1. Understanding the Audiogram
Dr. Nancy Gillispie

2. Understanding the Audiogram
Introduce basic terminology & basic anatomy
Introduction of various audiological tests
Audiogram
Type
Degree
Configuration
Speech Audiometry

3. Nancy Gillispie Au.D. CCC-A, F.A.A.A.
(304)
Dr. Nancy Gillispie has been working within the field of audiology since She received a master’s degree from West Virginia University and thereafter earned her Doctorate degree from Salus University. Dr. Gillispie is a licensed and certified clinical audiologist through WVBESLPA. She maintains national certification as a member of the American-Speech-Language-Hearing Association (ASHA) and a fellow of the American Academy of Audiology (AAA). Dr. Gillispie specializes in hearing evaluations, hearing aid technology, and FM system technology to persons of all ages. This also includes hearing technology monitoring, counseling, educational training and technical assistance, as well as direct aural (re)habilitation services.

4. Basic Terminology

5. Air Conduction
Air-Bone Gap
Audiogram
Audiology
Audiometry
Auditory Nerve
Auris Dextra – AD
Auris Sinistra – AS
Auris Utraque – AU
Behavior Test
Bilateral
Bone Conduction
Cerumen
Cochlea
Conditioned Play Audiometry
Conductive Hearing Loss
Dynamic Range
External Auditory Meatus
Incus
Inner Ear
Inner Hair Cells
Internal Auditory Meatus
Malleus
Middle Ear
Mixed Hearing Loss
Most Comfortable Loudness
Ossicular Chain
Otoacoustic Emission Testing
Otoscopy
Outer Ear
Physiological Test
Pinna
Pure Tone
Sensorineural Hearing Loss
Speech Awareness Threshold
Speech Discrimination Score
Speech Reception Threshold
Spondees
Stapes
Threshold
Tympanic Membrane
Tympanometry
Uncomfortable Loudness
Unilateral
Visual Reinforcement Audiology

6. Anatomy

8. https://youtu.be/eQEaiZ2j9oc

9. Audiological Evaluations
Physiological & Behavioral Testing

10. Otoscopy Instrumentation: Otoscope
visual examination of the auditory canal and the eardrum
Results typically include “normal” and “abnormal”
The goal is to identify a medical condition or best describe the health of the outer ear.

11. Tympanometry Instrumentation: Tympanometer or Acoustic Bridge
Can also be identified as Acoustic Immittance
Results are reported in “types”
Type A – normal middle ear functioning
Type AD – Normal but highly compliant middle ear
Type AS – Normal but less compliant middle ear
Type B – abnormal middle ear functioning
Normal ear canal volume
Abnormal ear canal
Type C – abnormal middle ear functioning

12. Otoacoustic Emission (OAE)
Instrumentation: Computerized Instrument
Evaluation Options:
Type:
Distortion Product Otoacoustic Emissions (DPOAE)
Transient Evoked Otoacoustic Emissions (TEOAE)
Results:
Screening (single intensity level over limited frequencies)
Outcome: Pass or Refer
Diagnostic (conducted several times at several intensity levels at a wide range of frequencies)
Outcome: Normal, Abnormal, or Absent

13. Auditory Brainstem Response (ABR)
Instrumentation: Computerized Instrument
Can also be identified as Brainstem Response Testing (BSER)
Evaluates the response of the cochlea and the brain pathways for hearing
Can be conducted sedated or non-sedated
Results are frequency and intensity specific

14. Pure Tone Audiometry & Speech Audiometry
Audiogram
Pure Tone Audiometry & Speech Audiometry

15. Types of Audiograms

16. Pure Tone Audiometry Instrumentation: Audiometer Tests
Air Conduction
Stimuli is presented via Headphones, Inserts, or Sound-field
Bone Conduction
Stimuli is presented via Bone Oscillator
Results identify:
Type of Hearing Loss
Degree of Hearing Loss
Configuration of Hearing Loss
Results should also include validity (acceptable/questionable) and reliability (good/fair/poor).

