CHAPTER 69

AUDIOMETRY
Gerald A. Amundsen

Hearing is measured according to its two main components: frequency/pitch and intensity/loudness. Audiometry is a procedure
used to measure and graph an individuals hearing over a range of
frequencies (measured in cycles per second [Hz, for Hertz]) at various
intensity levels (measured in decibels [dB]). Although it is used
frequently to test young children and the elderly (the groups at
highest risk for hearing loss), audiometry is also an important component of any successful occupational hearing loss prevention
program. In many instances, formal audiometry is performed by an
audiologist; however, because screening audiometry is not a complex
procedure and only a minimal amount of equipment is required, it
is often performed by primary care clinicians. Even if not performing
audiometry, primary care clinicians should have a basic understanding of not only the procedure but also the possible results.
An audiometer consists of a variable frequency oscillator that
produces electrical impulses across the audible/perceptible frequencies, a transducer to convert the electrical impulses into sound or
vibrations, and an attenuator to create variations in intensity. The
device may be a stationary part of a designated testing facility or a
portable unit with the flexibility to be used in a variety of settings.
When sound is transmitted through headphones or an earpiece worn
by the patient, and the patient responses are then recorded, an air
conduction audiogram is produced. Air conduction audiometry evaluates both sensorineural and conductive hearing.
Sensorineural hearing refers to that produced by the cochlea of
the inner ear, the auditory nerve, and the cochlear nuclei of the
brain. There are both acquired and congenital causes of sensorineural hearing loss (Box 69-1). To test sensorineural hearing alone, a
bone conduction audiogram is performed. With this procedure, similar
to using a tuning fork when performing a physical examination, a
bone conduction oscillator or vibrator is held against the mastoid
process or forehead. Usually secured by a headband, the vibrator sets
the skull into oscillation, producing a disturbance of the fluid in the
cochlea. This disturbance is sensed by the cochlea and transmitted
down the auditory nerve to the cochlear nuclei, all without use of the
middle ear system. Results are graphed as the bone conduction audiogram. With pure sensorineural hearing loss, both air and bone conduction are impaired, and the impairments are about the same.
With air conduction hearing loss (usually due to middle or outer
ear problems), air conduction is impaired but bone conduction is
preserved. In the normal ear, the differences between the air and
bone conduction thresholds, or the airbone gap, should not exceed
10dB. A gap larger than this indicates an air conduction problem
(again, usually due to a middle or outer ear problem) as the source
of hearing loss. Patients with air conduction hearing loss frequently
respond to surgery; new surgical treatments for sensorineural hearing
loss are also on the horizon. In many patients, hearing impairment
is due to a combination, or a mixed hearing loss, and these also usually
respond somewhat to surgery.
The symbols used on an audiogram (Fig. 69-1) have been standardized by the American Speech-Language Hearing Association
(ASHA; www.ahsa.org). Traditionally, symbols representing the
right ear were recorded in red, whereas results from the left ear were

recorded in blue. Because color is potentially lost in photocopying,

different symbols specific to each ear are now used on most
audiograms.
Frequency is represented on the horizontal axis of the graph from
low to high, from left to right. Although the normal human ear is
capable of hearing a range from 20 to 20,000 Hz, an audiogram
usually tests the range most necessary for hearing and the understanding of speech (usually 250 to 8000Hz). Intensity, the measurement of loudness, is represented on the vertical or left axis of the
graph, and usually ranges from 0 to 120dB. Data points plotted on
the graph represent the lowest decibel intensity that can be heard
by the individual 50% of the time at each frequency, and this is the
auditory threshold for that particular frequency.
Results are interpreted relative to 0 dB, or audiometric zero.
Audiometric zero is defined as normal by the American National
Standards Institute (ANSI) and is derived from sampling a large

Box 69-1. Causes of Sensorineural

Hearing Loss
Newborn
Anoxia, asphyxia, hypoxia
Bacterial infections
Birth trauma
Congenital syphilis
Genetic causes, expressed at birth
Hyperbilirubinemia requiring exchange transfusion
Prematurity
TORCH syndrome (toxoplasmosis, other agents, maternal
rubella, cytomegalovirus, herpes simplex)
Acquired
Autoimmune inner ear disorders
Bacterial meningitis
Congenital or acquired syphilis
Cranial radiation therapy
Excessive occupational noise or exposure to loud music
Genetic
Glomus tumors
Head trauma (temporal bone fractures or labyrinthine
concussion)
Herpes zoster
Human immunodeficiency virus infection/acquired
immunodeficiency syndrome
Labyrinthitis
Lyme disease
Measles
Menieres disease
Mumps
Ototoxic medications
Vascular disorders

