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Medicine Decoded

Showing posts with label ENT. Show all posts

Friday, March 20, 2009

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30 challenging Questions in ENT

Labels: ENT, MCQs

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1. Which are the three most common organisms causing acute sinusitis ?
2. What are Ducts of Rivinus ?

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3. Whartons duct?
4. What is the most probable diagnosis when the findings are as follows : erythematous aryepiglottic folds, grey granulation tissue in the interarytenoid region and posterior
thirds of vocal cords, ulcers in the posterior thirds of vocal cords ?


5. What is the deformity seen in post mandibulectomy patients called as ?

6. Which anti-microbial drug should not be given in Infectious mononucleosis ?

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7. What is your first diagnosis is an elderly male who comes with progressively worsening stridor of 3 months duration ?
8. A 3 yr old boy comes with the complaint of foul smelling sero sanguinous discharge from one nostril. What is your first diagnosis ?
9. In which condition is steeple sign seen ?
10. Expand Gd-DTPA.


11. What is ELSA ?

Anatomy pearls (2)

12. What is Dorello's canal ?

13. What is the part of the tuning fork that we place on the mastoid called ?
14. Which is the causative organism of acute epiglottitis ?
15. Which ear drops will you prescribe for a person with right ear TM rupture due to trauma ?
16. What is the most common cause for intraoperative bleeding in adenoidectomy ?
17. Which is the most feared complication during removal of a foreign body from the nose of a child ?
18. What is the procedure of choice for severe air hunger in supine position in a man with supraglottic growth ?
19. "cobblestone" esophagus seen in?
20. What is the lateral rhinotomy incision also known as ?
21. What are the temperatures of water used in the Bithermal test for vestibular function ?
22. Romberg's test positive signifies _______ disorder or _________ disorder.
23. What is chondrodermatitis chronicus pinna also known as ?
24. Collar stud abscess seen in?

clinical image (7)

clinical skills (7)
Downloads (7)
ecg made easy (6)
ENT (12)
Ever wondered why (1)
Gyn-Obs (3)

25. Cork screw esophagus seen in?

just4fun (2)

26. What is Woolnerian tip?

27. The Cody tack operation is used in the treatment of?
28. Wullsteins classification?

MCQs (8)

29. Blainville ears?

medical high yield facts (24)

30. Submandibular space infection is known as?

medical podcasts (1)

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microbiology high yield facts (2)

1. Pneumococcus, H.influenzae, Moraxella catarrhalis

2. Minor ducts of the sublingual salivary gland .Some directly open into oral cavity& some unite to form major duct of Bartholin.
3. Submandibular gland duct
4. Laryngeal findings in pachyderma laryngis.

Mnemonic for today (1)

neurology (4)
ophthalmology (10)
pathology (3)
pediatrics (6)
pharmacology (2)
Radiology (6)
skin (6)
surgery pearls (7)
Videos (5)

5. Andy Gump deformity .This anatomic defect results from resection of the anterior mandibular arch without adequate reconstruction.

Website Links (7)

6. Ampicillin (can cause rash)

7. Laryngeal Cancer.
8. Foreign body Nose
9. Acute laryngotracheobronchitis .(check this post for all other signs in ENT)
10. Gadolinium Diethylene Triamine Pentaacetic Acid (It is a type of contrast agent.A substance used in magnetic resonance imaging (MRI) to help make clear pictures of the
brain, spine, heart, soft tissue of joints, and inside bones. )
11. Endoscopic Ligation of Sphenopalatine Artery .Endoscopic ligation of the sphenopalatine artery (ESPL) has recently become the treatment of choice for refractory epistaxis.
12. Abducent nerve canal .
13. Footpiece (not base)
14. Hemophilus influenzae type B
15. Don't give any ear drops
16. Adenoid tags
17. Aspiration into airway
18. Cricothyrotomy
19. Moniliasis.In the diagnosis of Candida esophagitis, double contrast esophagography shows a sensitivity of about 90% , demonstrating discrete plaque-like filling defects
which have a finely nodular and granular, distinctive cobblestone or snakeskin-like appearance and correspond to the distinctive white plaques seen at endoscopy.

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These plaques consist of heaped-up areas of necrotic epithelial debris or actual colonies of C.
albicans on the esophageal mucosa; the esophagus per se has an irregular or shaggy appearance .
20. Moure incision. The incision is started from the inner extremity of the eyebrow, descending along the lateral wall of the nose over the naso labial fold. It is curved up to the
alar margin. The classic Moure's incision should not extend into the vestibule of the nose. The advantage of this incision is that it can be extended above and below to
facilitate better exposure of midface, anterior skull base and orbit. The incision heals with minimal scarring.

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21. 30 C and 44 C
22. Vestibular or Posterior column
23. Also known as Winkler's disease . Chondrodermatitis nodularis chronicis helicis is an painful, inflammatory nodule of the external ear. nonwhites have been noted
occasionally to have lesions in areas other than the helix, such as the antihelix or antitragus. The lesions are believed by several researchers to relate to trauma or sun
damage. The nodules are more commonly reported on the right ear, which is believed to be the preferred resting side during sleep.
24. TB lymphadenitis.Cervical lymphadenopathy is also termed scrofula, meaning glandular swelling in Latin. The nodes coalesce, break down and perforate the deep fascia,
resulting in the characteristic collar-stud abscess, which this case resembles.
25. Diffuse esophageal spasm.
26. Darwin's tubercle is a congenital ear condition which often presents as a thickening on the helix at the junction of the upper and middle thirds.However Darwin himself
named it the Woolnerian tip, after Thomas Woolner, a British sculptor who had depicted it in one of his sculptures and had first theorised that it was an atavistic feature.

27. Menieres disease

28. Classification is
Type 1

ossicular chain intact, only ear drum is

repaired.Myringoplasty is synonymous with
tympanoplasty type 1

Type 2

Graft placed on incus or remnant of malleus

Type 3

INCUS & MALLEUS absent & the grafted drum is

placed in contact with the HEAD of STAPES (

Type 4

refers to the baffle effect of a tympanic membrane

protecting the round window, while leaving open the
mobile stapes footplate of the oval window

Type 5

fenestration of the lateral semicircular membrane in

the presence of a fixed footplate and an intact
tympanic membrane.


Asymmetry in size or shape of the auricles.


