UNIT 3: HEARING AIDS

Audiograms and auditory masking

Types of hearing loss

• Conductive hearing loss -
• dysfunction of outer and middle ear
• Deficit of loudness only
• Sensori-neural hearing loss
• Dysfunction of inner ear or auditory nerve
• Permanent and untreatable
• High frequency loss is common
• Middle ear is intact
• Mixed hearing loss
• Both conductive and sensori-neural hearing loss
• Noise induced hearing loss

Hearing assessment
• Accurate otologic diagnosis depends on reliable andaccurate tests of
hearing.
• The results help in finding the point of lesion andtype of treatment to
be given.
• Patients may be screened in a course way or more sophisticated
testing procedures may be followed.

Screening
• In conversation, how does the person respond whenyou speak to
him/her?
• Does the person have to see your face to understandwhat you are
saying?
• Does the person tend to favor one or the other ear?
• Using a tuning fork may help evaluate the nature of ahearing loss
short of an audiologic examination

Air conduction
• The process of transmitting sound waves to thecochlea by way of the
outer and middle ear.
• In normal hearing, practically all sounds are transmitted in this way,
except those of the hearer’s
• own voice, which are transmitted partly by boneconduction.

Bone conduction
• Bone conduction is the conduction of soundto the inner ear through
the bones of theskull.
• Bone conduction is the reason why a person'svoice sounds different to
him/her when it isrecorded and played back. Bone conduction tends
to amplify the lower frequencies, andso most people hear their own
voice as beingof a lower pitch than it actually is.

Audiometric tests for adults

Audiometric tests normally includes
• pure-tone testing of threshold by both
o air and bone conduction,
• speech reception threshold (SRT), and
• speech discrimination score (SDS).
o These tests normally require the cooperation of thesubject
whose response to a sound is indicated bysome gesture (e.g.
raised hand).
o Testing is typically carried out in a sound-attenuatedroom with
the subject listening to carefully calibratedsounds.

Threshold sensitivity testing using airconductedpure tones

• Testing is done using earphones thereby allowing each ear tobe
examined independently.
• Tones are reduced in intensity until they are no longer heard, at which
point the examiner alternately raises and lowers the intensity of the
sound until a just-detectable threshold isdetermined.
• This is repeated at several frequencies within the audible rangeand the
results plotted as an audiogram.
• The shape of the curve is a measure of the frequencysensitivity of
both the middle ear and the inner ear.
• To differentiate between middle ear (conductive) and inner
ear(sensorineural) components to a hearing loss it is necessary
toconduct additional tests.

Threshold sensitivity testing using boneconductedpure tones

• Testing is done with a vibrator placed somewhere on the skull(usually
the mastoid).
• The testing and plotting procedures are the same as with
airconduction testing.
• sound is transmitted directly to the cochlea via bone
conduction,thereby by-passing the transmission mechanism of
themiddle ear.
• Thus, audiograms obtained using both bone and air conductedsounds
provide information about the integrity of both the middle and inner
ears.
• Difficulty in hearing only air conducted sounds results in aseparation
of the bone and air conduction audiograms - the socalled"air-bone
gap".

Diagnosis
• The shape of the bone conductionaudiogram is a measure of
thesensitivity of the inner ear alone,
• while the difference between airconduction and bone conduction is
ameasure of the degree of hearing lossattributed to the middle ear .

What is an audiogram?
• Audiogram is a graph showing the information abouta person’s
hearing abilities (result of a hearing test)
• It is a loudness Vs frequency curve
• Sound intensity or loudness is measured in dB
• Sound intensity is listed from top to bottom from -10dB to 110 dB
• Frequency from 125 Hz to 8000 Hz

Audiogram
• Normal hearing
o 25 dB or less
o Understand speech in the noise environment
o No amplification is required
• Mild hearing loss
o 26 – 40 dB
o Difficulty hearing in the noisy environment
• Moderate hearing loss
o 41 – 55 dB
o Frequent difficulty in understanding speech
o Requires hearing aid
• Moderately severe
o 56 – 70 dB
o May still have communication problems with hearing aids
• Severe hearing loss
o 70 – 90 dB
o Difficulty with shouted speech
o Requires training to get maximum benefit with hearing aid
• Profound hearing loss
o 91 dB and above
o Extensive training is required

What do these symbols mean?

