Braz. j. . vol.81 número5

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Benchmarks

for

the

Dichotic

Sentence

Identification

test

in

Brazilian

Portuguese

for

ear

and

age

夽

,

夽夽

Adriana

Neves

de

Andrade

_,

_Daniela

_Gil,

_Maria

_Cecilia

_Martinelli

_Iorio

DepartmentofSpeechTherapy,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil

Received27June2013;accepted4October2014 Availableonline21July2015

KEYWORDS

Hearing; Hearingtests; Auditorycortex; Speechdiscrimination test;

Validityoftests; Spatialprocessing

Abstract

Introduction:Dichotic listeningtests shouldbeusedinlocallanguagesandadaptedforthe population.

Objective: StandardizetheBrazilianPortugueseversionoftheDichoticSentenceIdentification testinnormallisteners,comparingtheperformanceforageandear.

Methods:Thisprospectivestudyincluded200normallistenersdividedintofourgroups accord-ingtoage:13---19years(GI),20---29years(GII),30---39years(GIII),and40---49years(GIV).The DichoticSentenceIdentificationwasappliedinfourstages:training,binauralintegrationand directedsoundfromrightandleft.

Results:Betterresultsfortherightearwereobservedinthestagesofbinauralintegrationin allassessedgroups.Therewasanegativecorrelationbetweenageandpercentageofcorrect responsesinbothearsforfreereportandtraining.Theworstperformanceinallstagesofthe testwasobservedfortheagegroup40---49yearsold.

Conclusions: Referencevaluesfor theBrazilianPortugueseversionoftheDichoticSentence Identification testinnormal listeners aged13---49 yearswere established accordingto age, ear,andteststage;theyshouldbeusedasbenchmarkswhenevaluatingindividualswiththese characteristics.

© 2015Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.

夽

Pleasecitethisarticleas:AndradeAN,GilD,IorioMCM.BenchmarksfortheDichoticSentenceIdentificationtestinBrazilianPortuguese forearandage.BrazJOtorhinolaryngol.2015;81:459---65.

夽夽_{Institution:UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil.} ∗_{Correspondingauthor.}

E-mail:[email protected](A.N.Andrade). http://dx.doi.org/10.1016/j.bjorl.2015.07.003

PALAVRAS-CHAVE

Audic¸ão; Testesauditivos; Córtexauditivo; Testesde discriminac¸ãoda fala;

Validadedostestes; Processamento espacial

Valoresdereferênciaparaotestedeidentificac¸ãodesentenc¸asdicóticas emportuguêsbrasileirosegundoorelhaeidade

Resumo

Introduc¸ão:Ostestesdeescutadicóticadevemserutilizadosnalínguanativaeadaptadospara apopulac¸ãoalvo.

Objetivo:Estabelecer critérios de referência para o teste DSI em indivíduos normouvintes segundoaorelha,faixaetáriaeetapadoteste.

Método: Estudoprospectivotransversalcom200indivíduosnormouvintes,separadosemquatro grupos:13a19anos(GI),20a29anos(GII),30a39anos(GIII)e40a49anos(GIV).Oteste DSIfoi aplicadoemquatro etapas:Treino,integrac¸ãobinaural,escutadirecionadadireitae esquerda.

Resultados: Foram observados melhores resultados para a orelha direita nas etapas de integrac¸ãobinauralemtodososgruposavaliados.Houvecorrelac¸ãonegativaentrea porcent-agemdeacertoseaidade,bilateralmente, paraasetapasdetreinoeintegrac¸ãobinaural. Opiordesempenho,emtodasasetapasdoteste,foiobservadoparaafaixaetáriade40a 49anosdeidade.

Conclusões:Osvaloresdereferênciapara aversãoem portuguêsbrasileirodotesteDSI em indivíduosnormouvintesde13a49anosdeidadeforamestabelecidossegundoaidade,orelha eetapadotesteedevemserutilizadoscomopadrõesdereferêncianaavaliac¸ãodosindivíduos comessascaracterísticas.