Ludwigs angina

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Tuesday, March 3, 2009

Fistula test, Hennebert sign & Tullio Phenomenon .

Labels: ENT

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Fistula test or Perilymphatic fistula test : The fistula test is performed by applying positive and negative pressure to the intact eardrum using a pneumatic
otoscope or by pressing tragus.
Used to detect Perilymph fistula.

Perilymphatic Fistula)


when positive pressure is

when positive pressure is applied
applied with the pneumatic with the pneumatic otoscope
Onset of Nystagmus towards
ipsilateral ear.

No changes noted.

when negative pressure is when positive pressure is applied

applied with the pneumatic with the pneumatic otoscope
Nystagmus also reverses &
changes its direction towards
contralateral ear.

No changes noted.

The type of nystagmus seen can be deducted from the picture below.

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Ok first let me try to explain you the figure given above.

First lets take a normal person as an example ,in him when,
This will be the direction of slow phase of
nystagmus in ear with fistula

SCC which is stimulated

right horizontal semicircular canal is stimulated

it causes movement of both eyes towards the

opposite(left) side.

right posterior semicircular canal is stimulated

it causes downward movement of both eyes as

well as intorsion of right eye& extorsion of left eye.

right anterior semicircular canal is stimulated

it causes upward movement of both eyes as well

as intorsion of right eye& extorsion of left eye.

Now lets come to left vestibular system

left horizontal semicircular canal is stimulated

it causes movement of both eyes towards the

opposite(right) side.

left posterior semicircular canal is stimulated

it causes downward movement of both eyes as

well as intorsion of left eye& extorsion of right eye.

left anterior semicircular canal is stimulated

it causes upward movement of both eyes as well

as intorsion of left eye& extorsion of right eye.

So, if there is fistula in right ear,then

if fistula on right horizontal SCC(that means
when positive pressure is applied, the right
horizontal SCC will get stimulated)

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when positive pressure applied via pneumatic

otoscope causes slow component of nystagmus
towards opposite ear .
As per convention direction of nystagmus is
towards fast component, therefore we say that

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nystagmus is towards ipsilateral ear.

if fistula on right posterior SCC

when positive pressure is applied to right ear, then

according to the diagram we see that it will cause
nystagmus with slow component towards
downside& intorsion of eyeball.
As per convention direction of nystagmus is
towards fast component, therefore we say that the
nystagmus is upbeating& extorion type.

Perilymphatic fistula:
A perilymph fistula (PLF) is an abnormal opening between the air-filled middle ear and the fluid-filled inner ear. It may occur due to a defect in one of three locations:
Oval Window (most common site)
Stapedectomy surgery (for otosclerosis)
Head trauma or barotrauma (pressure injury)
Acoustic trauma
Round window Barotrauma -- SCUBA diving, airplane pressurization
Congenital malformations (such as Mondini dysplasia)
Otic capsule-Another possible location for a fistula is in the bone of the ear (the otic capsule). This is a rare condition where the bone between the ear and brain area is missing or
thin, causing symptoms very similar to that of a round or oval window fistula. Problems in the otic capsule that may cause a perilymph fistula include:
Superior canal dehiscence syndrome (anterior SCC)
Fenestration -Another type of bony fistula can occur after a surgical procedure called fenestration previously done for otosclerosis;
Temporal bone fracture
The most common type of otic capsule fistula is located just above the superior semicircular canal and is called the superior canal dehiscence syndrome.

False positive fistula

test(Hennebert sign)

False negative fistula test

Congenital syphilis
(here stapes footplate is hypermobile, so even
small pressure changes in ear, cause excessive
movement of stapes footplate & excessive
stimulation of utricular macule)

In Dead ear ( inner ear is damaged), there will

be NO response even if a Perilymphatic fistula

25% cases of Meneires disease.

(here in 25% cases of menieres ,fibrous bands
form connecting to utricular macule to stapes

Also seen when cholesteatoma covers the site

of fistula & doesnt allow pressure changes to be
transmits to labyrinth.


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It is a false positive fistula test i.e, when there is no evidence of middle ear disease causing fistula of horizontal semicircular canal.
It is seen in 25% cases of meniere's disease or congenital syphilis.
Hennebert sign- pressure induced nystagmus &
Hennebert symptom- pressure induced dizziness.

Tullios phenomenon:
Sound-induced vestibular symptoms such as vertigo, nystagmus, oscillopsia, and postural imbalance .
Tullio's phenomenon is seen mainly in:
Superior canal dehiscence,
Meniere's syndrome,
other causes of perilymph fistula,
post fenestration surgery(for otosclerosis).

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Friday, February 27, 2009

Onodi cell & Haller cell

Labels: ENT

Onodi cell(sphenoethomoid cell):

This is formed by lateral and posterior pneumatization of the most posterior ethmoid cells over the sphenoid sinus.
Because the Onodi cells are posterior ethmoid cells that are positioned superolateral to the sphenoid sinus ,the optic nerve & carotid artery may often course through
the lateral aspect of onodi cell instead of sphenoid sinus proper.
Kainz and Stammberger defined an Onodi cell as a posterior ethmoid cell with an endoscopically visible bulge of the optic canal.

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The vulnerability of the optic nerve with or without the presence of an Onodi cell is further compounded by the thin lamina papyracea in the posterior ethmoid area .
This anatomic variation is found in 8-14% of cases according to studies using CT in association with recent developments in endoscopic sinus surgery.
The presence of Onodi cells increases the chance that the optic nerve and/or carotid artery would be exposed (or nearly exposed) in the pneumatized cell.
The optic nerve, and more rarely, the internal carotid artery, may be exposed within or lie immediately adjacent to such an air cell.
During endoscopic sinus surgery attempts to localise the sphenoidal sinus via instrumentation through the posterior most ethmoidal air cells can lead to
optic nerve, and even, internal carotid artery, injury.

Haller cell (infraorbital cell or infraorbital extension of ethmoid cell):

The Haller cell is usually situated below the orbit in the roof of the maxillary sinus.(i.e., in the orbital floor).

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It occurs in 10% of people.

It is a pneumatized ethmoid cell that projects along the medial roof of the maxillary sinus.
As it is closely related to ethmoidal infundibulum enlarged Haller cells may contribute to narrowing of the ethmoidal infundibulum and recurrent sinus


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Thursday, February 12, 2009

Eponymous Signs in ENT

Labels: ENT
Below are the compilation of all the eponymous signs in ENT from all over the net.Read & enjoy..

