How to decipher an audiogram - a detailed guide from a doctor. Hearing test What method of hearing test is considered physiological

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These methods include anamnesis, physical examination, hearing examination (acumetry, audiometry), additional research methods (radiography, CT, MRI).

Anamnesis

Patients suffering from hearing loss usually complain of hearing loss, tinnitus, less often - dizziness and headache, irritability, reduced speech intelligibility in a noisy environment, and a number of others. Some patients point to the cause of hearing loss (chronic inflammation of the middle ear, an established diagnosis of otosclerosis, a history of skull trauma, activities in industrial noise conditions (mechanical assembly and blacksmith shops, the aviation industry, work in an orchestra, etc.). Of the comorbidities, patients may indicate the presence of arterial hypertension, diabetes mellitus, osteochondrosis of the cervical spine, hormonal dysfunction, etc.

The purpose of the anamnesis of an audiological patient is not so much to ascertain the fact of hearing loss, but to identify its cause, to establish concomitant diseases that aggravate hearing loss, occupational hazards (noise, vibration, ionizing radiation), and past use of ototoxic drugs.

When talking with the patient, the nature of his speech should be assessed. For example, loud and clear speech indicates the presence of acquired bilateral sensorineural hearing loss in years when the articulatory function of the speech motor apparatus was fully formed. Slurred speech with articulation defects indicates that hearing loss occurred in early childhood, when basic speech skills were not yet formed. Quiet intelligible speech indicates a conductive type of hearing loss, for example, in otosclerosis, when tissue conduction is not impaired and fully provides auditory control of one's own speech. You should pay attention to the "behavioral" signs of hearing loss: the patient's desire to approach the doctor with a better hearing ear, putting his palm to his ear in the form of a mouthpiece, an attentive look fixed on the doctor's lips (lip reading), etc.

Physical examination

Physical examination includes the following techniques and methods: examination, palpation and percussion of the facial and auricular-temporal regions, endoscopy of the ear, examination of the barofunction of the auditory tube, and some others. Endoscopy of the nose, pharynx and larynx is carried out according to the generally accepted method.

At external examination pay attention to the anatomical elements of the face and its appearance: the symmetry of facial expressions, nasolabial folds, eyelids. The patient is offered to bare his teeth, wrinkle his forehead, close his eyes tightly (control of the function of the facial nerves). Tactile and pain sensitivity is determined by the zones of innervation of the branches of the trigeminal nerve. When examining the ear region, the symmetry, size, configuration, color, elasticity, state of tactile and pain sensitivity of its anatomical formations are evaluated.

Palpation and percussion. With their help, skin turgor, local and distant pain are determined. When complaining of pain in the ear, deep palpation and percussion are performed in the antrum projection area, the mastoid platform, the scales of the temporal bone, the temporomandibular joint area and the retromandibular fossa in the area of ​​the parotid salivary gland. The temporomandibular joint is palpated when opening and closing the mouth to detect clicks, crunches and other phenomena indicating the presence of arthrosis of this joint.

Otoscopy. When examining the external auditory canal, pay attention to its width and contents. First, they examine it without a funnel, pulling the auricle up and backwards (in infants backwards and downwards) and at the same time pushing the tragus anteriorly. The deep sections of the ear canal and the tympanic membrane are examined with the help of an ear funnel and a frontal reflector, while the presence or absence of certain identifying signs of it and pathological changes (retraction, hyperemia, perforation, etc.) is noted.

Hearing test

The science that studies the auditory function is called audiology(from lat. audio- I hear), and the clinical direction that deals with the treatment of hearing-impaired people is called audiology(from lat. surditas- deafness).

The hearing test is called audiometry. This method distinguishes the concept acumetry(from Greek. akouo- I listen), which is understood as the study of hearing with live speech and tuning forks. In audiometry, electronic-acoustic devices (audiometers) are used. The responses of the subject (subjective reaction) serve as evaluation criteria: “I hear - I don’t hear”, “I understand - I don’t understand”, “louder - quieter - equally loud”, “higher - lower” according to the tone of the sound test, etc.

The sound pressure equal to 2.10:10,000 microbars (µb), or 0.000204 dynes/cm 2 , at a sound frequency of 1000 Hz, was taken as the threshold value of auditory perception. A value 10 times greater is equal to 1 bela (B) or 10 dB, 100 times greater (×10 2) is 2 B or 20 dB; 1000 times greater (×10 3) - 3 B or 30 dB, etc. The decibel as a unit of sound intensity is used in all threshold and suprathreshold audiometric tests related to the concept volume.

In the XX century. for the study of hearing, tuning forks became widespread, the method of using which in otiatry was developed by F. Bezold.

The study of hearing "live" speech

Whispered, colloquial, loud and very loud speech (“cry with a ratchet”) is used as testing speech sounds (words) when the opposite ear is muffled with a Barani rattle (Fig. 1).

Rice. one.

In the study of whispered speech, it is recommended to pronounce the words in a whisper after a physiological exhalation, using the reserve (residual) air of the lungs. In the study of colloquial speech, ordinary speech of medium volume is used. The criterion for assessing hearing in whispered and colloquial speech is distance from the researcher to the subject, from which he confidently repeats at least 8 out of 10 words presented to him. Loud and very loud speech is used for hearing loss of the third degree and is pronounced over the patient's ear.

Hearing test with tuning forks

When studying hearing with tuning forks, a set of tuning forks of different frequencies is used (Fig. 2).

Rice. 2.

When examining hearing with tuning forks, a number of rules must be observed. The tuning fork should be held by the leg without touching the jaws. Do not touch the branches of the auricle and hair. When examining bone conduction, the tuning fork leg is placed on the crown or forehead along the midline (when determining the phenomenon literalization sound a) or on the site of the mastoid process (when determining playing time tuning fork). The leg of the tuning fork should not be pressed too strongly against the tissues of the head, since the pain sensation that arises in this case distracts the subject from the main task of the study; in addition, it contributes to the accelerated damping of vibrations of the tuning fork branches. It should be borne in mind that sounds of 1000 Hz and above are able to bend around the head of the subject, therefore, with good hearing in the non-examined ear, the phenomenon over-the-air listening. Relistening may also occur in the study of tissue conduction; it occurs when there is a perceptual hearing loss, and the opposite ear either hears normally or has a conductive type of hearing loss, such as cerumen plug or scarring.

With the help of tuning forks, a number of special audiometric tests are carried out for differential diagnosis between perceptual and conductive types of hearing loss. It is advisable to record the results of all acumetric tests carried out using live speech and tuning forks in the form of the so-called auditory passport(Tables 1, 2), which combines five aspects of the study:

1) detection of spontaneous irritation of the sound analyzer according to the SN test ( subjective noise);

2) determination of the degree of hearing loss in relation to live speech according to the SR tests ( whispered speech) and RR ( colloquial speech). With a high degree of hearing loss, the presence of hearing is determined by the test "cry with a rattle";

3) determination with the help of tuning forks of the sensitivity of the organ of hearing to pure tones during air and tissue conduction of sound;

4) identification of certain correlation dependencies between the perception of low and high tones during air and bone conduction of sound for differential diagnosis of forms of hearing loss;

5) establishing the lateralization of sound by bone conduction to establish the type of hearing loss in the worse hearing ear.

Table 1. Hearing passport in violation of sound conduction

	Tests
	Cr with ratchet	Mute
	C to 128 (N-40 c)
	Schwabach experience
	Weber's experience
	Rinne experience
	Bing's experience
	The Jelle experience
	Lewis-Federici experience

Table 2. Hearing passport for impaired sound perception

	Tests
	Cr with ratchet	Mute
	C to 128 (N-40 c)
shortened	Schwabach experience
	Weber's experience
	Rinne experience
	The Jelle experience

SSH test reveals the presence of irritation of the peripheral nervous apparatus of the organ of hearing or the state of excitation of the auditory centers. In the hearing passport, the presence of tinnitus is marked with a “+” symbol.

Living speech research. This study is carried out in the absence of extraneous noise. The examined ear is directed towards the examiner, the other ear is tightly closed with a finger. The results of the live speech study are recorded in the auditory passport in meters in multiples of 0.5: 0; “at cancer”, which means “hearing at the shell”; 0.5; one; 1.5 m, etc. The result is recorded at the distance from which the subject repeats 8 out of 10 named words.

When examining hearing with tuning forks, the tuning fork is brought to the external auditory canal with the plane of the branch at a distance of 0.5-1 cm with a frequency of once every 5 s. The entry in the passport is made with the same multiplicity, i.e. 5 s; 10 s; 15 s, etc. The fact of hearing loss is established in cases where the time of sound perception is shortened by 5% or more relative to passport norm tuning fork.

Evaluation criteria for tuning fork tests of a typical hearing passport

• With air conduction of sound:
• conductive (bass) hearing loss: a decrease in the duration of perception of the tuning fork C 128 with near-normal perception of the tuning fork C 2048;
• perceptual (treble) hearing loss: near-normal time of perception of a tuning fork C 128 and a decrease in the duration of perception of a tuning fork from 2048.
• With tissue (bone) conduction of sound (only C 128 tuning fork is used):
• conductive hearing loss: normal or increased duration of sound perception;
• perceptual hearing loss: a decrease in the duration of sound perception.

Allocate also mixed type of hearing loss, at which there is a shortening of the perception time of the bass (C 128) and treble (C 2048) tuning forks with air sound conduction, and the bass tuning fork with tissue sound conduction.

Criteria for evaluating tuning fork tests

Schwabach experience (1885). Classic variant: the leg of the sounding tuning fork is applied to the crown of the subject until he stops perceiving the sound, after which the examiner immediately applies it to his crown (it is assumed that the examiner should have normal hearing); if the sound is not heard, this indicates the normal hearing of the subject, if the sound is still perceived, then the subject's bone conduction is "shortened", which indicates the presence of perceptual hearing loss.

Weber's experience(1834). The leg of the sounding tuning fork is applied along the midline to the forehead or crown, the subject reports the presence or absence of lateralization of the sound. With normal hearing or with its symmetrical decrease, the sound will be felt "in the middle" or "in the head" without a clear lateralization. If the sound conduction is disturbed, the sound is lateralized into the worse hearing ear, if sound perception is impaired, it is lateralized into the better hearing ear.

