Audiometric Testing and Interpretation

Presenter:
Stephen A. Hallenbeck, AuD
[Photo Manager Product Training
of Presenter] ReSound
Learning Objectives
 Perform a comprehensive audiologic assessment including air
conduction, bone conduction, speech audiometry and
immittance measures
 Identify the type, degree and configuration of a hearing loss
 recommend further tests and/or the candidacy for
amplification
Agenda
 Review the procedures for the following tests:
 Case history
 Pure-tone audiometry via air and bone conduction
 Speech audiometry
 Masking for pure-tone and speech audiometry
 Tympanometry
 Along the way…
 Interpret results
 Discuss red flags for referral
 Discuss candidacy indicators for amplification
Case History
Case Hx
 A questionnaire-written or verbal
 Begin General and Focus accordingly:
 Primary complaint
 Unilateral or bilateral presentation of symptoms
 Time course questions:
 How recent did x occur? Days, Weeks, Months ,Years
 How Frequently does x occur?
 How long does x occur?
 What treatments have you tried?
Case Hx: Medical Questions
 Highlight medical concerns and Reasons for referral
(Electrophysiologic tests or balance assessment)
 Tinnitus
 Dizziness
 Otalgia
 Otorrhea
 Hx of Otitis Media
 Exposure
 Noise
 Ototoxicity
 Family History
Case Hx: Advanced Topics
 1st opportunity to establish rapport

 Use the case history to uncover the broader impact of

hearing loss

 Uncover any self-stigmatization

 Assess technology attitudes towards hearing aids and beyond

 Help organize test procedures

Pure-Tone Testing
Pure tone audiogram
 THE AUDIOGRAM:

Graphic representation of the thresholds of hearing sensitivity as a

function of frequency

 “Picture of Hearing”
Audiometric symbols
No response symbols
Complete Pure-Tone Audiogram
Why dB “Hearing Level”
 Clinical testing is recorded in dB HL

 Hearing sensitivity in dB SPL changes per frequency

 0 dB HL represents an intensity equal to the threshold of

sensitivity of the average normal ear at each frequency.
ASHA/ANSI Threshold
 Threshold: Lowest intensity at which the listener can
identify a signal at least 50% of the time

 Minimum responses: two out of three presentations in an

ascending direction

 Threshold’s are obtained using the --“Down 10, Up 5”--

Bracketing rule (Modified Hughson-Westlake)
CLASSIC PSYCHOPHYSICAL METHODS

 METHOD OF LIMITS
 Most like Bekesy Audiometry
 METHOD OF ADJUSTMENT
 Developed by Fechner with the tester in control
 METHOD OF CONSTANT STIMULI
 Stimuli presented at random limits
ASHA (1978) Method
 Start by presenting a tone at 30 dB if hearing is suspected to
be normal

 If hearing loss is suspected or no response start at 50 dB

 If no response increase in 10 dB steps until response is

obtained

 Once positive response is obtained begin down 10 dB up 5

dB bracketing
Air Conduction (AC) and Bone
Conduction (BC)
 Air conduction: Transmission of sound via an earphone or
speaker through the outer and middle ear to the cochlea

 Bone conduction: the transmission of sounds to the

cochlea by vibration of the skull
Air Conduction Transducers
 TDH39 or TDH49 earphone mounted in a telephonics 51 or MX-
41AR cushion. (per ANSI S3.6-2004)

 DISADVANTAGES:
o Possible leakage of ambient noise (only an issue when testing
outside a booth)
o Possibility of collapsing ear canal
o Reduced interaural attenuation
o Creation of occlusion effect
o Frequency response up to 8 kHz
Insert ear phones/ER 5A or 3A
 Insert phones are superior because of:
o increased interaural attenuation
o infection control
o reduces problem/occurrence of collapsed ear canals
o overall comfort
Bone Conduction Oscillator
 BC testing is conducted with an oscillator that consists of a
vibratory unit housed in an ANSI standard plastic unit mounted to
a headset.
 The most common bone conductor is called a Radioear B-71.
 The oscillator is calibrated so that it produces pure tones of the
same intensity and frequency as those used in air conduction.
BC output limits
 Output for BC is less than AC
 LF less than HF
 BC not reliable above 4K

