SUBJECTIVE AND OBJECTIVE ASSESMENT

OF INNER EAR & RETROCOCHLEAR

Supervisor : Dr. Ratna Anggraeni A., dr., Sp THT-KL (K), M. Kes

Deptartement of Otorhinolaryngology – HNS

Hasan Sadikin General Hospital
Bandung
2020
 INTRODUCTION
• About 2 to 3 out of every 1,000 children in the United
States are born with a detectable level of hearing loss
in one or both ears.
• Approximately 15% of American adults (37.5 million)
aged 18 and over report some trouble hearing.

Centers for Disease Control and Prevention (CDC). Identifying infants with hearing loss - United States, 1999-2007.
MMWR Morb Mortal Wkly Rep. 59(8): 220-223. Vohr B.
ANATOMY AND PHYSIOLOGY OF
EARS

http://encyclopedia.lubopitko-bg.com/Sense_of_Hearing.html
ANATOMY AND PHYSIOLOGY OF HEARING

6
http://encyclopedia.lubopitko-bg.com/Sense_of_Hearing.html
 5

Sound

Auditory cortex

Wernicke’s area

Broca’s area

Respiratory system, phonation,

articulation

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 HEARING ASSESMENT
Subjective: Objective:
• Speech test • Electroacoustic imitance
• Tunning fork test • Acouctic Reflexs
• Pure tone audiometry • OAE
• Play Audiometry • BERA/ ABR
• Speech Audiometry • ASSR
• BOA (Behaviour
Observational Audiometry)
• VRA (Visual Reinforcement
Audiometry)
 Speech test

Tunning Fork test

Pure Tone Audiometry

Play Audiometry

SUBJECTIVE Speech Audiometry

HEARING
ASSESMENT BOA (Behaviour Observational Audiometry)

VRA (Visual Reinforcement Audiometry)

SISI test (short increment sensitivity index)

ABLB test (alternate binaural loudness balans

test)
 SPEECH TEST
• Speech testing is one of the
more simple types of hearing
loss
• Involves testing ability to
hear words without using any
visual information
• Patient should repeat 5
words
• Non-Test Ear should be
blocked or masked
 TUNNING FORK TEST
• Used to differentiate
between conductive and
sensorineural hearing loss
• Performed with different
types of frequency (256, 512,
1024 Hz)
• Weber, Rinne, Bing,
Swabach
 PURE TONE AUDIOMETRY
• PTA is the most common measurement of hearing
sensitivity stimuly
• Stimuly are pure tones at frequencies typicall from 250 Hz-
8000Hz
• Test results in many clinic are graphed on an audiogram
• Knowledge of the type hearing loss, determined by
means of comparison of the hearing threshold for air and
bone conduction signal)

Hall JamesW, Antonelli Patrick J. Bailey Head & Neck Surgery Otolaryngology : Assesment of Peripheral and Central
Auditory Function. 2014 : 2274-2286
 PLAY AUDIOMETRY
• >2-3 years old
• A standard pure tone audiometer uses headphones
and a feedback device so a patient can respond to
different sound levels
• Because the test is too hard for young children and
preschoolers to understand, we replaces the user
feedback button with an activity instead.
 13

SPEECH AUDIOMETRY

• Indication : Assessment of degree and type

of hearing loss
• Examination of word recognition abilities
• Examination of discomfort or tolerance to
speech stimuli determination of proper
gain and maximum output of amplifying
devices
• Procedure : patient is asked to repeat the
words from a recorder
 14

• Interpretation:
speech discrimination score :
90-100% normal
75-90% mild hearing loss
60-75% moderate hearing loss
50-60%difficult to follow daily conversation
<50% severe hearing loss

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 BEHAVIOUR
OBSERVATIONAL
AUDIOMETRY

• BOA is a test used to

observe hearing behaviour
to sound when VRA is not
possible.
• This is often used for infants
less than 6 months of age or
who are developmentally
not able to turn their head
towards a sound.
 VISUAL REINFORCEMENT
AUDIOMETRY (VRA)
• This hearing test is typically used
for infants over 6 months of age
who are not yet developmentally
ready for Conditioned Play
Audiometry.
• This test takes advantage of your
baby's natural head turn to look
for sounds in his or her
environment. The audiologist will
train your baby to turn towards
sounds, using of toys that light up
as a visual reward.
• Sounds are presented through
earphones and/or speakers.
 17

SISI TEST (SHORT INCREMENT

SENSITIVITY INDEX)
• Indication : to differentiate between cochlear and
retrocochlear  recruitment
• How : by determining the threshold of the patient first
i.e 30 dB, added stimulation 20 dB become 50 dB, after
that another stimulation 5dB, then downing to 4dB 
3dB2dBlast 1dB, if the patient can differentiate it 
positive
• Interpretation: - recruitment + score 70-100%
- unlikely if score 0-70%

