Clinical Experience With

Impedance Audiometry
James Jerger, PhD, Houston

Impedance audiometry was performed as part cal procedure and to evaluate its diagnostic
of routine clinical examination in a consecu-
the
value in a typical audiologic case load.
tive series of more than 400 patients with various In general we found that the testing pro-
types and degrees of hearing impairment. An cedure was easily mastered, even by audio-
electroacoustic bridge (Madsen, ZO 70) was used logically unsophisticated personnel, that val-
to out the measurement of tympanometry,
carry
id and meaningful results could be obtained
impedance, and threshold for the acous- for almost every patient, and that, with
acoustic

tic
reflex. Results indicate that, while individual
certain reservations, the data of impedance
components of the total impedance battery lack
diagnostic
precision, the overall pattern of results audiometry constitute extremely valuable di-
yielded by the complete battery can be of great agnostic information.
diagnostic value, especially in the evaluation of
young children. Subsequent sections present statistical in-
formation when patients are grouped ac-
cording to age and type of hearing loss, and
individual case reports illustrating the diag-
T
t , development of impedance audiome- nostic value of impedance audiometry.
the Past decade has added new g Method
sco anC*
Bawl on the to clinical audiology. dimension
Sui pioneering efforts of Metz,1
,
Apparatus.—Impedance audiometry was car-
e<ÎUen* workers have refined instrumen- ried outby means of an electroacoustic imped-
tati ance bridge (Madsen, type ZO-70) and an
(ju
'
technique, and interpretation to pro- associated pure-tone audiometer (Beltone, type
nosjThsan »"valuable tool for differential diag-
A
10D). Figure 1 shows a schematic diagram of
the principal components of the impedance
mer), Vei°Pment of contemporary instru- bridge.
,.

the v,. 1.°n for impedance audiometry has, in A probe tip containing three tubes is sealed
Paths t"' the followed two essentially parallel in the external meatus, forming a closed cavity
his c 11 gues2"° United States, Zwislocki and bounded by the inner surface of the probe tip,
chani° if Ídge- Indeveloped electrome- an the walls of the external meatus, and the tym-
kildscíT Eur°Pe> Thomsen, Ter- AA
and otners'710 Pioneered the
panic membrane. One tube is used to deliver,
into this closed cavity, a probe tone generated
aPplicat n °* tne eieetroacoustic approach, by a 220-hertz oscillator driving a miniature
Cu-lmin r lTi the receiver. The second tube is connected to a
availaui 6 nf
e
present commercially miniature probe microphone which monitors
The ctroac°ustic bridge. the sound pressure level of the 220-Hz probe
GxPeri
on
enreSen* PaPer reports clinical
with the latter instrument based e
our tone in the closed cavity and delivers the trans-
its duced voltage through an amplifier to a bridge
4°0 succ°Ut.me
°d- Our
administration to well
^1Ve Puente one-year peri- over a
over circuit and balance meter. The balance meter is
nulhd by an SPL of exactly 95 dB in the
el^"—~~L
ectroacaiUstlc
m approach efficacy
^3S to the of the
routine clini-
assess
as a
closed cavity. A potentiometer on the output of
the 220-Hz oscillator permits variation of the
SPL over a range corresponding to a compli-
Accepted June 19,1970. for
publication ance variation (equivalent volume) of 0.2 to 5.0
Department
the
From of Otolaryngology, Baylor cc. The third tube is connected to an airpump
College
and the Audio-Vestibular Lab-
which permits variation in air pressure in the
oratory,
Reprint
the
Methodist
requests
of
Medicine,

Hospital, Houston.
to 11922 Taylorcrest, Houston7 024. closed cavity over a range of ±400 mm (water).
Air pressure is read on an electromanometer.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 The receiver and probe microphone are con- described by Lidén. This discrepancy is un-
tained in a small housing mounted at the end doubtedly due to the difference in probe fre-
of a conventional headband. They are connect- quency used in tympanometry. Lidén has used
ed to the probe tip by small rubber hoses. A a probe frequency of 800 Hz, whereas the
third rubber hose delivers air to the probe tip. bridge we employ uses a probe frequency "f
At the opposite end of the headband a conven- 220 Hz. Indeed, in recent still unpublished
tional earphone is mounted. When connected to work by Lidén, Peterson, and Björkman (made
a suitable sound source it delivers signals to the available to us by Dr. John Peterson, Louisiana
ear opposite the one in which the probe tip is State University School of Medicine) the a"'
sealed, in order to measure threshold for the thors demonstrate, in a case of hypermobil''
acoustic reflex. In our project the sound source tympanic membrane that whereas a probe fre'
was a standard clinical audiometer (Beltone, quency of 800 Hz shows a clearly defined Lide'1
type 10D) feeding an earphone (Telephonic function, the double maximum is greatly attefl'
TDH-39) mounted in a cushion (M X 41/AR). unted by changing the probe frequency to 62¡>
When the headband is positioned on the pa- Hz and entirely abolished by shifting to 2*
tient's head, the earphone cushion covers one Hz. It is not surprising, therefore, that oDe
ear and the probe tip, attached to the housing does not observe Lidén's function with t|"
on the headband by the three rubber hoses, bridge we use. Instead, cases of ossicular d'5'
may be conveniently sealed in the external continuity typically show exceedingly deel
meatus of the opposite ear. type A functions.
With this instrumentation the three basic In the unit we employ acoustic impedance •
derived from two input potentiometer setting
'

components of impedance audiometry—tym-

panometry, acoustic impedance, and acoustic Z, and Z2 (expressed in equivalent air voU»11^
threshold—may be carried out.
reflex or acoustic ohms). Z1 is obtained by introdu

