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PubMed2004

Auditory brainstem implantation in patients with neurofibromatosis type 2.

OBJECTIVES: Multichannel auditory brainstem implants (ABI) are currently indicated for patients with neurofibromatosis type II (NF2) and schwannomas involving the internal auditory canal (IAC) or cerebellopontine angle (CPA), regardless of hearing loss (HL). The implant is usually placed in the lateral recess of the fourth ventricle at the time of tumor resection to stimulate the cochlear nucleus. This study aims to review the surgical and audiologic outcomes in 18 patients implanted by our Skull Base Surgery Team from 1994 through 2003. STUDY DESIGN: A retrospective chart review of 18 patients with ABIs. METHODS: We evaluated demographic data including age at implantation, number of tumor resections before implantation, tumor size, surgical approach, and postoperative surgical complications. The ABI auditory results at 1 year were then evaluated for number of functioning electrodes and channels, hours per day of use, nonauditory side effect profile and hearing results. Audiologic data including Monosyllable, Spondee, Trochee test (MTS) Word and Stress scores, Northwestern University Children's Perception of Speech (NU-CHIPS), and auditory sensitivity are reported. RESULTS: No surgical complications caused by ABI implantation were revealed. A probe for lateral recess and cochlear nucleus localization was helpful in several patients. A range of auditory performance is reported, and two patients had no auditory perceptions. Electrode paddle migration occurred in two patients. Patient education and encouragement is very important to obtain maximum benefit. CONCLUSIONS: ABIs are safe, do not increase surgical morbidity, and allow most patients to experience improved communication as well as access to environmental sounds. Nonauditory side effects can be minimized by selecting proper stimulation patterns. The ABI continues to be an emerging field for hearing rehabilitation in patients who are deafened by NF2.

Adolescent↗
PubMed1985

Similarity of dynamic range adjustment in auditory nerve and cochlear nuclei.

Rate versus level functions were recorded for responses to best-frequency (BF) tones of 116 cochlear nucleus units and 53 auditory-nerve fibers in the presence of interrupted tone backgrounds and continuous noise backgrounds of various intensities. The backgrounds shifted the dynamic ranges of rate-level functions to higher test intensities, so in the presence of backgrounds, rate saturation occurred at higher intensities than in quiet. The shift in saturation intensity evoked by each background was measured by comparing the rate-level function recorded with the background to one recorded without. The relation between change in saturation intensity and background intensity could be approximated by the formula (formula: see text) delta Isat is the shift in saturation intensity, I is the background intensity, theta is the threshold for evoking shift, and A is the ratio of shift to background intensity re theta. In the appendix, it is shown that A is a measure of a unit's ability to avoid saturation by the background stimulus. The optimal value of A is unity, at which point a unit's operating range is infinite. The value of A depended on BF for interrupted tone backgrounds, but not for continuous noise backgrounds. For BF less than 10 kHz, the mean value of A for tone backgrounds was 0.33 in the auditory nerve, 0.37 in the ventral cochlear nuclei (VCN), and 0.47 in the dorsal cochlear nucleus (DCN). The difference between auditory nerve and VCN was not statistically significant. For BF greater than 10 kHz, the mean A was 0.16 in auditory nerve and 0.30 in VCN. The mean value of A for noise backgrounds was 0.79 in auditory nerve, 0.86 in VCN, 0.86 in DCN units of response types II and III, and 1.04 in DCN type IV units. Only the differences between DCN type IV and the non-DCN unit groups were statistically significant. The qualitative changes produced in rate-level functions by tone and noise backgrounds were similar in auditory nerve and cochlear nuclei except for DCN type IV units. The shifts in rate functions produced by interrupted tone backgrounds did not prevent saturation of the rate response at background intensities above the dynamic range of the unit as recorded in quiet. However, the rate response to test tones was preserved in the presence of all noise background levels used (up to a 30-dB spectrum level). The shift in rate function produced by the noise was almost sufficient to allow the unit to encode test intensity relative to noise background intensity.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1975

Modification of auditory and somatosensory system activity during pupillary conditioning in the paralyzed cat.

