Development of An Audiological Test Procedure Manual For First Year Au.D. Students
Development of An Audiological Test Procedure Manual For First Year Au.D. Students
Development of An Audiological Test Procedure Manual For First Year Au.D. Students
Students
Patricia I. Carr
Doctor of Audiology
Development of an Audiological Test Procedure Manual for First Year Au.D. Students
Patricia I. Carr
(ABSTRACT)
ACKNOWLEDGEMENTS
I would like to thank God for giving me the strength, encouragement, and ability to complete this
project. I am still in awe as to how my fingers would flow across the keyboard and at how the
words just appeared on the screen.
Furthermore, I would like to thank my loving husband, James, and our two wonderful children,
James and Becca. They have put up with a lot over the past several years. I did my best to be
there at those special moments and times of need, but couldn’t be there for all of them. Yet you
were all there when I needed the encouragement during the numerous times when I wanted to
quit. I will now be able to make up for the time lost with each of you and as a family, which will
take the rest of our lives.
I would like to express my sincere appreciation and gratitude to my committee head, Dr. Hurley,
who provided me with his expertise, guidance and support throughout the entire professional
research project process. In addition, I would like to thank my committee members, Dr. Hnath-
Chislom, and Dr. Lister, for their ongoing support and encouragement. For without all of them,
this would not have been possible.
As for my students, I would like to thank the first and second classes since the inception of the
Au.D. program for their continued patience, encouragement, and support. They have been an
inspiration. A special thanks to my graduate assistant Tim Skinner for his assistance and
support.
Thanks Mom and Dad for listening to me during this great challenge. Lastly, I must not forget
Lindsay and Allie who periodically checked on me and assisted my family in maintaining some
sense of sanity in our household.
Patricia I. Carr 4.
CHAPTER 1
Key Words
Air conduction Audiometer Automatic Audiometry
Bone conduction Hughson-Westlake Manual pure tone audiometry
Method of limits Threshold
Normative pure tone threshold values have existed since 1951 with the publication of the
American Standards Association Document: “Audiometers for General Diagnostic Purposes”.
(ASA, 1951). Pure-tone audiometry began after the Bunch and Dean presentation of the “Pitch
Range Audiometer” in 1919 before the American Otologic Society (Bunch, 1943). In 1978, the
standard procedure for pure-tone threshold testing was established. (ANSI, 1978).
Pure-tone audiometry is part of the basic audiometric evaluation and consists of air
conduction (AC) and bone conduction (BC) testing. There are two methods that may be used in
the clinical setting. These are manual pure tone audiometry and self tracking automatic
audiometry (Bekesy-type audiometry). The reader is encouraged to refer to the references for
further information regarding the Bekesy-type automatic audiometry. This manual will
concentrate on the method known as manual or conventional pure tone audiometry.
Prior to obtaining thresholds, the tester must decide which psychophysical threshold
procedure to use with the particular patient. The procedure selected depends on the reason for
the evaluation, stimuli available, and the patient. There are a variety of threshold procedures
such as single stimuli, counting, forced choice, adjustment, limits, tracking, and staircase that the
tester may select to use, either alone, modified, or in combination, in the determination of
hearing thresholds. The reader is directed to the references for further detail on each of these
Patricia I. Carr 5.
methods. The method discussed here is an ascending technique using a modified method of
limits procedure; the modified Hughson-Westlake technique (Carhart & Jerger, 1959).
Definition
Pure-tone audiometry is used to determine the threshold of hearing of the patient and is
defined as the lowest hearing level at which the patient responds at least 50% of the time to
auditory stimuli. Thresholds are generally obtained for each ear separately. These thresholds are
obtained using procedures as recommended by the American Speech-Language-Hearing
Association (ASHA) 1977 Guidelines, the American National Standards Institute (ANSI) 1987
and 1992 Guidelines, and the International Standards Organization (ISO) 1982 and 1984
Guidelines. (Wilber, 1999).
Test Procedure
There are several techniques that may be used by audiologists in the clinical setting.
These include the Carhart-Jerger (1959) modification of the Hughson-Westlake (1944) ascending
technique, and the ANSI (1978) and ASHA (1978) testing guidelines. The various techniques
may also be described by the direction of intensity change (ascending or descending). The
ascending approach will be discussed at this time and the reader is directed to the references for
information regarding the descending approach. Typically, the auditory stimuli are first
presented at supra-threshold levels. For each of the techniques, a tone familiarization process is
conducted to determine a dB level near the patient’s threshold. From there, the intensity of the
stimulus is increased or decreased depending on the patient’s response. If the patient responds to
Patricia I. Carr 6.
the tone, the intensity of the next tone is decreased in 10 dB steps until the patient ceases to
respond. If the patient does not respond to a tone, the intensity of the tone is increased in 5 dB
steps until the patient responds. This is known as the “up-5 down-10” technique. This “up-5
down-10” process is repeated until the level at which the patient responds to two out of three
presentations or three out of six presentations is determined. Stimuli are presented for one to two
seconds with varying time intervals between presentations. The patient indicates that auditory
stimuli were heard by responding via handraising, raising a finger, or pushing a button. See for
“Step-by-Step Procedures” below for details.
Other procedures may be necessary for children, older patients, and difficult to test
patients. The standard procedures for threshold determination will be covered at this time, the
reader is directed to the references for further information regarding testing special populations.
INSTRUMENTATION
Audiometer
A diagnostic audiometer is capable of producing pure tones at various frequencies as well
as broad-bands of noise and narrow-band noise. Another type of audiometer that usually
produces pure tones is the screening audiometer. The diagnostic audiometer is the instrument
that will be discussed in this manual. The reader is directed to the references for information
regarding screening audiometers. The audiometer used in pure tone audiometry must meet the
specifications as outlined by the American National Standard Specifications for Audiometers
S3.6-1969 (ANSI, 1969). The major components of an audiometer are the oscillator, the
attenuator, and the interrupter switch. The oscillator produces pure tones at octave and half-
octave frequencies from 125 to 8000 Hz. Some audiometers may have extended high frequency
capabilities up to 20,000 Hz. The attenuator controls the intensity level of the pure tones in 5-dB
steps and some audiometers are capable of producing 1-or 2-dB steps. The interrupter switch
controls the length of time the pure tone is presented to the patient. For other features available
on an audiometer, the reader is directed to the manufacturer’s manual that accompanies the
audiometer to be used. At the beginning of each test day the tester must perform a biological
listening check to ensure that all components are functioning properly. Refer to the listening
check procedure used by your testing facility.
Patricia I. Carr 7.
GO TO LABORATORY
EXERCISE # 1.0
Calibration
The audiometer used in pure tone testing along with the earphones, insert receivers, and
speakers should be calibrated at least annually based on the ANSI S3.6 – 1996 Guidelines
(ANSI, 1996). The bone vibrator should be calibrated at least annually based on the ANSI
S3.43- 1992 Guidelines (ANSI, 1992) for frontal or mastoid placement.
Test Environment
Pure tone threshold testing should be administered in a sound controlled room to avoid
masking by unacceptable noise levels in the room (Wilber, 1999). Appendix A shows the
acceptable ambient noise levels, as stated in ANSI S3.1 (ANSI, 1991), that may be present in a
room so that thresholds as low as 0 dB HL may be obtained.
Key Words
Acoustical radiations Azimuth Bilateral hearing loss
Circumaural earphones Collapsing ear canal Conductive hearing loss
False-negative response False-positive response Graphic audiogram
Insert receivers Interaural attenuation Mixed hearing loss
Numerical audiogram Peripheral hearing Pulse-tone
Sensorineural hearing loss Speakers Standing waves
Steady tone Supra-aural earphones Tactile responses
Transducer Unilateral hearing loss Warble tone
Background Information
Hearing thresholds are obtained to determine whether the patient has a peripheral hearing
loss: a hearing loss in the external ear, the middle ear, or the cochlea. Air conduction (AC)
Patricia I. Carr 8.
thresholds are obtained for a frequency range for each ear and are defined as the lowest hearing
level at which the patient responds at least 50% of the time to auditory stimuli.
INSTRUMENTATION
Test Stimuli
The test stimuli used in AC testing are pure tones of different frequencies. Usually the
patient’s thresholds are determined using the octave frequencies from 250 to 8000 Hz. There are
some instances, especially in the monitoring of high frequency hearing loss due to ototoxicity
where frequencies above 8000 Hz and up to 20,000 Hz are assessed. Tones used in pure tone
audiometry include continuous pure tone, pulsed pure tone, or warble tone.
Patricia I. Carr 9.
Transducer
AC testing may be administered using earphones, insert receivers, or speakers (ANSI,
1996). The selection of the appropriate transducer to use with a patient is usually determined by
patient factors.
Earphones
If earphones are the selected transducers, the tester must place the earphone diaphragm
over the opening of the ear canal. To avoid low frequency transmission loss, the earphones must
fit snugly over the patient’s ears. Loose fitting earphones could be reflected as an erroneous low
frequency hearing loss on the audiogram (Wilber, 1999). The tester, however, must be alert to
the possibility of a collapsing ear canal in some patients, especially young children and geriatric
patients. A collapsing canal is created by the pressure of the earphone on the pinna, which then
occludes the ear canal and creates a conductive hearing loss in the presence of a normal
tympanogram (Wilber, 1999). To avoid the possibility of collapsing ear canals the tester is
advised to routinely use insert receivers (see below). Supra-aural earphones rather than
circumaural earphones are the selected earphones for AC testing at this time. Although, the use
of circumaural earphones are indicated for extended high frequency (above 8000 Hz) testing.
The reader is directed to the references for further information regarding circumaural earphones.
Note that the interaural attenuation for earphones is considered to be 40 dB across frequencies
(Gelfand, 1997).
Insert receivers
The advantages of utilizing insert receivers include increased interaural attenuation,
increased ambient noise attenuation, elimination of ear canal collapse, and increased patient
comfort (Hall & Mueller, 1998; Yacullo, 1996). The interaural attenuation for insert receivers is
approximately 60 dB across frequencies (Sanders & Hall, 1999). The tester should not use insert
receivers in the presence of atresia, a stenotic ear canal, or a draining ear (Stach, 1998).
In order to receive the best benefit from proper insertion of foam tips, the tester may use
the following steps (Yacullo, 1996):
1. Prior to insertion ask the patient if he/she has any jaw problems.
2. Attach the receivers to the patient’s clothing, red for right and blue for left.
Patricia I. Carr 10.
3. Place the appropriate sized foam tips to the end of the each plastic tubing via
the white nubbin.
4. Squeeze the foam tip between your fingers prior to inserting to the patient’s
ear.
5. Gently pull up and back on the patient’s pinna to straighten out the ear canal
and then insert the foam tip quickly. The goal is to insert the foam tip so that
the outer edge is at the aperture of the patient’s ear canal.
6. While the foam tip is conforming to the shape of the patient’s ear canal, have
the patient open and close their mouth several times as you gently wriggle the
pinna.
Insertion of the foam tip is important to the accuracy of test results. The deeper insertions
without touching the tympanic membrane offer reduced occlusion effect and greater interaural
attenuation values over that of shallow insertions. It is advised that the tester check the tubing
for cracks, holes, kinks, and occluding debris on a periodic basis. Check for occlusion if the
patient exhibits an unexpected mild conductive hearing loss by removing the insert and then
examining the insert for blockage with cerumen. Upon completion of testing, the tester is to
properly dispose of the foam tips, making sure that the white nubbin remains attached to the
tubing.
Speakers
Speakers in the soundfield should be used for special testing such as determining
functional gain on hearing aids and for patients, especially young children, who refuse to wear
earphones. Also, patients who cannot use earphones or insert receivers due to draining ears and
excessive cerumen may be tested using speakers. During soundfield testing, the patient is seated,
with ears uncovered, at the point to which the speakers were calibrated. Refer to the procedures
used by your testing facility. The patient is seated at a certain azimuth that is used to describe
the relationship between the patient’s head (ears) and the sound source. Zero degree (0o)
azimuth means that the patient is facing the speaker. An azimuth of 90o, means that the patient is
seated so that the speaker is directed to the right ear. When the patient has her/his back to the
speaker that denotes an azimuth of 180o. An azimuth of 270o means that the patient is seated so
that the speaker is directed to the left ear (Wilson & Strouse, 1999).
Patricia I. Carr 11.
When testing in the sound field at azimuths of 0o and 180o , stimuli reach both ears at
equal intensity and therefore threshold values are not obtained for each ear separately. The
resulting threshold could be for the better ear, if the sensitivity of one ear is better than the other,
or both ears if the hearing is the same in both ears. The tester does not know which ear is
responding. The recommended speaker azimuths are 90o and 270o to take advantage of the 10-15
dB attenuation of the stimulus at one ear (head shadow effect). If responses are bilaterally
symmetrical, then ears are of equal sensitivity. If there is a 10-15 dB difference between
responses, it is unclear which ear is responding.
Warble tones or pulsed narrow bands of noise must be used when testing in the sound
field to avoid the occurrence of standing waves. The warble tone stimulus is the preferred
auditory stimulus over the pulsed narrow bands of noise for use in the sound field, especially for
patients with high frequency hearing losses (Wilbur, 1999).
Response Mode
The patient may indicate that auditory stimuli were heard by raising her/his hand, by
pushing a button, or by responding verbally. The response mode selected by the tester depends
on the needs of the patient. If the patient has limited arm mobility, then the hand raise method is
inappropriate. The verbal response mode is inappropriate for patients with a speech, voice, or
language disorder. The hand raise or button-pushing responses are preferred because they are
clear-cut actions seen by the tester and they are noiseless. Responses made verbally are the least
preferred of the three modes for several reasons:
1. Jaw movements may alter the acoustics of the ear canal and may sporadically create a
collapsing ear canal (Hall & Mueller, 1998);
2. Test tones may be masked by the patient’s voice if they talk at the time a tone is
presented (Gelfand, 1997); and
3. Some patients don’t limit their responses to “yes”, but will add comments thought to
be helpful to the tester. This is to be discouraged as it lengthens test time.
During threshold determination, the tester should be aware of false-positive and false-
negative responses made by the patient. False-positive responses occur when the patient
Patricia I. Carr 12.
responds to a tone that was not presented. False-negative responses occur when the tone was
presented at a level above the patient’s threshold, but the patient did not respond to the tone.
False-positive responses may occur for the following reasons (Gelfand, 1997):
1. Technical problems such as tactile stimulation and/or acoustical radiations.
2. The patient may experience tinnitus that was confused with the tone.
3. The patient may not have understood the instructions.
4. The patient may not have learned the proper way to respond, or may have lax
response criteria.
5. The tester presented tones in a rhythmic pattern, rather than at irregular times
intervals.
Reasons for the occurrence of false-negative responses are as follows (Gelfand, 1997):
1. Equipment problems or tester error (e.g., the tone never reached the patient because
the incorrect transducer was selected on the audiometer.
1. The patient may experience tinnitus that was confused with the tone.
2. The patient may not have understood the instructions.
3. The patient may not have learned the proper way to respond, or may have very strict
response criteria.
4. The patient may present with an unconscious or conscious functional hearing loss.
5. Technical problems such as the occurrence of collapsed ear canals and standing
waves.
Presentation Mode
Stimuli are presented at various interstimulus intervals from one to three seconds apart.
Keep in mind that some patients may need longer time intervals in which to produce a response
due to the presence of some neurologic dysfunction. (Wilber, 1999). Tones are usually presented
for a one to two second duration.
Patient Positioning
In the test room, the patient should be seated in a comfortable chair with armrests. The
armrests allow the patient to rest their arm and reduce fatigue that may be experienced from the
Patricia I. Carr 13.
hand or finger raising response. Swivel or reclining chairs should be avoided because patients’
movements in them are noisy and distracting.
The patient is seated in the test room in one of several directions; facing the tester, with
their back to the tester, or facing sideways. Most testers prefer to have the patient facing her/him
during testing for several reasons:
1. Allows the tester to monitor the patient’s facial expressions and bodily changes,
including those that are subtle;
2. Allows the tester to provide the patient with encouragement and retraining through
nonverbal reinforcement; and
3. Allows the tester to see the patient’s lips and face to make accurate judgements
during speech audiometry (Gelfand, 1997).
If the tester selects this seating arrangement, care must be taken that the tester does not provide
the patient with cues that stimuli are being presented. Seating the patient away from the tester
prevents the patient from “reading” the tester. If the patient is very sensitive to movements made
by the tester, it is best to place this patient sideways.
The tester must be cautious that cues are not being provided inadvertently to the patient.
If a patient has a “functional” hearing loss, the tester must be extra cautious in the use of
advertent and inadvertent cues. For the patient who is apprehensive, the tester may need to
provide more cues of encouragement than for a patient who is not apprehensive.
