Hearing assessment methods. Methods for examining the organ of hearing and the auditory tube

A timely identified disease is much easier to treat than advanced forms. The same applies to auditory function. If you have the slightest suspicion of hearing loss, you should definitely consult a doctor. With the help of modern diagnostic tests, it is possible to detect pathology in time and begin its treatment.

Diagnosis of hearing acuity

A hearing test should begin with a consultation with an audiologist. The specialist performs an otoscopy - this procedure consists of examining the organ of hearing. During this simple procedure, the doctor can identify mechanical damage and other ear abnormalities.

Of no small importance for the audiologist are the patient’s complaints about the symptoms of various pathologies - unintelligibility of speech during a conversation or the appearance of. After performing an otoscopy, the specialist selects a method for diagnosing hearing acuity based on the clinical picture.

Hearing acuity is understood as a constant value. Therefore, accurate measurements are used to assess this indicator. Today there are quite a lot of informative diagnostic methods, so only a doctor should select them.

Indications

Diagnostic studies are required in the following situations:

• or, which are characterized by hearing loss;
• that are associated with damage to the cerebral cortex;
• or heads that provoked;
• presence of suspicion of professional;
• varying degrees of severity;
• necessity ;
• development ;
• unknown origin;
• adenoids;

Methods

There are quite a few different diagnostic procedures that allow you to obtain objective results and determine the severity of hearing loss and the causes of its development.

Audiometry

This is an effective procedure that allows you to determine hearing acuity and identify various disorders. The study is performed using an audiometer - an electroacoustic device that converts alternating electrical voltages into sounds.

Audibility is measured in decibels. Thanks to this study, the doctor has the opportunity to compare the data obtained with normal values.

It is carried out to solve the following problems:

• assessment of hearing acuity;
• determination of sensitivity to sounds of different frequencies;
• air and bone conduction sound analysis
• assessment of speech recognition quality;
• choice .

This procedure has no contraindications and does not cause pain. During this procedure, the patient wears headphones through which signals are sent. If a person hears a sound, he needs to press a button. As a result, the doctor receives a test that allows you to determine the presence or absence of pathology.

How is audiometry performed?

Tympanometry

This procedure is an objective diagnosis of diseases of the auditory organs. To carry it out, a special medical device is used - a tympanometer, which supplies sound pressure to the ears.

After which the device records the resistance that the wave encounters while moving through the auditory canals. The result of such research is a graph.

Thanks to this, it is possible to establish:

• middle ear pressure level;
• eardrum mobility;
• the presence of abnormal discharge in the external auditory canal;
• integrity and mobility of the auditory ossicles;
• condition of the inner ear and pathways.

This procedure does not cause discomfort and has no restrictions. Therefore, it is performed on everyone if there are appropriate indications.

Impedancemetry

This term refers to a whole range of diagnostic studies that make it possible to assess the condition of the auditory tube, as well as the middle ear. This method falls into the category of objective procedures because it does not require patient participation. The procedure does not depend on the conditioned reactions of a person, therefore it can be performed even on young children.

During the test, sound or pressurized air is introduced into the ear canal. This is done through a special rubber plug. Thanks to this, it is possible to check the mobility of the membrane and evaluate the unconditioned acoustic reflex.

Allows you to determine a person’s physiological ability to hear, which does not depend on his perception and consciousness. This method is often used to perform differential diagnosis of various pathologies of the hearing organ. It also helps to monitor the effectiveness of the therapy.

Testing with tuning forks

The undoubted advantage of this technique is the comparative simplicity of the device used, a slight change in acoustic characteristics, portability and excellent sound purity. The tuning fork makes it possible to evaluate air and bone conduction.

During an air conduction test, the patient must close his eyes and then answer whether he can hear sound. If the answer is yes, he must determine which ear.

When assessing the bone conduction threshold, a specialist places the stem of a tuning fork on the mastoid process in the area where the auricle attaches or to the midline of the skull. Then you need to establish the duration of the patient’s perception of sound.

Testing with tuning forks according to the method of Rinne and Weber

Additional studies or tests

The simplest and most accessible method is considered to be hearing testing using live speech. To do this, you need to close one ear with your finger, and then ask the patient to repeat the words that the doctor speaks in a whisper or in a voice of medium volume.

Typically, hearing acuity is assessed by the distance at which whispered speech is heard. Healthy people can hear it from 15-20 m. It is important to consider that the distance largely depends on the composition of the words. Thus, words with low-frequency sounds are perceived from a distance of 5 m. If words have a treble characteristic, they can be recognized from 20-25 m.

Also, to assess hearing acuity, the doctor may prescribe the following tests:

1. Electrocochleography is used to measure the electrical potentials of the auditory nerve and inner ear. Thanks to this, it is possible to detect pathologies that accompany vestibular hydrops.
2. Otoacoustic emissions - involves the recording of sounds that come from the inner ear. Based on their vibration data, it is possible to assess the functions of the outer hair cells. Thanks to such research, it is possible to identify hearing impairment in young children.
3. The method of acoustic brainstem evoked potentials is based on the study of bioelectric reactions of subcortical structures. Thanks to this, it is possible to determine the degree of perception of sounds by the subcortex of the brain.

Watch the video on how audiometry is performed:

Prevention of hearing loss

To prevent hearing loss, you need to prevent the following diseases:

• Do not listen to loud music on headphones;
• children need to be vaccinated against measles, rubella and mumps in a timely manner;
• It is recommended to avoid loud noise;
• You can use headphones and earplugs to protect your ears from loud sounds;
• You should not turn on several devices at the same time.

To cope with this, you need to carry out a comprehensive diagnosis in a timely manner. Thanks to this, the specialist will be able to establish the causes and severity of the disease and select adequate therapy.

Modern audiology has many methods for studying auditory function. Among them, there are four main groups of methods.
In practice, the most common psychoacoustic methods of audiometry are based on recording the subjective auditory sensation of the subjects. But in some cases, psychoacoustic methods do not have an effect. This applies, for example, to the assessment of the auditory function of newborns and young children, the mentally retarded, patients with mental disorders, the determination of feigned deafness and hearing loss, the examination of hearing disabilities, and professional selection.
In such cases, there is often a need to use objective methods of hearing research, which are based on recording the bioelectrical responses of the auditory system to acoustic signals, in particular the acoustic reflex of the intraaural muscles and auditory evoked potentials.

Psychoacoustic methods of audiometry form the basis of modern audiometry. They involve the study of hearing using live speech, tuning forks and special electroacoustic devices - audiometers. Examination of hearing using speech and tuning forks is called acumetry, and examination using audiometers - audiometry.

