Audiogram. Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

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1 Audiogram Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

2 Purpose of Audiogram Degree of hearing loss Configuration Site of lesion ( Conductive, Sensory, Neural or mixed) Need for further test or Rx Help non-surgical language,..) surgical (Hearing aid, sign

3 Audiogram Battery Pure Pure tone audiogram Speech Speech audiogram Impedance

4 Pure tone audiogram Reference levels of the db Hearing level Sound intensity for the average normal ear to perceive a specific frequency Sensory level Sound intensity for the individual ear to perceive a specific frequency

5 .

6 Pure tone audiogram Air conduction Lowest dbhl at which subject perceives % of pure tone via air ( earphone, speaker) Bone conduction Lowest dbhl at wich ear perceives % of pure tone via boe oscillator Do it when you need it Pure tone average Speak frequency, 1 &

7 Configuration HL 9Flat 9Rising 9Sloping 9Cookie bite

8 X

10 Masking Interaural attenuation Reduction in sound energy travelling through the skull db AC & db BC Noise introduced to prevent crossover Bilateral HL+ ABG > db masking dilemma Do it when you need it

11 Pure Tone Audiogram o o o o Better ear first Air conduction first % correct Threshold Bone conduction & masking when needed

12 Audiogram Battery Pure Pure tone audiogram Speech Speech audiogram Impedance

13 Speech audiogram Speech reception threshold SRT Lowest dbhl subject can repeat a spondee ( 2 Syllable words with balance accent) % Ex: sidewalk, eardrum Speech discrimination score Percentage monosyllabic words repeated correctly at 4 dbsl above SRT Normal > %

14 Recruitment & Rollover Recruitment Out-of of-proportion perception of loudness Cochlear loss Metz (AR SRT < db) Rollover Paradoxical decrease in discrimination with increasing loudness Retro-Cochlear

15 Audiogram Battery Pure Pure tone audiogram Speech Speech audiogram Impedance

16 Impedance 1. Acoustic reflex 2. Tympanogram 3. Volume 4. Acoustic reflex decay % X 1 sec (db) = Hz

19 Medical Legal Requirements Patient s s name Unit Identification Code Examiner s s name Date of Test Reliability

20 Case #1 23-year old male no complaints of hearing loss, No dizziness No o tinnitus No history of otologic disease.

21 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) EFFECTIVE MKING TEOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P P P P P TEOAE Present P P P P P DPOAE DPOAE EAR MKING MKING PURE-TONE AVERAGE 2 FREQ. 3 FREQ. SDT WORD-RECOGNITION PERFORMANCE MLV SRT db HL db HL db HL MCL UCL N.U. No. 6 MARYLAND 92% 1% 45 CNC W-22 96% 1% Compact Disc PICTURE IDENTIFICATION RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI REMARKS: Tympanograms normal AU LT, FIRST, MI Case #1 DATE SS# AGE 23 SIGNATURE OF EXAMINING AUDIOLOGIST

22 Case #2 45-year old female Right progressive, hearing loss. localizing sounds, understanding conversations family history of hearing loss.

23 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) NR CONTRA NR IPSI & CONTRA TEOAE TEOAE DPOAE DPOAE EAR PURE-TONE AVERAGE 2 FREQ. 3 FREQ. SDT SRT WORD-RECOGNITION PERFORMANCE 7 db HL db HL db HL MCL UCL % 84% 1% MKING % 1% RELIABILITY MKING REMARKS: Weber lateralized right ; Bing was negative in the right ear and positive in the left ear. LT, FIRST, MI Case #2 DATE SS# AGE 45 SIGNATURE OF EXAMINING AUDIOLOGIST TYMPANOGRAMS cm 3 (in acoustic mmhos) Hz Y cm 3 (x 3 in acoustic mmhos) Hz B G Ear Canal Pressure (in dapa) surgical findings confirmed otosclerosis in the right ear Ear Canal Pressure (in dapa)

24 Case #3 4-year old male history of ear infections bilaterally since infancy.

25 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) NR IPSI & CONTRA NR IPSI & CONTRA EFFECTIVE MKING 1 khz 2 khz 3 khz 4 khz.5 khz 6 khz 1 khz 2 khz 3 khz 4 khz.5 khz 6 khz TEOAE TEOAE DPOAE DPOAE EAR MKING MKING Compact Disc PURE-TONE SDT WORD-RECOGNITION AVERAGE PERFORMANCE MLV 2 3 SRT FREQ. FREQ. db HL db HL db HL MCL UCL N.U. No % 1+ MARYLAND CNC W % PICTURE IDENTIFICATION RELIABILITY GOOD FAIR POOR UNMKED M KED UNMKED MKED IPSI ACOUSTIC REFLEXES CONTRA REMARKS: Weber was midline and Bing was negative AU at 2 & Hz LT, FIRST, MI Case #3 DATE SS# AGE 4 SIGNATURE OF EXAMINING AUDIOLOGIST TYMPANOGRAMS cm 3 (in acoustic mmhos) Hz Y cm 3 (x 3 in acoustic mmhos) Hz B G Ear Canal Pressure (in dapa) Ear Canal Pressure (in dapa)

