ASSIGNMENT OF DIAGNOSTIC AUDIOLOGY

*TONE DECAY TEST-

 The tone decay test (also known as the threshold tone decay
test or TTDT) is used in audiology to detect and measure auditory
fatigue.
 It was developed by Raymond Carhart in 1957. In people with
normal hearing, a tone whose intensity is only slightly above
their absolute threshold of hearing can be heard continuously for 60
seconds.
 The tone decay test produces a measure of the "decibels of decay",
i.e. the number of decibels above the patient's absolute threshold of
hearing that are required for the tone to be heard for 60 seconds. A
decay of between 15 and 20 decibels is indicative of cochlear hearing
loss. A decay of more than 25 decibels is indicative of damage to
the vestibulocochlear nerve.

*PROCEDURE-
 A tone at the frequency of 4000 Hz is presented for 60 seconds at an
intensity of 5 decibels above the patient's absolute threshold of
hearing. If the patient stops hearing the tone before 60 seconds, the
intensity level is increased by another 5 decibels with the procedure
repeated until the tone can be heard for the full 60 seconds or until no
decibel level can be found where the tone can be heard for the full 60
seconds. The resultant measure is given as the decibels of decay.

*INTERPRETATION OF TDT-
 TD is a procedure for diagnosing retro-cochlear pathology (RCP,
damage to the auditory nerve). It is part of battery of tests that aim to
differentiate between cochlear and retro-cochlear pathology.
 According to Rosenberg, 1958:
 0-5 dB Decay - Normal or Conductive
 10-15 dB Decay - Mild
 20-25 dB Decay - Moderate
 30->35 dB Decay - Marked Decay

 Glaslow, 1968 stated that positive TD is one where there is at

least 30 dB decay.
 Tillman, 1969 agreed that patients with RCP, typically have TD
exceeding 30 dB.
 However, at the same time it would be dangerous to assume
that anyone with 30 dB decay, has RCP.
 A more predictive way of looking at TD is that each dB of
decay above 15 dB, should raise the suspicion that RCP lesion
may exist. The greater the TD and the number of frequencies
involved, particularly the low frequencies, and then there is
greater possibility of serious pathology.
 The index of suspicion should also be raised if the rate of decay
does not diminish with increased stimulus intensity. Patients
with acoustic tumor, frequently exhibit extreme an often
complete TD.
Fowler noted that equal loudness between the recruiting impaired ear
with normal ear can be achieved only with larger sensation levels
(SLs) to the normal ear. E.g. A tone at SL of 60 dB in normal ear and
30 dB in impaired ear may sound equally loud. This result suggests
that the growth of loudness requiring an intensity increase of 60 dB in
normal ear is achieved with an intensity increase of 30 dB in impaired
ear. This indicates that recruitment for loudness growth must be
occurring much more in impaired ear. This is due to abnormality in
cochlea such as hypersensitivity of haircells due to damage.
Recruitment is a landmark feature of SNHL of cochlear origin.

*ADVANTAGES-

 Low cost and general accessibility.

*DISADVANTAGES-
 The Pathophysiology behind tone decay is not very well known. The
actual value of any tone decay procedure in accurately identifying 8
cranial nerve pathology has not been extensively investigated.

*BEKESY TEST-
 A Bekesy test is an automatic test method used to measure hearing
thresholds. It can be used for audiometric screening and is often used
to screen for noise-induced hearing loss (NIHL).
 The Bekesy test uses pulsed tones that automatically change in
frequency, intensity, and ear, according to a pre-set programme.
Pulsed tones can be easier to hear for someone with tinnitus, so it is
a more effective test to perform in this instance.
 A Bekesy test requires a high level of concentration from the patient.
During the test the patient controls the intensity of the stimulus by
pressing a response button whenever they hear the tone, and
releasing the response button when they can no longer hear the tone.
 When the response button is pressed, the intensity level is
automatically reduced, and when the response button is released the
intensity level is automatically increased. The patient’s response will
be recorded as a trace on the test screen. The mid-point of that trace
is used to calculate the threshold.

*HOW IS THE BEKESY METHOD CARRIED OUT?

1. Start by providing the patient with clear instructions i.e., You will
hear a series of tones. Press the response button for as long as
you hear a tone and then release when the tone is no longer
heard, no matter how loud or how quiet or which ear you hear
the tones in
2. Select ‘auto Bekesy’ test on the audiometer
3. Familiarise the patient with the auto Bekesy test and the type of
sound they will hear
4. The test will automatically begin once the familiarisation
process is complete
5. The patient controls the intensity by pressing the response
button
 6. The intensity is automatically reduced in steps until the patient
no longer presses because the signal has become inaudible
7. The audiometer automatically reverses the procedure and
increases the level until the patient presses the button again
8. This produces a zigzag trace of troughs and valleys (otherwise
known as excursions)
9. The mid-point of this is what gives the threshold
10. The lowest frequencies are presented first, moving
through to the higher frequencies
A common sequence is to include 500 Hz, 1KHz, 2KHz, 3KHz,
4KHz, 6KHz, 8KHz
11. The threshold/s will be stored automatically.

*BENEFITS OF USING BEKESY TEST-

*The Békésy test has both advantages and disadvantages when compared
to a Hughson Westlake test. A case study (Ventry, 1971) found that the
major advantage of the Békésy test is that it can highlight functional
hearing loss. Pulsed tones can also be easier to hear for someone with
tinnitus, and can therefore be a more effective test to perform in this
instance. However, the Bekesy test is a more demanding test than the
Hughson and Westlake test and requires a high level of concentration, and
therefore may have a higher level of inconsistency in some people.

