Pure-Tone-Audiometry Sociedad Britanica Audiologia

Recommended Procedure
Pure-tone air-conduction and bone-

conduction threshold audiometry with and
without masking
Date of version: September 2011 [Minor amendments:
February 2012, and December 2015]
Date for
Date of review: September 2016
Pure Tone Audiometry
BSA
2011
General foreword
This document presents a Recommended Procedure by the British Society of Audiology (BSA). A
Recommended Procedure provides a reference standard for the conduct of an audiological intervention
that represents, to the best knowledge of the BSA, the evidence-base and consensus on good practice
given the stated methodology and scope of the document and at the time of publication.
Although care has been taken in preparing this information, the BSA does not and cannot guarantee the
interpretation and application of it. The BSA cannot be held responsible for any errors or omissions, and
the BSA accepts no liability whatsoever for any loss or damage howsoever arising. This document
supersedes any previous recommended procedure by the BSA and stands until superseded or
withdrawn by the BSA.
Comments on this document are welcomed and should be sent to:
British Society of Audiology

Blackburn House,
Redhouse Road
Seafield,
Bathgate
EH47 7AQ
Tel: +44 (0)118 9660622
[email protected]
www.thebsa.org
Published by the British Society of Audiology
© British Society of Audiology, 2011
All rights reserved. This document may be freely reproduced in its entirety for educational and not-for-profit
purposes. No other reproduction is allowed without the written permission of the British Society of Audiology.
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1. Contents
2. Introduction ………………………………………………………………………………..…… 5
3. Scope ………………………………………………………………………………..……………… 5
3.1 Subject ………………………………………………………………………..………. 5
3.2 Procedures …………………………………………………...………………..…… 5
4. Equipment and test environment ........................................................ 6
4.1 Audiometric Equipment ………………………....……………….…….…… 6
4.2 Audiometric Test Environment ……………………….………………….. 6
5. Preparation for testing ……………………………………………………….……….…… 6
5.1 Preparation of test subjects …………………………….…………….……. 6
5.2 Test Time ………………………………………………………………….…….…… 7
6. Air-conduction audiometry without masking …….………………………….…. 8
6.1 Instructions ……………………………………..……..……………………...….. 8
6.2 Subjects response ……………………………………….….…………………… 8
6.3 Earphones ……………………………………………………..……………………. 8
6.4 Test Order ……………………………………………………………………………. 9
6.5 Timing of test stimuli …………………………………………………..………. 10
6.6 Initial Familiarisation ……………………………………..…..……………….. 10
6.7 Method of finding threshold ………………………………………………… 10
6.8 Variations in method ……………………………………………………..……. 11
7. Bone-conduction audiometry without masking ………………………………… 11
7.1 Bone vibration ……………………………………………………..………….….. 12
7.2 Test frequencies and test order ………………………………..…………. 12
7.3 Test stimuli ………………………………………………………………..………… 12
7.4 Instructions ………………………………………..……………….………………. 12
7.5 Methods for finding thresholds ……………………..…..……………….. 12
7.6 Vibrotactile threshold ………………..………………………………………… 13
7.7 Limitations of bone vibrators ……………..………………..……………… 13
8. Cross-hearing and masking …………..………………………………………………….. 13
8.1 Cross-hearing and its prevention by masking ……….……………… 14
8.2 The principles of masking……………………………………………………… 14
8.3 Masking noise…………………………..………………………………………….. 15
8.4 Effective masking level…………………………………………..…………….. 15
8.5 Measuring the thresholds for masking noise (M) if required... 16
8.6 Indicators of cross-masking and rules of masking…………………. 16
8.6.1 Rule 1……………………………………………………………..……….. 16
8.6.2 Rule 2…………………………………………..………………………….. 16
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8.6.3 Rule 3………………………..…………………………………………….. 17

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8.7 Instructions for masking………………………………….……………………. 17
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8.8 Procedure for masking…………………………………………….…………… 18

8.9 Masking during bone conduction testing………………..………..….. 20
8.10 Interpretation of the masking function…………………………………. 20
8.10.1 When cross-hearing is not present…………………………… 20
8.10.2 When cross-hearing is present…………………………………. 21
8.10.3 Central masking……………………………………………………….. 23
8.10.4 Cross masking………………………………………..………………… 24
8.11 Caution…………………………………………………………………………………. 25
9. Audiometric descriptors……………………………………………………………………. 26
10. Recommended format for audiogram forms ………………………………..….. 27
10.1 Audiogram forms………………………………………………………………….. 27
10.2 Symbols……………………………………………………….……………………….. 27
10.3 Working Audiograms……………………………………………………………. 29
10.4 Masking Levels………………………………………….…….……………………. 30
10.5 Notes………………………………………………………….………………………… 30
11. Calibration………………………………………………………………………………………… 30
11.1 Stage A: routine checking and subjective tests……………………… 30
11.2 Stage B: periodic objective tests…………………………………………… 32
11.3 Stage C: basic calibration tests……………………………………………… 32
12. References………………………………………………………………………………………… 34
Appendix A. Authors and acknowledgments………………………………………………….. 36
Appendix B. Standards relevant to audiometry……………………………………………… 36
Appendix C. Permitted ambient noise levels for audiometry…………………………. 37
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2. Introduction
This document replaces the previous version (BSA 2004). Its purpose is to describe
standard procedure and recommendations for effective pure-tone audiometry carried
out in most audiological contexts. It also includes descriptors for pure-tone audiograms
and the recommended format for audiogram forms. This document is not intended to
provide guidance on specific circumstances or on interpretation of results. It is
important that the competent person carrying out, or responsible for, the test (the
‘tester’) uses professional judgement when deciding on the particular approach to be
used with each person being tested (the ‘subject’), given the specific circumstances and
the purposes of the test, and the tester’s level of competency. The BSA has produced a
separate procedure for the determination of uncomfortable loudness levels (BSA).
The term ‘shall’ is used in this document to refer to essential practice, and ‘should’ to
refer to desirable practice.
Unless stated otherwise, this document represents the consensus of expert opinion and
evidence as interpreted by the Professional Practice Committee of the BSA in
consultation with its stakeholders (Appendix A). The document was developed in
accordance with the BSA Procedure for Processing Documents (BSA).
3. Scope
3.1 Subjects
This document describes procedures suitable for routine clinical use with adults and
older children. It may not be appropriate for certain populations (e.g. adults with
learning difficulties and younger children). In these cases some modification of the test
method may be required, although this may result in a less accurate measurement of
hearing threshold levels.
3.2 Procedures
Procedures are described for manual pure-tone audiometry, using both air-conduction
(a-c) and bone-conduction (b-c) testing, with and without masking. The document does
not cover high-frequency audiometry (>8000 Hz), screening audiometry, use of short-
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duration tone bursts, self-recording audiometry or sound-field audiometry.
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4. Equipment and test environment

