Tuning-fork tests

A qualitative assessment of hearing loss can be carried out with a tuning fork. Such tests exploit the ability of sound to be conducted through the bones of the skull.

In the Rinne test the sounding tuning fork is placed on the mastoid process, and the person being tested is asked to report when it is no longer heard. The examiner then removes the fork immediately and holds the prongs close to the open ear canal. The normal ear continues to hear it for about 45 seconds, and this “positive” result occurs also with incomplete sensorineural impairment of hearing. When the result is “negative” and the fork is heard longer by bone conduction than by air conduction, a conductive type of deafness is present. In the Schwabach test the presence of a sensorineural impairment is indicated when the individual being tested cannot hear the bone-conducted sound as long as the examiner with normal hearing can. The individual with a conductive hearing loss, however, can hear the fork for a longer period of time than the examiner because the conductive lesion excludes the extraneous airborne masking noise of the surroundings. A bone-conduction audiometer would give a similar result.

For the Weber test, the fork is simply placed on the person’s forehead, and the examiner asks in which ear the person hears it. If a sensorineural lesion is present in one ear, the person will localize the sound in the opposite, or “better,” ear. If a conductive defect is present, the person will localize it in the “worse” ear—i.e., the one that is protected from interference by extraneous sounds. This simple test has been a valuable aid in the diagnosis of otosclerosis for many years.

Audiometry

With the introduction of the electric audiometer in the 1930s, it became possible to measure an individual’s hearing threshold for a series of pure tones ranging from a lower frequency of 125 hertz to an upper frequency of 8,000 or 10,000 hertz. This span includes the three octaves between 500 and 4,000 hertz that are most important for speech.

The audiometer consists of an oscillator or a signal generator, an amplifier, a device called an attenuator, which controls and specifies the intensity of tones produced, and an earphone or loudspeaker. The intensity range is usually 100 dB in steps of 5 dB. The “zero dB” level represents normal hearing for young adults under favourable noise-free laboratory conditions. It was established in 1964 as an international standard.

In pure-tone audiometry, each ear is tested separately while the other is shielded against sound. The person being tested wears an earphone or sits in front of a loudspeaker in a quiet test chamber, having been instructed to give a hand signal whenever a brief tone is sounded. The audiologist proceeds to determine the lowest intensity for each frequency at which the person reports being just able to hear the tone 50 percent of the time. For example, one who hears the tone of 4,000 hertz only half the time at the 40-dB setting has a 40-dB hearing level for that frequency—i.e., a threshold 40 dB above the normal threshold. A graph showing the hearing level for each ear by octaves and half octaves across the frequency range of 125 to 8,000 hertz is called an audiogram. The shape of the audiogram for an individual who is hard of hearing can provide the otologist or audiologist with important information for determining the nature and cause of the hearing defect. (The audiologist is primarily concerned with measuring the degree of hearing impairment; the otologist diagnoses and treats defects and diseases of the ear by medical or surgical means.)

A calibrated bone-conduction vibrator usually is furnished with the audiometer so that hearing by bone conduction also can be measured. When an individual has otosclerosis or another conductive defect of the middle ear, there may be a sizable difference between the air-conduction and bone-conduction audiograms, the so-called air-bone gap. This difference is a measure of the loss in transmission across the middle ear and indicates the maximum improvement that may be obtained through successful corrective surgery. When the defect is confined to the organ of Corti, the bone-conduction audiogram shows the same degree of loss as the air-conduction audiogram. In such cases of sensorineural impairment, surgery is seldom capable of improving hearing, but a hearing aid may be helpful.

Although faint sounds may not be heard at all by the ear with a sensorineural impairment, more intense sounds may be as loud as they are to a healthy ear. This rapid increase in loudness above the threshold level is called recruitment. When the opposite ear has normal hearing, recruitment can be measured by the alternate binaural loudness balance test. The subject is asked to set the controls so that the loudness of the tone heard in the defective ear matches that of the tone heard in the normal ear. By repeating the comparison at several intensity levels, the presence or absence of recruitment can be demonstrated. When recruitment is excessive, the range of useful hearing between the threshold and the level at which loudness becomes uncomfortable or intolerable may be narrow, so that the amplification provided by a hearing aid is of limited value to the subject.

