Auditory tests with

disease
specific significance
AUDIOMETRY
Pure Tone • A single frequency sound.

Complex • Sound with more than one frequency.

Sound • Human voice

• A complex sound has a fundamental

frequency i.e. the lowest frequency at
Overtones which a source vibrates. All frequencies
above that tone are called overtones
• It determines the quality/ timbre of sound
 Pure tone

Pure tone
 Conductive Hearing Loss

“Any disease process which interferes with

the conduction of sound from the outer ear
to the cochlea”
 Sensorineural Hearing Loss

“It results from lesion of the cochlea

(sensory type) or VIIIth nerve & its central
connections( neural type) .”
 Mixed Hearing Loss

“A loss with both conductive and

sensorineural component.”
 DEGREES OF HEARING LOSS

• Normal hearing (0-25 dB)

• Mild hearing loss (26-40 dB)
• Moderate hearing loss (41-55 dB)
• Moderate-severe hearing loss (56-70 dB)
• Severe hearing loss (71-90 dB)
• Profound hearing loss (>90 dB)
 Audiogram

• The audiogram is a chart of hearing sensitivity

with frequency charted on the
X- axis and intensity on the Y-axis. Intensity is
the level of sound power measured in
decibels; loudness is the perceptual correlate
of intensity.
 Conductive Hearing loss (deafness)

• If B.C level <20 dB

• A-B gap is >=25 dB
• A.C threshold >30 dB
• Examples of abnormalities include perforated
tympanic membranes, fluid in the middle ear
system, or scarring of the tympanic
membrane.
 Sensorineural Hearing Loss (Deafness)

• If B.C level >20 dB

• A-B gap is < 20 dB
• AC threshold >30 dB
• This type of hearing loss is secondary to
cochlear abnormality and/or abnormality of
the auditory nerve or central auditory
pathways.
 Mixed Hearing loss (deafness)
• If B.C level is >20 dB
• A-B gap >20 dB
• AC Threshold >45dB
• This type of hearing loss has sensorineural and
conductive components.
This is an audiogram of
normal hearing. The red
and blue marks show the
softest sounds this person
could hear in his right (red)
and left (blue) ears. The
shaded areas show the
range of speech sounds.
This is called the "speech
banana"
This person can hear
sounds even softer than
the speech sounds. But if
he can't hear sounds in the
area of the speech banana,
he will have trouble
understanding what
people say.
From top to bottom –
hearing threshold
(loudness)

The loudness of a sound

is measured in decibels
(dB).

Loud sounds are towards

the bottom of the
audiogram.

Quiet sounds are

towards the top of the
audiogram.
For Conductive
lesions, it has been
found that pathologies
which increase
stiffness ( like
otosclerosis) present a
left sloping audiogram
(i.e., more loss in the
lower frequencies)
Pathologies which
increase mass (like
secretory otitis media)
present a right sloping
audiogram ( more loss in
higher frequencies)
An ascending curve (
slopes to left) is
usually found in early
endolymphatic
hydrops.
IMPEDENCE AUDIOMETRY
(TYMPANOMETRY)
 Tympanometry
“The measurement of the change in impedance of
the middle ear at the plane of the tympanic
membrane as a result of changes in air pressure in
the external auditory meatus”

In this way, the air pressure at which the ear

functions most effectively, i.e., transmit the
highest amount of sound, can also be determined.
This particular pressure is the pressure of the air
inside the middle ear cavity & is referred to as the
Middle ear pressure.
• The middle ear acts as the impedence
matching device such that most of the sound
energy coming from the air is transmitted to
the cochlear fluid.
• All ME pathologies alter this impedence
matching function & result in lesser sound
energy being transmitted to the cochlear fluid
thus causing conductive deafness.
• It is based on simple principle, i.e. when a
sound strikes tympanic membrane, some of the
sound energy is absorbed while the rest is
reflected.
• A stiffer TM would reflect more of sound
energy than a compliant one.
• By changing the pressures in a sealed EAC &
then measuring the reflected sound energy, it is
possible to find the compliance or stiffness of
the tympano-ossicular system & thus find the
healthy or diseased state of the middle ear.
• The pressure within the sealed cavity in the EAM
can be varied from +300 to -600 mm of water
pressure.
• The purpose of varying the air pressure is to
produce a change in the stiffness of the TM, so
that the amt of sound energy that is being
reflected back from the TM can be measured in
relation to the change of stiffness of TM.
Tympanogram of a normal subject
 Impedance audiometry
• Tympanometry:
• Measure the impedance of eardrum and
ossicular chain
• Jerger classification.
• Type A: normal
• Type As (Reduced compliance): otosclerosis,
tympanosclerosis
• Type C: auditory tube dysfunction
• Type B (no compliance): TM perforation
or effusion
• Type Ad (Increased compliance): laxity of
TM(Thinned TM) or disruption of ossicular
chain
ACOUSTIC/STAPEDIAL
REFLEX TESTS
• Loud sound reaches ear intra-aural muscles
contract i.e stapedius muscle pulls the stapes
outward & upward, & contraction of tensor
tympani pulls the TM slightly inward