 Limits: 250– approx 35 dB, 500 approx 50 dB 750-4K

around 65 dB (if you go higher, a vibrotactile (VB) response
is likely)
 VB response: When patient can feel vibration output from
the BC stimulation
Audiogram Interpretation
The Audiogram
 When looking at an audiogram, you should see:
 Degree of loss
 Type of loss
 Configuration of loss
Normal Hearing: Pure-tone audiometry

 When air conduction (AC) and bone conduction (BC)

thresholds are within normal limits.
 Normal threshold for an adult: 0-25 dB
 Normal threshold for children: 0-15 dB
 AC and BC thresholds should be within 10 dB
Degree of loss
Conductive Hearing Loss

 Air conduction thresholds

will be 25 dB level or
higher. Bone conduction
thresholds are within
normal limits of 0-25 dB
 Air-bone gap – When
there is a 10 dB (or
greater) difference
between AC and BC
thresholds
 Can be candidates for
amplification after medical
consult
Sensory-Neural Hearing Loss (SNHL)

 AC and BC scores will be

greater than 25 dB and the
AC and BC will be within
10 dB
 SNHL does not indicate
where the problem lies
 Rule out neural problems
with advanced diagnostics
 Many are excellent
candidates for hearing aids
Mixed Hearing Loss

 Contains both sensory-

neural and conductive
components
 AC and BC thresholds are
25 dB or greater
 An air-bone gap of greater
than 10 dB
 Can be candidates for
amplification after medical
consult
CONFIGURATION OF HEARING LOSS

 Flat – Little or no change in thresholds (+ or – 20 dB)

across frequencies
 Sloping – As frequency increases, the degree of hearing
loss increases.
 Rising – As frequency increases, the degree of hearing
loss decreases.
 Trough (cookie bite) – The greatest hearing loss is
present in the mid frequencies; hearing sensitivity is
better in the low and high frequencies
MCL/UCL
Loudness Perception
 MCL: Most comfortable loudness
 UCL: Uncomfortable Loudness Level/LDL Loudness
discomfort level
 Typically obtained with running speech
 Bracketing procedure used
 UCLs tend to be slightly higher when they are measured
upon repeated trials
 Need to be completed for amplification
 Dynamic range: threshold to UCL
 Reduced in cochlear hearing loss
Speech Audiometry
We use Speech to test hearing….
 Pure-tones, or Narrow Bands of Noise, don’t have much
“value” in the real world
 Identifying a pure-tone is a low-level auditory task
 Speech testing can provide:
 Improved sensitivity to various pathologies
 Addresses symptoms of “Can hear but can’t understand”
 Provides info regarding higher auditory functions
Speech Reception Threshold
Speech Reception Threshold (SRT)
 Lowest intensity level at which 50 percent of spondaic words
can be recognized

 In the SRT, the patient must repeat two-syllable words,

which are typically presented via monitored live voice
(MLV)

 Most popular:
 Airplane, baseball, cowboy, farewell, greyhound, hardware, iceberg,
mousetrap, mushroom, northwest, oatmeal, playground, railroad,
sidewalk, stairway, sunset, toothbrush, whitewash, woodwork, workshop
2 Purposes of the SRT
 Provides intertest reliability check between pure tone and
speech threshold

 Good Agreement: within 6dB

 Fair Agreement: within 7 to 12
 Poor Agreement: greater than or equal to 13.

