Beruflich Dokumente
Kultur Dokumente
AUDIOMETRY
Gerald A. Amundsen
Hearing is measured according to its two main components: frequency/pitch and intensity/loudness. Audiometry is a procedure
used to measure and graph an individuals hearing over a range of
frequencies (measured in cycles per second [Hz, for Hertz]) at various
intensity levels (measured in decibels [dB]). Although it is used
frequently to test young children and the elderly (the groups at
highest risk for hearing loss), audiometry is also an important component of any successful occupational hearing loss prevention
program. In many instances, formal audiometry is performed by an
audiologist; however, because screening audiometry is not a complex
procedure and only a minimal amount of equipment is required, it
is often performed by primary care clinicians. Even if not performing
audiometry, primary care clinicians should have a basic understanding of not only the procedure but also the possible results.
An audiometer consists of a variable frequency oscillator that
produces electrical impulses across the audible/perceptible frequencies, a transducer to convert the electrical impulses into sound or
vibrations, and an attenuator to create variations in intensity. The
device may be a stationary part of a designated testing facility or a
portable unit with the flexibility to be used in a variety of settings.
When sound is transmitted through headphones or an earpiece worn
by the patient, and the patient responses are then recorded, an air
conduction audiogram is produced. Air conduction audiometry evaluates both sensorineural and conductive hearing.
Sensorineural hearing refers to that produced by the cochlea of
the inner ear, the auditory nerve, and the cochlear nuclei of the
brain. There are both acquired and congenital causes of sensorineural hearing loss (Box 69-1). To test sensorineural hearing alone, a
bone conduction audiogram is performed. With this procedure, similar
to using a tuning fork when performing a physical examination, a
bone conduction oscillator or vibrator is held against the mastoid
process or forehead. Usually secured by a headband, the vibrator sets
the skull into oscillation, producing a disturbance of the fluid in the
cochlea. This disturbance is sensed by the cochlea and transmitted
down the auditory nerve to the cochlear nuclei, all without use of the
middle ear system. Results are graphed as the bone conduction audiogram. With pure sensorineural hearing loss, both air and bone conduction are impaired, and the impairments are about the same.
With air conduction hearing loss (usually due to middle or outer
ear problems), air conduction is impaired but bone conduction is
preserved. In the normal ear, the differences between the air and
bone conduction thresholds, or the airbone gap, should not exceed
10dB. A gap larger than this indicates an air conduction problem
(again, usually due to a middle or outer ear problem) as the source
of hearing loss. Patients with air conduction hearing loss frequently
respond to surgery; new surgical treatments for sensorineural hearing
loss are also on the horizon. In many patients, hearing impairment
is due to a combination, or a mixed hearing loss, and these also usually
respond somewhat to surgery.
The symbols used on an audiogram (Fig. 69-1) have been standardized by the American Speech-Language Hearing Association
(ASHA; www.ahsa.org). Traditionally, symbols representing the
right ear were recorded in red, whereas results from the left ear were
453
454
CONTRAINDICATIONS
Response*
Modality
>
]
<
[
Inexperienced technician
Acute otitis media
Local pinna infection that would cause pain from the earphone
or earpiece application
Uncooperative patient
Uncontrollable background noise in the room when testing
Occlusion of the canal by cerumen (see Chapter 72, Cerumen
Impaction Removal) or a foreign body (see Chapter 76, Removal
of Foreign Bodies from the Ear and Nose)
EQUIPMENT
>
Right
>
Left
Ear
Unspecified
NOTE:
INDICATIONS
General screening in children at the earliest age possible
Exposure to one (or more) of the causes for sensorineural hearing
loss (see Box 69-1)
Speech delay in children
Persistent behavioral problems or changes in children or the
elderly
Screening of the elderly, especially when performing geriatric
assessment (see Chapter 232, Special Considerations in Geriatric
Patients)
Patient complaints of hearing loss
Persistent serous otitis media, especially bilateral in children
Anyone undergoing tympanometry with suspected sensorineural
hearing loss (an abnormal tympanogram usually implies conductive hearing loss; however, sensorineural hearing loss may also be
present)
Formal audiometric evaluation of a failed screening test
NOTE: Up to 5% of school-age children will have fluctuating
hearing loss during the school year because of middle ear effusions. Retesting is imperative.
Patient complaints of tinnitus, dizziness, or vertigo
After severe head trauma
After use of ototoxic drugs
After meningitis, encephalitis, or other serious viral or bacterial
infections that could affect hearing
Occupational screening and follow-up for individuals with noisy
work environments
TECHNIQUE
1. The examination must be administered using a properly calibrated instrument in a room with an acceptable level of background noise. The ear canal should have been checked for
patency by the clinician.
2. The patient should be comfortably seated facing neither the
monitor nor the examiner. (Usually patients are seated in a
position that provides a side profile view to the examiner.)
3. Anything that may interfere with earphone application (or
earplug insertion) should be removed (earrings, glasses, hats),
and the headphones must be appropriately seated on the
patients head (or the earplugs properly inserted), sealing the
ears from environmental noise.
