AUDIOMETRY

Task:
1. Using a clinical audiometer, perform two threshold tests:
a) measure your own audiogram for air-conduction of sound for your left and right ear
b) measure your own audiogram for bone-conduction of sound
2. Using a clinical audiometer, perform one supra-threshold test:
a) measure the recruitment of your own ear using Short Increment Sensitivity Index (SISI-test)

Introduction:
Audiometry deals with objective measurement of the auditory organ. However a major difficulty is
encountered when we attempt to apply objective physical methods to measure subjective sensation. While
some parameters of hearing can be assessed quantitatively (numerically), this is the exception and very
often we have to accept a qualitative assessment.

Hearing, like other sense organs, is an unusual organ from the viewpoint of biophysics. The extreme
sensitivity of the hearing apparatus and its ability to discriminate significant sound signals from
superimposed background sound (also called noise) which may be more intense than the signal of interest to
the perceiving subject are among some of the ways in which hearing is unusual.

The exceptional qualities of hearing are generally well known but in some cases not very satisfactorily
explored and explained. It is known, for example, that the threshold sensitivity of the hearing organ is better
than the value of 10
-12
W.m
-2
in a fully sound adapted healthy individual. This value represents the
international standard for the zero sound loudness level and known as the conventional value of the auditory
threshold (0 dB) at the reference frequency of 1000 Hz.

At the threshold intensity of sound, the tympanic membrane moves with an amplitude comparable to or
lower than the diameter of an atom. The basilar membrane oscillations are of similar amplitude. However
the mechanism which converts these minute amplitudes into stimulations of the nerve fibers is still
unknown.

The same oscillations of the tympanic membrane are induced by natural fluctuations in the impacts of air
molecules on the membrane. These impacts result from the thermal (Brownian) motion of gas molecules
which must necessarily cause permanent noise, the bioelectrical features of which can be proved by direct
measurement. However, such noise is not heard owing to its reduction by the auditory organ. On the other
hand, the ear registers actual sound signals of equal intensity.

It is obvious that such a sensitive organ can be permanently or temporarily damaged by various agents:
chemicals, drugs (some antibiotics), alcohol, infections, extremely intensive or long-lasting noise, etc. and
these factors are of interest in many fields of medicine: environmental hygiene, occupational, industrial and
preventive medicine, toxicology and ear, nose & throat medicine.

Another remarkable quality of the auditory organ is its extraordinary potential to process sound stimuli
across a wide range of intensities. The numerical expression of the fraction of minimal/maximal intensity
(auditory threshold to pain threshold) is greater than one to a million. The ability of the auditory organ to
process such a wide range of sound intensities has one unfavourable consequence: a low ability to
discriminate the levels of sound intensity. In the range presented, the human ear can distinguish about 130
degrees (loudness levels) only. For the basic terminology of audiometry, see textbooks of biophysics
available at the Dept. of Biophysics.

Relative and Absolute Audiograms
An absolute audiogram is a graphic record of hearing threshold and refers to a certain conventional
relation given in Wm
-2
or dB, respectively, and this varies with sound frequency. Its frequency course is the
expression of the average value of hearing threshold in a large number of healthy individuals.

The system of curves in Figure 1 presented shows the sound field. The sound field is the field within which
the human ear is capable of sound perception. It is limited by the 0 Ph curve (auditory threshold curve) and
130 Ph curve (pain threshold curve). These curves are called Fletcher-Munson curves or curves of equal
loudness levels. The projection method used in Fig. 1 is the one used in conventional physiological
acoustics. The sound intensity levels or loudness levels, respectively, are drawn on the y axis in the +
orientation. In audiometry, the convention is to draw the values of intensity in the negative orientation of the
y axis (see the printed form for audiometry).

Relative (apparent) audiogram: In audiometry, it is routine practice to draw the audiogram in a relative
way, or as differences from the normalised - conventional course. The relative audiogram shows the
quantitative difference in hearing of the examined person compared to that found in the average healthy
population. For a healthy ear, the relative audiogram is represented with a line at the 0 dB level.


Fig.1

Audiometers are instruments designed strictly for measuring relative audiograms only. They contain
correction circuits which change the sound intensity level in the headphones automatically in concordance
with the course of the auditory threshold curve 0 Ph or with other curves of equal loudness, respectively.

Bone-conduction
If we determine the bone-conduction threshold and compare it with the value found for the air-conduction
threshold, we can assess the condition of the inner ear. If the bone-conduction threshold is normal, the
actual sense organ is normal. If the bone-conduction threshold is elevated, the perceptual organ is damaged
or a lesion is present. In examining the bone-conduction threshold, the sound is brought to the hearing
apparatus by a bone vibrator attached to the mastoid process (a standard position) or to the frontal bone (a
non-standard position).

