ASSESSMENT OF HEARING

Pathways for air and bone conduction

Why do we test hearing

To detect one of major hearing
impairment
Sensorineural hearing loss
Conductive
hearing loss
Mixed

Methods of hearing
evaluation
Speech test
Loud
Whisper

Tuning fork test

Weber
Rinne
Bing
Schwabach

Audiometry
Objective
Subjective

Speech test
App. 5 meter distance
Each ear must be test separately
Patient should repeat 5 words whispered by the
doctor, 5 words told loudly
High-frequency words
Low-frequency words
Results: lost of high frequencies perception disease
(f.e. presbyacusis)
low frequencies conductive disease (f.e. otitis media)

Tuning fork tests

these allow one to distinguish (much
more clearly) between conductive and
sensorineural deafness

Rinnes test
comparison is made between bone
and air conduction
base of a tuning fork is placed to the
mastoid area (bone), and then after
the sound is no longer appreciated,
the vibrating top is placed near the
external ear canal (air)
positive Rinne healthly or perceptive
disease
negative conductive disease

Webers test
tuning fork is placed on the patient's
forehead (or in the middle line)
If the sound lateralizes (is louder on
one side than the other), the patient
may have either an ipsilateral
conductive hearing loss or a
contralateral sensorineural hearing
loss

Bing test
fork is struck and placed on the patient's
mastoid tip
examiner alternately occludes the
patient's external meatus
patient with normal hearing or a
sensorineural loss, he or she will notice
a change in intensity with occlusion
patient with conductive hearing loss, he
or she will notice no change

Schwabachs test
compares the patient's bone
conduction to that of the examiner's
If the patient stops hearing before the
examiner, this suggests a
sensorineural loss
If the patient hears it longer than the
examiner, this suggests a conductive
loss
This test is contingent on the examiner having normal hearing..

audiometry
Subjective (needs patient verbal
response)
Objective (combination wit EEG)

Pure Tone Audiometry

Major behavioral auditory measure

Measurement of pure tone thresholds between
250-8000 Hz
Air conduction
Bone conduction

Pure Tone Audiometry

The results of PTA tell us
1. Hearing by air conduction across frequency in each ear
tells us if hearing is normal or not
2. If hearing by air conduction is NOT normal, the
thresholds tell us the degree of hearing loss
3. Differences between hearing by air conduction and
hearing by bone conduction tell us the type of hearing
loss

Air Conduction vs Bone

Conduction Testing
Air conduction
tests the entire
auditory system.
Bone conduction
bypasses the
conductive
mechanism, so it
tests only the
inner ear.

The Audiogram

What the Audiogram Says About

the Impairment

Within normal
limits
Mild
Moderate
Severe
Profound/deaf

Hearing abnormalities and

audiometry
Sensorineural impairment
disease

Conductive

What the Audiogram Says About

the Impairment
The degree of hearing loss
The configuration of the hearing loss
The type of hearing loss
Conductive
Sensorineural
Mixed

Speech Audiometry
Another behavioral measure of
auditory ability
Speech thresholds
Speech

Reception threshold
Speech Awareness threshold

Word recognition testing

Imepedence
Audiometry
(Tympanometry + stapedial reflex)

Tympanometry

Definition:
Tympanometry is an
electronic and acoustic
measurement technique to
assess middle ear status
Combined with otoscopy, it is
an objective, fast, and highly
accurate way to rule out outer
and middle ear pathology

Principles of
Tympanometry
Introduces a pure tone into ear canal through 3function probe tip

Manometer (pump) varies air pressure against TM (controls

mobility)
Speaker introduces 220Hz probe tone
Microphone measures loudness in ear canal

Normal tympanogram (Type

A)
Peak at 0 daPa
Best movement
of drum when
no extra
pressure on
either side of
TM

Other Type A
tympanograms

Peak at 0daPa, but

unusually high
amplitude
? Ossicular disruption

Peak at 0daPa, but

unusually low
amplitude
? Stapes fixation

Flat tympanogram (Type B)

No Peak
No best TM
movement at
any pressure

Flat tympanogram (Type B)

When tymp is flat,
usually means 1 of 3
things:
1. Artefact
2. Fluid in ME
3. Perforation
Look at EAM vol.
If large = perf
If normal = fluid