AQUINO'S SIGN is the blanching of the tympanic mass with gentle pressure on the carotid artery.Seen in Glomus tumors .
BATTLE SIGN- Bruising behind ear at mastoid region, due to petrous temporal bone fracture (middle fossa #)


Inflammatory edema at the tip of the mastoid process in
BOCCAS SIGN - Absence of post cricoid crackle(Muirs crackle) in Ca post cricoid
Refers to the blanching noted when applying positive pressure{with Siege's speculum} to the tympanic membrane of a patient with Glomus tumor.

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BRYCE SIGN - If combined laryngocele & external laryngocele is presenting as a neck mass, compression will cause a hissing sound as the air escapes from it into the
larynx. This test is fraught with danger in cases of combined laryngoceles because air from the external component may get forced into the internal component causing acute
airway obstruction.
Lateral sinus thrombosis on CT or MRI with contrast shows an empty triangle appearance of the thrombosed sinus surrounded by contrast enhanced dura{since contrast may

flow around the clot to outline the periphery of the sinus}. It is also called as empty triangle sign.

DODDS SIGN/CRESCENT SIGN- X-ray finding-Crescent of air between the mass and posterior pharyngeal wall. positive in AC ployp Negative in Angiofibroma
FURSTENBERG'S SIGN-Positive in Encephaloceles.Owing to the intracranial connection, there is pulsation and expansion of the mass with crying, straining, or compression of
the jugular vein (Furstenberg test).This is used to differentiate Nasal Encephaloceles from other congenital midline nasal masses like Nasal Gliomas.
GRIESINGER'S SIGN-Erythema and oedema posterior to the mastoid process resulting from septic thrombosis of the mastoid emissary vein. seen in lateral sinus thrombosis
HALO SIGN/ HANDKERCHIEF SIGN - A finding in CSF rhinorrhea when CSF is mixed with Blood.
In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult.
CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign.
CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo.
Blood alone does not produce a ring.
The best ring is obtained with a 50: 50 mix of blood and CSF.
More importantly, they found that the presence of a ring was not exclusive for CSF.
Blood mixed with tap water, saline, and rhinorrhea fluid also produced a ring.
The halo sign does occur, but clearly does not clinch the diagnosis.

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HITSELBERGERS SIGN - In Acoustic neuroma- loss of sensation in the postero-superior part of external auditory meatus supplied by Arnolds nerve( branch of Vagus nerve to
ear )
HOLMAN MILLER SIGN, ANTRAL SIGNThe anterior bowing of the posterior wall of the antrum seen on lateral skull film .Pathognomic for juvenile nasopharyngeal angiofibroma.

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HONDOUSA SIGNX-ray finding in Angiofibroma.

indicating infratemporal fossa involvement characterised by widening of gap between ramus of mandible and maxillary body.
It is a false positive fistula test when there is no evidence of middle ear disease causing fistula of horizontal semicircular canal. It is seen in 25% cases of meniere's disease or
congenital syphilis.In 25% cases of Meneires ,fibrous bands form connecting utricular macule to stapes footplate. In syphilis due to hypermobile stapes footplate.[Hennebert signpressure induced nystagmus, Hennebert symptom- pressure induced dizziness]
IRWIN MOORES SIGN positive squeeze test in chronic tonsillitis.
LAUGIER'S SIGN-Blood behind the eardrum suggests basilar skull fracture.
LEUDET'S SIGN-Inflammation of the eustachian tube can produce a bright clicking sound heard by the examiner through the otoscope while the patient experiences it as
tinnitus.caused by reflex spasm of the tensor palati muscle.
LIGHT HOUSE SIGNA small pin hole perforation with a pulsatile ear discharge is seen in Acute suppurative otitis media.
LYRES SIGN - splaying of carotid vessels( at junction of External & internal carotid artery) in carotid body tumor.

MILIANS EAR SIGN- Erysipelas can spread to pinna(cuticular affection), where as cellulitis cannot.
Cellulitis and erysipelas manifest as areas of skin erythema, edema and warmth in the absence of underlying suppurative foci.
They differ in that erysipelas involves the upper dermis and superficial lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat.
As a result, erysipelas has more distinctive anatomic features than cellulitis; erysipelas lesions are raised above the level of surrounding skin, and there is a clear line of
demarcation between involved and uninvolved tissue.
Classic descriptions of erysipelas note "butterfly" involvement of the face.
Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas since this region does not contain deeper dermis tissue.

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Paul Dudley White's winking ear lobe sign-Movement of the ear lobe coincident with the pulse suggests tricuspid insufficiency.
PHELPS SIGN - loss of crest of bone (as seen in CT-scan) between carotid canal and jugular canal in glomus jugulare.
RAT TAIL SIGN /Bird-beak sign-Sign in barium swallow of achalasia. The oesophagus is dilated, and contrast material passes slowly into the stomach as the sphincter
opens intermittently. The distal oesophagus has a narrow segment and the image resembles a bird's beak.

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This is in contrast to the rat's tail appearance of carcinoma of oesophagus.Barium swallow shows characteristic rat tail appearance with irregular mucosa margins in
carcinoma esophagus.
There is red vascular hue seen behind the intact tympanic membrane. it is seen in glomus tumour, high jugular bulb and aberant carotid artery in the floor of middle ear.
RACCOON SIGN-Indicate subgaleal hemorrhage,and not necessarly base of skull .
It is also called flamingo flush sign. it is seen because of increased vascularity in submucous layer of promontory in active phase of otosclerosis(otospongiosis).
STEEPLE SIGN- X-ray finding in Acute laryngotracheobronchitis (CROUP).The steeple sign is produced by the presence of edema in the trachea, which results in elevation of
the tracheal mucosa and loss of the normal shouldering (lateral convexities) of the air column.

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STANKIEWICKS SIGN - indicate orbital injury during FESS. fat protrude in to nasal cavity on compression of eye ball from outside .
Seen in Orbital floor fracture. It is defined as tear drop shaped opacification seen hanging from the roof of the maxillary sinus on water's view. The floor of the orbit is the most
common portion of the orbit to sustain fracture. A classic radiographic finding in blow-out fractures is the presence of a polypoid mass (the tear-drop) protruding from the floor of the
orbit into the maxillary antrum The tear-drop represents the herniated orbital contents, periorbital fat and inferior rectus muscle.

