Continuing Education:
TYMPANOMETRY
Figure 1. The Middle ear is a closed space and thus, quite
inaccessible to scrutiny from the outside.
Written by: Ted Venema Tympanometry is a non-behavioral test
of middle ear function, which means it
Figure 1. The Middle ear is a
requires no voluntary response on the
inaccessible
part to scrutiny
of the client being tested. It canfrom
be
routinely utilized by the HIS clinician
continuing education in private practice, and should become
a regular part of a client test battery. As
The purpose of this health care professionals know, one cannot
article is to describe base conclusions on one single test. As
math teachers always say, “It takes two
the principles behind dots to make a line.” In our field, air-
commonly used bone gaps seen in Pure Tone Testing can
be backed up by a quick, five-minute
Tympanometry, how assessment of Tympanometry.
it is done, and how to
The purpose of this article is to describe
interpret the results. the principles behind commonly used
Tympanometry, how it is done, and how
to interpret the results. The general thrust
here is to familiarize clinical practitioners,
in the clearest way possible, with generally
known and widely accepted procedures of
Tympanometry.
I. Why Do We Have Middle
Take the Quiz
on page 30 Ears in the First Place?
Figure 1 (above) shows the middle ear is a
to earn 1 Continuing closed space, filled with air. One purpose
of the middle ear is to change or transduce
Education Credit incoming sound waves into mechanical
piston-like energy. The cochlea of the
22
inner ear is filled with fluids called
perilymph and endolymph. Perilymph,
closed space and thus, quite
which fills the outer two boney labyrinths
theisoutside.
similar to the fluid that surrounds the
brain; namely, cerebral-spinal fluid. The
inner membranous labyrinth is filled
with endolymph, which has the opposite
chemical composition. The job of the
cochlea is to transduce fluid motion
energy into electrical energy, because this
is the “language” the brain understands.
The Middle Ear Increases
Sound Pressure
2. 2.
1.
3.
TM at rest
Buckling action Umbo 1.
Figure 2. The Middle Ear Increases Sound Pressure 3 Ways:
1. TM is larger than footplate of Stapes (17:1)
2. Leverage action of ossicles (Malleus is 1.3:1 longer than Incus)
3. Buckling action of TM (2:1)
Figure 2 shows that the middle ear in-
creases the pressure of airborne sound so
that it can activate the fluid-filled cochlea.
Airborne sound cannot otherwise activate
a fluid-filled cochlea. Think of having your
head under water in a swimming pool as
 120
In Summary:
100 1. Eardrum – Stapes size: 17:1
2. Ossicles leverage action: 1.3:1
you try to hear someone speaking who is 3. Eardrum buckling action: X 2:1
standing on the edge. You won’t hear much 80 44:1
because almost all of the airborne sound
dB This corresponds to an increase between 30-35 dB
will bounce off the water. The same would SPL 60
happen if we didn’t have middle ears.
Almost all of the mechanical energy from 120
In Summary:
40
the middle ear would bounce off from the 100
33dB1. Eardrum – Stapes size:
2. Ossicles leverage action:
17:1
1.3:1

20
3. Eardrum buckling action: X 2:1
cochlea. The middle ear increases sound dB
80 44:1
This corresponds to an increase between 30-35 dB
pressure in three ways. First, the working SPL 60

surface area of the tympanic membrane 40 0

33dB
(TM) is 17 times larger than the footplate of 20 0 10 100 1000 10,000 100,000 1,000,000
44:1 1,000,000 Pressure
the stapes which sits inside the oval window, 0
0 10 100 1000 10,000 100,000
the entrance to the cochlea. Pressure is 44:1 Pressure
force over an area. To appreciate this, push Figure
Figure 3. The 3. The
middle ear must increase middle
the pressure ofear must increase the pressure of air-borne
air-borne

hard with your whole palm of your hand sound because the cochlea is filled with fluid!
sound because the cochlea is filled with fluid!

against your cheek and feel the pressure.

Now push against your cheek with the same 30
30 Total Ear Canal
30
30
Total Ear Middle Ear
force using just your finger tip. You’ll feel & Canal Middle Ear
&

+
lots more pressure. It’s the same reason why 20 Concha 20
20 Concha 20
a sharp knife cuts through bread. In the
10 10
middle ear, force upon the large TM area 10 10
is converged onto a much smaller area of
0 0
the stapes, and this increases the pressure 0 250 500 100030 2000 4000 8000 0 250 500 1000 2000 4000 8000
30
250
Total Ear Canal 500 1000 2000 4000
Middle Ear
8000 250 500 1000 2000 4000 8000
by 17 times. Second, the middle ear ossicles &

