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Comparing pure-tone audiometry and

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Otolaryngology–Head and Neck Surgery (2007) 136, 966-971
ORIGINAL RESEARCH
Comparing pure-tone audiometry and auditory
steady state response for the measurement of
hearing loss
Joong Ho Ahn, MD, Hyo-Sook Lee, MA, Young-Jin Kim, MD,
Tae Hyun Yoon, MD, and Jong Woo Chung, MD, Seoul, South Korea
OBJECTIVE: To compare pure-tone audiometry and auditory
steady state response (ASSR) to measure hearing loss based on the
severity of hearing loss in frequencies.
STUDY DESIGN AND SETTING: A total of 105 subjects
(168 ears, 64 male and 41 female) were enrolled in this study. We
determined hearing level by measurement of pure-tone audiometry
and ASSR on the same day for each subject.
RESULTS: Pure-tone audiometry and ASSR were highly cor-
related (r ⫽ 0.96). The relationship is described by the equation
PTA ⫽ 1.05 ⫻ mean ASSR – 7.6. When analyzed according to the
frequencies, the correlation coefficients were 0.94, 0.95, 0.94, and
0.92 for 0.5, 1, 2, and 4 kHz, respectively.
CONCLUSION: From this study, authors could conclude that
pure-tone audiometry and ASSR showed very similar results and
indicated that ASSR may be a good alternative method for the
measurement of hearing level in infants and children, for whom
pure-tone audiometry is not appropriate.
© 2007 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
A uditory deterioration in infants and children with early
hearing loss has been shown to be reduced by auditory
intervention within 6 months after birth.1 As a result, the
average age for cochlear implantation is decreasing. Obtain-
ing early, precise, and objective hearing information for a
subject with which to guide cochlear implant and other
treatment decisions is therefore becoming increasingly im-
portant.2 Information on hearing status is commonly ob-
tained with the use of pure tone audiometry; however, it is
not always possible to obtain reliable hearing information
for infants and children using pure-tone audiometry as a
From the Department of Otolaryngology, Asan Medical Center, Uni-
versity of Ulsan College of Medicine, Seoul, Korea.
Reprint requests: Jong Woo Chung, MD, Department of Otolaryngol-
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2006.12.008
result of a lack of cooperation and an inability to understand
the test. Similarly, visual reinforcement tools and play au-
diometry may also be inadequate, as it is often impossible to
perform audiometric tests on severely hearing impaired in-
fants and young children.
As an objective alternative method for acquiring pure-
tone audiograms for infants and children not suited to be-
havior observation audiometry, the auditory brain stem re-
sponse (ABR) can be used.3-5 This technique can, however,
face difficulties in the determination of the participating
frequency ranges because the test collects responses from
the whole basement membrane with a stimulus tone of short
duration. As a result, the ABR method has little frequency
specificity. In addition, ABR tests conducted with click
stimuli are of limited use in identifying threshold levels at
low frequency ranges.6 The ABR test is also inappropriate
for determining the characteristics of severe hearing loss
over 90 dBHL because this range is beyond its detection
limit.7
Several other audiometric tests have been introduced to
measure the frequency specific threshold level, especially
for low-frequency hearing loss subjects, although they are
not widely used because of their many shortcomings.8,9 The
newly introduced Auditory Steady State Response (ASSR)
method is a more promising approach, as it provides fre-
quency specific information facilitated by the use of a mod-
ified pure tone for gathering the response. The ASSR is a
scalp-recorded auditory evoked potential that is captured by
far-field electrodes like the ABR.10 Although there are some
similarities with the ABR, these techniques have very dis-
ogy, Asan Medical Center, University of Ulsan College of Medicine, 388-1
Pungnap-Dong Songpa-Gu, Seoul, 138-736, Korea.
