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

Timely detected 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 studies, it is possible to detect pathology in time and begin its treatment.

Hearing acuity diagnostics

Hearing testing should begin with a consultation with an audiologist. The specialist performs an otoscopy - this procedure consists in 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. After performing 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 evaluate this indicator. Today, there are quite a few informative diagnostic methods, so only a doctor should select them.

Indications

Diagnostic studies are required in such situations:

• or, which are characterized by hearing loss;
• that are associated with damage to the cerebral cortex;
• or the heads that provoked;
• the presence of suspicion of a 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 reasons for its development.

Audiometry

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

Hearing is measured in decibels. Thanks to this study, the doctor has the opportunity to compare the data obtained with the norm.

It is carried out to solve such problems:

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

This procedure has no contraindications and does not provoke pain. During the procedure, the patient is put on headphones through which signals are given. If a person hears a sound, he needs to press a button. As a result, the doctor receives, which allows you to establish the presence or absence of pathology.

How is audiometry performed?

Tympanometry

This procedure is an objective diagnosis of diseases of the auditory organs. For its implementation, a special medical device is used - a tympanometer, which supplies sound pressure to the ears.

After that, the device fixes the resistance that the wave encounters while moving through the auditory canals. The result of this study is a graph.

Thanks to the implementation, it is possible to establish:

• pressure level in the middle ear;
• mobility of the eardrums;
• 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 provoke discomfort and has no restrictions. Therefore, it is carried out by everyone in the presence of relevant indications.

Impedancemetry

This term is understood as 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 is included in the category of objective procedures, since it does not require the participation of the patient. The procedure does not depend on the conditional reactions of a person, therefore it can be performed even for young children.

During the study, sound or air under pressure is fed 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 the physiological capabilities of a person to hear, which do 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 control the effectiveness of the therapy.

Test 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 purity of sounds. The tuning fork makes it possible to evaluate air and bone conduction.

When analyzing air conduction, the patient should close his eyes, and then answer if he hears a sound. If the answer is yes, he must determine which ear.

When assessing the threshold of bone conduction, the specialist puts the stem of the tuning fork to the mastoid process in the area of ​​​​attachment of the auricle or to the midline of the skull. After that, you need to set the duration of the perception of sound by the patient.

Tuning fork test according to the Rinne and Weber method

Additional studies or analyzes

The simplest and most accessible method is the study of hearing with the help of live speech. To do this, one ear must be closed with a finger, and then the patient should be asked to repeat the words that the doctor says in a whisper or in a voice of medium volume.

As a rule, 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. So, 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 such studies:

1. Electrocochleography - is performed to measure the electrical potentials of the auditory nerve and the inner ear. Thanks to this, it is possible to detect pathologies that accompany vestibular hydrops.
2. Otoacoustic emission - involves the registration of sounds that come from the inner ear. According to their fluctuations, it is possible to evaluate the functions of the outer hair cells. Thanks to such a study, it is possible to establish hearing impairments in young children.
3. The method of acoustic stem evoked potentials is based on the study of bioelectrical 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 a video of how audiometry is performed:

Prevention of hearing loss

To prevent hearing loss, you need to deal with the prevention of such diseases:

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

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

Modern audiology has many methods for studying auditory function. There are four main groups of methods among them.
In practice, the most common psychoacoustic methods of audiometry, based on the registration of the subjective auditory sensation of the subjects. But in some cases, psychoacoustic methods do not work. This applies, for example, to assessing the auditory function of newborns and young children, mentally retarded, mentally ill patients, determining feigned deafness and hearing loss, examination of hearing disabilities, and professional selection.
In such cases, it is often necessary to use objective methods for studying hearing, which are based on recording the bioelectric responses of the auditory system to acoustic signals, in particular, the acoustic reflex of the intra-ear muscles and auditory evoked potentials.

Psychoacoustic methods of audiometry form the basis of modern audiometry. They provide for the study of hearing with the help of live speech, tuning forks and special electro-acoustic devices - audiometers. The examination of hearing with the help of speech and tuning forks is called acumetry, and the examination with audiometers - audiometry.