Hearing test using live speech . To study hearing, whispered and spoken speech is used, and in severe forms of hearing loss and deafness, loud speech and screaming are used. When examining hearing, the unexamined ear is covered with a finger moistened with water, turunda with Vaseline, or the noise from friction is muffled with waxed paper or a Barany rattle.
To standardize the research conditions and reduce the percentage of variable data, it is recommended to conduct a hearing test in a whispered speech after a quiet exhalation - with reserve air. In this case, the voice strength does not exceed 35-40 dB, so the discrepancies in the results of hearing tests by different researchers are reduced.
The patient stands with the ear being examined facing the doctor. The study begins from a maximum distance (5-6 m), gradually approaching the place from which the subject can repeat all the words spoken to him. In the conditions of a JTOP cabinet, the length of which does not exceed 5-6 m, it is almost impossible to determine the exact distance of perception of whispered speech by a healthy person. Therefore, hearing is considered normal if the subject perceives whispered and spoken speech from a distance of more than 5 m in the absence of complaints of hearing loss.
If there is no perception of whispered speech or if it is reduced, they move on to the next stage - the study of the perception of ordinary (spoken) speech. To keep the voice strength approximately constant, it is recommended to adhere to the old rule during a hearing examination - pronounce words and numbers with reserve air after exhalation. In everyday practice, most specialists use a random set of numbers during a hearing examination using speech, for example: 35, 45, 86, etc.

Hearing testing using tuning forks . For medical needs, tuning forks are made that are tuned to the “C” tone in different octaves. Tuning forks are respectively designated by the Latin letter “C” (designation of the note “C” on the musical scale) indicating the name of the octave (superscript) and the frequency of vibrations per 1 s (lower index). Despite the fact that tuning forks have recently begun to be replaced by modern electroacoustic devices, they remain valuable tools for hearing research, especially in the absence of audiometers. Most experts consider the use of tuning forks C128 and C42048 sufficient for differential diagnosis, since one tuning fork is bass and the other is treble. Impaired perception of bass sounds is more typical for conductive hearing loss, while treble sounds are more typical for sensorineural hearing loss.
After “launching” the tuning fork, the length of perception of its sound is determined by air and bone-tissue conduction. When examining hearing acuity by air conduction, the tuning fork is placed at a distance of 1 cm from the auricle, without touching the skin and hair. The tuning fork is held so that its jaws are perpendicular to the auricle. Every 2-3 seconds, the tuning fork is moved away from the ear to a distance of 2-5 cm to prevent the development of adaptation to tone or hearing fatigue. When examining hearing using bone-tissue conduction, the stem of the tuning fork is pressed against the skin of the mastoid process.

Study of sound perception by air and bone tissue conduction is important for the differential diagnosis of dysfunction of the sound-conducting and sound-perceiving systems. For this purpose, many tuning fork tests have been proposed. Let us briefly dwell on the experiments that are the most common.
1. Weber's experience. Provides for determining the side of sound lateralization. The stem of a sounding tuning fork C|28 is applied to the middle of the crown of the head and the subject is asked where he hears the sound - in the ear or head. Normally and with symmetric hearing impairment, sound is felt
in the head (there is no lateralization). In case of unilateral violation
When performing the function of the sound-conducting apparatus, the sound is lateralized into one hundred
towards the affected ear, and in case of bilateral damage - towards the more affected ear. With unilateral dysfunction of the sound-receiving apparatus, the sound is lateralized towards the healthy ear, and with bilateral dysfunction - towards the ear that hears better.

2.Rinne's experience. The essence of the study is to determine and compare the duration of perception of the tuning fork Cp8 by air and bone-tissue conduction. A sounding tuning fork C.8 is placed on the mastoid process. After the patient stops hearing the sound, a tuning fork is brought to the auricle to determine whether the patient can hear the sound. Under normal conditions and when the function of sound perception is impaired, air conduction predominates over bone conduction. The result is assessed as positive (“Rinne+”). If the sound conduction function is impaired, bone conduction does not change, but air conduction is shortened. The experience is assessed as negative (“Rinne-”). Thus, experience allows us to differentiate damage to the sound-conducting and sound-receiving apparatus in each specific case.
3. Bing's Experience. A sounding tuning fork C|28 is placed on the skin of the mastoid process, while the researcher on the side of the ear being examined alternately opens and closes the external auditory canal with his finger. Normally and when the function of sound perception is impaired, when the ear canal is closed, the sound will be perceived as louder - the experience is positive (“Bing+”). If there is damage to the sound conduction function, closing the ear canal does not affect the volume of the sound - the experience is negative (“Bing- ").
4. Federici's experience. The results of the perception of the sound of a C128 tuning fork are compared, the stem of which is alternately placed either on the skin of the mastoid process or on the tragus. Normally, and if the sound-receiving apparatus is damaged, the sound of a tuning fork mounted on the tragus is perceived as louder, which can be regarded as a positive experience. This result is designated “K>S”, i.e. the perception from the tragus is louder than from the mastoid process. If the function of sound conduction is impaired (otosclerosis, rupture of the eardrum, absence of a chain of auditory ossicles, etc.), the tuning fork from the tragus is heard worse than from the mastoid process - the experience is negative.
5. Schwabach experience. The stem of the tuning fork C.28 is placed on the mastoid process and the time of perception of its sound is determined. A decrease in perception time is characteristic of sensorineural hearing loss.
6. The Jelle experience. The stem of the tuning fork C]28 is placed on the mastoid process, and the air in the external auditory canal is condensed and rarefied by pressing on the tragus and releasing it. This leads to vibrations of the base of the stapes and a change in the perception of sound. It becomes quieter as the air thickens and louder as the air becomes thinner. If the base of the stirrup is stationary, the sound does not change. This happens with otosclerosis.

The study of hearing with tuning forks is currently used for the approximate differential diagnosis of damage to the sound-conducting and sound-receiving apparatus.

Hearing test using an audiometer . Currently, the main method of determining hearing is audiometry, i.e., the study of hearing using an electroacoustic device called an audiometer. The audiometer consists of three main parts: 1) a generator of various acoustic signals (pure tones, noise, vibration), which can be perceived by the human ear; 2) ultrasonic signal regulator (attenuator); 3) a sound emitter that transforms electrical signals into acoustic ones by transmitting sound vibrations to the subject through air and bone telephones.
Using modern clinical audiometers, hearing is examined using tone threshold, tone suprathreshold and speech audiometry.
Tone threshold audiometry is designed to study the thresholds of auditory sensitivity to tones of fixed frequencies (125-10,000 Hz). Pure-tone suprathreshold audiometry allows you to assess the loudness function, i.e. the ability of the auditory system to perceive and recognize signals of suprathreshold strength - from quiet to maximum loud. Speech audiometry provides data on the thresholds and recognition capabilities of the speech signals being studied.