GO TO LABORATORY
EXERCISE # 1.1
Step-by-Step Procedures for Air Conduction Testing (ASHA, 1990; Margolis, 1997; Hall &
Mueller, 1998; Martin, 1998; Stach, 1998; Wilber, 1999):
1. After completion of the case history, otoscopic examination, and acoustic
admittance, the patient is seated in a comfortable chair in a sound controlled
examining room. The tester instructs the patient as described above.
Patricia I. Carr 14.
c. Present the stimulus in increments of 5 dB steps until the patient again responds
(ascending).
d. Once the patient responds, present the stimulus in decrements of 10 dB steps
until the patient no longer responds.
e. Continue the up in 5 dB steps until the patient responds and the down in 10 dB
steps until the patient does not respond, when two out of three or three out of five
correct responses are obtained at the lowest ascending test level. This is the
patient’s threshold and the tester records the dB HL, the frequency, and the ear
tested on the audiogram.
6. Repeat step “5” for the remaining frequencies in the following sequence: 2000, 4000,
8000, 500, and 250 Hz.
a. The threshold at 1000 Hz is rechecked after 8000 Hz has been tested. If the
thresholds are within + 5 dB of each other proceed with 500 and 250 Hz. If they
are not in agreement, the patient may have become more comfortable with the
testing process or the tester may need to reinstruct the patient.
b. Thresholds are obtained for the inter-octave frequencies (750, 1500, 3000, 6000
Hz) when a > 20 dB difference is present between adjacent octave frequencies
(Gelfand, 1997; Margolis, 1997; Wilber, 1999).
c. 125 Hz may be tested in cases of low frequency hearing loss.
7. Use masking when indicated. If using earphones, consider reestablishing thresholds
if there is a > 40 dB difference between ears or between the bone conduction
thresholds (500 – 4000 Hz) of the non-test ear and the AC thresholds of the test ear.
If using insert receivers, masking is necessary when there is a > 60 dB difference
between ears or between the bone conduction thresholds (500 – 4000 Hz) of the non-
test ear and the AC thresholds of the test ear.
8. Obtain thresholds for the opposite ear by repeating steps 5 through 7.
9. If the patient presents with reduced air conduction thresholds and abnormal
admittance results (see Chapter 3 of this manual), bone conduction testing should be
completed. Proceed with bone conduction testing as described in the next section.
However, if the patient presents with thresholds within normal limits and normal
admittance results, proceed with speech audiometry (Chapter 2).
Patricia I. Carr 16.
Numerical Audiogram
Results are recorded numerically for the right and left ears separately in a table in which
the frequencies tested are shown across the top of the table. See Figure 1.0 for sample of a table
used in the numerical recording of the patient’s responses. The numerical audiogram allows for
rapid recording of responses and, when masking is needed, ease of making calculations (Gelfand,
1997). However, it is difficult for some to visualize the audiometric shape from digital values.
When recording “no response”, the tester would record as “NR,” “+,” or “!” along with the
maximum testing level for that frequency. For example “NR70,” “70NR,” “70+,” or “70!”
(Gelfand, 1997).
AIR CONDUCTION
RIGHT LEFT
250 500 750 1000 1500 2000 3000 4000 6000 8000 250 500 750 1000 1500 2000 3000 4000 6000 8000
BONE CONDUCTION
RIGHT FOREHEAD LEFT
500 1000 1500 2000 3000 4000 500 1000 1500 2000 3000 4000 500 1000 1500 2000 3000 4000
Figure 1.0: Form used for numerical recording of patient’s responses in air and bone conduction
pure tone threshold determination.
Patricia I. Carr 17.
Note. From Exercises in audiometry: a laboratory manual (p. 28) by F. N. Martin, 1998, Needham
Heights, MA: Allyn and Bacon. Copyright 1998 by Allyn and Bacon. Adapted with permission.
Graphic Audiogram
Figure 1.1 depicts a sample of a graph in which the tester would insert symbols, indicating
thresholds, in the appropriate place on the audiogram. Notice that frequency measured in Hz is shown
across the top of the audiogram (250 to 8000 Hz) and that sound intensity measured in dB hearing level
(dB HL), from –10 dB at the top to 120 dB at the bottom, is shown on the y-axis. Across the top of the
audiogram is the 0-dB HL line, which corresponds to the level of average normal hearing in healthy
young adults. The reader is directed to the ASHA (1990) Guidelines for Audiometric Symbols for
specifics on constructing an audiogram. The tester may record the thresholds for the right ear in red ink
and those for the left ear in blue ink, but is not necessary, as the color coding is lost with photocopying.
Some facilities plot a separate audiogram for each ear; others plot both ears on the same audiogram. For
discussion in this paper, thresholds for both ears will be plotted on the same audiogram.
If the tester utilizes the audiogram to plot the patient’s thresholds, he/she must use the
appropriate symbol for the transducer used. Because there are several versions of audiometric
symbols available, the symbol system used to plot the audiogram is generally placed in a key on
the evaluation form. The tester is to keep in mind that the symbols correspond to transducer
placement and may not reflect that the sound was even heard in that ear (ASHA, 1990; Gelfand,
1997). Table 1.1 shows the ASHA (1990) suggested audiometric symbol system the tester may
use when plotting a patient’s audiogram. The tester records the patient’s response by drawing
the appropriate symbol so that the center of the symbol is on the intersection of the vertical and
horizontal axes for the frequency and intensity tested ASHA, (1990). If no response was
obtained at the limits of the audiometer, the tester plots the appropriate symbol at the intensity
depicting the highest testable level. An arrow is then drawn downward, attached at the bottom of
the symbol at a 45-degree angle to the right for the left ear symbol and to the left for the right ear
symbol (ASHA, 1990; Gelfand, 1997). Refer to Table 1.1 for the no response symbols. This
indicates to the reviewer of the audiogram that testing was attempted at that frequency. Once all
of the thresholds have been determined, the tester then connects the air conduction symbols
where responses were obtained with a solid line. The lines are drawn so that they do not go
Patricia I. Carr 18.
through or touch the symbol. Symbols representing “no response” are not to be connected to
each other or to any of the symbols indicating a response (ASHA, 1990).
In some testing facilities, the tester may record thresholds using the numerical audiogram
for ease of calculating noise levels needed for masking and then the thresholds are transferred to
the graphic audiogram for ease of counseling results to the patient. If a procedure other than the
standard procedure for threshold determination was used to determine a patient’s thresholds, the
tester must indicate this on the audiogram.
FREQUENCY IN HERTZ
30
40
(ANSI – 1996)
50
60
70
80
90
100
110
120
Note. From Clinical Audiology: an introduction, (p. 201) by B. A. Stach, 1998, San Diego: Singular
Publishing Group, Inc. Copyright 1998 by Singular Publishing Group, Inc. Adapted with permission.
And from Audiologists’ desk reference, volume 1, (p. 98) by J. W. Hall, & H. G. Mueller, 1997, San
Diego: Singular Publishing Group, Inc. Copyright 1997 by Singular Publishing Group, Inc. Adapted
with permission.
Table 1.1: Audiometric symbols used when plotting air and bone conduction thresholds on an
audiogram. R – response and NR – no response.
Masked ] ]" [ #
[
Bone Conduction – forehead
Unmasked ∨ ∨
!
Masked " #
Air Conduction - soundfield
S S
!
Note. From “Guidelines for audiometric symbols,” (pp. 84-86), by ASHA, 1990
in ASHA, 32, (Suppl.). Copyright 1990 by ASHA. Adapted with permission.
Patricia I. Carr 20.
Upon completion of the AC thresholds, the tester calculates the pure tone average (PTA) for each
ear. This is the mean of the AC thresholds at 500, 1000, and 2000 Hz. The PTAs for each ear are then
recorded in the appropriate area of the audiogram so that they may be compared to the Speech
Recognition Threshold (SRT) discussed in Chapter Two.
GO TO LABORATORY
EXERCISE # 1.2
TEST INTERPRETATION
The audiometric configuration is another aspect of the patient’s audiogram that may need to be
described. Stach (1998) provides the following terms with descriptions for defining audiometric
configuration:
1. Flat - thresholds are within 20 dB of each other across the frequency range.
2. Rising - thresholds for low frequencies (250 – 500 Hz) are at least 20 dB poorer than for high
frequencies.
3. Sloping - thresholds for high frequencies 1000 – 4000 Hz) are at least 20 dB poorer than for
low frequencies.
Patricia I. Carr 21.
4. Low-frequency – hearing loss is restricted to the low-frequency region (< 1000 Hz) of the
audiogram.
5. High-frequency – hearing loss is restricted to the high-frequency region (> 2000 Hz) of the
audiogram
6. Precipitous – steeply sloping high frequency hearing loss of at least 20 dB per octave.
Table 1.1: Depicts several classification systems for the determination of hearing loss.
1. Note. From “Reference zero levels for pure-tone audiometer” by A. Goodman, 1965, ASHA, 7,
262-263. Copyright 1965 by ASHA. Adapted with permission.
2. Note. From “Measurement of hearing in adults” (p. 1226), by J. Jerger & S. Jerger, 1980, in
Otolaryngology by M. M. Paparella & D. A. Shumrick (Eds.), Philadelphia: W. B. Saunders.
Copyright 1980 by W. B. Saunders. Adapted with permission.
In terms of symmetry, the tester may describe that the hearing levels are essentially the same for
both ears or that one ear is better than the other. A patient is reported as having a bilateral hearing loss if
a hearing loss is present in both ears and a unilateral hearing loss if the hearing loss is present in only
one ear. A hearing loss may also be described as asymmetrical when a significant difference is present
Patricia I. Carr 22.
between ears. There is no agreed upon definition of asymmetry; however the one commonly used is that
an asymmetrical hearing loss is present when a > 15 dB difference exists between ears at two or more
consecutive octave frequencies.
Lastly, the type of hearing loss is included in the interpretation statement of the patient’s hearing
loss. There are three types of peripheral hearing losses that are considered - conductive, sensorineural,
and mixed.
Recall that AC testing evaluates the integrity of the entire auditory system and that BC
testing evaluates the sensorineural portion. If there is a difference in the thresholds obtained
Patricia I. Carr 23.
between these two tests then a problem is evident in the conductive (outer and/or middle ear)
system (Gelfand, 1997). When this difference, AC – BC, is observed at the same frequency, it is
known as an air-bone-gap (A-B gap). When there is at least a 10 dB A-B gap, this is considered
to be significant and suggests the presence of a conductive component.
4. The presence of collapsed ear canals appears on the audiogram as an unexpected high-
frequency conductive hearing loss with an A-B gap of 10 to 50 dB (Coles, 1967). This
occurs during AC testing when the pressure from the earphones causes the cartilaginous
portion of the patient’s ear canal to collapse. The elderly population tends to have a higher
incidence of collapsed ear canals due to reduced tissue elasticity (Randolf and Schow, 1983).
The occurrence of collapsed ear canals can be avoided by the use of insert receivers. If the
patient cannot be tested using insert receivers, the earphone can be held loosely over the ear
canal to reduce the pressure. Thresholds are retested and if a > 15 dB improvement is noted,
and then the occurrence of collapsed ear canals is confirmed.
Test Limitations
1. Accurate thresholds may not be obtained if the earphone is to one side, if the ear canal is
collapsed, or if headband pressure is insufficient (Wilber, 1999).
2. Accurate thresholds may not be obtained if the insert receiver is blocked, up against the ear
canal, or is not inserted firmly and deeply into the ear canal (Wilber, 1999).
3. Accurate thresholds may not be obtained in the sound field if the patient is not placed
properly in the examination room (Wilber, 1999).
4. Test equipment may be out of calibration and result in erroneous thresholds.
5. The patient may be uncooperative or fatigued and inaccurate results may occur (Wilber,
1999).
6. The ventilation and temperature of the examination room may affect the patient and lead to
inaccurate results (Wilber, 1999).
7. Transducer jacks may not be inserted securely into the wall panel, which may result in a 20
to 30 dB reduction in signal intensity (Hall & Mueller, 1998).
Definition
BC testing is used to determine the hearing threshold of the patient through the bone
vibtrator. Thresholds are obtained for octave and ½ octaves between 500 – 4000 Hz for each ear
are defined as the lowest hearing level at which the patient responds at least 50% of the time to
auditory stimuli.
INSTRUMENTATION
Test Stimuli
Same as for AC testing.
Transducer
The BC vibrator can be placed on the patient’s mastoid or forehead. Placement of the
bone vibrator on the patient’s mastoid is the placement most often used clinically for two
reasons:
1. The availability of a wider range of hearing levels over that for frontal
placement; and
2. Convenience (Wilber, 1999).
The bone vibrator is placed on the mastoid with a headband type device exerting a force of 5.4
Newtons or 400 grams (ANSI, 1996; Dirks, 1964b). The tester is advised not to hand hold the
bone vibrator as the pressure will not be constant and the output of the vibrator may be
dampened (Wilber, 1999). It is necessary for the tester to make sure that the bone vibrator does
not touch the patient’s pinna, that there is very little hair as is possible under the vibrator, and
that the disk part of the vibrator sits flatly on the skin of the mastoid process. The patient should
remove eyeglasses so that they do not come in contact with the vibrator. Testing will proceed
with that placement (Gelfand, 1997). Generally, thresholds are obtained with the opposite ear
and the test ear unoccluded.
In forehead placement, the bone vibrator is placed in the center of the forehead. The
maximum testable intensity level for forehead placement is less than for mastoid placement
(ASHA, 1990; Gelfand, 1997). However, thresholds tend to be more reliable with this placement
than for mastoid placement (Dirks, 1964b; Studebaker, 1962). Masking should be completed
when obtaining thresholds for each ear.
Note: that the interaural attenuation for BC testing is considered to be 0 dB.
GO TO LABORATORY
EXERCISE # 1.3
Patricia I. Carr 27.
Response Mode
Same as for AC testing.
However, if the tester recorded the AC thresholds numerically on a chart, then the BC
thresholds are recorded on the same chart. See Figure 1.0 for sample of chart used in the
numerical recording of the patient’s responses. If a procedure other than the standard procedure
for threshold determination was used to determine a patient’s thresholds, the tester must indicate
this on the audiogram.
Test Interpretation
AC thresholds should be the same as or poorer than the BC thresholds. On occasion a
patient exhibits BC thresholds that less sensitive than AC thresholds. This is because BC norms
are based on “median” masked values. Thus, it is possible for a patient to have 5 dB or so poorer
Patricia I. Carr 29.
BC thresholds. In the presence of an A-B gap, the degree of the patient’s hearing loss is based
on the AC threshold. Refer to the “Interpretation” section under “Air Conduction Testing.”
GO TO LABORATORY
EXERCISE # 1.4
Test Limitations
1. Test equipment may be out of calibration and result in erroneous thresholds.
2. During BC testing, the vibrator may not maintain a stable position on the patient’s mastoid,
or may contact the pinna; thus producing erroneous thresholds (Wilber, 1999).
3. The pressure of the vibrator on the mastoid may be insufficient and cause incorrect
thresholds (Wilber, 1999).
4. The patient may be uncooperative or fatigued and inaccurate results may occur (Wilber,
1999).
5. The ventilation and temperature of the examination room may affect the patient and lead to
inaccurate results (Wilber, 1999).
Laboratory Exercises:
Goals
1. To understand and manipulate the working components of the audiometer used in pure tone
audiometry.
2. To be aware of the intensity versus frequency limits of the audiometer as they pertain to the
various transducers.
3. To become familiar with the various pure tone stimuli used in pure tone audiometry.
Patricia I. Carr 30.
Exercises
1. Turn on the audiometer and locate the following components, refer to manufacturer’s manual
as needed:
a. Attenuator/intensity dial for both Channels 1 and 2.
b. Frequency selector
c. Interrupt/on-off switch used to present stimuli
d. Transducer selector – phone, insert, bone, speaker
e. Routing selector – right, left, both
f. Stimulus selector – tone – steady/pulsed/warble, microphone, tape/CD
g. dB step regulator – 1 dB/5 dB steps
h. Talk forward knob
i. Talk back knob
j. VU meter
k. Monitor speaker
2. Set up the audiometer using a steady tone and determine the lower and upper intensity limits
in dB HL by frequency for each of the following transducers. Record your findings in a
chart:
a. Earphones
b. Insert receivers
c. Bone vibrator
d. Speakers
3. Set up the audiometer as specified in the following scenarios:
a. Scenario # 1: Transducer: insert receiver Routing: left
Stimulus Intensity: 35 dB HL Stimulus Frequency: 500 Hz
Stimulus Type: warble dB step: 5 dB
Channel: 2
Questions
1. Review the chart you developed for exercise # 2 above. Discuss the differences noticed in
output limits between the transducers. How did frequency range change between
transducers?