Hearing research using live speech . To study hearing, whispered and colloquial speech is used, and in severe forms of hearing loss and deafness, loud speech and screaming are used. When examining hearing, the non-examined ear is covered with a finger moistened with water, turunda with petroleum jelly, or drowned out by friction noise with waxed paper, Barany's ratchet.
To standardize the research conditions, reduce the percentage of variable data, it is recommended to conduct a hearing test in whispered speech after a calm exhalation - with reserve air. In this case, the voice power does not exceed 35-40 dB, so the discrepancies in the results of hearing studies by different researchers are reduced.
The patient becomes so that the studied ear is turned towards the doctor. The study begins from the maximum distance (5-6 m), gradually approaching the place from which the subject can repeat all the words spoken to him. Under the conditions of a JTOP cabinet, the length of which does not exceed 5-6 m, it is practically 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.
In the absence of perception of whispered speech or with its decrease, they proceed to the next stage - the study of the perception of ordinary (colloquial) speech. In order to keep the strength of the voice approximately constant, it is recommended during the hearing examination to adhere to the old rule - to pronounce words and numbers with reserve air after exhalation. In everyday practice, most specialists use an arbitrary set of numbers during a hearing examination using speech, for example: 35, 45, 86, etc.

Hearing test with tuning forks . For the needs of medicine, tuning forks are made, tuned to the tone “to” in different octaves. Tuning forks, respectively, are denoted by the Latin letter "C" (the designation of the note "to" on the musical scale) indicating the name of the octave (superscript) and the frequency of vibrations for 1 s (subscript). Despite the fact that tuning forks have recently been superseded by modern electroacoustic devices, they remain valuable tools for hearing research, especially in the absence of audiometers. Most specialists consider it sufficient to use C128 and C42048 tuning forks for differential diagnosis, since one tuning fork is bass and the other is treble. Violation of the perception of bass sounds is more typical for conductive hearing loss, treble - for sensorineural.
After the "launch" of the tuning fork, the length of the 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 branches are perpendicular to the auricle. Every 2-3 seconds, the tuning fork is removed from the ear at a distance of 2-5 cm in order to prevent the development of adaptation to tone or hearing fatigue. When examining hearing by bone-tissue conductivity, the tuning fork leg 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 impaired function of the sound-conducting and sound-perceiving systems. For this, 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 leg of the sounding tuning fork C|28 is applied to the middle of the crown and the subject is asked where he hears the sound - in the ear or head. In normal and with symmetrical hearing impairment, the sound feels
in the head (no lateralization). With a unilateral violation
function of the sound-conducting apparatus, the sound is lateralized in one hundred
the crown of the diseased ear, and in case of bilateral violation - towards the more affected ear. With a unilateral violation of the function of the sound-perceiving apparatus, the sound is lateralized towards the healthy ear, and with a bilateral violation - towards the ear that hears better.

2.Rinne experience. The essence of the study is to determine and compare the duration of perception of the Cp8 tuning fork by air and bone tissue conduction. The sounding tuning fork C,8 is placed on the mastoid process. After the patient ceases to hear the sound, the tuning fork is brought to the auricle, determining whether the patient hears the sound. Normally, and in violation of the function of sound perception, air conduction prevails over bone conduction. The result is assessed as positive ("Rinne+"). If the function of sound conduction is impaired, bone conduction does not change, and air conduction is shortened. The experience is assessed as negative ("Rinne-"). Thus, experience allows in each specific case to differentiate the defeat of the sound-conducting and sound-receiving apparatus.
3. Bing's experience. The 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 meatus with a finger. Normally and in violation of the function of sound perception, when the auditory canal is closed, the sound will be perceived as louder - the experience is positive ("Bing +"), If there is a lesion in the function of sound conduction, closing the ear canal does not affect the volume of the sound - the experience is negative ("Bing- ").
4. The Federici Experience. Compare the results of perception of the sound of the C128 tuning fork, the leg of which is alternately placed on the skin of the mastoid process, then on the tragus. Normally, and under the condition of damage to the sound-perceiving apparatus, the sound of a tuning fork mounted on a tragus is perceived as louder, which can be regarded as a positive experience. This result is designated as "K> C", 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 tympanic membrane, absence of the auditory ossicles, etc.), the tuning fork is heard worse from the tragus than from the mastoid process - the experience is negative.
5. Schwabach experience. The leg of the tuning fork C,28 is placed on the mastoid process and the time of perception of its sound is determined. Reducing the time of perception is characteristic of sensorineural hearing loss.
6. The Jelle experience. The leg of the C]28 tuning fork is placed on the mastoid process, and in the external auditory canal the air is thickened and rarefied by pressing and releasing the tragus. This causes the base of the stirrup to vibrate and change the perception of sound. It becomes quieter when the air is thicker and louder when rarefied. 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 an approximate differential diagnosis of damage to the sound-conducting and sound-perceiving apparatus.

