Otorhinolaryngology

Audiology
Dr. the who/December 9, 2010

Definition: Note that:

Science Noises over 40 db SPL may cause pain
1. Evaluation of hearing Long exposure to noises over 90 db SPL eventually harm hearing
a. Etiological diagnosis
b. Assessment of the impact of hearing impairment which can Routes for Hearing
limit attentionskills, language development, speech precision 1. Air Conduction – utilizes the external and middle ear in the
and general communication effectiveness transmission of sound to the cochlea and to the upper centers
2. Rehabilitation of Individuals with communication problem guided 2. Bone Conduction – the skull is set into vibration setting
by the hearing measurements along with other variables such as the cochlear fluids into motion, thus bypassing the external and
intelligence, motivation, family support, social & vocational middle ear.
needs. - Traditionally has been treated as a measure of the integrity of
the cochlea.
HEARING = SOUND
Sound
-simplest form is a pure tone (single freq.)
-frequency (cycles/sec) in hertz (hz)
-always a combination of various frequencies at varying intensities
-intensity in decibels (db)

Advantages of listening with two EARS

1. The ability to discriminate speech in the presence of background
noise or competing speech.
2. Binaural summation which results in a positive loudness
difference compared to loudness`when listening to the same signal
monoaurally.
3. The “squelch” effect of suppression of background noise when
attending to a primary signal.
4. The elimination of the head shadow effect.
5. Localization
6. Judgment of naturalness

Sound Pressure Level Associated with Different Sounds

SOUND DECIBELS (db SPL)
Rocket launching pad 180
Jet plane 140
Gunshot blast 140
Riveting steel tank 130
Automobile horn 120 HEARING LOSS
Sandblasting 112 1. Conductive – if the SN ( BC ) is normal while the total
Woodworking shop 100 System ( AC ) is impaired, the impairment
Punch press 100 is judged to have resulted from damage in
the EAC or ME>
Pneumatic drill 100
Boiler shop 100 2. Sensorineural- if bone conduction measurement is no more
Hydraulic press 100 sensitive than air conduction, the total
Can manufacturing plant 100 impairment is judge to have resulted from
Subway 90 damage to the cochlea or retrocochlear
3. Combination
Average factory 80-90
Computer card verifier 85
Noisy restaurant 80
Office tabulator 80
Busy Traffic 75
Coversational speech 66
Average home 50
Quiet office 40
Whisper 30
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Measure of Threshold
1. The vibrating TF is held close to the ear
2. The pt. is advised when the sound is no longer audible,
then the TF is placed near the examiner’s ear
3. the interval between the time when the sound is no longeraudible
to the pt. and to that of the examiner is measured
a) provides a rough estimate of the relative sensitivity
b) with different TF used, it can offer a differentialpitch pattern,
high, low or a flat hearing impairment

WEBER’S Test
 the stem of the vibrating TF is held in the midline of the
forehead, vertex of the skull, or best the incisors
 The pt. Is asked to which ear it is best heard or midline
 results:
lateralization:
a) to the poorer ear – hearing loss is conductive
reasons:
1) attenuation of air conducted
background noise
2) prevention of loss of acoustic
energy from the EAC
b) to the better ear – hearing loss is SN
c) midline – 1) = SN hearing loss
2) normal hearing AU
3) equal conductive hearing loss

RINNE’S Test
E V A L U A T IO N  Compares the pts. Hearing by bone conduction against air
1. Etiology – diagnosis conduction
2. Tools for hearing evaluation  the hilt of the vibrating TF is held against the pt’s mastoid
a) TUNING FORK TEST process until no longer heard and the tines placed close tothe
b) PURE TONE AUDIOMETRY orifice of the EAC, same ear, until no longer heard
c) SPEECH AUDIOMETRY  normally AC>BC by a ratio of 2:1
d) TYMPANOMETRY
e) BERA Reason: the intrinsic impedance mismatch in the fork skull
3. Degree of Hearing Loss relationship
a) mild
b) moderate results hearing status locus
c) severe a)positive AC>BC normal or SN none or cochlear,
impairmentretrocochlear
TUNING FORK TEST b)negative AC<BC conductive EAC/ME
Reference Comparison
a.) Examiner – standard or golden ear
b.) Patient’s own normal ear – for unilateral hearing loss
c.) Third person with normal hearing acuity
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3 ESSENTIAL PARTS (PTA)
1. Variable frequency oscillator to produce sounds
2. Attenuator to permit variations in intensity
3. Transducer, either an earphone, bone vibrator or a loud
speaker to convert electrical to acoustic energy

