Braz. j. . vol.83 número1

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

CASE

REPORT

Speech

auditory

brainstem

response

(speech

ABR)

in

the

differential

diagnosis

of

scholastic

difficulties

夽

Potencial

auditivo

de

tronco

encefálico

com

estímulo

de

fala

(PEATE-fala)

no

diagnóstico

diferencial

de

dificuldades

escolares

Milaine

Dominici

Sanfins

,

Letícia

Reis

Borges

,

Thalita

Ubiali

,

Maria

Francisca

Colella-Santos

a_{UniversidadeEstadualdeCampinas(UNICAMP),FaculdadedeCiênciasMédicas,ProgramadeSaúdedaCrianc¸aedo}

Adolescente,Campinas,SP,Brazil

b_{UniversidadeEstadualdeCampinas(UNICAMP),FaculdadedeCiênciasMédicas,CursodeFonoaudiologia,Campinas,}

SP,Brazil

Received8April2015;accepted29May2015 Availableonline6November2015

Introduction

Learningspokenandwrittenlanguagedependsonthe assim-ilation of acoustic elements and the representation of phoneticcharacteristicsofalanguage.1_{Auditoryprocessing,} phonological awareness, and auditory discrimination are factors that affect the learning of reading and writing, because they are directly related to receptive hearing.2 Researchershave associatedthe presenceof learning dis-abilitieswithhearingdeficitsinchildren.3

Afteranacousticstimulation,electrophysiological eval-uationofhearingcanestablishananatomicalandfunctional correlation in the central auditory nervous system that occursthroughtheactivationofseveralstructures through-outthe system. Thus,in cases of learningdisabilities, an

夽 _{Please cite this article as: Sanfins MD, Borges LR, Ubiali T,}

Colella-SantosMF.Speech-evokedauditorybrainstemresponsein thedifferentialdiagnosisofscholasticdifficulties.BrazJ Otorhino-laryngol.2017;83:112---6.

∗_{Correspondingauthor.}

E-mail:[email protected](M.D.Sanfins).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.

analysisoftheintegrityandfunctionoftheauditory path-waysisrecommended.4

Speechauditorybrainstem response(SpeechABR) test-ingcanbeelicitedbyawidevarietyofsoundstimuli:click, puretone,maskedtone,andcomplexsounds(speech). Stud-ieshavedocumentedthenormalresponsesusingtheclick stimuliinchildrenwithlearningdisabilities;however,recent studies suggest thepresence of alterationsin responseto speechstimuli,duetotheexistenceofsubcorticaldeficits associatedwithlearningdisorders.5---7

Case

report

The subjectsselected forthis studywere individualswith scholasticdifficultieswithadiscrepancybetweenabilityand academicperformance.Thediagnosiswasbasedonalong anddetailedstudycarriedoutbyamultidisciplinaryteam, consistingof apsychologist,speechtherapist,educational psychologist,physicaltherapist,psychomotrician, neurolo-gist,andpsychiatristoftheResearchLaboratoryofLearning Disorders,Disabilities,andAttentionDeficitDisorderofthe FaculdadedeCiênciasMédicas(LaboratóriodePesquisaem Distúrbios, Dificuldades de Aprendizagem e Transtorno de Atenc¸ão da Faculdade de CiênciasMédicas --- DISAPRE) of http://dx.doi.org/10.1016/j.bjorl.2015.05.014

Table1 Assessmentvaluesofauditoryprocessing.

Procedures Case1 Case2

Rightear Leftear Rightear Leftear

DD 87.5% 92.5% 100% 95%

FPT(naming) 48.27% 58.62% 43.33% 26.66%

GIN% 71.66% 58.33% 73.33% 65%

GIN 4ms 8ms 5ms 6ms

SSI(relation---15dB) 70% 50% 60% 30%

Speechinnoise 88% 80% 84% 72%

DD,DichoticDigitstest;FPT,FrequencyPatternTest;GIN,gapinnoise;GIN%,gapinnoise(%);SSI,syntheticsentenceidentification testwithipsilateralcompetingmessage.

Table2 Valuesoftheperformedhearingassessments.

