1. Jelaskan anatomi, fisiologi dan histologi sistem pendengaran?

Conduction of Sound, Sound Sensors

Sound waves are transmitted to the organ of hearing via the

external ear and the auditory canal, which terminates at the
tympanic membrane or eardrum. The sound waves are conducted
through the air(airconduction)and set the eardrum in vibration.
These are transmitted via the auditory ossicles of the tympanic
cavity (middle ear) to the membrane of the oval window (!A 1,2),
where the internal or inner ear (labyrinth) begins. In the middle
ear, the malleus, incus and stapes conduct the vibrations of the
tympanic membrane to the oval window. Their job is to conduct
the sound from the low wave resistance/impedance in air to the
high resistance in fluid with as little loss of energy as possible. This
impedance transformation occurs at f!2400Hz and is based on a
22-fold pressure amplification (tympanic membrane area/oval
window area is 17:1, and leverage arm action of the auditory
ossicles amplifies force by a factor of 1.3). Impairment of im-
pedance transforming capacity due, e.g., to de-
struction of the ossicles, causes roughly 20dB
of hearing loss (conduction deafness).
Muscles of the middle ear. The middle ear contains
two small muscles—the tensor tympani (insertion:
manubrium of malleus) and the stapedius (insertion:
stapes)—that can slightly attenuate low-frequency
sound. The main functions of the inner ear muscles
are to maintain a constant sound intensity level, pro-
tect the ear from loud sounds, and to reduce dis-
tracting noises produced by the listener.

Bone conduction.
Sound sets the skull in vibration,and these bone born evibrations
are conducted directly to the cochlea. Bone conduction is fairly in-
Significant for physiological function, but is useful for testing the
hearing. In Weber’s test, a vibrating tuning fork (a 1 ) is placed in
the middle of the head. A person with normal hearing can
determine the location of the tuning fork because of the
symmetrical conduction of sound waves. A patient with unilateral
conduction deafness will perceive the sound as coming from the
affected side (lateralization) because of the lack of masking of
environmental noises in that ear (bone conduction). A person with
sensorineural deafness, on the other hand, will perceive the sound
as coming from the healthy ear because of sound attenuation in
the affected internal ear. In Rinne’s test, the handle of a tuning
fork is placed on one mastoid process (bony process behind the
ear) of the patient (bone conduction). If the tone is nolonger
heard, the tines of the tuning fork are placed in front of the ear
(air conduction). Individuals with normal hearing or
sensorineural deafness can hear the turning fork in
the latter position anew (positive test result),
whereas those with conduction deafness cannot
(test negative).

The internal ear consists of the equilibrium organ (!p.342) and the
cochlea, a spiraling bony tube that is 3–4cm in length. Inside the
cochlea is an endolymph filled duct called the scala media
(cochlear duct); the ductus reuniens connects the base of the
cochlear duct to the endolymph-filled part of the
equilibrium organ. The scala media is accompanied
on either side by two perilymph-filled cavities: the
scala vestibuli and scala tympani. These cavities
merge at the apex of the cochlea to form the heli-
cotrema. The scala vestibuli arises from the oval win-
dow, and the scala tympani terminates on the mem-
brane of the round window (!A2). The composition
of perilymph is similar to that of plasma water
(!p.93C), and the composition of endolymph is
similar to that of the cytosol (see below). Perilymph
circulates in Corti’s tunnel and Nuel’s spaces (!A4).
Organ of Corti. The (secondary) sensory cells
of the hearing organ consist of approximately
10000–12000 external hair cells (HCs) and
3500 internal hair cells that sit upon the
basilar membrane ( !A4). Their structure is
very similar to that of the vestibular organ
(!p.342) with the main difference being that
the kinocilia are absent or rudimentary.
There are three rows of slender, cylindrical outer
hair cells, each of which contains approximately 100
cilia (actually microvilli) which touch the tectorial
membrane. The bases of the hair cells are firmly at-
tached to the basilar membrane by supporting cells,
and their cell bodies float in perilymph of Nuel’s
spaces (!A4). The outer hair cells are principally in-
nervated by efferent, mostly cholinergic neurons
from the spiral ganglion (N M -cholinoceptors;
!p.82). The inner hair cells are pear-shaped and
completely surrounded by supporting cells. Their
ciliaprojectfreelyintotheendolymph.Theinnerhair
cells are arranged in a single row and synapse with
over 90% of the afferent fibers of the spiral ganglion.
Efferent axons from the nucleus olivaris superior
lateralis synapse with the afferent endings.
Sound conduction in the inner ear. The stapes
moves against the membrane of the oval win-
dowmembrane,causingittovibrate.Theseare
transmitted via the perilymph to the mem-
brane of the round window (!A2). The walls
of the endolymph-filled cochlear duct, i.e.
Reissner’s membrane and the basilar mem-
brane (!D1) give against the pressure wave
(migrating wave, !B and C). It can therefore
take a “short cut” to reach the round window
without crossing the helicotrema. Since the
cochlear duct is deformed in waves, Reissner’s
membrane and the basilar membrane vibrate
alternately towards the scala vestibuli and
scala tympani (!D1,2). The velocity and
wavelength of the migrating wave that started
at the oval window decrease continuously
(!B), while their amplitude increases to a
maximum and then quickly subsides (!B, en-
velope curve). (The wave velocity is not equal
to the velocity of sound, but is much slower.)
The site of the maximum excursion of the
cochlear duct is characteristic of the
wavelength of the stimulating sound. The
higher the frequency of the sound, the closer
the site is to the stapes (!C).
Outer hair cells. Vibration of the cochlear
duct causes a discrete shearing (of roughly
0.3nm) of the tectorial membrane against the
basilar membrane, causing bending of the cilia
of the outer hair cells (!D3). This exerts also a
shearing force between the rows of cilia of the
individual external hair cell. Probably via the
”tip links” (!p.342), cation channels in the
ciliary membranes open (mechanosensitive
transduction channels), allowing cations (K + ,
Na + , Ca 2+ ) to enter and depolarize the outer
hair cells. This causes the outer hair cells to
shorten in sync with stimulation (!D3). The
successive shearing force on the cilia bends
them in the opposite direction. This leads to
hyperpolarization (opening of K + channels)
and extension of the outer hair cells.
Themechanismforthisextremelyfastelectromotil-
ity (up to 20kHz or 2·10 4 times per second) is un-
clear, but it seems to be related to the high turgor of
outer hair cells (128mmHg) and the unusual struc-
ture of their cell walls.
These outer hair cell electromotility con-
tributes to the cochlear amplification (ca. 100-
fold or 40dB amplification), which occurs
before sound waves reach the actual sound
sensors, i.e. inner hair cells. This explains the
very low threshold within the very narrow lo-
cation (0.5nm) and thus within a very small
frequency range. The electromotility causes
endolymph waves in the subtectorial space
which exert shearing forces on the inner hair
cell cilia at the site of maximum reaction to the
sound frequency (!D4), resulting in opening
oftransductionchannelsanddepolarizationof
the cells (sensor potential). This leads to trans-
mitterrelease(glutamatecouplingtoAMPAre-
ceptors; !p.55F) by internal hair cells and
the subsequent conduction of impulses to the
CNS.
Vibrationsintheinternalearsetoffanoutwardemis-
sion of sound. These evoked otoacoustic emissions
can be measured by placing a microphone in front of
the tympanic membrane, e.g., to test internal ear
function in infants and other individuals incapable of
reporting their hearing sensations.
Inner ear potentials (!p.369C). On the cilia
side,thehaircellsborderwiththeendolymph-
filled space, which has a potential difference
(endocochlear potential) of ca. +80 to +110mV
relative to perilymph (!p.369C). This poten-
tialdifferenceismaintainedbyanactivetrans-
port mechanism in the stria vascularis. Since
the cell potential of outer (inner) hair cells is
–70mV (–40mV), a potential difference of
roughly 150–180mV (120–150mV) prevails
across the cell membrane occupied by cilia
(cellinteriornegative).SincetheK + conc.inthe
endolymph and hair cells are roughly equal
(!140mmol/L), the prevailing K + equilibrium
potential is ca. 0mV (!p.32). These high
potentials provide the driving forces for the in-
flux not only of Ca 2+ and Na + , but also of K + ,
prerequisites for provoking the sensor poten-
tial.
Hearing tests are performed using an audiometer.
The patient is presented sounds of various frequen-
cies and routes of conduction (bone, air). The sound
pressure is initially set at a level under the threshold
of hearing and is raised in increments until the
patient is able to hear the presented sound (thresh-
old audiogram). If the patient is unable to hear the
 sounds at normal levels, he or she has an hearing
loss, which is quantitated in decibels (dB). In
audiometry, all frequencies at the normal threshold
of hearing are assigned the value of 0dB (unlike the
diagram on p.363B, green curve). Hearing loss can
be caused by presbycusis (!p.362), middle ear in-
fection (impaired air conduction), and damage to
the internal ear (impaired air and bone conduction)
caused, for example, by prolonged exposure to ex-
cessive sound pressure (!90dB, e.g. disco music,
pneumatic drill etc.).

