There are various different ways to test hearing, depending on the age of the person involved and the type of hearing loss. The medical term for hearing tests is audiometry. Note: the information below is a general guide only. The arrangements, and the way tests are performed, may vary between different hospitals. Always follow the instructions given by your doctor or local hospital.
Structure of the ear
The ear is roughly divided into three parts. The outer (external) ear includes the part you can see (called the pinna) and the narrow tube-like structure (the ear canal) which your health professional can look down with a torch. At the end of the canal is the eardrum. This separates the external ear from the middle ear. The eardrum is a tightly stretched membrane, a bit like the skin of a drum.
The middle ear is an air-filled compartment. Inside it are the three smallest bones in the body, called the malleus, incus and stapes. These bones are connected to each other. The last in the line, the stapes, also makes contact with the inner (internal) ear. The air space of the middle ear connects to the back of the nose by the Eustachian tube.
The inner ear is made up of two components - the cochlea and the vestibular system. The cochlea is involved with hearing. The vestibular system helps with balance. The cochlea is a snail-shaped chamber filled with fluid. It is lined with special sensory cells called hair cells. These cells transform sound waves into electrical signals. The cochlea is attached to a nerve that leads to the brain.
The vestibular system is made up of a network of tubes, called the semicircular canals, plus the vestibule. The vestibular system also contains special sensory cells; however, here they detect movement instead of sound. Both the cochlea and the vestibular system are connected to a nerve which carries electrical signals to the brain.
How do we hear?
Sound waves are created when air vibrates. To hear, the ear must change sound into electrical signals which the brain can understand. The outer part of the ear (the pinna) funnels sound waves into the ear canal. When sound waves reach the eardrum they make it vibrate. Vibrations of the eardrum make the tiny bones in the middle ear move too. The last of these bones (the stapes) passes on the vibrations to the fluid-filled chamber called the cochlea. When the vibrations reach the cochlea, the fluid inside it moves. As the fluid moves it causes the special sensory cells to create an electrical signal. This electrical signal is sent to the brain. Special areas in the brain receive these signals and translate them into what we know as sound.
Your ears create electrical signals that represent an extraordinary variety of sounds. For example, the speed at which the eardrum vibrates varies with different types of sound. With low-pitched sounds the eardrum vibrates slowly. With high-pitched sounds it vibrates faster. This means that the special hair cells in the cochlea also vibrate at varying speeds. This causes different signals to be sent to the brain. This is one of the ways we are able to distinguish between a wide range of sounds.
What can cause hearing loss?
Damage to any part of the ear can cause a hearing loss.
If there is a problem in the ear canal or the middle ear, this causes what is known as a conductive hearing loss. In conductive hearing loss, the movement of sound (conduction) is blocked or does not pass into the inner ear. There are several causes of conductive hearing loss and they may result in a permanent or a temporary hearing loss. In children, a common cause is the build-up of fluid in the middle ear space, otherwise known as glue ear. See separate leaflet called Glue Ear for more details.
If the fluid-filled chamber called the cochlea or the hearing nerve is not working properly this causes what is known as a sensorineural hearing loss. Usually this means that hair cells in the cochlea are not working properly or there is a problem with the hearing nerve so that some or all sounds are not being sent to the brain. Sensorineural hearing losses are usually permanent. They can be mild, moderate, severe or profound and affect one or both ears.
It is also possible for sensorineural and conductive hearing losses to occur together in a mixed hearing loss.
How do hearing tests work?
There are various types of tests that can be carried out to check how well you are hearing. They vary according to who is being tested and why. Babies are obviously not able to say when they have heard a sound, so special methods are used when testing babies. In children, the principles of testing may be the same; however, the way in which the tests are carried out may be varied to obtain the most accurate results. There are also additional tests which help to check how well the middle ear and the brain are working in the hearing pathway.
The most common tests of hearing are described below.
Testing newborn babies
The automated otoacoustic emissions (AOAE) test is a quick, simple and painless way to screen newborns for hearing loss. A small earpiece containing a microphone and a mini-loudspeaker is placed in the ear. The loudspeaker makes clicking sounds in the ear. These are passed to the fluid-filled chamber called the cochlea. If the cochlea is working normally, it responds by sending a sound back to the ear canal. This is detected by the microphone. The test is extremely sensitive so that even a slight hearing loss can be detected and if there is a good response then no further checks are needed.
Sometimes, the response cannot be detected when the test is done. This could be because of hearing problems but initially it is more likely to be due to other factors. This could be because the baby is unsettled, the room was noisy or there was some fluid left in the ear after birth. The test will usually be repeated and if there is still not a good response then it will be followed up with another type of test called an automated auditory brainstem response (AABR) test.
In an AABR test a small earphone plays clicks into the baby's ear. If the baby can hear the click, the electric signal in the hearing nerve on its way to the brain can be picked up by sensors that are placed on the baby's skin over their head. The loudness of the clicks is set to a particular level. If this does not produce a response, further different tests will be needed.
Both AOAE and AABR testing are best done when the child is asleep, as the response to be detected is very small and can be difficult to pick up if there is a lot of movement.
Testing in babies and young children
In young children a technique called visual reinforcement audiometry is used. In this test the child hears sounds, usually through speakers in the testing room. When the child hears the sound and turns their head towards it they are given a reward. Usually this is a visual reward such as the flashing lights of a toy. The person testing the child's hearing continues to reinforce this behaviour with a reward every time the child turns towards a sound. Then the person carrying out the test begins to assess the child's hearing by seeing if they respond to different types of sound. By doing this it is possible to find the quietest sound the child can hear.
Different variations of this reward-based test are used as a child becomes older and finds it easier to communicate.
Testing in older children and adults
In older children and adults testing mainly uses a technique called pure tone audiometry. This uses a machine called an audiometer to play a series of tones through headphones. The tones vary in pitch (frequency, measured in hertz) and loudness (intensity, measured in decibels).
The health professional conducting the test will control the volume of a tone and reduce its loudness until you can no longer hear it. Then the tone will become louder until you can hear it again. You signal by raising your hand or pressing a button every time you hear a tone, even if the tone you hear is very faint. The health professional will then repeat the test several times, using a higher-pitched tone each time. Each ear is tested separately.
The results of the test are plotted on a special graph called an audiogram which helps to show the pattern of any hearing loss.
What are hearing tests used for?
Hearing tests are used in a number of different circumstances including:
- To evaluate possible hearing loss in anyone who has noticed a persistent hearing problem in one or both ears or has had difficulty understanding words in conversation.
- When determining the type and amount of hearing loss (conductive, sensorineural, or both).
- Screening babies and young children for hearing problems that might interfere with their ability to learn, speak, or understand language.
- To screen for hearing loss in people who are repeatedly exposed to loud noises or who are taking certain antibiotic medicines, such as gentamicin.
What should I do to prepare for a hearing test?
Usually very little preparation is needed for a hearing test. If you are known to have wax in your ears you may have to have this removed before the test, so that it does not interfere with the results.
Let the person doing the test know if you have had, or the child being tested has had, a recent cold or ear infection, as this may interfere with the results.
Are there any side-effects or complications from hearing tests?
These are very safe tests; complications arising from these tests are extremely rare.
Further reading and references
Walker JJ, Cleveland LM, Davis JL, et al; Audiometry screening and interpretation. Am Fam Physician. 2013 Jan 187(1):41-7.
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