Rinne experience(1885). With the help of C 128 or C 512, the sounding time of the tuning fork during air conduction is determined; then determine the sounding time of the same tuning fork during tissue conduction. Normally and with sensorineural hearing loss, the duration of sound perception with air sound conduction is longer than with tissue sound conduction. In this case it is said that " Rinne's experience is positive”, and in the auditory passport this fact is noted in the corresponding cell with a “+” sign. In the case when the sounding time with tissue sound conduction is longer than the sounding time with air conduction, they say that " Rinne's experience is negative", and a sign is affixed in the auditory passport"-". A positive "Rinne" is typical of normal hearing with normal air and bone conduction times. It is also positive in sensorineural hearing loss, but at lower time values. Negative "Rinne" is typical for a violation of sound conduction. In the absence of sound perception through air sound conduction, one speaks of an “infinitely negative Rinne”, in the absence of bone conduction, one speaks of an “infinitely positive Rinne”. “False negative Rinne” is noted when listening through the bone with the other ear if the hearing in this ear is normal, and there is a pronounced sensorineural hearing loss in the examined ear. In this case, to study hearing, a healthy ear is muffled with a Barani ratchet.

The Jelle experience(1881). Designed to determine the presence or absence of mobility of the base of the stirrup and is mainly used to detect ankylosis of the stirrup in otosclerosis. The experiment is based on the phenomenon of a decrease in the volume of a sounding tuning fork during bone conduction during an increase in pressure in the external auditory canal. For the experiment, a low-frequency tuning fork with a long sounding time and a Politzer cylinder with a rubber tube with an olive pointed at its end are used. The olive, selected according to the size of the external opening of the auditory canal, is firmly inserted into the external auditory canal, and the sounding tuning fork is placed with a handle on the site of the mastoid process. If the sound gets quieter, talk about " positive» experience of Gellet, if it does not change, then the experience is defined as « negative". The corresponding symbols are put down in the auditory passport. The negative experience of Gellet is observed in the dissociation of the auditory ossicles as a result of trauma, perforations of the tympanic membrane and obliteration of the windows of the ear labyrinth. Instead of a tuning fork, you can use the bone phone of an audiometer.

Tone threshold audiometry

Tonal threshold audiometry is a standard, generally accepted method for studying auditory sensitivity to "pure" tones in the range of 125-8000 (10,000) Hz for air conduction of sound and in the range of 250-4000 Hz for bone conduction of sound. For this purpose, special sound generators are used, the scales of which are calibrated in dB. Modern audiometers equipped with a built-in computer, the software of which allows you to record the study with display on the display tone audiogram and its fixation in a "hard copy" on a special form using a printer indicating protocol data. For the right ear on the form of a tone audiogram, red is used, for the left - blue; for air conduction curves, a solid line; for bone conduction, a dotted line. When conducting tonal, speech and other types of audiometric examination, the patient must be in a sound-damped chamber (Fig. 3). Each audiometer is additionally equipped with a generator of noise narrowband and broadband spectra for conducting research with the masking of an unexplored ear. To study air conduction, specially calibrated headphones are used; for bone conduction - "bone phone" or a vibrator.

Rice. 3. Audiometer; in the background is a sound-damped mini-camera

In addition to the threshold tone audiogram, modern audiometers contain programs for many other tests.

In normal hearing, the curves of air and bone conduction pass near the threshold line with a deviation at different frequencies within ± 5-10 dB, but if the curves fall below this level, this indicates a hearing impairment. There are three main types of changes in the tone threshold audiogram: ascending, descending and mixed(Fig. 4).

Rice. 4. The main types of tone threshold audiograms: I - ascending in violation of sound conduction; II - descending in violation of sound perception; III - mixed in violation of sound conduction and sound perception; RU - cochlear reserve, indicating the potential for hearing to be restored to the level of bone conduction, provided that the cause of hearing loss is eliminated

suprathreshold audiometry

Above-threshold audiometry includes audiometric tests in which test tones and speech signals exceed the threshold of hearing sensitivity. With the help of these samples, the following goals are achieved: identifying slew rate phenomenon and adaptation reserves hearing organ, definition level of hearing discomfort, degree speech intelligibility and noise immunity, a number of other functions of the sound analyzer. For example, using the Luscher-Zviklotsky test, they determine differential intensity threshold in differential diagnosis between conductive and perceptual types of hearing loss. This test is presented as a standard test in any modern audiometer.

Speech audiometry

In this test, separate specially selected words containing low and high frequency formants are used as testing sounds. The result is evaluated by the number of correctly understood and repeated words as a percentage of the total number of words presented. On fig. 5 shows examples of speech audiograms for various types of hearing loss.

Rice. five. Speech audiograms for various types of hearing loss: 1 - curve for conductive hearing loss; 2 — a curve at a cochlear form of relative deafness; 3 — a curve at the mixed form of relative deafness; 4 — a curve at the central type of relative deafness; a, b — different positions of the speech intelligibility curve in the conductive type of hearing loss; c, d — downward deviations of the curves with a decrease in USD (in the presence of FUNG)

Spatial Hearing Test

The study of the function of spatial hearing (ototopics) is aimed at developing methods for topical diagnosis of the levels of damage to the sound analyzer.

The study is carried out in a soundproof room equipped with a special acoustic installation consisting of a sound generator and loudspeakers located in front of the subject in the vertical and horizontal planes.

The task of the subject is to determine the localization of the sound source. The results are evaluated by the percentage of correct answers. With sensorineural hearing loss, the accuracy of determining the localization of the sound source is reduced on the side of the worse hearing ear. The vertical localization of sound in these patients varies depending on the hearing loss to high tones. With otosclerosis, the possibility of localizing sound in the vertical plane is completely excluded, regardless of the frequency spectrum of the testing sound, while horizontal localization changes only depending on the asymmetry of the auditory function. With Meniere's disease, there is a constant violation of ototopics in all planes.

Methods of objective research of hearing

Basically, these methods are used in relation to young children, persons undergoing an examination for the presence of auditory function, and patients with a defective psyche. The methods are based on the assessment of auditory reflexes and auditory evoked potentials.

auditory reflexes

They are based on reflex connections of the organ of hearing with the sensorimotor sphere.

Preyer's auropalpebral reflex(N. Preyer, 1882) - involuntary blinking that occurs with a sharp sudden sound. In 1905, V. M. Bekhterev suggested using this reflex in order to detect simulation of deafness. Various modifications of this reflex were used in N. P. Simanovsky's clinic. Currently, this reflex is used to exclude deafness in infants.

Aurolaryngeal reflex(J. Mick, 1917). The essence of this reflex lies in the fact that under the influence of an unexpected sharp sound, a reflex closing of the vocal folds occurs, followed by their dilution and a deep breath. This reflex in the expert sample is very reliable, since it refers to unconditional reactions that do not depend on the will of the subject.

auropupillary reflex(G. Holmgren, 1876) consists in reflex expansion, and then in the narrowing of the pupils under the influence of a sudden strong sound.

Freschels reflex(Froeschels). It consists in the fact that with a sharp sound there is an involuntary deviation of the gaze towards the source of the sound.

Tsemakh's reflex(Cemach). With a sudden loud sound, there is a tilt of the head and torso (removal reaction) in the direction opposite to that from which a sharp strong sound was heard.

Sound motor reflexes of the muscles of the tympanic cavity. These unconditioned reflexes, which occur in response to suprathreshold sound stimulation, are widely used in modern audiology and audiology.

auditory evoked potentials

The method is based on the phenomenon of generation in the neurons of the auditory zones of the cerebral cortex of bioelectric evoked potentials, arising from the sounding of the receptor cells of the spiral organ of the cochlea, and the registration of these potentials with the help of their summation and computer processing; hence the other name of the method - computer audiometry. In audiology, auditory evoked potentials are used for topical diagnosis of central disorders of the sound analyzer (Fig. 6).

Rice. 6. Schematic representation of the average auditory evoked biopotentials

Methods for the study of the auditory tube

The study of the auditory tube is one of the main methods for diagnosing diseases of both this organ and the middle ear and their differential diagnosis.

Scoping Methods

At otoscopy dysfunctions of the auditory tube are manifested by: a) retraction of the relaxed and stretched parts of the tympanic membrane; b) an increase in the depth of the cone of the tympanic membrane, due to which the short process of the malleus protrudes outwards (symptom of the “index finger”), the light reflex is sharply shortened or completely absent.

At epipharyngoscopy(posterior rhinoscopy) assess the condition of the nasopharyngeal mouths of the auditory tubes (hyperemia, senechia, damage, etc.), the condition of the tubal tonsils and adenoid tissue, choanae, vomer, retrospective of the nasal passages.

Pneumootoscopy

The technique is carried out using a Siegle funnel (1864), equipped with a rubber canister to influence the eardrum with an air jet (Fig. 7).

Rice. 7. Siegle funnel with pneumatic attachment

With normal ventilation function of the auditory tube, an impulse increase in pressure in the external auditory canal causes vibrations of the tympanic membrane. In violation of the ventilation function of the auditory tube or in the adhesive process, the mobility of the membrane is absent.

Salpingoscopy

To examine the nasopharyngeal mouth of the auditory tube, modern optical endoscopes are used.

Currently, to examine the auditory tube, the thinnest fiberscopes with controlled optics at the distal end are used, which can penetrate through the auditory tube into the tympanic cavity to conduct tubotympanic microfibroendoscopy.

Blowing out the auditory tube. This method is used for both diagnostic and therapeutic purposes. For it, a special rubber balloon is used, connected by means of a rubber tube to the nasal olive, which is inserted into the nostril and tightly clamped together with the other nostril. The subject takes a sip of water, during which the nasopharyngeal cavity is blocked by the soft palate, and the pharyngeal opening of the auditory tube opens. At this moment, the balloon is squeezed, air pressure rises in the nasal cavity and nasopharynx, which, during the normal functioning of the auditory tube, enters the middle ear. Instead of a sip of water, you can pronounce sounds, during the articulation of which the nasopharynx is blocked by a soft palate, for example, “also-also”, “cuckoo”, “steamboat”, etc. When air enters the tympanic cavity in the external auditory canal, you can hear a kind of noise. When listening to this noise, apply Lutze otoscope, which is a rubber tube, at the ends of which there are two ear olives. One of them is inserted into the external auditory canal of the examiner, the other - into the external auditory canal of the subject. Listening is carried out during a sip with a pinched nose ( toynbee test).

A more effective way to determine the patency of the auditory tube is Valsalva test, which consists in an attempt to exhale with a tightly clamped nose and lips. With this test, in the case of patency of the auditory tube, the subject has a feeling of fullness in the ears, and the examiner listens with the help of an otoscope a characteristic blowing or popping sound. Below is a list of the most famous samples.

The principles of assessing the patency of the auditory tube by degrees have survived to this day. A. A. Pukhalsky (1939) proposed to classify the state of the ventilation function of the auditory tubes into four degrees:

• I degree - the noise is heard with a simple sip;
• II degree - noise is heard during the Toynbee test;
• III degree - noise is heard during the Valsalva maneuver;
• IV degree - the noise is not heard in any of the listed samples. Complete obstruction is assessed by the absence of noise during the Politzer test with a sip of water. If it is impossible to determine the patency of the auditory tube by the above methods, they resort to its catheterization.