17. Basic Audiogram Symbols
Red = Right Ear Blue = Left Ear

18. Measures ability to hear pure tones at specific frequencies &decibels.
The Audiogram
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
PITCH
Measures ability to hear pure tones at specific frequencies &decibels.
LOUDNESS

19. Sounds occur at different intensity (loudness) and frequency (pitch).
Common Sounds
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Sounds occur at different intensity (loudness) and frequency (pitch).
Vowels
Consonants

20. Range of Normal Hearing
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 O
Range of Normal Hearing x
Hearing Threshold

21. Mild Hearing Loss x O Hearing Loss Consonants Vowels Hearing Threshold
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss x O
Vowels
Consonants
Hearing Threshold

22. High Frequency Hearing Loss
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 x
Hearing Loss O
Vowels
Consonants
Hearing Threshold

23. Moderate Hearing Loss O x Hearing Loss Consonants Vowels
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss x O
Vowels
Consonants
Hearing Threshold

24. Severe Hearing Loss x O Hearing Loss Consonants Vowels
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss
Vowels
Consonants x O
Hearing Threshold

25. Profound Hearing Loss x O Hearing Loss Consonants Vowels
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss
Vowels
Consonants x O

26. https://hearinghealthfoundation.org/degrees-of-hearing-loss

28. Types of Hearing Loss
The type of hearing loss is determined by the agreement or difference between the air conduction thresholds and bone conduction thresholds for each ear. The difference between the thresholds are identified as an Air-Bone Gap.

29. Conductive Hearing Loss Sensorineural Hearing Loss Mixed Hearing Loss
Occurs when the outer or middle ear is not functioning optimally. Sound is unable to reach cochlea optimally. This type of loss can typically be corrected medically. Causes can include cerumen/debris blockage, outer ear infections, Eustachian tube dysfunction, perforated tympanic membrane, ossicular chain disarticulation, or atresia of the canal. Identified on the audiogram typically by an Air-Bone Gap.
Occurs when there is damage to the inner ear/cochlea or neural pathways.
This type of hearing loss can not medically corrected.
Causes can include genetics, ototoxic medication, presbycusis, head trauma, noise exposure, and physical malformation of the structure(s).
Occurs when a conductive hearing loss and a sensorineural hearing loss is present simultaneously.

30. Degrees of Hearing Loss
Audiometric thresholds or degree of hearing loss refers to the severity of the hearing loss. Percentages are given by some professionals that try to relate to a patient’s or caregiver’s curiosity. Typically percentages refer to degree of disability or compensation in which refers to monetary and/or benefit awards.

31. Degree of Hearing Loss Hearing Loss Range
(dB HL)
Normal
-10 to 15
Slight
16 to 25
Mild
26 to 40
Moderate
41 to 55
Moderately Severe
56 to 70
Severe
71 to 90
Profound
91+

32. Image from http://alphaonenow.com/userfiles/image/aud_audiogram.gif

34. Configuration of Hearing Loss
The configuration of a hearing loss is also the shape of the thresholds across the frequencies on the audiogram.

35. All thresholds are the same severity across the audiogram.
Flat Configuration
All thresholds are the same severity across the audiogram.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss
Vowels
Consonants O

36. Sloping Configuration
Thresholds are increasing in severity across the audiogram.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120
Hearing Loss x O
Vowels
Consonants
Hearing Threshold

37. Inverse Configuration
Thresholds are improving in severity across the audiogram.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 x O
Hearing Loss
Vowels
Consonants
Hearing Threshold

38. Precipitous Configuration
Thresholds suddenly drop in severity.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 x
Hearing Loss O
Vowels
Consonants
Hearing Threshold

39. Cookie Bite Configuration
Thresholds are best in the low and high frequencies.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 x O
Vowels
Consonants
Hearing Loss
Hearing Threshold

40. Inverse Configuration
Thresholds are worse in the low and high pitched frequencies.
Frequency (Hz)
Intensity (dB HL) 20 40 60 80
100
120 x O
Vowels
Consonants
Hearing
Loss
Hearing Threshold

41. Other Descriptors of Hearing Loss
Bilateral or Unilateral
Symmetrical or Asymmetrical
Progressive or Sudden
Fluctuating or Stable

42. Speech Audiometry Instrumentation: Audiometer & Word Lists
Word Lists (W1, W2, W22, PBK50, WIPI, SPIN) are presented
via headphones or sound-field
by Monitored Live Voice or Recorded Speech Stimuli.
may require masking
Outcomes are measured in decibels or percentages depending on the type of test
Purpose of testing is to identify the patient’s ability to detect/hear spoken words clearly. The goal is to identify the patient’s receptive communication abilities.
Modifications can be made due to a patient’s ability to vocalize, vocabulary knowledge, cognition, and motor involvement and should be identified on the audiogram.
Results also include validity (acceptable/questionable) and reliability (good/fair/poor).

