ASSESSMENT OF HEARING

PRESENTED BY : AASHISH SAPKOTA

PREPARED BY : ABDUR RAUF, AVANTIKA RAI & AASHISH

SAPKOTA
 TERMINOLOGIES
• Frequency. It is the number of cycles per second , unit : hertz
• Pure Tone. A single frequency sound is called a pure tone , e.g. a sound of 250, 500 or 1000 Hz
• Intensity : Loudness
Whisper = 30 dB
• Decibel (dB). It is 1/10th of a bel.Sound in dB = 10 log Normal conversation = 60 dB
S1= sound being described Shout = 90 dB
S0= reference sound Discomfort of the ear = 120 dB
Pain in the ear = 130 dB
• Noise : aperiodic complex sound
-- White noise: contains all frequencies
-- Narrow band noise: frequency range smaller than broad band white noise
-- Speech noise: noise having frequencies in speech range( 300-3000 Hz)

• Masking :It is a phenomenon to produce inaudibility of one sound by the presentation of

another.Masking of nontest ear is essential in all bone conduction tests, but for air conduction
tests, it is required only when difference of hearing between two ears exceeds 40 dB.
TYPES OF HEARING LOSS :
 Assessment of hearing

Clinical Tests Audiometric tests Special tests

A)RECRUITMENT
A)FINGER FRICTION TEST A)PURE TONE
B)SHORT INCREMENT SENSITIVITY
B)WATCH TEST AUDIOMETRY INDEX (SISI TEST)
C)SPEECH TEST B)SPEECH C)THRESHOLD TONE DECAY TEST
D)TUNNING FORK TEST AUDIOMETRY D)EVOKED RESPONSE
C)BEKESY AUDIOMETRY
E)AUDITORY STEADY STATE
AUDIOMETRY
RESPONSE(ASSR)
D)IMPEDANCE F)OTOACOUSTIC EMISSIONS
AUDIOMETRY (OAEs)
G)CENTRAL AUDITORY TESTS
F) HEARING ASSESSMENT IN
INFANT AND CHILDREN
 CLINICAL TEST OF HEARING
A. FINGER FRICTION TEST
-Rubbing or snapping the thumb and finger
close to patient's ear
B. WATCH TEST
-clicking watch is brought close
-distance at which
C.SPEECH TEST it is heard is measured

-examiner at 6m for both conversation and whisper

-eye closed of patient
-uses spondee words (e.g. black-night, football, daydream) or numbers
with letters (X3B, 2AZ, M6D)
-gradually walks and distance at which conversational voice and the
D.TUNNING FORK TEST
whispered voice are heard is measured
 TUNNING FORK TEST (preliminary test )
• The following are the routinely done tuning fork
tests:
• 1. Rinnes test
• 2. Weber test
• 3. Absolute bone conduction (ABC) test
• 4. Schwabach’s test
• 5. Bing test
• 6. Gelle’s test

• The tuning fork tests are most commonly done

with the 512 Hz frequency because it is better
heard.
• 126 Hz tuning forks for they produce more of
vibration sense.
• > 512 Hz Dampens very fast .

By the tuning fork tests we test the Air conduction (AC)

and the Bone conduction (BC)
 • Air conduction: To test the Air BONE CONDUCTION :To test the Bone
conduction (AC) the vibrating tuning fork is conduction (BC) the vibrating tuning fork is placed
over the mastoid.
placed 2 cm in front of the pinna.

• Sound vibration → Pinna → EAC → TM → Vibrating tuning fork → vibrates skull cochlear
Ossicular chain → foot plate of stapes (oval fluid moves → stimulates organ of Corti →8th
window) → organ of Corti → 8th nerve → nerve auditory pathway auditory cortex
Auditory pathway → Auditory cortex. ( area no. 41)
• Air conduction (AC) is a measure of all the
three pathways, i.e. conductive, sensory as •
Bone conduction (BC) is a measure of the latter
well as neural. two pathways, i.e. the sensory and the neural pathway

ir conduction is better than bone conduction,because amplified sound ( impedance matching in middle ear)
eaches sensory neural pathway.
 1. RINNE TEST :
• Threshold:A vibrating tuning fork
is placed on the patient’s mastoid
and when he stops hearing, it is
brought beside the meatus. If he
still hears, AC is more than BC
• Loudness: the patient is asked
to compare the loudness of sound
heard through air and bone
conduction. Rinne test is called
positive when AC is longer or louder
than BC
 RINNE TEST: Normal ear : as described earlier
• Here we test the AC and BC and compare SNHL: Both AC and BC decreases but ,
the two in the same ear. AC being amplified by middle ear , heard more effective
. than BC in defective ear.
so AC>BC