Eustachian tube catheterization

The following instruments are required for catheterization of the auditory tube (Fig. 8): Politzer balloon (7) for blowing the auditory tube; Lutze otoscope (2) for listening to ear noise that occurs when air passes through the auditory tube, and an ear catheter (Hartmann cannula) for direct blowing of the auditory tube by catheterization.

Rice. eight. A set of instruments for catheterization of the auditory tube: 1 - rubber balloon; 2 - otoscope - a rubber tube for listening to noise; 3 - catheter for direct probing of the auditory tube

Eustachian tube catheterization technique

The catheter is inserted along the common nasal passage with the beak down until it touches the posterior wall of the nasopharynx, it is turned 90° towards the opposite ear and pulled up until it touches the vomer. Then the catheter is turned with its beak down by 180° towards the studied auditory tube so that the beak faces the side wall of the nasopharynx. After that, the beak is turned upwards by another 30-40 °, so that the ring located at the catheter funnel is directed towards the outer corner of the orbit. The final stage is to search for the pharyngeal opening of the auditory tube, during which the ridges of this opening (posterior and anterior) can be determined. Getting into the hole is characterized by a feeling of "capture" of the end of the catheter. Next, the conical end of the balloon is inserted into the catheter socket and air is pumped into it with light movements. With the patency of the auditory tube, a blowing noise is heard, and during otoscopy after blowing, the injection of the vessels of the tympanic membrane is detected.

Ear manometry is based on the registration of an increase in pressure in the external auditory canal, which occurs when pressure increases in the nasopharynx and the presence of patency of the auditory tube.

Currently, the study of the function of the auditory tube is carried out using phonobarometry and electrotubometry.

Phonobarometry allows you to indirectly set the amount of air pressure in the tympanic cavity and control the state of the ventilation function of the auditory tube.

Impedance Audiometry(English) impedance, from lat. impedio I resist, resist. Under acoustic impedance understand the complex resistance experienced by sound waves passing through certain acoustic systems and leading these systems into forced oscillations. In audiology, the study of acoustic impedancemetry is aimed at determining the qualitative and quantitative characteristics of the sound-conducting system of the middle ear.

Modern impedance measurement includes the measurement of the absolute value of the input impedance, i.e., the acoustic impedance of a sound-conducting system; registration of changes in the input impedance under the influence of contraction of the muscles of the tympanic cavity and a number of other indicators.

Acoustic reflexometry allows you to evaluate the reflex activity of the muscles of the tympanic cavity and diagnose auditory dysfunction at the level of the first neuron. The main diagnostic criteria are: a) threshold value stimulating sound in dB; b) latency period acoustic reflex, reflecting the functional state of the first neuron, from the beginning of the sound stimulus to the reflex contraction of the ipsi- or contralateral stapedial muscle; in) nature of change acoustic reflex depending on the magnitude of the suprathreshold sound stimulus. These criteria are identified when measuring the parameters of the acoustic impedance of the sound-conducting system.

Otorhinolaryngology. IN AND. Babiak, M.I. Govorun, Ya.A. Nakatis, A.N. Pashchinin

The main task of hearing research is to determine the acuity of hearing, i.e., the sensitivity of the ear to sounds of different frequencies. Since the sensitivity of the ear is determined by the hearing threshold for a given frequency, in practice, the study of hearing consists mainly in determining the perception thresholds for sounds of different frequencies.

3.1. Hearing test by speech

The simplest and most accessible method is the study of hearing by speech. The advantages of this method lie in the absence of the need for special instruments and equipment, as well as in its compliance with the main role of the auditory function in humans - to serve as a means of verbal communication.

In the study of hearing by speech, whispered and loud speech is used. Of course, both of these concepts do not include the exact dosage of the strength and pitch of the sound, however, there are still some indicators that determine the dynamic (power) and frequency response of whispered and loud speech.

In order to give whispered speech a more or less constant volume, it is recommended to pronounce words using the air remaining in the lungs after a calm exhalation. In practice, under normal research conditions, hearing is considered normal when the perception of whispered speech at a distance of 6-7 m. The perception of a whisper at a distance of less than 1 m characterizes a very significant decrease in hearing. The complete absence of perception of whispered speech indicates a sharp hearing loss that makes speech communication difficult.

As mentioned above, speech sounds are characterized by formants of different heights, that is, they can be more or less "high" and "low".

By selecting words consisting of only high or low sounds, one can partly differentiate the lesions of the sound-conducting and sound-perceiving apparatuses. Damage to the sound-conducting apparatus is considered to be characterized by a deterioration in the perception of low sounds, while the loss or deterioration in the perception of high sounds indicates damage to the sound-perceiving apparatus.

For the study of hearing in whispered speech, it is recommended to use two groups of words: the first group has a low frequency response and is heard with normal hearing at an average distance of 5 m; the second - has a high frequency response and is heard on average at a distance of 20 m. The first group includes words that include vowels y, o, from consonants - m, n, p, in, for example: raven, yard, sea, number , Moore and. etc.; the second group includes words that include hissing and whistling sounds from consonants, and from vowels - a, and, e: hour, cabbage soup, cup, siskin, hare, wool, etc.

In the absence or a sharp decrease in the perception of whispered speech, they proceed to the study of hearing in loud speech. First, they use speech of medium, or so-called conversational, loudness, which is heard at a distance of about 10 times greater than whispered. To give such speech a more or less constant volume level, the same technique is recommended that is suggested for whispered speech, i.e., use the reserve air after a calm exhalation. In cases where the speech of conversational loudness is distinguished poorly or does not differ at all, speech of increased loudness (cry) is used.

The study of hearing by speech is carried out for each ear separately: the ear under study is turned to the source of the sound, the opposite ear is muffled with a finger (preferably moistened with water) or a wet ball of cotton. When blocking the ear with a finger, do not press hard on the ear canal, as this causes noise in the ear and can cause pain. When examining hearing in conversational and loud speech, the second ear is turned off using an ear ratchet. Plugging the second ear with a finger in these cases does not achieve the goal, since in the presence of normal hearing or with a slight decrease in hearing in this ear, loud speech will differ, despite the complete deafness of the ear being examined.

The study of speech perception must begin at close range. If the subject correctly repeats all the words presented to him, then the distance gradually increases until most of the spoken words are indistinguishable. The speech perception threshold is considered to be the greatest distance at which 50% of the presented words differ. If the length of the room in which the hearing test is performed is insufficient, i.e., when all words are clearly distinguishable even at the maximum distance, then the following technique can be recommended: the examiner becomes his back to the subject and pronounces the words in the opposite direction; this roughly corresponds to doubling the distance.

When examining hearing by speech, it must be taken into account that the perception of speech is a very complex process. The results of the study depend, of course, on the acuteness and volume of hearing, that is, on the ability to distinguish sounds of a certain height and strength, corresponding to the acoustic properties of speech. However, the results depend not only on the acuteness and volume of hearing, but also on the ability to distinguish in the audible such elements of speech as phonemes, words, their combination into sentences, which, in turn, is due to how well the subject has mastered sound speech.

In this regard, when examining hearing with the help of speech, one must take into account not only the phonetic composition, but also the availability of the words and phrases used for understanding. Without taking into account this last factor, one can come to an erroneous conclusion about the presence of certain hearing defects where, in fact, these defects do not exist, but there is only a discrepancy between the speech material used for the study of hearing and the level of speech development of the subject.

For all its practical significance, the study of hearing by speech cannot be accepted as the only method for determining the functional ability of the auditory analyzer, since this method is not entirely objective both in terms of dosage of sound intensity and in terms of evaluating results.

3.2. Hearing test with tuning forks

A more accurate method is the study of hearing with the help of tuning forks. Tuning forks emit pure tones, and the pitch (oscillation frequency) for each tuning fork is constant. In practice, tuning forks tuned to the tone C (do) in different octaves are usually used, including tuning forks C, C, c, cv c2, c3, c4, c5. Hearing tests are usually performed with three (C128, C512, C2048 or C4096) or even two (C128 and C2048) tuning forks (FOOTNOTE: For clarity, tuning forks are designated by a letter corresponding to the name of the tone emitted by this tuning fork, and a number indicating the number of vibrations (C256, C1024, etc.) per second).

The tuning fork consists of a stem and two branches (branches). To bring the tuning fork into a state of sound, the branches hit an object. After the tuning fork has begun to sound, you should not touch its branches with your hand and you should not touch the branches to the ear, hair, clothes of the person under study, as this stops or reduces the sound of the tuning fork.

With the help of a set of tuning forks, it is possible to study hearing both in terms of its volume and in terms of acuity. In the study of the volume of auditory perception, the presence or absence of perception of a given tone is determined, at least at the maximum sounding power of the tuning fork. In the elderly, as well as in diseases of the sound-perceiving apparatus, the volume of hearing decreases due to the loss of perception of high tones.

The study of hearing acuity with tuning forks is based on the fact that the tuning fork, being brought into vibration, sounds for a certain time, and the strength of the sound decreases in accordance with the decrease in the amplitude of the vibrations of the tuning fork and gradually disappears.

In view of the fact that the duration of the sounding of a tuning fork depends on the force of the blow with which the tuning fork is brought into a state of sounding, this force must always be maximum. Low tuning forks hit their branches on their elbow or knee, and high ones on the edge of a wooden table, on some other wooden object.

studies of the air conduction of the branch of the tuning fork brought into the state of sounding are brought to the external auditory canal of the ear under study (Fig. 18) and the duration of the sounding of the tuning fork is determined, i.e. the time interval from the beginning of sounding to the moment the audibility of the sound disappears.

Rice. 18. Study of hearing with a tuning fork (air conduction)

Bone conduction is examined by pressing the leg of the sounding tuning fork to the mastoid process of the ear under study or to the crown (Fig. 19) and determining the time interval between the beginning of sounding and the cessation of sound audibility. Only low tuning forks (usually C128) are used to study bone conduction. High tuning forks are unsuitable for this purpose, since the vibrations of the branches of a high tuning fork are transmitted through air much better than the vibrations of its legs through the bone, and therefore bone conduction is masked in these cases by air.

Rice. 19. Study of hearing with a tuning fork (bone conduction)

The study of air and bone conduction is of significant diagnostic value, since it makes it possible to determine the nature of hearing damage: whether only the function of the sound-conducting system is affected in this case or there is a lesion of the sound-perceiving apparatus. For this purpose, three main experiments are carried out: 1) determination of the duration of perception of the sound of a tuning fork during bone conduction; 2) comparison of the duration of perception of the sound of a tuning fork during air and bone conduction; 3) the so-called experience of lateralization (from Latin laterum - side, side).

