\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Advantages of Narrow Band CE-Chirp ABR Compared to Tone Burst ABR in
Adults with Normal Hearing}



\author[1]{Seval Ceylan}%
\author[2]{Akif İşlek}%
\author[1]{Pınar Baba}%
\author[1]{Yılmaz Özkul}%
\affil[1]{Izmir Katip Celebi University}%
\affil[2]{Nusaybin State Hospital}%


\vspace{-1em}



  
  \date{May 14, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: In this study, we aimed to compare the ABR's (Auditory
Brainstem Response) estimated behavioral thresholds, wave V latencies,
and amplitudes, obtained using Tone Burst and Narrow Band (NB) CE-Chirp
stimuli in adults with normal hearing. Design: A prospective study was
designed. Setting: Otorhinolaryngology and Audiology Clinic of the
tertiary university. Participants: Twenty-four adults with normal
hearing (17 males, 7 females) participated in this study. Main outcome
measures: ABR was recorded using Narrow Band (NB) CE-Chirp and Tone
Burst (TB) for four frequencies (0.5, 1, 2, 4 kHz). Wave V obtained for
60, 40, and 20 dB nHL intensity levels for both two procedures.
Behavioral hearing thresholds (BHT) were identified at 0.5, 1, 2, 4 kHz.
Duration of TB and NB CE Chirp ABR tests for each ear was recorded. Wave
V latencies, amplitudes, BHTs, duration of tests were compared. Results:
The thresholds obtained from NB CE-Chirp stimulus (20, 19, 16, 15 dB
nHL) at 0.5, 1, 2 and 4 kHz were significantly closer to the behavioral
hearing thresholds (11, 10, 9, 9 dB HL) compared to Tone Burst ABR
thresholds (25, 23, 20, 19 dB nHL) (at all frequencies p \textless{}
0.001, CI = 2.0- 5.9). The absolute latencies of peak V with TB stimuli
were significantly longer than latencies obtained with NB CE Chirp
stimuli at 0.5, 1, and 2 kHz at all sound intensity levels
(p\textless{}0.001). The mean test time for NB CE-Chirp ABR was 23.6 \selectlanguage{ngerman}±
3.9 minutes and significantly shorter than the TB ABR test time (28.2 ±
4.5), (p=0.011). Conclusion: Frequency-specific behavioral thresholds
are estimated better with NB CE-Chirp than TB ABR.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Key Points:}

1- NB CE-Chirp ABR thresholds were found closer to PTA thresholds than
the TB ABR thresholds.

2- NB CE-Chirp ABR significantly shortens the test time.

3- Chirp stimulus is more available for hearing screening.

4- NB CE-Chirp ABR can be used in the prediction of behavioral hearing
thresholds in adults whose behavioral hearing thresholds are difficult
to determine.

5- Chirp stimulus provides larger and more detectable wave V amplitudes
according to Tone Burst.

\textbf{1. Introduction~}

The auditory brainstem response (ABR) is an objective method to evaluate
the neurologic functioning of the auditory pathway, auditory brainstem
neurologic integrity, and an estimate of hearing thresholds in
individuals (1). ABR waveforms include a series of positives and
negatives waves occurring during the first 10 ms following an acoustical
stimulation. They reflect the synchronous activity of the auditory
system, and phrases with roman numerals (I--V) (2). (ABR) is used in
children and adults for universal newborn hearing screening, evaluation
of hearing functions, diagnosis of peripheral and central nervous system
diseases, and also intraoperative monitoring ( 3, 4). The ABR evaluation
represents a standardized and comprehensive method for determining the
potential risk of drug-induced hearing dysfunction (5). Also, ABR
studies have reported abnormal (prolonged) latencies for waves III
and/or V with autism spectrum disorders (6). Stimulus variants used in
ABR according to frequency bands (350-10,000 Hz) are click stimulus (all
frequency bands), Tone-Burst (TB) stimulus (narrow frequency band) and
chirp stimulus ( 1, 7). Chirp stimulus was developed to compensate for
the delay of the cochlear wave traveling in ABR by stimulated different
neural units along with the cochlear partition. (8). Different models of
chirp stimulus have been identified in the literature to obtain
efficiently ABR (9, 10).

