Puretone and Speech Testing

puretone testing

quantify auditory access to each frequency needed for speech perception

ear specific information

helps us predict communication struggles (speech banana and articulation index)

used to prescribe hearing aids, cochlear implants or other strategies

below line

where is auditory access on this audiogram? meaning where can the patient hear

audiometer

device used for testing hearing loss (screening and diagnostic purposes)

two channels allow for testing and masking (you can put different sounds in each ear independently)

controls of audiometer

includes stimulus, transducer, and routing

puretone, live voice, recorded speech, noise, or other

what is the stimulus control on an audiometer?

supra-aural headsets, inserts, speaker, bone oscillator

what are the transducers in an audiometer?

a transducer is a device that converts electrical energy from an audiometer into energy to test hearing

right, left, and both

what are the routing controls in an audiometer?

supra-aural earphones/headphones

a type of transducer that is easy to clean and is familiar to patients

cons: collapsed canal, more crossover of sound, standing wave at 8k (distance from earphone to eardrum can cause wave to cancel itself out), sudden drop at 8k…think standing wave

circum-aural earphones/headphones

a type of transducer that is less constricting and more comfortable, typically used for higher frequency testing above 8000 hz, usually for tinnitus patients

cons: sound leaks around headset, less accurate results

insert earphones

a type of transducer with no standing wave, less masking needed, and no collapsed canals

cons: disposable (cannot reuse and costs more money), can’t use with drainage

bone oscillator/conductor

a type of transducer that is placed on the mastoid bone but NOT touching the pinna (placement is very important), can test on forehead if not fitting on bone

pitfalls: may fall off easily, move during testing

speaker

a type of transducer that is in a booth, which can be used with difficult patients/babies, useful for functional benefits of hearing aid/cochlear implant

cons: no ear specific info (can’t tell right vs left)

attenuators

is a device that reduces the power or amplitude of a signal without significantly distorting its waveform

equipment that measures decibels and frequency

decibels attenuator

measures loudness

-10 dB HL to 120 dB HL (some equipment only goes to 110 dB HL)

frequency attenuator

measures pitch

125-8000 Hz (some equipment has high frequency capability to 12,000 Hz)

calibration

annual assessment

computer based equipment tends to be more stable

portable equipment highly susceptible to errors

correction factors

dB HL to add/subtract per frequency

sticker placed on audiometer

can be different for each transducer

are based on certain frequencies

testing environment

quiet room for screening, diagnostic in sound treated room (not soundproof), is a double walled booth with sound absorbing material between two metal walls and walls have small holes to expose absorption materials

the floor is carpeted with padding and is raised off the ground to reduce vibration noise

double doors with thick soft molding to reduce infiltration of outside noise

fire alarm/sprinklers

lighting specially insulated to reduce outside noise infiltration

ventilation - needs to be very quiet system

no

is a sound treated room soundproof?

so patient can’t see audiologist and the buttons they are pressing

why is there a specially insulated window between patient and tester sides of a testing environment booth?

order of audiologic evaluation

case history, otoscopy, tympanometry (acoustic reflexes, otoacoustic emissions), pure tone testing, SRT, WRS, and bone conduction

pre-evaluation

file review, case history, self rating scales (assess impact and readiness to use hearing aids), conversation (pay attention to patient when conversing), malingerers, assess communicative function, and otoscopy after pre-assessment

testing

seating - eye contact or no? no eye contact so patient doesn’t think to press button but important to see if patient is uncomfortable

instructions - be clear, concise, adjust to patient (stick to 6th grade reading level)

response mode - hand raise, button, game, yes/no, nod

transducer selection and placement - supra-aural headsets, inserts, or bone oscillator

threshold search

finding the softest sound that the patient can hear

includes tone presentation, either an ascending technique or descending technique, combination approach, threshold criteria, and frequency progression

happens in a booth

tone presentation

give one presentation at dB SL to alert (50 dB)

all presentations are 1-2 second duration

pure tone, warble or pulsed tones

vary wait time/presentations (don’t get into a rhythm)

