NEWBORN HEARING SCREENING AND ASSESSMENT

Guidelines for the Assessment and Management of

Auditory Neuropathy Spectrum Disorder in Young Infants

Version 2.2

August 2013

NHSP Clinical Group

Rachel Feirn1 (Editor), Graham Sutton2, Glynnis Parker3, Tony Sirimanna4, Guy
Lightfoot5, Sally Wood2

1
Formerly of Bristol Royal Hospital for Children, UK
2
Newborn Hearing Screening Programme Centre, Public Health England, London, UK
3
Sheffield Children’s Hospital, Sheffield, UK
4
Great Ormond St Hospital for Sick Children NHS Trust, London, UK
5
Formerly Dept of Medical Physics & Clinical Engineering, Royal Liverpool University Hospital,
Liverpool, UK

With thanks to Linda Hood, Steve Mason, John Stevens and the late Judy Gravel for their
contributions to previous versions.

Correspondence to Newborn Hearing Screening Programme Centre, 344-354 Grays Inn Rd, London
WC1X 8BP, UK.

NHSP ANSD guidelines v 2.2 Page 1 of 29

 Amendment History:

Version Date Amendment History

1.0 October 2004 First version created following meeting with national and
international scientists/audiologists, and extensive subsequent
correspondence and discussion. Edited by Graham Sutton
1.1 May 2008 A number of minor corrections (mostly typographical and to
references) made. Addendum on interpretation of CM added.
September 2011 Separate CM protocol issued (v2.0), replacing old Appendix 2
2.1 September 2012 Complete revision by members of NHSP Clinical Group. Edited
by Rachel Feirn
2.2 July 2013 Minor revision to clarify and update some areas

Forecast Changes:
Anticipated Change When
Further Review 2015

NHSP ANSD guidelines v 2.2 Page 2 of 29

CONTENTS

Introduction ........................................................................................................... 4
Main changes to these guidelines from previous versions .................................. 4

1. Background ....................................................................................................... 5
1.1 Definitions and Terminology .......................................................................... 5
1.2 Prevalence .................................................................................................... 6
1.3 Aetiology and Risk Factors ........................................................................... 6
1.4 Natural History and Prognosis ...................................................................... 7

2. Initial Assessment ............................................................................................. 9

3. Management .................................................................................................... 12
3.1 Information and Support.............................................................................. 12
3.2 Ongoing Audiological Assessment .............................................................. 13
a) Behavioural thresholds ............................................................................. 13
b) Electrophysiology ..................................................................................... 13
c) Tympanometry / Stapedial reflexes........................................................... 13
3.3 Monitoring and Assessment of Communication Development .................... 14
3.4 Intervention / Aids to Communication.......................................................... 14
a) Modes of Communication ......................................................................... 14
b) Conventional Hearing Aids ....................................................................... 14
c) FM Systems .............................................................................................. 15
d) Cochlear Implants ..................................................................................... 15
3.5 Medical Referral .......................................................................................... 16
3.6 Management of Unilateral ANSD ................................................................ 17

Acknowledgements............................................................................................. 17

References ........................................................................................................... 18

Appendix 1 Case scenarios ................................................................................. 21

Appendix 2 Delayed maturation and the timing of repeat ABR testing................. 27

Appendix 3 Additional Tests ................................................................................ 28

a) Speech Discrimination testing ........................................................ 28
b) Advanced Electrophysiological techniques .................................... 28

Appendix 4 Medical Assessment ......................................................................... 29

NHSP ANSD guidelines v 2.2 Page 3 of 29

 INTRODUCTION
This document outlines the recommendations of the Newborn Hearing Screening
Programme (NHSP) in England for the assessment, diagnosis and management of infants
5 suspected of having Auditory Neuropathy Spectrum Disorder (ANSD). It should be read in
conjunction with the NHSP Guidelines for Cochlear Microphonic Testing.1

This document has been updated in the light of recent work and other published guidelines.
Many controversies and areas of uncertainty remain in the diagnosis and management of
10 ANSD. These guidelines are likely to be subject to further revision in the light of new
evidence in the future.

Main changes to these guidelines from previous versions:

15 Changes in version 2.2 (2013) from version 2.1 (2012)

Minor changes have been made to clarify some points. In particular, issues around the
definition and initial diagnosis of ANSD in sections 1&2 and the timing of possible cochlear
implant referral in section 3.4d have been clarified. Slight changes to section 2 (‘Initial
Assessment’) have also been made for consistency with the 2013 revision of the NHSP
20 Early Assessment guidelines.

Main changes in version 2.1 (2012) from version 1.1 (2008)

 The name used for the condition was updated from ‘Auditory Neuropathy / Auditory
Dys-synchrony’ to ‘Auditory Neuropathy Spectrum Disorder’, in accordance with
25 recent international guidelines.
 A section on Aetiology was added.
 The section on ‘Initial Assessment’ was updated in line with the NHSP guidelines for
Early Audiological Assessment (2011) and Cochlear Microphonic testing (2011).
 Version 1.1 recommended a repeat ABR assessment at a corrected age of 9-15
30 months (to test for possible delayed maturation). In versions 2.1 & 2.2 the guidance
is to consider a repeat ABR at 12-18 months corrected age, depending on the
circumstances of the individual case. Appendix 2 discusses the issues around this
decision. (Guidance on an earlier repeat ABR at 8-10 weeks corrected age is
unchanged.)
35  Section 3.4 on Intervention was re-ordered to highlight the importance of early
communication support, before the age at which decisions about amplification can be
made.
 A brief section on the management of unilateral ANSD was added.
 Some example case scenarios, illustrating the diversity and spectrum of the disorder,
40 are given in Appendix 1.
 Appendices on additional audiological tests (including recent work in
electrophysiology) and on medical assessment were added.
 Previous (version 1.1) Appendices 1 (timeline) and 2 (cochlear microphonic testing,
plus addendum) were removed. This information is now incorporated into the main
45 document and into the separate ‘Guidelines for cochlear microphonic testing’.
 The References section was updated.

NHSP ANSD guidelines v 2.2 Page 4 of 29

 1. BACKGROUND

50 1.1 Definitions and Terminology

This document addresses the practical issues in the identification, assessment, diagnosis
and management of infants presenting with the following pattern of test results at the initial
audiological assessment after the newborn screen:
 Auditory Brainstem Response (ABR) absent or with severely abnormal
55 morphology at high stimulus levelsa, with
 Otoacoustic emissions (OAEs) and/or cochlear microphonic (CM) present.

We thus have objective tests that demonstrate the presence of pre-neural responses but
absent or abnormal neural responses.
60
This suggests relatively normal activity in the outer hair cells, but disruption of transmission
at some point from the inner hair cells along the neural pathway to the brainstem. In some
cases, the underlying reason for this initial pattern of test results will become evident,
whereas in others the underlying reason may not be found. In some cases, neural firing may
65 be occurring but with a lack of synchrony, so that no clear ABR is recordable. In some
cases dys-synchrony may also arise due to delayed maturation or myelination of the auditory
pathway.

The term ‘Auditory Neuropathy’ was originally described by Starr and colleagues in 19963.
70 Other workers have preferred terms such as ‘Auditory Dys-synchrony’4, ‘Auditory De-
synchrony’ or ‘Auditory mismatch’, feeling that these terms better attempt to describe what is
happening in the auditory system without implying a particular locus of pathology5. To
encompass these different opinions, the term ‘Auditory Neuropathy/Dys-synchrony (AN/AD)’
came into use, and was used in previous versions of the NHSP guidelines.
75
At the International Guidelines Development Conference (at Como, Italy, in 20086), a
consensus was reached to adopt the term ‘Auditory Neuropathy Spectrum Disorder’ (ANSD).
This term includes both true auditory neuropathy (i.e. a true neural abnormality) and other
possible underlying mechanisms resulting in neural dys-synchrony, as well as delayed
80 maturation of the lower level auditory pathway. The term ANSD was also considered helpful
as it expresses the wide range of presentations, prognoses, and underlying aetiologies
associated with the disorder.

