Pure tone audiometry: basis of a hearing evaluation

 Measure hearing threshold for pure tone at various frequencies

 Hearing threshold: lowest sound level needed for a person to detect a signal ~50% of the time
 Pure-tone threshold at 500, 1000, and 2000 Hz can estimate the hearing loss for speech and the
potential handicapping effects of the impairments  by average loss of hearing for 3 F’s
 Normal limits: < 25 dB HL
Audiometer
 Instrument to measure
hearing threshold
 Range: 125-80000 Hz
 Human most sensitive
1000-4000 Hz
 Speech recognition
threshold (SRT): lowest
level which speech can be
recognized accurately 50%
of the time
Measurement of hearing
 Threshold are obtained by
air and bone conduction
 Air conduction: the
different pure –tone stimuli are transmitted through earphones
 Signal travel through the ear canal  middle ear cavity (via ossicles)  cochlea  auditory
central nervous system.
 Reflect the integrity of total peripheral auditory mechanism
 If deficit  not possible to determine the location of pathology along the auditory pathway
 Conductive hearing loss: reduction in air conduction, normal bone conduction
1. Result of problem in the outer or middle ear
2. Difficult at level of the cochlea
3. Damaged along the neural pathways to the brain
4. Some combination
 Conductive is prevalent among preschooler and young school aged children who have middle
ear infection
 Other causes: congenital atresia (absene of ear canal), blockage of occlusion of ear canal
(earwax), perforating or scarring of the tympanic membrane, ossicular chain disruption, and
otosclerosis
 Air-bone gap: difference between air conduction threshold and bone conduction threshold
 > 10 dB: significant conductive hearing loss; require referral
 Bone conduction: signals are transmitted via a bone vibrator that is usually placed on the mastoid
prominence of a skull (behind pinna; above concha level)
  Signal transduced through the vibrator causes the skull to vibrate
 Pure tone stimulates cochlea, bypass the outer ear and middle ear
 Sensorineural hearing loss: air cond ~ bone cond (65 dB) at all test F’s
1. Congenital or acquired
2. Heredity; Complications of maternal viral, and bacterial infections, and birth trauma
3. Noise
4. Aging
5. Inflammatory disease
6. Ototoxic drugs (antibiotics)
 Characterized by flat, trough-shaped, slightly to steeply slopping in high F’s audiometric
configurations
 Hearing loss greatest at low and intermediate F’s; normal hearing at high F’s
 Mixed hearing loss
 Bon + air cond threshold reduced in sensitivity, but bone is better than air
 Damaged to hair cells or nerve endings in inner ear
Procedures for obtaining threshold
 Begin with air conduction at octave intervals ranging form 125 or 250 Hz to 8000 Hz
 Then bone conduction at octave interval ranging from 250-4000 Hz
1. Respond to pure-tone signals: respond as soon as the tone is heard, and stop responding when
sound is inaudible
 Earphone provided so signal source is directed to the
opening of the ear canal
 1000 Hz most easily hear under headphones, and most
reliable  initial test
 Right year tested first
 The process is continued until the listener responds
positively at lease 50% of the time to an intensity level in an ascending series  threshold
 Low frequencies, 500 and 250 Hz presented last
 Bone conduction test only F from 250 – 5000 Hz
Factors influence threshold
 Proper maintenance and calibration of thee audiometer
 Test environment
 Earphone placement
 Placement of the bone vibrator
Procedures for young children (5 mon-5 yr)
 Infant’s response to speech noise changes at
different ages
 Auditory brainstem response (ABR) can be
served to provide indirect estimates of hearing
 threshold in many difficult-to-test population (children, and infants)

 Infant, 5 months – 2 years old

 Visual reinforcement audiometry (VRA): Conditioned orientation reflex or visual
reinforcement audiometry
 Delivery of a visual stimulus after the appropriate head-turn response serves to enhance
the response behavior by delaying habituation and leads to a more accurate threshold
measurements
 Sound field (loud speaker) audiometry with young infants limitations:
 The inability to obtain threshold from each ear separately
 The inability to obtain bone conduction threshold
 Failure to obtain responses from young children who have severe or profound hearing
loss.
