HEARING

EVALUATION
Dr SRAVYA M V
First year PG
Salakyatantra
Gavc Trippunithura
Hearing loss
Conductive – external ear to stapediovestibular joint

Sensorineural – sensory – lesions of cochlea

- neural – retrocochlear
- central

Mixed
Find out :-

Type

Degree – mild
moderate
moderately severe
severe
profound/total

Site of lesion
Causes

- congenital traumatic infective

neoplastic degenerative metabolic

ototoxic vascular autoimmune

Assessment of hearing

1. Clinical tests

• Finger friction test

• Watch test

• Speech test

• Tuning fork test

2. Audiometric tests –

• Pure tone audiometry

• Speech audiometry

• Bekesy audiometry

• Impedance audiometry
3. Special tests

• Recruitment

• short increment sensitivity index (SISI test)

• Threshold tone decay test

• Evoked response audiometry

• Auditory steady state response (ASSR)

• Otoacoustic emissions (OAEx)

• Central auditory test

• Hearing assessment in infants & children

Subjective tests

• Response depends upon the pt

• Tuning fork tests,pure tone audiometry,speech
audiometry

Objective tests

• Response is automatically recorded

• Impedance audiometry ,electrocochleography, BERA,
Clinical tests

1. Finger friction test

- Rubbing or snapping the thumb & a finger close to

pt’s ear

- Rough & quick method of screening

2. Lever pocket watch test

- A clicking watch is brought close to the ear

- Distance at which it is heard is measured

3. Speech(voice) test

Can be done as,

a. Freefield speech test by whisper,conversation

b. Recorded voice test
c. Speech audiometry
d. Monitored speech through a closed circuit
Freefield speech test

Conversational voice – 12m

(20-40 feet) Normal

Whisper - 6m (12 feet)

For both 6m – for test

Whisper with residual air after full expiration

Requirements

- Quite surrounding

- Pt stands with his test ear towards the examiner at

6m distance

- Eyes are shielded to prevent lip reading

- Non test ear blocked by intermittent pressure on tragus

- Examiner uses spondee words ( football,daydream) or

numbers with letters ( X3B,2AZ)

- Gradually walks towards the patient

- Distance at which both conversational and whispered

voice heard is measured
30 dB loss – whisper- heard at 3 feet distance

60 dB loss – conversation - heard at 3 feet distance only

Disadvantages –

- Lack of standardisation in intensity & pitch of voice used

- Ambient noise of testing place

4. Tuning fork test

• Qualitative test

• 128,256,512,1024,2048,4096 Hz

• 512 Hz – ideal

• Lower frequency forks- produce sense of bone vibration

• Higher – shorter decay time

- Tuning fork – activated by striking it gently against the
examiner’s elbow,heel of hand,rubber heel of
shoe,femoral condyle

- The prong should be struck at a point about 1/3rd of its

length from the free end – min.overtone & producing a
pure tone
To test air conduction

