Chapters 4 & 5 Behavioral Testing Perry C. Hanavan, Au.D. Audiologist

Audiometer

Earphones Ear Insert Earphones Reduce masking Reduce ear canal collapse Enhanced stability of sound delivered to ear Increase Comfort Reduce spread of bacteria Supra-aural Earphones

Audiogram Styles

Audiogram Styles

Recording AC Thresholds

Degree of Loss Normal 10 or better Minimal 11-25 dB HTL Mild 26-40 Moderate 41-55 Moderately severe 56-70 Severe 71-90 Profound greater than 90

Type of Loss Compare air conduction and bone conduction thresholds Outer Ear Conductive Loss Middle Ear Sensorineural Loss Inner Ear Auditory Nerve Mixed Loss

Audiogram 2-27 Number Yes/No

Air Bone

Configurations

Symptoms - Dysfunction Symptoms/Complaints Tinnitus Dizziness Ear pain Ear fullness/pressure Communication difficulty Potential Dysfunction Non (Normal or Functional Ear canal obstruction Middle ear disorder Inner ear disorder Auditory nerve disorder Auditory processing disorder

Potential Site of Lesion Symptoms Referral source info Rule out system Audiologic tests Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

Audiology Test Battery Case History Otoscopic exam Immitance battery SRT Pure tone AC and BC Speech recognition tests Otoacoustic emissions (OAE) ABR and/or CAEP (Evoked Potentials)

Central auditory system Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system 33 year old male. Otoscope exam: Normal Physician report indicated symptoms included hearing loss, vertigo, pulsatile tinnitus, autophony, and oscillopsia. 

Diagnosis of 33 year old male Temporal bone CT in the Posterior Semicircular Canal (A)

Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

CROSS CHECK SRT should be within +/- 10 dB of PTA

Purpose of Masking A procedure audiologists use while testing to separate the two ears, acoustically Noise is introduced to one ear while the other ear is tested with a pure tone (or speech signal) To indicate that the hearing thresholds were obtained using masking, masked threshold symbols are used on the audiogram

Masking Crossover Results when sound presented to one ear through earphones crosses to the head via bone conduction and is perceived by the opposite ear

Masking Interaural attenuation (air conduction pure tone) Reduction in sound energy of a signal as it is transmitted by bone conduction from one side to the other Hz Supra-aural Insert Bone 250 40 75 0 500 40 75 0 1000 40 60 0 2000 45 55 0 4000 50 65 0 8000 50 65

Masking Types Narrowband Broadband (White Noise or Pink Noise Pure tone testing Broadband (White Noise or Pink Noise Speech Testing

AC Masking Supra-aural earphone Insert earphone PTACTE – PTBCNTE >= 40 dB HL then mask Insert earphone PTACTE – PTBCNTE >= 70 dB HL then mask Interaural attenuation is 40 dB HL or supra-aural phones and 70 dB HL for insert phones

BC Masking Bone oscillator A-B gapTE > 10 dB HL (mask) (interaural attenuation is 0 dB for BC)

Speech Masking Supra-aural phones: Speech Test LevelTE – best BCNTE => 40 dB Insert Phones Speech Test LevelTE – best BCNTE => 70 dB ( Evaluate any speech test such as SRT and/or SRA and compare to the best BC of the non-test or opposite ear)

Normal Functional Outer ear Middle ear Inner ear Auditory nerve Central auditory system

Speech Audiometry Purpose Attempt to measure the ability to understand everyday conversational communication

Uses of Speech Audiometry Measure of speech threshold Cross-check pure tone results Measure of supra-threshold speech recognition ability Differential diagnosis Measure of auditory processing ability Estimation of communication function

SPEECH TESTING SRT (speech recognition threshold) Measure of speech threshold Typically use spondees SRA (speech recognition ability) Measure of clarity Supra threshold Typically use monosyllabic or sentence material

Speech Threshold Lowest level at which speech can be recognized or detected SRT (could be any kind of speech material) ST (spondee threshold) SAT (speech awareness threshold) SDT (speech detection threshold)

Spondee Threshold Trochees (not used for assessing SRT) ST – the lowest level in decibels spondees can be recognize correctly Measure of threshold sensitivity for recognizing speech Provides estimation of hearing sensitivity in the primary speech frequencies Comparable estimation of PTA (useful for cross-check) Spondee bisyllabic word enunciated with equal stress on both syllables Trochees (not used for assessing SRT) bisyllabic word with unequal stress on both syllables

ST Materials Baseball Cowboy Hotdog Sunset Ice cream Railroad Sidewalk

SRT Speech Recognition Threshold Lowest level in decibels at which speech can be recognized correctly with at lease 50% criterion Sentences, spondees, etc. Typically use spondees unless otherwise indicated

