Lesson 17 Masking for Air Conduction Lesson 17 Masking for Air Conduction Proficiency in performing audiometric testing is a core competency of the profession, and mask- ing isan integral component of threshold determination. Lessons 15 Pure Tone Air Conduction Audiometry and 16 Pure Tone Bone Conduction Audiometry provided the knowledge about threshold determination which has been applied during practicum experiences, This lesson com pletes the study of ai conduction measurement of hearing levels, Required Reading ‘Textbook: Chapter 6 ~ Pure Tone Audiometry. Learning Objectives Asa result of mastering this lesson, the apprentice is expected to: 1. Discuss the principles of masking, including interaural attenuation and crossover; 2. Demonstrate the application of appropriate masking techniques; and 3. Accurately determine and document masked AC thresholds for each car Although the term “masking” may be new to you, its effects occur daily. For example, you are watching TV and someone turns the dishwasher on, ‘The TV is not loud enough for you to hear and understand over the noise of the dishwasher. The dishwasher (the masket) masks out the TV (the signal). Masking s applied in audiometry o eliminate the participation of che non-testear while measuring some aspect of auditory function in the test ear. As will be clear by the end of this lesson, the terms “test eat” (TE) and “non-test ear” (NTE) are frequently mentioned when masking is discussed, so these concepts are important to understand. Further, masking is needed for air conduction when 4 hearing asymmerry is apparent. This asymmetry can be evident by comparing the right and left AC thresholds or when comparing the AC thresholds of one ear to the BC thresholds of the other cat. To determine if masking is needed for BC testing, the relationship between the same ear’ AC. and BC thresholds must be considered. Therefore, examining these threshold relationships quickly and accurately is essential for the valid and reliable measurement of auditory function. Interaural Attenuation and Crossover Interaural attenuation (IA) is a very important masking concept. Interaural refers to “between cars” Attenuation isa decrease in signal intensity. IA refers to the decrease in signal intensity as the sound travels intracranially from one cochlea to the other. IA occurs through bone conduction, The concept is applied to determine when masking is necessary. The discussion of interaural attenuation is critical ro understanding why masking may be needed when measuring auditory function. Consider the scenario in which a patcntclient has pure tone AC thresholds that are symmetrical or not excessively asymmetrical. Ifa signal is presented to one car at a high intensity, the patientclient perceives i to be heard in that ear only. This is monaural stimulation,N Lesson 17 Masking for Air Conduction ! nr OS’ 86 If che signal is made sufficiently intense in the monaural condition that the opposite cochlea is stimulated intracranially through bone conduction, then that inner ear may also respond to the signal presented to the opposite side but ata significantly lower intensity. This lower intensity is determined by the amount of IA. However, given the above scenario (symmetrical hearing bue monaural stimulation), the listener typically cannot even detect that both cochleas are being stimu- lated and hears the tone only in the ear that is stimulated or in the ear where the signal is louder. Certainly, both cochleas are stimulated but the listener's perception remains monaural as a result of the difference in intensity of the signal that is stimulating both inner ears. Contrast the above to the situation in which the patient’/client’s AC thresholds are 40 4B or more asymmetrical. When a tone is delivered to the poorer ear at a high enough intensity level, intra- cranial stimulation of the opposite cochlea can result. In this case, it is uncertain which ear was responsible for the patient's/client’s positive response to signal presentation. Did the ear stimulated (TE) really hear the pure tone or did the patient/client respond because the opposite ear (NTE) was stimulated instead? The correct application of masking eliminates the uncertainty regarding which ear heard the tone and threshold can be measured with confidence. ‘The amount of IA varies with frequency, transducer, and personal attributes such as skull density and/or fat deposits behind the ear. Clinically we need to be conservative so the lowest average val- ues for IA are used for audiometric testing. ‘The values directly relate to the rules for masking and are as follows: + AC supra-aural and circumautal headphones = 40 dB + AC insert earphones = 70 dB + BCoscillaror = 0 dB IA is the decrease in sound intensity when the sound travels through the skull. By contrast, cross- over isthe intensity of the sound that is heard by the opposite cochlea duting high intensity mon- aural stimulation of the other ear. The amount of crossover in dB equals the intensity ofthe sound delivered minus the IA. ag ACATATAAATATAATATAATATAADADADADATADADTADADsezuseses gs Figure 17-1. In this example, 2 1000 Hz tone is presented ‘The patienv/client indicates that they can hear the tone. Cot ac was presented to the left ear? Yes! Interaural attenuation iphones is 40 dB. ‘Therefore, the right cochlea might actually be responding to that signal being sated to the left eat Figure 1 to the left ear. Lesson 17 Masking for Air Conduction to the left ear via headphones at 65 dB HL. nuld the right ear be responding to the tone for air-conducted sound using circumaural 2. In this example, a 1000 Hz. tone is presented to the left ear via insert earphones at 80 ‘The patient/lient indicates that they can hear the tone, Could the right ear be responding to thar was presenced co the left ear? Yes! Interaural attenuation for air-conducted sound using hones is 70 dB. Therefore, the right cochlea might actualy be responding to that signal being 8788 Lesson 17 Masking for Air Conducti ‘A phenomenon related to interaural attenuation and crossover is the shadow curve. Iti the result of the better ear hearing the cone that was delivered ro the poorer eat. Figure 17-2 shows an au- diogram that reflects crossover to the right ear (non-test ear) with better hearing obtained while testing the left ear (test ear) with considerably more hearing loss. In other words, the thresholds measured for the left ear were actually the result of the non-test car (right ear) responding to the tones delivered to the test ear (left ear). Masking Noise ‘A pure tone presented to the test ear cannot be masked by simultaneously presenting the same frequency pure tone to the non-test ear. As you will learn, threshold is measured in the TE while a