1. Having brought the tuning fork into the state of sounding, put its leg to the crown of the head and determine the duration of perception of its sounding. A shortening of bone conduction compared to the norm indicates damage to the sound-perceiving apparatus. In case of violation of the sound-conducting function, an elongation of bone conduction is observed.

2. Compare the duration of the sound of a tuning fork when perceived through the external auditory canal (air conduction) and through the mastoid process (bone conduction). With normal hearing, as well as with damage to the sound-receiving apparatus, sound through the air is perceived longer than through the bone, and if the sound-conducting apparatus is disturbed, bone conduction turns out to be the same as air and even exceeds it.

3. The leg of the sounding tuning fork is placed in the middle of the crown. If the subject has a unilateral hearing loss or a bilateral lesion, but with a predominant hearing loss in one ear, then the so-called lateralization of sound is noted during this experiment. It lies in the fact that, depending on the nature of the lesion, the sound will be transmitted in one direction or another. If the sound-perceiving apparatus is damaged, the sound will be perceived by the healthy (or better hearing) ear, and if the sound-conducting apparatus is disturbed, the sound will be felt in the diseased (or hearing worse) ear.

With prolonged continuous sounding of the tuning fork, phenomena of adaptation of the auditory analyzer occur, i.e., a decrease in its sensitivity, which leads to a shortening of the time of perception of the sound of the tuning fork. In order to exclude adaptation, it is necessary, when examining both air and bone conduction, from time to time (every 2-3 seconds) to remove the tuning fork from the ear under study or from the crown of the head for 1-2 seconds and then bring it back.

By comparing the time during which the sound of the tuning fork is perceived by the ear under study, with the duration of the sound of the same tuning fork for a normal hearing ear, the acuity of hearing to the sound emitted by this tuning fork is determined. The duration of sounding with normal hearing, or, as they say, the norm of sounding, must be determined in advance for each tuning fork, and, moreover, separately for air and bone conduction. The numbers characterizing the sounding rate of each tuning fork must be attached to each set. They represent the so-called tuning fork passport.

Table 3. An approximate table of the results of the study of hearing with tuning forks Right ear Tuning forks Left ear

20s C128(40s) 25s

20s C256(30s) 20s

15s C512(70s) 20s

5 s C1024(50s) 10 s

0 s S2048(30s) 5 s

0 s С4096(20s)

Bone conduction 0 s

3 s С129(25s) 4 s

The numbers in brackets near the names of the tuning forks in the middle column of the table indicate the duration of the sound of the tuning forks in the norm (passport data of the tuning forks). In the right and left columns, the duration (in seconds) of the sound of the tuning forks obtained during the study of this subject is put down. Comparing the duration of perception of the sound of tuning forks by the subject with the duration of their sound for normal hearing, one can get an idea of ​​the degree of hearing preservation at certain frequencies.

A significant disadvantage of tuning forks is that the sounds they produce do not have sufficient intensity to measure thresholds with very large hearing losses. Low tuning forks give a volume level above the threshold of only 25-30 dB, and medium and high - 80-90 dB. Therefore, when examining people with severe hearing loss with tuning forks, not true, but false hearing defects can be determined, i.e., the hearing gaps found may not correspond to reality.

3.3. Hearing test with an audiometer

A more advanced method is the study of hearing with the help of a modern device - an audiometer (Fig. 20).

Rice. 20. Hearing test with an audiometer

An audiometer is a generator of alternating electrical voltages, which, with the help of a telephone, are converted into sound vibrations. To study auditory sensitivity during air and bone conduction, two different phones are used, which are respectively called “air” and “bone”. The intensity of sound vibrations can vary within very wide limits: from the most insignificant, lying below the threshold of auditory perception, to 120-125 dB (for medium frequency sounds). The height of the sounds emitted by the audiometer can also cover a large range - from 50 to 12,000-15,000 Hz.

Measuring hearing with an audiometer is extremely simple. By changing the frequency (pitch) of the sound by pressing the corresponding buttons, and the intensity of the sound by rotating a special knob, the minimum intensity is set at which the sound of a given pitch becomes barely audible (threshold intensity).

Changing the pitch is achieved in some audiometers by smooth rotation of a special disk, which makes it possible to obtain any frequency within the frequency range of this type of audiometer. Most audiometers emit a limited number (7-8) of certain frequencies, either tuning fork (64,128,256, 512 Hz, etc.) or decimal (100, 250, 500, 1000, 2000 Hz, etc.).

The audiometer scale is calibrated in decibels, usually relative to normal hearing. Thus, having determined the threshold intensity of the subject on this scale, we thereby determine his hearing loss in decibels for a sound of a given frequency in relation to normal hearing.

The subject signals the presence of audibility by raising his hand, which he must keep raised during the entire time he hears the sound. The lowering of the hand is the signal for the disappearance of audibility.

bulb on the panel of the audiometer. The subject keeps the button pressed all the time while he hears the sound - therefore, the signal light is on all this time. When the audibility of the sound disappears, the subject releases the button - the light goes out.

When examining hearing with an audiometer, the subject should be placed so that he does not see the front panel of the audiometer and cannot follow the actions of the examiner, switching knobs and buttons of the audiometer.

The result of a hearing test with an audiometer is usually presented in the form of an audiogram (Fig. 21). On a special audiometric grid, on which sound frequencies are plotted horizontally (64, 128, 256, etc.), and vertically - the volume levels of the corresponding sounds at the threshold of hearing (or, what is the same, hearing loss) in decibels, applied in the form of dots audiometer readings for each ear separately. The curve connecting these points is called an audiogram. Comparing the position of this curve with the line corresponding to normal hearing (usually this line is presented as a straight line passing through the zero level), one can get a visual representation of the state of auditory function.

Rice. 21. Sample audiogram

The results of the study of both ears are entered on the same form. To distinguish between audiograms for each ear, it is recommended to plot the results of the study of the right and left ears on the audiometric grid with different conventional signs. For example, for the right ear - in circles, and for the left - with crosses (as shown in Fig. 21), or draw curves with pencils of different colors (for example, for the right ear - in red pencil, for the left - in blue). Curves depicting the result of a bone conduction study are plotted with a dotted line. All symbols are specified in the margins of the audiometric form.

The audiogram not only gives an idea of ​​the degree of impairment of the auditory function, but also allows, to a certain extent, to determine the nature of this impairment. Here are two typical audiograms as an example. On fig. 22 is an audiogram representative of a conduction disorder, as evidenced by relatively mild hearing loss, an ascending air conduction curve (i.e. better perception of high tones compared to low tones), and normal bone conduction. On fig. 23 shows an audiogram typical of damage to the sound-perceiving apparatus: a sharp degree of hearing loss, a descending audiometric curve, a significant decrease in bone conduction, a break in the curve, i.e., no perception of high tones (4000-8000 Hz).

125 250 500 1000 2000 4000 8000 Hz

Rice. 22. Audiogram in violation of sound conduction

Rice. 23. Audiogram in violation of sound perception (symbols are the same as in Fig. 22)

Recently, the so-called speech audiometry has been widely used in the practice of hearing research. While conventional, or tone, audiometry examines auditory sensitivity in relation to pure tones, speech audiometry determines the speech discrimination threshold. In this case, either natural speech (through a microphone) or speech previously recorded on tape using a tape recorder is fed to the audiometer. The threshold of discrimination, or the minimum intensity of speech at which the subject distinguishes most of the words presented to him, is determined in the same way as in tone audiometry, and is measured in decibels (Fig. 24).

10 20 30 40 50 60 70 80 90 100 110 120dB

Rice. 24. Speech audiograms.

Speech intelligibility curves: I - normal; II - in violation of sound conduction;

III - in violation of sound perception

Compared with other methods, the study using an audiometer has a number of advantages. These benefits include the following.

1. Significantly greater measurement accuracy. The inaccuracy of the results of measuring hearing acuity by voice and speech has already been mentioned, as for the study with tuning forks, this method cannot claim accuracy either, since the duration of the sound of a tuning fork depends on a number of reasons, in particular, on the initial amplitude, i.e., on the strength hit.

2. Significantly greater possibilities regarding the range of audio frequencies. The highest tuning fork has an oscillation frequency of 4096 Hz, an audiometer can give, as indicated, up to 12,000-15,000 Hz; in addition, an audiometer with a smooth change in frequencies can produce sounds that not only correspond in height to tuning forks, but also any intermediate frequencies.

3. Significantly greater possibilities in terms of the volume of sounds emitted. Tuning forks and the human voice have a maximum loudness estimated at 90 dB, while using an audiometer, you can get a loudness of up to 125 dB, which makes it possible to determine the thresholds of unpleasant sensations in some cases.

4. Significantly greater convenience of research, especially in relation to the amount of time spent on research.

5. Ability to assess hearing acuity in generally accepted and easily comparable units (decibels).

6. Possibility to study bone conduction for high sounds, which is excluded when examining hearing with tuning forks.

Like other methods based on the testimony of the subject, the study using an audiometer is not free from some inaccuracies associated with the subjectivity of these testimony. However, by repeated audiometric studies, it is usually possible to establish a significant constancy of the results of the study and thus give these results sufficient credibility.

3.4. Hearing test in children

The study of hearing in children should be preceded by the collection of brief anamnestic information: the course of the early physical development of the child, speech development, the time and causes of hearing loss, the nature of speech loss (simultaneously with deafness or after some time, immediately or gradually), the conditions for raising the child.

At different periods of a child's life, the occurrence of hearing loss and deafness is associated with certain typical causes that make it possible to identify risk groups. For example: causes that affect the auditory function of the fetus during pregnancy (congenital hearing loss and deafness) are toxicosis, the threat of miscarriage and premature birth, Rhesus conflict between mother and fetus, nephropathy, uterine tumors, maternal diseases during pregnancy, primarily such like rubella, flu, treatment with ototoxic drugs. Often deafness occurs during pathological childbirth - premature, rapid, prolonged with the imposition of forceps, with cesarean section, partial detachment of the placenta, etc. Deafness that occurs in the early neonatal period is characterized by hyperbilirubinemia associated with hemolytic disease of the newborn, prematurity, congenital malformations development, etc.

In infancy and early childhood, risk factors are past sepsis, fever after childbirth, viral infections (rubella, chicken pox, measles, mumps, influenza), meningoencephalitis, complications after vaccination, inflammatory diseases of the ear, traumatic brain injury, treatment ototoxic drugs, etc. Affects congenital deafness and heredity.

