Otolaryngology: Open Access Ansari et al.

, Otolaryngol (Sunnyvale) 2016, 6:4

DOI: 10.4172/2161-119X.1000259

Research Article Open Access

Auditory Brainstem Response Characteristics of Children with Cerebral Palsy:

Clinical Utility and Prognostic Significance
Mohammad Shamim Ansari1*, Rangasayee Raghunathrao2, Mohammad A Hafiz Ansari3
1Department of Speech and Hearing, Ali Yavar Jung National Institute for the Hearing Handicapped, K.C. Marg, Bandra (W), Mumbai-40050.Maharashtra, India
2Technical Department, Dr. S.R. Chandrasekhar Institute of Speech and Hearing, Hennur Main Road, Lingarajapuram, Bnagalore-560084. Karnataka, India
3Department of Physiology, Grant Medical College and Sir J. J. Groups of Hospital, Mumbai-400008, India
*Corresponding author: Mohammad Shamim Ansari, Lecturer, Department of Speech and Hearing, Ali Yavar Jung National Institute for the Hearing Handicapped, K.C.
Marg, Bandra (W), Mumbai-40050.Maharashtra, India, Tel: +919769399711; E-mail: [email protected]
Received date: July 15, 2016; Accepted date: August 24, 2016; Published date: August 31, 2016
Copyright: © 2016 Ansari MS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Cerebral palsy affects body muscle and movement coordination due to organic complications in
the peripheral and central nervous systems and therefore often accompanied by other disorders of cerebral function.
CP with additional impairment of hearing results in severe developmental deficits in communication, speech and
language and cognitive skills. Thus it is important to examine the auditory nervous system to identify the
complications caused by the hidden hearing loss. Auditory Brainstem Responses (ABR) provides objective measure
of auditory system function and can be an important adjunct to the clinical neurophysiologic examinations. However,
there is scanty information about the neurophysiologic investigations in children with spastic cerebral palsy.

Aim: To investigate whether the children affected with spastic CP exhibit distinct neural responses than the age
matched normal hearing children.

Methodology: ABR measures were obtained for 50 children with spastic CP in the age range 3 to 12 years. The
results were subsequently correlated with birth weight, gestational age, etiology and type of CP, neuroradiological
findings, additional impairments and disabilities (including the ability to walk independently). 50 typically normal
hearing children served as reference group for comparisons of neurophysiologic measures of auditory brainstem
responses.

Results: A significant difference was found in the ABR latencies between the children with cerebral palsy and
atypical children. Abnormal ABR measures in children with spastic CP demonstrated a correlation with the presence
of moderate to severe developmental delay.

Conclusion: It can be concluded that ABR measures of CP group revealed a statistical difference with that of the
typically developing children and it has demonstrated a statistically significant correlation with the presence of
neurological deficits. Therefore, Auditory Brainstem Response measurement being a non-invasive neurophysiologic
investigation can serve as important tool in the diagnostic work up of spastic CP.

Keywords: Spastic cerebral palsy; Additional impairment; Hearing commonly occurring in 65% of cerebral palsied population [5].
loss; Peripheral auditory system; Click evoked auditory brainstem Prevalence of Cerebral palsy is increasingly encountered in neonatal
response clinics since more number of premature infants survives because of
advance neonatal care and better medical facilities for treatment of
Abbreviations: perinatal infections.

ABR: Auditory Brainstem Response; CP: Cerebral Palsy Cerebral palsy is often accompanied by other disorders and
problems of cerebral function, in particular intellectual impairment,
speech and language deficits, epilepsy, vision and hearing disorders
Introduction [6,7]. Recent studies have shown that hearing impairment occurs in 4
Cerebral palsy (CP) is a group of non-progressive neurological to 25% of children with CP [6]. These children with additional
disorders [1,2] which affects body muscle tone and movements impairment of hearing presents ranges of special educational and
coordination [3]. CP occurs due to abnormal development of the psychological needs, to an even greater degree than for children with
cerebral motor cortex during fetal growth (embryonic period) or due single disability [7].
to injury to the motor control centers of the developing brain during Presence of reduced hearing acuity during infancy and early
birth or after birth up to age about 2-3 years [4,5]. childhood in children with CP may have more deleterious effect on
The four major subtypes of Cerebral palsy are spastic, athetoid, communication abilities, speech and language and cognitive
ataxic and mixed cerebral palsy. The spastic form of CP is the most development that can severely interfere with their psycho-, difficulties

Otolaryngol (Sunnyvale), an open access journal Volume 6 • Issue 4 • 1000259

ISSN:2161-119X
Citation: Ansari MS, Raghunathrao R, Ansari MAH (2016) Auditory Brainstem Response Characteristics of Children with Cerebral Palsy: Clinical
Utility and Prognostic Significance. Otolaryngol (Sunnyvale) 6: 259. doi:10.4172/2161-119X.1000259