Tympanometry.—Tympanometry describes ing a positive air pressure of 200 mm a_

how eardrum compliance changes as air pres- adjusting the probe tone oscillator potentioa1
sure is varied in the external canal. The basic ter until the balance meter is nulled. Z«
datum is the pressure-compliance function, a obtained by setting the air pressure to l ,

a
graph relating compliance change to pressure value which yields maximum compliance
variation. The shapes of pressure-compliance rebalancing the meter. ..

functions fall into three basic types—A, B, and Impedance, in acoustic ohms, is given by
C. The three types are illustrated, in idealized relation:
form, in Fig 2.
The type A function is characterized by a
z = JÍLJk.
Zj Z2
—

ç.
relatively sharp maximum at or near 0 mm. Acoustic Reflex Threshold.—In the meas«
Type A functions are found in normal and ment of the acoustic reflex threshold the & .

otosclerotic ears. The type B function shows troacoustic bridge is used only to show reía ^
little or no maximum. Compliance remains es- changes in impedance. The balance mete ¡5
sentially unchanged over a large range of pres- first nulled to zero. Then an acoustic signfl. ¡5
sure variation. Type B functions are found in introduced to the opposite ear. If the sig"'
ears with serous or adhesive otitis media. sufficient to elicit the bilateral acoustic te ,

In the type C function the maximum is the resulting contraction of the stapedius >' .jj
shifted to the left of zero by negative pressure cle in the ear containing the probe tip i(.
in the middle ear. Slight negative pressure is increase the impedance at the eardrum, xe ce
ing in an upward deflection of the t>a jv
'

quite common in many otherwise normal ears,

but when the maximum equals or exceeds ap- meter. In order to determine the reflex «* y
proximately 100 mm (water) significant nega-
tive pressure in the middle ear may be pre-
old the tester varies the signal level u
has identified the lowest level capable of m
c ',¡(¡1
sumed. ing an observable deflection of the t>a
Lidén11-12 describes a fourth type of function meter. u5i
characterized by a double maximum at or near Procedure.—The bridge we employ was m
0 mm. Such functions are found, according to to carry out impedance audiometry as a r° ^
Lidén,12 in cases with discontinuity of the procedure on virtually every patient test
ossicular chain. In our experience with the the Audiology Service of the Methodist **. J
bridge we have never encountered this func-
tion. All of our cases of ossicular chain discon-
tal during 1969. Of the more than 400
on whom the procedure was attempted,
su P"^-
^o¡
tinuity show relatively deep type A functions, ful results were obtained in approximately ¡,
indicating considerable compliance change, but of the cases. The primary reason for j c'
we have not observed the double maximum was inability to achieve a lasting airtig'"

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 F¡g i_:Schematic diagram of principal components of the electroacoustic impedance bridge.

lt,hissm
erri^robe tipUn(*oubtedly
in the external canal. This prob-
have been in
overcome,
Fig 2.—The three types of tympanometry curves
(pressure-compliance functions): Type A curves are
n found in normal and otosclerotic ears; type B curves
such .number of cases, by special measures, are found in serous and adhesive otitis, type C curves
e*trao a*a^e cun?s- custom molding, or are due to negative pressure in the middle ear.
H-
Pose w lnary sealing procedures, but our pur-
r°utineaS 1° evaluate the efficacy of the test as a
Point it 1S nical Procedure. From this stand-
•

n°teworthy that in the overwhelming

niajorit °fpatients
achievril (96%) an airtight seal was
Wlthout Particular difficulty,
The
arose freCOnc*Veryxnost for failure
common reason

rnaintai "j1, re<3u'site

y°ung children who could not B
a
period degree of immobility for
(usual|v suflicient complete data
to obtain
children *° ten
minutes). Some of these
^^ retested under sedation (chloral
ádrate)
In
'' Usually with successful results,
'he patie t carry out impedance audiometry,
and the h WaS seated in a comfortable chair
'hat the t nd was carefully positioned so
l>robe t¡ est earphone covered one ear. The
c.atlal of t^8 tnen sealed into tne external
''P- Durin e.J°Pposite ear by means of an ear
We Used
[J16 »nstru
tlf
6 h
firSt six months of the Proiect
d rubber ear tips supplied with
ave aban 1 ^ore recently, however, we
'

f yP made°fned
Ur,d that ti?"1
the hard rubber tip in favor of
a siucone material. We have
-200 -100 0 +100 +200
Pstablishm latter Sreatly facilitates the
ntt of an
adequate seal. Air pressure in mm (water)

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 The intensity of the pure
NORMAL SENSORI-NEURAL CONDUCTIVE tone was varied until the test-
er had identified the lowest
2-5
hearing level (HL) at which
50 7, a deflection of the balance
meter, synchronous with the
onset and offset of the tone
0
// ''/ (making suitable allowance
6-13
for the latency of the reflex

50
'// response), could be observed-
This level was recorded a3
the acoustic reflex threshold

0 7 '//, HL. In this fashion refle*

thresholds were measured for
// 14-39 signals of 500, 1,000, 2,00"
and 4,000 Hz.
w 50 '// It should be noted that tl»e

wDêl
k_
acoustic reflex phase of the
o
UJ
0 f/. total procedure tests the ea
opposite to the ear in whicn

I %
o 40-59
tympanometry and iroPed'
anee measures have been ca
^o 50
t ried out. For tympanomef"
and impedance the left ear
tested by inserting the pro<^
'

60-89 tip in the left ear. For refl<?

