ANSI S3.

21-2004

Reaffirmed by ANSI
April 16, 2009

AMERICAN NATIONAL STANDARD

Methods for Manual Pure-Tone Threshold

Audiometry
ANSI S3.21-2004

Accredited Standards Committee S3, Bioacoustics

Standards Secretariat
Acoustical Society of America
35 Pinelawn Road, Suite 114 E
Melville, NY 11747-3177

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 The American National Standards Institute, Inc. (ANSI) is the national coordinator of
voluntary standards development and the clearinghouse in the U.S.A. for information
on national and international standards.

The Acoustical Society of America (ASA) is an organization of scientists and

engineers formed in 1929 to increase and diffuse the knowledge of acoustics and
to promote its practical applications.

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 ANSI S3.21- 2004
(Revision of ANSI S3.21-1978)

AMERICAN NATIONAL STANDARD

Methods for Manual Pure-Tone Threshold

Audiometry

Secretariat

Acoustical Society of America

Approval date: April 8, 2004

American National Standards Institute, Inc.

Abstract

This Standard is a revision of the American National Standard ANSI S3.21-1978 Methods for Manual
Pure-Tone Threshold Audiometry.
This Standard provides a procedure for pure-tone audiometry that will serve the needs of persons
conducting threshold measurements in industry, schools, medical settings, and other areas where
valid audiometric threshold measurements are needed.

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 AMERICAN NATIONAL STANDARDS ON ACOUSTICS

The Acoustical Society of America (ASA) provides the Secretariat for Accredited Standards Committees
S1 on Acoustics, S2 on Mechanical Vibration and Shock, S3 on Bioacoustics, and S12 on Noise. These
committees have wide representation from the technical community (manufacturers, consumers, trade
associations, general interest, and government representatives). The standards are published by the
Acoustical Society of America as American National Standards after approval by their respective
Standards Committees and the American National Standards Institute.

These standards are developed and published as a public service to provide standards useful to the
public, industry, and consumers, and to Federal, State, and local governments.

Each of the accredited Standards Committees, operating in accordance with procedures approved by
American National Standards Institute (ANSI), is responsible for developing, voting upon, and maintaining
or revising its own Standards. The ASA Standards Secretariat administers Committee organization and
activity and provides liaison between the Accredited Standards Committees and ANSI. After the
Standards have been produced and adopted by the Accredited Standards Committees, and approved as
American National Standards by ANSI, the ASA Standards Secretariat arranges for their publication and
distribution.

An American National Standard implies a consensus of those substantially concerned with its scope and
provisions. Consensus is established when, in the judgment of the ANSI Board of Standards Review,
substantial agreement has been reached by directly and materially affected interests. Substantial
agreement means much more than a simple majority, but not necessarily unanimity. Consensus requires
that all views and objections be considered and that a concerted effort be made towards their resolution.

The use of an American National Standard is completely voluntary. Their existence does not in any
respect preclude anyone, whether he or she has approved the Standards or not, from manufacturing,
marketing, purchasing, or using products, processes, or procedures not conforming to the Standards.

NOTICE: This American National Standard may be revised or withdrawn at any time. The procedures of
the American National Standards Institute require that action be taken periodically to reaffirm, revise, or
withdraw this Standard.

Acoustical Society of America

ASA Secretariat
35 Pinelawn Road, Suite 114E
Melville, New York 11747-3177
Telephone: 1 (631) 390-0215
Fax: 1 (631) 390-0217
E-mail: asastds@aip.org

© 2004 by Acoustical Society of America. This standard may not be reproduced in whole or in part in any form for
sale, promotion, or any commercial purpose, or any purpose not falling within the provisions of the Copyright Act of
1976, without prior written permission of the publisher. For permission, address a request to the Standards
Secretariat of the Acoustical Society of America.