• Right ear
o Air conduction
Unmasked – O
Masked - B
o Bone conduction
Unmasked - <
Masked - [
• Left ear
 o Air conduction
Unmasked – X
Masked -
o Bone conduction
Unmasked - >
Masked - ]

Diagnosis
• Bone conduction in the mild region
o Sensorineural hearing loss is mild
• Air conduction in the moderate to severeregion
o Conductive hearing loss

Speech Reception Threshold (SRT)

o The threshold for hearing easily-recognized bisyllabic words (e.g.
baseball, iceberg,eardrum)
o Since speech is made up of pure tones, this threshold should be very
close to pure tonethresholds up to about 4 kHz, which is therange of
frequencies occupied by mostnormal speech sounds.

Speech discrimination score (intelligibility)

 Is the person's ability to not only hear words but toidentify them.
 The procedure includes presentation of 50 selectedmonosyllabic
words at an easily detectable intensitylevel.
 The speech discrimination score (SDS) is thepercentage of words
correctly identified.
 Pathology of the inner ear, auditory nerve, and/orcentral auditory
pathways can affect this score.The ability of an individual to
discriminate speech isnot well predicted by the pure-tone audiogram.
Anindividual may hear a sound well enough, but theneural signals
may be altered to the extent that thesound is unintelligible.
 Individuals suffering only a conductive hearing losswill be able to
identify words if the sound is loudenough.
 For persons with sensorineural hearing loss, there isa marked drop in
the score without a proportionateloss of pure-tone or speech
sensitivity.

Hearing tests for infants

 Should be accurately assessed for hearing loss
 Infants respond to sounds with facial expressions(smiles, eye brow
raising, ..) turning head, etc.,
 At 24 months old other test strategies can be used.
 Play audiometry technique (like a game)

Need for an objective method

 Unbiased
 Independent of human intervention
 Reliable
 Quantitative

Objective methods
• Tympanometry
• Electrochochleography
• Auditory Evoked potential
o Unable or unwilling to respond to the tests (mentally
retarded,infants)
• Tympanometry
o This method assesses the mobility or compliance of
thetympanic membrane and thereby provides
importantinformation about the function of the middle ear
includingthe tympanic membrane, ossicles, and Eustachian tube.

Tympanometry
• Tympanometry is an examination used to test the condition ofthe
middle ear and mobility of the eardrum (tympanic membrane) and the
conduction bones by creating variations ofair pressure in the ear
canal.
• Tympanometry is an objective test of middle-ear function.
• It is not a hearing test, but rather a measure of energytransmission
through the middle ear.
• The test should not be used to assess the sensitivity of hearingand the
results of this test should always be viewed inconjunction with pure
tone audiometry.A tone is generated by the tympanometer into the ear
canal,where the sound strikes the tympanic membrane,
causingvibration of the middle ear, which in turn results in the
conscious perception of hearing.
• Some of this sound is reflected back and picked up by theinstrument.
• Most middle ear problems result in stiffening of the middle ear,which
causes more of the sound to be reflected back.
• The general term used to describe how energy is transmittedthrough
the middle ear is admittance.
• The instrument measures the reflected sound and expresses itas an
admittance or compliance, plotting the results on a chartknown as a
tympanogram.

Electrocochleography (ECoG)
• Cochlear and auditory nerve electrical activity can be recorded from
human patients from electrodes advanced through the tympanic
membrane and placed on the oticcapsule.
• This method allows assessment of cochlear and auditorynerve
function independent of the patient's subjectiveresponse.
• Two electrical events are recorded from the inner ear inresponse to
sound:
• the cochlear microphonic (receptor) potential and
• the compound action potential of the auditory nerve.
• Distortion of the waveform of either of these potentials is
anindication of inner ear disease.
• An evoked potential (or "evoked response") is an electrical
• potential recorded from a human following presentation of a
• stimulus, as distinct from spontaneous potentials as detected by
• EEG or EMG.
• Evoked potential amplitudes tend to be low, ranging from lessthan a
microvolt to several microvolts, compared to tens ofmicrovolts for
EEG, millivolts for EMG, and often close to a voltfor ECG.
• Auditory evoked potentials by a click or tone stimulus
presentedthrough earphones