453

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EYES, EARS, NOSE, AND THROAT

CONTRAINDICATIONS

Response*
Modality

>
]

<
[

Inexperienced technician
Acute otitis media
Local pinna infection that would cause pain from the earphone
or earpiece application
Uncooperative patient
Uncontrollable background noise in the room when testing
Occlusion of the canal by cerumen (see Chapter 72, Cerumen
Impaction Removal) or a foreign body (see Chapter 76, Removal
of Foreign Bodies from the Ear and Nose)

EQUIPMENT

>

Bone conduction: forehead

Unmasked
Masked
Air conduction: sound field

Right

>

Air conduction: earphones

Unmasked
Masked
Bone conduction: mastoid
Unmasked
Masked

Left

Ear
Unspecified

Figure 69-1 Standardized symbols for recording audiogram results. *For

no response, use a downward 45-degree arrow pointing to the left for
the right ear symbols, and to the right for left ear symbols (e.g.,
for no
response in the right ear unmasked).

population of ear-diseasefree young adults. In other words, if a

persons threshold at a given frequency is 20dB, it means that the
individual can hear sound at that frequency only when it is 20dB
louder than that needed by an average disease-free young adult.
From 1 to 6 of 1000 newborns have severe hearing loss,
usually sensorineural in origin. The Joint Committee on Infant
Hearing and the National Institutes of Health Consensus Statement
recommend screening all infants for hearing loss at no later than 1
month of age. If the screening test result in the very young is abnormal, they should have comprehensive audiologic evaluation at no
later than 3 months of age (e.g., behavioral observation audiometry,
auditory brain stem response, otoacoustic emissions testing, visual
reinforcement audiometry, conditioned play audiometry). Such an
evaluation is beyond the scope of this text.

NOTE:

INDICATIONS
General screening in children at the earliest age possible
Exposure to one (or more) of the causes for sensorineural hearing
loss (see Box 69-1)
Speech delay in children
Persistent behavioral problems or changes in children or the
elderly
Screening of the elderly, especially when performing geriatric
assessment (see Chapter 232, Special Considerations in Geriatric
Patients)
Patient complaints of hearing loss
Persistent serous otitis media, especially bilateral in children
Anyone undergoing tympanometry with suspected sensorineural
hearing loss (an abnormal tympanogram usually implies conductive hearing loss; however, sensorineural hearing loss may also be
present)
Formal audiometric evaluation of a failed screening test
NOTE: Up to 5% of school-age children will have fluctuating
hearing loss during the school year because of middle ear effusions. Retesting is imperative.
Patient complaints of tinnitus, dizziness, or vertigo
After severe head trauma
After use of ototoxic drugs
After meningitis, encephalitis, or other serious viral or bacterial
infections that could affect hearing
Occupational screening and follow-up for individuals with noisy
work environments

Audiometer: These range from simple hand-held screening

instruments that test one ear at a time with a limited range of
frequencies and intensities to more comprehensive devices. Audiometers may test air conduction alone or may be equipped to test
both bone and air conduction. The most comprehensive units
test frequencies from 125 to 8000Hz at 0 to 100dB. Audiometers
are either stationary or portable, and many modern units interface
directly with a laptop computer to record, store, and interpret
patient evaluations.
An individual trained in proper techniques for obtaining reliable,
reproducible, and valid test results. (For occupational/industrial
screening, the individual should be certified by the Council for
Accreditation of Occupational Hearing Conservationists [www.
caohc.org].)
Quiet or sound-treated room, preferably tested (by an outside
company) for acceptable background/ambient noise levels. If
ambient noise levels are too high, thresholds may be artificially
elevated, particularly in the lower frequencies.

PREPROCEDURE PATIENT PREPARATION

The indications for the procedure should be explained to patients,
and they should be reassured that the process is painless. Patients
should know that they will be hearing tones of varying degrees of
loudness and pitch, and that they should signal both when they first
hear a tone and when the tone disappears. They should know how
they are expected to demonstrate or signal when they hear the tone
(e.g., raising their hand, pushing a button). Patients should sit in a
relaxed and comfortable position and look straight ahead. If they
can hear noise from outside the earphones or earpiece, they should
inform the clinician. If bone conduction testing will be performed,
the source and nature of the vibrations should be explained to the
patient.

