Page10

E
stimating hearing thresh-
olds using electrophysio-
logic measures in infants,
children, and difficult-to-test
patients is an especially chal-
lenging task. The ABR has been a good friend
for 30 years, but there are some limitations
to its prediction precision and the range of
hearing losses that it can predict.
The auditory steady-state response:
Variations of the MLR have been studied
in an attempt to find a procedure that is effec- A primer
tive in gathering more frequency-specific infor-
mation. You might recall terms such as the By Brad A. Stach
SSR, SSEP, and the 40-Hz ERP. Over the
years, researchers have continued to refine
these procedures, and new research with
what we now call the ASSR (auditory steady-
state response) is very encouraging. The cur-
rent application of this evoked potential,
elicited with modulated tones (modulations
1 What is the auditory steady-state response?

around 90 Hz), shows promise as a reliable
predictor of hearing sensitivity.
Back in the 1980s at Baylor College of
Medicine, a young doctoral candidate com-
pleted a dissertation titled: “Optimum Stim-
ulus Rate for Measurement of the Auditory
Steady-State Evoked Potential.” In general,
the research supported the use of the 40-Hz
ERP. Now a seasoned audiologist, Brad
Stach, PhD, has stopped by Page Ten to tran-
sition us from the 40-Hz ERP of the ‘80s to
today’s ASSR. As Brad says, “It looks like I
only missed it by about 50 Hz.”
Dr. Stach is the director of audiology and
clinical services, Central Institute for the Deaf,
and professor and director of the Audiology
Graduate Program, Washington University,
St. Louis. He is the author of the Compre-
hensive Dictionary of Audiology, is complet-
ing the Encyclopedia of Audiology, and has
a best-selling textbook, Clinical Audiology.
Brad was a founder of the American Acad-
emy of Audiology, and currently is its presi-
dent-elect. You regular Journal readers
The auditory steady-state response (ASSR) is an auditory evoked
potential, elicited with modulated tones, that can be used to pre-
dict hearing sensitivity in patients of all ages. The response itself
is an evoked neural potential that follows the envelope of a com-
plex stimulus. It is evoked by the periodic modulation, or turn-
ing on and off, of a tone.
Stach The neural response is a brain potential that closely follows the
time course of the modulation. The response can be detected objec-
tively at intensity levels close to behavioral threshold. Emerging data suggest that the
ASSR will yield a clinically acceptable, frequency-specific prediction of behavioral thresh-
olds in patients, regardless of age, subject state, or degree of hearing loss.
2 Sounds perfect, but do we really need another auditory
evoked potential?
Well, yes, it would be nice, and here’s why. The earliest averaged evoked potentials,
described over 4 decades ago, are what we now refer to as the auditory middle-latency
and late-latency responses. The late responses, as you know, can be elicited with tonal
stimuli, permitting the electrophysiologic prediction of an audiogram. However, these
potentials are fatally confounded by subject state of consciousness, rendering them unac-
ceptable for routine clinical use in anyone but awake, cooperating adults.

probably recall his previous visits to Page
Ten, and his annual contributions to our Jour-
nal Club Review of the Best of Audiology Lit-
erature.
As Brad points out in this excellent review
of the ASSR, we still have much to learn, and
some of the techniques need further refine-
ment. But, research to date strongly suggests
that the ASSR has the potential to be a valu-
able clinical procedure for the assessment of
hearing loss, and may even have applica-
tions in the diagnosis of neurologic pathol-
ogy. Stay tuned for further developments in
this exciting area.
Gus Mueller
Page Ten Editor
10 The Hearing Journal
3
But what about the ABR?
Be patient. I was getting to that. The auditory brainstem response (ABR), discovered
about 3 decades ago, currently stands as the gold standard for threshold prediction. Its
immunity to subject state makes it an excellent choice for predicting hearing in sleeping
infants or sedated children.
However, there are two important limitations to the ABR. First, it is best elicited using
a click stimulus, which is not frequency-specific and generally only allows an estimate
over a broad range of higher frequencies. Tone-burst-elicited ABRs, albeit more frequency-
specific, can be difficult to record and observe at near-threshold levels, especially at lower
frequencies. So, ABR provides a good prediction of high-frequency hearing in a broad
sense and, often, an idea of the shape of the audiogram. Unfortunately, the precision
across frequencies remains less than optimal.