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

Tone threshold audiometry . The first stage of audiometry is the measurement of auditory sensitivity - auditory 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 strength of the sound with the help of special devices placed on the audiometer panel, the researcher determines the moment at which the subject will hear a barely perceptible signal. Sound is transmitted from the audiometer to the patient using air conduction headphones and a bone vibrator. When a sound appears, the subject signals this by pressing the remote button of the audiometer, the signal lamp lights up. First, the thresholds for the perception of tones are determined by air conduction, and then by bone and tissue. The results of the study of sound perception thresholds are applied to the audiogram blank, where the abscissa axis indicates the frequencies in hertz, and the ordinate axis indicates the intensity in decibels. At the same time, the perception thresholds for tones by air conduction are indicated by dots and are connected by a solid line, and the perception thresholds 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 up to 10-15 dB at each frequency.
The indicators of the perception of sounds transmitted through the air are characterized by the state of the sound-conducting apparatus, and the indicators of the perception of sounds transmitted through the bone are characterized by the state of the sound-perceiving system. In case of violation of the sound-conducting apparatus, the curves of the perception of tones by air and bone-tissue conduction do not coincide and are located at a certain distance from each other, forming a bone-air interval. The greater this interval, the greater the damage to the sound-conducting system. In case of complete damage to the sound conduction system, the maximum value of the air-bone interval is 55-65 dB. A sample of tone threshold audiometry in violation of the function of sound conduction is shown in fig. 11a (see insert). The presence of an air-bone gap 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 placed side by side (i.e., there is no bone-air interval), then such an audiogram indicates a violation of the function of the sound-perceiving apparatus (see insert, 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-perceiving systems is ascertained (see insert, Fig. 11, c). Assessing the state of hearing in the elderly, the obtained curve of bone-air sound conduction should be compared with the age norm of hearing.

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

Tonal suprathreshold audiometry . Threshold audiometry determines the state of auditory sensitivity, but does not give an idea of ​​a person's ability to perceive various sounds of superthreshold intensity in real life, including speech sounds. There are cases when normal conversational speech is not perceived or is perceived poorly due to hearing defects, and loud speech is not tolerated due to an unpleasant painful sensation of loud sounds (auditory discomfort). In 1937, the American scientist Fowler (E.R. Fowler) found that with pathological changes in the spiral organ, an increased sensitivity of the ear to loud sounds develops. At the same time, the sensation of loudness with sound amplification grows faster compared to a healthy ear. Fowler called this phenomenon the loudness leveling phenomenon ( loudnessrecruitment). In domestic literature, such a state is described as a phenomenon of an 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.

At present, the following methods are the most common in suprathreshold audiometry: 1) identification of the leveling phenomenon using the differential sound intensity perception threshold (DPVSZ) in the modification of 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 allow you to recreate an oscillatory 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 threshold of perception. DPVSZ in people with normal hearing at a signal intensity above the hearing threshold of 20 dB is 1.0-2.5 dB. In persons with the phenomena of the alignment phenomenon (positive recruitment), the change in sound volume is perceived at a lower tone intensity: DPVSZ fluctuates in them 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 the 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 to the definition of the DSAP 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 with an intensity of 20 dB above the threshold of perception is fed into the ear of the subject. 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 served. Then the index of small increments of intensity (IMPI) is calculated, i.e., the percentage of audible amplifications of the sound. Normally, with violations of the sound-conducting apparatus and retrocochlear parts 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 is 70-100% of the answers (i.e., patients distinguish between 14-20 sound amplifications).

