12

Acoustic Reflex Evaluation for Site of Lesion

WHAT IS A REFLEX?
A reflex is an involuntary action or movement. We have hundreds of reflexes in our bodies. Examples
include the pupillary light reflex involving cranial nerve II and III, the patellar reflex involving the
femoral nerve, and the acoustic reflex involving cranial nerves VII and VIII.
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The Acoustic Reflex

The acoustic reflex arc is bilateral; a loud sound to one ear evokes a stapedial contraction bilaterally.
When the stapedial muscles contract, the result is a momentary reduction in middle ear peak
admittance, which we measure with our equipment.

Acoustic Reflex Pathway

• outer, middle, inner ear on stimulated side
• VIII nerve on stimulated side
• ventral cochlear nucleus on stimulated side
• superior olivary complex and motor nuclei of VII nerves bilaterally
• VII nerves bilaterally
• stapedial branches of the VII nerve bilaterally
• stapedial muscles bilaterally

ACOUSTIC REFLEX TEST CONDITIONS

Acoustic reflex measures are made in four test conditions. Table 12–1 shows those conditions,
including the presentation ear (which receives the tone), the measurement ear (in which the reflex is
measured), and anatomical sites involved.

THE ACOUSTIC REFLEX THRESHOLD (ART)

The measure referred to above is the ART, which is the lowest intensity level that will evoke a reflex.
For tone stimuli, ART is measured from 70 to 100 dBHL for 500 Hz to 4000 Hz pure-tones in normally
hearing individuals (Newman & Sandridge, 2007).
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 Table 12–1. Acoustic Reflex Threshold Test Conditions, Presentation and Measurement Ears, and Anatomical Sites
Involved

THE ART MEASUREMENT

Instructions
Instruct the patient regarding the purpose of the task, what they will hear, and that they need not
respond but instead should remain quiet and still. Assure patients that the tones will not be loud enough
to cause damage.

Procedure
Use an ascending threshold search approach to avoid discomfort; start at 70 dBHL or 80 dBHL. Watch
for signs of patient discomfort and consider omitting the procedure altogether for tinnitus evaluations
or when hyperacusis is reported. Present one-second duration tones with 3- to 5-second rest periods
between tone presentations. Changes in the peak acoustic admittance equivalent to at least .02 cm 3
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 cm3. For safety we recommend not exceeding presentation levels of 105 dB HL.

Test Frequencies
We measure ART at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. We do not test 250 Hz, as
low-frequency tones might interact with the Y226 Hz measurement probe tone, giving inaccurate
results. Higher frequencies are omitted because many people without disorder nonetheless have
abnormal high-frequency acoustic reflex thresholds.

INTERPRETATION: SEVEN RULES

Rule 1: Normal
Acoustic reflex thresholds in patients with normal hearing and normal middle ear function will occur between 70 and
100 dBHL.
—Newman and Sandridge, 2007, page 115
Note. They will also be at >60 dB SL

Rule 2: Conductive Disorder

. . . the probe ear principle states that acoustic reflexes are usually absent when there is a conductive pathology in the
probe ear. In this case, the conductive pathology prevents us from being able to monitor changes in acoustic

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 immittance at the probe tip (even though the stapedial muscle may be contracting).
—Gelfand, 2009, page 198

Rule 3: Conductive Disorder

. . . the stimulus ear principle states that a conductive disorder in the stimulus ear reduces the stimulus level reaching
the cochlea by the amount of the air-bone gap. As a result the ART is elevated by the amount of the air-bone gap and
will be absent if it is elevated beyond the maximum available stimulus level.
—Gelfand, 2009, page 198

Rule 4: Cochlear Pathology

. . . the acoustic reflex is elicited at sensation levels of less than 60 dB[SL] in ears with cochlear lesions . . . there is a
90% likelihood of observing the acoustic reflex as long as the cochlear hearing loss is less than 60 dB[HL]. As the
cochlear loss increases above 60 dB[HL], chances of observing the reflex decreases.
—Northern, Gabbard and Kinder, 1985, page 482
Same rule, different authors:
Mild cochlear hearing loss has little effect on acoustic reflex thresholds. In contrast, reflexes probably will be absent
when audiometric thresholds exceed 80 dBHL. When the cochlear hearing loss is <80 dBHL, acoustic reflex
thresholds may be present but at reduced sensation levels.
—Newman and Sandridge, 2007, page 115

