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Audiology: DR Humra Shamim
Audiology: DR Humra Shamim
part i
Dr Humra
Shamim
Evolution of audiology
• Prior to World War II, hearing-care services were provided by
physicians and commercial hearing aid dealers.
• Because the use of hearing protection was not common until
the latter part of the war, many service personnel suffered the
effects of high-level noise exposure from modern weaponry.
• It was the influx of these service personnel reentering civilian
life that created the impetus for the professions of otology
(the medical specialty concerned with diseases of the ear) and
speech pathology (now referred to as speech-language
pathology) to work together to form aural rehabilitation
centers.
Some of the earliest tests of hearing probably consisted merely
of producing sounds of some kind-
• such as clapping the hands or
• making vocal sounds
• the ticking of a watch
• the clicking of two coins
These tests provided little information of either quantitative or a
qualitative nature.
CLINICAL TESTS OF HEARING
1. Easy to perform
2. Can even be performed at bed side
3. Will give a rough estimate of the patient’s hearing acuity
The following tests can be performed using a tuning fork:
1. Weber test
2. Rinne test
3. Absolute Bone Conduction test
4. Schwabachs test
5. Bing test
6. Stenger’s test
7. Gelle test
8. Chimani-Moos test
METHODOLOGY OF USING TUNING FORK
• The tuning fork must be struck against a firm surface (rubber pad / elbow
of the examiner). The fork should be struck at the junction of upper 1/3
and lower 2/3 of the fork. It is this area of the fork which is capable of
maximum vibration.
• Vibrating fork should be held parallel to the acoustic axis of the ear being
tested.
Bone conduction:
• Cochlea gets stimulated in 3 ways
when bone is stimulated
• The three normal routes of bone
conduction of sound vibrations to the
inner ear:
route A: via the skull bone;
route B: via the ossicular chain;
route C: via the external auditory
canal.
• In a normal ear, when the skull is
vibrated by bone-conduction, it not
only vibrates the cochlea via route A,
but it also vibrates the tympanic
membrane and ossicular chain (route
B) and the air in the external auditory
canal (route C).
• In the presence of a conductive
defect, the osseous route A is the
only route for sound vibrations to
reach the inner ear. When there is a
middle ear conductive defect, routes
B and C are materially diminished in
magnitude
OUTER EAR COMPONENT OF BONE
CONDUCTION
• The middle ear component of bone conduction is the inertial lag of the
ossicles . Middle ear ossicles are not directly attached to the skull, but are
instead suspended by ligaments and tendons and attached at either end
to the elastic tympanic and oval window membranes. The ossicles are free
to move out of phase with skull vibrations and will do so because of
inertia, much as coffee would lag and spill from a cup moved precipitously.
• Middle ear ossicles vibrate relative to the skull in a like manner as during
air conduction hearing, and thus energy is propagated into the inner ear.
The middle ear component occurs mainly at and above 1,500 Hz and is
especially significant near 2,000 Hz, the approximate resonant frequency
of the middle ear
INNER EAR COMPONENT OF BONE
CONDUCTION
• Inner ear bone conduction has been described as resulting from alternate
compressions and expansions or distortions of the bony cochlear capsule.
In turn, cochlear fluids are displaced and basilar membrane-traveling
waves are initiated.
• One factor making cochlear fluid displacement possible is the out-of-
phase and disproportionate yielding of the round and oval cochlear
windows, which creates alternating spaces for fluid displacement.
Cochlear fluid movement, in turn, displaces the basilar membrane and
initiates traveling waves.
• Transmission routes for air conduction, right ear example
(narrow arrows) and bone conduction, right mastoid
example (bold arrows). Note: Higher intensity air-conducted
signals can activatethe bone conduction transmission route.
RINNES TEST
• In this test air conduction of the ear
is compared with its bone
conduction. 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.
• Alternatively, 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. It is seen
in normal persons or those having
sensorineural deafness.
• A negative Rinne (BC > AC) is seen in
conductive deafness. A negative
Rinne indicates a minimum air-bone
gap of 15–20 dB.
• False Negative Rinne It is seen in severe unilateral sensorineural hearing
loss. Patient does not perceive any sound of tuning fork by air conduction
but responds to bone conduction testing.
• This response to bone conduction is, in reality, from the opposite ear
because of transcranial transmission of sound. In such cases, correct
diagnosis can be made by masking the non-test ear with Barany's noise
box while testing for bone conduction.
• A prediction of air-bone gap can be made if tuning forks of 256, 512 and
1024 Hz are used.
Rinne test equal or negative for 256 Hz but positive for 512 Hz indicates
air-bone gap of 20-30 dB.
Rinne test negative for 256 and 512 Hz but positive for 1024 Hz indicates
air-bone gap of 30-45 dB.
Rinne negative for all three tuning forks, indicates air-bone gap of 45-60
dB .
Remember that a negative Rinne for 256, 512 and 1024 hz indicates a
minimum AB gap of 15, 30, 45 dB respectively
Rinnes Test
• Pts. with normal hearing and SNHL will hear the tone louder at the ear
(Because AC is a more efficient means of sound transmission to the IE than
BC) than behind the ear (Positive Rinne)
• Pts. with CHL (more than mild) or MHL will hear the tone louder with the
stem of the fork behind the ear because their BC hearing is better than
their AC hearing (Negative Rinne)
• The 256-Hz Rinne tuning fork test
will detect a conductive deafness
above 30 dB in 90 %of patients.
Between 20 and 30 dB, the
sensitivity will fall to 70 % and
between 10 and 20 dB will be less
than 50%
• The specificity of the test is high
above 30 db conductive deafness,
but falls as the air–bone gap
narrows.
Weber test