AUDITORY AND VESTIBULAR

MEDICINE CLINIC

Audiometry: Masking
Mohamed A. Hamid , MD, PhD; Kenneth H. Brookler, MD

Frequency In Hertz (Hz)

125 2SO 500 1000 2000 4000 8000

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Figure. The unma sked left BC (» thresholds mirror the normal
right ear hearing . BC thresholds with no plat eau (J--J) show
a low-frequency A-B gap that disappe ared when the plateau \Vas
appli ed ([ - - - J)./n this situation, the right BC thresholds should
be tested below 0 dB. (0 = right AC; J = left BC masked; x =
left AC; 0 = left masked AC.)

Audiometry provides information about hearing func-
tion, not about diagnosis. Many different causes ofhearing
impairment produce similar aud iometric results.Neverthe-
less, we rely upon audiometric test results to help establish
a diagnosis, so it is essential that they be accurate. One
common source of error occurs when the audiometric
stimulus is perceived in the contralateral (nontest) ear,
and patient responses are unknowingly recorded as if they
had resulted from stimulation of the test ear. Audiologists
avoid this error by expert use of masking.
Since pat ients with conductive or mixed hearing loss
have a good chance of being successfully treated with
surgery, it is critical to determine the degree of the con-
ductive component in these cases. However, testing of
patients with conductive or mixed hearing loss poses a
challenge to the audiologist. For example, interaural at-
tenuation produces cross -hearing in the nontest ear via
bone conduction (BC). Although interaural attenuation is
frequency-dependent, hearing scientists and audiologists
gen erally accept a level of 40 dB across all frequencies
for air-conduction (AC) test ing. Masking is applied to the
nontest ear if the AC threshold of the test ear is greater
than 40 dB above the BC threshold of the nontest ear.
During BC testing, masking is app lied to the non test ear
whenever there is an air-bone (A-B) gap greater than 10
dB in the test ear. Masking should be applied whenever
the difference between the BC ofthe two ears at any given
frequency exceeds 5 dB .
Audiometers are calibrated so that a 10-dB masking
noise will block a 10-dB pure -tone signal. Masking of the
nontest ear is achieved by using "effective masking" (i.e.,
40 dB greater than the nontest-ear threshold) and/or by
reaching a plateau of 15 dB (in 5-dB increments), during
which the test ear hears the pure tone at the same level.
Effective masking is used primarily to save time . Mask-
ing without a plateau can lead to either undermasking or
overmasking.
Undermasking leads to false A-B gaps and is usually

From the Cleveland Hearing and Balance Center, Beachwood, Ohio (Dr. Hamid), and Neurotologic Associates, PC, New York City (Dr. Brookler).

646 ENT-Ear, Nos e & Thr oa t Journal· October 20 06

 AU DITORY AND VESTIBU LAR MEDICIN E C LINIC
the resu lt of operator inexperience or a fai lure to follow
masking rules. In the case illustrated here (figure) , the
left, low-frequency A-B gap occurred as a resu lt of not
using the plateau method, and it disappeared when proper
masking was applied. In this situation, the results of the
256 - and 5 12-Hz tuning fork tests, which lateralized to the
right ear, were a tell tale sign of a false A-B gap . A lthough
uncommon, BC hypersensitivity (BC thresholds in the
nontest ear less than 0 dB) can lead to undermasking ifthe
true threshol ds are not used to calculate effective masking
leve ls. (We described BC hypersensitivity, which is usu-
ally present wit h superior canal dehiscence, in the August
2006 AUDITORYANDVESTIBULAR M EDICINECLINIC.') In such
cases, it is recommended tha t true BC thres ho lds be used
for effective masking.
Overmasking is common ly encountered in patients with
Reach More Patients.
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Volume 85, Num ber 10
bilateral conduct ive hearing loss. In such patients, in order
to provide 40-dB masking above the BC threshold in the
nontest ear, the masking level may exceed interaural at-
tenuation and produce an inadvertent threshold elevation
by masking the test ear, as we ll. It is difficult to establish
an accurate masking platea u in this patient populat ion .
This is referred to as a "masking di lemma," and it can
be rec tifie d by using insert earphones, which have higher
interaural attenuation levels.
In summary, masking is critical during audiome try. Mask-
ing rules , effective masking, masking plateaus, and insert
earphones should be used rout inely to achieve proper mask-
ing and to avo id under- and overmasking problems.
Refe rence
I . Broo kler KH, Hamid MA . The "normal" audio gram. Ear No se
Thro at J 2006;85:486.
eq uip men t does no t fit th em all. Mak e oro p haryngea l surgery
easie r w ith a simp le ex tensio n . Th e C A N T Co rpo ra tio n h as
crea te d th e D edo Ext en sion th at fit s b et w e en th e M ayo Sta nd
an d th e Crewe- Dav is mouth gag so th at it can b e adj us te d t o
fit lar ger pati ent s. Th e DE 98- A mo un ts to th e squa re- sided
M ayo Stan d , w hi le th e D E98-13 fit s th e tubula r- sided su p po rt.
Th e D ed o Ex tension - a sim p le but effec tive sol utio n .
Applicable Pro cedures
T&A 's
• Uv uloplas ty
Palatoplasty
All oro phary ngeal procedur es using
a Crew e- Davis mouth gag
• PO Bo x 3 522 • Laf a y e t t e ,L A 7050 2 cmnT
C DR PO RATl o n
647