2. When completing exercise # 3 above, did anything change automatically to any of the
settings in Channel 2, if yes, when?
Goals
1. To properly provide instructions needed for AC pure tone audiometry.
2. To properly place and be comfortable with the placement of earphones and insert receivers.
3. To be aware of proper seating of the patient in the sound treated room for soundfield testing.
Exercises
1. Practice giving instructions for AC pure tone audiometry on ____ lab mates.
Patricia I. Carr 32.
2. Practice placement of each of the following transducers on ____ lab mates. Note: perform
otoscopy on each lab mate prior to transducer placement. After insert receiver placement,
leave the white nubbin attached to the tubing and dispose the foam insert in the appropriate
manner.
a. Earphones
b. Insert receivers
3. Practice placing ____ lab mates in the sound treated room for soundfield testing in each of
the following directions and create a sketch indicating each azimuth:
a. 0o azimuth
b. 90o azimuth
c. 180o azimuth
d. 270o azimuth
Questions
1. When giving instructions to your lab mates, did they have any questions regarding your
presentation? Did you notice any differences in your presentations, if so what were they?
2. In the transducer exercise, explain any differences noted in transducer placement among your
lab mates. Did you experience any difficulties; if so, what were they and how did you solve
them?
Goals
1. To determine thresholds for AC pure tone audiometry using the modified Hughson-Westlake
procedure.
2. To be able to record AC thresholds using the numerical audiogram and the graphic
audiogram.
3. To use the appropriate AC symbols on the graphic audiogram.
Patricia I. Carr 33.
Exercises
1. Using a computer-simulated program of pure tone audiometry, obtain AC thresholds on __
cases. Record half of the cases on a numerical audiogram and half of the cases on a graphic
audiogram.
2. Obtain AC thresholds on 12 volunteers using the procedure described in the manual.
Perform the testing as follows:
a. For 2 of the volunteers, obtain thresholds for each ear using pulse tone stimuli and
earphones. Record responses on a numerical audiogram.
b. For 2 of the volunteers, obtain thresholds for each ear using warble tone stimuli and
insert receivers. Record on a numerical audiogram.
c. For 2 of the volunteers, obtain thresholds for each ear using pulse tone stimuli and
earphones. Record on a graphic audiogram.
d. For 2 of the volunteers, obtain thresholds for each ear using warble tone stimuli and
insert receivers. Record on a graphic audiogram.
e. For 2 of the volunteers, obtain thresholds in the soundfield using warble tone stimuli and
a 90o azimuth. Record on a graphic audiogram.
f. For 2 of the volunteers, obtain thresholds in the soundfield using warble tone stimuli and
a 0o azimuth. Record on a graphic audiogram.
Questions
1. You have had the opportunity to record thresholds on the two types of audiograms
(numerical and graph), explain which you prefer and why.
2. Explain the benefits of the two types of audiograms and in what situations you would use
each one.
3. You have had a chance to obtain thresholds using a variety of transducers and stimuli,
discuss differences you noticed with your volunteers. Did you experience any problems,
what were they, and what were your solutions? What helpful hints do you have for your lab
mates?
Patricia I. Carr 34.
Goals
1. To properly place the bone vibrator on the mastoid process.
2. To understand the differences in thresholds obtained from forehead and mastoid placement of
the bone vibrator.
3. To understand the difference of BC thresholds obtained with the contralateral ear unoccluded
and occluded.
Exercises
1. Practice placing the bone vibrator on the mastoid process of 5 lab mates.
2. Using the modified Hughson-Westlake method of threshold determination, obtain BC
thresholds, unoccluded, with the bone vibrator on the mastoid process and on the forehead of
5 lab mates. Record results on a chart listing results for each placement by frequency.
3. Using the modified Hughson-Westlake method of threshold determination, obtain BC
thresholds with the bone vibrator on the mastoid process of 2 lab mates under the following
test conditions. Record results on a chart listing results for each test condition by frequency.
a. The test ear and contralateral ear is unoccluded.
b. Contralateral ear occluded. Note: this means with an earphone over the ear opposite
the test ear or the bone vibrator.
c. Test ear occluded.
d. Both ears occluded.
Questions
1. Review your results obtained for exercise # 2 above. Discuss the differences noticed
between the results obtained via forehead placement and those obtained via the mastoid
placement. How do you account for those differences?
2. Review your results obtained for exercise # 3 above. Discuss the differences noticed
between the results obtained under the various test conditions using the mastoid placement.
How do you account for those differences?
Patricia I. Carr 35.
3. Review both exercise # 2 and # 3, which test condition do think provides the most accurate
results of your lab mates’ bone conduction hearing? Why?
Goals
1. To determine thresholds for BC pure tone audiometry using the modified Hughson-Westlake
procedure.
2. To be able to record BC thresholds using the numerical audiogram and the graphic
audiogram.
3. To use the appropriate BC symbols on the graphic audiogram.
4. To interpret and describe pure tone audiometric results in terms of degree, type, shape, and
symmetry.
Exercises
1. Using a computer-simulated program of pure tone audiometry, obtain air and bone
conduction thresholds on __ cases with normal hearing and __ cases with hearing
impairment. Record half of the cases on a numerical audiogram and half of the cases on a
graphic audiogram.
2. Obtain air and bone conduction thresholds on 8 volunteers (those using the procedure
described in the manual. Perform the testing as follows:
a. For 2 of the volunteers, obtain AC thresholds for each ear using pulse tone stimuli and
earphones. Then obtain BC thresholds using the unoccluded mastoid placement.
Record responses on a numerical audiogram.
b. For 2 of the volunteers, obtain thresholds for each ear using warble tone stimuli and
insert receivers. Then obtain BC thresholds using the unoccluded mastoid placement.
Record on a numerical audiogram.
c. For 2 of the volunteers, obtain thresholds for each ear using pulse tone stimuli and
earphones. Then obtain BC thresholds using the unoccluded mastoid placement. Record
on a graphic audiogram.
Patricia I. Carr 36.
d. For 2 of the volunteers, obtain thresholds for each ear using warble tone stimuli and
insert receivers. Then obtain BC thresholds using the unoccluded mastoid placement.
Record on a graphic audiogram.
3. Describe the degree, shape, type, and symmetry of the results you obtained for each of the
simulated-computer cases and of the 8 volunteers in exercises # 1 and # 2.
Questions
1. Review the results obtained in all the cases for exercises # 1 and # 2, based on the limited
knowledge regarding masking up to this point, is masking needed for any of them? Indicate
the cases. Then for each case where masking is indicated state whether masking is needed
for AC, BC, or both.
2. When you were describing your pure tone audiometric test results did you experience any
difficulties? If so, indicate the case(s) and state the problem(s).
Patricia I. Carr 37.
CHAPTER 2
SPEECH AUDIOMETRY
Key Words
Speech awareness threshold
Speech detection threshold Phonetically balanced
Speech recognition threshold Monitored live voice
Speech recognition tests Word recognition tests
Speech audiometric measurements are a routine part of the audiologic evaluation. These
measurements may include:
1. The patient’s threshold for speech, the lowest level at which the patient detects or
recognizes speech, known as the speech awareness threshold (SAT) or the speech
detection threshold (SDT).
2. The lowest level at which the patient is able to identify speech serves as a crosscheck
of pure tone thresholds. This is known as the speech recognition threshold (SRT).
3. The patient’s ability to process and understand speech at suprathreshold levels is the
word recognition score (WRS).
These three speech measurements will be discussed in the following sections.
Patricia I. Carr 38.
Features common to all speech audiometric tests (differences particular to each test will be
discussed under that test):
Audiometer
As per ASHA, 1988 suggested guidelines, “speech audiometry shall be accomplished
with a speech audiometer capable of transducing speech as defined and calibrated according to
the American National Standard Specifications for Audiometers (ANSI S3.6-1969)”. A two-
channel audiometer is needed to administer speech audiometric testing so that the tester may
present speech stimuli to the patient in a variety of ways depending on the particular speech
measurement being administered. The possibilities are as follows:
1. The tester may present speech stimuli to both ears;
2. The tester may present speech stimuli to one ear and speech masking to the
other ear;
3. The tester may present speech stimuli to one ear and speech masking to the
same ear;
4. The tester may present speech stimuli and speech masking to both ears.
When performing speech audiometric testing, the speech mode/channel of the audiometer
is selected. The tester then selects a means of presenting stimuli to the patient such as recorded
material or microphone for live voice testing. If recorded material is selected, the tester selects
Compact Disc (CD) player or tape deck. An attenuator is needed so that the tester may control
the level of the speech material presented to the patient. Lastly, the tester selects the desired
output transducer in order to deliver the stimuli to the patient – earphones, insert receiver, sound
field, or bone oscillator.
Test Environment
Same as for pure tone audiometry. See the first part of this manual.
Presentation mode
Although, speech materials may be prerecorded materials or the monitored live voice
(MLV) mode, prerecorded materials are preferred. The use of prerecorded materials offers better
Patricia I. Carr 39.
control over the level and quality of the speech signals presented to each patient, as well as
allowing for standardization from test to test. Standardization of test procedures is critical to the
quality of care to the patient; therefore, the tester must attempt to utilize prerecorded materials as
much as possible (ASHA, 1988, Mendel & Danhauer, 1997, Gelfand, 1997, and Wilson &
Margolis, 1999). Table 2.0 provides the tester with a number of reasons why recorded materials
should be used during speech audiometric testing and MLV testing should be avoided. However,
according to ASHA (1988) administration of the SRT and SDT by MLV may be needed when
testing very young children or the difficult-to-test patient. In the MLV mode, the tester presents
the spoken word into a microphone while monitoring her/his voice on the audiometer’s VU
meter. A disadvantage of MLV testing is that of maintaining vocal quality and intensity within
the test session and between patients.
Table 2.0: Seven reasons why you shouldn’t routinely use the monitored-live-voice (MLV)
method for presentation of word recognition materials.
1. Word recognition scores obtained for different talkers are not equivalent.
2. Word recognition scores for the same talker at different times are not equivalent.
3. “Each speaker of word recognition materials constitutes a different test that may
produce different psychometric articulation functions (percent correct performance as a
function of presentation level)” (Wiley et al., 1994, p. 29).
4. With MLV presentation, the acoustic characteristics of the signal are highly variable,
just as Jennifer’s voice is distinctly different from Jay’s, and Gus has totally different
vocal characteristics than both of them (e.g., pitch, articulation, rate of speech, dialect).
5. With MLV presentation, the difficulty of the items (single words) is dependent, in part,
on who’s talking.
6. Most testers today are not sitting in a sound-treated control room. Background sounds
reaching the patient through the open microphone may confuse the patient and influence
test results.
Patricia I. Carr 40.
On most CDs, there is a track that contains the recorded reference/calibration tone used in
the calibration of the CD for use during speech audiometric assessment. For instance, AuditecTM
recordings on the CD containing CID W-1, CID W-22, and NU-6 word lists, the calibration tone
is on “track one”. To determine the location of the calibration tone on a CD, the tester is
encouraged to read the manual that accompanied the test materials. Further, the volume (VU)
meter must have ballistic characteristics that conform to the ANSI, C16.5-1954 standard for VU
meters.
4. While the calibration tone is playing, adjust the control knob for the VU meter until
the level of the calibration tone is at 0 dB on the VU meter.
5. Repeat the above steps for Tape 2 or Tape B in Channel 1.
6. Repeat the above steps for Tape 1 or Tape A in Channel 2.
7. Repeat the above steps for Tape 2 or Tape B in Channel 2.
GO TO LABORATORY
EXERCISE # 2.0
NOTE: Of the various tests utilizing speech materials, only speech detection threshold (SDT),
speech recognition threshold (SRT), and word recognition testing (WRT) will be covered in this
manual.
In these instances, the SDT is obtained by presenting a variety of speech stimuli using the
monitored live-voice test mode. The SDT is often the first test administered to very young
children, as they tend to respond better to speech materials than to pure tones. The SDT obtained
provides guidance to the tester in the establishment of pure tone thresholds.
INSTRUMENTATION
Test Stimuli
A variety of speech stimuli may be used in the determination of the SDT. Speech
materials may include the following:
a. Continuous discourse;
b. Spondees, see Appendices B, C, and D;
c. The child’s name;
d. CV syllables (“bye-bye”, “uh-oh”);
e. Short phrases (“hey, pretty girl”);
f. Words familiar to the child; and
g. Individual speech sounds (/m/, /sh/, /ah/).
Patricia I. Carr 43.
Transducer
The SDT may be obtained using earphones, insert receivers, loudspeakers, or the bone
vibrator. Earphones, insert receivers, and the bone vibrator may be used depending on the
acceptance level of the patient. If the patient does not accept earphones or insert receivers, the
tester must resort to soundfield testing. In these instances, the better ear responses will be
obtained rather than separate ear measures.
Response mode
A number of response modes may be used to obtain the SDT; usually, they are nonverbal
in nature. Some examples of response modes are hand raising or button pushing.
Step-by-Step Procedures
1. The tester first instructs the patient or the caregiver of the patient if the patient is
unable to understand directions.
2. The tester selects speech stimuli that are appropriate for the patient. Keep in mind
that several of the speech stimuli listed above may need to be used by the tester in
order to obtain reliable responses from the patient.
3. The tester selects the transducer most readily accepted by the patient. Try insert
receivers first, then earphones. As a last resort, use loudspeakers if the patient will
not tolerate the insert receivers or headphones. Attempt use of the bone oscillator
when needed to determine the type of hearing loss (conductive or sensorineural).
4. The tester then determines the SDT using the same test technique as for pure tone
threshold estimation. If insert receivers or earphones are the accepted transducers, the
tester attempts to obtain the SDT for each ear. If the tester needs to resort to
loudspeakers, then an SDT in the soundfield will be obtained.
5. Masking should be applied when indicated.
Recording and Scoring of Test Results
When the SDT is established; the following should be recorded on the audiogram:
1. If the tester obtained the SDT with insert receivers or earphones the results are
recorded in dB HL for each ear separately. If the SDT was obtained in the
soundfield, record in dB HL under soundfield findings.
Patricia I. Carr 44.
2. Record the type of response observed to obtain the SDT. Types of responses may
include handraise, button push, eye widening, head turn, smile, and cessation of
activity.
3. Record the type of stimulus used to obtain the SDT (i.e. continuous discourse,
spondees, and Ling 6 sounds).
Test Interpretation
The SDT often relates to the best single pure tone threshold in the 250 – 4000 Hz range,
but is most closely related to the average of 250 and 500 Hz (Olsen & Matkin, 1979;
Rintelmann, 1991). The average SDT is approximately 7-9 dB lower than the average SRT.
Others have reported great variation between the SDT and the SRT by as much as 2 dB or even
16 dB (Thurlow, Silverman, Davis, & Walsh, 1948; Chaiklin, 1959; Martin, 1986; and
Rintelmann, 1991).
Test Limitations
1. The SDT often reflects the best single pure tone threshold in the 250 – 4000 Hz range
and thus does not provide a representation of the configuration or degree of hearing
loss at the various frequencies.
2. The SDT indicates the lowest loudness level in which a patient can detect speech, but
does not provide information of how that patient hears speech above threshold.
GO TO LABORATORY
EXERCISE # 2.1
interclinician and interclinic comparison of test results, it is suggested that the tester follow a
standard procedure (ASHA, 1988).
to ensure that the patient knows the test vocabulary and is able to recognize each word auditorily,
and that the clinician can accurately interpret the patient’s responses” (ASHA, 1988, p. 100).
Tilman and Jerger (1959) reported that using non-familiarization, the average SRT was about 4
to 5 dB poorer than when the patients were familiarized with the word list.
The tester may familiarize the patient with the word list in one of several ways. They
may either read the alphabetized word list (See Appendix B) to the patient in a face-to-face
situation, or present the test list through the microphone circuit of the audiometer at a
comfortable level for the patient. The patient is to repeat the word to demonstrate recognition of
each word on the list. If the patient responds incorrectly or does not respond to any of the words,
the tester should eliminate those words from the list. Also, any word that the tester has any
difficulty understanding should be eliminated from the test list. In situations where the tester is
certain that the patient would have no difficulty understanding the words, give the patient the
alphabetized list to read to themselves prior to test administration.
INSTRUMENTATION
Test Stimuli
When determining the SRT, typically, the test stimuli consist of at least 12 spondaic (two
syllable words in which each syllable is presented with equal stress) words that were found to be
appropriate for adults. See Appendix C for this list. This spondaic word list, which is a revision
of the CID W-1/W-2 list, is recommended by ASHA (1988) as the standard test materials for
determination of the speech recognition threshold.
Transducer
Headphones, insert receivers, bone vibrator, or speakers may be used to obtain the SRT.
Typically, headphones or insert receivers will be the transducer of choice.