E-mail address: jwchung@amc.seoul.kr
Ahn et al Comparing pure-tone audiometry and . . .
tinctive features. The ASSR is evoked by an AM/FM-
modulated tonal stimuli.11 Each stimulus is a continuous
tone with a carrier frequency of 0.5 to 4 kHz that is ampli-
tude (100%) and/or frequency modulated (eg, 20%) at a
modulation frequency of about 80 to 100 Hz. The power
spectrum of the stimulus shows primary energy at the car-
rier frequency and two sidebands separated from the carrier
by the modulation frequency. Automatic measurement is
also possible with this method. The test has been evaluated
as an objective method to effectively predict hearing level
as it offers the advantage of detection of a wider range of
hearing test threshold levels than the ABR method.9
Although the ASSR measurement is able to predict
threshold levels with 40 Hz-stimulation,12 the standard test
is highly affected by test subjects’ behavioral status (eg,
sleeping or awake),13 and it is therefore difficult to gain
reliable results from infants.14,15 A second disadvantage is
that ASSR has reduced response amplitude when several
stimuli are introduced simultaneously.16 For better perfor-
mance, Cohen et al13 collected responses with modulation
frequencies greater than 70 Hz as this reduced the effect of
sleeping status of test subjects, and simultaneous response
collection was enabled in each frequency zone without the
reduction of response amplitude.17 Moreover, the use of a
high modulation frequency (80 Hz) was found to be an
objective measurement tool for patients with hearing
loss.18,19
The ASSR measurement uses higher strength stimulus
tones than the ABR test, and due to the continuous and
regular characteristics of the tones, the technique can detect
more frequency specific responses.20 Hence, the ASSR
measurement can be used to obtain an overview of the
variation in hearing threshold level with frequency and is
expected to yield better hearing information even for indi-
viduals with profound sensorineural hearing loss (⬎90 dB
HL), for whom the ABR cannot be applied.2
In the present study, we compared the pure-tone audi-
ometry and the ASSR measurement for measurement of
hearing loss according to severity of hearing loss and fre-
quency in order to evaluate the applicability of ASSR as a
diagnostic tool capable of gathering accurate frequency-
specific hearing information.
TEST SUBJECTS AND METHODS
Test Subjects
Before recruitment of patients, approval was obtained for
this study from the Institutional Review Board at Asan
Medical Center (Seoul, Korea). During the period of Feb-
ruary to December 2004, tests were conducted on patients
who visited the Department of Otolaryngology at Asan
Medical Center suspected of abnormal hearing and on
young adults with normal hearing. Patients were excluded if
they had an ear disease such as chronic otitis media or otitis
media with effusion, or if they refused further evaluation
after hearing measurement had been conducted on one side.
967
In total, 105 test subjects (64 males and 41 females)
participated in the study and 168 ears were tested. The
average age of test subjects was 31.2 ⫾ 21.2 years (range,
5 to 74 years). All test subjects had normal mobile eardrums
as determined by otoscopy. The pure-tone audiometry and
the ASSR measurement were performed on all subjects. Of
these, 18 ears were excluded from the study because their
hearing loss was so severe that neither pure-tone audiometry
nor ASSR could measure any hearing thresholds over the
frequency range of 500 to 4000 Hz. For a total of 111 of 150
ears, hearing thresholds could be measured over all frequen-
cies with both the pure-tone audiometry and the ASSR.
Hearing thresholds at specific frequencies were measured
from different numbers of ears (range, 115 to 150 ears).
Methods
For the most precise comparison between the methods,
results of the pure-tone audiometry were reconfirmed before
the ASSR measurements were taken. Each test subject was
rested before the test by providing them with a bed, and
chloral hydrate (50 mg/kg) was administered to children to
induce sleep before the tests.
Stimulus and acquisition. The pure-tone audiometry was
conducted with the ORBITER (Madsen, Electronics, Taas-
trup, Denmark) and GSI61 (Grason-Stadler, Madison, WI,
USA) systems. At each frequency, hearing was tested at 5
dB intervals; specifically, threshold levels were determined
with increasing increments of 10 dB, followed by decreas-
ing increments of 5 dB.
A MASTER (Bio-logic, Inc, Mundelein, IL) system was
used for the ASSR measurement. A TDH39 headphone and
ER-3A tube phones with foam earplugs were used as trans-
ducers. Eight simultaneous multiple modulating frequencies
(82, 84, 87, 89, 91, 94, 96, and 99 Hz) were used when the
test was conducted on subjects with less than 90 dB HL. In
subjects with greater than 90 dB HL, a single modulating
frequency, either of 67 or 69 Hz, was used. At each fre-
quency (0.5, 1, 2, or 4 kHz), we measured the hearing at
each decibel level more than 256 times, with 16 epochs of
16 sweep counts, and both AM and FM modes with depths of
20% for FM and 100% for AM. As for the pure-tone audiom-
etry, hearing thresholds were measured with a 10 dB-up and 5
dB-down regimen. An initial intensity of 60 dB HL was used
when simultaneous multiple stimuli were allowed.
