Basic Audiology

ENT
Norberto V. Martinez
November 26, 2007

Hearing loss → most common neural loss; should be diagnosed in

the newborn

Ears → first sensory organ to develop and the last sensory organ to
go

Philippine Pediatric Society, INC

Recommendations for Preventive Pediatric Health Care 2002
- Hearing Screening Auditory Evoked Response
- At birth to 3 months - Objective test
- Objective/subjective hearing screening - Delivers 2000 clicks which would trigger tissues to produce
EEG waves
Hearing Impairment is the single most common condition - Waves → indicates response of auditory pathway
affecting newborns - 8th cranial nerve
- Cochlear nucleus

1-3 per 1000 in well-baby - Olivary nucleus

2-4 per 100 in the NICU - Lateral lemniscus
- Inferior coliculus
High Risk Registry - If given a large range of stimulus and no response was elicited
- A pgar score < 5 in 5 minutes → hearing loss (flat wave)
- B acterial meningitis
Babies should be tested by 3 months of age
- Hearing loss → most common morbidity post-bacterial
Hearing abilities should have doubled by 6 months, if not give
meningitis (25%) hearing aid (rehabilitation) → so can develop good speech
- Spread through patent cerebral aqueduct → goes to inner
Early diagnosis → proper amplification → early rehabilitation
ear
- Causes ossification of cochlea → surgical emergency!
- C ongenital infection (TORCH)
- Especially Rubella → rubella congenital vaccine as the
cause
- Especially during the first trimester → congenital heart, eye
and hearing loss
- D efects of head and neck
- e.g. cleft lip
- E levated bilirubin level
- Bile pigment may lodge in cochlear nuclei causing hearing
loss
- F amily history
- Most commonly autosomal recessive (25%)
- Autosomal dominant (50%)
- Syndromic →occurs with other defects
- Non-syndromic → occurs alone
- G ram weight < 1500grams
- Prematurity
- H istory of NICU enrollment
- >10 days
- I ntake of ototoxic drugs Auditory Milestones
- most common → aminoglycosides

Vascular insult → ↓ simple diffusion → hypoxia in inner ear (end
Age (months) Description
organ) → ↓ inner ear function
0-3 Startles at a loud sound or noise

Only 50% of newborn with hearing loss would have exhibit the risk
Stops moving or crying when you call
factors, other 50% would not show signs of hearing loss → therefore
→detects mild degree of hearing loss
screening should be done to all
3-6 Turns head or move eyes to a familiar sound

Hearing disables if → 30db – children
(Localization)
→ >40db – adults
6-10 Responds to his/her own voice (babble or coo)
Otoacoustic Emission 10-15 Repeats simple words and sounds you make
- Put a probe on external ear which delivers sound to the inner 15-18 Understand simple phrases and can point to body
year → reaches hair cell → if viable → sound will be echoed parts
back → reach probe 18-24 Should have at least 150 spoken vocabulary
- (+) echo → good hearing
Diagnosed at least 1y/o
- Objective test
- Done in 2nd day of life prior to discharge Behavioral Observation Audiometry
- Blocked if: - Used in testing children from birth to 8 months
- External ear → blocked by vernix caseosa - Requires two clinician (1 distracts and observes; 1 present the
- Middle ear → blocked by fluids (amniotic fluid) stimulus)
- Internal ear → non-viable hair cells - Toys, noisemakers or phonemes representative of different
- If baby did not pass the test, do again in a month, if still failed frequencies may be used
→ do further diagnostic testing - Some expected behavioral responses
- Startle reflex
- Auropalpebral reflex/Eye-blink Reflex
- Eye movements
- Head movements

1
Visual Response Orientation Audiometry Moderate Hearing Loss
- In the first stage the audiologist positions the infant so that it is - 41-60dB
looking straight forward - Can understand face-to-face conversation at a distance of 3-5
- Next, a sound will be made to the child side, and the audiologist feet is structure and vocabulary is controlled. May miss 50-75%
checks to see if the child turns to the direction of the noise. This of a spoken message is the pure tone average is 40 dB. Will
indicates that the child has heard the sound benefit from hearing aid.
- This is repeated as the sound gets softer. To ensure that the Frequency
child makes the effort for the quieter sounds, the child is 250Hz 500Hz 1000Hz 2000Hz 4000Hz
0
rewarded with a puppet show for each successful head turn
- Pavlovian conditioning 10
- Subjective test 20
30
Visual Reinforcement Observation Audiometry 40
- Some observable responses 50
- Head turn toward the sound 60
- Head turn toward visual reinforcer 70
- Change in facial expression 80
- Cry
90
- Vocalize response
100
110
Play Audiometry
120
- Use in testing 2 to 5 years of age
- Child is conditioned to respond by accomplishing a task which
is usually in the form of a play
- E.g. Tone → put coin in bank
- Test for threshold for hearing → minimum sound that the child
hears
- Modes of responses:
- Dropping
- Hitting
- Stacking
- Throwing
- Pushing buttons
- Building

Degree of Hearing Loss

Normal Hearing Level Severe Hearing Loss

- 0-25dB - 61-80dB
- Can hear all sounds - May not even hear voices, unless speech is very loud. Without
amplification, the individual will not recognize any speech
Mild Hearing Loss through listening. Can be a candidate for cochlear implantation
- 26-40dB or hearing aids.
- Will miss consonants. At 30 dB can miss 25-40% of speech
signal. Degree of difficulty depends on noise level, distance Frequency
from speaker, and configuration of the hearing loss. Will benefit 0 250Hz 500Hz 1000Hz 2000Hz 4000Hz
from hearing aid
10
Frequency 20
0 250Hz 500Hz 1000Hz 2000Hz 4000Hz 30
10 40
20 50
30 60
40 70
50 80
60 90
70 100
80 110
120
90
100
110
120
Right ear
Left ear