It is a thumb like impression (due to enlarged epiglottis) seen on X-ray lateral view neck in patients with acute epiglottitis.Direct visualization of the epiglottis by laryngoscope, if
attempted, reveals a beefy red, edematous epiglottis.

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In acute otitis externa there is marked tenderness when tragus is pressed against the pinna.
TEA POT SIGN is seen in CSF rhinorrhoea.This could be related to the relationship of the sphenoid ostium to the sinus floor. The sphenoid ostium lies at an appreciable distance
anterosupe-rior from the sinus floor. An increase in the CSF rhinorrhea therefore occurs in a case of sphenoid sinus leak when the patient bends forward as an increasing amount of
CSF gains access to the ostium "teapot" sign.

uvula pointing sign - uvula points to side of palatal palsy

Uvula pointing sign- seen in rhinoscleroma .when scleroma involve nasopharynx ,uvula point towards roof of nasopharynx.
WOODS SIGN palpable jugulodigastric lymphnodes.


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Bezold eponyms in ENT

Labels: ENT
1. Bezold's triad

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1. Diminished perception of the deeper tones,

2. retarded bone conduction, and
3. negative Rinne's test,
pointing, in the absence of objective signs, to otosclerosis
2. Bezold's abscess
abscess deep in the neck parapharyngeal space associated with suppuration in the mastoid cells
3. Bezold's sign / symptom
Inflammatory edema at the tip of the mastoid process in mastoiditis
4. Bezold's ganglion
An aggregation of nerve cells in the interatrial septum
5. Bezold's mastoiditis
Mastoiditis with perforation medially into the digastric groove and forming a deep neck abscess
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Wednesday, January 21, 2009

Delphian node
Labels: ENT
A midline prelaryngeal (cricotyhroid) lymph node.

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Receives lymphtic drainage from larynx & thyroid gland.

Can be enlarged in thyroid carcinoma or advanced larygeal cancer.
This node gets its name from Greek mythology. The Oracle of Delphi, called Pythria, was a Priestess who would answer questions posed to her, never concealing nor
revealing the truth. Thus, an enlarged Delphian node may, or may not, indicate the presence of thyroid cancer.
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Sunday, January 11, 2009

Lines of Dolan and the elephants of Rogers

Labels: ENT
What are the lines of Dolan?
They are three anatomic contours best seen on the Waters view (occipitomental view )of the face, and they were first popularized by Dolan et al.
As you can see, the 3 lines of Dolan lead the eye along some facially important structures.
Lee Rogers pointed out that the 2nd and 3rd lines together form the profile of an elephant.

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ZMC fractures = Zygomaticomaxillary complex fractures or Tripod fractures

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Thursday, August 21, 2008

Assessment of Hearing
Labels: ENT
In this post we will deal with the techniques followed to assess auditory function
we should be able to know theses 4 things after doing the tests:

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type of hearing loss:

degree of hearing loss
Degree of hearing loss

hearing loss range(dB)

Not significant






Moderately severe





more than 91dB

site of lesion

Tests for hearing:

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These 3 tests are non-specific & they don't indicate the type of deafness.they only give a rough idea about the hearing loss.
Finger friction test

rubbing or snapping thumb & finger

close to patients ear

Watch test

clicking watch brought near the

patients ear

Speech test

patient stands with his test ear towards

examiner at distance of 6metres.

Tuning fork tests:remember these ,its very important

512Hz tuning fork is ideal(forks of lower frequency - produce sense of bone vibration forks of higher frequency- shorter decay time )
When we test air conduction ,we actually check the functioning of both conductive & sensorineural(cochlea)
When we test Bone conduction ,we actually measure only cochlear function
Normally hearing through air conduction is louder & heard twice as long as through bone conduction route(AC better than BC)

Rinne test:
method:To perform this test, a 512Hz vibrating tuning fork is placed on the mastoid bone and then moved next to the external ear. The patient indicates at which of the two sites
the sound is louder.
principle:Sound transmitted through an external ear traverses the middle ear and is perceived by the cochlea (inner ear). Sound can

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be transmitted directly to the cochlea, skipping the external and middle ear, by placing the vibrating tuning fork on the mastoid bone
directly behind the ear. This is the basis for the Rinne hearing test.




SN deafness

(Rinne +)

(Rinne -)


rinne (-)ve

256Hz fork

512Hz fork

1024Hz fork

air-bone gap




False negative Rinne :

in Severe Unilateral sensorineural hearing loss.
Patient does not perceive sound by air conduction ,but responds to bone conduction
response to bone conduction is because the patient perceives sound from opposite ear because of transcranial transmission of sound.
corrected by :masking opposite ear with Barany's noise box ,so that transcranial transmission of sound is not perceived.
note:A Barany noise box can also be used to see noise based vertigo (Tullio phenomenon). This commercially available box simply
makes a loud (100 dB) noise. When the box is slowly moved towards the patient's symptomatic ear, the vertiginous symptoms may be

Weber test:
method:Place the tuning fork in the center of the forehead and the physician asks the patient where he or she hears it.
The occlusion effect is responsible for this phenomenon. Sound conducted through bone causes the
cochlea, the ossicular chain, and the air in the external auditory canal to vibrate. Some lower frequency
sound, as produced by the 512 Hz tuning fork, escapes from the canal. When the ear is occluded, these
frequencies cannot escape and the sound seems to become louder.
it is the occlusion effect, rather than elimination of environmental sound, that is responsible for the improved bone conduction
threshold when occluding a normal ear.
Middle ear effusion and ossicular chain disruptions cause a "mass loaded" middle ear, with lowering of the inherent resonant frequency.
Ossicular chain fixation causes a phase shift in the sound wave. Both cause preferential transmission of lower frequencies to the




SN deafness

not lateralised

lateralised to
poorer ear

lateralised to
better ear

note:lateralisation of sound in Weber test with a tuning fork of 512Hz implies either
conductive loss of 15-20dB in ipsilateral ear (or)
sensorineural deafness in contralateral ear

Absolute bone conduction test(ABC) test:


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patients bone conduction compared to that of examiner(presuming that examiner has normal hearing)by keeping on mastoid.
External auditory meatus of both patient & examiner is occluded by pressing tragus inwards ,this is to prevent external ambient noise entering through air
conduction route.
ABC test


SN deafness

hear the fork for hear the fork

same duration for same
as examiner
duration as


Schwabach test:
method:same as ABC test,but meatus is not occluded.