An F-ratio with a P value smaller than 0.05 was assumed
to represent a response and a rejection level of 40 to 80 ␮V
was used.
ANALYSIS OF THE RESULTS
The Pure-tone average (PTA) for a subject was calculated
by averaging the values at 0.5, 1, 2, and 4 kHz from the
pure-tone audiometry. Like pure-tone audiometry, mean
ASSR was also calculated by averaging the values at 0.5, 1,
968 Otolaryngology–Head and Neck Surgery, Vol 136, No 6, June 2007
Figure 1 Relationship between the mean hearing threshold
results obtained from the pure tone audiometry and the auditory
steady state response (ASSR) methods in dB HL (n ⫽ 111). The
correlation coefficient (r) is 0.96. The relationship is described by
the equation PTA ⫽ 1.05 ⫻ mean ASSR – 7.6.
2, and 4 kHz. Subjects who showed no response at all
frequencies in both the pure-tone audiometry and the ASSR
measurement were excluded from the correlation analysis.
The methods were compared with an assessment of the
correlation between the results of the two methods.
Statistical Methods
Simple regression analyses were conducted using the sta-
tistical package SPSS 10.0 version (SPSS, Chicago, IL).
RESULTS
Measuring Average Hearing Threshold
Levels
Measurable hearing threshold levels at all frequencies from
both pure-tone audiometry and ASSR measurement were
obtained for 111 ears. Results for hearing threshold levels
between the two methods were highly correlated (r ⫽ 0.96,
P ⬍ 0.0001, Fig 1). The relationship between the pure-tone
audiometry and ASSR measurement for measuring average
hearing threshold levels is described by the equation: PTA
⫽ 1.05 ⫻ mean ASSR – 7.6.
Measuring Hearing Threshold Levels
According to Frequency
When the results were analyzed for single frequencies, hear-
ing threshold levels as measured with the pure-tone audi-
ometry and the ASSR were again highly correlated, with
correlation coefficients of 0.94, 0.95, 0.94, and 0.92 for
frequencies of 0.5, 1, 2, and 4 kHz, respectively (Fig 2). The
relationships between the pure-tone threshold (PTT) and the
ASSR thresholds for the frequencies tested are described by
the following equations: at 0.5 kHz, PTT ⫽ 1.08 ⫻ ASSR
threshold – 10.4; at 1 kHz, PTT ⫽ 1.13 ⫻ ASSR threshold
– 9.6; at 2 kHz, PTT ⫽ 1.07 ⫻ ASSR threshold – 5.3; and
at 4 kHz, PTT ⫽ 0.99 ⫻ ASSR threshold – 6.3.
Measuring the Degree of Hearing Loss
We classified the level of hearing loss into three categories
with pure-tone audiometry results. The normal hearing
range was defined as less than 25 dB HL, the mild to
moderate hearing loss range was defined as 26 to 55 dB HL,
and the severe to profound hearing loss range was defined as
greater than 56 dB HL. On the basis of this classification,
the results obtained from the ASSR measurement were
highly correlated with the pure-tone audiometry results for
the mild to moderate (r ⫽ 0.91) and the severe to profound
(r ⫽ 0.91) hearing loss groups; results for the normal hear-
ing group were less strongly correlated between the two
methods (r ⫽ 0.62).
Cases Not Measured by Either Method
Among the 168 ears included in the analysis, we could not
measure hearing thresholds levels in 18 (10.7%) ears at 0.5
kHz, 27 (16.1%) ears at 1 kHz, 35 (20.8%) ears at 2 kHz,
and 53 (31.6%) ears at 4 kHz by either the ASSR or the
pure-tone audiometry methods (Fig 3).
DISCUSSION
In the ASSR measurement, an auditory-evoked response is
elicited from a subject with pure tones as stimuli that are
periodically modified in amplitude or frequency. The test
can be used while subjects are asleep, and the automated
threshold measurement method allows for simple operation
even by unskilled operators. These advantages have led to
an increase in its use as an objective hearing test tool for
infants and children. In addition, the test can be used to
evaluate hearing impairment levels by collecting objective
hearing data at numerous frequencies, and is thus a useful
aid for preparing medical reports.