Of great importance for the initial judgment about the state of hearing in a child with suspected hereditary hearing loss is the maternal history:

When interviewing the parents of a child under the age of 4 months, it turns out: whether unexpected loud sounds awaken the sleeping person, whether he shudders or cries; for the same age, the so-called Moro reflex is characteristic. It is manifested by raising and lowering the arms (grip reflex) and stretching the legs with strong sound stimulation;

For the approximate detection of hearing impairment, the congenital sucking reflex is used, which occurs in a certain rhythm (as well as swallowing). A change in this rhythm during sound exposure is usually caught by the mother and indicates the presence of hearing. Of course, all these orienting reflexes are rather determined by the parents. However, these reflexes are characterized by rapid extinction, which means that with frequent repetition, the reflex may cease to be reproduced. At the age of 4 to 7 months, the child usually makes attempts to turn to the source of the sound, i.e. already determines its localization. At 7 months, he differentiates certain sounds, reacts even if he does not see the source. By 12 months, the child begins to attempt verbal responses (“cooing”).

To study the hearing of children aged 4-5 years, the same methods are used as for adults. Starting from the age of 4-5, the child understands well what they want from him, and usually gives reliable answers. However, in this case, it is necessary to take into account some features of childhood. So, although the study of hearing in whispered and colloquial speech is very simple, it is necessary to follow the exact rules for its conduct in order to obtain a correct judgment about the state of the child's auditory function. Knowledge of this particular method is especially important, since it can be carried out by a doctor himself, and the identification of any hearing loss is the basis for a referral to a specialist. In addition, it is necessary to take into account a number of features of a psychological nature that take place in the study of this technique in childhood.

First of all, it is very important that trust arises between the doctor and the child, otherwise the child simply will not answer questions. It is better to give the dialogue the character of a game with the involvement of one of the parents in it. At the beginning, when addressing the child, you can interest him to some extent, for example, with such a question: “I wonder if you will hear what I will now say in a very quiet voice?” Usually, children are sincerely happy if they can repeat the word, and are willingly involved in the research process. And, on the contrary, they get upset or withdraw into themselves if they do not hear the words the first time.

In children, you need to start the study at close range, only then increasing it. The second ear is usually muffled to prevent overhearing. In adults, the situation is simple: a special ratchet is used. In children, its use usually causes fright, so silencing is caused by light pressure on the tragus while stroking it, which is best done by parents.

Hearing examination should be carried out in complete silence, in a room isolated from extraneous noise. To exclude the possibility of vibrational perception of sounds, a soft rug should be laid under the feet of the child under study, and also make sure that there is no mirror or any other reflective surface in front of the child’s eyes, which would allow him to observe the actions of the hearing examiner.

In order to exclude or at least reduce the reaction of the child and to establish contact with him more quickly, it is recommended to conduct a hearing test in the presence of parents or a teacher. When a child has a sharply negative attitude towards the study, it may be useful to conduct a hearing test in other children in his presence, after which the negativism is usually removed.

Before the study, it is necessary to explain to the child how he should react to the audible sound (turn around, point to the source of the sound, reproduce the sound or word he heard, raise his hand, press the signal button of the audiometer, etc.).

To eliminate the tactile sensation from the air jet and the possibility of reading from the lips when examining hearing with voice and speech, you need to use a screen that covers the examiner's face. Such a screen can be a piece of cardboard or a sheet of paper.

The study of hearing in children is fraught with great difficulties. They are due to the fact that babies cannot concentrate on one activity and are easily distracted. Therefore, the study of hearing in young children should be carried out in an entertaining way, for example in the form of a game.

In the study of hearing in children of pre-preschool and younger preschool age (2-4 years), speech, as well as various sounding toys, can already be used.

The study of auditory perception of the voice is combined with the determination of the ability of children to distinguish between vowels, which are first taken in a certain sequence, taking into account the degree of their audibility, for example, a, o, e, and, y, s, and then, in order to avoid guessing, they are offered in random order . For the same purpose, diphthongs ay, ua, etc. can be used. The distinction of consonants in words that differ from each other in one consonant sound, or in syllables, is also investigated.

In the study of auditory perception of such elements of speech as words and phrases, material is used that corresponds to the level of speech development of children. The most elementary material is, for example, words and phrases such as the name of a child, for example: Vanya, mom, dad, grandfather, grandmother, drum, dog, cat, home, Vova fell, etc.

Distinguishing the elements of speech is best done with the help of pictures: when the researcher pronounces a particular word, the child must show the corresponding picture. When examining hearing for speech in children who are just starting to speak, you can use onomatopoeia: "am-am" or "av-av" (dog), "meow" (cat), "mu" (cow), "whoa" ( horse), “tu-tu” or “bi-bi” (car), etc.

To study the distinction between whispered speech in children of senior preschool and primary school age, the following approximate table of words can be used (Table 4).

Table 4 Tables of words for the study of whispered speech in children

Words with a low frequency response Words with a high frequency response

Vova Sasha

Window Bump

Sea Match

Fish Chizhik

Wolf checker

City Bunny

Raven Cup

Soap Birdie

Lesson Brush

Bull Seagull

To study phonemic hearing, i.e. the ability to distinguish from each other individual acoustically similar speech sounds (phonemes), it is necessary, where possible, to use specially selected pairs of words that are accessible in meaning and that would differ from each other phonetically only by sounds, the differentiation of which is being studied. As such pairs, for example, such as heat - ball, cup - checker, dot - daughter, kidney - barrel, goat - braid, etc. can be used.

Such pairs of words can also be successfully used to study the ability to differentiate vowel phonemes. Here are some examples: a stick - a shelf, a house - smoke, a table - a chair, a bear - a mouse, a mouse - a fly, etc.

If it is impossible to select the appropriate pairs of words, the study of the distinction of consonant sounds can be carried out on the material of syllables such as ama, ana, ala, avya, etc.

Table 5 An approximate table of the results of a hearing test for voice and elements of speech Voice intensity Task Discrimination of words and phrases Distance

does not distinguish does not distinguish

Vowel distinction U / r (a, y) Does not distinguish

Distinguishing consonants U / r (r, w) Does not distinguish

Distinguishing words and phrases Does not distinguish Does not distinguish

Vowel distinction U/r (a, y, o, i) U/r (a, y)

Distinguishing words and phrases U / r (dad, Does not distinguish

Vova, grandmother)

Carrying out tuning fork and audiometric studies in children under 4-5 years of age is practically impossible and succeeds only as a rare exception. In older preschoolers, in many cases it is possible to conduct a hearing test with tuning forks or an audiometer, but such a study requires some preparatory techniques.

Before the study, you need to explain to the child what is required of him. First, an indicative study is carried out, i.e., they find out whether the child understood the task. To do this, bring a tuning fork that sounds at maximum volume, or a loud-sounding telephone earphone of an audiometer, to the ear under test, and, having received a signal (verbal or by raising a hand) about the presence of sound, immediately, imperceptibly for the subject, drown out the tuning fork by touching the finger to its jaws or turn off the sound of the audiometer. If the subject signals the termination of audibility, then he correctly understood the task and correctly reacts to the presence of a sound stimulus and its absence.

Sometimes you have to spend a lot of time for the child to begin to react to the sound of a tuning fork or an audiometer, and in some cases such a reaction is developed only with repeated studies.

Particular difficulties arise in the study of auditory perception in children who do not speak and do not show obvious remnants of hearing. The use of an audiometer and tuning forks often does not lead to the goal, since children may not understand the task assigned to them. Therefore, the primary study of such children is best done with the help of sounding toys and voices. The behavior of a child handling sounding toys, and the absence or presence of a reaction to a sound suddenly made by a toy, help determine whether a child has hearing.

As sounding objects, musical instruments can be used: a drum, a tambourine, a triangle, an accordion, a metallophone, a pipe, a whistle, a bell, as well as sounding toys depicting animals that make sounds of different tones. First, the child is given the opportunity to get acquainted with these objects and their sound, hold them in their hands, and then they bring one of the toys of a similar set into sound so that the child does not see it, and ask him to show which object sounded.

When using sounding toys, this technique can be recommended. The child is given two similar toys: two pipes, two harmonicas, two roosters, two cows, etc. One of these toys sounds, the other is spoiled. In most cases, it is possible to notice a distinct difference in the behavior of a deaf child and a child with more or less significant remnants of hearing. A hearing child usually easily detects that one of the toys does not sound, and begins to manipulate only the sounding one. A deaf person either pays equal attention to both toys, or leaves them both unattended.

If the child does not detect reactions even to very loud sounds (yelling or loud-sounding toys) and at the same time clearly responds to vibrational stimuli, for example, turns around when tapping his foot on the floor or knocking on a door, then it is possible with a significant degree of probability to conclude that there is deafness.

Lack of response to stimuli such as knocking on a door, hitting a table, stamping a foot on the floor may indicate not only deafness, but also a violation of other types of sensitivity or a sharp decrease in general reactivity. In these cases, the child should be examined by a neuropsychiatrist.

When examining hearing in children, clapping behind the child's back is often used. This technique is not reliable enough, since a response in the form of turning the head can also occur in a deaf child as a result of exposure to air shocks on the skin.

In general, it should be emphasized that a single primary study of hearing in children rarely gives completely reliable results. Very often, repeated studies are required, and sometimes a final conclusion on the degree of hearing impairment in a child can be given only after a long (six months) observation in the process of upbringing and education in a special institution for children with hearing impairments.

When studying the perception of speech elements by deaf and hard-of-hearing children, the corresponding speech material (phonemes and words) is first offered for discrimination simultaneously by ear, by reading from the lips and using tactile-vibrational perception. The researcher pronounces a phoneme or word loudly, and the child listens, looks at the researcher's face and holds one hand on the researcher's chest, the other on his chest. Only after the child begins to confidently differentiate the elements of speech with such a complex perception, can one proceed to the study of their perception only by ear.

The study of hearing with the help of speech in children with hearing and speech disorders cannot, as a rule, reveal the true state of auditory sensitivity. In this category of children, hearing the elements of speech, being in direct proportion to the degree of hearing impairment, is at the same time in connection with speech development. A child with reduced hearing, who is fluent in verbal speech, differentiates in the elements of speech presented to him all or almost all acoustic differences accessible to his hearing, since these differences have a signal (sense-distinctive) value for him. Another thing is a child who does not own speech or owns it only in its infancy. Even in those cases when one or another element of speech is accessible to his auditory perception in terms of its acoustic characteristics, it may not be recognized by such a child due to the absence or insufficient strengthening of its signal value. Thus, the study of hearing with the help of speech in children with impaired speech development gives only a general idea of ​​how the child is currently using his auditory capabilities to distinguish between certain elements of speech.