The role of sensory systems in the development of behavioral conditioned responses was investigated by recording multiple-unit activity in the auditory and somatosensory pathways during Pavlovian conditioning of the pupillary-dilation responses of paralyzed cats. Establishment of conditioned pupillary-dilation responses to a white noise CS+, pupillary discrimination between the CS+ and a tone CS-, and subsequent discrimination reversal provided the behavioral foundation for examining neural changes related to behavioral learning. Multiple-unit responses to the acoustic CS+ were significantly enhanced in the auditory cortex, cochlear nucleus, and somatic cortex, but not in the cuneate nucleus. The possibility that these effects could be due to changes in stimulus intensity at the sensory receptor, to mo-ement artifacts, or to feedback from skeletal responses were ruled out because the animals were immobilized. Nor could these neural changes be attributable to sensitization, as those brain areas which showed conditioned enhancement to the CS+ exhibited significantly larger responses to the CS+ than to the CS-. Furthermore, the changes in neural activity followed the significance of the CS; after reversal of the reinforcement contingencies, the amount of multiple-unit activity evoked by the stimuli gradually reversed too. Although the somatic cortex showed conditioning and discrimination, greater stimulus specificity was found in the auditory system. Only in the somatic cortex was there a significant increase in responses to the CS- as well as the CS4. Furthermore, both somatosensory loci exhibited enhanced responses to those tactile probes presented during the acoustic CS, suggesting a phasic increase in neural excitability to all stimuli. Analysis of the number of trials required to attain an acquisition criterion indicated that the neural changes occurred first in the auditory cortex, then the cochlear nucleus, followed in turn by the somatic cortex, and finally the cuneate nucleus. However, none of these neural changes preceded acquisition of conditioned pupillary dilations. These results suggest that sensory system changes are not essential for the initial associative process. These findings indicate that the study of autonomic conditioned responses may prove beneficial in seeking the critical neural events which underlie the initial association between two stimuli. A hypothetical model, which explains the development of pupillary and sensory system conditioned responses, was also presented.

Acoustic Stimulation↗
PubMed1986

The central projections of intracellularly labeled auditory nerve fibers in cats: an analysis of terminal morphology.

The axons of physiologically characterized spiral ganglion neurons (type I) were stained throughout their arborizations in the cochlear nucleus by the intracellular injection of horseradish peroxidase (HRP). The tips of the axonal branches were marked by distinct swellings, ranging in size and shape from small boutons to large perisomatic ramifications. Electron microscopic analysis of such swellings revealed ultrastructural features characteristic of primary auditory synapses, consistent with the hypothesis that terminal swellings identifiable in the light microscope represent presynaptic endings. On the basis of light microscopic differences in size, these endings were organized into three categories. Endings of relatively small size (terminal boutons, free endings, boutons with filopodia, string endings, and small complex endings) composed 94% of all terminal endings. Within this category of small endings, there were predictable variations in relative size and regional distribution that related to the spontaneous discharge rate (SR) of the fiber. The endings of low and medium SR fibers (SR less than or equal to 18 spikes/second) were smaller on average than those of high SR fibers (SR greater than 18 spikes/second). Furthermore, there were more endings arising from the ascending branch than from the descending branch when comparing fibers of the low and medium SR group with those of the high SR group. There were not, however, obvious morphological features of this ending category that correlated with the characteristic frequency (CF, the pure tone frequency to which the neuron is most sensitive). A second category contained medium-sized complex endings, most of which formed axosomatic contacts. This category composed 4% of the population and was found in close proximity to the perikarya of globular, octopus, and spherical cells. The endings from low and medium SR fibers were smaller on average than those from high SR fibers. These endings did not vary in their parent branch distribution with respect to fiber SR, nor did they exhibit morphological features that correlated with fiber CF. The third category contained large complex endings (endbulbs of Held) and composed 2% of the ending population. Within the anteroventral cochlear nucleus, these large, complex endings made axosomatic contact with spherical cells in the anterior division and with globular cells in the posterior division. There were no systematic variations in ending size or branch distribution that correlated with fiber SR. There was, however, a relationship between ending size and fiber CF such that fibers having CFs below 4 kHz gave rise to the largest endbulbs.

Action Potentials↗
PubMed2006

Unipolar brush cells of the cerebellum are produced in the rhombic lip and migrate through developing white matter.

