EARS, NOSE & THROAT (ENT)

Topic: Basic Audiology

Lecturer: Dr. See, Nixon

AUDIOLOGY Tuning fork Tests:

 Is a subspecialty in the field of ENT-HNS that deals with the evaluation  Weber Test
of hearing and rehab of individuals with communication problems o Test of lateralization
 Reasons for Evaluation: o Result: if tone lateralize to:
o Medical diagnosis of the locations and type of diseases  Better ear – sensory loss
o Assessment of the impact of hearing problem  Poor ear – conductive loss

 Types of Hearing Evaluation:  Rinne’s Test

o Tuning fork – can test for: o Compares bone against air conduction
 Conductive hearing impairment o If the result is:
 Sensory hearing impairment  (+): AC > BC  normal or Sensory hearing loss
 EXCEPT FOR mix type  (-): BC > AC  conductive hearing loss
o Pure tone audiometry
o Speech audiometry  Schwabach’s Test
o Special tests: o Compares patient’s bone with the examiner (assuming the
 Impedance examiner is normal)
 BERA Comparing the patient’s ability to hear the tuning fork vs.
the examiner’s
TYPES OF HEARING IMPAIRMENT
 Conductive Type Hearing Loss o Result:
o Problem lies in the external and middle ear  Equal with examiner: Normal
 Sensory Neural Hearing Loss  Prolonged: conductive
o Problem lies in the inner ear and the whole auditory pathway  Diminished: sensory
o Auditory pathway: (COLIMA)
 Cochlea  Bing’s Test
 Superior Olives o “Occlusion test”
 Lateral lemniscus o Result:
 Inferior colliculus  Positive: increasing and decreasing hearing ; normal
 Medial geniculate body or sensory loss
 Auditory cortex  Negative: no change in variation or conductive loss
 Mixed Type
AUDIOMETRY
Lecture Discussion: Pure Tone Audiometry
 Audiometer – an electronic device w/c produces sound free of noise
Conductive and Sensorineural hearing loss can be diagnosed with a tuning
(sound energy or overtones)
fork EXCEPT for the third type (mixed type  combination of conductive and
sensorineural, it can only be determined by audiological evaluation)  Parts:
o Attenuator: variation of sound intensity; measured in decibels
TUNING FORK TESTS o Frequency oscillator: changes the frequency pitch; measured
 Measured in hertz (cycle per second) in hertz
 128, 256, 512, 1024, 2048, 4096 and 8192 Hz o Transducers: earphones and bone vibrators
512, 1024, 2048  these are part of your speech frequency.
 Lower than that (256, 128 Hz) we call it “low frequency tuning Lecture Discussion:
fork” Audiometer – has different parts similar to that of a radio
 Higher than that (4096, 8192 Hz) we call it “high frequency  Attenuator – similar to a volume regulator
tuning fork”  Frequency oscillatory – (comparing it to a radio) it could change the
different stations of the radio
 Transducers – (comparing to a radio) it would be the speakers

Figure Above: Figure Above: Basic Audiometer & Head Phone, Bone Vibrator
The low frequency tuning forks (C-128, C-256)  they have a rounded tip on Head phone – we use the headphone for air conduction testing
top which we call “Dampers,” these are there to prevent the production of Bone vibrator – we use it for bone conduction testing
overtones when you overstimulate the tuning fork by hitting it too much.
Below it are your “Tines or Prongs/Tongs,” then the “Body” and the “Stem
or Neck.”
Underneath is the “Hilt or Base”  part of the tuning fork that should touch
the patient’s head