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 Contents

1 Scope .........................................................................................................................................1

1.1 Purpose of standard ..............................................................................................................1

1.2 Limit of standard....................................................................................................................1
1.3 Modifications of standard procedures ......................................................................................1
1.4 Source..................................................................................................................................1
2 Normative References ..................................................................................................................1

3 Definitions ...................................................................................................................................2

4 General Requirements .................................................................................................................4

4.1 Ear canal ..............................................................................................................................4

4.2 Earphone placement ..............................................................................................................4
4.3 Instructions ...........................................................................................................................4
4.4 Response task ......................................................................................................................4
4.5 Interpretation of response ......................................................................................................4
4.5.1 On response and off response.........................................................................................5

4.5.2 Latency of response........................................................................................................5

4.5.3 False responses .............................................................................................................5

5 Determination of threshold ............................................................................................................5

5.1 Familiarization procedure.......................................................................................................5

5.2 Determination of threshold .....................................................................................................5
5.2.1 Tone duration .................................................................................................................5

5.2.2 Interval between tones ....................................................................................................5

5.2.3 Level of first presentation ................................................................................................6

5.2.4 Levels of succeeding presentations..................................................................................6

5.2.5 Threshold of hearing .......................................................................................................6

6 Standard Procedures for Air-Conduction Measures ........................................................................6

6.1 Test environment ...................................................................................................................6

6.2 Instrumentation and calibration ...............................................................................................6
6.3 Frequency.............................................................................................................................6
6.4 Order ....................................................................................................................................6
6.5 Masking in air-conduction audiometry .....................................................................................6
6.6 Recording of result ................................................................................................................7
6.6.1 Audiogram form ..............................................................................................................7

6.6.2 Audiogram Symbols........................................................................................................7

6.6.3 Other information ............................................................................................................7

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 7 Standard Procedures for Bone-Conduction Measures in Diagnostic Audiometry ..............................7

7.1 Instrumentation .....................................................................................................................7

7.2 Calibration ............................................................................................................................7
7.3 Vibrator placement ................................................................................................................7
7.4 Covering of ear......................................................................................................................7
7.5 Frequencies ..........................................................................................................................8
7.6 Order ....................................................................................................................................8
7.7 Masking ................................................................................................................................8
7.8 Recording of results...............................................................................................................8
Annex A .............................................................................................................................................9

A.1 Air-conduction symbols ..........................................................................................................9

A.2 Bone-conduction symbols ......................................................................................................9
A.3 Symbols representation .........................................................................................................9
A.4 Multiple notation ....................................................................................................................9
A.5 No response .........................................................................................................................9
A.6 Separate forms.................................................................................................................... 10
A.7 Lines connecting symbols .................................................................................................... 10
A.8 Color coding........................................................................................................................ 10
Annex B ........................................................................................................................................... 12

B.1 General information ............................................................................................................. 12

Figures

Figure A.1 – Recommended form of audiogram and audiogram symbols.............................................. 11

ii

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 Foreword

[This foreword is for information only and is not an integral part of ANSI S3.21-2004 American National
Standard Methods for Manual Pure-Tone Threshold Audiometry.]
This American National Standard was developed and approved by Accredited Standards Committee S3,
under operating procedures approved by the American National Standards Institute (ANSI). Accredited
Standards Committee S3, Bioacoustics has the following scope:

Standards, specifications, methods of measurement and test, and terminology in the fields of
psychological and physiological acoustics, including aspects of general acoustics, shock, and
vibration which pertain to biological safety, tolerance and comfort.
This second edition replaces ANSI S3.21-1978 American National Standard Methods for Manual Pure-
Tone Threshold Audiometry. It has been revised to include current standard references which appear in
the text and other types of earphones (insert and circumaural) to be used to elevate collapsing ear canals
(see clause 4.1 note). All other changes are purely formative or editorial and do not change the technical
intent of this standard.

This American National Standard presents procedures for accomplishing manual hearing-threshold
measurement with pure tones that are applicable in a wide variety of settings.

Although the standard has been written to aid in the accomplishment of a measurement, it is appropriate
to point out that it differs from other measurement techniques in that it deals with human behavior. Rigid
adherence to the procedure in every circumstance will not necessarily produce effective results. See
Clause 1.3 for more detail.

iii

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 At the time this Standard was submitted to Accredited Standards Committee S3, Bioacoustics, for final
approval, the membership was as follows:

R.F. Burkard, Chair

C.A. Champlin, Vice Chair
S. Blaeser, Secretary

Acoustical Society of America ......................................................................................................R.F. Burkard

.................................................................................................................. C.A. Champlin (Alt.)