CHL: sensorineural pathway is good and defect is in

conductive pathway , so BC heard better than AC.

severe unilateral SNHL: because of vibration of

whole of the skull, transcranial transmission of
sound occurs leading to the stimulation of the
opposite ear ,so, BC better heard than AC by
opposite ear .( defective ear doesnot respond to
both )
(FALSE NEGATIVE )

Can be corrected by masking

2. WEBER TEST
• In this test the vibrating tuning fork is
placed over the forehead/vertex or teeth
(incisors) and the lateralisation of the
sound is asked for (i.e. in which ear the
sound is heard louder).
• Sensitive test shows lateralization with
512 Hz TF 15- 25 Db hearing loss.
WEBER TEST

In SNHL: IN CHL:
Sound is lateralized to sound is lateralized
better ear. to defective ear.
3. ABSOLUTE BONE CONDUCTION TEST :
• BC of the patient is compared with
the examiner.
• External auditory meatus of both
the patient and examiner should be
occluded (by pressing the tragus
inward).
4. SCHWABACH’S TEST :
• Meatus is not occluded
BC
5.BING Test: 6.GELLE TEST
• no change in hearing in positive: change in hearing with
releasing and pressing tragus: change in air pressure
CHL (normal,SNHL)
• change in hearing in releasing • negative: no change in
and pressing tragus:SN hearing with change in
pressure(ossicular
discontinuity,otosclerosis)
AUDIOMETRIC TESTS
1. PURE TONE AUDIOMETRY
2. IMPEDANCE AUDIOMETRY
a.TYMPANOMETRY
b. ACOUSTIC REFLEX
MEASUREMENT
3. SPEECH AUDIOMETRY
a.SPEECH RECEPTION THRESHOLD
b. SPEECH DISCRIMINATION SCORE
 1.PURE TONE AUDIOMETRY (Subjective Test)
• An audiometer is an electronic device
(AUDIOMETER) which produces pure tones,
the intensity of which can be increased or
decreased in 5 dB steps
• Graph: audiogram
• AC:125, 250, 500, 1000, 2000, 4000 and
8000 Hz
• BC: 250, 500, 1000, 2000 and 4000 Hz
• difference in the thresholds of air and bone
conduction (A–B gap)

measure of conductive deafness

Audiometer is so calibrated that,in normal
person hearing at 0 db AC and BC is equal
(BC>AC or BC=AC)
-When difference between the two ears is 40 dB or above in air conduction
thresholds, the better ear is masked to avoid getting a shadow curve from the nontest
better ear.
-masking is essential in all bone conduction studies
(By employing narrow band noise to nontest ear)

Uses of Pure Tone Audiogram

• (a) It is a measure of threshold of
hearing by air and bone conduction
and thus the degree and type of
hearing loss.
• (b) A record can be kept for future
reference.
• (c) Audiogram is essential for
prescription of hearing aid.
• (d) Helps to find degree of handicap
for medicolegal purposes.
 CALCULATING HEARING IMPAIRMENT :
• Step 1: Take the average of hearing threshold of frequencies 500, 1000 and
2000 Hz (i.e. speech frequencies) from the audiogram.
• Step 2: Deduct 25 dB from this average (since uptill 25 dB, the hearing is
considered as normal).
• Step 3: Multiply the result with 1.5 to get the percentage.

• Example: Hearing threshold in frequencies 500, 1000 and 2000 Hz is 30 dB, 45

dB and 60 dB respectively. So average (30 dB + 45 dB + 60 dB)/3 = 45 dB.
Then 45 dB – 25 dB = 20 dB. So percentage hearing loss = 20 ×1.5 = 30%.

• To calculate the total handicap of hearing, the following procedure is followed:

• (% hearing impairment of the better ear × 5) + (% hearing impairment of the
worse ear) divided by 6.
CONDUCTIVE HEARING LOSS AUDIOGRAM :

• BC : Normal
• AC : Defective
• ( Normal SN + Defective C)

• In speech frequency , 50 db
loss

• AB Gap >15-20 db
S.N. CONDITION HEARING LOSS

1 Complete obstruction of ear canal 30 dB

2 Perforation of tympanic membrane (It 10–40 dB
varies and is directly proportional to the
size of perforation)
3 Ossicular interruption with intact drum 54 dB
4 Ossicular interruption with perforation 38 dB
5 Malleus fixation 10–25 dB
6 . Closure of oval window 60 dB

Note here that ossicular interruption with intact drum

causes more loss than ossicular interruption with perforated
drum.
SENSORINEURAL HEARING LOSS AUDIOGRAM :

• BC : DEFECTIVE
• AC : DEFECTIVE
• AB GAP < 15-20 db
MIXED HEARING LOSS AUDIOGRAM :

