INTEGRATED AUDIOMETRIC TESTSFOR COCHLEAR AND ETROCOCHLEARPATHOLOGIES

Jyotsna Nadkarni Audiologist and Speech Pathologist, Bombay Hospital Medical Research Centre, Mumbai 400 020.

In the earlier years differential diagnosis for audiometric test results were limited. The first audiometric test battery came into existence with the inclusion of speech tests in 1924. Supra-threshold audiometric tests were reported in 1930s. With the pure tone Audiogram, comparison of air and bone conduction results assisted in the diagnosis of conductive, sensorineural and mixed hearing impairment. Speech tests alone were of little diagnostic value. So the special audiometric test to differentiate cochlear pathology vs retro-cochlear pathology came into existence. Indications for the Special Audiometric Test are sensori-neural hearing loss associated with the symptoms like giddiness, tinnitus, vomiting, nausea, positional vertigo, imbalance etc. SPECIAL AUDIOMETRIC TESTS I. Subjective (Behavioral) Tests Pure Tone Audiometry Tests i) TDT : (Tone Decay Test) : TDT is the most commonly used tests because the test can be reliably carried out on any pure tone audiometer and helps in diagnosing neural lesions like acoustic neuroma. In TDT a sustained air conducted ear tone is presented while assessment of resulting changes in auditory threshold is made. There are two commonly used methods: 1. Carharts TD Test 2. Rosenbergs TD Test Results of TDT 1. Normal 2. Mild 0.5 dB in 60 seconds. 10-15 dB in 60 seconds.

3. Moderate 20-25 dB in 60 seconds. Marked TD Indicates Retro-Cochlear Pathology II. SISI : (Short Increment Sensitivity Index)

The SISI test determines the capacity of a patient to detect a brief 1 dB increment at a 20 dB suprathreshold tone (called carrier tone) in various frequencies (preferably at 1000 Hz and 4000 Hz). This increase in the intensity of the carrier tone may be varied from 6 dB to 1 dB, Twenty such 1 dB increments are presented in the test ear and patient is asked to count how many of these 1 dB increments he could correctly identify. This multiplied by 5, gives the percentages SISI score. Interpretation of SISI Test Jergers classification for the test is done at 1000 Hz and above: - If SISI score is above 70% (+ve SISI) Cochlear pathology. If SISI score is < 30% (-ve SISI) - Disorder elsewhere than inner ear. Though SISI test is useful in distinguishing between cochlear and retro-cochlear lesions, it is not entirely foolproof and has its own limitations. So it should be used as a part of audiological test battery and the results must be interpreted in the light of other audiological findings. III. Other Audiological Tests for Recruitment Recruitment : A patient with a loudness recruitment responds to increased stimulus intensity with an abnormally rapid rise in the loudness. Often occurs in cochlear pathology. This phenomenon is often related to dysfunction of sense organ and may occur in cochlea with an alteration in endolymph as well as in those with structural changes in organ of corti. Recruitment Tests a. Loudness discomfort level (LDL) : In the normal ear, the LD threshold is between 90 dB and 105 dB. Narrow dynamic range indicate abnormal loudness growth and recruitment which is observed in the cochlear pathology. b. ABLB : (Alternate Binaural Loudness Balance) : It is a standard behavioral test for recruitment. A pure tone test is done when there is a threshold difference of > 20 dB between the ears at the test frequency (the better ear is relatively normal). The purpose of ABLB test is to compare the growth of loudness in the impaired ear with the growth of loudness in the opposite (normal) ear to demonstrate the degree of recruitment. This test is mainly used for unilateral hearing loss cases where the two different loudness levels of a tone is alternately given in a test ear and normal ear. Patient is asked to find out whether they heard equal in loudness or one is softer or louder than the other and then ladder gram is plotted to find out whether there is a recruitment in the test ear. Limitation This test can be administered mainly in unilateral hearing loss.
REFLEX DECAY It is interesting that you ask about the Acoustic Reflex Decay Test. In 1970, it was felt that acoustic reflex decay was common in the presence of acoustic tumors. However, later research showed that in fact the acoustic reflex will more likely be absent or entirely normal rather than decay when a tumor is present. Therefore you must first ask yourself why you are doing the procedure. If there is a strong suspicion of the presence of an acoustic tumor, then ABR would be the diagnostic procedure of choice.

The Acoustic Reflex Decay test is given with the stimulus presented in the ear contralateral to the probe tip. A continuous pure tone stimulus is presented 10 dB above acoustic reflex threshold for 10 seconds. Be careful, you must use good clinical judgment when presenting acoustic stimulation at intense levels, and you should not use stimuli that are above 105 dB HL or 115 dB SPL. The test is positive if the magnitude of the reflex decreases by more than 50% in ten seconds. In a normal ear, the reflex should stay contracted for the full 10 seconds. You are testing the ear which received the stimulus (not the probe ear). This concept tends to trouble many of my students. When eliciting the Acoustic Reflex you must first ask what you are trying to measure. If you want to determine presence or absence of the reflex then the test ear is the ear with the probe tip. However if you are making dynamic measures of the acoustic reflex such as threshold, latency or decay, then the test ear is the one with the stimulus. It all depends on the question you are asking; presence/absence is not the same question as threshold or decay - two different questions; two different ears. Dr. Gerald T. Church has been educating audiologists for many, many years. He is a professor and Director of the Au.D. Program at Central Michigan University. He is currently an empty nester who is living the part of the story that begins happily ever after with his wife of 29 years in the wonderful town of Mt. Pleasant, Michigan. He may be reached at churc1g@cmich.edu.