Tone-Burst (TB) stimulus type is widely used to obtain
frequency-specific responses (11). However, the TB stimuli causes
cochlear wave travelling delay in a specific frequency range (12). It is
also difficult to identify the wave V at low stimulus levels
(\textless{}60 dB nHL) with Tone-Burst stimuli (13). Although the design
of CE-Chirp stimulation is an important development in the auditory
electrophysiological field, CE-Chirp stimulus is insufficient in the
estimation of frequency-specific thresholds (14). The Narrow Band (NB)
CE-Chirp stimulus has been developed for compensating for some
deficiencies of the Tone-Burst stimulus (9, 15). NB CE-Chirp stimulus
has designed for including four central frequencies as 0.5, 1, 2, 4 kHz.
The stimulated area of the NB CE-Chirp stimulus is slightly wider than
the TB stimulus and allows synchronized firing of different neural units
along the base to the apical end of the cochlea. (3). Ferm et al. (16)
compared NB Chirp and TB ABR and NB CE-Chirp ABR wave V amplitudes were
found to be larger than TB ABR wave V amplitudes. Rodrigues at al.(12)
detected that NB CE-Chirp ABR wave V amplitudes were greater than TB ABR
wave V amplitudes at all levels except 500 Hz 80 dB nHL.

Studies about the behavioral hearing thresholds (BHT) estimation by
electrophysiological methods are up to date in the literature(17). For
many years, TB ABR has been used to estimate behavioral hearing
thresholds (18). The elimination of the delay in the cochlear traveling
wave with the chirp stimulus and the synchronous stimulation of the
afferent nerves are superior to the traditional click stimulus. For this
reason, studies about the prediction of behavioral hearing thresholds
with chirp stimulus are increasing in the recent literature (19). BHT is
used clinically to detect hearing loss and to prescribe the
amplification of suitable hearing aids (20). In determining hearing
thresholds, PTA is used preferential, and Tone Burst ABR is commonly
used in children with hearing loss and neurological disease (21, 22).
Also, repeated measurements showed that hearing thresholds may be
detected false and not consistent with previous thresholds in 50\% of
newborns with hearing loss, therefore the accurate estimation of
thresholds becomes essential (22).

In addition, there may be adults who cannot fully adapt to subjective
hearing tests (PTA). This can happen due to poor understanding of the
test procedure and low motivation. Even though there is no pathology in
the hearing system, people can act as if they have a hearing loss to get
personal or financial profit. This situation is called ``nonorganic
hearing loss'', ``pseudohypacusis'' or ``functional hearing loss'' (23).
It is difficult to accurately determine behavioral hearing thresholds in
adults with nonorganic hearing loss or and intellectual deficit.

In this study, we aimed to determine which Tone Burst ABR and NB
CE-Chirp ABR thresholds are closer to frequency-specific behavioral
hearing thresholds in normal hearing adults. Thus, it can be determined
which ABR stimulus is more effective in estimating hearing thresholds in
adults whose behavioral hearing thresholds are difficult to determine

Accurate estimation of frequency-specific hearing thresholds can also
allow proper hearing aid adjustment in adults with hearing loss and
intellectual deficit.

\textbf{2. Materials and methods~}

\textbf{2.1Study Design:} This study designed prospectively in the
audiology department of a tertiary university hospital between June 2018
and October 2018. The study included 24 adults (17 males, 7 females)
aged 20-48 years with normal hearing. Participants were tested in a
sound-treated room, pure-tone audiometer Interacoustics model AC40
(calibrated as per ANSI S3.6, 1996) (Interacoustics AS, Assens,
Denmark). Pure-tone audiometry for both air conduction (for the
frequency range 250--8000 Hz) and bone conduction (for the frequency
range: 500--4000 Hz) were tested using headphones TDH 39 (Telephonics
Co.Farmingdale, NY, USA) and bone vibrator RadioEar B-71 (RadioEar Co.
Middelfart, Denmark). Only those participants whose hearing sensitivity
was [?] 20 dB HL at each frequency (250-8000) without any otological,
psychological or neurological dysfunction were selected for the study.
ABR recordings were taken using the Eclipse Ep 25 ABR system.

The assessment was done with two stimuli namely, NB CE-Chirp and Tone
Burst at four frequencies 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz. The
stimuli were calibrated to ISO 389-6 (2007) for the click and to
manufacturer's data for the chirps. Positive (active) electrode was
placed on the top of the forehead (Fz), ground electrode was placed at
the bottom up the forehead (Fpz), reference electrodes were placed on
the right (M2) and left (Ml) mastoids, The measured potentials were
recorded with impedance below 5k\selectlanguage{greek}Ω.

\selectlanguage{english}The four (0.5, 1, 2, 4 kHz) Tone Bursts and NB CE-Chirps\selectlanguage{ngerman}® were presented
with rarefaction polarity through insert ER-3A (Etymotic Research)
earphones at a rate of 44.1/s. Measurements were carried out using High
Pass Filter (HPF): 75 Hz and Low Pass Filter (LPF): 1500 Hz. Tone Bursts
and Narrow Band CE-Chirps were presented monaurally.

