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ince the earliest testing using tuning


forks, assessment of bone-conducted
hearing sensitivity has been an essential component of audiometric differential
diagnosis. It was Bekesy, in 1932, who
demonstrated that it was possible to cancel
a bone-conducted tone by introducing an
air-conducted tone of the same frequency,
but with different phase. This supported the
notion that the two signals had the same
mechanical displacement patterns at the
basilar membranea topic of some debate
at the time. In the 1960s Tonndorf added to
Bekesys work by providing a detailed
description of three different modes of boneconduction transmission.
From a clinical standpoint, boneconduction testing has pretty much always
been a routine part of an audiologic evaluation (at least since these evaluations have
been called audiologic). Today, the testing
is so routine that it sometimes is conducted
in a rather casual manner. When immittance
findings are normal, maybe its not conducted
at all. But like all things that we do over and
over, its useful to step back and take a critical
look at what we are actually doing. Weve
found an author to provide us that perspective on bone-conduction testing for this
months Page Ten.
Robert H. Margolis did his early audiologic training at Kent State University before
earning his PhD from the University of Iowa.
He worked at the UCLA Department of
Otolaryngology and the Syracuse University
Department of Communication Sciences and
Disorders before joining the University of
Minnesota Department of Otolaryngology as
professor of audiology in 1988. His research
has focused on developing improved methods
for hearing assessment, including acoustic
immittance, electrocochleography, and puretone and speech audiometry.
In 2000 he established Audiology Incorporated to develop and commercialize automated hearing tests. His work on automated
audiometry has been supported by small business technology transfer grants from the
National Institutes of Health. He is currently a
collaborator on the NIH Toolbox project
(www.nihtoolbox.org) to provide a standard
hearing assessment tool for large epidemiologic and clinical outcome studies.
When Bob isnt thinking about boneconduction secrets or automated testing,
you can find him on the tennis court (where
he prefers to serve wide to the ad court) or
carefully pouring a dark Belgian beer (which
he prefers to serve in the middle of the backcourt). For now, Dr. Margolis is serving up
some useful information about that old test
of ours, bone conduction. Hes provided a
few things to think about that might alter your
clinical practices.

GUS MUELLER
Page Ten Editor

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THE HEARING JOURNAL

A few secrets about


bone-conduction testing
By Robert H. Margolis
Arent you the guy who published an
article on bone conduction called
Audiologys Dirty Little Secret? Why are
you airing audiologys dirty laundry in
public?

That was me, but I was not referring to boneconduction in general, just one or two specific little secrets. Frequently during my short 35-year career
in this field, I have heard complaints about air-bone
gaps and bone-air gaps (bone-conduction threshold worse than air-conduction threshold) that dont
fit the patients audiometric picture and therefore
Robert H. Margolis
must be wrong. That is, you see a significant airbone gap when youre pretty convinced its a completely sensorineural hearing
loss. Or even more puzzling, bone scores that are 10-15 dB worse than air scores.
In the development of AMTAS, an automated pure-tone test (see www.
audiologyincorporated.com), we have noticed these errors even more frequently than
we see them in manual audiometry. So Ive been trying to get to the bottom of it.

But doesnt that simply mean that audiologists get more


accurate thresholds than automated procedures?

Maybebut maybe not. Lets refresh our memory on the variability associated with
air-bone gaps. This is not a new topic. Studebaker addressed this very issue in an
attempt to clarify that when there is variability associated with a measurement,
the measured value doesnt always land on the mean.1 He modeled the air-bone
gap as a normally distributed variable with a standard deviation of 5 dB. His model
predicts that in the absence of a conductive hearing loss the air-bone gap is 0 dB
only 38% of the time. If four frequencies are tested, air-bone gaps at all frequencies would be zero only 2% of the time and gaps of 10, 15, and 20 dB are expected
to occur much more often than you might think.

Interesting. Do you have anything to contribute to the


explanation?