Audiometry is used to accurately determine auditory sensitivity and volume of auditory perception. However, the use of conventional audiometry in children with hearing and speech impairments encounters significant difficulties, which are due to two main reasons: firstly, such children do not always understand the verbal instruction, which explains the task presented to the child and how he responds to sound signals, and secondly, secondly, such children usually lack the skills of listening to sounds of low intensity. In these cases, the child reacts to the sound not at its minimum (threshold) strength, but at a certain, sometimes quite significant excess of the threshold intensity.

Thus, the study of the auditory function of children, even at the age of 4-5 years, presents significant difficulties compared to the study of adults, although they are also based on the answers of the subject. All these methods using speech, tuning forks or audiometers are called psychophysical.

However, unfortunately, these psychophysical methods can be used in children not earlier than 4-5 years of age, because before this age the child, as a rule, is not able to give the correct answer. Meanwhile, it is at this and even earlier age that there is an urgent need to identify hearing loss, since it is most closely related to the development of the child's speech function and intelligence. In addition, 80% of hearing impairment occurs in children in the 1st-2nd year of life. The main problem here is that the late diagnosis of hearing loss leads to an untimely start of treatment, and, consequently, to late rehabilitation, a delay in the formation of speech in a child. The modern concept of conducting deaf pedagogical work and hearing aids is also based on an earlier start of education.

The optimal age for hearing aids is 1-1.5 years of age. If this time is missed, which, unfortunately, happens in every third patient, it is already much more difficult to teach him speech - which means that the child is more likely to become deaf and mute.

In all this multifaceted problem, one of the most important issues is the early diagnosis of hearing loss, which is in the field of activity of a pediatrician and an otolaryngologist. Until recently, this problem remained almost unsolvable. As already noted, the main difficulty was the need to conduct an objective study based not on the child's answers, but on some other criteria that did not depend on his consciousness.

In the study of hearing in infants and young children, the methods are based on the registration of some kind of response (motor reaction, change in electrical potential, etc.) to sound stimulation, which does not depend on the child's consciousness.

Currently used hearing research methods can be divided into three large groups: 1) the method of unconditional reactions; 2) the method of conditioned reflex connections; 3) objective electrophysiological methods.

Methods of unconditioned reflexes. This group of methods is quite simple, but highly inaccurate. The definition of hearing here is based on the occurrence of unconditioned reflexes in response to sound stimulation. By these most diverse reactions (increased heart rate, pulse rate, respiratory movements, motor and autonomic responses), one can indirectly judge whether the child hears or not. A number of recent scientific studies show that even the fetus in the womb from about the 20th week reacts to sounds by changing the rhythm of heart contractions. Very interesting data suggests that the embryo hears the frequencies of the speech zone. On this basis, a conclusion is made about the possible reaction of the fetus to the speech of the mother and the beginning of the development of the psycho-emotional state of the unborn child. The main contingent of application of the method of unconditioned reactions are newborns and infants. A hearing child should respond to sound immediately after birth, already in the first minutes of life. In these studies, various sound sources are used: sounding toys pre-calibrated with a sound level meter, rattles, musical instruments, as well as simple devices, such as sound reactometers, sometimes narrow-broadband noise. The intensity of the sound is different.

The general principle is that the older the child, the less sound intensity is needed to detect his reaction. So, at 3 months it is caused by an intensity of 75 dB, at 6 months - 60 dB, at 9 months, 40-45 dB is already enough for a hearing child to show a reaction.

Both the correct conduct and the interpretation of the results of the technique are very important: the study should be carried out 1-2 hours before feeding, since later the reaction to sounds decreases. The motor response may be false, that is, not to sounds, but simply to the approach of an adult or the movement of his hands, so pauses should be made in dealing with a child. To exclude false positive reactions, two or three times the same answer can be considered reliable. Many errors in determining the unconditioned reaction are eliminated by the use of a “baby crib” specially equipped for hearing research. The most common and studied types of unconditioned reflexes are: blinking in response to sounds; pupil dilation; motor orienting reflexes; violation of the rhythm of inhibition of the sucking reflex.

Some responses can be objectively registered, for example, changes in the lumen of blood vessels (plethysmography), heart rhythms (ECG), etc.

The advantages of this group of methods include simplicity, accessibility in any conditions, which allows them to be widely used in the medical practice of neonatologists and pediatricians.

The disadvantages of the methods of unconditioned reflexes are that a rather high sound intensity and strict adherence to the rules of the study are necessary to exclude false positive answers, mainly with unilateral hearing loss. In addition, you can find out if the child hears, without characterizing the degree of hearing loss and its signs, although this is extremely important. Using this technique of unconditioned reflexes, one can also try to determine the ability to localize a sound source, which normally develops in children already from 3-4 months after birth.

Thus, it can be noted that the group of methods of unconditioned reflexes is widely used in practical work for the purpose of screening diagnostics, especially in risk groups. If possible, all newborns and infants still in the maternity hospital should carry out such studies and consultations, but they are mandatory in the so-called risk groups for hearing loss and deafness.

Methods based on the use of conditioned reflex reactions. For these studies, it is first necessary to develop an orienting reaction not only to sound, but also to another stimulus that reinforces the sound. So, if you combine feeding with a strong sound (for example, a call), then after 10-12 days the sucking reflex in a child will appear only in response to the sound.

There are numerous methods based on this pattern. Only the nature of the reinforcement of the reflex changes. Sometimes pain stimuli are used as it, for example, the sound is combined with an injection or directing a strong air stream into the face. Such sound-reinforcing stimuli elicit a (rather stable) defensive reaction and are used primarily to detect aggravation in adults, but cannot be applied to children for humane reasons.

In studies of children, such modifications of the conditioned reflex technique are used, which are based not on a defensive reaction, but, on the contrary, on positive emotions and the natural interest of the child. Sometimes food is given as such a reinforcement (sweets, nuts), but this is not harmless, especially with repeated repetition, when you need to develop reflexes to different frequencies. Therefore, this option is more applicable for training animals in the circus.

Today, play audiometry is often used in clinics (Fig. 25), in which the natural curiosity of the child is used as a reinforcement. In these cases, sound stimulation is combined with showing pictures, slides, videos, moving toys (for example, a railway), etc. The scheme of the technique is as follows: the child is placed in a sound-dampened and isolated chamber. An earpiece connected to a sound source (audiometer) is put on the ear to be examined. The doctor and recording equipment are outside the cell. At the beginning of the study, high-intensity sounds are delivered to the ear, which the child obviously needs to hear. The child's hand is placed on the button, which, when the sound signal is given, is pressed by the mother or assistant. After a few exercises, the child usually learns that the combination of a sound with a button press leads either to a change in pictures or to a continuation of the video, in other words, to the continuation of the game. Therefore, he already presses the button on his own when the sound appears. Gradually, the intensity of the supplied sounds decreases.

Thus, conditioned reflex reactions make it possible to identify: 1) unilateral hearing loss; 2) determine the thresholds of perception; 3) to give a frequency response of disorders of the auditory function.

The study of hearing by these methods requires a certain level of intelligence and understanding on the part of the child. Much depends on the ability to establish contact with parents, qualifications and skillful approach to the child on the part of the doctor. However, all efforts are justified by the fact that already from the age of three, in many cases, it is possible to conduct a study of hearing and obtain a complete description of the state of the child's auditory function.

Objective electrophysiological methods. Measurement of acoustic impedance, i.e., the resistance that a sound-conducting apparatus has to a wave.

Under normal conditions, this resistance is minimal: at frequencies of 800-1000 Hz, almost all sound energy reaches the inner ear without resistance, and the acoustic impedance is zero.

In pathology associated with the deterioration of the functions of the tympanic membrane, auditory ossicles, labyrinth windows, part of the sound energy is reflected. This is the criterion for changing the magnitude of the acoustic impedance.

This study is as follows. An impedancemeter sensor is hermetically inserted into the external auditory canal; a sound of constant frequency and intensity, called "probing", is fed into a closed cavity. Data obtained from acoustic impedancemetry are recorded as various curves on tympanograms (Fig. 25).

Learn three tests:

Tympanometry (gives an idea of ​​the mobility of the eardrum and pressure in the cavities of the middle ear);

static compliance (makes it possible to differentiate stiffness of the ossicular chain);

The threshold of the acoustic reflex (based on the contraction of the muscles of the middle ear, allows you to differentiate the defeat of the sound-conducting and sound-perceiving apparatus).

Features that should be taken into account when performing acoustic impedancemetry in childhood. In children of the first month of life, the study does not present great difficulties, since it can be carried out during a sufficiently deep sleep that occurs after the next feeding. The main feature at this age is associated with the frequent absence of an acoustic reflex.

Tympanometric curves are recorded quite clearly, although there is a large spread in the amplitude of the tympanogram, which sometimes has a two-peak configuration. The acoustic reflex can be determined from about 1.5-3 months. However, it should be borne in mind that even in a state of deep sleep, the child has frequent swallowing movements, so the recording may be distorted by artifacts. For sufficient reliability, studies should be repeated.

The possibility of errors in acoustic impedance measurement due to the compliance of the walls of the external auditory canal and changes in the size of the auditory tube during screaming or crying should also be taken into account. Of course, anesthesia can be used in these cases, but this leads to an increase in the thresholds of the acoustic reflex. We can assume that tympanograms become reliable from the age of 7 months and give a reliable idea of ​​the function of the auditory tube.

The method of objective determination of auditory evoked potentials using computer audiometry (Fig. 26). Already at the beginning of the century, with the discovery of electroencephalography, it was clear that in response to sound stimulation (stimulation) in various parts of the sound analyzer (cochlea, spiral ganglion, brainstem nuclei and cerebral cortex), electrical responses (auditory evoked potentials) arise. However, it was not possible to register them due to the very small amplitude of the response wave, which was less than the amplitude of the constant electrical activity of the brain (a-, y-waves). It was only with the introduction of electronic computing technology into medical practice that it became possible to accumulate in the memory of the machine individual, insignificant responses to a series of sound stimuli, and then sum them up - the summation potential

Rice. 26. Hearing study using objective computer audiometry for auditory evoked potentials

A similar principle is used when conducting objective computer audiometry. Multiple sound stimuli in the form of clicks are fed into the ear, the machine remembers and summarizes the answers (if, of course, the child hears), and then presents the overall result in the form of a curve.

Objective computer audiometry allows you to study hearing at any age of the child, even in the fetus, starting from its 20th week.

In order to get an idea of ​​the location of the lesion of the sound analyzer, on which hearing loss depends (topical diagnosis), the following methods are used.