ABRs records obtained for 0.5, 1, 2, 4 kHz and 60, 40, and 20 dB nHL
intensity levels for both Narrow Band (NB) CE-Chirp and Tone Burst (TB)
stimuli. Behavioral hearing thresholds (BHT) were identified at 0.5, 1,
2, 4 kHz. The ABR threshold was taken as the lowest of levels containing
a clear response. Tests were started from 60 dB nHL level, stimuli were
decreased until no response was obtained. Initially 10 dB nHL decreases
were used to estimate BHT, and then 5 dB nHL changes were made to
determine a clear wave V response. Each measurement was carried out
using an average of 2000 sweep to clarify the waveforms.

The absolute peak amplitude and absolute peak latencies were recorded
for wave V in all four frequencies (0.5, 1, 2, 4 kHz) for TB and NB
CE-Chirp stimulus. ABR wave V amplitudes and absolute latencies were
determined by visual inspection. Duration of TB and NB CE Chirp ABR
tests for each ear was recorded. The study was prepared with the
reporting guideline of the STROBE checklist.

\textbf{2.2. Participants:} Inclusion criteria were: adults with no
history neurological or otological dysfunction and audiometric
thresholds \selectlanguage{english}[?] 20 dB HL for the 250-8000 Hz frequencies. Patients with
hearing loss, neurological, psychological were excluded from the study.
Also, patients with previous ear surgery, chronic otitis media,
Meniere's disease, subjective tinnitus, tympanosclerosis were excluded,
Patients with chronic systemic disease (diabetes mellitus, autoimmune
diseases), chronic systemic drug use were not included in the study.

\textbf{2.3. Statistical Analysis:} Results were analyzed with the SPSS
22.0 package program. Threshold values were compared with the Paired
t-test and test times were compared with the Wilcoxon test and the
results with p significance value less than 0.05 were considered as
significant. Intraclass correlation coefficient (ICC) was used to
determine consistency of thresholds identify by PTA, TB, and NB CE-Chirp
stimulus. Sample calculation and power analysis were assessed with the G
Power 3.1 package program. By using the result of similar research of
Mourtzouchos and et al. (24), the effect size (d) 1.21 specified as
\selectlanguage{greek}α\selectlanguage{english}=0.05 and \selectlanguage{greek}β\selectlanguage{english}=0.80 and the sample size was calculated as 20.

\textbf{2.4. Ethics Committee Approval:} Verbal and written consent was
obtained after all participants were informed. This study was conducted
in accordance with the Declaration of Helsinki. Ethics committee
approval was obtained.

\textbf{3. Results}

In this study, Tone Burst and NB CE-Chirp ABR data of 24 adults (31
ears) were analyzed retrospectively. The tests could not be completed in
both ears, since 17 individuals could not tolerate repeated ABR
measurements for each ears. The mean age of the participants was
detected at 30.4 \selectlanguage{ngerman}± 8.6 (min: 20 max: 48). Test data of 18 ears from 17
men and 13 ears from seven women were analyzed. The research included 18
(58.1\%) right ears and 13 (41.9\%) left ears. The absolute latencies of
peak V with TB stimuli were significantly longer than latencies obtained
with NB CE Chirp stimuli at 0.5, 1 and 2 kHz at all sound intensity
levels (p\textless{}0.001) \textbf{(Figure 1, 2)} . There was no
difference between TB ABR and NB CE-Chirp ABR latencies at 4 kHz-20 dB
nHL (p=0.374) \textbf{(Table 1)} . The amplitudes of peak V detected
with NB-CE Chirp were significantly larger than TB amplitudes in the
level of 4 kHz 60 dB nHL (p=0.038). However, there was no significant
difference was detected at other frequencies for the amplitude in both
TB and NB CE-Chirp ABR (p\textgreater{}0.05).

NB CE-Chirp ABR threshold values closer to PTA 0.5 1, 2 kHz thresholds
than the TB ABR thresholds (p\textless{}0.001, CI=2.0-5.9
dB)\textbf{(Table 2)} \textbf{(Figure 3).} While the thresholds obtained
with PTA, TB and NB CE-Chirp stimuli were showing the highest
correlation at the 2 kHz, the least correlation between the measurements
was found at 4 kHz (respectively ICC= 0.855 and 0.673), \textbf{(Table
2).} The correction factor, which was calculated from the mean
difference in the paired t-test, between thresholds obtained from NB
CE-Chirp and TB stimuli and BHT determined by PTA is given in Table 3.
In the posthoc power analysis, the power for the difference between the
threshold values at all frequency and all sound intensities was measured
as 90\% and above.

