Clinical Hearing Tests

MEDICAL UNIVERSITY – PLEVEN

DEPARTMENT OF OTORHINOLARYNGOLOGY

Subjective Tests

• Tuning fork tests*

• Speech test *
• Speech audiometry*- Lists of two-syllable words with equal stress on both syllables are
administered by air conduction through earphones or in free-field to both ears. The intensity
of the words is varied through the audiometer attenuator. The patient is asked to repeat the
words and the results are plotted on a special graph (speech audiogram).
• Pure-tone audiometry

* These tests are often not performed if there is easy access to an audiology department that can perform an
audiogram. However, these tests remain useful when audiology is not available.

Objective Tests

• Tympanometry
• Acoustic reflex(Stapedial reflex) - The stapedial muscles contract bilaterally when one of
the two ears is stimulated with a sufficiently loud sound.
• Evoked response audiometry - The main applications of evoked potential audiometry are
(1) to diagnose hearing impairment in non-cooperative patients (infants and handicapped
adults) and (2) to identify retrocochlear disorders (site-of-lesion tests). Acoustically evoked
bioelectric responses of the cochlea, auditory nerve, auditory tract neurons, or cerebral
cortex are analyzed using surface electrodes and averaging techniques.
• Otoacoustic emissions - Otoacoustic emissions are frequently used in screening of
newborns and to monitor the status of the cochlea during treatment with ototoxic drugs. A
microphone probe is used to measure sound events in the ear canal that are produced by
spontaneous or acoustically evoked active biomechanical vibrations in the cochlea.

Conductive deafness is caused by an abnormality Sensorineural deafness is caused by an abnormality

of the external or middle ear. of the cochlea or the auditory nerve.
 Tuning Fork Tests

• Weber test
• Rinne test
• Bing test
• Schwabach’s test
• Gelle test

The goal of tuning fork tests is to differentiate between conductive and sensorineural hearing loss.
Two tests are adequate for this purpose: the Weber test and the Rinne test.

Technique: A tuning fork that vibrates between about 250 and 800 Hz is used (most often 512-Hz (c2)
aluminium tuning fork). The tuning fork should be set in motion by striking it on the examiner’s
elbow or knee.

Weber test

Technique: the tuning fork is placed in the midline of the skull, usually on the vertex or the forehead.
The vibrations are transmitted by bone conduction to the cochlea. Ask the patient whether they hear
it loudest in the right, the left or the middle and note the result.
Interpretation:
• Normal – the vibrations are perceived as equally loud on both sides, and so the sound is
heard midway between the ears. In an abnormal test, the sound will be lateralized to one
side or other.
 If the patient has sensorineural hearing loss, the tuning fork is lateralized to the better-
hearing ear.
 If the patient has conductive hearing loss, the tuning fork is lateralized to the affected ear
because the vibrational energy is more poorly transmitted from the cochlea through the
middle ear and it is more difficult for ambient sounds to reach the cochlea. As a result, more
vibrational energy is present in the normally functioning cochlea, and the sound is perceived
as louder.
 Rinne test

Principe: the Rinne test compares the levels of air and bone conduction in the same ear.

Technique: Place a vibrating 512 Hz tuning fork firmly on the test ear mastoid process.This tests the
bone conduction. Next, place the tuning fork in front of the test ear with the tuning fork’s tines
perpendicular to the head, hence testing air conduction.The patient is asked to state whether it is
heard better by BC or AC. If the patient is unsure which is louder, air and bone conduction can be
compared by testing for threshold: the tuning fork is struck and pressed to the mastoid, and the
patient tells the examiner when the sound becomes inaudible. Then the tuning fork (without being
struck again) is shifted to a position just outside the ear canal.

Interpretation:
 Normal (positive Rinne test) - the tuning fork vibration is transmitted to the cochlea better by
air conduction than by bone conduction. Air-conducted sound is perceived as louder than
bone-conducted sound and lasts at least 15 seconds longer.
 Negative Rinne test – when conductive hearing loss is present, the sound is perceived as
louder on the mastoid than outside the ear canal.
 Positive Rinne test by sensorineural hearing loss- If the tone is louder by air, this indicates
sensorineural hearing loss. Air-conducted sound is perceived as louder than bone-conducted
sound and lasts less than 15 seconds.
 Speech test
The severity of the hearing loss can be clinically assessed without instrumented test methods by
having the patient listen to and repeat spoken numbers. The range for hearing whispered speech and
speech at a normal conversational level is tested separately for each ear. The non-test ear should be
masked to preclude crossover hearing. Now the examiner whispers two-digit numbers with his head
turned away from the patient and instructs the patient to repeat the words aloud. If the patient does
not understand the numbers, the examiner presents them again at progressively smaller distances
from the test ear. If the numbers are still not understood when whispered just outside the ear canal,
the test is repeated with the numbers spoken at a normal loudness level. The range of hearing can be
tested in meters if a large testing suite and an assistant are available. The patient turns the test ear
toward the examiner, who whispers numbers toward the patient from a distance of 6 meters. If the
patient does not understand the numbers, the examiner moves closer and determines the range at
which the words become intelligible. In a normal test, the subject can understand two-digit numbers
whispered from approximately 6 m away.

Pure-tone Audiometry

Pure tone audiometry provides a measurement of hearing levels by AC and BC and depends on the
cooperation of the subject. The test should be carried out in a sound-proofed room. The audiometer
is an instrument that generates pure tone signals ranging from 125Hz to 8 000 Hz, beginning with
1,000 Hz at variable intensities. Audiometry is done separately for the left and right ears. The signal is
fed to the patient through earphones for AC and through a small vibrator applied to the mastoid
process for BC. Signals of increasing intensity at each frequency are fed to the patient, who indicates
when the test tone can be heard. The threshold of hearing at each frequency is charted in the form
of an audiogram, with hearing loss expressed in decibels (dB). Decibels are logarithmic units of
relative intensity of sound energy. When testing hearing by BC, it is essential to mask the opposite
ear with narrow-band noise to avoid cross-transmission of the signal to the other ear.
 Tympanometry
Tympanometry is an objective method serving to evaluate the mobility of the tympanic membrane
and the functional condition of the middle ear, as pressure is altered in the external auditory canal
from +400 to –600 daPa. A pure tone signal of known intensity (usually 220 Hz) is fed into the
external auditory canal and a microphone in the ear probe measures reflected sound levels.The
external auditory canal is hermetically sealed with a probe that has various access ports. Thus, the
sound admitted to the ear can be measured. Most sound is absorbed when the compliance is
maximal, and, by altering the pressure in the external canal, a measure can be made of the
compliance at different pressures. Impedance tympanometry measures not hearing but, indirectly,
the compliance of the middle-ear structures. A tympanogram is the graphic representation.

 Type A curve in patients with a normal tympanic membrane, good tube function (normal
patients and patients with a sensorineural loss).

 Type B - hypomobile or non-mobile tympanic membrane owing to the presence of fluid in

the middle ear (otitis media with effusion), tympanic perforation, patent transtympanic
drainage (vent tube) or ear canal totally occluded by wax.

• Type C - mobile tympanic membrane with poor Eustachian tube function (in some cases, with
a small amount of fluid in the middle ear).