应用40Hz听觉事件相关电位（40HzAERP）和听觉脑干诱发电位（ABR）客观评定听阈的法医学研究
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摘要
前言
在临床法医学活体鉴定中，涉及听力障碍程度评定的案例很多，听力障碍程度的不同直接关系到案件的裁定与判决。在实际工作中，无论是损伤程度鉴定还是伤残等级评定，对听力损害等级的划分均以言语频率纯音测听气导听阈均值下降的分贝数作为评定损伤程度或伤残等级的依据。但由于被鉴定人进行纯音测听时经常存在诈聋及夸大听力损失的情况，因此，运用客观听力检测方法进行听阈评定在法医学上具有十分重要的意义。
近年来，由于听觉脑干诱发电位(ABR)不受被检者主观意识、睡眠、药物的影响，因此作为客观听力检测方法在法医学鉴定中已广泛应用。鉴定中主要根据其V波反应阈值来评估主观听阈。但由于ABR潜伏期很短(仅1～2ms)，因此诱发它的刺激声音的有效部分不能比它长，一般多用宽频的瞬态声—短声。虽然短声频谱较宽，但以3～4kHz为主，主要反映高频听力情况。因此，要了解受试耳对言语的听觉状况，则需用500～2000Hz频率特性的声音刺激。要用低强度低频声引出可辨认的ABR，必须用上升时间短的刺激声。而对低频声来说，上升时间越短，不应有的声能就越多，因此要用500Hz或1000Hz低频声，同时又要有效地引出ABR，是很难办到的。因此用短声诱发的ABR主要提供高频听力信息，难以很好反映低频听力的信息，不能精确测定频率特性与强度关系。因此，单独用ABR进行客观听力检测难以准确评定言语频率范围的听力情况。
40Hz听觉事件相关电位(40Hz AERP)，是用每秒40次重复率的刺激声所诱发出的听觉中潜伏期反应(MLR)，又称为40Hz听稳态诱发电位。其原理是MLR的三个主要波峰Pa、Pb和Pc的
波间期大约为 25 ms，因此重复率为 25 ms的声刺激能使这些波的
出现时间互相重叠，各波的振幅增大而易于辩认。Szyfer等证实，
40HZ AERP阈值比 ABR阈值更接近主观听阈，且具有良好的频率
特性，涵盖了人耳的言语听阈，可以比较准确地反映言语频率的听
阈，对听力障碍者是一种贿频率特异性听阈评估的有效方法尼
弥补ABR在反映低频听力时的不足。
由于40Hi AERP目前在国内的应用较少，特别是在法医学鉴
定中如何应用40Hi AEgn客观评价听觉功能障碍还有待进一步
研究。为此，本研究拟对40Hi AERP和 ABR的频率特性、与主观
听阈之间的关系及其在法医学上应用的意义等进行研究，旨在寻
找法医学鉴定中客观听力评估的最佳方法、注意事项等，进而提高
听觉功能障碍客观评定的科学性与准确性。
试验对象和方法
选纯音测听主观听阈结果可信，年龄17－53岁，分为听力正
常组和听力障碍组。听力正常组40人62耳，听力异常组20人共
24耳，进行40HZ AERP及ABR的测定。40HZ AERP用每秒重复
39．1次的短纯音（Tone）作刺激声。刺激频率为0．sk、Ik．Zk、
4kHz，刺激持续时间 100po，带通滤波 10J，叠加 500次。电
极用针刺电极，颅顶中心部置记录电极，受试侧乳突置参考电极，
前额部近发际处置接地电极，电极阻抗小于5 kfl，电极间电阻相
差小于3kfl。受试者中10人20耳进行自然睡眠及清醒两种状态
下的 IkHZ的 40HZ AERP反应阈测定。ABR用短声＊阮k）刺激，
带通滤波 100－1500Hi，刺激声重复率 9．8似S，刺激持续时间
100呷，叠加三mO次。受试者闭目安静躺于隔声电屏蔽实验室内
的检查床上。测试频率从 0．sk开始，依次为 Ik在广kffe，每测定
40Hi AERP一个频率休息5J 分钟。从60dB开始引出波形后
向下每10dB一档下降，接近反应阈时按sdB～档下降，重复记录
·2·
2次。此外，记录 60dB、40 dB＼30dB、20 dB处的波幅。ABR刺激
声从80dB开始，引出波形后再做60dB、40dB，然后再向下每 10dB
一档下降。接近反应阈时按5 dB一档下降，重复记录2次。
结 果
86耳给予 0．5－4kHZ 60dB以上强度的声刺激，84耳引出
40HZ AE班，其中有听力障碍的 2耳在 0、sk、Ik、Zk HZ 80dB时引
出 40Hi n旺，82耳引出 ABR，有4耳在 105dB时也未引出 ABR。
62例正常耳40HZ AERP及ABR与纯音测试结果：40HZ AEAERP反
应阈较纯音测听气导主观听阈高，两者之间有一定的差值，在不同
的频率差值不同，在 0．skHz为 6．57。3．519dBnHL（以下简称
dB），IkHZ为 7．82。3．52dB，ZkHZ为 10．65 i4．46dB，4 kHz为
13．99。5．13dB。40HZ AEgy反应阈与纯音测听主观听阈均值比
较图显示在0．skJ 在 HZ时40HZ AERP反应阈直线部分与主
观听阈几乎平行，接近主观听阈，而在ZkHz到4kHZ段两条线逐
渐远离。以反应阈为自变量，主观听阈为因变量作40HZ AERP反
应阈与纯音测听主观听阈的线性回归方程，其中在0．sk＊ 上。
4kHz回归方程分别是：Y＝0．90x－4．52，相关系数为 0．90；Y＝
0．94－6．49x，相关系数为 0．89 ； Y＝0．75x－5．53，相关系数为 0．
78；卞一0．79X一8．52，相关系数为 0．79。ABR反应阈与 0．sk、Ik。
ZkAkHz不同频率纯青测听主观听阈之间差值的均值分别为：6．
外士
Introduction
