Acoustic Reflex: Presented by Arief Fakhrizal, DR Supervisor: Dr. Wijana, SP - THTKL (K)

ACOUSTIC REFLEX
Presented by Arief Fakhrizal, dr

Supervisor: dr. Wijana, Sp.THTKL (K)
Departemen Ilmu Kesehatan Telinga Hidung Tenggorok – Bedah Kepala Leher

Fakultas Kedokteran Universitas Padjadjaran
RSUP Hasan Sadikin Bandung
2022
TABLE OF CONTENTS
ANATOMY &
1 PHYSIOLOGY
2 ACOUSTIC REFLEX
3 TYMPANOMETRY
1
ANATOMY &
PHYSIOLOGY
ANATOMY & PHYSIOLOGY
● Stapedius muscle inserts on the stapes
● Contraction  stiffening the sound conduction apparatus
Changes the impedance of the middle ear and tympanic membrane
Measured with a tone emitted by probe placed in ear canal

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018
● Stapedius muscle contracts as an reflex in response to additional

acoustic stimuli of a certain intensity
● Normal hearing  stimulus about 70-100 dB HL  sufficient to

evoke the stapedial reflex
● Broadband stimuli  evoke the reflex at sound levels that are about
1 0 to 20 dB lower.


Sound is delivered to only one ear
Stapedius muscles on both sides contract via acousticofacial reflex arc
Uncrossed or ipsilateral stapedial

Stimulated side
reflex
Crossed or contralateral stapedial

Opposite side
reflex
2
ACOUSTIC
REFLEX
INTRODUCTION
Also known as the stapedius reflex refers to an
involuntary muscle contraction of the stapedius
muscle in response to a high-intensity sound
stimulus.
Clark, Jackie. Acoustic (Stapedius) Reflexes.

ACOUSTIC THRESHOLD
An acoustic reflex threshold is the lowest intensity level at which an acoustic
reflex is elicited at each frequency for each ear.
Stapedius muscle contraction  increases as the stimulus intensity is

increased
To determine: increasing the stimulus by 5 dB steps,

beginning at 80 dB HL

ACOUSTIC
REFLEX
THRESHOLD
Example (right ear) of acoustic reflex
threshold obtained from an immittance
instrument. Results shown would indicate
85 & 90 dB HL thresholds for 1000 and
2000 Hz respectively, which would be
expected for a normal ear

THRESHOLD
Acoustic reflex contralateral: 500,
1000, 2000, 4000 Hz
Stimulus intensities
Ipsilateral frequencies:  85-90 dB HL
1000, 2000 Hz

FACTORS AFFECTING ACOUSTIC REFLEXES
IPSILATERAL IPSILATERAL
OSSICULAR
CONDUCTIVE SENSORINEURAL
DISARTICULATION
HEARING LOSS HEARING LOSS
TYMPANIC NEGATIVE/
MIDDLE EAR
MEMBRANE ABNORMAL MIDDLE
EFFUSION
PERFORATION EAR PRESSURE
FACIAL NERVE
STAPES FIXATION
DYSFUNCTION

IPSILATERAL CONDUCTIVE
HEARING LOSS IPSILATERAL
SENSORINEURAL HEARING
- 40% of patients with LOSS
conductive hearing loss of >20
dB HL  do not have an - Obstruct transmission 
acoustic reflex reduced or absent contraction
- Conductive hearing loss (40 db - Loudness  acoustic reflexes
HL)  80% do not have a  normal or partially elevated
reflex
STAPES FIXATION OSSICULAR

DISARTICULATION
- Stapes footplate  more or less
fixed to the surrounding bone - Otosclerosis  conductive
with otosclerosis  interfere hearing loss
acoustic reflex - Lateral to stapes  prevents
- Conductive hearing loss + stiffening of the ossicles and
reduced mobility of the stapes tympanic membrane

MIDDLE EAR EFFUSION TYMPANIC MEMBRANE

PERFORATION
- Causes a conductive hearing
loss - Causes a conductive hearing
- Reduce compliance of the loss
tympanic membrane and middle - Perforation  changes
ear structures compliance caused by
- Mask the presence of an contraction of stapedius muscle
acoustic reflex cannot be measured