43. Speech Awareness Threshold (SAT)
Also known as Speech Detection Threshold (SDT)
SAT is the lowest level at which speech can be detected in quiet.
This is typically a level that is below the level that one can understand speech.
The test utilizes various stimuli such as numbers, body parts, spondees, or even a presentation of a pure tone that one would localize to illustrate detection.
Results are reported in decibels (dB) and are typically 5dB to 10dB lower than the Speech Reception Threshold (SRT).

44. Speech Reception Threshold (SRT)
Speech stimuli (Spondees) is presented in quiet.
The test identifies the lowest level at which speech can be heard and understood or how loud speech must be for the patient to hear and understand.
The threshold is identified at a level when at least two different words (or 50% of the words) can be repeated correctly.
Testing is typically conducted for each ear separately via headphones but may also be conducted in the sound-field.
Results are reported in decibels (dB).
Modifications can include the patient pointing to body parts or pictures or presentation via sound-field or bone oscillator.

45. Speech Discrimination Score (SDS)
The speech stimuli of an open set of 50 phonetically balanced monosyllabic words within connected speech (W22, Maryland CNC, NU #6) is presented suprathreshold (typically 40dB) in quiet via headphones or bone oscillator.
SRT+40dB = presentation level
Presentation Level may be varied by the clinician
Presentation also uses a carrier phrase(i.e. “Say the word “day.”)
Results are reported in percentages of words repeated correctly.
Patients may repeat, write, or verbally spell responses for open set word lists
Patients may point to pictures, retrieve items, or play “Simon Says” for closed set
Scores can be used to determine:
How clearly one hears speech when delivered under optimal settings,
The site lesion along the auditory pathway,
Candidacy for various aural (re)habilitation programs (hearing aids, cochlear implantation, surgical procedures, etc.

46. Speech In Noise Testing
There are various types of testing available that requires the speech stimuli to be presented in various levels of noise (narrow band noise, multi-talker, etc.) such as the Speech-Perception-In-Noise (SPIN).
The test reduces the amount of speech sound redundancy.
Noise is either presented to the test or non-test ear at various levels depending on the test being completed.
Results are reported in the percent of words correct.
Results are utilized to determine
Maturation of the auditory pathway,
Site of lesions along the auditory pathway,
Candidacy for various aural (re)habilitation programs (hearing aids, cochlear implantation, surgical procedures, etc.

47. Functional Listening Evaluation (FLE)
Speech stimuli (typically Children's’ Nonsense Phrases or Common Children's’ Phrases) is presented in quiet and noise and while at varying presentation distances.
Requires the use of a sound level meter to determine the speech-to- noise ratio.
Results are reported in percent of words correct.
The measures are used to illustrate the effects of noise, distance, and visual input in test conditions that can be correlated to real-life communication environments.

48. Other Speech Measures Most Comfortable Loudness Level (MCL)
Can be used as the presentation level utilized for Speech Discrimination testing rather than the +40dB
Can be utilized to determine the limits of amplification
Patient is instructed to signal when the speech stimuli is comfortably loud as the intensity is increased.
Uncomfortable Loudness Level (UCL) or Threshold of Discomfort (TD)
The level in which the loudness of speech becomes uncomfortably loud.
This measure assists in determining maximum stimulus levels, establishing amplification settings, and a patient’s dynamic range.
Patient is instructed to signal when the speech stimuli becomes uncomfortable loud as the intensity is increased slowly above the MCL.
Dynamic Range (DR)
The difference between a patient’s SRT and UCL
Represents the limits of useful hearing that is used in aural (re)habilitation

49. Examples of Audiograms

66. Aural (Re)Habilitation

67. Digital Hearing Aids 10011 11011 00111 11100 11001 11000 Analog To
ADC
Speaker (Receiver)
Mic

68. FM Systems Personal Assistive Listening Devices/Systems
Phonak Focus, Roger TouchScreen Microphone, Roger Receivers, Table Mic & Pens, and TV Connector
Soundfield Systems
Phonak Roger Sound-Field System 0r Front Row Sound-field System

69. Questions?
Dr. Nancy Gillispie
(304) 784 – 2552

70. Thank You!
Dr. Nancy Gillispie
(304) 784 – 2552

71. References
Katz, Jack. Handbook of Clinical Audiology. Baltimore, Maryland: Williams & Wilkins, 1994