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R3 Ahn Seong yong

Department of Otolaryngology,
College of Medicine, Gyeong-sang National University.

Sound wave
(Sound wave) : (compression phase) (rarefaction
phase)


(intensity) : (amplitude)
(pitch) : ( frequency) .
* ( frequency) : , hertz ; Hz
, ,
* : decibel; dB=1/10 Bell

===>

Amplitude, Frequency, Phase

dB SPL : , (P)
dB SPL= 20 log(P / P0) , P0 : , P :
0 dB SPL = P0 : 0.0002 dyne/cm2 (=20Pa)
dB HL :
0 dBHL : 0 audiometric zero( ANSI standards)

dB SL : .

Audible range; 16-20,000 Hz
Conversational range; 250-2,000 Hz


: ,
, ,

( )

: ,
matching,

:

electrochemically
transduction
, : electrochemical
processing, central signal processing


(Tuning fork test)
(Pure tone audiometry)
(Speech audiometry)
(Impedence
audiometry)
(Bekesy audiometry)
(Test for recruitment
phenomenon)
(Tone decay test)
(Evoked response
audiometry)
(Atoacoustic emissions test)

(Test for pseudohypacusis)

Tuning fork test


Weber test
Rinne test
Schwabach test
Gelle test
Bing test

Type of HL

Weber

Rinne

Schwabach

Normal

No lateralization

AC>BC Same

Conductive

Lateralize to bad ear

AC<BC Pt. > examiner

Sensorineural

Lateralize to good ear AC>BC Pt. < examiner

Weber test

Rinne test

512 Hz 1 cm
,

Rinne : , - >
Rinne : - >

256 Hz:15 dB, 512 Hz:25-30dB, 1024 Hz: 35dB

Schwabach test
( )
256 Hz


- - ,

.

Gelle test
,

politzer bag pneumatic ostoscope
(
)

- Gelle

Gelle

Bing test

occlusion effect



tragus .
- or ,
-

PURE-TONE AUDIOMETRY

Audiomeric frequency range (250-8000 Hz)

-10 130 dB HL

Air conduction & Bone conduction audiometry

Important role of PTA


1. testing auditory function
2. evaluation of hearing aid
3. rehabilitation planning

I. Threshould of audibility
Definition
: 50%

3 2

(dB HL)
: the minimum effective sound pressure level of an acoustic signal
producing an auditory sensation 'in a specified fraction of the trials"
- the Americal National Standards Institute(ANSI) S3.20-1970
* Threshould : the lowest signal intensity at which multiple presentation
are dectected 50% of the time

II. Threshold determination


1. descending method
:

2. ascending method(Hughson and Westlake, 1944)
:
(5-10 dB )
3. modified ascending method
: 30 50dB
20dB ,
10dB down, 5dB up
-up 5 dB down 10 dB,
- 3 2
- stimulus on-time was from 1-2 sec,
separated by toneless intervals of at least 3 sec

III. Equipment required

Basic control
1. Power switch
2. Frequency selector
3. Hearing-level control (attenuator)
4. Output selector(bone, right, left)
5. Interrupter switch
6. Switch & attenuator for masking noise

: 40 dB

: ,
,

,
15 dB

: teat the better ear first


, .
.

IV. Pure tone audiogram


o:

X:
: ,

: ,

< :
> :
[ : ,

V. Air conduction audiometry

1. ,
.
2. 1kHz 2, 4, 8kHz
3. 1kHz .
4. 500, 250, 125Hz .

1KHz 10dB
.

20dB 750Hz, 1.5, 3,


6kHz .

VI. Bone conduction audiometry

3
1. compressional bone conduction( )
: (compression) (expansion)


2. inertial bone conduction( )
:
3. osseotympanic bone conduction( )
:

bone vibrator turning fork

mastoid or forehead

1, 2, 4kHz, 500Hz, 250Hz .