Response Mode
When obtaining the SRT, the usual patient response is a verbal repetition of the stimulus
item heard. At times, other response modes may be necessary such as signing, visual scanning,
Patricia I. Carr 47.
or picture pointing. The tester must select the response mode most appropriate for the patient
and instruct the patient accordingly.
Step-by-Step Procedures
The test procedure selected by the tester in the determination of the SRT depends on the
patient’s behavior and pure tone thresholds. While there is no single SRT technique in universal
use, all are an adaptation of ascending and descending techniques. The descending approaches
begin with the presentation of spondees above the patient’s estimated SRT with subsequent
blocks of spondees presented at progressively lower hearing levels. The ascending approaches
start at presentation levels below the patient’s estimated SRT with subsequent spondees
presented at higher hearing levels. Wall, Davis, and Myers (1984) and Jahner, Schlauch, and
Doyle (1994) found that the differences between the ascending and descending approaches were
clinically insignificant. The procedure discussed here is the guidelines suggested by ASHA
(1988). The steps in determination of the SRT consists of two phases, and are as follows:
Figure 2.0: Tally sheet used when determining the SRT using the ASHA (1988) method.
The right side shows an example of how to use the tally sheet. Count the number of correct
words from the starting level to the stopping level. In this case there were 10 correct
responses. The number of correct responses is then subtracted from the starting dB level
Patricia I. Carr 49.
(50 dB HL – 10= 40). Then a 2 dB correction factor is added to that total to arrive at an
SRT of 42 dB HL.
Note. From Essentials of Audiology (p. 260), by S. A. Gelfand, 1997, New York: Thieme
Medical Publishers, Inc. Copyright 1997 by Thieme Medical Publishers, Inc. Adapted with
permission.
Another procedure known as the “Martin and Dowdy Spondee Threshold Procedure”
(1986), based on the Hughson-Westlake pure tone procedure, may be used to obtain the SRT.
The steps ( Hurley, 1999) are as follows:
1. Familiarize the patient with the spondee list. Use 10-12 spondaic words: “The 13
Most Homogeneous Spondaic Words (See Appendix C)”.
2. Start level at 30 dB HL. Present one spondee. If a correct response is obtained
decrease presentation level by 10 dB. If there is no correct response, raise the
presentation level in 10 dB steps, presenting one spondee at each increment until a
correct response is obtained or the limits of the equipment is reached.
3. After a correct response is obtained, lower the presentation level in 10 dB steps until
an incorrect response is given.
4. When and incorrect response is given, raise the presentation level 5 dB and present
one spondee. If a correct response is given, lower the intensity 10 dB. If an incorrect
response is given, continue raising the intensity in 5 dB steps until a correct response
is obtained.
5. Intensity is increased in 5 dB steps after an incorrect response and decreased in 10 dB
steps after a correct response. In short, up by 5 dB and down by 10 dB until three
correct responses have been obtained at a given presentation level. Same process as
for pure tone threshold estimation.
6. Threshold is defined as the lowest level at which three correct responses were
obtained.
Patricia I. Carr 50.
SPEECH AUDIOMETRY
Procedure RE LE BC SF SF
AIDED
PURE TONE AVERAGE
(AC)
SPEECH RECOGNITION
THRESHOLD (SRT) dB HL 0 5
SPEECH DETECTION
THRESHOLD (SDT) dB HL
WORD RECOGNITION
SCORE (WRS) _ 40_dB HL 96% 100%
____ dB HL
MOST COMFORTABLE
LOUDNESS (MCL)
UNCOMFORTABLE
LOUDNESS LEVEL (UCL)
Word Recognition List ___NU-6______ Tape CD MLV # of test items__25__
(Circle one)
Patricia I. Carr 51.
Figure 2.1: Depicts what the speech audiometry section may look like on the patient’s
audiogram.
Test Interpretation
Once the SRT is obtained, it is compared to the best pure tone average (PTA) for the
respective ear. Hall and Mueller (1997) report that the calculated SRT should be within + 7 dB
of the best PTA. In order to obtain the best SRT-PTA agreement, the tester must consider the
following factors in the selection of the most appropriate PTA formula:
1. Generally the “three frequency pure-tone average” is utilized in the determination of
SRT/PTA agreement. The thresholds for 500, 1000, and 2000 Hz are averaged for
each ear (Fletcher, 1929). This works best for flat and gently sloping hearing losses.
2. When the shape of the puretone audiogram slopes sharply or when there is more than
a 20 dB difference between two of the three frequencies a “two-frequency pure-tone
average” is often used. The best two of the three frequencies (500, 1000, and 2000
Hz) are used to calculate the PTA. (Fletcher, 1950).
3. Carhart (1971) suggests a formula of averaging puretone thresholds at 500 and 1000
Hz and then subtracting 2 dB in cases of sloping hearing loss.
4. When the shape of the puretone audiogram slopes precipitously, it is often necessary
to compare the SRT to the one frequency that has the best threshold. The best
threshold is often at 500 Hz and may even be 250 Hz. (Gelfand & Silman, 1985,
1993; Silman & Silverman, 1991).
If there is lack of agreement upon comparison in the SRT-PTA values, the tester must stop
testing and determine the possible cause of the inconsistency. The tester may search for
examiner error, equipment problems, and suspected functional hearing loss. After the tester has
investigated these three areas, he/she may need to reinstruct, and retest the patient’s hearing in
attempt to obtain of the SRT-PTA values. In cases when the SRT is lower (better) than the PTA,
psuedohypacusis is suspected.
Test Limitations
1. The spondees are not representative of the speech that the patient uses when
communicating on a daily basis.
Patricia I. Carr 52.
GO TO LABORATORY
EXERCISE # 2.2
Definition
The word recognition score (WRS) is the percentage of words correctly identified at
some specified level above threshold. The WRS is also known as “the speech recognition
score”, “the speech discrimination score”, or “ PB scores”. However, the term “word recognition
score (WRS)”, has become the accepted term when nonsense syllables and monosyllabic words
are the test materials and will be used in this portion of the manual.
2. The patient is to repeat the word or the last word of the sentence heard;
3. The patient is encouraged to guess as some of the items may be difficult to
understand;
4. Each ear is to be tested separately.
An example of instructions the tester may use is as follows:
You are going to hear a person telling you to say some words. The words will be
presented at a level comfortable for you. They will remain at the same level and will not get
louder or softer. For example, if you hear “Say the word GIRL,” just repeat “GIRL.” If you are
unsure of a word, repeat what you think you heard. Do you have any questions?
INSTRUMENTATION
Test Stimuli
There are a number of variables the tester may need to take into consideration in the selection
of appropriate speech test materials for the determination of word recognition scores. These
include:
1. Test materials
2. Number of test items
3. Recorded or monitored live voice presentation
4. Open-set vs. closed-set test format
5. Stimulus type
6. Word familiarity
7. Communication mode of the patient
Test Materials
The tester may select from a variety of test materials depending on the purpose of the
speech recognition task. When determining the WRSs for adults, the most commonly used tests
include the CID W-22, the NU-6, and the PB-50 word lists. See Appendices E and F.
present 10, 25 or, 50 words per ears depending on the number of errors made by the patient. If
the patient responds correctly to all ten words, testing stops. Otherwise, continue presenting the
next 15 words for a total of 25 words. If there are more than four errors at the completion of the
25 words, a full 50-word list should be administered. Consider presenting a 10 word-screening
test when the patient presents with normal hearing or a conductive hearing loss.
The tester is alerted to the variability in WRSs that occurs in relation to the number of
test items presented (Raffin and Thornton 1980). The standard deviation of the test score which
is used to define its variability, is dependent upon the percent correct score and the number of
test items administered. The difference between two speech recognition scores are seen as
significant within the confidence limits of 95%. For further details, the reader is directed to
Raffin and Thornton (1980) or to the discussion by Gelfand (1993).
Stimulus Type
The tester may select nonsense syllables or monosyllabic words as stimuli to obtain the
WRS. Monosyllabic words will be the only stimulus type discussed at this time, as they are the
most commonly used test stimuli for assessing word recognition.
Transducer
The tester may select to use insert receivers, headphones, or loudspeakers to obtain the
WRSs.
Response Mode
The response mode typically used during word recognition testing is a verbal response
from the patient. In some instances, the patient may need to write or sign their response such as
when the patient is apraxic, dysarthric, a laryngectomee, severely hoarse, has a profound hearing
loss, or the tester has a hearing loss that interferes with her/his ability to monitor the patient’s
responses.
Patricia I. Carr 55.
Presentation Mode
Speech materials are presented to the patient through a compact disc (CD) player with the
audiometer set up on the player so the patient avoids hearing the introduction to the test stimuli.
Presentation Level
The speech recognition test is typically administered at 30-40 dB above the patient’s
SRT. Typically, WRS is obtained at the presentation level of 40 dB SL re: patient’s SRT. It is
now more common to administer a word recognition test at a second higher SL such as 90 dB
HL (Wilson & Strouse, 1999; Gelfand, 1997) as a screening to differentiate between cochlear
and retrocochlear dysfunction. WR testing at the patient’s most comfortable loudness level
(MCL) is not recommended as this is a range and not a level (Wilson & Strouse, 1999; Gelfand,
1997). Dirks & Morgan (1983) found the highest WRSs occur at SLs higher than the patient’s
MCL.
Step-by-Step Procedures
1. Prepare the audiometer for use of recorded speech materials. Set up the recording so
that the patient only hears the test items and not the identifying components of the test
stimuli.
2. Select the most appropriate speech material to be used to obtain the word recognition
scores. CID W-22, NU-6, or PB-50.
3. Select the transducer preferred.
4. Select the better ear or the right ear if better ear is not indicated.
5. Set the presentation level 40 dB above the SRT for that ear. (40 dB SL, re: patient’s
SRT for the ear tested.).
6. Begin presenting test stimuli and keep track of the number of test items the patient
correctly identifies.
7. A percent correct score is obtained for each ear separately.
8. Use masking when appropriate.
Patricia I. Carr 56.
Test Interpretation
The WR score suggests the approximate degree of difficulty the patient experiences
understanding speech for each ear in quiet. When interpreting WR scores, consider the
following:
1. For patients with normal hearing, the speech recognition score is expected to be
above 92% correct (Gelfand, 1997; Wilson & Strouse, 1999).
2. For most patients with a conductive hearing loss, the speech recognition score is
typically between 80% and 100%. The speech recognition score has been found to be
as low as 60% in cases of glomus tumor (Gelfand, 1997). Stach (1998) reports that
the WR scores should not be effected by the presence of a conductive hearing loss
due to a middle ear disorder.
3. For patients with cochlear hearing loss, the speech recognition score is usually
consistent with the degree of hearing loss. The greater the hearing loss, the poorer the
score. The speech recognition score may range from 0% to 100% depending on the
etiology and degree of hearing loss. (Bess, 1983; Gelfand, 1997; Wilson & Strouse,
1999). Stach (1998) states that WR scores will be poorer than expected in relation to
the degree of hearing loss in cases of endolymphatic hydrops or Meniere’s disease
4. For patients with lesions beyond the cochlea, the speech recognition score will be
poorer than expected for the amount of hearing loss. Scores will appear to be
“abnormally low”.
The tester, upon completion the word lists for WR testing then determines if there is a
significant difference in the test scores between ears by referring to the Thornton & Raffin data
shown in Appendix G. When word recognition scores are abnormally low, be cautious when
interpreting the scores. It is possible that the presentation level was not high enough and the
Patricia I. Carr 57.
tester must retest at a higher hearing level. The tester then refers to Table 2.1 to determine how
the degree of hearing loss affects the word recognition score.
Table 2.1: How degree of hearing loss affects speech recognition (Tye-Murray, 1998).
Note. From Foundations of Aural Rehabilitation: Children, Adults, and Their Family Members
(p. 97), by N. Tye-Murray, 1998, San Diego, CA: Singular Publishing Group, Inc. Copyright by
Patricia I. Carr 58.
Singular Publishing Group, Inc. Adapted with permission. The author of the table is C. Flexor,
1994, Facilitating hearing and listening in young children. San Diego, CA: Singular Publishing
Group.
Test Limitations
1. The SL of 40 dB re: SRT may not be the best presentation level during WR testing and
results may lead to misdiagnosis and mismanagement of the patient (Hall & Mueller, 1997).
2. Wilson & Strouse (1997, p. 26) report “ adding a fixed sensation level to the SRT, however,
will not always result in a valid maximum word recognition score, especially for patients
with sensorineural hearing loss. The level at which scores are obtained differs substantially
among patients.”
3. The CID W-22 and NU-6 are the least sensitive to differences in hearing loss among patients
(Hall & Mueller, 1997).
4. Utilizing a single presentation level in sensorineural hearing loss may not differentiate
cochlear from retrocochlear pathology ( Wilson & Strouse, 1997; Stach, 1998; Gelfand,
1997).
5. Shortening of the number of test items on some word lists may invalidate the test (Wiley, et
al., 1994; Gelfand, 1997).
6. Word recognition testing as described here does not assess how the patient performs in the
presence of noise. Some patients may perform differently in noise than in quiet (Wilson &
Strouse, 1997).
7. Whole-word scoring does not provide information regarding how the patient utilizes the
acoustical cues of speech (Gelfand, 1997).
8. Tye-Murray (1998, p. 105) reports “use of word stimuli may not reflect very well how an
individual performs in everyday listening situations because we typically listen to connected
discourse”.
Laboratory Exercises
Goals
1. To be able to set up the audiometer and the CD player for speech audiometry, including the
use of all transducers.
2. To be able to set up the audiometer for monitored live voice testing, including the use of all
transducers.
3. To be able to calibrate the audiometer using the CD player.
4. To be able to calibrate the audiometer using the tester’s own voice.
5. To be familiar with the functioning of the CD player and manipulate it during testing in a
timely manner.
Exercises
1. Practice setting up the audiometer in the following scenarios, include calibrating with the
calibration tone:
a. Input: Channel 1, Tape B, recorded speech/Channel 2, speech noise
Output: Channel 1, insert receiver, right ear/Channel 2, insert receiver, left ear
Stimulus: Channel 1, children’s spondees located on a CD such as that
formatted by Auditec/Channel 2, speech noise
b. Input: Channel 1, Tape A, recorded speech/Channel 2, Tape B, recorded speech
Output: Channel 1, headphone, left ear/Channel 2, headphone, right ear
Stimulus: Channel 1, NU-6 word list located on a CD such as that formatted by
Auditec or the Veteran’s Administration/Channel 2, speech babble located on
the same CD as the word list.
c. Input: Channel 1, Tape A, recorded speech/Channel 2, speech noise
Output: Channel 1, insert receiver, right ear/Channel 2, insert receiver, right ear
Stimulus: Channel 1, PAL PB-50 word list located in a CD such as formatted by
Auditec or the Veteran’s Administration/Channel 2, speech noise.
d. Input: Channel 1, headphone, recorded speech/Channel 2, headphone, speech noise
Output: Channel 1, headphone, left/right/Channel 2, headphone, left/right
Stimulus: Channel 1, CID W-22 word list/Channel 2, speech noise
2. Practice using the monitored live-voice mode of the audiometer for speech. Set up the
audiometer for monitored live-voice testing using Channel 1 as your primary channel. Select
Patricia I. Carr 60.
microphone as the input source of the presentation of speech material to the patient. Then
select a transducer through which the speech signal will be transmitted to the patient. Press
the interrupt button to the constantly “on” position. Locate the VU adjustment knob on the
audiometer panel. While speaking at a natural rate into the microphone manipulate the knob
until your speech is “peaking” at 0 dB VU meter. Then present the following speech stimuli
at a natural rate, with equal stress while attempting to peak at 0 dB on the VU meter. Keep
your eyes on the VU meter and record your observations:
a. Select a single syllable word and repeat it five times
b. Select seven different single syllable words and repeat
c. Select seven two syllable words and repeat
d. Select seven sentences of five to seven words in length and repeat.
Questions
1. Review exercise #1 above and determine two other possible scenarios, taking into
consideration the transducers and other options on the audiometer you have available to you.
2. For exercise #2 above, summarize your observations and discuss how this may or may not
effect your test results. Utilize references if needed to support your arguments.
3. Based on these two exercises you have completed and literature that you have read, which
presentation mode (recorded or MLV) is preferred? Why?
Goals
1. To be able to obtain speech recognition thresholds using the ascending and descending
approaches as suggested by the ASHA 1988 guidelines.
2. To be able to obtain speech recognition thresholds using 2 dB and 5 dB steps.
3. To be able to determine the PTA utilizing the most appropriate formula based on the
configuration of the patient’s hearing loss and then comparing to the SRT to determine
SRT/PTA agreement.
Patricia I. Carr 61.