4.1 Audiometric equipment
The audiometer, transducers and response button shall be clean. Audiometers shall
meet the performance and calibration requirements of the relevant and current BS EN
ISO standards (see Section 11 and Appendix B).
4.2 Audiometric test environment

The subject’s face shall be clearly visible to the tester. The subject shall not be able to
see or hear the tester adjust the audiometer controls. When the test is controlled from
outside the audiometric test room, the subject shall be monitored through a window or
by a closed-circuit TV system. Audible communication with the subject should also be
possible.
Excessive ambient noise will affect the test results, and ambient noise should not exceed
the levels set out in the BS EN ISO standards (see Appendix C for further comments and
details of the permitted ambient noise). The problems caused by ambient noise are
greater when testing by b-c as there are no earphones in place to reduce the noise
reaching the ears. Testers should also be alert to the problems of intermittent or
transient noise during the test.
In general, the ambient noise should not exceed 35 dB(A). If it is higher than this then it
is recommended that audiometry should not proceed.
5. Preparation for testing

5.1 Preparation of test subjects
The tester shall adopt an effective communication strategy with the subject throughout.
This must take account of the subject’s age, hearing, language skills and any other
possible communication difficulties. Any significant communication problems shall be
recorded as these may affect the subject’s performance.
Audiometry shall be preceded by otoscopic examination (see Recommended Procedure:

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Ear Examination (BSA)) and the findings recorded, including the presence of wax.
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Occluding wax may be removed prior to audiometry but if wax is removed the
procedure shall only be undertaken by someone who is qualified and competent to do
so.
If there is a likelihood of ear canals collapsing with supra-aural earphones in position this
shall be recorded as it may lead to measurement of a false air-bone gap. In some cases
the use of insert earphones (e.g. Etymotic ER3 and ER5) will avoid this problem (see
Section 6.3).
The subject shall be asked about any exposure to loud noise during the previous 24
hours, as this can cause a temporary hearing loss. If the answer is yes then more details
should be obtained regarding the exposure and results recorded. ‘Loud’ can be
determined by having to shout or use a raised voice to communicate at a distance of 1
metre or 3 feet. If the results may have been affected by recent noise exposure then it
may be necessary to re-test the subject at a time when they have had no recent
exposure to noise.
Subjects shall be asked if they have tinnitus, as this may affect their ability to detect
tones in one or both ears (see Section 6.8). Subjects shall be asked if they have better
hearing in one ear; if so testing should commence with that ear, otherwise testing can
start in either ear.
If applicable, inform the subject about intercom facilities. After giving the test
instructions, remove any hearing aids, also any glasses, headwear or ear-rings that may
obstruct the correct placement of the transducers, cause discomfort or affect sound
transmission. Wherever possible, hair, scarves etc, should not be allowed to sit between
the ear and the transducer.
5.2 Test time

Care should be taken not to fatigue the subject as this can affect the reliability of the
test results. If the test time exceeds 20 minutes, subjects may benefit from a short
break.
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6. Air-conduction audiometry without masking

6.1 Instructions
Instructions shall give clear information about the task. This could be as follows:
“I am going to test your hearing by measuring the quietest sounds that you can hear. As
soon as you hear a sound (tone), press the button. Keep it pressed for as long as you
hear the sound (tone), no matter which ear you hear it in. Release the button as soon as
you no longer hear the sound (tone). Whatever the sound, and no matter how faint the
sound, press the button as soon as you think you hear it, and release it as soon as you
think it stops.”
Alternative wording is acceptable providing the same points of instruction are included.
The provision of an abbreviated printed version of these instructions may be
advantageous. The subject should be asked if they understand the instructions. They
should also be told that they should sit quietly during the procedure and may interrupt
the testing in case of discomfort.
Subjects with tinnitus present at the time of the test should be asked to ignore their
tinnitus as much as possible and to respond to the test tones. They should be instructed
to inform the tester if they experience difficulty in discriminating between their tinnitus
and the test tones. A note to that effect should be made on the audiogram form,
including which frequencies were affected (see also Section 6.8).
6.2 Subject’s response

The subject’s response to the test tone should clearly indicate when the test tone is
heard and when it is no longer heard. The response system should be inaudible, with a
response button connected to a signal light the preferred method. When testing
younger children, adults with learning difficulties or subjects with attention difficulties a
more engaging response method may be required, and, if so, this shall be recorded.
6.3 Earphones
There are three main types of transducers that can be used for air-conduction
audiometry: supra-aural, circumaural and insert earphones. Supra-aural earphones (e.g.
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Telephonics TDH39 and TDH49) rest on the ear and have traditionally been used for a-c
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audiometry. Circum-aural earphones (Sennheiser HDA200) surround and cover the
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entire ear. However, both supra- and circum-aural earphones can be cumbersome,
particularly when used for masking bone-conduction thresholds, and may cause the ear
canal to collapse. Insert earphones (e.g. Etymotic Research ER3 and ER5) use a
disposable foam tip for directing the sound straight into the ear canal and therefore
prevent the ear canal from collapsing. Insert earphones are also associated with less
transcranial transmission of sound than supra-aural earphones so reduce the need for
masking (see Section 8.1). However, insert earphones may not be appropriate in ears
with infections, obstructions or abnormalities. In cases of excessive wax, insert
earphones could also push the wax further into the canal and therefore must be
avoided.
The tester shall fit the earphones and the subject should be instructed not to hold or
move them, after checking with the subject that there is no discomfort. The sound
opening of a supra- or circum-aural earphone shall be aligned with the ear canal
entrance. If insert earphones are used, the appropriately sized ear tip of an insert
earphone should be inserted so the outer end is flush with the entrance to the ear canal.
In all cases, incorrect placement may invalidate calibration and provide less protection
from ambient noise.
With a-c, vibrotactile perception can occur at frequencies of 500 Hz and below, and at
high hearing levels. The tester should be aware of the possibility that thresholds at these
frequencies and levels may be vibrotactile.
6.4 Test order

Start with the better-hearing ear (according to the subject’s account) and at 1000 Hz.
Next, test 2000 Hz, 4000 Hz, 8000 Hz, 500 Hz and 250 Hz in that order. Then, for the first
ear only, retest at 1000 Hz. If the retest value is no more than 5 dB different from the
original value take the more sensitive threshold as the final value, but if the retest value
differs from the original value by more than 5 dB then the reason for the variation shall
be investigated. The subject may need to be re-instructed and the full test repeated for
that ear (but see also Sections 5.2 and 6.8 regarding the effects of a test taking too
long). Unusually variable results shall be noted on the audiogram. Where needed and
practicable, test also at intermediate frequencies 750 Hz, 1500 Hz, 3000 Hz and 6000 Hz
(3000 Hz and 6000 Hz may be required in cases of high-frequency hearing loss). Test the
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opposite ear in the same order. The retest at 1000 Hz is normally not required in the
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second ear unless tests in the first ear revealed significant variation.
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6.5 Timing of the test stimuli