The second limitation of ABR is the range of hearing loss that can be estimated. As
a rule of thumb, if the high-frequency pure-tone average exceeds 70 dB, the ABR may
well be absent. Said another way, an ear with a 70-dB hearing loss will have the same
absent ABR as an ear with a loss of 80 dB, 90 dB, 100 dB, and so on. That is a rather
broad range of loss predicted by an absent ABR, especially if you are the one fitting a
hearing aid on that ear.
Page Ten September 2002 • Vol. 55 • No. 9
4 Okay, that’s convincing.
So, why is the ASSR better?
First, the ASSR is elicited by a tone. That
tone is modulated; you might think of
amplitude modulation as turning the tone
on and off periodically and frequency mod-
ulation as warbling it. Although the mod-
ulation expands the spectrum of the tone,
the frequency spread is narrower than a
tone-burst or, especially, a click. So, the
portion of the basilar membrane being
stimulated is more restricted, and a more
precise audiogram can be predicted.
Second, if the modulation rates are
high enough, the ASSR seems unaffected
by subject state. When the modulation
rate is greater than 60 times per second
(60 Hz), the response can still be recorded
reliably in sleeping babies.
5 Could you step back for a
minute? Is this the 40-Hz
response, or the SSEP, that they
talked about in the 1980s?
Well, yes and no. It is sort of a variation
on the theme. But first, let me clarify ter-
minology and acronyms. Several terms
have been used synonymously to describe
this modulation-following response. They
are the amplitude-modulation-following
response (AMFR), envelope-following
response (EFR), steady-state evoked
potential (SSEP), steady-state response
(SSR), and the auditory steady-state
response (ASSR). Perhaps the most pop-
ular has been the SSEP, but since that
acronym is also used for somatosensory
evoked potentials, ASSR is becoming the
more commonly used term.
6 Thanks, but would you
please answer my ques-
tion?
What a crab! The 40-Hz response was first
described by Galambos and his colleagues
in 1981.1 At that time, and still today, the
most common approach to electrophys-
iologic assessment was to measure tran-
sient evoked potentials. Transient
responses are those that are elicited by
rapid change in the auditory stimulus at
rates that allow the response to be finished
before the next stimulus presentation. For
a middle-latency response (MLR), for
example, a signal is presented, the response
is recorded for 100 milliseconds or so,
another signal is presented, the response
is recorded again, and so on.
14 The Hearing Journal
A steady-state evoked potential is an
on-going response and is elicited in
response to an on-going, periodically vary-
ing stimulus. The response is phase-locked
to the modulation envelope. That is, the
neural response closely follows the time
course of the modulation. The phase rela-
tion of the response to the modulation is
reasonably fixed or locked in time.
Galambos et al. noted in measuring
the transient MLR that, when the stim-
ulation rate was increased to a rate fast
enough to occur within the recording
epoch, responses could be overlapped. If
the rate corresponded to the period of
the major peaks of the waveform, the
response would appear as a rather robust
sinusoid. In adults, that occurred at rates
near 40/s.
The so-called 40-Hz response, or 40-
Hz event-related potential, was studied
fairly exhaustively over the ensuing sev-
eral years. David Stappells and his col-
leagues from Terry Picton’s lab2 and some
of us in Jim Jerger’s lab at the Baylor Col-
lege of Medicine3 began looking at it dif-
ferently. Instead of doing conventional
signal averaging, we measured how brain
activity at the frequency corresponding
to the click rate followed the envelope of
the interrupted transient signal. That is,
we turned a click or tone-burst signal on
and off at a rate of say, 40/s, and analyzed
the 40-Hz component of the brain activ-
ity to see if it increased in amplitude
and/or phase-locked to the periodic
change in the stimulus. So, viewed in that
way, the 40-Hz response could be con-
sidered an ASSR. The procedure worked
well, and we learned much about the
nature of the 40-Hz response and mea-
surement techniques.4,5
7 If the 40-Hz response was
so great, what happened?
Two things. First, we learned that the 40-
Hz response was strongly influenced by
subject state. Amplitudes varied tremen-
dously from waking to sleeping states. The
fact that there was a consistent phase rela-
tionship between the response and the
modulation across subject state was
encouraging.3
Second, it became readily apparent
that the 40-Hz response was not record-
able, at least not in any useful way, in
infants or babies.6 So, we stopped pursu-
ing the 40-Hz measure.
Page Ten
Fortunately, around this same time,
Field Rickards and his colleagues at the
University of Melbourne noted the abil-
ity to record this modulation-following
response at higher rates.7 They found that
ASSRs could be readily recorded and were
particularly useful at modulation rates of
greater than 60 Hz. Later, in the early
1990s, they found that at modulation
rates of around 90 Hz, robust ASSRs
could be recorded from sleeping adults
and infants.8-10 Researchers in Terry
Picton’s lab at the University of Toronto
were in hot pursuit as well.11 By the late
‘90s, clinical applications of the higher-
rate ASSRs were being developed and
implemented.
