+ taediatric audiology ‘Thon oP Chapter 6 Pure tone audiometry J i aig | stan a ri WALLY WOOD Introduction Hite tone audiometry is the procedure most commonly used for the Aieasurement of hearing impairment, Pure tones, that is tones with a " itagle frequency of vibration, are presented via headphones (air con is) duction) or via a bone vibrator (bone conduction) and the patient's _Weiistivity at discrete frequencies is measured. When stimuli are pre- "Waited through headphones the sound travels through the outer and ~__iilddte ear ~ the conducting mechanism ~ before reaching the cochlea il auditory nerve. Abnormal pathology at any stage in this pathway {hy affect air conduction sensitivity. When stinmuli are presented via the {inne conductor it is assumed that the stimulus reaches the cochlea lrough vibration of bone and soft tissue. Abnormal pathology occur « {hg at or beyond the cochlea may affect sensitivity of bone conduction. {lie lowest level at which a pure tone stimulus can be heard through tiie headphone is known as the air conduction threshold at that fre- fienicy and the quietest stimulus that can be heard when the bone | Uiliitor is placed on the mastoid bone is known as the bone conduc- Mon threshold for that frequency. Threshold is defined precisely later in ills chapter. Comparison of air and bone conduction thresholds (the lf-bone gap) provides a means of quantifying the amount of conduc- le hearing impairment. Some important provisos to the assumptions Iwlating to bone conduction will be discussed later. ‘The purpose of pure tone audiometry is to measure the threshold of MWiting using both air and bone conduction and thus to arrive at a ileneription of the degree and type of hearing impairment. the audiometer Aidiometers range from the simple screening types, with a facility for |] Aivconduction measurement at a restricted range of frequencies and liionsities, to the complex clinical types with facility for a range of clini- q 155156 Paediatric audiology Pure, cal tests as well a5 measurement of pure tone threshold. For clinical ‘hat comes purposes the frequency range usually extends from 125 Hz to 8 kHz in ues (Giosceee t0 the averag octave intervals, the octave increase corresponding to a doubling of the RETSPL) yar Fence equ, previous frequency. The steps are therefore: coupler Ra ith frequency i cial; 1252 250Hx Soovz 1kilz 2kiz 4k Sz ae This he acambiton ion, or 49 ‘The following intermediate frequencies are also inchuded in most Tom39 acoustic coupler is y clinical audiometers: Gushlons ore aa st Tor 15M Ski — 6kttz ce O97, mc ee brave earphone or ¢ ‘The intensity is calibrated in steps of 5 dB and extends from -10 dB techeteat can aificiat =f up to a maximum value which varies with frequency but is most com- | tionally ae, < Talent to th 314 monly 120 dB in the mid frequencies for air conduction. This decibel In recent regu Is for cin scale is known as dB HL and has been especially constructed for pure Insert eanphoca iMetestin the y tone audiometric measurements. The sensitivity of the human ear Problem of eons 2°, 9 Fequire varies with frequency, being most sensitive in the mid frequencies. It higher ambjo*PSIN8 ear canals, would be clumsy and inconvenient to have a normal value for thresh: Inca ee noise levels (Berg old that varies with the frequency under test and, therefore, the dB Hl (Frank and Richanga, MeMUation seale was constructed such that 0dB HL corresponds to the normal 1988; Fang s*95, 1991), Severet threshold (for young adults with no history of ear disease or noise Insere exon 204 Richards, 1999)", exposure) at each frequency. The actual output sound pressure level | Organization rs 2% RETSPLs have from the headphone (or bone vibrator) at a dial setting of 0 dB HL will Or Standardization (1s be different at different frequencies. Any pure tone threshold measur | jigne ent is, therefore, a statement of how many decibels better or worst ‘Conduction the hearing is than normal. Ihe bone vibrator j is calibrated i ‘oup! Standards for audiometers ‘The standard that governs the specification of audiometers is BS 590i | (1980), which is equivalent to IEC 645 (1988). Audiometers are divideil_) into five types, TEC types 1-5, according to the facilities that they poy | Mila static fo, refer to a sess. For each type egeaiar Te a toes frequencies that UMMM band = Of 5.4 N with nea be available, together with the maximum and minimum hearing I i I Ea, The vibeaeae cet OF 35 dB a for air and bone conduction at each frequency. It also defines the OF 150-200 sor Should have a pia tre and cutoff frequencies for narrow-band masking noise at each vibrators thar nn, ree Radioear f. quency and acceptable deviations from nominal performance in te! hanical couples SPY With the stanc of frequency, output, harmonic distortion levels and rise and fall ii | 9 4009 (agg 10°! 