Rehabilitation for hearing loss

• Person with hearing loss fitted with a hearing aid, a devicethat simply
amplifies the sound.
• Hearing aid may be helpful at any time in life and, because theyare
amplifiers only (and therefore make sounds louder butnot clearer),
they tend to work best in cases of conductivehearing loss.
• For treating profound sensorineural hearing loss, acochlear prosthesis
has been developed to aid thoseindividuals with little or no residual
hearing.
• Alternatively, other means of communication may be substituted(e.g.,
sign language, lip reading).
• In some cases, all means of communication are used.
Small increment sensitivity index (SISI)Test
The SISI test is widely used to determine whether the patient ishaving
cochlear pathology.
This test is based on a phenomenon known as recruitment(abnormal
loudness growth).Limen – threshold for physiological or psychological
response
Difference limen for intensity (DLI): is the smallest changein the
intensity of a pure tone which can just be detected.
It is usual for patients with normal hearing to have difficultyin detecting
small changes in intensity close to threshold.
Patients with cochlear pathology will be able to appreciatethe change in
intensity better because of the phenomenonof recruitment.
DLI could safely be assumed to be an indirect indicator ofthe
phenomenon of recruitment.
SISI introduced as a test for the phenomenon of recruitment.
In this test a pure tone was presented to the patient at a sound level of
20dB.
A small increase in intensity is superimposed upon the steady state
tone at periodic intervals.
The size of the increment varied from 5 - 1 dB.the ability to detect the 1
dB increments was restricted to patients withcochlear pathology.
This ability was absent in patients with normal hearing or with
aconductive hearing loss.
It just tests the cochlea's ability to respond to a transient signal ofsmall
amplitude.

A carrier tone is introduced into the patient's ear at aSound level of 20

dB.
Every 5 seconds a short increment is superimposed,starting with 5 dB
increments.
The signal has an on-off time of 50 msec and 5seconds elapse between
increments.
The patient is instructed to indicate when he hears abrief jump in the
loudness of the tone.
After 5 such jumps (to condition the patient) the sizeof the increment is
lowered to 1 dB marking thebeginning of the SISI test.Twenty 1 dB
increments are introduced and thesubject is required to indicate when the
increment isheard each time.
If a number of consecutive increments heard exceeds5 then the examiner
should delete several incrementsto ensure that the subject is responding
to thechange in intensity and not the time interval.
If the patient fails to respond to several increments ina row the
increment size can be increased forretraining the patient before
proceeding with thetest.
These steps will avoid false negative and falsepositive results.

SISI test variants

one dB increments at 20dB sound level (classical SISI) – Highscores
suggest a cochlear lesion.
Two to 5 dB increments at 20 dB sound level - Low scoressuggest a
retrocochlear lesion.
One dB increments at high sound levels (75dB) - Low scoressuggest a
retrocochlear lesion.
Increment sizes varied from 1 - 5 dB at 20 dB sound level -poorer scores
in one ear than the other (when their thresholdsare approximately equal)
suggests a central lesion opposite theear with the lower score.
One dB increments at sound levels ranging from 20 dB to high levels
(about 75dB) in 10 dB steps for both ears. Difference inthe rate at which
scores increase suggests a retrocochlearlesion. The disorder is located on
the same side as the earwhich has not shown normal increases in
intensity.
Auditory masking
Auditory masking occurs when the perception ofone sound is affected
by the presence of anothersound.
The phenomenon of masking is often used toinvestigate the auditory
system’s ability to separatethe components of a complex sound.
Masking can be
• simultaneous or
• non simultaneous.

Simultaneous masking
Simultaneous masking is when a sound is madeinaudible by a "masker",
a noise or unwanted soundfor the same duration as the original sound
(Moore2004).
Unmasked threshold :defined as the quietest level of the signal which
can beperceived without any masking present, and a

Masked threshold:is the quietest level of the signal perceived when

combinedwith a specific masking noise. The amount of masking is
thedifference between the masked and not masked thresholds.A sound of
cat scratching the post is played if it is heard at 10 dB _ unmasked
threshold. Now hold the original sound at the same level. Play the sound
of vacuum cleaner simultaneously.If the cat scratching sound is not
heard at all whenthe sound level of vacuum cleaner is increased to 28dB.
28 dB _ masking threshold
The difference between unmasked and maskedthreshold gives the
amount of masking.