Struktur Letak Fungsi

Telinga luar Samping kiri kanan di Mengumpulkan dan

bawah temporal.
Pinna (daun telinga) Lempeng tulang rawan yang Mengumpulkan gelombang
terbungkus kulit dan
terletak di kedua sisi kepala. mengandung rambut-rambut
Meatus auditorius Saluran dari ekterior
ekternus (liang melalui tuang temporalis ke
telinga) membran timpani.
Telinga tegah Rangkaian tulang yang
dapat bergerak yang
berjalan melintasi rongga
telinga tegah,maleus
melekat ke membran
timpani dan stapes melekat
pada jendela oval.
Maleus, inkus, Membran tipis di pintu
stapes masuk koklea,memisahkan
telinga tengah dengan skala
vestibuli
Telinga dalam: Kompartemen atas koklea
memindahkan gelombang suara
ke telinga tengah.
suara ke memban timpani
penyaring dan menyekresikan
kotoran telnga untu menangkap
partikel-partikel asing.
Bergetar secara sinkron dengan
gelombang suara
yangmengenainya menyebabkan
tulang-tulang pendengaran
telinga tengah bergetar.
Memindahkan getaran membran
timpani ke cairan di
koklea,dalam prosesnya
memperkuat energi suara.
Bersilia secara sinkron dengan
getaran membran timpani,serta
menimbulkangetaran seperti
gelombang di perlimfa koklea
dengan frekuensi yang sama.
Tempat sistem sensorik untuk
koklea dan kompartemen bawah
koklea.
Jendela oval Kompartemen tengah
koklea.
Skala vestibuli, skala Membentuk lantai duktus
timpani koklearis.
Duktus koklearis Terletak di bagian atas dan
(skala media) di sepanjang membran
basilaris.
Membran basilaris Membran stasioner yang
tergantung di atas organ
korti dan tempat sel-sel
rambut reseptor permukaan
tertanam di dalamnya.
Organ korti Membran tipis yang
memisahkan skala timpani
dari telinga tengah.
mendengar
Bergetar bersama dengan getaran
stpes yang melekat padanya.
Gerakan jendela oval
menyebabkan perlimfa koklea
bergerak.
Mengandung perlimfa yang
dibuat bergerak oleh gerakan
jendela oval yang didorang oleh
getaran tulang-tulang telinga
tengah.
Memgandung endolimfa: tempat
membran basilaris.
Mengandung endolimfe: tempat
membran basilaris.
Mengandung sel rambut,
reseptor untuk suara, yang
mengeluarkan potensial reseptor
sewaktu terbekuk akibat cairan
di koklea.
Tempat rambut sel-sel reseptor
tertanam di dalamnya menekuk
dan membentuk potensial
reseptor ketika membrane
basilaris bergetar terhadap
membran tektorial yang
stasioner.
Membran tectorial Tiga saluran semisirkuler
yang tersusun tiga dimensi
dalam bidang-bidang yang
tegak lurus satu sama lain di koklea, tidak berperan di dalam
dekat korteks jauh di dalam
tulang temporalis.
Jendela bundar Struktur seperti kantong
rongga antara koklea dan
kanalis semisirkularis.
Bergerak bersama dengan
getaran cairan di perilimfe untuk
meredam tekanan di dalam
penerimaan suara.
Tempat sistem sensoris untuk
keseimbangan dan memberikan
masukan yang penting untuk
mempertahankan postur dan
keseimbangan.

Telinga dalam Terletak disamping Mendeteksi: akselarasi

(aparatus utrikulus (percepatan) deselarasi
vestibularis) (perlambatan) rotasional atau
angular.