SN deafness


lengthened in reduced
patient(due to
absence of
ambient noise
the patient
hears it for
longer time)

Bing test::
determine whether closing of ear canal results in occlusion effect.
The Bing test can simulate unilateral (one-sided) conductive hearing loss results by placing a finger in one ear while performing the Weber test.
method:tuning fork placed on mastoid while examiner alternately closes & opens ear canal by pressing tragus inwards.
principle:same principle as Weber test(occlusion effect)

Bing test



SN deafness


no effect
(bing negative)


Gelle's test:
method:A vibrating tuning fork is applied over the mastoid process; if it is heard, the air in the external auditory canal is compressed, by means of a Siegle's

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a test of the mobility of the ossicles.

when air pressure is increased in ear canal, it pushes tympanic membrane inside & leading to increased stiffness of the ossicular chain & thus decreases
And when pressure is again released ,it again normalises.
Gelle's test

SN deafness

decreased in does not alter

intensity after

decreased in
intensity after

Audiometric tests:
Pure tone audiometry:
used to measure the auditory threshold of an individual
pure tone-a single frequency sound is used while testing ,audiometer-an electronic device which produces pure tones.
Audiometer: There are two types of audiometers widely used. They are:
1. Those that require a subjective response on the part of the patient and
2. Those that require no subjective response from the patient.
Examples include:
1. Pure tone audiometer is the classic example of the first type
2. Impedence audiometer / BERA (Brainstem Auditory Evoked Responses audiometer) are examples of the second type.
The frequencies generated are 125, 250, 500,750, 1000, 1500, 2000, 3000, 4000, 6000 and 8000 Hz.
Intensity is the level of sound power measured in decibels; loudness is the perceptual correlate of intensity.
Frequency is cycles per unit of time. Pitch is the perceptual correlate of frequency. Frequency is measured in hertz, which are cycles per second.
Usually frequencies of 250-8000 Hz are used in testing because this range represents most of the speech spectrum, although the human ear can detect
frequencies from 20-20,000 Hz.
The hearing level (HL) is quantified relative to "normal" hearing in decibels (dB), with higher numbers of dB indicating worse hearing. The dB score is not really percent
loss, but neverthless 100 dB hearing loss is nearly equivalent to complete deafness for that particular frequency. A score of 0 is normal. It is possible to have scores
less than 0, which indicate better than average hearing.
note:In a normal PTA audiogram we see that both AC(air conduction) & BC(bone conduction) are at the same 0dB level.But we know that AC is better than BC.So you

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note:In a normal PTA audiogram we see that both AC(air conduction) & BC(bone conduction) are at the same 0dB level.But we know that AC is better than BC.So you
may get a doubt how come they are same here.Actually In a clinic a calibrated audiometer is used to present the correct intensity for each tone such that 'normal
hearing' registers as 0 dB HL (audiometric zero) .This is done for the ease of reading the audiogram report.& standardisation
0 dB Hearing Level at 1000 Hz = 7 dB SPL
Pure tone air conduction testing:
This is a measurement of air conduction thresholds of audibility.
Pure tone air conduction threshold is tested using head phones:
note:when establishing threshold ,2 choices are ascending & descending way to change intensity.
ascending(Hughson - Westlake ascending technique)- begins with stimuli that are below patient's threshold & intensity is
increased until patient responds.
descending- stimuli presented first are above patient's threshold & intensity is decreased until the patient no longer
but both have drawbacks=
in descending technique the patient might continue to respond to stimuli ,when he no longer perceives (false +
in ascending technique the patient may fail to respond even when stimuli are audible.(false - response)
Modified Hughson - Westlake technique :this procedure uses an ascending technique to determine threshold .but each threshold search is preceeded by a
descending familiarization trial.
ex:"Up 5-down 10" method of threshold estimation
1. The better ear is tested first in order to determine the need for masking.
2. Start with a 1000 Hz tone at a level above the threshold to allow easy identification of the tone. This tone is selected because it is an important speech frequency, and
the patient is less apt to mistake the frequency. To ensure the subject is familiar with the task, present a tone of 1000 Hz that is clearly audible (e.g. at 40 dB
HL for a normally hearing subject or approximately 30 dB above the estimated threshold for a subject with a hearing impairment,)
3. If the patient is suspected to be having a profound hearing loss then the testing should be started with 250Hz frequency. This is because of the fact that the individuals with
profound hearing loss often have testable hearing only in the low frequency range.
4. Next, test 2000, 4000, 8000, 500 and 250 Hz in that order
5. As the threshold levels are being reached, a check should be made for the existance of abnormal tone decay. This is done by sustaining the tone for several seconds longer
than usual. If the index finger drops before the tone is discontinued, abnormal tone decay should be suspected.
6. "Up 5-down 10" method =The starting intensity of the test tone is reduced in 10 dB steps following each positive response, until a hearing threshold level is reached at
which the subject fails to respond. Then, the tone is raised by 5 dB, if the subject hears this increment, the tone is reduced by 10 dB; if the tone is not heard then ti is raised
by another 5 dB increment. This 5 dB increment is always used if the preceding tone is not heard, and a 10 dB decrement is always used when the sound is heard. The
threshold is defined as the faintest tone that can be heard 50% or more of the time, and is established after several threshold crossings.

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Testing of the second ear should begin with the last frequency used to test the first ear. There is no need to start again with a 1000 Hz tone because if one side of the
heard has learned the listening task, the other side knows it as well. The test is terminated after all desired frequencies have been examined.

Bone conduction audiometry:

This is an important measurement of hearing threshold using a bone vibrator. This helps to differentiate conductive from sensorineural hearing loss. The equipment necessary is
just a bone vibrator connected to the audiometer. The bone vibrator is placed over the mastoid process of the side to be tested. The auditory threshold is assessed as described
for air conduction assessment. The only difference is that the better hearing ear should be masked using a masking tone delivered via a head phone.
Limitations of bone vibrators
1. Bone vibrators tend to emit more sound than vibration at frequencies above 2000 Hz If testing at 3000 and 4000 Hz it is preferable to
insert an ear plug (eg E.A.R. plug as used for hearing protection purposes) into the test ear canal or cover the test ear with a supra-aural
earphone. This attenuates the air borne radiation from the bone vibrator to a satisfactory degree. Failure to occlude the ear canal
at high test frequencies is likely to lead to inaccurately acute bone conduction thresholds, resulting in a false air-bone gap in the
audiometric results. The canal must not be occluded at test frequencies below 3000 Hz since this may produce the occlusion effect in which
bone conduction thresholds are improved.
2. Testing is not recommended at frequencies below 500 Hz because the subjects threshold may relate to hearing at the second or third
harmonic rather than the fundamental.
3. In bone conduction audiometry high frequencies cannot be used for testing. Frequencies above 4000 Hz cannot be used because they are beyond the
vibrating capabilities of the bone vibrator.