Pure-tone threshold audiometry . The first stage of audiometry is the measurement of hearing sensitivity - hearing thresholds. The tone perception threshold is the minimum intensity of the acoustic signal at which the first sensation of sound occurs. By changing the frequency and intensity of sound using special devices placed on the audiometer panel, the researcher determines the moment at which the subject will hear a barely perceptible signal. Sound transmission from the audiometer to the patient is carried out using air conduction headphones and a bone vibrator. When a sound appears, the subject signals this by pressing the remote button of the audiometer, and the signal light lights up. First, the thresholds for the perception of tones are determined by air conduction, and then by bone-tissue conduction. The results of the study of sound perception thresholds are plotted on an audiogram form, where frequencies in hertz are indicated on the abscissa axis, and intensity in decibels is indicated on the ordinate axis. In this case, the thresholds for the perception of tones by air conduction are indicated by dots and are connected by a solid line, and the thresholds of perception by bone-tissue conduction are indicated by crosses, which are connected by a dotted line. An indicator of normal hearing is the deviation of the thresholds for the perception of tones from the zero mark of the audiogram within the range of 10-15 dB at each frequency.
Indicators of the perception of sounds transmitted through the air are characterized by the state of the sound-conducting apparatus, and indicators of the perception of sounds transmitted through the bone are characterized by the state of the sound-perceiving system. If the sound-conducting apparatus is disrupted, the curves for the perception of tones by air and bone-tissue conduction do not coincide and are located at some distance from each other, forming a bone-air interval. The longer this interval, the more significant the damage to the sound-conducting system. In case of complete damage to the sound conduction system, the maximum value of the bone-air interval is 55-65 dB. A sample of pure-tone threshold audiometry for impaired sound conduction function is presented in Fig. 11, a (see insert). The presence of a bone-air interval always indicates a violation of sound conduction or a conductive type of hearing loss. If the hearing thresholds for air and bone-tissue conduction are increased to the same extent, and the curves are located nearby (i.e., there is no bone-air interval), then such an audiogram indicates a dysfunction of the sound-receiving apparatus (see inset, Fig. 11, b). In cases of an unequal increase in the thresholds for the perception of tones by air and bone-tissue conduction with the presence of a bone-air interval between them, a combined (mixed) dysfunction of the sound-conducting and sound-receiving systems is stated (see inset, Fig. 11, c). When assessing the hearing status of older people, the resulting bone-air sound conduction curve should be compared with the age-related hearing norm.

Rice. 12. Variants of speech test intelligibility curves: 1 - damage to the sound-conducting apparatus or retrocochlear sections of the vestibulocochlear organ; 2 - damage to the sound-receiving apparatus (spiral organ) with impaired loudness function; 3 - slow increase in speech intelligibility with so-called cortical hearing loss

Pure tone suprathreshold audiometry . Threshold audiometry determines the state of auditory sensitivity, but does not provide an idea of ​​a person’s ability to perceive various sounds of above-threshold intensity in real life, including speech sounds. There are cases when normal spoken speech is not perceived or perceived poorly due to hearing defects, and loud speech cannot be tolerated due to the unpleasant painful sensation of loud sounds (auditory discomfort). In 1937, the American scientist E.R. Fowler revealed that with pathological changes in the spiral organ, increased sensitivity of the ear to loud sounds develops. At the same time, the sensation of loudness increases faster when the sound is amplified compared to a healthy ear. Fowler called this phenomenon the loudness equalization phenomenon ( loudnessrecruitment). In Russian literature, this condition is described as a phenomenon of accelerated increase in volume. As a rule, this phenomenon is detected when the spiral organ is damaged. Violation of the function of sound perception outside the cochlear structures is not accompanied by such a phenomenon.

Currently, the most common methods in suprathreshold audiometry are: 1) identification of the alignment phenomenon using the differential threshold for the perception of sound intensity (DPTSP) as modified by E. Luscher; 2) determination of the sensitivity index to short-term increases in intensity (SISI test); 3) determination of the level of auditory discomfort.
The study of DPVSZ is based on determining the ability of the subject to distinguish between minimal changes in the strength of the testing tone. Measurements are carried out on clinical audiometers, which are equipped with special devices that make it possible to recreate the vibrational tone when its intensity changes from 0.2 to 6 dB. The test can be carried out at different frequencies of the tone scale of the audiometer, but in practice it is performed at frequencies of 500 and 2000 Hz with a test tone intensity of 20 or 40 dB above the perception threshold. DPHS in people with normal hearing at a signal intensity above the hearing threshold of 20 dB is 1.0-2.5 dB. In individuals with symptoms of the equalization phenomenon (positive recruitment), a change in sound volume is perceived at a lower tone intensity: the DPVS ranges from 0.2 to 0.8 dB, which indicates damage to the spiral organ of the inner ear and a violation of the loudness function. If the sound-conducting apparatus and auditory nerve are damaged, the value of the differential threshold does not change compared to the norm, and if the central parts of the sound analyzer are damaged, it increases to 6 dB.

One of the modifications of the definition of ARP is SISI-test (ShortIncrementSensitivityIndex- index of sensitivity to short-term increases in intensity). The test is performed as follows. An even tone with a frequency of 500 or 2000 Hz and an intensity of 20 dB above the perception threshold is applied to the subject’s ear. At certain intervals (3-5 s - depending on the type of audiometer), the sound is automatically amplified by 1 dB. A total of 20 increments are fed. Then the small intensity increment index (SII) is calculated, i.e. the percentage of audible increases in sound. Normally, in case of disorders of the sound-conducting apparatus and retrocochlear sections of the sound analyzer, the index is 0-20% of affirmative answers, i.e., the subjects practically do not differentiate the increase in sound. If the spiral organ is affected, the SISI test accounts for 70-100% of responses (i.e., patients distinguish 14-20 increases in sound).

The next suprathreshold audiometry test is determination of auditory discomfort thresholds. Thresholds are measured by the level of intensity of test tones at which the sound is perceived as unpleasantly loud. Normally, the thresholds of auditory discomfort for low- and high-frequency tones are 70-85 dB, for mid-frequency ones - 90-100 dB. If the sound-conducting apparatus and retrocochlear parts of the auditory analyzer are damaged, the sensation of auditory discomfort is not achieved. If hair cells are affected, discomfort thresholds increase (the dynamic range of hearing narrows).
A sharp narrowing of the dynamic range (up to 25-30 dB) impairs speech perception and is often an obstacle to hearing aids.
Speech audiometry. Pure-tone audiometry provides insight
about the quality of perception of pure tones, the study of speech intelligibility - about the function of the sound analyzer as a whole. Therefore, assessment of the state of auditory function should be based on the results of studies of both tonal and speech signals.
Speech audiometry is characterized by the social adequacy of hearing; its main purpose is to determine the percentage of speech intelligibility at different ultrasound signals of speech signals. The results of speech audiometry are of great importance for differential and topical diagnosis, choice of treatment tactics, assessment of the effectiveness of auditory rehabilitation, and solving a number of issues of professional selection and examination.
Research is carried out using an audiometer and a tape recorder connected to it. The tape recorder ensures the reproduction of words from a ferromagnetic tape, and the audiometer ensures their amplification to the required level and delivery to the ear of the subject through air and bone telephones. The results are assessed by the number of words recognized by the test subject in one group. Since the group contains 20 words, the value of each individual word is 5%. In practice, four indicators are measured: 1) the threshold of undifferentiated speech intelligibility; 2) threshold of 50% speech intelligibility; 3) threshold of 100% speech intelligibility; 4) percentage of speech intelligibility within the maximum intensity range of the audiometer. Normally, the threshold of undifferentiated speech intelligibility (sensation threshold - 0-level) is 7-10 dB, 50% intelligibility threshold is 20-30 dB, 100% intelligibility threshold is 30-50 dB. When speech signals of maximum strength are applied, i.e., at the limit of the capabilities of an audiometer (100-110 dB), speech intelligibility does not deteriorate and remains at a 100% level. The intelligibility curves of speech tables in Ukrainian in persons with normal hearing and in patients with impaired function of sound conduction (conductive hearing loss) and sound perception (sensoneural hearing loss) are shown in fig. 12.