50
'// thresholds, however, the Ie
ear is tested by introducá«
'// sound to the left ear while th
7. '/. probe tip is inserted in '"
0 right ear.
a result of this reverb
ACB ACB ACB As
there is some confusion
Tympanometry Type the literature over the apP (
Fig 3.—Distributions of types of tympanometry curves as functions of priate symbol to indicate t'1
age and type of audiometric configuration. sound is presented to one-6
and the reflex is detected^
>*
After the adequacy of the seal had been the contralateral ear. Some investigators1-''
verified by the introduction of positive air pres- that they are testing the right ear when ,

sure in the external canal, the tester proceeded bridge is connected to the right ear and s°. ¡,t
to plot the pressure-compliance function (tym- is introduced to the left ear. Others14 feel
panometry). Compliance, in arbitrary units, they are testing the right ear when sound
'

was plotted as a function of varying air pres- troduced to the right ear and the bridge is
sure. The latter was varied in steps of 10 to 20 nected to the left ear. ,((,r
mm (water) until the shape of the pressure- The present paper conforms to the '' ,.

compliance function, and the position of its convention. The symbol "O" indicates the ^
maximum, had been defined. est hearing level at which sound present' ^
The second step in the examination was the the right ear elicited an acoustic refle j]f
measurement of acoustic impedance. Compli- detected by the bridge in the left ear- j
ance values, in acoustic ohms, necessary to symbol "X" indicates the lowest hearing ¡(.
balance the null meter, first with air pressure at which sound presented to the left eaX Ms
at +200 mm (Z,), then with air pressure at the ed an acoustic reflex as detected by the
*> ^
maximum value of the pressure-compliance in the right ear. /¡r?'
function (Z„), were determined. When testing had been completed on
The final step in the examination was the ear, headband, earphone, and probe tip j.
p1^!''
t
measurement of the acoustic reflex. With the reversed, and the entire procedure was .^
balance meter set to maximum sensitivity and ed on the opposite ear. Typically the (r)i
nulled to zero, pure tones were introduced to procedure on both ears required five ^y
the opposite ear by means of the audiometer. minutes of testing time. Longer testing

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 0 NORMAL
SENSORI-NEURAL
0 CONDUCTIVE

yA
'ÍA
6-13 14-39 40-59 60-79

Age in years
'"
D'str'Dut'ons (median and semi-interquartile ranges) of acoustic impedance as functions of age and
tyPe nf
audiometric configuration.

seal 0ecasionah,y required when an adequate Distributions.—In order to analyze distri-

hothCOUld n0' be read"y obtained on one or butions as functions of age and type of loss, a
subsample was formed from the total sample
c0n ..^t8—The total group of patients tested according to the following criteria: (1) age
of yUtfà relatively representative sampling
a
a greater than 2 years; (2) audiometric pat-
t>ent<iyïanged
PlCal bosljital audiologic
caseload. Pa-
in aSe from 10 months to 81 tern consistent with normal hearing, pure
vears and included conductive loss (excluding ossicular discon-
de»,.' IOSS" virtually every type and or pure sensorineural loss; and (3)
tinuity),
tric c
°n
sample Si10Wed APProximately
a
32% of the total
purely sensorineural audiome- no history of middle ear surgery.
^^tion. Conductive and mixed Patients with either suspected or con-
'erns pat-
The r^rnC0-Urited 18%
airunS
for 28% and 22% respectively.
showed normal sensitivity.
firmed retrocochlear disorder and patients
with either suspected or confirmed function-
Results al hearing problems were excluded from the
analysis. These criteria yielded usable data
first^í 3re presented in two sections. The for 554 ears of 316 patients. Table 1 sum-
marizes the breakdown of these subjects and
the
•raped'distr'h"Utlon
.SUmmarizes statistical date on
°f the various measures of ears by age and type of loss.

PresentsCe
'be diarnf
audiometry. The second section
S^"es °^ case reports illustrating
Tympanometry.—Figure 3 shows the per-
cent of ears in each age and type-of-loss
fe ostic value of
try. impedance audiome- category yielding either type A, B, or C
pressure-compliance functions.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 In the sensorineural group*
2-5 like the normal group, the
30
type A function predomi-
20 nates, but the type C curve
occurs in an alarming 31%
10 h of ears in the 2 to 5 age
group. This percentage grad-
ually declines with increas-
6-13 ing age.
In the conductive group jt
is interesting to observe a
gradual increase in the per-
centage of ears showing type
A functions as age increases-
This change perhaps reflects
l4-39\ the differing distributions <>f
middle ear pathological ab-
normality characterizing tbe
various age groups. In very
young children one mig"
anticipate that otitis medí*1
d—b and faulty eustachian tube
40-59 function would account '°
the majority of middle ea
problems, thus
for the predominance
accounting
types B and C. In adultf-
however, one would ant'
pate a relatively lower i*f
70 80 90 100 110 >II0 dence of such problems P
Reflex HL in dB a relatively higher inciden
of stapes fixation due to °
Fig 5.—Distributions of acoustic reflex threshold hearing levels as func-
tion of age in subjects with normal hearing. sclerosis. Hence, the *ncre^e
in the type A curve and
Roughly, the distributions in Fig 3 are decrease in the B and C curves is not n*1"*
according to expectation. In ears with either pected. tfj.
normal or sensorineural audiometric pat- Impedance.—Figure 4 shows the
terns, the type A curve predominates. In bution of acoustic impedance values f°r j„
dlS{j,c
ears with conductive audiometric findings,
however, types B and C curves
various groups. The solid horizontal
predominate. each vertical box is the median value- ,,e
k8-^.
It is instructive, however, to study the distri- box itself encompasses the semi-interqua
butions in the age category of 2 to 5 years. range or middle 50% of the impedance
Here we observe that, in both the normal tribution. jji
and sensorineural groups, there appears to No data are shown for normal grow ^
be a higher incidence of types B and C the age categories of 40 to 59 and 60 t 0\
patterns than would be predicted from the years, since we have not tested nurnbe .^
distributions for older children and adults. patients with truly normal sensitive y
This is especially true of the children from 2 these age categories sufficient to ensure
to 5 years with normal audiograms. The ble medians and semi-interquartile rang" .^
appearance of some B and a fair number of The primary message of Fig 4 is a m
C curves in this group suggests the presence made by previous investigators,"15 ".^i1
of undetected middle ear problems in chil- that there is considerable overlap Ve
dren without obvious audiometric evidence of the impedance distributions of norma ^
^i
a conductive component. disordered middle ears. As a very roug