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 18

Indication : diagnostic
to compare loudness
growth in an impaired
ABLB TEST ear versus a normal
hearing ear
(ALTERNATE
BINAURAL
LOUDNESS Discovery of
abnormal loudness
BALANCE) growth in cochlear
pathology

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 19

HOW TO DO :
• Test is performed by alternating a fixed frequency
between the two ears, keeping the intensity in the
good ear constant while varying the intensity in the
impaired ear
• The client's task is to state whether the signal is “softer
between the two ears,” “louder than” or “equal” in
loudness to the reference (normal/good) ear

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 20

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 21

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
OBJECTIVE  Impedance audiometry
 Otoacoustic emission
HEARING  Evoked response audiometry
ASSESMENT  ASSR
 23

IMPEDANCE AUDIOMETRY
checking the flexibility of tympanic membrane by
certain pressure through meatus acusticus eksterna.
a. Timpanometry
b. Eustachian tubal function
c. Stapedial reflex : normal  reflex show in stimuli
above threshold 70-80 dB

• In cochlear origin lesion : stapedial reflex decreasing.

• In retrocochlea origin lesion : threshold increasing

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 TIMPANOMETRY
• Tympanometry is an
examination used to
test the condition of
the middle ear and
mobility of the
eardrum (tympanic
membrane) and the
conduction bones by
creating variations of
air pressure in the ear
canal
 TIMPANOMETRY
• Static Acoustic Admittance (SAA) / Compliance: Child 0,2 –
0,9 mmho, adult 0,3 – 1,4 mmho
• Tympanometric Peak Pressure (TPP): Child -50 daPa - +50
daPa, Adult -100 daPa - +100 daPa
• Equivalent Ear Canal Volume (Vec): Child 0,4 – 0,9 cm3,
Adult 0,6 – 1,46 cm3
• Tympanogram Width (TW) and Gradien: OME identification
 EUSTACHIAN TUBE FUNCTION

1. Intact tympanic membrane

• 3 pressure: check pressure with conventional
Tympanometry  Toynbee Valsava
• Patent: > 15 daPa
2. Perforated Tympanic membrane
• this test lasts for 60 seconds  1st 10’ give pressure of 250-
400 mmHG  Toynbee every 10’ step ladder
 STAPEDIAL REFLEX
• Definition: an involuntary muscle contraction that
occurs in the middle ear in response to loud sound
stimuli or when the person starts to vocalize
• The acoustic reflex threshold (ART) is the sound pressure
level (SPL) from which a sound stimulus with a given
frequency will trigger the acoustic reflex (70-100 dB SPL)
• acoustic reflex requirements: The hearing threshold and
middle ear condition of the ear that is given a stimulus,
N. VIII, Brainstem, N. VII Contralateral
 OTOACOUSTIC EMISSION
• Otoacoustic emissions (OAEs) are sounds of cochlear
origin, which can be recorded by a microphone fitted
into the ear canal.
• Caused by the motion of the cochlea's sensory hair cells
as they energetically respond to auditory stimulation
• The OAE test is often part of a newborn hearing screening
program
• OAE: Spontaneous OAE, Evoked OAE (Transient Evoked
OAE, Distorsion Product OAE, Stimulus Frequency OAE)

Brad A Stach. Clinical Audiology. Second Edition. Delmar Cengage Learning. New York. 2010. 61-69 34
 32

BRAINSTEM Brainstem Evoke Response

Audiometry (BERA) is a neurologic
EVOKE test for the functioning othe brain
RESPONSE stem to sound stimulus (click)
AUDIOMETRY
(BERA)

Audiology: Diagnosis. Edited by Roeser, Valente, and Hosford-Dunn. Thieme Medical Publishers,Inc., New York.2000
 COCHLEAR DEAFFNESS
Latensi absolut V
Latensi absolut III

Latensi absolut I

IPL I – III IPL III - V

IPL I - V
 RETROCOCHLEAR
DEAFFNESS

Rasio
Amplitudo
V /I

IT5

IPL I - III IPL III - V

IPL I - V
 RETROCOCHLEAR DEAFFNESS

a. b.
• Interpeak intervals decrease

• I-to-III interval 2.5 ms, III-to-

V interval 2.3 ms, I-to-V
interval 4.4 ms

• Interaural wave V latency

difference (IT5) ≥ 0.2 ms

• ABR test more significant to

tumor size >1 cm

Brad A Stach. Clinical Audiology. Second Edition. Delmar Cengage Learning. New York. 2010. 61-69
 ASSR
• The auditory steady-state response (ASSR) can be
thought of as an electrophysiologic response to rapid
auditory stimuli.
• The goal of ASSR is to create an estimated audiogram
from which questions regarding hearing, hearing loss,
and aural rehabilitation can be answered.
 HIGHLIGHT
• There are several mechanisms that underlie peripheral
hearing disorders
• All the assessment are supporting to each other to
make a firm diagnostic for the next evaluation for
treatment
• Assessment of inner ear disorders with subjective and
objective assesment
Thank you