Old Dogs and New Tricks An Update on Pure Tone Audiometry Audiometer

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					    Old Dogs and New Tricks
An Update on Pure Tone Audiometry

          Robert H. Margolis
          margo001@umn.edu

        University of Minnesota
      Department of Otolaryngology
        Audiology Incorporated

          AudiologyNow! 2010
                 LM112
Robert H. Margolis
margo001@umn.edu
                                                                                UTILIZATION
                                                                                PROCEDURE
                                                       1 JULY 93 - 30 JUNE 94
                                           Cents per Dollar Billed




                                                10
                                                       15
                                                                                      20
                                                                                              25
                                                                                                   30




                                       0
                                           5
                         Pure Tone
                        Audiometry


                           Acoustic
                         Immittance



                     Tympanometry



                           Speech
                        Audiometry


                     ABR Threshold
                       Evaluation

                          Pediatric
                           Hearing
                                                                                                        LM112




                         Assessment

                     Intraoperative
                       Monitoring



                               Other
                                                                                                                AudiologyNow!2010




                     Electrocochleog
                         raphy


                     ABR Neurologic
                       Evaluation
                                                                                                                                    Old Dogs and New Tricks




                         Otoacoustic
                         Emissions
                     Old Dogs and New Tricks
                            AudiologyNow!2010
                                     LM112


                     Non-electric Hearing Test Device
                                  c. 1850



Fillmore




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                       History of Pure Tone
                      Audiometry in the U.S.




Robert H. Margolis
margo001@umn.edu
                            Old Dogs and New Tricks
                                AudiologyNow!2010
                                      LM112


                     1876



  Grant                                       A.G. Bell (1847-1922)
                                              invents the telephone




Robert H. Margolis
margo001@umn.edu
                           Old Dogs and New Tricks
                                  AudiologyNow!2010
                                          LM112



                     Bell’s “Electometer-Audiometer”
                                 1879-1880



 Hayes




Robert H. Margolis
                                                       From Fellendorf, 1976
margo001@umn.edu
                             Old Dogs and New Tricks
                                     AudiologyNow!2010
                                               LM112


                      1906

                      Lee de Forest (USA) invents the Audion vacuum tube


T. Roosevelt


                                                       DeForest received an
                                                       Academy Award in 1959 for
                                                       introducing sound to movies




 Robert H. Margolis
 margo001@umn.edu
                             Old Dogs and New Tricks
                                       AudiologyNow!2010
                                                    LM112


                      1908
                      Robert Barany (Austria) invents the Noise Box for audiometric
                      masking. Barany was awarded the Nobel Prize in 1914 while he was
                      a prisoner in a Russian POW Camp.



T. Roosevelt




 Robert H. Margolis
 margo001@umn.edu
                            Old Dogs and New Tricks
                                 AudiologyNow!2010
                                          LM112


                     1917


                     C.C. Bunch is hired at the University of Iowa
                     To develop hearing tests and test patients.
Wilson               Developed the first sweep frequency audiometer




Robert H. Margolis
margo001@umn.edu
                            Old Dogs and New Tricks
                                AudiologyNow!2010
                                      LM112


                     1922
                                              Fowler and Wegel
                                              develop the first
                                              vaccuum tube
                                              Audiometer –
Harding                                       Western Electric 1A

                                              Also the first U.S.
                                              commercial audiometer
                                              Price - $1500

                                              25 are sold

Robert H. Margolis
margo001@umn.edu
                            Old Dogs and New Tricks
                                AudiologyNow!2010
                                      LM112

                     1924

                                              Jones and Knudsen,
                                              American otologist
                                              and physicist publish
                                              the first detailed paper
Coolidge                                      on audiometric
                                              methods.




Robert H. Margolis
margo001@umn.edu
                            Old Dogs and New Tricks
                                   AudiologyNow!2010
                                            LM112


                     1925

                     Western Electric produces the first widely used
                     Audiometer – the 2A


Coolidge




Robert H. Margolis
margo001@umn.edu
                            Old Dogs and New Tricks
                                   AudiologyNow!2010
                                            LM112


                     1925

                     Western Electric produces the first widely used
                     Audiometer – the 2A


Coolidge




Robert H. Margolis
margo001@umn.edu
                           Old Dogs and New Tricks
                                  AudiologyNow!2010
                                        LM112

                      1944 (January)

                                                Hughson and
                                                Westlake publish
                                                their Manual for
                                                Rehabilitation of
F. Roosevelt
                                                Aural Casualties




 Robert H. Margolis
 margo001@umn.edu
                        Old Dogs and New Tricks
                               AudiologyNow!2010
                                        LM112




                           American Standards Association
                                    Z24.5-1951
Truman

