another name for speech detection threshold

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Determining Threshold Level for Speech

About this document.

These guidelines were prepared by members of the ASHA Committee on Audiologic Evaluation: Sandra Gordon-Salant, chair; Martin S. Robinette, past chair; Carmen C. Brewer; Margaret F. Carlin; John D. Durrant; Thomas A. Frank; Gregg D. Givens; Michael P. Gorga; Carol Kamara, ex officio; Robert H. Margolis; Laura Ann Wilber; and Gilbert H. Herer, then vice president for clinical affairs and current president-elect. These guidelines replace previous ASHA “Guidelines for Determining the Threshold Level of Speech” ( Asha, 1979 ). The guidelines were approved by the ASHA Legislative Council in November 1987 (LC 2-87).

Table of Contents

General considerations for clinical determination of the speech threshold, determination of speech recognition threshold, descending technique, appendix a — alphabetical list of spondaic words, appendix b — streamlined spondaic word list for adults, appendix c — children's picture spondaic word list.

Historically, the first speech tests were spoken or whispered messages presented at measured distances between the talker and the listener. These tests provided a gross estimate of an individual's ability to hear speech. Clinical speech audiometry developed from a need to quantify this ability. The Western Electric 4A (later 4C) test, a phonographic recording of spoken digits, was the first widely used recorded auditory test for determining hearing losses for speech ( Fletcher & Steinberg, 1929 ). Later, Harvard's Psycho-Acoustic Laboratory (PAL) developed word lists that serve as a basic model for today's clinical measurement of speech threshold ( Hudgins, Hawkins, Karlin, & Stevens, 1947 ). Central Institute for the Deaf (CID) published Auditory Tests W-1 and W-2 (Spondaic Word Lists), which were modifications of the PAL lists ( Hirsh, Davis, Silverman, Reynolds, Eldert, & Benson, 1952 ).

In 1978, the ASHA Legislative Council approved the “Guidelines for Determining the Threshold Level for Speech,” which were published in 1979 ( Asha , 1979 ). These guidelines presented a recommended set of speech threshold procedures based on consensus. The guidelines specified spondaic words (spondees) as standard test material. Consequently, the term spondee threshold (ST) was recommended for reporting a speech threshold rather than the more general term speech reception threshold. The advantage of using spondee threshold was that the term specified the test material. When a speech threshold was obtained with material other than spondaic words, the term speech reception threshold was recommended for reporting and notation of the test material was required. These guidelines also recommended that the speech threshold be obtained using an ascending technique in 5-dB steps paralleling the ASHA Guidelines for Manual Pure-Tone Threshold Audiometry ( Asha , 1978 ). The ASHA Guidelines for Determining the Threshold Level for Speech included a list of spondaic words of which 28 were from the ClD W- 1 and W-2 lists and eight were other alternatives from the original PAL lists. This modified list represented an effort to increase phonetic dissimilarity and improve homogeneity of audibility.

Several concerns have been raised about the adequacy of the 1979 ASHA Guidelines for Determining the Threshold Level for Speech. These concerns have included the fact that the recommended speech threshold procedures were not based on experimental evidence ( Ventry, 1979 ), a clear-cut 50% speech threshold criteria could not be found using the procedures ( Olsen & Matkin, 1979 ), the procedures were too time-consuming ( Olsen & Matkin, 1979 ), and the guidelines did not specifically define procedures for speech awareness.

Therefore, a new set of Guidelines for Determining the Threshold Level for Speech has been developed. The guidelines define common terminology and recommend a speech threshold procedure which has been supported in terms of length, reliability, and validity by research ( Seattle, Forrester, & Ruby, 1977 : Huff & Nerbonne, 1982 ; Martin & Stauffer, 1975 ; Robinson & Koenige, 1979 ; Tillman & Olsen, 1973 ; Wall, Davis, & Myers, 1984 ; Wilson, Morgan, & Dirks, 1973 ). The spirit of these guidelines, as in prior guidelines, is not to mandate a single way of accomplishing the clinical process. The intention is to suggest a standard procedure that will improve interclinician and interclinic comparison of data that, in the final analysis, will benefit the people we serve.

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Speech threshold audiometry is the procedure used in the assessment of an individual's threshold of hearing for speech. There are differing opinions regarding the clinical utility of this measure. For a discussion of the utility of the test, the reader is referred to Wilson and Margolis ( 1983 ).

The basic purpose of a speech threshold is to quantify an individual's hearing threshold level for speech. Clinically, the primary purpose of a speech threshold is to serve as a validity check for the pure tone audiogram. Experimental evidence obtained from 100 ears with varying degrees, configurations, and types of hearing loss ( Wilson et al., 1973 ) indicates that minimal differences exist between thresholds for spondaic words and averages of pure tone thresholds (0.3–3.1 dB). Pure tone averages were calculated using three methods based on thresholds at 500, 1000, and/or 2000 Hz; X loss at the three frequencies ( Fletcher, 1929 ), X loss at the two frequencies with best sensitivity ( Fletcher, 1950 ), and X loss at 500 and 1000 Hz minus 2 dB (Carhart, 1971). Further, correlation coefficients among the speech threshold and pure tone averages were extremely high (0.95–0.98). The high correlation between thresholds for speech and pure tones, as well as the minimal differences between them, confirm the value of using the speech recognition threshold to validate the pure tone average, assuming that pure tone thresholds are obtained using the preferred clinical procedure ( Asha, 1978 ). Although for most clinical cases there will be good agreement between the three-frequency pure tone average and the speech recognition threshold, in cases with a sloping loss agreement may be better between the speech recognition threshold and the two-frequency pure tone average ( Fletcher, 1950 ). Disagreement between the speech recognition threshold and pure tone average is an indication of inconsistency in test results. This inconsistency may provide an early indication of pseudohypacusis. It may also be due to test variables such as equipment malfunction or misunderstanding of the instructions by the patient. Other factors which can contribute to a discrepancy include developmental level, irregular auditory sensitivity ( Berlin, Wexler, Jerger, Halperin, & Smith, 1978 ; Roeser, 1982 ), or the presence of a cognitive, language or central auditory disorder. The speech threshold can also be useful during evaluation of difficult-to-test individuals. It may be used in audiological rehabilitation, particularly in hearing aid evaluations.

If one chooses to measure a speech threshold, then these guidelines present a standardized measurement method that has been statistically validated and should yield a speech recognition threshold that agrees closely with the pure tone average The purpose of these guidelines is to recommend a simple, rapid, statistically based descending procedure for determining the speech recognition threshold and to define common terminology associated with its use. In some cases, however, such as suspected pseudo-hypacusis, an ascending procedure may be more appropriate and can be used. The procedures described in these guidelines are usable in a variety of clinical circumstances; however, certain individuals such as young children and mentally disabled, uncooperative, or neurologically disabled individuals may require modification of the procedure. Modifications should be noted in recording and reporting the results.

Speech Threshold Definitions

Speech Recognition Threshold (SRT). The speech recognition threshold is the minimum hearing level for speech (see ANSI S3.6-1969 standard or subsequent superseding standards) at which an individual can recognize 50% of the speech material. A recognition task is one in which the subject selects the test item from a closed set of choices. The individual should repeat or in some other way indicate recognition of the speech material 50% of the time. The term speech recognition threshold is synonymous with speech reception threshold. Speech recognition threshold is the preferred term because it more accurately describes the listener's task. Spondaic words are the usual and recommended test material for the speech recognition threshold, Spondaic words are two-syllable words with equal stress on both syllables. It should be noted that other test materials can be used. If so, then the test material should be noted in recording and reporting the results.

Spondee Threshold (ST). Spondee threshold also refers to a speech recognition threshold obtained with spondaic words. This is not a preferred term because it does not describe recognition or reception of the material.

Speech Detection Threshold (SDT). The speech detection threshold is the minimum hearing level for speech at which an individual can just discern the presence of a speech material 50% of the time. The listener does not have to identify the material as speech, but must indicate awareness of the presence of sound. The material used to obtain a speech detection threshold should be noted in recording and reporting the results.

Speech Awareness Threshold (SAT). The speech awareness threshold is a commonly used synonymous term for speech detection threshold. Speech detection threshold is the more accurate term because it specifies the listener's task.

Instrumentation and Calibration . Speech threshold audiometry shall be accomplished with a speech audiometer or diagnostic audiometer capable of transducing speech as defined and calibrated according to the American National Standard Specifications for Audiometers (ANSI S3.6-1969, or subsequent superseding standards). The reader is referred to Asha ( 1987 ) for a review of recommended procedures for calibration of speech signals delivered via earphones.

Test Environment . The test environment shall meet the criteria for background noise in audiometric rooms as specified by the American National Standard Criteria for Permissible Ambient Noise During Audiometric Testing (ANSI 53.1-1977 or subsequent superseding standards).

Test Material . Spondaic words are the standard test materials for determination of the speech recognition threshold. An alphabetical list of 36 spondaic words, appropriate for adults, is presented in Appendix A . Appendix B presents 15 homogeneous words from Auditec recordings of CID W-1 ( Young, Dudley, & Gunter, 1982 ). These words are homogeneous in terms of audibility in those specific recordings. Recommended procedures for determining homogeneity of other tape-recorded lists are described in Wilson and Margolis ( 1983 ) and Young et al. ( 1982) . Numerous variables associated with monitored live voice testing renders exact specification of homogeneity impossible with this procedure.

Appendix C presents a list of spondaic words appropriate for most children aged 5 to 12 years. These words can be represented pictorially, and if so, would be appropriate for children under age 6, depending on their capabilities.

There may be circumstances or individuals that require a modification of the standard word list, in which case alternative test materials would be used. The selection of such materials should be made with consideration of the person under test. Some factors to consider are age, language facility, and the physical condition of the client. Different lists of spondaic words may be required for different clinical populations and to accommodate certain physical or developmental limitations. It should be recognized, however, that the use of speech stimuli with less homogeneity than spondaic words may compromise the reliability of this measure.

When circumstances or individual capabilities prevent determination of a speech recognition threshold, the speech detection threshold may be determined instead. The speech detection threshold (in dB) should be consistent with the best pure tone threshold (in dB) between 250 and 4000 Hz ( Olsen & Matkin, 1979 ) and should also be obtained at levels 8–9 dB weaker than the speech recognition threshold ( Chaiklin, 1959 ). The type of speech material is not as critical for this measure because it reflects detection and not recognition. Some common materials are speech babble, running speech, or familiar words. Nevertheless, specification of the type of material helps to ensure test-retest reliability and may be useful information for future hearing evaluations.

Response Mode . The usual response mode for obtaining the speech recognition threshold is repetition of the stimulus item. For many patients it is not possible to obtain verbal responses, necessitating the use of alterative response modes. Many alternatives are acceptable but must convey recognition of test items from a closed set of choices. For example, response modes can take the form of picture pointing, signing, or visual scanning. In addition, if a picture-pointing task is used for obtaining the speech recognition threshold in children, then the clinician should be cautious in choosing the number of response items. Too few items increases the probability of chance performance and too many items may be distracting and increase response time (e.g., between 8 and 12 words usually is appropriate).

For assessing the speech detection threshold, a number of response modes can be used to convey signal detection. Usually, these response modes are non-verbal. Whenever a response mode other than repetition of a spondaic word is used, it should be specified in recording and reporting the results.

Recorded vs. Live Voice Presentation of the Test Material . Either a recorded or a monitored live voice technique can be used to obtain the speech threshold. Recorded presentation of the test material is the preferred procedure. The use of recorded material standardizes the composition and presentation of the test list. It allows for better control of the intensity of the test items and ensures that the speech pattern of the recorded talker will be consistent to each client. In other words, recorded presentation is preferred because the stimuli are consistent to each patient tested with a given set of recorded test materials. It must be remembered that phonographic recordings and tape recordings become worn after extensive use, introducing distortion and noise into the test system. The audiologist must be alert to such problems and periodically replace phonograph records or tape recordings. Further, cartridge needles must be replaced periodically, and tape playback units must be cleaned and demagnetized regularly. Many of these problems may be obviated by use of digitized speech recordings.

The use of recorded test materials may limit flexibility of the test procedure in terms of selection of test words and rate of presentation. Certain clinical situations arise which favor use of monitored live voice presentation. The disadvantages of live voice presentation are the problems and difficulty in monitoring the test words to a consistent hearing level. In addition, it is impossible to present each spondaic word in the same manner to every client, even if each syllable of each spondaic word peaks at 0 dB on the VU-meter. When monitored live voice is used, it should be noted with the test results.