Masking presents a constant noise to the nontest ear to prevent crossover from the test ear. The purpose of masking is to prevent the nontest ear from detecting
the signal (line busy), so only the test ear can respond.
When a signal is presented to the test ear, the signal may also travel through the head and reach the cochlea on the other side. However the intensity of the signal from
the test to the nontest ear can be reduced by the mass of the head. This signal reduction is called interaural attenuation.(transcranial transmission loss)
For bone conduction, the interaural attenuation may be as low as 0 dB because the bones of the skull are very efficient at transmitting sound. Thus, any
suspected difference in bone conduction between the test and nontest ears requires masking. (ie,Masking is done in all Bone conduction studies)
Crossover occurs when sound presented to the test ear travels across the head to the nontest ear. This occurs at approximately 40 dB for circumaural earphones
across all frequencies.Interaural attenuation for air conduction can range between 40 and 80 dB. Masking should be used if the difference in air conduction in
one ear and bone conduction in the other ear is 40 dB or greater.(ie,masking required when there is difference b/w the 2 ears of minimum 40dB in air conduction
threshold )
When the difference in the thresholds of the two ears is greater than the transcranial transmission loss, cross-hearing may occur and the apparent threshold of the
worse ear is in fact a shadow of the better ear.
Narrow band masking noise is used

red indicates right ear
blue indicates left ear.

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eg: high-frequency sensorineural hearing loss in the right ear.

Audiogram depicting a mild rising conductive hearing loss in the left ear:

The 3 types of hearing loss can be differentiated as follows:

Conductive hearing loss has normal bone-conduction thresholds, but air-conduction thresholds are poorer than normal by at least 10 dB.
Sensorineural hearing loss has bone- and air-conduction thresholds within 10 dB of each other, and thresholds are higher than 25 dB HL.
Mixed hearing loss has conductive and sensorineural components.Pure-tone air-conduction thresholds are poorer than bone-conduction thresholds by more than 10
dB, and bone-conduction thresholds are less than 25 dB

Speech audiometry:

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test patient's ability to hear & understand speech is measured.

different parameters are measured like:
(a)speech recognition threshold :Speech reception threshold:or Spondee threshold
minimum intensity at which 50% of words repeated correctly by patient.
Spondee words are used.Spondees are two syllable words with equal accent (emphasis) on each syllable. Baseball, northwest, oatmeal and hotdog are
examples of spondees.
The term speech recognition threshold is synonymous with speech reception threshold. Speech recognition threshold is the preferred term because it more
accurately describes the listener's task.
SRT should be within 10dB of PTA.(since SRT encompasses far more frequencies than PTA , SRT is less than PTA )
If the SRT is significantly better than the PTA, the possibility of pseudohypoacusis(patient is not co-operating properly) should be considered

note:P ure tone av erage( P T A) =av erage of pure tone thres hold of 3 s eparate f requencies ( 500 ,1000 ,2000H z) as meas ured by pure tone audiometry .

(b)Speech detection threshold:

Speech-awareness threshold (SAT) is also known as speech-detection threshold (SDT).
The objective of this measurement is to obtain the lowest level at which speech can be detected at least half the time. This test does not have patients repeat
words; it requires patients to merely indicate when speech stimuli are present.
Speech materials usually used to determine this measurement are spondees
note:SRT differs from SDT in that SDT is merely the level at which the individual becomes aware that speech is present & SRT is level at which speech is loud
enough for the individual to understand it.
(c)speech recognition score :
Speech discrimination score or word recognition score(when words used) or sentence recognition score(when sentences used)
the lowest intensity speech stimulus that an individual can detect at least 50% of the time.
discrimination means judging two things whether they are same or not ,but this is not done in this test .theref ore the term "speech discrimination score' not used now.

here patient doesn't repeat words ,just a measure of patient's ability to understand speech.
here Phonetically balanced words(PB) used=single syllable words=pin,bus
phonetically balanced means that the distribution of phonetic elements in list of words approximates the distribution found in everyday conversations.
list of 50 words given & then the number of correctly heard words multiplied by 2 to get score.
done at supra-threshold level i.e, at 30-40dB above SRT.
in normal people & those with conductive deafness have a high score of 90-100%.

within normal range


slight difficulty


moderate difficulty


poor discrimination


very poor

PB max: performance intensity function for PB words.

here PB scores are taken against several levels of speech intensity at 30-40dB above SRT(suprathreshold level) & maximum score (PB max) is obtained & also note the
intensity at which it is obtained.
this is used clinically to set volume of hearing aid.
Rollover phenomenon:

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defined as the decay of the speech discrimination score (greater than 20% change) with increased stimulus intensity,
When present, this finding is indicative of a retrocochlear lesion
When the ear with a damaged nervous system is stimulated with a very loud sound, the nerves may be unable to handle the increased signal load. Consider this
analogy. If you injured your arm, you might be able to lift a small weight, but would be unable to lift a heavy weight. Similarly, the damaged VIII nerve may be able to
transmit a conversational level speech signal, but tire out when faced with the demand of sending strong, sustained messages.
Impedence audiometry:::Acoustic immittance.Immittance is a term derived from the terms for two inversely related processes for assessing middle ear function, impedance
and admittance. Impedance is the resistance to the flow of acoustic energy. Admittance is the ease of which acoustic energy can flow. A middle ear with low impedence (high
admittance) more readily accepts acoustic energy, whereas a middle ear with high impedence (low admittance) tends to reflect energy consists of 1. tympanometry
2. acoustic reflex measurements
The primary purpose of impedence audiometry is to determine the status of the tympanic membrane and the middle ear.
The secondary purpose of this investigation is to evaluate the acoustic reflex pathway which include the 7th and 8th cranial nerves and the brain stem.

when a sound strikes tympanic membrane ,some of the sound energy is absorbed while rest is reflected.A stiffer membrane would reflect more sound energy than a
compliant (loose) one.
so by changing the pressure in a sealed external ear canal & then measuring the reflected sound energy ,we measure the compliance or stiffness of tympano-ossicular
system & thus find the healthy or diseased status of middle ear.
The maximum compliance occurs when the pressure of the external auditory canal and the middle ear becomes equal.
Only at this pressure maximal acoustic transmission occur through the middle ear & minimum sound energy is reflected back.