2
Profound Hearing Loss Sensorineural Hearing Loss
- >80dB - Air conduction → 60dB
- May not even hear voices, unless speech is very loud. Without - Bone conduction → 60dB
amplification, the individual will not recognize any speech - Inner ear problem
through listening. Can be a candidate for cochlear implantation
or hearing aids. Frequency
0 250Hz 500Hz 1000Hz 2000Hz 4000Hz
Frequency
0 250Hz 500Hz 1000Hz 2000Hz 4000Hz 10
10 20
20 30
30 40
40 50
50 60
60 70
70 80
80 90
90 100
100 110
110 120
120
Mixed Hearing Loss
- Air conduction → 60dB
- Bone conduction → 50dB
- Air-bone gap → mixed type of hearing loss
Frequency
0 250Hz 500Hz 1000Hz 2000Hz 4000Hz
10
20
30
40
50
60
70
80
The Speech Banana 90
- Hearing threshold should be above this for normal hearing 100
- Lowest frequency vowel → /u/ 110
- Highest frequency consonant → /s/, /ch/, /th/ 120
- Hearing impaired can sound monotonous because they cannot
hear high frequency sound
Noise induced hearing loss
- Low frequency sound → normal
Qualifying of Hearing Loss - High frequency sound → abnormal

Conductive hearing loss Speech Audiometry

- Outer, middle ear - May be used in testing children approximately 1 to 5 years of
- Before cochlea age
- Bone conduction is normal, air conduction is abnormal - Speech stimuli should be appropriate for their language skills

Conduction: - Examples of speech stimuli
- Bone conduction → test with bone vibrator → set skull in - Body parts
motion → displace fluid in cochlea - Naming/ pointing of pictures or objects
- Air conduction → test with speaker - Ling Six Sounds
- /a/, /u/, /i/, /s/, /sh/, /m/
Sensorineural hearing loss - Spondees- to syllable words with equal stress
- Vestibulocochlear - Eg. Hotdog,cowboy
- Asking questions
INTERPRETATION - For children 6 months to less than 5 years of age
Conductive Hearing Loss - Using noise makers
- Air conduction → 60dB - Drum → low frequency sound
- Bone conduction → 20dB Frequency - Bell → high frequency sound
250Hz 500Hz 1000Hz 2000Hz 4000Hz - Clapping your hands
0 - For children 3 to 5 years old
10 - Ask the child to speak simple words after you
20 - Pointing task
30
From a meter away:
40 - Whisper → 30dB
50 - Converse → 60dB
- Loud → 80dB
60
- Shout → 100dB
70 - Pain → 120dB
80
90 Auditory Evoked Response
100 - Is an activity within the auditory system produced or stimulated
110 by sound
120 - Two processes essential for detecting AER:
1. Amplify the voltage - 100,000 x
Air conduction
2. Signal averaging
Bone conduction

3
 - noise - EEG, electrical and muscle activity
movement of the jaw or neck
Behind-the-ear Hearing Aids
- Connected via earhook and tubing to earmold
- Earmold easily replaceable as required
- More comfortable and less cumbersome than body aid
- Ear mould should be sealed to the ear canal
- If not → sound goes back to microphone → feedback

Otoacoustic Emission
- Sounds generated by the cochlea that can be measured in the
external auditory canal
- Produced by the motile activity of the outer hair cells
- May miss problems with CN VIII → since viable hair cells will
still reflect vibration even if CN VIII is not viable Cochlear Implant Surgery
- Using signal averaging techniques, the AudioPath separates - If hearing aid is not successful after 6 months
the third tone from all other sounds within the ear canal and - For severe to profound hearing loss, with no benefit of hearing
displays the data on graphical display aid
- With hearing aid → still needs viable hair cells to deliver
Acoustic Reflex acoustic stimulus; with cochlear implant → electrical stimulus
- The lowest intensity of an acoustic stimulus at which minimal sent directly to nerve
change in the middle ear compliance can be measured
- ART for normal hearing subjects is 70dB to 100dB
- Stapedius and Tensor Tympani 3 4
- Stimulus: loud noise → stapedius and tensor tympani 7
muscle contract → causes ear ossicles to fuse together →
weakens vibration → ↓ vibration sent to hair cells →
protects the cochlea 1 Tempo+ Processor

Tympanogram
- Probe delivers pressure to tympanic membrane causing it to
move 6
- If tympanogram gives a flat reading: 2
- Fluid in middle ear
- Perforated drum
5
- Impacted cerumen
- Test for tympanic membrane and middle ear canal
Maximum
Displacement
1. Sounds picked up by microphone
2. Speech processor codes it into a signal of electrical pulses
3. Signal sent to headpiece
4. Signal transmitted across skin to implant (in skull)
5. Implant sends signal to electrodes in the cochlea (scala media)
6. Auditory nerve picks up signal and sends it to the brain
7. Brain recognizes this signal as sound

The only surgery that could replace a sensory organ

Especially helpful after post-meningitis ossification of the cochlea →
however surgery has to be done before the ossification process or else
cochlea becomes solid bone

Advances: Now there is brainstem implant into the inferior coliculus
→ useful for non-viable 8th cranial nerve; there is also a new midbrain
impant → penetrates directly into midbrain

Transcribed by: Fred Monteverde

Hearing Aid Block Diagram Notes from: Ads Pascual
Michelle Prestoza
Volume James Muyargas
control

Fred Monteverde
Emy Onishi
Cecile Ong
Mitzel Mata
Microphone Amplifier Receiver
Regina Luz
Section C 2009!

Battery