Hearing Research 306 (2013) 11e20

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Hearing Research
journal homepage: www.elsevier.com/locate/heares

Research paper

Transmission of bone conducted sound e Correlation between hearing

perception and cochlear vibration
Måns Eeg-Olofsson a, *, Stefan Stenfelt b, Hamidreza Taghavi c, Sabine Reinfeldt c,
Bo Håkansson c, Tomas Tengstrand d, Caterina Finizia a
a
Department of Otorhinolaryngology Head and Neck Surgery, Sahlgrenska University Hospital, The Sahlgrenska Academy, Göteborg University,
Gröna Stråket 5, S-413 45 Göteborg, Sweden
b
Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
c
Department of Signals and Systems, Chalmers University of Technology, Göteborg, Sweden
d
Department of Technical Audiology, Sahlgrenska University Hospital, Göteborg, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: The vibration velocity of the lateral semicircular canal and the cochlear promontory was measured on 16
Received 15 June 2013 subjects with a unilateral middle ear common cavity, using a laser Doppler vibrometer, when the
Received in revised form stimulation was by bone conduction (BC). Four stimulation positions were used: three ipsilateral posi-
26 August 2013
tions and one contralateral position. Masked BC pure tone thresholds were measured with the stimu-
Accepted 28 August 2013
Available online 15 September 2013
lation at the same four positions. Valid vibration data were obtained at frequencies between 0.3 and
5.0 kHz. Large intersubject variation of the results was found with both methods. The difference in
cochlear velocity with BC stimulation at the four positions varied as a function of frequency while the
tone thresholds showed a tendency of lower thresholds with stimulation at positions close to the co-
chlea. The correlation between the vibration velocities of the two measuring sites of the otic capsule was
high. Also, relative median data showed similar trends for both vibration and threshold measurements.
However, due to the high variability for both vibration and perceptual data, low correlation between the
two methods was found at the individual level. The results from this study indicated that human hearing
perception from BC sound can be estimated from the measure of cochlear vibrations of the otic capsule. It
also showed that vibration measurements of the cochlea in cadaver heads are similar to that measured in
live humans.
Ó 2013 Elsevier B.V. All rights reserved.

1. Introduction transducer results in a standardized and known perception of the

If the vibration level of a transducer is high enough, stimulation
of bone conducted (BC) sound can be heard from any position of the
head, and most probably from other positions on the body as well.
One problem is that in practice, only stimulation at the mastoid
(and to some extent, the forehead) using a Radioear B-71
Abbreviations: AC, air conduction; BAHA, Bone anchored hearing aid; BC, bone
conduction; BCI, bone conduction implant; CSF, cerebrospinal fluid; dB, decibels;
HL, hearing level; LDV, laser Doppler vibrometer; LSCC, lateral semicircular canal;
MAPP, mastoid surface area that attaches to the petrous part of the temporal bone;
SD, standard deviation; SNR, signal to noise ratio; TA, transcranial attenuation
* Corresponding author. Tel.: þ46 706569586.
E-mail addresses: manseegolofsson@gmail.com, m.eeg-o@bredband2.com
(M. Eeg-Olofsson), stefan.stenfelt@liu.se (S. Stenfelt), taghavi@chalmers.se
(H. Taghavi), sabine.reinfeldt@chalmers.se (S. Reinfeldt), boh@chalmers.se
(B. Håkansson), tomas.tengstrand@vgregion.se (T. Tengstrand), caterina.finizia@
orlss.gu.se (C. Finizia).
BC stimulation, as specified by the Reference Equivalent Threshold
Force Level in the international standard ISO 389-3 (1994). This
means that when the transducer and/or position are altered, the BC
perception is altered and reference data are required (McBride
et al., 2008). Such normalization is burdensome and requires a
large number of humans for the data to be reliable. Another way to
estimate the sensitivity of the BC stimulation has been proposed by
the measure of cochlear vibration (Buchman et al., 1991; Eeg-
Olofsson et al., 2008, 2011; Håkansson et al., 2008; Håkansson
et al., 2010; Stenfelt, 2005; Stenfelt, 2006; Stenfelt and Goode,
2005b; Stenfelt et al., 2000, 2002, 2003b, 2004a, 2004b). Even if
vibration data have shown correlation to perceptual data (Stenfelt,
2012), there are no publications of direct measures linking BC
perception and cochlear vibrations.
One issue is how valid the cochlear vibrations are for estima-
tions of BC hearing and another issue is how the vibrations of the
cochlea should be measured. Unlike for air conduction (AC), where