I have a friendly amendment to the Studebaker model, one that was suggested to
me by my friend and colleague Aaron Thornton. Aaron pointed out that the airbone gap is a normally distributed variable, as Studebaker told us, but it is the difference between two normally distributed variables (the air- and bone-conduction
thresholds) that have different variances. That produces a normally distributed
variable with variability that is greater than either air conduction or bone conduction alone. If we assume standard deviations of 5 dB for air-conduction thresholds and 7 dB for bone-conduction thresholds, the standard deviation of the
air-bone gap is 8.6 dB. The new model predicts air-bone gaps of 0 dB for only
21% of thresholds and gaps of 10 dB or more (air-bone gaps and bone-air gaps)
almost half the time (48% of thresholds).
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AMTAS Audiometric Report


Session
Test Date

: X00000-20071126-3
: Mon Nov 26 16:48:07 2007
AUDIOGRAM
Frequency (Hz)

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QUALITY ASSESSMENT
(Air & Bone)
(Patent Pending)

Overall
Quality

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Value

%ile

Predicted
Avg. Abs.
Difference

6.930

39

Masker
Alert
Rate

0.000

50

Time
per
Trial

4.133

71

60

False
Alarm
Rate

0.091

64

70

Avg. Test
Retest
Diff.

2.500

80

QC Fail
Rate

0.038

90

ABG > 50

0.000

100

ABG > -10

0.000

110

AVG ABG

8.125

64

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Hearing Level (db HL)

FAIR

Quality
Indicators

30
40

Effective Masking Levels (dB EML)

AMCLASS Audiogram Classification

patient history, tympanometry,


and otoscopy that the patient
has a sensorineural hearing loss.
But the likelihood, based on
variability of air-conduction and
bone-conduction testing that
the patient has 0-dB air-bone
gaps at four frequencies in each
ear is 1 in 250,000. Let me repeat that: 1 in 250,000!
Most of us should not see
an audiogram like this in our
professional careers. The audiogram in Figure 1 is plausible.
The one in Figure 2 is almost
certainly fudged. But, if everything matches nicely, the ENT
doctor wouldnt walk back to
the booth and question it. (Its
our dirty little secret.) I know,
youre thinking that youve seen
many audiograms conducted
by competent audiologists
where everything matches up
nicely. What Im saying is that
audiologists dont always report
air-bone gaps that occur in
patients with sensorineural
hearing loss.
So youre saying that
audiologists are inherently dishonest?

5
Figure 1. Audiogram with air-bone gaps that are expected from variability of air-conduction
and bone-conduction thresholds (except at 4000 Hz).
Lets look at the example in Figure 1. This audiogram was
obtained from a patient who is an experienced listener, having participated in many research studies. The audiometer
was calibrated to the ANSI standard (S3.6-2004)2 and bone
conduction was tested with the vibrator on the forehead,
using the appropriate mastoid-forehead corrections. Ignoring 4000-Hz for a moment, the air-bone gaps are well within
the expected variability for patients with sensorineural hearing loss. But it looks a little sloppy, right? Note that
AMCLASS, our validated audiogram classification system,
called the hearing loss in the right ear a mixed loss because
of the air-bone gap at 4000 Hz.3-5 If this was a manual audiogram and I had any doubt about the bone-conduction thresholds, I would be tempted to nudge them toward smaller
air-bone gaps, especially if I had already obtained normal
immittance results.

I agree. It doesnt look quite right.

But wait, I wasnt finished telling the story. Now lets look at
another example in Figure 2. Whats wrong with this audiogram? Nothing, right? I know from previous audiograms,
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I would never say that. I am


saying that bone conduction is
a biased experiment. When we are testing bone conduction
we almost always have an idea of what the result is going to
be. We get these premonitions from previous audiograms,
thresholds at other frequencies, other test results like immittance and otoscopy, and patient history. If all these sources of
information point toward sensorineural hearing loss, the audiologist is biased toward recording bone-conduction values that
are equal to air-conduction thresholds.
But if audiologists are honest people, why
would they report inaccurate bone-conduction
thresholds?

Two reasons. First, it is the nature of bias that we dont always


recognize that our behavior is affected by biasing factors. There
is literature on effects of bias on human behavior that shows
that performance is affected even when the person is aware of
the potential for bias. See, for example, Messick and Sentis.6
Second, as an audiologist, I want to communicate the
correct status of the patients hearing. If I know in my heart
that the patient has a sensorineural hearing loss, I am less
likely to report air-bone gaps that are expected to occur as a
result of the inherent variability of the measurements. I might

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FEBRUARY 2010 VOL. 63 NO. 2

Is this just something related to the variability


youve been talking about?