• A vibrating fork is placed vertically in line with the

meatus

• About 2 cm away from the opening of EAC

• Sound waves TM middle ear ,ossicles

inner ear
• Function of both conducting mechanism & cochlea are

tested

• AC>BC – normal
To test bone conduction

• Footplate of vibrating fork is placed firmly on

the mastoid bone

• Cochlea is stimulated directly by vibrations conducted

through skull bones

• BC - measure of cochlear function only

A . Rinne test

• AC is compared with BC

• Vibrating tuning fork placed on pt’s mastoid

• When he stops hearing it is brought beside the meatus

• If he still hears, AC>BC

• AC >BC – Rinne test positive – in normal,sensorineural
deafness

• BC >AC – Rinne test negative – conductive deafness

min air bone gap of 15-20dB

• AC=BC – Rinne equivocal – mild CHL

Prediction of air- bone gap

Rinne test :-

• equal/-ve for 256 Hz +ve for 512 Hz gap 20-30dB

• -ve for 256 &512 Hz +ve for 1024Hz gap of 30-45 dB

• -ve for 256,512,1024 Hz gap of 45-60dB

• -ve Rinne for 256 Hz min AB gap of 15 dB

512 Hz 30dB

1024Hz 45dB
 False –ve Rinne

• Unilateral sensorineural hearing loss

• Pt doesnot percieve any sound of tuning fork by air

conduction but responds to bone conduction testing

• BC from the opposite ear by transcranial transmission

of sound
- Correct diagnosis by masking the non test ear with

Barany’s noise box while testing for BC

Clockwork device which emits noise, raises

the threshold of hearing in non test ear
B. Weber test

• Vibrating tuning fork is placed in the middle of the

forehead /vertex /central incisor

• Pt is asked in which ear the sound is heard

• Equally in both ears – normal

• Lateralised to worse ear – conductive deafness

• Better ear – sensorineural deafness

• Centrally heard – equal conductive deafness in both ears

• Sound travels directly to the cochlea via bone

• Lateralisation 512 Hz – conductive loss of 15-25 dB – in

ipsilateral ear/

- Sensory loss in contralateral ear

C.Absolute bone conduction test (ABC test)

• Pt’s BC is compared with that of examiner (normal

hearing in examiner)

• EAC of both occluded

• Vibrating tuning fork is placed on the mastoid of the

pt,when he no longer hears any sound, fork is shifted to
examiner’s mastoid of same ear to compare
• Conductive deafness – both hear for same duration

• Sensorineural deafness – pt hears for shorter duration-

ABC down/short

• ABC interpreted as normal/short

D. Shwabach’s test

• BC compared with that of examiner with normal hearing

• Same as ABC, without occluding EAC

• Sensorineural – reduced

• Conductive - lengthened
 Tuning fork tests and their interpretations
Test Normal Conductive SN deafness
deafness
Rinne AC>BC BC>AC AC>BC
(Rinne +ve) (Rinne –ve)
Weber Not lateralised Lateralised to Lateralised to
poorer ear better ear
ABC Same as Same as Reduced
examiner’s examiner’s
Schwabach Equal Lengthened Shortened
E. Bing test

• Test of BC

• Examines the effect of occlusion of ear canal on

hearing
• Principle:-
When a vibrating fork is placed on the cranium & it ceases to
be heard (primary perception)in the normal ear & when the
EAC is plugged hears it again (secondary perception)
• Vibrating tuning fork on the mastoid

• Alternatively close and open the ear canal by pressing

on the tragus inwards

• Bing + ve normal/SNHL- louder when

occluded ( secondary perception),softer when opened

• Bing – ve - no change - conductive hearing loss

F.Gelle’s test

• Test of BC,functioning of ossicular chain (esp.stapes)

• Examines the effect of increased air pressure in the ear

canal on hearing

• By using Siegel’s speculum – pushes TM & ossicles

inwards,raises intralabyrinthine pressure
Siegel’s speculum
• Causes immobility of basilar membrane

• Decreases hearing

• Ossicular chain – fixed/disconnected – no change in

hearing
• Place vibrating fork on the mastoid

• Air pressure changed with Siegel’s speculum

• Gelle’s test +ve normal,SNHL- reduced hearing

• -ve ossicular chain fixed/disconnected – no alteration

• To find out stapes fixation in otosclerosis

Tuning fork test for malingering/non organic deafness

1.Stenger’s test

• If 2 equal & identical sounds strike normal ears,the

individual receives the impression in one ear only,ie,one
nearest to the sound

• 2 similar vibrating forks held at 25 cm from each ear of a

blind folded pt
• Malingerer will say that he hears in the normal ear only

• Fork on the deaf side is advanced by 8 cm towards the

ear

• He will deny hearing sound at all

• Can be done by 2 channel audiometer more precisely

2. Chimani Moos test

• Tuning fork placed on the forehead,malingerer says that

he hears the sound in his good ear (simulating SNHL)

• If the meatus of good ear is occluded,the truly deaf pt

still hears the sound in the occluded ear

• Malingerer may deny that he hears the tuning fork at all

3. Teal test

• For pts claiming unilateral conductive hearing loss

• Pt is blind folded,tuning fork is placed over mastoid

• Pt claims of hearing

• Say you are repeating the test

• Place one vibrating fork in front of the ear & next non
vibrating over the mastoid