There was no significant difference between thresholds obtained from
PTA, TB and NB CE-Chirp for right and left ears at all frequencies
(p\textgreater{}0.05, paired t-test). While the most consistent
(test-retest reliability) threshold value obtained with PTA at 4 kHz
frequency with TB ABR in the right ear (r=0.709, p=0.001), it obtained
at 2 kHz with NB CE-Chirp ABR in the left ear (r= 0.743, p= 0.004). The
estimated thresholds were similarly correlated with PTA in the right and
left ears. The mean test time with NB CE-Chirp ABR was calculated as
23.6 ± 3.9 minutes and the mean test time with Tone Burst ABR was
measured as 28.2 ± 4.5 minutes. NB CE-Chirp ABR test time was
significantly shorter than the TB ABR test time (p=0.011).

\textbf{4. Discussion~}

Ferm et al. (16) compared NB Chirp and Tone pip ABR findings at 1 and 4
kHz and 40 dB nHL of 42 ears of 30 infants in the newborn screening
program. As a result of this study, NB CE-Chirp ABR wave V amplitudes
were found to be larger than Tone pip ABR wave V amplitudes (p=0.001).
In 40 children with normal hearing, the findings of the 0.5, 1, 2, 4 kHz
NB CE-Chirp ABR and Tone-Burst ABR were compared at 80, 60, 40, 20 dB
nHL by Rodrigues at al.(12). At all levels except 500 Hz 80 dB nHL, NB
CE-Chirp ABR wave V amplitudes were found to be greater than Tone-Burst
ABR wave V amplitudes (p\textless{}0.05).

In our study, only at 4 kHz 60 dB nHL level, NB CE-Chirp ABR wave
amplitudes were found to be greater than TB ABR wave amplitudes
(p=0.038). Similar to our research results, Megha et al. (25) found no
significant difference in any of the frequencies for amplitude parameter
in TB and NB CE Chirp ABR. At high levels of chirp stimulus,
desynchronization develops as a result of overstimulation on the
cochlear basilar membrane. As a result, it is stated that the wave V
amplitudes decrease (25-27). This effect can be observed, especially
when a high stimulus level is sent to subjects with normal hearing (25,
27).

Studies comparing NB CE-Chirp ABR and Tone Burst ABR in the literature
were frequently conducted with infants. For example, Rodrigues et al.
(12) found that NB CE Chirp ABR latencies were shorter than Tone Burst
ABR latencies in infants at 0.5, 1, 2 kHz. In this study; the mean wave
V latency evoked by 500 Hz (60 dB nHL) NB CE-Chirp was found to be 3.57
(SD: 0.70). In this study, longer wave latencies were found compared to
our research. Because the value of the peak V latency varies among
different age person (28). Our study was carried out with adults.

Megha et al. (25) conducted a study that researched the effects of noise
using NB CE Chirp ABR and TB ABR. Similar to our research, in this
study; the mean wave V latency evoked by 500 Hz NB CE-Chirp was found to
be 2.45 (SD: 0.68) in the control group with normal hearing. Especially
at low frequencies, NB CE-Chirp ABR wave V latencies were observed to be
very short. For Tone Burst stimulus, the ABR mean latencies increased
with decrease in frequency. But NB CE-Chirp stimulus, the ABR means
latencies decreased with decrease in frequency. This is explained by
eliminating the delay in the cochlear travelling wave by using different
transmission times for each of the chirp stimulus frequencies. The low
frequencies in the NB CE-Chirp are being presented early than high
frequency octave bands. Thus NB-CE Chirp provides maximum stimulation
into the cochlea (12, 25).

Ferm et al. (16) reported that the NB CE-Chirp ABR thresholds were found
to be lower than the tone pip thresholds. For this reason, it was
emphasized that NB CE-Chirp stimulus can provide closer responses to
behavioral thresholds.

In our study, ABR thresholds with Narrow Band CE-Chirp stimulus at 0.5,
1 and 2 kHz were found significantly closer to the behavioral hearing
thresholds compared to Tone Burst ABR thresholds (p\textless{}0.001,
CI=2.0-5.9). Talaat et al. (29) investigated which of the NB CE-Chirp
ABR and Tone Burst ABR thresholds were closer to the frequency specific
behavioral hearing thresholds. As a result, it was stated that NB CE
Chirp-ABR provides higher sensitivity and accuracy than TB ABR in
estimating behavioral hearing thresholds in young children. Van et al.
(30) compared the proximity of NB CE-Chirp ABR and Tone Burst ABR
thresholds to behavioral hearing thresholds in 23 adults with normal
hearing. In this study, it was stated that using NB CE-Chirp is more
reliable than TB ABR in estimating behavioral hearing thresholds.
Similarly, the ASSR thresholds determined by the NB CE-Chirp stimulus
are highly correlated with the behavioral thresholds (0.5, 1, 2, 4 kHz)
defined with PTA according to the TB ABR thresholds (31, 32).