The next test for suprathreshold audiometry is determination of thresholds of auditory discomfort. Thresholds are measured by the level of intensity of the test tones at which the sound is perceived as uncomfortably loud. Normally, the thresholds of auditory discomfort for low- and high-frequency tones are 70-85 dB, for mid-frequency tones - 90-100 dB. With the defeat of the sound-conducting apparatus and retrocochlear parts of the auditory analyzer, the sensation of auditory discomfort is not achieved. If the hair cells are affected, the discomfort thresholds are raised (the dynamic range of hearing is narrowed).
A sharp narrowing of the dynamic range (up to 25-30 dB) impairs speech perception and is often an obstacle for hearing aids.
Speech audiometry. Pure tone audiometry gives 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, the assessment of the state of the auditory function should be based on the results of the study of both tonal and speech signals.
Speech audiometry is characterized by the social adequacy of hearing, its main goal is to determine the percentage of speech intelligibility at different SPLs of speech signals. The results of speech audiometry are of great importance for differential and topical diagnostics, the choice of treatment tactics, the evaluation of the effectiveness of auditory rehabilitation, and the solution of a number of issues of professional selection and examination.
Studies are 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 amplifies them to the required level and feeds them to the ear of the person under study by means of air and bone telephones. The results are evaluated by the number of words recognized by the 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) 50% speech intelligibility threshold; 3) 100% speech intelligibility threshold; 4) percentage of speech intelligibility within the maximum intensity of the audiometer. Normally, the threshold for undifferentiated speech intelligibility (sensation threshold - 0-level) is 7-10 dB, 50% intelligibility threshold - 20-30 dB, 100% intelligibility threshold - 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 the pathological state of the auditory system, the indicators of speech audiometry differ from the norm. If the sound-conducting apparatus or the retrocochlear parts of the auditory analyzer are affected, then the curve of the increase in speech intelligibility with the amplification of the ultrasound of acoustic signals runs parallel to the curve in the norm, but lags behind it by the average loss of tonal hearing (dB) in the speech frequency range (500-4000 Hz). For example, if the hearing loss with pure tone audiometry is 30 dB, then the studied speech intelligibility curve will be shifted to the right of the normal curve by 30 dB, while maintaining its exact configuration (Fig. 12, 1). If the sound-perceiving apparatus is affected and there are signs of an equalization 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., a well-known phenomenon of a paradoxical drop 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 CNS disorders and damage to the cortical auditory analyzer (cortical hearing loss), the increase in speech intelligibility slows down, the curve acquires 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 loss. But these methods are insufficient or completely ineffective for the study of hearing in young children, persons with neuropsychiatric disorders, mentally retarded, emotionally unbalanced, simulating deafness during forensic medical examinations, etc.
It is possible to determine the state of auditory function in such cases by using the methods of the so-called objective audiometry. It is based on unconditioned reflexes (vegetative, motor and bioelectric) that occur 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 means and methods of objective examination of auditory function in clinical practice, acoustic impedancemetry and registration of auditory evoked potentials are most often used.
Acoustic impedancemetry is based on the measurement of acoustic resistance (impedance), which is exerted on the sound wave by the structures of the middle ear, which transmit 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 tympanic membrane, the ossicular chain, the function of the intra-ear muscles.
Numerous studies have established that the pathology of the middle ear significantly changes the value of AI compared to the norm. By the nature of AI changes, it is possible to objectively characterize the state of the middle ear and the function of the intra-auricular muscles. Thus, increased AI is observed in acute otitis media, cicatricial changes in the tympanic membrane, fixation of the ossicular chain, the presence of a secret in the tympanic cavity, and violation of the ventilation function of the auditory tube. The AI ​​value decreases when the ossicular chain breaks. In audiological practice, the results of AI are evaluated according to the acoustic reflex tympanometry.
Tympanometry (TM) is based on the registration of AI shifts in the process of an artificially created air pressure drop in a hermetically sealed external auditory canal. In this case, pressure changes are ± 100-200 mm of 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 the external auditory canal, the acoustic impedance of the tympanic membrane increases and, accordingly, AI increases. 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 "V", the top of which corresponds to atmospheric air pressure (pressure 0) in the external auditory canal. On fig. 13 shows the main types of tympanograms characteristic of various conditions of the middle ear.
Tympanogram type A corresponds to the normal function of the middle ear, 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 (normal); 2 - type B (perforation of the tympanic membrane, secretory otitis media); 3 - type C (Estachian tube dysfunction); 4 - type Ad (rupture of the ossicular chain); 5 - type /4s (otosclerosis); 6 - type D (adhesive otitis media)
Type B indicates minor changes in AI with 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 cavity of the middle ear.
Type D is determined by the bifurcation of the top of the tympanogram into two peaks in the area close to zero pressure, which occurs with destructive changes in the tympanic membrane (atrophy, scars).
Type Ad - outwardly, the curve resembles a type A tympanogram, but has a very high amplitude, due to which the apex looks cut off; this type is determined in the event of a rupture of the ossicular chain.
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.