Exercises
1. Gather _____ classmates and/or volunteers and determine their SRT as described in the
ASHA (1988) guidelines. Prior to determining SRTs, obtain AC thresholds for both ears. Set
up the audiometer for speech audiometric testing, via insert receivers, in the CD mode using
the spondee word list. Remember to familiarize your volunteer with the alphabetized
spondee word list prior to SRT determination. Use the attached tally sheet to assist you in
keeping track of volunteer responses. Once you have obtained the SRTs for your volunteer
under the following test conditions, record results and test condition on a piece of paper,
calculate the PTA, and determine SRT/PTA agreement. Test conditions are as follows:
a. Descending approach in 2 dB steps
b. Descending approach in 5 dB steps
c. Ascending approach in 2 dB steps
d. Ascending approach in 5 dB steps
Questions
1. Review the exercise completed above.
a. Did you notice any differences in the SRT when you utilized the descending approach
versus the ascending approach? If so how much?
b. Did you notice any differences in the SRT when you utilized 2 dB steps versus 5 dB
steps? If so, how much?
c. Were there any differences in the SRT/PTA agreement between the test conditions? If
so, which test condition provided the best SRT/PTA agreement?
2. Review the article, A comparison of American Speech-Language Hearing Association
Guidelines for Obtaining Speech-Recognition Thresholds. Ear & Hearing 1994, 15, 324-329.
Discuss the results of the study and any impact the study has on clinical practice.
Goals
1. To be able to administer word recognition tests using a variety of word lists.
Patricia I. Carr 62.
2. To be able to determine when to use the 10, 25, or 50-item word lists when obtaining the
word recognition scores.
3. To be able to interpret the word recognition score in comparison to the audiogram.
4. To be aware of other types of speech stimuli used to obtain the word recognition score.
Exercises
1. Obtain the recorded word recognition score at 40 dB SL re: SRT on _____ volunteers for
both ears using the CID W-22 word lists:
a. Present the first 10 words, note the length of time needed to complete each ear.
b. Present the first 25 words, note the length of time needed to complete each ear.
c. Present the full 50 words, note the length of time needed to complete each ear.
2. Obtain the recorded word recognition score at 40 dB SL re: SRT on _____ volunteers for
both ears using the NU-6 half lists:
a. Present the first 10 words, note the length of time needed to complete each ear.
b. Present the first 25 words, note the length of time needed to complete each ear.
c. Presenting the full 50 words, note the length of time needed to complete each ear.
3. Obtain the recorded word recognition score at 40 dB SL re: SRT on _____ volunteers for
both ears (50 words per ear) using the PB-50 word list, note the length of time needed to
complete each ear.
4. Obtain the recorded word recognition score on _____ volunteers using the first 25 words of
the CID W-22 word List 1 for the right ear and List 2 for the left ear presented at 50 dB HL
and 80 dB HL.
5. Utilize references available to you, review and record using other speech stimulus types that
are available for word recognition testing. Include some examples of each and in what
situations you would utilize them.
Questions
1. Review the results you obtained for exercise 1 above. Compare and contrast the 10, 25, and
50 item presentations of the test.
2. Review the results you obtained for exercise 2 above. Compare and contrast the 10, 25, and
50 item presentations of the test.
Patricia I. Carr 63.
3. Review the results you obtained from exercises 1 and 2, compare and contrast the CID W-22
and the NU-6 word lists.
4. Review the word recognition scores obtained when 50 words were presented for the CID W-
22, the NU-6, and the PB-50 word lists. Discuss any simililarities and differences noted.
Chapter 3
ACOUSTIC IMMITTANCE AUDIOMETRY
Key Words:
The study of the clinical application of immittance measurements was begun in 1939 by
Otto Metz in Copenhagen, Denmark. He developed the “theory of acoustic impedance of the
ear” (Margolis and Hunter, 1999) and published his findings based on normal and abnormal ears
using the Schuster device in the 1940s. In the 1960s and 1970s, research revealed a variety of
tympanometric patterns for different ages, different probe frequencies, and for different ear
diseases. A group of physicists at the University of Antwerp investigated the relationship
between the various tympanometric patterns and the physics of the middle ear. They developed
the Vanhuyse model, which provides “the basis for clinical interpretation of tympanograms and a
tool for experimental studies of pathology on middle ear function” (Margolis & Hunter, 1999).
Patricia I. Carr 64.
Some of the other significant contributors to this research include Bekesy, Zwislocki, Jerger,
Colletti, and Van Camp. In 1970, Jerger published the results of his study on the clinical
application of immittance measurements of over 400 subjects titled “Clinical experience with
impedance audiometry.”
Administration of the complete immittance test battery provides a quick and relatively
inexpensive objective assessment of the status of the middle ear, cochlea, VIIth and VIIIth
nerves, and lower brainstem. Immittance audiometry, which typically consists of tympanometry,
static immittance, and ipsilateral and contralateral acoustic reflexes, is usually completed before
pure tone and speech audiometry. The immittance test battery is much more sensitive to middle
ear disorders than the determination of air-bone gaps. (Stach, 1998). If the results on all the
subtests are within normal limits in the presence of a hearing loss, the hearing loss is
sensorineural in nature, and BC testing does not need to be performed. (Stach, 1998).
Before discussing the clinical application of the immittance test battery, it is important for
the tester to understand some of the basic concepts of acoustic immittance. This will assist the
tester in understanding the relationship between the patterns of results and middle ear disorders.
For an expanded discussion of acoustic immittance, the reader is directed to the references.
Margolis and Hunter (1999) state that “the acoustic immittance measurement is a method for
analyzing the responses of acoustic systems to sound” and “the acoustic immittance measured in
the ear canal is a result of the combined effects of the air volume in the canal and the
characteristics of the middle ear” (p. 91). Stach (1998) describes immittance audiometry as a
way of assessing the manner in which energy flows through the outer and middle ears to the
cochlea (p. 262).
acoustic energy increases through the middle ear, the acoustic admittance will increase and the
resulting acoustic impedance will decrease. The opposite will occur when the flow of acoustic
energy decreases through the system as the impedance of the system increases. Acoustic
impedance and acoustic admittance are comprised of the following components Gelfand, 1997;
Wiley & Fowler, 1997; Margolis & Hunter, 1999):
Acoustic Impedance
1. The friction component, acoustic resistance (Ra), is measured in acoustic ohms.
2. The stiffness component, negative acoustic reactance (-Xa), is measured in acoustic
ohms.
3. The mass component, positive acoustic reactance (Xa), is measured in acoustic ohms.
Acoustic Admittance
1. The frictional component, acoustic conductance (Ga), is measured in acoustic mmhos.
2. The stiffness or compliant component, acoustic susceptance (Ba), is measured in
acoustic mmhos.
3. The mass component, negative acoustic susceptance (-Ba), is measured in acoustic
mmhos.
The immittance of the ear is influenced by the sources of mass, friction, and stiffness.
The ossicles, the pars flaccida of the eardrum, and the perilymph influence the mass components.
The friction components respond to changes presented by the perilymph, the mucous membrane
linings of the middle spaces, the narrow passages between the middle ear and mastoid air
cavities, the tympanic membrane, and the various middle ear tendons and ligaments. The
stiffness components react to the volumes of air in the spaces of outer ear and middle ears, the
tympanic membrane, and tendons and ligaments of the ossicles. Gelfand (1997) also reports that
the contraction of the middle ear muscles and the presence of various middle ear pathologies
affect the immittance of the middle ear.
For the most part, in the clinical setting, the tester will utilize immittance measures
pertaining to acoustic admittance. Wiley and Fowler (1997) state that the mathematic and
engineering principles are easier with acoustic admittance measures than with acoustic
impedance measures. From this point on the term acoustic admittance will be used to discuss
immittance. The equipment available for clinic use is based on acoustic admittance measures.
Patricia I. Carr 66.
A review of the history and background information reveals the following. Research has
demonstrated that with an understanding of some basic physical principles and the use of a
device, which makes admittance measurements of the middle ear possible, the tester is able to
diagnose ear disease and its effects on middle ear function. (Margolis & Hunter, 1999).
Instrumentation
The acoustic admittance measurements are made utilizing a device which consists of a
probe assembly, headphone or insert receiver, analysis system, and display. The devices used
are developed and calibrated according to the ANSI 1987 specifications. See Figure 3.0 of a
block diagram displaying the major components of a clinical acoustic admittance device.
The probe assembly is comprised of four components: the probe tone speaker (receiver),
which delivers the probe tone to the ear canal; the monitor microphone, which monitors the
probe tone within the ear canal; the air pressure pump and manometer, which controls the air
pressure in the ear canal; and a second loudspeaker, which delivers stimuli used in ipsilateral
acoustic reflex testing. A removable soft cuff surrounds the probe tip, which is available in a
number of sizes to accommodate the ear canal size openings across patients. This cuff, when is
of the size appropriate for the patient, allows for the creation of an hermetic seal in the ear canal
required for the completion of acoustic admittance measurements.
During admittance testing, a probe tone is introduced into the ear canal and the SPL of
the signal is measured. The microphone located in the probe assembly monitors the decreases or
increases in the level of this tone. These decreases and increases in the level of the probe tone are
due to the various admittance properties of the ear. Generally, an 85 dB SPL, 226 Hz probe tone
is used for most admittance measures. The reader is directed to the references for more
information regarding the selection of the 226 and the 660-678 Hz probe tone frequencies. Other
probe frequencies, such as 800 and 1000 Hz, may be available depending on the instrument.
These higher frequencies tend to be more sensitive to certain middle disorders than the lower
frequencies. For discussion at this time only the 226 Hz probe tone will be considered. See
Table 3.0 for a brief list of definitions provided by the 1987 ANSI guidelines. (Margolis &
Hunter, 1999).
Patricia I. Carr 67.
Calibration
The acoustic immittance instrument must be calibrated on an annual basis. The features
that need to be calibrated include the probe assembly and the measurement/analysis system. The
226 Hz probe tone must be in agreement with standards by 3%, in another words between 219
and 233 Hz, and the sound pressure level must be < 90 dB measured in a 2 cm3 (HA-1) coupler.
(Margolis & Hunter 1999).
Probe
Tone
Loudspeaker
Monitor
Microphone
Probe
Tip
Immittance Device Pressure Pump
And
Manometer
Ipsilateral
Reflex
Loudspeaker
Figure 3.0: A block diagram displaying the major components of a clinical acoustic
immittance device.
Note. From Essentials of Audiology (p. 218), by S. A. Gelfand, 1997, New York, NY: Thieme
Medical Publishers, Inc. Copyright 1997 by Thieme Medical Publishers, Inc. Adapted with
permission.
Patricia I. Carr 68.
Table 3.0: Terms used in acoustic immittance measurements provided by the 1987 ANSI
guidelines.
Term ANSI 1987 Definition
Acoustic immittance Refers collectively to acoustic impedance, acoustic admittance,
and all of their components
Acoustic compliance The reciprocal of acoustic stiffness, is the ratio of a change in
volume displacement to a change in sound pressure.
Compliance is a characteristic of spring. The correct unit of
measure is the millimho (mmho).
Compensated static The immittance that has been compensated (or corrected) for
acoustic immittance the acoustic immittance of the ear canal. This value represents
the acoustic immittance of the middle ear at the tympanic
membrane.
Peak compensated The static immittance obtained with the ear canal air pressure
static acoustic adjusted to produce a peak in the measured immittance.
immittance This is frequently referred to as the static admittance or the peak
admittance.
Measurement-plane A measurement of acoustic immittance at the probe tip and
Tympanometry represents the combined acoustic immittance of the ear canal
and middle ear.
Compensated A measurement of acoustic immittance that has been
Tympanometry compensated (or corrected) for the acoustic immittance of the
ear canal.
Note. Table was adapted by P. Carr, 2001, utilizing information from Contemporary
perspectives in hearing assessment (p. 100-101), by R. H. Margolis & L. L. Hunter, 1999,
Needham Heights, MA: Allyn & Bacon. Adapted with permission.
The tester should routinely perform a calibration check of the instrument on a daily basis
by using a device provided by the manufacturer containing three calibration cavities with volume
Patricia I. Carr 69.
of 0.5, 2.0, and 5.0 cm3. (Margolis & Hunter, 1999). The tester should also perform the test
battery on herself/himself to ensure proper functioning of the instrument.
Test Limitations
The following are general test limitations of the admittance test battery. Limitations
specific to each measurement (tympanometry, static admittance, and acoustic reflex threshold)
will be mentioned under that measurement.
1. Acoustic admittance measures may vary depending upon on the depth of probe
insertion (Wiley & Fowler, 1997).
2. Acoustic admittance measurements are affected by the differences in ear canals
among patients (Wiley & Fowler, 1997).
3. A hermetic seal necessary for completion of the immittance test battery may not be
able to be obtained or maintained for every patient.
TYMPANOMETRY
Key Words
Decapascals (daPa) Equivalent ear canal volume
Single-frequency tympanometry Static Admittance Tympanogram
Tympanometric peak pressure Tympanometric Shape
Vector tympanometry
Background Information
Definition: The ANSI, S3.39-1987 guidelines define tympanometry as the dynamic
measurement of acoustic immittance in the external ear canal as a function of changes in air
pressure in the ear canal. It can also be described as the measurement of the acoustic admittance
of the ear using various amounts of air pressure in the ear canal. There are several
tympanometric measurements that may be obtained such as single-frequency/ single-component
tympanometry and multi-frequency/multi-component tympanometry. At this point in time, the
Patricia I. Carr 70.
most common method of evaluating the middle ear, single frequency/component tympanometry
also known as vector tympanometry, will be discussed.
1.5
Immittance in mmho
Increased admittance
0.3
0
-300 -200 -100 0 100 200
Air Pressure in daPa
Figure 3.1: This figure depicts the admittance measured in mmho on the y-axis and air
pressure in daPa on the x-axis. It also shows that as the pressure is varied above and below
the point of maximum transmission, the sound pressure level of the probe tone in the ear
canal increases, reflecting a reduction in sound transmission through the middle ear
mechanism.
probe tip in the opening of your other ear. You will feel some pressure in your ear similar to
when you go up in an elevator. Also, you will hear a humming sound. From time to time you will
hear some loud beeps, you do not need to tell me when you hear the beeps. Please try to sit very
still and try not to talk, as any movement or sound can affect the test results. If you should feel
any intolerable pain or too much discomfort, please tell me and I will stop the test. Do you have
any questions?
Note: Make sure that the patient removes any gum or candy he or she may have in his or
her mouth prior to testing.
INSTRUMENTATION
Test set up
Acoustic immittance instrument is set up to perform tympanometry, review
manufacturer’s manual for specifics.
Test stimuli
The test stimulus will consist of a probe tone frequency of 226- Hz. The probe tone
sound pressure level is 85 dB SPL. The air pressure will sweep from a positive (200 daPa) to a
negative pressure (-400 daPa).
Transducer
Probe tip assembly to one ear and headphone or insert to the opposite ear.
Response Mode
As the acoustic immittance test battery is an objective test, the patient is not required to
respond. The patient however must sit quietly and avoid talking throughout the test battery as
any movement or sound made by the patient will interfere with the test.
Step-by-Step Procedures
The following are suggested procedures for obtaining tympanometric measures:
1. The tester is to perform an otoscopic examination to determine the following:
a. External ear canal pathologies;
b. Perforated tympanic membrane;
Patricia I. Carr 73.
GO TO LABORATORY
EXERCISE # 3.0
Test Interpretation
When interpreting the tympanograms of a patient, the tester must review the
tympanometric shape, the amplitude of the tympanogram, the static admittance, equivalent ear
canal volume, and tympanometric peak pressure. Interpretation of tympanograms may be based
on a qualitative (tympanometric shape) or quantitative approach (static admittance,
tympanometric peak pressure, and equivalent ear canal volume).
Tympanometric Shapes: Liden (Liden, 1969; Liden et al., 1974) and Jerger (1970)
provide qualitative classifications of tympanograms based on the height and location of the
tympanometric peak. See Table 3.1 depicting a qualitative classification system for
tympanometric shape.
Static Admittance: Static admittance, also known as the peak compensated static acoustic
admittance, is sensitive to many middle ear conditions. These may include otitis media with
effusion, some chronic otitis media sequelae such as cholesteatoma, ossicular adhesions,
ossicular discontinuity, eardrum perforation, and ear canal occlusion. Also, space-occupying
lesions of the middle ear that are in contact with the eardrum or ossicular chain such as glomus
tumors affect static admittance measurements. (Margolis & Hunter, 1999). Static admittance is
Patricia I. Carr 76.
an estimate of the admittance at the lateral surface of the tympanic membrane, excluding the
effects of the ear canal volume. (VA, 1997). Norms are shown in Table 3.2. See the section
following tympanometry for more discussion on static admittance.