0378-5955/$ e see front matter Ó 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.heares.2013.08.015
12 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
the ear canal sound pressure serves as an easily accessible good
proxy of the cochlear stimulation (given a normal functioning
middle ear), the measurement of cochlear vibration during BC vi-
bration is complicated. As a consequence, most measures of
cochlear vibration have been conducted in temporal bones, dry
skulls, and cadaver heads (Eeg-Olofsson et al., 2008, 2011;
Håkansson et al., 2008; Håkansson et al., 2010; Stenfelt, 2006;
Stenfelt and Goode, 2005b; Stenfelt et al., 2000, 2002, 2003b,
2004a, 2004b). To complicate things further, BC perception is not
an isolated phenomenon but several pathways contribute to the
perception (Stenfelt, 2011; Stenfelt and Goode, 2005b; Stenfelt
et al., 2002, 2003a; Tonndorf, 1966). However, it has been shown
that a vibration of the otic capsule produces basilar membrane
vibration patterns similar to that with AC stimulation (Stenfelt
et al., 2003b). Also, it is hypothesized that inertial effects of the
fluid in the cochlea is the major cause for BC response in the normal
ear at frequencies below 4.0 kHz (Stenfelt, 2011; Stenfelt and
Goode, 2005b; Stenfelt et al., 2004a). Thus, when the cochlea vi-
brates the inner ear fluid flows between the scala vestibuli and the
scala tympani without any deformation of the cochlear walls.
Above 4.0 kHz other pathways contribute to the basilar membrane
stimulation, for example compression and expansion of the
cochlear walls (Stenfelt and Goode, 2005a; Tonndorf, 1962). Stim-
ulation of the inner ear through the cerebrospinal fluid (CSF) has
also been proposed as a contribution to BC sound perception
(Sohmer et al., 2000) based on the connection between the inner
ear and the CSF through bony canals. If sound transmission from
the CSF is important for BC sound, the vibration of the cochlea may
not be related to the perception of BC sound and estimation of BC
sound from cochlear vibrations would be invalid. However, there is
no indication that the CSF route is a major contributor for BC sound
in the normal ear (Stenfelt and Goode, 2005b).
The vibration of the cochlea has been measured with acceler-
ometers (Buchman et al., 1991; Stenfelt, 2005; Stenfelt, 2006;
Stenfelt and Goode, 2005b; Stenfelt et al., 2000) or by a laser
Doppler vibrometer (LDV) (Eeg-Olofsson et al., 2008, 2011;
Håkansson et al., 2008; Håkansson et al., 2010; Stenfelt, 2006;
Stenfelt and Goode, 2005b; Stenfelt et al., 2002, 2003b, 2004a,
2004b). Even if only accelerometers have been reported for the
estimation of the three-dimensional response of the cochlea
(Stenfelt and Goode, 2005b; Stenfelt et al., 2000), LDVs can be used
to measure the cochlear vibration in three-dimensions as well. The
drawback of using accelerometers is their size and that they require
a physical bond with the vibrating surface. The latter is difficult to
accomplish when measuring the cochlear vibrations, especially in
live humans. The LDV measures the velocity of the vibrations at a
point with a thin laser beam enabling contactless measurements.
Studies on dry skulls and cadaver heads have used a single point
LDV measuring one-dimensional response of the cochlear prom-
ontory (Eeg-Olofsson et al., 2008, 2011; Håkansson et al., 2008;
Håkansson et al., 2010; Stenfelt and Goode, 2005b; Stenfelt et al.,
2000). These studies have used the lateral-medial direction (here-
after termed x-direction) as the response direction with the argu-
ment that it is close to the maximum vibration level of the cochlea
for any direction when the stimulation is at the skull surface
(Stenfelt and Goode, 2005b). As stated above, there are several
studies that have measured the cochlear vibration in cadaver heads
but no reports on the cochlear vibration in live humans. Moreover,
no study on the correlation between the cochlear vibration and the
perceptual data in the same subjects has been published.
To enable comparison of cochlear vibration and perception of BC
sound, for example BC hearing thresholds, hearing assessment and
visible cochlear structures are required in the same subjects. Such
subjects can be found among individuals who have been treated for
chronic ear disease with a surgical method of the middle and the
outer ear called “radical mastoidectomy”. This surgical method
implies that the posterior ear canal wall is removed and the ear
canal opening is widened. If the middle ear space is sealed, it is
called a modified radical mastoidectomy. The result in both cases is
called a middle ear common cavity. When examining an ear with a
middle ear common cavity, the lateral semicircular canal (LSCC) is
often exposed as well as the cochlear promontory. In previous
cadaver studies (Eeg-Olofsson et al., 2008, 2011; Håkansson et al.,
2008; Håkansson et al., 2010; Stenfelt and Goode, 2005b; Stenfelt
et al., 2000) the cochlear promontory was used as a target for the
laser beam. The cochlear promontory is easily exposed when lifting
the tympanic membrane and removing the middle ear ossicles. In a
live human with normal ear anatomy, this is not possible unless it is
done during middle ear surgery. Therefore, in this study, we have
included subjects with a middle ear common cavity where the laser
beam can be aimed through the wide ear canal opening. In these
subjects, the LSCC and/or the cochlear promontory are accessible
for vibration measurements using an LDV.
Both the LSCC and the cochlear promontory are part of the hard
bone encapsulating the inner ear structures. This hard bone is
called the otic capsule. At low enough frequencies, the otic capsule
is expected to vibrate as a rigid body in response to BC stimulation.
This means that the LSCC and the cochlear promontory velocity
responses are hypothesized to be similar. However, this hypothesis
needs to be validated.
The aims of this study are to:
1. Investigate the vibration pattern of the otic capsule in live
humans during BC stimulation and compare it to similarly ob-
tained cochlear vibration patterns in human cadavers presented
in the literature.
2. Investigate the relation between the otic capsule vibration and
BC hearing thresholds.
3. Investigate the relation of the vibration level between the
cochlear promontory and the LSCC during BC sound stimulation.
2. Materials and methods
This study was approved by the Regional Ethical Review board,
Göteborg.
2.1. Subjects and stimulation positions
The estimation of a sufficient sample size for the statistical an-
alyses was based on a power analysis using LDV data from a pre-
vious cadaver study (Eeg-Olofsson et al., 2008) with a power of 0.8.
The power analysis was based on the frequency response of the
cochlear vibration from ipsilateral BC stimulation positions similar
to those in the current study. The results from the power analysis
suggested that 14 subjects should be included. Patients were
identified from the database at the clinic of Otolaryngology Head
and Neck surgery at the Sahlgrenska University Hospital, Göteborg,
Sweden, as being due for a “cleaning of a middle ear common
cavity”. In total, 21 subjects were invited with the following in-
clusion criteria: (1) unilateral middle ear common cavity (test ear
side). (2) No major conductive impairment at the contralateral
(non-test) ear (an average air-bone gap 25 dB was accepted at
frequencies between 0.5 and 4.0 kHz). Sensorineural hearing loss at
the contralateral ear was accepted. (3) Either the LSCC or the
cochlear promontory (or both) visible in the test ear with an ear
microscope.
Of the 21 invited subjects, 4 declined to participate. One addi-
tional subject terminated the study after some initial testing.
Consequently, 16 subjects (7 females, 9 males, average age 48 years
 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20 13