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

of
thumb,
that the highest 20% of
one might say i-1-1-1-1-1-1-1-1-1-1-r

\
normals overlap the lowest \
20% of conductives. This lOOh •
\
overlap limits the diagnos- \
tic value of the 1- oo o
impedance o G o o
\
score when viewed in isola- \
tion. As we shall m so \- 8 8 o o

to attempt 8o o o o o\
show in subsequent sec- V
tions, however, the imped- \
ance may have substantial 60 h so 8
o oce o>
w o
8
o oo
\
diagnostic value when con- _l o

(/) \ o o o oo o o
go^
ooN
sidered within the frame- \ Aooo o oo 8 \
work of complete impedance S 40 \
o ooo
°
8 oo oo o\
audiometry. V
ooo o
o ooo OOO
o o
\ o 8 o o
It is also interesting to \ \
a:
oo
g go o

"ote, in Fig 4; that> in the 20 \ oo \

to 5 age \
group both the \ o o o

orinal and sensorineural \

°
\
°

attributions \ \
are displaced
»Pward relative to the adult
distributions.
' I_I_I_I_I_I_I_l_
The shift is 0 20 40 60 80 100
2ecially obvious in the HL in dB (ISO-64)
Jnsonneura]
'
its are
group Thege
consistent with Fig 6.—Relation between reflex SL and degree of hearing loss in
patients with sensorineural (presumably cochlear) loss.
Be
fu«
high incidence of types
i-
C tympanometry
fum u118n0ted earlier> and SEROUS OTITIS MEDIA

nSf
fiddle
added evide™e of
ear problems in
these EAR TYMP. TYPE IMPEDANCE
ery young vi 3«£
children.™ 7500 n
Using the distributions of * <¡>
™
normal and sensorineu- ^ K7
^<$> *^. 11667 S2

age Î"*
in the 14 to 39
¿e sroup as a standard we
iri*6
rnidri,0
r°^ rule of
that most normal AC O

PeZlearS
C^res in ohms,
Wi" yield im-
the range
Has
BC
SAL -/
C r,1'000:3'°00 but 250 500 IK 2K 4K AR ::
Wan0"3117
200 ohr! high 4>°r 3S
SC°reS aS
as
Fig 7.—Impedance audiometry in a 7-year-old boy with serous otitis
«hms be expected.
can media. Note type B tympanometry curves, very high acoustic impedance
, ^oushc Aefe._Fi.rure scores, and bilateral absence of acoustic reflex.

hecessT distribution of the hearing level age groups. Second, the distribution is about
analyse p ^licitto
Metric ilnilted
S iS
the acoustic
with
reflex. The
normal audio-
ears
40 dB wide. Third, there is a fairly high
incidence of ears in which the reflex could
clUenei(>!0n^gUrations- Data for all four fre- not be elicited (>110 dB) in the 2 to 5 age
have been" 1'°°^'
2'°°°' and
'

IiO0'ed'
Hz~ 4'000 group. This is consistent with the previous
fa¡led t°
Suggest
SJnce preliminary analysis findings of Robertson et al.17 The distribu-
effeç,. a significant frequency tions exhibit two relatively systematic
Th trends with age. First, there is a tendency
5- First6 tS/gnificant
' ne
factors emerge from Fig
m°dal reflex HL is 85 dB in all
toward narrowing and sharpening of the
distribution as age increases. Second, there

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 OTOSCLEROSIS

TYMR TYPE IMPEDANCE

>. ;/ 4680 S2
+.
Ï! -.•> 5525 S2 Fig 8.—Impedance audlometry
in a 54-year-old man with °t0'
$ "^$ sclerosis. Note type A curves, re'3'
tively high impedance scores, and
^o AC o
bilateral absence of acoustic re-
flex.
BC
a m
> /
250 500 IK 2K 4K

LABYRINTHINE H Y DR OP S

EAR TYMP TYPE IMPEDANCE

¡m 84 4 n
audiome'
\°°\^
HHf#
n 1784 n
Fig 9.—Impedance
]-" in a 59-year-old woman with
rinthine hydrops. Note type .