Table 3.1: Tympanometric shape classification system by Jerger (1970) and Liden (1969).
Tympanometric Description
Shape
Type A Has a normal peak height and location of the
tympanometric peak on the pressure axis.
Associated with normal middle ear function.
Note. Table was designed by P. Carr, 2001, utilizing information from Acoustic immittance
measures in clinical audiology: a primer (52-54), by T. L. Wiley & C. G. Fowler, 1997, San
Diego, CA: Singular Publishing Group, Inc. and from Essentials of audiology (223-224), by S.
A. Gelfand, 1997, New York, NY: Thieme Medical Publishers, Inc.
Patricia I. Carr 77.
Table 3.2: Norms for static admittance (Y), and equivalent ear canal volume (Vea)
Note. From Contemporary Perspectives in Hearing Assessment (p. 104), by R. H. Margolis and
L. L. Hunter, 1999, Needham, Heights, MA: Allyn & Bacon. Copyright 1999 by Allyn &
Bacon. Adapted with permission.
Tympanometric Peak Pressure: The tympanometric peak pressure (TPP) is the ear canal
air pressure at which the peak of the tympanogram occurs. The TPP is the point at which the
same pressure is present on both sides of the tympanic membrane. Margolis and Hunter (1999)
report that TPP is an indicator of the pressure in the middle ear space, but tends to overestimate
the actual ear pressure of the middle ear. Therefore, the tester should take caution when using
this value in isolation (Cantekin, Doyle, Phillips, & Bluestone, 1980; Magnuson, 1981, 1983;
Ostfeld & Silberberg, 1992). Margolis and Hunter (1999) reveal that, in the absence of other
tympanometric, audiometric, or otoscopic abnormality, negative middle ear pressure alone is not
an indication of a significant middle ear disorder. For example, Margolis and Nelson (1992)
reported that positive pressure (> 50 daPa) has been observed in patients with acute otitis media.
Positive peak pressure has also been associated with nonpathologic causes such as rapid elevator
rides, crying, or nose blowing. (Harford, 1980). According to Gelfand (1997), abnormally
negative tympanometric peak pressures are associated with eustachian tube disorders that can
occur either with or without the presence of middle ear fluid. See Table 3.2 for norms.
Patricia I. Carr 78.
Equivalent Ear Canal Volume: In the presence of a flat tympanogram, an estimate of the
volume of air in front of the probe can be useful for detecting eardrum perforations, evaluating
the patency of tympanostomy tubes, and evaluating the effects of cerumen in the ear canal.
When flat tympanograms are obtained, it is necessary for the tester to review the ear canal
volume measurements to determine the presence of various middle ear conditions. The ear canal
volume values may be abnormally large, abnormally small, or within normal limits. In the case
of a tympanic membrane perforation, the equivalent ear canal volume is an abnormally large
estimate of the middle ear space, contiguous mastoid air cells, and ear canal volume (Margolis &
Hunter, 1999). Abnormally large ear canal volume/flat tympanogram may be attributed to:
1. A perforated tympanic membrane;
2. In the presence of a tympanostomy tube, a patent tube; or
3. The absence of a hermetic seal, especially if the ear canal volume measurements
exceed 2.0 mmhos in children and 2.5 mmhos in adults. (Van Camp et al, 1986;
Silman & Silverman, 1991).
If the ear canal volume measurements are unusually small (at or close to 0 mmhos), the flat
tympanogram could be attributed to:
1. A clogged probe tip;
2. A probe tip that is pushed against the ear canal wall;
3. Impacted cerumen or another obstruction in the ear canal;
4. In the presence of a tympanostomy tube, a clogged tube (Gelfand, 1997); or
5. In the presence of a flat tympanogram, normal or near normal ear canal volume
measurements may be indicative of a fluid filled or tissue-filled middle ear cavity.
The tester must keep in mind, however, that a normal ear canal equivalent volume does
not always rule out perforation (Margolis & Hunter, 1999). Shanks & Lily (1981) report that
when maximum pressure is presented to the ear canal using a 226 Hz probe tone, the eardrum
and ear canal walls are not perfectly rigid. Therefore, the resulting equivalent ear canal volume
overestimates the ear canal volume by about 25 % in adults. The average tympanometrically
measured equivalent ear canal volume is about 0.3 cm3 in 4-month infants (Holte, Margolis, &
Cavanaugh, 1991), 0.75 cm3 in preschool-aged children (Margolis & Heller, 1987) and 1.0 to 1.4
cm3 in adults (Margolis & Heller, 1987;Wiley, Cruikshanks, Nondahl, Tweed, Klein, & Klein,
Patricia I. Carr 79.
1996). The tester should practice caution when reviewing ear canal volumes as a normal volume
does not rule out an eardrum perforation.
When interpreting flat tympanograms, the tester should consider the following as ears
with past or present middle ear disease have smaller middle ear/mastoid volumes than normal
ears for several reasons:
1. An ear with active disease may contain fluid, inflammation, granulation, fibrosis,
and cholesteatoma that reduce middle ear/mastoid volume.
2. Ears with active disease may have obstructions of the mastoid air cell system
reducing the total mastoid volume
3. When chronic disease occurs in infancy, there is an interruption of the
pneumatization process resulting in a smaller air-filled space (Palva & Palva, 1966).
4. Chronic disease is more prevalent in ears with poorly pneumatized mastoids
(Diamant et al., 1958).
5. Ears with perforations have abnormally large volumes when they are free of active
disease. However, when perforations occurred in the presence of active disease, the
equivalent ear canal volume was often normal (Shanks, 1985).
6. Progressively larger equivalent ear canal volume following tube insertion is an
indication of recovery from otitis media. However, when the equivalent ear canal
volume remains small, it is an indication of persistent disease (Takasaka, Hozawa,
Shoji, Takahashi, Jingu, Adachi, & Kobayashi, 1996).
7. Ears with equivalent ear canal volumes of 1.5 cc or less should be followed more
closely for recurrent otitis media (Margolis & Hunter, 1999).
Test Limitations
1. When utilizing only the 226 Hz probe tone, some middle ear disorders that are
affected by high frequencies will be missed (Wiley & Fowler, 1977).
2. There is no agreed upon cutoff value that determines abnormally negative
tympanometric peak pressure. Jerger (1970), Fiellau-Nikolajsen (1983), and Silman
et al (1992) recommend a cutoff value of –100 daPa. Renvall and Liden (1978) and
Patricia I. Carr 80.
Davies, John, Jones, and Stephens (1988) suggest using –150 daPa as the cutoff
value. Brooks (1969) reported the use of –170 daPa.
3. There is no one particular cutoff value for tympanometric peak pressure that reliably
distinguishes between the presence and absence of middle ear effusion (Gelfand,
1997).
4. The tester needs to practice caution when reviewing equivalent ear canal volumes as
perforation may be present with normal volume measurements.
5. The tester must review tympanometric results along with case history and other
audiometric findings as these results cannot be interpreted alone.
6. It is difficult to determine the presence or absence of middle ear disorder by the static
admittance results alone. Jerger (1970) and Feldman (1976) demonstrated that the
range of static admittance values found with various types of middle ear disorders
overlaps values considered to be in the normal range.
7. Norms do not always specify recording parameters such as recording speed, direction
of pressure change, and number of tympanograms measured sequentially. All of
these parameters affect test interpretation (Wiley & Fowler, 1997).
Laboratory Exercises
Goals
1. To be able to select the appropriate size probe tip and obtain a hermetic seal.
2. To be able to troubleshoot when a hermetic seal is unable to be obtained and maintained.
3. To be able to set up the acoustic immittance instrument and perform tympanometric
measurements.
Exercises
1. Practice calibrating the immittance instrument using the device containing the 0.5, 2.0, and
5.0 cm3 cavities.
Patricia I. Carr 81.
a. Place the probe tip assembly in the 0.5 cm3 cavity and run a tympanogram by selecting
the appropriate buttons as specified in manufacturer directions. Repeat tympanograms
for the 2.0 and 5.0 cm3 cavities.
b. Determine that the results are within ANSI 1987 specifications.
c. If the facility has a daily calibration log, record completion of calibration in the log.
2. Practice performing tympanometry on _____ volunteers for both ears. Make sure the
instrument is set for the 226 Hz probe tone frequency, the Y mode, pump speed of 200
daPa/sec, and the pressure direction from 200 daPa to –400 daPa.
a. Perform otoscopic exam and record findings on the audiogram
b. Begin with the right ear and determine the appropriate probe tip size. Obtain a
tympanogram.
c. Repeat for the left ear.
d. Repeat the tympanograms for both ears using a pump speed of 50 daPa/second.
e. Repeat the tympanograms for both ears using the pressure direction from –400 daPa to
200 daPa and pump speed of 200 daPa/second.
f. Repeat the tympanograms for both ears using the pressure direction from –400 daPa to
200 daPa, pump speed of 50 daPa/second.
Questions
1. Review the tympanometric peak pressure (TPP), static admittance, and equivalent ear canal
volume (EECV) results obtained for the second exercise above.
a. Were there any differences between the three measurements when the pump speed was
varied?
b. Were there any differences between the three measurements when the direction of
pressure change was varied?
Goals
1. To be able to determine if tympanometric results are normal or abnormal.
Patricia I. Carr 82.
2. To be able to predict the possible pure tone results and condition of the middle ear based
upon the TPP, the static admittance, and EECV results.
Exercises
1. Following are some cases depicting TPP, static admittance, and EECV results. Review the
results, state the tympanometric shape (A, Ad, As, B, C), whether the results are normal or
abnormal, and speculate the possible condition based on the results.
Case # 1:
TPP º -50 daPa
Static admittance º 0.4 cm3
EECV º 0.7 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition? __________________________________________
Case # 2:
TPP º no pressure reading
Static admittance º no peak reading
EECV º 0.5 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition?
__________________________________________
Case # 3:
TPP º no pressure reading
Static admittance º no peak reading
EECV º 0.1 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition?
__________________________________________
Patricia I. Carr 83.
Case # 4:
TPP º no pressure reading
Static admittance º no peak reading
EECV º 3.1 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition? __________________________________________
Case # 5:
TPP º -350 daPa
Static admittance º 0.4 cm3
EECV º 0.6 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition? __________________________________________
Case # 6:
TPP º 5 daPa
Static admittance º 0.3 cm3
EECV º 0.5 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition? __________________________________________
Case # 7:
TPP º -15 daPa
Static admittance º 2.1 cm3
EECV º 0.7 cm3
Normal/Abnormal (circle one) Shape______
Indicative of what condition? __________________________________________
Questions
1. Upon completion of the two exercises, describe any patterns noted between pure tone results
and tympanometric measurements.
2. As a tester, do the tympanometric results alone provide you with enough information to
comfortably formulate a diagnosis? Why or why not? If additional information is needed in
formulating your diagnosis, what is it and why?
Key Words
Acoustic mmhos (a mmhos) Compensated static acoustic admittance
Total immittance Tympanometric peak
Background Information
Definition: Wiley and Fowler (1997) define compensated static acoustic immittance or
static acoustic immittance (SAI) as the amplitude of the tympanogram (the height of the
tympanometric peak) measured at the plane of the tympanic membrane. The measurement
estimates the acoustic admittance at the plane of the tympanic membrane and the middle ear
system combined, excluding the ear canal value.
Total immittance measurements are based on the SPL reading at the probe tip and reflect
the acoustic immittance of the ear at that point of the measurement. The total immittance
measurements are the combined effects of the ear canal, the tympanic membrane, the middle ear
system, and the coupling of the ossicular chain to the cochlea. Our focus is on the acoustic
immittance of the middle ear, which is measured at the plane of the tympanic membrane. In
order to do this we need to subtract out the effects of the ear canal from the total immittance.
Patricia I. Carr 85.
This is done by first measuring the total acoustic admittance of the ear at either atmospheric
pressure (0 daPa) or ambient ear canal pressure, or at the peak of the tympanogram. Wiley and
Fowler (1997) report that the tympanometric peak value is the preferred measurement for use in
the clinic for several reasons:
1. It is the most stable of the two methods of measuring the SAI as it is unaffected
by small, normal fluctuations caused by swallowing and respiration.
2. It provides an estimate of the best possible function of the middle ear system.
Once the total acoustic immittance value is determined, a high amount of pressure
(negative or positive) is presented to the ear canal. This creates a stiffened tympanic membrane
so that essentially no flow of acoustic energy passes through to the middle ear and a
measurement of the ear canal is obtained. These measurements may be taken from the positive or
negative tails of the tympanogram. Most norms are based upon measurement taken from the
positive tail. Shanks and Lily (1981) report that measurements taken from the negative tail,
which are higher in peak value than those taken from the positive tail, provide a more accurate
estimate of ear canal volume. This value (the ear canal volume) is subtracted from the total
acoustic admittance to arrive at an estimate of the middle ear acoustic admittance at the lateral
surface or plane of the tympanic membrane, the SAI. (Gelfand, 1997; Wiley & Fowler, 1997).
The final SAI values usually represent the calculations automatically determined by the
instrument’s analysis system.
GO TO LABORATORY
EXERCISE # 3.2
Instrumentation, test set-up, test stimuli, transducer, response mode, step-by-step procedures
SAI is part of the tympanometric measurement, therefore follow for tympanometry.
Test Interpretation
The SAI, the tympanometric peak, values obtained are then compared to the norms.
There are no universally accepted norms for the SAI. When interpreting SAI values and
comparing to the norms, the tester must take into consideration the pump speed utilized during
the procedure and whether measurements were taken from the positive or negative tails. Fast
pump speeds are often used during immittance screening procedures. See Table 3.3 depicting
several sets of norms. The SAI values may be interpreted in the following ways:
Normal: if the SAI results fall within the range of normal
Below Normal: if the SAI results fall below the normal range. This is often seen as a low
peak on the tympanogram and corresponds to abnormally low admittance. Reduced SAI values
can occur due to stiffening conditions such as otosclerosis, cholesteatoma, and middle ear fluid.
While SAI values at or near 0 mmhos are usually seen in cases where the middle ear is filled
with fluid, ears impacted with cerumen or perforated tympanic membranes exhibit SAI values
that are at or near 0 mmhos. (Gelfand, 1997; Wiley & Fowler, 1997).
Above Normal: if the SAI values fall above the normal range. This is usually depicted as
a very high peak on the tympanogram and corresponds to abnormally high admittance.
Increased SAI values are seen in middle ear pathologies that add mass to the middle ear system.
Conditions such as ossicular discontinuity and ear drum pathology such as external otitis, or
cerumen or water adhering to the surface of the tympanic membrane present themselves with
increased SAI values. (Gelfand, 1997; Wiley & Fowler, 1997).
Patricia I. Carr 87.
Table 3.3: Depicts various norms for static acoustic admittance at the 90% range in a mmhos.
1. Note. From “Guidelines for screening for hearing impairment and middle-ear disorders,” by
American Speech-Language-Hearing Association, 1990, ASHA, 32 (Suppl. 2) p. Copyright
1990 by the American Speech-Language-Hearing Association. Adapted with permission.
2 & 3. Note. From Essentials of Audiology (p. 225), by S. A. Gelfand, 1997, New York, NY:
Thieme Medical Publishers, Inc. Copyright 1997 by Thieme Medical Publishers, Inc. Adapted
with permission.
Patricia I. Carr 88.
4. Note. From Manual of Tests Procedures: these materials were prepared for use in COMD
6203: “Advanced Diagnosis in Audiology,” Spring Term, 1999, 1999, by R. M. Hurley.
Adapted with permission.
5. Note. From Contemporary Perspectives in Hearing Assessment (p. 104), by R. H. Margolis
and L. L. Hunter, 1999, Needham, Heights, MA: Allyn & Bacon. Copyright 1999 by Allyn &
Bacon. Adapted with permission.
GO TO LABORATORY
EXERCISE # 3.3
Limitations
1. There is variability of norms due to differences among researchers in terms of
measurement and recording parameters.
a. Some norms determine the static admittance measurement from the positive tail
of the tympanogram and others from the negative tail of the tympanogram. The
measurements taken from the positive tail are smaller than those taken from the
negative tale (Gelfand, 1997; Wiley & Fowler, 1997) and may possibly be less
accurate although it is unlikely to have a significant clinical effect.
2. There is an overlap of SAI values obtained from normal ears and ears with middle
ear pathology making it difficult to separate the normal ears from the abnormal ears.
( Margolis & Heller, 1987; Nozza, et al., 1992; Shanks & Sheldon, 1991).
3. Males tend to exhibit higher values than females suggesting that norms may need to
be available for each group. ( Jerger, Jerger, & Maudlin, 1972; Wiley et al., 1996;
Zwislocki & Feldman, 1970).