ranging from 24 to 70 years) remained and completed the study

(see Table 1). Twelve subjects had access to both the cochlear
promontory and the LSCC, one subject only to the cochlear prom-
ontory, and in three subjects only to the LSCC.
The BC stimulation was generated by a B-71 transducer (Radi-
oear corp., USA) that was placed at four different predefined loca-
tions on the head. The same transducer was used for all
measurements. The B-71 was calibrated for the output force level
using a Brüel & Kjær artificial mastoid Type 4930 (Brüel & Kjær,
Nærum, Denmark) before and after the tests. A steel-spring head-
band kept the transducer at the positions with a static force of
approximately 5.4 N (Newtons). The four stimulation positions
where termed position A to D. Positions A, B and C were on the
ipsilateral side of the skull (the same as the test ear) and position D
was on the contralateral side opposite to position A (Fig. 1). First, a
straight line was identified with the direction from the lateral angle
of the eye (angulus oculi lateralis) and the upper boarder of the
pinna. Position A was the point where a 55 mm line from the
posterior boarder of the ear canal opening attached to the first line.
This is normally the position where an implant for the Bone
anchored hearing aid (BAHA) is attached (Tjellström et al., 2001).
Position B was as close to the pinna as possible on the line between
position A and the ear canal opening. During the measurements,
the pinna was pushed forward and secured with sticky tape to
avoid contact between the transducer casing and the pinna. Posi-
tion C was on the zygomatic root close to, but without touching, the
tragus. The distances between positions A and B as well as between
positions A and C were recorded. Position D was located using the Fig. 1. The four stimulation positions are shown and their identification illustrated.
same procedure as for position A, but on the contralateral side. Position A is 55 mm behind and slightly above the ear canal opening (normal site for
Bone anchored hearing aid implant). Position B is closer to the ear canal opening, on
the line between position A and the ear canal opening. Position C is on the zygomatic
2.2. Hearing thresholds root in front of the tragus. Position D is same as position A but on the contralateral side.

Hearing thresholds were obtained in a 6.5 m2 and 14.9 m3 sound
attenuated room according to ISO 8253-1 (2010). Masking in the
contralateral (non-test) ear was achieved by a deeply inserted
standard ER-2 plug. All thresholds were estimated by the ascending
method of Hughson-Westlake (ISO 8253-1 (2010)). First, non-
masked AC hearing thresholds at the non-test ear was obtained
for the frequencies 0.25, 0.5, 1, 2, 4, 6, and 8 kHz using a 5 dB step-
size. These thresholds were used to determine the masking levels
for the BC threshold measurements with stimulation at the posi-
tions AeD. Then, at the same ear and for the same frequencies,
masked BC thresholds were obtained using narrow-band masking
noise according to ISO 389-4 (1994). Masked BC hearing thresholds
at one-third octave frequencies between 0.25 and 8 kHz (total 16
frequencies) were then obtained with stimulation at the positions
AeD using 5 dB step-size and narrow-band masking of the non-test
ear.
To ensure that the thresholds were not affected by airborne
sound radiation from the BC transducer, the ear canal sound pres-
sure was monitored at 1 and 4 kHz using an ER7C probe-tube
microphone (Etymotic research Inc, Elk Grove Village, IL 60007,
USA). The ear canal sound pressure was measured with BC stimu-
lation at positions A, B and C at a level of 50 dB HL and the results

Table 1
Individual data for the 16 subjects. BAHA ¼ Bone anchored hearing aid; A, B, C, ¼ stimulation positions; Prom ¼ Promontory; LSCC ¼ Lateral semicircular canal; PTA ¼ Pure tone
average; nt ¼ non-test ear; t ¼ test ear; SSD ¼ Single sided deafness.

Subject Sex Age BAHA Distance (mm) Prom LSSC PTA AC nt PTA BC nt PTA AC t 1/3 octave
AeB/AeC 0.25, 0.5, 1.0, 2.0/4.0, 6.0, 8.0 kHza 0.25, 0.5, 1.0, 2.0/4.0, 6.0, 8.0 kHz 0.25e2.0/2.5e8.0 kHz

