ASSESSMENT OF HEARING

CHOYTOO Shiksha
ENT
29.02.16
SSR Medical ollege, Mauritius
AUDIOMETRIC TESTS (condt.)

• Bekesy audiometry
• Impedance audiometry
 BEKESY AUDIOMETRY
• Self recording audiometry

• various pure tones frequencies automatically

move from low to high while the patient control
the intensity through a button

• Two tracings are obtained- one with continuous

tone and the other with pulsed tone

• Helps to differentiate
– Cochlear from retrocochlear HL
– Organic from functional HL
• Various types of tracings are obtained
– Type I: normal hearing or CHL
– Type II: cochlear loss
– Type III: retrocochlear or neural lesion
– Type IV: retrocochlear or neural lesion
– Type V: non organic hearing loss

• Seldom performed these days

 IMPEDANCE AUDIOMETRY

• Widely used test

• Consists of
– Tympanomety
– Acoustic reflex measurement
 TYMPANOMETRY
• Of all the sounds that strikes the TM, some sound energy is
absorbed while others are reflected.

• Stiff tympanic membrane will reflect more sound energy

that compliant one

• By changing the pressure in EAC, and then measuring the

reflected sound energy, it is possible to find out the degree
of compliance or stiffness of the Tympanossicular system

• Thus we can get an idea about the health status of middle

ear

• Tympanometry has also been used to find the fx of ET in

cases of intact or perforated TM
Type A Normal tympanogram
Type As Compliance is lower at ambient pressure
-otosclerosis , malleus fixation

Type AD Compliance is high at ambient pressure

-ossicular discontinuity or thin and lax
TM

Type B No change in compliance at ambient

pressure.
- Fluid in middle ear or thick TM
membrane

Type C Maximum compliance at negative

pressure
- Retracted TM or some fluid in middle
ear
 ACOUSTIC REFLEX MEASUREMENTS
• Based on the fact that a loud sound 70-100dB
above the threshold of hearing of a particular
ear causes bilateral contraction of the
stapedial muscles which can be detected on
tympanogram

• Tone can be delivered to one ear and the

reflex can be picked from same or
contralateral ear.
• Useful in several ways:

– Test hearing in infants and young child (objective

method)
– To find malingerers (feigns total deafness and does
not give any response to pure tone audiometry
but shows positive stapedial reflex)
– Detect VIII th nerve lesions
– Detect facial nerve lesions
– Detect brainstem lesions
SPECIAL TESTS FOR HEARING
• Recruitment
• SISI test
• Evoked response audiometry
• Auditory steady state response
• Otoacoustic emissions
• Central auditory tests
 RECRUITMENT
• Phenomenon of abnormal growth of loudness

• Ear which does not hear low intensity sound begin to hear
greater intensity sound as loud

• Patient with recruitment – poor candidate for hearing loss

• Recruitment is seen in cochlear lesions

• Helps to differentiate a cochlear from retrocochlear

sensorineural hearing loss

• Alternate binaural balance loudness test-detect

recruitment in unilateral cases
SHORT INCREMENT SENSITIVITY INDEX
(SISI)
• Patients with cochlear lesions distinguish smaller
changes in intensity of pure tone better that normal
person and those with conductive or retrocochlear
pathology

• In this test, continuous tone is presented 20dB above

the threshold and sustained for about 2 min

• Every 5s, tone is increased by 1 dB and 20 such blings

are presented

• Patient indicates the bling heard

• SISI scores:

– CHL 15 %
– Cochlear deafness 70-100%
– Nerve deafness 0-20 %
 THRESHOLD TONE DECAY TEST
• Measure of nerve fatigue

