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Demystifying Hearing Testing—
The Eight Steps Necessary for a Complete Audiological Evaluation and What It All Means

Question: I need to get my hearing tested, but I hate taking tests. What is a hearing test like? What all will a hearing test tell me?—H. T.
Answer: You are not alone in your dislike of taking tests. There are a number of people that don’t like getting their hearing tested. To them, it is a test. They hated taking tests during their school days, and they hate them now. To them, taking a test implies a strong chance of failing the test. If this has been your attitude towards hearing testing, you’re in for a surprise. Here’s the good news. You can’t “fail” a hearing test.
I actually look forward to getting my hearing tested. You see, I’m curious to know whether anything about my hearing has changed since the last time.
Actually, “testing” is a misnomer. It is really a hearing evaluation to see how well, or how poorly, you hear and understand speech. Furthermore, it is not just one “test” or evaluation. The testing process consists of a whole series of evaluations.
In case you are not aware of it, you don’t just want a “hearing test.” You really want a complete audiological evaluation, which is only done by audiologists. This process should consist of 8 or more separate tests or evaluations, depending on your particular situation. Each of these 8 evaluations are necessary, so if your audiologist skips any of them (and some do), ask that he fully complete each one of them.
Note: hearing testing is done under carefully-controlled clinical conditions. These tests are not meant to reflect real-world listening situations. Rather, they are designed to make it possible to give consistent results no matter who tests your hearing; to document and compare changes in your hearing from one year to another; and to compare your hearing loss to hearing losses of other people. This means that the results of these tests only reflect how well you will hear under ideal listening situations. In real-world situations, your hearing will typically be worse.
The 8 steps in the complete audiological evaluation are normally completed in the following logical sequence as each step typically builds on what has been learned in the previous steps.

1.     Hearing History

Typically, your audiologist first gathers (and evaluates) information about your hearing history. She will ask you a number of questions regarding your ears and hearing loss that may include questions such as:

• What brought you here today?
   
• How long have you noticed difficulty with your hearing?
   
• Has your difficulty with hearing had a gradual or sudden onset?
   
• Is there a family history of hearing loss?
   
• Do you know what caused your hearing loss?
   
• Does your hearing problem affect both ears or just one ear?
   
• Have you exposed your ears to loud noise?
   
• Do your ears ring?
   
• Do you experience dizziness or vertigo?
   
• Do you have a history of ear infections?
   
• Have you noticed any pain, or discharge from your ears?
   
• Do you have greater difficulty hearing women’s, men’s or children’s voices?
   
• Are there situations where it is particularly difficult for you to follow conversations?

Note: Good audiologists will also ask you what medications you are on. Then they will check to see if any of your medications have ototoxic side effects that could be causing your hearing problems. This is a very important step so don’t let your audiologist overlook it. A number of audiologists use the book “Ototoxic Drugs Exposed” for this purpose.
Also, during this step feel free to volunteer any other information that you think may be relevant to your hearing loss so your audiologist understands as much as possible of your hearing situation.

2.     Physical Inspection—Ear Canal & Ear Drum

Following your hearing history, your audiologist will use an otoscope (basically a combined flashlight and magnifying glass) to physically inspect your ears for ear wax (cerumen) or foreign objects that might be blocking your ear canals. Anything partially or completely blocking your ear canals can adversely affect your hearing, and consequently corrupt any testing results.
Your audiologist will also inspect your ear canals and ear drums for problems (holes in your ear drum, signs of infection in your ear canal or middle ear, etc.). If he sees any serious problems, he will refer you to an ear specialist (medical doctor) for treatment. Remember, audiologists assess hearing. They do not treat ears medically.
However, some audiologists are trained to remove any excess ear wax they find, and then continue on with the evaluation process. Others will send you to a medical doctor for this procedure. If this is the case, you will have to come back later for your hearing tests.
Instead of using an otoscope, some audiologists now use a tiny TV camera that they insert into your ear canals to inspect your ears. This way both you and your audiologist can see what your ear canals and ear drums look like. This is cool to watch.