The duration of the presented tone shall be varied between 1 and 3 seconds. The
interval between the tones shall be varied between 1 second and at least 3 seconds. The
tester must ensure that the timing of each tone is not predictable; random variations in
durations are intended as a check against false positive responses. It is important that
the tester does not stop the signal as soon as the subject responds, signals must be of
the full duration and the subject must respond throughout each one.
6.6 Initial familiarisation

To ensure the subject is familiar with the task, present a tone of 1000 Hz that is clearly
audible (e.g. at 40 dB HL for a normally hearing subject or approximately 30 dB above
the estimated threshold for a subject with a hearing impairment, but never more than
80 dB HL). If there is no response, increase the level of the tone in 10-dB steps until a
response occurs. If the tone is still inaudible at 80 dB HL, increase the level of the tone in
5-dB steps until a response occurs, taking care to monitor the subject for discomfort.
If the responses are consistent with the tone presentation (i.e. onset and offset) the
subject is familiarised with the task. If not, repeat. If after this repeat the responses are
unsatisfactory, re-instruct the subject.
6.7 Method for finding threshold

1. Following a satisfactory positive response, reduce the level of the tone in 10-dB
steps until no further response occurs.
2. Increase the level of the tone in 5-dB steps until a response occurs.
3. After the first response using an ascending approach, decrease the level by 10 dB
and begin another ascending 5-dB series until the subject responds again.
4. Continue to decrease the level by 10 dB and increase by 5 dB until the subject
responds at the same level on two out of two, three or four (i.e. 50 % or more)
responses on the ascent. This is the hearing threshold level. Threshold is defined as
the lowest level at which responses occur in at least half of a series of ascending
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trials with a minimum of two responses required at that level.

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5. Proceed to the next frequency, starting at a clearly audible level (e.g. 30 dB above
the adjacent threshold, but see notes on familiarisation in Section 6.6) and use the
10-dB-down, 5-dB-up sequence described in Step 4 until the threshold criterion is
satisfied.
6.8 Variations in method

There will be situations where the test frequencies will vary from those in Section 6.4.
For example, industrial audiometry (Health & Safety Executive, 2005, Appendix 5)
requires testing at 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz, 6000 Hz and 8000 Hz.
Subjects with short attention spans, and some elderly subjects, may find the full test
rather tiring. In these cases it may be appropriate to test fewer frequencies, as it is
better to test fewer frequencies accurately than to attempt a complete test on an
uncooperative subject where the accuracy will be in doubt. When frequencies are
omitted from the test the reason shall be recorded. With such subjects other
modifications to technique may be required, such as the use of longer test tones or
alternative response methods. Again these variations in technique shall be recorded.
If the subject is unable to perform an accurate test at some frequencies due to an

inability to distinguish between their tinnitus and the test tone, then a frequency-
modulated or warble tone may be used as a stimulus. Subjects often find a warble tone
easier to hear against their tinnitus than a pure-tone. However, there are calibration and
perception problems with warble tones, and the thresholds measured may be in error
as a result. It is essential to record at which frequencies and in which ears warble tones
were used. The use of pulsed tones and narrow-band noise is not advised due to
calibration and perception problems.
If there is reason to suspect that the hearing thresholds are exaggerated, published
variations in technique may help with this (e.g. Cooper & Lightfoot, 2000). When used, a
note citing the method shall be added to the audiogram form (Section 10).
7. Bone-conduction audiometry without masking

Without masking, it is not possible to determine which ear is responding to bone-
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conduction testing. Calibration standards for b-c apply only to monaural hearing and
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were derived using approximately 35 dB sensation level of masking noise in the non-test
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ear. When testing without masking, thresholds may appear more acute by about 5 dB
due to binaural stimulation.
7.1 Bone vibrator

The bone vibrator is normally initially placed over the mastoid prominence of the worse
hearing ear (as defined by the a-c thresholds averaged between 500 Hz and 4000 Hz),
with the required area of the vibrator in contact with the skull. It shall be placed as near
as possible behind the pinna without touching it and without resting on hair. The
vibrator shall be held firmly in place by means of a headband that holds it against the
skull with the required static force. The side on which the vibrator was placed shall be
noted on the audiogram form. See Section 10.2 for details of the use of symbols. An
alternative placement of the bone vibrator is on the forehead but this site requires a set
of correction values, which are available in BS EN ISO 389-3.
7.2 Test frequencies and test order

The preferred test order is similar to that used in a-c audiometry starting at 1000 Hz,
however alternatives are acceptable. Bone-conduction should only be performed in the
frequency range 500 Hz to 4000 Hz, and it may not be necessary or appropriate to test
at all these frequencies in every case. No retest is required at 1000 Hz. See Section 7.7
for comments on limitations of bone vibrators, the need to use ear plugs and for test
frequencies outside this range.
7.3 Test stimuli

The requirements for timing of the test stimuli are the same as for a-c audiometry. See
Section 6.5.
7.4 Instructions
Instructions are the same as for a-c audiometry, as described in Section 6.1. However,
emphasis should be given that the subject should respond regardless of the side on
which the sound (tone) is heard.
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7.5 Methods for finding threshold

Ear-specific b-c audiometry requires masking of the non-test ear. Where an ear-specific
measure is not required, b-c audiometry may be undertaken without masking. The ear
being tested by b-c should not be occluded, except as described in Section 7.7. If it is
occluded, it shall be noted on the audiogram form.
Determine hearing threshold levels as described in Section 6.7.
7.6 Vibrotactile threshold

For mastoid location of the bone vibrator, vibrotactile threshold may be as low as 25 dB
at 250 Hz, 55 dB at 500 Hz and 70 dB at 1000 Hz (Boothroyd and Cawkwell, 1970).
However, there is large inter-subject variation in vibrotactile thresholds. Care must be
taken not to misinterpret vibrotactile perceptions as hearing. Any threshold considered
to be vibrotactile shall be noted on the audiogram form.
7.7 Limitations of bone vibrators