TECHNIQUE
1. The examination must be administered using a properly calibrated instrument in a room with an acceptable level of background noise. The ear canal should have been checked for
patency by the clinician.
2. The patient should be comfortably seated facing neither the
monitor nor the examiner. (Usually patients are seated in a
position that provides a side profile view to the examiner.)
3. Anything that may interfere with earphone application (or
earplug insertion) should be removed (earrings, glasses, hats),
and the headphones must be appropriately seated on the
patients head (or the earplugs properly inserted), sealing the
ears from environmental noise.
4. Instruct the patient to respond to the faintest detectable sound
at each frequency. Responses can consist of raising a hand or
finger or pressing a test button when sound is first heard. The
patient should continue to signal for the duration of audible
sound. Having the patient indicate the entire duration of
audible sound allows the examiner to determine if the responses

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69 AUDIOMETRY

Air conduction testing alone can approximate the degree of hearing

loss. However, to differentiate between conductive, sensorineural,
and mixed hearing loss, it is often best to test both air and bone
conduction hearing.
A threshold of up to 20 dB is considered normal. Above that,
hearing loss can be divided into degrees of severity (Table 69-1).
Certain patterns of hearing loss, especially unilateral, can indicate
specific diseases. Hearing asymmetry of more than 20dB, especially
if it is suspected to be sensorineural in origin, may indicate a retrocochlear lesion or mass (Fig. 69-2). Such patients should be evaluated further with imaging or referred. The tympanometer may be
used as an additional tool to assess mobility of the tympanic membrane when conductive hearing loss is diagnosed by audiometry.
Conversely, audiometry is often used as an adjunct to tympanometry

TABLE 69-1

Loss

Classification of Severity of Hearing

Degree of Hearing Loss (dB)

Level of Severity

020
2140
4155
5670
7190
>90

Normal
Mild
Moderate
Moderately severe
Severe
Profound

HL in dB (ANSI-69)

HL in dB (ANSI-69)

90
80
70
60
50
40
30
20
10
0
250

1000

4000

250

Frequency (Hz)
Right ear

1000

4000

Frequency (Hz)
Left ear

Air conduction (unmasked)

Air conduction (masked)
Bone conduction (unmasked)
Bone conduction (masked)
Figure 69-2 Sixty-year-old man with suspected right acoustic neuroma.
Note the unilateral hearing loss. (The corresponding tympanograms would
be type A or normal.) (Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic
Audiology. Austin, Tex, Pro-Ed, 1991.)

when a persistently abnormal tympanogram is present (see Chapter

75, Tympanometry, for more details).
Figures 69-2 through 69-11 illustrate classic patterns of hearing
loss. In the examples, hearing thresholds have been converted to
hearing loss (HL). In addition, because each ear was recorded separately, the standardized symbols were not necessary to distinguish
left from right.

100
90
80
70
60
50
40
30
20
10
0

100
90
80
70
60
50
40
30
20
10
0
250

HL in dB (ANSI-69)

INTERPRETATION

100
90
80
70
60
50
40
30
20
10
0

100

HL in dB (ANSI-69)

are reproducible. If reproducible, the threshold should be the

same at the beginning and at the end for a particular frequency,
at least 50% of the time; this can then be recorded. Patients
should be tested from low to high decibels and then back to
low. This step helps the examiner exclude false-positive
responses.
5. Threshold testing is initiated in the better ear (or the right ear
if hearing is equal in both) with the following recommended
sequence of frequencies: 1000, 2000, 4000, 8000, 1000
(repeated), 500, and 250Hz. Start with 0dB hearing levels and
produce the tones for 1 to 2 seconds unless the patient responds.
6. Increase the tone by 5dB, and, if the patient responds, reduce
it by 10-dB increments until it is inaudible.
7. Continue repeated ascents in 5-dB increments and descents in
10-dB increments until a 50% reproducible response is obtained.
Generally this requires three to four repetitions, with the patient
attaining the same response at least half of the time. This
result is then entered with the appropriate symbol on the
audiogram.
8. Test through the frequencies sequentially as previously noted,
starting 15 to 20dB below the threshold of the previously tested
frequency. Continue testing until all frequencies have been
tested.
9. If bone conduction testing is planned, this same sequence
can be applied and the results recorded with the appropriate
symbols.
10. It may be necessary to mask or obscure one sound with another
when the difference in hearing loss between the ears is great
(e.g., a 40-dB difference for air conduction testing, a 5-dB difference for bone conduction hearing) or there is a 10-dB air
bone gap in the ear being tested. In these situations, crossover
of sound to the better ear may occur and artificially lower the
threshold of the impaired ear, so masking is applied to the
nontest ear. Audiometers are calibrated so that a 10-dB masking
noise will block a 10-dB pure signal.