There are many cases involved the degree of injury and the grade of disability because of the auditory obstacles on the living body appraisal in clinical forensic medicine. The various degrees of the auditory obstacles are directly related to judge the cases. But in practice we evaluate the degrees of injury and disability caused by traffic incident. The divide of the degree of auditory injury is basis on the dB decrease of equal number about pure tone of speaking frequency - testing threshold of audibility through air. The patients appear the different phenomena of pretending deafness and aggrandizing the auditory losing. So the methods of objective auditory testing have very important significance in forensic medicine research.
In recent years ABR have been widely applied to forensic medicine appraisal as a way of objective auditory test because it is not affected by the subjective consciousness, sleeping of the examinee and the medicament. Behavior threshold of audibility are usually computed with the threshold of V - wave reaction. ABR latent period disappear very quickly just in 1 ~ 2ms. The effective port of sound stimulation, which induces ABR, could not be longer than it and just be wink -sound and short sound in wide frequency. But the short sound is wider and hard to test the relationship between frequency characteristic and intension. So ABR caused by short sound could only provide the information of auditory in higher frequency, but not in lower one. That is to say that the accurateness of results is influenced if ABR is only used in objective auditory testing.
Szyfter has approved that 40 Hz AERP threshold volume is closer to subjective auditory threshold than ABR, and that it has well frequency characteristic, and include spoken language auditory threshold of human ears. AERP is sensitive to the auditory losing in low, middle, and high frequency, which could reflect accurately spoken language auditory threshold. So it is an effective evaluation method of auditory threshold that has frequency specialty for auditory obstacle. So it makes up the lack of ABR reflection on low frequency audibility.
Now there is very limit about combining 40 Hz AERP and ABR to evaluate the objective audibility. It is also waiting for the further research that how to apply 40 Hz AERP to evaluate auditory obstacles objectively in forensic medicine. For this my research plans to study frequency specialty of 40Hz AERP, relationship with the subjective auditory threshold and significance of the combining use with ABR in forensic medicine. I aim to look for the best way and notice items, which enhance the evaluation scientifically and accurately.