supra-threshold masker is introduced continuously to the NTE. The patient/client must be able to differentiate the pure tone from the masker at two very different sensation levels, and respond only to the pure tone for threshold determination. A masker with an acoustic spectrum very different yet related to the pure tone being tested is the perfect solution. Audiometers provide several kinds of masking noise. One type is called narrowband noise. Narrowband noise is used for pure-tone testing because it is easier for the listener to distinguish the tone in the TE from the broader band masking noise in the NTE. The center frequencies of the narrowband noises match the pure-tone frequencies tested audiometrically. In addition, the lower intensity sidebands of the masker give it a noisy quality Another masker used for audiometry is speech noise, Speech noise is effective for speech testing, but is not used for pure-tone testing. Speech noise is broadband noise that is filtered to most ef- ficiently mask the speech frequencies. The Rule for Masking for Air Conduction ‘Asa way of simplifying practice, the rule for each transducer is stated below. According to the masking rule for AC, it is necessary to perform both AC and BC testing without masking in order to determine whether it is needed. Lesson 16 Pure Tone Bone Conduction Audiometry introduced the fact that BC thresholds can be no worse than AC thresholds. Therefore, the masking rule for AC threshold measurement can be modified for practice as stared below: * Deliver narrowband noise masking to the non-test ear (NTE) when AC thresholds are 40 dB (supra-aural and circumaural earphones) of 70 dB (insert earphones) different between the ears at any frequency. AT | ATLCATCAAATAATALTATAUTATADADADUDATAUDAUTADAAT1 6 Masking Procedure for Pure Tone Air Conduction (Plateau Method) Use the procedure below for the measurement of masked AC thresholds: Determine the need for AC masking by applying the Rule for Masking at each frequency. Masking is @ tool that improves accuracy and validity of threshold measurements. Any threshold measurements obtained without masking when it is needed are inaccurate, in- valid, and unreliable, Any failure to follow testing protocols seriously impacts the hearing healthcare practitioner's professionalism and jeopardizes the quality and accuracy of hear- ing instrument fittings. If performed correctly, masking ensures that the ear being tested (TE) is the only car participating in or contributing to the threshold measurements. There are no shortcuts Testing mut be performed in each eat by both AC and BC in order to appropriately apply the following rule for AC masking: Calculate the initial amount of narrowband masking noise needed in the NTE: Add 10 dB to the unmasked AC threshold in the NTE at the frequency being measured. This 10 dB above threshold ensures that the masking noise is audible in the NTE. Confirm that the patient/client hears the masking noise in the NTE. Re-instruct the patient/client using the audiometer’s talk-over system: For example, “You will hear a static or windy noise in the right/left (whichever is being tested) ear; ignore it, even when it gets louder. Respond only when you hear a tone, no matter how soft itis and no matter which ear you think you hear the tone in. Do you have any questions?” Set the audi meter output as follows: a. Air Conduction to insert earphones (or supra-aural earphones if inserts are not available) b. Pure Tone to TE ©. Narrowband Masking Noise to NTE Deliver the initial masking level to the NTE (see formula above). Present the tone to the TE at the previously established threshold level. a. If there is a response, decrease the intensity of che tone by 10 dB and re-establish threshold using the ascending/descending method. ‘b. If there is no response, increase the intensity of the tone in 20 dB steps until the tone is heard. Re-establish threshold using the ascending/descending method. Increase masking noise by 5 dB in the NTE and re-establish threshold in the TE. Repeat chis process until masking has been increased three times and the threshold in the TE has Lesson 17 Masking for Air Conduction 8990 Lesson 17 Masking for Air Conduction TUT not changed. There is actually a 20 dB plateau from the initial threshold measured across to the threshold measured after the third 5 dB masking increase. The true masked AC threshold in the TE has been established at that frequency. 8. Record the masked AC threshold on the audiogram using the appropriate symbol and document the final or effective masking level used. 9, Repeat this procedure to measure the AC threshold for each ear at every frequency where masking is required. Review of Symbols Symbols used ro identify that masking was used in air conduction testing arc a triangle for the right car and a square for the left car. Review the audiogram key in Figure 17-3, Auiogram key Fight_Let Urmastes 1K] Masked -A,| nmsia Air conduction Bone conduction ‘mastoid Masked & Noresponse | AC! 4 [oe Habre Figure 17-3. Pure Tone Symbols Masking Definitions Plateau is the range of masking intensities over which the masked threshold does not shift. Effective masking isthe range of masking intensities required to establish the threshold plateau. In other words, effective masking is the amount of masking noise required to appropriately distract or “keep busy” the NTE to prevent it from detecting a crossed-over signal and falsely contributing to the responses of the TE. It can be seen from Figure 17-4 that 3 increases in masking intensity will define the plateau of effective masking. Undermasking occurs when the masking noise presented co the NTE is not intense enough to climinace crossover. When insufficient masking levels are used, false responses are obtained and the results are not valid. To eliminate undermasking, increase the narrowband masking levels in 5 dB steps until effective masking is established and the threshold plateau is identified. ‘Overmasking occurs when the masking noise presented to the NTE is so intense that it crosses over to the TE, causing a threshold elevation that does not represent the true threshold at that frequency: False and invalid thresholds are obtained when overmasking occurs. QALAAAVADTUAADATALADALATADUADUDAUUADAUDADANALesson 17 Masking for Air Conduction re 17-4 illustrates che masking concepts covered in this lesson. Keep in mind that Figure 17-4 presents the idealized masking function. In practice, sufficient masking is often applied to the NTE initially, resulting in three masking increases without a change in measured threshold in the In other words, the practitioner is on the plateau from the start of the masking procedure. Or, » one of two masking increases are needed before the