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What do we find out during the assessment ?

 Is the hearing
 Normal
 Abnormal
 Type of hearing loss
• CHL
• SNHL
• MIXED HL
 Degree of hearing loss
 Site of lesion
 Cause of hearing loss

 Malingner
Hearing test’s
 Can be classified as
 Subjective
 Objective

 Alternatively as,
 Clinical
 Audiometric
 Special
Clinical tests
of hearing
Finger friction test
 Rough
 Quick method of screening
 Consists of rubbing the thumb and the finger close to
the patient’s ear
Watch test
 Popular screening test in past
 Obsolete now
 Lever pocket watch was brought close to the patient’s
ear and the distance at which it was heard was
measured
Speech (voice) tests
 Can be done in the following ways;
 Free field hearing test by
 Conversation voice
 Forced whisper

 Recorded voice test


 Speech audiometry
 Normally, a person hears conversational voice at 12
metres (40 feet) and whisper (with residual air after
normal expiration) at 6 metres (20 feet), but for
practical purposes of the test, 6 meters is taken as
normal for conversation and whisper tests.

 Procedure -----
 Drawback’s
 Speech tests lack standerdisation in intensity and pitch
of the voice for testing and the level of ambient noise.
Tuning fork tests
 Performed using the tuning forks of different
frequencies (64 Hz ----- 4096 Hz), but routinely with
256 Hz and 512 Hz.
 512 Hz is ideal !!!!
 TF of lower frequencies produce a sense of bone
vibration while those of higher frequencies have a
shorter decay time, and are thus not used routinely.
 They are used to differentiate b/w a CHL and a SNHL.
TFT’s
 AC testing  function of both the conducting
mechanism and the cochlea are tested.
 BC testing  measures cochlear function only.
Pathways for air and bone conduction
TFT Pre-requsites
 Quite surroundings
 Detailed description of the test procedure to the patient.
 Prongs should be struck sharply against some resistance
---- (not against hard objects  generates Harmonics)
 Masking should be applied to the nontest ear (barany
noise box, rubbing paper against the ear).
Various TFT’s
 Routinely performed TFT’s are,
 Rinne test
 Weber test
 Absolute bone conduction test (modified schwabach’s)
 Schwabach’s test
 Bing test
 Gelle’s test

 TFT for malingering or non organic deafness


 Stenger’s test
 Chimani moos test
 Teal test
 Lombard test
Rinne test

 In this test the AC of the ear is compared with its BC.


 Procedure ---
 Conventional method
 Threshold comparison method
 Interpretation

TEST NORMAL CONDUCTIVE SENSORINEURAL


HEARING LOSS HEARING LOSS
RINNE AC > BC BC > AC AC > BC
RINNE POSITIVE RINNE NEGATIVE
Serial tuning fork test
 A prediction of air-bone gap can be made if tuning
forks of 256, 512, 1024 Hz are used.
False negative Rinne
 Seen in severe U/L SNHL
 Patient does not perceive any sound of TF by air
conduction but responds to BC testing, which in
reality is from the other ear b/c of transcranial
conduction of sound.
 In such cases, correct diagnosis can be made by
masking the nontest ear with Barany’s noise box.
 Weber test further helps as it gets lateralised to the
better ear.
Weber test
 Procedure---
 Here the sound travels directly to cochlea via bone.
 Lateralisation of sound in weber test with a tuning fork
of 512 Hz implies a CHL of 15-20 dB in I/L ear or a
SNHL in the C/L ear.
 Interpretation.
TEST NORMAL CONDUCTIVE SENSORINEURAL
HEARING LOSS HEARING LOSS
WEBER NOT LATERALISED TO LATERALISED TO
LATERALISED POORER EAR BETTER EAR
Absolute bone conduction test
(modified schwabach’s test)
 Bone conduction is the measure of cochlear function.
 Here the patient’s bone conduction is compared with
that of the examiner.
 Procedure ------ (EAC of patient & clinician r occluded)

 Interpretation
TEST NORMAL CONDUCTIVE SENSORINEURAL
HEARING LOSS HEARING LOSS
ABC SAME AS SAME AS REDUCED
(MODIFIED EXAMINER EXAMINER
SCHWABACH’S)
Schwabach’s test
 Procedure ---