 Children 2 – 5 years old
 Conditioned-play audiometry (2+ years w/o multiple handicaps)
 Best accepted procedure for measuring the hearing thresholds of children in this age
 Play serves as visible response and reinforcement
 Followed by a threshold-seeking period
 May be employed in a sound-fielded condition/earphone and bone conduction
measurements
 Tangible reinforcement operant conditioning audiometry (TROCA) (2+ years)
 Highly structured test procedure as a means of assessing the hearing sensitivity of
developmentally delayed children
 Tangible material (e.g., candy –reinforce) is automatically dispensed if the child depressed
a button when a tone is perceived.
 Difficult to test distractible and hyperactive children
 Can be used in a sound-field /earphone and bone conduct
 Visual reinforcement operant conditioning audiometry (VROCA)
 Visual reinforcement is used in place of a tangible reinforces
 Conversational (hand-raising) audiometry
  Masking
 Non test ear is stimulated by the sound
 Help clinician eliminate the nontest ear from participation in the measurement of hearing
threshold for the test year
 AuD introduces into the nontest ear an amount of masking noise that is sufficient to make any
sound crossing the skull from the test ear inaudible
1. When testing by AC, masking is required at a given frequency if AC threshold of the test
ear exceeds the BC threshold of the non test ear by >35 dB
 BC thresholds may be equivalent or better than AC, NEVER POORER
 Interaural (between-ear) attenuation = 40 dB
2. For testing by BC, masking is needed whenever the difference between the AC threshold of
test ear and BC of the test ear at the same frequency (air=bone gap) is > 10 dB
 Interaural (between-ear) attenuation = 0 dB
 BC threshold is always determined by the ear having the better BC hearing
Speech Audiometry
 Speech audiometry: a technique designed to assess a person’s ability to hear and understand
speech
 Typically assess by AC only
 0 dB HL = 20 dB SPL when measured through earphones
 ~7.5 dB between earphone and sound-field threshold measurements for speech signals.
 Speech Recognition Threshold (SRT): intensity at which an individual can identify simple
speech materials ~50% of the time
1. Check on validity of pure-tone thresholds
 Strong correlation between the average of the pure-tone thresholds obtained at the F
know to be important for speech (500, 1000, and 200 Hz) and SRT
 Large discrepancies between the SRT and pure tone average (PTA) suggest function,
/nonorganic hearing loss
2. Provide a basis for selecting the sound level at which a patient’s speech recognition ability
should be tested
3. SRT is useful in the determination of functional gain in the hearing aid eval process
 Use spondaic words (2 syllable words spoken w/ equal stress on each syllable)
 Provide an index of the degree of hearing loss for speech
 Suprathreshold speech recognition: estimate a person’s ability to understand conversational
speech
Acoustic admittance measurement
 Impedance: opposition to the flow of energy through a system
 When an acoustic wave strikes the eardrum of the normal ear, a portion of the signal is
transmitted through the middle ear to the cochlea, while the remaining part of the wave is
reflected out the external canal
 The reflected energy forms a sound wave traveling outward with an amplitude and phase the
 depend on opposition encountered at the tympanic membrane
 The energy of the reflected wave is greatest when the middle year system is stiff or immobile
 Ear with acicular-chain interruption will reflect les sound into canal bc of reduced stiffness
 Admittance: relative ease with which energy flows through a system
 An ear with high impedance has low admittance
 Immittance: refer to either impedance data or admittance data
 Acoustic immitttance at tympanic membrane: identify the presence of fluid in middle ear, evaluate
Eustachian tube and facial nerve function to determine the nature of hearing loss, Dx the site of
auditory lesion
 Tympanometry: measurement of the mobility of the middle ear when air pressure in the external
canal varies from +200 to -400 daPa.
 Acoustic immittance at the tympanic membrane of a normal ear changes as air pressure in the
external canal varies above and below ambient air pressure
 Frequency 220 and 660 Hz are most
commonly used.
A. Normal tympangram for an adult: has a peak
btwn -100 & 30 daPa  middle ear functions
optimally at or near ambient pressure
B. Negative peak: Peak below the normal ranges
 malfunction of the middle ear
pressure-equlizing system (maybe result of
Eustachian tube malfunction, early or
resolving serous otitis media or acute otitis
media)
C. Flat tympangram: ears that contain fluid
behind the eardrum; high impedance or low
admittance vlue w/o a peak pressure point 
imply an excissvely stiff system that does not
allow for an increase in sound transmission
through the middle ear under any pressure
state.