plateau is reached. When the hearing aid pecialise starts with the appropriate amount of masking in the initial step and follows the standard ocedure, overmasking is seldom a problem, Minimum Maximum ‘masking masking i — g ss s & gs Ngo level in NTE (28) Figure 17-4. Figure 17-4 illustrates undermasking as successive increases in masking intensity in the NTE that sult in equal increases in threshold in the TE. Once the plateau is reached, increases in masking nitensicy do not change chreshold in the TE. Overmasking is the result of increases in the masking noise in the NTE that cross over and increase threshold measurements in the TE. Note that from the change-over threshold to the threshold measured after the thitd masking in- ©. a 15 dB plateau is defined. A 15 to 20 dB plateau defines effective masking and the hearing < specialist can be certain that the hearing sensitivity in the TE was accurately measured. » summary, undermasking results in false, better hearing thresholds. Overmasking results in false, worse hearing thresholds. Effective masking results in accurate and valid thresholds. Refer to the instruction sheet that accompanies this workbook for the 6 correct URL to take the online test for this lesson.Lesson 18 Masking for Bone Conduction Lesson 18 Masking for Bone Conduction Mascery of masking continues with this lesson on its application to BC threshold measurement, Required Reading Textbook: Chapter 6 — Pure Tone Audiometry Learning Objectives Asa resule of mastering this lesson, the apprentice is expected to accurately determine and document masked BC thresholds for each ear. As presented in Lesson 17 Masking for Air Conduction, the amount of interaural attenuation LA) varies with frequency, transducer, and personal attributes regarding the patient’/client’s skull J was also mentioned that IA for BC is 0 dB. This is a very important consideration for accurate and reliable BC threshold measurement since it may make masking for BC thresholds a more com- mon procedure than for AC threshold testing. When the BC oscillator is placed on the right mastoid process, don't assume that the results reflect ar (TE) auditory function. Since IA by BC is 0 dB the only assumption that is valid is that patient’/elient’s responses reflect the hearing in the better cochlea. This may, in fact, be the correct ear, but this is not a certainty; it may be the left ear (NTE) responding. Only by using the proper masking procedure will che condition of the test ear be determined wich certainty. other words, mask the NTE when an air-bone gap is present at any frequency. Apply this rule co the unmasked thresholds measured at every frequency. 93Lesson 18 Masking for Bone Conduction iW Iyywe Here are some examples. Figure 18-1 shows hearing loss with interweaving or equivalent AC and BC thresholds, Both co- chileas have equal auditory Function; one is nor better than the other. 100) ir) 129] (acing, 8c abe) Figure 18-1. Figure 18-2 shows unmasked left ear BC thresholds to be much better than the AC thresholds for both ears. Can you be certain that the measured left ear BC thresholds reflect responses from the left cochlea? All you know is that the better cochlea responded, although both may have equal function. It remains unknown given the information provided. Also, it cannot be assumed that the better cochlea is the better ear by air conduction. Remember that just because you placed the oscillator on the left mastoid, it does not mean that you tested the left inner ear. Whichever cochlea was better at that frequency responded. In this situation masking will be required to obtain true bone conduction thresholds. 94 win CLALATALUULADUAAAINAUTDANAATUDUAAAUTA AeLesson 18 Masking for Bone Conduction Figure 18-2. acement of che bone conduction oscillator anywhere on the skull may excite both cochleas cause the IA for BC is 0 dB. The signal may stimulate both cochleas but itis unknown which car is responsible for the positive response. Therefore, masking is necessary to obtain an accurate AC threshold in the TE. The masking noise keeps the NTE “busy” in order to accurately measure hold of the TE. jon effect (OE) is a critical concept that must be applied in BC testing when masking is sary It is the enhancement in the loudness of bone-conducted signals due to the occlusion of -.cernal ear canal by the earphone which delivers the masking stimulus. This is primarily a low cy phenomenon. The OE must be considered to compensate for its impact on threshold cerement. The chart below indicates the amount of OE to include when determining the ini- al masking levels with BC testing, Occlusion Effect in dB Frequency (H2) 250 500 2000 (Occlusion Effect (4B) 15 6 10 ° o OE faciors are only applied in BC threshold measurements with masking. They are never -d in AC threshold determination since both ears are occluded by the inserts or headphones.I f Lesson 18 Masking for Bone Conduction Ir 96 ATT Masking Procedure for Pure Tone Bone Conduction (Plateau Method) 1. 10. Determine the need for BC masking by applying the Rule for Masking at cach frequency. Arrange the transducers: With eyeglasses removed, place the BC oxillator on the mastoid of the TE, making certain ic does not come in contact with che pinna. Place the insert earphone only in the NTE. (If there is a need to use conventional earphones, place one earphone on the NTE and place the other earphone above the TE or on the patient’s/ clients cheekbone while adjusting che headband as necessary.) With either transducer, do not occlude or cover up the TE. Always keep the TE unoccluded when measuring BC thresholds. Covering both ears leads to inaccurate thresholds. Calculate the initial amount of narrowband masking noise needed in the NTE: Add 10 dB to the unmasked AC threshold in the NTE at the frequency being measured. Next add the amount of masking needed to compensate for the occlusion effect. Confirm that the patient/client hears the masking noise in the NTE. Re-instruct the patient/client using the audiometer’s talk-over system: For example, “You will hear a static or wind-like noise in the rightilefe (whichever is being tested) eat; ignore it, even when it gets louder. Respond only when you hear a tone, no matter h and no matter which ear you think you hear the tone in. Do you have any questions?” v soft it is Sec the audiometer output as follows: a. Test Ear (TE): Pure tone to BC oscillator b. Non-test Ear (NTE): Masking to AC NTE insert earphone (or supra-aural earphone if inserts are not available) Deliver the initial masking level to the NTE (see formula in step 3). Present the BC tone to the TE at the previously established threshold level. a. If there is a response, decrease the intensity of the tone by 10 dB and re-establish threshold