Understanding the Audiogram

and Audiometric Testing: So

What?

Larry Medwetsky, Ph.D.

Gallaudet University
larry.medwetsky@Gallaudet.edu
Background
Initially, as a consumer I often did not understand what
the different procedures were examining and why they
were being done
As an audiologist:
Often read that consumers forgot much of the presented
information (it is hard to remember if one does not
completely understand the information or if presented too
quickly)
Often have heard from consumers that audiologists did not
explain information and not really understand the results
Todays Presentation Goals
By the end of this presentation you will be better able to
understand:
the nature of the tests that you may have had done at a
hearing test (or will have done at future testing)
the audiometric results, such that you may better
understand what they mean as they apply to you
I will describe the tests (and interleave their audiometric
interpretation) that may occur over course of a hearing
assessment.
Case History
Although the case history is obviously not an audiometric test, the
information gleaned:

May indicate a possible underlying medical condition and need

for possible subsequent referral

Provides a framework as to why the individual has come for a

hearing test

Sets the stage for the type of tests that will be administered

Provides means of examining if results align with major issues

expressed by the client
Otoscopy
Entails use of instrument consisting of a magnifying lens
and light to examine the external ear canal and the
Tympanic Membrane (eardrum)

Allows the audiologist to determine:

If cerumen (earwax) is present, and, if so, how much
If the Tympanic Membrane looks abnormal in any
fashion (e.g., appears very red or bulging)
Speech Reception Threshold (SRT) Testing

SRT is often first test administered, as provides initial idea

as to what individuals hearing acuity in each ear may be

Consists of spondees (compound words of equal stress,

such as Cow-Boy; Hot-Dog)

Goal to find softest level individual able to hear and able

to repeat approximately of the words correctly
Speech Reception Threshold (SRT) Testing

Audiologist usually starts at a level knows that client can

easily hear and presents all of the words at that level
(i.e., familiarizes the client)

The audiologist then decreases the intensity in 5 or 10

decibel steps, and presents spondees at each level

If client correctly responds to all spondees correctly, then

audiologist decreases intensity by another 5 or 10 dB
SRT Testing- contd
If level reached where individual cant repeat any of the words
or less than 50%, then level increased in intensity by 5 decibels
The point at which approximately 50% of the spondees
are repeated accurately is considered to be the SRT
The SRT typically approximates the thresholds obtained at 500,
1,000 Hz and 2,000 Hz
Note for sharply falling audiogram where the high frequencies
are much worse than the low frequencies, the SRT is similar to
the average of 500 and 1,000 Hz
SRT Interpretation

An Adult SRT is within normal hearing range if it occurs at

25 dB HL or less
Even if SRT falls in normal range, does not mean that
hearing loss is not present

For example, if an individual only has a hearing loss at

3,000 Hz and above, he or she has good enough hearing in
lower frequencies to accurately perceive the spondees at
normal hearing levels
SRT Interpretation

That is, spondees requires one to only have good

hearing in the low-to-mid frequencies

In turn, SRT results provide audiologist basis for

estimating the level at which to conduct
pure-tone testing
Speech Awareness Threshold

The Speech Awareness Threshold (SAT) is sometimes

obtained when an individual has a hearing loss so great
that able to hear the spondees but not understand
what was said

In this case, the SAT refers to the softest level that an

individual can hear a presentation approximately 50%
of the time
Speech Awareness Threshold
The SAT usually coincides with the frequency of
individuals best (lowest) threshold

For example, if a client has:

o 80 dB HL (250 Hz)

o 100 dB HL (1,000 Hz)

o 100 dB HL (8,000 Hz),

the SAT will likely be at 80 dB HL

Pure-Tone Audiometry

Tones of different frequencies are presented:

Goal is to find softest intensity level at which

individual can hear the different tones
This test is usually administered in one of two ways:

1. Air Conduction Audiometry

2. Bone Conduction Audiometry
Pure-Tone Audiometry

Air Conduction Audiometry- placement of headphones

over the ears or insert earphones- placing foam tips
into the individuals ear canal

Bone Conduction Audiometry- involves placement of a

vibrating device on a persons skull
 Vertical axis represents the intensity levels, descending from soft
to louder

Horizontal axis represents the frequency- as on a piano going

from bass (low frequency) to treble (high frequency) sounds
Air Versus Bone Conduction Audiometry
By comparing results of both procedures, one can determine:

If there is a hearing loss present and degree of severity

If the results across all frequencies are similar;

if so, means there is no difference whether tones are

presented via outer/middle and inner ear (air
conduction) versus the inner ear (bone conduction)
Air Versus Bone Conduction Audiometry

Thus, no conductive component present (i.e., no

problem with either the outer/middle ear- such as
cerumen or middle ear fluid, etc.)