ascending technique

start at 0 dB HL and work up in 10 dB steps

typically used for hard to test patients and children

descending technique

start at alerting tone, work down in 10 dB steps

used more often

combination approach

give alerting tone and work down in 10 dB steps, once patient misses response, go up in 5 dB steps to find threshold

threshold criteria

respond 50% of the time

2/3 presentations elicit response

frequency progression

start at 1k, then 2k, 3k, 4k, 6k, 8k Hz

return to 1k (reliability check) then 250, 500 Hz

more than 20 dB difference between frequencies, add more interoctave testing (750 Hz, 1500 Hz)

calculating pure tone average

add up thresholds at 500, 1k, 2k Hz and divide by 3

15 dBs

how many dBs between the right and left ear signals asymmetry?

500, 1k, 2k, and 4k Hz

what frequencies (Hz) are the most important to test since they most resemble speech sounds?

no response to 1k Hz tone

increase by 20 dB HL, and try again

switch to 500 Hz at some dB HL and try again

reinstruct

false positives

when a patient says they hear the sound even if they don’t

could be because they are eager to please, ringing, nervous, afraid to fail

reinstruct, change waith/off time, change Hz

use another signal (pulse, NBN, warble)

false negatives

this is when patients feel like they have to be sure and want to be 100% sure they heard the noise

could be from being afraid, confused, malingering, ADD/ADHD

reinstruct, change signals, give reassurance of correct responses

pediatric testing

use second tester to assist (define roles and set up communication)

try to get low frequency and high frequency info for each ear (500 Hz, 4000 Hz)

need to move quickly to keep attention

use reinforces like verbal/social praise, food, stickers, games, etc

variations in results

5 to 10 dB HL difference is normal

comparison of serial audiograms can show slow progression vs normal fluctuations

psychoacoustics

auditory access and perception

may affect results: attention to task, state of alertness, motivation, anxiety, barometric pressure, recent noise exposure

pure tone average (PTA)

500 Hz + 1k Hz + 2k Hz / 3

may not reflect slope/configuration of loss

may underestimate the communicative impact of loss

tactile responses

low frequencies are affected (are felt instead of heard), does not affect frequencies above 1000 Hz

transducer contact (bone conductor touching pinna or glasses, earphones touching glasses)

profound hearing loss (bone conduction and air conduction - can look like false air-bone gap)

useful for “teaching” to respond by placing BC in hand to feel

bone conduction testing

threshold search: combination of ascending/descending technique, alerting tone, down 10 dB, up 5 dB, 50% or 2/3 correct responses

unmasked thresholds could be “better ear” response - need to use masking for those

1k, 2k, 3k, 4k, 250 and 500 Hz

what is the frequency progression of bone conduction testing (different from air conduction)

placement options during bone conduction testing

could be placed on the mastoid bone or forehead

mastoid bone placement

placement during bone conduction testing

pros: less dB to elicit response, more likely test ear

cons: can fall off easily, can move, might touch pinna, patient has to remove glasses to avoid contamination

forehead placement

placement during bone conduction testing

pros: easier to place on children, does not touch pinna, does not interfere with glasses

cons: needs higher dB to elicit response (need to use correction factors), localizes to better ear

masking

intentional use of a stimulus to eliminate participation of the non-test ear, second signal that interferes with the primary (test) signal and causes a shift in threshold (distract better ear)

2 channel audiometer required

asymmetrical

is masking used when there is symmetrical or asymmetrical loss?

masking stimulus

includes speech or noise

speech: babble, nonsense, speech weighted noise

noise: narrow band noise, white noise, pink noise, or fresh noise

effective masking

interaural difference of 40 dB (earphones)

interaural difference of 50 dB (inserts)

just enough to occupy better ear

threshold of better ear (non-test ear) +10 dB HL

(when sound crosses over from one ear to the other, since better ear helps the bad ear)

undermasking

insufficient masking, better ear still contributing

overmasking

excessive masking noise crosses over into test ear

overestimates the hearing loss in the test ear

occlusion effect

is basically when we close our ears and sound is amplified

decrease (improvement) in bone conduction thresholds at 1k or lower frequencies because of tightly fitting earphones

seen only in normal listeners and sensorineural losses

(not conductive losses)

masking dilemma

bilateral conductive hearing loss

any attempt to mask the non-test ear, crosses over into test ear bone conductor thresholds; creates overestimate of hearing loss

speech testing

measures communication skills (quiet vs noise and S/N ratios), site of lesion diagnosis (speech recognition scores), reliability check (consistency/accuracy), and compromised patients (young children, developmental disabilities, and dementia)

intelligibility

audibility ≠ what?