88d for bone cons for pure tone stimuli. . ?. whlch is equivalent n Air conduction 1) Wilbration of audiom, 3S 2497 (1972) (and is equivalent ISO 389 (1991)) give values for | MIWA sacies (a ans sound pressure levels produced in the acoustic coupler or artificlal In Performan en 1968; Fearn, 19%Hille tone audiometry 157 |_Pednreaudtohay ment of gute tireshold. For clinienl ge usualy ete fom 125 Fiz. to 8 KEK I nncrease carting to a doubling of the 3s are ther: {lit correspond to the average normal threshold of hearing, These val- © its (known as reference equivalent threshold sound pressure levels ~ HWTSPL) vary with frequency and are measured either in an acoustic ip {oupler or in aa artificial ear. They are a function of the precise ear- | hone/cushion combination used. The most common combination in {lw UK is the TDH 39 or 49 earphone with MX 41 AR supra-aural cush- | In, ‘The acoustic coupler is used for the calibration of Telephonics J1I-39 and Beyer D1-048 earphones used with MX 41 AR supra-aural uishlons. The characteristics of the acoustic coupler are given in BS AjO8 (1973), which is technically equivalent to IEC 303 (1970a). All Jahr types of earphone or earphone/eushion combinations are cali- ¢ Sie tik due okt: date freqenis x so inchuded in mnt it i i ae i SH Bend with an artificial ear complying with BS 4669 (1971), which is ee from -10 ii) Welsneally equivalent to IEC 318 (1970). There are as yet no interna- Ee a arnt is most cone il Jhowsilly accepted standards for circumaural cushions. pe aren i Tn recent years interest in the use of insert earphones has increased. frequence lita cnduction. This decibel and hasbectepaily constructed for purl rements Iiesaitity of the human car we norman fem ) | __Iiwert earphones do not require the use of a headband, prevent the © finblem of collapsing ear canals, allow audiometry to be ¢arried out in "higher ambient noise levels (Berger and Killion, 1989) and provide liWressed intra-aural attenuation ,thus reducing the need for masking onvenietb fees urnal value for et tdnk and Richards, 1991). Several scadies (Wilber, Kruger and Killion, Cetin Wht; Frank and Richards, 1991) have investigated the calibration of haku Fe eponds liwert earphones and RETSPLs have been specified by the International ut winter das of | yunaton frSandudton (30 39,989) sone vibav) tad setting of 0 dB HL will sequencis Al pure ione threshold measure: 7 None conduction ‘ement offi taly decibels better or Worst The bone vibrator is calibrated in terms of the vibratory force fevels a. wansmitted to the mechanical coupler when che vibrator is excited Aalectrically at the level corresponding to normal hearing threshold. Liometn ‘ose values (known as reference equivalent threshold force levels - Wet) are given in BS 6950 (1988), which is technically equivalent to mn is BS 5966 as the siti of audiomerers is BS 5904 9) i) 9566 (1987), and refer to a vibrator applied to the mastold process goto Rene) close so ivi TP With static force of 5.4 N with the nontest ear being masked by a nar- 2115, ast ais that th? POE cr ea level of 35 dB above the pare fone threshold of a ee eae thie ear. The vibrator should have a plane circular driving face with an ith the ates minimum hearing fev! 7 (oi of 150-200 mm®. The Radioear B-71 and B-72 are widely used ction atexhlewency. It also defines the cent jes for nsmind masking noise at each fe deviatiowtin wninal performance in ternit armonic tis levels and rise and. fall time | Ione vibrators that comply with the standard. The characteristics of the inechanical coupler used for bone conduction calibration are given in IW 4009 (2991), which is equivalent to IEC 373 (second edition) (1990). (Calibration of audiometers lioyeral studies (Martin, 1968; Fearn, 1976) have highlighted the varia- ‘ for the aicqprdtt 9 0991)) give vals ) Won in performance of audiometers in regular clinical use. Regular producditteustic coupler or artificial ear |