Laboratory Exercises
Goals
1. To determine how the SAA values are calculated manually and therefore have a greater
understanding of the admittance of the middle ear at various pressure points.
Patricia I. Carr 89.
2. To become more familiar with functions available on the acoustic admittance instrument.
Exercises
NOTE: in order to complete the following exercises the acoustic immittance device needs to be
equipped with the following capabilities:
1. Baseline “on” and “off”
2. Varying pump speed
3. Change the direction of the pressure change
4. Frequencies 226 and 678 Hz
1. Run an acoustic admittance (Y) tympanogram with the baseline function “off” on _____
volunteers.
a. Set up the acoustic admittance device as follows:
• 226 Hz probe tone frequency
• Baseline function is turned “off”
• Positive to negative tracing
• Pump speed of 50 daPa/sec
b. Run the tympanogram on both ears
c. Calculate the SAI or peak admittance as follows:
• Determine the height of the peak. Look at the peak of the tympanogram and estimate
the distance from the peak to the X-axis in a mmho. This will be your C2 value, the
total admittance value that corresponds to the measurement of the middle ear and the
ear canal.
• Next, estimate the distance from the tracing at 200 daPa to the X-axis in a mmho.
This will be your C1 value, the admittance value of the ear canal.
• Finally, calculate the SAI as C2 – C1. This is the peak admittance of the middle ear.
• Repeat the above calculations measuring from –200 daPa.
2. Run an acoustic admittance (Y) tympanogram with the baseline function turned “on” on
_____ volunteers.
a. Set up the acoustic admittance device as follows:
• 226 Hz probe tone frequency
• Baseline function is turned “on”
Patricia I. Carr 90.
Questions
1. Review the results you obtained for exercises 1 and 2. Discuss differences observed between
baseline function, direction of tracing, ears, or calculations from 200 daPa or –200 daPa.
2. Review the results you obtained for exercises 3 and 4. Discuss differences observed between
baseline function, direction of tracing, ears, or calculations from 200 daPa or –200 daPa.
3. Review the results obtained regarding pump speeds for exercises 1-4. Discuss differences
observed.
4. Review results obtained for exercise 5. How did they compare to your results obtained with
the 226 Hz probe tone?
Goals
1. To be able to interpret SAI values as normal or abnormal.
2. To speculate as to the possible middle ear condition present.
Exercises
1. In LABORATORY EXERCISE # 3.2 compare your results obtained to two of the sets of
norms shown in Table 3.3. Determine the following regarding your SAI results:
a. Are they normal or abnormal?
b. If they are abnormal, are they above or below the normal range?
c. If they are abnormal, what is the speculated middle ear condition?
2. Review the following cases:
a. Case # 1, a 7 year old child:
SAI º 0.30 a mmhos. Normal/abnormal (circle one). Possible middle ear
condition________________________________________________________.
Questions
1. Review your interpretations in the two exercises above. Discuss what you observed.
2. Based on information provided by the available references, discuss disadvantages and
advantages of relying in the SAI values alone in the determination of the presence of a
middle ear condition.
Key Words
VIIIth cranial nerve Acoustic reflex Acoustic reflex threshold
Admittance Afferent Brainstem
Contraction Contralateral acoustic reflex
Crossed acoustic reflex Efferent Elevated
Extra-axial Facial Nerve Immittance
Patricia I. Carr 93.
The acoustic reflex is elicited as a contraction of the stapedius muscle in both ears when a
sufficiently intense sound is presented to either ear. This contraction creates a change in the
immittance of the middle ear by stiffening the middle ear system through the stapedius tendon.
The change in immittance is seen as a decrease in the admittance of the middle ear system. This
decrease in the ear’s admittance is measured in the ear containing the probe tip, also known as
the probe ear. The stimulus ear is the ear that receives the stimulus used to activate the reflex.
The stimulus may be delivered to either ear from the receiver in the probe tip or the
earphone/insert receiver on the opposite ear. When the stimulus is delivered to the probe ear, the
ipsilateral or uncrossed acoustic reflex is being measured. Thus, in the ipsilateral test mode, the
ear containing the probe is the same ear that receives the stimulus and it also monitors the
changes in immittance. See Figure 3.30 and 3.31. When the probe tip is in one ear and the
stimulus is presented to the other ear this is known as the contralateral or crossed acoustic reflex.
During measurement of the contralateral acoustic reflex, the stimulated ear is used to identify the
reflex (according to ANSI specifications, 1987). See Figure 3.32 and 3.33. The “right
contralateral acoustic reflex” indicates that the stimulus was delivered to the right ear and the
Patricia I. Carr 94.
probe in the left ear is monitoring the reflex response. The “left contralateral acoustic reflex”
means that the stimulus was delivered to the left ear and the probe in the right ear is monitoring
the reflex response. The ipsilateral acoustic stapedius reflex is generally elicited at a slightly
lower loudness level relative the contralateral acoustic reflex.
acoustic reflex . The right ear receives the acoustic reflex. The left ear
stimulus and the left ear contains the probe. receives the stimulus and
the right ear contains the probe.
Note: the stimulated ear is the test ear.
When the stapedius muscle contracts, the tendon exerts tension on the stapes; the stapes
footplate is moved laterally from the oval window and the head of the stapes is drawn
posteriorly, at right angles to the direction of the ossicular chain. The ossicular chain is then
stiffened and there is a reduction of low frequency energy transmission through the middle ear.
As a result of this reduced energy transmission, there is a noticeable increase in the SPL reading
in the external ear canal. Upon elicitation of the acoustic reflex, its contraction tends to act as a
high pass filter of the transmission of sound through the middle ear. Rabinowitz (1977)
reported attenuation of low frequency signals with the maximum effect for approximately 600
Hz. He also noted little, if any, effect of the acoustic reflex on the loudness level for
frequencies above 1000 Hz that reached the inner ear. The stapedius muscle in both ears
contract as a result of sound being delivered to either ear.
Borg (1973) described the acoustic reflex arc based on his research in rabbits. As an
example, the pathway is as follows when the normal right ear has been stimulated:
1. The sound is presented to the right ear, passes through the middle ear and then
through the cochlea.
Patricia I. Carr 96.
2. The stimulus then proceeds through the afferent (sensory) and efferent (motor) parts
of the acoustic reflex arc as follows:
a) Afferent:
1) The stimulus passes along the auditory (VIII) nerve from the right ear;
2) then goes to the right (ipsilateral) ventral cochlear nucleus;
3) from there the neurons go to the superior olivary complexes on both sides
of the brain stem; and then
4) signals from the right and left superior olivary complexes are sent to the
facial (seventh) nerve nuclei on their respective sides to complete the
afferent part of the acoustic reflex pathway.
a) Efferent:
1) The signal then proceeds through the efferent part of the acoustic reflex
pathway by involving the right and left facial nerves;
2) This in turn directs the stapedius muscles to contract in both ears.
Keep in mind that the tensor tympani muscles also respond to extremely intense sounds but
evidence supports that the acoustic reflex in humans is a stapedius reflex (Gelfand, 1990). The
stapedius reflex is also activated to nonacoustic stimulation such as tactile stimulation of the
external ear or a puff of air to the eye (Wiley & Block, 1984).
GO TO LABORATORY EXERCISE
AR # 3.4
INSTRUMENTATION
Test Set up
1. Turn on the immittance device and calibrate as specified by the manufacturer.
2. Complete tympanometry for the right ear first, leave probe assembly on the patient. Prior to
inserting the headphone or insert to the left ear, instruct your patient as suggested below
under “Instructions to the patient”.
3. The ART test is usually administered using a 220 or 226 Hz probe tone.
4. When testing neonates, a 660 Hz probe tone is used as their acoustic reflexes are often
elevated or absent with a 226 Hz probe tone. The reflexes of neonates is more similar to that
of adults when a 660 Hz probe tone is used (Bennett & Weatherby, 1982; Gelfand, 1984;
Sprague et al, 1985.
5. Research has documented that the stimulus presentation level should not exceed 105 dB HL
(110 dB SPL) for several reasons (Wilson & Margolis, 1999). Presentation levels at these
high levels may be upsetting to the patient. Patients may experience a temporary and/or
permanent hearing loss following acoustic reflex testing. (Stach, 1998).
Now you will hear some loud beeps, you do not need to tell me when you hear the
beeps. Please continue to sit very still and avoid talking, as any movement or sound can
affect the test results. If you should feel any intolerable pain or too much discomfort,
please tell me and I will stop the test. Do you have any questions? Now I will place this
headphone over your other ear.
Step-by-Step Procedures
The following are suggested procedures for completing ipsilateral and contralateral ART’s:
1. Complete tympanometry on the right ear first.
2. Verify that the immittance probe is in one ear, and the supra-aural or insert earphone
for contralateral stimulation is properly seated in the other ear.
3. Adjust the ear canal pressure to the point at which the tympanometric peak is at its
maximum value. This is done automatically by some immittance instruments.
4. Select the ipsilateral acoustic reflex mode on the immittance instrument.
5. Present a 1000 Hz tonal signal at 85 dB HL (this is the average normal acoustic reflex
threshold level). Avoid presentation levels in excess of 105 dB HL.
6. Determine by visual inspection whether the admittance tracing changed immediately
after presentation of the signal. Also inspect the admittance change as indicated
numerically (e.g., 0.04 ml) on the instrument screen. The lowest amount of
acceptable admittance change varies from instrument to instrument, it is important to
read the manual for the instrument used to determine this value.
7. If there was acoustic reflex activity at the initial signal intensity level, decrease the
intensity by 10 or 5 dB and repeat. Using the bracketing approach, obtain two
responses at the lowest intensity level where the least amount of appropriate
deflection occurs as specified by the manufacturer of the instrument.
8. If there was no acoustic reflex activity at the initial signal intensity level, increase the
intensity in 10 dB steps until a response is obtained and continue as in Step 7.
9. Select the contralateral acoustic reflex mode and pulsed tone stimulus type.
10. Present a 1000 Hz tonal signal at or 10 dB above the ipsilateral ART, but be cautious
not to exceed a 105 dB HL presentation level.
11. Repeat steps 6, 7, and 8.
Patricia I. Carr 99.
12. Continue to obtain contralateral ART’s for 2000 Hz and 500 Hz.
13. Reverse ears and repeat these procedures.
14. Record all ART’s on an audiogram form.
15. Interpret the acoustic reflex pattern.
16. Consider measurement of acoustic reflex decay before removing the probe tip from
the patient’s ear.
17. Record the acoustic reflex threshold results on the audiogram.
GO TO LABORATORY EXERCISE
# 3.5
the artifact is seen as an upward deflection that is a decrease in admittance. The additive artifact
can occur during ipsilateral or contralateral recording, but is more likely to be seen in the
ipsilateral recording. It is due to the compilation of the energy in the reflex-activator signal to
the energy of the probe signal. In the recording, the artifact is seen as downward deflection that
is an increase in admittance. This artifact can be misinterpreted as a true reflex (Margolis &
Gilman, 1977; Popelka & Dubno, 1978).
A. ---------------------------------
B. ---------------------------------
C. ---------------------------------
D. ---------------------------------
E. ---------------------------------
F. ---------------------------------
Patricia I. Carr 101.
Fig. 3.4: Deflections that may be observed upon acoustic reflex threshold determination.
A. Normal deflection. B. Variation of the normal deflection. C. Abnormal deflection as
seen in cases of early otosclerosis. D. Tympanic membrane artifact. E. Additive artifact.
F. Tympanic membrane artifact and the true acoustic reflex deflection.
Transference of acoustic reflex results from the strip chart or impedance device screen to the
audiogram
1. Locate the Acoustic Stapedial Reflex Thresholds section of the audiogram.
2. When preparing to transfer the ipsilateral acoustic reflex for the right ear (probe right
and stimulus right), take into consideration the probe ear (right ear), test mode
(ipsilateral), test frequency (1000 Hz), and the lowest dB HL at which the acceptable
amount of admittance change occurred. Record the threshold value obtained onto the
audiogram.
3. Next, transfer the contralateral acoustic reflexes for the left ear (probe right, stimulus
left) for frequencies 500, 1000, and 2000 Hz onto the audiogram.
4. Repeat steps 2 and 3 for the ipsilateral ART for the left ear (probe right and stimulus
right) and the contralateral ART for the right ear (probe left and stimulus right) onto
the audiogram.
5. If there is a sensorineural hearing loss as indicated by the pure tone audiogram and
there is a designated place in the audiogram, calculate sensation levels (SL) for the
contralateral acoustic reflexes. This calculation is used to confirm cochlear hearing
loss as discussed under TEST INTERPRETATION.
6. To determine the SL values, the pure tone thresholds of the right ear are subtracted
from its respective contralateral ART’s for the right ear. Record these calculations on
the audiogram if applicable.
Patricia I. Carr 102.
GO TO LABORATORY EXERCISE
# 3.6
Test Interpretation
The acoustic stapedial reflex may be present, absent, elevated, or reduced depending
upon the hearing sensitivity and the presence or absence of pathological conditions of the outer,
middle, and inner ear. Below are acoustic reflex outcomes and some associated possible
pathological conditions to consider when interpreting acoustic reflex patterns:
Acoustic reflex is absent
1. Facial lesion
2. Abnormalities in the middle ear muscles
3. The ossicular chain is immobile or interrupted
4. Brain stem lesion
5. Severe cochlear hearing loss
6. Retrocochlear lesions
Stach (1998) provides a diagram, see Figure 3.5 , that represents the auditory and nervous
system structures and depicts possible causes for the absence of a right crossed acoustic reflex.
When interpreting the contralateral acoustic reflexes, refer to the norms as suggested by
Silman & Gelfand (1981). See Table 3.4. The patient’s ART’s are
Patricia I. Carr 103.
Ventral Superior
Cochlear Olivary
Nucleus Complex
compared to the respective 90th percentiles that correspond to his hearing thresholds for the
frequencies tested. If the patient’s ART value falls on or below the depicted 90th percentile, then
it is considered to be essentially within the normal and /or cochlear distribution. On the other
hand, if the patient’s ART falls above the depicted 90th percentile value, the threshold is
considered to be abnormally elevated. If a conductive disorder is not present in a patient and the
reflexes are abnormally elevated or absent, then the patient is considered to be at risk for eighth
nerve pathology in the ear that received the stimulus (Gelfand, 1994). Lesions in the higher
areas of the auditory cortex usually produce no abnormalities in either contralateral or ipsilateral
reflexes because these centers are above the acoustic reflex arc.
Table 3.4: Acoustic reflex threshold 90th percentile cutoff values as a function of hearing level at
500, 1000, and 2000 Hz.
90th Percentile Acoustic Reflex Threshold Norms (dB HL)
Silman & Gelfand (1981) Gelfand, Schwander, & Silman (1990)
500 Hz 1000 Hz 2000 Hz 500 Hz 1000Hz 2000 Hz
dB HL
0 95 100 95 95 95 95
5 95 100 95 95 95 95
10 95 100 100 95 95 95
Patricia I. Carr 105.
15 95 100 100 95 95 95
20 95 100 100 95 95 95
25 95 100 100 95 95 95
30 100 100 105 95 95 100
35 100 100 105 95 95 100
40 100 105 105 95 95 100
45 100 105 105 95 95 105
50 105 105 110 100 100 105
55 105 105 110 105 105 110
60 105 110 115 105 110 115
65 105 110 115 110 110 115
70 115 115 125 115 115 120
75 115 115 125 120 120 125
80 125 125 125 120 125 NR*
85 125 125 125 NR NR NR
>90 125 125 125 NR NR NR
Note. From Essentials of Audiology (p. 244), by S. A. Gelfand, 1997, New York, NY: Thieme
Medical Publishers, Inc. Copyright 1997 by Thieme Medical Publishers, Inc. Adapted with
permission.
Patricia I. Carr 106.
Loss (severe)
R: VIIIth hearing Absent Present Absent Present
loss Or Or
L: Normal hearing Elevated Elevated
R: Normal hearing Absent Present Present Absent
(VIIth nerve)
L: Normal hearing
R: Normal hearing Present Present Present Absent
L: Normal hearing
(Brainstem)
R: Normal hearing Present Present Absent Absent
L: Normal hearing
(Brainstem)
R: Normal hearing Present Present Present Present
(Cortex)
L: Normal hearing
Table 3.5: A quick reference of theoretical acoustic reflex patterns and possible associated pathologies.
108
Patricia I. Carr 109.
The patient presents with a bilateral conductive hearing loss, the following acoustic
reflex threshold pattern may occur:
Ipsilateral right – absent Air-bone gap reduces the effective level of stimulus
Contralateral left – absent that reaches the cochlea (stimulus ear rule) and the
Ipsilateral left – absent conductive pathology prevents an immittance
Contralateral right - absent change from being monitored even if the reflex
is activated (probe ear rule).