0- Ki>À curves, normal impedances, an,

reduced reflex SL at 500 an
1,000 Hz on right ear (due
* AC loudness recruitment).
BC
SAL > y
250 500 IK 2K 4K a

RIGHT ACOUSTIC NEURINOMA

EAR TYMP TYPE IMPEDANCE

y 4/25 X2 Fig 10.—Impedance aud¡°^,h

try in a 60-year-old man ,e
03 ck 2250 n a right acoustic neurinoma- .^
<W type A curves. Impedance ¡s ^
(4,125 ohms) on the right ¡\
but is still within the "O t(,e
°
range. Absence of reflexes ^nt
0 right ear indicati
AC
KM is not present.
BC

— —* SAL V
250 500 IK 2K 4K AR

top™
is a decreasing incidence of ears that fail to Although the acoustic reflex to pure ,v
show a reflex response. These trends could occurs atsensation level of approxima
a
be interpreted to support a hypothesis of 85 dB in the average normal ear, the t ^
maturation of the reflex arc, up to perhaps SL is reduced by the presence of l°u m*
early adulthood. On the other hand, one recruitment.13-18-1 This occurs because ,

cannot exclude the possibility that the high reflex is apparently mediated by the ^
incidence of no-response in the 2 to 5 age ness of the sound signal. In the norm3' ,«;
this loudness level is reached for pure ^
to'1'
group merely reflects the middle ear prob-
lems suggested by the B and C tympanome- at sensation levels of 70 to 100 dB.t:i
ln
$e
try types and shifted impedance distribu- ear with loudness recruitment, howeve aei
'

tions noted earlier. loudness level required to elicit the

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 TOTAL LEFT FACIAL PARALYSIS BELL S PALSY
-

EAR TYMP TYPE IMPEDANCE

'-<*>
$-$-^-' 2338 S2
trv ? ti—Impedance audiome-
2057 n
leftc'vt3 22-year-old woman with
facial Para|ysis- Absence
of r «
to in! on r'9nt ear is due

ls
din« '"nervation to left Stape-
muscle.
ES-tS-EB-E AC O

m m m
SAL > -/
250 500 IK 2K 4K D

EAR TYMP. TYPE IMPEDANCE

,&>-&>' 1737 S2

try ¡n 2-~—|rnpedance audiome- A 3619 S2

Type B a ChHd of 37 montns-
on le« tuUrve- higher Impedance
lateral ah ence
°" r'9nt ear- and bN
indicatec°nductive loss
of acoustic reflex
on left ear. AC
BC
A A SAL M
250 500 IK 2K 4K AR

EAR TYMP. TYPE IMPEDANCE

0.-Û S 1710 SI

try In a „k. JmPedance audiome- 1636 S2

A curves n °f 27 months- TVPe
n°rmal á "ornial impedances, and
StlC ref|exes confirm
behavioral lmPression
hearing. of normal
* AC
BC
SAL /
250 500 IK 2K 4K AR

Table 1.—Wo. of Subjects and Ears by Age and Type Categories

Type Category
Normal Sensorineural Conductive
Age ,- -. ——- -. .-> -

(yr) Subjects Ears Subjects Ears Subjects Ears

2-5 19 35 22 41 15 27
6-13 25 49 25 44_19_33
14-39 19 38 25 47_30_43
40-59 10 20 22 41 30_47
60-89 -_—_35 61_20_28
Total 73 142 129 234 114 178

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 EAR TYMP. TYPE IMPEDANCE

6000 n
SFSp 2150 S2

Fig 14.—Top, Impedance audi-

AC O ometry carried out under sedation
in a child of 10 months. Behav-
BC ioral obs-rvation suggests rela-
$ A A SAL > -/ tively normal sensitivity, but high
impedance (6,000 ohms) and bi-
250 500 IK 2K 4K AR lateral absence of acoustic reflex
suggest conductive loss on righ
ear. Bottom, Same child tw°
EAR TYMP TYPE IMPEDANCE months later after medical treat-
ment for otitis media. Decrease o
SF$p 2000 S2 impedance from 6,000 to 2,00"
ohms and appearance of acousti
2111 n reflex bilaterally indicate that mid-
dle ear problem has been résolve^-

AC O
BC
SAL >
250 500 IK 2K 4K AR a

will be reached at a much lower level above the principle that the reflex threshold leve
the impaired threshold. cannot be used to predict the absolu
Figure 6 shows how the reflex SL declines threshold level with any degree of
as a function of increasing hearing loss in Nevertheless, the rule that reflex response
precision^
patients with loudness recruitment. The means a hearing level of 80 dB or better &»
data are taken from the test results of sen- be extremely useful in the evaluation of ve y
sorineural patients in the age range from 14 young children. «

to 59 years. Illustrative Case Reports.—Figure

Figure 6 shows that, as sensorineural shows conventional and impedance audio
hearing loss increases, the reflex SL decreas- etry in a 7-year-old boy with serous oti
es in regular, one-to-one fashion. The rela- media. Results are consistent with mass
tionship is linear and of unit slope. Note, sions in the middle ears. Tympanomea
also, that for any particular level of hearing curves are type B, impedance values
loss, the range of variability among patients well above the normal range of 1,000
is about 40 dB, a range comparable to the 3,000 ohms, and acoustic reflexes cannot
distribution of reflex levels in normal ears. elicited. ,¿
Analysis of the trend in Fig 6 suggests Figure 8 shows results in a 54-year- ^
two conclusions. First, when the reflex SL is man with bilateral otosclerosis. TymPa ^
less than 60 dB, the presence of loudness metry curves are type A, impedance
recruitment may be reasonably inferred. are above the normal range, and acou
sc0.¡c
Second, most sensorineural losses with re- reflexes are absent. i¿
cruitment should yield reflex responses until Figure 9 shows results in a 59-year-
the hearing level exceeds about 80 dB. This man with a unilateral loss due to endov
means that, when a reflex is observed at a phatic hydrops. Tympanometry curves .^
particular frequency, the hearing level at type A, and impedance values are wi
that frequency must lie somewhere between normal limits on both ears. In this
0 and 80 dB. Eighty decibels is, to be sure, a acoustic reflexes occur at the expected
fairly substantial range, and well illustrates mal hearing levels on both ears. The