ANSD may affect neural processing of auditory stimuli, which may reduce a child’s ability to
85 understand speech and may affect ability to detect sound to various degrees. All such
children need to be reviewed and monitored in a similar way, and their management differs
a
There is some lack of consensus about the definition of “severely abnormal ABR morphology”. We
2
suggest that of Sininger (2002) : “The neural response (ABR) will be poor or completely absent but
will occasionally show a small wave V response [at high stimulus levels]. The majority of cases of
[ANSD] have a poor ABR preceded by a large inverting CM that can last up to 5 or 6 ms.”
1
As a guideline for “high stimulus levels” we suggest 75 dBeHL or above . If the audiologist is unsure
about ABR morphology then an expert opinion on the traces should be sought.
Occasionally, babies may present with more moderately raised ABR thresholds and TEOAEs present.
Our current advice is that such cases should not be labelled as ANSD and that an expert paediatric
audiology centre should be consulted.
NHSP ANSD guidelines v 2.2 Page 5 of 29
 from that of children with ‘conventional’ sensorineural or conductive hearing loss in important
ways.

90 1.2 Prevalence
Sininger2 estimates that ANSD occurs in about 1 in 10 children with permanent hearing
lossb, though prevalence estimates vary between studies. The true prevalence of ANSD in
the paediatric population with hearing loss has not been determined in large, prospective
multi-centre investigations and is therefore uncertain. Initial prevalence figures from the
95 English NHSP are in line with the Sininger estimate. These children, because of absent
ABR, might at first sight be thought to have severe/profound sensorineural (cochlear)
hearing loss until tests of cochlear function are carried out.

Although the majority of ANSD cases occur among special care / neonatal intensive care
100 babies (see section 1.3), some studies have indicated that a significant number may occur in
the well baby population2. Many newborn hearing screening programmes, including the
NHSP protocol, currently only screen for evidence of ANSD in infants admitted to NICUc,
and do not offer ABR screening to all well babies. Cases of ANSD occurring in the well baby
population may therefore remain undetected.
105
Cases of ANSD may be referred at a later stage and will need to be investigated, identified
and managed following diagnosis. The assessment and management of these older cases is
outside the scope of this document.

110 1.3 Aetiology and Risk Factors

ANSD is a label for a pattern of test results as defined above. It is not a diagnosis and further
investigation is needed to ascertain this.

ANSD may arise from a diverse range of aetiologies. Infants with ANSD therefore require
115 assessment, investigation and monitoring of neurodevelopmental progress by a physician
with appropriate skills and an understanding of the condition. Diagnosis of the underlying
aetiology may determine the most appropriate further management, including specific
intervention if indicated.

120 Risk factors for ANSD from the neonatal history include:2,7,8,9
 Extreme prematurity <28 weeks gestation
 Low birth weight / intrauterine growth restriction
 Hyperbilirubinaemia reaching exchange transfusion levels
 Hypoxic ischaemic encephalopathy / intraventricular haemorrhage (as is likely to
125 occur in infants with prolonged assisted ventilation / severe sepsis)

Genetic conditions that may give rise to this pattern of test results include, among others:
 Otoferlin mutations (DFNB9 – autosomal recessive)12

b
For the purposes of this document, ‘permanent hearing loss’ is defined as bilateral permanent
childhood hearing impairment averaging ≥ 40 dBHL (0.5-4kHz). This is the definition used by the
NHSP.
c
In this document ‘SCBU/NICU’ means those infants classified as such by the NHSP screening
protocol –i.e. those who are admitted to special care / neonatal intensive care for over 48 hours.
NHSP ANSD guidelines v 2.2 Page 6 of 29
  Pejvakin mutations (DFNB59 – autosomal recessive)13
130  Familial delayed auditory maturation14
 Neurodegenerative conditionsd: Charcot Marie Tooth, Friedreich’s Ataxia3
 Metabolic conditionsd e.g. Maple syrup urine disease15
 Mitochondrial disorders16

135 Some anatomical anomalies may also give rise to this pattern of test results. These cases
should be defined by the abnormality identified, rather than continuing to use the label
ANSD. Management of such cases is outside the scope of this document.
Examples include:
 Hydrocephaluse 2,7
140  Brainstem anomalies10
 Auditory nerve hypoplasia or aplasia11
 Other anatomical brain anomalies, e.g. microcephaly, space-occupying lesions such
as cerebellar tumours.

145 1.4 Natural History and Prognosis

The impact of ANSD on a child’s hearing ability varies amongst individuals. It is not possible
to predict either a degree of hearing loss or a prognosis for speech and language
development and communication ability based on the diagnosis of ANSD.
 Both ABR and behavioural thresholds are poor predictors of speech discrimination
150 ability.
 The ABR may recover so that it is consistent with the behavioural threshold and has
normal morphology17,18. If the problem is due to delayed maturation, recovery would
normally be complete by 12-18 months of age (see Appendix 2). It may not be helpful
to continue to use the label of ANSD for these cases once maturation of the ABR has
155 been confirmed.
 Behavioural thresholds may improve over the first 1-2 years of life8.
 In some cases, the behavioural thresholds may appear to be satisfactory, with age-
appropriate speech development, but the child may exhibit features consistent with
auditory processing difficulties. There should be a local protocol for the ongoing
160 monitoring of such cases.
 OAEs which are present at initial assessment may disappear over time, whether or
not the child is aided.2,19,20

Children with ANSD should be monitored carefully. We should guard against giving false
165 hope that the condition will recover, but equally we should be careful to avoid assigning a
long-term diagnosis prematurely.

When older, children with ANSD may exhibit some or all of the following features:
 Absent or elevated stapedial reflexes (SRs)

d
These conditions usually give a delayed onset presentation
e
Note that hydrocephalus may interfere with the recording of the ABR so presenting with wave I only.
ABR thresholds may improve after shunt insertion and it is therefore advisable to wait until after shunt
insertion before performing the ABR assessment.
NHSP ANSD guidelines v 2.2 Page 7 of 29
170  Behavioural thresholds anywhere in the range from normal to profound, and any
configuration.
 Variable responses from one test session to another, but generally reliable within a
single session.
 Speech discrimination poorer than the behavioural audiogram would suggest.
175  Hearing aids may be of less benefit than the behavioural audiogram would suggest.
 Greater difficulties hearing in competing noise than expected from the behavioural
audiogram, and other features indicative of auditory processing difficulties.

As thresholds usually bear little relationship to speech discrimination ability, management

180 decisions for these children should be guided much more by functional communication
development rather than behavioural or ABR thresholds.

NHSP ANSD guidelines v 2.2 Page 8 of 29

185 2. INITIAL ASSESSMENT
In the NHSP early audiological assessment protocol21, 4kHz tone pip ABR assessment will
usually be the first investigation for babies referred following the screenf. (Note that with
babies born prematurely, the initial ABR assessment should not be performed until the baby
has reached or is close to term, to allow some time for neural maturation.) Where there is no
190 ABR response at the normal maximum recommended stimulus levelsg, or a severely
abnormal response at 75dBeHL or above, investigations to differentiate between ANSD and
sensory (cochlear) hearing loss must be performed.

In an infant, abnormal or absent ABR may be due to:

195  ‘Conventional’ hearing loss – cochlear, conductive or mixed
 ANSD due to delayed neural maturation
 ANSD due to other causes.