In a pathological condition of the auditory system, speech audiometry indicators differ from the norm. If the sound-conducting apparatus or the retrocochlear sections of the auditory analyzer are damaged, then the curve of increase in speech intelligibility with amplification of ultrasound acoustic signals runs parallel to the normal curve, but lags behind it by the amount of the average loss of tonal hearing (dB) in the range of speech frequencies (500-4000 Hz). For example, if the hearing loss on pure-tone audiometry is 30 dB, then the speech intelligibility curve under study will be shifted to the right of the normal curve by 30 dB, while maintaining its exact configuration (Fig. 12, 1). If the sound-receiving apparatus is damaged and there are signs of the leveling phenomenon, i.e., the loudness function is impaired, 100% speech intelligibility does not occur, and after reaching its maximum, a further increase in signal intensity is accompanied by a deterioration in speech intelligibility, i.e., the well-known phenomenon of a paradoxical decrease in intelligibility is noted ( PPR), characteristic of auditory pathology with impaired loudness function. In such cases, the speech intelligibility curve resembles the shape of a hook (Fig. 12, 2). In elderly people with central nervous system disorders and damage to the cortical part of the auditory analyzer (cortical hearing loss), the increase in speech intelligibility slows down, the curve takes on a pathological appearance and, as a rule, even with the maximum SPL of speech signals (110-120 dB), 100% speech intelligibility is not achieved (Fig. 12, 5).

Objective audiometry. Psychoacoustic methods for studying the function of the sound analyzer in most cases make it possible to reliably determine the nature and degree of hearing impairment. But these methods are insufficient or completely ineffective for studying hearing in young children, persons with neuropsychic disorders, the mentally retarded, the emotionally unbalanced, those feigning deafness during forensic research, etc.
The state of auditory function in such cases can be determined by using methods of so-called objective audiometry. It is based on unconditioned reflexes (vegetative, motor and bioelectrical), which arise in the human body under the influence of various acoustic stimuli, regardless of the subjective responses of the subject, his will and desire.
Currently, among the many tools and methods for objective research of auditory function in clinical practice, acoustic impedance measurement and recording of auditory evoked potentials are most often used.
Acoustic impedance measurement is based on measuring the acoustic resistance (impedance) that the structures of the middle ear provide to the sound wave, transmitting it to the cochlea. The acoustic impedance (AI) of the middle ear has a number of components - the resistance of the external auditory canal, the eardrum, the chain of auditory ossicles, and the function of the intraauricular muscles.
Numerous studies have established that middle ear pathology significantly changes the value of AI compared to the norm. By the nature of AI changes, one can objectively characterize the state of the middle ear and the function of the intraauricular muscles. Thus, increased AI is observed in acute otitis media, cicatricial changes in the eardrum, fixation of the chain of auditory ossicles, the presence of secretions in the tympanic cavity, and impaired ventilation function of the auditory tube. The AI ​​value decreases when the chain of auditory ossicles is broken. In audiological practice, the results of AI are assessed according to the acoustic reflex tympanometry data.
Tympanometry (TM) is based on recording AI shifts during an artificially created air pressure difference in the hermetically sealed external auditory canal. In this case, pressure changes are ±100-200 mm water. Art. It is known that the air pressure in the external auditory canal of a healthy person is equal to the air pressure in the tympanic cavity. With unequal air pressure in the middle ear and external auditory canal, the acoustic resistance of the eardrum increases and AI increases accordingly. The dynamics of changes in AI with a difference in air pressure in the external auditory canal can be recorded graphically in the form of a tympanogram.
Normally, the tympanogram is shaped like an inverted letter “V”, the top of which corresponds to the atmospheric air pressure (pressure 0) in the external auditory canal. In Fig. 13 presents the main types of tympanograms characteristic of various conditions of the middle ear.
Tympanogram type A corresponds to normal middle ear function, the pressure in the external auditory canal is equal to atmospheric pressure.

Rice. 13. Variants of tympanometric curves and their designations(according to J. Jerger, 1970): 1- type A (norm); 2 - type B (tympanic membrane perforation, secretory otitis media); 3 - type C (dysfunction of the auditory tube); 4 - type Ad (break in the chain of auditory ossicles); 5 - type /4s (otosclerosis); 6 - type D (adhesive otitis media)
Type B indicates minor changes in AI due to changes in air pressure in the external auditory canal; observed with secretory otitis, in the presence of exudate in the tympanic cavity.
Type C is characterized by a violation of the ventilation function of the auditory tube with the presence of negative pressure in the middle ear cavity.
Type D is determined by bifurcation of the apex of the tympanogram into two peaks in an area close to zero pressure, which occurs with destructive changes in the eardrum (atrophy, scars).
Type Ad - the curve externally resembles a type A tympanogram, but has a very high amplitude, due to which the apex looks cut off; this type is determined when the chain of auditory ossicles is broken.
Type As - resembles a type A tympanogram, but with a very low amplitude, observed with ankylosis of the stapes (otosclerosis).

Acoustic reflex (AR) - one of the protective reflexes of a person, the physiological purpose of which is to protect the structures of the inner ear from damage by strong sounds. The arc of this reflex is formed due to the presence of associative connections between the auditory nuclei of the upper olivar complex and the motor nuclei of the facial nerve. The latter innervates not only the muscles of the face, but also the stirrup muscle, the contraction of which limits the movement of the ossicular chain, the tympanic membrane, sharply increasing the acoustic impedance of the middle ear. It should be noted that this reflex occurs both on the side of stimulation (ipsilateral) and on the opposite (contralateral) side due to the presence of a decussation of the conduction pathways of the auditory analyzer.
The main diagnostic criteria for AR are the value of its threshold, the nature of suprathreshold changes under different conditions of suprathreshold stimulation, and the latent period.

To study AR, special equipment is used - impedance meters. Normally, the contraction of the intra-ear muscles occurs when the intensity of sound stimuli is 70-85 dB above the hearing threshold. A sample of the recording of AR depending on the sound pressure level (SPL) of the acoustic stimulus is shown in Fig. 1. 14. The condition for registration of AR are tympanograms of type A or As and hearing loss not exceeding 50 dB SPL.

