A guide to conducting speech audiometry testing

Overview of this guide

Welcome to this guide on conducting speech audiometry testing. It will help you to: understand the purpose of speech audiometry clarify what client information you need outline the equipment you need conduct the test record and interpret the results, and determine if your client needs a referral to either a general practitioner or ear, nose and throat specialist.

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Speech audiometry
Speech audiometry is an important part of audiological assessment. We use it to evaluate: speech perception threshold speech reception threshold, or SRT speech discrimination a ility, and to chec! the validity of pure tone audiogram test results.

With this information the clinician can uild up a picture of the client"s needs to determine appropriate hearing aids.

Information needed before conducting the test

There are some !ey pieces of information you will need efore conducting speech audiometry testing. #ltimately, you are trying to wor! out if speech mas!ing is required and if so to what level. $ur ears can compensate for each other especially if the hearing in one ear is etter than the other. %n audiometer can generate noise in the non&test ear to mas! or remove it from the test. This prevents the good ear from affecting the accuracy of the results. To determine speech mas!ing follow these steps: Step ' & $ tain a pure tone audiogram for the client. Step ( & )rom the audiogram calculate the three frequency average hearing level, or *)%+,. This is calculated from the hearing threshold level, or +T,, at frequencies of -..+/, '...+/ and (...+/. Step * & The three frequency average is then used to calculate the presentation level, or 0,, for each ear. Step 1 & )ind the minimum discrimination score level, or 23S,, for the test audiometer. Step - & #se the three frequency average hearing level, the presentation level, the minimum discrimination score level and the interaural attenuation, or I%, to calculate the cross&heard signal. The cross&heard signal tells you if the good ear is helping the ad ear.

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Step 4 & )ind the effective speech mas!ing level, or 5S2,, for the test audiometer. Step 6 & 7alculate the level of mas!ing required.

Understanding the audiogram

0ure tone audiograms contain several !ey features you need to understand to e a le to perform speech mas!ing calculations.

the results for the right ear are shown as circles the results for the left ear are shown as crosses the hori/ontal or 8&a8is indicates frequency in hert/ 9+/: the vertical or y&a8is indicates the hearing threshold level in deci els 9d;: additional sym ols are used to show left and right ear one conduction.

Calculating the 3FAH and !

To calculate the three frequency average hearing level and the presentation level follow these steps:

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3o the calculation for one ear at a time. Typically you start with the ear showing the most hearing loss. In this e8ample the left ear. Read from the pure tone audiogram the hearing threshold levels, for -..+/, '...+/ and (...+/. These three frequencies are always included in the test. #sing the e8ample audiogram start with the left ear which has the lower level of hearing. )ind -..+/, drop down to the hearing threshold, then loo! across at the value in deci els. In this case it is *.d;. %t '...+/ the hearing threshold is 1.d;. %t (...+/ the hearing threshold is -.d;. %dd all three hearing threshold levels together. The result in the e8ample is '(.d;. <ow divide y three to get the average. The e8ample three frequency average hearing level for the left ear is 1.d;. To calculate the presentation level add *.d;. *.d; is a standard used to ring the presentation level up to a comforta le starting point. In this e8ample add *.d; and the resulting presentation level for the left ear is 6.d;. Repeat these calculations for the other ear. In this e8ample the right ear shows '.d; for all three frequencies, so the average is '.d;. %dd *.d; to get a presentation level for the right ear of 1.d;.

Calculate the cross"heard signal

The cross&heard signal is a measurement to determine if any of the test sounds will cross&over and e heard y the non&test ear.

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To calculate the cross&heard signal you need the following: The three frequency average hearing level and presentation level for each ear. The interaural attenuation, or I%. This indicates the loss in energy as sound passes from one side of the head to the other. )or supra&aural earphones the interaural attenuation is 1.d;. )or insert earphones the interaural attenuation is 4.d;. The minimum discrimination score level, or 23S,. The 23S, is pre&determined for each audiometer. If there is no value availa le use &-.

The formula is & cross&heard signal equals presentation level of the test ear, minus the interaural attenuation, minus the three frequency average hearing level 9 one conduction: in the non&test ear, minus the minimum discrimination score level.

In the e8ample, the cross&heard signal equals the presentation level of the left ear which is 6.d;, minus 1.d; interaural attenuation for supra&aural headphones, minus the three frequency average hearing level for the right ear which is '.d;, minus minus - or plus - for the minimum discrimination score level. The resulting cross&heard signal is (-d;. 3oes this level of cross&heard signal require mas!ing= This is determined y as!ing if the cross&heard signal is greater than or equal to the three frequency average hearing level 9 one conduction: of the non&test ear. In other words will the non&test ear help the test ear= In the e8ample, the (-d; cross&heard signal is greater than the '.d; three frequency average hearing level in the non&test ear. Therefore mas!ing will e required.