Several studies have noted average hearing threshold
level differences (up to 10 dB) between the pure-tone au-
diometry and the ASSR, although better agreement has been
reported as the degree of hearing loss increases from severe
to profound.19,21 In the present study, results obtained from
the pure-tone audiometry and the ASSR for measuring av-
erage hearing threshold levels were found to be highly
correlated (r ⫽ 0.96). This indicates that average threshold
levels obtained from the ASSR results can be assumed to be
close to those that would have been obtained with the
pure-tone audiometry. For the severe to profound hearing
loss group, results from the two tests were highly correlated
(r ⫽ 0.91). For the normal hearing group, however, the
correlation appeared somewhat weaker (r ⫽ 0.62). This
Ahn et al Comparing pure-tone audiometry and . . . 969

Figure 2 Relationship between hearing thresholds obtained from the pure-tone audiometry and the auditory steady state response (ASSR)
methods in dB HL according to frequency. The correlation coefficients (r) are 0.94, 0.95, 0.94, and 0.92 for 500, 1000, 2000, and 4000 Hz,
respectively. The regression equations are given in the lower right corner of each panel.

suggests that the ASSR may be less suitable to test subjects
with normal hearing.
Lins and Picton17 suggested that the ASSR results should
be interpreted with caution at 0.5 kHz due to internal jitter-
ing caused by neurologic asynchronicity, which indicates
potential difficulties in determining threshold levels for low-
frequency stimuli compared with high-frequency ones.
Aoyagi et al22 report correlation coefficients between the
two methods of 0.73, 0.86, 0.88, and 0.92 at frequencies of
0.5, 1, 2, and 4 kHz, respectively, with 80 Hz of high
modulation frequency (MF). Lins et al18 reported correla-
tion coefficients of 0.72, 0.70, 0.76, and 0.91 for the same
frequencies with modulation frequencies of 70 ⬃ 110 Hz.
The current study yielded high correlation coefficients be-
tween the two methods of 0.94, 0.95, 0.94, and 0.92 at 0.5,
1, 2, and 4 kHz. Although the correlation coefficients were
higher in all frequencies than previous studies, the current
study showed a relatively lower correlation coefficient at 4
kHz than at the other frequencies. Unlike previous studies,
we used different modulating frequencies to measure hear-
ing thresholds, and we applied different sets of modulating
frequencies to determine whether the hearing of tested ear
was over 90 dB HL.
In a few cases, we failed to measure hearing threshold
levels with either the pure-tone audiometry or the ASSR
measurement, particularly for profound hearing loss pa-
tients with greater than 90 dB HL. Diverging results be-
tween the two methods were found with increasing fre-
quency. This may be due to differences in equipment
limitations for each method; the pure-tone audiometry could
be used up to 120 dB HL, whereas the ASSR measurement
was useful only to 110 ⬃ 115 dB HL.
In a previous study, strong correlations were found
between the threshold of ABR and the 2 to 4 kHz ASSR-
based average hearing.23 Therefore, the pure-tone audi-
ometry or the ABR measurement could be substituted in
970 Otolaryngology–Head and Neck Surgery, Vol 136, No 6, June 2007
Figure 3 Proportion of cases in which hearing thresholds could
not be calculated with either the pure-tone audiometry or the
auditory steady state response (ASSR) methods. The proportions
increased from 10.7% to 31.6% as the frequency rose.
cases of severe or profound hearing loss where the ASSR
measurement has poorer performance, although there is
some disagreement between the pure-tone audiometry
and ASSR measurement in clinical use. We suggest that
the ASSR measurement is suitable when collecting data
on peripheral hearing loss that are required for planning
rehabilitation processes, when considering treatment us-
ing cochlear implants, or when controlling the amplitude
of tests is important. Furthermore, the ASSR measure-
ment is the only test able to measure residual hearing at
low frequencies in infants or young children or in pa-
tients who have unreliable results from the pure-tone
audiometry tests.
In summary, the ASSR measurement appears highly suit-
able to test hearing of infants or young children when
specific medical therapy is required. The test can also be
used as a supplementary test for adults.
CONCLUSION
The present study showed that the pure-tone audiometry
and the ASSR gave very highly correlated results when
they were used to measure the degree of hearing loss (as
derived from measuring average hearing threshold levels)
and to determine hearing threshold levels according to
frequency.
We conclude that the ASSR is a useful diagnostic tool
that provides important hearing information for guiding
medical therapy decisions, such as whether to supply hear-
ing aids or whether cochlear implantation is warranted. The
ASSR measurement is especially suitable for infants and
children for whom the pure-tone audiometry and the behav-
ior observation audiometry testing methods may not be
appropriate.
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