Kanalis semi Mendeteksi: 1) perubahan posisi

sirkularis
kepala menjauhi sumbu vertikal,
2) mengarahkan akselarasi dan
deselerasi linear secara
horizontal.
Utrikulus Mendeteksi: 1) perubahan posisi
kepala menjauhi sumbu
horizontal, 2) mengarahkan
akselarasi dan deselerasi linear
secara vertikal.
Sakulus
(ILMU PENYAKIT THT, FK UNDIP)

Berikut fungsi komponen utama telinga yang di tuliskan dalam tabel :

2. Mekanisme pembentukan, penyaluran, ekskresi serumen?

Di prod oleh kelenjar seruminosa dan kelenjar sebasea (minyak
berfungsi sbg pelindung)
Serumen mengandung asam lemak tak jenuh keratinosit protein
 Epitel squamos kompleks keratin akan memperbarui 20 hari yg atas akan
terdeskuamasi, sel serumen dan sebasea berkumpul membentuk
serumen
Jk berhubungan dg dunia luar, aktivitas produksi akan meningkat
Kelenjar hanyaterdapat di 1/3 luar tlinga
Jk mengorek telinga bs melukai membran tympani
Serumen bisa keluar sendiri dg migrasi epitel dibantu dg gerakan rahang
sewaktu mengunyah, kemungkinan yg keluar yg keras
Membersihkan serumen maksimal sebulan sekali
Jk sering dikorek perlindungan akan menurun
Kalau suhu tinggi bisa mempengaruhi produksi serumen meningkat dan
keadaan telinga lembab
Sel sebasea ada di kulit tipis
Jk serumen berlebih akan menyebabkan kurang pendengaran
Tahapan 1 : 25 desibel (Bisikan halus)
45 desibel tdk bs mendengar normal
Karena membatasi pergerakan telinga

Kenapa serumen ada yg keras ada yg lunak?

Ada yg kelenjar sebasea berlebih ada yg kurang, sebasea seperti pelarut
Kulit kering : serumen kering
3. Mengapa rasa nyeri saat ditarik auricula atau di tekan tragusnya sampai
kepala dan saat penderita menelan?
 Innervasi auricula : ramus auricularis cabang n 10, n.9, pleksus servikal
Kemungkinan kelainan di meatus akustikus eksternus, di innervasi ramus
auricularis cabang dari n.9 n.10 jadi bs tjd refered pain
Di innervasi n. mandibularis (otot mastikasi, dan mandibula, sensorik :
wajah bawah dan kepala) jk terangsang rasa nyeri bs sampai kepala