1000
4000
Frequency (Hz)
Right ear

250

1000
4000
Frequency (Hz)
Left ear

Air conduction (unmasked)

Bone conduction (unmasked)
Figure 69-3 Nine-year-old boy with right acute otitis media with effusion. Using masking, the curves would probably appear the same; however,
there would be slightly more assurance of the accuracy of the study. (The
corresponding tympanogram would be type B.) (Redrawn from Jacobsen JT,
Northern JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)

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EYES, EARS, NOSE, AND THROAT

100
90
80
70
60
50
40
30
20
10
0

1000

4000

250

Frequency (Hz)
Right ear

1000

4000

Figure 69-4 Forty-year-old woman with bilateral otosclerosis. (The

corresponding tympanograms would be type A or AS.) This disorder is
autosomal dominantly inherited with about 40% penetrance. (Redrawn from
Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)

100
90
80
70
60
50
40
30
20
10
0

250

4000
1000
Frequency (Hz)
Right ear

250

1000

4000

Air conduction (unmasked)

Bone conduction (masked)
Figure 69-6 Fifteen-year-old girl with right tympanic membrane perforation. (The corresponding right ear tympanogram would be type B.)
(Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin,
Tex, Pro-Ed, 1991.)

1000

4000

Frequency (Hz)
Left ear

Air conduction (unmasked)

Air conduction (masked)
Bone conduction (masked)
Figure 69-5 Twenty-year-old man with ossicular disruption on the left
after mild head trauma. (The corresponding left ear tympanogram would be
type AD.) (Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic Audiology.
Austin, Tex, Pro-Ed, 1991.)

HL in dB (ANSI-69)
1000
4000
Frequency (Hz)
Left ear

250

Frequency (Hz)
Right ear

100
90
80
70
60
50
40
30
20
10
0

100

HL in dB (ANSI-69)

HL in dB (ANSI-69)

90
80
70
60
50
40
30
20
10
0

HL in dB (ANSI-69)

250

Frequency (Hz)
Left ear

Air conduction (unmasked)

Bone conduction (unmasked)

100

90
80
70
60
50
40
30
20
10
0

90
80
70
60
50
40
30
20
10
0

HL in dB (ANSI-69)

250

100
90
80
70
60
50
40
30
20
10
0

100

HL in dB (ANSI-69)

90
80
70
60
50
40
30
20
10
0

HL in dB (ANSI-69)

HL in dB (ANSI-69)

100

250

1000

4000

Frequency (Hz)
Right ear

250

1000

4000

Frequency (Hz)
Left ear

Air conduction (unmasked)

Bone conduction (unmasked)
Figure 69-7 Forty-year-old man with suspected functional (factitious)
hearing loss after industrial accident with a single exposure to high-intensity
noise (e.g., an explosion). Bone conduction should be intact after a single
exposure. (The corresponding tympanograms would be type A or normal.)
(Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin,
Tex, Pro-Ed, 1991.)

457

69 AUDIOMETRY

1997

20

90
80
70
60
50
40
30
20
10
0

1993
10
250 500 1000 2000
4000 8000
Frequency (Hz)
Left ear
Air conduction

250 1000 4000 800016000

Frequency (Hz)
Right ear

60

40

40

20
0

10

250

1000

4000

Frequency (Hz)
Right ear

Figure 69-9 Eighty-year-old man with presbycusis, or hearing loss

caused by advancing age. It is usually bilateral, and in men it often affects
the higher frequencies more severely. In women, in addition to symmetric
high-frequency loss, there may be hearing loss in the lower frequencies. (The
corresponding tympanograms would be type A or normal.) (Redrawn from
Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)

100
90
80
70
60
50
40
30
20
10
0

100

20

0
10

Air conduction
Bone conduction

250

1000

4000

Frequency (Hz)
Left ear

Air conduction
Bone conduction
Figure 69-10 Fifty-year-old woman with long-term exposure to loud
occupational noise, which could include loud music. Note the speech frequencies are more affected than the higher frequencies. (The corresponding tympanogram would be type A or normal.) (Redrawn from Jacobsen JT,
Northern JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)

HL in dB (ANSI-69)

60

HL in dB

HL in dB

Figure 69-8 Fifty-five-year-old man with gradually progressive left neurosensory hearing loss over several years. Such a hearing loss can be seen in a
person who hunts and shoots left-handed. In most such cases, the audiogram
differs from that of presbycusis because it spares the upper frequencies
(8000Hz). (The corresponding tympanogram would be type A or normal.)
(Redrawn from Jacobsen JT, Northern JL [eds]: Diagnostic Audiology. Austin,
Tex, Pro-Ed, 1991.)