NEGATIVE/ABNORAL
FACIAL NERVE
MIDDLE EAR PRESSURE
DYSFUNCTION
Reflex will be detected  pressure
- Stapedius muscle  innervated
on either side of tympanic
by the facial nerve
membrane has to be equal 
- Contraction  ipsi and
match the peak pressure
contralateral acoustic reflexes

TECHNIQUE
IPSILATERAL TESTING
● Probe ear  stimulated with tone pulses at 500 – 4,000 Hz or with

broadband stimuli at incremental sound pressure levels that are 70 to
90 dB above the normal hearing threshold.
● The first impedance change recorded in response to the probe tone is

equal to the stapedial reflex threshold.

TECHNIQUE
CONTRALATERAL TESTING
- Which follows the same principle

- The "probe ear" or "response ear" is different from the "stimulus ear."

INTERPRETATION
Ossicular chain pathology Lesion of the brainstem
 Disruption or stiffening  Multiple sclerosis
 Due to otosclerosis  Hemorrhage
Abnormal sound reception Lesion of the facial nerve

 Vestibular schwannoma  Idiopathic facial nerve
 Tumors of the internal auditory  Inflammatory changes
canal
 Cerebellopontine angle Disease of the stapedius muscle
 Myasthenia gravis

INTERPRETATION OF ACOUSTIC REFLEX
ABSENT
IPSILATERAL PARTIALLY PRESENT
REFLEX
Reflex recorded in ear to Some frequencies and No reflex elicited
which auditory stimulus is absent at others
presented
CONTRALATERAL ELEVATED THRESHOLD

Contralateral to which Reflex thresholds
auditory stimulus is elicited >100 dB HL
presented
PARTIAL OR ELEVATED
REFLEX THRESHOLD
Indicate the presence of hearing loss at the
frequencies where they are specifically
absent

ABSENT REFLEX
- Observed in normal or near-normal hearing

- Indicate middle ear disease/neurological involvement
Absence of acoustic reflex  lesion

in the neural pathway proximal to
stapedius nerve
FACIAL NERVE
PARALYSIS
Presence of an acoustic reflex 
lesion is distal to the origin of the
nerve
INTERRUPTIO
N OF NEURAL
TRANSMISSIO
N
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WIDEBAND REFLECTANCE TECHNIQUE
Newer measuring technique to assess acoustic stapedius reflex threshold by
using complex wideband (125 - 10,000 Hz range) reflectance with a stimulus
resembling “chirplike” sounds instead of a single probe tone frequency
More reliable results than the single probe tone technique
Clinical procedure for measuring acoustic reflexes for

normal-hearing who fail
ACOUSTIC REFLEX DECAY
This is powerful differential diagnostic test and has a high degree of

sensitivity to identify retrocochlear pathology due to e.g tumours of
cerebellopontine angle
In order to examine acoustic reflex decay, an extended duration

signal (>10 seconds) is presented, using low frequency stimuli
(500, 1000 and 2000 Hz) contralateral to the probe (test) ear.

● Standard procedure: present the stimulus contralaterally at 10 dB SL or
between 90 and 105 dB HL for 10 seconds
● Abnormal reflex decay is evidenced by an inability of the stapedius

muscle to maintain full contraction (amplitude) for the duration of the
stimulus signal.
● When reflex decay occurs within 5 seconds or at frequencies less than

1000 Hz, it is suggestive of 8 th nerve dysfunction.

Causing temporary or permanent
auditory threshold shifts as a
consequence of presenting acoustic
stimuli for extended periods of time at
exceptionally high intensities.
Administer acoustic reflex decay

(A) Normal and (B) abnormal findings on acoustic reflex decay test
tests and never to exceed 105
dB HL
ACOUSTIC REFLEX GROWTH FUNCTION
Acoustic reflex growth functions are estimated by measuring the
increase in acoustic reflex amplitude with the increase in stimulus
intensity level.
There are several measurement factors that affect the ARGF:

1. Probe tone frequency
2. Stimulus frequency
Tripathy, Rajesh. Measurement Variable Affecting the Evaluation of Acoustic Reflex in Huasns. 2018
Probe tone frequency
- Shallower ARGF  high frequency probe tone was used for reflex
measurements
- Normal hearing adults  stiffness dominated
Acoustic stiffness Main determiner of acoustic

compliance at low probe tone
frequency
Probe tone frequency increases  approaches resonant
frequency of middle ear  acoustic compliance less influenced
Stimulus frequency
Similar ARGFs for pure-tones of frequency range from 500 to 2000Hz

but comparatively shallower ARGFs were found at 4000 Hz pure-tone.
ACOUSTIC REFLEX LATENCIES
 Describe the temporal characteristics of an acoustic reflex which

illustrate the time course of the reflex
Factors that affect:

1. Stimulus frequency
2. Stimulus intensity
3. Rise time of the stimulus
Stimulus Frequency
There are conflicting results about the effect of stimulus frequency on
ARL
- Hung and Dallos  shorter latencies at 1000 Hz when compared to

the frequencies below 300 Hz
- Clemis and Sarno  smaller onset latency for 1000 Hz as
compared to 2000 Hz
- Borg  shorter onset latencies but longer offset latencies at 500Hz
in comparison to 2000 Hz
Stimulus Frequency
- Gorga and Stelmachowicz  similar onset latencies at 500 and
1000 Hz but latencies got prolonged as the stimulus frequency
was increased from 2000 Hz to 4000 Hz
- Qiu and Stucker found shorter ARL (10% On Latency, 90% On

Latency, 10% Off Latency, 90% Off Latency, rise time and fall time)
at 500 and 1000 Hz in contrast to 2000 and 4000 Hz
STIMULUS
ACOUSTIC INTENSITY
RISE TIME OF THE
REFLEX General agreement that STIMULUS
ARL decreases as the
LATENCIE stimulus intensity • Important factor 
S increases rise time of stimulus
• ARL increases as the
stimulusrise time
increases
3
TYMPANOMETRY
INTRODUCTION
Tympanometry is an objective test that measures
the mobility (loosely termed “compliance”) of
the middle ear at the tympanic membrane as a
function of applied air pressure in the external ear
canal.
Lalwani, anil. Current Diagnosis & Treatment Otolaryngology Head and Neck Surgery. 2012
TYMPANOMETRY
Laurent, Claude. Tympanoetry. University of Umea

TYMPANOMETRY
Tympanometric peak  maximum flow of acoustic energy into the
middle ear, occurs when the pressure in the ear canal and middle ear is
equal
Eustachian tube = normal Middle ear = not properly aerated

Peak pressure  0 daPa Pressure  >100 daPa
Infant and neonates, tympanograms should be obtained using a

higher-frequency probe tone (660 or 1000 Hz) due to resonant
differences in small ear canals.
INDICATION
- Suspected middle ear effusion (OME)

- Patency of tympanostomy/ventilation tubes/grommets
- Whether there is a perforation in the eardrum
- Mobility of the eardrum
- Mobility of the ossicular chain

PRINCIPLES
Tympanometry provides a measurement of impedance of the middle
ear system including the eardrum. It allows one to determine how
much resistance the middle ear system renders to passage of sound to the
inner ear.
Impedance increased Impedance reduced
- Middle ear is filled with - Eardrum is overly mobile

fluid or flaccid
- Increased stiffness of the - There is disruption of
ossicular chain the ossicular chain
ADVANTAGES
- It is an objective audiometric method because it does not depend
on information that the patient gives us but rather measures
something without subjective feedback from the patient.
- The patient then becomes the object and does not have to say
whether he or she has heard or experienced anything.
- It also does not require clinical expertise to diagnose middle ear

effusions.

HOW DOES TYMPANOMETRY WORK?
- Low constant low-pitch sound (~220Hz)  ear
through an opening in the head (tip) of the
tympanometer
- The same tip there is another opening that leads to a

microphone
- A third opening in the tip  connected to an air

pump  change the air pressure applied to the
eardrum

HOW DOES TYMPANOMETRY WORK?
- Between the tip of the tympanometer and the eardrum  a small

“chamber” created in the deep ear canal  the sound level is constantly
measured
- The least amount of sound is reflected
- When the eardrum is however pressed outwards or retracted inwards it

becomes stiffer and more sound is reflected back from its surface into the
“chamber”.