8 So, you losers back in the
‘80s were just looking at
the wrong modulation rate.
Please, don’t sugarcoat it. Actually, steady-
state responses can be recorded over a
range of modulation rates. Different mod-
ulation rates result in stimulation of dif-
ferent portions of the auditory nervous
system. It now appears that lower rates
(<20 Hz) reflect activity of the genera-
tors responsible for late-latency response,
moderate rates (20 Hz-60 Hz) reflect
those responsible for the middle-latency
response, and higher rates (>60 Hz) reflect
activity from the brainstem.12 It is no
wonder, then, that the lower modulation
rates are more vulnerable to subject state
than the higher rates,13 just as middle
and late responses are.
9
Okay, I think I understand
it theoretically, but how do
you actually record it?
The stimulus is a pure tone. In clinical
applications, the frequencies of 500 Hz,
1000 Hz, 2000 Hz, and 4000 Hz are
commonly used. The pure tone is either
modulated in the amplitude domain or
modulated in both the amplitude and fre-
quency domains. Optimum modulation
strategies continue to be evaluated.14-16
Electrodes are placed on the scalp at loca-
tions typically used for the recording of
other auditory evoked potentials. Brain
electrical activity is pre-amplified, filtered,
sampled, and then subjected to spectral
analysis. The frequency of interest in the
brainwaves is that corresponding to the
modulation rate.
September 2002 • Vol. 55 • No. 9
10 Huh?
Let me explain. When a tone of any fre-
quency is modulated periodically at a rate
of 90/s, the 90-Hz component of the brain
electrical activity is measured; when mod-
ulation rate is 96/s, the 96-Hz compo-
nent is measured, and so on. Measurement
is of some aspect of amplitude or phase.
Amplitude of the response and its vari-
ability are ways of detecting a response.
Various strategies for objective determi-
nation of significant signal-to-noise ratios
(SNR) are proving successful.
Another way of detecting a response is
by analyzing phase and its variability. As
an example, the concept of phase coher-
ence has proven to be useful. Imagine that
a sinusoid is modulated periodically and
that the brain wave of the frequency cor-
responding to that modulation rate is fol-
lowing right along. The lag between the
modulating signal and the response, if in
fact the brain is following the signal, should
be fairly constant. This lag can be mea-
sured as the phase angle.
The variability of the lag over succes-
sive samples represents the coherence of
the phase relationship. A robust following
response to the modulating tone will have
a fairly consistent or coherent phase rela-
tionship. If the brain is not responding to
the sound, then the phase relationship to
the modulation will be random. A crite-
rion level for significant phase coherence
is then used to determine objectively
whether or not a response occurs.
11 Does everyone measure
it the same way?
That would be too simple. I’ll give you
two examples. The strategy derived from
the Melbourne group uses a modulation
frequency of 90 Hz.10 Amplitude mod-
ulation depth is 100%; frequency mod-
ulation depth is 10%. Automatic
determination of a response is based on
phase coherence. One audiometric fre-
quency is tested at a time.
The Toronto group takes a different
approach.17 They use a stimulus that is a
combination of four carrier frequencies
of 500 Hz, 1000 Hz, 2000 Hz, and 4000
Hz, each of which is modulated at a
slightly different frequency. For example,
the 500-Hz tone is modulated at 77 Hz,
the 1000-Hz tone at 85 Hz, the 2000-Hz
tone at 93 Hz, and the 4000-Hz tone at
September 2002 • Vol. 55 • No. 9
101 Hz. The four brainwave frequencies
are analyzed independently to determine
the presence of a response at each audio-
metric frequency. Just to make it more
efficient, they use the same approach in
the other ear, with each frequency assigned
a slightly different modulation rate. In
that way, both ears can be tested at all fre-
quencies simultaneously. Analysis of the
waveforms is made with fast Fourier trans-
form, and detection is accomplished with
statistical F ratios.
12 Whew! After all that,
please tell me there are
clinical advantages to using the
ASSR. For starters, can it pre-
dict threshold?
Yes. Various studies have shown that it
can provide a reasonably accurate predic-
tion of behavioral thresholds.8,10,11,18-20
It appears to be comparable in accuracy
to the ABR.12 Interestingly, some of the
earlier work showed it to be a strong pre-
dictor of thresholds in patients with hear-
ing loss, but a less than adequate predictor
of normal hearing.20 That is probably an
SNR issue that will be solved with tech-
nologic advancements.