 Interpretation
TEST NORMAL CONDUCTIVE SENSORINEURAL
HEARING LOSS HEARING LOSS
SCHWABACH EQUAL LENGTHENED SHORTENED
Bing test
 Test of BC, and examines the effect of occlusion of ear
canal on the hearing.
 Procedure---
 A normal person or one with SNHL hears louder when
ear canal is occluded and softer when the canal is open
(bing +ve). A patient with CHL will appreciate no
change (bing –ve).
 Interpretation
TEST NORMAL CONDUCTIVE SENSORINEURAL
HEARING LOSS HEARING LOSS
BING +VE -VE +VE
Gelle’s test
 A test of BC, and examines the effect of increased air
pressure in ear canal on hearing.
 Procedure---
 Interpretation

TEST NORMAL CONDUCTIVE SENSORINEURAL


HEARING LOSS HEARING LOSS
GELLE’S +VE -VE +VE
 In was a popular test to find out stapes fixation in
otosclerosis but has now been superceded by
tympanometry.
Stenger’s test
 Stenger's test: This test is based on "Stenger's phenomenon". In
stenger's phenomenon when a listener is presented with the
same type of sound in both ears he /she will hear a single sound,
that too only in the ear in which it is louder.

Procedure: Two tuning forks with frequency of 512 Hz are kept


equidistantly from both ears, one should be able to hear equally
well in either side. In malingering say i.e. left ear, even if the
tuning fork is moved too close to the left ear, the patient denies
that he is hearing in the right side also.
Chimani moos test
 Modification of weber’s test
 TF is placed over forehead, malingerer states that he
hears the sound in his good ear (simulating SNHL). If
the meatus of good ear is occluded, a truly deaf patient
still hears the sound in the occluded ear, where as a
malingerer may deny that he hears any sound atall.
Teal test
 Teal's test: In this test a vibrating tuning fork is
applied over the mastoid process of the so called deaf
ear, the patient accepts to hear it. Then the patient is
blind folded and with a non vibrating fork on the
mastoid process, the malingering patient claim's to
hear the sound.
Audiometric tests
 Pure tone audiometry
 Impedance audiometry
 Bekesy’s audiometry
 Speech audiometry
 BERA
Pure tone audiometry
 It includes measurement of hearing acuity by using pure
tones (single frequency sounds) to estimate the AC and BC
thresholds of hearing for various frequencies.
 AC threshold
 BC threshold
 Pure tone thresholds indicate the softest sound audible to
an individual at least 50% of the time and the hearing
levels are measured in decibles.
 Usually frequencies of 250 – 8000 Hz are used in testing, as
this range represents most of the speech spectrum.
 This hearing sensitivity is plotted on a graph known as
audiogram (displaying intensity as a function of frequency)
 Usually AC thresholds are measured for tones of 125 –
8000 Hz and BC thresholds are measured for tones of
250 – 4000 Hz.

 The amount of intensity that has to be raised above the


normal level is a measure of degree of hearing
impairment at that frequency.

 The difference in the threshold of AC and BC (A-B


gap) is a measure of the degree of conductive deafness.
High frequency audiometry
 b/w 8000 – 20000 Hz (Routinely uptill 8000 Hz)
 Done by incorporating a separate audio-oscillator in
the pure tone audiometer and using special ear
phones.
 At present, its use is very limited, except for;
 Patients with tinnitus
 Monitoring the effects of ototoxic drugs
Aims of performing a PTA
 Whether the subject has any definite hearing loss.
 Whether the HL is conductive/ sensorineural / mixed.
 If sensorineural, then whether it is cochlear or
retrocochlear.
 The degree of dysfunction.
Symbols in audiogram
Degree of hearing loss
S. DEGREE OF dB
N HEARING LOSS
O.
1. NORMAL HEARING < 25 dB
2. MILD HL 26 – 40 dB
3. MODERATE HL 41 – 55 dB
4. MODERATELY 56 – 70 dB
SEVERE HL
5. SEVERE HL 70 – 91 dB
6. PROFOUND HL > 91 dB
IMPORTANT
At Iowa State Fair in 1935, 10 000 young
women had their hearing measured
This established the normal hearing
levels for pure tone Audiometry (0
db Threshold).
Air conduction