speech awareness threshold (SAT)

also known as speech detection threshold (SDT), can detect speech but can’t understand words

±10 dB from pure tone average

patient can detect speech happening but doesn’t understand

speech recognition threshold (SRT)

also known as speech reception threshold, where patient can hear and understand words

50% accurate word recognition using spondee words

should = pure tone average ±10 dB HL (can be influenced by configuration of hearing loss)

used to determine dB SL for discrimination testing

speech awareness threshold (SAT)

includes any speech material (BaBaBa, name, counting, ABCs, reading passage), tends to be 10 dB below SRT (can be due to a single frequency), use ONLY in patients who cannot give SRT (young children, profound deadness, cognitive disabilities, foreign language student), and ascending/descending technique (50% accuracy)

speech reception threshold (SRT)

uses spondee words (words that are familiar, closed set - knows they’re coming or open set - doesn’t know), transducer (inserts, earphones, speaker, bone conductor), signal (either live voice or recorded materials), and routing can be left ear, right ear, or both ears

spondee words

2 syllable words with equal stress on both syllables (like hot dog, baseball, airplane, etc)

go down 10 dB till patient can’t hear (should be close to pure tone average) which is around the softest they are able to hear

50%

what percent accuracy is needed for accurate word recognition using spondee words on an SRT?

live voice presentation

uses a VU meter

pros: can control rate of presentation, local/native speech patterns, can use non-standardized materials, and can repeat items (not standardized procedure)

cons: hard to keep voice within ±3 dB HL, tendency to overarticulate, and accent/articulation issues

VU meter

equalizes voice so doesn’t go above presentation level

can be a light or needle

O (on the meter) = exactly correct dB presentation

stay within ±3 dB HL for presentation

recorded materials

use calibration tone to set VU meter (dial to set at 0)

pros: keeps presentation level very steady, more standardization (less variability) across patients, no over articulation, and smooth rate of presentation

cons: presentation pace often too fast/slow and some materials may not be available

intelligibility testing

is a test where a word list is presented to a patient and they have to repeat the exact word to get correct

is presented as a percent correct score where word recognition score/word discrimination score

presented as dB SL: SRT + 35 dB HL (or 40)

monosyllabic words with carrier phrase like “say the word…” and are not spondee words

can be open set or closed set

open set

in intelligibility testing where there are phonetically balanced word lists and phonemes are proportionate to typical english language

no idea what word will be presented

closed set

in intelligibility testing used for patients who cannot repeat words and is easier to pick the right word from a set

patient knows what words are coming

open set lists

includes PBK, CID W-22, and NU 6

PBK

is a type of open set list that is normed on kindergarten children

easy word lists (mostly nouns/verbs)

for children and special needs patients

CID W-22

is a type of open set list that is phonetically balanced and contains adult word lists (can use with older children too)

NU 6

is a type of open set list where there is a consonant, nucleus, consonant with harder vocabulary

is used for adults

categories of performance

can be scored as poor, excellent, good, or satisfactory

relevance depends on test materials (open vs closed set, difficulty of word list, and how it compares to real life vocab)

booth effect (sound treated room with no distractions, patient focused on testing)

presentation levels

includes sensation level and conversational level

sensation level

typically 35-40 dB above SRT

noted as + ____ dB HL or as dB SL

provides discrimination accuracy at sufficient volume above threshold

may be inadequate depending on hearing loss configuration (cookie cut, ski slope, etc)

conversational level

is presented at 50-55 dB HL

helpful in looking at real world communication skills

may help person see need for hearing aids

masking for speech testing

noise choice could be speech babble, multi-talker babble, speech weighted noise (speech spectrum noise), running discourse, or white noise

dynamic range

is the range of threshold to loudness discomfort level (shorter range for patients with hearing loss), threshold to discomfort

includes MCL and LDL

reduced range is problematic (ex: SRT = 60 dB HL and LDL = 100 dB HL… only gives you 40 dB HL to work with)