Rice. 14. Recording of the acoustic reflex of a healthy person during acoustic stimulation of the ear with bandpass noise (100-4000 Hz) of varying duration and intensity: 1 - acoustic reflex curve; 2 - the sound pressure value of the acoustic stimulus in decibels; 3 - time indicator (in milliseconds); a - acoustic reflex threshold; b and c - change in the amplitude of the reflex and its duration with increasing sound pressure and duration of the acoustic stimulus

In a pathological condition of the middle ear, the protective mechanism of the AR is disrupted. In this case, AR changes compared to the norm. The data obtained are used in the practice of audiometry to improve the differential diagnosis of diseases of the hearing organ.
Registration of bioelectric reactions - auditory evoked potentials (AEPs) arising in response to sound stimuli is a common method of objective audiometry.

Isolation and summation of SEP against the background of spontaneous bioelectrical activity of the auditory system and biopotentials of other brain stem structures is carried out using special electroacoustic devices, the basis of which is a computer with high-speed analog-to-digital converters.
The use of computers to study auditory function using ERP recordings has received the name ERA (evoked response audiometry) abroad, i.e. evoked response audiometry, or computer audiometry. Different components of SVP have been identified. Based on the location of the corresponding electrode, in clinical audiology it is customary to distinguish between cochlear (electrocochleography) and cerebral (vertex potentials) SVPs.

Rice. 15. Schematic representation of auditory evoked potentials(noT.W. Picton et al., 1974): 1 - short-latency; 2-medium latency; 3 - long latency

In electrocochleography, the active electrode is placed on the medial wall of the tympanic cavity in the area of ​​the promontory (promontorium). When recording brain SEPs, the active electrode is fixed in the area of ​​the crown (vertex), and the grounded electrode is fixed on the skin of the mastoid process. Cochlear SEPs include microphone and summation potentials, the action potential of the auditory nerve; to the brain - the biopotentials of the cochlear nuclei, brainstem neurons, the activity of the auditory zone of the cerebral cortex.

Based on the time of their occurrence, SEPs are divided into three main groups: short-, medium- and long-latency. Short-latency SEPs are the earliest: they occur in the first 10 ms after the action of an acoustic stimulus and reflect the reaction of the hair cells of the spiral ganglion and the peripheral endings of the auditory nerve fibers. Within short-latency SEPs, a number of components (waves) are distinguished, designated by Roman numerals. The waves differ from each other in localization, amplitude of evoked potentials and latent period of their occurrence. In Fig. Figure 15 shows a schematic representation of ERP recordings from a healthy person. In the group of short-latency SEPs, waves I-II characterize the electrical activity of the cochlea and auditory nerve, waves III-IV - responses of neurons of the superior olivary complex, nuclei of the lateral lemniscus and inferior colliculi. The time of occurrence of medium-latency SEPs ranges from 8-10 to 50 ms after the onset of sound stimulation, long-latency ones - from 50 to 300 ms.

The components that make up medium- and long-latency SVPs are designated by the Latin letters P and N, respectively. The origin of medium-latency SVPs has not yet been determined. It is assumed that this group of biopotentials has not so much an intracranial (cerebral) origin as an extracranial one, caused by myogenic reactions (postural, temporal, cervical, etc.). Therefore, medium-latency SVPs were not widely used in clinical practice. Long-latency SEPs, from the point of view of most researchers, characterize the electrical activity of the auditory zone of the cerebral cortex.
Comparison of the quantitative values ​​of the latent period and the amplitude of the waves (peaks) of the SEP allows us to objectively determine the disease of the peripheral and central parts of the sound analyzer, in particular the sound conducting systems, the sound-receiving apparatus of the cochlea, the acoustic neuroma, pathological changes in the nuclei of the brain stem and auditory cortical structures.
Computer audiometry is a promising and very valuable method for the clinical diagnosis of hearing impairment, identifying malingering and aggravation of feigned deafness and hearing loss.

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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 decreased hearing, tinnitus, and less often - dizziness and headache, irritability, decreased speech intelligibility in a noisy environment, and a number of others. Some patients indicate the cause of hearing loss (chronic inflammation of the middle ear, an established diagnosis of otosclerosis, a history of skull trauma, activity in conditions of industrial noise (mechanical assembly and forge shops, aviation industry, work in an orchestra, etc.). Of the concomitant diseases, 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 state 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 previous use of ototoxic drugs.

When talking with a patient, you should evaluate the nature of his speech. For example, loud and clear speech indicates the presence of acquired bilateral sensorineural hearing loss in the years when the articulatory function of the speech-motor apparatus was fully formed. Slurred speech with articulatory 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 completely ensures auditory control of one’s own speech. You should pay attention to “behavioral” signs of hearing loss: the patient’s desire to approach the doctor with the better hearing ear, placing his palm to his ear in the form of a mouthpiece, an attentive gaze directed at 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 auriculotemporal areas, endoscopy of the ear, study of the barofunction of the auditory tube and some others. Endoscopy of the nose, pharynx and larynx is performed according to generally accepted methods.

At external inspection pay attention to the anatomical elements of the face and its appearance: symmetry of facial expressions, nasolabial folds, eyelids. The patient is asked to bare his teeth, wrinkle his forehead, and 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 area, the symmetry, size, configuration, color, elasticity, state of tactile and pain sensitivity of its anatomical formations are assessed.

Palpation and percussion. With their help, skin turgor, local and distant pain are determined. If there are complaints of pain in the ear, deep palpation and percussion are performed in the area of ​​the projection of the antrum, the area of ​​the mastoid process, the scales of the temporal bone, the area of ​​the temporomandibular joint and the retromandibular fossa in the area of ​​the parotid salivary gland. The temporomandibular joint is palpated when opening and closing the mouth to identify 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 upward and backward (in infants, posteriorly and downward) and at the same time moving the tragus anteriorly. The deep parts of the ear canal and the tympanic membrane are examined using an ear funnel and a frontal reflector, and the presence or absence of certain identifying signs and pathological changes (retraction, hyperemia, perforation, etc.) is noted.

Hearing function test

The science whose subject of study is auditory function is called audiology(from lat. audio- I hear), and the clinical area dealing with the treatment of hard of hearing people is called audiology(from lat. surditas- deafness).

The hearing test method is called audiometry. This method distinguishes between the concept acumetry(from Greek akouo- listening), which is understood as the study of hearing using live speech and tuning forks. For audiometry, electronic-acoustic devices (audiometers) are used. The assessment criteria are the responses of the subject (subjective reaction): “I hear - I don’t hear”, “I understand - I don’t understand”, “louder - quieter - equally loud”, “higher - lower” in the tonality of the sound test, etc.

The threshold value for auditory perception is a sound pressure equal to 2.10:10,000 microbars (μb), or 0.000204 dynes/cm2, at a sound frequency of 1000 Hz. A value 10 times greater is equal to 1 belu (B) or 10 dB, 100 times greater (×10 2) - 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 20th century For hearing research, tuning forks became widespread, the method of using which in otiatry was developed by F. Betzold.

Hearing test using live speech

Whispered, spoken, loud and very loud speech (“cry with a rattle”) is used as testing speech sounds (words) while the opposite ear is muffled with a Barany rattle (Fig. 1).

Rice. 1.

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

Hearing testing using tuning forks

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

Rice. 2.