3.     Tympanometry & Acoustic Reflexes

After your audiologist inspects your ear canals, the next step in the complete audiological evaluation process goes by the name of Impedance Audiometry or Acoustic Immittance Testing. Impedance Audiometry consists of two parts. The purpose of this test is to evaluate how well your outer and middle ears are working.
The first part, called tympanometry (tim-pan-AHM-ih-tree), is a quick and easy test that takes longer to explain than to carry out. This test measures how easily your ear drums vibrate, and at what pressure these vibrations are the easiest.
Here’s how it all works. Your middle ears are normally filled with air at a pressure equal to the surrounding atmosphere. Your ear drums vibrate best when the air pressure inside your middle ears is the same as the outside atmospheric pressure.
To test whether this is the case, or not, a special probe, much like an ear plug, is placed snugly in your ear canal. A tympanometer connected to this probe then automatically varies the air pressure in your ear canal while producing a clear tone. It measures and records how your ear drums respond to the pressure changes in the presence of sound.
The result is shown on a tympanogram. A tympanogram is a graph of the relationship of the air pressure in your ear canal to the impedance of your middle ear. (The easiest way to understand impedance is to think of impedance as resistance to movement.) Impedance is lowest when the outside air pressure is equal to the air pressure in your middle ear.
Your audiologist will classify the results of your tympanometry as either Type A, B or C.
Type A is the result you want (Fig . 1). It indicates your middle ear mechanism is working normally. The graph looks like a mountain peak—not too high or too low—and centered in the middle of the graph (Fig. 1, solid line).
There are two variations in Type A. Type AD has a taller than normal peak (Fig . 1, dashed line). This indicates one (or more) of the bones in your middle ears are dislocated or damaged, or there may be a loss of elastic fibers in your ear drums. Type AS (Fig. 1, dotted line) has a shorter peak than normal. This often indicates a “stiff” system such as might occur if you have otosclerosis.¹
Type B (Fig. 2) shows a more or less flat graph resulting from little or no variation in impedance. This indicates a conductive hearing loss at all frequencies. Typically, this is the result of middle ear infections where your middle ear fills with fluid thus preventing your ear drum from vibrating freely. A Type B tympanogram may also result from a hole in your ear drum, or from ear wax blocking your ear canal.
Type C tympanograms (Fig. 3) show a peak similar to Type A tympanograms, but the peak is shifted off center. If the peak is shifted to the left (indicating negative air pressure in the middle ear), your ear drum is sucked in (Fig. 3, solid line). If the peak is shifted to the right (indicating positive pressure in the middle ear), your ear drum is bulged out (Fig. 3, dashed line). In either case, the result is a conductive hearing loss at both low and high frequencies. Type C tympanograms generally indicate that your Eustachian tubes are blocked, or otherwise are not working properly.²
The second part of the Impedance Audiometry test is measuring your Acoustic Reflex (AR). Your Acoustic Reflex is how well the tiny muscles in your middle ears contract in response to loud sounds. This testing is automatically done at the same time as the tympanometry testing so you might not even be aware it was done.
What is an Acoustic Reflex? Glad you asked. The Acoustic Reflex is an automatic mechanism God designed to help protect your inner ears from damage from loud sounds. Here’s how it works. There are tiny muscles (called the stapedius muscles) that are attached to the third bones (stapes or stirrup) in your middle ears. These muscles automatically contract when your middle ears are exposed to sounds over about 80 dB. When these muscles contract, they pull your stirrup bones (stapes) away from your oval windows so they won’t transmit this sound as loudly to your inner ears.³
At the same time, tiny muscles that are attached to your ear drums (called the tensor tympani) also contract in response to louder sounds. This stretches your ear drums slightly, thus reducing their mobility. This also reduces the volume of sounds transmitted through the bones of your middle ears, again helping prevent inner ear damage.
During this portion of the test, the impedance audiometer sends a louder tone into your ear canals. If these two muscles automatically contract at the presence of this sound, it shows your ears received the sound and attempted to protect themselves from it. This means your Acoustic Reflex mechanism is working properly.
If there is no Acoustic Reflex, it could indicate you have a conductive loss in your middle ears, you have a severe sensorineural hearing loss or your have a lesion(s) on your auditory nerve.