• BC : Defective ( Defective
SN)
• AC: Defective
• AB Gap > 15-20 db
(AC is much more decreased
than the bone conduction, so there
is an additional air-bone gap also
present)
CHARACTERISTICS AUDIOGRAM :
 Down-sloping : High frequency
hearing loss.
a. Noise induced hearing loss
b. Ototoxicity
c. presbycusis
 Up-sloping : Low frequency
hearing loss.
a.meniere’s disease
 DIP at 4000 Hz : Noise induced
hearing loss.
 Carhart’s notch : otosclerosis
 U-shaped / cookie bite :congenital
SNHL
IMPEDANCE AUDIOMETRY

• TYMPANOMTRY:
• when a sound strikes tympanic
membrane, some of the sound energy
is absorbed while the rest is reflected.
• A stiffer tympanic membrane would
reflect more of sound energy than a
compliant one.
• By changing the pressures in a sealed
external auditory canal and then
measuring the reflected sound energy
• , it is possible to find the compliance or
stiffness of the tympano-ossicular
system
Terms for tympanometry
--Static compliance: maximum compliance
Normal range--(0.3ml-1.7ml)
--Peak pressure: pressure at which static compliance appears
Normal range: +100 to -100mmH2O
--Volume: 0.9cc-2.5cc
 TYPES OF TYMPANOGRAMS :
• Type A: Normal tympanogram.
• Type As :Compliance is lower at
or near ambient air pressure
normal peak pressure,normal
volume seen in
fixation of ossicles, e.g.
otosclerosis ,tympanosclerosis,t
hick graft in myringoplasty
• Type Ad: High compliance at or
near ambient pressure, normal
volume
Seen in (a) ossicular
discontinuity (if air-bone gap is
>60 dB), (b) flaccid tympanic
membrane and (c) monomeric
tympanic membrane.
• Type B : flat curve denoting that pressure
changes do not have much effect on the
compliance. The possible causes from the
external canal inwards are:
1. Impacted wax
2. Foreign body
3. Secretory otitis media
4. Adhesive otitis media
5. Perforated TM(volume
increases>2.5cc
6. Patent grommet

• Type C: Maximum compliance occurs with

negative pressure in excess of 100 mm
H2O. Seen in retracted tympanic
membrane, Early secretory otitis
media ,Eustachian tube dysfunction
 ACOUSTIC REFLEX :
• Based on the fact that a loud sound, 70–100 dB above the threshold of hearing of a
particular ear, causes bilateral contraction of the stapedial muscles which can be
detected by tympanometry.

• Tone can be delivered to one ear and the reflex picked from the same or the
contralateral ear.

• .Ipsilateral: CN VIII → ventral cochlear nucleus → CN VII nucleus ipsilateral

stapedius muscle.

• Contralateral: CN VIII → ventral cochlear nucleus →contralateral medial superior

olivary nucleus → contralateral CN VII nucleus → contralateral stapedius muscle.
USES:

1. To differentiate cochlear and retrocochlear hearing loss.

2. To identify Malingerers.

3. Identification of the site of lesion in facial nerve palsy.

4.Lesion of brain stem.

SPEECH AUDIOMETRY

• Patient’s ability to hear and understand speech is

measured.
• Two parameters:
• 1)speech reception threshold
2)speechdiscrimination score
Speech Reception Threshold (SRT)

• minimum intensity at which 50% of the words are

repeated correctly by the patient.
• spondee words (two syllable words with equal stress on
each syllable, e.g. baseball, sunlight,daydream, etc.) is
delivered to each ear through the headphone.
• Normally, SRT is within 10 dB of the average of pure tone
threshold.
• An SRT better than pure tone average by more than 10
dB suggests a functional hearing loss
Speech discrimination score/speech
recognition/word recognition score.
• measure of patient’s ability to understand speech
• phonetically balanced (PB) words (single syllable words,
e.g. pin, sin, day, bus, etc.) is delivered to the patient’s
each ear separately
• 30–40 dB above his SRT
• percentage of words correctly heard by the patient is
recorded.
• normal persons +CHL = 90–100% can be obtained
Occurs in retrocochlear hearing loss
Uses of speech audiometry

• find speech reception threshold correlates with average of

three speech frequencies of PTA
• differentiate organic from nonorganic (functional) hearing
loss.
• find discrimination score :helpful for hearing aid and
setting its volume for maximum discrimination
• differentiate a cochlear from a retrocochlear sensorineural
hearing loss.
REFERENCE
-Dhingra-Diseasea of ear,nose,throat
-Textbook of Ear, Nose, Throat and Head Neck Surgery- P.Hazarika
Thank you