©2015Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Auditory processing assessment targets the understand-ing of the auditory function and its association with communicationandisperformedthroughspecialbehavioral auditorytestsaimed at assessingtheindividual’s auditory performance in similarsituations to thoseexperienced in dailylife.

Dichotic listening tests are amongthe types of stimu-lation used for auditory capacity assessment. In dichotic listening tests with linguistic materials, most individuals tend to display better performance for the informa-tion offered to the right ear compared to the left ear.1

Among the dichotic listening tests utilized in Brazil is theDichotic Sentence Identification (DSI) test, which was originallycreatedinEnglish.2

TheBrazilianPortugueseversionoftheDSI3_hassixparts:

calibration,training.binaural integration,directedreport ontheright, directedreportontheleftear,andtraining. This test allows assessing theauditory capacity of figure-backgroundforverbalsounds(identifyingspeechsoundsin the presence of other speech sounds), with verbalsound recognition in dichotic listening acting as the underlying auditory physiological mechanism.3 _{After the tool}

devel-opment for auditory processing assessment, the authors4

studied the incidence of errors in the sentences given in theDSI inBrazilianPortugueseaccordingtogender.Inthe study,ahigherincidenceoferrorswasobservedwhenthe following sentencewaspresented: ‘‘That ignores the pri-marypurposeistowin,’’regardlessofthetestpresentation stage.

The authors hypothesized that the high incidence of errors in this sentence could berelated to a difficulty in visualprocessingormemory,dependingonthestrategyused bytheindividualtoindicatethesentencethatwasheard.4

Severalfactorsmayinfluencetheindividuals’resultsin behavioralhearingtests;amongthesefactorsisage.Studies haveshownthatwithincreasingagetheremaybeadecline intheproductionandcomprehensionofsyntactically com-plexsentencesandchangesmay alsoariseinthe working memoryoperationpatterns.5

It is known that to achieve the diagnosis of auditory processing disorder, it is necessary touse tools thathave beenvalidatedforthepopulationtobeanalyzedafter cul-turaladaptation,controllingallfactorsthatareextrinsicto theassessment.3_{The adequate useof auditoryprocessing}

testscomplementsperipheralhearingevaluation6_andmust

alsobeperformedwhenassessingindividualswithhearing loss, whether or not theyare users of individual hearing aids.Therefore,thecorrectinterpretationofresultsisvital for diagnostic purposes and toassist in the rehabilitation process.6---8

Consideringtheuseofstandardizedteststoassess audi-toryprocessingandtheeffectofageandearonthedichotic listeningtasks,thisstudyaimstoestablishreferencevalues fortheBrazilianPortugueseversionoftheDSIinnormal lis-tenersaged13---49yearsold,accordingtotheear,agerange, andteststage.

Methods

toparticipateinthestudythroughInternetadvertisement, leafletdistribution,exhibitionofpostersinplaceswithhigh concentrationsofpeople(shoppingmalls,restaurants, busi-nesses, and public and private educational institutions), andverbalinvitationsmadebytheresearcherand/orthird parties.The following equipmentwas usedfor thestudy: MiniHeine3000otoscope,PhilipsExpaniumcd-playerwith MP3, Grason-Stadler GSI --- 61 audiometer, with a pair of TDH-39supra-auralearphones,AT235himmittanciometer, compactdiskwithdichoticdigittest,9_andDSI.3

