BASIC HEARING EXAMINATION, VESTIBULAR EVALUATION AND

AUDIOGRAM INTERPRERTATION
NEUROBEHAVIOR AND SPECIAL SENSES (NBSS) SYSTEM

Introduction
Hearing loss and vestibular disorders can occur at any age, ranging from infancy to
old age. They affect the quality of life. Basic hearing examinations such as the tuning
fork test and voice test, also the Romberg and gait test are easily practiced even in
remote areas and very useful to detect hearing loss and vestibular disorders. Although
not precise but may help in giving a rough guide about the patients condition.
Usage of an audiology device needs special training and practice, though students still
can learn the basic audiogram interpretation.
This learning guide includes:
Tuning fork test.
Voice test.
Pure Tone Audiogram interpretation.
Gait test.
Romberg test.

Knowledge
After following the exercise, the students should be able to describe:
Anatomy and physiology of the ear.
Mechanism of hearing, describing the conduction and sensorineural component.
Basic hearing examination using the tuning fork and voice test.
Basic pure tone audiogram interpretation.
Basic vestibular examination through gait and romberg test.

Skills
Tuning fork examination.
Voice test examination.
Interpret the result of pure tone audiometry.
 Gait test.
Romberg test.

Method
a. Presentation.
b. Demonstration.
c. Exercise.
d. Independent exercise in standardized patient.

Evaluation

Equipment
- Presentation: audiovisual.
- Demonstration and exercise: tuning fork and audiogram chart.

Communication skills
Students should be able to communicate to explain the examination procedure to
assure the patients cooperativeness during examination.

Management skills
Students should be able to develop an appropriate evaluation report from each
examination with each ears described separately, because this report will have an
effect on further decision making for this patient.

Attitudes and Professional behavior:

Students should be able to:
Appreciate patients preferences such as receiving an explanation on his/her
condition.
Make an appropriate referral to an otorhinolaryngologist for further management in
complicated cases.
Basic hearing examination procedure: tuning fork and voice test

TUNING FORK TEST

To differentiate conductive or sensorineural hearing loss.
Tuning forked used are the 512 Hz or 256 Hz.
Among other tuning fork tests, the Rinne and Webers tuning fork test are the
mostly used.
Rinne test:
- Hold the tuning fork with one hand.
- Vibrate and place it on the mastoid bone on one side until the patient can not
hear the sound.
- Move it in front of the external ear (external auditory canal) and ask the
patient whether he/she still can hear the sound.
- Perform the same procedure on the opposite site.

Rinne test

Rinne Test Interpretation:

Rinne positive: patient still can hear sound when the tuning fork is placed in
front of the external auditory canal.
 Rinne negative: patient can not hear sound when the tuning fork is placed in
front of the external auditory auditory canal.

Weber Test:
- Hold the tuning fork with one hand.
- Vibrate the tuning fork.
- Place it in the center of the forehead.
- Ask the patient to indicate that he/she can hear the sound louder at the right
side or the left side or he/she can hear the same loudness on both ears.

Weber test
VOICE TEST

This picture shows a voice test being

performed, the examiner in the left of
the picture while the patient on the right
1 mtr with the distance only one meter from
one another. Note that one of the ears of
the patient is being masked by a
Barany noise box device.

Principles:
A basic examination to roughly predict a level of hearing loss.
Hearing examination is performed with the distance between the examiner and
the patient just 1 (one) meter apart, done in a sound-proof room. With the patient
sitting sideways in front of the examiner, so that the tested ear will face the
examiner. This position is to prevent lip movement reading by the patient,
because most deaf patients are experts at reading lip movements.
Each ear is examined one at a time, the untested ear is given a masking voice
such as produced by a barany noise box device, otherwise a noisy ticking wrist
watch will suffice. Just place the wrist watch by pressing against the non-test ear.
Masking on the non test ear is crucial to prevent cross hearing.

Picture of various types of tuning forks and a Barany Noise Box

Hearing Interpretation:
Normal ( 0-25 dB): Hears whisper.
Mild hearing loss (26-40 dB): Able to hear and repeat words produced with a
loudness of a normal communication voice.
Moderate hearing loss (41-60 dB): Able to hear and repeat words produced
with a loud voice.
Severe hearing loss (61-80 dB): Able to hear and repeat words shouted near
the ear.
Profound hearing loss (> 80 dB): Not able to hear and repeat words shouted
near the ear.

AUDIOMETRY
- Is a hearing assessment using pure tone audiometer with test results written into a
graphic that is named an audiogram.
- Written in the audiogram are two hearing components: the air conduction and
bone conduction, both written with specific symbols to differentiate each
component and in different colours to specifiy right from left ear.
- Symbols used in an audiogram:
Results for the left ear is written in blue and right ear in red.
Non masking symbols for air conduction
o X for left ear
o O for right ear
Non masking symbols for bone conduction
o < for right ear
o > for left ear
- Interpretation of audiogram.
Hearing depends on the integrity of the air conduction component, the level
of hearing will be measured from this component.
Level of hearing for each air conduction components: counted by the adding
each decibel-results on each communication freq as at 500, 1000, 2000 and
4000 Hz, finally the total sum is divided in 4, the result will be the mean-level
of hearing for each air conduction component.
 Compare the equation result with the hearing loss chart, define the patients
level of hearing loss of each ear.
Define the type of hearing loss; conductive, sensorineural, or mixed (will be
discussed below).
Lastly, write the interpretation, that consists of the degree of hearing followed
by the type of hearing loss, example: moderate sensorineural hearing loss,
severe mixed hearing loss, etc.

