Audiometry and

Occupational
Hearing Loss

Hearing
Sound
External ear canal
Tympanic membrane
Ossicles and muscles
Oval window
Cochlea
Sensory hair cells
Sensory nerve fibers
8th. Cranial nerve

Introduction
Sound: small, rapid, local fluctuations in
atmospheric pressure
SPL (sound pressure level): amplitude or
loudness of sound

Dynes/cm2
dB (a logarithmic scale)

Frequency (Hz)

Introduction (cont.)
0 dB (zero reference level): the faintest
sound the average normal young humans
can hear
Human range of hearing (SPL): 0-120dB
Human range of hearing (frequency): 2020000 Hz
Some examples:

Conversation: 60-70 dB
Some industrial machinery: 80-100 dB
Chainsaw: 110 dB

Introduction (cont.)
Hearing threshold: minimum SPL that
sound is first recognized for a given
frequency
Sound types:

Pure tone: regular at a single frequency

complex

Normal threshold: -0.5 25 dB

Mild Hearing Loss: 25 - 40 dB HL

Moderate Hearing Loss: 40 - 55 dB HL

Difficulty with loud speech

Severe Hearing Loss: 70 - 90 dB HL

Difficulty with normal speech

Moderately Severe Hearing Loss: 55 - 70 dB HL

Difficulty with soft speech

Can only understand shouting

Profound Hearing Loss: > 90 dB HL

Cannot understand even amplified speech

Audiometric testing
Pure tone audipmetry (PTA)
Speech audiometry (SRT,SDS)
Impedance audiometry
Auditory Brainstem Response (ABR)
Otoacoustic Emissions

Pure Tone Audiometry

Most common test

Threshold of hearing in different frequencies
Comparing hearing threshold with zero reference
level
Two kinds:

Air conduction assesses entire system

Bone conduction assesses cochlea onwards

BC with and without masking

A graph showing HTL as a function of frequency

Frequencies: 125, 500, 1000, 2000, 4000,
8000Hz and 3000, 6000 Hz

Standard signs in
audiometry
O---O: right AC
---: left AC
>--->: right BC
<---<: left BC
[----[ : right BC with masking
]----] : left BC with masking

Speech audiometry
SRT (speech reception threshold)
Balanced two-syllable words (spondee
words)
Intensity at which listener can repeat 50%
of words
Close agreement with average hearing
threshold (500-3000 Hz)

Speech audiometry
(cont.)

SDS (speech discrimination score)

Phonetically balanced one-syllable words
Intensity: SRT + 25-40 dB
Percentage of words correctly repeated
Normal: 88-100%

Impedance audiometry
Tympanometry:
Measure the impedance of eardrum and
ossicular chain:
Type An: normal

Type As (Reduced compliance):

otosclerosis, tympanosclerosis

Type C: auditory tube dysfunction

Type B (no compliance): TM perforation or

effusion

Type Ad (Increased compliance): laxity of

TM or disruption of ossicular chain

ABR
Evoked potentials in response to clicking
noise
Localizing retrococlear lesions
Five waves:

8th cranial nerve to

inferior colliculus)

OAE
A test for non-organic pathology
35-40 dB hearing threshold produce OAE
Hair cell damage
Sensory hearing loss
In conductive hearing loss OAE can not be
performed

Principles of Hearing Evaluation

Normal hearing
Hearing by AC=BC and both are within normal limits

Conductive hearing loss

Hearing by AC is poorer than hearing by BC and BC is within
normal limits

Sensorineural hearing loss

Hearing by AC=BC and both are impaired to the same degree

Mixed hearing loss

Hearing by AC is poorer than hearing by BC and both are
impaired

Conductive hearing loss

Hearing

loss due to
impairment of
conducting sound
down ear canal to
inner ear.