American Academy of Audiology ........................................................................ .L. Shotland

........................................................................................................................ D.A. Fabry (Alt.)

American Academy of Otolaryngology, Head and Neck Surgery, Inc. ……………….R.A. Dobie
..................................................................................................................... L.A. Michael (Alt.)

American Industrial Hygiene Association .............................................................. J. Banach

....................................................................................................................... D. Driscoll (Alt.)

American Speech-Hearing-Language Association (ASHA) ......................................... G. Linn

...................................................................................................................... R. Levinson (Alt.)

Audio Engineering Society, Inc. ....................................................................... R.H. Campbell

........................................................................................................................ M.R. Chial (Alt.)

Caterpillar, Inc. ......................................................................................................... D. Roley

....................................................................................................................... K.G. Meitl (Alt.)

Chase Ergonomics, Inc. ......................................................................................... G. Shumate

.......................................................................................................................... D. Chase (Alt.)

Council for Accreditation in Occupational Hearing Conservation (CAOHC) ..........R.D. Bruce

...................................................................................................................... E.H. Berger (Alt.)

Hearing Industries Association .......................................................................... T.A. Victorian

....................................................................................................................... C.M. Rogin (Alt.)

Howard Leight Industries ....................................................................................... V. Larson

.............................................................................................................................E. Woo (Alt.)

International Hearing Society ............................................................................... . K. LaFerle

John Deere ............................................................................................................ L. DeVries

National Institute of Standards and Technology .............................................V. Nedzelnitsky

........................................................................................................................ R. Wagner (Alt.)

Power Tool Institute ................................................................................................. VACANT

J. Nosko (Alt.)

iv

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 U.S. Army Aeromedical Research Lab ................................................................... W. Ahroon
............................................................................................................................ N. Alem (Alt.)

U.S. Army CERL ......................................................................................................... L. Pater

....................................................................................................................... D. Delaney (Alt.)

U.S. Army Human Research & Engineering Directorate .....................................T.R. Letowski

..............................................................................................................................J. Kalb (Alt.)

U.S. Department of the Air Force ......................................................................... R. McKinley

........................................................................................................................S.D. Smith (Alt.)

U.S. Department of Transportation .................................................................. E.D. Sussman

........................................................................................................................ T. Raslear (Alt.)

Individual Experts of Accredited Standards Committee S3, Bioacoustics, were:

J.R. Bareham K.D. Kryter P.D. Schomer

R.W. Benson R. McKinley H.E. von Gierke
A.J. Brammer C.W. Nixon D.E. Wasserman
A.J. Campanella D.D. Reynolds L.A. Wilber
J.L. Fletcher J.D. Royster W.A. Yost
T.A. Frank L.H. Royster

Working Group S3/WG35, Audiometers, which assisted Accredited Standards Committee S3,
Bioacoustics, in the preparation of this Standard, had the following membership at the time of final
approval:

R.L. Grason, Chair

S. Benson T. Frank R. Veillette

J. Foreman R. Grason L. Wilber
S. Fournier T. Letowski

Suggestions for improvement will be welcomed. Send suggestions for improvement to Accredited
Standards Committee S3, Bioacoustics, in care of the ASA Standards Secretariat, 35 Pinelawn Road,
Suite 114E, Melville, New York 11747-3177. Telephone: +1 631-390-0215; FAX: +1 631-390-0217. E-
mail: asastds@aip.org

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 AMERICAN NATIONAL STANDARD ANSI S3.21-2004

American National Standard

Methods for Manual Pure-Tone Threshold Audiometry

1 Scope

1.1 Purpose of standard

Pure-tone threshold audiometry is the procedure used in the assessment of an individual’s threshold of
hearing for pure tones. Pure-tone threshold audiometry includes manual air-conduction measurements at
octave intervals from 250 through 8000 Hz and at intermediate frequencies as needed. When abrupt
differences of 20 dB or more occur between adjacent octave frequencies, additional frequencies may be
included at the discretion of the tester. Bone-conduction measurements may be carried out if indicated by
the test requirements at octave intervals from 250 through 4000 Hz. Also, when required, masking is to
be used. The purpose of this standard is to present procedures for conducting manual pure-tone
threshold audiometry whose use will minimize intertest differences based on test method.

