CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION

The hearing threshold level of the subject only provides half of the information required for the

diagnosis of any hearing loss. The measured threshold needs to be compared with some

reference level indicative of normal hearing. The reference equivalent threshold sound pressure

level or RETSPL establishes this reference level. It has been determined by measuring the

hearing threshold levels of a large group of ‘otologically normal’ young adults and establishing

the average value of these measurements, with each hearing threshold being established in terms

of the SPL developed in an ear simulator. This is referred to as the equivalent threshold.

The hearing level of a subject is then defined as the difference (in decibels) between the

measured hearing threshold level of the subject and the RETSPL. This type of measurement is

built-in to most audiometers, which report the hearing level as a function of frequency in the

form of an audiogram.

Thus, the role of the ear simulator in hearing measurement is two-fold. It has been used initially

to establish the reference level, the RETSPL, and is also used for the routine calibration of

audiometers.

Standardisation of RETSPL data is key to the consistent measurement of hearing threshold level

which in turn reflects on the accuracy of medical diagnosis of hearing loss, the educational

placement of children and the auditory rehabilitation of adults.

At present two types of ear simulator exist for the calibration of audiometers fitted with supra

aural earphones (earphones designed to rest on the pinna, and the most commonly used type in

audiometry). These devices are the reference coupler and the artificial ear† . Associated the

values for each of the ear simulators, for use with specific or limited earphone types, are

specified in ISO 389-1. Unfortunately the earphone types that can be used with each ear

simulator are mutually exclusive, so every calibration laboratory needs to maintain examples of

both in order the cover the full range of earphones found in use. This adds cost and, in certain

circumstances, leads to ambiguity over which ear simulator should be used. It has long been

suggested that a single type of ear simulator for all types of earphone might improve this

situation. Furthermore, if this ear simulator were able to offer a good simulation of the human

ear, a single, universal set of RETSPL values is all that would be required.

2.2 AUDITORY SYSTEM

Our system of hearing comprises of two sections viz. a peripheral section which is our ear and a

central section located in the brain, which carries the sensation from the ears to the auditory area

of the cerebral cortex. The auditory area of the cerebral cortex (called auditory cortex) is the area

of the brain, which is dedicated to and specialised in interpreting the sound. The ear receives the

sound in the form of sound energy, which is a form of vibration. This vibrating energy enters the

external part of the ear (called external auditory meatus) and vibrates the eardrum (technically

known as tympanic membrane). This vibration of the tympanic membrane is picked up by a

chain of small bones called malleus, incus and stapes, which conduct vibration to a specialised

organ called cochlea.

The cochlea is the transducer of the hearing system. The function of the cochlea is to convert the

vibratory energy into electrical energy. Once this has been achieved, this electrical energy enters

the nerve of hearing (called auditory nerve) and carries the sensation through different parts of

the brain to the auditory cortex, where the sensation of sound is analysed and interpreted. The

phenomenon by which sound reaches the inner ear through the eardrum is called air conduction.

Sound, particularly in the low frequency range, may reach the inner ear via the bones in the head

rather than from the eardrum. This phenomenon is called bone conduction. Wearing earplugs

results in a greater percentage of the sound heard coming from bone conduction. Normally only a

small fraction of sound is received in this way; however, deaf people whose inner ear still

functions normally may be able to hear sound conducted to the ear in this way. For proper

hearing each and every part of this system right from the external auditory meatus to the auditory

cortex has to be normal.

2.3 CLASSES OF AUDIOMETER AND THEIR APPLICATIONS

An audiometer is referred to a complex instrument which helps to measure a person's ability to

hear. Various audiometric techniques and procedures are used to identify the hearing ability of a

person.

1. Pure-tone audiometry
Pure-tone audiometry is considered to be the gold standard in the evaluation of auditory

sensitivity. The extent of hearing loss and the cause is determined using pure-tone audiometry. It

helps in finding out the hearing thresholds at different frequencies.

The range of pure-tone audiometers vary from simple inexpensive devices to elaborate and

expensive diagnostic audiometers. In this test, a pure tone is presented to the ear through an
earphone, and the lowest intensity at which the tone is perceived 50% of the time is measured in

decibels (dB). This measurement is termed as ‘threshold’. The output is plotted as a graph known

as audiogram. Testing procedure is performed at specific frequencies ranging from 250 to 8000

Hz.