Although hearing thresholds for pure tones give some indication of the person’s ability to hear speech, direct measurement of this ability is also important. Two types of tests are used most often. In one test the speech reception threshold is measured by presenting words of spondee pattern—i.e., words containing two syllables of equal emphasis, as in “railway” or “football”—at various intensity levels until the level is found at which the person can just hear and repeat half the words correctly. This level usually corresponds closely to the average of the person’s thresholds for frequencies of 500, 1,000, and 2,000 hertz. A more important measure of socially useful hearing is the discrimination score. For this test a list of selected monosyllabic words is presented at a comfortable intensity level, and the subject is scored in terms of the percentage of words heard correctly. This test is helpful in evaluating certain forms of hearing impairment in which the sounds may be audible but words remain unintelligible.

Such tests are usually carried out in a quiet, sound-treated room that excludes extraneous noise. They may give an overly optimistic impression of the ability of the individual with a sensorineural impairment to understand speech in ordinary noisy surroundings. For this reason, speech tests are best carried out against a standardized noise background as well as in the quiet. A person with a conductive defect may be less disturbed by the noisy environment than a healthy subject. More elaborate tests, which often involve speech or sound localization, are available for evaluating hearing when central defects of the auditory system are suspected as a result of aging, disease, or injury. Their interpretation may be difficult, however, and the diagnostic information they furnish may be unclear.

When the hearing of infants or others who are unable to cooperate in standard audiometric tests must be measured, their thresholds for pure tones can be established by electrophysiological means. One type of test is the electrocochleogram (ECoG). Electric potentials representing impulses in the cochlear nerve are recorded from the outer surface of the cochlea by means of a fine, insulated needle electrode inserted through the tympanic membrane to make contact with the promontory of the basal turn. This test provides a direct sampling of cochlear function.

A noninvasive, painless, and more frequently used test is brain-stem-evoked response audiometry (BERA). In this test electrodes are pasted to the skin (one placed behind the ear) and are used to record the neural responses to brief tones. The minute potentials evoked by a train of brief sound stimuli are suitably amplified and averaged by a small computer to cancel out background activity, such as potentials from muscles or the cerebral cortex. The typical recording shows a series of five or six waves that represent the responses of successive neural centres of the auditory pathway of the brainstem and provide information about the strength and timing of their activity.

A simple and objective means of testing hearing at the level of the cochlea and brainstem is supplied by impedance audiometry. Two small tubes are sealed into the external canal. Through one tube sound from a small loudspeaker is injected into the canal. The portion that is reflected from the tympanic membrane is picked up by the other tube and led to a microphone, amplifier, and recorder. When a sudden moderately intense sound is applied to the opposite ear, the stapedius muscle contracts, the impedance is increased, and the recorder shows a slight excursion as more sound is reflected. This test can provide information not only about the condition of the cochlea and the auditory pathways of the medulla but also about the facial nerve that innervates the stapedius muscle. However, it does not give an actual measurement of the acoustic impedance of the ear, representing the state of the ossicular chain and the mobility of the tympanic membrane. This information can be obtained by means of the acoustic bridge—a device that enables the examiner to listen simultaneously to a sound reflected from the tympanic membrane of the subject and a sound of equal intensity reflected in an artificial cavity, with the volume being adjusted to equal that of the external canal of the ear being tested. When the two sounds are matched by varying the acoustic impedance of the cavity, the impedance of the ear is equal to that of the cavity, which can be read directly from the scale of the instrument.

Conductive defects of the middle ear, including disarticulation (separation) of the ossicular chain and immobility of the malleus or stapes, can be recognized by the characteristic changes they cause in the impedance of the ear as revealed by tympanometry. This test procedure consists in raising and lowering the air pressure in the middle ear to alter the stiffness in the tympanic membrane while measuring the changes in its compliance in terms of the amount of sound reflected from it.

Profound sensorineural deafness can occur as a result of viral or other infection, including mumps, measles, and meningitis. Rubella (German measles) in the mother during pregnancy can cause severe damage to the organ of Corti, resulting in profound hearing impairment in the child. Cochlear abnormalities may be present also as a result of genetic defects. The electrophysiological hearing tests described above—BERA and ECoG—make it possible to detect such loss in infants. In all such cases of deafness in young children, it is essential that the condition be recognized as early as possible so that appropriate counseling in matters of care and education may be obtained. As an important aid in learning to speak, surgical implantation of an electronic cochlear prosthesis (cochlear implant) should be considered before the child reaches school age. This device, while controversial within the deaf community, has proved effective in restoring a significant degree of hearing to many young children with congenital deafness.