Forinclusioninthisstudy,thefollowingeligibility crite-riawereused:agebetween13and49years(bothgenders), Portugueseasthenativelanguage,preferablyrighthanded, readingfluency,noevident neurologicalalterationand/or mental disorders, auditory threshold lowerthan 25dB HL between 250 and 8000Hz, type A tympanometric curves andpresence ofacousticreflexes withcontralateral stim-ulation,differencebetweenhearingthresholdsintheright andleftear<10dBHLinalltheassessedfrequencies,and performanceof≥95%correctanswersinthedichoticdigit

test.9

Duringa12-monthperiod,atotalof256individuals vol-untarilycametotheservice,ofwhom56wereexcludedfor notmeetingall theeligibilitycriteria. The studyincluded 200 individuals, matched for gender, with fluent read-ing, level of schoolingof 3---20 years(mean 13.1 yearsof schooling),dividedintofourgroups accordingtoage:GI ---50subjects(25femalesand25males)agedbetween13and 19years;GII--- 50subjects(25femalesand25males)aged between 20 and 29 years;GIII --- 50 subjects (25 females and25males)agedbetween30and39years;andGIV---50 subjects(25 females and25 males)agedbetween 40 and 49years.

AllsubjectsweresubmittedtotheEdinburghHandedness Inventory,10,11 _{basic audiological assessment (anamnesis,}

meatoscopy, pure tone audiometry, speech audiometry, acousticimmittance measures, and contralateralacoustic reflex)andbehavioralauditoryprocessing(sound localiza-tiontest,sequentialmemorytestforverbalandnon-verbal sounds,dichotic digittest ---appliedandanalyzed accord-ing tothe criteriaproposed by Pereira and Schochat)9 _to

excludethepresenceofperipheralhearinglossand/or audi-toryprocessingdisorder.Aftertheseprocedures,theDSItest in Brazilian Portuguese was applied in four stages: train-ing,binaural integration,directedreportontheright and directedreportontheleft.

Inallteststages,theassessedsubjectheardtwo simul-taneous sentences --- one in each ear --- and the response depended on the task. At the binaural integration stage (trainingandbinauralintegration),theindividualwasasked toindicate both sentences; for the directed report stage (right andleft), the subjectshouldonly indicatethe sen-tenceprovidedtotheearunderassessment.

The analysis of resultswasperformed using the statis-tical software Minitab version 15 and SPSS version 11. A significancelevelof0.05wassetforeachhypothesistest.

Results

The test stage and ear variables were crossed with the covariateage,usingAnalysisofCovariance(ANCOVA)with

repeatedmeasures.Asaresult,therewasanassociationof dependencebetweenthedifferencesofthemean percent-ageofcorrectanswersineachstageofthetest(p=0.000*) andineachear(p=0.007*).

Spearman’s coefficient was usedto verifythe correla-tion between the percentage of correct answers in each teststagebyearandage. Therewasastatistically signif-icant correlation between age and the stages of training andbinaural integration,for both the right andleft ears (p<0.001).

The behaviorof thepercentagesof correctanswersby the assessed population is shown in the scatter plots for thetrainingstage(Fig.1),binauralintegration(Fig.2),and directedreport(Fig.3).Basedonthedispersionofcorrect answerpercentages,aLOWESScurvewasdrawntoaid visu-alizationofpossibletrends.

The results showed there was a negative correlation betweenageandpercentageofcorrectanswersforthe bin-auralintegration stages of the DSI (training and binaural integration), witha sharper decline to theleft. The per-centagesof correctanswers in thedirectedreport stages werehigherthaninthebinauralintegrationstages.

Using analysis of covariance (ANCOVA) with repeated measures,astatisticallysignificantinteractionwasobserved betweenthe test stages and theside of the earassessed for individuals aged 13---19 years (p=0.001), 30---39 years (p=0.039),and40---49years(p=0.007).

Afterverifyingtheeffectoftheinteractionbetweenthe teststagesbyearandage,themeanpercentageofcorrect answersobtainedin differentagegroups were compared, accordingtotheteststageandear,usingtheKruskal---Wallis test.Theagerangeinfluencedtheindividuals’performance forthe stages of binauralintegration (trainingand binau-ralintegration)oftheDSI(p<0.004),andcomparisonswere madetolocatethesedifferences(Table1).