Recording of Results . The speech recognition threshold or speech detection threshold shall be recorded in dB HL. The results should be recorded for each ear on the same form that contains the client's results for pure tone audiometry. Additional space should be available to report other pertinent information that describes the test situation, such as alternative materials or response modes.

Masking of Nontest Ear . When the obtained speech recognition threshold (or speech defection threshold) in one ear exceeds the apparent speech recognition threshold (or speech detection threshold) or a pure tone bone conduction threshold at either 500, 1000, 2000 or 4000 Hz in the contralateral ear by 40 dB or more, masking should be applied to the nontest ear. Of course, the criteria for the use of masking should consider the signal's spectrum and transducer. The appropriate masker for a speech stimulus must have a wideband spectrum (e.g., white noise or speech-spectrum noise). The level of effective masking used should be sufficient to eliminate reception by the nontest ear without causing overmasking and should be recorded on the same form as that used to record audiometric results.

The basic procedure consists of instructions, familiarization, a single series of descending threshold determination, and calculation of threshold hearing level.

Instructions . The specific wording of the instructions must be phrased in language appropriate to the client and should

Orient the client to the nature of the task,

Specify the client's mode of response.

Indicate that the test material is speech and specify that the client should respond with only words from the test list, and

Stress the need for the client to respond at faint listening levels and encourage the client to guess.

Familiarization . The first step in the testing procedure is to familiarize the client with the exact spondaic words in the word list. This necessary step ensures that

The test vocabulary is familiar to the client,

The client can auditorily recognize each test word, and

The client's responses can be accurately interpreted by the clinician.

The audiologist may read the test list to the client in a face-to-face situation or present the test list through a speech audiometer. In either case, visual cues should be eliminated during familiarization with the test words. The client repeats or in some other way demonstrates recognition of each word on the list.

The audiologist should emphasize that the client is to respond only with words from the test list. If the client has any difficulty understanding or responding to any spondaic word, then that word should be eliminated from the test list. Any spondaic word that the audiologist has any difficulty understanding should be eliminated from the test list.

Familiarization with the test list is essential to control for the effects of prior knowledge of test vocabulary on the speech recognition threshold ( Tillman & Jerger, 1959 ). It should not be eliminated from the procedure.

Descending Threshold Determination . The method described in this document closely follows the procedures originally used in PAL Auditory Test Number 9 ( Hudgins et al., 1947 ) and CID W-2 recordings ( Hirsh et al., 1952 ). The basic procedure, which was described by Wilson et al. ( 1973 ), involves a preliminary phase and a test phase. During the test phase, different spondaic word pairs are presented at 2 dB decrements until at least five of the last six test words are missed.

Threshold for the hearing level of speech is calculated to estimate the 50% point on the psychometric function. When variations in the standard technique are used, the nature of the variation should be recorded with the results. The current procedure is a 2 dB descending approach but can be modified to a 5 dB descending approach. (Footnotes detail modifications for using a 5 dB rather than a 2 dB descending approach.)

Preliminary Phase to Obtain Starting Level

Set the hearing level to 30–40 dB above the estimated speech recognition threshold and present one spondaic word to the client. [1] If the response is correct, then descend in 10 dB decrements, presenting one spondaic word at each level until the client responds incorrectly. If the client does not respond correctly to the first spondaic word at the first level, then increase the level in 20 dB steps until a correct response is obtained ( Martin & Stauffer. 1975 ). Then initiate the 10 dB decrements ( Martin & Stauffer, 1975 ). In cases where a speech recognition threshold cannot be estimated prior to testing, the procedure for determining a starting level reported by Martin and Stauffer ( 1975 ) may be used. [2]

When one word is missed, present a second spondaic word at the same level. Continue this process of descending in 10 dB steps until a level is reached at which two consecutive words are missed at the same hearing level.

Increase the level by 10 dB (above the level at which two spondaic words were missed). This defines the starting level .

Present two spondaic words at the starting level and at each successive 2 dB decrement. [3]

Continue this process if five out of the first six words are repeated correctly. If this criterion is not met, then increase the starting level by 4–10 dB.

The descending series is terminated when the client responds incorrectly to five of the last six words presented. [4]

Figure 1 presents a worksheet for tallying responses and calculating the speech recognition threshold for both 2 dB and 5 dB step sizes, using this formula.

Speech recognition thresholds determined with this procedure and calculation method provide standardization and therefore reduce variability in threshold estimates. An ascending procedure, which may be warranted in certain instances, is described in Footnote [6] .

Determination of the speech detection threshold involves a detection task that is similar to the one used in pure tone threshold audiometry. Stimulus familiarization is unnecessary. Test technique should follow the one used for pure tone threshold estimation, including appropriate modification for the client's capabilities (see ASHA Guidelines for Manual Pure Tone Threshold Audiometry, 1978 ).

American National Standards Institute. (1970). American National Standard Specifications for Audiometers (S3.6-1969) . New York: American National Standards Institute.

American National Standards Institute. (1977). American Standard Criteria for Permissible Ambient Noise During Audiometric Testing (S3.1-1977) . New York: American National Standards Institute.

American Speech-Language-Hearing Association. (1987). Calibration of speech signals delivered via earphones. Asha, 29 (6), 44–48.

American Speech-Language-Hearing Association. (1978). Guidelines for manual pure tone threshold audiometry. Asha, 20 , 297–301.

American Speech-Language-Hearing Association. (1979). Guidelines for determining the threshold level for speech. Asha, 21 , 353–355.

Beattie, R. C., Forrester, P. W., & Ruby, B. K. (1977). Reliability of the Tillman-Olsen procedure for determination of spondaic word threshold using recorded and live voice presentation. Journal of the American Audiological Society, 2 , 159–162.

Berlin, C. I., Wexler, K. F., Jerger, J. F., Halperin, H. R., & Smith, S. (1978). Superior ultra-audiometric hearing: a new type of hearing loss which correlates highly with unusually good speech in the “profoundly deaf”. Otolaryngology, 86 , 111–116.

Chaiklin, J. B. (1959). The relation among three selected auditory speech thresholds. Journal of Speech and Hearing Research, 2 , 237–243.

Finney, D. J. (1952). Statistical method in biological assay . London: C. Griffen.

Fletcher, H. (1929). Speech and hearing . New York: Van Nostrand.

Fletcher, H. (1950). A method of calculating hearing loss for speech from an audiogram. Acta Otolaryngologica, 90 (Supplement), 26–37.

Fletcher, H., & Steinberg, J. C. (1929). Articulation testing methods. Bell Telephone Systems Technical Publications, 8 , 806–854.

Frank, T. (1980). Clinical significance of the relative intelligibility of pictorially represented spondee words. Ear and Hearing, 1 , 46–49.

Hirsh, L., Davis, H., Silverman, S., Reynolds, E., Eldert, E., & Benson, R. (1952). Development of materials for speech audiometry. Journal of Speech and Hearing Disorders, 17 , 321–337.

Hudgins, C., Hawkins, J., Karlin, J., & Stevens, S. (1947). The development of recorded auditory tests for measuring hearing loss for speech. Laryngoscope, 57 , 57–89.

Huff, S. J., & Nerbonne, M. A. (1982). Comparison of the American Speech-Language-Hearing Association and revised Tillman-Olsen methods for speech threshold measurement. Ear and Hearing, 3 , 335–339.

Martin, F. N., & Stauffer, M. D. (1975). A modification in the Tillman-Olsen methods for speech threshold measurement. Journal of Speech and Hearing Disorders, 40 , 25–28.

Olsen, W. O., & Markin, N. D. (1979). Speech audiometry. In W. Rintelman (Ed.), Hearing and assessment (pp. 133–206). Baltimore: University Park Press.

Robinson, D., & Koenige, M. J. (1979). Comparisons of procedures and materials for speech reception thresholds. Journal of the American Audiological Society, 4 , 223–230.

Roeser, R. (1982). Moderate-to-severe hearing loss with an island of normal hearing. Ear and Hearing, 3 , 284–286.

Spearman, C. (1908). The method of “right and wrong cases” (“constant stimuli”) without Gauss's formulae. British Journal of Psychology, 2 , 227–242.

Tillman, T. W., & Jerger, J. (1959). Some factors affecting the spondee threshold in normal-hearing subjects. Journal of Speech and Hearing Research, 2 , 141–146.

Tillman, T. W., & Olsen, W. O. (1973). Speech audiometry. In J. Jerger (Ed.), Modern developments in audiology (pp. 37–74). New York: Academic Press.

Ventry, I. (1979). Communication guidelines (letter to editor). Asha, 21 , 639.

Wall, L. G., Davis, L. A., & Myers, D. K. (1984). Four spondee threshold procedures: A comparison. Ear and Hearing, 5 , 171–174.

Wilson, R. H., & Margolis, R. H. (1983). Measurement of auditory thresholds for speech stimuli. In D. F. Konkle & W. F. Rintelmann (Eds.), Principles of speech audiometry (pp. 79–126). Baltimore: Academic Press.

Wilson, R., Morgan, D., & Kirks, D. (1973). A proposed SRT procedure and its statistical precedent. Journal of Speech and Hearing Disorders, 38 , 184–191.

Young, L. L., Dudley, B., & Gunter, M. D. (1982). Thresholds and psychometric functions of the individual spondaic words. Journal of Speech and Hearing Research, 25 , 586–593.

Table 2. Half Lists of Spondaic Words

These spondaic word lists are revisions of the Central Institute for the Deaf W-1 Auditory Tests, emphasizing the criteria of dissimilarity and homogeneity of audibility ( Asha, 1979 ).

Spondaic words suggested by Young et al. ( 1982 ).

These 20 spondaic words include those recommended by Frank ( 1980 ).

[1] A lower starting level may be required in certain cases of sensorineural hearing loss where tolerance problems may exist.

[2] In the Martin and Stauffer modification, the subject is presented the first spondaic word at 50 db HL, rather than at 30–40 dB above an estimated speech recognition threshold.

[3] An acceptable alternative is to present five words in 5 dB steps.

[4] If five words are presented in 5 dB steps, then the descending series is terminated when all words at a single intensity are not correctly recognized.

[5] For presentation in 5 dB steps, the correction factor is +2 dB ( Wilson et al., 1973 ).

[6] In an ascending procedure, start at a level where five out of five or two out of two items are missed and stop the procedure where five out of five or two out of two items are correct. Scoring is identical to the descending procedures.

Index terms: speech audiometry

Reference this material as: American Speech-Language-Hearing Association. (1988). Determining threshold level for speech [Guidelines]. Available from www.asha.org/policy.

© Copyright 1988 American Speech-Language-Hearing Association. All rights reserved. Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.GL1988-00008

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• Back to Basics: Speech Audiometry

Janet R. Schoepflin, PhD

• Hearing Evaluation - Adults

Editor's Note: This is a transcript of an AudiologyOnline live seminar. Please download supplemental course materials . Speech is the auditory stimulus through which we communicate. The recognition of speech is therefore of great interest to all of us in the fields of speech and hearing. Speech audiometry developed originally out of the work conducted at Bell Labs in the 1920s and 1930s where they were looking into the efficiency of communication systems, and really gained momentum post World War II as returning veterans presented with hearing loss. The methods and materials for testing speech intelligibility were of interest then, and are still of interest today. It is due to this ongoing interest as seen in the questions that students ask during classes, by questions new audiologists raise as they begin their practice, and by the comments and questions we see on various audiology listservs about the most efficient and effective ways to test speech in the clinical setting, that AudiologyOnline proposed this webinar as part of their Back to Basics series. I am delighted to participate. I am presenting a review of the array of speech tests that we use in clinical evaluation with a summary of some of the old and new research that has come about to support the recommended practices. The topics that I will address today are an overview of speech threshold testing, suprathreshold speech recognition testing, the most comfortable listening level testing, uncomfortable listening level, and a brief mention of some new directions that speech testing is taking. In the context of testing speech, I will assume that the environment in which you are testing meets the ANSI permissible noise criteria and that the audiometer transducers that are being used to perform speech testing are all calibrated to the ANSI standards for speech. I will not be talking about those standards, but it's of course important to keep those in mind.