Electrocochleography is used to measure the electrical activity of the cochlea and the coiled knot. To do this, the electrode, with the help of which electrical responses are diverted, is installed in the region of the wall of the external auditory canal or on the tympanic membrane. This procedure is quite simple and safe, but the discharged potentials are very weak, since the cochlea is quite far from the electrode. Therefore, in necessary cases, the eardrum is pierced with an electrode and it is placed directly on the inner wall of the tympanic cavity near the cochlea, i.e., at the site of potential generation. In this case, it is much easier to measure them, however, such transtympanic ECOG has not received wide distribution in pediatric practice. The presence of spontaneous perforation of the tympanic membrane greatly facilitates the situation. ECOG is a fairly accurate method and gives an idea of ​​hearing thresholds, helps in the differential diagnosis of conductive and sensorineural hearing loss. Up to 7-8 years it is carried out under anesthesia, at an older age - under local anesthesia. ECOG makes it possible to get an idea of ​​the state of the hair apparatus of the cochlea and the spiral knot.

The definition of short-, medium- and long-latency auditory evoked potentials is carried out to study the state of the deeper parts of the sound analyzer. The thing is that the response to sound stimulation from each department occurs somewhat later in time, that is, it has its own latent period, more or less long. Naturally, the reaction from the cerebral cortex occurs last, and thus long-latency potentials are precisely their characteristic. These potentials are reproduced in response to sound signals of sufficient duration and differ even in tone. The latent period of short-latency stem potentials lasts from 1.5 to 50 mg/s, cortical - from 50 to 300 mg/s. The sound source is sound clicks or short tonal bursts that do not have a tonal color, which are fed through headphones, a bone vibrator. Active electrodes are placed on the mastoid process, attached to the earlobe, or fixed at some point on the skull. The study is carried out in a sound-dampened and electrically shielded chamber in children under 3 years of age in the state of their medical sleep after the administration of Relanium (Seduxen) or a 2% solution of chloral hydrate rectally at a dose corresponding to the child's body weight. The study lasts an average of 30-60 minutes in the supine position.

As a result of the study, a curve is recorded with up to 7 positive and negative peaks. It is believed that each of them reflects the state of a certain department of the sound analyzer: I - auditory nerve; II-III - cochlear nuclei, trapezoidal body, upper olives; IV-V - lateral loops and superior tubercles of the quadrigemina; VI-VII - internal geniculate body (Fig. 27). There is a large variability in the responses of short-latency auditory evoked potentials (SEPs) not only in the study of hearing in adults, but also in each age group. The same applies to long-latency auditory evoked potentials (LEPs). In this case, many factors should be taken into account in order to get an accurate picture of the state of the child's auditory function and the localization of the lesion site.

Rice. 27. Hearing study using back acoustic emission

Literally recently, a new method has been introduced into the practice of hearing research in pediatrics - registration of delayed evoked acoustic emission from the cochlea (Fig. 27). These are extremely weak sound vibrations generated by the cochlea, which can be recorded in the external auditory canal using a highly sensitive and low-noise microphone. In essence, it is like an echo of the sound delivered to the ear. Acoustic emission reflects the functional ability of the outer hair cells of the organ of Corti. The method is very simple, it can be used for mass hearing examinations already starting from 3-4 days of a child's life. The study takes several minutes, and the sensitivity is quite high.

Thus, electrophysiological methods for determining auditory function remain the most important, and sometimes the only option for such a study of hearing in children of the neonatal period, infancy and early childhood, and are now becoming more widespread in medical institutions.

In case of hearing impairment, a comprehensive audiological examination is indicated for the diagnosis and appointment of adequate and effective treatment.

Distinguish between subjective and objective methods hearing research. Studies of hearing acuity, based on the responses of the subject, are classified as subjective. The results in these cases depend on many subjective factors - the psycho-emotional state of the patient, his education, age, mood, etc.

How is hearing tested?

As a rule, the examination begins with a study of hearing in whispered and colloquial speech. This study is the most adequate method for assessing hearing and is expressed in the distance in meters from which the subject hears a whisper, conversational speech or a cry. A person with normal hearing hears whispered speech from a distance of at least 6 m, and conversational speech from a distance of at least 20 m. In case of pathology of the sound-conducting apparatus, the intelligibility of low-frequency sounds is primarily impaired, with sensorineural hearing loss, the perception of the high-frequency spectrum suffers, which leads to a decrease in the intelligibility of words, their containing.

Then they proceed to a tuning fork study of hearing, which allows you to determine the degree of perception of low, medium and high frequencies by each ear according to air and bone conduction, as well as to establish the predominant lesion of the sound-conducting and sound-perceiving apparatus. With the help of tuning forks, it is possible to determine the perception of sounds both in air and in bone. The quantitative assessment of the results of the study is reduced to determining the time during which the subject hears the sound through the air or through the bone. The results of speech and tuning fork studies are recorded in the auditory passport. At the end of the auditory passport, a conclusion is made, in which it is noted what type of hearing impairment the patient has.

Audiometry

To determine the threshold of hearing and assess the degree of impaired auditory function, a hearing test is performed using an audiometer - audiometry. There are tonal, speech and noise audiometry.

Pure tone audiometry

Pure tone audiometry can be threshold and suprathreshold.

With tone threshold audiometry, the study of the hearing of each ear is carried out separately for air and bone conduction by means of air and bone telephones, delivering the sounds of the audiometer through the external auditory meatus or through the bone, respectively. Air examination is carried out at frequencies from 125 to 8000 Hz, bone thresholds are examined at frequencies of 250-6000 Hz. Normally, the thresholds of air and bone sound conduction coincide, the bone-air interval should not exceed 10 dB. The results of the study are recorded on a special form - an audiogram, which is a graphic representation of a person's ability to hear sounds of different frequencies.

Performing pure-tone threshold audiometry is not difficult if there is the same hearing in both ears of the subject. With asymmetric hearing loss and with unilateral hearing loss, the phenomenon of overhearing occurs, which requires the use of masking of the better hearing ear.

Tonal threshold audiometry allows you to determine the localization of pathology in the departments of the sound analyzer only in the most general form, without more specific detail. Refinement of the extended range of frequencies, speech and noise audiometry and hearing studies with ultrasound and low-frequency tones.

An analysis of the extended frequency range (up to 20,000 Hz) makes it possible to detect early hearing changes that are not recorded by other methods (damage to the sound-perceiving section of the sound analyzer).

suprathreshold tone audiometry. With some pathological changes in the receptor of the diseased ear, along with a decrease in hearing acuity, an increase in sensitivity to loud sounds develops. This phenomenon is called the loudness acceleration phenomenon (FUNG). This phenomenon appears when the peripheral part of the sound-perceiving apparatus is damaged. At the same time, the amplification of the supplied sound above the threshold is felt by the patient as loudly as with normal hearing, i.e. the increase in volume is accelerated. With bilateral lesions, the SiSi test is most often used to detect this phenomenon, the determination of the discomfort threshold and the Luscher test, (differential threshold for the perception of sound intensity), with unilateral hearing loss, the Fowler loudness equalization test is used.

Given that suprathreshold audiometry is also a subjective technique, two or more suprathreshold tests are required to detect FUNG.

Speech audiometry

Speech audiometry is a subjective method for studying hearing. Unlike tone audiometry, speech stimuli are used in speech. Speech audiometry allows you to identify the social suitability of hearing in a given subject. Speech audiometry records the threshold of hearing sensation, which is usually achieved at an intensity of 5–10 dB above the hearing threshold of a tone of 1000 Hz. Speech intelligibility curves are different for various forms of hearing loss, which is of differential diagnostic value and helps to determine at what level hearing loss occurs.

Noise audiometry

Noise audiometry carried out in order to determine the nature and intensity of subjective tinnitus. The patient is given an experimental tone, which is compared to the subjective noise of the patient. A graphical representation of the established subjective noise overlap thresholds in the form of wavy lines is called an overlap noise profile.

All of the above research methods are subjective. However, in some cases there is a need to obtain information about the state of the auditory function of a person without using his subjective testimony. In such cases, objective methods of hearing assessment are used. These methods are based on the registration of unconditioned reflexes to sound, vascular reactions, and changes in the biopotentials of nerve structures during stimulation with sound signals. They are used in the examination of patients with lesions of the central parts of the auditory analyzer, in the conduct of labor and forensic medical examination, in the study of hearing in children. These include electrocochleography, registration of otoacoustic emissions, which are carried out in specialized medical institutions and require the use of special equipment.

Why is a hearing test needed?
The need for a hearing test arises quite often, since modern civilization creates many situations and circumstances that threaten the proper functioning of the hearing organs or that are traumatic and disrupt hearing. Early noticed hearing impairment, caused, for example, by the noise of machines at work, can save an employee from deep deafness, warn of the need to change jobs. Hearing should be checked regularly for those who suffer from acute and chronic ear diseases, as well as those who take medications that can damage the structure of the inner ear.

How to test hearing?
Audiologists can test hearing in several ways. The easiest is to check with a whisper and loud speech. This does not require any equipment, a room with a length of about 7 m is sufficient.
The patient stands at a distance of 6 m from the examiner, turns to him with one ear, covers the other with his finger. Hearing is normal, if the patient hears and repeats all the words that sound in a whisper at a distance of 6 m, it is best to pronounce the numbers: 99, 88, 76, 54, 47, 32, 29, 11, 7.
If the patient does not hear, the examiner reduces the distance until the patient repeats the numbers that have been spoken. If the patient does not hear a whisper even at close range, colloquial speech is used for further verification. For such a test, the untested ear is isolated using a special ratchet.

What is the Medonsky test?
There is an easy way to determine the nature of hearing loss. This is the so-called Medonsky test, which allows you to determine whether the sound transmission apparatus (elements of the outer and middle ear) or the receiving apparatus (sensory-nerve, inner ear) is damaged. The inspector pronounces the words above the patient's head so loudly that he hears and repeats them. After a few words, the tester presses with his index fingers on both ear tragus of the patient, closing the auditory canals, while not interrupting speech. A patient with damage to the middle ear still hears and repeats sounding words, while with damage to the outer ear he does not hear at all or hears only some words.

What other methods of hearing research exist?
Other methods of hearing research are more complex and require not only certain skills, but also appropriate equipment. The main method of hearing research, carried out in otolaryngological and audiological rooms, is an audiometric study, the result of which is presented in the form of a graph on an audiogram. Audiometric curves indicate hearing impairments for each of the transmitted tones, which is expressed in decibels. Audiometric research allows to give a quantitative and qualitative assessment of hearing impairment, it also makes it possible to determine the state of the hearing organ.

Hearing examination in a polyclinic. Selection of a hearing aid

How to check the hearing of a child or even an infant? If you are asking this question, and also do not know where you can check your child's hearing, contact the nearest clinic. All children with risk factors for hearing loss and deafness, as well as those who are often ill, should be taken under the special supervision of a pediatrician and an otorhinolaryngologist of the district clinic. It is necessary to use simple methods that do not require sophisticated equipment to test hearing in children.