AUDIOGRAM
• a graph of the patient’s hearing sensitivity for various
frequencies
• measures are recorded for each ear separately with frequency
on the abscissa & intensity on the ordinate

THRESHOLD
• the lowest intensity level in db that can be heard for each
SCHWABACH’S Test frequency
 compares the pt’s bone conduction against a normalreference
 the stem of the vibrating TF is held against the mastoidprocess AUDIOMETRIC ZERO (ANSI)
of the pt until inaudible, then applied to the sameagainst a • the median average threshold of a large sample of young
normal reference& the time measured until no longer adults with no hearing complaints, no history of ear disease &
perceived no recent colds
• each frequency has its separate zero with zero calibrated
results hearing status locus values built into the audiometer
equal normal none
prolonged conductive EAC/ME INTERPRETATION
diminished sensorineural coclear/retrococlear 1. Degree of hearing loss
a.) Mild
BING’S Test b.) Moderate
 application of the so-called occlusion effect c.) Severe
 while the stem of the vibrating TF is held against the pt’s d.) Profound
mastoid process, the EAC is alternately occluded 2. Configuration or pattern of loss
- certain disorders or diseases seem to have associated
results hearing status locus audiometric signature
positive increase/decrease normal/SN none/coclear/ 3. Air conduction – Bone conduction Relationship
in loudness retrocochlear a) when BC thresholds are better than air conduction by 10 db or
negative none conductive EAC/ME more & are normal, the loss is conductive
b) when bone conduction thresholds are the same as air
Reliability: conduction& neither is normal, the loss is sensorineural
- problems of reliability ensue from judgment errors of both the c) when bone conduction thresholds are reduced but are still
patient & the examiner as to the moment of inaudibility as the tonal better than air conduction by 10 db or more, the loss is mixed
experience decays into silence or combined
- the 256 TF is the most accurate in determining slight conductive
hearing loss but requires control of background noise
- the 512 TF is better able to provide useful Bing’s test
- the incidence of false negative rinne and false increased
schwabach arises from the nature of bone conduction:
a) the vibrating TF applied to the skull will vibrate the entire
head, thus both ears stimulated. The result will therefore reflect the
ear with better bone conduction.

- because of these problems of validity & reliability, it is wise use a

battery of TF test, affording an opportunity for comparison

PURE TONE AUDIOMETRY

• Developed in the early 1920’s made possible by the invention
of the vacuum tubes to produce electronic tones
• It samples the octave series of the C scale (125, 250, 500, 1000,
2000,4000,8000 Hz) *classmates may mga graphs na hindi ko gets, you may refer sa ppt
• Tones at half octave intervals are also provided(750, 1500, na lang.
3000, 6000 Hz)
• The tonal intensity could be maintained at a fixed level or
interrupted at will at fixed intervals
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SPEECH AUDIOMETRY 7. Felt 20. Earn 33. Give 46. Dad
Although inferences are drawn & speculations are made from pure 8. Stove 21. Twins 34. True 47. Up
tone thresholds regarding the ability to hear and understand speech, 9. Hunt 22. Could 35. Isle 48. Bells
PTA is not a direct measure of those abilities and is subject to error 10. Ran 23. What 36. Or 49. Wire
11. Knees 24. Bathe 37. Law 50. Ache
1. Speech Reception Threshold - measure of sensitivity 12. Not 25. Ace 38. Me
2. Speech Discrimination - measure of understanding 13. New 26. You 39. None