Procedures Case1 Case2

Rightear Leftear Procedures Rightear

Meanof500,1000,and2000Hz 5dB 5dB 10dB 5dB

SRT(dB) 5dB 5dB 10dB 5dB

SRI(%) 100% 96% 96% 100%

Tympanogram TypeA TypeA TypeA TypeA

Ipsilateralandcontralateralacousticreflexes Present Present Present Present

TOAEs Present Present Present Present

DPOAEs Present Present Present Present

AP Altered Altered Altered Altered

ABR(click) Normal Normal Normal Normal

ABR(speech) Altered Unrealized Altered Unrealized

LLR Normal Normal Normal Normal

SRT,speechrecognitionthreshold;SRI,speechrecognitionindex;TOAEs,transientotoacousticemissions;DPOAEs,distortionproduct otoacousticemissions;AP,auditoryprocessing;ABR,auditorybrainstemresponse;LLR,longlatencyresponses.

the Universidade Estadual de Campinas (UNICAMP), Cam-pinas, SãoPaulo, Brazil. The diagnosis wasfinalized after ruling outgenetic,organic, psychological, andpsychiatric disorders that couldcause those alterations. The present study reports two male cases (10 and 11 years old) who wereassessedforaMasterDegree’sdissertation.The par-ents/guardianswereinformedofthestudygoalsandsigned thefreeandinformedconsentformNo.431,184/2013.

A basic audiological evaluationwasperformed and the results were within the normal range, bilaterally. At the behavioralassessmentofauditoryprocessing(AP),an alter-ationwasidentifiedintheauditoryabilitiesoffigure-ground for verbal sounds, temporal ordering, and temporal res-olution (Table 1), whereas at the AP electrophysiological evaluation,theresponseswerewithinthenormalrangein the ABR (click) andlong latency responses (LLR; Table 2) wereobserved. The results oftransient otoacoustic emis-sions(TOAEs)anddistortion productotoacoustic emissions (DPOAEs)werenormalbilaterally.

ABR with speechstimuli wascarried outwith the syn-thesizedsyllable/da/,atarateof10.9stimulipersecond, providedbytheBioMARKTM_{softwareoftheBiologicdevice.} Atotalof6000stimuliweregivenintwoburstsof3000,and theanalysiswasperformedonthesumofthetracing.The stimuliwereappliedthroughaninsertionphoneintheright earat80SPL(soundpressurelevel),becauseoftheknown superiorityofthelefthemisphereforspeechprocessing.8

The stimulusconsisted ofthe consonant/d/(transient portion---onset)andashortvowel/a/(sustainedportion ---frequencyfollowingresponse).TheCwaveformrepresents thetransitionbetweenconsonantandvowel,whereastheO waverepresentstheendofthevowel(Fig.1).Afterthe col-lection,thelatencyandamplitudeofthetransientportion (VandAwaves) andtheVA slope (VAamplitude/VA dura-tion)wereanalyzed using thenormative BioMARKTM _wave asthebasisforanalysis.Inbothcases,abnormalresponses wereobservedinthelatencyvaluesofthewavesV,A,and VAslope(Figs.2and3).

Discussion

Intheanalysisoftheresults,ABRwithclickstimuluswere normalinbothcases,inagreementwithstudiesinthe lit-erature that indicate that only the processes involved in encodingspeechsignalsinthebrainstemregionarealtered inchildrenwithlearningdisabilities.Theseresultsshowthat the ABR withclick and speech stimuli differ in how they stimulate the auditory structures along the central audi-torynervoussystem(CANS),asthedifferentacousticstimuli reflectdistinctneuralprocess.5,7

10

Transient portion (onset)

20 30

Sustained portion (FFR-frequency following response)

40

Final A

D

Transition

Consonant /d/ Short vowel /a/ Electrophysiological response to synthesized syllable /da/

Amplitude (µV)

Latency (ms)

E

F

C

O

Figure1 Representationofelectrophysiologicalresponsetosynthesizedsyllable /da/.Personalfileoftheinvestigatorofan assessmentperformedwithBioMARKTM _software.

the VA slope. Studies support these findings anddescribe adifferencebetween theV andA wavelatency valuesin childrenwithlearning disabilitieswhencompared to chil-drenwithnormaldevelopment.This suggestsarethinking ofhowspeechsoundsareencodedandthefunctionalrole

ofthestructuresresponsibleforgeneratingthesewaves(the regionofthelaterallemniscusandinferiorcolliculus).5---7

Thefindingsofthisstudysuggesttheexistenceof func-tional impairment in speech processing in the brainstem region,identifiedbyprolongedlatenciesofVandAwaves

22

Score: 12 (abnormal BioMARK)

BioMARK results

Based on normative data for age 5-12 years

The results of the speech-evoked brainstem response are interpreted as abnormal.