+4040
20 Concha 20

are shaped the particular way that they are, 10 10

Note how important speech Hz
s

=
so they can act like a lever. The malleus dB 25 Note how important speech Hz
s
0
250 500 1000 2000
dB
40008000 25
0
250
500 1000 2000 4000 8000 are emphasized
is 1.3 times as long at the long process of SPL10 are emphasized
40
SPL
Note how10
important speech Hz
s
the incus. This increases the pressure by
a factor of 1.3:1. Third, the TM itself does
= dB 25
SPL10
are
0 emphasized
0
0
125 250 500 1000 2000 4000
not move as a whole in exactly the same 125 250 500 125 2000
1000 250
4000
8000 Hz
500 1000 2000 4000
8000 Hz
8000 Hz
way. When activated by airborne sound, it Figure 4. The resonances of the Outer and Middle ears serve to
Figure
Figure 4.4. The
The resonances
resonances of of the
the Outer
Outer and
and Middle
create an equal loudness curve that shows our best hearing
Middle earsears serve
serve toto
buckles, such that parts of it move more sensitivity is between 1000 to 4000 Hz.
than other parts. This increases the pressure
create
create anan equal
equal loudness
loudness curvecurve that
that shows
shows our our best
best hearing
hearing
by a factor of 2:1. sensitivity
it is
is between
mathematically
sensitivity works out to 1000
between to
to 4000
an increase
1000 4000 Hz.
Hz.
be otitis media with fluid in the middle
of somewhere between 30-35 dB. ear space or otosclerosis. This is why
Figure 3 (above top) shows how these
conductive HL can often be greater than
three pressure increases multiply together, One might think then that the maximum
30-35 dB HL.
and also how this translates into a decibel conductive hearing loss (HL) would
(dB) increase. The total pressure increase be between 30-35 dB HL. As we know
(17 X 1.3 X 2) works out to something however, a conductive HL due to otitis Outer and Middle Ear
media (OM) or otosclerosis can easily be
close to 44:1. Readers may recall from past
more than this. How? Any pathology that
Resonances and Speech
studies of sound that if sound pressure is
Figure 4 (above) shows that our outer and
increased by 10 times, there is a 20 dB prevents the stapes from pushing into the
middle ears actually improve our hearing
increase; if the pressure increase is 100:1, oval window, and consequently bulging
for the high-frequency consonants of
there is a pressure increase of 40 dB. The out the round window, will add even
44:1 pressure increase offered by the more dBs to the HL than the middle ear speech. The middle ear ossicles resonate
middle ear is between 10:1 and 100:1, and normally provides. Examples here could continued on page 24

23
 continuing education ... cont’d.
best at around 2000 Hz, and the middle
ear space has two other resonances of 750-
900 Hz and 1200 Hz. The outer ear canal
resonance falls roughly between 1500 and
4000 Hz. Together, the outer and middle
ears thus serve to create the human
hearing sensitivity curve, which shows our
very best hearing sensitivity to be between
1000-4000 Hz. This all contributes to
better hearing for speech.
II. Tympanometry and the
Middle Ear
Speaker
Tone in
Air Pressure
Speaker
changes
Tone in
Microphone
Air Pressure
Tone
changes
out
Microphone
Tone out
Figure 5. Tympanometry enables examination of the closed
Middle ear space from the Outer ear canal.
Figure 5. Tympanometry enables examination of the closed
Figure
Middle 5 shows
ear space from thethat
OuterTympanometry
ear canal.
involves the use of a probe inserted into
the ear canal with a tight seal, so that
no air can leak out. The assumption
behind Tympanometry is that in order
for the middle ear to be most efficient at
passing incoming sounds through it, air
pressure should be even on both sides
of the TM. Contrary to common belief,
Tympanometry does not determine “how
much the eardrum wiggles.” The probe
has three holes in it to provide: 1) a tiny
speaker, 2) a tiny microphone, and 3) a
way to change air pressure. The client
can feel these air pressure changes during
the test. During the air pressure changes,
a steady low-frequency tone at 70 dB
sound pressure level (SPL) is presented
through the probe speaker, and the probe
microphone picks up whatever sound
bounces back off from the TM. If the least
amount of sound bounces back off the TM
when the air pressure in the outer ear canal
is at regular room air pressure, this means
24
the air pressure behind the TM is the same. resonates with low frequencies. A low-
In this way, Tympanometry measurement frequency tone is used so that some sound
in the outer ear canal tells us about the will bounce off from the TM, even when
middle ear air pressure behind the TM! the middle ear is least stiff. If it didn’t,
the sound would pass through the TM
and there would be nothing left for us to
Why Does Tympanometry measure!
Typically Use a Low-
Now consider the normal situation, when
Frequency Tone? the air pressures inside the outer ear
With Tympanometry, we test the com- canal and the middle ear space are both at
pliance of the middle ear by measuring the regular room air pressure. When the low-
amount of low-frequency tone reflecting frequency Hz tone is presented at 70 dB
off the stiff middle ear as a function SPL, some of it will pass through the stiff
of air pressure changes. Compliance middle ear system, but because the middle
is the opposite or inverse of stiffness. ear is a stiffness dominated system, some
Tympanometry uses a low-frequency tone of it will bounce back off the TM. With
because the middle ear is a “stiffness positive or negative air pressure in the
dominated system.” The middle ear system, outer ear canal however, the air pressure
which involves the TM and ossicular chain, is made to be different from that inside
is always stiff, but it is least stiff when the middle ear space, and this makes the
the air pressure is even on both sides of normally stiff middle ear system become
the TM. The middle ear ossicles are tiny stiffer yet. In these situations, even more
and therefore, do not have much mass. sound bounces off the TM and less goes
Stiffness is therefore the main source of through it. In other words, with uneven
opposition to the passage of sound through air pressure on both sides of the TM, the
the middle ear. Stiffness opposes the Middle ear is made temporarily more
passage of low frequencies and resonates stiff than it usually is and therefore, less
with high frequencies, while mass opposes efficient. Consequently, more of the low-
the passage of high frequencies and frequency sound bounces off the TM.
Least SPL picked up
by probe microphone
1.  Middle ear is most efficient High
when air pressure is equal
on both sides of the TM.
2. When least probe tone
Compliance
SPL is picked up by
probe microphone,
Least SPL picked up
most
1.  Middle ear is most is High
efficient gettingbythrough
probe microphone
when air pressure is equal
on both sidesto theTM. Middle ear.
of the
2. When least probe tone
Compliance
SPL is picked up by
3. At this peak, the air
probe microphone,
most is getting through
pressure behind the
to the Middle ear.
Most SPL picked up
3.
TM must therefore
At this peak, the air
pressure behind the
be by probe mic
the same
TM must therefore be
Most SPL picked up
Low as that in the
Low
the same as that in the
by probe mic
Outer ear canal.
Outer ear canal.
Negative 0 Positive
Air Pressure
Negative 0 Positive
Air Pressure
Figure 6. The normal Tympanogram is shaped like a Tent.
Figure 6. The normal Tympanogram is shaped like a Tent.
 Type A
High
Type C

