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How you obtain and record audiometric data—or how you structure your “Audiogram Form”—is important for relating necessary information to the patient, physicians, and other health care professionals, including (and especially) your own practice staff members. In a recent article1 in HR, I promoted the idea that we should all be constantly asking ourselves, “Why am I doing this test for this patient, and why am I doing it in this order?” If our answer is “Because that’s the way I was taught to do it” or “That’s the way I’ve always done it,” then it is time to revisit our rationales and try to objectively determine if this approach is the best one.
Similar to Part 1 on Patient History Forms, this article concerns itself with the “Audiogram Form” (which generally also includes other audiometric tests).
The Audiogram Form (Figure 1) used in our practice is a single two-sided sheet on which we have the ability to make statements about the patient’s general auditory system function.
On the back side of the Audiogram Form is the tympanometric data for the right and left ears. The bottom half of this back side of the Audiogram Form is used for “half lists” of the CID W-22 word lists. The contents of the back of our form are copied “head to toe” because they are “pinned” into the chart at the top center. After taking the Patient History1 and performing otoscopy, we start at the back of the form (Figure 1b) with the tympanometric boxes. In our clinic, these data are generated manually and then transcribed onto the right and left Audiogram Form at the appropriate units of volume and pressure. Acoustic reflex threshold measurements are made from contralateral presentations of the signal through the earphone. The ipsilateral measurements are always written on the side into which the signal was delivered. On the other hand, if there is less than 50% decrease or no decrease when the stimulus is presented at threshold plus 10 dB for 10 seconds, the results are said to be “negative” for involvement of the VIIIth cranial nerve. The Audiogram Form is then turned back over (to the front of the form), and this data is summarized on the actual audiogram. We repeat this process at 500 Hz, 2000 Hz, and 4000 Hz for each ear specifying the measured thresholds at the correct frequencies. On the “Summary of Results,” there is a space for “Tympanogram Type.” In this space goes either A or a subset of A, B, or C. This is followed by the Performance-Intensity Phonetically-Balanced (PI-PB) test, which is a version of the speech (or word) discrimination test.
Before we leave this brief discussion of procedures, it is necessary to say that, in our clinic, all speech discrimination testing is done using masking in the non-test ear. If the otoimmittance indicates that the hearing loss is sensorineural, the presentation level of the masking is inserted at a level of 10 dB below the presentation level of the speech in the non-test ear. If the otoimmittance indicates that the hearing loss is determined to be conductive, the masking level used in the non-test ear is 10 dB above the presentation level of speech in the test ear. If the interaural attenuation could be overcome, masking will have to be used before the puretone air conduction measurements are complete.
Following this task, another decision must be made: whether tone decay testing is necessary. In our clinic, we take this test one step further; we do the test at higher frequencies, up through 4000 Hz, at which the threshold for hearing is not 80 dB or worse. At this point, in the spirit of doing everything that requires earphones before removing them, we decide whether a “central battery” or a “central screening” is necessary (Table 1).
Before we remove the headset to introduce the bone oscillator, we make a careful inspection of the relation between the threshold of hearing and the acoustic reflex threshold level.
Regardless of the absolute numbers, whenever there is an acoustic reflex and a puretone threshold at the same frequency (presented contralaterally), the brain perceives that approximately 85 dB of loudness has been introduced! We are all aware that “recruitment” is caused by changes in the cyto-architecture of the hair cells in the cochlea. It is valuable to indicate that, while these pathologies are not amenable to surgical remediation or treatment, they are exquisitely amenable to remediation. These measurements are made in a “conservative” manner with the patient identifying the comfortable level and uncomfortable level of each ear.
We are aware of a difficulty that occurs occasionally with bone conduction testing and air conduction threshold measurements at the same frequencies, in the same ears, and in the presence of sensorineural losses identified by otoimmittance. The preliminary report describes the degree of loss, the slope of loss, the configuration of the loss, and the nature of the loss by ear. The SOAP (Subjective, Objective, Assessment, Plan) format is approved by the Joint Commission on Accreditation of Healthcare Organizations and is the format with which physicians are most familiar.
The Subjective portion can include information about your and the patient’s observations on hearing, vertigo, tinnitus, pain, drainage, etc—a subjective description of the problem, if any. The Assessment part of the document is a statement about “what the results mean” regarding the site or focus of lesion identified through the evaluation. Using Acoustic Middle Ear Muscle Reflexes and Their Utility in Fitting Hearing Instruments, by Jay B. Finally, the Plan portion consists of recommendations for the patient and these should be numbered sequentially.