ANSD must always be excluded before proceeding to hearing aids on the basis of objective
200 test results. The ANSD test protocol should be followed as part of the assessment of every
suspected case of permanent hearing loss with absent/severely abnormal ABR, whether or
not there are known risk factors for ANSD. Refer to NHSP guidance for the specific tests 1,22.

The assessment should include:

205
1) ABR – if tone pip ABR responses are absent or very abnormal as described above, a
click ABR should be performed, ideally using insert earphones, at 85dBeHL.

2) Tests of outer hair cell function: If click ABR is absent or severely abnormal at 75
210 dBeHL, perform at least one of the following, as appropriate:

a) Diagnostic OAEsh– transient evoked (TEOAE) are recommended. If a robust

OAEi is found to be clearly present and repeatable, assume ANSD may be present.
(Note that OAEs may be absent due to overlying conductive lossj so the absence of a
215 recordable OAE cannot be taken as evidence for the absence of ANSD)

b) Cochlear Microphonics: Perform click CM with separate runs of condensation and

rarefaction at the same stimulus level (not exceeding the NHSP recommended
normal maximum stimulus levelg) as was used for the click ABR test, using insert
220 earphones. If a cochlear microphonic (inverting with click polarity) is present and
there is still no later true neural ABR response (i.e. not inverting with click polarity),

f
For well babies, current NHSP guidance is that it is acceptable to use TEOAEs as the first test. For
babies admitted to NICU > 48 hours, and any baby where there is suspicion of, or a possible risk
21
factor for, ANSD, ABR must be peformed.
g 21
Refer to the NHSP ‘Guidelines for early audiological assessment’ for guidance on maximum
recommended stimulus levels
h
‘Diagnostic OAE’ means an OAE carried out in the diagnostic Audiology clinic, with visual display of
waveforms, not just on screening equipment.
i 22
Refer to the NHSP guidelines on TEOAE testing in babies for minimum ‘pass’ criteria
j
Tympanometry (using a 1000Hz probe tone for infants < 6 months) should be performed to aid in the
interpretation of an absent OAE.
NHSP ANSD guidelines v 2.2 Page 9 of 29
 assume ANSD may be present. Refer to the NHSP ‘Guidelines for Cochlear
Microphonic Testing’1 for detailed notes on CM recording and interpretation.

225 Note that significant overlying conductive loss may prevent the CM from being
detected. When abnormal tympanograms are present it is not possible to exclude the
possibility of ANSD; however, in cases where there is no other evidence for ANSD
this should not delay the management of the child’s hearing loss.

230 If a robust diagnostic OAEh,i has already been recorded, CM testing is not necessary
(although it may be useful as confirmation). However, studies show that a substantial
proportion of patients with ANSD and present CMs do not have recordable OAEsk.
Therefore all children with absent or severely abnormal ABR and absent OAE
should be tested for a cochlear microphonic.
235
Optionally, particularly for infants aged above about 6 months, include if possible:
3) Stapedial reflexes (SRs)l

Interpretation:
240
ABR (AC and BC) absent / severely abnormala ]
CM or OAEs present ] implies ANSD
(SRs absent / elevated) ]

245 ABR (AC and BC) absent / severely abnormala ]

CM and OAEs not recordable* ] implies SNHLm

ABR (AC and BC) present but elevated ] implies SNHLm

] - CM test not indicated
250

*The absence of OAEs and CM does not categorically rule out ANSD, but when both are
absent it is reasonable to assume conventional hearing loss and proceed to manage the
hearing loss on this basis. However, if robust OAEs and/or CM have been found to be
255 present on one diagnostic test occasion and are not recordable at a future date, the label
ANSD should be maintained unless the ABR morphology also improves to become
consistent with the behavioural thresholds. There are anecdotal reports that in some cases
of ANSD the OAE and/or CM can “burn out” with time. These cases are still likely to have
ANSD, although they may additionally have hair cell damage, and should be managed
260 accordingly.
k 9
In the study by Rance et al all subjects had evidence of outer hair cell function in the form of the
cochlear microphonic but only about half had OAEs; this is presumably because the CM is less
affected by middle ear factors.
l 23
Stapedial reflexes appear to be invariably absent or elevated in cases of ANSD . The NHSP team
has not previously recommended their use in infants under about 6 months (where high frequency
(1000Hz) probe tones must be used), due to doubts about their reliability and a lack of normative
24,25
data. There is now emerging evidence on reliability and normative data in this young age group ,
so this test may become a more standard part of the test battery for ANSD at this age in the future.
m
Or mixed SNHL & conductive loss
NHSP ANSD guidelines v 2.2 Page 10 of 29
 A key issue with ANSD is distinguishing long-term ANSD from delayed maturation
particularly in babies who have been in neonatal intensive care. Care should be taken when
interpreting ABR results for babies born prematurely or for those who have delays in other
265 aspects of development, as the ABR response may still be maturing. To help differentiate
neural maturation changes from other causes of ANSD, whenever possible ABR should be
repeated before a definitive initial diagnosis is made; this should preferably be at around 8-
10 weeks corrected age (i.e. around 2 months after the first ABR).

270 As improvements in ABR and in behavioural thresholds over the early months of life have
been reported in some infants8,17,18, a further repeat ABR at a later age may be helpful in
order to confirm the diagnosis. If this is felt to be helpful for the management of the individual
case, then a re-test at around 12-18 months of age should be considered. For a discussion
of the issues around this decision, see Appendix 2.
275
Remember that in ANSD, ABR thresholds do not predict behavioural thresholds or
functional hearing ability.

280

NHSP ANSD guidelines v 2.2 Page 11 of 29

 3. MANAGEMENT
This section refers primarily to the management of bilateral ANSDn. However, some of this
guidance will also be relevant to the management of unilateral ANSD.

285 The management of the child with ANSD requires a multidisciplinary team approach,
working in partnership with the family. As a minimum we suggest the team should include a
Paediatric Audiologist, a medical person (Audiological Physician, ENT consultant or
Paediatrician), a Speech-Language Therapist, a Teacher of the Deaf, and a Neurologist.
The timing of involvement of these professionals will depend on the individual case and the
290 wishes of the family. One member of the team should be designated to take ultimate
responsibility for the management of the case. All the members should be familiar with and
knowledgeable about the condition.

The management of ANSD presents great practical challenges, and the number of cases
295 occurring in any one area is very small. While it is entirely feasible for departments that
perform ABR to carry out CM and OAE testing and raise the initial suspicion of ANSD, we
recommend that those with little or no experience of these cases should seek advice from
centres with high levels of expertise and more experience, to obtain a firm diagnosis and
start the management process. Such centres need to be able to offer support and guidance
300 in diagnosis and management, ensure that families get the best information and advice, and
build confidence in the local staff. In many cases, referral of the patient on to such centres
may be appropriate.

3.1 Information and Support

305 The lack of certainty around prognosis can make ANSD a particularly difficult diagnosis for
parents and families to deal with. In addition, many infants with ANSD will have other
medical issues and/or have had a stormy neonatal course, meaning that hearing may not
initially present a high priority for parents26.

310 The confusion that parents are likely to feel may have a negative impact on the relationship
between parents and professionals. Ongoing communication, support, encouragement,
and information for parents are critical to successful management. It is important to
provide written informationo regarding the condition to families as well as to other
professionals involved with the child, such as Health Visitors, GPs and Paediatricians.
315 ANSD should be described specifically, including what is known and not known about the
condition.