 Provides a starting point for determining the level to begin a

suprathreshold test, such as word recognition
SRT Method
 Familiarize patient (closed set)
 Face to face, suprathreshold
 Assess patient’s ability to hear with few acoustic cues– this is
why its “okay” to guess
 Live voice is acceptable because response is primarily to intense
vowel sounds (equated by peaks on VU meter)
 Carrier phrase does not effect SRT
SRT Method Continued
 ASHA:
 Present at 30-40dB above estimated SRT
 Present a word at the starting level and decrease in 10 dB steps for each
correct response
 If an incorrect word is repeated, present another word.
 If the 2nd word is correct continue dropping by 10 dB
 When 2 consecutive incorrect responses are obtained. Increase 10dB and
Begin 2 word, 2 dB step decrements until 5 out of six incorrect words are
obtained
 Subtract the number of correct responses from the starting level and add a 1
dB correction factor.
 Most audiologists use a 5 dB approach-requiring a 2 dB correction factor
SRT Method
 Martin and Dowdy 1986:
 Begin at 30 dB, if no response 50 dB, if still no response
increase by 10 dB until response is obtained
 Use bracketing method similar to PT Testing
 Threshold is defined as lowest level with 3 correct responses
 Most clinicians use this method
Word Recognition Testing
Speech Recognition/Word Rec
 Suprathreshold

 Patient is asked to recognize monosyllabic word and repeat

 Presented by recorded voice (CD)

 When attempting to compare clinics or normative data,
recorded words are absolutely necessary

 NU6, CID W-22

Purposes of Speech Recognition
Testing
 Individuals with similar hearing thresholds may demonstrate
very different speech processing abilities

 Assessment of speech perception performance

 Potential diagnostic value for retrocochlear lesions
 Planning and management in audiologic habilitation
 Prediction of performance
 Hearing aid benefit
Methods and Interpretation
Presentation level
 Suprathreshold
 Average conversational speech (50-55 dBHL around 70 dB SPL)
 MCL
 Presentation levels are usually 25, 30-40 dB SL re: SRT
 95 dB SPL—75 dB HL
 SL rel 2 kHz
 UCL-5 dB
 prob: slope of the hearing loss
Presentation level: Guthrie and
Mackersie, 2009
Test List Size
 Most standard speech recognition tests include 50 monosyllabic
words
 Many clinicians use 25
 W-22 can be ranked (first 10 are most difficult) Runge and
Hosford-Dunn (1985)
 Give first 10 – all correct stop, 1 or more wrong, give next 15
 If less than 4 are missed in first 25, stop
 Otherwise complete all 50
Interpretation
Interpretation
 Word recognition testing has regularly been used in the
differential diagnosis of retrocochlear disorders

 Asymmetries in word recognition scores between the ears is

the hallmark sign for referral for advanced tests

 How much of a difference is significant?

Length of Word Lists
 Reliability improves as number of test items increases

 Speech recognition scores become more variable (less

reliable) as they go from either extreme 100 to 0 (toward
50%)

 20 % difference will be significant relative to 95% confidence

limits if a 50 word list is used

 Use 25% for 25 word lists

SPRINT Chart
Word Recognition in Noise Tests
 Word recognition tests in quiet are a weak predictor of
hearing aid benefit
 Quiet-rarely happens in the real world
 Words in isolation
 Word recognition tests in noise are a better predictor
 Hearing In Noise Test (HINT)
 Quick Speech-In-Noise (SIN)
 Use sentences with keywords for scoring
 Presented with background noise of varying levels
Masking
Masking
 When the threshold of hearing for one sound is raised by the
presence of another (masking) sound

 Used when large asymmetries between ears are present

 Keeps the non-test ear “busy”

 Like when using a map to navigate

 Many different ways to get from point A to point B

 Rules based on assumptive logic

Terminology
 Test Ear- (TE) the ear receiving pure-tone stimulus during
AC or BC testing

 Non-Test Ear- (NTE) the ear that is not intentionally

receiving the pure-tone stimulus

 Masking in the NTE is needed if it is assumed a sound

stimulus presented to the TE reaches the NTE
Crossover
 When a signal is presented to the test ear at an intensity great
enough to stimulate the non-test ear.

 Masking is necessary whenever the possibility of crossover

exists.

