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Audiogram

An audiogram is a graphical representation of the results from a pure-tone audiometry test, which measures an individual's hearing sensitivity by plotting the softest audible sounds—known as thresholds—at various frequencies against their intensity levels.^[1]^[2] This tool is essential in audiology for quantifying the degree and type of hearing loss, including sensorineural, conductive, or mixed categories, and serves as a foundational diagnostic output for clinicians.^[1]^[3] Audiograms are typically obtained in a sound-treated environment using an audiometer, where pure tones are presented via headphones for air conduction testing or a bone vibrator placed on the mastoid process for bone conduction.^[1] The horizontal axis represents frequency in Hertz (Hz), ranging from low frequencies like 250 Hz on the left to high frequencies up to 8000 Hz on the right, while the vertical axis indicates intensity in decibels Hearing Level (dB HL), from 0 dB (softest sounds) at the top to 120 dB (loudest) at the bottom.^[2]^[3] Symbols on the graph denote results for each ear: red "O" or blue "X" for air conduction in the right and left ears, respectively, and brackets or angles for bone conduction, allowing audiologists to compare pathways and identify discrepancies.^[2] The testing follows standardized procedures, such as the Hughson-Westlake method, to ensure thresholds reflect the intensity at which a tone is detected 50% of the time.^[1] Interpretation of an audiogram reveals the configuration and severity of hearing loss, classified as normal (0–25 dB HL), mild (26–40 dB HL), moderate (41–55 dB HL), moderately severe (56–70 dB HL), severe (71–90 dB HL), or profound (>90 dB HL) based on average thresholds at key speech frequencies (500, 1000, and 2000 Hz).^[3] An air-bone gap exceeding 10–15 dB HL indicates conductive hearing loss due to outer or middle ear issues, while equivalent air and bone thresholds suggest sensorineural loss from inner ear or neural damage; mixed loss combines both.^[1] Clinically, audiograms guide treatment decisions, such as recommending hearing aids, surgical interventions, or further evaluations for conditions like presbycusis or otitis media, and are crucial for monitoring hearing health across populations.^[3]^[1]

Fundamentals

Definition and Purpose

An audiogram is a graphical representation of an individual's hearing sensitivity across various frequencies, typically plotted as hearing thresholds in decibels hearing level (dB HL) on the vertical axis against frequency in Hertz (Hz) on the horizontal axis.^[4] This plot derives from pure-tone audiometry, where the lowest detectable sound levels are measured to assess auditory function.^[5] The primary purpose of an audiogram is to quantify the degree, type, and configuration of hearing loss, enabling the diagnosis of conditions such as sensorineural or conductive hearing impairment.^[1] By identifying patterns in threshold elevations, it helps clinicians differentiate between impairments originating in the outer/middle ear (conductive) and those affecting the inner ear or auditory nerve (sensorineural), informing subsequent management strategies.^[6] The audiogram originated in the early 20th century, evolving from rudimentary tuning fork tests to formalized measurements with the invention of electronic audiometers.^[7] In 1922, physicists Harvey Fletcher and R.L. Wegel developed the first commercially available audiometer and devised the pure-tone audiogram recording form, marking a pivotal advancement in audiological assessment.^[8] For adults, the standard frequency range tested spans 250 Hz to 8000 Hz, with particular emphasis on speech-relevant frequencies between 500 Hz and 4000 Hz that are critical for understanding spoken language.^[1]

Key Components

The audiogram is presented as a graph with a horizontal axis representing sound frequency, typically ranging from low to high pitches in hertz (Hz), such as 125 Hz, 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz, and 8000 Hz.^[1] The vertical axis measures hearing intensity or threshold level in decibels hearing level (dB HL), inverted so that lower values (near 0 dB HL) indicate better hearing sensitivity, with 0 dB HL defined as the average threshold for young adults with normal hearing.^[1] This setup allows thresholds to be plotted as points where the softest detectable sound occurs at each frequency.^[2] Standard symbols on the audiogram follow conventions outlined in audiometric guidelines to distinguish between ears, conduction types, and masking conditions. For air conduction thresholds, an unmasked right ear is marked with a red circle (O), while the unmasked left ear uses a blue X; masked air conduction employs a red square (□) for the right ear and a blue square (S) for the left.^[1] Bone conduction symbols include a red < for unmasked right ear and blue > for unmasked left ear, with brackets [ for masked right bone conduction and ] for masked left bone conduction.^[1] Masking notation ensures accurate isolation of the test ear by indicating when noise was applied to the non-test (contralateral) ear, preventing cross-hearing. This is typically denoted by enclosing symbols in brackets (e.g., [O] for masked right air conduction) or using numbers adjacent to the symbol to specify the masking level in dB, such as "40 dB" to confirm the intensity of noise delivered.^[9] These notations appear directly on the graph to clarify whether thresholds reflect isolated ear responses.^[9] Threshold configurations describe the overall shape of the plotted points across frequencies, providing a visual pattern without implying specific diagnoses. A flat configuration shows thresholds varying by no more than 20 dB across frequencies, indicating relatively uniform sensitivity.^[10] Sloping configurations feature thresholds that worsen progressively at higher frequencies, while rising ones improve toward higher frequencies.^[10] Notched patterns exhibit a dip at specific mid-frequencies, such as around 4000 Hz, with better thresholds elsewhere.^[1]

