Audiometric testing

Presented By:
Azmat Tahira
ASSESSMENT OF HEARING
AUDIOMETRIC TESTS (condt.)

• Bekesy audiometry
• Impedance
audiometry
 BEKESY AUDIOMETRY
• Self recording audiometry

• various pure tones frequencies automatically

move from low to high while the patient control
the intensity through a button

• Two tracings are obtained- one with continuous

tone and the other with pulsed tone

• Helps to differentiate
– Cochlear from retrocochlear HL
– Organic from functional HL
• Various types of tracings are obtained
– Type I: normal hearing or CHL
– Type II: cochlear loss
– Type III: retrocochlear or neural lesion
– Type IV: retrocochlear or neural lesion
– Type V: non organic hearing loss

• Seldom performed these days

 IMPEDANCE AUDIOMETRY

• Widely used test

• Consists of
– Tympanomety
– Acoustic reflex measurement
 TYMPANOMETRY
• Of all the sounds that strikes the TM, some sound energy is
absorbed while others are reflected.

• Stiff tympanic membrane will reflect more sound energy

that compliant one

• By changing the pressure in EAC, and then measuring the

reflected sound energy, it is possible to find out the degree
of compliance or stiffness of the Tympanossicular system

• Thus we can get an idea about the health status of middle

ear

• Tympanometry has also been used to find the fx of

ET in cases of intact or perforated TM
Type A Normal tympanogram
Type As Compliance is lower at ambient pressure
-otosclerosis , malleus fixation

Type AD Compliance is high at ambient pressure

-ossicular discontinuity or thin and lax
TM

Type B No change in compliance at ambient

pressure.
- Fluid in middle ear or thick TM
membrane

Type C Maximum compliance at negative

pressure
- Retracted TM or some fluid in
middle
ear
 ACOUSTIC REFLEX MEASUREMENTS
• Based on the fact that a loud sound 70-100dB
above the threshold of hearing of a
particular ear causes bilateral contraction of
the stapedial muscles which can be detected
on tympanogram

• Tone can be delivered to one ear and the

reflex can be picked from same or
contralateral ear.
• Useful in several ways:

– Test hearing in infants and young child (objective

method)
– To find malingerers (feigns total deafness and does
not give any response to pure tone audiometry
but shows positive stapedial reflex)
– Detect VIII th nerve lesions
– Detect facial nerve lesions
– Detect brainstem lesions
SPECIAL TESTS FOR HEARING
• Recruitment
• SISI test
• Evoked response audiometry
• Auditory steady state
response
• Otoacoustic emissions
• Central auditory tests
 RECRUITMENT
• Phenomenon of abnormal growth of loudness

• Ear which does not hear low intensity sound begin to hear
greater intensity sound as loud

• Patient with recruitment – poor candidate for hearing loss

• Recruitment is seen in cochlear lesions

• Helps to differentiate a cochlear from retrocochlear

sensorineural hearing loss

• Alternate binaural balance loudness test-detect

recruitment in unilateral cases
SHORT INCREMENT SENSITIVITY INDEX
(SISI)
• Patients with cochlear lesions distinguish smaller
changes in intensity of pure tone better that normal
person and those with conductive or retrocochlear
pathology

• In this test, continuous tone is presented 20dB above

the threshold and sustained for about 2 min

• Every 5s, tone is increased by 1 dB and 20 such blings

are presented

• Patient indicates the bling heard

• SISI scores:

– CHL 15 %
– Cochlear deafness 70-100%
– Nerve deafness 0-20 %
 THRESHOLD TONE DECAY TEST
• Measure of nerve fatigue

