ACSD 622: Auditory

Diagnostics I, Laboratory

Lab Manual

Course Instructor: Candace Robinson, Au.D.

Manual created and updated by:

Jennifer Smart, Ph.D.

ACSD 622: Auditory Diagnostics I, Laboratory

Dr. Robinson

Table of Contents

Pure Tone Audiometry Procedure

Modified Hughson Westlake Procedurepage 2

ASHA 2005 Procedurepage 2

Bone Conduction Testing - Unmaskedpage 3

GSI Audiometerpage 3

Describing Audiometric Resultspage 4

Practice Audiograms

Conductive Hearing Losspages 5-8

Sensorineural Hearing Losspages 9-12

Mixed Hearing Losspages 13-16

Speech Audiometry Procedure

Audiometer Instructionspage 17

Speech Recognition Testingpages 17-19

Word Recognition Testingpages 19-20

Speech Recognition Thresholds (Familiarization & Thresholds)pages 21-22

Reporting Results of Pure Tone and Speech Audiometrypage 23-24

Masking

Audiometer Set-Uppages 25-26

Masking Rules and Regulationspage27-28

Acoustic Immittance Testing

Tympanometrypage29

Acoustic Reflex Threshold Testingpage 29-30

Tympanometry Normative Datapage 31

Sample Report Wording for Immittance Testingpage 31

Otoacoustic Emissions

Brief Description and Equipment Instructionspage32-36

Sample Clinical Reportpages 37-39

Referencespage40

Pure Tone Audiometry Procedures

Modified Hughson-Westlake Technique: (this is the same as your clinic manual)

Harrell, R.W. (2002). Puretone evaluation. In J. Katz (Ed.),Handbook of clinical audiology (5th

ed.) (pp.71-87). Philadelphia:Lippincott Williams & Wilkins.

  1. Present tone at audible level (30 dB if normal hearing, 70 dB HL if suspected hearing loss)
  2. If no response, increase in 20 dB steps until patient responds
  3. Once patient responds, level is reduced in 10 dB steps until patient does not respond
  4. Then “up 5, down 10” begins
  5. Use the ANSI S3.21 determination for threshold (50% of ascending trials, with a minimum of 2 out of 3 responses required at a single level)

For this technique you begin at 30 dB HL or suprathreshold for all test frequencies

Test frequencies and order: 1, 2, 4, 8, 1, .5, .25 kHz and interoctaves when 20 dB or greater difference in thresholds is found for adjacent test frequencies

Interoctaves (3 & 6 kHz) should be tested when a noise-induced hearing loss is suspected and/or hearing aids will be recommended

ASHA 2005 method

American Speech-Language-Hearing Association. (2005). Guidelines for ManualPure-Tone

Threshold Audiometry [Guidelines]. Available from

Familiarization (only for 1 kHz!):

  1. Begin at 1 kHz
  2. Present tone at audible level (30 dB if normal hearing, 50 dB HL if suspected hearing loss); If no response is obtained increase in 10 dB steps until patient responds.
  3. Once patient responds, level is reduced in 10 dB steps until patient does not respond any more
  4. Then “up 5, down 10” begins (find and record threshold at 1kHz)

Threshold seeking (use these rules for all other frequencies!):

  1. This method uses an ascending technique (you will begin with an inaudible signal, well below expected threshold) for all other test frequencies
  2. Then “up 5, down 10” begins
  3. Use the ANSI S3.21 determination for threshold is utilized (50% of ascending trials, with a minimum of 2 out of 3 responses required at a single level)

For this technique you begin at 30 dB HL or suprathreshold for 1 kHz only. All other test frequencies you begin below threshold (then start “up 5, down 10”)

Test frequencies and order: 1, 2, 3, 4, 6, 8, 1, .5, .25 kHz and interoctaves when 20 dB or greater difference in thresholds is found for adjacent test frequencies.

Bone Conduction Testing *** For BC testing, despite AC method, test 500, 1000, 2000 and 4000 (250 in special cases) at 10 dB poorer than AC threshold (e.g., AC = 30 dB HL, start testing unmasked BC at 40 dB HL). Continue the down 10 up 5 method and threshold should be based upon 2 ascending responses at the same level. ****

GSI-61 Clinical Audiometer

Describing Audiometric Results

Degree of Hearing Loss

Threshold in dB HL / Degree of Hearing Loss
≤ 15 / Normal hearing
16-25 / Slight hearing loss
26-40 / Mild hearing loss
41-55 / Moderate hearing loss
56-70 / Moderately-severe hearing loss
71-90 / Severe hearing loss
≥90 / Profound hearing loss