Unipolar brush cells (UBCs) are glutamatergic interneurons in the cerebellar cortex and dorsal cochlear nucleus. We studied the development of UBCs, using transcription factor Tbr2/Eomes as a marker for UBCs and their progenitors in embryonic and postnatal mouse cerebellum. Tbr2+ UBCs appeared to migrate out of the upper rhombic lip via two cellular streams: a dorsal pathway into developing cerebellar white matter, where the migrating cells dispersed widely before entering the internal granular layer, and a rostral pathway along the cerebellar ventricular zone toward the brainstem. Ablation of the rhombic lip in organotypic slice cultures substantially reduced the production of Tbr2+ UBCs. In coculture experiments, Tbr2+ UBCs migrated from rhombic lip explants directly into the developing white matter of adjacent cerebellar slices. The origin of Tbr2+ UBCs was confirmed by colocalization with beta-galactosidase expressed from the Math1 locus, a molecular marker of rhombic lip lineages. Moreover, the production of Tbr2+ UBCs was Math1 dependent, as Tbr2+ UBCs were severely reduced in Math1-null cerebellum. In reeler mutant mice, Tbr2+ UBCs accumulated near the rhombic lip, consistent with impaired migration through developing white matter. Our results suggest that UBCs arise from the rhombic lip and migrate via novel pathways to their final destinations in the cerebellum and dorsal cochlear nucleus. Our findings support a model of cerebellar neurogenesis, in which glutamatergic and GABAergic neurons are produced from separate progenitor pools located mainly in the rhombic lip and the cerebellar ventricular zone, respectively.

Animals↗
PubMed1991

Synaptic connections of the auditory nerve in cats: relationship between endbulbs of held and spherical bushy cells.

This report focuses on a class of large synaptic endings, the endbulbs of Held. These endings are located in the anteroventral cochlear nucleus and arise from the axons of type I spiral ganglion neurons. Axons were stained with horseradish peroxidase (HRP) using intracellular injections of single fibers or extracellular injections into the auditory nerve. Individual endbulbs or pairs of endbulbs that converged onto the same spherical bushy cell were examined with the aid of a light microscope and subjected to morphometric analyses. Endbulbs of fibers having low spontaneous discharge rates (SR, less than or equal to 18 spikes/sec) have a more complex shape than those of high SR fibers (greater than 18 s/s), a feature represented by systematic differences in endbulb silhouette perimeter without differences in endbulb silhouette area. Consequently, the ratio, silhouette area divided by silhouette perimeter, yields a "form factor" separating endbulbs of high SR from those of low SR. High SR fibers had ratios greater than 0.52 (mean = 0.63 +/- 0.09), whereas low SR fibers had ratios less than 0.52 (mean = 0.45 +/- 0.06). Pairs of endbulbs with unknown physiological properties had similar form factor values, despite the wide range of values observed in the endbulb population. These data imply that endbulbs converging upon the cell body of a spherical bushy cell arise from fibers of the same SR group. Electron microscopic examination was conducted on the endbulb of one physiologically characterized and intracellularly stained auditory nerve fiber (CF = 1.4 kHz; SR = 55 s/s) and its unstained endbulb mate with the aid of serial ultrathin sections. In addition to the well-known axosomatic synapses, these endbulbs formed axodendritic synapses: 11.7% for the HRP-labeled endbulb and 13.3% for the unlabeled endbulb. The axodendritic synapses appear to occur on dendrites of nearby spherical bushy cells and may represent a mechanism whereby single endbulbs can disperse activity to multiple neurons in the cochlear nucleus. We propose that axosomatic synapses preserve fiber SR groupings, whereas axodendritic synapses may not.

Animals↗
PubMed1997

Plasticity of the auditory brainstem: effects of cochlear ablation on GAP-43 immunoreactivity in the rat.