Speech Reception Threshold (spondee words) Impedance Audiometry

• spondee threshold is the faintest presentation level in db at Tympanometry
which the patient is able to correctly identify 50% of the test • indirect measure of the compliance (mobility) of the TM& the
words ossicular chain system under conditions of positive, normal &
• agrees closely with the PT average of 500, 1000 & 2000 Hz negative pressure
• test can be administered using either recorded words or live • device – probe with 3 channels
voice monitored with a VU meter 1. Sound source – 95 db SPL
• the usual response is a verbal repetition 2. Measures the reflected energy
• if the difference of 15 db or more between the spondee 3. Vary the pressure within the EAC
threshold & the PT average is noted, suspect • A Tympanogram is a graphic representation of the relative
a. equipment calibration error compliance and relative impedance of the tympano-ossicular
b. patient misunderstood the directions, uncooperative or system
is exaggerating for personal gain a.) maximum compliance is achieved at normal air pressure
b.)compliance is reduced at positive and negative pressures
Spondee Word List for CID Auditory Test W-1, List A
1. Greyhound 13. Padlock 25. Playground
2. Schoolboy 14. Mushroom 26. Airplane
3. Inkwell 15. Hardware 27. Woodwork
4. Whitewash 16. Workshop 28. Oatmeal
5. Pancake 17. Horseshoe 29. Toothbrush
6. Mousetrap 18. Armchair 30. Farewell
7. Eardrum 19. Baseball 31. Grandson
8. Headlight 20. Stairway 32. Drawbridge
9. Birthday 21. Cowboy 33. Doormat
10. Duck pond 22. Iceberg 34. Hothouse
11. Sidewalk 23. Northwest 35. Daybreak
12. Hotdog 24. Railroad 36. Sunset

Speech Discrimination (Phonetically Balanced)

• assessment of the pt’s ability to understand speech
• useful in:
a.) diagnosis of the site of lesion
b.) contributes to the consideration of the need for & selection of
a hearing aid
c.) assist in describing the pts. communication problem for
purposes of rehabilitation management, planning &
counseling
• utilizes a list of single syllable words
- balanced for vocabulary familiarity
- reflects the relative incidence of the various speech sounds
in the language chosen
• presented at a level 20 to 40 db above SRT or to the pt’s most
comfortable level
• SD score is a % based on the no. of words the pt. repeats
correctly
• expected score is 94 to 100%

Phonetically Balanced (PB) Word List for CID Auditory Test W-22,
List A

1. An 14. Low 27. As 40. Jam

2. Yard 15. Owl 28. Wet 41. Poor
3. Carve 16. It 29. Chew 42. Him
4. Us 17. She 30. See 43. Skin
5. Day 18. High 31. Deaf 44. East
6. Toe 19. There 32. Them 45. Thing
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Pediatric Audiometry Speech Audiometry
2 to 4-year-old
4 Categories  language chosen must be appropriate for the child’s age &
1. Behavioral Observation Audiometry
cultural environment
2. Play Audiometry
3. Speech Audiometry  the child is asked to repeat words or point to proper objects or
4. Objective Audiometry perform the requested action
• Early identification is critical  SRT is obtainable
- The normal development of speech & language VASC (Verbal Auditory Screening for Children)
communication, personal & family relationship, intellectual  offers recorded two – syllable words at progressively lower
& educational achievement depends upon intact hearing
intensities to a previously determined low fence intensity level
• A child who is not learning to talk by the age of 12 to 18
months should be a signal for hearing impairment for screening
 Speech Discrimination can be accomplished with single-syllable
Behavioral Observation Audiometry (Newborn to 6 months) word list at a kindergarten level (PB-K)
Stimuli – sounds of different frequencies  DIP,WIPI, G-P-W are picture identification task for children
• drums – low frequency
• horns& whistles – middle frequency
• squeaker toys – high frequency
• neometer (Zenith Corp) – provides a 3000 Hz warble
• tone calibrated to SPL of 70, 80, 90 & 100 db at a
• distance of 1 foot from the baby’s ear
Response – an alteration in the infant’s state or behavior occurring
immediately after the sound and is repeatable
a) Moro or startle reflex – 8 to 10 weeks
b) Cochlear – palpebral reflex
c) Eye widening
Special Objective Procedures
d) Facial grimace – localization is more accurate at 4 – 6 mo.
 Referred to as objective because of the necessary hardware but
e) Cessation of activity
all require judgment as to whether the derived data constitute
f) Deep inspiration
a response
g) Increase body movement
a.) Impedance audiometry
h) h.)eyes or head turning
- stapedial reflex  loudness dependent
* infants& babies habituate quickly –an interval of 45 to 60 seconds
- most popular because of its simplicity
between signals is preferred
b.) Evoked response audiometry
- samples the electrical activity of the auditory NS
Behavioral Observation Audiometry (6 to 24 months)
c.) Eletrocochleography
 warbled pure tones or narrow band noise around a center
d.) Cardiovascular (Heart Rate) audiometry
frequency are presented in a threshold finding maneuver with a
e.) Respiration audiometry
loudspeaker as a sound source & the stimulus intensity level
f.) Electrodermal audiometry or galvanic skin response
calibrated
audiometry
 localization of the sound source becomes more reliable st
*1 3 (a, b, c) are the most commonly used procedures
 an air conduction audiogram is produced
Stages of Hearing Development
Minimal Stimulus to Elicit a response AGE CHARACTERISTICS
 newborn – 80 to 90 db 0 – 4 months Awaken to loud noise
 12 weeks – 65 to 75 db Exhibit startle reflex to loud noise
 6 months – 30 to 35 db Cries with loud noise
5 – 7 months Turns to sound
Play Audiometry (Instrumental/Operant Conditioning) Follows sounds or voices
2 to 4-year-old 8 – 10 months Makes noise in response to voice or voices
 headphone is used Exhibit inflection in sounds – variable
 the child is conditioned to put an object in a specific place when Loudness of cry & vocalization
he/she hears a sound 11 – 14 months Mimics sound
 the attention span of the average 2 yr old will reflect the Makes variety of sound
ingenuity of the examiner & the variety of materials provided 14 – 24 months Voice has inflection
Vocabulary starts to develop
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High – Registry 1973 Joint Committee on Newborn Screening Treatment/Rehabiltation:
American Academy of Ophthalmology & Otolaryngology 1. Diagnosis
American Academy of Pediatrics 2. Reversibility of Hearing Loss
American Speech & Hearing Association 3. Degree of Hearing Loss
• Family history of childhood deafness 4. Occupational & Social needs
• Suspected maternal rubella
• All infants with structural abnormalities of the external ear,
cleft lip or palate, bifid uvula
• Bilirubin above 20 mg/100ml or history of exchange transfusion
• Birth weight below 1500 gm