Speech Threshold testing involves several considerations. They include the purposes of the test or the reasons for performing the test, the materials that should be used in testing, and the method or procedure for testing. Purposes of Speech Threshold Testing A number of purposes have been given for speech threshold testing. In the past, speech thresholds were used as a means to cross-check the validity of pure tone thresholds. This purpose lacks some validity because we have other physiologic and electrophysiologic procedures like OAEs and imittance test results to help us in that cross-check. However, the speech threshold measure is a test of hearing. It is not entirely invalid to be performed as a cross-check for pure tone hearing. I think sometimes we are anxious to get rid of things because we feel we have a better handle from other tests, but in this case, it may not be the wisest thing to toss out. Also in past years, speech thresholds were used to determine the level for suprathreshold speech recognition testing. That also lacks validity, because the level at which suprathreshold testing is conducted depends on the reason you are doing the test itself. It is necessary to test speech thresholds if you are going to bill 92557. Aside from that, the current purpose for speech threshold testing is in the evaluation of pediatric and difficult to test patients. Clinical practice surveys tell us that the majority of clinicians do test speech thresholds for all their patients whether it is for billing purposes or not. It is always important that testing is done in the recommended, standardized manner. The accepted measures for speech thresholds are the Speech Recognition Threshold (SRT) and the Speech Detection Threshold (SDT). Those terms are used because they specify the material or stimulus, i.e. speech, as well as the task that the listener is required to do, which is recognition or identification in the case of the SRT, and detection or noticing of presence versus absence of the stimulus in the case of SDT. The terms also specify the criterion for performance which is threshold or generally 50%. The SDT is most commonly performed on those individuals who have been unable to complete an SRT, such as very young children. Because recognition is not required in the speech detection task, it is expected that the SDT will be about 5 to 10 dB better than the SRT, which requires recognition of the material. Materials for Speech Threshold Testing The materials that are used in speech threshold testing are spondees, which are familiar two-syllable words that have a fairly steep psychometric function. Cold running speech or connected discourse is an alternative for speech detection testing since recognition is not required in that task. Whatever material is used, it should be noted on the audiogram. It is important to make notations on the audiogram about the protocols and the materials we are using, although in common practice many of us are lax in doing so. Methods for Speech Threshold Testing The methods consideration in speech threshold testing is how we are going to do the test. This would include whether we use monitored live voice or recorded materials, and whether we familiarize the patient with the materials and the technique that we use to elicit threshold. Monitored live voice and recorded speech can both be used in SRT testing. However, recorded presentation is recommended because recorded materials standardize the test procedure. With live voice presentation, the monitoring of each syllable of each spondee, so that it peaks at 0 on the VU meter can be fairly difficult. The consistency of the presentation is lost then. Using recorded materials is recommended, but it is less important in speech threshold testing than it is in suprathreshold speech testing. As I mentioned with the materials that are used, it is important to note on the audiogram what method of presentation has been used. As far as familiarization goes, we have known for about 50 years, since Tillman and Jerger (1959) identified familiarity as a factor in speech thresholds, that familiarization of the patient with the test words should be included as part of every test. Several clinical practice surveys suggest that familiarization is not often done with the patients. This is not a good practice because familiarization does influence thresholds and should be part of the procedure. The last consideration under methods is regarding the technique that is going to be used. Several different techniques have been proposed for the determination of SRT. Clinical practice surveys suggest the most commonly used method is a bracketing procedure. The typical down 10 dB, up 5 dB is often used with two to four words presented at each level, and the threshold then is defined as the lowest level at which 50% or at least 50% of the words are correctly repeated. This is not the procedure that is recommended by ASHA (1988). The ASHA-recommended procedure is a descending technique where two spondees are presented at each decrement from the starting level. There are other modifications that have been proposed, but they are not widely used.  

Suprathreshold speech testing involves considerations as well. They are similar to those that we mentioned for threshold tests, but they are more complicated than the threshold considerations. They include the purposes of the testing, the materials that should be used in testing, whether the test material should be delivered via monitored live voice or recorded materials, the level or levels at which the testing should be conducted, whether a full list, half list, or an abbreviated word list should be used, and whether or not the test should be given in quiet or noise. Purposes of Suprathreshold Testing There are several reasons to conduct suprathreshold tests. They include estimating the communicative ability of the individual at a normal conversational level; determining whether or not a more thorough diagnostic assessment is going to be conducted; hearing aid considerations, and analysis of the error patterns in speech recognition. When the purpose of testing is to estimate communicative ability at a normal conversational level, then the test should be given at a level around 50 to 60 dBHL since that is representative of a normal conversational level at a communicating distance of about 1 meter. While monosyllabic words in quiet do not give a complete picture of communicative ability in daily situations, it is a procedure that people like to use to give some broad sense of overall communicative ability. If the purpose of the testing is for diagnostic assessment, then a psychometric or performance-intensity function should be obtained. If the reason for the testing is for hearing aid considerations, then the test is often given using words or sentences and either in quiet or in a background of noise. Another purpose is the analysis of error patterns in speech recognition and in that situation, a test other than some open set monosyllabic word test would be appropriate. Materials for Suprathreshold Testing The choice of materials for testing depends on the purpose of the test and on the age and abilities of the patients. The issues in materials include the set and the test items themselves.  

Closed set vs. Open set. The first consideration is whether a closed set or an open set is appropriate. Closed set tests limit the number of response alternatives to a fairly small set, usually between 4 and 10 depending on the procedure. The number of alternatives influences the guess rate. This is a consideration as well. The Word Intelligibility by Picture Identification or the WIPI test is a commonly used closed set test for children as it requires only the picture pointing response and it has a receptive language vocabulary that is as low as about 5 years. It is very useful in pediatric evaluations as is another closed set test, the Northwestern University Children's Perception of Speech test (NU-CHIPS).

In contrast, the open set protocol provides an unlimited number of stimulus alternatives. Therefore, open set tests are more difficult. The clinical practice surveys available suggest for routine audiometric testing that monosyllabic word lists are the most widely used materials in suprathreshold speech recognition testing for routine evaluations, but sentences in noise are gaining popularity for hearing aid purposes.  

CID W-22 vs. NU-6. The most common materials for speech recognition testing are the monosyllabic words, the Central Institute of the Deaf W-22 and the Northwestern University-6 word list. These are the most common open set materials and there has been some discussion among audiologists concerning the differences between those. From a historical perspective, the CID W-22 list came from the original Harvard PAL-PB50 words and the W-22s are a group of the more familiar of those. They were developed into four 50-word lists. They are still commonly used by audiologists today. The NU-6 lists were developed later and instead of looking for phonetic balance, they considered a more phonemic balance. The articulation function for both of those using recorded materials is about the same, 4% per dB. The NU-6 tests are considered somewhat more difficult than the W-22s. Clinical surveys show that both materials are used by practicing audiologists, with usage of the NU-6 lists beginning to surpass usage of W-22s.

Nonsense materials. There are other materials that are available for suprathreshold speech testing. There are other monosyllabic word lists like the Gardner high frequency word list (Gardner, 1971) that could be useful for special applications or special populations. There are also nonsense syllabic tasks which were used in early research in communication. An advantage of the nonsense syllables is that the effects of word familiarity and lexical constraints are reduced as compared to using actual words as test materials. A few that are available are the City University of New York Nonsense Syllable test, the Nonsense Syllable test, and others.

Sentence materials. Sentence materials are gaining popularity, particularly in hearing aid applications. This is because speech that contains contextual cues and is presented in a noise background is expected to have better predictive validity than words in quiet. The two sentence procedures that are popular are the Hearing In Noise Test (HINT) (Nilsson, Soli,& Sullivan, 1994) and the QuickSIN (Killion, Niquette, Gudmundsen, Revit & Banerjee, 2004). Other sentence tests that are available that have particular applications are the Synthetic Sentence Identification test (SSI), the Speech Perception and Noise test (SPIN), and the Connected Speech test.

Monitored Live Voice vs. Recorded. As with speech threshold testing, the use of recorded materials for suprathreshold speech testing standardizes the test administration. The recorded version of the test is actually the test in my opinion. This goes back to a study in 1969 where the findings said the test is not just the written word list, but rather it is a recorded version of those words.

Inter-speaker and intra-speaker variability makes using recorded materials the method of choice in almost all cases for suprathreshold testing. Monitored live voice (MLV) is not recommended. In years gone by, recorded materials were difficult to manipulate, but the ease and flexibility that is afforded us by CDs and digital recordings makes recorded materials the only way to go for testing suprathreshold speech recognition. Another issue to consider is the use of the carrier phrase. Since the carrier phrase is included on recordings and recorded materials are the recommended procedure, that issue is settled. However, I do know that monitored live voice is necessary in certain situations and if monitored live voice is used in testing, then the carrier phrase should precede the test word. In monitored live voice, the carrier phrase is intended to allow the test word to have its own natural inflection and its own natural power. The VU meter should peak at 0 for the carrier phrase and the test word then is delivered at its own natural or normal level for that word in the phrase.  

Levels. The level at which testing is done is another consideration. The psychometric or performance-intensity function plots speech performance in percent correct on the Y-axis, as a function of the level of the speech signal on the X-axis. This is important because testing at only one level, which is fairly common, gives us insufficient information about the patient's optimal performance or what we commonly call the PB-max. It also does not allow us to know anything about any possible deterioration in performance if the level is increased. As a reminder, normal hearers show a function that reaches its maximum around 25 to 40 dB SL (re: SRT) and that is the reason why suprathreshold testing is often conducted at that level. For normals, the performance remains at that level, 100% or so, as the level increases. People with conductive hearing loss also show a similar function. Individuals with sensorineural hearing loss, however, show a performance function that reaches its maximum at generally less than 100%. They can either show performance that stays at that level as intensity increases, or they can show a curve that reaches its maximum and then decreases in performance as intensity increases. This is known as roll-over. A single level is not the best way to go as we cannot anticipate which patients may have rollover during testing, unless we test at a level higher than where the maximum score was obtained. I recognize that there are often time constraints in everyday practice, but two levels are recommended so that the performance-intensity function can be observed for an individual patient at least in an abbreviated way.

Recently, Guthrie and Mackersie (2009) published a paper that compared several different presentation levels to ascertain which level would result in maximum word recognition in individuals who had different hearing loss configurations. They looked at a number of presentation levels ranging from 10 dB above the SRT to a level at the UCL (uncomfortable listening level) -5 dB. Their results indicated that individuals with mild to moderate losses and those with more steeply sloping losses reached their best scores at a UCL -5 dB. That was also true for those patients who had moderately-severe to severe losses. The best phoneme recognition scores for their populations were achieved at a level of UCL -5 dB. As a reminder about speech recognition testing, masking is frequently needed because the test is being presented at a level above threshold, in many cases well above the threshold. Masking will always be needed for suprathreshold testing when the presentation level in the test ear is 40 dB or greater above the best bone conduction threshold in the non-test ear if supra-aural phones are used.  

Full lists vs. half-lists. Another consideration is whether a full list or a half-list should be administered. Original lists were composed of 50 words and those 50 words were created for phonetic balance and for simplicity in scoring. It made it easy for the test to be scored if 50 words were administered and each word was worth 2%. Because 50-word lists take a long time, people often use half-lists or even shorter lists for the purpose of suprathreshold speech recognition testing. Let's look into this practice a little further.

An early study was done by Thornton and Raffin (1978) using the Binomial Distribution Model. They investigated the critical differences between one score and a retest score that would be necessary for those scores to be considered statistically significant. Their findings showed that with an increasing set size, variability decreased. It would seem that more items are better. More recently Hurley and Sells (2003) conducted a study that looked at developing a test methodology that would identify those patients requiring a full 50 item suprathreshold test and allow abbreviated testing of patients who do not need a full 50 item list. They used Auditec recordings and developed 10-word and 25-word screening tests. They found that the four lists of NU-6 10-word and the 25-word screening tests were able to differentiate listeners who had impaired word recognition who needed a full 50-word list from those with unimpaired word recognition ability who only needed the 10-word or 25-word list. If abbreviated testing is important, then it would seem that this would be the protocol to follow. These screening lists are available in a recorded version and their findings were based on a recorded version. Once again, it is important to use recorded materials whether you are going to use a full list or use an abbreviated list.  

Quiet vs. Noise. Another consideration in suprathreshold speech recognition testing is whether to test in quiet or in noise. The effects of sensorineural hearing loss beyond the threshold loss, such as impaired frequency resolution or impaired temporal resolution, makes speech recognition performance in quiet a poor predictor for how those individuals will perform in noise. Speech recognition in noise is being promoted by a number of experts because adding noise improves the sensitivity of the test and the validity of the test. Giving the test at several levels will provide for a better separation between people who have hearing loss and those who have normal hearing. We know that individuals with hearing loss have a lot more difficulty with speech recognition in noise than those with normal hearing, and that those with sensorineural hearing loss often require a much greater signal-to-noise ratio (SNR), 10 to 15 better, than normal hearers.