Subjects and Methods
In my test, there are 17 - 53 years old people who are divided into normal group and abnormal group, normal group 40 people (62ears) , abnormal group 20 people (24ears) have experienced pure sound testing and the test of 40Hz AERP and ABR. 40Hz AERP use short pure sound ( Tone) repeated 39. 1 times per second as stimulate sounds. The stimulate frequency are 0. 5k, Ik, 2k and 4kHz, duration 100us, filter the waves 10 ~ 100Hz, repeat 500 times. Using needle electrode, placing record electrode on the center of skull peak, reference electrode on filter mastoid process in test direction and grounding electrode on forehead where is near the hair. Impedance of
electrode is lower than 5 k, and resistance discrepancy between the e-lectrodes is lower than 3kfl. In examinees 10 people (20ears) received the 40Hz AERP reaction threshold test of 1kHz both under natural sleepjng and waking. ABR sound stimulation use short sound (click) , filter the waves 100 -1500Hz, scan time 9. 8s, duration 100us, repeat 1000 times. Examinees close their eyes; keep quiet and lay on the examining table in the lab room equipped with sound insulation and electric shield facilities.
Results
Above the 60dB intensions (0. 5 ~4kHz) of sound stimulations are given to 86 ears, as the result 84 ears elicited 40Hz AERP, 82 ears elicited ABR. The test result of 40Hz AER
在临床法医学活体鉴定中，涉及听力障碍程度评定的案例很多，听力障碍程度的不同直接关系到案件的裁定与判决。在实际工作中，无论是损伤程度鉴定还是伤残等级评定，对听力损害等级的划分均以言语频率纯音测听气导听阈均值下降的分贝数作为评定损伤程度或伤残等级的依据。但由于被鉴定人进行纯音测听时经常存在诈聋及夸大听力损失的情况，因此，运用客观听力检测方法进行听阈评定在法医学上具有十分重要的意义。
近年来，由于听觉脑干诱发电位(ABR)不受被检者主观意识、睡眠、药物的影响，因此作为客观听力检测方法在法医学鉴定中已广泛应用。鉴定中主要根据其V波反应阈值来评估主观听阈。但由于ABR潜伏期很短(仅1～2ms)，因此诱发它的刺激声音的有效部分不能比它长，一般多用宽频的瞬态声—短声。虽然短声频谱较宽，但以3～4kHz为主，主要反映高频听力情况。因此，要了解受试耳对言语的听觉状况，则需用500～2000Hz频率特性的声音刺激。要用低强度低频声引出可辨认的ABR，必须用上升时间短的刺激声。而对低频声来说，上升时间越短，不应有的声能就越多，因此要用500Hz或1000Hz低频声，同时又要有效地引出ABR，是很难办到的。因此用短声诱发的ABR主要提供高频听力信息，难以很好反映低频听力的信息，不能精确测定频率特性与强度关系。因此，单独用ABR进行客观听力检测难以准确评定言语频率范围的听力情况。
40Hz听觉事件相关电位(40Hz AERP)，是用每秒40次重复率的刺激声所诱发出的听觉中潜伏期反应(MLR)，又称为40Hz听稳态诱发电位。其原理是MLR的三个主要波峰Pa、Pb和Pc的
波间期大约为 25 ms，因此重复率为 25 ms的声刺激能使这些波的
出现时间互相重叠，各波的振幅增大而易于辩认。Szyfer等证实，
40HZ AERP阈值比 ABR阈值更接近主观听阈，且具有良好的频率
特性，涵盖了人耳的言语听阈，可以比较准确地反映言语频率的听