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

duced sensation levels at which the reflex than the right ear value of 1,737 ohms adds
occurs on the right ear at 500 and
re due to the
1,000 Hz support to the overall picture of left middle
loudness recruitment phenom- ear involvement suggested by the type B
enon.
tympanometry function. Finally, the fact
Figure 10 summarizes results in a 60- that acoustic reflexes areabsent in both ears
year-old man with a right acoustic neuri- yields still more support for a left middle
°ma. As expected, tympanometry curves ear disorder. Failure to elicit reflexes when
®
type A in both ears, and impedance sound is introduced to the left ear results
va ues are
within the normal range. The from the fact that the conductive loss atten-
value of 4,125 ohms on the right ear is high, uates the loudness of the input signal to
as noted such an extent that, even at the maximum
>
earlier, a very small number of
orrnal ears may show
impedances as high output of the audiometer, 110 dB HL, the
f ,2°0 ohms. On the left ear, reflexes are loudness is not sufficient to trigger the
erved at the expected sensation levels of reflex. Failure to elicit reflexes when sound
0 to
90 dB, except at 4,000 Hz where is presented to the normal right ear results
oudness recruitment due to the high-fre- from the fact that, even though the loudness
!? ency cochlear loss causes the reflex to in the right ear is sufficient to elicit a reflex,
a*a sensation level of only 50 dB-
fr
ti,r
On e right ear reflexes are absent at all
the probe tip in the left ear will fail to
detect the contraction because of the middle
su ?Uenc*es- Since eighth nerve disorders, ear disorder.

Pa "

rf acoustic neurinoma, are not accom-

by loudness recruitment, sounds
This particular configuration of results
has considerable diagnostic value. It means,
p
att'ented in
to this patient's right
sufficient loudness to elicit the reflex,
ear never in effect, that the combination of unilateral
loss and bilateral absence of the acoustic
^
snows how facial nerve lesions reflex can only mean unilateral middle ear
cent i to
fjj the branch supplying the stape- disorder. In unilateral cochlear disorder one
m"Scle abolish the acoustic reflex.10 would always see the reflex on the good car
The
due ell'S jatlenthad
a left facial nerve paralysis

Sentedt the palsy- When sound was pre-

and, if the loss did not exceed 80 dB, on the
bad ear as well. In unilateral eighth nerve
left ear' and the probe tip W£>s disorder one would at least see the reflex on
Sealed m •

aPPe uninvolved right ear, reflexes the good ear. Only unilateral middle ear
at normal levels. However, when problems abolish the reflex bilaterally.
sound
the o u6re presented to the right ear, and In the case of this 3-year-old boy the
refleje Were tÍP Was sealed in the left ear, results of impedance audiometry pointed
not observed because the left unequivocally to a unilateral conductive
staped"njs muscle
p. could not contract, problem. Subsequent medical examination
anee ^-^
lustrâtes the value of imped-
a"dlometry
in very young children.
and treatment confirmed the accuracy of
this conclusion.
Tbe °gram °f this 3-year-°ld child SUS- The value of impedance audiometry in
Bested m''^
\
^asked "one unilateral loss. Properly
conduction thresholds were
this patient lay in the fact that it led to an
unequivocal diagnosis of conductive impair-
diffiCUj. obtain because of the child's age. ment without the need for bone conduction
Impeda nCe
audi°metry clearly demonstrat- audiometry. The clinician who has attempt-
ed, ho Ver'
^e c°nductive basis for the ed to measure bone conduction thresholds
teduceH
tympan S°nsitivity on the left ear. The left on children in this age range, while simulta-

iniPeda°metry Curve was type B and the neously masking the ear not being tested,
double °.nimpedance trf
^e *e^ side was rnore than will, perhaps, appreciate the value of such
finding ¡i] on the right. This diagnostic support.
absolutè 1Strates the diagnostic value of the Figure 13 shows the result of impedance
0verlap ln?pedance score in spite of the audiometry in a child of 27 months. The
value of
range, but "e fact
3°'7*9
described earlier. Here the
ohms is within the normal
audiogram suggested reasonably normal sen-
sitivity in both ears, but, again, one does not
that it is so much larger always feel comfortable about the validity of

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 Table 2.—Showing Hovi Results of Impedance Audiometry Help to Confirm
Impression In the Evaluation of Young Children
Audiometric
Confirm Behavioral
Tympanometry Impedance Acoustic Reflex Audiometric Impression of
A in both ears Normal in both Normal bilaterally Bilateral normal hearing
ears or
bilateral mild-moderate sensorineural loss
or
unilateral mild-moderate sensorineural loss_
A in both ears Normal in both Absent bilaterally Severe bilateral sensorineural loss
ears
A in one ear; Normal in A ear; Absent bilaterally Unilateral conductive loss
B or C in high in B or C
other ear ear
B or C in both High in both Absent bilaterally Bilateral conductive loss
ears ears

threshold estimates in children so young. In Comment

this case impedance audiometry served to
confirm the impression of normal hearing. In our experience, impedance audiometry
represents an invaluable diagnostic tool
J
The fact that all results were normal gave,
at least to us, valuable confirmation of our clinical audiology. It has become, in °

impression that the child suffered no signif- clinic, routine part of the audiologic a
a
icantear pathological abnormality. sessment of every patient. We frankly vV°
Figure 14, top and bottom, illustrates how der how we ever got along without it. .