This audiogram is written only the symbols of the air conduction,

note how the symbols differentiate left from right ear

Types of Hearing Loss

1. Conductive hearing Loss

Principles of interpretation:
BC tresholds within normal limit.
AC tresholds beyond the normal hearing range (greater than 25 dB).
2. Sensorineural hearing loss
Principles of interpretation:

Both BC and AC are not within the normal hearing range (> 25 dB).
Gap between the BC and AC < or = 10 dB, or both components are in one
line.

3. Mixed Hearing Loss

Principles of interpretation:
Both BC and AC components are not within the normal hearing range.
Air-bone gap between both components more than 10 dB.
VESTIBULAR EXAMINATION

Vestibular disorders can exist as a complication of the ear disease. It influences the
coordination system.

Romberg Test

1. Patient stands forward with the feet in a line, the heels and toes are touching.
Both hands in a cross position on the chest.
2. The examiners stands at the side of the patient to watch if the patient falls in
this test.
3. The patient is asked to close the eyes and the examiner notice the direction of
the fall of the patient.
4. Normal response is the patient should be able to maintain posture without
movement of the feet.

The Tandem Gait Test

1. The patient is asked to walk toward the examiner with one foot placed in front
of the other and the heel touching the toes at each step.
2. Normal response is the patient moves without any unsteadiness or sudden
lateral placement of one foot to maintain balance.
 LEARNING GUIDE
Basic Hearing and Vestibular Examination

PERFORMANCE
NO STEP SCALE

0 1 2
Preparation Client assessment
1 Greet the patient respectfully and with kindness, introduce
yourself.
2 Politely ask patient identification: name, age, education,
occupation, and address.
3 Ask the patient which ear has the hearing difficulty and
whether he/she has vestibular complains.
4 Wash your hands first with antiseptic soap and dry it with
paper tissues or towel, wear the mask and hand gloves.
5 With a headlight examine each outer ear canal to make sure
no cerumen, otherwise it will effect the hearing examination
result. This is done by holding the ear: the middle finger and
the thumb gently pulls the pinna outwards-upwards and the
index finger pushes the tragus forward, this is to straighten the
outer ear canal to assure the examiners view is not blocked by
the canal curve.
6 Give a brief and adequate explanation about the examination.
Rinne Test
7 Hold the tuning fork with one hand.
8 Vibrate and place it on the mastoid bone on one side until the
patient can not hear the sound.
9 Move it in front of the external ear.
10 Ask the patient whether he/she still hears the sound or not.
11 Perform the same procedur on the opposite side.
Weber Test
12 Hold the tuning fork with one hand.
13 Vibrate the tuning fork.
14 Place it in the center of the forehead.
15 Ask the patient to indicate on which side that he/she can hear
most or hears the sound symmetric on both ears.
Voice test
16 Hearing examination is performed with the distance between
the examiner and the patient just 1 (one) meter apart, done in
a sound-proof room. With the patient sitting sideways in front
of the examiner, so that the tested ear will face the examiner.
 17 Each ear is examined one at a time, the untested ear is given a
masking voice such as produced by a barany noise box
device, otherwise a noisy ticking wrist watch will suffice.
Just place the wrist watch by pressing against the non-test ear
to prevent cross-hearing.
18 Patient been told to repeat the word which whispered or said
by the examiner. The examiner uses different voice loudness
to examine the patients hearing, starting with the whispering
voice and then raised in loudness until the patients responds,
the hearing level is based on the patients respond to examiner
voice.
19 Decide the hearing intensity.
Normal, mild, moderate, severe or profound hearing loss.
20 Adjust the patients sitting position to examine the other ear in
the same manner.
Audiogram interpretation
21 Start by paying attention to the audiogram chart, define which
chart represents the right and left ear.
22 Decide the degree of hearing loss for each ear.
Start by counting the air conduction by adding the decibles
reached in each conversation frequency, the sum is divided by
4. Begin with the air conduction component pay attention on
each 500, 1000, 2000, and 4000 Hz frequency column, note
the results of decibels marked on each column and add all the
decibel results.

Degree of Hearing Loss

0 to 25 dBHL within normal limits
26 to 40 dBHL mild loss
41 to 60 dBHL moderate loss
61 to 80 dBHL severe loss
More 80 dBHL very severe loss (profound loss)
23 Observe the distance between the bone and air conduction
24 Define the type of hearing loss in each ear separately.
Type of hearing loss
Both component less than 25 dB or in normal area: normal
hearing
Both components sum greater than 25 dB and air bone
gap < 10 dB: sensorineural hearing loss.
Bone conduction less than 25, while air conduction greater
than 25 dB and air bone gap >10 dB: Conductive hearing
loss.
Both components greater than 25 dB and air bone gap >
10 dB with: mixed type hearing loss.
25 Make a report of the examination result, each examination
describes the left and right ear separately to aid for further
 examination.
Romberg Test
26 Patient stands forward with the feet in a line, the heels and
toes are touching. Both hands in a cross position on the chest.
27 The examiners stands at the side of the patient to watch if the
patient falls in this test.
28 The patient is asked to close the eyes and the examiner notice
the direction of the fall of the patient.
29 Normal response is the patient should be able to maintain
posture without movement of the feet.
The Tandem Gait Test
30 The patient is asked to walk toward the examiner with one
foot placed in front of the other and the heel touching the toes
at each step.
31 Normal response is the patient moves without any
unsteadiness or sudden lateral placement of one foot to
maintain balance.
32 Give the general result about the patients hearing and
balance.

CRITERIA OF PERSONAL PERFORMACE EVALUATION

Scale Performace Achievement

0 If student doesnt perform the task
1 If student performs the task incorrectly/incompletely
2 If student performs the task correctly and completely
Audiogram Interpretation Exercises: