Audiology presentation

Murad Almomani, Ph.D., CCC-A,

FAAA
American Board of Audiology
 Outline
• Students will be able
– Identify type, degree and configuration of hearing loss.
– Identify possible site of lesion for each type of hearing
loss.
– Determine middle ear function from Tympanometry
measurement.
– Understand origin, indications and clinical applications
of OAE, ABR and speech audiometry.
– Briefly recognize vestibular assessment test battery
and its clinical significance.
Pure tone audiometry
Ranges of Hearing Loss

 -10 – 25 dB HL = Normal range

 26 – 40 dB HL = Mild hearing loss

 41 – 55 dB HL = Moderate


 56 – 70 dB HL = Moderately Severe

 71 – 90 dB HL= Severe

 Greater than 90 dB HL = Profound

Normal Hearing
Conductive Hearing Loss
Sensorineural Hearing Loss
Mixed Hearing Loss
 Procedures for conventional pure-tone
audiometry
• After history taking and otoscopy we must
choose how to test the hearing thresholds.

• Before we do pure tone audiometry (PTA), we

usually perform middle ear immitance testing

• PTA will be almost done to all pts visiting us in

the clinic because it is the basic test and give
us a lot of information about the problem.
 PTA
• With PTA we can determine whether the pt has
peripheral hearing loss (that is at the level of outer,
middle, inner ear or the auditory nerve).

• PTA is administered both by air (air conduction PTA)

or by bone (bone conduction PTA).

• Air conduction tests are administered by

loudspeakers or ear phones.
 PTA
• After establishing threshold at 1 KHz, we move to the
frequencies (2000, 4000, and 8000Hz).

• If the difference between any two adjacent frequencies

is 20 dB or more, we must measure the threshold at
the inter octave frequencies.

• After we are done from the high frequencies, we

return back and check the 1 KHz again to check for
test-retest reliability.
• Then we test (500, 250 and 125 Hz).
 PTA
• If we test in the sound field, we must use warble
tones instead of pure tones to avoid the production
of standing waves.

• When using ear phones make sure that there is no

excessive wax in EAC and that the earphone is snugly
inserted in the canal.

• All equipment (audiometer, earphones, and testing

room should be calibrated according the standards
(will teach you how to do that in the instrumentation
course).
 PTA-BONE CONDUCTION
• The most commonly used procedure for bone-
conduction testing is mastoid placement
because it is more convenient.

• Frontal bone can be used as the place for the

bone vibrator.
 PTA.BONE CONDUCTION
• We should do bone conduction if the air conduction
thresholds are above the normal range otherwise we
do not need to do bone conduction testing.
• Some exceptions?

• We first do unmasked thresholds and then we should

apply masking to the contralateral ear in order to get
precise threshold measurement in this ear (will talk
about masking next lecture).
AUDIOGRAM
 Information we get from audiogram
• Degree of hearing loss.

• Type of hearing loss.

• Configuration of hearing loss.

 TYMPANOMETRIC FEATURES
• Tympanometric shapes.

• Static acoustic admittance.

• Tympanometric width (gradient).

• Tympanometric peak pressure.

• Equivalent ear canal volume.

 Sensitivity and specificity
• Sensitivity has been found to be around 82% for MEE.

• Normal type A has 100% specificity.

• Overall sensitivity of around 80% and specificity of

around 90%.

• That is good but means we need to interpret results

with caution.
Tympanogram Types
 Type A Tympanogram
OE ME IE AN CNS
 Type AD Tympanogram
OE ME IE AN CNS
 Type AS Tympanogram
OE ME IE AN CNS
 Type BLow Tympanogram
OE ME IE AN CNS
 Type BHi Tympanogram
OE ME IE AN CNS
 Type C Tympanogram
OE ME IE AN CNS
 Static Compliance
(Peak Compliance)
Acceptable Range by Age

Flaccid: disarticulation,
flaccid TM, etc.
0.9 1.4

Normal mobility

0.2 0.3 Stiff: otosclerosis fluid,

tympanosclerosis, etc.
Child Adult
 Tympanometry in infants
• Studies has found frequent occurrence of
double peaked tymps.