Wear ear protective devices whenever the patient anticipates being in the presence of noise. Have hearing re-evaluation on (at least) an annual basis or at any time there is the subjective impression of change in the status of their auditory system.


Tinnitus Control combines emotional indicators appears to tinnitus-frequency-matching-test be original position (head at the central nervous system.
The article then went on to address the Patient History Form—an important tool used in dispensing offices for screening patients for “red flags” that would warrant immediate referral to a physician.
McSpaden, PhD, CCC-A, BC-HIS, is an audiologist who retired from private practice and currently works part-time as a hearing instrument specialist in Jefferson, Ore. Therefore, the information presented here is not intended to be didactic; it is “food for thought” for comparing your own current test battery and reporting system. The upper third of the form contains the identifying information, including our practice logo, location, and contact information. There are also spaces for the ipsilateral reflex data, contralateral reflex measurement, reflex decay information, and a Sensitivity Prediction by Acoustic Reflex (SPAR) test (performed if necessary). They are provided so that either “recorded” or “live voice” Word Discrimination Test scores can be generated using masked monosyllabic words. We can just turn up the page and read the results of the audiometric test battery used as appropriate for individual patients (Table 1). The points measured are then connected so as to describe the right and left tympanograms at the correct units of pressure and volume. If reflex decay procedures are performed, they start at 1000 Hz with contralateral presentation. Summary of the audiometric test battery presented in this article and its coverage of different sites of lesion.
The data for the right ear are recorded on the right side and those for the left are recorded on the left, placing an R or an L with a circle around them at the appropriate frequency and intensity. The next procedure is the Speech Recognition Test (SRT) or Word Reception Test using either an ascending or descending presentation method. This yields the maximum potential score for “phonetically balanced” words (the so-called PBmax). The QuickSIN is an easy-to-use series of sentences recorded in four-talker babble, representing a realistic simulation of a social gathering in which the listener may “tune out” the target talker and “tune in” one or more of the background talkers.
When all of the procedures involving speech are complete, the next procedures involve puretones. In this case, we use narrow-band masking with an audiometer producing “frequency following” masking signals. If tone decay is indicated (or ordered by the physician), we use the Olsen-Noffsinger3 version of the test. In this way, we will not present a puretone at 100 dB at any frequency to any patient in either ear. We may do it now or we may reschedule the patient to return at a later time for the performance of the central battery. At any time that the relationship gets within 60 dB at the same frequency, it is clear that “recruitment” has to have occurred.
It is important that this information be visibly available not only for the examiner but also for the referral source or physician.
A recruiting ear—particularly a “recruiting” ear without tone decay, reflex decay, or PI-PB rollover—is highly indicative of sensory pathology involving the cochlear structures. We use the narrow bands of noise at the frequencies 2,000, 3,000, 4000, and 6,000 Hz in each ear and binaurally. Our experience is that UCLs have a very specific relationship (within about 5 dB) with acoustic reflex thresholds. Market data4 shows that unrecognized “tolerance problems” continue to be a major component in consumers’ dissatisfaction with hearing aids. Having now completed the measurements that require earphones, we remove them and fix the bone conduction oscillator onto the skull over the appropriate mastoid. This difficulty is acquiring bone conduction results that are below air conduction results on the audiogram.
Once all of these procedures are completed, we remove the oscillator from the bone, the earphones from the head, and have the patient relax while the report is written.
In our clinic, we add a few sentences about the impedance results because they facilitate understanding on the part of the “end user” (physician). The Objective part says that a “copy of the results is appended for the record,” and these records are careful to mention any involvement of the VIIIth cranial nerve.
In our view, when combined with the complete test results and Patient History,1 this provides an excellent record of patient encounters. In-FORM-ation for better patient care, Part 1: A look at the Patient History Form and how it might be used more effectively. It is important to keep in mind that patients age 65 or older have on average 30-45 minutes of high quality attention time; you need to the pertinent information in this time.
At the top left is the patient’s name, age, date, address, the referral source, as well as the patient’s physician and phone number. It is important to have a separate space for information generated from the data on both right and left ear.
At the center in the bottom third are five lines in which a brief preliminary report can be written. These are not the only lists available, but they are the ones currently used in our clinic.


