PEMERIKSAAN PENDENGARAN

Tuli Konduktif
Tuli Sensori Neural
Tuli Campuran
 ANALISIS TULI
Tipe
Derajat
Tempat Lesi
Etiologi
 Penilaian Pendengaran
Klinis
Audiometri
 KLINIS
1. Finger friction test
2. Watch test
3. Speech tests
4. Tuning fork tests
 Finger friction test
It is a rough but quick method of screening
and consists of rubbing or snapping the thumb
and a finger close to patients ear.
 Watch test
A clicking watch is brought close to the ear
and the distance at which it is heard is
measured.
It had been popular as a screening test before
the audiometric era but is practically obsolete
now. Clicking watches are also obsolete.
 Speech tests
The test is conducted in reasonably quiet surroundings.
The patient stands with his test ear towards the examiner at a
distance of 6 m. His eyes are shielded to prevent lip reading
and the nontest ear is blocked by intermittent pressure on
the tragus by an assistant. The examiner uses spondee words
(e.g. black-night, football, daydream) or numbers with letters
(X3B, 2AZ, M6D) and gradually walks towards the patient.
The distance at which conversational voice and the whispered
voice are heard is measured. The disadvantage of
speech tests is lack of standardization in intensity and pitch
of voice used for testing and the ambient noise of the testing
place.
 TES GARPU TALA
Mengukur konduksi udara dan konduksi
tulang
Pilihan frekuensi 128, 256, 512, 1024, 2048
and 4096 Hz
Ideal 512: tidak terlalu dipengaruhi bising
sekitar
 Konduksi Udara
Diukur dengan meletakkan garpu tala yang
telah digetarkan kurang lebih 2 cm dari liang
telinga
Konduksi udara lebih kuat dan durasi sekitar
dua kali konduksi tulang
 Konduksi Tulang
Garpu tala digetarkan, diletakkn di prosess
mastoid
Menilai fungsi koklea saja
 JENIS TEST GARPU TALA
Rinne
Weber
Swabach
Absolute bone conduction test
 Rinne
Membandingkan AC dan BC
Positif: AC lebih lama dari BC= normal/tuli
sensori neural
Negatif: tuli konduktif, minimal air-bone gap
15-20 db
 A Rinne test equal or negative for 256 Hz but
positive for 512 Hz indicates air-bone gap of
2030 dB.
A Rinne test negative for 256 and 512 Hz but
positive for 1024 Hz indicates air-bone gap of
3045 dB.
A Rinne negative for all the three tuning
forks of 256, 512 and 1024 Hz indicates air-
bone gap of 4560 dB.
 False negative Rinne
It is seen in severe unilateral sensorineural
hearing loss.
Patient does not perceive any sound of tuning
fork by air conduction but responds to bone
conduction testing. This response to bone
conduction is, in reality, from the opposite ear
because of transcranial transmission of sound.
 Weber test
Membandingkan BC antar kedua telinga
Garpu tala ditaruh di tengah
 Absolute Bone Conduction Test
is a measure of cochlear function
External auditory meatus of both the patient and
examiner should be occluded (by pressing the
tragus inwards)to prevent ambient noise entering
through AC route.
In conductive deafness, the patient and the
examiner hear the fork for the same duration of
time.
In sensorineural deafness, the patient hears the
fork for a shorter duration.
 Schwabachs test
Membandingkan BC pasien dengan pemeriksa
Liang telinga tidak ditutup
Schwabach is reduced in sensorineural
deafness and lengthened in conductive
deafness
 Tes Bing
Menilai BC dan efek oklusi meatus
Cek BC, lalu tutup liang telinga dengan tragus
Suara meningkat: normal/tuli sensorineural
Tidak ada perubahan: tuli konduktif
 Tes Stenger
Untuk menilai pura-pura tuli
Misalkan pura2 tuli kiri
Dua penala digetarkan, pertama taruh di
telinga normal, kedua digetarkan lebih keras
dan tarus di telinga sakit.
Normal: hanya telinga kedua yang mendengar
Benar-benar sakit: telinga pertama ttp
mendengar bunyi
 AUDIOMETRI
Audiometri nada murni
Audiometri tutur
Audiometri bekesy
Audiometri impedans
 An audiometer is an electronic device which
produces pure tones, the intensity of which
can be increased or decreased in 5 dB steps
 FUNGSI
(a) It is a measure of threshold of hearing by air
and bone conduction and thus the degree and
type of hearing loss.