using the ascending/descending method. b, IF there is no response, increase the intensity of the tone in 20 dB steps until the tone is heard, Re-establish threshold using the ascending/descending method. Increase masking noise by 5 dB in the NTE and re-establish threshold in the TE. Repeat this process until masking has been increased three times (this isthe 20 dB plateau) and the threshold in the'TE has not changed. The true threshold in the TE has been established. Record the masked BC threshold on the audiogram using the appropriate symbol and document the final or effective masking level used. Repeat this procedure to measure the masked BC threshold for each car at every frequency where masking is required. ATAATADATATAATATATCAATATATATADATAAAUUAUATATGATLesson 18 Masking for Bone Conduction Air Conduction Example in Fi 18-3 notice the left ear unmasked air conduction threshold at 500 Hz is 40 dB HL and ear bone conduction threshold is 0 dB HL. There is a 40 dB difference between the air conduction threshold of the rest ear (left car) and the bone conduction threshold of the non-test car). This meets the requirement for masking for air conduction threshold determina Son, Figure 18-4 illustrates patient/client responses for threshold determination using masking, Hus 250 sk a Figure 18-3. Unmasked Thresholds 28 "9 ~ Masked Thresholds, Left EarLesson 18 Masking for Bone Conduction | Masking Worksheet (500 Hz) | st (5! ) | Masking for Air Conduction Masking for Bone Conduction Ga Masked Ear Masked Ear sre nage [itn nas g (Right) (Righe) © Presentation R Presentation | Presentation Re Presentation 4 Level mn. Level Level eee Level 4 20 dB NR 40 dB 35dB NR dB & 20 dB NR 60 B 35.4B NR 20 4B = 20 dB R 80dB 35 dB NR 40 dB S 20 dB R 70 dB 35 dB R 60 dB & 20 4B NR 60 €B 354B NR 50d e 20 dB R 65 dB 35 dB R 55.dB @ 20 dB NR 55 dB 35dB NR 45.dB @ 20dB NR 60 dB 35 dB NR 50 dB @ 204B R 65dB 35.dB R 55 4B # 20 dB NR 55.dB 35 dB NR 45 dB i 20 4B NR 60 dB 35dB NR 50 dB eS eS 20 dB R 65 dB 35dB R 55 dB ¢ | 25 dB R 65 dB 40 dB R 55.dB & < 30 dB R 65 dB 45 dB R < 5 5 dl 55.48 e a 35 dB R 65 dB 50 dB R 55 dB ee R = response e NR = no response Ee Bone Conduction Example = Notice on the audiograms (Figures 18-3 and 18-4) the left ear unmasked bone conduction thresh- “ old at 500 He is 0 dB HL and the masked air conduction threshold is 65 dB HL. An ait-bone gap e has been identified, so masking is needed in the right ear for left car bone conduction threshold de- @e termination, Follow the left ear responses and the right ear masking increments in the chart above. @e @ e Refer to the instruction sheet that accompanies this workbook for the @e correct URL to take the online test for this lesson. e e 98 e e @Lesson 21 Masking for Speech Audiometry Lesson 21 Masking for Speech Audiometry 1» Lessons 17 Masking for Air Conduction and 18 Masking for Bone Conduction, an integral component of audiometry. The foundational concepts of masking are ap- his lesson to speech audiometry. Required Reading extbook: Chapter 7 ~ Speech Audiometry Learning Objectives As a result of mastering this lesson, the apprentice is expected to: 1, Demonstrate the application of appropriate masking techniques for speech audiometry: and. 2. Accurately determine and document masked speech audiometric measurements for each ear. ch pure tone threshold testing, masking is used for speech audiometry to eliminate the NTE cicipating in the measurements being conducted on the TE. The masking noise used is ed speech noise. Iris a broadband noise that is filtered to mimic the spectrum of average speech. nakes it an effective and efficient sound to distract the NTE, Rules for Masking for Speech Audiometry < use of masking for speech audiometry assures that che TE is hearing words and there is no crossover to the NTE ear. The rules that specify when masking is needed for specch audiometry are rnilar to the rule for masking for air conduction. They ate as follows: Rule for SRT Deliver speech spectrum masking noise to the NTE when the difference between the unmasked measured SRT of the TE and the best BC threshold of the NTE at 500, 1000, 2000, or 4000 Fiz exceeds the amount of IA for the transducer. + IA for Supra-aural and Circumaural Earphones = 40 dB + IA for Insert Earphones = 60 dB (NOTE: Although the IA for pure tones is 70 dB for inserts, a value to 60 dB is used for speech stimuli.) Rule for WR Testing Deliver speech spectrum masking noise to the NTE when the difference between the presentation intensity of speech to the TE and the best BC threshold of the NTE at 500, 1000, 2000, or 4000 Hz exceeds the amount of IA for the transducer. + IA for Supra-aural and Circumaural Earphones = 40 dB © IA for Insert Earphones = 60 dB (NOTE: Although the IA for pure tones is 70 dB for inserts, a value to 60 4B is used for speech stimuli.) -tone air and bone conduction thresholds must be determined (with masking when «) in order thac the rules for masking for speech audiometry can be accurately applied. ML12 Lesson 21 Masking for Speech Au N metry SRT Masking Procedure ‘When masking is needed in the NTE for accurate SRT determination based on the measured pure tone bone conduction thresholds and the unmasked SRT, the initial level of masking to be intro- duced to the NTE is its SRT + 10 4B. 1. Set the audiometer as follows: Air conduction b. Output transducer (insert or conventional earphones) c. External or recorded source ~ Calibrate the spondee speech list and the recording's calibration tone. dd. Speech masking to the NTE set to SRT, + 10 dB the VU meter 2. Using the audiometer’s talk-over microphone at a comfortable listening level for the patienv/client, re-instruct as follows: “Now; you will hear words in your (cight/lef) ear (whichever is the TE). You will also hear a continuous noise in your other ear. Ignore the noise and repeat the words. The noise will get louder, but continue to repeat each word you hear, Ifyou are not certain of a word, take a guess. Do you have any questions?” 3. Deliver the specch-masking noise to the NTE at the initial level. Present a spondee in the ‘TE at the previously established SRT. a. If the patient/client correctly repeats the spondee, decrease the speech presentation level by 10 dB and re-establish SRT using the ascending/descending method, b,IFthere is no response, increase the presentation level in 20 dB steps until a spondee is repeated correctly: Then, re-establish SRT using the ascending/descending method. 4, Increase the speech-masking noise in the NTE by 5 dB and re-establish SRT in the TE. Repeat this process until the speech-masking noise has been increased three times (the 20 dB plateau) and the SRT in the TE has not changed. The true SRT in the TE has been established. 