                     Audiometers for General Diagnostic Purposes




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                                       Carhart and Jerger report
                                       on the scientific basis
                                       of the Hughson-Westlake
                                       method and recommend its
Eisenhower                             use for clinical audiometry

                                       J. Speech Hear Dis (1959)




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                                  ANSI S3.21-1978
                                  Standard Method for Manual
                                  Pure Tone Audiometry



  Carter




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                                  ANSI S3.6 – 2004 American
                                  National Standard
                                  Specification for Audiometers



  Bush




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                     Test Environment



Robert H. Margolis
margo001@umn.edu
                       Old Dogs and New Tricks
                              AudiologyNow!2010
                                      LM112




                             ANSI S3.1-1999 (R2008)
    Test
Environment
                      American National Standard Maximum
                       Permissible Ambient Noise Levels for
                            Audiometric Test Rooms




 Robert H. Margolis
 margo001@umn.edu
                      Old Dogs and New Tricks
                           AudiologyNow!2010
                                   LM112


                        Audiometric Sound Room


    Test
Environment




 Robert H. Margolis
 margo001@umn.edu
                      Old Dogs and New Tricks
                          AudiologyNow!2010
                                LM112




    Test
Environment




 Robert H. Margolis
 margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                          Earphones



Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




Earphones

                                             Supra-aural




Robert H. Margolis
margo001@umn.edu
                                                 Old Dogs and New Tricks
                                                        AudiologyNow!2010
                                                                     LM112



                                                                             OCCLUSION
                                                 SUPRA-AURAL EARPHONE         EFFECT
                                                          OCCLUDED
                     Sound Pressure Level (dB)



Earphones                                                                    Sound Pressure Level in
                                                                             the ear canal unoccluded
                                                                             and with the ear covered
                                                                             by a TDH earphone with
                                                                             supra-aural cushion. The
                                                                             sound source was a bone
                                                                             vibrator placed on the
                                                       UNOCCLUDED
                                                                             forehead.




                                                        Frequency (Hz)



Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




Earphones




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                                LM112




                          Insert Earphones

Earphones




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




Earphones




Robert H. Margolis
margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                      Bone Conduction


Robert H. Margolis
margo001@umn.edu
                      Old Dogs and New Tricks
                          AudiologyNow!2010
                                LM112




  Bone
Conduction
                                          Forehead and
                                          Mastoid Placement




 Robert H. Margolis
 margo001@umn.edu
                                Old Dogs and New Tricks
                                            AudiologyNow!2010
                                                           LM112




  Bone
Conduction




                      Margolis, Glasberg, Creeke, & Moore (2010). AMTAS®: Automated method for testing
 Robert H. Margolis   Auditory sensitivity: Validation studies. Int J Audiol 49: 185-194.
 margo001@umn.edu
                     Old Dogs and New Tricks
                         AudiologyNow!2010
                               LM112




                      Air-Bone Gaps


Robert H. Margolis
margo001@umn.edu
                       Old Dogs and New Tricks
                              AudiologyNow!2010
                                       LM112




                       What’s wrong with this audiogram?

Air-Bone Gaps




  Robert H. Margolis
  margo001@umn.edu
                       Old Dogs and New Tricks
                           AudiologyNow!2010
                                 LM112




Air-Bone Gaps




  Robert H. Margolis
  margo001@umn.edu
                                      Old Dogs and New Tricks
                                                      AudiologyNow!2010
                                                                         LM112




Air-Bone Gaps
                           Studebaker (1967). Intertest variability and the air-bone gap. J. Speech Hear Dis 32, 82-86.



                       • The air-bone gap is a normally-distributed variable

                       •      Air-bone gap is zero 38% of the time




  Robert H. Margolis
  margo001@umn.edu
                                         Old Dogs and New Tricks
                                                              AudiologyNow!2010
                                                                               LM112


                       Distributions of air- and bone-conduction thresholds
                             Air conduction standard deviation = 5 dB
                           Bone conduction standard deviation = 7 dB

Air-Bone Gaps                                       Distribution of Thresholds (Mean ABG = 0 dB)

                                             45
                                                                                                     Air Cond
                                             40
                                                                                                     Bone Cond
                                             35
                        Percent Occurrence




                                             30
                                             25

                                             20
                                             15
                                             10
                                             5
                                             0
                                                  -25   -20   -15   -10   -5    0    5    10    15    20        25
                                                                    Normalized Threshold (dB)


  Robert H. Margolis
  margo001@umn.edu
                          Old Dogs and New Tricks
                                 AudiologyNow!2010
                                         LM112




                     • The air-bone gap is the difference between
                     two normally-distributed variables