2. Speech audiometry

The objective of the speech audiometry is to assess the integrity of the entire auditory system by

evaluating the hearing ability. Neural type of hearing loss can be identified with the help of

speech audiometry. Speech audiometric test is further categorized into speech discrimination test

and speech reception threshold test. Both the tests aim to identify the lowest decibel intensity at

which a patient can repeat 50% of the words correctly. While speech discrimination test uses

monosyllable test words, speech reception threshold test utilizes two syllable words with equal

stress (also referred to as “spondees”).

3. Suprathreshold audiometry

Recruitment is referred to the condition where patients having different degrees of hearing loss in

both ears experience enhancement in perceived loudness in response to small increase in the

intensity.

Recruitment detection tests are known as the suprathreshold audiometry. At a typical

conversational speech level, it helps detecting whether the listener can accurately recognize the

speech or not. Benefits to a patient due to the use of a hearing aid can also be determined by this

test.

4. Self-recording audiometry
Self-recording audiometry is also referred to as Bekesy audiometry. In 1947, George von Bekesy

first introduced this test. In this procedure, intensity and frequency are automatically changed

with the help of a motor.

The frequency can be changed in a forward or backward manner. This hearing test is performed

using a recording attenuator. At a fixed rate of so many decibels per second, the attenuator can

either increase or decrease the signal intensity. The attenuator action can be controlled by the

listener.

5. Impedance audiometry

The mobility and air pressure of the middle ear system and middle ear reflexes are measured in

impedance audiometry.

6. Computer-administered (microprocessor) audiometry

The first commercial microprocessor audiometer was introduced in 1975. The typical

microprocessor audiometer instrument contains a multifunctional keypad. Compared to the

manual and self-recording audiometers, microprocessor audiometers offer significant

advantages.

7. Subjective audiometry

In this test, the subjects are asked to respond when they hear the presented sound. This

audiometric test can present systematically varying acoustic stimuli to the subjects and record

their responses.

8. Objective audiometry
Unlike subjective audiometry, this test is not dependent on responses from the patients.

However, the subjects are asked to co-operate during the attachment of the measuring electrodes

or probes for carrying out the objective test.

Since audiometers are often not of one type exclusively, i.e., a pure tone audiometer may be a

portable group audiometer, perhaps a more meaningful way to consider them is in terms of the

purpose for the hearing measurements. Purposes for which hearing tests are usually conducted

are:

1. Diagnostic - gathering detailed information for use in arriving at the proper diagnosis of an

ear problem;

2. Monitoring- periodic checks of hearing in order to detect any change warranting special

medical and/or non-medical attention;

3. Screening - rapid detection of defective hearing by the use of limited test techniques;

4. Social-Communicative - gathering detailed information for use in understanding (a) the

detrimental effects of the hearing impairment on hearing and speech skills, and (b) the aural

rehabilitative needs, i.e., speech reading (lip reading) and hearing aids, necessary for

reestablishing or developing skills in communication.

2.3.2 Control Features Of An Audiometer

Although pure tone audiometers differ in many respects, they have certain operational controls in

common. Basic controls which can be noted are the:

Frequency Selector - for the selection of tones of different frequencies for use as test signals.

Intensity Dial- sometimes indicated as a Hearing Loss control, used to vary the loudness of the

test signals. '

Interruptor - for initiating and regulating the duration of the signal thereby enabling an

examiner to judge the validity of responses on the basis of whether or not they correspond to the

onset and duration of the tone.

Output Selector - for the routing of pure tones to the ear to be tested.

Masker - for controlled loudness presentation of a noise signal for masking or blocking out an

ear not under test. This becomes necessary when circumstances indicate that tones directed to a

test ear may be heard in the opposite or non-test ear first.

In selecting an audiometer, attention should be given to factors which facilitate the operation of

these controls. The size and shape of the controls, the visibility, their arrangement, the ease and

quiet of their manipulation, all are factors which bear on the effective operation of an

audiometer.

2.4 PREVIOUS RESEARCH REVIEWS ON AUDIOMETER

(Ashok D et al, 2019) A low-cost Audiometer was designed and constructed for carrying out

primarily, Pure Tone and Speech Audiometry. The Audiometer also included other standard

subjective behavioural tests: Tone Decay, SISI (Small Increment Sensitivity Index), ABLB

(Alternate Binaural Loudness Balance) Test and Stenger’s. Other standard features offered were:

output transducer options: Air Conduction Headphones, Bone Vibrator, and Free Field output,
Contralateral Masking, Audiogram (during Pure Tone test) on instrument’s LCD display, battery

operation.