阈，对听力障碍者是一种贿频率特异性听阈评估的有效方法尼
弥补ABR在反映低频听力时的不足。
由于40Hi AERP目前在国内的应用较少，特别是在法医学鉴
定中如何应用40Hi AEgn客观评价听觉功能障碍还有待进一步
研究。为此，本研究拟对40Hi AERP和 ABR的频率特性、与主观
听阈之间的关系及其在法医学上应用的意义等进行研究，旨在寻
找法医学鉴定中客观听力评估的最佳方法、注意事项等，进而提高
听觉功能障碍客观评定的科学性与准确性。
试验对象和方法
选纯音测听主观听阈结果可信，年龄17－53岁，分为听力正
常组和听力障碍组。听力正常组40人62耳，听力异常组20人共
24耳，进行40HZ AERP及ABR的测定。40HZ AERP用每秒重复
39．1次的短纯音（Tone）作刺激声。刺激频率为0．sk、Ik．Zk、
4kHz，刺激持续时间 100po，带通滤波 10J，叠加 500次。电
极用针刺电极，颅顶中心部置记录电极，受试侧乳突置参考电极，
前额部近发际处置接地电极，电极阻抗小于5 kfl，电极间电阻相
差小于3kfl。受试者中10人20耳进行自然睡眠及清醒两种状态
下的 IkHZ的 40HZ AERP反应阈测定。ABR用短声＊阮k）刺激，
带通滤波 100－1500Hi，刺激声重复率 9．8似S，刺激持续时间
100呷，叠加三mO次。受试者闭目安静躺于隔声电屏蔽实验室内
的检查床上。测试频率从 0．sk开始，依次为 Ik在广kffe，每测定
40Hi AERP一个频率休息5J 分钟。从60dB开始引出波形后
向下每10dB一档下降，接近反应阈时按sdB～档下降，重复记录
·2·
2次。此外，记录 60dB、40 dB＼30dB、20 dB处的波幅。ABR刺激
声从80dB开始，引出波形后再做60dB、40dB，然后再向下每 10dB
一档下降。接近反应阈时按5 dB一档下降，重复记录2次。
结 果
86耳给予 0．5－4kHZ 60dB以上强度的声刺激，84耳引出
40HZ AE班，其中有听力障碍的 2耳在 0、sk、Ik、Zk HZ 80dB时引
出 40Hi n旺，82耳引出 ABR，有4耳在 105dB时也未引出 ABR。
62例正常耳40HZ AERP及ABR与纯音测试结果：40HZ AEAERP反
应阈较纯音测听气导主观听阈高，两者之间有一定的差值，在不同
的频率差值不同，在 0．skHz为 6．57。3．519dBnHL（以下简称
dB），IkHZ为 7．82。3．52dB，ZkHZ为 10．65 i4．46dB，4 kHz为
13．99。5．13dB。40HZ AEgy反应阈与纯音测听主观听阈均值比
较图显示在0．skJ 在 HZ时40HZ AERP反应阈直线部分与主
观听阈几乎平行，接近主观听阈，而在ZkHz到4kHZ段两条线逐
渐远离。以反应阈为自变量，主观听阈为因变量作40HZ AERP反
应阈与纯音测听主观听阈的线性回归方程，其中在0．sk＊ 上。
4kHz回归方程分别是：Y＝0．90x－4．52，相关系数为 0．90；Y＝
0．94－6．49x，相关系数为 0．89 ； Y＝0．75x－5．53，相关系数为 0．
78；卞一0．79X一8．52，相关系数为 0．79。ABR反应阈与 0．sk、Ik。
ZkAkHz不同频率纯青测听主观听阈之间差值的均值分别为：6．
外士
Introduction
There are many cases involved the degree of injury and the grade of disability because of the auditory obstacles on the living body appraisal in clinical forensic medicine. The various degrees of the auditory obstacles are directly related to judge the cases. But in practice we evaluate the degrees of injury and disability caused by traffic incident. The divide of the degree of auditory injury is basis on the dB decrease of equal number about pure tone of speaking frequency - testing threshold of audibility through air. The patients appear the different phenomena of pretending deafness and aggrandizing the auditory losing. So the methods of objective auditory testing have very important significance in forensic medicine research.