In the adult brain, expression of the growth associated protein GAP-43 may serve as an indicator of synaptic remodeling. We have studied localization and time course of the re-expression of GAP-43 following deafening through cochlear ablation. As a consequence of unilateral cochlear lesioning, a substantial increase in the expression of GAP-43 was observed in the neuropil of all subnuclei of the ipsilateral cochlear nuclear complex. This expression of GAP-43 occurred in well-defined fibers and boutons. In the ventral cochlear nuclei, boutons immunoreactive for GAP-43 were often localized on cell bodies. However, they were found only on selected subpopulations of cochlear nucleus neurons, i.e., on cell bodies containing glutamate or calretinin immunoreactivity, but apparently not on GABAergic neurons. Olivocochlear neurons must have been axotomized by the operation. Following cochlear ablation, a dramatic re-expression of GAP-43 occurred in cell bodies of the ipsilateral lateral superior olive but not in the ventral nucleus of the trapezoid body. Position and number of these cells suggested that most, if not all, of them serve the lateral olivocochlear bundle. However, although axon collaterals are given off by certain types of olivocochlear neurons, a direct involvement of the immunoreactive cell bodies in the emergence of GAP-43 in the cochlear nucleus is not obvious. A transient rise of GAP-43 immunoreactivity that could not be attributed to axotomized neurons was observed in the contralateral dorsal cochlear nucleus and in the ipsilateral inferior colliculus. Given the functional significance attributed to GAP-43, we conclude that the sudden loss of spiral ganglion cells leads to a reactive synaptogenesis in complex patterns across several auditory brainstem nuclei.

Aging↗
PubMed1994

Electric auditory brain-stem responses in nucleus multichannel cochlear implant users.

OBJECTIVE: The electrically elicited auditory brain-stem response (EABR) has been proposed as a tool for use in cochlear implant device setting. To systematically examine the relationships of psychophysical perceptions and EABRs, implant users underwent a series of comparative measurements. The characteristics of the EABR were assessed for their predictive value in determining the subjective measures needed to set the implant device. DESIGN: Characteristics of the EABR and various perceptual measures in a group of cochlear implant users served as compared variables in a correlational study. SETTING: The study was carried out in the audiology clinic of a university hospital. The audiology clinic maintained a fully equipped evoked potential laboratory, and was part of an otolaryngology department that supported a cochlear implant program. SUBJECTS: The subjects consisted of 10 consecutively selected postlinguistically deafened adult multichannel cochlear implant users. MAIN OUTCOME MEASURES: Morphology, latency, and amplitude measures of the EABR recordings were compared with behavioral perceptions of threshold, most comfortable and uncomfortable loudness levels. RESULTS: Perceptual measures of threshold were found to be significantly related to the threshold of the EABR across subjects and electrode position. Simple linear regression analysis was used to measure the degree of the relationship. An r value of 0.89 attests to a significant relationship. The EABR wave latencies and amplitudes were found to have no significant relationship to any of the perceptual measures examined. CONCLUSIONS: Although EABR cannot replace behavioral measurements for device setting, in difficult cases EABR thresholds may be used as a starting point from which to estimate settings for the device.

Adult↗
PubMed1983

Enkephalin systems in diencephalon and brainstem of the rat.

The immunocytochemical distribution of [Leu]enkephalin and an adrenal enkephalin precursor fragment (BAM-22P) immunoreactivity was investigated in the diencephalon and brainstem of rats pretreated with relatively high doses of colchicine (300-400 micrograms/10 microliters intracerebroventricularly). The higher ranges of colchicine pretreatment allowed the visualization of extensive enkephalin-containing systems in these brain regions, some of which are reported for the first time. Immunoreactive perikarya were found in many hypothalamic and thalamic nuclei, interpeduncular nucleus, substantia nigra, the colliculi, periaqueductal gray, parabrachial nuclei, trigeminal motor and spinal nuclei, nucleus raphe magnus and other raphe nuclei, nucleus reticularis paragigantocellularis, vestibular nuclei, several noradrenergic cell groups, nucleus tractus solitarius, as well as in the spinal cord dorsal horn. In addition to the above regions, immunoreactive fibers were also noted in the habenular nuclei, trigeminal sensory nuclei, locus coeruleus, motor facial nucleus, cochlear nuclei, dorsal motor nucleus of the vagus, and hypoglossal nucleus. When adjacent sections of those stained for [Leu]enkephalin were processed for BAM-22P immunoreactivity, it was found that these two immunoreactivities were distributed identically at almost all anatomical locations. BAM-22P immunoreactivity was generally less pronounced and ws preferentially localized to neuronal perikarya. The results of the present as well as the preceding studies (Khachaturian et al., '83) strongly suggest substantial structural similarity between the adrenal proenkephalin precursor and that which occurs in the brain. Also discussed are some differences and parallels between the distribution of [Leu]enkephalin and dynorphin immunoreactivities.