• Usually we use higher probe frequency when

testing infants like 1000 Hz.
otoacoustic emissions
 Origin of OAE
• Initially reported by Kemp in 1978.

• OAE are considered a by-product of sensory OHCs

transduction and represent cochlear amplifier that thought to
be as a result of the contraction of OHCs in synchrony with
BM displacement.

• The contraction of the OHCs (movement) is then propagated

outward toward the middle ear and moves the TM.

• This in turn creates acoustic energy that is picked by the OAE

probe.
 Recording OAE’s
• OAEs are measured by presenting a series of very brief acoustic
stimuli, clicks, to the ear through a probe that is inserted in the
outer third of the ear canal. The probe contains a loudspeaker that
generates clicks and a microphone that measures the resulting
OAE’s that are produced in the cochlea and are then reflected back
through the middle ear into the outer ear canal.
• The resulting sound that is picked up by the microphone is digitized
and processed by specially designed hardware and software. The
very low-level OAEs are separated by the software from both the
background noise and from the contamination of the evoking clicks.
 OAE
• So in order to record OAE in EAC we need to
have normal middle ear function.

• Conductive pathologies can prevent the

recording of OAE but this does not mean that
OAE is not present.
 Types of OAE’s

Types

Distortion
Spontaneous Product Transient
OAE’s OAE’s Evoked
(SPOAE’s) (DPOAE’s) OAE’s (TEOAE’s)
 Spontaneous OAE’s
• Occurs in the absence of any intentional
stimulation of the ear.
• Prevalence is in about 40-60% of normal hearing
people.
• When you record SOAE’s, you average the
number of samples of sounds in the ear and
perform a spectral analysis.

• The presence of SOAE’s is usually considered to

be a sign of cochlear health, but the absence of
SOAE’s is not necessarily a sign of abnormality.
 Distortion Product OAE’s
• Result from the interaction of two simultaneously presented
pure tones.

• Stimuli consist of 2 pure tones at 2 frequencies (ie, f1, f2

[f2>f1]) and 2 intensity levels (ie, L1, L2). The relationship
between L1-L2 and f1-f2 dictates the frequency response.

• DPOAEs allow for a greater frequency specificity and can be

used to record at higher frequencies than TOAE’s.
Therefore, DPOAE’s may be useful for early detection of
cochlear damage as they are for ototoxicity and noise-
induced damage.
RESPONSE

NOISE
 Transient Evoked OAE
• TEOAE’s are frequency responses that follow
a brief acoustic stimulus, such as a click or tone burst.
• The evoked response from this type of stimulus covers
the frequency range up to around 4 kHz.
• In normal adult ears, the click-elicited TEOAE typically
falls off for frequencies more than 2 kHz, and is rarely
present over 4 kHz, because of both technical limitations
in the ear-speaker at higher frequencies and the physical
features of adult ear canals so that is why DPOAE’s would
be more efficacious.
• For newborns and older infants, the TEOAE is much more
robust by about 10 dB and typically can be measured out
to about 6 kHz indicating that smaller ear canals influence
the acoustic characteristics of standard click stimuli much
differently than do adult ears.
• TEOAE’s do not occur in people with a hearing loss
 TEOAE results

Normal hearing

High
frequency HL

Severe SN HL
TEOAE & DPOAE
 Acquisition
• Not affected by sleep but needs test subject to
be still and compliant
• Very quick
 Clinical applications of EOAE
• 1- can be used in newborn hearing screening.
The results will indicate either fail or pass. Fail
means that hearing thresholds are worse than
30 dB HL. Pass results means hearing
thresholds are 30 dB HL or better.

– So, we can not use this tool to measure threshold

of hearing.
 Applications of OAE
• TEOAE can be recorded in all non-pathologic ears that do not
display hearing loss of greater than 30 dB.