Monosyllabic words in noise have not been widely used in clinical evaluation. However there are several word lists that are available. One of them is the Words in Noise test or WIN test which presents NU-6 words in a multi-talker babble. The words are presented at several different SNRs with the babble remaining at a constant level. One of the advantages of using these kinds of tests is that they are adaptive. They can be administered in a shorter period of time and they do not run into the same problems that we see with ceiling effects and floor effects. As I mentioned earlier, sentence tests in noise have become increasingly popular in hearing aid applications. Testing speech in noise is one way to look at amplification pre and post fitting. The Hearing in Noise Test and QuickSin, have gained popularity in those applications. The HINT was developed by Nilsson and colleagues in 1994 and later modified. It is scored as the dB to noise ratio that is necessary to get a 50% correct performance on the sentences. The sentences are the BKB (Bamford-Kowal-Bench) sentences. They are presented in sets of 10 and the listener listens and repeats the entire sentence correctly in order to get credit. In the HINT, the speech spectrum noise stays constant and the signal level is varied to obtain that 50% point. The QuickSin is a test that was developed by Killion and colleagues (2004) and uses the IEEE sentences. It has six sentences per list with five key words that are the scoring words in each sentence. All of them are presented in a multi-talker babble. The sentences get presented one at a time in 5 dB decrements from a high positive SNR down to 0 dB SNR. Again the test is scored as the 50% point in terms of dB signal-to-noise ratio. The guide proposed by Killion on the SNR is if an individual has somewhere around a 0 to 3 dB SNR it would be considered normal, 3 to 7 would be a mild SNR loss, 7 to15 dB would be a moderate SNR loss, and greater than 15 dB would be a severe SNR loss.  

Scoring. Scoring is another issue in suprathreshold speech recognition testing. It is generally done on a whole word basis. However phoneme scoring is another option. If phoneme scoring is used, it is a way of increasing the set size and you have more items to score without adding to the time of the test. If whole word scoring is used, the words have to be exactly correct. In this situation, being close does not count. The word must be absolutely correct in order to be judged as being correct. Over time, different scoring categorizations have been proposed, although the percentages that are attributed to those categories vary among the different proposals.

The traditional categorizations include excellent, good, fair, poor, and very poor. These categories are defined as:  

• Excellent or within normal limits = 90 - 100% on whole word scoring
• Good or slight difficulty = 78 - 88%
• Fair to moderate difficulty = 66 - 76%
• Poor or great difficulty = 54 - 64 %
• Very poor is < 52%

A very useful test routinely administered to those who are being considered for hearing aids is the level at which a listener finds listening most comfortable. The materials that are used for this are usually cold running speech or connected discourse. The listener is asked to rate the level at which listening is found to be most comfortable. Several trials are usually completed because most comfortable listening is typically a range, not a specific level or a single value. People sometimes want sounds a little louder or a little softer, so the range is a more appropriate term for this than most comfortable level. However whatever is obtained, whether it is a most comfortable level or a most comfortable range, should be recorded on the audiogram. Again, the material used should also be noted on the audiogram. As I mentioned earlier the most comfortable level (MCL) is often not the level at which a listener achieves maximum intelligibility. Using MCL in order to determine where the suprathreshold speech recognition measure will be done is not a good reason to use this test. MCL is useful, but not for determining where maximum intelligibility will be. The study I mentioned earlier showed that maximum intelligibility was reached for most people with hearing loss at a UCL -5. MCL is useful however in determining ANL or acceptable noise level.  

The uncomfortable listening level (UCL) is also conducted with cold running speech. The instructions for this test can certainly influence the outcome since uncomfortable or uncomfortably loud for some individuals may not really be their UCL, but rather a preference for listening at a softer level. It is important to define for the patient what you mean by uncomfortably loud. The utility of the UCL is in providing an estimate for the dynamic range for speech which is the difference between the UCL and the SRT. In normals, this range is usually 100 dB or more, but it is reduced in ears with sensorineural hearing loss often dramatically. By doing the UCL, you can get an estimate of the individual's dynamic range for speech.  

Acceptable Noise Level (ANL) is the amount of background noise that a listener is willing to accept while listening to speech (Nabelek, Tucker, & Letowski, 1991). It is a test of noise tolerance and it has been shown to be related to the successful use of hearing aids and to potential benefit with hearing aids (Nabelek, Freyaldenhoven, Tampas, & Muenchen, 2006). It uses the MCL and a measure known as BNL or background noise level. To conduct the test, a recorded speech passage is presented to the listener in the sound field for the MCL. Again note the use of recorded materials. The noise is then introduced to the listener to a level that will be the highest level that that person is able to accept or "put up with" while they are listening to and following the story in the speech passage. The ANL then becomes the difference between the MCL and the BNL. Individuals that have very low scores on the ANL are considered successful hearing aid users or good candidates for hearing aids. Those that have very high scores are considered unsuccessful users or poor hearing aid candidates. Obviously there are number of other applications for speech in audiologic practice, not the least of which is in the assessment of auditory processing. Many seminars could be conducted on this topic alone. Another application or future direction for speech audiometry is to more realistically assess hearing aid performance in "real world" environments. This is an area where research is currently underway.  

Question: Are there any more specific instructions for the UCL measurement? Answer: Instructions are very important. We need to make it clear to a patient exactly what we expect them to do. I personally do not like things loud. If I am asked to indicate what is uncomfortably loud, I am much below what is really my UCL. I think you have to be very direct in instructing your patients in that you are not looking for a little uncomfortable, but where they just do not want to hear it or cannot take it. Question: Can you sum up what the best methods are to test hearing aid performance? I assume this means with speech signals. Answer: I think the use of the HINT or the QuickSin would be the most useful on a behavioral test. We have other ways of looking at performance that are not behavioral. Question: What about dialects? In my area, some of the local dialects have clipped words during speech testing. I am not sure if I should count those as correct or incorrect. Answer: It all depends on your situation. If a patient's production is really reflective of the dialect of that region and they are saying the word as everyone else in that area would say it, then I would say they do have the word correct. If necessary, if you are really unclear, you can always ask the patient to spell the word or write it down. This extra time can be inconvenient, but that is the best way to be sure that they have correctly identified the word. Question: Is there a reference for the bracketing method? Answer: The bracketing method is based on the old modified Hughson-Westlake that many people use for pure tone threshold testing. It is very similar to that traditional down 10 dB, up 5 dB. I am sure there are more references, but the Hughson-Westlake is what bracketing is based on. Question: Once you get an SRT result, if you want to compare it to the thresholds to validate your pure tones, how do you compare it to the audiogram? Answer: If it is a flat hearing loss, then you can compare to the 3-frequency pure tone average (PTA). If there is a high frequency loss, where audibility at perhaps 2000 Hz is greatly reduced, then it is better to use just the average of 500Hz and 1000Hz as your comparison. If it is a steeply sloping loss, then you look for agreement with the best threshold, which would probably be the 500 Hz threshold. The reverse is also true for patients who have rising configurations. Compare the SRT to the best two frequencies of the PTA, if the loss has either a steep slope or a steep rise, or the best frequency in the PTA if it is a really precipitous change in configuration. Question: Where can I find speech lists in Russian or other languages? Answer: Auditec has some material available in languages other than English - it would be best to contact them directly. You can also view their catalog at www.auditec.com Carolyn Smaka: This raises a question I have. If an audiologist is not fluent in a particular language, such as Spanish, is it ok to obtain a word list or recording in that language and conduct speech testing? Janet Schoepflin: I do not think that is a good practice. If you are not fluent in a language, you do not know all the subtleties of that language and the allophonic variations. People want to get an estimation of suprathreshold speech recognition and this would be an attempt to do that. This goes along with dialect. Whether you are using a recording, or doing your best to say these words exactly as there are supposed to be said, and your patient is fluent in a language and they say the word back to you, since you are not familiar with all the variations in the language it is possible that you will score the word incorrectly. You may think it is correct when it is actually incorrect, or you may think it is incorrect when it is correct based on the dialect or variation of that language. Question: In school we were instructed to use the full 50-word list for any word discrimination testing at suprathreshold, but if we are pressed for time, a half word list would be okay. However, my professor warned us that we absolutely must go in order on the word list. Can you clarify this? Answer: I'm not sure why that might have been said. I was trained in the model to use the 50-word list. This was because the phonetic balance that was proposed for those words was based on the 50 words. If you only used 25 words, you were not getting the phonetic balance. I think the more current findings from Hurley and Sells show us that it is possible to use a shorter list developed specifically for this purpose. It should be the recorded version of those words. These lists are available through Auditec. Question: On the NU-6 list, the words 'tough' and 'puff' are next to each other. 'Tough' is often mistaken for 'puff' so then when we reads 'puff', the person looks confused. Is it okay to mix up the order on the word list? Answer: I think in that case it is perfectly fine to move that one word down. Question: When do you recommend conducting speech testing, before or after pure tone testing? Answer: I have always been a person who likes to interact with my patients. My own procedure is to do an SRT first. Frequently for an SRT I do use live voice. I do not use monitored live voice for suprathreshold testing. It gives me a time to interact with the patient. People feel comfortable with speech. It is a communicative act. Then I do pure tone testing. Personally I would not do suprathreshold until I finished pure tone testing. My sequence is often SRT, pure tone, and suprathreshold. If this is not a good protocol for you based on time, then I would conduct pure tone testing, SRT, and then suprathreshold. Question: Some of the spondee words are outdated such as inkwell and whitewash. Is it okay to substitute other words that we know are spondee words, but may not be on the list? Or if we familiarize people, does it matter? Answer: The words that are on the list were put there for their so-called familiarity, but also because they were somewhat homogeneous and equal in intelligibility. I think inkwell, drawbridge and whitewash are outdated. If you follow a protocol where you are using a representative sample of the words and you are familiarizing, I think it is perfectly fine to eliminate those words you do not want to use. You just do not want to end up only using five or six words as it will limit the test set. Question: At what age is it appropriate to expect a child to perform suprathreshold speech recognition testing? Answer: If the child has a receptive language age of around 4 or 5 years, even 3 years maybe, it is possible to use the NU-CHIPS as a measure. It really does depend on language more than anything else, and the fact that the child can sit still for a period of time to do the test. Question: Regarding masking, when you are going 40 dB above the bone conduction threshold in the non-test ear, what frequency are you looking at? Are you comparing speech presented at 40 above a pure tone average of the bone conduction threshold? Answer: The best bone conduction threshold in the non-test ear is what really should be used. Question: When seeing a patient in follow-up after an ENT prescribes a steroid therapy for hydrops, do you recommend using the same word list to compare their suprathreshold speech recognition? Answer: I think it is better to use a different list, personally. Word familiarity as we said can influence even threshold and it certainly can affect suprathreshold performance. I think it is best to use a different word list. Carolyn Smaka: Thanks to everyone for their questions. Dr. Schoepflin has provided her email address with the handout. If your question was not answered or if you have further thoughts after the presentation, please feel free to follow up directly with her via email. Janet Schoepflin: Thank you so much. It was my pleasure and I hope everyone found the presentation worthwhile.

American Speech, Language and Hearing Association. (1988). Determining Threshold Level for Speech [Guidelines]. Available from www.asha.org/policy Gardner, H.(1971). Application of a high-frequency consonant discrimination word list in hearing-aid evaluation. Journal of Speech and Hearing Disorders, 36 , 354-355. Guthrie, L. & Mackersie, C. (2009). A comparison of presentation levels to maximize word recognition scores. Journal of the American Academy of Audiology, 20 (6), 381-90. Hurley, R. & Sells, J. (2003). An abbreviated word recognition protocol based on item difficulty. Ear & Hearing, 24 (2), 111-118. Killion, M., Niquette, P., Gudmundsen, G., Revit, L., & Banerjee, S. (2004). Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal-hearing and hearing-impaired listeners. Journal of the Acoustical Society of America, 116 (4 Pt 1), 2395-405. Nabelek, A., Freyaldenhoven, M., Tampas, J., Burchfield, S., & Muenchen, R. (2006). Acceptable noise level as a predictor of hearing aid use. Journal of the American Academy of Audiology, 17 , 626-639. Nabelek, A., Tucker, F., & Letowski, T. (1991). Toleration of background noises: Relationship with patterns of hearing aid use by elderly persons. Journal of Speech and Hearing Research, 34 , 679-685. Nilsson, M., Soli. S,, & Sullivan, J. (1994). Development of the hearing in noise test for the measurement of speech reception thresholds in quiet and in noise. Journal of the Acoustical Society of America, 95 (2), 1085-99. Thornton, A.. & Raffin, M, (1978). Speech-discrimination scores modeled as a binomial variable. Journal of Speech and Hearing Research, 21 , 507-518. Tillman, T., & Jerger, J. (1959). Some factors affecting the spondee threshold in normal-hearing subjects. Journal of Speech and Hearing Research, 2 , 141-146.