The Tympanogram
Figure 6 (below left) shows the

Compliance
Tympanogram as a “tent-shaped” graph.
The horizontal axis shows negative, High
Type A

neutral, and positive air pressure. The Type C

Type C going to Type B
air pressure units on the horizontal axis

Compliance
are either mm H2O or dekaPascals (daPa). Type B
These pressure units are essentially Low Type C going to Type B

the same in value. The vertical axis

Type B
Low
Negative 0 Positive
shows compliance (inverse of stiffness), Negative
Air Pressure
Air0 Pressure Positive

from minimum at the bottom towards Figure 7. Tympanogram progressions with various stages of

maximum as you go up the axis. The

compliance units have often been
designated in millilitres (ml) or cubic
centimetres (cc’s) of air. These units are
rather confusing however, because they
don’t intuitively convey stiffness to the
average clinician. We thus use a different
term today. Recall that middle ear
stiffness opposes the passage of the low-
frequency tone. The Ohm is a unit used to
describe opposition and resistance. Since
compliance is the inverse of stiffness, the
word “ohm” is simply flipped around to
read “mho.” The ear is small however, and
so the “mho” is too large a unit to use.
This is why we use thousandths of a mho
or millimhos (mmho’s) to indicate units
for compliance on the vertical axis of
the Tympanogram. Incidentally, the low-
frequency tone used in Tympanometry
has the specific frequency of 226 Hz. This
is mainly done for calibration reasons.
At regular sea-level air pressure, the
compliance of a 1 cc of air to a 226 Hz
tone is exactly one mmho.
Figure 7. (OM).
Otitis Media Tympanogram
Type A = normal, Type Cprogressions
= early OM with
negative Middle ear pressure, Type B = advanced OM with fluid.
Otitis Media (OM). Type A = normal, Type C = early OM with
negative Middle
is to examine ear pressure,
the physical propertiesTypeof
the middle ear. As a stiffness dominated
system, we want to test its stiffness (or
compliance) per se. Also, if we reported
the Tympanogram in terms of amount of
dB SPL bouncing back, the amount would
vary hugely across individuals, and so
would the size of resultant Tympanograms!
This is because different probe insertion
depths change the ear canal volume in
any one person; furthermore, ear canals
themselves vary in size across individuals.
Measuring compliance in units of mmhos
renders similar sized Tympanograms
independently from the depth of probe
insertion or ear canal size. It allows for a
fairly standard range of Tympanogram size
and shape to be used as normative. The
thing to remember is that changes in dB
SPL bouncing back off the TM correspond
to changes in compliance; the less sound
that bounces back, the more compliance
you have.
with various stages of
B = 226
advanced
Hz tone atOM
70 dBwith fluid.
SPL went through
the TM and some of it bounced back and
was picked up by the probe microphone.
The “tails” of the normal Tympanogram
are situated at positive and negative air
pressures. These show that when Outer
ear canal air pressure was made either
positive or negative, relatively more sound
bounced off the TM and less went through
it. If we follow this logic, to the client
being tested, audibility of the 226 Hz tone
would normally be greatest at 0 regular
room air pressure, and softest at positive
and negative air pressures.
III. Four Tests Done with
Routine Tympanometry
There are four tests that are performed
during routine Tympanometry. These are:
1) classification of Tympanogram Types,
2) Static Compliance, 3) Physical Volume
testing, and 4) Acoustic Reflex testing.