impedance audiometry can be carried out Equally clear, however, is the fact to
under sedation in the very young child. the technique is useful only as a comP1 ,

Figure 14, left, shows the result of our first battery and that diagnostic judgments m
examination of a child of 10 months. Orient- be based on the overall configuration
ing responses to familiar speech sounds in a tympanometry, acoustic impedance, and
sound field (SFSP) suggested a threshold acoustic reflex. &
sensitivity level of about 30 dB. Impedance Tympanometry alone is useful only *v
audiometry, carried out under chloral hy- limited degree. Types B and C cur g
drate sedation, showed type C tympanome- strongly suggest middle ear disorder but»
try functions in both ears. On the left ear illustrated in Fig 3, type A curves also oc
impedance was well within the normal range in a large percentage of conductive 1°
(2,150 ohms), but on the right ear a value of especially in older adults. ¡g
6,000 ohms, well above the normal range, The acoustic impedance score, per s ' .g
was noted. In addition, there was no reflex simply too variable for accurate diag11 0{
bilaterally. We interpreted these findings to As shown in Fig 4, there is an overlaP ^
indicate a right middle ear disorder. After
two months of medical treatment the child
about 20% between normals and
fives. An impedance in the vicinity of • „\
cOÎ]g(fi
was retested (Fig 14, right). The speech ohms is quite ambiguous. It may be n° j„
awareness level had improved only slightly, or it may indicate a considerable increa .

to 15 dB, but changes in impedance audi- a patient whose impedance is normally

ometry were dramatic. Although the tym- than 2,000 ohms. aP%
panometry curve was still type C, indicating Of the three measures the acoustic .¿.
continuing negative pressure, the impedance thresholds are probably most useful in ir.
had dropped from 6,000 to 2,000 ohms on ually. But here, again, there may be am (i,
the right ear. Impedance was unchanged on
the left ear. In addition, reflexes could be
ity. Absence of the reflex may be
conductive loss, to cochlear loss greate ^
"l^
elicited from both ears at expected levels. 80 dB, to eighth nerve loss at virtually"
This case illustrates the value of imped- level, or to a facial nerve lesion. ¿¿tv
ance audiometry in detecting middle ear Individually, then, each measure ha ^x,
problems in the child too young for conven- ous limitations. In combination, b° ,$.
tional play audiometry. they yield patterns of great diagnostic

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 In unilateral conductive loss, for example, difficult to interpret unless they easily ex-
we have noted the recurrence of the follow- ceed the normal range. Finally, there is a
ing pattern: (1) tympanometry of types B very small percentage of otherwise normal
or C on the bad
ear; (2) impedance higher individuals who simply do not show the
than normal on the bad ear; and (3) acous- acoustic reflex at any level.17
tic reflex absent in both ears. Nevertheless, the expected patterns recur
This pattern points, unequivocally, to the with sufficient regularity so that we find
presence of middle ear disorder on the bad them distinctly advantageous in clinical
ear. There are only two common exceptions work. They are especially useful in the eval-
to this pattern. Otosclerotics will usually uation of very young children. Here we find
give a type A function rather than a B or C. that impedance audiometry is valuable in
Cases of ossicular discontinuity may give either confirming or denying the diagnostic
unusually deep type A functions and lower impressions gained from observation and be-
than normal impedance. Also, in the latter havioral audiometry.
group, there may be an observable acoustic Table 2 shows how the overall pattern of
reflex at high levels when sound is intro- impedance data can be helpful in confirming
duced to the good ear. the tester's clinical impression based on
In unilateral cochlear loss with loudness behavioral observation. Table 2 is also use-
recruitment the following pattern recurs: ful in denying the likelihood that one's clini-
(!) tympanometry of type A
on both ears; cal impression is correct. If, for example,
(2) impedance normal both ears; and
on one cannot observe response to sound at any
(3) acoustic reflex elicited at normal HL in level, yet acoustic reflexes occur at normal
both ears (ie, at reduced SL in the bad ear). levels bilaterally, it is unlikely that the
be only common exception to this pat- behavioral impression of total deafness is
tern occurs when the loss on the bad ear correct. One must then seek other reasons
exceeds about 80 dB. Then the reflex is for the child's failure to respond behavioral-
posent on the bad ear, but still present on
the good ear.
ly. Similarly, if the child seems to be re-
In unilateral eighth nerve loss the follow-
sponding behaviorally at moderate sound
levels, yet the reflex is bilaterally absent in
g Pattern recurs: (1)
tympanometry of spite of normal impedance and type A tym-
ype A on both panometry, then the validity of the behav-
°n both
ears; (2) impedance normal
ears; and (3) acoustic reflex elicited ioral responses is rendered suspect. Finally,
at
°« formal
the bad
HL on the good ear, but absent the results of impedance audiometry can be
ear. extremely valuable in identifying middle ear
he only exceptionto this pattern occurs disorders in children whose bone conduction
enthe loss on the bad ear is very mild, levels cannot be validly measured either
^S circumstance the sound may because of age and cooperation factors or
re if"
atach a loudness sufficient to elicit a reflex because the sensorineural loss is too
the\n0rrnal
refl
°r greater than normal SL on severe.2224 In our clinical experience the
ear' Under this circumstance the combination of play or conditional orienting
ap4ex
of +Lmay
amPlitude decay test of Anderson et reflex (COR) audiometry and impedance
be applied for further confirmation audiometry yields a reasonably accurate es-