1 M 70 Y 38/80 Y Y SSD SSD 59/70

2 M 67 N 30/59 N Y 38/58 24/45 72/71
3 F 64 Y 36/72 Y Y 28/65 34/62 (no result 8 kHz) 80/95 (no result 4, 5, 6.3, 8 kHz)
4 M 56 Y 36/76 Y Y 10/47 24/33 (no result 8 kHz) 95/>110 (discharge test ear)
5 M 54 N 38/69 N Y 28/55 6/50 47/72
6 F 54 Y 29/67 Y Y 31/38 26/45 74/65
7 F 53 Y 40/73 Y Y 5/28 25/12 79/78
8 M 51 N 24/64 N Y 23/47 16/22 49/74 (no result 8 kHz)
9 F 48 Y 37/77 Y N 28/28 0/10 56/41
10 M 47 N 20/59 Y Y 8/17 8/13 41/51
11 F 41 Y 26/72 Y Y 9/12 10/8 45/43
12 M 41 N 31/71 Y Y 1/15 11/20 67/46
13 F 36 N 32/62 Y Y 4/8 8/10 45/41
14 F 31 N 31/65 Y Y 4/8 10/17 59/57
15 M 24 N 27/68 Y Y 9/8 0/0 55/62
16 M 38 N 30/66 Y Y 11/18 0/17 27/43
a
Unmasked.
14 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
were recalculated to the sound pressure level at BC hearing
thresholds. The same transducer was used at all measurements.
The results showed that the calculated sound pressure level in the
ear canal at masked BC threshold for position A, B and C were lower
than the masked AC threshold of the test ear for all subjects. In
other words, the thresholds were not affected by airborne sound
radiation from the BC transducer.
During the initial analysis of the results an unfortunate proce-
dural error was discovered and the threshold measurements were
remeasured. When the initial thresholds for position D were
measured, the masking was incorrectly in the test ear. Another
problem at the initial threshold measurements was that the stan-
dard masking procedure (plateau technique) was not always suf-
ficient to mask the non-test ear. A substantial part of the thresholds
were heard in the non-test ear or in the middle of the head. As a
result, at the second session when the thresholds were remeasured,
the masking procedure was changed (described below) and warble
tones were used. Both sessions included threshold measurements
at all positions at 16 frequencies between 0.25 and 8.0 kHz with 1/3
octave resolution. The following presents the masking level pro-
cedure used at the second session which always started at position
D:
An initial non-masked threshold was obtained. If the tone was
heard in the test-ear, the masking level was set as the AC threshold
of the non-test ear plus 20 dB. However, if the tone was heard in the
non-test ear, the masking level was raised starting at the AC
threshold level of the non-test ear until:
a. the tone was not heard. Then the masking level and the tone
level were raised parallel until the tone was heard in the test ear.
b. the tone was heard in the test ear.
The masking level was then set at a 20 dB higher level. There-
after, a masked threshold was obtained using 5 dB step size. From
this threshold, a more detailed masked threshold was obtained
using a 2 dB step size. The same threshold procedure was applied at
the other positions using the stored masking level obtained for
position D at each frequency.
If the tone was heard in the non-test ear or in the middle of the
head despite the described masking procedure, the subject was
instructed to indicate this and the threshold obtained was marked
as “wrong ear” or “both ears”. These marked thresholds were not
included in the analysis of the thresholds. Also, if no threshold
could be obtained for the reason of overmasking, no result was
registered for that specific frequency.
2.3. Laser measurements
The identification of the 4 positions A, B, C and D was done by
the first author. The measurements order for the LDV testing was:
A, B, C, D, A. The data from the second measurement at position A
were compared to the first measurement at position A and used to
estimate the test-retest reliability.
The beam of the LDV (HLV-1000, Polytech Gmbh, Waldbronn,
Germany) was aimed at the skin covered cochlear promontory or
the LSCC. To ensure a good reflection of the laser beam, small glass
spheres (P-Retro-x, Polytec) 45e63 mm in diameter were posi-
tioned on the cochlear promontory and/or the LSCC using a thin
steel pin with a cotton tip. The glass spheres were removed after
finishing the measurements. The signal level to the B-71 was
0.25 V rms and was fed from a signal analyzer (Agilent 35670A).
The level 0.25 V rms was chosen since it was deemed to be suffi-
ciently high to exceed the noise floor but still presented the sound
at a level below the discomfort level. Thus the output level in dB HL
was varying depending on the properties of the transducer at
different frequencies. The same signal analyzer recorded the
response signal from the LDV. The stimulation was a stepped sine
between 0.1 and 10 kHz with a 1/64 octave band frequency reso-
lution (total 401 frequencies). The result was a frequency response
function of the velocity of the cochlear promontory and the LSCC.
Three measurement sweeps were done and averaged for each
stimulation position, both for the cochlear promontory and the
LSCC.
Two noise estimates were made to investigate the quality of the
measurements; one estimate with 100% laser beam reflection and
one with approximately 50% laser beam reflection as indicated on
the LDV apparatus. Almost all measurements of the LSCC and the
cochlear promontory vibration were done with a laser beam
reflection close to 100%. The results were recalculated to a BC
stimulation level of 1 N using the calibration data of the B-71
transducer. This recalculation allowed comparisons with previous
studies (Eeg-Olofsson et al., 2008, 2011).
2.4. Statistical methods
Wilcoxon’s signed rank test was used in order to test differences
between positions within each frequency (third octave band).
Spearman correlation was calculated for a pair of variables within
each frequency band. The correlation coefficients were then tested
with Wilcoxon’s signed rank test. All tests were two-tailed.
3. Results
3.1. General results
The distance between position A and B was on average
32  6 mm (1 standard deviation (SD)), and between position A and
C on average 69  6 mm (1 SD). The individual results are given in
Table 1. The distance variation is primarily caused by the subjects’
anatomy differences, but also a result from BAHA fixture abutments
in two subjects. These abutments were at, or in the vicinity of,
position A and in subjects 3 and 9 position A was slightly behind
and below the normal position A to avoid interference with the
BAHA abutment.
Due to the generic design of the transducer (B71), the stimula-
tion force levels at the transducereskull interface are low at low
and high frequencies. To ensure a valid response of the LDV mea-
surements it was decided to only include data with a signal to noise
ratio (SNR) of a minimum 10 dB. When the responses from the LDV
were analyzed and compared to measurements of the noise only, a
valid frequency range for all measurements was determined to be
at frequencies between 0.3 kHz and 5.0 kHz. As a consequence,
even if all LDV measurements were done with a frequency range of
0.1e10.0 kHz, the LDV results are only presented at frequencies
between 0.3 and 5.0 kHz. When the first and second measurement
at position A was analyzed, the test-retest difference was on
average below 0.5 dB (the average absolute difference was below
2.8 dB).
3.2. Velocity response of the otic capsule
In three subjects the promontory was not exposed and in one
subject the LSCC was not exposed. In the twelve subjects with both
measurement sites exposed, the measured velocities were analyzed
and compared. For all four stimulation positions, the mean differ-
ence between the promontory and the LSCC was close to 0 dB
(range: 0.1 dB to 0.3 dB) and the mean absolute difference was
below 1.7 dB. Together with the high correlation between results
from the two sites (r > 0.8, p < 0.001) they were deemed similar. As
a consequence, data from the subjects with both sites measured
 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
Fig. 2. The magnitude of the velocity of the otic capsule measured by the LDV at 1 N
stimulation at position A. The thin lines show the individual results from 16 subjects
and the thick line shows the median result.
were calculated as the average from those sites, and used in the
analysis.
The vibration magnitude from 16 subjects as well as their me-
dian result is shown in Fig. 2 as the velocity response of the otic
capsule when the B71 transducer was at position A. All data are
recalculated to a stimulation level of 1 N. Even if all curves have
similar morphology, there are differences in the vibration magni-
tude amounting to about 4 times between the highest and lowest
magnitude. It should be noted that there is no overall best and
