13

Hearing Threshold Estimation by Acoustic Reflex

Threshold (ART)

OVERVIEW
Acoustic reflexes are evoked by loud sounds. Researchers have studied the relationship between
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acoustic reflex thresholds and hearing thresholds and have proposed ways to use the former to predict
the latter. Though the resulting predictions are imperfect, they might be useful as a screening tool,
especially with patients unwilling or unable to cooperate in behavioral testing. Four methods will be
discussed here:
1. Broadband noise (BBN) acoustic reflex threshold (ART) screening
2. Sensitivity prediction by acoustic reflex (SPAR) and a SPAR shortcut
3. The 10th percentile table
4. ART at audible level rule

BBN SCREENING TOOL

Procedure
Start a BBN ART search at 60 dB SPL because BBN stimulates more hair cells and neurons than
puretones do, and thus BBN tend to evoke ART at lower intensity levels than seen with pure-tones.
Changes in the peak acoustic admittance equivalent to at least .02 cm3 likely indicate an acoustic
reflex. However, this threshold should be confirmed by establishing the response again at that same
intensity level or if possible by increasing 5 dB and seeing a growth of at least .02 cm 3. For safety we
recommend not exceeding presentation levels of 90 dB SPL.

Interpretation
A BBN ART at 85 dB SPL suggests three-frequency pure-tone average (PTA) 40, that is, no worse
than a mild PTA hearing loss. This screening tool has a sensitivity of 97% and specificity of 87%
(Keith, 1977).

SPAR
Sensitivity Prediction by Acoustic Reflexes (SPAR; Jerger, Burney, Mauldin, & Crump, 1974;
Niemeyer & Sesterhenn, 1974) is based on comparing the BBN ART to tone evoked ART at 500 Hz,
1000 Hz, and 2000 Hz. ART differences for BBN and tones have been documented for normally
hearing listeners and for listeners with various degrees of hearing loss; this allows hearing sensitivity
prediction.
Copyright 2017. Plural Publishing, Inc.

Procedure
Obtain the following ART and make the following calculations:
A. = 500 Hz ART in dB HL. Add 13 dB to convert to dB SPL
B. = 1000 Hz ART in dB HL. Add 7 dB to convert to dB SPL
C. = 2000 Hz ART in dB HL. Add 11 dB to convert to dB SPL
D. = (A + B + C) ÷ 3

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 E. = Lowest of A, B, and C
F. = BBN reflex threshold (no dB SPL conversion needed)
G. = D F
H. = A F
I. = E F
J. = (G + H + I) ÷ 3

SPAR Interpretation
• J 20 and BBN at any level, predicts WNL
• J 15 to 19 and BBN 80, predicts WNL
• J 15 to 19 and BBN >80, predicts mild-mod loss
• J 10 to 14 and BBN any level, predicts mild-mod loss
• J <10 and BBN 89, predicts severe loss
• J <10 and BBN >89, predicts profound loss
Example using the first author’s ART
A. = 95 dB HL + 13 = 108 dB SPL
B. = 85 dB HL + 7 = 92 dB SPL
C. = 95 dB HL + 11= 106 dB SPL
D. = (A+B+C)/3 = 102 dB SPL
E. = Lowest of A, B, and C = 92 dB SPL
F. = BBN reflex = 80 dB SPL
G. = D – F = 102 – 80 = 22
H. = A – F = 108 – 80 = 28
I. = E – F = 92 – 80 = 12
J. = (G+H+I) ÷ 3
= 22 + 28 + 12 ÷ 3
= 62 ÷ 3
= 20.67, which predicts normal hearing, no worse than a mild hearing loss in the 500- to 2000-Hz range

Spar Sensitivity (Jerger, Hayes, Anthony, & Mauldin, 1978)

• 100% of those predicted to have normal hearing sensitivity showed normal hearing sensitivity on their audiograms
(100% specificity).
• 85% of those predicted to have severe hearing loss showed severe hearing loss on their audiograms (85% sensitivity
for severe or greater loss).
• 54% of those predicted to have moderate hearing loss showed moderate hearing loss on their audiograms (54%
sensitivity for moderate loss).

MARTIN AND CLARK (2015) SPAR SHORTCUT

A. = 500 Hz ART converted from dB HL to dB SPL (add 13)
B. = 1000 Hz ART converted from dB HL to dB SPL (add 7)
C. = 2000 Hz ART converted from dB HL to dB SPL (add 11)
D. = BBN reflex
E. = (A+B+C) ÷ 3
F. E BBN ART

Interpretation (Martin & Clark, 2015, p. 378)

• Normal = “about 25 dB”
• Mild to moderate losses “show only a 10 to 20 dB difference”
• Moderately severe losses “show less than 10 dB difference”
• Severe losses “show no acoustic reflexes”

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 Example using the first author’s ART
A. = 95 dB HL + 13 = 108 dB SPL
B. = 85 dB HL + 7 = 92 dB SPL
C. = 95 dB HL + 11= 106 dB SPL
D. BBN reflex = 80 dB SPL
E. = (A+B+C) ÷ 3 = 102 dBS PL
F. 102 80 = 22 dB SPL which predicts normal hearing

THE 10TH PERCENTILE: ANOTHER USEFUL TOOL FOR PSEUDOHYPOACUSIS

The 10th percentile cutoffs in Table 13–1 (Gelfand, 2002, p. 228) shows the lowest ART that can be
accepted without suspicion for functional hearing loss. For example, a patient with a 500 Hz audiogram
threshold of 80 dB HL would have inner hair cell damage and thus would be unlikely to have an ART
less than 100 dB HL. Lower intensity ART for this patient would be inconsistent with inner hair cell
damage, suggesting the 80-dB HL audiogram threshold to be invalid.

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 Table 13–1. The Lowest Acoustic Reflex Thresholds that Can Be Accepted Without Suspicion for Functional Hearing
Loss (Gelfand, 2002, p. 228)

ART AT INAUDIBLE LEVELS

As shown in Table 13–1, acoustic reflex thresholds are unlikely to be obtained at very low dB SL.
Extending the concept, acoustic reflex thresholds cannot be obtained at inaudible levels. Therefore, if
ARTs are measured below audiogram thresholds, pseudohypoacusis is likely.

REFERENCES
Gelfand, S. A. (2002). The acoustic reflex. In J. Katz (Ed.), Handbook of clinical audiology (6th ed., pp. 205–232).
Baltimore, MD: Lippincott Williams & Wilkins.
Jerger, J., Burney, P., Mauldin, L., & Crump, B. (1974). Predicting hearing loss from the acoustic reflex. Journal of
Speech and Hearing Disorders, 39, 1122. http://dx.doi.org/10.1044/jshd.3901.11
Jerger, J. F., Hayes, D., Anthony, L., & Mauldin, L. (1978). Factors influencing prediction of hearing levels from the
acoustic reflex. Monographs in Contemporary Audiology, 1, 120.

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 Keith, R. W. (1977). An evaluation of predicting hearing loss from acoustic reflex. Archives of Otolaryngology, 103(7).
419424. http://dx.doi.org/10.1001/archotol.1977.00780240077012
Martin, F. N. (1994). Introduction to audiology (5th ed.). Boston, MA: Allyn & Bacon.
Martin, F. N., & Clark, J. G. (2015). Introduction to audiology (12th ed.). Boston, MA: Pearson.
Niemeyer, W., & Sesterhenn, G. (1974). Calculating the hearing threshold from the stapedius reflex threshold for
different sound stimuli. Audiology, 13(5), 421427. http://dx.doi.org/10.3109/00206097409071701

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