For the study of 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 band noise (100-4000 Hz) of different duration and intensity: 1 - acoustic reflex curve; 2 - the value of the sound pressure 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 an increase in sound pressure and the duration of the acoustic stimulus

In the pathological condition of the middle ear, the protective mechanism of the AR is violated. At the same time, AR changes compared to the norm. The data obtained are used in the practice of audiometry to improve the differential-topic diagnosis of diseases of the organ of hearing.
Registration of bioelectric reactions - auditory evoked potentials (AEPs) that occur 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 brainstem structures is carried out using special electroacoustic devices, which are based on a computer with high-speed analog-to-digital converters.
The use of computers for the study of auditory function using the recording of SVP was called ERA (evoked response audiometry) abroad, i.e. evoked response audiometry, or computer audiometry. Various components of the SVP have been identified. According to the location of the corresponding electrode in clinical audiology, it is customary to distinguish between cochlear (electrocochleography) and cerebral (vertex potentials) SEPs.

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

With electrocochleography, an active electrode is placed on the medial wall of the tympanic cavity in the region of the cape (promontorium). When registering cerebral SEPs, the active electrode is fixed in the region of the crown (vertex), and the grounded electrode is fixed on the skin of the mastoid process. The cochlear SEPs include the microphone and summation potentials, the action potential of the auditory nerve; to the brain ones - the biopotentials of the cochlear nuclei, brain stem neurons, the activity of the auditory zone of the cerebral cortex.

SVP according to the time of their occurrence is 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, reflect the response of the hair cells of the spiral ganglion and the peripheral endings of the auditory nerve fibers. In the composition of short-latency SVPs, a number of components (waves) are distinguished, denoted by Roman numerals. Waves differ from each other in localization, amplitude of evoked potentials and latent period of their occurrence. On fig. 15 is a schematic representation of the SVP records of a healthy person. In the group of short-latency SEPs, waves I-II characterize the electrical activity of the cochlea and the auditory nerve, waves III-IV characterize the responses of neurons of the upper olivar complex, nuclei of the lateral loop, and inferior colliculi colliculi. The time of occurrence of medium-latency SEPs ranges from 8-10 to 50 ms after the onset of sound stimulation, long-latency - from 50 to 300 ms.

The components that make up medium- and long-latency SVPs are denoted 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) as an extracranial origin, due to myogenic reactions (postural, temporal, cervical, etc.). Therefore, medium-latency SEPs 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 SEP waves (peaks) makes it possible 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, acoustic neuroma, pathological changes in the nuclei of the brain stem and auditory cortical structures.
Computed audiometry is a promising and very valuable method for clinical diagnosis of hearing impairment, detection of simulation 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 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. 1.

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 ( Speaking). 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; 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 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. 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 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. 8. A set of instruments for catheterization of the auditory tube: 1 - rubber balloon; 2 — an otoscope — a rubber tube for hearing of 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; V) 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

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

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

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

The 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. Expert devices of the GUTA CLINIC audiology center allow you to fix hearing thresholds not only at standard frequency levels, but also in an extended range from 8 to 20 kHz. The method of speech audiometry reveals the maximum possible parameters of speech intelligibility for the patient, as well as efficiency. The assessment of the latter is affected 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 deciding on the advisability of hearing aids or cochlear implantation.

Objective methods allow you to examine both adults and newborns. Since objective diagnosis does not depend on the behavioral factor and the physical condition of the patient, it can also be used in the assessment of hearing in patients who are not able to contact an audiologist. In some cases, it is necessary to conduct hearing studies in a state of medical sedation (superficial sleep). Objective diagnostics is based on the fixation of electrical signals of various elements of the hearing system in response to the impact of sound stimuli.