1.2 Limit of standard

This standard is limited to a description of the measurement method of manual pure-tone threshold
audiometry. Hearing screening techniques are outside its purview.

1.3 Modifications of standard procedures

The procedures described in this standard are usable in a wide variety of circumstances. However,
certain individuals, such as young children, developmentally delayed persons, uncooperative persons, or
neurologically handicapped persons may require modifications of the procedures. In any instance where
response behavior is apt to veer from the usual, the procedure should be modified; however, the
modification shall be readily identified and specified by the user, the modifications shall be noted in the
reporting of results. Another kind of modification is exemplified as follows: The user of the standard who
functions in a work setting which requires monitoring audiometry or diagnostic audiometry will use
instrumentation which pertains to that particular setting and the frequencies at which threshold is
measured will be dictated by that situation. The choice of frequencies will depend on the purpose for
which the procedure is being used.

1.4 Source

The procedures detailed in this standard are adapted from those described in the Draft Guidelines for
Manual Pure-Tone Audiometry (Wilson et al. 1974) and the Guidelines for a Training Program for
Audiometric Technicians (NASNRC, 1973).

2 Normative References
The following Standards contain provisions which, through reference in this text, constitute provisions of
this American National Standard. At the time of publication, the editions indicated were valid. All
standards are subject to revision, and parties to agreements based on this American National Standard
are encouraged to investigate the possibility of applying the most recent editions of the standards
indicated below.

1
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 ANSI S3.21-2004

ANSI S3.1-1999 (R 2003), American National Standard Maximum Permissible Ambient Noise Levels for
Audiometric Test Rooms

ANSI S3.6-1996, American National Standard Specification for Audiometers

ANSI S3.13-1987 (R 2002), American National Standard Mechanical Coupler for Measurement of Bone
Vibrators

ANSI S3.20-1995 (R 2003), American National Standard Bioacoustical Terminology

3 Definitions
For the purpose of this Standard, the definitions given in ANSI S3.20-1995 and the following apply.

Note: All Definitions are technically equivalent to ANSI S3.20-1995 although some have editorial
differences and been expanded for the user of this standard.

3.1 air conduction. Transmission of sound through the outer and middle ear to the inner ear.

3.2 bone conduction. Transmission of sound to the inner ear primarily by means of mechanical vibration
of the cranial bones.

3.3 threshold of hearing. For a specified signal, the minimum average (time-mean-square) sound
pressure level that is capable of evoking an auditory sensation in a specified fraction of trials. The
characteristics of the signal, the manner in which the signal is presented to the subject, and the point at
which the sound pressure level is measured should be specified.

3.4 reference equivalent threshold sound pressure level. At a specified frequency, the mean/modal
value of the equivalent threshold sound pressure levels of a sufficiently large number of ears of
otologically normal persons of both sexes aged between 10 and 30 years inclusive, expressing the
threshold of hearing in a specified acoustical coupler or artificial ear for a specified type of earphone.
Abbreviation, RETSPL; unit decibel (dB).

NOTE The values for air conduction of reference equivalent threshold sound pressure levels are specified in
ANSI S3.6 – 1996 American National Standard Specification for Audiometers.

3.5 reference equivalent threshold force level. At a specified frequency, the mean value of the
equivalent force levels, in decibels relative to 1µN, derived from a sufficiently large number or ears of
otologically normal persons of both sexes aged between 18 and 30 years, inclusive, expressing the
threshold of hearing in a specified mechanical coupler for a specified configuration of bone vibrator.
Abbreviation, RETFL; unit decibel (dB), symbol LF

Note – The values for bone conduction of reference equivalent threshold force level (RETFL) are specified in
ANSI S3.6 – 1996 American National Standard Specification for Audiometers.

3.6 otologically normal subject. Person in a normal state of health who is free from all signs or
symptoms of ear disease and from excessive wax in the ear canal, which would block incoming sound
and has no history of undue exposure to noise.

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 ANSI S3.21-2004

3.7 hearing level for pure tones. Hearing threshold of a given ear at a specified frequency and for a
specified type of transducer when measured with an audiometer calibrated to reference equivalent
threshold levels for air or bone conduction. The ETSPL or ETFL minus the appropriate RETSPL or
RETFL. Abbreviation HL.