SAT/SDT Speech awareness or detection level Lowest level in decibels at which speech is detected Used when patient unable to respond to spondees (infants, developmental delays, etc.) Approximately 10 dB better threshold than SRT threshold Audiometers calibrated to speech recognition level than detection levels

Ling 6 Sounds

Supra-threshold Speech Recognition Ability Ability to correctly recognize speech at supra-threshold levels (reported in percentage of words correct at intensity level of presentation) 100% at 80 dB HL 96% at 40 dB SL Measured scores are generally predictable from degree, configuration and type of loss from pure tone results

Speech Recognition Ability Materials Discourse Sentences Words syllables Phonemes Nonsense words Synthetic sentences Speech in noise Filtered speech

Speech Test Administration Monitored Live Voice Speaker variations Scores affected by rate and quality of presentation May not provide sufficient test-retest reliability Recorded Recommended procedure Greater test-retest reliability Normative data (for word recognition scores – WRS…speech recognition ability scores)

Open Vs. Closed Set Closed Set Open Set Limited set of response possibilities Useful for young children with limited vocabulary, patients with poor articulation, developmental delays Scores may be 10% better compared to open set scores Open Set More challenging as response possibilities are somewhat unlimited

NU-6 (CNC) (Open Set)(Recorded or Live)

CID W-22 (PB Word Lists) (Open Set)(Recorded or Live)

CUNY Nonsense Syllable Test (Closed Set)(Recorded)

Minimum Age of Administration

WIPI (25 Word Lists) (Closed Set)(Recorded)

NU-CHIPS (Closed Set)(Recorded)

Dichotic Sentence Identification (Closed Set)(Recorded) The DSI test uses 6 of the same sentences as the SSI-ICM test but presents 1 sentence to each ear simultaneously at 50-dB SL, and the participant is asked to select from a printed list which 2 sentences were heard. Fifer et al showed that the test is resistant to the effects of SNHL below 50 dB HL. The DSI test is administered in both a free and a directed mode. In the directed mode, only the sentence heard in test ear is noted, whereas in the free mode, the sentences heard in both ears are reported. Five presentations are used if the score is 100%; otherwise, another 5 sentences per ear are administered. Scores are better in the directed mode than in the free mode, and the right ear scores are normally higher in adults than the left ear scores, presumably due to age related corpus callosum dysfunction. Normal scores are 80% correct and above.

Pediatric Speech Intelligibility (Closed Set)(Recorded) PSI Both monosyllabic words and sentences recorded in quiet and with competition. Employs color plates with pictures of animals (animals used to avoid ethnic biases) which represent either the sentences or the words. Investigates peripheral and auditory processing disorders.

BKB-SIN (Adults) (Open Set)(Recorded)

BKB-SIN (Children) (Open Set)(Recored)

Quick-SIN for Adults Open Set-Recorded

QuickSIN Test for SNR

Redundancy vs. HL Sensitivity less more Syllables Words Sentences Redundancy of Informational Content Sensitivity to Hearing Loss less more

Significant Difference Compare test results When is there a significant difference between test scores on speech scores? These data permit comparison of scores to determine whether there is a significant difference

Lower Confidence Levels

yes/no number

Count the Dots Each dot represents 1% of the information contributing to speech clarity. The number of dots audible predict how well one understands quiet speech from a six foot distance. The dots are unevenly distributed, with many more of them filling in the gray zone between 1000 and 3000 Hz than in the 250 to 500 Hz area. Count the dots that are below a person’s audiometric threshold. The more dots below threshold, the better one is able to hear normal conversational speech. The fewer dots below threshold, the more difficulty hearing conversational speech.

SII and AI Relationship

SII and AI Relationship of Various Speech Materials

Count the Dot (AI)

SNR Loss for 110 HA Wearers

26% AI Understand 90% Sentences

SNR Loss

PI & Site of Lesion

Pathologic PI Calculate PI for SN When .40 or greater, suggests neural rather than cochlear

yes/no number

Number of Words for SRA

Speech Site of Lesion Diagnosis ME OE IE AN A-B Gap Excellent SRA No Rollover A-B Gap Excellent SRA No Rollover SN Loss XX No Significant Rollover SRA above lower confidence limits SN Loss Significant Rollover XX SRA below Lower confidence Limits (scores lower than expected for degree of loss)

Audigram 5-23

Audiogram 5-4

Speech Masking Supra-aural earphone Insert earphone Speech LevelTE – BCNTE(best tone) >= 40 dB HL Insert earphone Speech LevelTE – BCNTE(best tone) >= 70 dB HL

Audiogram 2-20

Audiogram 2-25