worst subject in terms of vibration magnitude but the high and low
results differ among the subjects at the different frequencies. There
are indications of both resonances and anti-resonances in the re-
sponses, but no general similarity of their appearances among the
curves is apparent. The term “anti-resonance” is here used to
denote sharp minima in the measured response.
Fig. 3. The magnitude of the velocity of the otic capsule measured by the LDV at 1 N
stimulation. The results are presented as the median result of positions AeD from 16
subjects. Position A: solid line; position B: dashed line; position C: dashed-dotted line;
position D: dotted line.
15
Fig. 4. The velocity magnitude of the otic capsule measured by the LDV at position B
(standard position for BC audiometry). The stimulation level is recalculated to the
reference equivalent threshold force level (RETFL) at 0 dB HL. For frequencies in-
between standard frequencies the data are interpolated. Included is also an arbitrary
velocity with a constant acceleration of the cochlea. Position B: solid line; constant
acceleration: dotted line.
3.3. Velocity response at different positions
In Fig. 3 the median absolute velocity responses from positions
A, B, C and D are displayed. Below 1.0 kHz there is an anti-resonance
around 0.4 kHz followed by a steep increase in velocity. From 1.0 to
2.0 kHz stimulation at position B gives the highest vibration ve-
locity. Above 2.0 kHz, the velocity responses are similar for the
stimulation positions. In Fig. 4 the vibration velocity response of the
otic capsule is shown when the stimulation is at position B. Here,
the stimulation is recalculated to 0 dB HL, i.e. the threshold level for
normal hearing subjects. Reference force levels are taken from ISO
389-3 (1994) and levels at frequencies not included in the standard
were interpolated. When shown in this way, there is a general
decrease in the vibration level with frequency. Also included in the
figure is an arbitrary dotted line with a slope of 20 dB/decade. As
can be seen, the slope of the dotted line follows approximately the
slope of the cochlear vibration response at frequencies between
0.4 kHz and 4.0 kHz. The dotted line corresponds to a constant
acceleration level, and it can be concluded that at this frequency
range, normal hearing thresholds are obtained at the same cochlear
acceleration level.
In Fig. 5 the velocity responses from position B, C and D in
relation to position A are displayed. The response functions are
recalculated from the initial 1/64 octave resolution to 1/3 octave
resolution for two reasons. First, the primary aim of this study was
to compare the vibration of the otic capsule with perceptual data,
and the tone thresholds were obtained at a resolution of 1/3 octave.
Second, the statistical analyses was based on 1/3 octave resolution
to make the result meaningful. Looking at the median data for all
subjects there are large response differences for the stimulation
positions in the frequency range 0.3 kHze2.0 kHz. Above 2.0 kHz
the different positions give a similar velocity response with only
minor differences.
3.4. Tone thresholds at different positions
All results of the threshold measurements with BC stimulation
at the four positions are from the second session. The result from
16 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
Fig. 5. The median velocity level of the otic capsule at positions B, C, D relative to
position A with a 1/3 octave frequency resolution. Position B re A: solid line; position C
re A: dashed line; position D re A: dotted line.
the threshold measurements are presented as relative differences
in threshold level related to position A (Fig. 6). As displayed here, a
positive result means better sensitivity (lower threshold) at the
position compared with position A. There is an overall trend of
better thresholds with stimulation closer to the cochlea (positions B
and C). In more detail, position B gives 0e5 dB better thresholds
than position A except between 2.5 kHz and 5.0 kHz where they are
similar or position A slightly better. Position C is up to 5 dB more
sensitive at the higher frequencies but at the low frequencies,
below 0.8 kHz, the thresholds are 5e10 dB worse than position A.
Position D has overall 0e5 dB worse thresholds than position A.
3.5. Correlation between tone thresholds and the velocity response
of the otic capsule
LDV data are compared with tone thresholds from session two.
The median data for the LDV and the hearing thresholds are dis-
played in Fig. 7aec. There are general similarities between the LDV
and threshold data, but also differences. The largest differences are
found at the lowest frequencies for all positions, but general
agreement is seen at frequencies above 0.8e1.0 kHz.
3.6. Comparison of the two tone audiogram sessions
The two separate tone audiograms were executed with an in-
terval of 2e5 months. Data from the first audiogram session are not
presented in the current article. When comparing the two sessions
there was an overall higher threshold level in the second session,
most likely due to the change of masking procedure. In session one,
12% of the results were disregarded in the analysis due to hearing
the tone in the wrong ear or that the tone was heard in the middle
of the head. In session two, this percentage was 1%.
3.7. Statistical analysis
The high correlation between the vibration results of the
promontory and the LSCC was described previously. However,
there were large individual differences in the relative vibration
response and tone thresholds for the stimulation positions. Wil-
coxon’s signed rank test showed significant differences of the ve-
locity response at the otic capsule from stimulation at positions B
Fig. 6. BC tone audiometry at 16 frequencies with a 1/3 octave frequency resolution.
The results are presented as the median threshold from positions B, C, D relative to
position A. A positive value indicates better (lower) threshold at the position compared
with position A. The threshold difference is given on the left y-axis with thick lines
while the standard deviations of the estimates are presented on the right y-axis with
thin lines. Position B re A: solid line; position C re A: dashed line; position D re A: dotted
line.
and C in relation to position A: at 1.0e1.6 kHz for position B
(p < 0.05) and at 0.315e1.0 kHz and 2.5 kHz for position C
(p < 0.05). No significant differences were found for stimulation at
position D in relation to position A. Significant threshold differ-
ences between positions B, C and D in relation to position A were
found between 0.5e1.6 kHz and at 8.0 kHz for position B (p < 0.05),
at 0.315, 0.4, 2.5, 3.15 and 8.0 kHz for position C (p < 0.05), and at
0.3e0.5, 0.8 and 1.25e2.0 kHz (p < 0.05) for position D. Moreover
the correlation between the relative tone thresholds and the rela-
tive vibration results was low while Wilcoxon’s signed rank test
only indicated a statistical significant difference below 0.8 kHz for
positions B, C and D, and at one additional frequency at 2.0 kHz for
position D.
4. Discussion
4.1. Laser Doppler vibrometry measurements
Laser Doppler vibrometry has been reported in measurements
of cochlear vibration in cadavers and dry skulls. The rationale for
those studies, e.g. (Eeg-Olofsson et al., 2008, 2011; Håkansson et al.,
2008; Håkansson et al., 2010; Stenfelt and Goode, 2005b; Stenfelt
et al., 2000) is that the vibration of the cochlea is correlated to a
hearing perception. To our knowledge, this is the first time that
vibration measurements of the otic capsule during BC stimulation
of live humans are reported. This is also the first time these vi-
brations are compared to hearing thresholds in the same
individual.
To ensure quality of the data, a restrictive SNR of better than
10 dB was used for the measurements. According to that restriction,
data are presented in the frequency range 0.3e5.0 kHz where the
measurements gave results above this SNR limit. The problem with
the stimulation levels and low SNRs in the measurements are
inherent to the B-71 transducer and the transducereskull interface.
At low frequencies, the skull impedance is high, which reduces the
vibration stimulation from the transducer, and an increase of
stimulation level (higher input to the transducer) would result in
large amount of distortion from the transducer itself, which is not
acceptable. At the high frequencies, it is primarily a resonance in
 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20 17