                     •   Air-bone gap is zero 21% of the time




Robert H. Margolis
margo001@umn.edu
                                                  Old Dogs and New Tricks
                                                                         AudiologyNow!2010
                                                                                                              LM112



                              Expected distribution of air-bone gaps
                             Air conduction standard deviation = 5 dB
                            Bone conduction standard deviation = 7 dB
Air-Bone Gaps
                                                         Distribution of Air-Bone Gaps (Mean=0)

                                            25
                                                                                                                                                         0 dB air-bone gaps – 1 in 5
                                                                                                  21.2
                       Percent Occurrence




                                            20                                         19.6                  19.1
                                                                                                                                                         Differences > 10 – 40%
                                            15
                                                                                                                     12.5
                                                                           10.6
                                            10

                                                                   5.6                                                       5.9
                                            5
                                                           1.8                                                                          2.2
                                                   0.4                                                                                             0.8
                                            0
                                                 -25     -20     -15     -10      -5          0          5      10      15         20         25
                                                                               Air-Bone Gap (dB)



  Robert H. Margolis
  margo001@umn.edu
                       Old Dogs and New Tricks
                           AudiologyNow!2010
                                 LM112




Air-Bone Gaps




  Robert H. Margolis
  margo001@umn.edu
                             Old Dogs and New Tricks
                                      AudiologyNow!2010
                                                LM112



                                     The Dirty Little Secret
                        (adults only – some material may be offensive)
Air-Bone Gaps
                       Bone Conduction Testing is a Biased Experiment



                                    In manual pure-tone audiometry
                       Air Conduction and Bone Conduction are NOT Independent




  Robert H. Margolis
  margo001@umn.edu
                       Old Dogs and New Tricks
                           AudiologyNow!2010
                                 LM112




Air-Bone Gaps
                                               4 kHz Air-Bone Gaps




  Robert H. Margolis
  margo001@umn.edu
                          Old Dogs and New Tricks
                                            AudiologyNow!2010
                                                                      LM112



                       Air-Bone Gaps in Sensorineural Hearing Loss
                                                        AIR-BONE GAPS (dB) IN SNHL


Air-Bone Gaps              20                                                            19.3

                           18
                           16
                           14
                           12
                           10                                                     13.2
                                            5.0
                            8
                            6                               2.9             3.8
                                4
                                2     0.7
                                0                     0.0                                         AMTAS
                                                                      0.4
                                    0.5                                                         Manual
                                                  1
                                                                  2
                                                                                  4
                                     FREQUENCY (kHz)



  Robert H. Margolis
  margo001@umn.edu
                       Old Dogs and New Tricks
                           AudiologyNow!2010
                                 LM112




Air-Bone Gaps




  Robert H. Margolis
  margo001@umn.edu
                           Old Dogs and New Tricks
                                   AudiologyNow!2010
                                            LM112




                            Another Dirty Little Secret
Air-Bone Gaps

                       Your audiometer may be calibrated off standard
                                     at 4 kHz (bone)




  Robert H. Margolis
  margo001@umn.edu
                                 Old Dogs and New Tricks
                                        AudiologyNow!2010
                                                LM112




                             •   How to eliminate the 4 kHz air-bone gap:

Air-Bone Gaps          •     Calibrate 4 kHz bone conduction to a Reference
                           Equvalent Force Level 13 dB lower than standard

                                    •   Mastoid - 22.5 dB re: 1µN

                                   •    Forehead – 30.5 dB re: 1µN



  Robert H. Margolis
  margo001@umn.edu
                       Old Dogs and New Tricks
                           AudiologyNow!2010
                                 LM112




                     Automated Audiometry


Robert H. Margolis
margo001@umn.edu
                        Old Dogs and New Tricks
                                 AudiologyNow!2010
                                             LM112




                      In Diagnostic Audiology

Automated
Audiometry
                      In Industrial/Military Audiology




                      The “Otogram”




 Robert H. Margolis
 margo001@umn.edu
                                Old Dogs and New Tricks
                                             AudiologyNow!2010
                                                            LM112




                                                 AMTAS®
Automated
                      •   Automated, patient controlled threshold measurement
Audiometry
                      •   Self-paced
                      •   Contralateral masking always presented
                      •   Adult and child versions
                      •   Complete air and bone conduction audiogram without examiner intervention
                      •   Remote Monitor
                      •   Quantitative quality assessment




 Robert H. Margolis
 margo001@umn.edu
                          Old Dogs and New Tricks
                                AudiologyNow!2010
                                       LM112




Automated
Audiometry
                      REIMBURSEMENT FOR AUTOMATED AUDIOMETRY




 Robert H. Margolis
 margo001@umn.edu

				
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