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A tympanogram is a graphic representation of the relationship of external auditory canal air pressure to impedance
Pressure in the external auditory canal is varied from -200 daPa(decaPascal=mmH2O) through +200daPa while monitoring impedance
The Jerger system is the most commonly used classification system for tympanograms

Type A. The peak compliance occurs at or near atmospheric pressure indicating normal pressure in the middle ear. There are three subgroups. Compliance peak is 150 to +100 daPa
A - normal shape reflects a normal mechanism .immittance is 0.2-2.5 millimhos(unit of conductance)
AD - A deep curve with a tall peak indicates an abnormally compliant middle ear, as seen in ossicular dislocation or erosion, or loss of elastic fibers in
the tympanic membrane. immittance is less than 0.2 mmhos
AS - A shallow curve indicates a stiff system, as in otosclerosis. immittance is more than 2.5 mmhos

Type B - No sharp peak, with little or no variation in impedance over a wide range, usually secondary to non-compressible fluid in the middle ear (otitis media), tympanic
membrane perforation or obstructing cerumen.

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This Type B curve must always be interpreted in conjunction with the ear canal volume. Average ear canal volume in children ranges between 0.42 - 0.97 ml,
while in adults it ranges between 0.63 - 1.46 ml.
1. Type B curve with normal ear canal volume suggests otitis media.
2. Type B curve with small canal volume suggests that the ear canal could be occluded by the presence of wax, or the probe of the impedance
audiometer has not been properly placed.
3. Type B curve with large canal volume suggests that there could be perforation of the ear drum. (so middle ear volume is added up to volume of
ear canal)
Type C - Peak compliance is significantly below zero, indicating negative pressure (sub-atmospheric) in the middle ear space. This finding is often indicative
eustachian tube dysfunction. compliance peak is less than -150 daPa
Testing for the presence of absence of perilymph fistula:
Testing implies presence or absence of a fistula (ie, an abnormal opening in the inner ear labyrinthine system).
This can be indirectly assessed by the presence of intense giddiness along with nystagmus when the external canal pressure in increased by increasing the probe
pressure. This sign is also known as the Hennebert's sign. This sign is manifested only in the presence of perilymph fistula.
Testing function of eustachian tube:
A negative or positive air pressure is created (-200 to +200) in middle ear & person is asked to swallow 5 times in 20 sec.
the ability to equate the pressure indicates normal tubal function.
also used to test patency of grommet placed in tympanic membrane in cases of serous otitis media.
Physical volume of ear canal:(Equivalent ear canal volume)Includes the volume between

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probe tip(of impedence audiometer) & tympanic membrane ,if tympanic membrane is intact. (or)
volume of ear canal & middle ear space if tympanic membrane is perforated.
it is derived from acoustic admittance of volume of air medial to probe.
Under reference conditions ,a given volume of air has a known acoustic admittance, which can be used to calculate the equivalent volume of air.
eg;when a 226Hz probe tone is used ,1cubic cm of air has admittance of 1acoustic mmho under standard atmospheric conditions.
so, if admittance of air b/w probe & tympanic membrane is 1.5 acoustic mmho ,then equivalent volume is 1.5 cubic cm.
Average ear canal volumes for children are 0.42-0.97 mL. Average adult volumes are 0.63-1.46 mL.
Used in case of Type B tympanograms(flat) to know the cause:
Type B curve with normal ear canal volume suggests otitis media.
Type B curve with small canal volume suggests that the ear canal could be occluded by the
presence of wax, or the probe of the impedance audiometer has not been properly placed.
Type B curve with large canal volume suggests that there could be perforation of the ear drum.
(so middle ear volume is added up to volume of ear canal)
Static compliance:
Measure of middle ear mobility.
it is measures in equivalent volume in cc's, based on 2 volume measurements.
C1= made with tympanic membrane in position of poor compliance with +200 mmH2O in external canal.
C2= made with tympanic membrane at max compliance
C1-C2= Static compliance, which cancels out the compliance due to column of air in external canal.the remainder is compliance due to middle ear mechanisms.
static compliance is low when value is less than 0.28cc & high when more than 2.5cc

its major contribution is to differentiate b/w fixed middle ear & middle ear discontinuity.
Acoustic reflex:

Contraction of the stapedius muscle occurs with loud sounds, producing a measurable change in compliance.
When the stapedius muscle contracts in response to a loud sound, that contraction changes the middle ear immittance. This change in immittance can be detected as
a deflection in the recording.
A significant change in middle ear immittance immediately after the stimulus is considered an acoustic reflex.
A stapedial muscle contraction in response to an intense signal occurs bilaterally in normal ears with either unilateral or bilateral stimulation. This reaction occurs
because the stapedial reflex pathway has both ipsilateral and contralateral projections

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we should first know a few basic terminology used here,

the immittance change caused by stapedius muscle contraction is measured in the ear containing the probe tip --this is PROBE EAR.
the ear receiving the stimulus to activate the reflex is --STIMULUS EAR.
either ear can be stimulus ear --i.e, the stimulus can even originate from the probe tip as well as from the ear phone on the opposite ear.
Absent reflex means even 125dB of sound doesn't elicit contralateral reflex.
Elevated reflex : the patient's threshold is compared to respective 90th percentiles that apply to his hearing threshold for the frequencies tested.If ART falls
above the 90th percentile it is considered elevated.
Ipsilateral or uncrossed acoustic reflex: here the stimulus is presented to the probe ear ,which is the same ear in which immitance change is measured.
Contralateral or crossed acoustic reflex: here the reflex is measured in the ear with probe tip ,but stimulus is given to opposite ear.

"right contralateral acoustic reflex" means stimulus is in right ear & probe in left ear.