5. Record the masked SRT on the audiogram in dB HL. Also record the final or effective masking level used. 6. Repeat procedure in the other ear, if necessary. WR Masking Procedure Since WR testing is always performed at a suprathreshold level, the need for masking occurs more frequently than for SRT. Whenever masking is needed for SRT, it will also be needed for WR test- ing. If masking is not needed for SRT, the rule for WR masking must still be applied. ‘When masking is needed for accurate WR determination, based on the measured pure tone bone conduction thresholds and the presentation level ofthe target PB words, the initial level of masking to be introduced to che NTE is Presentation Level for PB Words,, minus 20 dB. If the patient! client reports the loudness of the masker to be uncomfortable, then decrease the masking intensity by 10 dB. AQLALLATULALALTATLALTALATAAAAUUDATAATUAAdannhLesson 21 Masking for Speech Audiometry Set the audiometer as follows: 2. Air conduction b. Ourpur transducer (insert or conventional earphones) | Csing the audiomerer’ talk-over microphone at comfortable listening level for the pa “ne/client, instruct as follows: “You will hear the recording of a man's voice in your right/ left ear (whichever is being tested). You will also hear a continuous noise in the other eat, {gnore the noise and repeat each word you heat. IF you are not sure, please make your best. ss. Do you have any questions?” * Set the attenuator at the patient¥/cliene’s MCL + 10 dB. (Refer to Lesson 20 Speech Audiometry for instructions on establishing MCL.) Present 25 PB words. Tally the correct responses. Any response other than the word pre« sented isan error and is marked wrong, for example, changing a singular toa plural or vice 5. Calculate the WRS. Each correct response is worth 4%, & Record the WRS on the audiogram along with the level of speech-masking noise used. Repeat procedure on the other car if necessary. Refer to the instruction sheet that accompanies this workbook for the correct URL to take the online test for this lesson. 11396 Note: A BC threshold may be slightly poorer than the AC threshold at the same frequency. Since hearing through the BC mechanism depends on the integrity of the cochlea, B thresholds at a given fie- quency for any reason related to auditory function. AC thresholds will be equal to > thresholds cannot be worse chan AC BC thresholds if there is no middle ear dysfunction present or AC can be worse than BC if the middle ear is involved. Therefore, if B AC, another factor must be ruled out. Inaccurate placement of the Bt the most common cause and occurs most often at 500 Hz. Reposition the trans- ducer and remeasure threshold. Other conditions that may affect BC threshold measurements include the thickness of the skull, damage to a pare of the skull thresholds are worse than © oscillator is that rescricts proper vibration, or excess fat covering the bones of the skull. Always record thresholds as measured — don't assume that they are identical to the AC thresholds Masking for Pure Tone Audiometry situation presents during audiometry which requires the tester to ensure that the car being tested is truly the ear responding to the test signals. A procedure called masking is used to eliminate any participation of the non-test TE) during. threshold determination in the test ear (TE). The concepts of interaural attenua- ry to measuring auditory tion and crossover are the reason masking may be neces function accurately. I Attenuation and Crossover ‘The phenomenon of interaural attenuation (IA) mak Ince masking necessary for some patients/clients. Interaural refers to “between ears.” Attenuation is defined as.a decrease in signal intensity. IA is the decrease in signal intensity as the sound travels intracranially through bone conduction from one cochlea to the other. ‘When a tone is delivered to the poorer ear ata high enough intensity, intracranial stimulation of the opposite cochlea can result. Therefore, it is uncertain which ear was responsible for the patient’/client’s positive response to signal presentation. Did the ear stimulated (TE) really hear the pure tone or did the patient/client respond because the opposite ear (NTE) was stimulated instead by the high inten- sity test signal? The correct application of masking eliminates the uncertainty re- garding which ear heard the signal and allows for accurate threshold measurement. ‘The amount of IA varies with frequency, transducer, and the patient’/elient’s per- sonal attributes such as skull density and/or fat deposits behind the ear. It is neces sary to be conservative, so the lowest average values for IA are used for audiomect testing. The IA values directly relate to the rules for masking and are as follows: + AC insert earphones = 70 dB * AC supra-aural headphones = 40 4B * BC oscillator = 0 dB Crosse when ¢ present below potent concep be usec Mask Maskir sound. audion preven When poor he test to) withouCrossover is the intensity of the sound that is heard in the NTE during high inten E. Iris not measured, but it mustbe understood sity monaural stimulation of the T when discussing the need for masking. Crossover is stated in dB and equals the presentation intensity minus A for the transducer delivering the signal. The table below demonstrates the relationship between IA for different transducers and the potential amount of crossover in dB. see, oe 2S ‘As demonstrated in the table, che intensity level that crosses over intracranialy, through BC from the TE to the NTE is easily calculated ated with the transducer and the ces signal intensity level delivered to the TE. This knowing the LA associ- concept is applied when examining an audiogram to determine if masking should bbe used. The term cross-hearing is also used in place of crossover. Masking Masking occurs when any sound or noise interferes with the audibility of another sound. In the home environment, the television, dishwasher, washing machin or air conditioner will mask conversations or other household sounds. During audiometry masking is introduced to isolate the NTE to hearing only noise, thus preventing its participation in measuring the pure rone threshold of the TE. When a patient/client has one ear with good hearing but the other ear d by the loud poor hearing, itis possible that the better ear (NTE) can be stimula test tones being delivered to the TE. The patient/client responds as instructed without mentioning that they heard all of the tones in the NTE. This situation and can produce a shadow can result in the recording of false thresholds in the T oT98. curve or shadow audiogram. A shadow curve is the audiometric contour of the better ear elevated by the amount of IA. A shadow curve and the actual hearing levels are