3.8 occlusion effect. Increase in loudness of bone-conducted signals, usually at frequencies below
2000 Hz when the external ear(s) are covered. Typically observed in bone-conduction audiometry as an
improvement in threshold when an ear is covered with an earphone (occluded) or external ear is occluded
compared with an ear being uncovered (unoccluded).

3.9 masking. (a) The process by which the threshold of hearing for one sound is raised by the presence
of another (masking) sound. (b) The amount by which the threshold of hearing for one sound is raised by
the presence of another (masking) sound, expressed in decibels.

3.10 effective masking level for pure tones. Sound pressure level of a band of noise, whose geometric
center frequency coincides with that of a specific pure tone that masks the pure tone to 50% probability of
detection. The hearing level reference of the masking signal is equal to that of the pure tone. Unit,
decibel (dB).

NOTE 1 Effective masking level is analogous to hearing level, i.e., a measure of sound on a physical scale,
independent of the ear under test.

NOTE 2 On a normally hearing ear the amount of effective masking, abbreviated EM, is equal to the number of
decibels that a given band of noise shifts a pure-tone threshold. For example, 20 decibels EM would produce a
threshold shift of 20 decibels when the band of noise and the pure tone are presented simultaneously to the same
ear.

NOTE 3 Typically, the output of a pure-tone audiometer for bands of noise is calibrated in effective masking level.

3.11 manual pure-tone threshold audiometry. Manual pure-tone threshold audiometry is the
measurement of an individual’s threshold of hearing for pure tones in which the signal presentations,
frequencies, and levels are controlled manually by the person administering the test.

3.12 screening audiometry. Is a method of testing in which a selected hearing level is held constant
while frequency is varied. Screening audiometry separates test subjects into only two groups, those who
respond at or below a certain hearing level, and those who do not.

3.13 pulsed tone. A tone which is pulsed automatically by the audiometer during stimulus presentation.

3.14 frequency modulation signals. Is a tone that is frequency modulated in a sinusoid pattern, above
and below the test-tone frequency, sometimes referred to as a warble tone.

3.15 audiogram. Graph of hearing threshold level as a function of frequency. See Appendix A for
symbols. NOTE - Format is shown in ANSI S3.6 – 1996 American National Standard Specification for
Audiometers (Annex E).

3.16 pure-tone audiometer. Device used to measure hearing sensitivity, specifically hearing level for
pure tones, as a function of frequency.

3
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 ANSI S3.21-2004

4 General Requirements

4.1 Ear canal

The ear canal opening shall be inspected for blockage by cotton or other foreign objects and to recognize
soft-walled canals that may “collapse” with or without earphones.

NOTE - Collapse of canal, if suspected, may be obviated by using calibrated insert earphones or circumaural
earphones as specified in ANSI S3.6 – 1996 American National Standard Specification for Audiometers. The type of
earphone used should be noted on the audiogram form.

4.2 Earphone placement

1) Supra-aural earphones shall be mounted on a headband that applies them to the outer ear with a
force between 4 and 5 N.

2) The earphone should be centered over the ear and its position should be adjusted by test subject for
most comfortable listening (or loudest signal) at 250 Hz.

3) The space under the earphone should be clear of long hair, glasses, hearing aids, and other
obstacles.

4.3 Instructions

The instructions shall be phrased in language appropriate to the test subject. The subject shall be told
that smoking or gum chewing interfere with the test and are not allowed.

1) Indicate the purpose of the test, to find the faintest tone that can be heard.

2) Indicate the need to respond whenever the tone is heard, no matter how faint it may be.

3) Indicate the need to respond overtly as soon as the tone comes on and to respond overtly
immediately when the tone goes off.

4) Indicate that each ear is to be tested separately.

4.4 Response task

Overt responses are required from the test subject to indicate when he hears the tone go on and off; any
response task meeting this criterion is acceptable. Examples of commonly used responses are, (1)
raising and lowering the finger, hand, or arm, and (2) pressing and releasing an indicator-light switch.

4.5 Interpretation of response

The primary parameters used in determining threshold are presence of on and off responses, latency of
responses, and number of false responses.