26 Case #4 58-year old diabetes male bilateral tinnitus, Lt > Rt difficulty understanding conversation Noise for over 3 y

27 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) EFFECTIV E MKING 7 UNMKED, UNOCCLUDED.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz TEOAE TEOAE DPOAE DPOAE EAR MKING MKING PURE-TONE AVERAGE 2 FREQ. 3 FREQ. SDT WORD-RECOGNITION PERFORMANCE MLV SRT db HL db HL db HL MCL UCL N.U. No. 6 MARYLAND 84% % 65 1 CNC W-22 76% % Compact Disc PICTURE IDENTIFICATION RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI REMARKS: Tympanograms normal AU; Weber lateralized ; Bing positive AU = no response at limits of equipment LT, FIRST, MI Case #4 SS# SIGNATURE OF EXAMINING AUDIOLOGIST DATE AGE 58

28 Case #5 33-year old female fluctuating hearing loss in the right ear, Vertigo tinnitus fullness

29 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) EFFECTIV E MKING TEOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P P P P P TEOAE A bsent P P P A A DPOAE DPOAE EAR MKING MKING REMARKS: PURE-TONE AVERAGE 2 FREQ FREQ. SDT WORD-RECOGNITION PERFORMANCE Compact Disc SRT db HL db HL db HL MCL UCL N.U. No. 6 52% % MARYLAND CNC W-22 96% Stenger 1 Hz; tympanograms normal AU; Weber lateralized left; Bing was positive AU 7 4 1% MLV PICTURE IDENTIFICATION RELIABILITY GOOD FAIR POOR UNMKED M KED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI LT, FIRST, MI Case #5 SS# SIGNATURE OF EXAMINING AUDIOLOGIST DATE AGE 33

30 Case #6 47-year old male nausea, disequilibrium, right ear hearing loss tinnitus fullness -ve PMH.

31 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) EFFECTIV E MKING TEOAE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P Absent A A A TEOAE Absent A A A A A DPOAE EAR MKING MKING Compact Disc PURE-TONE WORD-RECOGNITION SDT AVERAGE PERFORMANCE MLV 2 3 SRT FREQ. FREQ. db HL db HL db HL MCL UCL N.U. No % 8 1+ MARYLAND CNC W PICTURE IDENTIFICATION % 88% 1+ RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI REMARKS: Stenger 1 Hz; tympanograms normal AU; Weber lateralized ; Bing was positive AU = no response at limits of equipment LT, FIRST, MI Case #6 DATE SS# AGE 47 SIGNATURE OF EXAMINING AUDIOLOGIST

32 Case #7 17-year old man served in World War I. difficulty understanding telephone with his right ear only 4 years of noise exposure hearing aids did not help.

33 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) NR IPSI NR IPSI EFFECTIV E MKING 8 8 UNMKED, UNOCCLUDED.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz TEOAE TEOAE DPOAE DPOAE EAR MKING MKING REMARKS: Compact Disc PURE-TONE WORD-RECOGNITION SDT AVERAGE PERFORMANCE MLV SRT FREQ. FREQ. db HL db HL db HL MCL UCL N.U. No % 16% 75 MARYLAND CNC W-22 4 PICTURE IDENTIFICATION % % 8 95 RELIABILITY GOOD 4 FAIR POOR tympanograms normal AU UNMKED MKED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI = no response at limits of equipment LT, FIRST, MI Case #7 SS# SIGNATURE OF EXAMINING AUDIOLOGIST DATE AGE 17

34 Case #8 35-ear old female feeling lightheaded for the past 8 months. Left ear 5 m decreased hearing tinnitus

35 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) NO ACOUSTIC REFLEXES EFFECTIV E MKING TEOAE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P P A P P P A bsent TEOAE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz P P P P P P P P EAR MKING MKING Compact Disc PURE-TONE WORD-RECOGNITION SDT AVERAGE PERFORMANCE MLV SRT FREQ. FREQ. db HL db HL db HL MCL UCL N.U. No % 1% 48 1 MARYLAND CNC W-22 PICTURE IDENTIFICATION % 26% % 7 1+ RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED ACOUSTIC REFLEXES CONTRA IPSI REMARKS: tympanograms normal AU LT, FIRST, MI Case #8 DATE SS# AGE 35 SIGNATURE OF EXAMINING AUDIOLOGIST

36 Case #9** 29-year old male severe hearing loss in the left ear following a work-related related head injury (blow to head). significant noise exposure during a 2-year2 The patient repeatedly expressed hearing problems during the interview, despite having no complaints of hearing loss in the right ear