presented in Figures 6-8 and 6-9. Figure 6-8, Shadow curve using supra-aural earphones Figure 6-9. Actual masked lefe thresholds of example given in Figure 6-8ring Audiometers provide narrow band noise (NBN) masking for pure tone testing. very narrow band- width. The center frequencies of the NBNs available in the audiometer have 1 It is generated by electronically filtering white noise to ha same frequencies as the audiometric pure tone test signals. A noisy masker is used for pure tone testing because the patient/client can easily distinguish the tone in the TE from the constant NBN in th sented through insert or supra-aural/circumaural earphones, that is by AC, even TE. The masking noise is always pre- ‘when masking is needed for BC threshold measurements. Masking is an audiometric procedure that improves accuracy and validicy of threshold measurements. Failure to follow established testing protocols jeopardizes the quality and accuracy of hearing instrument fittings and reflects on the hearing healthcare practitioner's professionalism. If performed correctly, masking ensures that the ear being tested (TE) is the only ear participating in or contributing to the threshold measurements Masking Rules for Air Conduction ‘The rules of masking were formulaced based on the IA values for the different a way of simplifying prac- transducers used for measuring auditory function. A tice, the rule for each transducer is stated below. + Rule for Supra-aural and Circumaural Earphones: Deliver NBN masking, to the non-test eat (NTE) when there is a 40 dB or greater difference berween the measured AC threshold of the TE and the measured BC threshold of the NTE. Apply this rule to every frequency tested. The application of the above rule is demonstrated in Figure 6-10. Deliver NBN masking to the NTE when there ince between the measured AC threshold of the + Rule for Insert Earphone is a 70 dB or gres "TE and the measured BC threshold of the NTE. Apply this rule to every fre- quency tested, The application of the above rule is demonstrated in Figure 6-11 99.* Accordi eee ety te recog» ing rule 100 followFigure 6-11, Example of masking needed using insert earphones According to the masking rule for AC, it is necessary to perform both AC and BC testing withour masking in order to determine whether it is needed. However, itis AC thresholds. Therefore, the mask- ¢ modified for practice as stated on the known that BC thresholds can be no worse ing rule for AC threshold measurement « following page when the air conduction thresholds of each ear have been measured: 9]+ Deliver NBN masking to the NTE when AC thresholds are 40 dB (supra- aural and circumaural earphones) or 70 dB (insert earphones) or greater between the ears at any frequency. The application of the above rule is demonstrated in Figures 6-12 and 6-13. Figure 6- g needed using simplified rule (supea-aural earphones) 2. Example of maski 102eee ter Figure 6-13. Example of masking needed using simplified rule (insert earphones) 103Masking Rules for Bone Conduction When the BC oscillator is placed on the right mastoid process, don't assume that ear auditory function, Since IA by BC is 0 dB the only valid the results reflect rigl assumption is that the patient/client’s responses reflect the hearing in the better cochlea. This may, in fact, be the TE, but this is not a certainty; the NTE may be responding. Only by using the proper masking procedure will the auditory acuity of the TE be determined with certainty The masking rule for accurate threshold measurement by BC is: + Deliver narrow band noise masking to the NTE when there is a 15 dB or greater difference between the measured AC and BC thresholds of the TE. In other words, mask the NTE when an ait-bone gap is present at any frequency Apply this rule to the unmasked thresholds measured at every frequency. An ex ample is given in Figure 6-14 104re Tone Audiometry = thac alid ay be 1B or eTE. Figure 6-14. Example of masking nceded for bone conduction 105106 The Plateau Method Unmasked AC thresholds for both ears must be obtained before the masking pro cedure can be applied. The masking signal is presented to the NTE always by AC and the stimulus is presented to the TE by AC or BC, whichever is being tested. Effective masking (EM) is defined as the final masking level in dB HL. following a series of 5 dB increases in masking intensity without a threshold shift in the TE. The EM level is recorded on the au highest masking level that has produc: jogram for each frequency masked as the 15 dB threshold plateau in the TE. Minimum Maximum masking masking Etectivo masking s es & 8 & Masking lvel In NTE (6 HL Figure 6-15. Plateau method of masking Effective masking is essential to accurate threshold measurement and is achieved through use of the plateau method. As demonstrated in Figure 6-15 the initial lev el of masking was applied and the TE pure tone threshold was measured to be 60 dB HL. Masking was then raised in the NTE by 5 dB, and the re-established TE pure tone threshold was 65 dB HL. The next 5 dB increase in masking level pro- duced a TE threshold of 70 dB HL. With the next three additional 5 dB increases in masking intensity, the TE threshold remained at 70 4B HL. This is the platcau that indicates the true threshold in the TE and effective masking in the NTE Tivo masking levels define the threshold plateau, The minimum effective mask- ing level is the lowest masking intensity delivered to the NTE thar marks the ue threshold, The maximum masking level is the masking, intensity that precedes overmasking. The plateau is defined by the minimum and first measurement of maximum effective masking levels Over The n old m Unde false Prope duris Place Use th 1D fc ‘There when IA for insert 2. ¢ Nving TE. the Overmasking can occur if the masking intensity continues to be raised and the measured TE threshold increases by the same amount as the masking step size The masking noise presented to the NTE becomes so intense that it crosses over thresh- intra-cranially and stimulates the TE. As a result, the increases in meas old mirror the amount of the masking increases. Undermasking occurs when the masking noise presented to the NTE is not in- tense enough to eliminate crossover. When insufficient masking levels are use false responses ate obtained and the results are not valid. Undermasking is ov come because the masking procedure dictates that NBN be increased until effec tive masking is established and the threshold plateau is identified. Proper use of the plateau procedure eliminates false positive responses which occur during undermasking and overmasking Plateau Method for Pure Tone AC Threshold Measurement Use the procedure below for the measurement of masked AC thresholds: 1, Determine the need for AC masking by applying the Rule for Masking at each frequency. ‘There are no shortcuts! Deliver narrow band noise masking to the NTE when there is a difference in threshold between the ears that exceeds the IA for that transducer (supra-aural earphones, circumaural earphones, or insert earphones). 