4.     Pure Tone Testing

Now that the preliminaries are out of the way, we come to what everyone thinks of when they think of hearing testing—what is called pure tone testing. The primary purpose of pure-tone testing is to determine the type (conductive, sensorineural, mixed), degree (mild, moderate, severe, etc.), and configuration (shape of loss, etc.) of your hearing loss. (Learn more about the shape of hearing losses in the article "Kinds of Hearing Losses.")
Pure-tone audiometry is done in a soundproof booth to ensure that background noise does not affect the test results. As a result, you will only hear those sounds that your audiologist introduces into the room, either though earphones (air conduction response), bone conduction oscillator (bone conduction response) or though speakers located in the room (sound field response).⁴
During a complete audiological evaluation, your audiologist will test your hearing first using air conduction testing, then using bone conduction testing. (Sound field testing [4c] is usually reserved for later when you are fitted with hearing aids.)

4a.    Air Conduction Testing

The purpose of the pure-tone air-conduction hearing test is to document the softest tones you can hear at least 50% of the time at selected test frequencies. During this test, you wear headphones and listen for these tones—first in one ear, then in the other ear. Each time you hear a tone, you typically press a button to indicate this.
Your audiologist will use a specially-calibrated device called an audiometer (ah-dee-AHM-it-ter) to measure your hearing loss. The audiometer produces a series of tones ranging from very low to very high pitches (frequency). At each pitch (frequency) of sound, you will hear a series of tones (beeps) of varying intensities (loudness). Your audiologist will lower the volume of this tone until you no longer respond consistently. Then she will do the same with a different frequency. She does this for the standard test frequencies between 250 Hz and 8,000 Hz. because these are the frequencies you use for speech.
The frequency or pitch of the sound is referred to in Hertz (Hz). The intensity or loudness of the sound is measured in decibels (dB). The softest level at which you can hear each tone is called your pure-tone threshold. Your audiologist will record your responses on a chart called an audiogram that graphically portrays your hearing loss, i.e. the softest sounds you can hear at each frequency tested.⁵
By convention, the air conduction results are displayed on your audiogram using blue Xs for your left ear and red Os for your right ear.
If you have tinnitus and you have trouble distinguishing the faint test tones from your tinnitus, ask your audiologist to use warble tones instead of pure tones. The warble tones are most distinctive and thus are easy to separate from your tinnitus. This is what I do. If the audiometer can’t produce warble tones, ask your audiologist to use the “double-beep” option—the tones are all repeated twice separated by a short pause (beep-beep). These “beep-beep” tones are not as easy to distinguish as warble tones, but are much easier to distinguish than the standard single tones.
Since your hearing loss likely varies by frequency, the standard way to express your degree of hearing loss is to calculate your Pure Tone Average (PTA)—the average of your hearing loss at 500, 1000 and 2000 Hz.—and use this figure to describe your hearing loss.
For example, if your hearing loss was 35 dB, 45 dB and 55 dB at 500, 1,000 and 2,000 Hz respectively, then your PTA would be 45 dB.
The proper way to express the results of your pure tone average (PTA) are as follows:

	Normal	0 – 25 dB
	Mild hearing loss	26 - 40 dB
	Moderate hearing loss	41 - 55 dB
	Moderately Severe hearing loss	56 - 70 dB
	Severe hearing loss	71 - 90 dB
	Profound hearing loss	>90 dB

      Thus, from the above example, you would describe your hearing loss either as a 45 dB loss, or as a moderate hearing loss.
Note: Never say you have a 45% hearing loss. This is totally meaningless. You cannot express decibels (dB) as percentages because decibels are not linear units of measurement. Stick to decibels, or use the mild, moderate, severe format.

