standard be now abandoned in favour of the worse ear. Their data are critically reviewed and shown to be subject to cumulative errors of methodology and interpretation.

Masking level difference: another tool for the evaluation of peripheral and cortical defects.

Masking level difference (MLD) due to binaural unmasking was measured for speech signals (5-word meaningful sentences) masked by broad-band noise. Tests were carried out in a group of patients with unilateral cerebral lesions of vascular origin and apparently normal pure-tone audiograms (CNS patients), in a control group (normally hearing young adults) and in 5 other groups of patients (conductive symmetrical hearing loss, conductive asymmetrical hearing loss, bilateral presbyacusis, unilateral sudden deafness, Menière's disease). Testing pattern implied three or more S/N ratios in the listening conditions, of SmNm, Sdelta tNo and SmNu (noise correlated), and the speech signal intensity was 70 dB SPL re 20 muPa for the control group, whilst for the pathological cases, speech level intensities were established by means of alternate binaural loudness balance and simultaneous balancing median-plane localization procedures to assess subjective suprathreshold sound image localization at the midline. The results obtained in the control group and in the patients are discussed. With specific reference to the CNS patients, a statistically significant tendency was evident for the binaural condition to produce more MLD when the ear leading in time was ipsilateral to the normal hemisphere. The importance of this and of sensitized speech testing methods in CNS disorders is discussed on the basis of the results obtained in the CNS patients.

Changes in loudness after stapedectomy.

Twenty subjects who had undergone unilateral stapedectomy and three subjects suffering from unilateral Bell palsy were tested to determine (1) the presence of phonophobia by means of the loudness discomfort levels (LDL) and threshold of the acoustic reflex, where measurable, (2) changes in loudness function by means of alternate binaural loudness balance (ABLB) measures, and (3) presence of distortion at high intensity levels (overload) by means of speech discrimination scores at high intensity levels. Both groups responded similarly in that many, but not all patients demonstrated (1) no change in LDL to pure tones but 5 to 8 dB lowering of LDL in the affected ear for speech; (2) unusual changes in loudness perception at suprathreshold levels only; and (3) decrease (rollover) in discrimination scores at high intensity levels in the affected ear.