D. Shallow amplitude: Stiff middle ear  high
acoustic impedance or low admittance
E. High amplitude: ear with abnormally low acoustic impedance or high admittance
Acoustic reflex threshold
 Acoustic reflex threshold: lowest possible intensity needed to elicit a middle ear muscle
contraction
Pure tone audiometry: measure hearing sensitivity
Auditory Brainstem Response (ABR)
 Peripheral and central auditory nervous system generates a series of electrical signals in response
 to a transient acoustic stimulus
 Signals synchronized electrical impulses from the auditory nerve through brainstem
 Prediction of hearing sensitivity in infants, young children or adults who are unable to provide
voluntary behaviors responses
 Advantage: infants and very young children can be evaluated in a natural sleep or with mild
sedation
 Explains the functional integrity of auditory nerve and brainstem pathway
 Provide information about auditory physiology
 Magnetic resonance imaging (MRI): limited the frequency of evoked-response studies in clinical
practice; largely remain an anatomic imaging test; gives more accurate information about
structural problems.
Otoacoustic Emissions (OAE) –nerborn hearing screening
 Small acoustic signals in the external auditory meatus
 Occur spontaneously or in response to stimulation
 Generated in the outer hair cells of cochlea and can be detected and recorded by sensitive/small
microphone in the external auditory meatus
 Only generated when the organ of Corti is healthy and the emissions are detected only when the
middle ear system is normal
 NOT considered a measure for hearing
1. Spontaneous otoacoustic omissions (SOAEs): continuous signals that are generated by the cochlea
in the absence of auditory stimulation (infants, children, adults)
2. Evoked otoacoustic emissions (EOEs)
 OAEs are present in listeners with normal hearing who have normally functioning outer and
midde ear
 If OHC of the cochlea is damaged  OAEs may not be present
 Objective measure that requires no voluntary response
 Can evaluate individuals with pseudohypoacusis = who exhibit audiometric evidence of hearing
loss with is no organic basis to explain the impairment
 Disadvantage: Do not reveal middle ear disease  earlier middle ear problems result in an absent
response to click stimuli  absent OAE can be outer, middle, or inner ear problem
Auditory processing disorders, or central auditory processing disorder (CAPD)
 Dysfunction in the auditory portion of the central nervous system
 Difficulty understanding speech in noisy environments, following directions, and discriminating
(or telling the difference between) similar-sounding speech sounds.
 In school, children with APD may have difficulty with spelling, reading, and understanding
information presented verbally in the classroom.
Preschool Children (3-5 year old)
 Pass-refer procedure to identify individuals who require further audiologic evaluation or other
assessment
 Pass if child’s responses are judged to be clinically reliable at least 2/3 at the criterion dB
 level at each frequency in each ear
 Refer if child does not respond at least 2/3 at criterion dB level at any F
 Hearing impairment: unilateral or bilateral sensorineural and or conductive hearing loss greater
than 20 dB HL in the frequency region from 1000 -4000 Hz
 If child can participate in conditioned play audiometry or conventional audiometry screen under
earphones using 1000, 2000 and 4000 Hz at 20 dB HL.
 Preschooler who cannot be conditioned for play audiometry , screen by VRA
 Conditioned Play Audiometry (CPA): most commonly employed behavioral audiometric procedure
for preschooler
Guidelines
 Purpose of screening: detect, among apparently healthy persons, those individuals who
demonstrate a greater probability for having a disease or condition, so they may be referred for
further eval
 Disorder: any anatomic abnormality or pathology. May or may not result in a change in function of
a given organ or organ system.
 Impairment: any loss or abnormality of psychological or physiological function. Some functional
aspect of an organ, system, or mechanism is outside a normal range
 Disability: restriction or lack of ability to perform an activity by an individual (result from
impairment)
 Handicap: difficulty experienced by an individual as a result of an impairment or disability and as
function of barriers, lack of accommodations, and /or lack of appropriate auxiliary aids and
services required for effective communication.