• OAE can be recorded in both adults and infants.

• Accordingly TEOAE and DPOAE can be used to screen for

hearing loss in infants.

• DPOAE provide more frequency specific evaluation that TEOAE.

 Clinical applications of EOAE
• 2- in differential diagnosis of hearing loss (site of lesion). This
can help in differentiating sensory from neural hearing loss.

• 3- monitoring of the effect of ototoxicity or noise exposure.

• 4- although still under research: DPOAE can be used to screen

for the carriers of the recessive hearing loss genes: many
studies found that DPOAE is larger (especially at high
frequencies) in carriers than in non carriers when using f2/f1
of 1.3 and low stimulus levels of 50-60 dB.
 clinical limitations
• Problems because of middle ear disease
• Not sensitive for neonates within 24 hours of
birth
• Results affected by test conditions
– Noise

• Not a test of hearing- limited application

Clinical applications of ABR

Murad Almomani, Ph.D., CCC-A, FAAA

 The normal ABR waveform
• Is characterized by 5-7 peaks.

• Occurs in a latency epoch of 1.4 – 8.0 ms.

• Responses are usually displayed with positive peaks reflecting

neural activity toward the vertex.

• These peaks are labeled with the roman numerals I through

XII.

• The most prominent waves are I, III, and V.

Generators of the ABR
Auditory cortex

VI Medial geniculate body

Inferior colliculus
V
Lateral lemniscus

Superior & accessory olive area

Dorsal cochlear nucleus
IV Ventral cochlear nucleus
III VIIIth nerve
II
I
 Medial
Ventral &Dorsal Superior Lateral Inferior
Cochlea Geniculate
CochlearNucleus Olive Lemniscus Colliulus
Body

VIII

ACOUSTIC
STIMULATION
V
IV
III
II
I ABR
Latency, ms

0 1 2 3 4 5 6 7 8 9 10
 Characteristics of normal ABR
• Information to determine normal ABR waveform
depends on:
– Waves absolute latency.
– Waves interpeak intervals.
– Latency-intensity function.
– Wave V/I amplitude ratio.
– Interaural wave V latency difference.

• Research established normal ranges of the above

parameters.
 Characteristics of normal ABR
• Normal ranges for the above parameters are not universal.

• There are some variation among different research

findings.

• Many factors affects normal values including age, sex,

temp and other factors.

• It is always better for each practice to establish its own

norms.
 Characteristics of normal ABR
• Absolute latency of ABR waves in adults:
– Wave I: at around 1.6 ms +/- 0.2 ms.
– Wave III: at around 3.7 ms +/- 0.2 ms.
– Wave V: at around 5.6 ms +/- 0.2 ms.

• Interwave latency intervals:

– I-III: 2.0 ms+/- 0.4 ms.
– III-V: 1.8 ms +/- 0.4 ms.
– I-V: 3.8 ms +/- 0.4 ms.
 Characteristics of normal ABR
• Wave V latency-intensity function: increases
by around 0.3 ms per 10 dB decrease of the
stimulus level.

• V/I amplitude ratio: greater than 1.0.

• Wave V latency difference: less than 0.4 ms.

 Example Normal Hearing

18 Month-Old – 2000 Hz Tone-Burst

70 dBnHL

10 dBnHL
 Clinical applications of ABR
• There are two main applications for ABR in the clinical settings:

– Neurodiagnosis: to assess the auditory pathway. This feature is

specially used in adult populations.
• Waves absolute latency.
• Interpeak intervals.
• Interaural wave V latency difference.
• Absence of waves.

– Hearing thresholds estimation: mainly used in infants and children

population.
• Wave V threshold.
• Wave V latency-intensity function.
 Neurodiagnosis
• Who should be tested? Patients with:
– Dizziness.
– Unilateral tinnitus.
– Asymmetrical hearing loss.
– Sudden onset of hearing loss.
– Progressive hearing loss.
Using ABR to estimate hearing thresholds

• Can be obtained by progressively decreasing

intensity of the stimulus (click or toneburst) and
observing wave V.