Bone vibrators tend to emit levels of air-borne sound sufficient to influence b-c results
at frequencies above 2000 Hz (Lightfoot, 1979; Bell et al, 1980; Shipton et al, 1980).
When testing b-c thresholds at 3000 Hz and 4000 Hz, in order to prevent the subject
hearing any air-borne sound, an ear plug should be inserted into the test ear canal (e.g.
a foam plug as used for hearing protection purposes) or covering the test ear with a
supra-aural or circum-aural earphone. This attenuates the air-borne radiation from the
bone vibrator to a satisfactory degree. The tester shall record whether or not the test
ear was occluded. It is not necessary to occlude the non-test ear. Failure to occlude the
ear canal at high test frequencies is likely to lead to artificially acute b-c thresholds,
resulting in a false air-bone gap in the audiometric results. The canal must not be
occluded at test frequencies below 3000 Hz, as this may artificially improve b-c
thresholds due to the ’occlusion effect‘. The problem of air-borne sound might be
reduced using forehead placement as described in Section 7.1 above, provided that
calibration issues are accounted for (see Fagelson and Martin, 1994; Harkrider and
Martin, 1998; BS EN ISO 389-3).
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The standard bone vibrator used in audiometry (Radioear B71) has poor distortion
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performance at low frequencies (Lightfoot, 2000). Testing is not recommended at
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frequencies below 500 Hz because the subject’s threshold may relate to hearing at the
second or third harmonic rather than the fundamental. Bone-conduction tests at 6000
Hz and above are also problematic due to transducer limitations and should be avoided
(Lightfoot and Hughes, 1993). However, there may be exceptional circumstances when
tests at the lower and higher frequencies are required, depending on the investigation
performed. A check must be made that these frequencies have been included in
periodic objective calibration tests, and caution is advised in the interpretation of the
results.
Headband tension has an impact on the sound levels delivered. It is difficult to measure
the actual headband tension in situ, but testers need to be aware of this source of error
(e.g. with a small head) and record any suspected errors from this source.
8. Cross-hearing and masking

8.1 Cross-hearing and its prevention by masking
Although earphones allow sound to be presented to one ear at a time, it is not always
certain that the intended (test) ear is the one actually detecting the sound. When the
hearing acuity of the ears is very different it is possible that, when testing the worse ear,
the better (non-test) ear detects the test signals more easily despite the fact that the
signals reaching it are attenuated.
This interaural attenuation, also referred to as transcranial transmission loss, varies

considerably from person to person. It is also earphone dependent. It varies between
40-80 dB when using supra-aural or circum-aural earphones. When using insert
earphones, the transcranial transmission loss is higher, with a minimum transcranial
transmission loss of 55 dB if the earphones are inserted correctly (Munro and Agnew,
1999). The situation with b-c is very much worse, and there can be little or no
transcranial transmission loss.
When the difference in the thresholds of the two ears is greater than the transcranial
transmission loss, cross-hearing may occur and the apparent threshold of the worse ear
is in fact a ‘shadow’ of the better ear.
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Reliance should not be placed on the subject to make an accurate report of the ear in
which the sounds were heard, since many people are unable to make such judgements
easily and the sound may not be fully lateralised to one ear.
8.2 The principles of masking

The problems of cross-hearing can usually be overcome by temporarily elevating the
hearing threshold of the non-test ear by a known amount so as to enable an accurate
assessment of the test ear threshold to be made. This may be achieved by presenting a
masking noise into the non-test ear at the appropriate intensity to prevent it from
detecting the test signals, and at the same time measuring the apparent threshold of
the test ear with the test signals. There is normally a 1:1 relationship between the
increase in masking noise and the elevation of the masked threshold of the non-test ear.
The term ‘not-masked’ is used to describe measurements made without masking, rather
than the term ‘unmasked’ which refers to different psychophysical phenomena.
8.3 Masking noise

Narrow-band masking noise of the type specified in BS EN ISO 389-4 should be used,
where the geometric centre frequency coincides with that of the test tone and the
bandwidth of the noise is between one-third and one-half of an octave.
8.4 Effective masking level

Masking noise should be calibrated in terms of effective masking level (EML) according
to BS EN ISO 389-4. In the presence of noise at a particular centre frequency and
effective masking level, the pure-tone threshold of hearing (dB HL) at that frequency will
be raised to that level. For example, a 1000 Hz noise at 50 dB EML presented to an ear
will normally raise its hearing threshold for a 1000 Hz pure-tone to 50 dB HL.
When masking noise is calibrated in terms of effective masking level it is not necessary
to measure the subject’s hearing threshold for the masking noise prior to testing with
masking (see Section 8.8).
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8.5 Measuring the threshold for masking noise (M) if required

When the noise is not calibrated in effective masking level, the threshold for masking
noise (M) shall be measured. This indicates the lowest level of a masking noise that can
be detected, measured in dB (relative to an arbitrary zero). The initial masking level
used shall be M+10 (see Section 8.8).
If possible the same method as used for pure-tone threshold determination should be
used to determine M. The procedure should be repeated for each narrow-band noise
corresponding to the frequencies of the pure-tones to be masked. Where it is not
possible to determine M using the usual threshold technique, perhaps because of
audiometer design, care should be taken to determine M as accurately as possible.
8.6 Indicators of cross-hearing and the rules for masking

The indicators (or ‘rules’) given below are to be considered independently at each
frequency. Note that words such as ‘better’ and ‘worse’ etc. describe hearing as
measured by air-conduction. The test ear is always the ear whose hearing threshold is
being sought; it is the ear being presented with the pure tone directly. The non-test ear
is the ear which may have to be masked to prevent detection of the pure-tone.
It is preferable to mask two or three frequencies properly, rather than incorrectly or

hurriedly masking more frequencies. It is not essential to mask in the order that the
rules are given below.
8.6.1 Rule 1
Masking is needed at any frequency where the difference between the left and right
not-masked a-c thresholds is 40 dB or more when using supra- or circum-aural
earphones or 55 dB or when using insert earphones.
8.6.2 Rule 2
Masking is needed at any frequency where the not-masked b-c threshold is more acute
than the air-conduction threshold of either ear by 10 dB or more. The worse ear (by air-
conduction) would then be the test ear and the better ear would be the non-test ear to
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be masked.
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Notes on Rule 2:
Although this rule may frequently indicate the need for masking, there will be occasions
where this is not warranted, depending on the purpose of the investigation. For
example it may not benefit patient management to mask more than two b-c frequencies
on one ear, or to mask small air-bone gaps.
If the b-c threshold with masking remains the same or only increases by 5 or 10 dB, it is
possible that the not-masked b-c result was from the ear with the worse a-c threshold,
and it may be necessary to test the better ear whilst applying masking to the worse ear.
8.6.3 Rule 3
Masking will be needed additionally where Rule 1 has not been applied, but where the
b-c threshold of one ear is more acute by 40 dB (if supra or circum-aural earphones have
been used) or 55 dB (if insert earphones have been used) or more than the not-masked
a-c threshold attributed to the other ear.
Notes on Rule 3:
Rule 3 is necessary because an a-c frequency that does not require masking under Rule
1, may need to be masked if the b-c results show that the non-test ear has a conductive
element. Note that it is the sensitivity of the non-test cochlea (as indicated by the b-c
threshold) that is the important factor in cross-hearing, and that Rule 1 is merely a
convenient way of anticipating the need to mask in many cases.
At frequencies where no b-c thresholds have been measured, doubt may exist regarding
the possible effect of Rule 3. If there is a possibility that a-c thresholds at these
frequencies (including 250 Hz and 8000 Hz) are not the true thresholds, they should be
masked or marked accordingly on the audiogram form.
8.7 Instructions for masking