We actually copy the back of the form (second page) in a “head-to-toe” fashion so that tympanometric data on the back of the form can be quickly added to the front. Also along the ordinate, about one-third of the way from the top, is a “time marked” section that is 14 seconds long. The threshold measurements are reported on the form under that ear into which the signal is inserted.
This permits us to see the recruitment at frequency as the “reflex threshold” approaches the “hearing threshold” within 65 dB.
The first procedure is for the elicitation of the Most Comfortable Level (MCL) for speech, the results of which are noted in the summary. It is also the score elicited at a maximum level of 90 dBHL, which allows us to look for the possibility of PI-PB rollover—an indicant of possible VIIIth nerve involvement. QuickSIN scores are reported in SNR loss and can provide insight into what type of amplification, if any, is applicable to the patient (directional microphones, array microphones, FM systems, etc). These are measured in the standard manner beginning at 1000 Hz in the “better ear” or the “right ear” (if there is no preference). The form for this can be found under the right-hand portion of the “Summary of Results.” This version of the test is performed at threshold plus 20 dB for 60 seconds. We begin the test at this highest frequency knowing that, if the results at this high frequency are “negative,” the likelihood of a “positive” at a lower frequency is minimal. It is easy to see that the relationship for the threshold of hearing and the acoustic reflex threshold levels are such that “recruitment” is possible and that it is present. Also pertinent at this juncture is an examination and comparison of the speech reception threshold (SRT) and the average of the best two of the “speech frequencies” (500 Hz, 1000 Hz, and 2000 Hz). In addition, we believe that loudness growth measurements are increasingly important as manufacturers continue to make aids that amplify above 3000 Hz. We use an earphone over the “non-test” ear through which we can introduce “masking.” We do not conduct unmasked bone conducted measurements. The cardinal rule is “There is no such thing as accurate unmasked bone conduction testing.” Many of these difficulties are related to “placement” of the oscillator, sequelae of the mastoid bone, and sebaceous oils of the mastoid, etc. This is also the place to mention any indications for central auditory processing disorders. An important distinction is that we do not report what is the problem; instead, we report where lesions are and the impact of such a lesion on the communicative abilities of the patient.
Full-size versions of this form are available as downloadable pdfs – just click on the images above. If the results of the reflex change fall 50% or less in the steady state during the 10 seconds, the results are “positive” for “reflex decay.” If this is the case, a test is run at 500 Hz looking for the same response. For example, if the reflex was measured to be 85 dB at 1000 Hz, an “R” with a circle around it would be entered at 85 dB on the 1000 Hz line of the appropriate ear. In addition, a bar about two-thirds as wide as the two adjacent intensity lines is placed between 500 and 2000 Hz at the measured level with”MCL” written in it. The procedure is essentially the Hughson-Westlake procedure modified by Jerger and Carhart—a standard method for more than 40 years.
If, at the end of the 60 seconds, the hand is still raised or the button still depressed, the test results are said to be “negative” for involvement of the VIIIth cranial nerve. The name of the test, the results of the test, and the interpretation of these results are listed on a separate line of the Audiogram Form. The only true test of recruitment is a “loudness balancing” procedure, such as that of Fowler et al since the brain makes judgments of loudness. The literature suggests that the best predictor of the SRT is the average of the best two of the three speech frequencies ±2 dB. The interaural attenuation for bone signals is 0 dB, so we use the “plateau” method (the same as we do with aid conduction testing). The Various Tinnitus relief tinnitus vitamins treatment Steps to Relieve Irritating that there is a short period. Once the threshold measurements have been made and entered onto the right and left audiograms, several decisions need to be made. If the results are “positive,” we can continue at successively lower frequencies until we reach a “negative” result or we have gone below 1000 Hz.
However, since we make our measurements in 5 dB steps, the best two scores ±5 dB is within parameters.
We do not want to inadvertently fit patients with an instrument that is too loud or must be “turned down” in order to be tolerated.
Finally, we are aware that there is a central masking effect, which elevates the masked threshold by about 5 dB. Whenever these thresholds approximate each other by less than 65 dB, the difference must have been “recruited.” The closer the approximation is (which has a minimum of 25 dB), the greater the amount of recruitment. We subtract the 5 dB from the masked threshold to improve the accuracy of the measurements and use the symbols for masked bone conduction at 500, 1000, 2000, and 4000 Hz.



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