Page 2 of 5

in parent-child and peer-child interactions, low self-esteem, linguistic Participants

and educational development [8]. However, a child's overall future and
success can be improved greatly through the early identification of Total 100 participants of both the sexes in the age range 3–10 years
hearing loss, establishment of its site of lesion, and subsequent (mean=6.6 years, SD=2.12 years) were recruited for the study. The
institution of intervention strategies may improve learning and subjects were divided into two groups. The Group A consisted of 50
language development [6,9]. subjects with spastic cerebral palsy (37 male and 23 females with mean
age of 6.8 years, SD=1.92 years) diagnosed by pediatrician and Group
Children with cerebral palsy have an organic complication in the B included 50 normal hearing children (33 male and 27 female with
peripheral and central nervous systems [7-9]. Thus it is important to mean age of 5.9 years, SD=2.32 years) with no known history of
examine the auditory nervous system to identify and reduce neurological, psychiatric and otological disease or trauma.
complications of hidden hearing loss. Although clinical evaluation may
suggest hearing loss, a definitive diagnosis requires an audiological Demographic data of confirmed spastic CP and typically developing
assessment [9]. children were collected through medical reports, parental interview,
case histories about age, prenatal, perinatal and postnatal events, and
Auditory Brainstem Response (ABR) measurements is an non history of epilepsy. Group B subjects evidenced normal peripheral
invasive and objective method [8-10], can be used to assess hearing hearing sensitivity, defined as pure-tone thresholds (≤ 25 dB HL, re:
capabilities in infants younger than 6 months of age and in older ANSI, 1996) for each ear at octave frequencies between 250 and 8000
children who are unable to perform conventional or conditioned play Hz. Normal middle-ear admittance and presence of acoustic reflexes at
audiometry due to motor or intellectual problems [7-9]. 500 and 1000 Hz for all subjects were confirmed by means of
ABRs are electrical potentials that are produced in response to a immittance measures.
brief stimulus like click and are recorded from disk electrodes attached
to the scalp. The early potentials reflect electrical activity at the cochlea, Stimuli and recording parameters
8th cranial nerve, and brain stem levels and may be analyzed to
ABRs were elicited by an acoustic 100 µs click stimulus. Responses
estimate the magnitude of hearing loss and to differentiate among
were recorded via four Ag-AgCl surface electrodes having absolute
cochlea, 8th nerve, and brainstem lesions [7-9]. Therefore, ABR can be
contact impedance of <5 kΩ with no more than 3 kΩ difference
an important adjunctive diagnostic tool for the clinical
between each of the two electrodes. Before connecting the electrodes,
neurophysiologic examinations of hearing loss in children with
the skin was cleaned thoroughly to ensure good contact between the
cerebral palsy.
skin and the electrode surfaces. Non inverting electrode was
In recent years, the neurophysiologic examination of children with positioned centrally on the scalp at Cz, two inverting electrodes were
Cerebral palsy has been of increasing interest to audiologists, placed behind the mastoid (A1 and A2) and ground electrode was
otologists, pediatricians and other researchers to evaluate normal attached at forehead (FPz).
physiological maturation and integrity of the auditory system, in the
Monaural auditory stimulus consisting of alternating polarity clicks
screening of hearing impairments of infants, to diagnose and
were delivered into the ear at a rate of 11.1/s at intensity level of 80
demonstrate brainstem damage and to provide prognosis for the
dBnHL through electrically shielded insert earphones (ER-3). The
patients with various neurological disorders [8,9].
sampling rate was 20000 Hz and responses were online band passed
In a retrospective study of 75 children with spastic cerebral palsy filtered from 100 to 3000 Hz. Artifacts greater than ± 35 µV were
(CP), 17 (22.7%) had abnormal ABR waveform [10-12]. Another study rejected online. Two traces of 2000 sweeps were collected at alternating
concluded that one of the specific feature i.e., sensorineural hearing polarity. Responses of alternating polarities were added together to
loss in athetoid CP caused by kernicterus can be identified by the ABR minimize contributions from the cochlear micro phonic responses
[13]. These authors concluded that ABR can provide new insights into [12]. Responses to 2000 click presentations were averaged for 12 ms.
mechanisms of brain damage and neural plasticity in children with During testing, the children were in the supine position with eyes
cerebral palsy. In spite ABR being very promising diagnostic tool in closed.
assessment of hearing in difficult to test populations including the
children with cerebral palsy, very fewer studies on auditory brainstem Result analysis
responses are available Indian literature.
In 50 children with spastic cerebral palsy (CP), Auditory Brainstem
Hence the present study was undertaken to characterize the Responses (ABRs) were recorded and subsequently correlated with
electrophysiological findings in children with spastic cerebral palsy and birth weight, gestational age, etiological factors and additional
correlate with their clinical features. impairments and disabilities (including the ability to walk
independently).
Materials and Methods Identification of brainstem recorded wave by the click stimulus was
done based on the conventional clinical analysis. The peaks were
Research design marked by the two independent observers. The identities and the
This prospective survey was done at our institute’s diagnostic categorizations of the children were blinded to the
electrophysiological laboratory in accordance with Institutional ethical observers. The observers were also requested to rate the individual
norms. The necessary informed consent by the parents of the children wave morphology as poor, fair and good.
was obtained. ABR measures like absolute peak latencies of I, III, V waves, inter-
peak latencies of I-III, III-V, and I-V were considered for comparison
between the two groups. The mean, median, standard deviation,
minimum, and maximum values for normal distribution of responses