The results are based on the following information:

Abnormal brainstem function has been associated with impaired auditory perception and literacy skills. Research has found that children with abnormal brainstem function can benefit from auditory training programs. Auditory training can alter the neural encoding of speech and serves as a promising remediation strategy.

Measure

Wave V latency Wave A latency VA Slope First formant frequencies

High frequencies

15.53 ms

1.73 0.98

NO NO NO Yes Yes 19.20 ms

–0.24 uV/ms

Result Within normal limits 17

Result.: 12

Deficit magnitude

Abnor

mal

Nor

mal

11

5

0

22

Score: 14 (abnormal BioMARK)

BioMARK results

Based on normative data for age 5-12 years

The results of the speech-evoked brainstem response are interpreted as abnormal.

The results are based on the following information:

Abnormal brainstem function has been associated with impaired auditory perception and literacy skills. Research has found that children with abnormal brainstem function can benefit from auditory training programs. Auditory training can alter the neural encoding of speech and serves as a promising remediation strategy.

Measure

Wave V latency Wave A latency

VA slope First formant frequencies

High frequencies

11.45 ms

1.72 0.73

NO NO NO Yes Yes 15.28 ms

–0.11 uV/ms

Result Within normal limits 17

Result.: 14

Deficit magnitude

Abnor

mal

Nor

mal

11

5

0

Figure3 Auditorybrainstemresponse(ABR)withspeechstimulusandabnormalresponses.Researcher’sdatafromamalepatient (11yearsold).

and VA slope, suggesting that the physiological mecha-nisms are altered,even without a proven neurobiological abnormalityinpatientsexhibitingscholasticdifficulties.As a result of this deficit in speech perception, there is an impairmentofthecommunicationandlanguageprocesses, withconsequentdegradationoflinguisticandparalinguistic informationthatcausesdifficultiesinacademicskills.This canresultinsevereconsequencesinqualityoflifeandsocial interactionsandculminateinlearningdisorders.Thus,there isanegativeimpactontheprocessingoffastacousticsignals inthespecializedcorticalstructures,whichdonotrespond tothesoundstimulusinasynchronousandorganizedfashion andthusrendertheinterpretationandunderstandingofthe meaningdifficultforchildrenwithscholasticdifficulties.

Several abnormalities in sound processing can be observedinpatientswithlearningdisabilities.Thus differ-entlevelsoftheauditorytrajectoryshouldbeinvestigated toestablishadifferentialdiagnosis.Onewaytoevaluatethe CANSis throughbehavioraltests; however,the evaluation istime-consumingandrequireseffectivepatient participa-tion.Forpatientswithlearningdifficulties,ABRwithspeech stimulusisindicated,sinceitisanobjective,practical,and effectivetestthatdoesnotdependonthepatient’sresponse and is independent of attention; additionally,it provides an analysis of numerical measures that can be used as a predictorofthedegreeofthedisorder.

AccordingtoChandrasekaranandKraus,9_{theanalysisof} absolute latency values for ABR with speech stimuli can helpdifferentiateandestablishdifferentclinicalpictures, andallow for an objective measureof subcortical speech processing.Thisanalysiswouldbeveryimportantin cases oflearningdisabilitiesthatincludeseveralothersubgroups

of disorders, including scholastic difficulties. Researchers stressthatthisprocedurecanbeusedtoevaluateauditory functionandprovideadditionalinformationinthediagnosis oflearningdisabilitiesandauditoryprocessingdisorders.10

The present findings suggest that changes in the per-ceptionandprocessingofauditoryinformationobservedin childrenwithscholasticdifficultiesappeartobethesame asthose seen in children with learning disabilities.Thus, the authors stress the importance of evaluating children withscholasticdifficulties, considering that alterations in speechsoundprocessingappeartobeofcrucialimportance inthelearningprocess.Knowingthemagnitudeofhearing alterationsin thesepatients maysuggest moreaggressive actionsfortheprevention,detection,andtreatmentofthis disorder.

Conclusion

Analysis of these two cases showed the value of using ABR with speech stimuli in the evaluation of children with scholastic difficulties, considering the abnormalities detected in this study. This procedure is objective, fast, andeffective. It does notrequire the patient’s conscious participationandprovidesnumericaldatathatcan demon-stratetheCANSmaturationand,therefore,canfunctionas abiomarkerofscholasticdifficulties.

astoinvestigateandmonitortheconsequencesofimpaired speechperceptionincasesofscholasticdifficulties.

Funding

ThisstudywasfundedbyFAPESP.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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