"left contralateral acoustic reflex" means stimulus is in left ear & probe in right ear.
Probe ear principle:acoustic reflexes are usually absent when there is conductive pathology in probe ear.
stimulus ear principle: a conductive disorder in the stimulus ear reduces the stimulus level reaching the
cochlea by the amount of air-bone gap,As a result ART is elevated by the amount of air-bone gap.
2 basic acoustic reflex tests:
1. acoustic reflex threshold(ART)--lowest stimulus which produces reflex
2. acoustic reflex decay--measure of how long reflex lasts when stimulus is kept for a period of time

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Acoustic reflex thresholds generally are determined in response to stimuli of 500, 1000, 2000, and 4000 Hz. For screening purposes, or for a general check of the
pathway's integrity, usually test at 1000 Hz.
Range of ART :loud sound 70-100dB above threshold of hearing of that particular ear is used
The greater the hearing loss, the higher the acoustic reflex threshold for conductive hearing loss.
For sensorineural hearing loss, acoustic reflex thresholds may be within the normal range, particularly for mild-to-moderate hearing losses with
Absent(means even 125dB of sound doesn't elicit contralateral reflex) in:

1. Reflexes usually are absent or cannot be recorded if the patient has type B tympanograms; therefore, acoustic reflexes generally are not tested in these ears.

For example,
if the ear canal is occluded with cerumen, a type B tympanogram with low volume will be recorded. In this case, acoustic reflexes cannot be measured because middle
ear immittance is not being measured. (Cerumen blocks the signal.)
For a type B tympanogram with normal volume (as in otitis media) no pressure peak for immittance is obtained. The pressure between the ear canal and middle ear are
not equilibrated, and acoustic reflexes cannot be recorded.
For a type B tympanogram with high volume (as in the presence of patent pressure equalization tubes or perforated tympanic membranes), an open exchange of air
occurs between the ear canal and middle ear; thus, any contraction of the stapedius muscle cannot be measured.
2. In the presence of severe-to-profound sensorineural hearing loss in the stimulated ear, acoustic reflexes may be absent secondary to insufficient stimulation.
3. Similarly, a conductive component may attenuate the signal intensity, preventing sufficient stimulation in the stimulated ear or precluding a clear response in the recording
Typical patterns for the interpretation of acoustic reflex abnormalities are as follows:
With unilateral conductive deafness:

In the given image ,right contralateral reflex absent or elevated (due to probe principle)
but left ear ipsilateral absent (due to both probe ear & stimulus ear principles)

So in ipsilateral both principles are operative (ie,stimulus is attenuated due to conductive disorder & even immitance
change cannot be measured due to conductive disorder)

Due to this double effect ipsilateral acoustic reflex are so sensitive to conductive disorder.

Bilateral conductive disorder:

both contra & ipsilateral reflexes absent in both ears.

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Acoustic reflex decay test (adaptation):

it is measure of how long the response lasts if stimulus is kept on for a period of time.
The acoustic reflex decay test is used to assess the integrity of CN VIII. Using a stimulus of either 500 or 1000 Hz, a
contralateral continuous tone is presented for 10 seconds at a stimulus level 10 dB above the acoustic reflex
threshold for that stimulus frequency in that ear. This suprathreshold acoustic reflex then is recorded over the 10-second stimulation period. If the amplitude of the
recorded deflection on the screen decreases by 50% or more within 10 seconds, the test is considered positive.
In some cases of muscular or neuromuscular disorder, tone decay results also may be positive secondary to muscle fatigue.
along with ART (absent or elevated),acoustic reflex decay is used to detect retro-cochlear disorder
useful in:
test hearing in infants & young children - since it is objective test
find malingers- a person who feigns total deafness & doesn't give any response on PTA ,but shows +ve stapedial reflex is malingerer.
detect cochlear pathology - presence of stapedial reflex at lower intensities like 40 -60 dB than usual 70dB indicates recruitment & thus cochlear type hearing loss
lesions of facial nerve- absence of reflex when hearing is normal indicates lesion of facial nerve proximal to nerve to stapedius.
lesion of VIIIth nerve- Acoustic reflex decay test
lesion in brain stem:ipsilateral reflex present but contralateral absent indicates lesion is in crossed pathways in brain.

Bekesy audiometry:A subject-controlled auditory threshold testing procedure.method:

the patient has to press a button
the button controls a motor ,which in turn controls attenuator & a pen.
patient is told to hold button down when he can hear a tone & release it when he cannot.
holding the button causes the intensity to fall & releasing to rise.intensity change 2.5dB/sec
this course of events will cause the level of of tone to rise & fall around the patient's threshold.
the pen tracks the level of of tone on a paper resulting in zigzag pattern around the patient's threshold.
the width of the zigzags is EXCURSION WIDTH & the patient's threshold is midpoint of these thresholds.
Conventional Bekesy audiometry:

Bekesy audiograms are obtained either

one frequency at a time(fixed frequency Bekesy audiometry):one frequency for a given period of time.
test frequency changes from low to high.(sweep frequency Bekesy audiometry):test tone increases smoothly from 100 to 10,000Hz at rate of 1 octave/sec
Each Bekesy audiogram is obtained twice
once with a continuous tone (CONTINUOUS TRACING)
other with a tone that pulses on & off 2.5 times/sec(PULSED TRACING)

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Types of tracing:the shifting of tracing is result of tone decay.

continuous tracing -(C)
p u lse d tra c in g - (P)
types pattern

seen in

(C) &(P)

normal hearing &

conductive hearing loss.


continuous cochlear loss

& pulsed
overlap up
to 1000Hz
& then (C)
tracing falls
by an
that is less
than 20dB
of (C)
up to even
3-5dB wide


(C) tracing retrocochlear lesion

falls below
(P) at 100
to 500Hz
,even up to
& even up

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(C) falls
retrocochlear lesion
below (P)
up to
1000Hz by
more than
25dB but
not to

(C) above

non -organic hearing


Modifications of Bekesy audiometry:

Reverse Bekesy tracings:
Here the sweep of the (C) tracing is from high to low frequency & compared with (P) tracing from low to high.
advantage is that the patients with sensorineural loss as a result of retrocochlear pathological condition in the region of brain stem had more hearing loss with
this procedure.
Bekesy comfort loudness test:
Patients are instructed to respond to suprathreshold stimuli rather than threshold stimuli.(at a comfortable loudness rather than too loud or too soft)
reason:retrocochlear disorders initially appear at suprathreshold levels.

We will discuss about the "special tests for hearing assessment" in the next post.

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