Chair, Communication Sciences and Disorders, Adelphi University

Janet Schoepflin is an Associate Professor and Chair of the Department of Communication Sciences and Disorders at Adelphi University and a member of the faculty of the Long Island AuD Consortium.  Her areas of research interest include speech perception in children and adults, particularly those with hearing loss, and the effects of noise on audition and speech recognition performance.

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Speech Audiometry

Audiometry guides, introduction.

Speech audiometry is an important component of a comprehensive hearing evaluation. There are several kinds of speech audiometry, but the most common uses are to 1) verify the pure tone thresholds 2) determine speech understanding and 3) determine most comfortable and uncomfortable listening levels. The results are used with the other tests to develop a diagnosis and treatment plan.

SDT = Speech Detection Threshold, SAT = Speech Awareness Threshold.   These terms are interchangeable and they describe the lowest level at which a patient can hear the presence of speech 50% of the time.   They specifically refer to the speech being AUDIBLE, not INTELLIGIBLE.

This test is performed by presenting spondee (two-syllable) words such as baseball, ice cream, hotdog and the patient is to respond when they hear the speech.   This is often used with non-verbal patients such as infants or other difficult to test populations.   The thresholds should correspond to the PTA and is used to verify the pure tone threshold testing.    

How to Test:      

Instruct the patient that he or she will be hearing words that have two parts, such as “mushroom” or “baseball.” The patient should repeat the words and if not sure, he or she should not be afraid to guess.

Using either live voice or recorded speech, present the spondee word lists testing the better ear first. Start 20 dB above the 1000 Hz pure tone threshold level. Present one word on the list and, if the response is correct, lower the level by 5 dB. Continue until the patient has difficulty with the words. When this occurs, present more words for each 5 dB step.

Speech Reception Threshold (SRT)

SRT, or speech reception threshold, is a fast way to    help verify that the pure tone thresholds are valid. Common compound words - or spondee words - are presented at varying degrees of loudness until it is too soft for the patient to hear. SRT scores are compared to the pure tone average as part of the cross check principle.   When these two values agree, the reliability of testing is improved.

Word Recognition

Instruct the patient that he or she is to repeat the words presented. Using either live voice or recorded speech, present the standardized PB word list of your choice. Present the words at a level comfortable to the patient; at least 30 dB and generally 35 to 50 dB above the 1000 Hz pure tone threshold. Using the scorer buttons on the front panel, press the “Correct” button each time the right response is given and the “Incorrect” button each time a wrong response is given.

The Discrimination Score is the percentage of words repeated correctly: Discrimination % at HL = 100 x Number of Correct Responses/Number of Trials.

WRS = Word Recognition Score, SRS = Speech Reception Score, Speech Discrimination Score.   These terms are interchangeable and describe the patient’s capability to correctly repeat a list of phonetically balanced (PB) words at a comfortable level.   The score is a percentage of correct responses and indicates the patient’s ability to understand speech.

Word Recognition Score (WRS)

WRS, or word recognition score, is a type of speech audiometry that is designed to measure speech understanding. Sometimes it is called word discrimination. The words used are common and phonetically balanced and typically presented at a level that is comfortable for the patient. The results of WRS can be used to help set realistic expectations and formulate a treatment plan.

Speech In Noise Test

Speech in noise testing is a critical component to a comprehensive hearing evaluation. When you test a patient's ability to understand speech in a "real world setting" like background noise, the results influence the diagnosis, the recommendations, and the patient's understanding of their own hearing loss.

Auditory Processing

Sometimes, a patient's brain has trouble making sense of auditory information. This is called an auditory processing disorder. It's not always clear that this lack of understanding is a hearing issue, so it requires a very specialized battery of speech tests to identify what kind of processing disorder exists and develop recommendations to improve the listening and understanding for the patient.

QuickSIN is a quick sentence in noise test that quantifies how a patient hears in noise. The patient repeats sentences that are embedded in different levels of restaurant noise and the result is an SNR loss - or Signal To Noise ratio loss.   Taking a few additional minutes to measure the SNR loss of every patient seen in your clinic provides valuable insights on the overall status of the patient' s auditory system and allows you to counsel more effectively about communication in real-world situations. Using the Quick SIN to make important decisions about hearing loss treatment and rehabilitation is a key differentiator for clinicians who strive to provide patient-centered care.

BKB-SIN is a sentence in noise test that quantifies how patients hear in noise. The patient repeats sentences that are embedded in different levels of restaurant noise an the result is an SNR loss - or signal to noise ratio loss. This test is designed to evaluate patients of many ages and has normative corrections for children and adults. Taking a few additional minutes to measure the SNR loss of every patient seen in your clinic is a key differentiator for clinicians who strive to provide patient-centered care.

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Speech Audiometry

Speech audiometry involves two different tests:

One checks how loud speech needs to be for you to hear it.

The other checks how clearly you can understand and distinguish different words when you hear them spoken.

What Happens During the Test

The tests take 10-15 minutes. You are seated in a sound booth and wear headphones. You will hear a recording of a list of common words spoken at different volumes, and be asked to repeat those words.

Your audiologist will ask you to repeat a list of words to determine your speech reception threshold (SRT) or the lowest volume at which you can hear and recognize speech.

Then, the audiologist will measure speech discrimination — also called word recognition ability. He or she will either say words to you or you will listen to a recording, and then you will be asked to repeat the words. The audiologist will measure your ability to understand speech at a comfortable listening level.

Getting Speech Audiology Test Results

The audiologist will share your test results with you at the completion of testing. Speech discrimination ability is typically measured as a percentage score.

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Speech Reception Threshold (SRT)

What is the speech reception threshold (srt).

Speech reception threshold (SRT) is a measure of hearing ability that is used to assess the lowest intensity level at which an individual can repeat familiar two-syllable words, known as spondee words, more than half of the time. Spondee words are chosen because they are easy to understand and are not affected by the pitch or voice quality of the speaker.

• How is SRT performed?

SRT is performed by a hearing healthcare professional using a calibrated audiometer. The audiometer presents a series of spondee words at different intensity levels, starting at a very soft level and gradually increasing in volume. The individual is asked to repeat each word as they hear it. The lowest intensity level at which the individual can repeat 50% of the words correctly is their SRT.

• What is the difference between SRT and speech discrimination?

SRT and speech discrimination are two different measures of hearing ability. SRT measures the lowest intensity level at which an individual can hear speech, while speech discrimination measures the ability to understand speech in noise. Speech discrimination is typically measured using a test of word recognition, in which the individual is asked to identify a list of words presented at a fixed intensity level.

• What is a normal speech recognition score?

A normal speech recognition score is typically considered to be 90% or higher. However, this can vary depending on the age of the individual and the type of hearing loss they have.

• What is a good SRT score?

A good SRT score is typically considered to be 20 dB HL or lower. However, this can vary depending on the age of the individual and the type of hearing loss they have.

SRT is a valuable measure of hearing ability that can help to assess the severity of hearing loss and the need for hearing amplification. It is also a useful tool for monitoring the progression of hearing loss over time.

If you are concerned about your hearing, you should talk to your doctor or a hearing healthcare professional. They can perform a hearing test, including SRT, to assess your hearing ability and recommend the best course of treatment.

©2024 Ask An Audiologist. All rights reserved.

Speech Detection Thresholds – Procedure and Application

Speech Detection Thresholds – Procedure and Application:  The threshold for speech can mean the lowest level at which speech is either just audible or just intelligible. The lowest level at which the presence of a speech signal can be heard 50% of the time is called the speech detection threshold (SDT) or the speech awareness threshold (SAT).

Purpose of speech detection thresholds:

• To assess the awareness of the presence of sound and to confirm the client’s thresholds.
• The speech detection threshold is generally used when an SRT (speech reception threshold) is not obtainable.
• This test is to be performed only when we can`t perform SRT (speech reception threshold), for individuals who are not able to repeat words such as non cooperative patient, testing in their second / foreign language and the stroke victims etc.

Materials for speech detection thresholds:

• The type of speech material is not as critical because it reflects detection and not recognition. Some common materials are speech babble, cold running speech (speech which doesn’t change intonation), or familiar words.
• Running speech and sentences are more preferable. Nevertheless, specification of the type of material helps to ensure test-retest reliability and may be useful information for future hearing evaluations.

Procedure of speech detection thresholds:

• Determination of the SDT involves a detection task that is similar to the one used in pure tone threshold audiometry .
• Stimulus familiarization is unnecessary.
• No specific steps ( ascending – ascending “10 dB up & 5 dB down or descending method – “10 dB down & 5 dB up” ).
• The test can be conducted through head phone or speakers.
• Response mode: A number of response modes can be used to convey signal detection even without repeating it correctly by verbal, hand signal, or push the buttons. Usually, these response modes are nonverbal.

Interpretation of speech detection thresholds:

• The SDT shall be recorded in dB HL. The results should be recorded for each ear on the same form that contains the client’s results for pure tone audiometry.
• The SDT will be 10-12 less than SRT. Generally, the recognition or understanding of the speech stimuli does not occur until about 7-9 dB above the level of detection.

Application of speech detection thresholds:

• SDT is used to cross check the PTA threshold and find out the level of speech recognition also.
• SDT is also helps in better Hearing aid selection.
• Speech detection thresholds also used to find out the differential diagnosis.
• SDT aslo helps to detect functional (Non organic) hearing loss and find out severity of hearing loss .

References :

⇒ https://www.ishaindia.org.in/pdf/Guidelines-Standard-Audiometric-Screening-Procedures.PDF ⇒ Introduction to Audiology –  Frederick N.Martin (Book) ⇒ Essentials of Audiology – Stanley A. Gelfand, PhD (Book)

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Speech Audiometry

• Author: Suzanne H Kimball, AuD, CCC-A/FAAA; Chief Editor: Arlen D Meyers, MD, MBA  more...
• Sections Speech Audiometry
• Indications
• Contraindications
• Pediatric Speech Materials

Speech audiometry has become a fundamental tool in hearing-loss assessment. In conjunction with pure-tone audiometry, it can aid in determining the degree and type of hearing loss. Speech audiometry also provides information regarding discomfort or tolerance to speech stimuli and information on word recognition abilities.

In addition, information gained by speech audiometry can help determine proper gain and maximum output of hearing aids and other amplifying devices for patients with significant hearing losses and help assess how well they hear in noise. Speech audiometry also facilitates audiological rehabilitation management.

The Technique section of this article describes speech audiometry for adult patients. For pediatric patients, see the Pediatric Speech Materials section below.

Speech audiometry can be used for the following:

Assessment of degree and type of hearing loss

Examination of word recognition abilities

Examination of discomfort or tolerance to speech stimuli

Determination of proper gain and maximum output of amplifying devices

Speech audiometry should not be done if the patient is uncooperative.

No anesthesia is required for speech audiometry.

In most circumstances, speech audiometry is performed in a 2-room testing suite. Audiologists work from the audiometric equipment room, while patients undergo testing in the evaluation room. The audiometric equipment room contains the speech audiometer, which is usually part of a diagnostic audiometer. The speech-testing portion of the diagnostic audiometer usually consists of 2 channels that provide various inputs and outputs.

Speech audiometer input devices include microphones (for live voice testing), tape recorders, and CDs for recorded testing. Various output devices, including earphones, ear inserts, bone-conduction vibrators, and loudspeakers, are located in the testing suite. [ 1 ]

Tests using speech materials can be performed using earphones, with test material presented into 1 or both earphones. Testing can also be performed via a bone-conduction vibrator. In addition to these methods, speech material can be presented using loudspeakers in the sound-field environment.

Speech-awareness thresholds

Speech-awareness threshold (SAT) is also known as speech-detection threshold (SDT). The objective of this measurement is to obtain the lowest level at which speech can be detected at least half the time. This test does not have patients repeat words; it requires patients to merely indicate when speech stimuli are present.