Such an objective method as . The stapedial (acoustic, or auditory) reflex is also associated with it - studies of dynamic indicators. Impedancemetry diagnoses the condition of the middle ear and the conduction pathways of the auditory analyzer.

The condition of the tympanic membrane, the mobility of the ossicular chain, the pressure in the middle ear, the work of the auditory tube is determined by tympanometry.

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

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

Diagnosis of acoustic stem 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 the patient's central nervous system (CNS) to changes in the sound signal in the headphones.

The objectivity of the method of auditory evoked potentials (SEP) 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 calves), which makes it possible to assess the degree of concentration of attention, the work of the cerebellum and the brain stem. Registration of SVP is carried out in the state of wakefulness and natural sleep of the patient. In some cases (more often in children with CNS pathology), medical sedation (superficial sleep) is used.

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

Hearing loss is one of the main signs that indicate pathological processes in the ear. It is important to note the appearance of this symptom in time and consult an otolaryngologist for advice, because many diseases require qualified and timely treatment, and delay in therapy can lead to hearing loss. What are the hearing test methods? Can I diagnose myself?

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

According to the forecast, hearing loss can be:

1. reversible, that is, temporary. Most often, such hearing impairments cause inflammation 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 responsible for receiving sound information.

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

Violation of sound conduction

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

1. in the outer ear, such diseases and conditions can be otitis media, a foreign body in the ear canal, sulfuric plug;
2. in the middle ear, acute, exudative and chronic otitis, myringitis and tubo-otitis can interfere with the passage of sound vibrations;
3. in the inner ear, labyrinthitis can lead to impaired sound conduction.

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.

Violation of sound perception

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

The following can lead to hearing loss:

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

Why is hearing acuity monitored?

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

Identification of hearing impairment in optimal terms allows:

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

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

Modern techniques

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

Objective Methods

Such techniques are considered the most reliable, since their action is based on fixing 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 the audiometry of newborns, which is carried out for every newborn baby in the maternity hospital. The study is carried out using special equipment that captures the acoustic emission of each ear of the baby.

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

Subjective Methods

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

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 give such an accurate picture of the quality of sound perception of patients as objective audiometry.

Acumetric techniques

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

Spoken language check

The patient is asked to turn away from the tester and cover one ear. The otolaryngologist comes close to him and loudly pronounces phrases containing voiced and deaf 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.

Whispered speech check

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

Tuning fork tests

A similar diagnosis of hearing is used if the patient has problems in sound perception during standard checks of spoken and whispered speech. With the help of this musical instrument, the otolaryngologist will check the sounds of what key the patient hears the worst.

Audiometry

If standard tests show that the patient has a hearing problem, audiometry is shown to him. A special apparatus 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 professional examinations and special commissions, many of us do not visit the otolaryngologist's office for years. In the meantime, we are constantly surrounded by noise that can adversely affect the state of the hearing organs and even cause progressive irreversible hearing loss.

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

You can also test your hearing at home. Experts have developed several simple techniques that help determine whether a person has impaired functionality of his ears.

Such a hearing test is carried out in spacious rooms, as protected from extraneous noise as possible. Two people must be involved in the diagnosis - the test subject, who needs to check the hearing acuity, and the tester.

1. At a distance of 2-3 meters from the subject, a few phrases are whispered, which he must repeat.
2. At a distance of 6 meters, whispering and colloquial speech is tested.

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

• you must recognize fluctuations of different frequencies - from the low rumble of appliances, to the high ticking of the clock and the singing of birds outside the window;
• you should not have problems with perception during telephone conversations;
• you should not constantly ask the interlocutors again;
• your loved ones should not complain that you turn on the TV too loudly;
• you do not think that most of your interlocutors speak indistinctly, unintelligibly and somehow quietly.

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

Hearing test apps

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

1. uHear and Hortest. These applications test each ear of the test subject in turn for the perception of different frequencies of sounds. The vibrations are transmitted through the headphones, and the "patient", having heard them, must press the 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 goes according to the standard scenario - through the headphones, sound vibrations are fed into the ear of the person being checked, 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 by the state of sound perception of your ears. If the numbers are incorrect, contact an otolaryngologist.