It is helpful to cover the following points:

320

n
Or bilateral absent / severely abnormal ABR where at least one ear has evidence of ANSD – see
section 3.6
o
Helpful sources of written information may include the relevant NDCS factsheet or the leaflet on
ANSD produced by Newborn Hearing Screening Wales.
NHSP ANSD guidelines v 2.2 Page 12 of 29
  The term ANSD is a label for a pattern of test results; it is not a label for a child.
 It is not immediately possible to predict the impact on the child or even the most
successful form of treatment.
 An absent ABR does not necessarily imply a profound hearing loss.
325  We need to monitor this child closely, as the child may not respond to sound in a
typical way.
 Many children with ANSD are able to make good use of their hearing.
 However the majority of children with this pattern of test results do turn out to have
hearing problems of some degree.
330  While we cannot predict the impact of ANSD on the child at this early stage, by
pooling test results and observations from parents, audiologists and other
professionals we will be able to do as much for the child as possible.
 Establishing the child’s early communication and language skills is important, and
use of visual cues is advisable until the child’s true hearing ability is known.
335
Families of children with ANSD should be offered referral for early support. Children with
ANSD are at risk for communication difficulties and need to be monitored accordingly. The
overall goal is to begin management as soon as the parents/carers feel ready to proceed
and to establish a communication method for use by the child and family, and put in place a
340 plan for continuing assessment of hearing and communication.

3.2 Ongoing Audiological Assessment

The audiological profile of children with ANSD may not be stable. Therefore ongoing and
regular monitoring of auditory status (behavioural, electrophysiological and middle ear) and
345 hearing, speech, language and general development is required.

Audiological assessments must include:

a) Behavioural thresholds in each ear determined by an age-appropriate method (VRA
with insert earphones, Play Audiometry, conventional Pure Tone Audiometry). These can be
350 acquired from a developmental age of around 6 months.

Some children may have complex medical and developmental factors which present a
challenge for behavioural testing. Such children must be assessed by suitably experienced
and skilled professionals and results should be viewed in the context of the child’s
355 developmental status. If reliable results cannot be obtained because of significant
developmental delay, Behavioural Observational Audiometry (BOA) and informal
observation may be useful in guiding management. Any BOA should be carried out and
interpreted with extreme care.22

360 b) Electrophysiology: as discussed in Section 2, repeat ABR, CM and OAE recording at 8-

10 weeks corrected age. Consider further repeat at 12-18 months, depending on the clinical
situation of the individual patient.p

c) Tympanometry/ Stapedial Reflexes. Monitoring of middle ear status is important as the

365 presence of fluid in the middle ear will affect other tests, and children with ANSD are as likely
p
For a discussion of the relevant issues, see Appendix 2
NHSP ANSD guidelines v 2.2 Page 13 of 29
 as any other to develop middle ear effusion. This should be done in conjunction with other
testing. SRs (using both tonal and broad band stimuli) should also be measured, particularly
in infants over about 6 months of age.l

370 Additional tests that may be appropriate in the ongoing assessment of children with ANSD
are discussed in Appendix 3.

3.3 Monitoring and Assessment of Communication Development

Monitoring and assessment of language and communication development is the key
375 determinant of management options. Close monitoring of communicative and developmental
progress by parents and professionals together should be undertaken using the Early
Support Monitoring Protocol27 or other appropriate monitoring tools. In addition, regular
standardised assessments of language and communication should be undertaken by
qualified Teachers of the Deaf or specialist Speech and Language Therapists. The
380 development of more sophisticated monitoring tools would be helpful in the early monitoring
and management of infants with ANSD.

3.4 Intervention / Aids to Communication

a) Modes of Communication
385 This should be determined by the needs and desires of the family, taking into account the
observed progress of the child. For most children with ANSD, use of a combination of
communication systems that incorporates visual support is appropriate (e.g. auditory/aural
with lipreading and natural gesture, total communication, sign language). On the other hand,
an auditory-only approach (such as auditory-verbal therapy) is very unlikely to be successful.
390
Regardless of communication method, it is important that parents become proficient in the
method and use it regularly in the home. Such approaches can be put into place at an early
stage, before behavioural thresholds and the child’s ‘true’ hearing ability are known, in order
to lay the foundations of communication and language development.
395
b) Conventional Hearing Aids
There is increasing evidence that a substantial number of children with ANSD derive benefit
from hearing aid fitting if there is a significant behavioural hearing loss. About 50% of the
children in one study gained significant benefit9, although some clinics report much lower
400 success rates28. Therefore a trial of amplification should be undertaken. However, due to
doubt as to the benefit in children where behavioural thresholds are near-normal, we would
only recommend aiding for a child whose behavioural thresholds are reliably
elevated. A number of other considerations and complications apply – for further details
and discussion please see reference6.
405
The decision on whether to aid must be based on behavioural results and
observations from families and early interventionists regarding the child’s responses
to sound and early communication development. If reliable behavioural hearing
thresholds are not yet available and there is significant concern from the family and early
410 interventionist, hearing aid fitting can begin based on these concerns and behavioural
observation audiometry (unaided and aided) in the test situation.

NHSP ANSD guidelines v 2.2 Page 14 of 29

 The fitting of hearing aids to children with ANSD should be based on a prescriptive method
specifically developed for infants and young children29 (e.g. DSL). The behavioural
415 thresholds (not ABR / electrophysiological thresholds) should be used to establish
amplification targets. In order to provide the best chance of benefit, it is important that
optimal audibility of speech sounds above threshold is achieved. Therefore, provided
reliable behavioural thresholds are available, aids should be fitted to target based on these
thresholds, rather than adopting a ‘conservative’ approach.q
420
Where there is a lack of reliable behavioural thresholds on which to base the prescription, a
conservative approach should be adopted, beginning with low hearing aid gain and
increasing the gain gradually if no responses from the child are observed.
DSP hearing instruments should be used, in keeping with MCHAS29 and NHSP30 guidelines.r
425
Hearing aid benefit should be determined. Benefit is determined primarily based on the
development of speech perception skills, not on aided detection thresholds. Monitoring of
the child’s hearing aid fitting is essential – refer to the appropriate MCHAS guidelines29.

430 Recent studies indicate that the late (cortical) evoked potentials may help to differentiate
those who are able to use hearing aids effectively to understand speech31-33. This technique
is discussed further in Appendix 3.

c) FM Systems
435 FM systems (with or without personal hearing aids) may be beneficial for children with ANSD
who have residual speech recognition in quiet but experience difficulty in noise35. A trial with
an FM system should be considered as part of the hearing aid fitting process, particularly
when the child is involved in a day care or educational setting in which poor acoustic
conditions restrict access to spoken language.
440
d) Cochlear Implants (CIs)
The literature has shown increasing numbers of children with ANSD who benefit from
cochlear implants4,6,28,36, and this option should be considered when behavioural responses
indicate the child is behaving like a child with a severe/profound hearing loss, and/or when
445 the child is not making progress with hearing aids (i.e. they show no or very limited speech
discrimination abilities). A trial of conventional amplification is important prior to cochlear
implantation (this is an area where we need more research). Behavioural thresholds are not
a good guide to candidacy, and ANSD patients with even relatively mild hearing losses on
behavioural testing may be CI candidates if they do not show good progress with other
450 interventions.

q
If behavioural thresholds fluctuate from test to test, the “best” thresholds obtained should be used, to
avoid risk of over-amplification.
r
Note that current hearing aid technology and prescription techniques (including the use of wide
dynamic range compression and advanced signal processing strategies) have generally been
developed to address the difficulties typically experienced by patients with conventional sensory
hearing loss. Some of these features may be less helpful for patients with ANSD. For example, low
frequency information, where temporal cues are most important, may be less useful. Further work is
needed in this area.
NHSP ANSD guidelines v 2.2 Page 15 of 29
 Infants identified with ANSD can be referred to a cochlear implant centre for assessment as
soon as there are significant concerns about behavioural responses to sound and/or
communication/speech/language development. (It is not appropriate to refer infants with
455 ANSD for cochlear implantation based purely on ABR results, and generally behavioural
measures will need to have been obtained). However, in view of the reports of significant
improvement in auditory function in some infants with ANSD over time, the final decision to
implant should not be made until audiological test results are stable and demonstrate
unequivocal evidence of permanent ANSD.6 (The exception to this is where there is a
460 strong suspicion of a genetic cause for the ANSD known to be associated with profound
deafness and good CI outcomes; such cases can be referred and implanted in a similar
timescale to infants with profound conventional SNHL.)

