Audiogram interpretation.
Symbols on the audiogram show air-conduction and bone-conduction thresholds for
each key frequency. Different audiogram symbols are used to distinguish between airconduction and bone-conduction measurements for each ear.
Vowels are low frequency sounds with a higher volume than consonants, which are
soft, high frequency sounds. Vowels carry the loudness impression of speech and the
consonants carry the meaning, e.g. house versus mouse.
Masking During Hearing Testing
Masking means that one puts in some "noise" in the opposite ear while testing an ear.
The reason to do this is to prevent sound from the side being tested from going over
to the good side This is called the "cross-over problem". See the illustration below for
an example of the cross-over problem.
When to do masking -
Bone conduction testing in persons with hearing loss should be done with
masking to prevent sound from the stimulated side from going over to the good
side.
Air conduction testing should be done when there is a 40 db or greater
threshold.
Method of masking
If one is doing pure-tone testing, the masking signal should be narrow band noise
centered on the test frequency. If one is doing speech, one should use speech noise.
Masking is not always needed. When doing air conduction audiograms, this cross-over
problem occurs to a different extent depending on the earphone being used.
Earphones that go around the ear run into cross-over problems when the sound is
about 40 db or louder. Earphones that go into the ear (inserts) have problems at about
60 db. Thus if the ears are both normal, masking is not needed. One should
always mask air conduction if there is a 40db or greater threshold.
For bone conduction testing, the sound always goes to both ears, and one cannot test
one ear by itself (usually) without using masking. The best strategy therefore, for
bone conduction testing, is to always mask.
Example of situation where masking is necessary for correct results.
When masking is not used is that one may incorrectly conclude that there is better
hearing in a "bad" ear, than is really the case, because without masking, some of the
sound is actually appreciated by the good ear.
This person is completely deaf
on the right side. However,
because masking was not used,
the bone lines (top) make it
appear that they could have
normal hearing.
This is the same person as above, tested this time with masking. Here it is
clear that the patient cannot hear on the right side. This is the correct
result.
Masking Dilemma
This situation occurs when there is a conductive type hearing loss in both ears, which
is moderate to severe. The dilemma is that an adequate intensity to mask the nontest ear crosses over to the testing ear and invalidates the thresholds.
Enough masking is too much masking. There are several "work arounds" to this. When
one is masking air conduction, if one can (i.e. no perforation) use insert earphones.
Other methods include using bone-ABR testing, ABR is unaffected by the central effect
of masking but the sound still stimulates both ears and also one is limited by one's
bone stimulator. Another method is the SAL (sensorineural acuity level) technique. In
the SAL method, both ears are masked equally through an oscillator placed over the
forehead. This is done by performing air conduction thresholds while using bone
masking, and then doing some adjustments for the "air conduction shift". This method
involves a large number of subtractions of noisy values, and for this reason seems (to
us) to be an intrinsically unreliable (and unwieldy) method.
The bottom line is that when one encounters the "masking dilemma", usually this is
simply noted on the audiogram and one accepts that it is impossible to determine the
details of the hearing loss.
Brainstem auditory evoked responses (ABR), also known as auditory brainstem
evoked response (ABR), test both the ear and the brain. They measure the timing of
electrical waves from the brainstem in response to clicks or tone bursts in the ear.
Computer averaging over time to filters background noise to generate an averaged
response of the auditory pathway to an auditory stimulus Three waves (1, 3 and 5) are
plotted for each ear. The waveform represents specific anatomical points along the
auditory neural pathway: the cochlear nerve and nuclei (waves I and II), superior
olivary nucleus (wave III), lateral lemniscus (wave IV), and inferior colliculi (wave V).
Delays of one side relative to the other suggests a lesion in the 8th cranial nerve
between the ear and brainstem or the brainstem itself