When examining hearing with tuning forks, a number of rules must be followed. The tuning fork should be held by the stem without touching the jaws. The jaws should not touch the ear and hair. When studying bone conduction, the stem of the tuning fork is placed on the crown or forehead along the midline (when determining the phenomenon literalization sound a) or on the platform of the mastoid process (when determining playing time tuning fork). The stem of the tuning fork should not be pressed too tightly against the tissues of the head, since the pain that arises in the subject distracts him from the main task of the study; in addition, this contributes to the accelerated damping of vibrations of the tuning fork jaws. It should be borne in mind that sounds at 1000 Hz and higher are capable of bending around the head of the subject, therefore, with good hearing in the non-examined ear, the phenomenon may occur over-the-air interceptions. Overhearing can also occur during tissue conduction studies; it occurs if the ear being tested has perceptual hearing loss, and the opposite ear either hears normally or has a conductive type of hearing loss, such as cerumen or a scarring process.

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

1) identification of spontaneous irritation of the sound analyzer using the SS test ( subjective noise);

2) determination of the degree of hearing loss in relation to live speech using the ShR tests ( whispered speech) and RR ( Speaking). With a high degree of hearing loss, the presence of hearing is determined using the “cry with rattle” test;

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

4) identification of certain correlations between the perception of low and high tones during air and bone conduction of sound for the 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 for sound conduction disorders

	Tests
	Kr with ratchet	Muting
	C to 128 (N-40 c)
	Schwabach experience
	Weber's experience
	Rinne's experience
	Bing's Experience
	The Jelle experience
	Lewis-Federici experiment

Table 2. Hearing passport for impaired sound perception

	Tests
	Kr with ratchet	Muting
	C to 128 (N-40 c)
Shortened	Schwabach experience
	Weber's experience
	Rinne's experience
	The Jelle experience

Test SS reveals the presence of irritation of the peripheral nervous system of the organ of hearing or the state of excitation of the auditory centers. In the hearing certificate, the presence of tinnitus is marked with a “+” symbol.

Live speech research. This study is carried out in the absence of extraneous noise. The ear being examined 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 hearing passport in meters, a multiple of 0.5: 0; “u rak”, which means “hearing at the sink”; 0.5; 1; 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 jaw at a distance of 0.5-1 cm at intervals of once every 5 seconds. The entry in the passport is made with the same frequency, 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 passport norm tuning fork.

Criteria for evaluating tuning fork tests of a typical hearing passport

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

Also distinguished mixed type of hearing loss, in which there is a shortening of the perception time of the bass (C 128) and treble (C 2048) tuning forks with air sound transmission, and the bass tuning fork with fabric sound transmission.

Criteria for evaluating tuning fork tests

Schwabach experience (1885). Classic version: the stem of a sounding tuning fork is applied to the crown of the subject until he stops perceiving sound, after which the examiner immediately applies it to his crown (it is assumed that the examinee must have normal hearing); if the sound is not heard, this indicates 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 stem of the sounding tuning fork is applied along the midline to the forehead or crown of the head, the subject reports the presence or absence of lateralization of the sound. With normal hearing or with symmetrical hearing loss, the sound will be felt “in the middle” or “in the head” without clear lateralization. If sound conduction is impaired, the sound is lateralized to the worse hearing ear; if sound perception is impaired, it is lateralized to the better hearing ear.

Rinne experience(1885). Using C 128 or C 512, the sounding time of the tuning fork during air conduction is determined; then the sounding time of the same tuning fork during tissue conduction is determined. 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 they say that " Rinne's experience is positive”, and in the hearing passport this fact is noted in the corresponding cell with a “+” sign. In the case when the sounding time during tissue sound conduction is longer than the sounding time during air conduction, it is said that “ Rinne's experience is negative", And a sign is placed on the hearing 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 characteristic of 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, the healthy ear is muffled with a Barany 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. An olive, selected according to the size of the external opening of the auditory canal, is tightly inserted into the external auditory canal, and a sounding tuning fork is placed with the handle on the mastoid area. If the sound becomes quieter, they say " positive" Jelle's experience, if it does not change, then the experience is defined as " negative" The corresponding symbols are placed on the hearing passport. Jelle's negative experience is observed with dissociation of the auditory ossicles as a result of trauma, perforation of the eardrum and obliteration of the windows of the ear labyrinth. Instead of a tuning fork, you can use the bone telephone of an audiometer.

Pure-tone threshold audiometry

Tone threshold audiometry is a standard generally accepted method for studying auditory sensitivity to “pure” tones in the range of 125-8000 (10,000) Hz with air conduction of sound and in the range of 250-4000 Hz with 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 pure 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 tonal threshold audiograms: I - ascending when sound conduction is impaired; II - descending in violation of sound perception; III - mixed in violation of sound conduction and sound perception; RU - cochlear reserve, indicating the potential possibility of restoring hearing to the level of bone conduction, provided that the cause of hearing loss is eliminated

Suprathreshold audiometry

Suprathreshold 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, degrees 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 the 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, individual specially selected words containing low and high frequency formants are used as test sounds. The result is assessed by the number of correctly understood and repeated words as a percentage of the total number of words presented. In Fig. 5 shows examples of speech audiograms for various types of hearing loss.

Rice. 5. 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 subject's task is to determine the location of the sound source. The results are assessed by the percentage of correct answers. With sensorineural hearing loss, the accuracy of determining the localization of the sound source decreases 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 ability to localize 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. In Meniere's disease, there is a constant violation of ototopy in all planes.

Methods for objective hearing testing

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

Auditory reflexes

They are based on reflex connections between the hearing organ and the sensorimotor sphere.

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

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

Auropupillar reflex(G. Holmgren, 1876) consists of a reflex dilation and then constriction of the pupils under the influence of a sudden strong sound.

Freschels reflex(Froeschels). It consists in the fact that when a sharp sound occurs, an involuntary deviation of the gaze towards the source of the sound occurs.

Tsemakh reflex(Cemach). When a sudden loud sound occurs, the head and torso tilt (withdrawal reaction) in the direction opposite to the one from which the sharp, strong sound came.

Sound motor reflexes of the muscles of the tympanic cavity. These unconditioned reflexes, arising in response to suprathreshold sound stimulation, have become widespread in modern audiology and audiology.

Auditory evoked potentials

The method is based on the phenomenon of generation of bioelectrical signals in the neurons of the auditory zones of the cerebral cortex. evoked potentials, arising from the sounding of the receptor cells of the spiral organ of the cochlea, and the registration of these potentials using their summation and computer processing; hence another name for 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 averaged evoked auditory biopotentials

Methods for examining the auditory tube

Examination 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.

Scopic methods

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

At epipharyngoscopy(posterior rhinoscopy) evaluate the condition of the nasopharyngeal orifices of the auditory tubes (hyperemia, senechias, damage, etc.), the condition of the tubal tonsils and adenoid tissue, choanae, vomer, and a retrospective view of the nasal passages.

Pneumootoscopy

The technique is carried out using a Siegle funnel (1864), equipped with a rubber balloon for exposing the eardrum to an air stream (Fig. 7).