If hearing loss present in this case, referred to as

sensorineural hearing loss
Air Versus Bone Conduction Audiometry
If is a difference between air versus bone conduction thresholds
(i.e., bone conduction thresholds are significantly better),
suggests conductive component present:
Results obtained via air conduction (outer/middle/inner ear)
are worse than the bone conduction (inner ear)
Indicates issue in either the outer ear canal
(e.g., cerumen) and/or middle ear (middle ear fluid or
problem with middle ear bone movement)
Thus, sounds stimulate inner ear more easily via bone
vibrator (which bypasses the outer and/or middle ear)
Air Versus Bone Conduction Audiometry
If the bone conduction results are normal, hearing loss
referred to as a Conductive hearing loss

If, bone conduction (inner ear) results reveal hearing loss,

and air conduction results are worse (referred to as a
air/bone-conduction gap, Mixed hearing loss is said to be
present)
Example of a Conductive Hearing Loss
Understanding the Signs of Hearing Loss
Early Signs Of Hearing Loss
The individual:
has trouble hearing when people talk softly
hears but doesnt always understand
says that many people sound as if they are
mumbling
often finds him (her) self straining to hear others
Early Signs Of Hearing Loss contd

has difficulty hearing when people dont look at him

(her) or if they are in another room

has TV turned up loud/trouble hearing on the phone

(phone: usually more hearing loss present)

has trouble hearing when there is much noise

Word Recognition Score (WRS)
Depending on the degree of hearing loss, an audiologist will
present 25 or 50, single syllable words at one or more listening
levels:

Everyday Conversational Level (approximately 50 dB HL

at 5 feet distance)

Goal, to see how easy to perceive/recognize words at an

everyday talking level
Word Recognition Score (WRS)

Comfortable Listening Level

Depends on degree of hearing loss: Once

audiologist determines how much louder
individual needs to comfortably follow
conversation, then assesses how individual does
at this preferred (most comfortable) listening
level
Word Recognition Score- contd
WRS Test in Quiet:

Unaided- examines much difficulty individual has at:

o Everyday Conversational Level (50 dB HL)

o Most Comfortable Listening Level (MCL)

determine if performance improves at the
individuals preferred louder, listening level
Word Recognition Score- contd

Poor performance at 50 dB HL shows that the

individual likely experiences difficulty if people are
not facing him at average talking levels at six feet
away

Improved performance at MCL indicates that

individual likely to do much better with hearing
aid(s)
Word Recognition Score- contd
Note that individuals with a milder hearing loss who
indicate hearing okay 1-1 in quiet at 5 feet, but
complain of hearing at a distance or if people talk at a
soft level:
o Can conduct WRS testing at 35 dB HL- a soft
speaking level and see how individual does

One can also compare unaided versus aided

performance at the soft and average conversational
level to see degree of improvement
Word Recognition Score- contd

WRS testing discussed on previous slides referred to

testing in quiet

One can also administer test in background noise to see

how much additional difficulty individual may experience
(gives audiologist additional information)
Word Recognition Score- contd

Note there are other tests that are presented in noise

One test presents sentences in cocktail party noise at

different speech-to-noise ratios (how loud speech is
relative to noise)

The results inform the audiologist if hearing aid(s)

likely to provide individual benefit in noise, or, if a
hearing assistive device- such as an FM or Blue-Tooth
enabled device would also need to be recommended
Loudness Discomfort Level (LDL)
If individual needs hearing aids, important to not only
determine how much amplification person needs to hear
soft and moderate level sounds, but also need to ensure
amplification not so much that it will bother individual

Consequently, LDLs (i.e., loudest levels individual can

tolerate without being uncomfortably loud) are
determined:
o Speech
o Specific frequencies
Immittance Audiometry
Immittance Audiometry refers to a series of tests
that can be conducted to assess middle ear function
Is one of the objective test measures that an
audiologist can administer without need for
behavioral responses from client

Tympanometry
Audiologist places a rubber tip (must be just the
right size) into the ear canal
Gradually changes air pressure in the ear canal
 Tympanometry- contd

Results indicate:
Tympanic Membrane (eardrum) mobility relative to
normative values
Air pressure which Tympanic Membrane (TM) moves
best:
o If the outer/middle ear canal is normal, TM moves
best in range similar to atmospheric pressure
Tympanometry- contd

o If pressure that TM moves best is negative relative to

atmospheric pressure, indicates air is prevented from
entering the middle ear from Eustachian Tube in
normal fashion (e.g., mucus from cold)

o If tracing is flat curve, indicates TM is either thickly

scarred or middle ear fluid is present (determination
of such is based on looking at other test results)
Acoustic Reflex (AR) Testing
Administered after tympanometry with seal in place

Loud sounds are presented, goal to determine level at

which the stapedius muscle contracts (i.e., audiologist may
see deflection on a monitor if sound loud enough to elicit
contraction for that individual- as long as no middle ear
problem present)

Stapedius muscle is connected to the stapes (stirrup),

the last of the three middle ear ossicles; connects to
the Oval Window of the Inner Ear
Acoustic Reflex (AR) Testing

Believed that stapedial reflex protects inner ear

somewhat from loud sounds

The pattern of AR results- combined with the rest of the

test battery- provides additional information concerning
middle and inner function
Concluding Statements

Hoped information provided today helps you better

understand procedures typically administered by an
audiologist and clinical information that can provide
Also, hope you better understand how to read an
audiogram and able to see which type of speech sounds
are likely to be audible:
Of course, depends on talker level, distance from
talker, and if noise is present
Concluding Statements

If you would like more information on these

topics, please go to the May/June and
September/October 2014 Hearing Loss
Magazines and see the articles by Larry
Medwetsky