Bone conduction
Advantages of PTA
 Tests various frequencies
 Both qualitative and quantitative (type and severity of HL)
 Documentation
 Compare serial audiograms, pre and post treatment
 May give clue to the diagnosis
Drawback’s of PTA
 Subjective test
 Patient should understand instructions – can not be
done in children and psychiatric patients
 Masking is needed to avoid the involvement of the C/L
ear
Procedure of PTA
 Examination of the patient
 Detailed explanation to the patient about the test
procedure
 Methods
 Conventional Hughson – Westlake technique (modified
by Carhart and Jerger)
 American speech and hearing association technique
Procedure
 Better ear is tested first
 Position of head phones
 Reasonably noiseless environment
 Test is begun with a 1000 Hz sound and then other
frequencies are tested in increasing order 8000 Hz (or till
available), 1K is repeated again and then we proceed towards
the lower end.
 Is the difference b/w these octaves is more than 20 dB then
the half octaves i.e., 750, 1500, 3000 and 6000 is tested.
 In each frequency the threshold is ascertained by 5-up -10-
down method.
Detailed procedure---
 Examiner familiarises the patient with the tone by
introducing the sound at an arbitrarily presumed
supra threshold level.
-------- (3 out of 5 correct responses)
 As this is completely a subjective test, there is always a
possibility of the patient not having responded
correctly and hence repetitions of the test are
mandatory.
For BC testing
 Placement of bone conduction vibrator
 Frontal placement V/S mastoid placement
 Frontal placement is superior to mastoid placement as regards
 Consistency of results
 Less variation of amount of tissue b/w the vibrator and the bone
 Lesser artifacts
 Mastoid placement
 Slightly more sensitive area
 With the usual bone vibrators, threshold on mastoids is about 10 -15
dB better than those with frontal placement.
 If the BC vibrator has been calibrated for mastoid
placement, then a Correction factor has to be substracted
to get the actual bone conduction hearing threshold from
frontal placement.
 15 dB for 250 and 500 HZ
 10 dB for 1K to 4K Hz
 eg; BC threshold at 500 Hz is 25 dB HL on frontal
placement then the threshold should be accepted as 25 –
15 = 10 dB HL.
 Remaining technique remains the same (5 up and 10
down)
Masking
 What is masking ????

 When to mask ????

 How much to mask ????


Masking
 In PTA clinician wants to ascertain the exact hearing
threshold by the air and bone conduction, for different
frequencies in each of the two ears separately and
individually.
 Therefore it is essential to keep the non test ear out the test
process.
 Because individual evaluation is essential for diagnostic as
well as rehabilitative decision making.
 Concept of shadow curve.
 If the non test ear is not masked, then the threshold of the
test ear is erroneously shown to be lower (better) than what
it actually is.
 The problem of cross hearing is a hazard arising not
only during PTA but also during other audiometric
tests like tone decay test, SISI test, speech audiometry
and even during BERA.
 In fact, cross hearing is the M/C cause of error in all
forms of audiometry.
 Therefore the clinicians need to take vigilant decisions
in 2 aspects namely,
 When to mask ?
 How much to mask ?
When to mask
 During the AC test, the test tone if loud enough passes
to the non-test ear and stimulates the cochlea of the
non-test ear.
 But while passing the sound loses certain portion of
the sound energy.
 This loss is k/a INTERAURAL ATTENUATION, and is
usually b/w 45 dB HL and 80 dB HL, but may be as low
as 40 dB in some cases.
 THE MORE THE INTERAURAL ATTENUATION, THE
LESS IS THE CHANCE OF CROSS HEARING.
 However during the BC test, irrespective of the placement
of the bone vibrator, the cochlea of both sides are equally
stimulated, i.e., the interaural attenuation is 0 dB.
 Hence the hazard of cross hearing is much more during the
BC tests than it is for AC tests.
 Cross hearing during AC tests should be suspected if ,
 AC (test ear) – BC (non-test ear) > IA
 Where AC = AC threshold of test ear
BC = BC threshold of non test ear
IA = interaural attenuation
 C/L masking should always be used during AC tests
whenever we are testing with sounds of 45 dB or more.
How much to mask ????
 For air conduction
 Minimum masking = At – 45 + (Am – Bm)
 Where
 Bt = BC threshold in the test ear