Thereweresignificantdifferencesbetweenperformance comparisonsintrainingfortheextremeagegroupsforthe right ear(13---19 vs. 40---49 years) andleft ear(20---29 vs.

40---49years).Forthebinauralintegrationstage,therewere significantdifferencesinperformancecomparisonsbetween theage groups 20---29 yearsvs. 30---39 yearsin both ears. Finally,thereferencevalueswereestablishedaccordingto theobservationofthefifthpercentileofpercentage distri-butionofcorrectanswersinagivenagegroup(Table2).

Theestablishedreferencevaluesweresimilarfortheage groupsof 13---29 yearsandthe performancedecrease was moremarkedafter30yearsofage.

Discussion

We comparison the results obtained in the DSI in Brazil-ianPortuguesewiththeresultsobtainedinothercountries, sincetheBrazilianPortugueseversionisrecent,compared totheversions inEnglish,andhasbeenlittlestudied.The meanperformanceintheDSItestinBrazilianPortugueseat thebinauralintegrationstageshowed 93.70%accuracy on therightand88.60%accuracyontheleft,withtheresults corroboratingstudiescarriedoutinotherlanguages,2,12_that

15 40 50 60 70 80 90 100

20 25 30 35 40 45 50

Age (years)

Right Left

Training

% Correct ans

w

ers

15 20 25 30 35 40 45 50

Figure1 Scatterplotsofcorrectanswerpercentagesinthetrainingstagebyageandear.

ontheleftfortheAustralianversionofDSI12_{inindividuals}

withouthearingloss.

With increasingage, there wasa decrease in the per-centageofcorrectanswersinthebinauralintegrationstage, demonstratedinthescatterplotsinwhichtheLOWESScurve showedadownwardconfiguration,withasharperdeclinefor theleftear.Aftertheageof30,testperformancetendedto decreaseinallassessedstages.Theperformancedecrease withincreasingageinindividualsassessedbydichotic listen-ingtestshasbeenpreviouslyreportedbyseveralstudies12---20

andhasbeenattributedtoachangeintheinterhemispheric transfer of auditory information via the corpus callosum. Thisscenariobecomesmoreevidentinelderlyindividuals, because in addition to the interhemispheric integration inefficiency,theremaybeother deficitssuch ascognitive

decline, which further hinders the capacity to recognize speechstimulipresentedtotheleftear.

The individuals showed worse performance in the bin-aural integration stages (training and integration) when comparedtothedirectedreportstages,withtherightear showingbetterperformancethantheleftearatthe binau-ralintegrationstagesfor allagegroups;thesedifferences werestatisticallysignificant.

Thesignificantadvantageoftherightearwithincreasing age in the three listening stages assessed in the DSI test hasbeen reported inanother study14 _{that found that,for}

thedirectedreportstage,therightearadvantagewasmore pronouncedafter40yearsofage.Toexplaintheeffectof the disadvantage of the leftear withincreasing age, the authorsdescribedthreepossibleoccurrences:14

15 40 50 60 70 80 90 100

20 25 30 35 40 45 50

Age (years)

Right Left

Integration

% correct ans

w

ers

15 20 25 30 35 40 45 50

15 40 50 60 70 80 90 100

20 25 30 35 40 45 50

Age (years)

Right Left

Directed report

% correct ans

w

ers

15 20 25 30 35 40 45 50

Figure3 Scatterplotsofcorrectanswerpercentagesinthedirectedreportstagebyageandear.

- Declineof knowncognitive factors, such asmemory or informationprocessingstrategies.

- More accentuated impairment of the auditory pathway structuresforinformationinputthroughtheleftear.One possibilitywould be a relatively higher decrease in the righthemisphere,whencomparedtothelefthemisphere, withincreasingage.

- Decreasedefficiencyintheinterhemisphericinformation transferdue tothereduction inneural elements in the corpus callosum,generating disadvantage for the infor-mationreceivedthroughtheleftear.

Therewasnosignificantcorrelationbetweenageandthe percentageofcorrectanswersinthedirectedreportstages, bothontherightandtheleft;therewasalsonoeffectof age rangeon the mean percentageof correctanswers in bothears in thedirectedreportstage. These results pos-siblyoccurred becausethe directedreportstages showed betterresultswhencomparedtotheotherDSIteststages, withsignificantdifferences.Thisresultwasexpected,asthe individualsincludedinthisstudyhadnoauditoryprocessing disorderandsowouldbeabletodirecttheirauditory atten-tion. The capacity to direct the auditory attention was

Table1 p-valuesobtainedfrommultiplecomparisonstolocatetheeffectofagerangeinthepercentageofcorrectanswers

byteststageandear.

Teststage Ear Comparison p

Training

Right

13---19yearsvs.20---29years >0.999 20---29yearsvs.30---39years 0.643 30---39yearsvs.40---49years >0.999 13---19yearsvs.40---49years 0.032a

13---19yearsvs.30---39years 0.315

20---29yearsvs.40---49years 0.089

Left

13---19yearsvs.20---29years 0.597

20---29yearsvs.30---39years 0.199

30---39yearsvs.40---49years 0.236

13---19yearsvs.40---49years 0.063

13---19yearsvs.30---39years >0.999

20---29yearsvs.40---49years 0.001a

Integration

Right

13---19yearsvs.20---29years 0.634

20---29yearsvs.30---39years 0.011a

30---39yearsvs.40---49years 0.711

Left

13---19yearsvs.20---29years 0.482

20---29yearsvs.30---39years 0.015a

30---39yearsvs.40---49years 0.068

Table2 ReferencevaluesfortheDichoticSentenceIdentificationtestbyearandagerange.

Teststage Ear Agerange

13---19years 20---29years 30---39years 40---49years

Training Right 80% 80% 60% 60%

Left 50% 60% 60% 40%

Integration Right 80% 80% 70% 70%

Left 70% 60% 60% 60%

Directed report

Right 90% 90% 90% 80%

Left 90% 90% 90% 70%

demonstrated by a mean performance of 98% of correct answersforallagerangesinthedirectedreportstages,both ontherightandontheleft.

TheDSItestwasdesignedtotestthecentralevaluation ofindividualswithperipheralhearingloss,asitsufferslittle influenceofsensorineural hearinglossofcochlear origin.2

However,toanalyzetheperformanceofspecialpopulations inbehavioralhearingtests,suchasindividualswithhearing loss,itisnecessarytoestablishnormalitycriteriafor indi-vidualswithgoodhearingacuitywithoutauditoryprocessing disorders.

Considering the requirements established in the inclu-sioncriteriaforparticipationinthisstudy,theresultscan beextrapolatedtothe adultpopulation. However,asage directly influences the results of the DSI test, it is sug-gestedthatnewstudiesbecarriedoutwithindividualsaged 50 years and older, to establish reference criteria for this population. It is also necessary to applythe DSI test to special populations, such as individuals with auditory processingdisorders,speechand/orlanguagedisorders,and sensorineuralhearingloss.

Conclusions

Aftercriticalanalysis ofthe results, thereference values establishedfortheBrazilian Portugueseversionof theDSI testinnormallistenersaged13---49yearsold,accordingto age,ear,andteststageare:

Age range 13---19 years old: 80% correctanswers (in the trainingandbinaural integrationstages---rightear[RE]), 50%correctanswers(inthetrainingstage---leftear[LE]), 70% correctanswers(inbinauralintegrationstage---LE), and90%correctanswers(inthedirectedreportstage). Age20---29yearsold:80%correctanswers(inthetraining and binaural integrationstages --- RE),60% (in the train-ingandbinauralintegrationstages---LE),and90%correct answers(inthedirectedreportstage).

Age30---39yearsold:60%correctanswers(inthetraining stages(REandLE)andbinauralintegration---LE),70% cor-rectanswers(inbinauralintegrationstage---RE),and90% correctanswers(inthedirectedreportstage).

Age range 40---49 years old: 60% correctanswers (in the trainingREandbinauralintegrationLEstages),40%(inLE trainingstage),70%correctanswers(inREbinaural inte-grationstage)80%correctanswers(inthedirectedreport

stageRE),and70%correctanswers(inthedirectedreport stageLE).

Funding

ThisstudywasfundedbyFundac¸ãodeAmparoàPesquisado EstadodeSãoPaulo(FAPESP).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.MartinJS,JergerJF.Someeffectsofagingoncentralauditory processing.JRehabilResDev.2005;42Suppl.2:25---44. 2.Fifer RC, Jerger JF, Berlin CL, Tobey EA, Campbell JC.

Development of a Dichotic Sentence Identification test for hearing-impairedadults.EarHear.1983;4:300---5.

3.Andrade AN, Gil D, Iório MCM. Elaborac¸ão da versão em português brasileiro do teste de identificac¸ão de sentenc¸as dicóticas(DSI).RevSocBrasFonoaudiol.2010;15:540---5. 4.Andrade AN, BucuvicEC, GilD, Iorio MCM. Análise de erros

nasfrasesapresentadasnaversãoemportuguêsbrasileirodo testedeidentificac¸ãode sentenc¸asdicótica. DistúrbComun. 2009;21:179---85.

5.KemperS.Languageandaging.In:CraikF,SalthouseTA,editors. Thehandbookofagingandcognition.Hillsdale,NJ:Lawrence Erlbaum;1992.p.213---70.

6.GilD,IorioMCM.Formalauditorytraininginadulthearingaid users.Clinics.2010;65:165---74.

7.Bamiou DE, Musiek FE, LuxonLM. Etiology and clinical pre-sentations of auditory processing disorders. Arch Dis Child. 2001;85:361---5.

8.Chermak GD, Musiek FE. Auditory training: principles and approachesforremediatingandmanagingauditoryprocessing disorders.SemHear.2002;23:297---308.

9.PereiraLD,SchochatE.Processamentoauditivocentral:manual deavaliac¸ão.1sted.SãoPaulo:Lovise;1997.

10.OldfieldRC.Theassessmentand analysisofhandedness:the EdinburghInventory.Neuropsychologia.1971;9:97---113. 11.BritoGNO,Brito LS,PaumgarttemFJR, LinsMF.Lateral

pre-ferences in Brazilianadults: an analysis with theEdinburgh Inventory.Cortex.1989;25:403---15.

13.CooperJCJr,Gates GA.Hearingintheelderly-the Framing-hamCohort,1983---1985:PartIIprevalenceofcentralauditory processingdisorders.EarHear.1991;12:304---11.

14.JergerJ,ChmielR,AllenJ,WilsonA.Effectsofageandgender onDichoticSentenceIdentification.EarHear.1994;15:274---86. 15.JergerJ,AlfordB,LewH,RiveraV,ChmielR.Dichotic-listening, event-relatedpotentials,andinterhemispheric-transferinthe elderly.EarHear.1995;16:482---98.

16.JergerJ.Asymmetry inauditoryfunction inelderly persons. SeminHear.2001;22:255---70.

17.Hällgren M,Larsby B, LyxellB, Arlinger S. Cognitive effects in dichotic speech testing in elderly persons. Ear Hear. 2001;22:120---9.

18.BellisTJ,WilberLA.Effectsofagingandgenderon interhemi-sphericfunction.JSpeechLangHearRes.2001;44:246---63. 19.GootjesL,StrienJWV,BoumaA.Ageeffectsinidentifyingand

localisingdichoticstimuli:acorpuscallosumdeficit?JClinExp Neuropsychol.2004;26:826---33.