The hearing thresholds specified as dB nHL in ABR is not equal to
behavioral thresholds determined as dB HL. As a result, it is suggested
to use the correction factor when calculating BHT thresholds (dB HL)
from the thresholds (nHL) determined by ABR (25, 28). The correction
factor, which is used to estimate behavioral hearing thresholds with
using of NB CE-Chirp ABR, can be reduced by up to 5 dB (21, 16).

The shortening of the test time with NB CE-Chirp stimulus is another
advantage. ABR amplitudes are not detectable in 30 \% of the click
stimulus and need more test time. Click stimulus produces larger and
easily detectable amplitudes. Likewise, the mean test time of NB
CE-Chirp ABR was detected shorter than the mean test time of TB ABR in
our research (p=0.011). Similarly to this study, Zirn et al. (33)
compared the duration of the test conducted with both ABR methods in
their study including 253 children, and as a result, NB CE-Chirp ABR was
found to shorten the recording time. Ferm et al. (16) reported that the
use of NB CE-Chirp stimulation produced larger response amplitudes, and
therefore increase the signal to noise ratio according to TB clicks, so
shortens the test time.

\textbf{Conclusion}

In our study, NB CE-Chirp ABR thresholds were found closer to PTA
thresholds than the TB ABR thresholds. NB CE-Chirp ABR significantly
shortens the test time. It has been observed that NB CE-Chirp ABR can be
used in the prediction of behavioral hearing thresholds in adults whose
behavioral hearing thresholds are difficult to determine. In mental
retarded patients with hearing loss, proper hearing aid adjustment can
be made as a result of accurate estimation of frequency specific hearing
thresholds. But the research needs to be repeated in larger samples
using appropriate randomization and blinded study protocol.

\textbf{Acknowledgements:} None

\textbf{Data Availability Statement:} The data can be shared upon
request.

\textbf{References}

1. Bargena GA. Chirp-Evoked Auditory Brainstem Response in Children: A
Review. Am J Audiol. 2015;24(4):573--83.

2. Biacabe B, Chevallier JM, Avan P, Bonfils P. Functional anatomy of
auditory brainstem nuclei: Application to the anatomical basis of
brainstem auditory evoked potentials. Auris Nasus Larynx.
2001;28(1):85--94.

3. Maloff ES, Hood LJ. A comparison of auditory brain stem responses
elicited by click and chirp stimuli in adults with normal hearing and
sensory hearing loss. Ear Hear. 2014;35(2):271--82.

4. Di Scipio E, Mastronardi L. CE-Chirp® ABR in cerebellopontine angle
surgery neuromonitoring: technical assessment in four cases. Neurosurg
Rev. 2015;38(2):381--4.

5. Abernathy MM, Gauvin D V., Tapp RL, Yoder JD, Baird TJ. Utility of
the auditory brainstem response evaluation in non-clinical drug safety
evaluations. J Pharmacol Toxicol Methods {[}Internet{]}. 2015;75:111--7.
Available from: http://dx.doi.org/10.1016/j.vascn.2015.05.005

6. Pillion JP, Boatman-Reich D, Gordon B. Auditory brainstem pathology
in autism spectrum disorder: A review. Cogn Behav Neurol.
2018;31(2):53--78.

7. Elberling C, Don M. Auditory brainstem responses to a chirp stimulus
designed from derived-band latencies in normal-hearing subjects. J
Acoust Soc Am. 2008;124(5):3022--37.

8. Elberling C, Don M, Cebulla M, Stürzebecher E. Auditory steady-state
responses to chirp stimuli based on cochlear traveling wave delay. J
Acoust Soc Am. 2007;122(5):2772.

9. Elberling C, Callø J, Don M. Evaluating auditory brainstem responses
to different chirp stimuli at three levels of stimulation. J Acoust Soc
Am. 2010;128(1):215--23.

10. Morimoto T, Fujisaka Y ichi, Okamoto Y, Irino T. Rising-frequency
chirp stimulus to effectively enhance wave-I amplitude of auditory
brainstem response. Hear Res {[}Internet{]}. 2019;377:104--8. Available
from: https://doi.org/10.1016/j.heares.2019.03.016

11. Purdy SC, Abbas PJ. ABR thresholds to tonebursts gated with Blackman
and linear windows in adults with high-frequency sensorineural hearing
loss. Ear Hear. 2002;23(4):358--68.

12. Rodrigues GRI, Ramos N, Lewis DR. Comparing auditory brainstem
responses (ABRs) to toneburst and narrow band CE-chirp ® in young
infants. Int J Pediatr Otorhinolaryngol. 2013;77(9):1555--60.

13. Kristensen SGB, Elberling C. Auditory brainstem responses to
level-specific chirps in normal-hearing adults. J Am Acad Audiol.
2012;23(9):712--21.

14. Sininger YS, Abdala C, Cone-Wesson B. Auditory threshold sensitivity
of the human neonate as measured by the auditory brainstem response.
Hear Res. 1997;104(1--2):27--38.

15. Dau T, Wegner O, Mellert V, Kollmeier B. Auditory brainstem
responses with optimized chirp signals compensating basilar-membrane
dispersion. J Acoust Soc Am. 2014;107(March 2000):1530--40.

16. Ferm I, Lightfoot G, Stevens J. Comparison of ABR response amplitude
, test time , and estimation of hearing threshold using frequency
specifi c chirp and tone pip stimuli in newborns. Int J Audiol.
2013;(January):419--23.

17. McCreery RW, Kaminski J, Beauchaine K, Lenzen N, Simms K, P. Gorga
M. The impact of degree of hearing loss on auditory brainstem response
predictions of behavioral thresholds. Ear Hear. 2015;(36(3): 309--319).

18. Gorga MP, Johnson TA, Kaminski JK, Beauchaine KL, Cassie A, Neely
ST. Using a combination of click- and toneburst-evoked auditory
brainstem response measurements to estimate pure-tone thresholds. Ear
Hear. 2006;27(1):60--74.

19. Cobb KM, Stuart A. Neonate Auditory Brainstem Responses to CE-Chirp
and CE-Chirp Octave Band Stimuli I: Versus Click and Tone Burst Stimuli.
Ear Hear. 2016;37(6):710--23.

20. Michel F, Jørgensen KF. Comparison of threshold estimation in
infants with hearing loss or normal hearing using auditory steady-state
response evoked by narrow band CE-chirps and auditory brainstem response
evoked by tone pips. Int J Audiol {[}Internet{]}. 2017;56(2):99--105.
Available from: http://dx.doi.org/10.1080/14992027.2016.1234719

21. Xu Z, Cheng W, Yao Z. Prediction of frequency-specific hearing
threshold using chirp auditory brainstem response in infants with
hearing losses. Int J Pediatr Otorhinolaryngol {[}Internet{]}.
2014;78(5):812--6. Available from:
http://dx.doi.org/10.1016/j.ijporl.2014.02.020

22. Louza J, Polterauer D, Wittlinger N, et al. Threshold changes of ABR
results in toddlers and children. Int J Pediatr Otorhinolaryngol
{[}Internet{]}. 2016;85:120--7. Available from:
http://dx.doi.org/10.1016/j.ijporl.2016.03.009

23. Katz J. Handbook of Clinical Audiology. In: Handbook of Clinical
Audiology. Wolters Kluwer Health; 2015. p. 617-619.

24. Mourtzouchos K, Riga M, Cebulla M, Danielides V, Naxakis S.
Comparison of click auditory brainstem response and chirp auditory
steady-state response thresholds in children. Int J Pediatr
Otorhinolaryngol {[}Internet{]}. 2018;112(January):91--6. Available
from: https://doi.org/10.1016/j.ijporl.2018.06.037

25. Megha KN, Divyashree KN, Lakshmi A, et al. Narrow-band chirp and
tone burst auditory brainstem response as an early indicator of
synaptopathy in industrial workers exposed to occupational noise.
Intractable Rare Dis Res. 2019;8(3):179--86.

26. Cebulla M, Elberling C. Auditory brain stem responses evoked by
different chirps based on different delay models. J Am Acad Audiol.
2010;21(7):452--60.

27. Rodrigues GRI, Lewis DR. Comparison of click and CE-chirp® stimuli
on Brainstem Auditory Evoked Potential recording. Rev da Soc Bras
Fonoaudiol. 2012;17(4):412--6.

28. Sharma M, Bist SS, Kumar S. Age-related maturation of wave V latency
of auditory brainstem response in children. J Audiol Otol.
2016;20(2):97--101.

29. Atef A, Talaat N, Fathi A, Mosleh M, Safwat S. Effect of the
thickness of the cartilage disk on the hearing results after
perichondrium/cartilage island flap tympanoplasty. Orl.
2007;69(4):207--11.