Local centres should be able to discuss cases of ANSD with the CI team, and it is important
465 that the CI team are able to accept referrals on the basis of assessment and advice, rather
than on the assumption that they will be candidates for surgery. The approach and timescale
for assessing such cases will need to be different from that for cases of conventional SNHL
(except in the event of a known genetic cause as defined above), and assessment for
possible delayed maturation must be carried out as part of the process of CI assessment. It
470 is important to make clear to parents and involved professionals that the referral at this stage
is for assessment and that it is not yet clear whether the child will turn out to be a candidate
for implantation. Responsibility for the ongoing monitoring of hearing and communication
development, with appropriate modification of management strategies, also needs to be
clearly agreed between the CI team and the local service.
475
Guidelines for cochlear implant assessment of children with ANSD in the UK have now been
developed by the British Cochlear Implant Group40. Cochlear implant funding bodies in the
UK also need to consider their approach to cases referred for ANSD based on the
accumulating evidence from around the world.
480
3.5 Medical Referral
Ongoing medical / neurological assessment is essential.

Some infants may already have an established neurological diagnosis. In others, ANSD
485 identified by newborn hearing screening may be the first indicator of an underlying
neurological condition. It is therefore recommended that all children who are diagnosed with
ANSD are assessed and investigated by an appropriately skilled and experienced
Audiovestibular Physician, Paediatrician or paediatric neurologist.

490 Key elements that should be included in the assessment are listed in Appendix 4.

As with any other child with a hearing problem, ENT involvement may be required to
manage any conductive element identified.

495

s
E.g. Otoferlin mutation
NHSP ANSD guidelines v 2.2 Page 16 of 29
 3.6 Management of Unilateral ANSD
a) Neonatal tests indicate unilateral ANSD with SNHL in the contralateral ear
Cases where the contralateral ear has a severe/profound hearing loss (i.e. absent/severely
abnormal ABR with no evidence of good outer hair cell function) should be managed with
500 caution, as it is possible that they may in fact be cases of bilateral ANSD. We would advise
aiding of the “non-ANSD” ear, but decisions about cochlear implantation of either ear should
not be made until there is unequivocal evidence of permanent profound hearing loss or
ANSD on behavioural testing.

505 b) Unilateral ANSD with normal hearing in the contralateral ear

There is little consensus about the management of unilateral ANSD in young infants. The
effects of unilateral SNHL are fairly well-understood, but the impact on speech/language and
educational progress varies between individuals. The effects of unilateral ANSD are less
well-understood. As discussed above, monitoring of hearing, communication and
510 speech/language development are important. Children with unilateral ANSD should also
receive a medical referral for aetiological investigation.

ACKNOWLEDGEMENTS
515 We would like to thank Sally Minchom, John Stevens, Rhys Meredith, Siobhan Brennan,
Rachel Booth, Gwen Carr and Elizabeth Midgley for their input and comments at various
stages in the development of the latest versions of these guidelines.

520

NHSP ANSD guidelines v 2.2 Page 17 of 29

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525 2. Sininger YS (2002). Identification of Auditory Neuropathy in Infants and Children. Seminars in
Hearing 23 (3), 193-200

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4. Berlin C, Li L, Hood L et al (2002). Auditory Neuropathy/Dys-Synchrony: After the Diagnosis, then

what? Seminars in Hearing 23 (3), 209-214

530 5. Rapin I, Gravel J (2003). “Auditory neuropathy”: physiologic and pathologic evidence calls for
more diagnostic specificity. Int J Ped Otorhinolaryngol 67, 707-728

6. Northern (Ed) (2008). Guidelines for Identification and Management of Infants and Young
Children with Auditory Neuropathy Spectrum Disorder. Available from the Bill Daniels Center for
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535 7. Berg AL, Spitzer JB, Towers HM, Bartosiewicz C, Diamond BE (2005.) Newborn hearing
screening in the NICU: Profile of failed auditory brainstem response/passed otoacoustic emission.
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8. Madden C et al (2002). Clinical and audiological features in auditory neuropathy. Arch

Otolaryngol Head Neck Surg 128, 1026-1030

540 9. Rance G, Beer DE, Cone-Wesson B et al (1999). Clinical findings for a group of infants and
young children with auditory neuropathy. Ear Hear 20, 238-252

10. Huang BY, Roche JP, Buchman CA, Castillo M (2010). Brain stem and inner ear abnormalities in
children with auditory neuropathy spectrum disorder and cochlear nerve deficiency. American
Journal of Neuroradiology 31: 1972-1079

545 11. Buchman CA, Roush PA, Teagle HFB, Brown CJ, Zdansk CJ, Grose JH (2006). Auditory
Neuropathy Characteristics in Children with Cochlear Nerve Deficiency. Ear Hear 27: 399-408

12. Varga R, Kelley PM, Keats BJ, Starr A, Leal SM, Cohn E, Kimberling WJ (2003). Non-syndromic
recessive auditory neuropathy is the result of mutations in the otoferlin (OTOF) gene. Journal of
Medical Genetics:40: 45-50

550 13. Delmaghani S, del Castillo FJ, Michel V et al (2006). Mutations in the gene encoding pejvakin, a
newly identifies protein of the afferent auditory pathway, cause DFNB59 auditory neuropathy.
Nature Genetics: 38 770-778

14. Aldosari M, Altuwaijri M, Husain AM (2004). Brain-stem auditory and visual evoked potentials in
children with Krabbe disease. Clinical Neurophysiology 115: 7: 1653-1656

555 15. Spankovich C, Lustig R (2007). Restoration of Brain Stem Auditory-Evoked Potential in Maple
Syrup Urine Disease. Medical Neurotology: 28:4: 566-569

16. Corley VM, Crabbe LS (1999). Auditory neuropathy and a mitochondrial disorder in a child: case
study. J Am AcadAudiol 10(9):484-488.

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 17. Psaromattis I et al (2006). Transient infantile auditory neuropathy and its clinical implications. Int
560 J PedOtorhinolaryngol 70 (9), 1629-1637

18. Attias J, Raveh E (2007). Transient deafness in young candidates for cochlear implants. Audiol
Neuro Otol 12 (5), 325-333

19. Deltenre P, Mansbach A L, Bozet C, Christiaens F, Barthelem, P, Paulissen D, Renglet T (1999).

Auditory neuropathy with preserved cochlear microphonics and secondary loss of otoacoustic
565 emissions. Audiology 38(4), 187-195.

20. Starr A, Sininger Y S, Pratt H (2000). The varieties of auditory neuropathy. Journal of basic and
clinical physiology and pharmacology 11(3), 215.