(b) A record can be kept for future reference.
(c) Audiogram is essential for prescription of
hearing aid.
(d) Helps to find degree of handicap for
medicolegal purposes.
(e) Helps to predict speech reception threshold.
 AUDIOMETRI TUTUR
Menilai fungsi mempersepsikan pembicaraan
Speech reception threshold (SRT)
Speech discrimination score
 Speech reception threshold (SRT)
Kemampuan untuk mengulangi kata-kata yang
benar sebanyak 50%
A set of spondee words (two syllable words with
equal stress on each syllable, e.g. baseball,
sunlight, daydream, etc.) is delivered to each ear
through the headphone of an audiometer.
The word lists are delivered in the form of
recorded tapes or monitored voice and their
intensity varied in 5 dB steps till half of them are
correctly heard.
 Speech discrimination score
Mengukur kemampuan mengerti pembicaraan
Here, a list of phonetically balanced (PB)
words (single syllable words, e.g. pin, sin, day,
bus, etc.) is delivered to the patients each ear
separately at 3040 dB above his SRT and the
percentage of words correctly heard by the
patient is recorded.
In normal persons and those withconductive
hearing loss a high score of 90100%
 AUDIOLOGI KHUSUS
Pemeriksaan untuk membedakan tuli koklea
dengan retrokoklea
 AUDIOMETRI KHUSUS
Mencari fenomena rekrutmen atau
kelelahan(decay)
Rekrutmen(pada tuli koklea): peningkatan
sensitifitas berlebihan di atas ambang dengar.
Misal: orang normal baru dapat membedakan
selisih 5 db, pada tuli retrokoklea 1 db bisa
dibedakan
Kelelahan(tuli retrokoklea)
 AUDIOMETRI KHUSUS
Tes SISI
Tes ABLB
Tes kelelahan
Audiometri tutur
Audiometri bekesy
SHORT INCREMENT SENSITIVITY INDEX
(SISI TEST)
Mencari rekrutmen
Nilai ambang dengar
Berikan rangsang tambahan 20 db
Lalu tambah 5-4-3-2-1
Bila semua dapat dibedakan maka rekrutmen positif
Cara 2: tiap 5 detik naikkan 1 db sampai 20 kali. Hitung
berapa persen benar.
Rekrutmen positif bila minimal 70%
In conductive deafness, SISI score
is seldom more than 15%; it is 70100% in cochlear
deafness and 020% in nerve deafness.
 Alternate binaural loudness balance
test
detect
recruitment in unilateral cases. A tone, say of 1000 Hz, is
played alternately to the normal and the affected ear and
the intensity in the affected ear is adjusted to match the
loudness in normal ear. The test is started at 20 dB above
the threshold of deaf ear and then repeated at every 20 dB
rise until the loudness is matched or the limits of
audiometer
reached. In conductive and neural deafness, the initial
difference is maintained throughout while in cochlear
lesions, partial, complete or over-recruitment may be seen
 Tes Kelelahan(Tone Decay)
Untuk menilai kelelahan saraf
Tuli retrokoklea
Dua cara:
Tone threshold decay(TTD)
Supra threshold adaptation test(STAT)
Audiometri Tutur
 Audiometri Bekesy
Pasien diberi rangsang suara terputus dan
terus menerus
 HASIL
Type I Continuous and pulsed tracings overlap. Seen in
normal hearing or conductive hearing loss.
Type II Continuous and pulsed tracings overlap up to 1000
Hz and then continuous tracing falls. Seen in cochlear loss.
Type III Continuous tracing falls below pulsed tracing at
100500 Hz even up to 4050 dB. Seen in
retrocochlear/neural lesion.
Type IV Continuous tracing falls below pulsed lesion at
frequencies up to 1000 Hz by more than 25 dB. Seen in
retrocochlear/neural lesion.
Type V Continuous tracing is above pulsed one. Seen in
nonorganic hearing loss.