In recent years ABR have been widely applied to forensic medicine appraisal as a way of objective auditory test because it is not affected by the subjective consciousness, sleeping of the examinee and the medicament. Behavior threshold of audibility are usually computed with the threshold of V - wave reaction. ABR latent period disappear very quickly just in 1 ~ 2ms. The effective port of sound stimulation, which induces ABR, could not be longer than it and just be wink -sound and short sound in wide frequency. But the short sound is wider and hard to test the relationship between frequency characteristic and intension. So ABR caused by short sound could only provide the information of auditory in higher frequency, but not in lower one. That is to say that the accurateness of results is influenced if ABR is only used in objective auditory testing.
Szyfter has approved that 40 Hz AERP threshold volume is closer to subjective auditory threshold than ABR, and that it has well frequency characteristic, and include spoken language auditory threshold of human ears. AERP is sensitive to the auditory losing in low, middle, and high frequency, which could reflect accurately spoken language auditory threshold. So it is an effective evaluation method of auditory threshold that has frequency specialty for auditory obstacle. So it makes up the lack of ABR reflection on low frequency audibility.
Now there is very limit about combining 40 Hz AERP and ABR to evaluate the objective audibility. It is also waiting for the further research that how to apply 40 Hz AERP to evaluate auditory obstacles objectively in forensic medicine. For this my research plans to study frequency specialty of 40Hz AERP, relationship with the subjective auditory threshold and significance of the combining use with ABR in forensic medicine. I aim to look for the best way and notice items, which enhance the evaluation scientifically and accurately.
Subjects and Methods
In my test, there are 17 - 53 years old people who are divided into normal group and abnormal group, normal group 40 people (62ears) , abnormal group 20 people (24ears) have experienced pure sound testing and the test of 40Hz AERP and ABR. 40Hz AERP use short pure sound ( Tone) repeated 39. 1 times per second as stimulate sounds. The stimulate frequency are 0. 5k, Ik, 2k and 4kHz, duration 100us, filter the waves 10 ~ 100Hz, repeat 500 times. Using needle electrode, placing record electrode on the center of skull peak, reference electrode on filter mastoid process in test direction and grounding electrode on forehead where is near the hair. Impedance of
electrode is lower than 5 k, and resistance discrepancy between the e-lectrodes is lower than 3kfl. In examinees 10 people (20ears) received the 40Hz AERP reaction threshold test of 1kHz both under natural sleepjng and waking. ABR sound stimulation use short sound (click) , filter the waves 100 -1500Hz, scan time 9. 8s, duration 100us, repeat 1000 times. Examinees close their eyes; keep quiet and lay on the examining table in the lab room equipped with sound insulation and electric shield facilities.
Results
Above the 60dB intensions (0. 5 ~4kHz) of sound stimulations are given to 86 ears, as the result 84 ears elicited 40Hz AERP, 82 ears elicited ABR. The test result of 40Hz AER
引文
1． 谭起．聋儿听力检测。听力学及言语疾病杂志，1996，4(2) ：105-107．
2． 顾瑞，于黎明．聋儿听性脑干反应和40Hz听觉相关电位测试． 中华耳鼻喉科杂志，1989，24(3) ：130-132．
3． Szyfter w ,Dauman R ,de Sauvage RC.40Hz middle latency re-sponses to low frequency tone pips in normally hearing adults.Oto-laryngol,1984,Oct,13(5) :275-80．
4． Musiek FE ,Geurkink Na ,Weider DJ ,et al.Past ,present ,and future applications of the auditory middle latency response.Laryngoscope ,1984,Dec ,94(12 pt 1) :1545-53．
5． Stapells DR,Linden D,Suffield JB,et al.Human anditory Steady state potentials.Ear Hear ,1984,Max-Apr,5(2) :105-13．
6． Lenarz T,Gulzow J,Grozinger M,et al.Clinical evaluation of 40Hz middle-latency responses in adults:frequency,specific threshold estimation and suprathreshold amplitude characteristics.ORL J Oto-rhinolaryngol Relat Spec,1986,48(1) :24-32．
7． 傅宝田．40Hz听觉相关电位的正常值．中华耳鼻咽喉科杂志， 1988，23(3) ：156-158．
8． Musiek FE ,Geurkink NA.Auditory brainstem and middle latency evoked response sensitivity near threshold.Ann Otol Rhinol Laryn-gol,1981,May-Jun ,90(3 PE 1) :236-40．
9． Kileny P,shea SL.Middle-latency and 40-Hz auditory evoked responses in normal-hearing subjects:click and 500-Hz thresholds.J Speech Hear Res,1986 ,Mar,29(1) :20-8．
10． Spydell JD,Patte G,Goldie WD.The 40Hert auditory event-related potential:normal values and effects of lesions.Electroencepha-
logr Clin Neurophysiol, 1985, May,62 (3): 193-202.