250 1000 4000 800016000

Frequency (Hz)
Left ear

90
80
70
60
50
40
30
20
10
0

HL in dB (ANSI-69)

HL in dB

40

100

90
80
70
60
50
40
30
20
10
0

HL in dB (ANSI-69)

2001

100

HL in dB (ANSI-69)

60

250

1000

4000

Frequency (Hz)
Right ear

250

1000

4000

Frequency (Hz)
Left ear

Air conduction (unmasked)

Air conduction (masked)
Bone conduction (unmasked)
Bone conduction (masked)
Figure 69-11 Fifty-two-year-old man with Menieres disease, predominantly affecting right ear. This hearing loss is often associated with episodes
of tinnitus and vertigo, frequently at the same time. Remission can occur,
as well as exacerbation. Over time, the hearing loss typically progresses to
moderate or moderately severe and persistent. (The corresponding tympanograms would be type A or normal.) (Redrawn from Jacobsen JT, Northern
JL [eds]: Diagnostic Audiology. Austin, Tex, Pro-Ed, 1991.)

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EYES, EARS, NOSE, AND THROAT

CPT/BILLING CODES

SUPPLIERS

92551

(See contact information online at www.expertconsult.com.)

92552
92553
92555
92556
92557

Screening test, pure-tone, air only (e.g., single-decibel-level

device with selected frequencies)
Pure-tone audiometry, threshold; air only
Pure-tone audiometry, threshold; air and bone
Speech audiometry, threshold
Speech audiometry, threshold; with speech recognition
Comprehensive audiometry, threshold evaluation and
speech recognition (92553 and 92556 combined)

ICD-9-CM DIAGNOSTIC CODES

388.2
389.00
389.02
389.03
389.04
389.05
389.06
389.2
389.8
389.9
389.10
389.14
389.15
389.18
951.5
V19.2
V72.11
V72.19

Hearing loss, sudden, unspecified

Hearing loss, conductive, unspecified
Hearing loss, tympanic membrane, conductive
Hearing loss, middle ear, conductive
Hearing loss, inner ear, conductive
Hearing loss, conductive, unilateral
Hearing loss, conductive, bilateral
Hearing loss, mixed conductive and sensorineural
Hearing loss, high or low frequency
Deafness
Hearing loss, sensorineural, unspecified
Hearing loss, central
Hearing loss, sensorineural, unilateral
Hearing loss, sensorineural, bilateral
Traumatic deafness
Family history of hearing loss
Hearing exam following failed hearing screening
Hearing exam

ACKNOWLEDGMENT
The editors wish to recognize the many contributions by Gregory J.
Forzley, MD, to this chapter in the previous two editions of this text.

Benson Medical Instruments

Castle Group
Gordon Stowe
Grason-Stadler, Inc.
Maico Diagnostics
Micro Audiometrics
Otometrics
Welch Allyn, Inc.

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American Academy of Pediatrics, Joint Committee on Infant Hearing: Year
2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 120:898921, 2007.
American Speech-Language-Hearing Association: Guidelines for audiometric symbols. ASHA 32(Suppl. 2):25, 1990.
American Speech-Language-Hearing Association: Guidelines for the Audiologic Assessment of Children from Birth to 5 Years of Age. 2004. Available at www.asha.org/policy. Accessed November 2007.
Cunningham M, Cox EO; Committee on Practice and Ambulatory Medicine and Section on Otolaryngology and Bronchoesophagology: Hearing
assessment in infants and children: Recommendations beyond neonatal
screening. Pediatrics 111:436440, 2003.
Hall JW III, Antonelli PJ: Assessment of peripheral and central auditory
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Williams & Wilkins, 2006, pp 19271942.
Isaacson JE, Vora NM: Differential diagnosis and treatment of hearing loss.
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