Fig. 7. Sensitivity difference between positions in dB for the cochlear velocity and the
Fig. 8. The relative level of the cochlea measured by the LDV in the current study from
tone threshold results. The data are displayed as the median velocity and threshold
the positions B, C, D relative to position A, compared with published cadaver data.
result from positions B (graph a), C (graph b), D (graph c) relative to position A. The
Position B (graph a), position C (graph b) and position D (graph c) relative to position A.
results are presented so that a positive value indicates improved sensitivity. Tone
Present study: solid line; Eeg-Olofsson et al., 2008 or 2011: dashed line.
thresholds: solid line; velocity: dashed line.
18 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
the transducer design at around 4 kHz that results in reduced
stimulation level above this resonance frequency. Once again,
higher stimulation levels might produce non-linear distortion as
well as being perceived as too loud for the test subjects with near-
normal cochlear function.
Another issue is the use of glass sphere reflectors to enhance the
backscatter of the laser beam. Similar glass spheres were used in
previous studies with valid results (Eeg-Olofsson et al., 2008, 2011;
Stenfelt and Goode, 2005b; Stenfelt et al., 2002). In this study the
same method was used but the glass spheres were larger in
diameter. The promontory and the LSCC are closely situated in the
same bony structure and thus the velocity response from BC
stimulation is expected to be similar using glass sphere reflectors.
Since the velocity responses from the promontory and the LSCC are
highly correlated, and the transfer function of vibrations in the skull
is assumed to be linear (Flottorp and Solberg, 1976; Håkansson
et al., 1996; Smith and Suggs, 1976) the vibration measured at the
otic capsule is suggested to be valid.
When the current results are compared with the velocity re-
sponses from previous studies (Eeg-Olofsson et al., 2008, 2011) the
current responses differ from previous data. One difference is that
the stimulation is through the skin in this study while previous
studies used a direct coupling to the skull. That can, at least partly,
explain the 5e10 dB lower results at the higher frequencies in the
current study, that are in line with previous estimates (Håkansson
et al., 1984, 1985; Stenfelt and Håkansson, 1999). It is also clear that
the dry skull data (Stenfelt et al., 2000) is dissimilar indicating that
a dry skull is not a good model for estimating cochlear response
during BC stimulation. However, there is a general agreement be-
tween cadavers’ and live humans’ cochlear response suggesting
that preserved human cadaver heads can be used to estimate skull
vibrations during BC stimulation. The caveat is that the current
study measured the vibration on the skin covering the otic capsule
and not directly at the bone as in the other studies. However, if the
difference is due to the skin at the stimulation site alone, or is also
affected by the skin covering the otic capsule in the current study is
impossible to determine. Consequently, even if the skin at the otic
capsule may have affected the current results, its effect is deemed
small.
The velocity response of positions B, C and D in relation to po-
sition A for the current study and Eeg-Olofsson et al. (2008, 2011)
are illustrated in Fig. 8aec. Even if the overall patterns are similar
there are minor differences, especially for position C. In the Eeg-
Olofsson et al. (2008) study, the velocity response differences at
the higher frequencies was 5e15 dB for position C relative to po-
sition A. This large difference is not found in the current study. The
difference in stimulation method, through the skin here and
directly to the bone in Eeg-Olofsson et al. (2008) does not explain
the difference seen as the data are relative measures. The root of the
zygomatic bone has a sharp lateral angle which can give difficulties
when trying to get a stable and medially directed stimulation force
for the transducer when applied on the skin. On the cadavers, the
transducereskull interface was through a rigid titanium screw
where both the stability and the direction of the stimulation force
were controlled. The method inequality and the fact that position C
in the cadavers was positioned slightly closer to the ear canal, could
explain the velocity response difference between cadavers and live
humans seen at position C.
Many authors have described a damping effect of BC vibration in
a live human skull (Franke, 1956; Gurdjian et al., 1970; Håkansson
et al., 1986; Khalil, 1979). These comparisons were made to dry
skulls but the difference between a human cadaver skull and a live
human skull is not described. The data from the current study
compared with previous cadaver head studies indicate that the
damping of BC sound in the human skull (e.g. damping of skull
resonances) are similar in the cadaver head and the live human
skull, but differ significantly to the dry skull. Another difference is
that the current study only included subjects with a middle ear
common cavity. In Eeg-Olofsson et al. (2008) the mastoids were
intact for the stimulation positions discussed here. Position B is
approximately 3.1 cm from the ear canal opening. This is on the
border of, or most likely, just outside the mastoid surface area that
attaches to the petrous part of the temporal bone (MAPP) (Eeg-
Olofsson et al., 2008). Within the MAPP-area, an increase in vi-
bration transmission to the ipsilateral cochlea was noted in Eeg-
Olofsson et al. (2008). An intact mastoid might have an important
influence on vibration transmission from the skull to the cochlea.
When the velocity data with stimulation at position B were
related to normal hearing thresholds (RETFL, Fig. 4) the response
was similar to a constant acceleration at frequencies between 0.4
and 4 kHz. This analysis is slightly outside the topic for the current
study, but the interesting finding is worth mentioning. The con-
stant acceleration implies that the mass of the cochlear interior, the
cochlear fluids, are affected by a constant force due to inertial ef-