• Malingerer will say he hears the sound , but genuine

one would not
4. Lombard test

• Person with unilateral deaf ear , is asked to read a page from

the book

• A Barany’s noise box applied to the good ear

• If there is organic HL in the suspected ear– the voice level is

raised by the person

• In non organic HL – there will be no change in the speech

Audiometric test

1. Pure tone audiometry

Audiometer – electronic devices produce pure tones

• Intensity can be increased/decreased by 5 dB steps

AC – 125,250,500,1000,2000,4000,8000 Hz
• The amount of intensity that has to be raised above
the normal level is a measure of degree of
hearing impairement at that frequency

• Charted in the form of a graph ‘audiogram’

• Threshold of BC – cochlear function

• A-B gap – degree of conductive deafness

• Normal person AC & BC at 0dB

• No A-B gap
• When difference b/w both ears is 40 dB or above in AC
theshold better ear is masked to avoid getting a shadow
curve from the non test better ear

• Masking is essential in all BC studies

• Done by employing a narrow band noise to the non test

ear
Air conduction
Bone conduction
 Right ear BC better than AC
Low to mid frequency conductive hearing loss
Left ear sensory neural hearing loss
Use of pure tone audiogram

• Measure of threshold of hearing by AC & BC & thus the

degree & type of hearing loss

• A record can be kept for future reference

• Essential for the prescription of hearing aid

• Helps to find degree of handicap for
medicolegal purposes

• Helps to predict speech reception threshold

2 Speech audiometry

• Pt’s ability to hear & understand speech is measured

2 parameters

• Speech reception threshold (SRT)

• Discrimination score
Speech reception threshold

• Min.intensity at which 50% of the words are repeated

correctly by the patient

• A set of spondee words is delivered to each ear through

the headphone of an audiometer
• The word lists are delivered in the form of recorded
tapes or monitored voice & intensity is varied in 5 dB
steps till half of them are correctly heard
• Normal SRT is within 10dB of average of pure
tone threshold of 3 speech frequencies (500,1000,2000)

• Functional hearing loss -SRT better than pure tone

average by more than 10dB
Speech discrimination score

• Speech recognition/word recognition score

• Measure of pt’s ability to understand speech

• A list of phonetically balanced (PB)words (single syllable

pen,pin…) delivered to pt’s each ear separately at
30-40dB above his SRT
• % of words correctly heard by the pt is recorded

• Normal,conductive hearing loss – high score of 90-100%

• Retrocochlear HL < 40%

SD score Ability to undersand
speech

90-100% Normal
76-88% Slight difficulty
60-74% Moderate difficulty
40-58% Poor
<40% Very poor
Perfomance intensity words for PB words

PB max.

• Chart PB scores against several levels of intensity & find

PB max a pt can attain

• Note the intensity at which PB max is attained

• Useful test to set the volume of the hearing aid

• Max volume of hearing aid should not be set above

PB max
Roll over phenonenon

• In retrocochlear hearing loss

• With increase in speech intensity above a particular

level PB word score falls rather than maintain a plateau
as in cochlear type of SNHL
Speech audiometry:- uses

• To find speech reception threshold which correlates well

with average of 3 speech frequencies with pure tone
audiogram

• To differentiate organic from non organic(functional)

hearing loss
• To find the intensity at which discrimination score is best

• Helpful for fitting the hearing aid & setting its volume for
max. discrimination

• To differentiate cochlear from retrocochlear SNHL

• Confirms PTA results

3.Bekesy audiometry

• Self recording audiometry

• Pure tone frequencies automatically move from low to

high while the patient controls intensity through
a button
2 tracings -

• One – with continuous tones

• Other – with pulsed tone

• Help to differentiate cochlear from retrocochlear

• Organic from functional hearing loss

Types of tracings

• Type 1 - Continuous & pulsed tracings overlap –

normal/CHL

• Type 2 - Overlap upto 1000 Hz & then continuous falls

down- cochlear loss
• Type 3 - Continuous falls below the pulsed at 100-500Hz
even upto 40-50dB – retrocochlear / neural lesion