 Crossover route for air conduction signals occurs by

bone conduction to the cochlea of the opposite ear.
Shadow curve
 Results when masking is
not used
 When thresholds from the
ear with the greatest
amount of hearing loss
mimic threshold from the
normal or better hearing
ear.
Interaural Attenuation
 Amount of energy lost during the crossover

 Helps predict how much has “crossed over”

 Values for AC vary as a result of:

 subject variability (skull properties etc.)
 frequency of the test signal
 earphone transducer type

 IA for BC = 0 dB theoretically, no energy is lost

When?: 2 General rules of Thumb
 1.) Supra-Aural Earphones: When a difference between
the BC threshold of the NTE and the AC threshold of the test
ear of 40 dB

 2.) Insert Earphones: When a difference between the BC

threshold of the NTE and the AC threshold of the test ear of
60 dB

 Shortcut: Mask when a 40 (earphones) or 60 (inserts) dB

difference between ears

 If a conductive loss is suspected use a conservative estimate

Visualization

75 65 5 5
When to mask: BC
 Mask when ABGs of more than 10 dB are present

 An ABG of 10 dB or less is considered to be too small for

clinical purposes
Types of masking noise
 Narrow band noise – Band-pass filtered noise centered
around a specific frequency.—used in PT Audiometry

 Speech noise – Broadband noise with approximately equal

energy per octave below 2000 Hz.
 Speech noise is also referred to as “pink noise”
 Speech noise is filtered to look like the speech spectrum
How much masking?
 The following formulas only give you the starting masking
level
 AC EM (effective masking) starting level = AC threshold of NTE
+ Safety factor (15 dB)

 BC EM starting level = AC threshold of NTE + Safety factor (15

dB) + Occlusion effect

 The occlusion effect is equal to 20 dB at 250 Hz; 15 dB at 500 Hz;

10 dB at 750 Hz; and 5 dB at 1000 Hz.

 Note: Don’t include the occlusion effect is you have an air-bone gap
greater than 10 dB in the non-test ear.
The Under/Over
 Under masking: Masking levels below the minimum
amount of masking needed in the NTE to prevent the
possibility of crossover to the TE

 Over masking: Levels presented to the NTE that is loud

enough to cross over and mask the TE
Plateau method (Hood, 1960)
 Widely accepted way of finding masked thresholds

 The plateau occurs when the NTE is effectively masked by

the noise so that the tone is heard by only the test ear

 The masking plateau range of effective masking is the

intensity range between the minimum necessary masking
level and the maximum permissible masking level
Plateau procedure:
 Present pure tone to TE at previously established threshold

 Introduce masking to the NTE (initial level calculated from

NTE threshold)

 Re-establish threshold (some do at end)

 If PT threshold remains the same, increase masking level by 5

dB

 If no response, increase the presentation level to the TE

Plateau
 Occurs when the threshold level does not change as the
masking level increases from minimum to maximum.

 A threshold shift will only occur when the non-test ear

threshold was contributing to the response
The masking plateau
 The masking plateau can be narrow or wide
 The wider the air-bone gap, the smaller the plateau.

 The wider the plateau, the more confidence you can have in
the validity of the mask threshold.

 Most audiologists typically require a plateau to be at least 15-

20 dB before accepting it as valid.
Masking: Speech Audiometry
Masking: Speech Reception
Threshold
 When the presentation level in the TE exceeds the best bone
conduction threshold of the speech frequencies in the NTE
by 40 (earphones) or 60 (inserts) dB HL

 Some look at average BC in speech freq

 Short cut: mask when SRT of TE exceeds SRT of NTE by 45

dB or more

 Formula: SRT EM= Presentation level (TE SRT)- 35 dB +

ABG of NTE
Masking: Word Recognition
 When presentation level of the TE exceeds the best bone
conduction threshold of any of the speech frequencies by 35
dB or more

 Shortcut: mask when the presentation level in the test ear

exceeds the SRT in the NTE by 35 dB or more

 Formula: WR EM= PL of TE – 25 plus ABG of NTE

Tympanometry
Middle Ear System: Pathology Overview
 Middle Ear System – “Tuned” for sound transmission
 Mass and Stiffness characteristics
 Pathologic Conditions- Alter the characteristics
 Tympanometry useful in assessing the status of the middle ear
system
Instrumentation
Instrumentation
 Y-226 tympanometry