Why we don’t simply use “dB SPL
bouncing back” as a unit for the vertical
axis? Tympanometry measures the
reflectance of a 226 Hz tone with air
pressure changes, so one might ask why
the vertical axis of the Tympanogram
does not simply read in “dB SPL bouncing
back.” The purpose of Tympanometry
The normal Tympanogram has a peak
showing greatest compliance over Tympanogram Types
neutral or 0 regular room air pressure. The top of Figure 7 (above) shows several
Compliance increases (stiffness decreases) Tympanograms. The top-most one is the
as you go up the vertical axis. The normal normal Tympanogram, and it is called a
Tympanogram indicates that when the “Type A.” It shows the good news that the
air pressure in the Outer ear canal was air pressure behind the TM is at regular
at neutral room air pressure, some of the
continued on page 26

25
 continuing education ... cont’d.
neutral room air pressure, and that there
is no Middle ear vacuum or pressure
buildup. Middle ear pathology of almost
any kind will instantly become apparent
with Tympanometry. For example, in
early stages of otitis media, there is
negative air pressure behind the TM.
Negative air pressure in the outer ear
canal therefore, will make air pressure
even on both sides of the TM. The top
left Tympanogram shows this negative
middle ear pressure, because it has a peak
that hovers over negative air pressure.
This Tympanogram is called “Type C.”
As otitis media advances, fluid becomes
built up behind the TM. As a result, the
Type C Tympanogram begins to develop a
rounded peak, as is shown by the middle
left Tympanogram. When increased fluid
buildup behind the TM continues, the
Tympanogram will begin to show no
peak at all. This is a “Type B” Tympano-
gram, and it is shown at the bottom left.
A “Type B” Tympanogram means that
no air pressure change in the outer ear
canal can result in maximum middle
ear compliance.
Static Compliance
Tympanograms show other middle ear
pathology besides otitis media. Oto-
sclerosis and other types of middle
ear pathology such as damaged TMs
and disarticulated ossicles can also
be indicated. Here we get into what is
known as “Static Compliance.” Static
compliance can be described as the
difference between maximum and
minimum compliance of the middle ear.
First, the compliance of the middle ear
is determined at positive + 200 daPa air
pressure. Next, compliance is determined
at the air pressure where greatest com-
pliance is found. Normally, this would
be at an air pressure of 0 daPa. Static
compliance thus works out to be the
26
height of the Tympanogram.
As a middle ear pathology, oto-sclerosis is
a hereditary condition where soft porous
boney growth surrounds the footplate of
the stapes, which prevents it from moving
easily in and out of the oval window. In
this case, it is not negative air pressure or
a fluid buildup that causes an abnormal
Tympanogram; Oto-sclerosis creates
excessive middle ear stiffness. Unlike
otitis media, the air pressure is even on
both sides of the TM. Tympanometry
thus reveals a Type A Tympanogram with
an abnormally low static compliance;
the resultant short or squat Type
Figure A
8. Physical Volume (PV) of ear canal is normally between
Tympanogram is called 1.0 to 1.5As.”
a “Type cc. AOn
large PV might
Type B Tympanogram
the other hand, disarticulated middle ear
then probe tip is against Outer ear canal wall.
ossicles or a scarred and damaged TM
which has become abnormally thin, will
cause an abnormally over-compliant
middle ear system. This is seen as a Type
A Tympanogram with abnormally high
static compliance; the resultant tall Type
A Tympanogram is called a “Type Ad.”
Physical Volume Testing
The was originally intended to imitate
the acoustic impedance of the closed ear
canal. Most of us also know that when
the adult ear canal volume is closed with
an insert headphone or a hearing aid in
place, its physical volume is smaller, and
actually closer to 1.5 cc’s. Since the 2cc
coupler is larger than the typical adult
closed ear canal, 2cc coupler measures
with a hearing aid tend to underestimate
the amount of SPL that the same hearing
aid would actually produce in the ear
canal.
Figure 8 (above) shows Physical Volume
testing during Tympanometry. This test
can be especially useful to get an instant
awareness of the client’s ear canal size.
Figure 8. Physical Volume (PV) of ear canal is n
1.0 to 1.5 cc. A large PV might indicate a perfor
Type B Tympanogram has normal PV. If Type B
then probe tip is against Outer ear canal wall.
Figure 8. Physical Volume (PV) of ear canal is normally between
1.0 to 1.5 cc. A large PV might indicate a perforated TM. True
Type B Tympanogram has normal PV. If Type B with tiny PV,
then probe tip is against Outer ear canal wall.
It canindicate
also bea useful
perforatedwhen TM. True
interpreting a
has normal PV. If Type B with tiny PV,
Type B Tympanogram. Maybe the Type
B Tympanogram isn’t showing fluid
build-up behind the TM. If the Type B
Tympanogram is accompanied by an
abnormally small volume, it is possible
that the probe tip may be lodged against
the client’s ear canal wall. That Type B
Tympanogram is then suspicious to begin
with. Then again, it is possible to see a
Type B Tympanogram along with an
abnormally large ear canal volume. This
might suggest a perforated TM, because
the abnormally large volume might just
include not only the air space in the
closed ear canal, but also the middle
ear space too!
Acoustic Reflex Testing
Acoustic Reflex (AR) testing utilizes
Tympanometry in a unique way. Instead
of stiffening the middle ear system with
positive or negative air pressures, AR
testing stiffens the middle ear system with
loud, low-frequency pure tones. When
the loud tone causes an AR, the result
is a temporary decrease in middle ear
compliance. The AR is read as a decrease
in static compliance. One could think of
 Brain Stem Incidentally, Bell’s palsy is a compromise
CN TT
TT
of the VII nerve. At any rate, this whole
VIII
nerve
afferent/efferent loop is known as the
AR arc.
SOCs
V V
Nerve Nerve The AR is a low-frequency phenomenon,
Loud
Sound which helps to explain why we have
Brain Stem
VII VII
TT CN
Nerve
TT
Nerve ARs in the first place. The AR is elicited
VIII
S
nerve S or caused by loud low-frequency tones,
Afferent Route
SOCs
Efferent Route
Loud
V
Loud incoming
Nerve
V
sound
Nerve
V Nerve
such as 500 or 1000 Hz. Many clinicians
Middle ear believe that the AR works as a natural
Sound
VII VII VII Nerve
Cochlea
Nerve Nerve
Tensor Tympani muscle (TT)
protection against loud sounds and that
S S
Afferent Route VIII Nerve Efferent Route Stapedius muscle (S)
Cochlear
Loud incoming sound
Nucleus (CN)
V Nerve
Middle ear
Cochlea
Superior Olivary Complex
s
VII Nerve
(SOCs)
Tensor Tympani muscle (TT) it helps to reduce noise induced hearing
VIII Nerve Stapedius muscle (S)