*PIPB FUNCTION TEST-

 PIPB Function – Procedure and Application: Patient’s speech

recognition performance depends on the intensity of the test materials
it is called PIPB ( Performance Intensity Phonetically Balanced)
Function Test when phonemically balanced PB words are used.
 The study of relative intelligibility of spondee at different intensity level
is termed as ‘Articulation curve’. The study of intelligibility of
phonetically balanced word at different intensity is termed as PIPB
function.
 *PURPOSE OF PIPB FUNCTION TEST-

 To assess patient speech recognition ability in the form of percentage

of word are repeated correctly at specified level of presentation.
 It helps in determining the level of presentation of speech signals in
speech discrimination test as well as some of the special test for central
auditory nervous system.

*PROCEDURE OF PIPB FUNCTION TEST-

 Instruct the client you will hear some words through headphones you
have to repeat the listen words(PB words)
 The test is begins by varying intensity at which the words are
presented.
 Take 3 frequencies PTA of 500, 1000, 2000 Hz and increase intensity
in 10dB step till platu is reached/ performance or discrimination score
reached at 100% or maximum.
 There is reduction of speech recognition scores that occurs intensities
above where PBmax obtained is called rollover of the PI function/PI
Rollover.
 Further increase the intensity results a lowest speech recognition score
over PBmax obtained is known as PBmin.

*INTERPRETATION OF PIPB FUNCTION TEST-

 The score are interoperated in the form of Rollover Index (RI) (Jerger
and Jerger, 1971).
RI = PB max – PB min / PB max.
APPLICATION OF PIPB FUNCTION TEST-

 Help in determine the site of lesion (to rule out RCP)

 Assess central auditory function
 Plan and evaluate aural rehabilitation programs
 Evaluate HA candidacy and select appropriate amplification.

* GLYCEROL TEST-
 This test provides information on the cochlear response to the osmotic
changes produced by glycerol in the inner ear, whereas modifications
in the vestibular labyrinth are usually not evaluated.
 This is the most important test for diagnosis of Meniere's disease.
 The assumption that an increase in endolymph volume, with its effect
on labyrinthine membrane behavior producing in part, the hearing loss
and vestibular deficit in Meniere’s disease has led to the administration
of dehydrating agents like glycerol. The goal is to reduce the volume
abnormalities in inner ear and produce a measurable change in
response that is improvement in behavioral audiometric test scores.
 The increased secretion of glycoproteins following administration of
glycerol induces endolymph flow into endolymphatic sac. Thus,
glycerol promotes the absorption of endolymph both in radial and in
longitudinal directions. This is a simple and rapid method that provides
information on the cochlear response to the osmotic changes produced
by glycerol in the inner ear.
 Glycerol is administered orally to patients to reduce fluid abnormalities
in the inner ear. It affects hearing temporarily (for a few hours), the
results of which are measured by audiogram.
*METHODS OF GLYCEROL TEST-

The patients are advised to report empty stomach on the day of

investigation. PTA test is performed before the administration of glycerol
and then patient is administered a solution of 86% of glycerol (1.5 mg/kg of
body weight) dissolved in equal volume of physiological saline.

Pure tone audiometry is then repeated at 1, 2 and 3 hours of glycerol

administration.

The glycerol test is regarded as positive:

 When the hearing threshold is lowered at least 15 dB at minimum

three frequencies or
 When there is a total pure tone threshold shift of 25 dB at three
consecutive frequencies or
 When there is a 16% improvement in speech discrimination.

In the study conducted at our department (whose results have yet to be

published), only those patients were included who had definite Meniere’s
disease based on the AAO-HNS criteria. All these patients were subjected
to glycerol testing to determine their suitability for administration of
hydrochlorothiazide. In this study, 74% of patients had a positive glycerol
test.

Another study has reported its experience of using the glycerol test in 122
patients with combination of sensorineural hearing loss, tinnitus or
vestibular symptoms, in which endolymphatic hydrops was considered a
possibility. Fifty percent of patients ultimately were found to have
endolymphatic hydrops and positive test.

In a study of series of 95 patients with Meniere’s disease, 47% were found

to have a positive glycerol dehydration test. Yet another study reported that
60% of patients with Meniere’s disease have positive tests. This study also
noted that positive tests were found only in ears with Meniere’s disease. In
another study, intravenous administration of glycerol was performed
instead of oral administration. Positive results were obtained in 50% (15 out
of 30) of patients 1 hour after administration. The positive ratio was same
as oral glycerol test. Thus, the results of glycerol testing in our study are
comparable with other studies. The relatively higher percentage of positive
glycerol test in our study could be due to the fact that subjects included in
our study met the criteria of “definite Meniere’s disease” as laid down by
AAO-HNS. In our study, the results of administration of hydrochlorothiazide
to patients who tested positive on glycerol testing indicate an across the
board improvement in symptoms of Meniere’s disease at the end of follow-
up. Thus, it may be concluded that glycerol testing in patients with “definite
Meniere’s disease” as assessed by AAO-HNS criteria is a good idea to
select patients who will respond to administration of osmotic diuretics.

Most patients may suffer headache and nausea after drinking the glycerol
for post-glycerol audiometric evaluation, which usually subsides after few
hours.