How much mas#ing is re$uired%

To calculate the level of mas!ing required you will need the following: The three frequency average hearing level, air conduction, for the non test ear. The cross&heard signal, and The effective speech mas!ing level for the audiometer you will e using. The 5S2, is pre&determined for each audiometer. If there is no value availa le and the audiometer uses speech&weighted noise, use a value of '..

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The formula is>mas!ing level equals, the three frequency average hearing level 9air conduction: for the non&test ear, plus the cross&heard signal, plus the effective speech mas!ing level.

In the e8ample, when testing the left ear, the mas!ing level equals the three frequency average hearing level 9air conduction: for the right ear which is '.d;, plus (-d; for the cross&heard signal, plus '.d; for the effective speech mas!ing level. The resulting mas!ing level for the right ear is 1-d;. ?ou now have all of the information required to conduct the speech audiometry test.

&hat e$uipment will you need%

To conduct speech audiometry testing you need the following equipment: %n audiometer.

% pair of earphones & the e8ample image shows a pair of supra&aural earphones ut you might also use insert earphones, and

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Recordings of word lists. ?ou may also provide the words to the client through the audiometer microphone ut you must ensure that the client does not @lip read" as you say the words.

Conducting the speech audiometry test

+ere is an overview of the steps you need to ta!e when performing speech audiometry testing: Step ' & 2a!e sure the client is seated comforta ly efore starting. Step ( & Aive the client an overview of how the test will e carried out and give them an opportunity to as! any questions.

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Step * & 0lace the earphones on the client and set the audiometer to the presentation level for the test ear. Test one ear at a time and start with the good ear.

Step 1 & Instruct the client through the headphones for any further instructions. Step - & Test the first word list. #se %; 9%rthur ;oothroyd: word lists which consist of ten words per list and each word has three phonemes or speech sounds. %lso e aware that the words you use must e culturally and age appropriate.

Step 4 & Record the client"s response as they repeat each word. If the client gets all three phonemes correct, give a score of '.. Two phonemes correct, a score of 6. $ne phoneme correct, a score of *. If they cannot repeat the word, a score of .. %dding together all the scores in the ten word list will give you a total score as a percentage.

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Step 6 & 3etermine the client"s speech reception threshold, or SRT. This is done y incrementally decreasing the presentation level until the score is close to -.B. 5ach decrease should e of '.d; and a new word list should e used.

Step C & 3etermine the client"s 0; ma8imum score, or 0;ma8. This is done y returning to the starting presentation level and incrementally increasing the level until the score is C.B or a ove. 5ach increase should e of '.d; and a new word list should e used. % person with normal hearing would e e8pected to score '..B. +owever, some people with hearing loss might only score up to, say, 6.B.

Step D & 3etermine the client"s 0; minimum score. $nce you have determined the 0;ma8 raise the presentation level y '.d; and test with a new word list. If the client"s score decreases, raise the presentation level y another '.d; and score again with a new word list. 7ontinue this process until the highest presentation level for the audiometer is reached. The lowest score o tained is the 0;min and will e used to detect rollover.

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Step '. & Repeat the test on the other ear, usually the worse ear. ?ou may have to apply mas!ing on the other ear, so remem er to set the audiometer for speech noise for the non&test ear. Remem er also that the worse ear will li!ely have a different initial presentation level. Step '' & 7reate a performance intensity function graph, or 0I graph.

Step '( E 7alculate the rollover ratio.

'emember to tell the client

?ou will need to provide the client with test instructions. 0roper instruction helps ensure that the test results are accurate and valid. There are a few important things to remem er to tell the client: they will hear words through the earphones one ear 9the etter ear: will e tested first they need to repeat each word after they hear it if they are unsure, they still need to repeat what they thin! they heard

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if they cannot ma!e out the word, they need to let you !now each word list will e at a different volume ignore any rushing sound in the other ear they need to tell you if they are not comforta le, and encourage the client to as! questions.

