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Audiology(Clinical Applications)
Sasan Dabiri, M.D. Assistant Professor
Department of Otorhinolaryngology – Head & Neck Surgery
Amir A’lam hospital
Tehran University of Medical Sciences
Last Updated in February 2015
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Anatomy
AnatomyAudiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Physiology
• Auricle (pinna)• Sound gathering & localization
• External Ear Canal• Resonance (specific frequencies)
• Tympanic Membrane & Middle Ear• Impedance matching (air fluid)
• Cochlea• Mechanical energy Electrical energy
• Cochlear nerve• Conduction to CNS
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Classification
• Primary Audiologic Evaluation– Audiometry (subjective)
• Pure Tone Audiometry
• Speech Audiometry
– Acuostic Immittance (objective)
• Tympanometry
• Acoustic Reflex
• Advanced Audiologic Evaluation– Otoacoustic Emissions
– Auditory Brainstem Response
– Electrocochleography
• Vestibular Evaluation
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
Sound Characteristics:• Intensity (SPL, HL) : decibel (dB)
• Frequency : Hertz (Hz)
Sound Threshold:• lowest signal intensity detected at
50% of presentations
Air conduction vs. Bone conduction
Air – Bone Gap (ABG)
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
– Normal
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
– Conductive
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
– Sensorineural
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
– Mixed
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
250 500 1000 2000 4000 6000 8000
Down to 25 dB Hearing Level = Normal
26 – 40 dB Hearing Level = Mild Hearing Loss
41 – 55 dB Hearing Level = Moderate Hearing Loss
56 – 70 dB Hearing Level =Moderately Severe Hearing Loss
71 – 90 dB Hearing Level =Severe Hearing Loss
Lower than 90 dB Hearing Level = Profound Hearing Loss
0
10
20
30
40
50
60
70
80
90
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
Average of hearing = .5 + 1 + 2 + 4 KHz
4
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
AudiometryAudiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Right Ear Left Ear
Bone Conduction
Unmasked < >
Masked [ ]
Air Conduction
Unmasked ○ x
Masked ∆ □
Audiometry
• Pure Tone Audiometry (PTA)
• Speech Audiometry
– Speech Reception Threshold (SRT)
– Word Recognition Score (WRS)
(Previously named SDS)
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Audiometry
• Pure Tone Audiometry (PTA)
• Speech Audiometry
• Prevention of errors in Audiometry
– Comparison of mean PTA & SRT
– Appropriate follow up in asymmetry
– Attention to technical errors – Compatibility to examination
– Masking
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Tympanic membrane movement
– Applications:
• Middle ear function
• External canal volume
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + AdmittanceImmitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type AN
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type AS
Ossicular fixation
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type AD
Atrophic TM
Ossicular
discontinuity
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type B
Glue in middle ear
Mass in middle ear
Perforation
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type C
Eustachian
dysfunction
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
– Type D
Scarred TM
Hypermobile TM
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
• Stapedial reflex
– Reflex threshold & Reflex decay
Immitance = Impedance + Admittance
Cochlear Nerve
Superior OlivaryNucleus
Cochlear Nucleus
Facial Nucleus
Facial Nucleus
Facial Nerve
Facial Nerve
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Acoustic Immittance
Immitance = Impedance + Admittance
• Tympanometry
• Stapedial reflex
– Reflex threshold & Reflex decay
– Appications:
• Evaluation of Auditory pathway
• Localization of Facial nerve lesion
Immitance = Impedance + Admittance
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
– Evaluation of cochlear function
– Applications:
• Neonatal hearing screening
• Auditory neuropathy
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
– Evaluation of cochlear function
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
• Auditory Brainstem Response (ABR)
– Evaluation of synchronized response of lower auditory pathway neurons
– 5 waves in diagram (I, II, III, IV, V)
– Applications:
• Evaluation of hearing sensitivity
• Otoneurologic evaluation
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
• Auditory Brainstem Response (ABR)
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
• Auditory Brainstem Response (ABR)
• Electrocochleography (ECoG)
– Evaluation of cochlear function
– Applications:
• Ménière’s disease
• Enhancing wave I in ABR
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Advanced Audiology
• Otoacoustic Emissions (OAE)
• Auditory Brainstem Response (ABR)
• Electrocochleography (ECoG)
– Evaluation of cochlear function
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Vestibular Evaluation
• Electronystagmography
• Videonystagmography
• Caloric Test
• Vestibular Evoked Myogenic P. Test
• Rotatory Chair Test
• Posturography
Audiology
Anatomy
Physiology
Classification
Primary Evaluation
• Audiometry
• A.I.
AdvancedEvaluation
• OAE
• ABR
• ECoG
Vestibular Evaluation
Audiology
Tinnitus - Definition
The perception of sound
in the absence of external stimuli
(tinnire means ringing in latin)
Tinnitus - Neurophysiology
Tinnitus - Classification
• Subjective Tinnitus:sound is only perceived by the patient (most common)
• Objective Tinnitus:sound produced bypara-auditory structures which may be heard by an examiner
• Non-pulsatile Tinnitus:
Perceived sound is continuous (most common)
• Pulsatile Tinnitus:
Perceived sound has cyclic non-continuous course that may be vascular or muscular
Tinnitus - Differential Diagnosis
Subjective
• Presbycusis
• Noise exposure
• Meniere’s disease
• Otosclerosis
• Head trauma
• Acoustic neuroma
Tinnitus
• Cerumen impaction
• Drugs
• Middle ear effusion
• TMJ problems
• Depression
• Hyperlipidemia
Pulsatile Tinnitus
• Venous Hum
• Benign Intracranial Hypertension
• Glomus Jugulare
• Glomus Tympanicum
• Arteriovenous Malformation
• Palatal Myoclonus
Tinnitus - Evaluation
• History Taking
Thorough and Complete Hx
• Physical Examination
– Head & Neck Examination
(including Otologic Examination)
• Paraclinic Evaluation
– Audiometry
– Imaging
Tinnitus - Management
• Medical
– Non-pharmacologic Behavioral Therapy (Retraining, Biofeedback)
Masking & Hearing aid
Electromagnetically
– Pharmacologic Antidepressants
Benzodiazepines
……
• Surgical (just for apparent otologic pathology)
Thanks for Your Attention