fects (inertial forces). It has been proposed that the cochlear
response during BC excitation at frequencies below 4 kHz is
dominated by fluid inertia (Stenfelt and Goode, 2005b). Even if the
current result is not an irrefutable evidence for fluid inertia being
an important contributor to BC hearing, it is a strong indication of
its importance.
4.2. Tone audiometry results
It should be noted that the threshold estimation is not done
according to normal standard procedure in several aspects. Hearing
thresholds were tested at 16 frequencies at all four positions on the
head. Further, the level resolution to obtain the thresholds was
2 dB. The masking procedure was also different from the standard.
These differences may alter the thresholds compared to normal
clinical routine. However, the focus was on the relative threshold
between stimulation positions, not the actual threshold per se. Even
if the resolution of 2 dB do not enhance the accuracy in terms of the
variance between tests (Jerlvall and Arlinger, 1986), it facilitates
higher precision in the comparisons with the laser results, espe-
cially at the individual level.
Several factors add to the uncertainty in psychoacoustic testing.
The approximate duration for the threshold measurements was 1 h
and 20 min including a 10 min pause. Fatigue can influence the
results. To minimize the effect of fatigue the test was balanced
between positions. Another issue is the masking noise that could
rise to high values, especially if the non-test ear had a hearing loss,
or if the sound transmission to the test ear was low. High masking
levels lead to a higher degree of central masking, and can also cause
masking noise to be transmitted by means of BC to the test ear.
However, since a fixed masking level procedure was used, the same
masking level was used for all four positions and the relative
measures are valid.
The transcranial attenuation (TA) is a measure that has a clinical
interest for masking in BC hearing assessment and also for reha-
bilitation in single sided deafness. Another important aspect is the
fact that BC sound stimulates both cochleae which has implications
for binaural hearing with bone conduction hearing devices. The
results from earlier studies (Hurley and Berger, 1970; Nolan and
Lyon, 1981; Snyder, 1973) show 0e15 dB TA in the frequency
range 0.25e4 kHz with large individual differences. A recent study
(Stenfelt, 2012) reported that the average TA in a group of in-
dividuals with single sided deafness was close to 2.5 dB comparing
the corresponding positions A and D in the current study. In the
same study, the TA was on average 5.0 dB when measured between
positions B on both sides of the skull. It was also concluded that the
 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
Fig. 9. The relative difference between tone thresholds and cochlear vibration when
the stimulation is at positions B, C, and D relative to position A. The data are arranged
so that a positive value indicates greater increase in vibration data compared with the
threshold data. The median relative difference is given on the left y-axis while the
standard deviations of the differences are presented on the right axis. Position B re A:
solid line; position C re A: dashed line; position D re A: dotted line.
average threshold improvement comparing positions B and A was
2.5 dB. The latter meaning that the difference in TA between po-
sitions A and B emanates from the relative thresholds at the ipsi-
lateral side. The results from Stenfelt (2012) are similar to this study
indicating limited threshold differences between positions and
large spread between individuals.
4.3. Correlation between tone audiometry and velocity response of
the otic capsule
One of the aims in this study was to investigate the correlation
of the velocity of the otic capsule during BC stimulation to hearing
thresholds. If the vibration of the otic capsule mimics that of
threshold measurements, vibration measurements can be used for
estimating the BC perception in humans. When investigating Fig. 2
it is clear that there are intersubject differences in the vibration
response of the otic capsule for the same BC stimulation position
that should be reflected in the individuals BC perceptual data.
However, since the subjects’ test ear was a middle ear common
cavity, thus deviating from the standards according to ISO 8253-1, it
is not possible to know the exact sensorineural component of the
ears. No comparison of absolute vibration as measured with the
LDV and thresholds was therefore made.
A way to compare the vibration and perceptual data is to
examine the relative sensitivity difference between the different
positions. The hypothesis is that a lowering of thresholds (i.e. better
sensitivity) is accompanied with higher vibration of equal level. All
such comparisons are done between position A and the positions B,
C, and D. When the median thresholds change is compared with the
median otic capsule vibration change, there are discrepancies at the
lowest frequencies (below 0.8e1.0 kHz), but at higher frequencies
there is a general correspondence of the curves (Fig. 7). However,
when the threshold change is compared with the associated vi-
bration change of the otic capsule in the individual subject, there is
low correspondence (low correlation) between the results. The
median result and standard deviation (Fig. 9) illustrates the low
individual correspondence. This finding can, at least partly, be
explained by the large variance of tone threshold measurements.
For example, a small change in stimulation position on the mastoid
19
can lead to large threshold alteration (Khanna et al., 1976; von
Békésy, 1960). As recently shown in unilateral deaf subjects, a
change in stimulation position between corresponding positions A
and B could give BC sensitivity differences of 20 dB or more
(Stenfelt, 2012). Such large changes are also found in the vibration
data for stimulation at adjacent positions. One explanation here is
that the multiple pathways and the vibration of the cochlea in
different directions add constructively or destructively resulting in
large differences both for the cochlear vibration and the hearing
perception (Stenfelt and Goode, 2005b). Also, even if the first