Animals↗
PubMed2001

Developmental expression of a voltage-dependent potassium channel (Kv3.1) in auditory neurons without cochlear input.

Kv3.1, a voltage-dependent potassium channel, has two forms, -a and -b, which differ in expression during development and at the onset of function in the auditory system. To determine whether cochlear nerve input could affect the expression of these two forms, cultures of the developing cochlear nucleus were explanted in the absence of the cochlear nerve at the beginning of cell migration (Hamburger-Hamilton stage 28-30), while neuroblasts continued to migrate onto the culture substrate. After 8, 15, and 22 days in vitro (three survival groups), cultures were immunostained with antibodies recognizing either both forms of Kv3.1 or only the -b form. Only young and newly migrated nerve cells were sampled. In the three survival groups, all nerve cells expressed Kv3.1, among which only 50% or less expressed the -b form. Some of the more differentiated multipolar cells expressed the -b form, but most were labeled with the antibody that recognizes both forms. Thus, in the absence of peripheral input, both forms of Kv3.1 appear at stages very early in development, although not all cells necessarily coexpress both forms. These results agree with other observations in the chick embryo in situ. They are consistent with previous work implicating Kv3.1 in cell migration during early development.

Age Factors↗
PubMed1987

Direct projections from the dorsal column nuclei and the spinal trigeminal nuclei to the cochlear nuclei in the cat.

A retrograde and anterograde wheat germ agglutinated horseradish peroxidase WGA-HRP study in the cat indicated that some neurons in the dorsal column nuclei and the interpolar and caudal spinal trigeminal nuclei send fibers to the dorsal and ventral cochlear nuclei; to the pyramidal cell layer of the dorsal cochlear nucleus and to the cochlear granule cell domain, bilaterally with an ipsilateral dominance.

Animals↗
PubMed1992

Distribution of neuronal cannabinoid receptor in the adult rat brain: a comparative receptor binding radioautography and in situ hybridization histochemistry.

The neuronal distribution of cannabinoid receptor in the adult rat brain is reported, combining receptor binding radioautography using the synthetic psychoactive cannabinoid ligand CP55,940 with in situ hybridization histochemistry using oligonucleotide probes complementary to rat cannabinoid receptor cDNA. In the cerebral cortex, especially in the frontal and cingulate cortex, dense binding was found in layers I and VI together with slight mRNA levels in a majority of both pyramidal and non-pyramidal-shaped neurons and of high mRNA levels in a moderate number of non-pyramidal-shaped neurons especially in layers II-III and V-VI. In the hippocampal dentate gyrus, very dense staining was found in the molecular layer together with high mRNA levels in a moderate number of hilar neurons close to the granular layer. In Ammon's horn, especially in the CA3 sector, very dense binding was found in the dendritic layers together with slight mRNA levels in the majority of the pyramidal cells and high mRNA levels in a moderate number of interneurons. In the basal ganglia, binding was very dense in the lateral putamen, substantia nigra pars reticulata, globus pallidus and entopeduncular nucleus, moderate in the medial putamen and caudate; and slight in the accumbens, together with slight to moderate mRNA levels in the striatal medium-sized neurons. Together with slight binding, slight to moderate mRNA levels were found in the majority of the neurons in the subthalamic nucleus. No binding and mRNA were found in the substantia nigra pars compacta and ventral tegmental area. Slight to moderate binding was found together with slight to moderate mRNA levels in the majority of neurons in the anterior olfactory nucleus; septum, especially medial septum and diagonal band of Broca; amygdala, especially basolateral amygdala; lateral habenula; ventromedial hypothalamic nucleus; lateral interpeduncular nucleus; central gray, dorsal cochlear nucleus; parabrachial nucleus; dorsal pontine tegmentum; pontine nuclei; commissural part of the nucleus tractus solitarius; inferior olive and dorsal horn of the spinal cord. In the cerebellum, very dense binding was found in the molecular layer together with slight mRNA levels in the majority of the granule cells and moderate mRNA levels in the basket and stellate cells. In conclusion, this study provides, for the first time, indirect assessment of the neurons containing cannabinoid receptor in the entire adult rat brain and will serve as a basis for future direct morphological confirmation using receptor immunohistochemistry and for functional studies.