CLASSIFICATION
Type A
- Normal peak height and pressure

- Variation :
1. Normal in pressure but shallow (As) 

otosclerosis or middle ear effusion
2. Peaked very high (Ad)  ossicular
discontinuity or monometric eardrum
CLASSIFICATION
Type B
- Flat appearance
- Indication lack of compliance
- Volume measurement  helps to
differentiate between a flat tympanogram
Intact eardrum with middle ear effusion vs a

perforated eardrum or ear with a patent
ventilating tube
CLASSIFICATION
Type C
- Has negative peak pressure

- Suggesting inadequate aeration
of the middle ear space
THANK
YOU

Acoustic Reflex: Presented by Arief Fakhrizal, DR Supervisor: Dr. Wijana, SP - THTKL (K)

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ACOUSTIC REFLEX

Presented by Arief Fakhrizal, dr

Departemen Ilmu Kesehatan Telinga Hidung Tenggorok – Bedah Kepala Leher

Changes the impedance of the middle ear and tympanic membrane

Measured with a tone emitted by probe placed in ear canal

● Stapedius muscle contracts as an reflex in response to additional

● Normal hearing  stimulus about 70-100 dB HL  sufficient to

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018

Stapedius muscles on both sides contract via acousticofacial reflex arc

Uncrossed or ipsilateral stapedial

Crossed or contralateral stapedial

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Stapedius muscle contraction  increases as the stimulus intensity is

To determine: increasing the stimulus by 5 dB steps,

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Clark, Jackie. Acoustic (Stapedius) Reflexes.

STAPES FIXATION OSSICULAR

Clark, Jackie. Acoustic (Stapedius) Reflexes.

MIDDLE EAR EFFUSION TYMPANIC MEMBRANE

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Clark, Jackie. Acoustic (Stapedius) Reflexes.

● Probe ear  stimulated with tone pulses at 500 – 4,000 Hz or with

● The first impedance change recorded in response to the probe tone is

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018

- Which follows the same principle

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018

Abnormal sound reception Lesion of the facial nerve

Probst, rudolf. Basic otorhinolaryngology 2nd edition. 2018

CONTRALATERAL ELEVATED THRESHOLD

Clark, Jackie. Acoustic (Stapedius) Reflexes.

- Observed in normal or near-normal hearing

Absence of acoustic reflex  lesion

Clark, Jackie. Acoustic (Stapedius) Reflexes.

More reliable results than the single probe tone technique

Clinical procedure for measuring acoustic reflexes for

This is powerful differential diagnostic test and has a high degree of

In order to examine acoustic reflex decay, an extended duration

Clark, Jackie. Acoustic (Stapedius) Reflexes.

● Abnormal reflex decay is evidenced by an inability of the stapedius

● When reflex decay occurs within 5 seconds or at frequencies less than

Clark, Jackie. Acoustic (Stapedius) Reflexes.

Administer acoustic reflex decay

There are several measurement factors that affect the ARGF:

Acoustic stiffness Main determiner of acoustic

Similar ARGFs for pure-tones of frequency range from 500 to 2000Hz

 Describe the temporal characteristics of an acoustic reflex which

Factors that affect:

- Hung and Dallos  shorter latencies at 1000 Hz when compared to

- Qiu and Stucker found shorter ARL (10% On Latency, 90% On

Laurent, Claude. Tympanoetry. University of Umea

Eustachian tube = normal Middle ear = not properly aerated

Infant and neonates, tympanograms should be obtained using a

- Suspected middle ear effusion (OME)

Laurent, Claude. Tympanoetry. University of Umea

Impedance increased Impedance reduced

- Middle ear is filled with - Eardrum is overly mobile

- It also does not require clinical expertise to diagnose middle ear

Laurent, Claude. Tympanoetry. University of Umea

- The same tip there is another opening that leads to a