MCL

a type of dynamic range that is the most comfortable listening level

patient’s subjective opinion

can be done with pure tones, but primarily used for speech testing

LDL (UCL/ULL)

a type of dynamic range where patient’s subjective opinion of uncomfortable level

pure tones, but primarily speech

dynamic range

the decibel range between SRT (speech reception threshold) and LDL (loudness discomfort level)

recruitment

unusual growth in loudness perception (limited distance from threshold to discomfort)

perception changes quickly with limited increase in dB (MCL may be only slightly above SRT, low % scores due to insufficient gain - trying to listen to speech at very soft levels)

creates a small (reduced) dynamic range - tend to do poorly with hearing aids, may not tolerate increased input levels

testing in noise

transducer: insert, earphones, speaker, or bone

routing: ipsilateral or contralateral (one or both ears, same side or opposite)

signal: speech weighted noise, multi-talker babble/cafeteria noise, running discourse

S/N ratio: percent correct at different S/N provides treatment/amplification info, can be used to show need for assistive devices

useful for aided testing (soundfield/speaker)

quantitative information: percent correct at varying levels

qualitative information: slower response rate, hesitation, guessing, request repetition

quickSIN speech-in-noise-test

the patient has to repeat back 6 sentences binaurally

each sentence is played with background noise of different S/N ratios

there are 5 key words the patient has to repeat correctly in each sentence

score is 25.5 - total score of words correct =

hearing in noise test (HINT)

is an open set speech test that is presented in quiet and noise, presentation levels for sentences changes using ascending/descending technique

noise (speech weighted noise) stays stable

uses formula to calculate RTS (reception threshold for sentences)

has normative data

can alter speech and/or noise presentation to simulate different listening situations

can evaluate aided (with cochlear implant) and unaided (natural hearing)

CID everyday sentences

is an open set speech test where 10 sentences are presented, 50 key words within sentences

percent correct of key words = percent correct score

speech perception in noise (SPIN)

is an open set speech test that assesses key word (last word in sentence)

high predictability vs low predictability lists

synthetic sentence identification

is a type of closed set speech test that has 10 nonsense sentences, present competing noise using connected discourse

pick correct sentence from list

must be able to read

word identification by picture identification (WIPI)

is a type of closed set speech test where there are 6 color pictures on a page

words sound similar

normed on 4-5 year olds

nu-chips

is a closed set speech test where there are 4 black/white pictures per page

normed on 3-4 year olds

california consonant test (CCT)

is a closed set speech test where there are 100 test items, pick from 4 choices

highly sensitive to high frequency losses

identifies consonant confusions

ling six sound test

a type of speech test where each sound representative of a frequency range, can help estimate threshold levels, can be used to check aided function, and can show reception or perception

body parts

a type of speech test that can give estimates of speech perception

can use parent, mr. potato head, or self to point to ear/hair, nose/toes, teeth/knee

same/different

a type of speech test with different levels: monosyllabic vs bi-syllabic, spondee words, monosyllabic with diverse vowels, and monosyllabic with diverse consonants

sound effects recognition test (SERT)

technically not a speech test but can give information about frequency perception and pattern perception

taped sounds, pick from four pictures

non-english patients

recorded materials in native language: many tests available in spanish and other

live voice in native language: how accurate is the pronunciations of tester?

use of interpreter/translator: breaks standardization but can give some qualitative information

other considerations

number of test items

fewer items = more variability in results

single word tests designed for 50-word presentation (many audiologists use only 25 words, increases variability between tests)

non-standardized materials: can be misleading to parents, patients, and therapists

lower

are stops and vowels higher or lower frequency?