Suitable instructions would be:
“In this next test, you will hear the sounds (tones) again, just as before. I would like you
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to press the button as soon as you hear the sound (tone) start and release it as soon as
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it disappears. Do this even for the very faint sounds (tones), and no matter which side
you seem to hear the sounds (tones).
For some of the time, you will also hear a steady rushing noise, but I want you to ignore
it and press the button only when you hear the sounds (tones). This steady rushing noise
will get louder at times.
I want you to tell me if any of the sounds become uncomfortably loud, or if you would
like me to explain the test again.”
The subject must not be told to expect to hear the pure-tone in the test ear. The very
fact that masking noise is required means that it is not known which ear is picking up the
signals.
8.8 Procedure for masking

This procedure is called the plateau-seeking method for masking. It is appropriate for
both air- and bone-conduction testing.
1. Re-establish threshold in the test ear without masking noise to remind the subject
what to listen for. This is always necessary for b-c because the occluded not-masked
hearing threshold level is required.
2. Introduce masking noise to the non-test ear. The initial level of masking noise should
be the effective masking level equal to the tonal hearing threshold level of that ear
at that frequency. Wait a few seconds for any erroneous response to occur (a
response at this stage may require brief re-instruction).
3. Re-measure the hearing threshold level in the test ear in the presence of masking
noise using the normal threshold technique as described in Sections 6.6 and 6.7.
Take this tone level as the pure-tone threshold at that level of masking.
4. Increase the level of masking noise by 10 dB. Re-measure the hearing threshold level
in the test ear. Take this tone level as the pure-tone threshold at that level of
masking.
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5. Continue repeating Step 4, using 10-dB increases in masking noise, until you have at
least four measurements, and until three successive measurements yield the same
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tonal threshold or until the level of the audiometer is reached or until the subject
finds the masking noise uncomfortable. (See also Sections 8.10 and 8.11)
6. When three successive levels of masking yield the same tonal threshold, or one
threshold no more than 5 dB different from the other two, this is the ‘plateau’ (see
Figures 1 and 2, and Section 8.10). The mode of the three hearing threshold levels at
plateau is taken as the correct hearing threshold of the test ear and no further
masking is required. Withdraw the masking noise and plot the hearing threshold
level on the audiogram.
The use of a masking chart to plot the relationship between the masking noise level and
pure-tone threshold can be helpful for interpreting difficult cases. Both axes of the
masking chart are marked in dB and the aspect ratio is 1:1. See Figure 1 for an example.
Notes on masking method:
It may be appropriate on occasions to use smaller step sizes when increasing the
masking noise, particularly where the plateau is not well defined (see also Sections
8.10.4).
Some testers use alternative techniques to determine the masked thresholds.

Techniques other than those described here are not recommended. Any deviation from
the methods described in this document shall be recorded in the subject’s records or on
the audiogram.
Masking noise above 80 dB EML or tones above 100 dB HL should only be used with
caution (see Step 5 above and Section 8.11).
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8.9 Masking during bone-conduction testing

An insert earphone should be used to deliver masking noise to the non-test ear for b-c
testing, for subject comfort and for the advantages of high transcranial transmission
loss. If the insert earphone is not of the type Etymotic ER3 or ER5 or has not been
calibrated to effective masking level, then it will be necessary to measure the threshold
of masking (M; Section 8.5). A supra-aural or circumaural earphone can be used if there
is no alternative.
Step1 of the masking function (which involves the re-determination of the not-masked
tonal threshold, but with the non-test ear occluded by an insert earphone, see Section
8.8) may lead to an improvement of the measured threshold. This is due to the
occlusion effect which is more pronounced at the lower frequencies. If an improvement
in threshold is noted, the original not-masked threshold value on the audiogram should
not be altered although the new value should be used on the masking chart.
8.10 Interpretation of the masking function

In the interpretation of the masking results, it is important to remember that all
threshold measurements are associated with a degree of uncertainty (at least  5 dB).
Consequently, the measured masking function may not exactly match the idealised
pattern and a ‘best fit’ approach should be adopted. The following sections provide
guidance on the interpretation of the idealised masking functions.
8.10.1 When cross-hearing is not present

This is when the original not-masked threshold measurement represents the true
threshold of the test ear, even though there was a risk of cross-hearing. It is most often
manifest by the measured tone thresholds at at least three masking levels being within
5 dB of the not-masked tonal threshold. An example is shown in Figure 1. 20
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Test details may be recorded as

follows:
Test frequency: 2000 Hz

Test ear: R / L
Test mode: a-c / b-c
Pure-tone threshold = 55 dB HL
Effective masking level (dB EML)
Figure 1 - Recommended design of masking chart and example of masking function

derived in a case where cross-hearing is not present. The horizontal arrow by the y axis
represents the not-masked hearing threshold level.
8.10.2 When cross-hearing is present

Cross-hearing occurs when the original not-masked threshold was a ‘shadow’ of the
non-test ear, with the test ear threshold being at a higher level. A typical masking
function is illustrated in Figure 2 and usually takes the form of a short (and sometimes
absent) initial horizontal line originating from the not-masked threshold (a), followed by
a sloping section (b), and then by a horizontal section, or plateau, (c).
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Test ear: R / L
Pure-tone threshold =35 dB HL
Figure 2 - Recommended design of masking chart and example of masking function

illustrating cross-hearing
In Figure 2:
(a) represents an initial condition where the masking noise though audible does not
have a masking effect. Low masking levels (up to 10 dB above the initial masking
level) are typical for this condition. Both tone and masking noise are heard in the
non-test ear.
(b) represents direct peripheral masking where the threshold of the non-test ear is
being raised by the presence of the noise but not enough to prevent it from
detecting tones more easily than the test ear. Again, both tone and masking noise
are heard in the non-test ear. Note that the slope of this part of the function is
always approximately 1 dB per dB (i.e. approximately 45 degrees assuming the
recommended chart with aspect ratio 1:1). In cases where this 1 dB per dB slope
continues to the audiometer’s tonal or masking maximum output limit, the true test
22
ear threshold has not been found and the appropriate audiometric symbol with a
downward pointing arrow should be drawn on the audiogram at the last employed
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(highest) pure-tone intensity (see Figure 6 below).
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(c) represents the true threshold of the test ear (35 dB HL in this example). At these
levels the masking noise has raised the threshold of the non-test ear to the extent
that the intensity of the test tone is sufficient to be just audible in this test ear. Note
that the function is horizontal at this point: the plateau. At the start of the plateau
the subject may hear the tones in the test ear for the first time or may hear the
tones centrally and will sometimes report this to the tester. At higher masking
intensities, the subject should hear the tone and masking noise in the ears to which
they are being presented. The maximum level of masking required to define the
plateau could be recorded for training or audit purposes (e.g. in Figure 2 this is 95 dB
EML).
8.10.3 Central masking

This refers to the inability of the brain to identify a tone in the presence of masking,
even when they are heard in opposite ears, hence masking is occurring centrally rather
than peripherally (in the cochlea). This effect is most commonly apparent at the higher
masking levels and may be evident as an upward slope of the masking function of
consistently less than 1 dB per dB (i.e. between 5 and 35 degrees) which may lead to an
inability to determine the plateau. See Figure 3.