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
Lecturer: Dr. See, Nixon

 Interaural Attenuation:  Procedure: HUGHSON WESTLAKE TECHNIQUE

o Is the reduction of a signal’s intensity as it is transmitted from Your textbook have described a technique but fails to acknowledge
one ear to the other the author of that technique. In the textbook, it is the Hughson
o Estimates: Westlake Technique  it is the most universally accepted (even in
 In Bone conduction testing, 0 dB other countries). This is also known as the 5 up 10 down technique
 In Air conduction testing, 45 db
1. Test better ear always at 1KHz, 2KHz, 4KHz, 8KHz, 500Hz,
250Hz - Air Conduction
We give 1000 Hz  this is the amount of initial sound
chosen because the speech frequency is between 500-2000
Hz, so 1000 Hz is the mid-speech frequency, patient will be
able to easily identify this tone when it is presented

2. Starting at 0 dB level and ascend by 10 dB increment

3. Follow the 5 up 10 down rule
4. Successive ascent of 5 dB increment until a typical response is
obtained
Lecture Discussion: Interaural Attenuation 5. Enter appropriate symbol
If the air conduction testing, you stimulate the right ear with 50 dB, 5 dB can 6. Proceed to the next frequency 15-20dB below the previous
be heard on the left ear (the non-tested ear)  patient will capable of threshold
responding to it but it is a false positive response 7. Same procedure done with Bone testing

For bone conduction testing, since we are vibrating the right mastoid  the Lecture Discussion: 5 up 10 down rule
whole skull will vibrate as well as the non-tested ear (the left ear)  patient For example you give stimulus at 0 dB, the patient did not respond. Give
will also be responding to that = false positive result another 10 dB, the patient did not respond. And then when you give it 30 dB,
the patient responded  that is not yet the threshold of the patient. You
follow the 5 up 10 down rule:
 Cross Hearing:  So you decrease 30 dB to 20 dB, the patient did not respond. Add
o Patient respond to the test signal on the non-tested ear another 5 (=25 dB), if the patient did not respond then add another
To eliminate the cross hearing or interaural attenuation  5. If the patient responded again at 30 dB  that means that it
we give another sound that is complex (a hissing sound to would be the threshold of the patient at 1000 Hz by air conduction
distract the non-tested ear so that the patient will
concentrate in responding to the interrupted tone given on The next test would be at 2000 Hz then followed by 4000 Hz, 8000 Hz, then
the tested ear) go back to the low frequency (500 Hz, 256 Hz). After getting the result by Air
The stimulus on pure tone audiometry is a series of pure conduction, you proceed with the same technique by Bone conduction
tone (interrupted tone) testing. The results can be placed on an audiogram

 Masking:
o Obscuring one sound by another sound
The sound you hear here is like that of in the T.V. when
stations are off

o Elevation of one signal produced by introduction of a 2nd sound

Lecture Discussion: Masking

This is a schematic representation of a masking noise on the non-tested ear
Lecture Discussion: Audiogram
 Threshold: The usual practice here in the Philippines is that we separate from the right
o Lowest intensity/loudness (dB) that patient can hear in ear and the left ear. In other countries, they only give you a single graph
different frequencies (Hertz) where all the threshold are placed in one graph  this is quite confusing
o Air Conduction Testing sometimes
o Bone Conduction testing
 INTENSITY: loudness, sound intensity (db)
 FREQUENCY: audible sound cycles per second (Hertz)

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
Lecturer: Dr. See, Nixon

 Sensory Neural Hearing Loss: both BC and AC are the same and neither
is normal

Lecture Discussion: Audiogram Key

But because we have internationally approved signs and symbols for right Lecture Discussion: If both bone conduction and air conduction thresholds
and the left ear by air conduction and by bone conduction, whether it is are abnormal, but without a gap of more than 10 dB patient will be
masked or unmasked, we could easily understand and interpret an diagnosed as sensory neural hearing loss
audiometric graph. Another widely accepted practice is to use a red pen for
the right ear and a blue pen for the left ear  Mixed Type Hearing Loss: both AC and BC thresholds are reduced, but
BC thresholds are still better than AC by 10 dB or more
 NORMAL: 0 – 20 dB
These are the normal threshold based on ANSI (American National
Standard Institute) but by WHO criteria  they allow 0-25 dB as
normal