VII. Interpreting the audiogram(I)

1. purpose
1) As aid to Dx. of the hearing impairment
2) As guide to rehebilitation

2. As aid to Dx.
1) pure conductive hearing loss
2) sensori-nerual hearing loss
3) mixed hearing loss

3. As guide to rehebilitation
1) estimate of the effect of the hearing loss on speech
2) hearing aid

VII. Interpreting the audiogram(II)



1.

2. (3 )
3 = (500Hz + 1kHz + 2kHz) / 3
4 = (500Hz + 1kHz + 2kHz + 3kHz) / 4
3.
4 = (500Hz + 21kHz + 2kHz) / 4
6 = (500Hz + 1kHz + 2kHz + 3kHz + 4kHz + 6kHz) / 6

VII. Interpreting the audiogram(III)


(Speech audiometry)
the evaluation of the listener's ability to detect and recognize speech
- SDT (speech detection threshold),
:
:
: usually coincides with the PTA
- SRT (speech reception threshold),
: 50%
: spondee word . dB
: SDT 8-9 dB .
: PTA 5-6 dB , 12 dB
.

* MCL (most comfortable loudness level),


; (running speech)
; 5 dB
; SRT 30-40 dB
* UCL (uncomfortable loudness level, threshold of discomfort),
;
; SRT 75-90 dB
* DR ( dynamic range)
;
; UCL-SRT

- Speech discrimination or speech recognition,


: MCL


: . %
* SDS (speech discrimination score)
; PB word :
; PB word list 50 MCL

(%)

* Performance-intensity function curve


; SRT (10 dB or 20 dB)
(%, performance) (dB, intensity)

* PB Max
;
* Phonemic regression
; PTA
; ( )

* Roll-over
;

PB Max

; :
70-80%
.
; , , (cochlear) PB max
.

Masking
1. :
-

2.
1) broad-band white noise
2) speech spectrum noise
3) narrow-band/filtered white noise
3. cross-over
:
:

: cross hearing, shadow hearing


* shadow curve : cross hearing

4. Interaural attenuation : transmission loss of the signal ( , )


:
: (minimum IA) - headphone : 40 dB
insert earphone : 50 dB
bone vibrator : 0 dB
5. Occlusion effect ( )
:
,

: 250, 500Hz 15dB, 1000Hz 10dB .
2000Hz .

6.
1) PTA
(1) Air-conduction masking
- TE NTE air-conduction threshold MIA

- TE NTE A-B gap MIA
(2) Bone-conduction masking
- B/C MIA 0dB
- TE A-B gap 10dB
2) SA
: IA 45dB
(1) SRT
- TE SRT NTE SRT or PTA 45dB
- TE SRT NTE bone-conduction PTA 45dB
(2) (speech discrimination)
- TE NTE SRT or PTA 45dB
- TE NTE (500, 1000, 2000Hz)

7.
1)
(1) NTE + 10 dB (Hood, 1960)
(2) NTE + 15 dB (Goldstein and Newman, 1994)
* NTE
2)
: occlusion effect
3) Plateau method
* Undermasking
:
undermasking
:
* Overmasking
:
.

8. Masking dilemma
1)
IA overmasking


) NTE unmasked : 60 dB(Lt)
unmasked : 0 dB(Rt)
:
70dB .
2) Central masking
: cross-over NTE CNS

. ( superior olivary nucleus efferent fiber


afferent impulse


(Impedence audiometry)

Tympanometry
: estimation of intraympaic pressure,
eustachian tube function,
tympanic membrane integrity & mobility,
continuity of the ossicular chain
:
(-400-+200mmH20)

: tympanogram ; admittrance

1. A type : -100- +100mmH20


2. As type: A
,

, ,
3. Ad type: A
,

, (healed perforation)
4. B type: flat or dome shape
,
5. C type: -100mmH20

ear canal volume : 0.5-1.0 ml in children, 0.6-2.0 ml in adults

Stapedial reflex
: acoustic reflex threshold & acoustic reflex decay
: changes in tympanic mem. compliance caused by contraction of the stapedius m.
: useful for differentiation of cochlear & retrocochlear
: , ,
,
1. acoustic reflex threshold
: 500, 1000, 2000Hz 70-100dB HL( 82dB HL)
, compliance
1% 0.02cc .
-ipsilateral or contralateral stimulation