 Am =AC threshold in the masked ear

 Bm = BC threshold in the masked ear

 Maximum masking = Bt + 45
 Where Bt = bone conduction threshold of the test ear
How much to mask ????
 For bone conduction
 Minimum masking = Bt + (Am – Bm)
 Where
 Bt = BC threshold in the test ear

 Am = AC threshold in the masked ear (non-test ear)

 Bm = BC threshold in the masked ear

 Maximum masking = Bt + 45
 Where Bt = bone conduction threshold of the test ear
 The aim is always to ensure that the intensity of
masking sound used is b/w the overmasking and
undermasking levels.
 No clinical opinion should be formed from an
audiogram, in which the masking sound level used for
each test frequency, both for AC and BC tests is not
mentioned.
 For clinical purposes, it is best to follow Hood’s Plateau
method of masking.
Sounds used for masking
 3 types of masking sounds is usually available, namely
 White noise (broadband or wideband noise)
 Ideally contains an equal amount of sounds of all frequencies,
starting from low to very high frequencies.
 Narrow band noise
 eg. For masking a tone of 2000 Hz, the narrow band masking
sound should have a frequency range from 1800 to 2200 Hz.
 The band width which will provide the maximum effective
masking for a tone of a particular frequency at minimum
intensity is called critical band width for that level particular
frequency.
 Most effective masking noise

 Complex noise
 Made up of low frequency fundamental plus the multiples of that
frequency upto 4000 Hz.
Interpretation of PT audiograms
 Quantitative information
 From the AC threshold levels the deafness can be
graded
 The dB calculated is the dB HL and the hearing level
mentioned is the pure tone average.
 Pure tone average is the average of hearing threshold
levels at 500, 1k and 2k Hz only (since human speech
compromises mainly of sounds of these frequencies )
`
 Qualitative information
 From the audiogram we can interpret whether the
deafness is conductive, mixed or sensorineural.
 The amount of hearing loss by AC and BC is seen
 A-B gap is calculated

 BC normal but AB gap > 20 dB or more  CHL


 BC level > 20 dB HL & AB gap is 15 dB or less  SNHL
 BC level > 20 dB & A-B gap > 20 dB or more  mixed HL
 From the statistical studies comparing the shape of PT
audiogram with the involved pathology, certain
parameters have evolved, which help us in predicting
the site and nature of the pathology to be expected
from the shape the audiogram.
 However, this is only a question of probability and for
confirmation, the specialised tests like tympanometry,
acoustic reflex tests, SISI, tone decay etc are essential.
Normal audiogram
For conductive lesions
 Pathologies which increase stiffness (otosclerosis)
present a left sloping audiogram (more loss in lower
frequencies).
 Pathologies which increase the mass (Secretory OM)
present a right sloping curve (more loss in higher
frequencies).
 Ossicular discontinuity will cause an A-B gap > 60 dB
 Carhart’s notch (dip in BC at 2000 Hz)
For SNHL
 Flat audiogram in SNHL  atrophy of stria vascularis
(usually found in presbyacusis, salicylate poisoning)
 Descending audiogram  stiffening of basilar membrane
 impedes normal basilar vibrations.
 Selective high frequency loss with near normal hearing in
low and middle frequencies  lesion in organ of corti.
 Acoustic trauma  notch at 4000 Hz
 Ascending curve (slope to left)  early endolymphatic
hydrops
 Trough shaped curve  congenital SNHL.
Features of CHL
 Normal BC thresholds
 Increased AC Thresholds
 A-B gap(>10 dB)
Features of SNHL
 Both AC and BC threshold are raised
 No A-B gap (< 10dB)
Mixed hearing loss
Limitations and fallacies of PTA
 Audiograms are very often inaccurate
 Improper technique
 Improper test conditions
 Improper examiner/interpreter
 A subjective and time consuming test
 Test does not identify the nature of pathology
 The BC test does not assess the true SN reserve
 Other sources of variances that bare not related to hearing
 Errors in instrument/ ambient noise level/ improper
placement of head phones and bone vibrators.
PTA can be used in conjunction with
 Weber’s test
 Bing test
 Gelle’s test
SPEECH AUDIOMETRY
• Patient`s ability to hear and understand speech is measured.
• Uses:
• Measure threshold for speech
• Cross check pure-tone sensitivity
• Quantify suprathreshold hearing
• Assist in differential diagnosis.