Hypacusis
Hearing is considered to be normal if the hearing threshold is not higher than 20 dB. Deafness is a condition
when the hearing threshold is higher than 90 dB at these frequencies. Hypacusis can be either uni - or
bilateral. Based on an investigation of the bone-conduction and the air-conduction hearing thresholds, three
types of hypacusis can be distinguished:
a) conductive hearing loss. Symptoms: normal bone-conduction threshold, elevated air-conduction
threshold. Cause: lesion in the transduction system.
b) sensorineural hearing loss. Symptoms: both bone-conduction and air conduction threshold elevated:
lesion in the perceptual system.
c) mixed hearing loss. Symptoms: bone-conduction threshold elevated, air-conduction threshold even more
elevated. Cause: a concomitant lesion in the perceptual system and in the transduction apparatus.

Recruitment. Diagnosing the Sensorineural Hearing Loss
The most common lesion causing sensorineural hearing loss is damage to the hair cells of the organ of
Corti. The inner and the outer hair cells of the organ of Corti are distinguishable. The outer hair cells have a
low stimulation threshold corresponding to the normal hearing threshold while the inner hair cells have a
much higher stimulation threshold and begin to react to sounds of around 50 dB of the loudness level. The
outer hair cells are therefore more sensitive to damage by harmful factors (noise, toxic substances, drugs).
Once the outer hair cells are damaged, the inner hair cells can manifest their qualities more apparently. In a
healthy ear, the subjective increase in loudness follows the Weber - Fechner law quite accurately. This is
not the rule when the outer hair cells are damaged. In this case, the hearing threshold deteriorates by 40 - 60
dB, but, with an increasing sound intensity level, subjective loudness rises faster than in the healthy ear and
the loudness of the subjective sensation becomes comparable to the healthy ear at about 80 dB of the
intensity level. The phenomenon is called recruitment. These characteristics can be demonstrated and
objectively measured in patients with differences in hearing damage on the right and on the left.

SISI - Test.
The Short Increment Sensitivity Index Test (SISI) is used to reveal the recruitment of the ear. This test is
based on evaluation of the ability of the ear to distinguish and identify a brief intensity increment in a
continuous tone. The increment is short increase of the loudness of the sound. Twenty increments of 1 dB
intensity and 200 ms duration are introduced at 5 s intervals to a continuous tone of intensity level 20 dB
above the hearing threshold. In total, the duration of the test is 1-2 minutes. The examined person signalizes
identification of the increment by pressing a button and the correct responses are automatically recorded on
a counter.

The results of the test are expressed in percentages. The full number (20) of identified increments represents
100%, none identified means 0%. One identified increment is 5%. There is no exact boundary between a
positive and a negative result of this test though there is a convention resulting from long-term experience
that people with normal hearing or with a conductive or a supracochlear (extracoclear) defect, respectively,
can distinguish between 0% and 20% of increments. Patients with the sensorineural hearing defect can
distinguish 70 - 100% increments.
Steps of the Examinations:
1. Run the software DANPLEX DA 65 by clicking on the icon Audiometry. The software allows on-line
controlling of audiometer and automatized data collection. It offers as well as common ambulatory agenda
related with patient register, including their basic medical information.
The main applications window is shown after the program startup.


2. Add patient by clicking on the icon Add patient. Fill out Patients card and press OK button.

3. View all patients examinations by a double click on his/her name. Then add new examination by
pressing New examination button and start examination by pressing F5 key or Audiogram button.


4. Press ON-LINE button and then Hearing testing.


5. Run the examination of loudness levels thresholds for air- and bone- conduction by pressing the arrow
(Start) button.

Program will automatically emit signal at default frequencies (you can change them in Audiometry
settings). Loudness level declines, when patient reacts to tone, and increased automatically, when patient
does not react in defined time (e.g.1.5 s depending on Audiometry setting). Before the bone conduction test
attach a bone vibrator to the mastoid process. Measurement is ended when the program has used all the
frequencies. Save measured values to audiogram by button . Select Overwrite all from an
option.

6. Print out your audiogram by pressing Print button.

7. Carry out the SISI test. Unfortunately, the test is not controlled by that software. All adjustments must be
done directly on the audiometer. Press the Menu button and then a button under the display viewing the
text SISI.

8. Set the frequency for the test to 1 000 Hz by turning of the middle big knob (usually is already adjusted
as the default value). Set the loudness level of the testing tone to the 20 dB higher than the value of the
hearing threshold determined in the previous task for air-conduction. Adjust this loudness level by the left
big knob. Set the value of the increment to 1 dB by the right big knob.

9. Press the "Start/Stop" button. 20 pulses (increments) will now be automatically introduced and they are
indicated by a flashing cursor on the display.

10. The tested person sitting separately from the device is all attention to the increments and indicates them
by pressing the button switch. The number of correct responses is expressed in the percentage.