4. Apa hubungan penyakit penderita dengan mengorek telinga dg cotton

bud?
Kalau mengorek telinga dg cotton bud sbg predisposisi otitis eksterna
akut, yang bs mendorong kotoran masuk kedalam dan menyumbat
membran tympani yg dpt mengganggu pendengaran
Kapas cotton bud kasar yg dpt menyebabkan kulit telinga terluka dan
menyebabkan infeksi
Jk mengorek dg hati2 tdk masalah jd harus pelan-pelan
 Penyebab sensasi gatal pada telinga??
Karena reseptor gatal sama dg reseptor nyeri/ nosiseptor, tp impuls
lebih kecil
Jk ada peradangan mengeluarkan histamin yg menyebabkan gatal
5. Mengapa sakit telinga kirinya disertai kurang pendengaran?
2.3.3. Jenis Gangguan Pendengaran
Ada tiga jenis gangguan pendengaran, yaitu konduktif, sensorineural, dan
campuran. Menurut Centers for Disease Control and Prevention pada gangguan
pendengaran konduktif terdapat masalah di dalam telinga luar atau tengah,
sedangkan pada gangguan pendengaran sensorineural terdapat masalah di telinga
bagian dalam dan saraf pendengaran. Sedangkan, tuli campuran disebabkan oleh
kombinasi tuli konduktif dan tuli sensorineural. Menurut WHO-SEARO (South East
Asia Regional Office) Intercountry Meeting (Colombo, 2002) faktor penyebab
gangguan pendengaran adalah otitis media suppuratif kronik (OMSK), tuli sejak
lahir, pemakaian obat ototoksik, pemaparan bising, dan serumen prop.
2.3.3.1.1. Gangguan Pendengaran Jenis Konduktif
Pada gangguan pendengaran jenis ini, transmisi gelombang suara tidak dapat
mencapai telinga dalam secara efektif. Ini disebabkan karena beberapa gangguan
atau lesi pada kanal telinga luar, rantai tulang pendengaran, ruang telinga tengah,
fenestra ovalis, fenestra rotunda, dan tuba auditiva. Pada bentuk yang murni (tanpa
komplikasi) biasanya tidak ada kerusakan pada telinga dalam, maupun jalur
persyarafan pendengaran nervus vestibulokoklearis (N.VIII).
Gejala yang ditemui pada gangguan pendengaran jenis ini adalah seperti berikut:
1. Ada riwayat keluarnya carian dari telinga atau riwayat infeksi telinga sebelumnya.
2. Perasaan seperti ada cairan dalam telinga dan seolah-olah bergerak dengan
perubahan posisi kepala.
3. Dapat disertai tinitus (biasanya suara nada rendah atau mendengung).
4. Bila kedua telinga terkena, biasanya penderita berbicara dengan suara lembut (soft
voice) khususnya pada penderita otosklerosis.
5. Kadang-kadang penderita mendengar lebih jelas pada suasana ramai.
Menurut Lalwani, pada pemeriksaan fisik atau otoskopi, dijumpai ada sekret dalam
kanal telinga luar, perforasi gendang telinga, ataupun keluarnya cairan dari telinga
tengah. Kanal telinga luar atau selaput gendang telinga tampak normal pada
otosklerosis. Pada otosklerosis terdapat gangguan pada rantai tulang pendengaran.
Pada tes fungsi pendengaran, yaitu tes bisik, dijumpai penderita tidak dapat
mendengar suara bisik pada jarak lima meter dan sukar mendengar kata-kata yang
mengandung nada rendah. Melalui tes garputala dijumpai Rinne negatif. Dengan
menggunakan garputala 250 Hz dijumpai hantaran tulang lebih baik dari hantaran
udara dan tes Weber didapati lateralisasi ke arah yang sakit. Dengan
menggunakan garputala 512 Hz, tes Scwabach didapati Schwabach memanjang
(Soepardi dan Iskandar, 2001).
2.3.3.2. Gangguan Pendengaran Jenis Sensorineural
 Gangguan pendengaran jenis ini umumnya irreversibel. Gejala yang ditemui pada
gangguan pendengaran jenis ini adalah seperti berikut:
1. Bila gangguan pendengaran bilateral dan sudah diderita lama, suara percakapan
penderita biasanya lebih keras dan memberi kesan seperti suasana yang tegang
dibanding orang normal. Perbedaan ini lebih jelas bila dibandingkan dengan suara
yang lembut dari penderita gangguan pendengaran jenis hantaran, khususnya
otosklerosis.
2. Penderita lebih sukar mengartikan atau mendengar suara atau percakapan dalam
suasana gaduh dibanding suasana sunyi.
3. Terdapat riwayat trauma kepala, trauma akustik, riwayat pemakaian obatobat
ototoksik, ataupun penyakit sistemik sebelumnya.
Menurut Soetirto, Hendarmin dan Bashiruddin, pada pemeriksaan fisik atau
otoskopi, kanal telinga luar maupun selaput gendang telinga tampak normal. Pada
tes fungsi pendengaran, yaitu tes bisik, dijumpai penderita tidak dapat mendengar
percakapan bisik pada jarak lima meter dan sukar mendengar katakata yang
mengundang nada tinggi (huruf konsonan).Pada tes garputala Rinne positif, hantaran
udara lebih baik dari pada
hantaran tulang. Tes Weber ada lateralisasi ke arah telinga sehat. Tes Schwabach ada
pemendekan hantaran tulang.
2.3.3.3. Gangguan Pendengaran Jenis Campuran
Gangguan jenis ini merupakan kombinasi dari gangguan pendengaran jenis konduktif
dan gangguan pendengaran jenis sensorineural. Mula-mula gangguan pendengaran
jenis ini adalah jenis hantaran (misalnya otosklerosis), kemudian berkembang lebih
lanjut menjadi gangguan sensorineural. Dapat pula sebaliknya, mula-mula gangguan
pendengaran jenis sensorineural, lalu kemudian disertai dengan gangguan hantaran
(misalnya presbikusis), kemudian terkena infeksi otitis media. Kedua gangguan
tersebut dapat terjadi bersama-sama. Misalnya trauma kepala yang berat sekaligus
mengenai telinga tengah dan telinga dalam (Miyoso, Mewengkang dan Aritomoyo,
1985).
Gejala yang timbul juga merupakan kombinasi dari kedua komponen gejala
gangguan pendengaran jenis hantaran dan sensorineural. Pada pemeriksaan fisik atau
otoskopi tanda-tanda yang dijumpai sama seperti pada gangguan pendengaran jenis
sensorineural. Pada tes bisik dijumpai penderita tidak dapat mendengar suara bisik
pada jarak lima meter dan sukar mendengar kata-kata baik yang mengandung nada
rendah maupun nada tinggi. Tes garputala Rinne negatif. Weber lateralisasi ke arah
yang sehat. Schwabach memendek (Bhargava,
Bhargava and Shah, 2002).