37 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) S S S S E FFECTIV E M KI NG UNMKED, UNOCCLUDED TEO AE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P P P P P P P TEOAE DP OA E.5 khz 1 khz 2 khz 3 khz4 khz 6 khz Present P P P P P P P P P EAR MKING MKING PURE-TONE AVERAGE 2 FREQ. 3 3 FREQ. SDT * S WORD-RECOGNITION PERFORMANCE 4 REMARKS: = Stenger Threshold Estimates *half-w ord respon se s = no response at limits of equipm ent 8 Compact Disc MLV SRT db HL db HL db HL MCL UCL N.U. N o. 6 1% 1% 45 MARYLAND CN C W-22 1% 7 PICTUR E IDENTIFICATION RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED AC OUSTIC REFLEXES CONTRA IPSI LT, FIRST, MI SS # Case #9 DATE AGE 29 SIGNATURE OF EXAMINING AUDIOLOGIST

38 Pseudohypacusis PTA & SRT 1 db Retest > 5 db No cross-over over AC > BC Objective test Acoustic reflex OAE ABR

39 Special test Stenger test Pseudohypacusis 5db above good ear & 5db below poorer ear No response ( +ve+ ve) Lee test Stutter with delay played back subjects sound Lombard test Increase voice with increasing background noise

40 Case #1 68-year old male gradual decrease in his hearing for years, occasional tinnitus. noise exposure in the armed services,

41 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) I I I I II E FFECTIV E M KI NG TEO AE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz P P?? resent P P?? TEOAE DP OAE.5 khz 1 khz 2 khz 3 khz4 khz 6 khz P P? A P P? A bsent Compact Disc EAR PURE-TONE WORD-RECOGNITION SDT AVERAGE PERFORMANCE MLV 2 3 SRT MCL UCL FREQ. FREQ. db HL db HL d B HL N.U. N o % % MARYLAND CN C W-22 MKING PICTURE IDENTIFICATION % 92% 68 1 RELIABILITY GOOD MKING FAIR POOR REMARKS: I tympanograms normal AU = Insert Earphone Thresholds UNMKED MKED UNMKED MKED AC OUSTIC REFLEXES CONTRA IPSI LT, FIRST, MI Case #1 DATE SS # AGE 68 SIGNATURE OF EXAMINING AUDIOLOGIST

42 Case #11 49-year old male hearing loss and mild periodic tinnitus. difficulty understanding the speech History of military noise exposure

43 AUDIOLOGICAL CONSULTATION LEFT EA R () RIGH T EA R ( ) HEARING LEVEL IN db (ANSI, 1996) A A A A A A A A A A A A E FFECTIV E M KI NG TEO AE DPOAE.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz Present P P A P P P A bsent TEOAE DP OA E.5 khz 1 khz 2 khz 3 khz4 khz 6 khz P P P A P P P A EAR MKING MKING REMARKS: PURE-TONE AVERAGE 2 FREQ. 3 FREQ. SDT WORD-RECOGNITION PERFORMANCE Compact Disc MLV SRT db HL db HL d B HL MCL UCL N.U. N o. 6 8% 1% 65 1 MA RYLA ND CN C W-22 84% 8 1% 65 1 Tympanograms normal AU A = thresholds through CIC hearing aid; binaural word recognition through CIC was 96% PICTURE ID ENT IF ICAT IO N RELIABILITY GOOD FAIR POOR UNMKED MKED UNMKED MKED AC OUSTIC REFLEXES CONTRA IPSI LT, FIRST, MI Case #11 DATE SS # AGE 49 SIG NATURE OF EXAMINING AUDIOLOG IST

44 Case #12 76-year old male sensorineural hearing loss years constant bilateral tinnitus behind-the the-ear ear hearing aids with little success can not use any telephone, including those equipped with amplifiers. The patient is in good medical condition.

45 LEFT EAR () AUDIOLOGICAL CONSULTATION RIGHT EAR () HEARING LEVEL IN db (ANSI, 1996) A A A A A E FFECTIV E M KI NG UNM KED, U NOCC LUD ED.5 khz 1 khz 2 khz 3 khz 4 khz 6 khz.5 khz 1 khz 2 khz 3 khz4 khz 6 khz TEO AE TEOAE DPOAE DP OA E EAR MKING MKING REMARKS: PURE-TONE AVERAGE 2 FREQ. 3 FREQ. SDT WORD-RECOGNITION PERFORMANCE 1 Compact Disc MLV SRT db HL db HL db HL MCL UCL N.U. N o. 6 4% >1 MARYLAND CN C W-22 % >1 PICTUR E IDENTIFICATION RELIABILITY GOOD FAIR POOR Tympanograms normal AU; Word recognition with hearing aid was 12%. UNMKED MKED UNMKED MKED AC OUSTIC REFLEXES CONTRA IPSI A = thresholds with hearing aid = no response at limits of equipm ent LT, FIRST, MI SS # Case #12 SIGNATURE OF EXAMINING AUDIOLOGIST DATE AGE 76

PERIPHERAL AND CENTRAL AUDITORY ASSESSMENT

PERIPHERAL AND CENTRAL AUDITORY ASSESSMENT Ravi Pachigolla, MD Faculty Advisor: Jeffery T. Vrabec, MD The University of Texas Medical Branch At Galveston Department of Otolaryngology Grand Rounds Presentation