4b.    Bone Conduction Testing

For bone conduction testing, you repeat the same procedure used for air conduction testing, but this time, instead of wearing earphones, you wear a special bone conduction oscillator (vibrator) placed on the mastoid process—the bony bump behind your ear. Bone conduction testing assesses how well you hear when the sound signal is transmitted through the bones of your skull to you cochlea. Since it bypasses your outer and middle ears, bone conduction testing can determine how well your inner ears work independent of any problems that might occur in your outer and middle ears. Bone conduction results are always better than, or equal to, your air conduction results.
Again, by convention, bone conduction results are displayed on your audiogram using angle brackets (<>)—blue “greater than” angle brackets (>) for your left ear and red “less than” angle brackets (<) for your right ear.
If your bone conduction results are normal and your air conduction results show a hearing loss, then you have a conductive loss. This means your middle ears are not working properly.
However, if both your bone conduction and air conduction results show the same degree of loss (within 10 dB), then you have a sensorineural hearing loss. This means your middle ears are working properly. Therefore, your hearing loss is in your inner ears or auditory nerves.
If both your air and bone conduction results show a hearing loss, and there is more than a 10 dB difference between the air conduction and bone conduction results (what they call the air-bone gap), then you have both a conductive loss (in your middle ears) and a sensorineural loss (in your inner ears). Appropriately, they call this a mixed loss.
At this point, I should briefly mention a bit about masking techniques. Masking is where your audiologist puts noise in the ear not being tested to prevent it from hearing sounds meant for the other ear. Masking is typically used if one of your ears hears much better than the other one. In this case, your better ear will hear (via bone conduction) the sounds being presented to your worse ear. As a result, you will likely respond when you shouldn’t. By masking your better ear, it can’t hear the test tones from the ear being tested, thus the test results are not corrupted.
In case you are interested, when you are wearing headphones it takes 40 dB of sound to vibrate your skull. (The corresponding figure is 60 dB when using insert earphones, and 0 dB for bone conduction.)⁶ This means that if you have normal hearing, when wearing headphones, the ear opposite to your test ear will typically hear any sounds though your skull (bone conduction) that are presented at a level greater than 40 dB).

4c.    Sound Field Testing

Sound field testing is simply testing while listening to loudspeakers in the sound booth, as opposed to listening through headphones/earphones or bone-conduction oscillators.
Sound field testing is usually reserved for testing how well you hear with your hearing aids on, since you can’t very well wear headphones and hearing aids at the same time or you risk getting feedback. Besides, it would be very uncomfortable.
During sound field testing, you sit in the soundproof booth facing the front and listen to sounds from two loudspeakers—one on each side of the booth set at 45 degrees to your ears.
The main purpose of sound field testing is to compare how well you hear with your hearing aids on as compared to how well you hear with your “bare ears.” Obviously, the results should be much better with your hearing aids on, or you are not getting any benefit from wearing them.
Normally, sound field testing is only done after your audiologist fits you with new hearing aids or significantly alters the settings on your existing hearing aids. This confirms whether your hearing aids are really helping you, or whether they need more “tweaking” to properly fit your hearing loss.