of f
TjsfleretrOCOchl
nS
these earsite-
recurring patterns as a frame
timate of both degree and type of loss in all
but a small percentage of the children re-
erence' we have employed the results ferred to our service.
°f im
d¡a pedance audiometry to great advantage Many studies published in the American
howevStlCally"
tio ,er' that
° t'le
Xt must te reemPhasized>
there will always be
literature3-4'6
excep- impedance
have dwelt on the value of
audiometry in distinguishing be-
cotrm exPected outcomes of individual tween stapes fixation and ossicular discon-
il ustr31^611*?
sensor
°* the impedance battery. As tinuity. As a result, there is a feeling in
^ *n ^ig ^ some normals and many many quarters that this is the principle ap-
try fUnn?llra's will give type C tympanome- plication of impedance audiometry. Otologic
0ns- And, as we have emphasized surgeons have, therefore, questioned wheth-
earljer
ac°ustic impedance values may be er the results of impedance audiometry are
'

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015

 of more than academic interest since surgi- lowing intra-aural muscles reflexes. Arch Otolaryng
cal intervention is indicated in either event. 66:484-488, 1957.
9. Terkildsen K, Nielsen SS: An electroacoustic
Our own experience certainly concurs impedance measuring bridge for clinical use. Arch
with the results of previous investigators in Otolaryng 72:339-346, 1960.
10. M\l=o/\llerA: Improved technique for detailed
demonstrating that the distinction between measurements of the middle ear impedance. J
fixation and discontinuity is dramatically Acoust Soc Amer 32:250-257, 1960.
revealed in both the pressure-compliance 11. Lid\l=e'\nG: The scope and application of cur-
rent audiometric tests. J Laryng 83:507-520, 1969.
function and the acoustic impedance. We 12. Lid\l=e'\nG: Tests for stapes fixation. Arch Oto-
have, however, purposely avoided extensive laryng 89:215-219, 1969.
discussion of this issue in the present paper 13. Jepsen O: Middle-ear muscle reflexes in man,
in Jerger J (ed): Modern Developments in Audiolo-
in order to emphasize, to the clinician, that gy. New York, Academic Press Inc, 1963, pp 193\x=req-\
impedance audiometry has far broader im- 239.
14. Anderson H, Barr B, Wedenberg E: Intra-aur-
plications for the diagnostic evaluation of al reflexes in retrocochlear lesions, in Hamberger C,
hearing disorder. Wersall J (eds): Disorders of the Skull Base Re-
gion. Stockholm, Almqvist & Wiksell, 1969.
This study was supported by grant FR-05426 15. Bicknell M, Morgan N: A clinical evaluation
from the Public Health Service. of the Zwislocki acoustic bridge. J Laryng 82:673\x=req-\
Mrs. Phyllis Segal, supervising audiologist, the 691, 1968.
Methodist Hospital, Houston, assisted in the collec- 16. Brooks D: The use of the electro-acoustic
tion of data. impedance bridge in the assessment of middle ear
function. Int Aud 8:563-569, 1969.
17. Robertson E, Peterson J, Lamb L: Relative
References impedance measurements in young children. Arch
Otolaryng 88:70-76, 1968.
18. Metz O: Threshold of reflex contractions of
1. Metz O: The acoustic impedance measured on muscles of middle ear and recruitment of loudness.
normal and pathological ears. Acta Otolaryng, suppl Arch Otolaryng 55:536-543, 1952.
63, 1946. 19. Ewertsen H, Filling S, Terkildsen K, et al:
2. Zwislocki J: Acoustic measurement of the mid- Comparative recruitment testing. Acta Otolaryng
dle ear function. Ann Otol 70:1-8, 1961. 140(suppl):116-122, 1958.
3. Feldman A: Impedance measurements at the 20. Klockhoff I: Middle ear muscle reflexes in
eardrum as an aid to diagnosis. J Speech Hearing man: A clinical and experimental study with special
Res 6:315-327, 1963. reference to diagnostic problems in hearing impair-
4. Feldman A: Acoustic impedance measurements ment. Acta Otolaryng, suppl 164, 1961.
as a clinical procedure. Int Aud 3:1-11, 1964.
5. Feldman A: Acoustic impedance studies of the
21. Lamb L, Peterson J, Hansen S: Application
of stapedius muscle reflex measures to diagnosisof
normal ear. J Speech Hearing Res 10:165-176, 1967. auditory problems. Int Aud 7:188-199, 1968.
6. Zwislocki J, Feldman A: Acoustic Impedance 22. Farrant R, Skurr B: Measuring the acoustic
of Pathological Ears, technical report LSC-S-5 of impedance of severely deaf ears to test for conduc-
the Laboratory of Sensory Communication. Syra- tive component. J Otolaryng Soc Aust 2:49-53, 1966.
cuse, NY, Syracuse University, 1969. 23. Brooks D: An objective method of detecting
7. Thomsen K: Employment of impedance mea- fluid in the middle ear. Int Aud 7:280, 1968.
surement in otologic and oto-neurologic diagnostics. 24. Djupesland G: Use of impedance indicatorin
Acta Otolaryng 45:159-167, 1955. diagnosis of middle ear pathology. Int Aud 8:570\x=req-\
8. Terkildsen K: Movements of the eardrum fol- 578, 1969.

Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/02/2015