Speech materials usually used to determine this measurement are spondees. Spondaic words are 2-syllable words spoken with equal emphasis on each syllable (eg, pancake, hardware, playground). Spondees are used because they are easily understandable and contain information within each syllable sufficient to allow reasonably accurate guessing.

The SAT is especially useful for patients too young to understand or repeat words. It may be the only behavioral measurement that can be made with this population. The SAT may also be used for patients who speak another language or who have impaired language function because of neurological insult.

For patients with normal hearing or somewhat flat hearing loss, this measure is usually 10-15 dB better than the speech-recognition threshold (SRT) that requires patients to repeat presented words. For patients with sloping hearing loss, this measurement can be misleading with regard to identifying the overall degree of loss.

If a patient has normal hearing in a low frequency, the SAT will be closely related to the threshold for that frequency, and it will not indicate greater loss in higher frequencies.

Speech-recognition threshold

The speech-recognition threshold (SRT) is sometimes referred to as the speech-reception threshold. [ 2 ] The objective of this measure is to obtain the lowest level at which speech can be identified at least half the time.

Spondees are usually used for this measurement. Lists of spondaic words commonly used to obtain the SRT are contained within the Central Institute for the Deaf (CID) Auditory List W-1 and W-2.

In addition to determining softest levels at which patients can hear and repeat words, the SRT is also used to validate pure-tone thresholds because of high correlation between the SRT and the average of pure-tone thresholds at 500, 1000, and 2000 Hz.

In clinical practice, the SRT and 3-frequency average should be within 5-12 dB. This correlation holds true if hearing loss in the 3 measured frequencies is relatively similar. If 1 threshold within the 3 frequencies is significantly higher than the others, the SRT will usually be considerably better than the 3-frequency average. In this case, a 2-frequency average is likely to be calculated and assessed for agreement with the SRT.

Other clinical uses of the SRT include establishing the sound level to present suprathreshold measures and determining appropriate gain during hearing aid selection.

Suprathreshold word-recognition testing

The primary purpose of suprathreshold word-recognition testing is to estimate ability to understand and repeat single-syllable words presented at conversational or another suprathreshold level. This type of testing is also referred to as word-discrimination testing or speech-discrimination testing.

Initial word lists compiled for word-recognition testing were phonetically balanced (PB). This term indicated that phonetic composition of the lists was equivalent and representative of connected English discourse.

The original PB lists were created at the Harvard Psycho-Acoustic Laboratory and are referred to as the PB-50 lists. The PB-50 lists contain 50 single-syllable words in 20 lists consisting of 1000 different monosyllabic words. Several years later, the CID W-22 word lists were devised, primarily using words selected from the PB-50 lists. Another word list (devised from a grouping of 200 consonant-nucleus-consonant [CNC] words) is called the Northwestern University Test No. 6 (NU-6). Recorded tape and CD versions of all these word-recognition tests are commercially available.

The PB-50, CID W-22, and NU-6 word lists each contain 50 words that are presented at specified sensation levels. Words can be presented via tape, CD, or monitored live voice. Patients are asked to repeat words to the audiologist. Each word repeated correctly is valued at 2%, and scores are tallied as a percent-correct value.

Varying the presentation level of monosyllabic words reveals a variety of performance-intensity functions for these word lists. In general, presenting words at 25-40 dB sensation level (refer to the SRT) allows patients to achieve maximum scores. Lowering the level results in lower scores. For individuals with hearing loss, words can be presented at a comfortable loudness level or at the highest reasonable level before discomfort occurs.

When words are presented at the highest reasonable level and the word-recognition score is 80% or better, testing can be discontinued. If the score is lower than 80%, further testing at lower presentation levels is recommended. If scores at lower levels are better than those obtained at higher presentation levels, "roll over" has occurred, and these scores indicate a possible retrocochlear (or higher) site of lesion.

Another use of suprathreshold word-recognition testing is to verify speech-recognition improvements achieved by persons with hearing aids . Testing can be completed at conversational levels in the sound field without the use of hearing aids and then again with hearing aids fitted to the patient. Score differences can be used as a method to assess hearing with hearing aids and can be used as a pretest and posttest to provide a percent-improvement score

Sentence testing

To evaluate ability to hear and understand everyday speech, various tests have been developed that use sentences as test items. Sentences can provide information regarding the time domain of everyday speech and can approximate contextual characteristics of conversational speech.

Everyday sentence test

This is the first sentence test developed at the CID in the 1950s.

Clinical use of this test is limited, because its reliability as a speech-recognition test for sentences remains undemonstrated.

Synthetic-sentence identification test

The synthetic-sentence identification (SSI) test was developed in the late 1960s. SSI involves a set of 10 synthetic sentences. Sentences used in this test were constructed so that each successive group of 3 words in a sentence is itself meaningful but the entire sentence is not.

Because the sentences are deemed insufficiently challenging in quiet environments, a recommendation has been made that sentences be administered in noise at a signal-to-noise (S/N) ratio of 0 dB, which presents both sentences and noise at equal intensity level.

Speech perception in noise test

The speech perception in noise (SPIN) test is another sentence-identification test. The SPIN test was originally developed in the late 1970s and was revised in the mid 1980s.

The revised SPIN test consists of 8 lists of 50 sentences. The last word of each sentence is considered the test item. Half of listed sentences contain test items classified as having high predictability, indicating that the word is very predictable given the sentence context. The other half of listed sentences contain test items classified as having low predictability, indicating that the word is not predictable given sentence context. Recorded sentences come with a speech babble-type noise that can be presented at various S/N ratios.

Speech in noise test

The speech in noise (SIN) test, developed in the late 1990s, contains 5 sentences with 5 key words per test condition. Two signal levels (70 and 40 dB) and 4 S/N ratios are used at each level. A 4-talker babble is used as noise. This recorded test can be given to patients with hearing aids in both the unaided and aided conditions.

Results are presented as performance-intensity functions in noise. A shorter version of the SIN, the QuickSIN, was developed in 2004. The QuickSIN has been shown to be effective, particularly when verifying open-fit behind-the-ear hearing aids.

Hearing in noise test

The hearing in noise test (HINT) is designed to measure speech recognition thresholds in both quiet and noise. The test consists of 25 lists of 10 sentences and noise matched to long-term average speech.

Using an adaptive procedure, a reception threshold for sentences is obtained while noise is presented at a constant level. Results can be compared with normative data to determine the patient's relative ability to hear in noise.

Words in noise test

The Words-in-Noise Test (WIN), developed in the early 2000s, provides an open set word-recognition task without linguistic context. The test is composed of monosyllabic words from the NU-6 word lists presented in multitalker babble. The purpose of the test is to determine the signal-to-babble (S/B) ratio in decibels for those with normal and impaired hearing. The WIN is similar to the QuickSIN in providing information about speech recognition performance.

The WIN is used to measure performance of basic auditory function when working memory and linguistic context is reduced or eliminated. This measure, by using monosyllabic words in isolation, evaluates the listener's ability to recognize speech using acoustic cues alone and by eliminating syntactical and semantic cues founds in sentences. The WIN materials allow for the same words to be spoken by the same speaker for both speech-in-quiet and speech-in-noise data collection.

Bamford-Kowal-Bench speech in noise test

Bamford-Kowal-Bench Speech-in-Noise Test (BKB-SIN) was developed by Etymotic Research in the early to mid 2000s. The primary population for this test include children and candidates or recipients of cochlear implants .

Like the HINT, the BKB-SIN uses Americanized BKB sentences. [ 3 ] These words are characterized as short, and the sentences are highly redundant; they contain semantic and syntactic contextual cues developed at a first grade reading level. Compared to the HINT, which uses speech-spectrum noise, the BKB-SIN uses multitalker babble. Clinicians can expect better recognition performance on the BKB-SIN and HINT in comparison to the QuickSIN and WIN because of the additional semantic context provided by the BKB sentences.

Selecting proper speech in noise testing

QuickSIN and WIN materials are best for use in discriminating those who have hearing loss from normal hearing individuals. The BKB-SIN and HINT materials are less able to identify those with hearing loss. [ 4 , 5 ] Therefore, the QuickSIN or WIN is indicated as part of the routine clinical protocol as a speech in noise task. The choice of QuickSIN or WIN is strictly a matter of clinician preference; however, the clinician must also consider whether or not the patient can handle monosyllabic words (WIN) or needs some support from sentence context (QuickSIN).

The BKB-SIN and HINT materials are easier to recognize because of the semantic content, making them excellent tools for young children or individuals with substantial hearing loss, including cochlear implant candidates and new recipients.

Most comfortable loudness level and uncomfortable loudness level

Most comfortable loudness level

The test that determines the intensity level of speech that is most comfortably loud is called the most comfortable loudness level (MCL) test.

For most patients with normal hearing, speech is most comfortable at 40-50 dB above the SRT. This sensation level is reduced for many patients who have sensorineural hearing loss (SNHL). Because of this variation, MCL can be used to help determine hearing aid gain for patients who are candidates for amplification.

MCL measurement can be obtained using cold running or continuous speech via recorded or monitored live-voice presentation. Patients are instructed to indicate when speech is perceived to be at the MCL. Initial speech levels may be presented at slightly above SRT and then progressively increased until MCL is achieved. Once MCL is achieved, a speech level is presented above initial MCL and reduced until another MCL is obtained. This bracketing technique provides average MCL.

Uncomfortable loudness level

One reason to establish uncomfortable loudness level (UCL) is to determine the upper hearing limit for speech. This level provides the maximum level at which word-recognition tests can be administered. UCL can also indicate maximum tolerable amplification.

Another reason to establish UCL is to determine the dynamic speech range. Dynamic range represents the limits of useful hearing in each ear and is computed by subtracting SRT from UCL. For many patients with SNHL, this range can be extremely limited because of recruitment or abnormal loudness perception.

UCL speech materials can be the same as for MCL. The normal ear should be able to accept hearing levels of 90-100 dB. Patients are instructed to indicate when presented speech is uncomfortably loud. Instructions are critical, since patients must allow speech above MCL before indicating discomfort.

While the use of speech testing in general has not necessarily been shown to predict hearing aid satisfaction, [ 6 ] the use of loudness discomfort levels (UCLs) has been shown to be useful in successful hearing aid outcomes. [ 7 ]

The Acceptable Noise Level (ANL) test is a measure of the amount of background noise that a person is willing to tolerate. [ 8 ] In recent years it has gained interest among researchers and hearing-care professionals because of its ability to predict, with 85% accuracy, who will be successful with hearing aids. [ 9 ]

For very young children with limited expressive and receptive language skills, picture cards representing spondaic words can be used to establish the SRT. Before testing, the tester must ensure that the child understands what the card represents. Once the child has been taught to point to the correct picture card, 4-6 cards are chosen and presented to the child. Then, the softest level at which the child can select the correct card at least half the time is established.

For children with typical kindergarten or first-grade language skills, the Children's Spondee Word List can be used instead of adult word lists. The CID W-1 list is appropriate for use with older children.

Word-recognition testing for children can be classified as open-message response testing or closed-response testing. Closed-response testing uses the picture-pointing technique.

Word intelligibility by picture identification test

One of the more popular closed-response tests is the word intelligibility by picture identification (WIPI) test. This test consists of 25 pages; on each page are 6 colored pictures representing an item named by a monosyllabic word. Four pictures represent a test item, while the other 2 serve to decrease probability of a correct guess.

WIPI was developed for use with children with hearing impairment and can be used for children aged 4 years and older.

Northwestern University children's perception of speech test

Another popular closed-response test is the Northwestern University children's perception of speech (NU-CHIPS) test. NU-CHIPS consists of 50 pages with 4 pictures per page.

This test was developed for use with children aged 3 years and older.

Pediatric speech intelligibility test

The pediatric speech intelligibility (PSI) test uses both monosyllabic words and sentence test items. The PSI test consists of 20 monosyllabic words and 10 sentences. Children point to the appropriate picture representing the word or sentence presented.

Test materials are applicable for children aged as young as 3 years.

Phonetically balanced kindergarten test

One of the more popular open-message response tests for children is the phonetically balanced kindergarten (PBK) test, which contains 50 monosyllabic words that the child repeats.

The PKB test is most appropriate for children aged 5-7 years.