(Manish K et al, 2018) discussed on advanced Audiometer: A Novel Signal Generator

Technique. Audiometry is the technique to identify and quantitatively determine the degree of

hearing loss of a person by measuring his hearing sensitivity, so that suitable medical treatment

or one of the appropriate hearing aids and assestive device can be prescribed. In audiological

investigations, the hearing sensitivity is tested for pure tones, speech or other sound stimulus.

The results when plotted graphically are termed as audiogram. The electronic instrument used for

measuring hearing threshold level is called an audiometer. Test tones of different frequencies and

levels are generated and presented to the subject. Hearing thresholds are determined on the basis

of responses from the subject. Different audiometric tests, techniques, and various audiometers

are discussed. A Novel signal generator technique for advanced audiometer is suggested which

gives finely tunable pure sine wave and noise signals with controlled spectrum. Because of

revolution in electronic science all the methods and algorithms can be embedded in one chip

with the help of hardware descriptive language and this chip can be a part of add on card, which

may be used in any high performance medical instruments.

(A A Kapul et al, 2010) The research focuses on a pure-tone audiometer designing. The

relevance of the study is proved by high incidence of an auditory analyser in older people and

children. At first, the article provides information about subjective and objective audiometry

methods. Secondly, we offer block-diagram and basic-circuit arrangement of device. We decided

to base on STM32F407VG microcontroller and use digital pot in the function of attenuator.

Third, we implemented microcontroller and PC connection. C programming language is used for

microcontroller’s program and PC’s interface. Fourthly, we created the pure-tone audiometer

prototype. In the future, we will implement the objective method ASSR in addition to puretone

audiometry.

(Alberto B et al, 2013) Illustrated and developed Audiometric booths that are used to reduce

background noise levels at testing locations to below values specified in the standards. As such,

they are considered inherent parts of the audiometric testing equipment. This paper presents the

results from a literature search of solutions that could ensure that background noise levels are

acceptable outside booths. The technology used is especially valuable for survey tests and for

locations where booths are unavailable or cannot be used for different reasons. However, its use

is recommendable for only screening hearing tests but not for clinical or research applications.

(Swanepoel et al, 2015) used a KUDUwave audiometer to compare the hearing of 149 school

children from two schools (average age 6.9 years), as tested in an audiometric room and in a

natural school environment. The tests were first conducted in rooms provided by the schools (a

classroom, administrative room, or media room). Then, the same evaluation was done within a

few days of the initial trial in an audiometric booth located in an audiological clinic. The average

differences between the measurements done in a natural environment and in an audiometric

booth were between 2.02 dB and 0.5 dB, with standard deviations between 2.5 dB and 4.7 dB

across the frequencies and ears. The authors concluded that the results confirmed statistically and

clinically equivalent hearing thresholds for children tested in a school environment compared to

a sound-treated booth. Again, there was no data regarding the sound levels in the school rooms

during the tests.

(Maclennane S et al, 2015) used the KUDUwave Plus to compare the pure-tone conducted

thresholds (250–8000 Hz) measured in retirement facilities with the thresholds measured in a

sound-treated booth. One hundred and forty-seven adults (average ages 76 ± 5.7 years) were

evaluated. The pure-tone averages were ≥25 dB in 59%, mildly elevated (>40 dB) in 23%, and

moderately elevated (>55 dB) in 6% of the ears. The measured thresholds (n = 2259)

corresponded within 0–5 dB in 95% of all comparisons between the two test environments. The

average threshold differences (−0.6 to 1.1) and standard deviations (3.3 to 5.9) were within the

typical test–retest reliability limits. The thresholds recorded showed no statistically significant

differences (paired samples t-test: p > 0.01), except at 8000 Hz in the left ear. The authors

concluded that valid diagnostic pure-tone audiometry can be performed in a natural environment

with the technology they used. This is significant, as it offers the possibility of access to

diagnostic audiometry in communities where sound-treated booths are nonexistent.

2.5 SELECTING AN AUDIOMETER

Considerations for selecting an audiometer should be based on the fact that a relatively simple

audiometer is all that is needed for hearing testing in industry. An air-conduction pure tone

audiometer designed for individual testing and threshold measurements would be satisfactory for

use in industry, as mentioned earlier. Considering the cost of an audiometer, one should

understand that it would increase as the complexity of the unit did. Buying an audiometer which

provides more testing facilities than needed would be a waste of money. Also, attention should

be given to the design and arrangement of controls from the standpoint of ease of operation.
Finally, consideration of the durability or expected life as well as the maintenance needs of an

audiometer will aid in the selection of one.

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