author placed the transducer in both the perceptual and vibration
measurements, the exact same position was difficult to reproduce.
This slight misplacement add to the variance and affects the cor-
relation between perceptual and vibration measures. These varia-
tions, together with the uncertainty associated with threshold
estimations, prevent a significant correlation when investigating
individual subjects. However, when the data are averaged over the
whole group, similarities between perceptual measures and vi-
bration measures are seen, indicating that the cochlear vibration
serves as a good indicator of the perceived BC response for the
group, but does a poor job of predicting BC response in an
individual.
According to previous studies (Stenfelt and Goode, 2005b;
Stenfelt et al., 2000) the x-direction (medial-lateral direction) is
the most important direction for measurement of BC stimulation at
the cochlea. This notion relies on findings that either the x-direc-
tion dominates the response (at low frequencies when the stimu-
lation direction coincides with the x-direction) or is at a similar
level as the other directions (primarily at high frequencies) (Stenfelt
and Goode, 2005b). Consequently, an increased vibration in the x-
direction implies the same increase of the basilar membrane vi-
bration. Also, relative threshold measures of the transcranial
transmission indicated good correspondence between perceptual
and x-direction measures (Stenfelt, 2012). However, that study
indicated that estimating the vibration response from all three di-
mensions was better than the x-direction alone. The caveat is that
the Stenfelt (2012) study compared vibration measurements in
cadaver heads and threshold measurements in a different group of
subjects; the current study compare thresholds and cochlear vi-
bration in the same subjects.
Another support of the x-direction importance for hearing
perception of BC sounds is found in individuals with middle ear
lesions. These are more affected when BC stimulation is on the
mastoid than on the forehead (Goodhill et al., 1970; Studebaker,
1962). The above made comparison indicates that the middle ear
is also sensitive to the vibration direction (Stenfelt et al., 2002).
Further the level of influence of the CSF pathway during BC
sound stimulation is not yet understood. In this perspective it is
difficult to draw any conclusions from the LDV measurements at the
individual level. At the median level, it seems more promising but
to get a statistical support, a larger material is needed. Even if the x-
direction is the most important vibration direction of the cochlea
for BC hearing, it is a limitation to measure in only one direction. By
measuring the vibrations in multiple locations at one target site
(promontory or LSCC) a clearer picture of the three dimensional
motion of the otic capsule could be achieved, and give more in-
formation to understand the divergence between the individual
LDV and tone threshold results.
4.4. Clinical implications
Results from the current study support findings from previous
studies on vibration of the otic capsule. By stimulating with a bone
conduction device closer to the cochlea than the standard BAHA
position, sound transmission improves to the ipsilateral cochlea.
20 M. Eeg-Olofsson et al. / Hearing Research 306 (2013) 11e20
Consequently, the vibration force can be lower for the same stim-
ulation of the basilar membrane resulting in lower distortion and
energy consumption. Moreover, a position closer to the ipsilateral
cochlea decreases the stimulation to the contralateral cochlea
which could be beneficial in binaural hearing with bilateral appli-
cation of bone conduction devices. A novel bone conduction
implant (BCI) (Håkansson et al., 2008, 2010) is under development
and long term human trials are ongoing. The position for the
transducer is 10 mm closer to the ear canal than position B in the
current study. Håkansson et al. (2008, 2010) has demonstrated that
the use of an inductive link through intact skin can result in 0e5 dB
higher cochlear acceleration level at the ipsilateral cochlea, and 10e
15 dB lower acceleration level at the contralateral cochlea
compared to the BahaÒ Classic and the BahaÒ Intenso (Cochlear
Bone Anchored Solutions AB, Göteborg Sweden). Another bone
conduction device (BonebridgeÔ, Med-El, Innsbruck, Austria) at-
taches the transducer at the approximately same position as the
BCI.
5. Conclusions
In 16 subjects a transducer was placed at four positions on the
skull and masked BC tone thresholds at 16 frequencies with 1/3
octave resolution were measured. The velocity response of the LSCC
and the cochlear promontory was measured at a frequency range of
0.1e10 kHz with an LDV. Noise limited the analysis to a frequency
range of 0.3e5.0 kHz. The velocity response from the LSCC and the
cochlear promontory was found to be highly correlated. The LDV
results from the current study on live humans compared to previ-
ous studies on cadavers showed a similar pattern although there
were differences in the magnitude of the velocity response be-
tween positions. There were discrepancies between the LDV results
and tone thresholds for frequencies below 0.8e1.0 kHz while there
were similarities at the higher frequencies. Although the correla-
tion at the individual level is low, the median results in this study
support that laser measurement in previous cadaver studies are
valid for predicting general BC outcomes in live humans. However,
for an individual, the vibration of the otic capsule does not provide
a reliable estimate of BC hearing.
Acknowledgment
The authors thank Ann-Christine Hermansson for the great help,
support and endurance in completing this study. This study is
partly supported by “The Health & Medical Care Committee of the
Regional Executive Board, Region Västra Götaland”, “The Göteborg
Medical Society” and “VINNOVA: Swedish Governmental Agency
for Innovation Systems” (Grant number 2009-00190). The study
has partly been presented at “The 12th International Conference on
Cochlear Implants and Other Implantable Auditory Technologies;
2012”, Baltimore, USA.
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