• Type 4 - Continuous below upto 1000 Hz by >25 dB –

retrocochlear / neural lesion

• Type 5 - Continuous above pulsed – non organic hearing

loss
Type 1
Type 2
4.Impedance audiometry

• Objective test

• Useful in children

Consists of ,
• Tympanometry
• Acoustic reflex measurements
Impedance audiometer
a. Tympanometry

Principle-
• when a sound strikes tympanic membrane
some of the sound energy is absorbed while the rest is
reflected

• A stiffer TM reflect more of sound energy than a

compliant one
• By changing the pressure in a sealed EAC then measuring
the reflected sound energy it is possible to find the
compliance or stiffness of tympano ossicular system

• Thus find the healthy/diseased status of the middle ear

Equipment consists of
Probe – snugly fits into the EAC
3 channels –

• To deliver a tone of 220 Hz

• To pick up the reflected sound through a microphone

• To bring about changes in air pressure in the canal

from +ve to normal & then to –ve
• By charting the compliance of tympano ossicular system
against various pressure changes different types of
graphs ‘ tympanogram’ are obtained which are
diagnostic of various middle ear pathologies
Types

• Type A – normal

• Type As – Compliance is lower at or near ambient air

pressure
In fixation of ossicles otosclerosis,malleus fixation

• Type AD – high compliance at or near ambient air

pressure
• Type B – Flat or dome shaped
No change in compliance with pressure changes
In impacted wax,FB,fluid in the middle ear

• Type C – Max compliance occurs with –ve pressure in

excess of 100 mm H2O
Peak is shifted to –ve side
Retracted TM,may show some fluid in middle ear
Testing function of eustachian tube

• In case of intact/perforated TM

• -ve /+ve pressure is created in the middle ear

• Pt is asked to swallow 5 times in 20s

• Ability to equilibrate pressure –normal tubal function

• To find out patency of grommet placed in TM in serous
otitis media
b. Acoustic reflex

• A loud sound 70-100dB above the threshold of

hearing of a particular ear causes b/l contraction of
stapedial muscles which can be detected by
tympanometry

• Tone can be delivered to one ear

• Reflex is picked from same / contralateral ear

Reflex arc,

• Ipsilateral CN 8 – ventral cochlear nucleus- CN 7 nucleus

ipsilateral stapedius muscle
• Contralateral CN 8 – ventral cochlear nucleus-
contralateral medial superior olivary nucleus
- contralateral CN 7 nucleus- contralateral
stapedius muscle
• To test hearing in infants& young children

• To find malingerers – a person who feigns total deafness

& does not give any response to pure tone audiometry
but shows a +ve stapedial reflex is a malingerer

• To detect cochlear pathology – presence of stapedial

reflex at lower intensities indicates recruitment
– cochlear hearing loss
• To detect 8th nerve lesion – If a tone of 500/1000 Hz
delivered 10dB above acoustic reflex threshold,for a
period of 10s brings the reflex amplitude to 50%
Shows abnormal adaptation,stapedial reflex decay

• Lesions of facial nerve – Absence of stapedial reflex

when hearing is normal- lesion of facial nerve proximal
to the nerve to stapedius
• Reflex can be used to find prognosis of facial paralysis-
appearance of reflex after it was absent – return of
function& favourable prognosis

• Lesion of brainstem – Ipsilateral reflex is present

contralateral reflex is absent – lesion in the area of
crossed pathway in the brainstem
Physical volume of ear canal

• Acoustic immittence can also measure the physical

volume of air between the probe tip & TM

• Normally upto 1 ml in children & 2 ml in adult

 >2ml in children,>2.5ml in adult – perforation in TM
(volume of middle ear + EAC)

• Used to find the patency of ventilation tube

Special tests

1. Recruitment

• Phenomenon of abnormal growth of loudness

• The ear which doesnot hear low intensity sound begins

to hear greater intensity sounds as loud or even louder
than normal hearing ear
• A loud sound which is tolerable in normal ear may grow
to abnormal levels of loudness in the recruiting ear &
thus become intolerable