Negative tympanogram (Type

C)
Peak at < 0daPa
Best movement
of drum when
negative
pressure in
EAM thus
middle ear
pressure must
be less than
atmospheric

Negative tympanogram (Type

C)
Can be further
divided into:
C1 peak
between 0 and
-200 daPa
C2 peak less
than -200daPa

Acoustic Reflex Testing

The stapedius muscle attaches to the neck of the stapes

Upon being triggered by loud sound, contraction of the
stapedius dampens motion of the stapes, reducing
effectiveness of the ossicular chain
In acoustic reflex testing, the probe tip produces a sudden
loud tone and simultaneously records any drop in compliance
If the compliance drops, the tympanometer records the
acoustic reflex as present
Interpret as no conductive component, and not more than
moderately severe hearing loss
If compliance is not affected, the tympanometer records the
reflex as absent
Subject to wide range of interpretation

Interpreting results of acoustic

reflex testing: Summary
Reflex present = probable normal middle ear function
Reflex absent = possible middle ear problem, severe
sensorineural hearing loss, or several other possible
explanations

OTOACOUSTIC EMISSIONS

OAEs
They are low intensity sounds
produced by outer hair cells of a
normal cochlea
Can be elicited by a very sensitive
microphone placed in EAC
Absent when OHC are damaged
Thus serve to test cochlear
functioning

Outer hair cells

Basilar membrane
Perilymph
Oval window
Ossicles
Tympanic membrane
EAC

OAEs

spontaneous

evoked

Transient
(click)

Distortion product
(paired tones)

Spontaneous OAE
They are present in healthy normal
hearing persons
When hearing loss does not exceeds
30 dB
May be absent in 50% of normal
persons

Transient Evoked OAE

-Evoked by clicks
-Clicks are presented at 80-85 dB

Distortion Product OTOACOUSTIC

EMISSIONS

USES of OAEs
As a screening test for neonates
Distinguish cochlear from
retrocochlear HL
To test hearing in meantally
challanged and uncooperative
individuals after sedation
(Note- sedation doesnt interferes with OAEs)

Brainstem Evoked Response

Audiometry
(BERA)

BERA
Brainstem Evoked Response Audiometry

Definition
Bera is an objective way of
eliciting brain stem potentials in
response to audiological click
stimuli. These waves are
recorded by electrodes placed
over the scalp.Thisinvestigation
was first described by Jewett and
Williston in 1971.

The standard electrode

configuration
--a non
inverting
electrode
over the
vertex of the
head
--an inverting electrodes placed over
the ear lobe or mastoid prominence.
--One more earthing electrode is placed
over the forehead

Superior olivary complex

Cochlear nerves

Nulclei of lateral lemniscus

Cochlear nucleus

Inferior colliculus

Uses of BERA:
1. It is an effective screening tool for
evaluating cases of deafness due to
retrocochlear pathology i.e. (Acoustic
schwannoma). An abnormal BERA is an
indication for MRI scan.
2. Used in screening newborns for deafness
3. Used for intraoperative monitoring of
central and peripheral nervous system
4. Monitoting patients in intensive care
units
5. Diagnosing suspected demyelinated
disorders

BERA findings suggestive of retrocochlear

pathology:

1. Latency differences between

interaural wave 5 (prolonged in
cases of retrocochlear
pathology)
2. Waves I - V interaural latency
differences - prolonged
3. Absolute latency of wave V prolonged
4. Absence of brain stem
response in the affected ear

Criteria for screening newborn

babies using BERA:
1. Parental concern about hearing
levels in their child
2. Family history of hearing loss
3. Pre and post natal infections
4. Low birth weight babies
5. Hyperbilirubinemia
6. Cranio facial deformities
7. Head injury
8. Persistent otitis media
9. Exposure to ototoxic drugs

Electrocochleography

Electrocochleography setup
Non invasive
Electrode
placed on
TM

Invasive
The recording electrode is a
thin needle passed through the
tympanic membrane onto the
promontory under L/A or G/A

ECochG
It measures electrical potentials
arising in the cochlea and VIII nerve
in response to auditory stimuli within
first 5 millisec
Response is in the form of Cochlear
microphonics, Summation potential
and Action potentials