5.     Speech Recognition Threshold (SRT)

So far, all the testing has been to determine the degree and type of your hearing loss. The following tests now look at how well you respond to speech.
The first speech test done is typically the Speech Recognition Threshold (SRT) test. It is sometimes called by its older name, Speech Reception Threshold.
The purpose of the Speech Recognition Threshold (SRT) test is to determine the softest level at which you just begin to recognize speech 50% of the time.
Audiologists determine your SRT by asking you to repeat a list of easy-to-distinguish, familiar spondee words. (Spondee words are just two-syllable words that have equal stress on both syllables. You’ll notice that when you repeat a spondee word, you speak each syllable at the same volume and take the same length of time saying each syllable.) Spondee words were chosen for this test because they are easy to understand at faint hearing levels. Some of the commonly-used spondee words in this test include airplane, baseball, cupcake, hotdog, railroad, cowboy, ice-cream, outside, playground and sidewalk.
Some people are concerned that because they have had their hearing tested so often they have memorized the SRT word list, and thus they will not get a reliable test. (You can read more about this in the article “Help, I’ve Memorized the Word List!”) This is not a problem. In fact, you should be familiar with all the spondee words in the list before testing commences because this familiarization results in an SRT that is 4 to 5 dB better than that obtained if you didn’t know them. Remember, the purpose of this test is not to test your hearing acuity, but to determine at which level you begin to recognize speech.
When you take the Speech Recognition Threshold test, your audiologist will tell you, “Say the word ‘baseball.’ Say the word ‘cowboy.’ Say the word ‘hotdog.’” etc. As she does this, she varies the volume to find the softest sound level at which you can just hear and correctly repeat 50% of these words. This level is your SRT score expressed in decibels (dB). You will have a separate SRT test for each ear.
The Speech Recognition Threshold test serves several purposes. First, it is a measure of the reliability of your pure-tone air-conduction test. In fact, your SRT should be within 5 dB of your Pure Tone Average (PTA). Second, the SRT suggests the level of loudness at which words should be presented for the Word Discrimination (WD) testing that will follow. Third, your SRT determines how much power (gain) you will need in a hearing aid that is right for your degree of hearing loss.
Here’s some interesting facts about SRT values and what they mean to you. If your SRT is 5 dB (normal), you can understand speech perfectly at 21 feet and still catch some words at over 100 feet. If you have a mild hearing loss—for example a SRT of 30 dB—you could only hear perfectly at 1 foot but could still hear some words at 18 feet. If your SRT is 60 dB (a moderately severe hearing loss), you would need the speaker to be only 1 inch from your ear in order to hear perfectly and within 1 foot to still hear some of the words correctly. You can readily see that if you have an SRT of 70 or more you won’t hear much at all without hearing aids or other amplification.⁷
Closely related to the SRT is the Speech Awareness Threshold (SAT), sometimes called the Speech Detection Threshold (SDT). Your SAT score is the lowest level at which you can identify, but not understand, sound as speech. Normally, SAT testing is only done if SRT testing cannot be done for some reason.

6.     Most Comfortable Listening Level (MCL)

After determining your SRT, your audiologist will typically determine your Most Comfortable (listening) Level by talking to you and making the volume louder and louder until you indicate that it is “just right.” This is the volume at which you likely best hear speech. Therefore, this is the volume at which you’d normally want your hearing aids set. Typically, your MCL is about 40 dB louder than your SRT level if you have normal hearing. If you have a hearing loss it may be different. For example, my MCL is only 20 dB above my SRT level.