Figure 9. The Acoustic Reflex arc includes an afferent (going to

Cochlear Nucleus (CN)
Superior Olivary Complex
s (SOCs) loss. Actually, the AR helps to reduce
Figure 9. The Acoustic Reflex arc includes an afferent (going to
the brain) path and an efferent (going from the brain stem) path
the brain) path and an efferent (going from the brain stem) path what is known as the “upward spread of
back to the Middle ears. Note the crossover; a loud sound to one
back to the Middle ears. Note the crossover; a loud sound to one
ear causes an AR in both ears. masking.” Low frequencies mask high
ear causes an AR in both ears. frequencies better than highs mask lows.
the AR as causing a temporary decrease conducting its mechanical energy to the This is why background noise which is
in the height of the Tympanogram. cochlea. mostly low in frequency content, serves as
an unfortunately effective masker for the
Figure 9 (above) shows the AR arc. The The AR involves nearly all parts of the high-frequency consonants of speech.
AR test can be best appreciated with an ear; namely, the outer, middle, inner, VIII
understanding of the AR itself, and its nerve, and brain stem. Note that three Have you ever noticed when you hear a
anatomy and physiology. As an arc, the cranial nerves are involved in the AR: recording of your own voice, you are the
AR has a loop or circuitous route, with the V, VII, and VIII. As we know, the only one who thinks you sound so weird?
an ear-to-Brain Stem going (afferent) VIII nerve is a sensory afferent nerve, Others however, think the recording
section and a Brain Stem back-to-ear sending neural information of sound to sounds just fine. This is because when
(efferent) section. If a loud (85 to 110 dB the brain. It takes cochlear information you hear yourself in a recording, you
HL) low-frequency sound hits the TM, the from the afferent Inner Hair Cells (IHCs) hear yourself in the way that others hear
normal reaction is to have an AR. What and sends this information to the cochlear you. While you talk, you hear yourself
is the AR? It is a reflex which is always nucleus of the brain stem. From there, by air conduction and also by bone
an involuntary reaction to something. In neural information goes to the Superior conduction. Others hear you only by way
the case of an AR, a loud low-frequency Olivary Complex (SOC) of the same side of air conduction. The intensity of normal
sound causes the reaction of two middle (ipsilateral) and also to the opposite SOC ongoing speech by air conduction is about
ear muscles that pull on the ossicles. The (contralateral). This crossover is called 65 dB SPL. You hear the intensity of
smaller but stronger of the two muscles is “decussation,” and it explains why a loud your own air plus bone-conducted voice
the stapedius. It pulls outward on the neck sound to one ear normally causes an AR however, closer to 85 dB SPL, and this
of the stapes to keep it from going in and to occur in both ears. From the brain stem is enough to cause an AR. The vowels
out of the oval window. The weaker and SOC’s, an efferent message is sent to the of speech are the loudest, and these are
yet larger of the two is the tensor tympani. V and VII cranial nerves. The V nerve is mainly low in frequency. We basically
It pulls inward on the malleus to reduce partially sensory (afferent) for feeling in have AR’s to help reduce the upward
the vibration of the TM. The AR thus the face, and partly motor (efferent) for spread of masking from the vowel sound
works to momentarily tense the whole activating muscles, one of them being the of our own voices. The AR therefore
middle ear system. For a split second, the Tensor Tympani. The VII nerve is a totally allows us to better hear high frequencies
AR thus renders the middle ear more stiff efferent motor nerve activating the cheek
(less compliant and thus less efficient) at muscles as well as the stapedius muscle. continued on page 28