 SPEECH FREQUENCY: 512 Hz, 1024 Hz, 2048 Hz

Interpretation:
 Normal: when bone conduction and air conduction thresholds are
between 0-20 dB

Lecture Discussion: If both AC and BC threshold are both abnormal but this
time there is a gap of more than 10 dB  a mixed type of hearing loss (you
cannot diagnose this by tuning fork test)

Degrees of hearing loss (according to ANSI):

 Mild 25-45 db
 Moderate 45 – 60 db
 Severe 55 – 70 db
 Profound 70-100 db
Lecture Discussion: Another international practice is that the bone
conduction threshold are joined by a dotted line. The air conduction
threshold are joined by a solid line. If both air conduction and bone
conduction results are between 0-20 dB  these represent a normal
tympanogram

 Conductive Type Hearing Loss: BC thresholds are normal and better

than AC by more than 10 dB

Lecture Discussion: If the bone conduction thresholds are within normal, and
the air conduction is below normal  this represent a conductive type
hearing loss

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
Lecturer: Dr. See, Nixon

IMPEDANCE AUDIOMETRY Lecture Discussion: Type A

 Tympanometry The graph peaked at 0 pressure, meaning to say both external and middle
 Acoustic Reflex ear pressure are the same so the tympanic membrane will move very freely
 OAE – otoacoustic emission test
 Type Ad
RA 9709 Universal Newborn Hearing and Intervention Act of 2009: o Very highly compliance at ambient pressure
 OAE – Otoacoustic emission test o Seen in ossicular discontinuity
By Philippine law, it is now obligatory to test all newborn for
hearing screening 24 hrs. after birth. If a patient fails this test 
it can be repeated after 1 month. If it fails again, you have to do
other confirmatory tests

 AABR – Automated Auditory Brainstem Response Audiometry

Confirmatory Test
 ABR – Auditory Brainstem Evoked Response audiometry
 ASSR – Auditory Steady State Response Audiometry
Lecture Discussion: Type Ad
It has the same pressure on both external and middle ear but the tympanic
membrane will move very loosely at 0 pressure because there’s no limitation
or restriction on the movement by the ossicles. This can be seen on patient
with ossicular chain discontinuity

 Type As
o Very low compliance at ambient pressure
o Seen in ossicular fixation

Lecture Discussion:
This is a schematic diagram of impedance audiometry. The external ear is
totally sealed off, no sound or pressure or stimulus can get in without being
measured and no sounds or echoes can come out without being measured
as well
Lecture Discussion: Type As
1. Tympanometry Similar with the first two types, the movement of the tympanic membrane is
 Is an indirect measure of the compliance (mobility) of the tympanic seen on 0 pressure. But it is now limited or restricted. This are usually seen if
membrane under conditions of (+), (-) or normal pressures the ossicular chain has a problem like fixation because of recurrent middle
Lecture Discussion: ear infection.
If you have a middle ear fluid, the tympanic membrane is bulging or under
The tympanic membrane will be able to move freely if the pressure
pressure. For sure it will not be able to move either on positive or negative
in the external ear is the same as the pressure in the middle ear
pressure
because they are both open to the atmosphere

 Type B (Flat)
 Purpose:
o Little or no change in middle ear compliance
o TM mobility
o Impacted cerumen, perforated ear drum, with middle ear fluid,
o Middle ear pressure
TM perforation
o TM perforation
o Patency of the eustachian tube
 Procedure:
o Acoustic energy ( 45 db SPL) is introduced into the ear.
Some are absorbed, others are reflected back (echoes)
and measured by another channel

Tympanogram
 Type A (Normal)
o Maximum compliance of tympanic membrane at 0 pressure Lecture Discussion: Type B
Impacted cerumen, perforated ear drum, etc  all these situations there will
be no movement of the tympanic membrane at all. So when you try to do
tympanometry, the graph will be very flat