21. Stevens J, Sutton G, Wood S (Eds) (2013). Guidelines for the early audiological assessment and
management of babies referred from the newborn hearing screening programme. NHSP Clinical
570 Group. Available at http://hearing.screening.nhs.uk/audiologyprotocols

22. NHSP assessment guidelines and protocols including ABR, OAE, CM, Tympanometry and BOA
guidelines at http://hearing.screening.nhs.uk/audiologyprotocols

23. Berlin CI, Hood LJ, Morlet T, et al (2005). Absent or elevated middle ear muscle reflexes in the
presence of normal otoacoustic emissions : a universal finding in 136 cases of auditory
575 neuropathy/dys-synchrony. J Am Acad Audiol 16, 546-553

24. Mazlan R, Kei J, Hickson L (2009). Test-retest reliability of the acoustic stapedial reflex test in
healthy neonates. Ear Hear 30 (3), 295-301

25. Kei J (2012). Acoustic stapedial reflexes in healthy neonates: normative data and test-retest
reliability. J Am Acad Audiol 23 (1), 46-56

580 26. Uus K, Young A, Day M (2012). Auditory neuropathy spectrum disorder in the wider health
context: Experiences of parents whose infants have been identified through newborn hearing
programme. Int J Audiol 51 (3), 186-193

27. Early support monitoring protocol at

http://www.education.gov.uk/childrenandyoungpeople/sen/earlysupport/resources/b0067411/the-
585 early-support-developmental-journals/monitoring-protocol-for-deaf-babies-and-children

28. Berlin CI, Hood LJ, Morlet T et al (2010). Multi-site diagnosis and management of 260 patients
with Auditory Neuropathy/Dys-synchrony (Auditory Neuropathy Spectrum Disorder). Int J Audiol
49 (1), 30-43

29. Modernising Children’s Hearing Aid Services (2003) Guidelines on hearing aid fitting, verification
590 and evaluation. http://www.psych-sci.manchester.ac.uk/mchas/guidelines/

30. Foley R (Ed) (2009). Guidelines for fitting hearing aids to young infants. NHSP Clinical Group.
Available at http://hearing.screening.nhs.uk/audiologyprotocols

31. Rance G, Cone-Wesson B, Wunderlich J, Dowell R (2002). Speech perception and cortical event
related potentials in children with auditory neuropathy. Ear Hear 23 (3), 239-253

595 32. Cone-Wesson B (2004). Auditory Neuropathy: Evaluation and habilitation of a hearing disability.
Infants and Young Children 17, 69-81.

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 33. Sharma A, Cardon G, Henion K, Roland P (2011). Cortical maturation and behavioural outcomes
in children with auditory neuropathy spectrum disorder. Int J Audiol 50, 98-106

34. Cardon G, Sharma A (2011). Cortical Auditory Evoked Potentials in Auditory Neuropathy
600 Spectrum Disorder: Clinical Implications. Perspectives on Hearing and Hearing Disorders in
Childhood. 2011; 21(1), 31-37.

35. Hood LJ, Wilensky D, Li L, Berlin CI (2004). The role of FM technology in the management of
patients with auditory neuropathy / dys-synchrony. From ACCESS- Proceedings of 1st
international FM conference (Fabry and Johnson eds) November 2003, 107-111, Phonak.

605 36. Shallop JK, Peterson A, Facer GW, et al (2001). Cochlear Implants in five cases of Auditory
Neuropathy: Postoperative Findings and Progress. Laryngoscope 111, 555-562

37. Gibson WP, Sanli H (2007). Auditory neuropathy: an update. Ear Hear 28 (2), 102S-106S

38. McMahon CM, Patuzzi RB, Gibson WP, Sanli H (2008). Frequency-specific electrocochleography
indicates that presynaptic and postsynaptic mechanisms of auditory neuropathy exist. Ear Hear
610 29, 315-325

39. Neary W, Lightfoot G (2012). Auditory Neuropathy Spectrum Disorder: Examples of poor progress
following cochlear implantation. Audiol Med 10 (3), 142-149

40. Ambler M et al (2013). Guidelines for Cochlear Implant Assessment of Children Diagnosed with
Auditory Neuropathy Spectrum Disorder. British Cochlear Implant Group. (draft for consultation
615 at the time of publication of version 2.2 of the NHSP guidelines)

Additional reading:

Sininger YS, Starr A, (Eds). (2001) Auditory Neuropathy: A New Perspective on Hearing Disorders.
Singular Thompson Learning; San Diego.
620
Berlin CI, Morlet T, Hood LJ (2003) Auditory neuropathy / dys-synchrony. Its diagnosis and
management. Pediatr clin N Am, 331-340

Franck KH, Rainey MS et al (2002). Developing a multidisciplinary clinical protocol to manage

625 pediatric patients with Auditory Neuropathy. Seminars in Hearing, Vol. 23, No 3, 225-237.

Rance G (2005). Auditory neuropathy/Dys-synchrony and its Perceptual Consequences. Trends in

Amplification 9, 1-43.

630 King AM, Purdy SC, Dillon H, Sharma M, Pearce W (2005). Australian Hearing protocols for the
audiological management of infants who have auditory neuropathy. The Australian and New Zealand
Journal of Audiology. 27(1), 69-77

NHSP ANSD guidelines v 2.2 Page 20 of 29

635 Appendix 1: Case Scenarios

Case example A
History summary:
Born at 26 weeks gestation.
640 Prolonged assisted ventilation; treatment for repeated episodes of sepsis; phototherapy for jaundice.
Home at 5 months on ambulatory oxygen.

Screen: NICU protocol

TEOAE: CR R&L AABR: NCR R&L
645
Initial Audiological Assessment:
8 weeks corrected age, shortly after discharge home. Parents unsure about responses to sound.

(R) ear:
650 4kHz tpABR: no response (RA) at 75 dBeHL
Switched to click ABR using inserts: no response at 85 dBeHL.
CM recorded at same level.

(L) ear:
655 Started with click ABR in view of result obtained on (R) and screen result on (L).
No response (RA) to click at 85 dBeHL
CM recorded at same level.
1kHz tpABR recorded to check for low frequency response: No response (RA) at 90 dBeHL

660 No obvious behavioural responses observed.

Interpretation
 History: high risk for SNHL and ANSD
 ANSD pattern R&L
665  Delayed maturation a possibility, though baby is now post-term.
Management
 Results discussed with parents, including explanation of ANSD and unpredictable outcome.
 Referral to ToD agreed. Encouraged visual input and close monitoring.
 For repeat ABR 8 weeks later, in view of possibility of delayed maturation.
670  Results discussed with neonatal paediatrician.

Repeat ABR: 16 weeks Corrected age

TEOAE: present R&L
Started ABR with click in view of previous lack of response. Click ABR: repeatable responses present
675 down to 60 dBeHL R&L though delayed waveforms.
4kHz tpABR: repeatable responses present down to 60 dBeHL though delayed waveforms.
BC 4kHz tpABR: no convincing response at 60 dBeHL.
High frequency tymps: normal R&L

680 Interpretation
 Some signs of maturation; need to continue monitoring.
Management
 Results discussed with parents: signs of improvement; still difficult to predict outcome
 Continue ToD support, visual support for communication, and monitoring
685  Review in Audiology for behavioural testing.
NHSP ANSD guidelines v 2.2 Page 21 of 29
 Audiology review: 7 months corrected age (i.e. 10 months chronological age)
Seems to respond well to sound at home; babbling tunefully; good physical development – just sitting
unsupported.
690 Conditioned well for insert VRA:

Minimal response level (dBHL)

Frequency (kHz) 0.5 1 2 4
(L) ear 30 30 N/T 25
(R) ear 30 25 20 30
Tymps: mobile R&L

Interpretation
695  Satisfactory VRA responses for developmental age. In view of previous results, need to
monitor to ensure good receptive & expressive speech & language development.
Management
 Discussed with parents: encouraging results; responding well to sound; too young to be sure
how useful hearing is for speech
700  Continued support & monitoring by ToD

Audiology review 6 months later

Seems to hear well at home; responds to quiet sounds.
Producing several recognisable words with meaning.
705 Insert VRA: Minimal response levels at ≤ 20 dBHL R&L at 0.5, 1, 2 & 4 kHz

Ongoing reviews
Repeat ABR successfully obtained under natural sleep at 21 months:
4kHz tpABR: CR R&L ≤ 30 dBeHL with normal waveform morphology (unable to attempt 1kHz
710 recording as child woke up)
Hearing and speech development monitored at least annually until aged 6 years
Age-appropriate speech and language development.