11. Osterhammel PA, Shallop JK, Terkildsen K. The effect of sleep on the auditory brainstem response(ABR) and the middle latency response(MLR). Scand Audiol, 1985,14(1): 47-50.
12．范利华，孙红，朱广友，等．应用40Hz听觉相关电位与听性脑干反应评估听阈．法医学杂志，2000，16(4)：193—195．
13. Jerger J, Chmiel R , Frost JD Jr, et al. Effect of sleep on the auditory steady state evoked potential. Ear Hear,1986, Aug,7(4) :240-245.
14．胡艾君，包仕尧，赵合庆．豚鼠颞叶和额叶损害后听觉中潜伏期反应．听力学及言语疾病杂志，1999，7(2)：95-98．
2． 顾瑞，于黎明．聋儿听性脑干反应和40Hz听觉相关电位测试． 中华耳鼻喉科杂志，1989，24(3) ：130-132．
3． Szyfter w ,Dauman R ,de Sauvage RC.40Hz middle latency re-sponses to low frequency tone pips in normally hearing adults.Oto-laryngol,1984,Oct,13(5) :275-80．
4． Musiek FE ,Geurkink Na ,Weider DJ ,et al.Past ,present ,and future applications of the auditory middle latency response.Laryngoscope ,1984,Dec ,94(12 pt 1) :1545-53．
5． Stapells DR,Linden D,Suffield JB,et al.Human anditory Steady state potentials.Ear Hear ,1984,Max-Apr,5(2) :105-13．
6． Lenarz T,Gulzow J,Grozinger M,et al.Clinical evaluation of 40Hz middle-latency responses in adults:frequency,specific threshold estimation and suprathreshold amplitude characteristics.ORL J Oto-rhinolaryngol Relat Spec,1986,48(1) :24-32．
7． 傅宝田．40Hz听觉相关电位的正常值．中华耳鼻咽喉科杂志， 1988，23(3) ：156-158．
8． Musiek FE ,Geurkink NA.Auditory brainstem and middle latency evoked response sensitivity near threshold.Ann Otol Rhinol Laryn-gol,1981,May-Jun ,90(3 PE 1) :236-40．
9． Kileny P,shea SL.Middle-latency and 40-Hz auditory evoked responses in normal-hearing subjects:click and 500-Hz thresholds.J Speech Hear Res,1986 ,Mar,29(1) :20-8．
10． Spydell JD,Patte G,Goldie WD.The 40Hert auditory event-related potential:normal values and effects of lesions.Electroencepha-
logr Clin Neurophysiol, 1985, May,62 (3): 193-202.
11. Osterhammel PA, Shallop JK, Terkildsen K. The effect of sleep on the auditory brainstem response(ABR) and the middle latency response(MLR). Scand Audiol, 1985,14(1): 47-50.
12．范利华，孙红，朱广友，等．应用40Hz听觉相关电位与听性脑干反应评估听阈．法医学杂志，2000，16(4)：193—195．
13. Jerger J, Chmiel R , Frost JD Jr, et al. Effect of sleep on the auditory steady state evoked potential. Ear Hear,1986, Aug,7(4) :240-245.
14．胡艾君，包仕尧，赵合庆．豚鼠颞叶和额叶损害后听觉中潜伏期反应．听力学及言语疾病杂志，1999，7(2)：95-98．