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
Lecturer: Dr. See, Nixon

 Present – Normal hearing

 Absent – 8th cranial nerve lesion
unilateral conductive
bilateral conductive
disarticulation
facial paralysis
stapedial fixation

Lecture Discussion: Lecture Discussion:

If you have a retracted ear drum  the tympanic membrane is adherent Acoustic reflex is present in normal individuals. It will be absent for any
already on the medial wall of the middle ear. Negative pressure should be bilateral lesion, whether conductive or sensory neural hearing impairment. If
applied to the external ear to equalize the pressure in the middle ear for the it is unilateral, we could still do ipsilateral testing if it’s needed. It will be
tympanic membrane to go back to its normal position. absent in facial nerve paralysis or stapedial fixation

 Type C SPEECH AUDIOMETRY

o Maximum compliance at negative air pressure greater than  Ability to hear and understand speech
100 mmH2O  Speech is the stimulus itself
o Poor ET function  2 Parts of Speech Audiometry:
o Speech reception thresholds
2. Acoustic Reflex  Level in dB at which the patient can identify 50% of
 Contraction of stapedius muscle in response to stimulation of sound of test words (spoken words) correctly
sufficient intensity  Countercheck of pure tone audiometry
 70 – 100 dB stapedius muscle contract bilaterally and reflexibly  Threshold average of 500 Hz, 1000 Hz, 2000 Hz
If a sound (very loud sound) is forced into the external ear, pressure These reception thresholds is the average of the
will be transmitted to your tympanic membrane (ear drum)  threshold of pure tone audiometry in speech
overstimulating the ossicles (maleus, incus, stapes) and force it frequency
inside the oval window  could rupture the oval window and
render the patient very dizzy for a long time and be totally deaf for o Speech discrimination
life. But because of the acoustic reflex, this rarely happens  Aka: speech intelligibility test
 Words are presented 40 dB louder than the SRT
 Also called stapedial reflex (speech reception threshold); patient is instructed to
If we look closely to the location of the stapedius muscle, when it repeat each word
contracts, it limits the movement of the stapes inwards towards the Example:
oval window. That is why acoustic reflex is considered a very Speech reception threshold of the patient is at 30
important protective reflex dB. You increase the volume by 40 dB to stimulate
the patient so that would be at 70 dB  that is
 Basic Components: quite loud for the patient to hear and at the same
o Afferent Limb - auditory fibers from the cochlea time understand the words
o Reflex Center – Caudal portion of the Pons
o Efferent Limb – facial nerve  Percentage of response is recorded:
90 – 100% Normal
75 – 90% Slight difficulty
60 – 75% Moderate difficulty
Poor discrimination
50- 60%
Difficulty in conversation
below 50% Very poor discrimination

 If the speech discrimination is >80%  they are good

candidates to wear hearing aids

Lecture Discussion:
Since the acoustic reflex is reflexive and bilateral, then we can take
advantage of this characteristic. We can do acoustic reflex contralaterally or
ipsilaterally.

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
Lecturer: Dr. See, Nixon

PEDIATRIC AUDIOMETRY
 Behavioral Audiometry
o Newborn to 24mos of age
o Difficult to handle and inconsistent
o replaced by BERA
 Play audiometry -2-4 years old
 Speech audiometry
 Objective audiometry
o Impendance Audiometry
o BERA
o Otoacoustic Emission test

ANATOMY AND DISORDERS OF THE FACIAL NERVE

Facial Nerve

Lecture Discussion: Hearing Aids

Hearing aids are very expensive so we have to identify which patients we
advise to buy hearing aids. Depending on the types and the value added to
it, then the cost would incrementally increase. You have different types of
hearing aids, you have:
 CIC – completely-in-the-ear hearing aids
 ITE – in-the-ear hearing aids
 ITC – in-the-canal hearing aids
 BTE – behind-the ear hearing aids