7.     Uncomfortable Loudness Level (UCL) or Threshold of Discomfort (TD)/Recruitment Testing

Typically after your audiologist finishes the MCL testing, he will test you for how loud a sound you can stand. This is your Uncomfortable Loudness Level (UCL) or Threshold of Discomfort (TD). It is sometimes called the Upper Level of Comfortable Loudness. No matter what you call it, it is the loudest level of sound that you would ever want to hear. Anything louder would be painful.
To do this test, your audiologist keeps talking to you and slowly raises the volume. You indicate when his voice is almost, but not quite, painful.
The UCL is very important for properly adjusting your hearing aids. Your hearing aids should be set so that no sounds ever exceed your UCL, and in fact, should stay 5 dB or so below this level.
Unfortunately, most audiologists consider the UCL test a test of recruitment (abnormal increase in loudness perception) at the same time. (You can learn more about recruitment by reading my article on “Recruitment.”) To a certain extent, UCL testing is a test of recruitment. However, it is not good enough because it does not identify the specific frequencies that cause your recruitment. As one audiologist told me recently, “We are so used to not seeing the frequency-specific UCL scores” that we don’t test for them. This needs to change.
It is my personal belief that many hearing aids end up in dresser drawers simply because they are not set to properly control recruitment—and this can only be done if you know which specific frequencies are causing recruitment. That is why frequency-specific recruitment testing is so important.
For example, in my 55 years of having my ears tested, frequency-specific recruitment testing has only been done once—and that was because I finally insisted it be done. It is no accident that my current hearing aids are the only ones I have worn in 51 years of wearing hearing aids that do not cause me pain because of recruitment. I no longer have to yank my hearing aids out just because my mother-in-law sets a glass on the table—and blows the top of my head off (figuratively, of course)—because recruitment levels were not set properly for how I perceive sound.
The proper way to test for recruitment is frequency by frequency for each ear in turn. To do this your audiologist uses the pure tone testing format and earphones. However this time, instead of seeing how soft a sound you can hear, he determines how loud a sound you can stand before your eyes blink, and you wince or jump as your recruitment kicks in.
These scores can be plotted on your audiogram just like the pure tones were, but using different symbols.
Your audiologist should then use these results to set your hearing aids so no sounds will ever equal or exceed these recruiting values at these frequencies. When this is done properly, the difference is like night and day. It is that wonderful!

8.     Word Recognition (WR) or Speech Discrimination (SD) Testing

The final speech test is Word Recognition (WR) testing, formerly called Speech Discrimination (SD) testing. The purpose of Word Recognition testing is to determine how well you hear and understand speech in a perfectly-quiet environment when the volume is set at your Most Comfortable Level (MCL).
To do this, your audiologist says a series of 25 or 50 single-syllable phonetically-balanced (PB) words. (Phonetically-balanced just means that the percent of time any given sound appears on the list is equal to its occurrence in the English language. The words in this test cover the whole spectrum of sounds made in English.) They are single syllable words such as chew, what, knees, etc.
For this test, your audiologist will say, “Say the word ‘come.’ Say the word ‘high.’ Say the word ‘chew.’ Say the word ‘knees,’” and so on. You repeat back what you think you hear.
Each ear is tested separately. During this test, your audiologist keeps her voice (or a recording on tape or CD) at the same loudness throughout. If you have normal hearing, the volume is typically set to 40 dB above your SRT (although it may range from 25 - 50 dB above your SRT level, depending on how you perceive sound). If you have a significant hearing loss, it is set to your MCL.
This is the only test where the results are recorded in percentages. The rest of the hearing tests are all expressed in decibels.
Your Word Recognition score is an important indicator of how much difficulty you will have communicating, and how well you may do if you wear a hearing aid. If your word recognition is poor, speech will sound garbled to you.
For example, a Word Recognition score of 100% indicates that you heard and repeated every word correctly. If your score was 0%, it means that you cannot understand speech no matter how loud it is—speech will be just so much gibberish to you. Scores over 90% are good and are considered to be normal. Scores below 90% indicate a problem with word recognition. If your score is under 50%, your word recognition is poor. This indicates that you will have significant trouble following a conversation, even when it is loud enough for you to hear. Thus, hearing aids will only be of very limited benefit in helping you understand speech. If your word recognition falls below 40%, you may be eligible for a cochlear implant.
Incidentally, people with conductive hearing losses frequently show excellent speech discrimination scores when the volume is set at their Most Comfortable Level. On the other hand, people with sensorineural hearing losses typically have poorer discrimination scores. People with problems in the auditory parts of their brains tend to have even poorer Word Recognition scores although they may have normal auditory pure-tone thresholds.
In addition to determining how well you recognize speech, Word Recognition testing has another use. Your audiologist uses it to verify that your hearing aids are really helping you. She does this by testing you first without your hearing aids to get the baseline Word Recognition score. Then, later she tests you with your hearing aids on. If your hearing aids are really helping you understand speech better, your Word Recognition scores should be significantly higher than they were without them on. If the scores are lower, your audiologist needs to “tweak” your hearing aids, or try different ones, to bring your Word Recognition scores up.