30. Van Yper L, Beynon A, Kestens K, Dhooge I. The clinical utility of
narrow-band chirp auditory brainstem responses: inter-rater reliability
and threshold estimation. J Hear Sci. 2017;7(2):69-70.

31. Ulrich D, Tobias S, Flemming A, Park JJ, Remmert S. Hearing
threshold estimation by auditory steady-state responses with narrow-band
chirps and adaptive stimulus patterns\selectlanguage{english} : implementation in clinical
routine. Eur Arch Otorhinolaryngol. 2015;(272:51--59).

32. Venail F, Artaud JP, Blanchet C, Uziel A, Mondain M. Refi ning the
audiological assessment in children using narrow-band CE-Chirp-evoked
auditory steady state responses. Int J Audiol. 2015;(54(2):106-13.).

33. Zirn S, Louza J, Reiman V, Wittlinger N, Hempel JM, Schuster M.
Comparison between ABR with click and narrow band chirp stimuli in
children. International Journal of. Int J Pediatr Otorhinolaryngol
{[}Internet{]}. 2014;78(8):1352--5. Available from:
http://dx.doi.org/10.1016/j.ijporl.2014.05.028

\textbf{Tables}

\textbf{Table 1} Comparison of the absolute latency of peak V between
Tone Burst and Narrow Band CE-Chirp with t-test statistics.\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllllll@{}}
\toprule
& & \textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp ABR} (msn
\selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp ABR}
(msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp
ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V for TB and
NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V for TB
and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V
for TB and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of
peak V for TB and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency
(ms) of peak V for TB and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) & \textbf{Mean
latency (ms) of peak V for TB and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}± sd) &
\textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp ABR} (msn \selectlanguage{ngerman}±
sd) & \textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp ABR}
(msn \selectlanguage{ngerman}± sd) & \textbf{Mean latency (ms) of peak V for TB and NB-CE-Chirp
ABR} (msn \selectlanguage{ngerman}± sd)\tabularnewline
\midrule
\endhead
& & \textbf{500 Hz} & \textbf{500 Hz} & \textbf{500 Hz} & \textbf{1000
Hz} & \textbf{1000 Hz} & \textbf{1000 Hz} & \textbf{2000 Hz} &
\textbf{2000 Hz} & \textbf{2000 Hz} & \textbf{4000 Hz} & \textbf{4000
Hz} & \textbf{4000 Hz}\tabularnewline
& & \textbf{60 dB} & \textbf{40 dB} & \textbf{20 dB} & \textbf{60 dB} &
\textbf{40 dB} & \textbf{20 dB} & \textbf{60 dB} & \textbf{40 dB} &
\textbf{20 dB} & \textbf{60 dB} & \textbf{40dB} & \textbf{20
dB}\tabularnewline
\textbf{S} & \textbf{TB} & 8.8\selectlanguage{ngerman}±0.9 & 10.3\selectlanguage{ngerman}±1.1 & 11.9\selectlanguage{ngerman}±1 & 7.8\selectlanguage{ngerman}±0.6 &
9.4\selectlanguage{ngerman}±0.8 & 10.8\selectlanguage{ngerman}±1 & 6.9\selectlanguage{ngerman}±0.5 & 8\selectlanguage{ngerman}±0.5 & 9.1\selectlanguage{ngerman}±0.6 & 6.2\selectlanguage{ngerman}±0.3 & 7.3\selectlanguage{ngerman}±0.5 &
8.3\selectlanguage{ngerman}±0.5\tabularnewline
& \textbf{NB} & 2.7\selectlanguage{ngerman}±0.4 & 4.6\selectlanguage{ngerman}±0.6 & 7.3\selectlanguage{ngerman}±0.2 & 4.8\selectlanguage{ngerman}±0.6 & 6.6\selectlanguage{ngerman}±0.9 & 8\selectlanguage{ngerman}±0.9
& 5.6\selectlanguage{ngerman}±0.3 & 6.9\selectlanguage{ngerman}±0.4 & 8\selectlanguage{ngerman}±0.4 & 6\selectlanguage{ngerman}±0.3 & 7\selectlanguage{ngerman}±0.4 & 8.1\selectlanguage{ngerman}±0.5\tabularnewline
\textbf{p} & \textbf{p} & 0.0001 & 0.0001 & 0.0001 & 0.0001 & 0.0001 &
0.0001 & 0.0001 & 0.0001 & 0.0001 & 0.043 & 0.030 & 0.374\tabularnewline
\textbf{CI} & \textbf{CI} & 5.7-6.3 & 5-6.1 & 4-5.3 & 2.7-5.3 & 2.4-3.2
& 2-3.2 & 1-1.4 & 0.8-1.2 & 0.8-1.5 & 0-0.3 & 0-0.40 &
0.4-0.9\tabularnewline
\bottomrule
\end{longtable}