Interpretation
715  Was ‘transient’ ANSD due to delayed maturation. ‘ANSD’ label no longer appropriate.
Management
 Discharged at 6 years of age after successful start at school. Advised to re-refer if any
concerns.

720

Case example B
History summary:
Born at term by emergency caesarean section due to reduced foetal movements.
725 Required intensive resuscitation, followed by assisted ventilation for 5 days.
Developed neonatal convulsions. Cranial ultrasound and MRI demonstrated cortical changes
consistent with hypoxic ischaemic encephalopathy.
Home at 6 weeks.

730 Screen: NICU protocol

TEOAE: CR (R), NCR (L) AABR: NCR R&L
Initial Audiological Assessment: Aged 6½ weeks

NHSP ANSD guidelines v 2.2 Page 22 of 29

 Parents feel baby sometimes responds to loud sounds.

735 (R) ear:

4kHz tpABR: no response (RA) at 75 dBeHL
Switched to click ABR using inserts: no response at 85 dBeHL.
Cochlear microphonic recorded at same level.
1kHz tpABR attempted to check for low frequency response: RA at 90 dBeHL
740
(L) ear:
4kHz tpABR: no response (RA) at 75 dBeHL
No response (RA) to click at 85 dBeHL
Woke before CM recording could be attempted.
745 Clear TEOAE recorded.

No obvious behavioural responses observed.

Interpretation
750  History: high risk for SNHL and ANSD
 ANSD pattern R&L
 Term baby, tested at 6 weeks, so delayed maturation less likely, but wise to repeat ABR to
confirm initial diagnosis.
Management
755  Results discussed with parents, including explanation of ANSD and unpredictable outcome.
 ToD referral offered but parents prefer to wait for now. Encouraged use of visual as well as
auditory stimulation.
 For repeat ABR in 6 weeks
 Neonatal paediatrician informed of results.
760
Repeat ABR: 12 weeks
Clear TEOAEs recorded R&L
Started with click ABR (inserts) in view of previous results. No repeatable response R or L at 85
dBeHL
765 Baby still sleeping, so CMs recorded R&L (not necessary for diagnosis in view of clear TEOAEs, but
useful for learning/training and completeness of results).
High frequency tymps: normal R&L

Interpretation
770  Bilateral ANSD with no indication of maturation so far.
Management
 Discussed results with parents and re-iterated importance of support for early communication
as it will be some time before we have an indication of true hearing ability
 Parents agreed to ToD referral
775  For regular support & monitoring by ToD, with feedback to Audiology. Audiology review for
behavioural testing.

Audiology review: 7 months

Parents & ToD feel child responds to some louder sounds at home, but little response seen to voices
780 or quieter toys. Some vocalisations but no real babble. Some developmental delay – not yet sitting
unsupported.

NHSP ANSD guidelines v 2.2 Page 23 of 29

 Unable to successfully condition to VRA. Repeatable responses obtained on a combination of
behavioural observation audiometry & distraction testing, as follows:
785
MRL to soundfield warble tones (dBA)
Frequency (kHz) 0.5 1 2 4
Presented on (L) 70 80 85 85
Presented on (R) 70 75 80
Responded to voice at 60-70 dBA; no response to ‘s’ or high frequency rattle at 60 dBA. Tymps:
mobile R&L.

Interpretation
790  Behavioural responses and parent/ToD observations consistent with moderate/severe
hearing loss, though responses recorded may not yet be quite threshold
Management
 Discussed with parents. Agreed to trial hearing aids
 Aids fitted programmed to behavioural responses, slightly conservatively initially in view of
795 lack of precision over thresholds and lack of ear-specific information. Alerted to sound with
aids, but no sign of loudness discomfort when checked with loud sounds.

Audiology review 6 weeks later

Conditioned to insert VRA using earmoulds:
800
Minimal response level (dBHL)
Frequency (kHz) 0.5 1 2 4
(L) ear 60 60 N/T 70
(R) ear 65 60 70 70
BC 40 60 70 70
Aids re-programmed to these results – now fitted accurately to target.

Ongoing reviews: every 3 months over next year

Insert VRA thresholds confirmed on subsequent tests – similar to above, with some variation between
805 assessments.
Parents report good responses to voice with aids. Wearing aids consistently.
Continued support from ToD and Speech & Language Therapist; signing introduced.
Child diagnosed with mild cerebral palsy – under care of paediatric neurologist.
Speech and language development delayed but showing steady progress.
810
At 2 years
Child had GA for orthopaedic procedure – opportunity used to repeat ABR.
No response R or L to 4kHz tp or click ABR at 85 dBeHL.
CMs recorded R&L at 85 dBeHL
815
Interpretation
 Bilateral ANSD confirmed.
 Moderate-to-severe loss on behavioural testing.
 Making good progress with hearing aids.
820 Management
 Continue with aids and ongoing monitoring.

NHSP ANSD guidelines v 2.2 Page 24 of 29

825 Case example C
History summary:
Born at 35 weeks gestation. Admitted to NICU for 10 days for temperature maintenance and to
establish feeding.
Discharged home well. Discharged from further follow-up by neonatal paediatricians after first
830 outpatient review.
st
1 child. No family history of deafness.

Screen: NICU protocol

TEOAE: NCR R&L AABR: NCR R&L
835
Initial Audiological Assessment:
0 weeks corrected age. Parents concerned about lack of response to sound at home.
Clear TEOAE recorded R&L.
ABR carried out as baby was in NICU > 48 hours:
840
(L) ear:
4kHz tpABR: no response (RA) at 75 dBeHL
Switched to click ABR: no response at 85 dBeHL.
nd
CM not attempted (wanted to move on and ensure 2 ear tested; clear TEOAE already obtained so
845 CM not necessary).

(R) ear:
4kHz tpABR: no response (RA) at 75 dBeHL
Switched to click ABR: no response at 85 dBeHL.
850 CM recorded at same level.
1kHz tpABR recorded to check for low frequency response: RA at 90 dBeHL

No obvious behavioural responses observed.

855 Interpretation
 History: slightly premature and in NICU > 48 hours, but no major risk factors for ANSD
 ANSD pattern R&L
 Delayed maturation a possibility – baby only just term – though was only 5 weeks prem.
Management
860  Results discussed with parents – fits with their concerns at home. Explained unpredictable
outcome.
 Referral to ToD agreed. Encouraged visual input and close monitoring.
 For repeat ABR in 8 weeks.
 Referred to paediatrician and Audiovestibular physician:
865 - Satisfactory general and neurological examination
- Neurological MRI, including internal auditory meati, performed without sedation
(under ‘feed and wrap’ protocol). Reported as normal including VIII nerve.
- Possible genetic cause for ANSD considered and referral made to genetic service.

870
Repeat ABR: 8 weeks CA
Still no repeatable response to click ABR at 85 dBeHL
CMs recorded R&L
No repeatable response to 1kHz tpABR at 90 dBeHL
875 No obvious behavioural responses.
NHSP ANSD guidelines v 2.2 Page 25 of 29
 Interpretation
 Bilateral ANSD with no evidence of maturation
 Possible genetic cause
Management
880  Parents commenced home sign language tuition
 For close support & monitoring from ToD
 Review for behavioural testing as early as possible

Audiology review: 5 months CA

885 Parents & ToD report no observed responses to loud sounds at home.
VRA: Conditioned to vibrotactile stimulation. No response to warble tones using inserts at maximum
levels – 100 dBHL at 0.5 kHz and 120 dBHL at 1,2 & 4 kHz R or L.
Tymps: normal R&L.