AUDIOGRAM
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Well, not entirely. Theres something else going on at 4000


Hz. Look at the audiogram in Figure 3. This patient has a sensorineural hearing loss. The air-bone gaps at 4000 Hz are
unlikely to be related to variability. You can prove that by testing the patient repeatedly. If you get the same air-bone gap all
the time its not the result of variability. Note that AMCLASS
wants to call the hearing loss mixed in both ears. AMCLASS was
validated against the judgments of expert audiologists. Unless
we ignore the air-bone gaps at 4000 Hz, the hearing loss is
mixed in both ears. But its not.

70

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90

Figure 2. Audiogram with all 0-dB air-bone gaps.

So where did that big air-bone gap come from?

My guess is that our bone-conduction, reference-equivalent


threshold force level at 4000 Hz is wrong. But in the study
that was the source of the standard bone-conduction thresholds,
subjects with sensorineural hearing loss were tested at three
locations to derive bone-conduction, reference-equivalent
threshold force levels (RETFL) that would produce 0-dB airbone gaps (on average).7
Then to verify that the values were correct, a new group of
subjects with sensorineural hearing loss was tested and, sure

You started out saying


that air-bone gaps in
patients with sensorineural
hearing loss occur more frequently with automated
tests. How do you account
for that?

Its very simple. AMTAS and


other automated tests are not
biased. They dont care if there
is an air-bone gap or a bone-air
gap. They report the results from
the patients behavior uninfluenced by any expectations. They
havent read Studebakers article
and they dont have any dirty little secrets.
Okay, Ill buy that. Ive
heard about erroneous
air-bone gaps at 4000 Hz.

8
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Hearing Level (db HL)

be concerned that an otolaryngologist would order further


testing and/or follow-up appointments because of this apparent conductive loss. And, of course, we all have been taught
that bone-air gaps are theoretically impossible, so I am biased
toward under-reporting those when they occur even though
they are the expected result of the variability of the measurements.
There is a good reason that
AMTAS Audiometric Report
clinical trials are designed as
Session
: X00000-20071205-1
double-blind experiments. When
Test Date : Wed Dec 5 09:34:13 2007
people have prior knowledge of
AUDIOGRAM
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the expected results, the outcomes
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are different from when they have
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no prior knowledge. And this is
0
true with the most honest, ethical humans on earthall of whom
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are audiologists!
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QUALITY ASSESSMENT
(Air & Bone)
(Patent Pending)

Overall
Quality
Quality
Indicators

GOOD

Value %ile

Predicted
Avg. Abs.
Difference

5.786

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Masker
Alert
Rate

0.000

50

Time
per
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3.448

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False
Alarm
Rate

0.048

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Ratest
Diff.

0.000

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QC Fail
Rate

0.000

90

ABG > 50

0.000

100

ABG > -10

0.000

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AVG ABG

7.500

64

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Effective Masking Levels (dB EML)

AMCLASS Audiogram Classification

Figure 3. Audiogram with erroneous air-bone gaps at 4000 Hz.

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FEBRUARY 2010 VOL. 63 NO. 2

enough, their air-bone gaps averaged 0 dB at all test frequencies, including 4000 Hz. The threshold levels were incorporated into the audiometer standard and we began calibrating
bone conduction to those levels. But soon audiologists began
noticing air-bone gaps at 4000 Hz in patients with sensorineural
hearing loss.
Is it possible that the patient can hear airconduction radiation from the bone vibrator
at 4000 Hz and that causes bone conduction to be
better than it should be?

10

That explanation continues to be kicked around, but it was


debunked early on by Frank and Holmes (1981).8 They tested
bone conduction in subjects with ears open and ears plugged
and got no difference at 4000 Hz.
In an AMTAS validation study we found the same unexplained air-bone gap at 4000 Hz with the ears covered by circumaural earphones and the bone vibrator on the forehead.8
If you can block the ear with an earplug as Frank and Holmes
did or with a sound-attenuating muff as we did and the airbone gap remains, it is not due to acoustic radiation.
But a lot of my friends dont get air-bone
gaps at 4000 Hz except when the patient
has middle ear disease. Why isnt it always there?