TB: Toneburst. NB: Narrow Band CE-Chirp, S: Stimulus, CI: \%95
Confidence interval, m\selectlanguage{ngerman}±sd: mean ± standard deviation

\textbf{Table 2} Tone Burst ABR and NB CE-Chirp ABR thresholds obtained
at different frequencies with Pearson correlation and paired t-test
statistics according to PTA thresholds.\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllllll@{}}
\toprule
\textbf{T} & \textbf{T} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values} & \selectlanguage{ngerman}\textbf{Threshold values dB(m ± sd) and
Pearson r and p values}\tabularnewline
\midrule
\endhead
& & \textbf{500 Hz} & \textbf{r} & \textbf{p} & \textbf{1000 Hz} &
\textbf{r} & \textbf{p} & \textbf{2000 Hz} & \textbf{r} & \textbf{p} &
\textbf{4000 Hz} & \textbf{r} & \textbf{p}\tabularnewline
\textbf{S} & \textbf{PTA} & 11.2\selectlanguage{ngerman}±4.4 & & & 10.6\selectlanguage{ngerman}±4.6 & & & 9.1\selectlanguage{ngerman}±4.8 & & &
9.1\selectlanguage{ngerman}±5.4 & &\tabularnewline
& \textbf{TB} & 24.8\selectlanguage{ngerman}±5.6 & 0.532 & 0.002 & 22.7\selectlanguage{ngerman}±5.2 & 0.608 & 0.001 &
20.1\selectlanguage{ngerman}±4.5 & 0.162 & 0.384 & 19.5\selectlanguage{ngerman}±3.7 & 0.428 & 0.16\tabularnewline
& \textbf{NB} & 20.6\selectlanguage{ngerman}±3.8 & 0.487 & 0.005 & 19\selectlanguage{ngerman}±4.9 & 0.582 & 0.001 &
16.9\selectlanguage{ngerman}±4.9 & 0.658 & 0.001 & 15.8\selectlanguage{ngerman}±3.8 & 0.538 & 0.002\tabularnewline
\textbf{ICC} & \textbf{ICC} & 0.761 & 0.761 & 0.761 & 0.826 & 0.826 &
0.826 & 0.855 & 0.855 & 0.855 & 0.708 & 0.708 & 0.708\tabularnewline
\bottomrule
\end{longtable}

PTA: Pure Tone Audiometry, TB: Toneburst, NB: Narrow Band CE-Chirp, S:
Stimulus, ICC: Intraclass Correlation, m\selectlanguage{ngerman}±sd: mean ± standard deviation,
T: Total of Ear

\textbf{Table 3} Correction factors for Tone Burst and NB CE-Chirp
thresholds according to PTA thresholds and t-test statistics.\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\textbf{Total of ears} & \textbf{Total of ears} & \textbf{Correction
factors for thresholds according to PTA* (mdB)} & \textbf{Correction
factors for thresholds according to PTA* (mdB)} & \textbf{Correction
factors for thresholds according to PTA* (mdB)} & \textbf{Correction
factors for thresholds according to PTA* (mdB)}\tabularnewline
\midrule
\endhead
& & 500 Hz & 1000 HZ & 2000 Hz & 4000 Hz\tabularnewline
\textbf{s} & \textbf{TB} & -14 & -12 & -10 & -10\tabularnewline
& \textbf{NB} & -9 & -8 & -7 & -6\tabularnewline
\textbf{p} & \textbf{p} & 0.0001 & 0.0001 & 0.0001 &
0.0001\tabularnewline
\bottomrule
\end{longtable}

PTA: Pure Tone Audiometry, TB: Tone Burst, NB: Narrow Band CE-Chirp, S:
Stimuli, mdB: mean dB, T: Total of Ear,*: mean of \%95 CI of Difference.

Figures

\textbf{Figure 1} Tone Burst and NB-CE-Chirp responses at 500 Hz

\textbf{Figure 2} Tone Burst and NB-CE-Chirp responses at 1000 Hz

\textbf{Figure 3} Thresholds for NB Chirp ABR and TB-ABR and PTA in
adults with normal hearing\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/FIG-1-tb-vs-nb-500/FIG-1-tb-vs-nb-500}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/FIG-2--tb-vs-nb-1000/FIG-2--tb-vs-nb-1000}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/FIG-3-TH/FIG-3-TH}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