Effect of frequency on masking patterns

• Frequency resolution or frequency selectivity
o Two signals of different frequency
o Ability of the system to differentiate between these 2 freq.
o Auditory filters in the cochlea
o These are critical bandwidths or the listening channels
o If the sounds fall in the same critical band it is perceived
assame sound

EAR DISORDERS AND HEARING LOSS

TYPES OF HEARING LOSS:

_ CONDUCTIVE
_ SENSORI-NEURAL
_ MIXED
_ NON-ORGANIC

CONDUCTIVE HEARINGLOSS
Occurs from adysfunction of theouter or middle ear can usually
betreated withmedicine or surgery. A deficit ofloudness only
Characteristics of ConductiveLoss:
_ Maintain soft speaking voice
_ Excellent speech discrimination
when speech is loud enough
_ Typically either low frequencyor flat hearing loss (equal at
allfrequencies)

CAUSES OF CONDUCTIVEHEARING LOSS:

Outer Ear:
_ Occlusion/foreignbody
_ Congenital Atresia
_ External Otitis
Middle Ear:
_ Otitis Media
_ TM Perforation
_ Cholesteatoma
_ Ossicular fixation
_ Otosclerosis
_ Ossicular
Disarticulation
_ Blocked EustachianTube, reduced middleear pressure,
TMretraction andeventual effusion.

TREATMENT:
CONDUCTIVEHEARING LOSSES
_ Conductive hearing losses are due toproblems that occur in the outer
and middleear which are usually temporary and/ortreatable with
antibiotics or surgery.
_ For those few people who haveuncorrectable conductive hearing
losses,hearing aids are of significant benefit assound remains clear if it is
made loudenough.

SENSORI-NEURAL HEARINGLOSSES
_ Dysfunction of the inner ear or auditory nerve,usually permanent and
untreatable
_ Results in loudness deficit and distorted hearing.
_ Nerve endings in cochlea or nerve pathways aredamaged.
_ Message does not effectively reach the brain.
_ Middle ear structures are intact.

Characteristics of SNHL:
_ Inappropriately loud voice
_ High frequency loss common, but anyconfiguration possible
_ Speech sounds distorted
_ Background noise makes listening moredifficult
_ Hearing aids may help

CAUSES OF SENSORI-NEURALHEARING LOSS:

_ Genetics/Congenital
_ Disease
_ Mumps, Measles
_ Meningitis, CMV
_ Ototoxic drugs
_ Head trauma
_ Presbycusis
_ Meniere’s Disease
_ Acoustic Neuroma
_ Ototoxin Exposure
_ Noise Exposure:
_ Prolonged exposure tohazardous noise causeshearing loss by
thephysical destruction ofthe hair cells in thecochlea.

Characteristics of NIHL:
(noise induced hearing loss)
_ Loss can be sudden, as with acoustictrauma from an explosion.
_ More often a gradual onset that may gounnoticed.
_ NIHL also known as noise induced permanentthreshold shift (NIPTS),
typically takes years ofexposure, gradual erosion of hearing
thateventually affects communication.Amount of loss varies from person
toperson.
_ Risk of noise-induced progressionstops if no longer in noise
exposed,but aging invariably worsens loss.
_ For most, aging effects aren’t significantbefore age 50+

Classic Symptoms ofNIHL:

_ A notch or drop in hearing at 4000 Hz.Generally affects 3000-6000 Hz
range first,then notch becomes deeper & wider
_ Typically bilateral and symmetrical
_ Reduced speech comprehension,particularly in background noise.
Why?
_ Vowels are low frequency sounds that carry 90% of speech energy (I
can hear you talking….)
_ Consonants are higher frequency sounds that carry mostof the meaning
of speech. NIHL begins in highfrequencies.(But I can’t understand what
you are saying.)

The “4 P’s”
Noise induced hearing loss is:
• Painless
• Progressive
• Permanent
• Preventable

TREATMENT:
_ Sensori-neural hearing loss is due toproblems that occur in the inner
ear and arealmost always permanent and untreatable.
_ Hearing aids will benefit most people withsensori-neural loss, but
results can vary.

MIXED HEARING LOSS:

_ Combination of conductive (outer or middleear) disorder and sensori-
neural hearing loss.
_ Treatment may be available for the conductiveportion; however, the
sensori-neural portionwill remain.
_ Causes can be unrelated (for example, NIHLplus TM rupture), or
related (for examplecochlear otosclerosis).