11

Heres another dirty little secret. Rumor has it that some calibration services have become tired of hearing complaints about
4000-Hz air-bone gaps and calibrate bone levels at that frequency off standard. And they dont always tell us they are
doing that.
It may be a reasonable solution because the source of the
problem appears to be an incorrect RETFL at 4000 Hz. But
if this really happens, they shouldnt do it without telling us.

12

Is that legal?

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Figure 4. High-frequency conductive hearing loss.

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Do we actually have the data?

We have some, but they are conflicting. The Dirks et al. data
show no air-bone gap at 4000 Hz6 and our data show a 12-dB
air-bone gap for manual testing and 22-dB air-bone gap for
automated testing.9 I suspect the difference is due to bias in
manual testing. We are testing a new group of sensorineural
hearing loss subjects now to shed more light on it. We hope
to report the results early this year.

14

If 4000-Hz bone conduction is such a


problem, why dont we just skip it?

I dont think that would be a good idea. High-frequency airbone gaps can be clinically important. Look at the audiogram
in Figure 4. This patient came in with a complaint of aural
fullness in the left ear. Her 226-Hz tympanogram was normal.
High-frequency hearing losses like this are usually sensorineural and it would be easy to send this person away without further evaluation.
But her 1000-Hz tympanogram was flat and an otomicroscopic examination revealed middle ear effusion. The hearing loss and abnormal high-frequency tympanogram are
consistent with mass loading of the middle ear. She was treated
for otitis media and the hearing loss resolved. Middle ear effusion in adults can be a sign of serious conditions such as
nasopharyngeal carcinoma. I wouldnt want to miss this case.
I think we should do more high-frequency bone-conduction
testing, not less.
How do you know that the 4000-Hz air-bone
gap in this case is real rather than the same
erroneous finding youve been talking about?

15

Im glad you asked that question. Some state licensure laws


require that testing be performed with a calibrated audiometer.

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That implies that levels are calibrated to the audiometer standard. If we have a good reason for doing it and we have data
to support it, we are probably on safe ground if we use a different reference level. But we should do it with our eyes open.

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Good question, and its not always an easy distinction. In this


case, the 3000-Hz bone threshold, the high-frequency tympanogram, and the careful ear examination confirmed that
there was a real high-frequency conductive hearing loss. The
case illustrates the importance of getting our 4000-Hz bone
thresholds right. We dont have a definitive answer yet, but
we should all know how our audiometers are calibrated and
use our diagnostic skills to interpret these cases appropriately.
If tympanograms and acoustic reflexes are
normal, do we really have to test bone
conduction at all?

16

Yes. Lets look at the case in Figure 5. This patient had fluctuating hearing loss and vertigo and, based on her symptoms,
could easily be diagnosed with Mnires disease. In spite of
normal immittance findings, there is an air-bone gap.
My colleague Lisa Hunter followed a group of patients like
this for several years before Rosowski and his colleagues at
Harvard-MIT explained that patients with dehiscent superior semicircular canals behave just like this.10,11 The enhanced
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FEBRUARY 2010 VOL. 63 NO. 2

is no advantage to forehead bone because you still have to


rearrange the transducers when you switch ears to leave the
non-test ear uncovered.
But if we had an earphone that didnt produce an occlusion effect, we could place the bone-conduction vibrator on
the forehead, earphones over both ears, and test air conduction and bone conduction without moving the transducers.
This would make manual testing more efficient and make
automated testing possible. Thats how AMTAS works.
There is a tendency to think that when we place the vibrator
on the right mastoid we are testing the right ear. Of course, we
learn in basic audiology that there is no interaural attenuation
for bone conduction, but inexperienced testers may forget that.
With forehead bone conduction it is clear that you only know
which ear heard the tone if you properly mask the non-test ear.

AUDIOGRAM
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Im liking the idea of using forehead


placement. Is there a good non-occluding
earphone that can be used for air-conduction
testing and for masked bone?