Conductive hearing loss

Otosclerosis
Tympanosclerosis
TM perforation
Middle ear effusion
Laxity of TM
Disruption of ossicular chain

Sensorineural Hearing Loss

Hearing loss due to loss of function, from cochlea

onwards

Cochlea (inner ear), auditory nerve (from cochlea

to brain), and auditory cortex (brain)

Sensorineural Hearing Loss

Sensorineural Hearing Loss

Presbycusis
Metabolic disorders
Infectious hearing loss
CNS disease
Meniere diseae
Noise-induced hearing loss

Mixed hearing loss

Occupational hearing
loss
Conductive
Sensorineural
Mixed

Occupational hearing
loss

Acute acoustic trauma

Ototoxic hearing loss
Hearing loss due to workplace injuries
Noise-induced hearing loss (NIHL)

Acute acoustic trauma

Brief exposure to extremely loud noise
(120-140 dB) or due to blast injuries
Conductive, sensorineural or mixed
Temporary or permanent
Vertigo, tinnitus and pain
Unilateral or bilateral
Follow-up for 4-6 months

Ototoxic hearing loss

Exposure to substances that injure the

cochlea
Non-occupational (Drugs):
Aminoglycosides (gentamicin)
Loop diuretics (furosemide)
Antineoplastic agents (cisplatin)
Salicylates (aspirin)

Occupational:

Heavy metals
As
Co
Pb
Hg

Cyanide
Benzene
Propylene glycol
CS2
Styrene

Ototoxic hearing loss

Bilateral high-frequency sensorineural

hearing loss

Importance:
Exposure to ototoxic substances makes the
worker more suceptible to NIHL

Workplace injuries

Conductive

Sensorineural

Blunt head trauma

Longitudinal temporal bone Fx
Burns (e.g. welders slag)
barotrauma
Blunt head trauma (labyrinth concussion,)
Transerve temporal bone Fx

Mixed

Blunt head trauma

Temporal bone Fx

NIHL
Noise: the most pervasive hazardous
agent in the workplace
NIHL: second most common acquired
hearing loss after presbycusis
Mechanism: trauma to the sensory
cochlear epithelium (esp. hair cells) due to
exposure to noise
TTS (temporary threshold shift)
PTS (permanent threshold shift)

NIHL

5% of individuals exposed to 80dB noise

levels develop a significant hearing loss.

5-10% for 85dB exposure

15-25% for 90dB exposure

NIHL
A sensorineural hearing loss
Mostly high-frequency
Most severe around 4000 Hz (notch)
Mostly bilateral (may be unilateral)
Related to intensity and duration of
exposure

NIHL
First asymptomatic
Gradual deterioration in hearing esp. in
the presence of background noise
Vowels better than consonants
Distortion of speech sounds (esp. highpitched)
Frequently accompanied by tinnitus

NIHL
Differential diagnosis:
Presbycusis
Atrophy of the hair cells or central auditory
pathways
Gradual, symmetric, progressive highfrequency sensorineural hearing loss

CNS pathologies (cerebellopontine

tumors):
Unilateral, sensorineural hearing loss

Meniere disease
Fluctuating low-frequency or flat unilateral
sensorineural hearing loss

Functional (non-organic) hearing loss

Poor correlation between SRT and average
threshold (SRT >15dB better than PTA)
Test-retest variability

Prevention of hearing loss

in workplace

OSHA TLV-TWA for exposure to noise: 90db

NIOSH exposure limit: 85dB
Noise> 85dB
Hearing conservation program (HCP):
Noise monitoring
Engineering controls
Administrative controls
Periodic audiometric evaluations
Worker education
HPDs

Noise monitoring
Sound level meter
Noise dosimeter

Engineering controls
3 important variables:
Source

Path

enclosure
barriers

Reciever

Increasing distance

Administrative controls
Purchasing suitable equipment
Reducing the exposure time:

Each 5 dB> 90 dB

exposure time is halved

95dB: 4h exposure/day
100dB: 2h exposure/day
105dB: 1h exposure/day
Ceiling: 115db: 15m. Exposure/day

Audiometric evaluations
1.
2.
3.
4.

5.

Pre-employment.
Prior to initial assignment in a hearing hazardous
work area.
Annually as long as the employee is assigned to a
noisy job (>85 dBA)
At the time of reassignment out of a hearing
hazardous job.
At the Termination of employment.

Audiometric evaluations
Baseline (after 16 h. away from exposure)
Periodic (do not require to be away from
exposure)
STS (standard threshold shift):
>10 dB decline from baseline, in average
2000, 3000, and 4000 Hz.

Retest 30 days later

Referring criteria

Baseline:

Average 500,1000,2000 and 3000 > 25dB in

each ear
Difference between two ears at 500, 1000,
2000>15dB or at 3000, 4000, and 6000>
30dB

Periodic:

>15dB decline from baseline at 500, 1000,

2000
>20 dB decline from baseline at 3000, 4000,
6000

HPDs
Ear plug (aural)
Canal cap (semiaural)
Ear muff (circumaural)

Ear muf