2. Calculate the initial amount of narrow band masking noise needed in the NTE: Add 10 dB to the unmasked AC threshold in the NTE at the frequency being measured. This 10 dB above threshold ensures that the masking noise is audible in the NTE, Initial Amount of Masking in NTE = AC, + 10.4B Confirm thae the patient/client hears the masking noise in the NTE 3. Reinstruct the patient/client either face to face of using the audiometer’s talk over system: For example, “You will hear a static or windy noise in the (right or lei) eat. Ignore it even when it gets louder. Respond only when you hear a tone, no matter how soft ic is and no matter which ear you think you hear the tone in. Do you have any questions?” 4, Set the audiometer output as follows: a. ‘TE: Pure tone AC to insert earphone (or supra-aural earphones if inserts are not available). b. NTE: Narrow Band Masking Noise co insert earphone (or supra-aural earphones if inserts are not available). Deliver the initial masking level to the NTE (see formula in Step 2 above). 107108. 6 Present the tone to the TE at the previously established threshold level a, IF there is a response, decrease the intensity of the tone by 10 dB and re- establish threshold using the ascending/descending method. b. IF there is no response, increase the intensity of the tone in 20 dB steps shold using the ascending/de- until the tone is heard. Re-establish hod. scending m Increase masking noise by 5 dB in the NTE and re-establish threshold in the TE. Repeat this process until masking has been increased three times and the threshold in the TE has not changed. This procedure establishes a 15 dB pla- ‘eau from the initial TE threshold measured to the threshold measured after the third 5 dB NTE masking increase. The true masked AC threshold in thi TE has been established at that frequency. 8. Record the masked AC threshold on the audiogram using the appropriate symbol and document the final or effective masking level used. 9. Repeat this procedure to measure the AC threshold for each ear at every fre- quency where masking is required. Undermasking and overmasking are not often experienced in the test situation. The initial level of masking and the following three 5 dB increases in masking intensity are often sufficient to achieve a 15 dB threshold plateau. The maximum effective masking level might not be reached, and this is fine. Figure 6-15 is an idealized figure and not always realized during testing. Undermasking and over: masking arc most likely to occur when the hearing levels are asymmetrical, when air-bone gaps are identified, ot when a bilateral conductive hearing loss is present, Plateau Method for Pure Tone BC Threshold Measurement The occlusion effect (OE) is an important factor that must be applied when mask- ing is indicated for the measurement of BC thresholds. OE is the increase in SPL of bone conducted signals due to the blocked opening of the external ear canal. It is an important consideration for bone conduction threshold measurements when masking is applied to the NTE since the NTE is occluded by the earphone deliv ering the masking stimulus. The OE is primarily a low frequency phenomenon. Masking for BC threshold measurements is delivered through an earphone. The carphone closes or occludes the NTE ear canal. As a result, a sound delivered via Be cluded ear irrespective of where the BC oscillator is placed (0 dB 1A). Failure to ill have an increased SPL in the ear canal and will sound louder in the oc- correct the initial masking intensity by the amount of the OE can result in signifi- cant undetmasking in many cases. The OE is also a consideration when fitting hearing instruments. The patient/cli wy report that speaking and chewing are very loud and annoying. When the external car canals are closed or occluded by a custom instrument, unvented dome,or earmold, the bone-conducted components of these self-generated activities re- verberate off the object, thereby increasing their SPL in the ear canal, This annoy- ing sound is delivered to the TM along with the amplified sound. When the eat canals are open, the BC vibrations caused by talking and chewing escape through the open ear canal and a When performing BC testing the OE must be considered t0 compensate for its impact on threshold measurement. The chart below indicates the amount of OE to include when determining the initial masking levels with BC testing Table 6-3. Occlusion Effect in dB Frequency (Hz) 250 500 1000-2000.» 4000 Occlusion Effect (4B) 15 5 10 0 0 ‘The OE factors are only applied in BC threshold measurements that require mask- ing. They are never applied in AC threshold determination since both ears are occluded by the inserts or headphones. 1. Determine the need for BC masking by applying the Rule for Masking at each frequency. 2. Arrange the transdi the mastoid of the pinna. Place the insert earphone only in the NTE. (If there is a need t0 use With eyeglasses removed, place the BC oscillator on making certain it does not come in contact with the conventional earphones, place one earphone on the NTE and place the other hheckbone while adjusting the headband as necessary.) With either transducer, do not occlude ot cover earphone above the TE or on the patient’/client’ up the TE. Always keep the TE unoccluded when measuring BC thresholds. Covering both ears leads to inaccurate thresholds. 3. Calculate the initial amount of narrow band masking noise neede NTE: Add 10 dB to the unmasked AC threshold in the NTE at the frequency being measured. Next add the amount of masking needed to compensate for the occlusion effect. Initial Amount of Masking in NTE = AC,.,, + 10. dB + OE Confirm that the patient/client hears the masking noise in the N1 4, Reinstruct the patienv/client: For example, “You will hear a static or windy noise in the (right of lei) eat. Ignore it even when it gets louder. Respond only when you heat a tone, no matter how soft it is and no matter which ear you think you hear the tone in, Do you have any questions?” 109no Set the audiometer output as follows: a, TE: Pure tone to BC oscillator. b, NTE: Masking to AC NTE insert are not available phone (or supra-aural earphone if 6. Deliver the initial masking level to the NTE (see formula in Step 3 on the previous page). Present the BC rone to the TE at the previously established threshold level a. If there isa response, decrease the intensity of the tone by 10 dB and re- establish threshold using the ascending/descending method. b. If there is no response, increase the intensity of che tone in 20 dB steps until the tone is heard. Re-establish threshold using the ascending/de- scending method. 