Rice. 7. Siegle funnel with pneumatic attachment

With normal ventilation function of the auditory tube, a pulsed increase in pressure in the external auditory canal causes vibrations of the eardrum. If the ventilation function of the auditory tube is impaired or during the adhesive process, there is no mobility of the membrane.

Salpingoscopy

Modern optical endoscopes are used to examine the nasopharyngeal opening of the auditory tube.

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

Blowing the auditory tube. This method is used for both diagnostic and therapeutic purposes. For it, a special rubber balloon is used, connected through 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 nasopharynx cavity is blocked by the soft palate, and the pharyngeal opening of the auditory tube opens. At this moment, the balloon is compressed, and air pressure increases in the nasal cavity and nasopharynx, which, during normal functioning of the auditory tube, enters the middle ear. Instead of taking a sip of water, you can pronounce sounds, the articulation of which causes the nasopharynx to be blocked by the soft palate, for example, “also-also,” “ku-ku,” “steamboat,” etc. When air enters the tympanic cavity, a peculiar noise can be heard in the external auditory canal. 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 examinee. 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 maneuver, 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 grade 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 swallow;
• II degree - a murmur is heard during the Toynbee test;
• III degree - a murmur is heard during the Valsalva maneuver;
• IV degree - noise is not heard during any of the listed tests. Complete obstruction is assessed by the absence of noise when performing the Politzer test with a sip of water. If it is impossible to determine the patency of the auditory tube using the above methods, resort to its catheterization.

Eustachian tube catheterization

To carry out catheterization of the auditory tube, the following tools are required (Fig. 8): Politzer balloon (7) for blowing out the auditory tube; Lutze otoscope (2) for listening to tinnitus 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. 8. Set of tools 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 comes into contact with the posterior wall of the nasopharynx, rotated 90° towards the opposite ear and pulled up until it comes into contact with the vomer. Then turn the catheter with its beak downwards 180° towards the examined auditory tube so that the beak faces the side wall of the nasopharynx. After this, the beak is turned upward 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 “grabbing” the end of the catheter. Next, insert the conical end of the balloon into the socket of the catheter and pump air into it with light movements. When the auditory tube is patent, a blowing noise is heard, and upon otoscopy after blowing, injection of the vessels of the tympanic membrane is detected.

Ear manometry is based on recording an increase in pressure in the external auditory canal, which occurs when the pressure in the nasopharynx increases and the auditory tube is patent.

Currently, research into the function of the auditory tube is carried out using phonobarometry And electrotubometry.

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

Impedance audiometry(English) impedance, from lat. impedio- I interfere, I resist). Under acoustic impedance understand the complex resistance experienced by sound waves passing through certain acoustic systems and causing these systems to undergo forced vibrations. In audiology, the study of acoustic impedanceometry is aimed at determining the qualitative and quantitative characteristics of the sound conducting system of the middle ear.

Modern impedance measurements include measuring the absolute value of the input impedance, i.e., the acoustic resistance of the sound-conducting system; registration of changes in 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 disorders of auditory function at the level of the first neuron. The main diagnostic criteria are: a) threshold value stimulus sound in dB; b) duration of the latent 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 stapedius muscle; V) nature of changes acoustic reflex depending on the magnitude of the suprathreshold sound stimulus. These criteria are identified when measuring the parameters of the acoustic impedance of a sound-conducting system.

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

As you know, a disease detected in time is much easier to cure than its advanced forms. This also applies to the pathology of human auditory function. If you suspect hearing loss in yourself or your child, we recommend that you contact us. Modern methods for diagnosing a decrease or increase in the hearing threshold will help to accurately identify the disease and prescribe its treatment.

In audiology, there are subjective and objective methods for diagnosing the auditory system.

Subjective methods include suprathreshold and threshold tests, which, in turn, are divided into pure-tone audiometry and speech. Audiometry determines hearing acuity and the sensitivity of the hearing system to sound waves of different frequencies. Hearing thresholds are determined using an audiometer.

The pure tone threshold audiometry method shows the minimum hearing threshold at different frequencies. The audiogram obtained as a result of pure-tone audiometry reflects how much the patient's hearing differs from the norm at certain frequencies. The expert instruments of the GUTA CLINIC audiology center make it possible to record hearing thresholds not only at standard frequency levels, but also in an extended range from 8 to 20 kHz. The speech audiometry method reveals the maximum parameters of speech intelligibility possible for the patient, as well as efficiency. The assessment of the latter is influenced by the percentage of speech intelligibility and the level of tonal hearing. During the examination, the patient is wearing a hearing aid.

Audiometric suprathreshold tests involve determining the level of damage to the auditory analyzer, treatment strategies and making a decision on the advisability of hearing aids or cochlear implantation.

Objective methods allow us to examine both adults and newborns. Since objective diagnosis does not depend on the behavioral factor and physical condition of the patient, it can also be used when assessing hearing in patients who are unable to contact an audiologist. In some cases, it is necessary to conduct hearing tests in a state of drug sedation (shallow sleep). Objective diagnostics is based on recording electrical signals of various elements of the hearing system in response to the influence of sound stimuli.

An objective method such as . The stapedial (acoustic or auditory) reflex is also associated with it - studies of dynamic indicators. Impedance measurement diagnoses the condition of the middle ear and the conduction pathways of the auditory analyzer.

The condition of the eardrum, mobility of the chain of auditory ossicles, pressure in the middle ear, and the functioning of the auditory tube are determined by tympanometry.

Using the stapedial reflex, the condition of the cochlea and audiometry readings are assessed.

The otoacoustic emission (OAE) method records sounds emanating from the inner ear using a high-sensitivity microphone. Based on the results of sound vibrations, the work of the outer hair cells is assessed. Otoacoustic emissions are the main method for diagnosing hearing loss in young children and are valued by doctors for their safety, painlessness and accuracy. The study can be carried out on the third or fourth day after birth.

Diagnostics of acoustic brainstem evoked potentials (ASEP) helps to assess the level of perception of sounds by the subcortex of the brain. The method is based on the analysis of bioelectrical responses from subcortical structures. The study is carried out using special equipment that records the response of parts of the patient’s central nervous system (CNS) to changes in the sound signal in headphones.

The objectivity of the method of auditory evoked potentials (AEP) is based on the fact that sound signals provoke electrical activity in different parts of the auditory analyzer (in the cochlea, auditory nerve, stem nuclei, cortical parts), which makes it possible to assess the degree of concentration, the functioning of the cerebellum and brain stem. Registration of SVP is carried out in a state of wakefulness and natural sleep of the patient. In some cases (more often in children with central nervous system pathology), medical sedation (superficial sleep) is used.

The diagnostic rooms of the audiological center "GUTA CLINIC" are equipped with modern high-tech equipment, which allows us to apply an integrated approach to the diagnosis of the auditory system. Using a combination of subjective and objective diagnostic methods is as effective as possible. This makes it possible to diagnose the disease as accurately as possible and choose the right tactics for its treatment. The result of a comprehensive diagnosis will be high-quality rehabilitation of the patient.