Bamford-Kowal-Bench Speech-in-Noise Test

As mentioned prior, the BKB-SIN materials are easier due to the amount of semantic content utilized which makes it an excellent tool for use with young children. [ 10 ]

Lewis MS, Crandell CC, Valente M, Horn JE. Speech perception in noise: directional microphones versus frequency modulation (FM) systems. J Am Acad Audiol . 2004 Jun. 15(6):426-39. [QxMD MEDLINE Link] .

Harris RW, McPherson DL, Hanson CM, Eggett DL. Psychometrically equivalent bisyllabic words for speech recognition threshold testing in Vietnamese. Int J Audiol . 2017 Aug. 56 (8):525-537. [QxMD MEDLINE Link] .

Bench J, Kowal A, Bamford J. The BKB (Bamford-Kowal-Bench) sentence lists for partially-hearing children. Br J Audiol . 1979 Aug. 13(3):108-12. [QxMD MEDLINE Link] .

Wilson RH, McArdle RA, Smith SL. An Evaluation of the BKB-SIN, HINT, QuickSIN, and WIN Materials on Listeners With Normal Hearing and Listeners With Hearing Loss. J Speech Lang Hear Res . 2007 Aug. 50(4):844-56. [QxMD MEDLINE Link] .

Carlson ML, Sladen DP, Gurgel RK, Tombers NM, Lohse CM, Driscoll CL. Survey of the American Neurotology Society on Cochlear Implantation: Part 1, Candidacy Assessment and Expanding Indications. Otol Neurotol . 2018 Jan. 39 (1):e12-e19. [QxMD MEDLINE Link] .

Killion MC, Gudmundsen GI. Fitting hearing aids using clinical prefitting speech measures: an evidence-based review. J Am Acad Audiol . 2005 Jul-Aug. 16(7):439-47. [QxMD MEDLINE Link] .

Mueller HG, Bentler RA. Fitting hearing aids using clinical measures of loudness discomfort levels: an evidence-based review of effectiveness. J Am Acad Audiol . 2005 Jul-Aug. 16(7):461-72. [QxMD MEDLINE Link] .

Nabelek AK, Tucker FM, Letowski TR. Toleration of background noises: relationship with patterns of hearing aid use by elderly persons. J Speech Hear Res . 1991 Jun. 34 (3):679-85. [QxMD MEDLINE Link] .

Nabelek AK, Freyaldenhoven MC, Tampas JW, Burchfiel SB, Muenchen RA. Acceptable noise level as a predictor of hearing aid use. J Am Acad Audiol . 2006 Oct. 17 (9):626-39. [QxMD MEDLINE Link] .

Neave-DiToro D, Rubinstein A, Neuman AC. Speech Recognition in Nonnative versus Native English-Speaking College Students in a Virtual Classroom. J Am Acad Audiol . 2017 May. 28 (5):404-414. [QxMD MEDLINE Link] .

• Speech audiogram. Video courtesy of Benjamin Daniel Liess, MD.

Contributor Information and Disclosures

Suzanne H Kimball, AuD, CCC-A/FAAA Assistant Professor, University of Oklahoma Health Sciences Center Suzanne H Kimball, AuD, CCC-A/FAAA is a member of the following medical societies: American Academy of Audiology , American Speech-Language-Hearing Association Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Otolaryngic Allergy , American Academy of Otolaryngology-Head and Neck Surgery , American Auditory Society , American Neurotology Society , American Otological Society , North American Skull Base Society , Society of University Otolaryngologists-Head and Neck Surgeons , The Triological Society Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Arlen D Meyers, MD, MBA Emeritus Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery , American Academy of Otolaryngology-Head and Neck Surgery , American Head and Neck Society Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Neosoma; MI10;<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Cliff A Megerian, MD, FACS Medical Director of Adult and Pediatric Cochlear Implant Program, Director of Otology and Neurotology, University Hospitals of Cleveland; Chairman of Otolaryngology-Head and Neck Surgery, Professor of Otolaryngology-Head and Neck Surgery and Neurological Surgery, Case Western Reserve University School of Medicine Cliff A Megerian, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery , American College of Surgeons , American Neurotology Society , American Otological Society , Association for Research in Otolaryngology , Massachusetts Medical Society , Society for Neuroscience , Society of University Otolaryngologists-Head and Neck Surgeons , Triological Society Disclosure: Nothing to disclose.

Medscape Reference thanks Benjamin Daniel Liess, MD, Assistant Professor, Department of Otolaryngology, University of Missouri-Columbia School of Medicine, for the video contributions to this article.

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What Is A Speech Test? Why You Might Need One

Speech testing evaluates your ability to detect speech and understand words and sentences. This guide will tell you the basics of speech testing.

According to the American Speech-Language-Hearing Association, trouble understanding everyday speech is typically one of the first signs of losing hearing.

That’s why speech testing is crucial to every screening test for hearing loss .

Speech audiometry is one of a battery of tests you will take during a standard hearing exam but is not a part of online hearing tests . The test is about 10 to 15 minutes, and it’s usually done right after pure tone audiometry.

While pure tone testing determines the type and severity of hearing loss, speech testing evaluates your speech-language abilities.  

A hearing aid specialist can use the test results to measure how much gain the hearing aid has to provide to make sounds clear.

An audiologist can also determine if there’s a significant difference between ears by mapping the results on “critical difference tables.”

Why Speech Testing Is Done

Speech testing is primarily used to understand the impact of hearing loss on a person’s speech levels.

Here are some reasons speech testing is commonly used in hearing exams:

• It confirms the pure tone audiometry results which are read on an audiogram.
• It measures speech intelligibility and hearing loss’s effect on an individual’s communication skills.
• It monitors loud speech and the efficacy of hearing aids over time.
• Speech recognition predicts the likelihood of treatment success.
• It helps diagnose certain underlying conditions.
• The test results provide helpful information for hearing aid fitting and programming.

How Is Speech Testing Done

Speech testing is typically performed by a licensed hearing care professional after the audiologist measures hearing thresholds using pure tones.

Environment

The speech testing environment has two soundproof rooms: the equipment and testing rooms.

The ambient noise levels in the testing environment should meet American National Standards Institute (ANSI)  specifications.

Audiologists manipulate the audiometers from the equipment room and the patient takes the test in the testing room, which has speakers, headphones, and other transducers.

Speech audiometry is performed using a speech audiometer built into the same device used for pure tone testing. Sounds are transmitted via headphones and speakers, and a microphone is used for instructing the patient and live voice testing.

The examiner may also play a set of wave files using an external sound player instead of live voice testing.

The diagnostic audiometers also come with a talk-back and talk-forward microphone for communication between the patient and the tester.

The test material needed for speech testing includes a list of monosyllabic words.

Generally, speech testing follows this process:

• The examiner will instruct the patient to repeat back the words presented.
• The audiologist will turn the volume to a level the patient can hear.
• The tester will present a list of 50 single-syllable words and record the patient’s correct and incorrect responses. Each ear may be tested separately.
• The tester calculates the word recognition score, which is the percentage of words repeated correctly.

Speech Audiometry Subtests

Speech testing consists of subtests that will yield a set of metrics the audiologist uses to evaluate your speech-language abilities.

Speech Recognition Threshold Tests

The speech recognition threshold refers to the minimum sound intensity level at which a person can detect the presence of speech at least 50 percent of the time.

It’s also known as speech awareness or speech detection threshold.

It is widely used to double-check the results of tone testing. Ideally, the speech recognition threshold should closely agree with the average pure tone threshold levels obtained at 500 Hz, 100 Hz, and 2,000 Hz.

Did you know you can also measure the range of frequencies you can hear using a sound frequency test ? Read more about it in our guide.

This test only requires the patient to detect the presence of speech. In other words, you don’t need to understand what is being said.

In speech recognition threshold tests you don’t need to understand what is being said, you just need to raise your hand or press a button when you hear a speech signal.

Speech Reception Threshold Tests

The speech reception threshold refers to the lowest volume at which an individual can identify speech at least half of the time.

During the speech reception test, the examiner will present a list of disyllabic words with equal stress placed on each syllable (E.g., football, hotdog, sidewalk). The patient will be instructed to repeat back the words heard.

SRT is also used to validate pure tone thresholds as the reception threshold should be very close to the average of pure tone thresholds obtained at 500 Hz, 1000 Hz, and 2000 Hz.

Word Recognition Testing

Speech discrimination testing checks a person’s ability to understand and repeat single-syllable words.

The tester presents a list of 50 single-syllable words (E.g. cat, dog, pool) at an audible level. The patient will be asked to repeat the words.

After the test, the hearing specialist will calculate the speech discrimination score, which is the percentage of words repeated correctly versus those incorrectly repeated.

A normal score would be between 85 to 100 percent.

An individual with a score below 85 percent will benefit from hearing aids.

Though it’s not common, an audiologist may administer a hearing-in-noise test (HINT) to test word recognition in background noise.

However, this is usually only given for hearing-critical and potentially life-threatening occupations where the ability to communicate clearly is essential, such as aviation, law enforcement, and the armed forces.  

Accuracy of Speech Testing

Speech testing is essential to planning your treatment, but the accuracy of tests can vary with factors such as patient cooperation and test procedure.

Typically the word list used in a speech discrimination test contains 50 monosyllabics. However, some examiners may use a half list to save time. This can affect the accuracy of the score.

For instance, if you correctly repeat 10 out of 20 words, your score would be 50 percent, whereas if you repeat 10 out of 50 words, your score would be 20%.

When administering speech discrimination tests, the tester can use recorded wave files or read the list aloud through a microphone.

Live voice tests are generally less accurate than tests that use recordings because the patient’s ability to understand the tester can vary with the voice quality or dialect used.

Therefore, the use of recorded speech would yield more accurate scores.

Speech audiometry is a subjective hearing test. This means the patient has to cooperate and follow the tester’s instructions to get accurate test results.

If a patient isn’t motivated enough to listen carefully and repeat back words, the score may not reflect the individual’s actual hearing ability.

Speech testing is a valuable part of the audiologist’s toolkit. It includes tests of a person’s ability to detect the presence of speech and repeat back individual words. Speech testing validates the results of tests that use pure tones and provides information that helps hearing professionals effectively treat your condition. Individuals with mild or moderate hearing loss but relatively high word recognition scores benefit the most from using hearing devices.

What is a Good Speech Discrimination Score?

A person with normal hearing should be able to hear 85 to 100 percent of the words that the tester presents.

Do I Need Speech Testing to Purchase Hearing Aids?

According to the American Speech-Language-Hearing Association, you can buy hearing devices online by taking an online screening test. However, these tests are less reliable than a professional audiological exam and cannot tell you the cause of your impairment. If you have difficulty hearing, you should consult an audiologist.

https://www.youtube.com/watch?v=mSTMGdqJrC0&lc=Ugwfu7U3qmrSVYSMk4V4AaABAg

https://www.interacoustics.com/guides/test/audiometry-tests/speech-audiometry

http://www.cochlea.eu/en/audiometry/subjective-measure/speech-audiometry

https://www.audiologyonline.com/articles/word-recognition-testing-puzzling-disconnect-11978

https://www.hopkinsmedicine.org/health/conditions-and-diseases/hearing-loss/speech-audiometry#:~:text=Your%20audiologist%20will%20ask%20you,also%20called%20word%20recognition%20ability .

https://www.asha.org/public/hearing/speech-testing/

https://www.entltd.com/throat-speech/speech-swallowing/speech-audiometry/#:~:text=What%20Is%20Speech%20Audiometry%3F,speech%20discrimination%20(SD)%20abilities

https://www.sciencedirect.com/topics/medicine-and-dentistry/speech-audiometry

https://emedicine.medscape.com/article/1822315-overview

https://www.audiologyonline.com/articles/back-to-basics-speech-audiometry-6828

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Speech Audiometry

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What is speech audiometry?

Most people acquiring hearing aids report trouble hearing speech, or more often trouble hearing speech in noise. Here speech testing becomes a strong test tool in the assessment of the problem the patient faces. Speech audiometry employs speech signals and can be used to examine the processing ability and if it is affected by disorders of the middle ear, cochlea, auditory nerve, brainstem pathway, and auditory centers of the cortex.

There is a variety of tests available with speech testing with the basic speech audiometry being an assessment of the reception, discrimination and recognition of speech. Reception refers to the level at which the patient can hear speech is present, discrimination refers to the level at which the patient can discriminate between words, while recognition refers to the level at which the patient can recognize and recall the word.