Test ear: R / L
Pure-tone threshold =35 dB HL (approx.)

23
Figure 3 - Illustration of central masking

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Line (d) in Figure 3 is an example of central masking. If a 5-dB increase in threshold is

seen at the third point of an otherwise possible plateau, it is wise to go on to mask at
higher levels in order to evaluate the slope and so aid interpretation of the masking
function. In these cases a reasonable estimate of the true threshold can be made from
the masking chart because cross-hearing has been ruled out. In figure 3 the true
threshold of 35 db HL is approximated, and this should be clearly indicated on the
audiogram.
8.10.4 Cross-masking
Once masking levels corresponding to the beginning of the plateau of a particular
masking function have been reached, additional increases in masking level further raise
the threshold of the non-test ear. This may not be apparent initially, since the test ear
pure-tone threshold has been reached and may not be adversely affected by the noise
(apart from any central masking effects). However, if at some stage the masking level
becomes sufficiently high, it may be capable of providing a masking effect in the test ear
through transcranial transmission. This is known as cross-masking.
Since cross-masking is of peripheral origin, this will be evident as a second

approximately 1 dB per dB slope (approximately 45 degrees) on the masking function, as
illustrated by line (e) in Figure 4. Even though the masking noise is reaching the test ear,
the subject will hear only the tone in that ear since the noise will be much louder in the
non-test ear.
Here the plateau (c) is shorter than usual, only being defined by two points, but is still
sufficient to define the true threshold in this instance; this is not always the case, see
notes below on shortened plateau. The highest level of masking noise used to define the
plateau was 85 dB HL.
Cross-masking is primarily through bone-conduction (as with cross-hearing; see notes on

Rule 3 in Section 8.6.3) and the point at which the masking signal is detected by the test
ear will depend on the bone-conduction hearing of that side.
Cross-masking will be a particular problem when the test ear has a conductive loss (with
good bone-conduction) and the non-test ear has at least a moderate loss. In this
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situation high effective masking levels will be required in the non-test ear, which may
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Test ear: R / L
Pure-tone threshold =35 dB HL
Figure 4 - Illustration of cross-masking
In cases when the potential for cross-masking is apparent, increase the masking level in
5-dB steps, rather than 10-dB steps, as this might help to identify a shortened plateau.
It may be impossible to accurately mask a conductive hearing loss if the plateau is not
well defined. Where the masking test could not be performed accurately, or the results
are results are in doubt, this should be clearly indicated on the audiogram.
There is less risk of cross-masking with insert earphones.
8.11 Caution
Care needs to be taken when using high levels of masking, particularly when testing at
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several frequencies, as it can present a risk to the subject (see The Control of Noise at
Work Regulations, Health & Safety Executive, 2005).
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In subjects with tinnitus, extra care should be taken when using high levels of masking
noise, as this can exacerbate the tinnitus. In some cases, it may be appropriate not to
perform masking.
9. Audiometric descriptors
The hearing threshold levels of an individual ear are often described in general terms
rather than in terms of the actual numbers at different frequencies on a pure-tone
audiogram. Recommendations are made below to associate particular descriptors with
bands of average hearing impairment.
Four audiometric descriptors are given. These are based on the average of the pure-
tone hearing threshold levels at 250, 500, 1000, 2000 and 4000 Hz. Averages do not
imply any particular configuration of hearing loss and do not exclude additional terms
(e.g. profound high-frequency hearing loss) being used.
Descriptor Average hearing threshold levels (dB HL)
Mild hearing loss 20-40
Moderate hearing loss 41-70
Severe hearing loss 71-95
Profound hearing loss In excess of 95
For the purposes of this document, in determining the five-frequency average value of
hearing loss, if at any frequency no response is obtained due to the severity of the loss,
this reading shall be given a value of 130 dB HL. Any hearing threshold level lower
(better) than 0 dB HL shall be given the value 0 dB HL.
Anomalies may occur in calculating the average hearing loss if an audiometer with
insufficient output is used in the measurement of severe and profound hearing loss.
Note:
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While audiometric descriptors may provide a useful summary of an individual’s hearing

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support. The ability to detect pure tones using earphones in a quiet environment is not
in itself a reliable indicator of hearing disability and audiometric descriptors alone shall
not be used as the measure of difficulty experienced with communication in background
noise, the primary complaint of individuals with hearing loss.
10. Recommended format for audiogram forms

10.1 Audiogram form
Hearing threshold level can be plotted graphically on an audiogram form. The aspect
ratio should be fixed at 20 dB:1 octave in all cases to ease interpretation. The
recommended format is shown in Figure 5. Other audiogram forms are acceptable, as
long as the information shown in Figure 5 is recorded.
10.2 Symbols
Symbols are shown in Figure 5. Air-conduction symbols should be connected with
continuous straight lines; bone-conduction symbols should be joined with broken lines.
For not-masked bone-conduction, the mastoid on which the bone vibrator was placed
can affect the results. For this reason, the mastoid on which the bone vibrator was
placed shall be noted.
If no response occurs at the maximum output level of the audiometer, a downward

arrow should be drawn, attached to the corner of the appropriate symbol, see Figure 6.
These symbols should not be connected with the line to symbols representing measured
thresholds.
Note:
Some of the symbols used in audiological software packages may differ from those
recommended here. This is acceptable as long as the results are clear and unambiguous.
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Pure-tone audiogram
Name: Date:
Date of birth: Case No:
RIGHT LEFT
Audiometer type & serial number:______________________________________
Earphone type:____________________________________________________
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Date of last objective calibration:______________________________________

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Tester:_______________________________Signature:___________________
Comments:_______________________________________________________
Figure 5 - Recommended format for audiogram form
10.3 Working audiograms

Working audiograms may be useful for some purposes, especially training, and they may
use shaded symbols for air conduction to indicate possible shadow points, which have
not been masked. Open symbols should be used to indicate the true hearing threshold,
which have been masked if necessary. Figure 6 is an example of a working audiogram.
The application of masking in the testing of the right a-c thresholds revealed shadows at
250 Hz and 500 Hz but not at 1000 Hz and 2000 Hz. (These latter two symbols could
have been half-filled in, indicating that masking had been performed, for training or
audit purposes.) The right ear threshold at 8000 Hz is greater than 120 dB HL, as
indicated by the arrow, and it should not be connected by line to the other results for
the right ear.
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Figure 6 - Illustration of a working audiogram.

