AUD4001 LECTURE NOTES

PURE TONE AUDIOMETREY IN ADULTS AND CHILDREN >5 YEARS OF AGE

Audiology appointment breakdown

1. Case hx: what brings them in?
2. Otoscopy: looking for wax, discharge, etc
3. PTA: softest sound a person can hear
4. Speech test: words at different volumes and repeating
(essentially a cross-check)
5. Tymps and reflex’s: looking at health of middle ear
6. Results and report sent back to referrer

Pure tone audiometry

The standard behavioural procedure for describing auditory
sensitivity.
 Playing a. series of sounds, patient will flag when they have heard it
 This is considered subjective
 This test looks at the hearing threshold which is the softest sound they can hear at a
certain pitch
 Most common frequency test is 250hertz-8000hertz

Measures hearing thresholds/sensitivity across a frequency range to determine degree, type

and configuration of hearing loss

Air conduction (AC)

Process of acoustic signals traveling from the outer inner and middle ear and arrive at the
cochlear

Testing air conduction pathway:

 Air Conduction Transducers: Earphones (Supra-aural;
Insert); SoundField
 Testing can be done through a pair of headphones
measuring individual ears
 Insert phones can also be used for this
 Aging can be a variable in this test (collapsing canal)

Bone conduction BC)

Transducer: Bone Conductor
A headband that sits over the head and rests of the bone behind the ear (vibrating)
 send signals straight into the inner ear
 bone conduction looks solely at the inner ear

Non-osseous bone-conduction pathways: Fluid motion

Cochlear contains moving fluid
Depending on the frequency/pitch of the sound this will vibrate
the fluid at different levels
 this vibration gets sent though hearing nerve and to the brain
and that is how we hear sound
Osseous Bone-conduction pathways:
 Cochlear shell
 Ossicles
 EAM

Skull vibration relates to compression and expansion of the

cochlea shell - to basilar membrane vibration – auditory sensation

How do these pathways help diagnosis?

If outer ear has a pathology, how would this affect:
 AC thresholds?
 Outer ear pathology: yes, this is the entire pathway so if there is an issue at the
beginning this will effect AC readings
 Inner ear pathology: yes, because air conduction looks at entire pathway
Middle section pathology: yes will effect
 effecting both: yes
 BC thresholds?
 Outer ear pathology: no, BC conduction should not effected levels as the cochlear
should not be effected by an outer ear pathology
 Inner ear pathology: yes, directly effects cochlear
 middle ear pathology: no will not effect as not in cochlear
 effecting both: yes

Mechanism of hearing: test

P2 - Measurment
Instructions

after case history and otoscopy (before placement of earphones)

 Instructions include: description of task, reminder of level to avoid bias e.g.

“You are going to hear a series of tones that sound like beeps/whistles, first in one ear
and then in the other. I would like you to respond to the tones by pressing the button
as soon as you hear one. Please release the button when the sound stops. Some of the
tones will be very soft, so listen carefully and respond each time you think you have
heard one. Do you have any questions?

Recommended procedure
Test order: Start with better ear
 1kHz at 40dBHL* (Or 30 dB HL above HL)

If no response, increase in 20 dB steps (5 dB steps past 80 dB HL

checking for comfort)* Some differences across countries - BSA suggest 40 dB HL, ASHA
suggest 30 dB HL

Finding threshold using Hughson-Westlake familiarisation method

AKA (Hughson-Westlake up-down procedure – or ‘down 10/up 5’)
If patient does the button the volume is lowered by 10.
If patient does not press button and they do not respond increase by 5

Hearing threshold
 Subject responds at same level 2/2 or ¾ responses on the ascent ( > 50% of the time)
 Minimum of 2 responses needed for threshold

Repeat
 Repeat threshold seeking procedure at 2, 4, 8 kHz, then 500, 250 Hz
 Re-test 1 kHz for better ear only (If re-test value differs by more than 5 dB check
other frequencies)
 If needed, test 750 Hz, 3 kHz, 6 kHz and 1.5 kHz (if > 20 dB HL difference in
thresholds)
 Test opposite ear

Bone conduction
 Placement on better hearing ear
 Only test 500, 1000, 2000 & 4000 Hz

Limitations of pure-tone measurement

1. Test-retest reliability
 Transducer placement
 Fatigue & cognition
 Tester

Solution: Assume SD of approximately 5 dB (i.e. notable

shift would be 10 dB or more)

Vibrotactile threshold
Solution: Ask client if they ‘feel’ or ‘hear’ the stimulus

PT 3 – INTERPRETATION
Describing and Interpreting Audiogram Results

[DEGREE] + [CONFIGURATION] + [TYPE] + [EAR/S]

* Also include symmetry if relevant

Degree = normal, mild, moderate, severe or profound

Configuration = shape of hearing loss

Audiogram
graph that hearing threshold are plot on

Left side axis: (decibel level) top to bottom goes soft to loud
Top axis is frequency: left to right is low to high pitch

[DEGREE] of loss

PTA = Average at 0.5, 1, and

2 kHz

Normal 20 dB or less
Mild 25 – 40 dB
Moderate 45 – 70 dB
Severe 75 – 85 dB
Profound 90 dB and greater
[CONFIGURATION] terminology

[TYPE OF LOSS]
 determined based on bone conduction test
Conductive: outer or middle ear (temporary as it has not effecting the hearing organ itself)
Sensorineural: effecting the inner ear (permanent)

Air bone gap

Used to determine whether or not hearing loss is sensorineural or conductive.