8. Increase masking noise by 5 dB in the NTE and re-establish threshold in the TE. Repeat this process until masking has been increased three times (this is the 15 dB plateau) and the threshold in the TE has not changed. The true threshold in the TE has been established. 9. Record the masked BC threshold on the audiogram using the appropriate symbol and document the final or e used. tive masking lev 10, Repeat this procedure to measure the masked BC threshold for each ear at every frequency where masking is required. Plareau Size (Range of Effective Masking) The use of 5 dB masking increments and a 15 dB threshold plateau are sufficient for effective masking and accurate masked threshold measurement. There is a mi- nor alternative to this procedure that uses 10 dB masking increments. The plateau is defined by the initial level of masking and followed by two 10 dB incre: masking intensity. This procedural alternative produces a 20 dB threshold plateau. Either procedure ensures accuracy of masked threshold measurements. Masking Dilemma A bilateral conductive hearing loss can make adequate masking impossible in ci- ther ear for AC or BC threshold measurement. The masking intensities delivered to the NTE may be so intense and the true BC thresholds of the TE may be so good that even the initial masking intensity crosses over from the NTE to the TE and continuously elevates the measured threshold with every masking increase. In other words, masking cannot be accomplished without affecting the test ear. This dilemma occurs commonly with bilateral conductive disorders, but can be miti- gated through the use of insert earphones. An example is shown in Figure 6-16. DocIn his Figure 6-16. Masking dilemma Document on the audiogram that the “masking dilemma” was encountered when am that masking, masking was attempted. This will inform others reviewing the aud masking was applied but threshold systematically increased with evred using stematic ar audi using ever talk- patient! ords used srspond- ards. ight/left) vords will 4, Establish the SRT as follows a. Present one spondee at 30 to 40 dB above the PTA. Ifthere is no response increase the presentation level in 20 dB steps until a spondee is repeated correctly. b. Decrease presentation intensity in 10 dB steps while presenting one spondee at each intensity level until the response is incorrect or there is no response (descending technique). Increase spondee presentation intensity in 5 dB steps while presenting four spondees at each step until 50% are repeated correctly at the same intensity level (ascending technique). 5. Document the unmasked SRT on the audiogram in dB HL 6. Apply the masking rule for SRT measurement and retest, if necessary (see procedure below). 7. Repeat procedure on the other ear. Always remember: + ‘The SRT should be within 10 dB of the pure tone averzge unless the audio- gram exhibits an unusual configuration, such as precipitous or reves ¢ slope. + The SRT should never be used as the sole indicator for hearing instrument candidacy, Many individuals with significant high frequency hearing loss have SRTS within normal limits, yer have significant difficulty hearing and under- standing speech Masked SRT Procedure When masking is needed in the NTE for accurate SRT determination based on the measured pure tone bone conduction thresholds and the unmasked SRT, the initial level of masking to be introduced to the NTE is its SRT + 10 dB. 1. Set the audiometer for SRT testing with the addition of speech spectrum masking delivered to the NTE set to SRT(NTE) plus 10 dB. 2. Using the audiometer’s talk-over at a comfortable listening level for the pa- tient/client, reinstruct as follows: “Now, you will hear words in your (right/ lefi) ear (whichever is the TE). You will also hear a contnuous noise in your other ear. Ignore the noise and repeat the words. The noise will get louder, but continue to repeat each word you hear. Ifyou are not certain of a word, take a guess. Do you have any questions?” 3. Deliver the speech masking noise co the NTE at the initial level. Present a spondee in the TE at the previously established SRT. 123SEE a. If the patient/client correctly repeats the spondee, decrease the speech presentation level by 10 dB and re-establish SRT using the descending! ascending method described on the previous page. b. If there is no response, increase the speech presentation level in 20 dB steps until a spondee is repeated correctly. The stablish SRT using the descending/ascending method described on the previous page 4. Increase the speech masking noise in the NTE by 5 dB and re-establish SRT in the TE. Repeat this process until the speech masking noise has been increased three times and the SRT in the TE has not changed (threshold plateau). The true SRT in the TE has been established. 5. Record the masked SRT on cffective masking level audiogram in dB HL. Also record the final or 6. Repeat masked SRT procedure in the other ear, if necessary. Speech Awareness/Detection Threshold The SRT should not be confused with the Speech Awareness Threshold (SAT) or Speech Detection Threshold (SDT). The SAT or SDT is used when a patient/ T testing usually shows better (lower) client is unable to clearly repeat words. thresholds than th ence of speech, not identify the words Establish the SAT/SDT as follows; T because the patient/client needs only to detect the pres- 1. Live voice should be used for this test but recorded speech is an acceptable alternative. Instruct the patient/client to respond (response button or hand. raise) when they are aware that voice is present. Use phrases such as “Do you hear my voice?” or “Do you hear me now?” 2. Present speech at 30 to 40 dB above their PTA. Ifthere is no response, increase the presentation level in 20 dB steps until the patient/client responds 3, Use the descending/ascending technique until the patient/client responds at the same presentation intensity 50% of the time. 4, Document the SAT/SDT on the audiogram in dB HL 5. Apply the masking rule as stated for SRT measurement and retest if necessary (sce procedure above). 6. Repeat procedure for the other ear The SAT can be used for patients/clients with limited English profic ant articulation errors in their speech. Patients/clients whose native is not English can have marked accents. Others may have a neurological condition that makes theit own speech very unclear. These situations can make the identi- fication of their spoken responses uncertain — did they repeat the word the way Binaura see Chi benefits Establis