Pure-Tone Audiometry

Pure-tone audiometry is the most common measurement

of hearing sensitivity. Stimuli are pure tones (sinusoids)

at octave frequencies typically from 250 Hz up to 8,000

2274

Hz and, often, two interoctave frequencies (3,000 Hz and

6,000 Hz). Interoctave hearing loss is a characteristic of

commonly encountered problems, such as noise-induced

cochlear dysfunction. High-frequency audiometry for stimulus frequencies greater than 8,000 Hz (up to
20,000 Hz)

is technically feasible and clinically useful to certain populations, such as patients at risk for ototoxicity.
Test results

in many clinics are graphed on an audiogram. Two versions of audiograms are illustrated in Figure 142.1.
All

audiograms include at the minimum a graph for plotting

hearing threshold levels as a function of the frequency of

pure-tone signals, although the exact format and symbols

vary.

The unit of stimulus intensity is the decibel (dB), a

logarithmic unit. The intensity of any sound is defined

by the ratio of its sound pressure or sound intensity to a

reference sound pressure or sound intensity. The reference

sound pressure is the amount of pressure against the eardrum, caused by air molecules when a sound is
present,

that vibrates the eardrum and can just be detected by a

normal human ear. Briefly, the relation for sound intensity is described as dB= 10 log10 (sound
intensity/reference

intensity) or for sound pressure as dB = 20 log10 (sound

pressure/reference pressure). The reference sound pressure

is defined as decibels sound pressure level ( dBSPL) and is

derived from one of two physical quantities: (a) 0.0002

dynefcm2 or (b) 20 micropascals root mean square (J.lPa)

= 2 x lQ-5 Pa.

Clinically, the intensity of sound is described in decibels

hearing level (dB HL), a biologic reference level, rather than

in sound pressure level. On an audiogram (Fig. 142.1), the

decibel scale has as its reference 0 dB, which is described as

audiometric 0. This is the standard for the intensity level

that corresponds to the mean normal hearing threshold

level, the minimal detectable intensity for each test frequency for young adults with normal hearing.
Another

common unit for expressing sound intensity is decibels sensation level (dB SL), which is intensity of the
stimulus

in decibels above an individual's hearing threshold. For

example. a word recognition test can be administered at an

intensity level of 40 dB SL ( 40 dB above the person's puretone average [PTA]).

In audiologic assessment of cooperative children

and adults, hearing thresholds for tonal or speech signals are measured separately for each ear with
earphones

(air-conduction stimulation). Insert earphones (ER-3A)

are now the transducer of choice for routine audiologic

assessment. They offer distinct advantages over traditional supraaural earphones, including increased
comfort,.

reduced likelihood of ear canal collapse, greater interaural

attenuation. and greater acceptance by young children. In

addition. insert earphones contribute importantly to the

control of infection in a clinical setting, as the insert portion is disposable. Pure-tone audiometry can be
performed

with stimuli presented with a bone-conduction oscillator

or vibrator placed on the mastoid bone. During pure-tone

audiometry, all equipment must meet the specifications of

theAmericanNational Standards Institute (ANSI). Periodic

equipment calibration and validation are necessary. Testing

is conducted according to clinical adaptations of psychoacoustic methods (1). Patients are instructed to
listen carefully for the tones and to respond, usually by pushing a

button that activates a response light on the audiometer or

by raising a hand, every time they believe they hear a tone.

To minimize interference by ambient background acoustic

noise. pure-tone audiometry always is performed with the

patient in a double-walled, sound-treated room that meets

ANSI specifications.

The clinically normal region on an audiogram is 0 to

20 dB HL, although for children hearing threshold levels exceeding 15 dB should be considered
abnormal.

Thresholds in the 20 to 40 dB HL region constitute mild

hearing loss, 40 to 60 dB HL thresholds define moderate

loss, and threshold levels greater than 60 dB HL are considered severe hearing loss (2). As a reference.
the intensity

level of whispered speech close to the ear is less than 25 dB

HL. Conversational speech is in the 40 to 50 dB HL region,

and a shouted voice within 1 foot (30 em) of the ear is at

a level of about 80 dB HL. The most important frequencies for understanding speech are 500 through
4,000 Hz,

although higher frequencies can contribute to discrimination between certain speech sounds. Hearing
sensitivity

within the speech frequency region often is summarized by

means of calculation of the PfA (PTA; hearing thresholds

for 500, 1,000, and 2,000 Hz divided by three and reported

in decibels). A four-frequency PfA including 3,000 Hz is

required by the American Academy of OtolaryngologyHead and Neck Surgery.

Audiometric results are valid only when the patient's

responses are caused by stimulation of the test ear. If a

sound greater than 40 dB HL is presented to one ear through

air conduction with supraaural earphones and cushions

(resting on the outer ear), the acoustic energy can cross

over from one side of the head to the other and stimulate

the ear not being tested. The main mechanism of crossover

is presumed to be bone-conduction stimulation caused by

vibration of the earphone cushion against the skull at high

stimulus intensity levels. The amount of sound intensity

needed before crossover occurs is a reflection of interaural

attenuation, that is, the sound insulation between the two

ears provided by the head. Interaural attenuation is usually

about 50 dB for lower test frequencies and 60 dB for higher

test frequencies, such as those contributing to the ABR.