Otolaryngol (Sunnyvale), an open access journal Volume 6 • Issue 4 • 1000259

ISSN:2161-119X
Citation: Ansari MS, Raghunathrao R, Ansari MAH (2016) Auditory Brainstem Response Characteristics of Children with Cerebral Palsy: Clinical
Utility and Prognostic Significance. Otolaryngol (Sunnyvale) 6: 259. doi:10.4172/2161-119X.1000259

Page 3 of 5

were calculated for the sample. An independent t-test was used to rated as having 3% poor 19% fair and 78% good wave morphology by
compare the mean value of the results. One way ANOVA was studied the peak observers. The neurophysiologic responses to click generated
at significance levels of 5% (P<0.05) to find the association between waves I, III and V were analyzed based on the conventional clinical
ABR abnormalities and clinical features, additional impairment and analysis of the absolute latencies and inter-peak latencies for both
risk factors. For statistical analysis, SPSS.16 software was used. groups. Table 1 indicating mean and standard deviation of absolute
and inter peak latencies and p-values between the groups.
Results The notable ABR abnormalities in CP children were prolongation of
The current study was designed to assess and compare the absolute latency of peak, III & V, inter-peak latencies of I-III and III–V.
brainstem responses to click stimuli in children with spastic cerebral Figure 2 showing the absolute peak latency and inter-peak latency in
palsy and typically normal hearing and healthy developing children. both the groups. The means of Group A for ABR parameters were
The Group A included 50 children suffering from spastic CP consisted statistically significant from the Group B at significance level of p<0.05.
of 14 spastic tetraplegic, 17 spastic diplegic, 11 left side hemiplegic and
8 right side hemiplegic (Figure 1).

Figure 2: Showing click evoked mean absolute peak latencies and

inter-peak latencies for Group A and B.
Figure 1: Showing sub-types of spasticity and severity of Group A.

Out of the total 50 subjects, 31 children with spastic CP presented

Inter- with associated clinical features and abnormalities such as
Absolute peak
Latencies Latencies microcephaly, mental retardation, delayed development and other risk
mean mean factors. The percentage of abnormal auditory brainstem responses
(SD) in (SD) in along with clinical feature of ABR findings are elucidated in Table 2.
ms ms
Abnormal ABR
I III V I-III III-V I-V
Clinical Features/Risk Factors N %
Group A 1.6 3.83 5.77 2.23 1.94 4.17
Normal Developmental Milestone 7 2 (28%)*
± 0.09 ± 0.14 ± 0.10 ± 0.13 ± 0.11 ± 0.10
Communication and Speech delay 31 31 (100%)**
Group B 1.5 3.61 5.54 2.11 1.91 4.04
Mental retardation/ Microcephaly 11 4 (36%)*
± 0.06 ± 0.13 ± 0.20 ± .15 ±.20 ± 0.18
Global delay 12 10 (75%) **
p-value at
Developmental Delay 7 4 (46%)*
<0.05 0.01* 0.01* 0.02* 0.43* 0.7 0.02*
Low birth weight 9 2 (40%)*
Table 1: Showing means and SD (in parenthesis) of absolute latency
Prematurity+LBW 9 3 (50%)*
(ms) of wave peaks I, III, V and Inter-peaks latency (ms) I-III, III-V
and I-V of click evoked ABR measures of Group A and Group B. Bilateral Sensorineural hg loss 4 4 (100%)**

The ABR wave morphology in clinical population was rated as 67% Birth asphyxia , Seizures/Epilepsy 8 4 (50%)*
poor, 31% fair and 2% good whereas normal hearing children were