• Use to detect retrocochlear lesions

• Normally, a person can hear a tone continuously for

60s

• In nerve fatigue, the person stops hearing earlier

• The result of the test is expressed as number of dB of

decay

• A decay of > 25 dB :diagnostic of retrocochlear lesion

 EVOKED RESPONSE AUDIOMETRY
• Objective test

• Measure electrical activity in the auditory

pathways in response to auditory stimuli

• Requires special equipment with an averaging

computer

• Two components of evoked electric response

have gained clinical acceptance
– Electrocochleography
– Auditory brainstem response
 ELECTROCOCHLEOGRAPHY
• Measures electrical potentials arising in the cochlea
and CN VIII th nerve in response to auditory stimuli
within first 5ms

• Response is in the form of 3 phenomenon

– Cochlear microphonics
– Summating potentials
– AP of CN VIII th nerve

• Recording electrode- thin needle passed through TM

onto the promontory

• Done under LA in adults ( apprehensive person and

children – GA)
• It is useful to
– Find threshold of hearing in young infants and
children within 5-10 dB
– To differentiate lesion of cochlear to that of CN VIII
th nerve

• Ratio between the amplitude of summating

potential to the AP is less than 30%

• Increase in ratio – indicative of

Ménière’s disease
 AUDITORY BRAINSTEM RESPONSE
• Also known as BERA ( brainstem evoked response
audiometry)

• Elicit brainstem responses to auditory stimulation

by clicks or tone bursts

• Non invasive technique to find integrity of central

auditory pathways through the VIIIth nerve,
pons, and midbrain

• Measures the hearing sensitivity in the range of

1KHz – 4KHz
• Normal person- 7 waves are produced in the
first 10ms

• First, third and fifth waves are most stable and

are used in measurement

• The waves are studied for absolute latency,

interwave latency ( wave I and V) and the
amplitude
• Use for:

– Screening procedure for infants

– Determine threshold of hearing in infants
(uncooperative)
– Diagnose retrocochlear pathology particularly in
acoustic neuroma
– Diagnose brainstem pathology
– To monitor CN VIII intraoperatively in surgery of
acoustic neuromas to preserve the function of
cochlear nerve
 AUDITORY STEADY STATE RESPONSE
(ASSR)
• Electrophysiological test which uses steady state pure tone
signals ( instead of transient signal of tone bursts in
ABR)

• Steady state signals are modulated rapidly in amplitude and

frequency and thus give a frequency specific audiogram

• Detect hearing losses > 80 dB

• Detect hearing sensitivity in severe to profoundly deaf

infants

• Helps in selection of children for cochlear implantation at

an early age
 OTOACOUSTIC EMISSIONS (OAE)
• Low intensity sounds produced by outer hair cells of a
normal cochlear

• Elicited by very sensitive microphone placed in external ear

canal and analysed by a computer

• Sound produced by outer ear travel in reverse direction:

outer hair cells-basilar membrane-perilymph- oval window-
ossicles- TM-ear canal

• help to detect fx of cochlear (OAEs produce only when

outer hair cells are healthy)

• Do not disappear in VIII th nerve pathology

 Types of
OAEs

Evoke Spontaneous
Two tones are d OAEs
simultaneously
presented to the
cochlear to produce
OAEs Present in healthy
distortion products.
Used to test hearing
Transient normal persons
where hearing loss
in the range 1-8 KHz evoked OAEs do not exceed 30dB.
A series of click They are absent in
stimuli are 50% normal persons
presented at Distorted
80-85 dB SPL Product OAEs
and response
are recorded
• Uses:
– Screening test of hearing in neonates,
uncooperative, and mentally challenged person
after sedation

– Distinguish cochlear from retrocochlear hearing

loss, OAEs are absent in cochlear lesions. They
detect ototoxic effects earlier than pure tone
audiometry

– Useful to diagnosed retrocochlear pathology

 CENTRAL AUDITORY TEST
• Patients with central auditory disorders have
difficulty to hear in noisy environments, or
when speech is distorted and not clearly
spoken

• 3 types of speech discrimination tests;

– Monotic test
– Dichotic test
– Binaural test
• Monotic test: test for lesions of brain and
cortex

• Dichotic test; test for temporal lobe lesions

• Binaural tests: identify integration of information

from both ears

• Not routinely used

THANK YOU