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 ANSI S3.21-2004

4.5.1 On response and off response

Each suprathreshold presentation should elicit two responses – one at the start and one at the end of the
test tone.

4.5.2 Latency of response

The latency of the on response varies usually with the level of presentation. The first response to a test
tone in an ascending series may be hesitant, but the response to a test tone presented 5 dB higher
should be without hesitation.

4.5.3 False responses

False responses may be of two types: 1) response when no tone is presented (false positive) or 2) failure
to respond on presentation of a tone, which the tester believes to be audible to the test subject (false
negative). Either type complicates the measurement procedure. Reinstruction may reduce the
occurrence rate of either type.

5 Determination of threshold

5.1 Familiarization procedure

The test subject shall be familiarized with the listening task by a signal presented at 1000 Hz at estimated
hearing level such as to evoke a prompt and clear response. One of the following methods should be
used:

Beginning with the tone continuously on but completely attenuated, gradually increase the sound
pressure level of the tone until a response occurs. Switch the tone off for at least 2 seconds and present
it again at the same level. If there is a second response proceed to threshold measurement. If there is
no second response, repeat the familiarization procedure.

Present the tone at a hearing level of 30 dB. If a clear response occurs, commence threshold
measurement. If no response occurs, present the tone at 50 dB HL and at successive additional
increments of 10 dB until a response is obtained.

Familiarization is preliminary to threshold determination.

5.2 Determination of threshold

The method described is considered the standard procedure for manual pure-tone threshold audiometry.

5.2.1 Tone duration

Threshold exploration is carried out by presenting tones of 1-2 seconds duration.

5.2.2 Interval between tones

The interval between successive presentations shall be varied, but shall not be shorter than the test tone.

5
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 ANSI S3.21-2004

5.2.3 Level of first presentation

The level of the first presentation of tone for threshold measurement is 10 dB below the level at which the
test subject responded during the familiarization procedure.

5.2.4 Levels of succeeding presentations

The level of succeeding presentation is determined by the preceding response. After each failure to
respond to a signal, the level is increased in 5 dB steps until the first response occurs. After the
response, the intensity is decreased 10 dB and another ascending series is begun.

5.2.5 Threshold of hearing

Threshold is defined as the lowest hearing level at which responses occur in at least one-half of a series
of ascending trials, with a minimum of two responses out of three required at a single level. If variation
occurs, limits shall be set as noted in Appendix B.

6 Standard Procedures for Air-Conduction Measures

6.1 Test environment

The test environment shall meet the specification detailed in ANSI Standard S3.1-1999.

6.2 Instrumentation and calibration

Air-conduction audiometry shall be accomplished with an audiometer and earphones that meet the
specifications of ANSI S3.6-1996 American National Standard Specifications for Audiometers.

6.3 Frequency

Threshold measurements shall be made at octave intervals from 250-8000 Hz and at intermediate
frequencies as required to satisfy the purposes for which the procedure is being used.

6.4 Order

When appropriate information is available, the better ear shall be tested first. The frequency of the first
test stimulus shall be 1000 Hz. Higher frequencies shall then be assessed in ascending order followed by
a retest of 1000 Hz, and finally the lower test frequencies, 500 and 250 Hz, shall be tested. If the retest
results of 1000 Hz differ from the first test by more than 5 dB, the lower of the two thresholds may be
accepted and at least one other test frequency should be retested.

Note – Presentation order of frequencies does not significantly influence test results: the above order is based on
an arbitrary choice which will ensure consistency of approach to each test subject and minimize the risk of
omissions.

6.5 Masking in air-conduction audiometry

When the air-conduction hearing level obtained in one ear exceeds the apparent or obtained bone-
conduction hearing level in the contralateral (nontest) ear by 40 dB or more, masking shall be applied to

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 ANSI S3.21-2004

the nontest ear. The type and magnitude of the masking sound should be noted on the form on which the
test results are recorded.

Note – A standard for procedures in masking does not exist.

6.6 Recording of result

Results shall be recorded in graphic or tabular form or both, and separate forms to represent each ear
may be used.