4. Instruct the patient to respond to the faintest detectable sound
at each frequency. Responses can consist of raising a hand or
finger or pressing a test button when sound is first heard. The
patient should continue to signal for the duration of audible
sound. Having the patient indicate the entire duration of
audible sound allows the examiner to determine if the responses
455
69 AUDIOMETRY
TABLE 69-1
Loss
Level of Severity
020
2140
4155
5670
7190
>90
Normal
Mild
Moderate
Moderately severe
Severe
Profound
HL in dB (ANSI-69)
HL in dB (ANSI-69)
90
80
70
60
50
40
30
20
10
0
250
1000
4000
250
Frequency (Hz)
Right ear
1000
4000
Frequency (Hz)
Left ear
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
250
HL in dB (ANSI-69)
INTERPRETATION
100
90
80
70
60
50
40
30
20
10
0
100
HL in dB (ANSI-69)
1000
4000
Frequency (Hz)
Right ear
250
1000
4000
Frequency (Hz)
Left ear
456
1000
4000
250
Frequency (Hz)
Right ear
1000
4000
100
90
80
70
60
50
40
30
20
10
0
250
4000
1000
Frequency (Hz)
Right ear
250
1000
4000
1000
4000
Frequency (Hz)
Left ear
HL in dB (ANSI-69)
1000
4000
Frequency (Hz)
Left ear
250
Frequency (Hz)
Right ear
100
90
80
70
60
50
40
30
20
10
0
100
HL in dB (ANSI-69)
HL in dB (ANSI-69)
90
80
70
60
50
40
30
20
10
0
HL in dB (ANSI-69)
250
Frequency (Hz)
Left ear
100
90
80
70
60
50
40
30
20
10
0
90
80
70
60
50
40
30
20
10
0
HL in dB (ANSI-69)
250
100
90
80
70
60
50
40
30
20
10
0
100
HL in dB (ANSI-69)
90
80
70
60
50
40
30
20
10
0
HL in dB (ANSI-69)
HL in dB (ANSI-69)
100
250
1000
4000
Frequency (Hz)
Right ear
250
1000
4000
Frequency (Hz)
Left ear
457
69 AUDIOMETRY
1997
20
90
80
70
60
50
40
30
20
10
0
1993
10
250 500 1000 2000
4000 8000
Frequency (Hz)
Left ear
Air conduction
60
40
40
20
0
10
250
1000
4000
Frequency (Hz)
Right ear
100
90
80
70
60
50
40
30
20
10
0
100
20
0
10
Air conduction
Bone conduction
250
1000
4000
Frequency (Hz)
Left ear
Air conduction
Bone conduction
Figure 69-10 Fifty-year-old woman with long-term exposure to loud
occupational noise, which could include loud music. Note the speech frequencies are more affected than the higher frequencies. (The corresponding tympanogram would be type A or normal.) (Redrawn from Jacobsen JT,
Northern JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)
HL in dB (ANSI-69)
60
HL in dB
HL in dB
Figure 69-8 Fifty-five-year-old man with gradually progressive left neurosensory hearing loss over several years. Such a hearing loss can be seen in a
person who hunts and shoots left-handed. In most such cases, the audiogram
differs from that of presbycusis because it spares the upper frequencies
(8000Hz). (The corresponding tympanogram would be type A or normal.)
(Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin,
Tex, Pro-Ed, 1991.)
90
80
70
60
50
40
30
20
10
0
HL in dB (ANSI-69)
HL in dB
40
100
90
80
70
60
50
40
30
20
10
0
HL in dB (ANSI-69)
2001
100
HL in dB (ANSI-69)
60
250
1000
4000
Frequency (Hz)
Right ear
250
1000
4000
Frequency (Hz)
Left ear
458
CPT/BILLING CODES
SUPPLIERS
92551
92552
92553
92555
92556
92557
ACKNOWLEDGMENT
The editors wish to recognize the many contributions by Gregory J.
Forzley, MD, to this chapter in the previous two editions of this text.
BIBLIOGRAPHY
American Academy of Family Physicians; American Academy of
Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion: Otitis media with
effusion [clinical practice guideline]. Pediatrics 113:14121429, 2004.
American Academy of Pediatrics, Joint Committee on Infant Hearing: Year
2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 120:898921, 2007.
American Speech-Language-Hearing Association: Guidelines for audiometric symbols. ASHA 32(Suppl. 2):25, 1990.
American Speech-Language-Hearing Association: Guidelines for the Audiologic Assessment of Children from Birth to 5 Years of Age. 2004. Available at www.asha.org/policy. Accessed November 2007.
Cunningham M, Cox EO; Committee on Practice and Ambulatory Medicine and Section on Otolaryngology and Bronchoesophagology: Hearing
assessment in infants and children: Recommendations beyond neonatal
screening. Pediatrics 111:436440, 2003.
Hall JW III, Antonelli PJ: Assessment of peripheral and central auditory
function. In Newlands SD, Calhoun KH, Curtin HD, et al (eds): Head
and Neck SurgeryOtolaryngology, 4th ed. Philadelphia, Lippincott
Williams & Wilkins, 2006, pp 19271942.
Isaacson JE, Vora NM: Differential diagnosis and treatment of hearing loss.
Am Fam Physician 68:11251132, 2003.