+ere is an e8ample of an audiologist instructing a client efore a test: Okay Audrey, weve finished your audiogram now. Were going to do some speech testing now. Im going to put some words into your ears and Id like you to repeat each word as you hear it. If youre not quite sure or you think you missed a little it, that doesnt matter, Id like you to repeat !ust e"actly what you heard.#

!erformance intensity function

% performance intensity function graph shows the percentage scores from the speech discrimination test 9the performance: against the presentation levels 9the intensity:. This graph can provide useful information towards an accurate diagnosis. % minimum of three word lists must e tested for each ear efore creating the graph. This should e done at the initial presentation level, (.d; elow and (.d; a ove. Where possi le four word lists per ear are prefera le. In the e8ample graph the lue line shows the normal increase in speech discrimination scores as the presentation level increases and soon, responses are '..B correct.

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5ven with normal responses, you can still use 0I function graphs to detect possi le central lesions. 7ompare the 0I graph of each ear to chec! if there is a significant difference etween ears. @Significant" means (. to *. percent difference and indicates that the client has a central lesion. The red line also shows a normal response ut shifted to a higher d; range indicating conductive hearing loss. The purple line shows slight rollover, where an increase in presentation level does not have a corresponding increase in speech discrimination score. The green line shows significant rollover. <ote the difference etween the performance at 6.d; 90;ma8: and at D.d; 90;min:.

'ollover
Rollo

ver occurs when a client"s speech discrimination score decreases even though the presentation level is increased. The presence of rollover can indicate a lesion on the side of the rain opposite the ear with the roll&over, or Cth nerve lesions on the same side. 7alculating the rollover ratio can give you a etter idea of which lesion type is present. The formula for rollover ratio is: 0;ma8, minus 0;min, divided y 0;ma8. In the e8ample 0I function graph 9the green line: the rollover ratio equals, 4-, minus *-, divided y 4-, which equals ..14. % rollover ratio of ..1 suggests cochlear lesions.

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% rollover ratio of ..1- or greater is a significant rollover and suggests Cth nerve lesions.

Cross"chec#ing the results with the audiogram

7ross&chec!ing the results o tained from speech audiometry tests with a pure tone audiogram can help validate your test results. This is particularly useful if you suspect a client is malingering or e8aggerating their hearing loss. It is quite hard to fa!e a speech test to the same e8tent that you can fa!e a pure tone audiogram. The three frequency average hearing level from the audiogram should closely match the speech reception threshold from the speech audiometry tests. In the e8ample results oth the three frequency average hearing level and the speech reception threshold are 1.d;. This helps validate the results and shows that the hearing loss is real.

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()plaining the results to the client

+ere is an e8ample of an audiologist e8plaining the results of a pure tone audiogram and speech audiometry tests to a client. $ow that weve done all the testing, I need to e"plain to you what weve done. We have the audiogram here, thats a graph of your hearing. %he red circles demonstrate the levels at which we recorded your right ear, thats the levels you can !ust hear sound and the lue crosses show the levels for your left ear. As you can see the left ear is a little it worse than the right ear. Anything down to this &' d( line would e considered within the normal limits, so your right ear is completely within normal limits, where we e"pect it to e. )our left ear is a little it elow that, and we would call this a mild to moderate hearing loss * and its a permanent type of hearing loss. When we did the speech, we tested you at different levels and in the right ear you did very well all along. +verywhere we e"pected you to score. In the left ear, we had to turn the sound up a little it for you to hear the same amount ut youre still hearing relatively well in that ear, as long as we turn up the volume for you. ,ounds you particularly had pro lems with, were the high frequency sounds so for e"ample the word fake you said fate, for chime you said time, thats very common, so in this speech anana you can see that the high frequency sounds which are words like th#, ter#, ker# are in the high frequencies and therefore, youre having trou le hearing those in the left ear.#

Further tests
)ollowing speech audiometry testing you may conduct further tests include tympanometry and acoustic refle8 testing. They are tests to see if the middle ear is functioning properly. Tympanometry 9or impedance testing: is conducted to test the volume of the ear canal, the air pressure of the middle ear, and the compliance of the tympanic mem rane.

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%coustic refle8 testing chec!s the function of the stapedius muscle tightening the stapes. This is done y su Fecting the ear to a loud noise to test the refle8 function of the muscles.

Remem er that your referral decisions should not e made on the asis of speech scores alone. Speech testing is part of a attery of hearing tests and all test results should e analysed in conFunction with each other.

Credits
0u lished y the 7entre for ,earning Innovation 97,I:. 7,I would li!e to ac!nowledge the following people and organisations who have contri uted to the development of this resource: Su Fect consultants: Signe 0eitersen ;ettina Turn ull

Reviewer: 0eter Ro inson ,ocation photographs ta!en at 7onnect +earing, ,ane 7ove.

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