6.6.1 Audiogram form

When the graphic form is used, the abscissa should be frequency on a logarithmic scale and the ordinate
should be hearing level in decibels on a linear scale. It is recommended that 1 octave on the frequency
scale be linearly equivalent to 20 dB on the hearing scale. The vertical scale is to be labeled: “Hearing
Level in Decibels (dB)”; the horizontal scale is to be labeled: “Frequency in Hertz (Hz)”. Conventionally,
normal hearing is at the top of the graph and hearing loss is plotted downward. (See Appendix A).

6.6.2 Audiogram Symbols

When the graphic form is used, the symbols presented in Appendix A are recommended for use.

6.6.3 Other information

Other pertinent information describing the test situation should be reported on the audiogram form.

7 Standard Procedures for Bone-Conduction Measures in Diagnostic

Audiometry

7.1 Instrumentation

The testing shall be accomplished with a wide-range audiometer as defined by the ANSI S3.6-1996
American National Standard Specification for Audiometers.

7.2 Calibration

The bone-conduction vibrator is to be calibrated in reference equivalent threshold force values (RETFLs ).
See Table 8 of ANSI S3.6-1996 American National Standard Specification for Audiometers and
incorporate the appropriate calibration for either mastoid or frontal placement.

7.3 Vibrator placement

Vibrator and support construction shall allow mastoid or forehead placement with appropriate calibration.

7.4 Covering of ear

The test ear should not be covered for standard bone-conduction measurements. The nontest ear should
be covered with an earphone for contralateral masking.

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7.5 Frequencies

Threshold should be obtained at octave intervals from 250-4000 Hz.

7.6 Order

The initial frequency tested shall be 1000 Hz which shall be followed by the higher test frequencies (2000
and 4000 Hz) in ascending order and finally, by the lower test frequencies as for air conduction.

7.7 Masking

Since the threshold values on which the calibration of bone vibrators were measured with 40 dB of
effective masking in the contra lateral ear, masking should be used in the testing procedure.

7.8 Recording of results

Results may be recorded in tabular of graphic form, and separate graphic forms may be used to represent
each ear. The set of symbols illustrated in Appendix A is recommended for use with the graphic form
(audiogram).

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Annex A
(normative)
Audiogram Symbols

A.1 Air-conduction symbols

The air-conduction symbols should be drawn on the audiogram so that the midpoint of the symbol centers
on the intersection of the vertical ruling and horizontal axis at the appropriate hearing level.

A.2 Bone-conduction symbols

The bone-conduction symbols, with one exception, should be placed adjacent to, but not touching, the
frequency coordinate ruling and centered vertically at the appropriate hearing level. The symbol for the
left ear should be placed to the right of the vertical ruling and that for the right ear to the left of the vertical
ruling. The symbol for unmasked forehead bone conduction should be centered on the vertical ruling at
the appropriate hearing level.

A.3 Symbols representation

Unless otherwise specified, symbols are to indicate that the test signals used were pure tones. The same
symbols may be used for warble tones and narrow-band noise, if so noted on the audiogram.

A.4 Multiple notation

When the two ears are being represented on the same graphic form and when the left-ear unmasked air-
conduction threshold is the same as the right-ear air-conduction threshold, the left air-conduction symbol
should be placed inside the right air-conduction symbol. When bone-conduction thresholds (except
unmasked forehead bone conduction) occur at the same hearing level as air-conduction thresholds, the
bone conduction symbols should be placed beside but not touching the air-conduction symbols. The
midline bone-conduction symbol in this circumstance should be placed with the point of the carat barely
entering the region of the air-conduction symbols.

When bone conduction is measured at the mastoid with unmasked and masked thresholds occurring at
the same hearing level, the unmasked symbol should be placed closest to the vertical ruling. The
masked symbol should surround, but not touch, the unmasked symbol.

A.5 No response
To indicate “no response” at the maximum output of the audiometer, an arrow should be attached to the
lower outside corner of the appropriate symbol and drawn downward and at about 45 degrees outward
from the vertical ruling – to the right for left-ear symbols and to the left for right-ear symbols. The arrow
for sound-field or unmasked forehead bone-conduction symbols should be attached at the bottom and
drawn straight downward.

The “no response” symbol should be placed on the audiogram at the Hearing Level representing the
maximum output limit for the particular test frequency, test modality and audiometer.