Modified from Gelfand, 2009

Configuration of Hearing Loss

Term / Description
Flat / ≤5 dB average difference/octave
Gradually sloping (or rising) / 6-10 dB fall or rise/octave
Sharply sloping (or rising) / 11-15 dB fall or rise/octave
Precipitously sloping (or rising) / ≥ 16 dB fall or rise/octave
Rising / Better hearing in the higher frequencies
Trough, saucer or cookie bite / ≥ 20 dB or more loss at middle frequencies (as compared to 250 Hz and 8000 Hz)
Notch / Sharply poorer at one frequency, with recovery at adjacent frequencies (e.g., noise notch)

Table 5.5 modified from: Harrell, R. (2002). In J. Katz (Ed.). Handbook of Clinical Audiology, 5th ed. Baltimore: Lippincott, Williams & Wilkins

Practice Audiograms

Please use the following as sample audiograms – practice writing out the descriptions (degree/type/configuration) for each audiogram.

Conductive Hearing Loss, pages 5-8

Sensorinueral Hearing Loss, pages 9-12

Mixed Hearing Loss pages, 13-16

CHL #1

CHL #2

CHL #3

CHL #4

SNHL #1

SNHL #2

SNHL #3

SNHL #4

Mixed HL #1

Mixed HL #2

Mixed HL #3

Mixed HL #4

Speech Audiometry Audiometer Instructions

GSI-61

  1. Select appropriate stimulus (“Mic” for monitored live voice or “Ext A” (or Ext B) for recorded speech)
  2. Select appropriate transducer.
  3. To calibrate for monitored live voice:
  4. Set stimulus intensity to -10 dB HL
  5. Press “Interrupt”
  6. Practice saying test words. Make sure your voice is peaking at 0 dB on the VU meter. If it is not, adjust the “Test Mic” dial.
  7. To calibrate for recorded speech:
  8. Set stimulus intensity to -10 dB HL
  9. Press “Interrupt”

Play the calibration track of your CD and adjust the sensitivity using the “Ext A” dial until the calibration tone peaks at 0 dB on the VU meter.

Astera

Speech Audiometry Testing Manual for Astera Audiometer

To speak directly to patient during testing:

  1. Press and hold “talk forward” button located at the bottom center of the audiometer control panel
  2. To change output level
  3. Press and hold “talk forward” button
  4. Use mouse to move the level indicator on the bar labeled “Output Level (dB HL)”
  5. When done speaking to patient, release the “talk forward” button

Speech Recognition Threshold (SRT) testing

To use Recorded Speech testing built into audiometer:

  1. Press SRT button to switch to speech screen (located under Test “Speech” options on control panel)
  2. Set-up channel settings in left box on screen
  3. Stimulus Source A
  4. Select Int. File (Internal File) from drop down menu located under stimulus
  5. To select pre-loaded spondee list:
  6. At center of screen in the “speech box” (has word list options, play, stop, etc.), select browse, the last option in the drop down menu
  7. Follow this sequence to use appropriate word list: Browse  GN Otometrics  OTO Suite  Word Lists  OTO Suite WordLists – US  Spondee Limited List
  8. Press OK
  9. To calibrate:
  10. Select “Track 1 – Calibration tone.mp3” from the drop down menu in the speech box
  11. Using the dB dial, turn the dB level to an in-audible level (-5 dB for example) before playing the calibration tone
  12. On the audiometer control panel, press “continuous on” located on the left side of the panel under channel 1 options and press “Monitor Speaker”
  13. Press the play symbol in speech box to play the calibration tone (should notice the stimulus bar on the top left of the screen turning green)
  14. Calibrate to 0 by clicking the up/down arrows for SOURCE A level in the bottom of the channel settings box under the heading “Monitor Level”
  15. When calibration is complete, press the stop symbol to turn off the tone
  16. To find SRT:
  17. From drop down menu in the speech box on the screen, select “02 – Adult Spondee List 1.mp3”
  18. Using the Channel 1 dB dial, adjust the presentation level to desired dB
  19. Make sure “continuous on” and “Monitor Speaker” are pressed in order to present stimulus
  20. Click the play symbol in the on screen speech box or the play symbol on control panel (located on the right side) to begin presentation of list
  21. Threshold seek by turning dB dial to change the presentation level
  22. When SRT is found, press the stop symbol to discontinue presentation
  23. To STORE threshold, press the “STORE” button on the control panel or click the “STORE” button located at the top left of the computer screen

To use Monitored Live Voice:

  1. Press SRT button to switch to the speech screen (located under Test “Speech” options on control panel)
  2. Set-up channel settings
  3. Stimulus Microphone
  4. Select “desktop mic” under “operator mic” options located on the left of the control panel
  5. To calibrate:
  6. Using the dB dial, turn the dB level to an in-audible level (-5 dB for example) before playing the calibration tone
  7. On the audiometer control panel, press “continuous on” located on the left side of the control panel under channel 1 options and press “Monitor Speaker”
  8. Begin speaking into table microphone (should notice the stimulus bar on the top left of the screen turning green)
  9. Calibrate to 0 by pressing the up/down arrows for MIC level in the bottom of the channel settings box under the heading “Monitor Level”
  10. When calibration is complete, press the “continuous on” button to turn off microphone while setting up for actual SRT testing
  11. To find SRT:
  12. Using the Channel 1 dB dial, adjust the presentation level to desired dB level
  13. Press the “continuous on” button for channel 1 to begin presentation of MLV
  14. Threshold seek by turning dB dial to change the presentation level
  15. When SRT is found, turn off the microphone by pressing the “continuous on” button
  16. To STORE threshold, press the “STORE” button on the control panel or click the “STORE” button located at the top left of the computer screen

Word Recognition Testing (to obtain a Word Rec. Score (WRS))

To use Recorded Speech testing built into audiometer:

  1. Press “WRS/SRS” button to switch to WRS testing (located under Test “Speech” options on control panel)
  2. Set-up channel settings in left box on screen
  3. Stimulus Source A
  4. Select Int. File (Internal File) from drop down menu located under stimulus
  5. To select pre-loaded spondee list:
  6. At center of screen in the “speech box” (has word list options, play, stop, etc.), select browse, the last option in the drop down menu
  7. Follow this sequence to use appropriate word list: Browse  GN Otometrics  OTO Suite  Word Lists  OTO Suite WordLists – US  NU-6 Ordered by Difficulty  NU-6 Ordered by Difficulty
  8. Press OK
  9. To calibrate:
  10. Select “01 Calibration Tone.mp3” from the drop down menu in the speech box
  11. Using the dB dial, turn the dB level to an in-audible level (-5 dB for example) before playing the calibration tone
  12. On the audiometer control panel, press “continuous on” located on the left side of the panel under channel 1 options and press “Monitor Speaker”
  13. Press the play symbol in speech box to play the calibration tone (should notice the stimulus bar on the top left of the screen turning green)
  14. Calibrate to 0 by pressing the up/down arrows for SOURCE A level in the bottom of the channel settings box under the heading “Monitor Level”
  15. When calibration is complete, press the stop symbol to turn off the tone
  16. To find WRS:
  17. From drop down menu in the speech box on the screen, select desired word list, always starting with words 1-10
  18. Using the Channel 1 dB dial, adjust the presentation level to desired dB
  19. Make sure “continuous on” and “Monitor Speaker” are pressed in order to present stimulus
  20. Click the play symbol in the on screen speech box or press the play symbol on the control panel (located on the right side) to begin presentation of list
  21. To keep track of correct and incorrect responses, click the +/- symbols in the speech box on the screen or press the “incorrect/correct” buttons on the right side of the control panel
  22. **NOTE** in order to present words 11-25 and 26-50 of selected word list, must select that CD track from the drop-down menu in the speech box and press play, the Astera will not automatically switch to the next track like a CD player
  23. When WRS testing is complete, press the stop symbol to discontinue presentation
  24. To STORE threshold, press the “STORE” button on the control panel or click the “STORE” button located at the top left of the computer screen

To use Monitored Live Voice:

  1. Use same steps as SRT MLV for channel set-up, calibration, and presentation (only difference is that “WRS/SRS” button should be selected for type of speech test)

To use CD player for SRT or WRS:

  1. Press “SRT” or “WRS/SRS” to specify which speech test is being completed
  2. Set-up channel settings in left box on screen
  3. Stimulus Source B
  4. Select “Line-In” from drop down menu located under stimulus
  5. Turn CD Player ON
  6. Select disc number
  7. To calibrate:
  8. Select Track 01 of CD (most likely the calibration tone unless otherwise noted)
  9. Using the dB dial, turn the dB level to an in-audible level (-5 dB for example) before playing the calibration tone
  10. On the audiometer control panel, press “continuous on” located on the left side of the control panel under channel 1 options and press “Monitor Speaker”
  11. Press the play symbol on the CD Player to play the calibration tone (should notice the stimulus bar on the top left of the screen turning green)
  12. Calibrate to 0 by pressing the up/down arrows for SOURCE B level in the bottom of the channel settings box under the heading “Monitor Level”
  13. When calibration is complete, press the stop or pause symbol on the CD Player to turn off the tone
  14. To find SRT or WRS:
  15. Using the Channel 1 dB dial, adjust the presentation level to desired dB
  16. Make sure “continuous on” and “Monitor Speaker” are pressed in order to present stimulus
  17. Press the play symbol on the CD Player
  18. Find SRT or WRS
  19. When SRT or WRS is found, press the stop symbol on the CD Player to discontinue presentation
  20. To STORE threshold, press the “STORE” button on the control panel or click the “STORE” button located at the top left of the computer screen