2. acoustic reflex decay test


: 500, 1000Hz 10dB 10

: 10 50% decay
: . 500Hz ,


(Otoacoustic Emission)
1.
:
,
: (outer hair cell)
(active apmlication process) (byproduct)

2.

* Gold(1946) : Cochlear feedback


: (cochlear) . (active) ,

(sharply tuned), (Nonlinear)

* Kemp(1978) : Cochlear echo
:

3.OAE
(1) (Spontaneous OAEs, SOAEs)
(2) (Evoked OAEs, EOAEs)
1) (Transient EOAEs, TEOAEs or TOAEs)
: tone bust click
2) (Distortion Product OAEs, DPOAEs)
:
3) (Stimulus Frequency OAEs, SFOAEs)
:


(Transient EOAEs, TEOAEs or TOAEs)
1)
: click tone burst, tone pip (transient)

2)
click : 80 dB pSPL(peak sound pressure level)
-
-
tone burst : duration

3)
80dB ,
100%


30-40dB HL
TEOAEs .
1-4kHz broad band noise
multipe narrow band peak .
peak 1-2kHz
.

4)
30dB
OHC
, ,

5) TEOAEs
91 Kansas symposium(ILO 88,92 )
-Echo responses 9dB( 5dB)
-reproducebility 50%
-probe stability 90%
*1. 5 3
3dB(5dB) S/N ratio
*2. reproducebility 50%


(Distortion Product OAEs, DPOAEs)
1)

: f1,f2


(generation site) OHC 3
3 (distortion product)
.
DPOAEs
2f1-f2 cubic distortion
product .
DPOAEs f1,f2
, (midfrequency) .

2)
,
.
L1 L2 0-15dB
f1/f2 1.21 .
DPOAEs 60dB SPL
30dB SPL .
3)DPOAEs
DP-gram
;
,
input-output
;

4)
DP-gram (noise floor) 3-5dB
input-output : noise floor dB
SPL .
5)
.
15dB 50dB
..
DPOAEs 0.5-8kHz .
1-4kHz
.

4.
(1) Screening Test
(2) monitoring
(3)
Malingering
SNHL
Meniere's disease: gycerol or urea test

(4)
(intraoperative monitoring)

5.

(1)
probe placement, fitting

(2)

(3)

data

(4)


V-T , OME

TEOAE /

A B R
(Auditory Brainstem Response)
* ABR ?
- ABR; 10 msec

- EP;evoked potencial :
; AEP, VEP, SEP

*
wave I : distal portion of the auditory nerve
wave II : proximal portion of the auditory nerve
wave III : cochlear nucleus
wave IV : superior olivary complex
wave V : lateral lemniscus termination in inferior colliculus

Threshold analysis
10 msec ABR
I, III, V . II, IV . V


I V
IV V V
IV V negative peak IV V

IV V shoulder
V IV shoulder
IV V negative peak


Latency(msec)
Amplitude( V)
I-III, III-V, I-V interpeak latency
, ,
.

* ABR

.
.
.

;click 1-4 KHz


.
.

* Clinical application

, ,
V (V )

: 5-10, 10-20dB .

: pure tone average(PTA's)=0.6 ABR threshold


(PTA's= 1KHz + 2KHz + 4KHz/3)


: amplitude latency ,
latency
->
: I latency , I-V latency .