890 Interpretation
 Behavioural testing and parental/ToD observations are all consistent with severe/profound
bilateral hearing loss
 Genetic cause suspected in view of lack of other risk factors
Management
895  Discussed with parents and agreed to hearing aid trial. Aids fitted, programmed to
behavioural responses.
 Cochlear implant referral discussed with parents.

At 7 months CA
900 Insert VRA continues to show profound bilateral hearing loss
Limited response to hearing aids
Producing vibrotactile vowel sounds only. Beginning to show understanding of sign.
Satisfactory developmental progress.

905 Interpretation
 Bilateral profound hearing loss with no evidence of maturation
 Genetic cause strongly suspected
Management
 After discussion, referred to cochlear implant programme
910 - Appropriate to go ahead with CI referral without further delay.

NHSP ANSD guidelines v 2.2 Page 26 of 29

 Appendix 2: Delayed maturation and the timing of repeat ABR testing

915 Version 1.1 of these guidelines recommended carrying out repeat ABR tests at 8-10 weeks corrected
age and 9-15 months to help differentiate long-term ANSD from delayed maturation. Guidance on the
repeat ABR at 8-10 weeks is unchanged, but we have now revised the guidance for the second
repeat ABR. We suggest that a re-test should be considered at 12-18 months of age but that the
decision whether or not to carry out this re-test should depend on the circumstances of the individual
920 case. In making this decision, the following factors need to be taken into account:

i) Age of maturation of ABR

Anecdotally, any maturation of the ABR occurs by around 18 months of age, but there appear to be
17
few reported studies in the literature. Psaromattis et al reported recovery of the ABR after 4-6
925 months in 12 out of 20 NICU graduates diagnosed with ANSD (original click ABR threshold >
18
70dBnHL; threshold on re-test ≤ 40 dBnHL). Attias& Raveh reported 5 cases of high risk neonates
being considered for cochlear implantation who showed full or partial recovery of the ABR on re-test
8
7-12 months after diagnosis. Madden et al reported improved behavioural thresholds 1-15 months
after diagnosis, with a stable audiogram reached by 11-25 months, in 9 out of 18 infants, but do not
930 report whether any changes in ABR were seen.

ii) Practicalities of testing

ABR testing under natural sleep is often difficult to achieve in this older age group, and sedation may
well be required. However co-morbidities in many of these children may mean that sedation is contra-
935 indicated. Sometimes the child may be undergoing sedation or anaesthesia for treatment of some
other condition, and it may be possible to arrange to repeat the ABR at the same time.

iii) Parent counselling

Experience has shown that careful counselling of parents around the repeating of ABR tests is
940 needed. As noted above, sleep can be difficult to achieve and the re-test session may prove to be a
long and difficult one for parent and child. In the case of a child who is showing good behavioural
responses to sound, it can be very discouraging to a parent if the repeat ABR still shows an abnormal
response. It is important that parents understand that active monitoring of the child’s behavioural
responses and speech & language development is the key factor in determining their ongoing
945 management and outcome. It helps if these issues have been discussed with parents to prepare
them for the different possible outcomes of the re-test before this is carried out.

iv) Patient management

The practical issues outlined above need to be weighed up against the likely usefulness of the repeat
950 ABR result in management of the patient. For example, if the child at this age is showing convincing
and reliable behavioural responses consistent with a severe/profound hearing loss, and poor speech
& language development, then active audiological management (including consideration of CI referral)
is clearly indicated and a further abnormal ABR test may not add to the picture. Conversely, if the
child is showing good behavioural responses and good speech & language development, whilst it
955 would be informative and encouraging to demonstrate an improved ABR, ongoing follow-up and
monitoring of the child’s speech & language development would still be recommended until more
subtle auditory processing difficulties have been ruled out. However, ongoing use of the ANSD label
in these cases may not be helpful.

NHSP ANSD guidelines v 2.2 Page 27 of 29

 960 Appendix 3: Additional Tests

The following tests may be valuable in the ongoing assessment of infants and children with ANSD.

a) Speech discrimination testing

965 This should be attempted at as young an age as possible, including testing in noise. In addition to
testing in the clinic, speech discrimination ability should also be evaluated in the child’s natural
environment (e.g. home, nursery) – this may be done in conjunction with education and/or speech-
language therapy colleagues. Further work is needed on developing age-appropriate tools that are
sophisticated enough to look in sufficient detail at early speech/language/communication development
970 in order to inform the management of young infants with ANSD.

b) Advanced electrophysiological techniques

i) Electrocochleography(ECochG) and Electrically-Evoked ABR (E-ABR)
Recent studies have indicated that these tests may have a role in narrowing down site of lesion and
37,38
975 helping determine cochlear implant candidacy . Studies using trans-tympanic electrocochleography
have identified two abnormal potentials in some ANSD patients: an “abnormal positive potential”
(enlarged summating potential) which has been interpreted as indicating a pre-synaptic disorder and
may give a good CI prognosis, and a “dendritic potential” which has been interpreted as indicating a
post-synaptic disorder and therefore likely to indicate poorer CI outcome. At implantation, ANSD
980 patients with a normal electrically-evoked ABR have gone on to have good post-implant speech
perception ability, whilst those with an abnormal E-ABR have had poor post-implant speech
perception ability. However, these are invasive techniques which are still at a research stage and
further work is needed.

985 ii) Cortical Auditory Evoked Potentials (CAEPs)

31-34,39
There is emerging evidence that the presence or absence of auditory cortical responses in
patients with ANSD might provide an insight into the degree of an individual’s dys-synchrony and
whether hearing aids are likely to be helpful. The mechanism of this is unclear. Sharma and
33,34
colleagues suggest abnormal, or dys-synchronous, patterns of sub-cortical transmission, which
990 occur in children with more disabling degrees of ANSD, have the potential to disrupt normal cortical
development and it is this abnormal cortical development that explains the failure to evoke cortical
responses. An alternative basis for the lack of recordable cortical responses in some patients with
39
ANSD has been proposed by Neary & Lightfoot : it requires only a modest degree of temporal dys-
synchrony to “smear” the relatively short latency responses of the ABR but it takes a correspondingly
995 greater degree of dys-synchrony to abolish the longer latency cortical response. So, if both the ABR
and CAEPs are absent then it is reasonable to conclude the dys-synchrony is profound and the
prognosis with amplification may be poor; if the ABR is absent but cortical responses are present the
degree of dys-synchrony is likely to be modest and therefore the prognosis for amplification is better.

1000 Thus, cortical testing may have potential in informing patient management and could guide the
expectations of patients or their parents. The recording of cortical responses to auditory stimuli is
practical in older children and adults but the routine testing of infants is currently not yet standard
clinical practice.

1005

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 Appendix 4: Medical Assessment

Key elements in the assessment of infants identified with ANSD should include:

1010  Detailed history, including family history, neonatal factors e.g. gestation, hypoxia, assisted
ventilation, hyperbilirubinaemia, intraventricular haemorrhage, hydrocephalus, convulsions

 Examination, particularly focused on neurological and developmental assessment

1015  Imaging – MRI brain and internal auditory meati to assess integrity of the VIIIth and VIIth
nerves

 Ophthalmology assessment – particularly looking for evidence of visual cortical dysfunction,

optic disc pathology
1020
 Peripheral nerve conduction studies –if generalized neuropathy suspected

 Referral to a geneticist, particularly if a neurodegenerative condition is suspected, although at

the time of publication of these guidelines genetic testing for OTOF or other implicated genes
t
1025 is not available via the NHS in the UK .

 Metabolic studies as indicated by relevant clinical features – e.g. urine amino acids

Acquired ANSD is particularly associated with a neurodegenerative or metabolic aetiology and

1030 these children especially require detailed neurological assessment and investigation.
Neurodevelopmental history, speech and language development, and neurological abnormalities
should be noted in detail.

t
This situation may change in the near future
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