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10.4 Masking levels

Less experienced testers and students might find it useful to retain any masking charts,
or record the masking levels used, for training or audit purposes.
10.5 Notes
If the tester has any doubts about the accuracy of any results, including any thresholds
where cross-hearing was indicated but masking not completed, these shall be noted.
The tester’s name, signature and date of test should be noted on the audiogram form.
For electronic copies of the audiogram, the tester’s name without signature is
acceptable. A note should also be made of the audiometer used, including the type of
earphones, and the date of the last objective calibration.
When a computerised audiometer is used, care must be taken to ensure all results are
recorded and stored correctly. In particular, some systems automatically delete not-
masked thresholds when masked thresholds are recorded, even though with bone-
conduction tests the initial not-masked result may correctly refer to the contralateral
ear. Testers should ensure all potentially useful data are retained.
11. Calibration
11.1 Stage A: routine checking and subjective tests
In order to check the audiometer is functioning across the range, checks shall be carried
out by someone with sufficiently good hearing to detect any faults such as described
below. They should be carried out in the normal test room, with the equipment set up
as installed. These checks should be logged. Where apparent faults are noted,
equipment shall not be used until correct performance has been confirmed.
Tests 1 to 8 should be carried out daily.
7. Clean and examine the audiometer and all accessories. Check earphone cushions,
plugs, main leads and accessory leads for signs of wear or damage. Any badly worn
30
or damaged parts should be replaced. If any transducers are replaced, then the
audiometer must undergo a Stage B check.
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8. Switch on equipment and leave for the recommended warm-up time. (If no warm-up
period is quoted by the manufacturer, allow 5 minutes for circuits to stabilise.) Carry
out any setting-up adjustments as specified by the manufacturer. On battery-
powered equipment, check battery state using the specified method. Check that
earphone and bone vibrator serial numbers tally with those on the instrument’s
calibration certificate. An instrument’s transducers shall not be changed unless a full
Stage B calibration is undertaken.
9. Check that the audiometer output is approximately correct on both a-c and b-c by
sweeping through at a hearing level of just audible tones (e.g. 10 dB HL or 15 dB HL).
This test should be performed at all appropriate frequencies and for both earphones
and the bone vibrator.
10. Check that the masking noise is approximately correct at all frequencies through
both earphones, at a level of 60 dB HL.
11. Perform a high-level listening check on a-c and b-c at all frequencies used, on all
appropriate functions and on both earphones (e.g. 60 dB HL for a-c, 40 dB HL for b-
c). Listen for proper functioning, absence of distortion, freedom from clicks when
presenting the tone etc.
12. Check all earphones and the bone vibrator for absence of distortion and
intermittency; check plugs and leads for intermittency.
13. Check that all the switches are secure and that lights and indicators work correctly.
14. Check that the subject response button works correctly.
Tests 9 to 12 should be carried out weekly.
15. Listen at low levels for any sign of noise or hum, for unwanted sounds or for any
change in tone quality as masking is introduced. Check that attenuators do
attenuate the signals over their full range and that attenuators which are intended
to be operated while a tone is being delivered are free from electrical or mechanical
noise. Check that interrupter keys operate silently and that no noise radiated from
the instrument is audible at the subject’s position.
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16. Check subject communication speech circuits.

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17. Check tension of headset headband and bone vibrator headband. Ensure that swivel
joints are free to return without being excessively slack. Check headbands and swivel
joints for signs of wear strain or metal fatigue.
18. Perform an audiogram on a known subject, and check for significant deviation from
previous audiograms (e.g. 10 dB or greater).
11.2 Stage B: periodic objective tests

Stage B checks are objective tests which ideally should be performed every 3 months,
although this period can be extended provided the Stage A checks are regularly and
carefully applied and it can be shown that the equipment is stable and reliable. The
maximum interval between checks should not exceed 12 months. They should
preferably be carried out in the normal test room, with the equipment set up as
installed, particularly if inter-connecting leads are used through a booth wall.
Measure and compare with the appropriate standards:
19. Frequencies of test signals

20. Sound pressure levels in an acoustic coupler or artificial ear from earphones
21. Vibratory force levels on a mechanical coupler from bone vibrators
22. Levels of masking noise
23. Attenuator steps over a significant part of the range
24. Harmonic distortion
11.3 Stage C: basic calibration tests

Stage C checks need not be employed on a routine basis if Stage A and B checks are
regularly performed. They will only be required when a serious error or fault occurs, or
when, after a long period of time, it is suspected that the equipment may no longer be
performing fully to specifications. It may be advisable to submit equipment for a Stage C
check after, for example, five years’ use if it has not received such a test in that time in
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the course of repair.

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Stage C checks should be such that after the audiometric equipment has been submitted
for a basic calibration, it shall meet the relevant requirements given in BS EN 60645-1. A
suggested minimum requirement for a Stage C check would include all items covered at
Stage B plus:
25. Rise and fall times of test tones

26. Interrupter effectiveness
27. Cross-talk between transducers and channels
28. Masking noise spectra
29. Distortion of speech and other external input systems
Note:
If insert earphones are used, separate measurements at all three stages must be made
for them. On some equipment it is possible to store two sets of calibration values,
however for others it may be necessary to use correction factors for the second set of
earphones.
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12. References
British Society of Audiology Procedure for Processing Documents. British Society of
Audiology. www.thebsa.org.uk
British Society of Audiology (2004). Pure tone air and bone conduction threshold
audiometry with and without masking and determination of uncomfortable loudness
levels. British Society of Audiology.
British Society of Audiology Recommended Procedure: Ear Examination. British Society

of Audiology. www.thebsa.org.uk
British Society of Audiology. Recommended Procedure: Determination of uncomfortable

loudness levels. British Society of Audiology www.thebsa.org.uk .
Bell I, Goodsell S, Thornton ARD (1980) A brief communication on bone conduction

artefacts. Br J Audiol 14: 73-75.
Boothroyd A, Cawkwell S. (1970) Vibrotactile thresholds in pure tone audiometry. Acta

Otolaryngol 69: 381-387.
Cooper J, Lightfoot G (2000) A modified pure tone audiometry technique for medico-
legal assessment. Br J Audiol 34: 37-45
Fagelson M, Martin FN (1994) Sound pressure in the external auditory canal during
bone-conduction testing. J Am Acad Audiol 5: 379-383
Harkrider AW, Martin FN (1998) Quantifying air-conducted acoustic radiation from the
bone-conduction vibrator. J Am Acad Audiol; 9: 410-416
The Health & Safety Executive (2005) Controlling Noise at Work. The Control of Noise at
Work Regulations 2005. Guidance on Regulations. Crown.
Lightfoot GR (1979) Air-borne radiation from bone conduction transducers. Br J Audiol

1979; 13: 53-56.
Lightfoot GR, Hughes JB (1993) Bone conduction errors at high frequencies: implications
34
for clinical and medico-legal practice. J Laryngol Otol 107: 305-308.