1. Behavioral screening

It is known that one of the most important conditions for the timely detection of hearing impairment in a child (infant) is preventive screening examinations. For this purpose, methods based on the registration of behavioral unconditional indicative (0-1.5-2 years) and conditioned reflex (2-3 years) reactions to sound, as well as a hearing examination by speech (from 2-3- x years). Such techniques do not require complex hardware and take no more than 5 minutes.

Practice shows that when registering unconditioned reflex reactions, the most informative and easily recorded in children of the first year of life are:

• blinking of the baby's eyelids;
• whole body startle reaction (Moro reaction);
• fading or "freezing" of the child;
• movement of limbs, breeding of arms and legs to the sides;
• turning the head towards or away from the sound source;
• grimace (frowning eyebrows, closing eyes);
• sucking movements;
• awakening of a sleeping child, combined with slight trembling of the whole body;
• change in the rhythm of breathing;
• wide eye opening.

During the examination, it should be remembered that the latent period of the child's reaction to sound can reach 3-5 seconds. Repeated signals should be given after the extinction of the previous reaction.

It is advisable to check the child's hearing when he feels comfortable. He is full, dry, healthy, he has established emotional contact with the person who checks his hearing. It is better to examine the hearing of children in the first three months of life in the stage of light sleep (1 hour before feeding or 1 hour after feeding).

In order to facilitate the “process” of responding to sound during a hearing test for an infant older than 3 months and to better see the manifestations of this reaction, each time, if the baby turns in search of a sound source, it is necessary to lay his head back on the back of his head. If, when presenting sound signals to the right and left, the child constantly turns his head in the same direction, regardless of the location of the sound source, this may indicate a unilateral hearing loss. Such a child should be sent for an audiological examination to a deaf and speech therapy room (center).

2. Hearing examination using a sound test

Tones with a frequency of 0.5, 2.0, and 4.0 kHz and broadband noise with an intensity of 40, 65, and 90 dB are used as sound stimuli in the sound test.

The choice of sound stimulus depends on the age of the baby:

• 0-4 months - broadband noise with an intensity of 90 dB,
• 4-6 months - broadband noise intensity 65 dB,
• 6-12 months - broadband noise with an intensity of 40 dB,
• 1-2 years - tone 4.0 kHz, and then 0.5 kHz with an intensity of 40 dB.

It is known that most children often respond to sound with the right ear (“right-handers”), so the examination should begin with the right ear. If there is a reaction, the sound is presented again. If the child responded to the repeated sound, the second ear is checked. In the absence of a reaction to 2-3 presentations of sound, its intensity increases.

Children over 2 years of age should be examined by whispering. If a child does not speak by the age of two, then the very fact of the absence of speech is a sufficient reason for examining his hearing in a specialized institution. His hearing can be checked with the help of a sound test based on the registration of a conditioned motor reaction to sound. The child is taught at the moment of sounding a tone of 0.5 kHz with an intensity of 65 dB to perform some game action: put a ring on the pyramid rod, throw a button into a jar, put a cube into the car. To do this, the inspector first performs the action with the child's hand, and then invites him to act independently. If the child responds to this sound, then the intensity level is reduced to 40 dB. It is then checked whether it senses a 4.0 kHz tone at a given intensity. If it is not possible to develop a conditioned motor reaction (with a low level of psychomotor development), then the child is examined on the basis of an unconditioned orienting reaction, as described above.

3. When should a child's hearing be tested and where? How to buy a hearing aid?

You should send your child for a hearing examination to the audiologist's office in the following cases:

• up to 4 months if it does not respond to broadband noise with an intensity of 90 dB (or there is a fuzzy reaction: that is, that is not);
• 4-6 months if he does not respond to broadband noise with an intensity of 65 dB (or there is a fuzzy reaction) and / or cannot locate the source of the sound, tk. the latter indicates the possibility of unilateral hearing loss;
• 6-12 months if he does not respond to broadband noise with an intensity of 40 dB (or a fuzzy reaction is noted) and / or cannot locate the source of the sound;
• older than a year, if he does not respond to audiometer tones of 4.0 and 0.5 kHz with an intensity of 40 dB (or a fuzzy reaction is noted) and / or cannot localize the sound source;

In the absence of a sound test or if it is impossible to conduct an examination with the involvement of a second person, it is possible to check the hearing of infants, as well as small, not yet speaking children, using the “pea test” method.

4. Hearing study using the method of "pea samples"

This method was proposed by the Institute of Early Intervention in St. Petersburg. It does not require any equipment and is available to ENT doctors, pediatricians, neuropathologists, nurses in the office of a healthy child.

For the examination, four plastic jars are needed, for example, from under the Kinder Surprise, photographic film or UPSA medicine packaging. Three jars are one-third full:

• the first - unshelled peas, the shaking of which creates a sound with an intensity of 70-80 dB;
• the second - with buckwheat, the shaking of which creates a sound with an intensity of 50-60 dB;
• the third - decoy, the concussion of which creates a sound with an intensity of 30-40 dB.
• the fourth jar remains empty. Jars should be replaced every three months.

It is desirable that the examination be carried out by two people (a doctor and a nurse): one gives signals, and the other observes the reactions of the child.

The baby is located on the changing table or sits in the arms of the mother, the doctor enters into emotional contact with him (the same as during the examination with a sound-reactotest). At his signal, the nurse standing behind the baby shakes the jars at a distance of 20-30 cm from the right and left ear. At the same time, she has a jar of cereal in one hand, and an empty jar in the other. Hand movements should be synchronous and symmetrical. When checking the second ear, the jars are swapped. The doctor observes the unconditional orienting reactions of the child when a sound signal is given: fading, activation of movements, blinking, searching for a sound source, etc.

Unconditional orienting reactions quickly fade away upon repeated presentations (that is, the child stops responding to sounds accessible to his hearing), so the examination should begin with quieter sounds: the first is a jar filled with semolina, then buckwheat and only then peas. If the child clearly reacts to the sound of a jar of semolina and can localize the sound, i.e. determine its direction (with normal hearing, this becomes possible from 4-5 months), then other sounds can be omitted.

In the event that the examination is carried out by one person, then he is located in front of the child in order to see changes in his reactions in response to sound stimuli. In this case, special attention should be paid to the symmetry and synchronism of the movements of both hands.

With normal hearing, a child older than 4 months has unconditionally orienting reactions to the sound of all three jars: with semolina, buckwheat and peas; it determines the direction of the sound, i.e. turns his head (or eyes) towards the jar with one or another filler. Up to 4 months, the baby reacts to the sound of jars of buckwheat and peas, but does not localize their sound; the baby usually does not react to the sound of a jar of semolina.

The child should be sent for a hearing examination to the deaf and speech therapy room:

• up to 4 months, if he does not respond to the sound of jars of buckwheat and peas (or there is a fuzzy reaction: that is, that is not),
• older than 4 months, if he does not respond to the sound of at least one jar, for example, with semolina, or cannot locate the source of the sound, because the latter indicates the possibility of unilateral hearing loss.

5. Hearing examination by speech

The hearing of children who already have some degree of speech should be checked by presenting them with well-known words in a whisper from a distance of 6 m.

The greatest difficulties arise when examining a child of the second or third years of life. If the baby already speaks, then, having established contact with him, you can check his hearing in the course of performing simple game exercises. It is necessary to find out from the mother what words and phrases the baby understands, how he calls objects, actions. You can place toys in front of your child: a doll, a bunny, a bear, a dog, and whisper phrases like: Show the bear; Where is the dog?; Show the doll's handles (mouth, eyes); Show the dog's tail. First, phrases are pronounced near the child, and then from a distance of 6 m (or 3 m if the child is standing with his back). If, when pronouncing tasks in a whisper (or naming toys, objects), the baby does not fulfill them, then instructions (words) are pronounced in a voice of conversational volume at a short distance from him. If successful, a similar phrase is pronounced in a whisper again from a distance of 6 m.

The hearing of children over 3 years old is tested with low- and high-frequency words that are well known to them. Two lists are composed of these words, each contains 5 low-frequency and 5 high-frequency words, for example:

• bunny, house, Vova, bump, fish, watch, bird, ear, tea, wolf;
• soap, smoke, cup, window, cabbage soup, Sasha, city, seagull, sea, match.

When examining the hearing of children, the words of each list are presented in a random sequence.

The child is placed sideways to the inspector. A cotton swab is inserted into the opposite ear, the surface of which is slightly moistened with some kind of oil, for example, vaseline.

The tester asks the child to repeat the words that he will pronounce in a whisper. The first two words are pronounced near him, and then from a distance of 6 m (or 3 m if the child is standing with his back). The child may be stubborn, shy and not repeat the words. In this case, you should offer him to show the appropriate pictures that are placed on the table in front of him. If the child does not recognize a word uttered in a whisper, it is repeated in a voice of conversational volume, and then in a whisper. After the presentation of the following words, the word that caused the difficulty is repeated again. Similarly, the other ear is tested with the second list of words.

If, due to a low level of general and / or speech development, it is not possible to examine the child's hearing with speech, he should be sent to a hearing center for the study of auditory function by objective methods.

If a child of preschool or school age (when examining both the right and left ear) adequately responds to the sound of low- and high-frequency words spoken in a whisper from a distance of at least 6 m, this is an indicator that his hearing is within the physiological norm.

If the child responds to whispers at a shorter distance or does not respond to it, you can suspect that he has a hearing loss. Such a child should be sent for examination to a deaf and speech therapy room (center).

Hearing examination in educational institutions and rehabilitation centers

It is well known that even a slight hearing loss can be one of the causes of deviations in the development of a child. This hearing loss plays a decisive role in the subsequent overall development of the child. That is why it is advisable to examine the hearing of all children, especially those who have risk factors for hearing loss and deafness, as well as those who lag behind in development.

Children's hearing should be tested:

• when a child enters an educational institution (both mass and special, correctional), a rehabilitation center,
• after a child has had a long or serious illness, flu, otitis media (after two weeks), mumps, measles, after treatment with antibiotics with ototoxic action,
• if the child has a delay in speech development,
• when sending a child for an examination (for example, to a psychological, medical and pedagogical commission (PMPC) in connection with a suspicion of developmental disabilities.

The methods described above do not require hardware. They are available to PMPK employees, teachers, psychologists, nurses, and parents. Despite their simplicity, they can identify children with suspected hearing loss. The choice of one or another examination technique depends on the age of the child and on whether he speaks.

Unfortunately, it is not possible to test hearing online, for a number of reasons that prevent the development of methods for testing hearing using the Internet or telephony. You can only test your ear for music online.

For a hearing test in children, you can contact the Children's Audiological Center.