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A.6 Separate forms

A separate graphic form may be used to represent each ear. (See Figure A.1)

A.7 Lines connecting symbols

Lines may be used to connect symbols on an audiogram. When used, a solid line should connect the air-
conduction threshold values. Bone-conduction symbols may be connected by a dashed line when an air-
bone gap exists. Symbols representing “no response” for air conduction or bone conduction should not
be connected to each other or to any of the response symbols.

A.8 Color coding

Color coding is not necessary to transmit information about sidedness in this symbol system. In practice,
it may be desirable to avoid color coding because of the increasing use of multiple-copy audiograms and
photo duplication of audiograms. However, if color is employed, red should be used for the right-ear
symbols and connecting lines and blue for the left -ear symbols and connecting lines, with a third color
used for the “both ears” symbols.

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Figure A.1 – Recommended form of audiogram and audiogram symbols.

(Modified from “Guidelines for Audiometric symbols” (American Speech and Hearing Association, 1974).

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Annex B
(informative)
Variability of Threshold Measures

B.1 General information

Upon retest, if a test subject shows variable threshold, a limitation should be set on the acceptable
variation. If the responses do not fall within the limitations, then the test subject should be referred to an
outside source since special methods and greater time may be necessary to obtain accurate results.

Several investigators have reported standard deviations for air-conducted signals of 5 to 10 dB. If the
audiometer in use has a 5-dB-step attenuator, 10 dB is considered the outside limit, attributable to causes
other than hearing.

In a study of reliability of pure-tone measures, Harris (1946) concluded that audiograms would be
consistent to at least 5 dB. Reasonably low noise levels, cooperative test subjects, and intelligent trained
operators are mandatory. The time between test and retests can affect consistency of the results. In a
five-year study of persons not exposed to damaging noise, Pell (1973) found some variation related to
aging, but a great deal of variation arose from test error and random fluctuations. If the variation is
always in the same direction of lower or higher thresholds, then one may attribute more significance to a
small shift.

Steinberg and Munson (1936) found variability related to the fit of the earphone with standard deviations
of 5-7 dB. The place and the method of measurement may contribute to variability. However, under
carefully controlled conditions, Myers and Harris (1949) found less than 1 dB of variability, when 1-dB
steps of attenuation were used.

Bone-conduction measurements were studied for stability and found to have good inherent test-retest
reliability similar to that of air conduction. For a complete and detailed discussion see Dirks (1964).

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Bibliography

[1] American Speech and Hearing Association (1974). Am. Speech Hear. Assoc., “Guidelines for
Audiometric Symbols”.

[2] Dirks, D.D. (1964). “Factors related to bone conduction reliability,” Arch. Otolaryngology. 79, 551-
558.

[3] Dirks, D.D., and Kanun, C. (1975) “Bone-vibrator measurements: Physical characteristics and
behavioral thresholds,” J. Speech Hearing Res. 18. 242-260.

[4] Harris, J.D. (1946). “Free voice and pure tone audiometer for routine testing of auditory acuity,”
Arch. Otolaryngology. 44, 452-467.

[5] Myers, C.K., and Harris, J.D. (1949). “The inherent stability of the auditory threshold,” Navy. Med.
Res. Lab. Rep. No.3.

[6] NASNRC Publ. (1973). “Guidelines for a Training Program for Audiometer Technicians,” Rep.
Working Group 66, Committee on Hearing. Bioacoustics, and Biomechanics.

[7] Pell, S. (1973). “An evaluation of a hearing conservation program – a five year longitudinal study.”
Am. Ind. Hyg. Assoc. J. 82-91 (February).

[8] Steinberg, J.C. and Munson, W.A. (1936). “Deviations in the loudness Judgments of 100 people,”
J. Acoust. Soc. Am. 8, 71-80.

[9] Wilber, L.A. (1972). “Comparability of Two Commercially Available Artificial Mastoids,” J. Acoust.
Soc. Am. 52, 1265-1266.

[10] Wilson, W.R., Graham, J.T., Chaikin, J.B., Sonday, FL, Schoeny, Z.G., Byers, V.W., and
Hopkinson, N.T. (1974). American Speech and Hearing Association, “Draft Guidelines for manual
Pure-tone Threshold Audiometry”.

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