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Lightfoot GR (2000) Audiometer calibration:interpreting and applying the standards. Br J

Audiol 34: 311-316
Munro KJ, Agnew N (1999) A comparison of inter-aural attenuation with the Etymotic
ER-3A insert earphone and the Telephonics TDH-39 supra-aural earphone. Br J Audiol
33: 259-262.
Shipton MS, John AJ, Robinson DW (1980) Air-radiated sound from bone vibration
transducers and its implications for bone conduction audiometry. Br J Audiol 14: 86-99.
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Appendix A. Authors and acknowledgments

This revision was conducted by the BSA Professional Practice Committee between
September 2008 and September 2011 in accordance with the BSA Procedure for
Processing Documents. The Committee thanks all involved with previous versions of this
document and all who contributed to this review including those who contributed
during two consultations (Spring 2009 and 25th October 2010 to 13th December 2010).
An electronic copy of the anonymised comments (from 19 individuals) received during
the most recent consultation, and the responses to these by the authors, is available
from BSA on request.
Appendix B. Standards relevant to audiometry

BS EN ISO 389-1: Acoustics. Reference Zero for the Calibration of Audiometric
Equipment. Part 1: Reference Equivalent Threshold Sound Pressure Levels for Pure
Tones and Supra-aural Earphones. (Identical to ISO 389-1)

Tones and Insert Earphones. (Identical to ISO 389-2)

Tones and Bone Vibrators. (Identical to ISO 389-3)

Equipment. Part 4: Reference Levels for Narrow-band Masking Noise. (Identical to ISO
389-4)

Tones and Circumaural Earphones. (Identical to ISO 389-8)
BS EN ISO 7029:2000. Acoustics. Statistical Distribution of Hearing Thresholds as a

Function of Age. (Identical to ISO 7029:2000.)
36
BS EN ISO 8253-1: Acoustics. Audiometric Test Methods. Part 1: Basic Pure Tone Air and
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Bone Conduction Threshold Audiometry. (Identical to ISO 8253-1)
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BS EN 60645-1: Electroacoustics. Audiological Equipment. Part 1: pure-tone

audiometers. (Identical to IEC 60645-1)
Further information relevant to audiometric standards can be found on the National

Physical Laboratory website: www.npl.co.uk.
Appendix C. Permitted ambient noise levels for audiometry

To enable the accurate testing of normal air- and bone-conduction hearing threshold
levels down to 0 dB HL, ambient sound pressure levels should not exceed any of the
levels shown in Tables 1 and 2 respectively (from BS EN ISO 8253-1). To measure
minimum hearing threshold down to levels other than 0 dB HL, calculate the maximum
permissible ambient sound pressure levels by adding the minimum hearing threshold
level required to the values in Tables 1 and 2. For example, to measure down to 10 dB
HL, add 10 dB to all the values in the table.
Table 1
Maximum permissible ambient sound pressure levels for measuring air-conduction audiometry
(supra-aural earphones) to a minimum hearing level of 0 dB HL between frequencies 250 Hz and 8000
Hz.
Mid-frequency dB Mid-frequency dB Mid-frequency dB
of one-third re 20 μPa of one-third re 20 μPa of one-third re 20 μPa
octave band octave band octave band
(Hz) (Hz) (Hz)
31.5 66 250 19 2000 30
40 62 315 18 2500 32
50 57 400 18 3150 34
63 52 500 18 4000 36
80 48 630 18 5000 35
37
100 43 800 20 6300 34

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125 39 1000 23 8000 33

160 30 1250 25
200 20 1600 27
Notes on ambient noise:
Insert earphones (e.g. Etymotic Research ER3 and ER5) and noise-excluding earphones
(e.g. Audiocups) will not require such stringent ambient noise levels as they reduce the
amount of ambient noise reaching the ears, if they are fitted correctly. However, full
details of the frequency-specific attenuation characteristics of these devices needs to be
considered, together with full details of the ambient noise, before tests can be carried
out in environments that exceed the noise levels listed above.
Table 2
Maximum permissible ambient sound pressure levels for measuring bone-conduction audiometry to
a minimum hearing level of 0 dB HL between frequencies 250 Hz and 8000 Hz.
Mid-frequency dB Mid-frequency dB Mid-frequency dB
of one-third re 20 μPa of one-third re 20 μPa of one-third re 20 μPa
octave band octave band octave band
(Hz) (Hz) (Hz)
31.5 63 250 13 2000 8
40 56 315 11 2500 6
50 49 400 9 3150 4
63 44 500 8 4000 2
80 39 630 8 5000 4
100 35 800 7 6300 9
125 28 1000 7 8000 15
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160 21 1250 7
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200 15 1600 8
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Recommended Procedure

Pure-tone air-conduction and bone-

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British Society of Audiology

Published by the British Society of Audiology

© British Society of Audiology, 2011

8.6.3 Rule 3………………………..…………………………………………….. 17

8.7 Instructions for masking………………………………….……………………. 17

8.8 Procedure for masking…………………………………………….…………… 18

duration tone bursts, self-recording audiometry or sound-field audiometry.

4. Equipment and test environment

4.2 Audiometric test environment

5. Preparation for testing

Audiometry shall be preceded by otoscopic examination (see Recommended Procedure:

5.2 Test time

6. Air-conduction audiometry without masking

6.2 Subject’s response

audiometry. Circum-aural earphones (Sennheiser HDA200) surround and cover the

6.4 Test order

6.5 Timing of the test stimuli

6.6 Initial familiarisation

6.7 Method for finding threshold

trials with a minimum of two responses required at that level.

6.8 Variations in method

If the subject is unable to perform an accurate test at some frequencies due to an

7. Bone-conduction audiometry without masking

7.1 Bone vibrator

7.2 Test frequencies and test order

7.3 Test stimuli

7.5 Methods for finding threshold

Determine hearing threshold levels as described in Section 6.7.

7.6 Vibrotactile threshold

7.7 Limitations of bone vibrators

performance at low frequencies (Lightfoot, 2000). Testing is not recommended at

8. Cross-hearing and masking

This interaural attenuation, also referred to as transcranial transmission loss, varies

8.2 The principles of masking

8.3 Masking noise

8.4 Effective masking level

8.5 Measuring the threshold for masking noise (M) if required

8.6 Indicators of cross-hearing and the rules for masking

It is preferable to mask two or three frequencies properly, rather than incorrectly or

8.7 Instructions for masking

8.8 Procedure for masking

Notes on masking method:

Some testers use alternative techniques to determine the masked thresholds.

8.9 Masking during bone-conduction testing

8.10 Interpretation of the masking function

8.10.1 When cross-hearing is not present

Test details may be recorded as

Test frequency: 2000 Hz

Effective masking level (dB EML)

Figure 1 - Recommended design of masking chart and example of masking function

8.10.2 When cross-hearing is present

Test frequency: 500 Hz

Pure-tone threshold =35 dB HL

Effective masking level (dB EML)

Figure 2 - Recommended design of masking chart and example of masking function

(highest) pure-tone intensity (see Figure 6 below).

8.10.3 Central masking