• Three parameters are studied:


a. Speech Reception/ Speech recognition or Spondee threshold
b. Discrimination score/ Word recognition score
c. Sensitized speech measures
Speech Reception Threshold(SRT)

• Cross checks the validity of pure tone thresholds


• Measure of threshold of sensitivity for identifying speech signals
• Minimum Intensity at which 50% words are repeated correctly by
the patient.
• Set of spondee words is delivered to each ear.
• Intensity is varied in 5dB steps till half of them are correctly heard.
• Normally SRT is within 6dB of the average of pure tone threshold of
3 speech frequencies(500, 1K, 2K Hz).
• SRT better than pure tone average by more than 6dB suggests a
functional hearing loss.
Discrimination score
• Estimates suprathreshold hearing ability
• Measure of patient’s ability to understand speech.
• List of phonetically balanced (PB) words (single syllable) is
delivered to each ear separately at several intensity levels
(extending from just above the speech threshold to upper
level of comfortable hearing)
• % of words correctly heard is recorded.
• In normal persons and with CHL score of 90 to 100% can be
obtained.
• Performance vs Intensity function is generated
• Roll over phenomenon
Bekesy Audiometry
• Behavioural measure of auditory adaptation
• Self recording audiometry where various pure tone
frequencies automatically move from low to high while
patient controls intensity through a button.
• Two tracings one with continuous and other with pulsed tone
are obtained.
• They help to differentiate a cochlear from retrocochlear and
organic from functional hearing loss.
• It is rarely done these days.
IMPEDANCE AUDIOMETRY
• Purpose of impedance/ immittance audiometry
• Sensitive in detecting middle-ear disorders
• Differentiates cochlear from retrocochlear disorder
• Helps in detecting peripheral hearing sensitivity loss
• Helps in cross checking PTA in pediatric assessment

• It is divided into 2 parts:


a. Tympanometry
b. Acoustic reflex measurements.
Tympanometry
• Altering the pressure in the EAC results in changes in
compliance because the TM is tense and ossicular chain
stiffened.
• Point of maximum compliance occurs when the pressure in
the meatus is equal to that in the middle ear.
• If the pressure exceeds or falls below the middle ear pressure,
compliance will be reduced.
• Indirectly middle ear pressure can be calculated from point of
maximum complaince.
Procedure

• Probe is inserted into the external auditory canal till a air


tight seal is obtained. Probe tone is presented typically at
226Hz into the ear canal while the air pressure of the canal is
altered between +200 and - 200 decapascals. The maximum
compliance occurs when the pressure of the external
auditory canal and the middle ear becomes equal.
• The compliance peak indicates the pressure of the middle
ear.
• The height of the compliance peak indicates the mobility /
stiffness of the tympanic membrane or the middle ear cavity.
• By charting the compliance of tympano-ossicular system
various pressure changes different types of tympanograms
are obtained.
Types of tympanograms:

(compliance) in cm3
Static admittance

Pressure in daPa

• Type A: Normal Tympanogram


• Type As: Reduced compliance at or near ambient air pressure, seen in fixation of
ossicles.
• Type Ad: Increased compliance at or near ambient pressure seen in ossicular
discontinuity or thin or lax TM.
• Type B: Flat or dome shaped graph. No change in compliance with pressure
changes. Seen in middle ear fluid or thick TM.
• Type C: Maximum compliance at pressures more than -100mmH2O (negative
pressure in middle ear).
Acoustic(Stapedial) reflex
Measurements
• A loud sound, 70-100dB above the threshold of hearing of a
particular ear causes bilateral contraction of the stapedial
muscle which can be detected by Tympanometry.
• Reflex arc is the VIIIth nerve, cochlear nucleus and complex
brainstem internuclear connections to the ipsilateral and
contralateral facial nuclei, facial nerve and the nerve to
stapedius.
• Minimal auditory stimulus that produces a contraction of
stapedius muscle is known as acoustic reflex threshold and
indicated on an audiogram by the letter ‘Z’.
• Uses:
• Screening for presence of hearing sensitivity loss
• Differential assessment of auditory disorder
Physical volume of ear canal
• Acoustic immitance can measure the physical volume of air
between probe tip and TM.
• Normally it is upto 1ml in children and 2ml in adults.
• If > 2ml in children and > 2.5ml in adults, indicates perforation
of TM.
Special Tests
Short Increment Sensitivity Index
(SISI Test)
• Used to determine cochlear pathology.
• Based on a phenomenon known as recruitment (abnormal
loudness growth).
• Recruitment: The ear which does not hear low intensity
sounds begins to hear greater intensity sounds as loud or even
louder than normal hearing ear.
• A continuous tone is presented 20dB above the threshold and
sustained for two minutes.
• Every 5 sec tone is increased by 1dB and 20 such blips are
presented. Patient indicates the blips heard.
• In conductive deafness SISI score is more than 15%, 70-100%
in cochlear deafness, 0-20% in nerve deafness.
Alternate binaural loudness
balance (ABLB)
• Measures recruitment
• Used in patients with unilateral hearing loss and identifies
Cochlear HL
• 1000Hz tone played alternately in both ears and intensity in
affected ear is matched to loudness of normal ear.

Masking level difference (MLD)


• Measure of lower brainstem function
• Measures binaural release from masking owing to interaural
phase relationships
• MLD is the difference in thresholds between the in-phase and
the out-of-phase conditions
• For 500Hz tone, MLD should be greater than 7 dB and usually
around 12 dB
Carhart’s tone decay test
• Measure of nerve fatigue

• Feature of retrocochlear hearing loss

• 4000 Hz tone is delivered at 5dB above patients threshold for


60 seconds. When patient stops hearing , intensity increased
each time by 5 dB. Continue till patient hears tone for 60 secs
or tones upper limit is reached

• Tone decay of >25dB is diagnostic for retrocochlear hearing


loss
Evoked Response Audiometry
Evoked Response Audiometry
• Measures electrical activity in the auditory pathways in
response to auditory stimuli

• Important component of evoked electrical response are:

a. Electrocochleography

a. Auditory brainstem response (ABR)

b. Auditory steady state response (ASSR)


• It objectively measures electrical potential arising in the cochlea and
CN VIIIth in response to auditory stimuli within first 5 milliseconds.

• There are three classes of potentials that can be recorded


• Compound action potential of auditory nerve (AP),
• Summating potential (SP)
• Cochlear microphonics
• Recording electrode is transtympanic. Other electrodes can be
intrameatal and surface electrodes
• In Adults it can be done under LA, but in children or anxious
individuals sedation or GA is required

• Uses:
a. Objectively assess hearing threshold in young infants and children
b. Assess functional integrity of cochlea
c. Diagnosis of Meniere’s disease
d. Differential diagnosis of various types of SNHL
e. Intraoperative monitoring during otoneurological procedures
f. Help in interpretation of BERA
• Action potential
• Potential of auditory nerve fibers
• It occurs at onset of stimulus
• Produced by clicks or tone pips.
• Characterized by predominantly negative peaks
i.e. N1 and N2 (independent of stimulus phase
and duration)
• Magnitude has a direct relationship to the
number of nerve fibers firing.
• Latency represents the time interval between
the onset of stimulus and the peak of N1.
• The presence of action potential is dependent
on the proper functioning of acoustic nerve
fibers.
• Wave N1 is absent in patients with
retrocochlear lesions.
• Cochlear microphonics:
• Generated predominantly by flow of K+
through OHC
• A.C. potential generated by basal turn of
cochlea
• Phase and duration are stimulus dependent.
It is diminised when stimulus is present with
alternating polarity.
• Helps in differentiating cochlear from nerve
deafness.