13 Can the ASSR be recorded
in infants?
Yes, it can. The response is present and
readily measurable in newborns,21 sleep-
ing infants,20 and sedated babies.
14 Is it frequency-specific?
As I stated before, the stimulus is a tone
that is only slightly distorted by modula-
tion. It stimulates a portion of the basilar
membrane that is restricted enough to
provide very acceptable frequency reso-
lution. Not unexpectedly, I suppose,
threshold prediction appears to be more
accurate for higher-frequency signals than
for lower-frequency signals.10,17 Never-
theless, the ASSR approach should enjoy
an advantage over tone-burst ABR pre-
diction of lower-frequency hearing. The
outcome should be a more precise pre-
diction of the audiogram.
15 And you say it can be
objectively detected?
Remember, the response itself is periodic
in nature and, when present, is at least
somewhat phase-locked to the eliciting
Page Ten
signal. Objective detection is made easier
by these factors.
The Toronto group derives a response
amplitude from a fast Fourier transform
of the brainwaves.17 The outcome is sub-
jected to a variance ratio test, or F test,
comparing the amplitude of the response
at the modulation frequency to the ampli-
tude at some distant frequency. When the
difference reaches a pre-determined sta-
tistical criterion, a response is deemed to
have occurred.
The Melbourne group analyzes the
variance, or coherence, of the phase rela-
tionship of the response to the modula-
tion envelope.10 If the phase coherence
reaches a pre-determined criterion, it is
assumed that the brain is responding to
the stimulus because the response is phase-
locked to it.
Refinements in these techniques, as
well as new techniques, will likely emerge.
The point is that it is the periodic nature
of the response that makes it so suscepti-
ble to objective detection.
16 Does the test take a long
time?
Accurate threshold detection across audio-
metric frequencies in both ears can take
a while—probably somewhere between
30 and 60 minutes. The speed of this
approach seems acceptable and is likely
to improve as the technology advances.
The Toronto approach provides a cre-
ative example of the potential for this tech-
nology. If each of eight frequencies (four
per ear) is assigned a different modula-
tion rate, ASSRs can be measured simul-
taneously at all frequencies in both ears
at a single intensity level.17,22 The devel-
opment of automated algorithms to
enhance the efficiency of the threshold
prediction process seems inevitable in the
near future.
17 You said something ear-
lier about dynamic
range. Could you go over that
again?
Sure. Gary Rance and his colleagues from
Melbourne taught us this.23 Remember
that modulated tones are being used to
elicit the ASSR. Maximum signal inten-
sity of modulated tones is comparable to
equipment limits for pure tones on mod-
ern clinical audiometers. This can be as
high as 120 dB HL.
The Hearing Journal 17

By comparison, air-conducted clicks
used to elicit ABRs typically have a maxi-
mum output of around 90 dB nHL. This
is adequate for predicting hearing thresh-
olds at the moderately severe level or bet-
ter. However, the likelihood is low of
recording an ABR in an ear with a high-
frequency hearing loss greater than 70 dB.
In those patients, threshold simply cannot
be estimated with ABR. Thus, infants and
young children with severe and profound
hearing loss will have absent ABRs, and
the audiologists will be left to guess whether
the loss is severe, profound, or complete.
The ASSR has the potential to give an
extra 50 dB worth of information about
degree of loss. That is very important in
determining early candidacy for amplifi-
cation or implantation.
18 Does the ASSR have its
own CPT code yet?
Um, no, it’s a little early for that.
19 Why don’t more people
use the ASSR?
For all the potential of the ASSR in pre-
Circle 104 on Reader Service Card
18 The Hearing Journal
dicting hearing loss, the emerging tech-
niques need refinement. Prediction of nor-
mal hearing thresholds and of low-
frequency thresholds has room for
improvement. In addition, ASSR clinical
recording systems are just now becoming
available commercially.
20 You’ve talked all about
threshold prediction.
Are there diagnostic applica-
tions?
Good question. As with the ABR, the
ASSR is abnormal in patients with audi-
tory dys-synchrony (auditory neuropa-
thy).23 How sensitive they might be to
other types of neurologic disorders remains
unknown.
An intriguing finding was reported
recently on the correlation of the ASSR
to speech perception.14 Results suggest
that steady-state response recordings to
multiple independent amplitude and fre-
quency modulations of a pure tone may
provide an objective assessment of
suprathreshold hearing. We obviously
have much more to learn.
Page Ten
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