Rule 5: VIII Nerve Pathology

When stimulating an ear with VIII nerve pathology, The presence of acoustic reflexes in eighth nerve disorders is the
exception rather than the rule as shown by many authors . . .
—Northern et al., 1985, page 484

Rule 6: VII Nerve Pathology

Acoustic reflexes are abnormal or absent when the probe is placed in the ear with facial nerve paralysis. Acoustic
reflex responses are obtained only if the site of lesion is central to the innervation of the stapes muscle.
—Newman and Sandridge, 2007, page 116
Same rule with more precise site of lesion evaluation:
If the acoustic reflex is present at normal [levels], the localization of pathology is likely distal to the stapedius branch
of the nerve. If reflexes are absent [or] present but elevated, the disorder is likely proximal to the nerve.
—Northern et al., 1985, page 485

Rule 7: Intra-Axial (Brainstem) Pathology

The absence of contralateral acoustic reflexes, with ipsilateral acoustic reflexes intact, may be seen in patients with . . .
brainstem pathology . . . in the area of the crossed brainstem pathways while the uncrossed pathways remain intact.
—Northern et al., 1985, page 485

Clinician Cheat Sheet

• Conductive hearing losses cause elevated or absent reflexes.
• Outer hair cell disorder results in reflexes at normal dB HL but low dB SL.
• Inner hair cell disorder causes elevated or absent reflexes.
• VII, VIII, and low to mid-brainstem disorder causes elevated or absent reflexes.

ACOUSTIC REFLEX TRACE ANOMALIES (GELFAND, 2002)

• Opposite phase at onset and offset: possible stapes fixation “. . . attributed to elasticity changes in the stapes and
annular ligament that are associated with the partial fixation of the footplate at the oval window” (page 209).
• Opposite phase at onset only: associated with a momentary decoupling of the interface between stapes and cochlea
fluids
• During ipsilateral testing, constructive or destructive interference of probe and stimuli tones in the ear canal can cause
artificially enhanced or diminished reflex traces.

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 ACOUSTIC REFLEX DECAY (ADAPTATION)
This supra reflex-threshold test is used to measure the magnitude of the acoustic reflex over time, thus
allowing the audiologists to assess adaptation, the inability of VIII nerve neurons to recover after firing.
Adaptation can be affected (lengthened) by VII or VIII nerve pathology.

Procedure
Test at 500 Hz and 1000 Hz if possible; the test can only safely be conducted if an ART was measured
at 95 dB HL or less. Test contralaterally if possible, if not attempt ipsilaterally testing (Martin & Clark,
2015). Present a tone for 10 seconds at 10 dB above the previously measured ART. Monitor acoustic
reflex amplitude.

Interpretation
Retrocochlear pathology is suspected if the reflex decays in magnitude by 50% at either test frequency
within 10 seconds. Sensitivity increases if decay occurs in 5 seconds or less.

REFERENCES
Gelfand, S. A. (2002). The acoustic reflex. In J. Katz (Ed.), Handbook of clinical audiology (5th ed., pp. 205221).
Baltimore, MD: Lippincott Williams & Wilkins.
Gelfand, S. A. (2009). The acoustic reflex. In J. Katz (Ed.), Handbook of clinical audiology (5th ed., pp. 189221).
Baltimore, MD: Lippincott Williams & Wilkins.
Martin, F. N., & Clark, J. G. (2015). Introduction to audiology (12th ed.). Boston, MA: Pearson.
Newman, C. W., & Sandridge, S. A. (2007). Diagnostic audiology. In G. B. Hughes & M. L. Pensak (Eds.), Clinical
otology (3rd ed., pp. 109120). New York, NY: Thieme.
Northern, J. L., Gabbard, S. A., & Kinder, D. L. (1985). The acoustic reflex. In J. Katz (Ed.), Handbook of clinical
audiology (3rd ed. pp. 476495). Baltimore, MD: Lippincott Williams & Wilkins.

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