• Summating potential:
• Direct potential from mainly IHC
• The direction of this potential is dependent
on complex interaction between the stimulus
parameters and the location of the recording
electrode.
Auditory brainstem response
(ABR)
• BERA is resistant to the effects of sleep, sedation and
anesthesia.
• Objective way of eliciting brain stem potentials in response to
audiological click stimuli
• Recorded by electrodes placed over the scalp.
• Non inverting electrode over the vertex of the head, and
inverting electrodes placed over the ear lobe or mastoid
prominence.
• Earthing electrode is placed over the forehead for proper
functioning of preamplifier.
BERA
• The positive peaks (vortex positive) are referred to by the Roman
numerals I – VII
• Analysis of latency, amplitude and wave morphology in 1-10 ms
• Sound evoked electrical activity is time specific
• These peaks are considered to originate from the following
anatomical sites:
1. Cochlear nerves - waves I and II
2. Cochlear nucleus - wave III
3. Superior olivary complex - wave IV
4. Nulclei of lateral lemniscus - wave V
5. Inferior colliculus - waves VI and VII
BERA CERA

Recording is made from brain stem potentials Recording is made from cortical potentials

Click stimulus is used Tone stimulus is used

Responses are not frequency specific Responses are frequency specific

Can be performed in awake and restless The patient must lie still through out the
patients process

Suitable for even young children Unsuitable for children

Response begins after 1 - 10 milliseconds after Response begins after 50 - 300 milliseconds
stimuli after stimulation
Uses of BERA
I. As a screening procedure for infants

II. To determine the threshold of hearing in children and adults who


do not cooperate and in malingerers

III. Detection and quantification of deafness in difficult patients

IV. To diagnose retrocochlear pathology particularly acoustic


neuroma.

V. To diagnose brainstem pathology e.g multiple sclerosis or pontine


tumors.

VI. To monitor CN VIII intraoperatively in surgery of acoustic


neuroma.
BERA findings suggestive of retrocochlear pathology:

1. Latency differences between interaural wave 5 (prolonged in


cases of retrocochlear pathology)

2. Waves I - V interaural latency differences – prolonged >0.4ms

3. Absolute latency of wave V - prolonged

4. Absence of brain stem response in the affected ear

BERA has 90% sensitivity and 80% specificity in identifying cases


of acoustic schwannoma. The sensitivity increases in proportion
to the size of the tumor.
Criteria for screening newborn babies using BERA:

1. Parental concern about hearing levels in their child

2. Family history of hearing loss

3. Pre and post natal infections

4. Low birth weight babies

5. Hyperbilirubinemia

6. Cranio facial deformities

7. Head injury

8. Persistent otitis media

9. Exposure to ototoxic drugs


Otoacoustic emissions (OAE)
• Sounds produced by motile elements of cochlear outer hair cells.
• Can be elicited by a very sensitive microphone placed in EAC.

Outer hair cells

Basilar Membrane

Perilymph

Oval window

Ossicles

TM

EAC
• OAEs are present when outer hair cells are healthy and absent
when they are damaged, thus help test function of cochlea.

• Uses:

1. To screen children and neonates for hearing disabilities

2. Estimate hearing sensitivity within a limited range of frequencies

3. To differentiate sensory and neural components in SNHL

4. To rule out malingering (functional hearing loss)


Role played by OAEs
OAE generated by OHC play the role of cochlear amplifier. In
SNHL the cochlear amplification is lost leading to:

a. Reduction in the hearing level

b. Reduction in the clarity of spoken words


Types of Otoacoustic emissions
• Classified according to the stimulus employed to elicit them, or by the
mechanism that causes them.

• Spontaneous OAE
• Synchronised OAE - Potentials generated by OHC,synchronised to
external stimuli using time averaging techniques
• Evoked OAE
1. Stimulus frequency OAE:The evoking acoustic stimulus is a pure tone
one with a low intensity level.
2. Distortion Production Otoacoustic emission: (DPOAEs): Low intensity
signals during stimulation of the ear. Present the ear with two
continous signals/primary tones (55 & 65dB) and analyse the spectrum
of sounds detected at EAC.
3. Transient evoked OAE: (TOAES)/Kemp echos –