Animals↗
PubMed2004

Group I and II metabotropic glutamate receptors are necessary for the activity-dependent regulation of ribosomes in chick auditory neurons.

Elimination of eighth-nerve activity results in the death of 30% of the neurons in the chick cochlear nucleus, nucleus magnocellularis (NM). One early event in this cell death cascade is the disruption of ribosomes in NM neurons which can be observed within 1 h following deafferentation. These rapid changes in ribosomes can be visualized using Y10B, a monoclonal antibody that recognizes ribosomal RNA. Previous studies using a brain slice preparation of the avian brain stem auditory system have shown that activation of metabotropic glutamate receptors (mGluRs) is necessary for the activity-dependent maintenance of Y10B antigenicity. The purpose of the present study was to determine if group I and/or II mGluRs are necessary for this activity-dependent regulation. This was accomplished by selectively blocking group I or II receptors while unilaterally stimulating the auditory nerve in vitro. In normal media, unilateral stimulation of the auditory nerve resulted in darker Y10B immunolabeling of NM neurons on the stimulated side of the slice. The group I antagonist (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA) and the group II antagonists LY341495 and (S)-alpha-ethylglutamic acid (EGLU) all prevented the activity-dependent difference in Y10B immunolabeling. These data suggest that both group I and II mGluRs play vital roles in the activity-dependent regulation of ribosomes in NM.

Animals↗
PubMed2004

Further prospective findings with compound action potentials from Nucleus 24 cochlear implants.

The purpose of this study was to gain greater understanding of compound action potential (CAP) specific characteristics including: slope of the growth function, P1-N1 amplitude, threshold and latencies of P1 and N1 measured in cochlear implant users. Experienced adult subjects underwent behavioral threshold (T) measurement and electrically elicited stapedial reflex (eSR) recording, followed by CAP measurements on six selected electrodes. Based on the electrically elicited stapedial reflex threshold (eSRT), maximum stimulation level for each measured electrode was set. Relationships among the three thresholds of the above measures and maximum CAP P1-N1 amplitude and slope of the growth function were statistically evaluated for each measured electrode. Threshold of the CAP response showed relationships of similar strength with eSRT and T (r=0.69 and 0.61, respectively). For both slope of the growth function and CAP P1-N1 amplitude, a statistically significant relationship with cochlear place was found. Both specific characteristics of CAP measurement for the most apical electrodes were roughly double those for the most basal electrode (alpha=0.05). This may be partially explained by cochlear anatomy and is consistent with prior mammalian and human studies showing increasing density and survival of spiral ganglion cells in the regions corresponding to intracochlear electrode placement from basal to apical electrodes (90-360 degrees ).

Action Potentials↗
PubMed1996

Explantation of a nucleus multichannel cochlear implant and re-implantation into the contralateral ear. A case report of a new strategy.

We present a unique case in which a multichannel cochlear implant device was explanted and the same device was re-implanted into the contralateral ear. A patient with bilateral total deafness secondary to head injury received an implant in his left ear but developed severe facial nerve stimulation. Because this stimulation could not be eliminated effectively with change of programming, it was decided to implant the contralateral ear. Since the device itself was functioning well, it was explanted from the left ear and re-implanted successfully into the right ear. Facial nerve stimulation was minimal in this ear and the patient demonstrated very good speech discrimination. To our knowledge, this is the first description of this strategy.

Aged↗
PubMed1998

The effects of processor strategy on the speech perception performance of pediatric nucleus multichannel cochlear implant users.

OBJECTIVE: The present investigation examined the speech perception skills of pediatric cochlear implant users who changed from their original speech processors and strategies to the Spectral Peak (SPEAK) strategy. DESIGN: A within-subjects design was used to compare individual subject's performance using the SPEAK strategy with that obtained with their previous speech strategy (FOF1F2 or Multipeak) in this retrospective study. The subjects demonstrated a wide range of perceptual abilities and had used a cochlear implant for varying lengths of time before converting to the SPEAK strategy. RESULTS: Nine of the 11 subjects showed significant improvement on at least one of the open-set word recognition measures, whereas two subjects showed no change on any of the open-set measures when using the SPEAK strategy. CONCLUSIONS: The present results suggest that the majority of pediatric cochlear implant users are likely to show improved speech perception performance when converting to the new SPEAK processing strategy.

Audiometry, Pure-Tone↗