• Use to detect retrocochlear lesions

• Normally, a person can hear a tone continuously for

60s

• In nerve fatigue, the person stops hearing earlier

• The result of the test is expressed as number of dB of

decay

• A decay of > 25 dB :diagnostic of retrocochlear lesion

 EVOKED RESPONSE AUDIOMETRY
• Objective test

• Measure electrical activity in the auditory

pathways in response to auditory stimuli

• Requires special equipment with an averaging

computer

• Two components of evoked electric response

have gained clinical acceptance
– Electrocochleography
– Auditory brainstem response
 ELECTROCOCHLEOGRAPHY
• Measures electrical potentials arising in the cochlea
and CN VIII th nerve in response to auditory stimuli
within first 5ms

• Response is in the form of 3 phenomenon

– Cochlear microphonics
– Summating potentials
– AP of CN VIII th nerve

• Recording electrode- thin needle passed through TM

onto the promontory

• Done under LA in adults ( apprehensive person and

children – GA)
• It is useful to
– Find threshold of hearing in young infants and
children within 5-10 dB
– To differentiate lesion of cochlear to that of CN VIII
th nerve

• Ratio between the amplitude of summating

potential to the AP is less than 30%

• Increase in ratio – indicative of Ménière’s

disease
 AUDITORY BRAINSTEM RESPONSE
• Also known as BERA ( brainstem evoked response
audiometry)

• Elicit brainstem responses to auditory stimulation

by clicks or tone bursts

• Non invasive technique to find integrity of central

auditory pathways through the VIIIth nerve,
pons, and midbrain

• Measures the hearing sensitivity in the range of

1KHz – 4KHz
• Normal person- 7 waves are produced in the
first 10ms

• First, third and fifth waves are most stable and

are used in measurement

• The waves are studied for absolute latency,

interwave latency ( wave I and V) and the
amplitude
• Use for:

– Screening procedure for infants

– Determine threshold of hearing in infants
(uncooperative)
– Diagnose retrocochlear pathology particularly in
acoustic neuroma
– Diagnose brainstem pathology
– To monitor CN VIII intraoperatively in surgery of
acoustic neuromas to preserve the function of
cochlear nerve
 AUDITORY STEADY STATE RESPONSE
(ASSR)
• Electrophysiological test which uses steady state pure tone
signals ( instead of transient signal of tone bursts in ABR)

• Steady state signals are modulated rapidly in amplitude and

frequency and thus give a frequency specific audiogram

• Detect hearing losses > 80 dB

• Detect hearing sensitivity in severe to profoundly deaf

infants

• Helps in selection of children for cochlear implantation at

an early age
 OTOACOUSTIC EMISSIONS (OAE)
• Low intensity sounds produced by outer hair cells of a
normal cochlear

• Elicited by very sensitive microphone placed in external ear

canal and analysed by a computer

• Sound produced by outer ear travel in reverse direction:

outer hair cells-basilar membrane-perilymph- oval window-
ossicles- TM-ear canal

• help to detect fx of cochlear (OAEs produce only when

outer hair cells are healthy)

• Do not disappear in VIII th nerve pathology

 Types of
OAEs

Evoked Spontaneous
Two tones are OAEs OAEs
simultaneously
presented to the
cochlear to produce Present in healthy
distortion products. Transient normal persons
Used to test hearing where hearing loss
in the range 1-8 KHz evoked OAEs do not exceed 30dB.
A series of click They are absent in
stimuli are 50% normal persons
presented at Distorted
80-85 dB SPL Product OAEs
and response
are recorded
• Uses:
– Screening test of hearing in neonates,
uncooperative, and mentally challenged person
after sedation

– Distinguish cochlear from retrocochlear hearing

loss, OAEs are absent in cochlear lesions. They
detect ototoxic effects earlier than pure tone
audiometry

– Useful to diagnosed retrocochlear pathology

 CENTRAL AUDITORY TEST
• Patients with central auditory disorders have
difficulty to hear in noisy environments, or
when speech is distorted and not clearly
spoken

• 3 types of speech discrimination tests;

– Monotic test
– Dichotic test
– Binaural test
• Monotic test: test for lesions of brain and cortex

• Dichotic test; test for temporal lobe lesions

• Binaural tests: identify integration of information

from both ears

• Not routinely used

THANK YOU