• Stiffens the ME conductive apparatus &

changes the impedence of the ME system.
• The lowest sound intensity that is capable
of eliciting a contraction of the stapedius
muscle is c/d acoustic reflex threshold.
• The normal range of acousic reflex
threshold is between 70 dB SL to 105 dB
SL( above the pure tone hearing
threshold).
• Acoustic reflex present means no lesion in any of
the constituents of the reflex arc.
• Possible disorders on afferent side-
a) Disease in I/L ME causing moderate to severe
conductive deafness.
b) Lesion in I/L cochlea or 8th cranial nerve.
c) Lesion in cochlear nucleus or superior olivary
complex.
• Possible disorders on the efferent side-
a) Lesion in facial nerve nucleus in brainstem
b) Facial nerve paralysis at a level proximal to the
nerve to stapedius like Ramsay Hunt Syndrome.
c) Disease of the stapedius muscle like myasthenia
gravis
• # of stapedial crura is the only ME pathology
which does not abolish the reflex.
 Interpretation of acoustic reflex
• Reflex is B/L.
• Ear having probe of the impedence audiometer
is referred to as the I/L ear & the ear having
the audiometer headphone is referred to as the
C/L ear.
• If the acoustic reflex is present it is very
unlikely that the ear has any sort of ME
disease except # of the stapedial crura.
• In B/L conductive deafness, the acoustic
reflexes will be absent both on ipsi & contra
stimulation bilaterally.
• In U/L severe SNHL the acostic reflex will be
present in the deaf ear only on C/L stimulation.
I/L reflex in normal ear will obviously be
present. Thus presence of acoustic reflex in
deaf ear on C/L stimulation rules out the
possibility of a conductive or mixed deafness
& indicates that the deafness is SNHL type.
• In B/L SNHL of severe degree the
reflexes will be absent since sufficient
sound impulse will not reach the centre of
the reflex arc.
• In case of B/L SNHL of moderate degree
& cochlear in nature then the reflex may
be bilaterally present on both ipsi & C/L
stimulation. This is due to loudness
recruitment.
• In central lesions i.e lesion in the
brainstem, reflexes are present bilaterally
on I/L stimulation only but absent
bilaterally on C/L stimulation.
 Uses of Acoustic Reflex Test
• Identification of the site of lesion in facial
nerve paralysis.
• Identifying Malingerers.
• Lesion of brainstem.
• To detect cochlear pathology.
• To detect VIIIth nerve lesion.
BERA
 INTRODUCTION
• Auditory brainstem response (ABR) is a
neurologic test of auditory brainstem
function in response to auditory (click)
stimuli.
• It’s a set of seven positive waves
recorded during the first 10 seconds
after a click stimuli. They are labeled as
I - VII
 PHYSIOLOGY
• Auditory brainstem response (ABR) typically
uses a click stimulus that generates a
response from the hair cells of the cochlea.
• The signal travels along the auditory
pathway from the cochlear nuclear complex
to the inferior colliculus in mid brain
generates wave I to wave V.
 PRINCIPLE OF BERA
• Passage of the impulse at different levels of
auditory pathway, generates electrical activity
• Monitored by surface electrode on the vertex
of the scalp.
• On Graphic recording electrical activity
presents a waveform with discrete peaks.
• Depends on the functional and structural
integrity of the pathway.
 Principle of BERA

16-07-2012 www.nayyarENT.com 51
Wave Site of Neural Generator
I Cochlear nerve (distal end)
II Cochlear nerve ( proximal end)
III Cochlear nucleus
IV Superior Olivary Complex
V Lateral Leminiscus & Inferior
Colliculus
VI & VII Not definitely known
 USES OF BERA
• Detection & quantification of deafness in difficult to
test patients.
• Detection of the nature of deafness.
• Identification of the site of lesion in retro-cochlear
pathologies.
• Study of central auditory disorders.
• Study of maturity of nervous system in newborns.
• Objective identification of brain death.
• Assessing prognosis in comatose patients.
OAE
 OTOACOUSTIC EMISSIONS

• These are the low intensity sounds produced

by the outer hair cells of cochlea and
recordable in the external ear canal.
 USES OF OTOACOUSTIC EMISSIONS
• As a Screening test for detection of hearing
loss esp. in neonates.
• To identify cochlear disorders like ototoxicity,
noise trauma.
• To identify auditory nerve disorders like
auditory neuropathy & acoustic neuromas.
• Tests for functional (feigned) hearing loss.
THANK YOU