Speech Recognition Thresholds: Familiarization and Threshold Seeking

Use of MLV or recorded speech (**this can also be used to familiarize your patient with the recorded spondees):

  1. Instruct patient on the task
  2. Familiarize the patient with the test words at a comfortable level (e.g., 50 dB HL if they have normal hearing). Present 4 words at comfortable level, then drop down 5 dB and present 4 new spondees, drop down 5 dB again and present 4 new spondee words (at this point you have exposed the patient to 12 spondee words and introduced the task).
  3. Begin testing the patient (you do not need to tell them you are beginning). Present the first word at 25 dB SL (re: 2 or 3 frequency PTA), if the patient is correct drop down 10 dB (continue to present one word and drop down in 10 dB increments until they get a word incorrect). Once they get a word incorrect begin DOWN 10 UP 5 threshold seeking method.
  4. Threshold is obtained on 2 ascending runs 50% of the time (2 out of 4 words correct for each of the ascending runs).

See example page 22

SRT Example: (MLV or recorded speech):= word was said correctly

Right PTA: 10

First RunSecond RunThird RunFourth Run

50 dB HL (familiarize)

45 dB HL (familiarize)

40 dB HL (familiarize)

35 dB HL

30 dB HL

25 dB HL

20 dB HL

15 dB HL

10 dB HL

5 dB HLNo No No (threshold = 5 dB HL)

0 dB HLNo No NoNo No No

-5 dB HLNo No No No No No

Reporting Results of Pure Tone and Speech Audiometry

Sample wording for pure tone testing and speech testing:

Example 1:

An otoscopic examination was performed. Both tympanic membranes were clearly visible and appeared intact; however, scarring was apparent on the left eardrum. Results of pure tone audiometry indicated hearing within normal limits with a mild conductive hearing loss at 500 Hz in the left ear only. An asymmetry of 20 dB HL was noted at 500 Hz. The 3-frequency pure tone averages (PTAs) were 8 dB HL in the right ear and 18 dB HL in the left ear.

Speech audiometry was also performed today. Speech Recognition Thresholds (SRTs) were obtained using recorded male speech of spondee words. The patient’s SRTs were 10 dB HL in the right ear and 15 dB HL in the left ear. These results are in good agreement with the patient’s PTAs bilaterally, indicating acceptable test validity. Word recognition testing was administered via monitored live female voice of NU-6 ordered-by-difficulty word lists. At presentation levels that were 40 dB SL (re: SRT), the patient had Word Recognition Scores (WRS) of 100% bilaterally. These scores are expected based on the patient’s pure tone averages (re: Dubno et al., 1995).

Example 2:

An otoscopic examination was conducted. The visual inspection revealed that both canals had a minimal amount of cerumen and pressure equalization tubes were present, which were verified as being patent via tympanometry. Pure tone testing revealed a mild conductive hearing loss (250-500 Hz) rising to normal hearing, bilaterally. The two frequency Pure Tone Averages (PTAs) were 13 dB HL bilaterally.

Speech Recognition Thresholds (SRTs) were 10 dB HL bilaterally. The PTA – SRT agreement was good, indicating acceptable test validity. Word Recognition Scores (WRS) were obtained using the CID W-22 wordlist 3A. Twenty-five words were presented per ear via monitored live female voice. A score of 100% was obtained at a presentation level of 50 dB HL (40 dB SL re: SRT), bilaterally.

Example 3:

An otoscopic examination was conducted. Both canals were free of cerumen and both tympanic membranes were clearly visible and intact. The pure tone thresholds were measured and results indicated a mild sloping to moderately-severe (1500-3000 Hz) rising to a moderate sensorineural hearing loss for the right ear and a mild (250-500 Hz) sloping to severe sensorineural hearing loss for the left ear. Three frequency Pure Tone Averages (PTAs) were 52 dB HL for the right ear and 58 dB HL for the left ear.

Speech Recognition Thresholds (SRTs) were 50 dB HL and 55 dB HL for the right and left ear, respectively. The PTA – SRT agreement was good, indicating acceptable test validity. Word Recognition Scores (WRS) were obtained using NU-6 word lists (ordered by difficulty) presented using monitored live female voice. A score of 76% was obtained for the right ear at a presentation level of 80 dB HL (30 dB SL re: SRT). A score of 42% was obtained for the left ear at a presentation level of 85 dB HL (30 dB SL re: SRT). Both presentation levels were presented at his Most Comfortable Listening Levels (MCLs). The word recognition scores obtained are consistent with the expectations based on his PTAs (re: Dubno et al., 1995).