V latency


( , ), , ,

latency

; Selters & Brackmass(1977)

1. V latency : 2.5 SD , 6.2 msec


2. V (interaural latency difference) 0.3 or 0.4 msec

3. I-V(I-III, III-V) (interpeak latency)


; I-V >4.4ms, or I-III, III-V 2+0.2 ms
4. (I-III, III-V)

+ ;

Selters & Brackmass(1977)

: 4000 Hz 50 dB 50 dB 10
dB
0.1 msec

Clinical Masking


Audiogram

(Air conduction
test)

Air Conduction test ,


(transducer)
- Headphone
- Insert phone
- Loud speaker

(Bone conduction
test)

Bone Conduction test,


: Bone vibrator

(shadow hearing) &


(Interaural
Attenuation)

(Masking)


( , shadow hearing or cross-over) .


(a)

IA
(b)

IA


(a) 0dB
(b) 10dB

(cross over)

Air conduction
Ossetympanic
Bone conduction

(cross hearing)

,

(crossover)
(cross hearing)
(shadow hearing)
.

(shadow curve)


Frequency
250

500

1000

2000

59, Liden et
al

45-75

50-70

45-70

45-75

67, Chaiklin

44-58

54-65

57-66

55-72

68, Cples et
al

50-80

45-80

40-80

45-75

73, Berrerr

48-54

52-61

57-66

62-64

73, Snyder

35-70

45-75

40-75

40-80

85, Killion et
al

45-65

52-65

52-65

50-68

50-68

52-74

87 Sklare et
al

45-60

45-75

60-65

45-70

45-70

60-75

40

40

40

45

94
Goldstein

3000

4000

6000

45-75
56-72

61-85

8000
45-80

56-76

51-69

50-85

40-85

50

40-80

50-80
50

ER-3A(with foam) insertphone


Frequency
250
62, Studebaker

500

1000

2000

14

12

14.5

3000

4000

6000

8000

10.5

62, Konig

28

25

24

18

22

28

83, Larson et
al

31

26

15

85, Killion et al

85100

90110

78-85

6085

6590

6595

87, Sklare et al

75100

85105

75-90

5590

5080

6085

90, Van Campen


et al

85-90

85-90

80-85

6580

17

13

6595

7585

7585

Air Conduction Masking

TE Threshold :

1. NTE AC Threshold >


IA
2. NTE BC Threshold >
IA

Bone Conduction Masking

1. MIA
Headphone : 40 dB
Insertphone : 50 dB
Bone vibrator : 0 dB
2. TE AC Threshold
BC Threshold
:
10(15)dB

Occulsion effect(barrel
effect)
Unoccluded ear
longwave-length low freq. Sounds

.
Occluded ear
longwave-length low freq. Sounds

.
Air-conduction transmission

Occlusion effect(OE),
: NTE mask

1kHz

Earphone
CHL OE .

. (occlusion effect)

Headphone, cushion
60 Huizing

Frequency
250

500

1000

13.0

15.0

8.0

63 Elpern et al

TDH-39, firm
rubber

28.0

20.0

9.0

65 Goldstein et
al

TDH-39, MX41/AR

19.4

12.6

5.7

66 Hodgson et
al

TDH-49, MX41/AR

22.0

19.0

7.0

67 Dirk et al

TDH-39, MX41/AR

23.7

19.3

7.5

73 Berrett

TDH-39, MX41/AR

19.0

17.7

9.0

83 Berger et
al

TDH-50, MX41/AR

20.3

21.6

7.5

15.0

15.0

10.0

85 Goldstein
et al

Air conduction Masking

Bone conduction Masking

(Plateau Method)

(plateau)

NTE TE




.

BC Masking

Worksheet (1000Hz)

Masked ear

vs Test ear
Response
30
NR
10
30
NR
15
30
NR
20
30
NR
25
30
R
30
35
NR
30
35
R
35
40
R
35
45
NR
35
45
NR
40
45
NR
45
45
R
50
50
R
50
55
R
50
60
R
50


1. (white noise)
2. (speech noise)
3. (narrow band noise)

(white noise)

Conductive Hearing loss

Sensorineural Hearing
loss

THE END