 AUDIOMETRI OBJEKTIF
Pasien tidak harus bereaksi
Contoh:
Audiometri impedans
Elektrokokleografi
Evoked response audiometry(BERA)
Oto Accoustic emmision(OAE)
 AUDIOMETRI IMPEDANS
Menilai tekanan liang telinga dan membran
timpani
Menggunakan probe berisi produksi suara dan
mikrofon
Jenis pemeriksaan
Timpanometri
Refleks stapedius
Menilai fungsi tuba eustachius
 TIMPANOMETRI
Saat gelombang suara menuju membran timpani
sebagian dihantarkan dan sebagian dipantulkan
Semakin kaku MT semakin banyak suara yang
dipantulkan
CARA:
(i) to deliver a tone of 220 Hz,
(ii) to pick up the reflected sound through a
microphone and
(iii) to bring about changes in air pressure in the ear
canal from positive to normal and then negative
HASIL
 Testing function of eustachian tube.
Tympanometry has also been used to find
function of eustachian tube in cases of intact or
perforated tympanic membrane.
A negative or a positive pressure (200 or +200
mm H2O) is created in the middle ear and the
person is asked to swallow five times in 20 s.
The ability to equilibrate the pressure indicates
normal tubal function.
The test can also be used to find the patency of
the grommet placed in the tympanic membrane
in cases of serous otitis media
 Acoustic reflex/refleks akustik
Refleks saat telinga menerima suara intensitas
tinggi (80-110 db di atas ambang dengar)
Terjadi pada kedua telinga meskipun stimulus
hanya diberikan pada satu telinga
Refleks berupa kontaksi m stapedius dan
tensor timpani
MT tertarik
 JARAS
Ipsilateral: CN VIII ventral cochlear nucleus
CN VII nucleus ipsilateral stapedius muscle.
Contralateral: CN VIII ventral cochlear
nucleus contralateral medial superior
olivary nucleus contralateral CN VII nucleus
contralateral stapedius muscle
 FUNGSI TES REFLEKS AKUSTIK
Tes fungsi pendengaran anak
Tes malingering
Mendeteksi kelainan koklea, adanya refleks
stapedius pada db lebih rendah menandakan
recruitment
Deteksi lesi nVIII
Deteksi lesi n VII: refleks(-) pendengaran normal
Deteksi lesi batang otak: ipsilateral+,
kontralateral(-)
 Electrocochleography (EcoG)
measures electrical potentials arising in the
cochlea and CN VIII in response to auditory
stimuli within first 5 ms
EcoG is useful (i) to find threshold of hearing
in young infants and children within 510 dB
and (ii) to differentiate lesions of cochlea from
those of the VIIIth nerve.
 BRAIN EVOKED RESPONSE
AUDIOMETRY
Menilai potensial listrik dari koklea sampai otak
Melekatkan elektroda di kulit kepala/dahi dan pada
mastoid/lobulus telinga
Non invasif
Beri rangsang klik-rekam
Early response kurang dari 10 ms= reaksi batang otak
Middle response 10-50 ms: talamus dan korteks
auditori primer
Late response- 50-500 ms: area auditori primer dan
sekitarnya
 PENILAIAN BERA
Masa laten absolut gelombang I, III, V
Beda antar masa laten
Beda masa laten antar telinga
Beda masa laten pada penurunan intensitas
bunyi
Rasio V/I
 FUNGSI BERA
(i) As a screening procedure for infants.
(ii) To determine the threshold of hearing in
infants; alsoin children and adults who do not
cooperate and in malingerers.
(iii) To diagnose retrocochlear pathology
particularly acoustic neuroma.
(iv) To diagnose brainstem pathology, e.g.
multiple sclerosis or pontine tumours.
(vi) To monitor CN VIII intraoperatively in surgery
of acoustic neuromas to preserve the function of
cochlear nerve.
 Emisi Otoakustik(OAE)
Mengukur respon gelombang yang dihasilkan
oleh sel rambut luar
Memasukkan probe ke liang telinga
Memberi stimulus suara
Lalu ukur gelombang yang diberikan
 Sound produced by outer hair cells travels in a
reverse direction: outer hair cells basilar
membrane perilymph oval window
ossicles tympanic membrane ear canal
 (a) Spontaneous OAEs. They are present in healthy normal
hearing persons where hearing loss does not exceed 30 dB.
They may be absent in 50% of normal persons.
(b) Evoked OAEs. They are further divided into two types
depending on the sound stimulus used to elicit them.
(i) Transient evoked OAEs (TEOAEs). Evoked by clicks. A series of
click stimuli are presented at 8085 dB SPL (sound pressure
level) and response recorded.
(ii) Distortion product OAEs (DPOAEs). Two tones are
simultaneously presented to the cochlea to produce distortion
products. They have been used to test hearing in the range of
10008000 Hz.