27
 continuing education ... cont’d.
around us while we talk. The AR is also
caused by chewing, and also of course by
other outside intense low-frequency pure
tones and noise.
Contralateral ARsARs
Contralateral werewere
1st 1to bebeDeveloped
st to Developed
Figure 10. AR stimuli: 500 or 1000Hz tones at 85 to 110 dB HL.
These are presented with headphone.
Ongoing 226 Hz tone at 70 dB SPL in opposite ear
measures AR. SPL increase at probe microphone indicates an AR.
Figure 10 shows the Contralateral
AR. The earliest AR’s were elicited
contralaterally, and it is easy to see why.
The manner in which ARs are tested
is actually quite amazing. With the
probe held in place in the ear canal, the
Tympanometer automatically adjusts
the air pressure in the outer ear canal to
whatever it was when the greatest middle
ear compliance was found. Normally, this
would be regular room air pressure (0
daPa). As in regular Tympanometry, the
226 Hz tone at 70 dB SPL is sent on into
the ear canal while the probe microphone
records some amount of the tone that
bounces back off from the TM. At the
same time, a loud low-frequency pure
tone of 500 or 1000 Hz at 85 dB HL is
briefly delivered by a separate headphone
to the opposite ear. Recall that due to
226 Hz tone
neural decussation or crossover, an AR isto measure226 ARHzHztone
AR. If the 85 dB HL tone does not cause
an AR, the intensity is increased to 90
dB HL, than to 95 dB HL, etc., until an
AR is elicited. AR’s are always reported
according to the ear that received the loud
low-frequency pure tone. For example, a
loud sound put into the left ear causing an
AR in the right ear, is called a “Left ear
Contralateral AR.”
Figure 11 (below) shows the Ipsilateral
AR. When looking at these, it is easy
to see why the Ipsilateral AR’s were
developed later on. Here, the ongoing
226 Hz probe tone at 70 dB SPL, and
also the loud, brief low-frequency AR
stimulus tones are put into the same ear
canal at the same time! The challenge for
Ipsilateral AR testing is to eliminate any
phase interaction between the probe tone
and the AR stimulus tones. As with the
Contralateral AR, the Ipsilateral AR is
said to occur if there is a sudden increase
of the 226 Hz tone picked up by the probe
microphone.
Reporting AR Findings. The AR stimulus
tones are calibrated and recorded on the
Tympanometer in dB HL. AR findings
or results however, are reported in dB
sensation level (SL). If an AR is recorded
with a 500 Hz tone at a stimulus level of
100 dB HL, it is reported in reference to
the client’s own hearing threshold for 500
Hz. If the client’s threshold for 500 Hz is
0 dB HL, then the AR is reported as
present at 100 dB SL. If the client’s
Ipsilateral ARs Came
Ipsilateral ARsLaterCameOn Later On
Ipsilateral ARs Came Later On
tone
226
threshold for 500 Hz is 30 dB HL how-
ever, then the AR is reported as present
at 70 dB SL. In any client and in any ear,
the AR findings might be reported as:
1) Present at normal SLs (85 – 110 dB HL),
2) Present at reduced SLs (from 20 to 85
dB SL), or 3) Absent.
AR Findings and HL. In general, normal
hearing renders both contralateral and
ipsilateral AR’s present at normal SLs.
Conductive HL most often results in
Absent ARs. Conductive HL tends to
obliterate AR’s for two reasons: a) like
a plug in the ear, the Conductive HL
prevents the AR stimulus tones from
being heard loudly enough to cause an AR,
or b) the middle ear pathology prevents
the mechanical muscle contraction of
the AR itself. Mild-to-moderate SNHL
often presents with AR’s at reduced SL’s,
and this is consistent with recruitment.
Recall that with SNHL, there is nothing
mechanically wrong with the middle
ears. As such, present AR’s at reduced
SL’s is a very good and normal finding for
SNHL. In general, the greater the SNHL,
the less the SL at which an AR will be
found. There is an almost direct inverse
relationship with degree of SNHL and the
SL for an AR. This relationship continues
until the SNHL becomes greater than
about 60 dB HL. Once the SNHL gets
to be worse than about 60 dB HL, the
AR’s are often absent. This is because
the severe degree of SNHL in that ear
prevents the AR stimulus from being loud
enough to cause an AR. VIII nerve and
low brain stem tumors also tend to result

caused in both ears even though only one

to
to measure
measure AR AR in Absent AR’s.
ear is stimulated. Recall also that the AR AR Patterns. From our previous discussion
causes a temporary stiffening or reduced 500 or 1000 Hz of contralateral and ipsilateral AR’s, one
AR stimulus
500tone
or 1000 Hz
compliance, of the middle ear system. If 500 or 1000 Hz
AR stimulus tone can see that there are then four sets of
AR stimulus tone
there is a sudden increase of the 226 Hz Figure 11. AR stimuli: 500 or 1000Hz tones at 85 to 110 dB HL AR’s that can be tested on a client: right
tone picked up by the microphone in the OngoingFigure 226 Hz11.tone
Ongoing
AR at
stimuli:
226 Hz
70 dB500
SPLorin1000Hz tones
same ear
tone at 70indicate
dB SPLan
at 85 to
measure AR!110 dB HL
same ear measure AR!
in AR.
ear contralateral & ipsilateral, and left ear
SPL increase at probe microphone
probe ear, the Tympanometer records an Figure 11. AR stimuli: 500 or 1000Hz
SPL increase at probe microphone indicate an AR. tones at 85 to 110 dB contralateral & ipsilateral. In the heady
HL
Ongoing 226 Hz tone at 70 dB SPL in same ear measure AR!
SPL increase at probe microphone indicate an AR.