The smaller it is, the more expensive your hearing aid will be but not
necessarily they are the most with important features. Every features that
you add on the hearing aid will entail another expense on the price of the Picture Above:
hearing aid
This is the reason why we see patient with facial nerve problem as well
(besides hearing problems). As the facial nerve exits the brainstem it enters
AUDITORY BRAINSTEM EVOKED RESPONSE
the internal auditory canal that is already part of your temporal bone so 70%
 Also called ABR (Auditory Brainstem Reflex) or BERA (Brainstem Evoked of the peripheral fiber of the facial nerve is within ENT.
Response Audiometry)
 Represent electrical response of CN VIII and some portions of the brain After it has passed through the internal auditory canal, it gives a peripheral
to auditory stimulus after being sensed by the inner ear branch to your lacrimal gland thru the greater petrosal nerve to control
 80 dB above threshold click stimulus at fixed repetitions e.g. 11/sec or lacrimation. It turns back and down towards the middle ear giving a branch
33/sec until 2000 click response have been average to your stapedial muscle. Then again, it turns back going to the mastoid. The
 Electrodes on mastoid vs. forehead  EEG pattern circled portion in this diagram is part of your middle and your mastoid. Along
 Series of waves ( I-VIII) are produced I and II are from the cochlea the mastoid it will give another branch which is the chorda tympani towards
Results: latency of each wave and interwave your tongue and your submandibular and sublingual gland. Before it exits the
stylomastoid foramen and give the famous 5 peripheral muscular innervation

 Five main functions of facial nerve:

 Wave I – 1st order neuron
o Lacrimation
 II – cochlea
o Salivation
 III - superior olives
o Impedance regulation of sound
 IV – V- inferior colliculus
o Pain, touch and temperature
o Taste – on the anterior 2/3 of the tongue
 Clinical Uses:
o Cerebellopontine angle
tumors – 95%
o Menniere’s disease
o Hearing threshold in infants

Lecture Discussion:
What is important are the early waves because your ABR was designed to
diagnose Cerebellopontine angle tumors. If we look at the sensitivity and
specificity of this test, it is at 95%. It is a very reliable test. Likewise, this ABR
is used as a mandatory confirmatory test for hearing evaluation in infants

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 EARS, NOSE & THROAT (ENT)
Topic: Basic Audiology
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o Nerve Function Tests:

 EMG – Electromyography
 normal
 fibrillation
 denervation
 bizarre pattern

EMG is usually done by a neurologist or by rehab

medicine. In EMG, what we usually look for is the
fibrillation potential that would indicate a good
chance of recovery of facial nerve paralysis, but
this will only be present after the 3rd week, that
Picture Above: Upper and Lower Motor Neuron Lesions would be too long and too late to initiate
rehabilitation. The principle of rehabilitation is
This illustrates which facial nerve needs to be attended by a neurologist and that we have to start rehabilitation at the time of
which facial nerve paralysis need to be treated by an otolaryngologist. You injury that is why they developed another test
remember the differentiation of having UMN type paralysis and LMN type which is ENog.
paralysis. For all cranial nerve, the level of decussation of its fiber (crossing
of the fiber to the opposite side) is at the level of the nucleus. The nucleus of
 ENog – Electoneurography
the facial nerve is in the pons. So fibers of the facial nerve innervates the
opposite upper and lower face BUT it also receives an ipsilateral innervation  Can be done earlier than 3 weeks
to the lower face. Prognosticates the recovery of the
patient much earlier than EMG
Knowing this, if the patient has UMN paralysis  it will block both
innervation to the contralateral upper and lower face. But since it will have  Persistence of paralysis 90% compare to the
an ipsilateral innervation to the upper face, the upper face will remain intact. normal side in 10 days indicate poor
If the upper face is intact  then it will be purely neurological case. prognosis

In case the patient has LMN paralysis  blocking both upper and lower  Maximal Stimulation Test
contralateral face, it will receive the same innervation also on the ipsilateral Is a crude test. An electrode is placed on the cheek
upper face but since this will also be blocked, then the patient has a total and electrical stimulation is given. This is quite
paralysis on the opposite, it will be 70% ENT. painful to the patient