The difference between AC and BC results at any given threshold

 15db or more is considered significant air bone
gap

This example has no significant air bone gap

Conductive example:

AC results: air bone gap

 mild hearing loss as O&X sit between
20-40

BC results:
 when all in normal range and there is
hearing loss in AC results this is
conductive hearing loss

Sensorineural example:

 between BC and AC there is no significant air bone gap. This means hearing loss is the
same.

 hearing is matched at cochlear level.

 no air bone gap and hearing loss is

Sensorineural.
Mixed example:
 still has air bone gap
 BC is not in normal range

Carhart notch

This shows a depression in the BC audiogram

Otosclerosis: the ossification of the bone

 when the three smallest bones of the middle ear begin to fuse
together

This is unusual and as a condition of the middle ear should not

normally effect BC conduction but it is seen this this disease

Pre-op audiogram, otosclerosis – calcification of the

stapes prevents the ossicular chain from being able to
contribute to BC pathway, resonant frequency of
ossicular chain is 2 kHz

CLINICAL MASKING IN ADULTS

Masking fundamentals
Cross hearing: the transmission of sound by
headphone (or bone conductor) from one ear to another
 e.g. being able to hear music from another house
when you are in your own home

So what’s the problem?

 If two ears (or cochlea) have very different
hearing thresholds, the better hearing ear will respond to the signal.
 In other words, if we play a tone to the ‘poorer’ ear and the level is loud enough, the
signal will be transmitted via the skull and the better ear will respond.
 Our measured threshold for the ‘poorer’ ear is therefore better than the true or actual
threshold for this ear.

Solution: masking
  this is how we overcome cross hearing

 masking noise acts as a ‘blindfold’

Shadow curve:

Masking terminology:

Test Ear (TE) is ear that is presented with the tone i.e. the ‘masked’ ear
Non Test Ear (NTE) is ear that is presented with the masking noise

Why do we mask?
 To determine what each ear’s hearing threshold is independently of the opposite ear
(i.e. you are not sure which cochlea responded to the signal you presented)
 If we don’t mask under these situations, we could…
 Under-estimate hearing losses
 Get site of lesion/pathology wrong
 Select inappropriate management

How to know when to mask

Interaural attenuation
amount of acoustic energy lost in
transmission when sound travels
from TE to NTE, from one side of head to other (key determinant of whether we need to
mask)

Bone conductor transducer: audiogram

Using IA values:
After carrying out unmasked air-conduction (bilaterally) and unmasked bone conduction
(unilaterally), examine the audiogram.
 If either of the following is present, you need to mask:
1. An air/bone gap 15 dB HL or greater
2. The AC threshold for either ear is 40 dB poorer than the unmasked BC (or 55 dB if
you have used inserts)

Example

 at level 1K we notice we need to mask left air

conduction threshold
 2K required in left ear
 4K required in left ear

 R ear no air conduction masking needed

 500 & 2 making required
Quick summary:
 When we examine an audiogram we need to decide whether cross hearing may have
occurred
 We mask whenever there is a possibility of cross hearing

how to mask: Hood’s technique

masking signals
Aim when selecting signal:
To achieve efficient masking with least overall noise intensity

Possibilities:
 Pure (sine wave) tones
 Broad band noise
 Narrow band noise (1/3rd octave)

Pure (sine wave) tones

 Confusing and beating with test tone
Broad band noise (BBN)
 Effective at masking but louder overall percept (may be uncomfortable)
Narrow band noise (NBN)
 1/3rd octave NBN as effective as BBN but more comfortable. Therefore this is used in
clinical practice

Hood’s technique in brief

1. Introduce masking noise to NTE 10dB SL
2. Present pure tone to TE at threshold
 If there is a response, increase masking by 10dB
 If there is no response, increase pure tone by 5dB
3. This process continues until you reach a plateau – the pure tone threshold stays
constant with increasing masking noise. The level of noise is increased over 20 dB
without shifting threshold of tone.

Client instructions:
 “This time you will be hearing two sounds – one is the tone as before and the other
will be a rushing sound.
 The rushing sound will be in your L/R ear continually and may get louder. Please just
ignore it and listen for the tone sounds.
 Press the button every time you think you hear a tone sound.”

Initial masking level

  Masking begins just above the pure tone
threshold that we want to mask in the ‘non-
test ear (NTE) ’
 Initial Masking Level = AC (NTE) + 10 dB
 In this example = 10 + 10 = 20 dB HL

Masking procedure

Masking procedure example 1

Masking procedure example 2

  Only one thing changing in each ear at a time
 Masing increases by 10 in person responds
 Is they don’t respond increase test ear by 5

Air conduction masking procedure

1. Present masking noise to NTE
2. Present tone to TE
3. If no response, increase tone in 5 dB steps
4. Once you get response, increase masking noise in NTE by 10 dB and re-present pure
tone in TE
5. Continue to increase masking level in 10 dB steps until plateau is reached (masking
level increased by 20 dB in total
6. Plot masked (true) threshold on audiogram
Stop procedure when:
 Plateau reached
 Patient complains of loudness discomfort
 Audiometer limitations
 Run out of masking’

Bone conduction masking technique

1. Same procedure to air masking
2. Place on headphones (correctly and carefully)
3. Present masking noise to NTE at 10dBSL of the pure-tone AC threshold
4. Present tone to TE at BC threshold 5. If no response, increase tone in
5. dB steps.
6. Once you get a response, increase masking noise in NTE by 10 dB and re-present
pure tone in TE
7. Continue to increase masking level in 10 dB steps until plateau is reached (masking
level increased by 20 dB)
8. Plot masked (true) threshold on audiogram
Stop procedure when:
 Plateau reached
 Patient complains of loudness discomfort
 Audiometer limitations
 ‘Run out of masking’