• The pts with recruitment are poor candidates for

hearing aids

• In lesions of cochlea, Meniere’s disease ,presbycusis

 Alternate binaural loudness balance test

• Used to detect recruitment in unilateral cases

• A tone is played alternately to normal and affected ear

• Intensity in affected ear is adjusted to match with

loudness in the normal ear

• Test is started at 20dB above the threshold of deaf ear

• Then repeated at every 20dB rise until the loudness
is matched or the limits of audiometer reached

• Conductive & neural deafness – initial difference

is maintained throughout

• Cochlear lesion – partial/ complete/ over recruitment

2. Short increment sensitivity index

• Pt with cochlear lesions distinguish smaller changes in

intensity of pure tone better than normal/conductive
deafness/retrocochlear pathology

• To differentiate cochlear from retrocochlear

• Continuous tone is presented 20dB above the
threshold & sustained for about 2 mins

• Every 5 s tone is increased by 1 dB & 20 such blips

are presented

• Pt indicates the blips heard

• Conductive deafness – seldom > 15%

• Cochlear 70-100,%

• Nerve deafness 0-20%

3. Threshold tone decay test

• Measure of nerve fatigue

• To detect retrocochlear lesion

• Normal – can hear a tone continuously for 60s

• Nerve fatigue – stops hearing earlier

• A tone of 4000 Hz presented 5 dB above pts threshold
of hearing continuously for a period of 60s

• If pt stops hearing earlier,intensity is increased by

another 5 dB

• The procedure is continued till the pt can hear the tone

continuously for 60s
• Or no level exist above the threshold where tone is
audible for full 60s

• The result is expressed as no. of dB of decay

• Decay >25dB – retrocochlear lesion

4. Evoked response audiometry

• Objective method

• Measures electrical activity in auditory pathways in

response to auditory stimuli

• Requires special equipment with an averaging

computer
• Components

- Electrocochleography(EcoG)
- Auditory brainstem response (ABR)
a. Electrocochleography

• Measures electrical potential arising in the cochlea

&CN 8 in response to auditory stimuli within first 5 mins

• Response is in the form of 3 phenomena

- Cochlear microphonics
- Summating potentials
- Action potential of 8th nerve
• The recording electrode is a thin needle passed through
TM onto promontory

• Adults – under local anaesthesia

• Children/anxious person – sedation/general anaesthesia

• Sedation does not interfere in these responses

• To find threshold of hearing in young infants
children within 5-10 dB

• To differentiate cochlear lesions from that of 8 th nerve

• Normal – ratio b/w amplitude of summating action

potential to that of action potential is <30%
Increase in the ratio – meniere’s disease
b.Auditory brainstem response

• BAER/BAEP (brainstem auditory evoked

response/potential)

• BERA (brainstem evoked response audiometry)

• Gold standard for evaluating hearing thresholds in young

infants & difficult to manage children
• To elicit brainstem responses to auditory stimulation by
clicks or tone bursts

• Non invasive technique to find the integrity of central

auditory pathway through 8th nerve, pons,midbrain
• Electric potentials are generated in response to several
click stimuli/tone bursts picked up from the vertex by
surface electrodes

• Measures hearing sensitivity in the range of

1000-4000Hz
4 electrodes :-

• Active electrodes kept on the

vertex,forehead

• Reference electrode kept on the

mastoid/ear lobe of tested ear

• Ground electrode kept on the

mastoid/ear lobe on the opposite
ear
• Normal – 7 waves in first 10 min
1st 3rd 5th waves – most stable- used in measurements

• The waves are studied for absolute latency,interwave

latency ( usually b/w wave 1 & 5 )& the amplitude
Sites

Wave 1 – distal part of CN 8

Wave 2 – Proximal part of CN 8 near the brainstem
Wave 3 – cochlear nucleus
Wave 4 – Superior olivary complex
Wave 5 – Lateral lemniscus
Wave 6&7- Inferior colliculus
EE COLI
• As a screening procedure for infants

• To determine the threshold of hearing in infants,in

children & adults who do not cooperate& in malingerers

• To diagnose retrocochlear pathology particularly

acoustic neuroma
• To diagnose brainstem pathology –
multiple sclerosis,pontine tumours