Brainstem Evoked Response Audiometry (BERA

• samples the electrical activity of the auditory nervous system &
what happens to the brain wave when sound is introduced
• electrodes are attached to the scalp & mastoid process to
record an electrical response evoked by sound stimuli Congenital Conductive HL
• stimuli – a series of rapid clicks (25+ per second) • Atresia of the EAC
st
• events are recorded during the 1 10 msec. Following the • Congenital Stapes Fixation
sound • Congenital Malleus Fixation
• because the potentials are small, a computer is required to • Ossicular Discontinuity or Maldevelopment
average the results • Primary Cholesteatoma
• measurement of the latency from the stimulus to the
appearance of waveforms and the appearance of characteristic Acquired Conductive HL
waveform pattern are compared to norms • Obstruction of the EAC
• it is an accurate measure of the auditory function & is • Tympanic Membrane Perforation
completely objective • Serous Otitis Media
• Adhesive Otitis Media
BERA • Ossicular Discontinuity - trauma, infection,cholesteatoma
 Wave I – auditory nerve 2 msec. • Tympanosclerosis
 Wave II – cochlear nucleus 3 msec. • Otosclerosis
 Wave III – superior olive 4.1 msec.
 Wave IV – lateral lemniscus 5.3 msec.
 Wave V – inferior colliculus 5.9 msec.

Clinical uses
1. Threshold testing in infants, young
children and malingerers
2. Diagnosis of acoustic neurinomas
3. Diagnosis of brainstem lesions
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Sample case:
Mr. Juan dela Cruz 23 y/o
CC: hearing loss
Otoscopy: AD-intact TM AS-perforated TM
TFT: 512
Weber: lateralize to the left Bing’s test : AD- positive
Rinne: AD- AC>BC AS- negative
AS- BC>AC Schwabach’s test: AU- diminished

Pre OP
250 500 750 1000 1500 2000 3000 4000 6000 8000

SRT: AD- 50 db AS-75db

MCL: AD- 90 db AS- 100db
SD: AD- 95% AS- 95%
TX: Tympanoplasty

Post Op
250 500 750 1000 1500 2000 3000 4000 6000 8000

SRT: AD- 50 db AS-45db

MCL: AD- 90 db AS- 85db
SD: AD- 95% AS- 95%
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Congenital Nongenetic SN Hearing Loss
Occurring Alone
• Ototoxic poisoning (streptomycin, quinine)
Occurring with Other Abnormalities
• Viral Infection
• Bacterial Infection
• Ototoxic Poisoning (thalidomide)
• Metabolic Disorders (cretinism)
• Radiation (1st trimester)
• Prematurity
• Birth Trauma, anoxia