• The time delay between the stimulus and response allows the
examiner to isolate these responses
• Echos recorded from normal ears always mirrors the spectrum of
the stimulating sound impulse.
• The probe used to record TEOAEs has two openings, one for the
presentation of a single stimulus like a click, and the other opening
microphone.
• Clicks are commonly used as stimuli, sometimes tone burst stimuli
can also be used.
• The stimulus used should be 80 - 85dB sound pressure level. The
rate of stimuli should be atleast 60 / minute. When present TOAES
occur at frequencies of 500 - 4000 Hz
Prerequesites for obtaining
OAEs:
1. Unobstructed EAC

2. Perfect seal of EAC with the probe

3. Optimal positioning of the probe

4. Absence of middle ear pathology

5. Functioning cochlear OHC

6. Relatively still patient

7. Quiet recording environment


Interpretation of recordings
made:
• SOAEs:
• It is generally not seen in patients with less than 30 dB hearing level
• If SOAEs are elicited in a patient the cochlea could be assumed to be in good
health
• More commonly recorded in females than in males.
• Not associated with tinnitus because the associated cochlear abnormality causes
the SOAEs to disappear.
• TEOAEs:
• Used to screen neonates for hearing disabilities
• Recorded only in response to short and transient stimuli with limited frequency
specificity
• Presence suggests the cochlear sensitivity in the region of 20 - 40 dB or better.
• DPOAEs:
• Greater frequency specificity
• Useful in early detection of cochlear damage i.e. due to noise or drug exposure.
Causes of absent OAEs:
Non pathological: Pathological causes:

1. Poor probe tip placement 1. Outer ear: Stenosis, otitis externa,


cysts etc
2. Standing waves
2. Tympanic membrane: Perforations.
3. Cerumen occlusion Grommets usually dont complicate
recordings
4. Vernix caseosa in infants
3. Middle ear: Otosclerosis, ossicular
5. Unco operative patient disruption, cholesteatoma, otitis
media

Central auditory disorders dont affect 4. Cochlea:Exposure to ototoxic drugs,


OAEs Noise exposure
Hearing assessment in Infants and
Children
Screening Procedures
• They are employed to test hearing in high risk infants and are
based on infants behavioral response to sound stimuli.
• Arousal test: High frequency noise is presented for 2 secs to
the infant when he is in light sleep. Normal hearing infant can
be aroused twice when 3 such stimuli are presented.
• Auditory response cradle: screening device for newborns
where baby is placed in a cradle and his behaviour in response
to auditory stimulation are monitored by transducers.
Behaviour Observation
Audiometry
• Auditory signal presented to an infant produces a change in
behaviour e.g alerting, cessation of an activity or widening of
eyes.
• Moro`s reflex: sudden movement of limbs and extension of
head in response to sound of 80-90 dB.
• Cochleopalpebral reflex: Child responds by a blink to aloud
sound.
• Cessation reflex: Infant stops activity or starts crying in
response to a sound of 90 dB.
Behaviour Observation
Audiometry
Visual Reinforcement
Audiometry(VRA)
• This test technique is suited to infants aged 7 or 8 months to 3
years developmentally.
• The child is taught (i.e., conditioned) to turn their head when a
sound is heard.
• Initial conditioning is achieved by the introduction of stimuli at
moderately high levels
• When child looks for source of sound they are shown a colourful,
moving puppet or toy under illumination as a reward.
• This puppet or toy "reinforces" the child's turning behaviour or
orientation and gives rise to the term Visual Reinforcement
Orientation Audiometry. Once this conditioned response is reliably
observed, the stimuli can be presented at ever decreasing levels
until auditory threshold or minimum audible levels have been
reached.
Visual Reinforcement
Audiometry(VRA)
Play Audiometry
• Play audiometry is suited to children aged around 3 to 7 years
developmentally.
• The child is taught to respond, using a pre-determined task,
whenever they hear tonal stimuli that are introduced through
headphones or through a bone conductor placed behind the
ear on the mastoid.
• Given sufficient cooperation from the child it is usually
possible to produce a complete and accurate "audiogram"
that illustrates their threshold of hearing for a pre-determined
frequency range.
Play Audiometry
Speech Audiometry
• Child is asked to repeat the names of certain objects or to
point them out on the pictures.
• Voice can be gradually lowered.
• In this way hearing level and speech discrimination can be
tested.
Final Thought
Tests are not infallible.
They are only as good as those taking,
administering and interpreting them…