NON-ORGANIC HEARINGLOSS
_ Non-Organic:
_ No medical or physical reason for hearing loss, may bevoluntary or
involuntary
_ Malingering:
_ Consciously faking or exaggerating a hearing impairment,often for
monetary or other personal gain, to escapeassignments or
responsibilities, or as an anti-establishmentgesture
_ Psychogenic Hearing Loss - Unconscious development of anon-
organic hearing loss – a compensatory protectivedevice, a psychogenic
problem (the patient believes theimpairment is real)

CENTRAL HEARING LOSS

_ Occurring within central nervous system(cortex, brainstem, or
ascending auditorypathways) as opposed to peripheral organs ofhearing
(cochlea and middle ear)
_ Often associated with other neurologicaldisorders (multiple sclerosis,
tumors)
_ Sometimes confused with non-organic hearingloss due to vague
symptoms or inappropriatetest behavior
_ Always requires diagnostic work-up by anaudiologist, otologist, and/or
neurologist;patient usually hears WNL for pure tones

IN SUMMARY….
_ Conductive Hearing Loss:
_ Usually low frequency or flat, affects outer and/or middle ear,usually
temporary - or at least medically or surgically treatable.
_ Sensori-neural Hearing Loss:
_ Often high frequency, affects inner ear, usually permanent.
_ Mixed Hearing Loss:
_ Usually affects both high and low freqs, both conductive and
sensori-neural components, but only conductive portion treatable.
_ Non-Organic Hearing Loss:
_ Typically display a flat loss or total deafness in one ear, but
mayexaggerate a true loss, may (rarely) be involuntary but
usuallymalingering is involved. Prior test results are your best clue.
_ Central Hearing Loss:
_ Hearing for pure tones often normal, problem is between cochleaand
cortex (receptor cells OK but a transmission or processingproblem).

HEARING AIDS
Organization
_ Relation b/w acoustics and perception
_ Normal auditory system
_ Speech analysis by the auditory system
_ Hearing loss
_ Aid for hearing

Production and perception of speech

_ Production of speech
_ Frequency contents
_ Parameters of sound
_ Intensity (loudness)
_ Frequency (pitch)
_ Measurement of strength of sound
_ Perception of speech

Speech production mechanism

Main function:
_ Detection and interpretation of sound
_ Conversion of acoustic energy to a mechanical
energy and then into nerve impulse
_ Body balancing
_ Hair cells
_ Otolithic
_ Connected to visual and skeletal system
_ Lateral movement, up and down movement

Normal hearing
_ Structures involved:
_ Outer ear – collects and channelize
_ Middle ear – vibrations of bone
_ Inner ear – fluid vibrations
_ Auditory nerve – nerve impulses
_ Brain - understanding
External ear
_ Pinna and ear canal (2cm)
_ Non-acoustic functions:
_ Protection of tympanic membrane (ear drum)
_ Maintenance of clear passage for sound
_ Acoustic functions:
_ Alters the amplitude of the incoming sound (5 -20dB) in 1.5 to 7 kHz
_ Reflection – torso, diffraction – head
_ Resonance of the external ear canal
_ Directional amplification of freq. of human speech(channeling)

Middle ear
_ Ear drum
_ Three interconnected tiny bones
_ Hammer (malleus)
_ Anvil (incus)
_ Stirrup connected to the inner ear (stapes)
_ Act as levers to amplify the vibrations of the sound wave
_ Due to mechanical advantage the displacement of stirrupis greater than
that of the hammer
_ Mechanical adv: relation b/w the force exerted and thedistance through
which the load moves
_ Since the force exerted on the larger eardrum isconcentrated into the
smaller stirrup, the force of thevibrating stirrup is A15 times greater than
that of theeardrum.
_ This helps us in understanding even the faintest sound
_ Middle ear is an air-filled cavity
_ Connected to the mouth through the
eustachian-tube – helps in the equalization ofpressure within the air-
filled cavities
_ Clogging causes earaches and painsImpedance matching b/w air and
fluid
_ Area of the eardrum is 21 times that of thestirrup
_ Pressure increase is proportional to theratio of the areas of the two
structureincreasing the intensity by ~ 30 dB (lossdue to air/fluid
interface)

Inner ear - How does the cochlea encodethe frequencies ?

Place theory:
_ Different frequencies cause maximum vibration amplitudeand create
traveling waves at different points along thebasilar membrane
_ Low frequency – apex
_ High frequency – base
_ the corresponding hair cells bent by the displacement of themembrane
_ This stimulates the adjacent the nerve fibres which areorganized
according to the frequency to which they are mostsensitive.
_ Each place is ‘best’ responding to a particular frequency.

Acoustic functioning of ear