• To monitor CN 8 intraoperatively in surgery of acoustic

neuroma to preserve the function of cochlear nerve
Disadvantages

• ABR cannot test hearing losses above 80dB

• It cannot detect hearing sensitivity in severe to

profoundly deaf infants

• ASSR is useful in such situations

5. Auditory steady state response

• Electrophysiological test uses steady state pure tone

signals instead of transient signals of tone bursts/clicks
used in ABR

• The steady state signals are also modulated rapidly in

amplitude & frequency & thus gives a frequency –
specific audiogram
• Hearing losses exceeding 80dB can be detected

• It can help in selection of children for cochlear

implantation at an early stage
6. Otoacoustic emissions

• Low intensity sounds produced by outer hair cells of a

normal cochlea elicited by a very sensitive microphone
placed in the EAC & analysed by a computer

• Sound produced by outer hair cells travles in reverse

direction

• Outer haircells basilar membrane perilymph

oval window ossicles TM EAC
• OAE s are present when outer hair cells are healthy

• Absent when they are damaged

• Helps to test function of cochlea

• Do not disappear in 8th nerve pathology (cochlear hair

cells are normal)
Types
a. Spontaneous
b. Evoked - elicited by a sound stimulus

a. Spontaneous OAEs

• Present in healthy normal hearing persons where

hearing loss does not exceed 30dB

• May be absent in 50% of normal persons

b. Evoked OAEs

• 2 types depending upon the sound stimulus used to elicit

them

1. Transient evoked OAEs

- Evoked by clicks

- A series of click stimuli presented at 80-85 dB

SPL (sound pressure level) & responses are
2.Distortion product OAEs

• 2 tones are simultaneously presented to the cochlea to

produce distortion products

• Used to test hearing in the range of 1000-8000 Hz

Uses

a). As a screening test of hearing in

neonates,uncooperative mentally challenged
individuals after sedation

b). Helps to distinguish cochlear from retro cochlear

hearing loss
• OAEs absent in cochlear lesions
• Ototoxic SNHL
• Detect ototoxic effects earier than PTA

c). Useful to detect retrocochlear pathology

• Auditory neuropathy- neurologic disorder of CN 8th
• Audiometric tests - SNHL for pure tones,impaired
speech discrimination score,absent/abnormal ABRs-
retrocochlear lesions – OAEs are normal
• OAEs absent in 50% normal,lesions of cochlea,middle
ear disorders ( sound travelling in reverse direction
cannot be picked up)when hearing loss exceeds 30dB
7. Central auditory tests

• Not used routinely

• Central auditory disorder – difficulty in hearing in noisy

surrounding/when the speech is distorted/not clearly spoken

3 types speech discrimination tests

a. Monotic test

Presented with speech message which is distorted

b. Dichotic test

• 2 different speech messages are presented

simultaneously

• One to each ear,pt is asked to identify both

staggered spondaic word test
• Pairs of spondaic words along with digits or non
sense words simultaneously presnted to the ears

• Temporal lobe lesions – difficulty in identifying the

words when presented to the ear opp to that of side
of lesion
c. Binaural test

• To identify integration of information from both ears

• Normal in cortical lesions

• Affected in lesions of brainstem

• Helps to localize the site of lesion

8. Hearing assessment in infants & children

1. Screening procedures
2. Behaviour observation audiometry
3. Distraction techniques
4. Conditioning techniques
5. Objective
• Evoked response audiometry
• Oto acoustic emmissions
• Impedance audiometry
References

1. Lt.Col.BS Tuli(ed.) Textbook of Ear Nose & Throat JPBMP

2005
2. Mohan Bansal Diseases of Ear Nose &Throat JPBMP 2013
3. P.Hazarika D R Nayak R Balakrishnan Hazarika’s textbook
on ENT CBS
4. P L Dhingra Shruti Dhingra Textbook of Ear Nose Throat
diseases Elsvier 6th edition 2014
5. S. Musheer Hussain (ed.)Logan Turner’s diseases of ear
nose & throat head & neck surgery Newyork CRS 11th
edition 2016
THANK YOU