28

days of the 70’s and 80’s, audiologists
were required to memorize patterns of
AR findings and relate these to unilateral
versus conductive HL, unilateral versus
bilateral SNHL, VIII nerve tumors, etc.
Today we have CT scans and MRI’s that
can help to detect the presence of various
types of pathology but in the 70’s and early
80’s these procedures were only beginning.
Consider now the following AR patterns
with the following types of pathology:
a) Bilateral Conductive HL:
contralateral and ipsilateral AR’s will
likely be absent for both ears.
b) Unilateral Conductive HL: ipsilateral
AR would likely be present at
normal SL’s for the normal ear; all
other AR’s would be absent. When
the loud stimulus tone is given to
the good ear, the contralateral AR
won’t occur in the bad ear due to
the mechanical problems in that
ear. The contralateral AR’s and
ipsilateral AR’s from the bad ear
are both absent because the hearing
loss in that ear prevents the AR
stimulus tones presented to that ear
from being heard loudly enough to
cause an AR.
c) Bilateral Mild-to-moderate SNHL:
contralateral and ipsilateral AR’s
often present but at reduced SL’s for
both ears.
d) Unilateral Mild-to-moderate SNHL:
contralateral and ipsilateral AR’s
present at normal SL’s for the good
ear. For the bad ear, contralateral and
ipsilateral AR’s will likely be present
but at reduced SL’s.
e) Bilateral Severe-to-profound SNHL:
contralateral and ipsilateral AR’s will
likely be absent for both ears.
f) Unilateral Severe-to-profound
SNHL: contralateral and ipsilateral
About Ted Venema:
Ted Venema earned a BA in Philosophy at Calvin College in 1977, and an
MA in Audiology at Western Washington University in 1988. After working
for three years as a clinical Audiologist at The Canadian Hearing Society
in Toronto, he went back to school and completed a PhD in Audiology
at the University of Oklahoma in 1993. He was an Assistant Professor at
Auburn University in Alabama for the next two years. From 1995 until
2001, he worked at Unitron Hearing in Kitchener Ontario Canada, where he
conducted field trials on new hearing aids and gave presentations, domestically and abroad.
He also taught in the Hearing Instrument Specialist (HIS) program at George Brown College in
Toronto Canada, from 1995 until 2004. From 2001 until 2006, Ted was an Assistant Professor
of Audiology at the University of Western Ontario. As of 2005, Ted created and began
Canada’s 4th and most recent HIS program at Conestoga College in Kitchener, Ontario. This
full time program is now 5 years old. He continues to give presentations on hearing, hearing
loss and hearing aids. Ted is the author of a small textbook, Compression for Clinicians.
This book was updated and released as a 2nd edition in 2006.
AR’s present at normal SL’s for the very different, in that they serve to help
good ear. Contralateral and ipsilateral the afferent IHCs sense soft input sounds
ARs would be absent for the bad ear. below 50 dB SPL. Most cases of mild-
g) VIII Nerve Tumor: The AR pattern to-moderate SNHL result from damage
would be similar to that for the primarily to the OHCs, and these hair
unilateral severe-to-profound SNHL. cells are not at all involved in the AR arc.
Severe SNHL results from damage to both
h) Low Brain Stem Tumor: ipsilateral
IHC’s and OHCs, and this is why ARs are
AR’s would be present at normal
absent in these cases.
SL’s, but due to decussation or neural
crossover problems, the contralateral As clinicians, we have all encountered
AR’s would likely be absent. people with similar degree of hearing
loss who have vastly different Speech
Figure
Figure 12
12 Discrimination (SD) scores. Have you
ever wondered why? Consider two people
Normal
Normal
Inner
Inner
with the same degree of mild-to-moderate
&
& SNHL; one has good SD scores while
Outer
Outer
Hair
Hair Cells
Cells the other has poor SD scores. It is very
possible that the person with the better SD
performance has mainly OHC damage.
This client will likely have AR’s that are
present at reduced SL’s. Some cases of
From
FromVenema,
Venema,T. T.
Compression
Compression for
Clinicians
for
Clinicians22ndnd edition,
edition,
mild-to-moderate SNHL however, result
Cengage
Cengage2006
2006
from a mixture of IHC and OHC damage,
AR’s and Speech Discrimination. Figure
and here there is some involvement in
12 shows normal IHC’s and Outer Hair
the AR arc. IHC damage implies that
Cells (OHCs). Recall from the previous
the cochlea sends a mixed-up message
discussion on the AR arc that the IHCs
towards the brain. This client will likely
of the Cochlea are afferent, meaning
also have absent AR’s. n
that they send information to the VIII
nerve, toward the brain. The OHCs are continued on page 30
29
 IHS Continuing Education Test
1. The normal Tympanogram should show 6. For normal hearing, AR’s occur for 10. Two people have the same flat 50dB
a peak at: sounds that are about dB SL. SNHL; one has AR’s, the other does
a) 0 mmho a) 100-120 not; the 1st will probably:
b) 0 cc’s b) 80-100 a) show worse speech discrimination
c) 0 ml c) 60-80 b) have a negative Tympanogram
d) n one of the above
d) 40-60 c) show better speech discrimination
d) have a Type B Tympanogram
2. The leverage action of the middle ear
ossicles increases sound pressure by a 7. What AR findings would likely
factor of: occur with a unilateral moderate
a) 1.3:1 Conductive HL?
b) 17:1 a) absent ipsilateral AR’s with present
c) 44:1 contralateral AR’s for both ears
d) 2 :1 b) present ipsilateral AR’s for the normal
ear, all other AR’s absent
3. As you go down the Y axis of a
c) absent contralateral AR’s with present
Tympanogram:
ipsilateral AR’s for both ears For continuing education credit, com-
a) audible probe sound gets softer for
the listener d) present ipsilateral & contralateral plete this test and send the answer
b) the amount of sound bouncing back AR’s for the normal ear only section at the bottom of the page to:
to the probe decreases International Hearing Society
c) the amount of sound going though 8. What AR findings would likely occur 16880 Middlebelt Rd., Ste. 4
the TM increases with a unilateral severe-profound Livonia, MI 48154
d) admittance increases SNHL?
• After your test has been graded,
a) absent ipsilateral AR’s with present
4. Otosclerosis may show a type you will receive a copy of the
contralateral AR’s for both ears
Tympanogram correct answers and a certificate
b) present ipsilateral AR’s for the normal
a) Ab of completion.
b) Ac ear, all other AR’s absent
c) absent contralateral AR’s with present • All questions regarding the
c) Ad
ipsilateral AR’s for both ears examination must be in writing
d) As
d) present ipsilateral & contralateral and directed to IHS.
5. If you could look at the Tympanogram AR’s for the normal ear only • Credit: IHS designates this
when AR’s occur, you’d actually see a professional and development
temporary: 9. Severe SNHL in both ears is most often activity for one (1) continuing
a) increase in the height of the education credit.
associated with:
Tympanogram
a) AR’s at normal SL’s for both ears • Fees: $29.00 IHS member
b) decrease in the height of the
Tympanogram b) AR’s at reduced SL’s for both ears $59.00 non-member
c) negative air pressure c) absent AR’s for both ears (Payment in U.S. funds only)
d) none of the above d) AR’s at elevated SL’s for both ears

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30