pure tone testing

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3 intrinsic factors that may affect thresholds

breathing; cardiovascular activity; (internal) criterion

3 non-auditory components tested during threshold measurement

motor control of arm and hands; expressive and receptive language abilities; cognitive function

3 options for responses during audiometric testing

press a button; raise a finger/hand/arm; verbal response

3 types of hearing loss

conductive; sensorineural; mixed

3 ways to deal with false negatives

watch the person, not just the response light (look for body movement, partial hand raise, facial expression, etc.); reinstruct; change response task (say yes instead of hand raise) or test method (may need physiologic measure)

4 extrinsic factors affecting thresholds

test environment (temperature, ambient noise levels); equipment calibration; procedural factors

4 methods for dealing with false positives

increase signal level to remind them of the tone; stop presenting until the subject stops responding with false positives; reinstruct (change the criteria from "when you barely hear it" to "when you're sure you hear it"; try pulsed or warbled tones

4 output transducer options in air conduction audiometry

supra-aural headphones (TDH-39, 49, 50); insert earphones (ER-3A, ER-5A); circumaural headphones (Sennheiser HDA-200); loudspeaker (sound field thresholds)

According to Mangham (1991), asymmetry of hearing loss with an average difference of _____ at _____ kHz was the most sensitive predictor for identifying acoustic tumors

>20; 1, 2, 4, and 8 kHz

According to Margolis and Saly (2007), hearing loss is asymmetric if interaural differences are

≥10 dB at 3 or more frequencies or ≥15 dB at 2 or more frequencies or ≥20 dB at 1 or more frequencies

After otoscopy, the next step in the process for measuring threshold is

give instructions to make the task and response clear

An air-bone gap of _____ is significant even if AC thresholds are normal

>10 dB

Air conduction threshold testing alone cannot identify

the site of a dysfunction

An audiogram showing AC thresholds >80 dB with no response to bone conduction testing at the limits of the audiometer (around 60 dB) is a _____ loss

cannot say definitively if this is a mixed loss (conductive component) because bone conduction thresholds could not be obtained--this may be a mixed or sensorineural

Before audiometric testing, it is important to set up the test area to ensure

safety and comfort (good lighting, ventilation, comfortable temperature)

Before starting threshold testing, it is important to perform _____ to rule out _____ such as _____

otoscopy; contraindications to testing; cerumen/foreign objects, active pathology, collapsing ear canal

The bone conduction pathway bypasses _____ and directly stimulates _____

outer and middle ear; both cochlea simultaneously

Bone conduction thresholds are measured using

a bone oscillator

A bone oscillator for measuring bone conduction thresholds is placed

on the mastoid process or the forehead

Common descriptors of hearing loss configuration include

flat; sloping; rising; trough (cookie bite); peak (reverse cookie bite/inverted V)

Comparing AC and BC thresholds helps isolate

the site of a dysfunction

The current method of threshold testing is based on a technique developed by

Hughson and Westlake

Describe flat hearing loss configuration

thresholds (in general) +/-20 dB

Describe peak hearing loss configuration

best thresholds are in the mid-frequency region

Describe rising hearing loss configuration

general trend of falling thresholds as frequency decreases

Describe sloping configuration of hearing loss

general trend of falling thresholds as frequency increases

Describe the recommended method for measuring pure-tone thresholds

Start AC at 1000 Hz; start with better ear if known or the right ear; test at octave intervals 250-8000 Hz and at 3000 Hz and 6000 Hz; include 125 Hz if low frequency loss is present; test inter-octaves if difference between octave thresholds is ≥20 dB

Describe the threshold search procedure

start threshold search at least 10 dB less than familiarization level; if positive response, decrease by 10 dB; after first NR, ascend in 5 dB steps until response and note the level of first response on an ascending run; drop down 10 dB and begin next ascending run; repeat process until 2/3 responses; repeat at 2K, 3K, 4K, 6K, and 8K Hz; recheck 1000 Hz (if threshold differs by >5 dB use lowest threshold and recheck at another frequency and use the better threshold); finish with 500 and 250 (and 125 if low frequency loss)

Describe trough configuration of hearing loss

poorest thresholds are in mid-frequency region

The familiarization process should begin _____ with intermittent presentations at _____ then _____ and increasing in _____ as needed

well above threshold; 30 dB; 50 dB; 10 dB steps

hearing loss asymmetry may indicate a risk factor for

retrocochlear pathology

In a conductive hearing loss, the difference between the air conduction threshold and the bone conduction threshold is called the

air-bone gap

In a conductive hearing loss, the site of the lesion is

the outer or middle ear

In air conduction audiometry, the signal source is the


In a mixed hearing loss, bone conduction thresholds are _____ and ABG is

not normal; >10 dB

In a sensorineural hearing loss, the site of lesion is

sensory (cochlea) or neural (VIII nerve or higher)

In bone conduction audiometry, the signal source is the


In conductive hearing loss, bone conduction thresholds are _____ and are _____ than air conduction thresholds

normal; better

In sensorineural hearing loss, air conduction and bone conduction thresholds are

about the same (ABG ≤ 10 dB)

In threshold testing, familiarization is the process of

finding a starting level

Measuring pure tone air conduction thresholds tests

the entire auditory system from outer ear to cortex and back to cochlea


maximum permissible noise level

MPNL varies based on

transducer type (supra-aural vs inserts; headphone vs sound field)

No matter where the bone oscillator is placed, the ear being measured in bone conduction audiometry is

the better hearing ear

The output transducer in bone conduction audiometry is

a bone oscillator (radio ear B-71)

Presentation of _____ may reduce false positives

pulsed tones

procedural factors affecting thresholds

instructions; response task; clinician interpretation of response; earphone placement; bone oscillator placement

Six points to cover in instructions for audiometric threshold measurement

purpose (find the faintest tone you can hear); sit quietly; respond when the tone comes on and goes off; each ear is tested separately; tones of different pitches; offer to answer questions

The stimulus presentation in threshold testing should last _____ and the time between presentations should be no shorter than _____

1-2 seconds; 1-2 seconds

Structures included in the air conduction pathway

outer ear, middle ear, inner ear and beyond

Two possible reasons for false negatives

patient could have a conservative criterion; may be giving a response that you aren't seeing

Two primary pathways for sounds to reach the inner ear

air conduction; bone conduction

We can describe thresholds in terms of

degree of loss; configuration of loss; type of loss (site of lesion)

When checking test-retest variability, thresholds should be between

+/-10 dB in most cases (assuming a standard deviation of 5 dB)

When doing audiometric testing, it is important to avoid

giving inadvertent visual cues

When doing audiometric testing, you should be able to see the patient in order to

allow for monitoring and reinforcement of responses

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