Ada floranormal di telinga ??????

6. Mengapa diberikan resep serumenolitik, antibiotik dan analgetik?
Serumenolitik untuk melunakkan serumen
Antibiotik karena curiga ada bakteri
 Analgetik karena ada nyeri

7. Misal tidak ditemukan furunkel dan jamur dan adanya batuk pilek akan
menyingkirkan DD apa?
Furunkel biasanya ciri dari otitis eksterna sirkumfekta di 1/3 luar
biasanya disebabkan staphilococcus albus
Batuk pilek bisa menyebabkan otitis media, krn ada tuba eustacii
8. Pemeriksaan penunjang untuk menegakkan diagnosis?
Referred Ear Pain
If examination of the drum and meatus is normal in a patient
complaining of earache, the pain is referred. Referred ear pain may be
from nearby structures such as the temporo-mandibular joint, neck
muscles, or cervical spine. It may also be from the teeth, tongue, tonsils,
or larynx. Cranial nerves V, IX, and X which supply these sites have their
respective tympanic and auricular branches supplying the ear. Earache
also frequently precedes a Bell’s palsy.
9. DD?

Otitis Externa
Eczema of the meatus and pinna (see Fig. 2.41) may be associated with
eczema elsewhere, particularly in the scalp, or it may be an isolated
condition affecting only one ear. Itching is the main symptom, with
scanty discharge. The eczematous type of otitis externa usually settles
with the use of a topical corticosteroid and antibiotic drop. Cleaning of
the meatus may also be necessary, either with cotton wool on a probe,
or suction and the Zeiss microscope. Otitis externa tends to recur.
The patient should avoid over-diligent cleaning of the meatus, or
scratching the ear with the finger, probes, or cotton wool buds. Cotton
wool buds, if used, should only be used to the orifice of the meatus.
Water entering the ear during washing or swimming also predisposes to
the recurrence of otitis externa.
10.Penatalaksaan dan terapi?

The discharging ear (otorrhoea)

Discharge from the ear is usually due to infection of the outer or middle
ear. Otitis externa is a diffuse inflammation of the skin of the ear canal.
The organism may be bacterial, viral or fungal and the patient usually
complains of severe pain. Gentle pulling of the pinna is tender and there
may be lymphadenopathy of the preauricular nodes.

Examination

may reveal debris in the canal which needs to be removed either by

gentle mopping or preferably by suction viewed directly under a
microscope. In severe cases the canal may be swollen and a view of the
tympanic membrane impossible. Any foreign body seen should be
removed with great care by trained personnel.

Treatment
 is with regular cleansing and topical antibiotics combined with
corticosteroids; it resolves in 3–4 days. Otitis media can also present
with discharge from the middle ear through a perforation of the
tympanic membrane. There are no mucous glands in the external ear
canal, however, and if the discharge is serous then middle ear pathology
is unlikely. Treatment is with systemic antibiotics.

11.Komplikasi ?
12.Pembagian telinga sakit( dg pendengaran turun dan pendengaran
normal)?
Hearing loss

Deafness can be conductive or sensorineural and these can be differentiated at the bedside
by the Rinne and the Weber tests (Box 20.1) or with pure-tone audiometry.

Rinne test

Normally a tuning fork, 512 Hz, will be heard as louder if held next to the ear (air conduction)
compared to being placed on the mastoid bone ( Rinne positive ). If the tuning fork is per-
ceived louder when placed on the mastoid (bone conduction), then a defect in the
conducting mechanism of the external or middle ear is present (true Rinne negative ).

Weber test

A tuning fork placed on the forehead or vertex of a patient with normal hearing (or with
symmetrical hearing loss) should be perceived centrally. Conductive hearing loss may be due
to many causes (Table 20.1) but wax is the commonest. Pure tone audiometry The patient is
asked to respond to a series of pure tones presented to each ear, in turn, in a soundproof
room. An audiogram is produced (Fig. 20.3).