Acquired Sensorineural Deafness

Etiologies
Genetic
• Deafness Occurring Alone
• Deafness Occurring with Other Abnormalities
Nongenetic
• Inflammatory Disease
• Ototoxic Poisoning
• Neoplastic Disorders
• Traumatic Injury
• Metabolic Disorders
• Vascular Insufficiency
• CNS disease

Permissible Exposure for Continuous Noise

Level (dB) Maximum Exposure (hr)
Congenital Sensorineural Deafness 90 8
Etiologies 95 4
Genetic Nongenetic 100 2
deafness occurring alone deafness occurring alone 105 1
deafness occurring with other deafness occurring with other 110 0.5
abnormalities abnormalities 115 0.25
chromosomal abnormalities
Delayed Genetic SN HL
Congenital Genetic SNHL Occurring Alone
Occurring Alone Michel’ Aplasia • Familial Progressive SN Deafness
Mondini’s Aplasia • Otosclerosis
Scheibe’s Aplasia • Presbycusis
Alexander’s Aplasia Occurring with Other Abnormalities
Occurring with Other Waardenburg’s Disease • Alport’s Syndrome
Abnormalities Albinism • von Recklinghausen’s Disease
Hyperpigmentation • Hurler’s Syndrome
Onychodystrophy • Klippel-Feil Syndrome
Pendred’s Disease • Refsum’s Disease
Jervell’s Disease • Alstrom’s Disease
Usher”s Disease • Paget”s Disease
With Chromosomal Trisomy 13-15 • Richards - Rundel Syndrome
Abnormalities Trisomy 16-18 • Crouzon’s Disease
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Classes of Hearing Handicap
Hearing
Average Hearing
Threshold
Threshold Level* Ability to
Level
Understand
more not
Degree of Speech
Class than more
Handicap
than
no significant
25 dB A not significant - 25 dB difficulty with
faint speech
difficulty only
40 dB B slight handicap 25 dB 40 dB with faint
speech
frequent
difficulty with
55 dB C mild handicap 40 dB 55 dB
normal
speech
frequent
70 dB marked
D 55 dB 70 dB difficulty with
handicap
loud speech
can
understand
90 dB E severe handicap 70 dB 90 dB only shouted
or amplified
speech
usually cannot
understand
extreme
F 90 dB - even
handical
amplified
speech
*for 500, 1000 and 2000 Hz in the Better Ear

Educational Needs of Children with Impaired Hearing

Group Hearing Level Educational Needs
1 Less than 45 dB Speech Reading
Favorable seating
2 41 to 55 dB Speech Reading
Hearing Aid & Auditory Training
Speech Correction & Conservation
Favorable seating How a Hearing Aid Works
3 56 to 70 dB Lip Reading 1. Sound waves are received by the microphone
Hearing Aid & Auditory Training 2. The signal from the microphone is sent along the cable to the
Special Language Work speech processor.
Favorable Seating or Special Class 3. The speech processor changes the sound into a coded signal
4 71 to 90 dB Probably special education that contains a very rapid pattern of small impulses.
procedures for deaf children w/ 4. The coded signal is sent back along the same cable to the
special emphasis on speech transmitter
auditory training and language, w/ a. The transmitter sends the coded signal via radio
the possibility that the child may transmission through the intact skin to the receiver
enter regular classes. 5. The implanted receiver decodes the signal and sends a pattern
5 More than 90 dB Special class or school for the deaf, of very rapid small electrical pulses to the
some are able to enter regular 6. electrodes in the coclea
school a. The small pulses delivered by the electrodes stimulates the
auditory nerve.
HEARING AIDS
Parts: Types: *Different parts of the nerve are stimulated according to the pitch of
1. Microphone 1. In the ear ( ITE) the sound waves received by the microphone. In response, the
2. Amplifier 2. Post-auricular auditory nerve carries out its natural function and conducts the
3. Speaker 3. In the eyeglass nerve impulses to the brain.
4. Battery 4. Body
Ei please see the ppt sent by judee sa mail for better appreciation of the pics.
Tnx. alex arjay.