• The last intensity that wave V appears at is

considered its threshold.

• ABR threshold is within 10-20 dB from the

subjective threshold.
 Eye Movement Recording
• In performing ENG/VNG,
the patient eye
movements are measured
relative to head position,
which can be achieved in
a number of ways.
• Measuring electric
potentials, measuring
magnetic potentials, using
video cameras or using
infrared technology and
direct observation.
Nystagmus
Left Beating Right Beating

Slow Fas
t
 VNG Test Battery
• Calibration
• Gaze
• Saccade
• Pursuit
• Optokinetic
• Positional
• Hallpike
• Caloric
 Gaze Test
• The function of the gaze system is to
maintain visual fixation of an object
on the fovea of the eye.
• To identify the presence of
spontanoues eye movement.
• Normal gaze, patient able to
maintain position with eyes opened
and closed.
Gaze results with peripheral &central
lesions
• Horizontal.
• Horizontal, vertical or
• Directional
rotatory.fixed.
• Suppressed
• Directionalwith visual
changing.
fixation.
• Enhanced with visual
fixation.
 Saccade (refixation ) Test.
• The function of saccadic eye movement
system is to redirect the eye from one target
to another in the shortest possible time.
• Inaccurate eye movement, where the eye
either undershot or overshot the target is
abnormal and seen frequently in patients with
cerebellar dysfunction.
Saccade Test
 Results:
• Normal saccadic eye
movement test should
produce rapid and
accurate eye movement.
• Inaccurate eye
movement, where the
eyes overshot or
undershot the target .
Saccade
 Ocular Pursuit Test
• The function of ocular
pursuit system is to
stabilize a slowly moving
object on the fovea of the
eye by matching the
angular velocity of the eye
with that of the moving
object.
Pursuit Test
 Results:
• When the pursuit system is impaired, small
corrective saccadic movements replace the
smooth pursuit movement, so the eye can
catch up the moving target.
• It may be the most sensitive subtest in ENG
battery for detection of brainstem and
cerebellar disorders.
Pursuit
Abnormal Pursuit
 Optokinetic Test
• Optokinetic system maintain visual fixation
when the head is in motion.
• Target is rapidly passed in front of the subject
in one direction, then the other.
• Eye movements are recorded and compared in
each direction.
• Asymmetry suggestive of central lesion
Optokinetic
Optokinetic
Optokinetic
 Dynamic Positional Test ( Hallpike )

• The patient complains a motion related

vertigo at certain position
• It is maneuver that places the patient head in
the position that creates the response.
• Criteria: Latency period, subjective vertigo,
Transient nystagmus, fatigable, lesion in the
undermost ear,
 Dix Hallpike maneuver
• Used to provoke nystagmus and vertigo
commonly associated with BPPV.
• Head turned 45 degree to maximally stimulate
posterior semicircular canal.
• Head supported and rapidly placed into head
hanging position.
• Frenzel glasses eliminate visual fixation
suppression of response or can be tested
Using VNG.
Dix Hallpike Maneuver
Caloric Test
 Caloric Tests
• Caloric test is a part of ENG/VNG.
• It reflects an attempt to discover the degree to
which the vestibular system is responsive and
also how symmetric the responses are,
between left and right.
• It is a test of the lateral semicircular canals.
• Most caloric tests are nowadays are done
using computerized systems, the computer
analyzes the caloric data, computing peak
slow-phase velocity.
Caloric Test
 Caloric Test (Procedure )
• Irrigations of EEC performed with cold and
warm water or air.
• Water - cool = 30 C; warm = 44 C
• Air - cool = 24 C; warm = 50 C
• Response pattern follows the form of COWS
• Nystagmus induced results are calculated to
obtain Unilateral Weakness and Directional
Preponderance
Caloric Test
Caloric Test
Caloric Test