109
Patricia I. Carr 110.
The patient presents with a severe sensorineural hearing loss in the right ear, and
normal hearing in the left ear. The following ART pattern may occur:
Retrocochlear Disorders
ARTs may be absent or elevated in the stimulus ear in either the ipsilateral or the contralateral
mode. The ART may be elevated by 20 to 25 dB even though hearing sensitivity is no more than
5 or 10 dB HL. As the hearing loss exceeds 70 to 75 dB, the ART become absent (Stach, 1998). Patient
presents with a VIIIth nerve lesion on the right side and normal hearing in the left. The lesion is extra
axial, it is along the auditory nerve, medial to the cochlea. This is considered to be a problem along the
afferent portion of the arc. The following ART pattern may occur:
Patient presents with normal hearing with a right facial lesion and normal hearing
in the left. The following ART pattern may occur:
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Patricia I. Carr 111.
Ipsilateral right – absent Note: When the probe is on the side of the VIIth
Contralateral left – absent nerve lesion during ipsilateral testing, the
Ipsilateral left – present ART will be absent. The VIIth nerve is the
Contralateral right –present motor leg or the efferent portion of the acoustic
reflex arc that innervates the stapedius muscle.
Cortical Disorders
Lesions in the higher areas of the auditory cortex usually produce no abnormalities
in either contralateral or ipsilateral reflexes because these centers are above the
acoustic reflex arc. Patient presents with cortical lesion with normal hearing in both ears may
produce the following ART pattern:
GO TO LABORATORY
EXERCISE # 3.7
Test Limitations
1. The clinician would be unable to perform ART testing on a patient with actively
draining ear(s).
2. The patient may be sensitive to intense sounds and would therefore be unable to
tolerate the ART test.
3. As with tympanometric testing, the clinician may be unable to maintain the hermetic
seal necessary to complete the testing.
4. Research recommends that the clinician not present stimuli at intensity levels greater
than 105 dB HL.
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Patricia I. Carr 112.
Laboratory Exercises
Goals
1. To be able to trace the pathway through the acoustic reflex arc of the ipsilateral acoustic
reflex response.
2. To be able to trace the pathway through the acoustic reflex arc of the contralateral acoustic
reflex response.
3. To be able to distinguish between the afferent and efferent portions of the acoustic reflex arc.
Exercises
1. In the Audiology lab, log onto the computer and locate computer software programs such as
Audiology Clinic and Clinical Journeys and view the ipsilateral and contralateral acoustic
reflex pathways.
2. Draw accurately the pathway through the acoustic reflex arc of the ipsilateral acoustic reflex
response for both ears.
3. Draw accurately the pathway through the acoustic reflex arc of the contralateral acoustic
reflex response for both ears.
Questions
1. Discuss briefly the nonacoustic stimulation of the acoustic stapedial reflex. Utilize sources
sited in the REFERENCES section of this unit.
2. Discuss briefly the role of the tensor tympani muscle in the acoustic stapedial reflex. Utilize
sources sited in the REFERENCES section.
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Patricia I. Carr 113.
Goals
1. Develop the ability to administer the ipsilateral and contralateral acoustic reflex thresholds
for various frequencies.
2. Develop the awareness of differences in thresholds obtained with broadband noise and pulsed
tone stimuli.
3. Develop the ability to determine acceptable acoustic reflex deflections when obtaining
thresholds.
Exercises
1. Perform acoustic reflex thresholds on __ classmates.
a. Obtain the ipsilateral acoustic reflex threshold for 1000 Hz for both ears using
pulsed tone stimuli.
b. Obtain the ipsilateral acoustic reflex threshold for both ears using broadband
noise.
c. Obtain the contralateral acoustic reflex threshold for 500, 1000, 2000, and 4000
Hz for both ears using pulsed tone stimuli.
d. Obtain the contralateral acoustic reflex threshold for both ears using broadband
noise.
2. Perform acoustic reflex thresholds on __ subjects, other than classmates and other
audiology students.
a. Obtain the ipsilateral acoustic reflex threshold for 1000 Hz for both ears
b. Obtain the contralateral acoustic reflex threshold for 500, 1000, and 2000 Hz for
both ears.
c. Determine pure tone thresholds for 500, 1000, and 2000 Hz for both ears.
Questions
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Patricia I. Carr 114.
1. Did you notice any differences in thresholds obtained with the two types of stimuli –
pulsed tone and broadband noise? Briefly state what differences you noticed and to what do
you account for these differences? Utilize sources such as those cited in the REFERENCES
section.
2. Did you notice any acoustic reflex threshold patterns occurring within subjects or between
subjects? If so, what were they?
Goals
1. Develop the ability to accurately transfer acoustic reflex thresholds to the audiogram.
2. Develop the ability to determine SL values for contralateral acoustic reflex thresholds.
3. To develop awareness of reflex patterns.
4. To formulate some basic diagnoses based on acoustic reflex thresholds.
Exercises
1. Transfer the acoustic reflex threshold results from the immittance strip charts or the
immittance device screen to the audiogram on the five sample cases provided.
2. Calculate the SL values for the contralateral acoustic reflex thresholds on the five sample
cases provided.
Questions
1. In general, state how the HL and SL values related to each other?
2. Did you notice any patterns in the appearance of the deflections within or between the
sample cases? State briefly your observations.
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Patricia I. Carr 115.
Goals
1. To be aware that pathological conditions can affect the presence or absence of the acoustic
reflex response.
2. To be aware that degrees of hearing loss can affect the presence or absence of the acoustic
reflex response.
3. To arrive at diagnoses based upon the ipsilateral and contralateral patterns of acoustic reflex
responses and audiometric results obtained on a patient.
4. To predict possible outcomes for ipsilateral and contralateral acoustic reflexes given
pathological conditions.
Exercises
1. Complete the ACOUSTIC PATTERNS EXERCISE as shown following this page.
Questions
1. Review literature and discuss what happens to the physical characteristics of the sound signal
(quality, intensity) as it travels through the auditory pathways of a patient with a conductive
hearing loss. How does this relate to the presence or absence of the acoustic reflex response?
2. What happens in patients with sensorineural hearing losses?
3. Review the resources to determine the sensitivity and specificity of the acoustic reflex
threshold test. How useful is this test in the differential diagnosis of various pathological
conditions?
STUDENT_________________
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Patricia I. Carr 116.
The following are situations you may encounter during clinic. Based upon the
information provided you may need to determine the condition (disorder) with given reflexes or
you may need to determine the reflexes given the condition:
Note: more than one condition/disorder may present for several of the situations.
1. Patient exhibits normal hearing in the left ear and a mild to moderate cochlear hearing loss in
the right ear. Complete the following reflexes you would expect to obtain:
• Ipsilateral right - __________________________________________
• Contralateral right - _______________________________________
• Ipsilateral left - ___________________________________________
• Contralateral left -_________________________________________
2. Patient exhibits a mild to moderate cochlear hearing loss for both ears. Complete the reflexes
you would expect to obtain:
• Ipsilateral right - _________________________________________
• Contralateral right - _______________________________________
• Ipsilateral left - __________________________________________
• Contralateral left -________________________________________
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Patricia I. Carr 117.
• Contralateral right - absent or elevated
• Ipsilateral left - present
• Contralateral left -present
5. Patient exhibits normal hearing in both ears. The acoustic reflexes are as follows:
• Ipsilateral right - present
• Contralateral right - absent
• Ipsilateral left - present
• Contralateral left -absent
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Patricia I. Carr 118.
6. The patient exhibits a bilateral conductive hearing loss, what reflexes would you expect to
obtain?
• Ipsilateral right - _____________________________________
• Contralateral right - __________________________________
• Ipsilateral left - ______________________________________
• Contralateral left -____________________________________
7. Patient exhibits normal hearing in the left ear and a conductive hearing loss in the right ear.
Complete the reflexes you would expect to obtain:
• Ipsilateral right -_____________________________________
• Contralateral right - _________________________________
• Ipsilateral left - _____________________________________
• Contralateral left -___________________________________
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Patricia I. Carr 119.
Why, what is happening? _______________________________________
___________________________________________________________
___________________________________________________________.
9. Patient exhibits normal hearing in both ears. The acoustic reflexes are as follows:
• Ipsilateral right - absent
• Contralateral right - present
• Ipsilateral left - present
• Contralateral left -absent
10. Patient exhibits normal hearing in both ears, but has been diagnosed with a lesion on the left
cortex. Complete the reflexes you would expect to obtain:
• Ipsilateral right -
• Contralateral right -
• Ipsilateral left -
• Contralateral left -
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Patricia I. Carr 120.
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Patricia I. Carr 135.
Zwislocki, J., & Feldman, A. S. (1970). Acoustic impedance of pathological ear.
(Monograph No. 15). Rockville, MD: American Speech-Language-Hearing Association.
APPENDIX A
Note. From ANSI criteria for permissible ambient noise during audiometric testing (ANSI, 1977)
and “Pure-tone audiometry: air and bone conduction” by L. A. Wilber, found in Contemporary
perspectives in hearing assessment (p. 11), by F. E. Musiek & W. F. Rintelmann (Eds.), 1999,
Needham Heights, MA: Allyn and Bacon. Copyright 1999 by Allyn and Bacon. Adapted with
permission.
APPENDIX B
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Patricia I. Carr 136.
List A List B
Airplane Armchair
Baseball Backbone
Blackboard Birthday
Cowboy Cookbook
Drawbridge Doorman
Duckpond Earthquake
Eardrum Eyebrow
Horseshoe Greyhound
Hot dog Hardware
Ice cream Headlight
Mousetrap Inkwell
Northwest Mushroom
Oatmeal Nutmeg
Pancake Outside
Playground Padlock
Railroad Stairway
Sunset Toothbrush
Whitewash Woodwork
Note. From “Guidelines for determining threshold level for speech,” by American Speech-
Language-Hearing Association, 1988, ASHA, p. 103. Copyright 1988 by the American Speech-
Language-Hearing Association. Adapted with permission.
APPENDIX C
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Patricia I. Carr 137.
Mousetrap Stairway Padlock Eardrum
Northwest Playground Woodwork Toothbrush
Drawbridge Railroad Birthday Iceberg
Sidewalk
Note. From Manual of Tests Procedures: these materials were prepared for use in COMD 6203:
“Advanced Diagnosis in Audiology,” Spring Term, 1999, 1999, by R. M. Hurley. These thirteen
spondees were judged to be homogeneous for intelligibility by 5 of 7 investigators as follows:
Beattie, et al. (1975), Journal of American Auditory Society, 1, pp. 97-101; Beattie, et al. (1975),
Journal of Speech and Hearing Disorders, 40, pp. 84-91; Bowling & Elpern (1961), Journal of
Auditory Research, 1, pp. 152-157; Conn et al. (1975), Journal of Speech and Hearing Disorders,
40, pp. 388-396; Curry & Cox (1966), Journal of Auditory Research, 6, pp. 419-424; Dubno et
al. (1984), Journal of the Acoustical Society of America, 76, pp. 87-96; Young et al. (1982),
Journal of Speech and Hearing Research, 25, pp. 586-593. Adapted with permission.
APPENDIX D
APPENDIX E
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Patricia I. Carr 138.
CID W-22 word list.
List 1A List 2A List 3A
1. an 26. you 1. yore 26. and 1. bill 26. aim
2. yard 27. as 2. bin 27. young 2. add 27. when
3. carve 28. wet 3. way 28. cars 3. west 28. book
4. us 29. chew 4. chest 29. tree 4. cute 29. tie
5. day 30. see 5. then 30. dumb 5. start 30. do
6. toe 31. deaf 6. ease 31. that 6. ears 31. hand
7. felt 32. them 7. smart 32. die 7. tan 32. end
8. stove 33. give 8. gave 33. show 8. nest 33. shove
9. hunt 34. true 9. pew 34. hurt 9. say 34. have
10. ran 35. isle 10. ice 35. own 10. is 35. owes
11. knees 36. or 11. odd 36. key 11. out 36. jar
12. not 37. law 12. knee 37. oak 12. lie 37. no
13. mew 38. me 13. move 38. new 13. three 38. may
14. low 39. none 14. now 39. live 14. oil 39. knit
15. owl 40. jam 15. jaw 40. off 15. king 40. on
16. it 41. poor 16. one 41. ill 16. pie 41. if
17. she 42. him 17. hit 42. rooms 17. he 42. raw
18. high 43. skin 18. send 43. ham 18. smooth 43. glove
19. there 44. east 19. else 44. star 19. farm 44. ten
20. earn 45. thing 20. tare 45. eat 20. this 45. dull
21. twins 46. dad 21. does 46. thin 21. done 46. though
22. could 47. up 22. too 47. flat 22. use 47. chair
23. what 48. bells 23. cap 48. well 23. camp 48. we
24. bathe 49. wire 24. with 49. by 24. wool 49. ate
25. ace 50. ache 25. air 50. ail 25. are 50. year
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Patricia I. Carr 139.
APPENDIX F
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Patricia I. Carr 140.
18. fall 43. size 18. witch 43. haze 18. team 43. cab 18. gas 43. perch
19. raise 44. mode 19. soap 44. 19. lid 44. hit 19. check 44. shirt
match
20. third 45. bean 20. 45. learn 20. pole 45. chat 20. join 45. bath
young
21. gap 46. tip 21. ton 46. shawl 21. road 46. 21. lease 46. time
phone
22. fat 47. chalk 22. keg 47. deep 22. shall 47. soup 22. long 47. hall
23. met 48. jail 23. calm 48. gin 23. late 48. 23. chain 48. mood
dodge
24. jar 49. burn 24. tool 49. goal 24. cheek 49. seize 24. kill 49. dog
25. door 50. kite 25. pike 50. far 25. beg 50. cool 25. hole 50.
should
APPENDIX G
“Lower and upper limits of the 95% critical differences for percentage scores. Values
within the range shown are not significantly different from the value shown in the
percentage Score columns (p > 0.05). From Thornton & Raffin (1978).” (Gelfand, 1997, p.
274).
% Score n = 50 N = 25 N = 10 % score N = 100a
0 0-4 0-8 0-20 50 37-63
2 0-10 51 38-64
4 0-14 0-20 52 39-65
6 2-18 53 40-66
8 2-22 0-28 54 41-67
10 2-24 0-50 55 42-68
12 4-26 4-32 56 43-69
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Patricia I. Carr 141.
14 4-30 57 44-70
16 6-32 4-40 58 45-71
18 6-34 59 46-72
20 8-36 4-44 0-60 60 47-73
22 8-40 61 48-74
24 10-42 8-48 62 49-74
26 12-44 63 50-75
28 14-46 8-52 64 51-76
30 14-48 10-70 65 52-77
32 16-50 12-56 66 53-78
34 18-52 67 54-79
36 20-54 16-60 68 55-80
38 22-56 69 56-81
40 22-58 16-64 10-80 70 57-81
42 24-60 71 58-82
44 26-62 20-68 72 59-83
46 28-64 73 60-84
48 30-66 24-72 74 61-85
50 32-68 10-90 75 63-86
52 34-70 28-76 76 64-86
54 36-72 77 65-87
56 38-74 32-80 78 66-88
58 40-76 79 67-89
60 42-78 36-84 20-90 80 68-89
62 44-78 81 69-90
64 46-80 40-84 82 71-91
66 48-82 83 72-92
68 50-84 44-88 84 73-92
70 52-86 30-90 85 74-93
72 54-86 48-92 86 75-94
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Patricia I. Carr 142.
74 56-88 87 77-94
76 58-90 52-92 88 78-95
78 60-92 89 76-96
80 64-92 56-96 90 81-96
82 66-94 91 82-97
84 68-94 60-96 92 83-98
86 70-96 93 85-98
88 74-96 68-96 94 86-99
90 76-98 50-100 95 88-99
92 78-98 72-100 96 89-99
94 82-98 97 91-100
96 86-100 80-100 98 92-100
98 90-100 99 94-100
100 96-100 92-100 80-100 100 97-100
a
If score is less than 50%, find % score = 100 – observed score and subtract each critical
difference limit from 100.
Note. From Essentials of Audiology (p. 274), by S. A. Gelfand, 1997, New York, NY: Thieme
Medical Publishers, Inc. Copyright 1997 by Thieme Medical Publishers, Inc. Adapted with
permission.
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Patricia I. Carr 143.
PATRICIA IRENE CARR
5423 Windbrush Drive
Tampa, Florida 33625
(813) 264-4791
143
Patricia Irene Carr
PRESENTATIONS
ACurrent Hearing Aid Issues.@ Presentation to a speech reading group at
the Gulfport Senior Citizen Center, Gulfport, Florida. February 1998
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MEMBERSHIPS
American Speech-Language-Hearing Association
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