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Figure 5. Audiogram from a patient with an inner ear


disorder (probably dehiscent superior semicircular canal)
that produces air-bone gaps.
bone-conduction sensitivity is explained by a third window
effect in which the opening of the bony labyrinth into the
subdural space results in greater cochlear stimulation by bone
conduction.
In some cases with normal immittance findings and a documented history of sensorineural hearing loss, bone-conduction
testing may be unnecessary. But more information is always
better if you want to understand your patients hearing. If you
dont do it you wont see the surprising cases that may teach us
something. And you may make the wrong diagnosis.
Lets back up a moment. Earlier you
mentioned forehead placement of the
bone-conduction vibrator. Is that a new way to
test bone conduction? How does it compare to
mastoid placement?

17

It was recognized very early in the development of hearing testing that it doesnt really matter where you place the bone vibrator. Forehead placement has been around for decades and the
reference equivalent threshold force levels are in the standard.
It takes roughly 10 dB more force to reach threshold with forehead placement than with mastoid placement. For many years
that was a problem because it restricted the maximum hearing
levels that could be produced. Current audiometers and bone
vibrators can reach higher levels, so its no longer a problem.

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So why do most people continue to use


mastoid placement?

The common use of mastoid placement is related more to the


earphone used to provide masking to the non-test ear than to
the bone vibrator. The supra-aural earphones that are most
commonly used produce a large occlusion effect in the low frequencies that shifts the bone-conduction thresholds. Thats
why we uncover the test ear during masked bone-conduction
testing. Then we have to turn the whole arrangement around
to test the other ear. When you use occluding earphones there
FEBRUARY 2010 VOL. 63 NO. 2

There certainly is. The Sennheiser HDA200 earphones that


many clinics use for extended high-frequency testing can be
used for the conventional frequency range as well. The reference equivalent threshold sound pressure levels are in the standard so it can be calibrated and used for air-conduction testing.
It is also a thousand times more comfortable than supra-aural
earphones and provides good ambient noise attenuation so you
can test in any reasonably quiet spacenot just sound rooms.
Mastoid bone or forehead bone. Automated
testing or manual testing. Supra-aural
earphones or circumaural earphones. There are
some choices in pure-tone testing, arent there?

20

Yes there are, but there has been very little innovation, despite
the fact that audiologists spend more time performing puretone audiometry than any other single activity. We have textbooks that have been teaching the same method for decades
and we have an audiometer standard that stifles innovation.
We can do better. We need to think outside the box.
REFERENCES
1. Studebaker GA: Intertest variability and the air-bone gap. J Sp Hear Dis 1967;
32:82-86.
2. American National Standards Institute: ANSI S3.6-2004, American National Standard Specification for Audiometers. New York: Acoustical Society of America, 2004.
3. Margolis RH, Saly GL: Toward a standard description of hearing loss. IJA 2007;
46:746-758.
4. Margolis RH, Saly GL: Distribution of hearing loss characteristics in a clinical population. Ear Hear 2008a;29:524-532.
5. Margolis RH, Saly GL: Asymmetrical hearing loss: Definition, validation, prevalence.
Otol Neurotol 2008b;29:422-431.
6. Messick DM, Sentis KP: Fairness, preference, and fairness biases. In Messick DM,
Cook KS, eds., Equity Theory: Psychological and Sociological Perspectives. New York:
Praeger, 1983.
7. Dirks DD, Lybarger SF, Olsen WO, Billings BL: Bone conduction calibration: Current status. J Sp Hear Dis 1979;44:143-155.
8. Frank T, Holmes A: Acoustic radiation from bone vibrators. Ear Hear 1981;2:59-63.
9. Margolis RH, Glasberg BR, Creeke S, Moore BCJ: AMTAS-Automated Method
for Testing Auditory Sensitivity: Validation studies. IJA 2009, in press.
10. Songer JE, Rosowski JJ: A mechano-acoustic model of the effect of superior canal
dehiscence on hearing in chinchilla. J Acoust Soc Am 2007;122:943-951.
11. Merchant SN, Rosowski JJ: Conductive hearing loss caused by third-window lesions
of the inner ear. Otol Neurotol 2008;29:282-289.

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