 Probe tip-rubber “earplug” sits on top of the probe creates a

hermetic seal

 Probe tip with 3 lumen connected to:

 Manometer-pressure change
 Receiver-probe tone
 Microphone-Measure SPL as pressure changes
Components of a Y-226 Tympanogram
Tympanic peak Static Admittance
pressure

Equivalent volume Tympanic Width

Tympanic Peak Pressure
Tympanic Peak Pressure
 The tympanic peak pressure: daPa at which the peak of the
tympanometric curve occurs

 Normal ME pressure is typically at 0 +/- 100 daPa

Tympanic Peak Pressure
Tympanic peak
pressure
Tympanic Peak Pressure
 Infection can cause swelling of the mucosa of the
nasopharynx reducing or eliminating ET function

 TM retracts- The pressure in the middle ear becomes

negative relative to the air pressure lateral to the TM

 Negative middle ear pressure is associated with

Eustachian tube dysfunction
Equivalent Ear Canal Volume
Equivalent Ear Canal Volume
 The volume of air between the probe tip and the TM

 Provides little diagnostic/physiologic data

 A flat tympanogram with a large or small ECV can indicate:

 Large volume: eardrum perforation or open PE tubes
 Small volume: wax blockage

 Flat tymp with normal volume cannot completely rule out

perforation due to active disease
Equivalent Ear Canal Volume

Equivalent volume
Equivalent Ear Canal Volume

Lower Limits Upper Limits

INFANTS and *.3-4 cm3 *1.0 cm3

Children
ADULTS .6 cm3 1.5 cm3

*Margolis et al., 1997 based on 3-6 year

old children
Equivalent Volume
 If volume exceeds upper limits suggests perforation or patent
PE tubes

 Compare ears when unsure if abnormal volume is

representative of variation or pathology

 Default reading probe tip lumen obstruction is 7.0

 Cerumen is not a contraindication for tympanometry

 Use to determine if cerumen may impact behavioral results
Static Admittance
Static Admittance
 Static admittance- the height of the tympanometric curve
measured at the plane of the TM.

 Static-measured at the tympanic peak pressure

 Height relative to chosen tail of tympanogram

Static Admittance
Static Admittance
Static Admittance
Lower Limits Upper
Limits
Infants <0.2 mmho
Childre <0.2 mmho > 0.9 mmho
n
Adults <0.3 mmho > 1.66 mmho
Static Admittance
 Static admittance below the lower limit measures
 Reduced static admittance
 Associated with a stiff middle ear system
 Middle ear fluid or a fixed stapes

 Static admittance above the upper limit

 Abnormally high static admittance
 Hyper compliant middle ear system
 Associated with a monomeric TM
 Mass dominated
Tympanic Width
Tympanic Width
• Width of the tympanogram in daPa measured at half
the height of the tympanogram.

• Quantifies shape of the tympanogram

• Wide tympanic width is associated with middle ear pathology

• Combination of normal ME pressure and wide tympanic

width is a good diagnostic sign for a middle ear problem
Tympanic Width

Tympanic Width
Tympanic Width Criteria

Upper Limit

Infants > 200 daPa

Children > 150 daPa

Adults > 110 daPa

Describing Tympanograms
 Use measured values for TPP, static admittance,
equivalent ear canal volume compared to normative data

 Relate tympanometric results to other results

 Jerger types- used a letter to indicate the overall shape of

the tympanogram.
Jerger Labeling
Tympanometry Limitations
 A unique pattern does not exist for every possible ME
pathology

 The most lateral pathology has a dominant effect on the

measurement
 Multiple middle ear pathologies can exist in the same ear

 Variability in tympanometry interpretation

 Tympanometry should be used in conjunction with other

measures.
Summary
 Perform a comprehensive audiologic assessment including air
conduction, bone conduction, speech audiometry and
immittance measures
 Identify the type, degree and configuration of a hearing loss
 recommend further tests and/or the candidacy for
amplification