More advanced speech testing takes into account how speech is understood in the presence of noise, with various noise types such as white noise, speech noise, babble noise, or running speech as noise source and provide information about the signal-to-noise ratio (SNR) at which the patient can understand speech. Other components such as the placement of the speech signal in relation to the noise source and the tonal differences between the speech signal and the masking signal, is some of the things incorporated into more advance speech testing.

Speech Detection Threshold (SDT)

Speech detection threshold (SDT) refers to the level at which the patient can hear speech is present in 50% of the cases. The speech detection threshold can be used as a cross-check of the air conduction audiometry and should closely agree with the PTA (Pure Tone Average). The PTA can be calculated in different ways but is usually the average of thresholds obtained at 500, 1000, and 2000 Hz. It is generally accepted that if the PTA and the SRT is within ± 6 dB of each other the accordance is good, if it is ±7 to 12 dB it is adequate, and if it is ±13 or more, it is poor.

Note: Speech detection threshold is sometimes referred to as speech reception threshold abbreviated - SRT, not to be confused with speech recognition threshold, abbreviated - SRT. For that matter the term speech detection threshold is used and abbreviated – SDT.

Speech Recognition Threshold (SRT)

The speech recognition threshold (SRT) examines at which level 50% of the speech material (usually numbers or spondaic words) is repeated correctly. In addition, SRT gives an index of the hearing sensitivity of speech and helps determine the starting point for other supra-threshold measures such as WR (Word Recognition).

Word Recognition Score (WR)

The word recognition score (WR) is sometimes also referred to as SDS (speech discrimination score) and represents the number of words correctly repeated, expressed as a percentage of correct (discrimination score) or incorrect (discrimination loss). Pressing correct means the word is a 100% correct, while incorrect correspond with 0% correct. The score can be obtained as a phoneme score that provides information about what phonemes the patient has difficulty hearing at a particular intensity level. This is helpful for counselling and rehabilitation purposes.

Discrimination score / discrimination loss

1. in the suite.

Correct : A mouse click on this button will store the word as correctly repeated. The left arrow key can also be used for storing as correct. Incorrect : A mouse click on this button will store the word as incorrectly repeated. The right arrow key can also be used to score as incorrect. Store : A mouse click on this button will store the speech threshold in the speech graph. A point can also be stored by pressing S .

2. On the standalone devices

Press incorrect on the keyboard to store the word as incorrect (0%) or press correct on the keyboard to store the word as correct (100%).

Phoneme score

When the speech material is indexed according to the number of phonemes in each word, the soft key numbers available for scoring will be active.

E.g. for a word with two phonemes the soft keys 0,1 and 2 will become available for scoring. The upper the display in the suites, while the lower displays the buttons on the standalone audiometer.

When the word is scored with the use of phonemes, the number of correct phonemes will appear below the word.

The percentage will be calculated as the numbers of phonemes correct out of the total number of phonemes that has been presented up until the given word.

Thereby the storing can be done at any time during the scoring.

Required equipment

• Headphones, insert phones, or free field speakers
• A microphone, external sound player, or built-in wave files
• Talk back microphone and talk forward microphone

Test procedure

Before performing speech audiometry you may wish to do the tone audiogram. This provides valuable predictive information useful in the speech testing, including information about when masking is needed during speech testing. For more information about masking please refer to the quick guide ‘Audiometric masking’.

• Press the Tests button and select the speech  test.
• If needed, select the measurement type (e.g. WR1, WR2, SRT), type of measure (word, numbers, multi syllabic numbers and multi syllabic words), and list of words using the soft buttons.
• Select the intensity levels for channel If masking is needed configure channel 2 also.
• Explain to the patient that he/she will now hear some words/numbers/sentences though the ear phones/free field speakers. Instruct the patient to repeat what is said even though it may be very Patients may also be encouraged to guess if they are unsure about the word/number/sentence. If performing the speech test in noise do not forget to instruct the patient not to focus on the noise but on the speech.
• Press Start to start presenting the words, numbers or sentences.

• Click on Store to store the results.

Speech results

1. table mode.

The SRT/WR displayed as a table allows for measuring multiple SRTs using different test parameters, e.g. Transducer, Test Type, Intensity, Masking, and Aided together with the SRT or WR score.

2. Graph mode

When showing the SRT in graph mode the speech audiogram calculates the SRT value based on the norm curve (the distance in dB from the point where the norm curve crosses 50% to the point where the speech curve crosses 50%) like shown below. The result is then an expression of how much you need to turn up the level compared to normal in order for the patient to be able to repeat 50%.

Use the m-curve for multi syllabic words and the s-curve if using single syllabic words. The curves can be edited according to the normative data you wish to use in the speech settings.

Note that the norm curves change based on the speech material. You must therefore ensure that WR1, WR2 or WR3 is linked to single or multisyllabic words to show the SRT. Calculating the WR SRT is only available when using the suite.

Speech setup

When running the speech test using wavefiles, the tester can decide to present manually , continuously or timeout for the speech setup.

1. Manual mode

Allows the tester to manually press the Tone Switch/Enter button to present the word and then score it as Incorrect of Correct before moving on to the next word.

2. Continuous mode

The next word will automatically be presented after scoring incorrect or correct.

3. Time Out mode

The word played will be scored as either correct or incorrect if no scoring is entered within 1 to 5 seconds.

Speech in noise

Problems understanding speech in noise is a common complaint from people with hearing loss. Having the ability to test the patient with speech in noise provides useful information about the impact of the hearing loss on the patient’s ability to communicate. It also provides information about whether the patient is actually getting the expected benefit from the hearing aids when communicating in noisy environments.

Testing the patient in a speech in noise setup can be done using a free field setup either by presenting the speech signal and noise signal from the same speaker or alternatively, separating the speech signal and noise signal by presenting the signal from two different speakers. It can be done by presenting the signal and noise to the same ear on the AC40 or by selecting the test speech in noise on the AD629.

Binaural speech

If the intention is to present the speech signal to both ears at the same time this is done by selecting the same output for both channels on the AC40. On the AD629 the binaural speech is selected by choosing the test Speech - Ch2on . Note this is only available with the AD629 extended.

Stach, B.A (1998) Clinical Audiology: An introduction, Cengage Learning

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speech recognition threshold level

4.62   speech recognition threshold level . For a given ear and a specified speech signal and method of presentation, the lowest hearing level at which the speech signal is recognized 50% of the time. Abbreviation, SRT; unit, decibel (dB).

Annotation         Speech recognition threshold was previously called speech reception threshold.

• Standards Terms: hearing level for speech
• Standards Terms: reference equivalent speech recognition threshold level
• Term: speech recognition
• Term: hearing level
• Term: speech
• Term: signal
• Term: decibel
• Term: level

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Iowa Head and Neck Protocols

How to read an audiogram.

• Audiograms are used to diagnose and monitor hearing loss.
• Audiograms are created by plotting the thresholds at which a patient can hear various frequencies.
• Hearing loss can be divided into two categories: conductive or sensorineural. 
• The results of an audiogram can help direct medical and surgical interventions to improve and/or preserve hearing function.

BACKGROUND INFORMATION

• Intensity of sound is measured in decibels (dB) which can be thought of as the ‘loudness' of the sound.
• An increase of 10 dB means a 10-fold increase in sound intensity.
• An increase of 20 dB means the sound is 100-fold more intense.
• For reference, normal conversation is around 60 dB

• Frequency is measured in Hertz (Hz), which is often thought of as the “pitch” of the sound.
• The average human can hear between 20 and 20,000 Hz 
• Human speech usually falls between 250Hz and 6000Hz.

AUDIOMETRIC TESTING:

• During testing, the audiometer delivers various “pure tone” sounds at particular frequencies and intensities, from low to high.
• The patient’s ability to hear these tones is plotted on a graph to create an audiogram.
• Evoked otoacoustic emissions (EOAE): test function of outer hair cells, often used as a newborn hearing screen
• Auditory brainstem response (ABR): use electrodes to monitor brain activity response to sound stimulus, can be done at any age but will often need to be sedated after 6mo
• Behavioral observation audiometry (BOA)(0 to 5 mo): observes child response to sound stimulus. Does not assess laterality
• Visual reinforcement audiometry (VRA) (6mo to 2yo): child turns to visual cue in response to sound stimulus
• Conditioned play audiometry (CPA)(2yo to 5yo): child interacts with toy or object in response to sound stimulus. Can assess laterality.
• Conventional pure-tone audiometry (5yo+): raising hand in response to sound stimulus.

TYPES OF HEARING LOSS

• sensorineural
• Conductive and sensorineural hearing losses can occur alone or in combination.
• A combination of conductive and sensorineural hearing loss is referred to as a “mixed hearing loss.”

CONDUCTIVE HEARING LOSS (CHL):

• A conductive hearing loss occurs when sound from the environment is unable to be ‘conducted’ to the structures of the inner ear.
• Cerumen impaction
• Perforated tympanic membrane
• Fluid in the middle ear space
• Otosclerosis
• Conductive hearing losses are more likely to be correctable with surgical intervention than sensorineural losses. 
• Air conduction refers to conduction through the entire outer ear mechanism: including auricle, external ear canal, tympanic membrane and ossicles/middle ear. Bone conduction refers to soudn vibration transmitted to the inner ear through the skull.
• Weber: Place the tuning fork in the midline and determine which ear its heard louder. Normal: heard equally loud in both ears (also equal in symmetric bilateral hearing loss). Unilateral conductive hearing loss: lateralize to affected ear. Unilateral sensorineural hearing loss: lateralize to contralateral ear.
• Rinne: Place the tuning fork in front of the ear and over the mastoid and determine in which position it is heard louder. Normal: air conduction > bone conduction (positive Rinne). Conductive hearing loss: bone conduction > air conduction (negative Rinne). Sensorineural hearing loss: air conduction > bone conduction (positive Rinne).
• A flipped 256 Hz fork corresponds to a 15 dB hearing loss. Whispered voice is about 20 dB and normal spoken voice is 50 to 60 dB.

SENSORINEURAL HEARING LOSS (SNHL):

• Sensorineural hearing loss occurs when there is damage to the structures of the inner ear or nervous pathways between the ear and brain 
• The most common cause of SNHL in the United States is chronic noise exposure. 
• SNHL is often not as amenable to surgical intervention compared to conductive hearing loss.
• Infectious: meningitis, mumps, measles, syphilis, etc. 
• Ototoxic Medications: aminoglycosides, platinum chemotherapeutics, methotrexate, furosemide, aspirin, etc. 
• Presbycusis
• Head trauma: temporal bone fractures
• Congenital malformations of the inner ear structures 
• Noise-induced hearing loss 
• Neoplastic: acoustic neuroma or meningioma
• The hearing test results are plotted on a graph with the y-axis representing hearing threshold and the x-axis representing frequency.
• The right ear is generally plotted with a O and the left ear with a X.
• Bone conduction is also plotted (to allow for differentiation of conductive and SNHL). The right ear is plotted as < and the left ear as >.
• Threshold = the lowest level of sound that can be heard 50% of the time.
• Speech reception threshold (SRT) = Softest intensity bisyllabic spondee (balanced syllable) words can be repeated 50% of the time
• Word recognition score = % of words discerned at threshold
• Speech discrimination = % single syllabic words identified and repeated at suprathreshold levels (generally 30 dB above SRT)
• Acoustic reflex = muscle contraction in middle ear in response to high intensity stimulus (contralateral and ipsilateral reflexes tested)
• Type A: normal
• Type B “flat”: limited mobility, fluid or TM damage
• Type C: negative pressure from retraction
• Take the thresholds for four frequencies (500,1000,2000,3000) for each ear and average them
• Increase by 1.5% for each dB above 25dB for each ear
• Multiply the better ear by 5 (to weight it more heavily). Add that number with the worse ear and divide by 6 to get your hearing handicap.
• This formula has many problems and is NOT the percent hearing loss

CHRONIC NOISE EXPOSURE:  

• Noise-Induced Hearing Loss (NIHL) typically demonstrates a “knoch” on the audiogram at 4000k.
• If you have to raise your voice to be heard, (normal conversation is around 60dB) you are most likely in an environment with at least 80 dB of noise. 

Image above taken from Wikimedia commons without alteration

How to Read an Audiogram and Determine Degrees of Hearing Loss . The National Hearing Test. http://www.nationalhearingtest.org/wordpress/?p=786 . Accessed March 13, 2019.

Walker JJ, Cleveland LM, Davis JL, Seales JS. Audiometry Screening and Interpretation. American Family Physician. https://www.aafp.org/afp/2013/0101/p41.html . Published January 1, 2013. Accessed March 13, 2019.