 DIAGNOSTIC PROCEDURES: DEGREE OF INJURY

o Audiologic Evaluation 1st Degree Neuropraxia - partial disruption of axonal activity
 Pure Tone Audiometry 2nd Degree Axonotmesis - wallerian degeneration
 BERA 3rd Degree Neurotmesis - aberrant regeneration can occur
 Tympanometry 4th Degree Perineural disruption – intraneural scarring
 Stapedial Reflex 5th Degree Complete Transection – no regeneration
o Schirmer’s Test
 Difference of 25% is Significant NEUROPATHOLOGY AND SPONTANEOUS RECOVERY OF FACIAL NERVE
In facial nerve localization, if the differentiation of INJURY
both eyes is >25%  that is considered significant,
meaning to say the lesion is at level of the greater DEGREE PATHOLOGY RECOVERY
petrosal nerve Compression: damming of axoplasm
1st 1 – 4 weeks
no morphologic changes
compression persist with increase
o Taste Sensation Stimulation 2nd 1 – 2 months
intraneural pressure, loss of axon
 Sweet and Sour – Tip
intraneural pressure increases
 Salt – Lateral 3rd 2 – 4 months
loss of myelin tubes
 Bitter – Base
above + disruption of perineurium
We do not use the bitter taste as a stimulus 4th 4-18 months
partial transection
because the facial nerve only access on the above + disruption of epineurium
anterior 2/3 of the tongue 5th Never
complete transection
To test for the salty sensation, you ask the patient
to protrude the tongue and place the salty
sensation or stimulus at the lateral part on one
side NOT on the center or on the tip. Do not ask
the patient to retract the tongue because the taste
stimulus will simply diffuse to the other side and
the patient can identify it. The same is true with
the sweet and sour taste.

o Salivation
 Cannulation of the Wharton’s Duct
 25% difference is significant

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Topic: Basic Audiology
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DISEASES OF THE FACIAL NERVE

1.) Congenital
 Mobius Syndrome – Fibrotic Facial nerve
 Traumatic Birth – more common than Mobius syndrome
The mastoid tip of a newborn is very superficial or nearly absent. So
the facial nerve is very superficial if you do not have the protection
of the mastoid. If a baby is delivered by high forceps  it could easily
injure the facial nerve of the baby

2.) Infections
 Herpes zoster Oticus
 Middle ear Infections

3.) Trauma
 Temporal Bone Fracture
o Longitudinal – parallel to the temporal bone
 Delayed complete paralysis
 Full recovery
o Transverse - perpendicular fracture
 25% full recovery
 Greater chance of permanent paralysis

4.) Neoplasm Involving the Facial Nerve

 Cerebellopontine Angle Tumors
o Acoustic Neuroma
o Meningioma
 Middle Ear Lesions (tumors):
o Glomus jugulare – a benign tumor on the floor of the middle ear
All benign tumors can slowly erode all surface (even bones)

o Histiocytosis – now classified as a variant of malignant lymphoma

o Rhabdomyosarcoma aggressive tumor in the head and
o Squamous cell carcinoma neck

5.) Idiopathic Cause

 Bell’s Palsy
o Treatment:
 Corneal Protection
 Steroids
 Fascial Slings
o Nerve Grafting:
 Spinal Accessory nerve
 Hypoglossal Nerve
o Muscle Slings:
 Temporalis Muscle
 Masseter Muscle

Lecture Discussion: Bell’s Palsy

If the paralysis has been there for a long time (6 months – 1 year) then facial
reanimation can be considered. Nerve grafting with the use of spinal
accessory nerve or hypoglossal nerve attaching to the orbicularis oris or oculi
muscles. Or Muscle slings, harvesting the temporalis muscle and joining it
with the orbicularis oculi or the masseter muscle, attaching it to your
orbicularis oris  you will have at least some facial animation

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