Hearing impairment is one of the main signs indicating pathological processes occurring in the ear. It is important to note the appearance of this symptom in time and consult an otolaryngologist, because many diseases require qualified and timely treatment, and delay in therapy can lead to hearing loss. What hearing testing methods are there? Is it possible to diagnose it yourself?

The general term “hearing loss” is classified by specialists into several groups.

According to the prognosis, hearing loss may be:

1. reversible, that is, temporary. Most often, such hearing impairments are caused by inflammatory processes in the ear or in the auditory tube;
2. irreversible. Such hearing impairments occur due to the death of receptors in the inner ear, irreparable damage to the auditory nerves, or pathologies of the cerebral cortex, which is responsible for receiving sound information.

Hearing loss can also be divided into 2 groups, based on the cause that caused this disorder.

Sound conduction disorder

Pathologies of this group are localized in the parts of the hearing organ - the outer, middle and inner ear. Sound vibrations from the external environment do not reach the brain because in one of the areas of the hearing organ a certain disease or condition does not allow them to pass through the chain:

1. in the outer ear, such diseases and conditions may include otitis media, a foreign body in the ear canal, or cerumen plug;
2. in the middle ear, acute, exudative and chronic otitis media, myringitis and tubootitis can interfere with the passage of sound vibrations;
3. In the inner ear, labyrinthitis can lead to disruption of sound transmission.

In case of sound conduction disorders, hearing loss is usually reversible, and with timely and qualified therapy, the functionality of the ear returns quite quickly.

Impaired sound perception

This group of diseases is considered quite dangerous and serious; most often such pathological processes are irreversible. Impaired sound perception is diagnosed if, during the course of research, a specialist determines that the sound-conducting functionality of the ear is not impaired, but by all indications it is clear that the work of the receptor apparatus is not performed properly.

The following can lead to disturbances in sound perception:

1. traumatic brain injury;
2. barotrauma;
3. temporal bone fracture;
4. infections (flu, measles, encephalitis, rubella);
5. taking ototoxic medications (gentamicin, aminoglycosides);
6. metabolic disorders in diabetes mellitus;
7. atherosclerosis of the vessels of the head and neck.

Why do you need to monitor your hearing acuity?

Regular hearing tests, especially after suffering from inflammatory diseases, are extremely important for the timely diagnosis of pathological disorders.

Detecting hearing loss at the optimal time allows you to:

• extinguish inflammatory processes in time before they spread to neighboring areas of the hearing organ or tissue;
• stop the irreversible processes of hearing loss and take measures to adapt the patient to the outside world.

If such a striking symptom as hearing loss is ignored, patients may face complete loss of ear functionality.

Modern techniques

All hearing testing methods that are available to otolaryngologists can be divided into two large groups: objective and subjective.

Objective methods

Such methods are considered the most reliable, since their action is based on recording the occurrence of unconditioned reflexes during diagnosis.

Most often, objective methods are used in relation to children under three years of age. One of them is audiometry of newborns, which is carried out for every baby born within the walls of the maternity hospital. The study is carried out using special equipment that records the acoustic emission of each baby's ear.

Audiometry is used to study hearing acuity in disabled and comatose patients, as well as to provide an impartial picture in controversial cases.

Subjective methods

These methods of hearing testing are used by otolaryngologists when diagnosing the functionality of the ears in children over 3 years of age who can speak, as well as in adults during medical examinations, commissions, and when patients have complaints about a decrease in the acuity of sound perception.

Subjective methods are based on whispered speech and tuning fork tests, when the patient must either reproduce a quietly spoken phrase or confirm that he hears a sound. Such methods are actively used by otolaryngologists because of their simplicity, but at the same time, they do not provide such an accurate picture of the quality of sound perception of patients as objective audiometry.

Acoustic techniques

Acumetric techniques are used by otolaryngologists during medical examinations and commissions. This hearing diagnostic allows you to quickly assess whether the patient has problems with the perception of sounds.

Spoken speech test

The patient is asked to face away from the testing provider and cover one ear. The otolaryngologist comes close to him and loudly pronounces phrases containing voiced and voiceless consonants, and the test person repeats what he heard. Gradually the specialist steps back; ideally, the final distance between the inspector and the person being checked should be 6 meters.

Whisper speech test

Acumetry in whispered speech is carried out in the same way as in the case of spoken speech: the patient stands with his back to the doctor and closes one ear. The specialist begins to whisper phrases to the person being tested, gradually moving back until he reaches a minimum distance of 6 meters.

Tuning fork tests

Such hearing diagnostics are used if the patient has problems in sound perception during standard tests of spoken and whispered speech. Using this musical instrument, the otolaryngologist will check which pitch the patient hears the worst.

Audiometry

If standard tests show that the patient has hearing problems, audiometry is indicated. A special device checks the air and bone conduction of sounds in each ear and records all data in the audiogram field.

Hearing test at home

Unfortunately, not all of us undergo medical examinations and special commissions; many of us do not visit the otolaryngologist’s office for years. Meanwhile, we are constantly surrounded by noise, which can negatively affect the state of our hearing organs and even cause progressive irreversible hearing loss.

In order not to forever lose the ability to hear well, it is important to regularly visit an otolaryngologist and contact him for a hearing test and consultation at the slightest suspicion of deterioration in sound perception.

You can also pre-test your hearing at home. Experts have developed several simple techniques that help determine whether a person’s ear functionality is impaired.

This type of hearing test is carried out in spacious rooms, protected as much as possible from extraneous noise. Two people must participate in the diagnosis - the subject who needs to test his hearing acuity, and the examiner.

1. At a distance of 2-3 meters from the subject, several phrases are whispered, which he must repeat.
2. Testing is carried out using whispered and spoken speech at a distance of 6 meters.

How to test your hearing at home alone? If you don't have a helper, listen to the sounds around you:

• you must recognize vibrations of different frequencies - from the low hum of appliances, to the high ticking of a clock and the singing of birds outside the window;
• you should not have problems with perception during telephone conversations;
• you should not constantly ask your interlocutors;
• your loved ones should not complain that you turn on the TV too loud;
• Don’t you think that most of your interlocutors speak indistinctly, unintelligibly and somehow quietly?

If any of the statements do not suit you, contact an otolaryngologist.

Hearing Test Apps

Another group of methods for self-testing hearing is special applications developed for mobile devices. With their help, hearing diagnostics is quick and easy.

1. uHear and Hörtest. These applications test each ear of the test subject in turn for the perception of different frequencies of sounds. The vibrations are transmitted through headphones, and the “patient”, having heard them, must press a button.
2. Mimi Hearing Test. Developed by a hearing aid company. Testing is ideal for those who are looking for ways to test their hearing on their own. It follows a standard scenario - through headphones, sound vibrations are sent to the ear of the person being tested, and he must press the “Right” / “Left” buttons on the smartphone screen when he hears them. At the end of the diagnosis, the program displays your age as a result, which it determined based on the state of sound perception of your ears. If the numbers are incorrect, contact an otolaryngologist.