Interaural attenuation is considerably higher for insert earphones (2). With bone-conduction
stimulation, interaural

attenuation is less than 10 dB. In clinical circumstances, the

examiner needs to assume conservatively that interaural

attenuation for bone-conducted signals is 0 dB. In other

words, even a very faint sound presented to the mastoid

bone of one ear by a bone-conduction vibrator can be

transmitted through the skull to either or both inner ears.

Perception of this bone-conducted signal depends on the

patient's sensorineural hearing sensitivity in each ear.

Masking is the audiometric technique used to eliminate participation of the ear not being tested
whenever

air- and bone-conduction stimulation exceeds interaural

attenuation. An appropriate noise (narrow-band noise for

pure-tone signals and speech noise for speech signals) is

presented to the ear not being tested when the stimulus

is presented to the test ear. With adequate masking, any

signal crossing over to the ear not being tested is masked

by the noise. The level of masking noise presented to the

ear not being tested must exceed the threshold of hearing for that ear. Excess levels of masking noise
must be

avoided because the noise can cross back over to the ear

being tested. Selection of appropriate masking can be difficult, especially when there is bilateral hearing
loss (2).

Indeed, patients with severe bilateral conductive hearing

loss may present the "masking dilemma," that is, when

enough masking to the nontest ear actually crosses over to

the test ear and interferes with accurate estimation of hearing threshold. An otolaryngologist
interpreting audiologic

results must verify that appropriate masking was used if

testing was not performed by an audiologist.

Knowledge of the type of hearing loss, determined by

means of comparison of the hearing thresholds for air- and

bone-conduction signals, is useful in classifying a hearing loss as sensorineural (no air-bone gap),
conductive

(normal bone conduction and a loss by air conduction),

or mixed (loss by bone conduction with a superimposed

air-bone conduction gap).

Configuration refers to hearing loss as a function of

the test frequency. With a sloping configuration, hearing

is better for low frequencies and then becomes poorer for

higher frequencies. The most common pattern associated

with sensorineural hearing loss is a deficit in thresholds

for higher test frequencies. The configuration can be gently sloping from low to high frequencies, be
precipitously

decreasing above a high frequency cutoff, such as 2,000 Hz, or be characterized by a notching deficit
within a certain

frequency region,. such as 4,000 Hz. A rising configuration is typified by relatively poor hearing for low-
frequency

stimuli and better hearing for the high frequencies. A rising configuration can be caused by varied types
of middle

ear abnormalities. An exception to the typical association of

conductive hearing loss with rising configuration is Meniere

disease (see Chapter 156). Meniere disease is one cochlear

abnormality that may produce a rising configuration. A flat

audiometric configuration often is recorded from patients

with mixed hearing loss, that is, both sensorineural and

conductive components are present Other configurations,

such as the midfrequency "cookie bite" pattern,. are encountered in clinical practice. Test-retest
variability in clinical

pure-tone threshold estimation is typically ±5 dB.

Guidelines for Evaluation of Hearing

Handicap

The results of pure-tone audiometry are adequately summarized in an audiogram and with the terms
just defined, such

as PIA and the degree.. configuration, and type of hearing

loss. It also is possible to quantify hearing loss in percentage units according to published and accepted
guidelines

(3). This approach sometimes is necessary in medicolegal

cases or when a patient seeks compensation for hearing

loss. According to the guidelines of the American Academy

of Otolaryngology Committee on Hearing and Equilibrium

and the American Council of Otolaryngology Committee

on the Medical Aspects of Noise (3), permanent hearing

impairment is defined as follows: "A change for the worse

in either structure or function, outside the range of normal,

is permanent impairment.... Permanent impairment is

due to any anatomic or functional abnormality that produces hearing loss." This is differentiated from
permanent

hearing handicap, which is defined as follows: "The disadvantage imposed by an impairment sufficient to
affect

a person's efficiency in the activities of daily living is a permanent handicap" (3). The guidelines also
detail the

approach for converting hearing handicap for one or both

ears into a percentage. The first step is to determine the

degree of sensorineural hearing loss for four test frequencies (500, 1,000,2,000, and 3,000 Hz) from the
audiogram

(Table 142.1). The next step is to follow the guidelines for

computation of percentage hearing loss (3):

If the monaural percent figure is the same for both ears,

that figure expresses the percent hearing handicap. If

the percent monaural hearing impairments are not

the same, apply the formula:

( 5 x % [better ear]) + ( 1 x % [poorer ear]) /6 = %

hearing handicap

The interoctave test frequency-3,000 Hz-in the calwlation of percentage of hearing handicap is very
important. It is good clinical practice to routinely obtain hearing thresholds

from each ear for the 3,000 Hz frequency. This frequency is

included in the formula for hearing loss (3) because much

of the spectral information vital for speech understanding is

within the 2,000 to 3,000 Hz region. Percentage of binaural

hearing handicap is easily calculated with a detailed tabular

matrix that relates the four-frequency degree of sensorineural

hearing loss for the better versus poorer ear ( 4 ).