Otolaryngol (Sunnyvale), an open access journal Volume 6 • Issue 4 • 1000259

ISSN:2161-119X
Citation: Ansari MS, Raghunathrao R, Ansari MAH (2016) Auditory Brainstem Response Characteristics of Children with Cerebral Palsy: Clinical
Utility and Prognostic Significance. Otolaryngol (Sunnyvale) 6: 259. doi:10.4172/2161-119X.1000259

Page 4 of 5

Neonatal Jaundice/ Encephalitis 16 8 (50%)* The findings of the current study as elucidated in Table 2. Wherein
31 (62%) subjects had communication and speech problems, 12 (24%)
had mental retardation, 19 (38%) had Global developmental delay, 13
Table 2: Depicting clinical features, associated abnormalities and risk
(26%) were unable to walk independently and 4 (8%) had hearing loss.
factors in children with spastic cerebral palsy, ** Statistically significant
There was a statistically significant association between abnormal ABR
correlation at p value 0.01, * Statistically significant correlation at p
recordings and preterm delivery, perinatal etiology of CP, hearing,
value 0.05.
speech and myoskeletal impairments, epilepsy and mental retardation
(p<0.001). These findings are in concurrence with previous reports.
Abnormal ABR in children with spastic cerebral palsy demonstrated
Though, the exact etiology of abnormal ABR remains to be unleashed
a statistically significant correlation at p value 0.001 with the presence
through this study. Hence, further research in this area is
of global developmental delay and additional disability of hearing loss,
recommended.
whereas prematurity, neonatal jaundice and encephalitis etc have
statistically significant correlation at p value 0.05. However, it can be concluded that abnormal ABR recordings in
children with spastic CP probably can be linked to the neurological
Discussion deficits in the light of earlier reports. Thus, it is suggested that ABR
testing should be incorporated in the diagnostic assessment of all
The ABR results were primarily analyzed for the presence of the children with spastic CP referred to Neurodevelopment Centers to
waves I, III and V. Wave I, or latency I is based on the transformation plan holistic intervention strategies including amplification devices.
of tone-specific responses in the hair cells into impulses travelling
along the auditory nerve, and after passing the cochlear nucleus of the
Conclusion
brainstem, the impulse reaches the superior olivary complex, forming
wave III or latency III [14,15]. Wave V is then produced in the inferior The study concludes that ABR measurement in spastic CP revealed
colliculus, and finally the temporal auditory cortex is reached [15-21]. marked differences with that of the typical children, delay in the
absolute latency as well as inter-peak latency differences are indicative
The study faithfully characterizes the electrophysiological responses
of neurological deficits. The clinical features, additional disabilities and
to click stimuli in children with spasticity and typically developing. It
risk factors have demonstrated a statistically significant correlation
can be observed from Tables 1 and 2 that the children with CP who
with the presence of abnormal ABR and thus neurological deficits.
had other associated neurological symptoms showed statistically
significant deviation from the regular pattern of ABR waveforms for ABR examinations can detect lesions that may be asymptomatic and
absolute peak latencies I, III and V and inter-peak latency between I- subtle to preclude the optimal development of the child. The hearing
III and III-V. impairment is frequent in children with cerebral palsy and causes
severe deficits in communication, development of speech & language
Most of the children with neurosensory disability, except one spastic
and cognitive skills. Thus it is important to examine the auditory
CP with microcephaly, had bilaterally absent or delayed responses in
nervous system to identify and reduce the complications caused by the
ABR components. 31 of 50 CP children with clinical features,
hidden hearing loss.
additional impairment and risk factors (Table 2), 17 had abnormality
in wave I, 14 in wave III, 29 in wave V, 23 in IPL between wave I–V, 19 Despite limitations of ABRs as time consuming tool, ABR is
in IPL III–V (Table 1). important tool to determinate the functional integrity of the auditory
tract and evaluation of hearing thresholds in patients with cerebral
This is in consonance with the reports of previous works which
palsy. Further, to conclude, since ABR measurement is non-invasive
reports that children with CP have abnormalities of the auditory
and objective neurophysiologic investigations, it can serve as
sensory pathways at greater rates than found in the neurologically
important adjunct to the clinical examinations and diagnostic work up
normal children [16,17]. These researches concluded that an abnormal
of spastic cerebral palsy.
ABR, manifested as an absence or prolongation of latencies have
positive association with adverse neurological development in children
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Citation: Ansari MS, Raghunathrao R, Ansari MAH (2016) Auditory Brainstem Response Characteristics of Children with Cerebral Palsy: Clinical
Utility and Prognostic Significance. Otolaryngol (Sunnyvale) 6: 259. doi:10.4172/2161-119X.1000259

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