Testing Methods

Pure-Tone Audiometry

Pure-tone audiometry is the standard clinical procedure for measuring hearing thresholds across specific frequencies, serving as the foundation for constructing an audiogram by determining the lowest intensity at which a patient can detect pure tones at least 50% of the time. The test is typically conducted in a sound-treated room to minimize ambient noise, with the patient instructed to respond to heard tones via a hand raise, button press, or verbal acknowledgment. Frequencies tested usually range from 250 Hz to 8000 Hz for air conduction and 500 Hz to 4000 Hz for bone conduction, starting with the better-hearing ear at 1000 Hz and proceeding in a specified order (e.g., 1000, 2000, 4000, 8000, 500, 250 Hz, with retesting at 1000 Hz).^[11] Thresholds are determined using the Hughson-Westlake ascending-descending method, a widely adopted technique that begins at an audible level and descends in 10 dB steps until no response, then ascends in 5 dB steps until a response is obtained; this bracketing continues until the patient responds at the same level on at least two out of three presentations, establishing the threshold.^[11] The audiometer, the core equipment, must be calibrated annually to meet ANSI/ASA S3.6 standards, which specify performance tolerances for pure-tone signals, including frequency accuracy within ±3% and output levels in 5 dB steps from -10 dB HL to 120 dB HL.^[12] Transducers include supra-aural or insert earphones for air conduction and a bone oscillator placed on the mastoid process for bone conduction, with daily functionality checks and periodic objective calibration ensuring reliability.^[11] Air conduction testing evaluates the entire auditory pathway, including the outer ear, middle ear, and cochlea, by delivering tones through headphones that stimulate the eardrum.^[9] In contrast, bone conduction bypasses the outer and middle ear by vibrating the skull directly to assess cochlear and neural function.^[9] Interaural attenuation—the reduction in sound intensity crossing from one ear to the other—is approximately 40 dB for air conduction with supra-aural headphones (or 55 dB with insert earphones) but negligible (0 dB) for bone conduction due to direct skull transmission.^[9] Masking with narrowband noise is required during bone conduction testing when the non-test ear's air conduction threshold is better by more than 10 dB than the test ear's bone conduction threshold, or when interaural differences exceed attenuation values (e.g., ≥40 dB for air conduction), to prevent cross-hearing and ensure ear-specific results.^[9]^[11] The masking level is adjusted using a plateau-seeking approach, starting 10-20 dB above the non-test ear's air conduction threshold and increasing in 5-10 dB steps until the bone conduction threshold stabilizes without overmasking the test ear.^[11]

Speech and Other Tests

Speech audiometry supplements pure-tone testing by assessing functional hearing for speech signals, providing insights into how hearing loss impacts communication. The speech detection threshold (SDT), also known as the speech awareness threshold, measures the lowest intensity level at which an individual can detect the presence of speech 50% of the time, typically using spondaic words (two-syllable words with equal stress, such as "baseball").^[13]^[14] This threshold is generally 5 to 10 dB better (lower) than the speech recognition threshold and correlates closely with the pure-tone average across speech frequencies, serving as a reliability check for air-conduction thresholds.^[14]^[3] The speech recognition threshold (SRT) determines the intensity level at which a listener correctly identifies 50% of spondaic words, evaluating the auditory system's ability to process speech content.^[15] This test is particularly useful for adults and older children who can verbalize responses, and the SRT typically aligns within 5 dB of the pure-tone average at 500, 1000, and 2000 Hz.^[3] Word recognition scores (WRS), obtained by presenting phonetically balanced word lists at a comfortable loudness level—often 25 to 40 dB sensation level (SL) above the SRT—assess maximum speech intelligibility as a percentage of correctly repeated words.^[16]^[17] High WRS values indicate good discrimination ability, while reduced scores suggest challenges in understanding speech, even if detection thresholds are normal. Beyond speech-based measures, immittance audiometry, including tympanometry, evaluates middle ear function by assessing eardrum mobility and pressure compliance in response to varying air pressure in the ear canal.^[18] This objective test helps identify conductive issues, such as fluid or eustachian tube dysfunction, that could invalidate pure-tone or speech results. Similarly, otoacoustic emissions (OAEs) detect faint sounds produced by outer hair cells in the cochlea in response to acoustic stimuli, confirming cochlear health and aiding in the validation of audiometric thresholds.^[19] These adjunct tests do not replace behavioral audiometry but enhance interpretation by ruling out peripheral factors affecting the audiogram. Speech audiometry results are integrated with pure-tone data for a holistic hearing profile, with SRT often noted on the audiogram near the speech frequency range or reported numerically alongside thresholds to verify consistency and assess real-world hearing functionality.^[20] Discrepancies between speech and pure-tone measures may prompt further investigation, ensuring comprehensive clinical evaluation.

Interpretation

Reading the Graph

To read an audiogram, begin by examining the air conduction thresholds for each ear, which are plotted as the primary lines representing hearing sensitivity via earphones. These thresholds indicate the softest sound levels detectable at various frequencies, typically from 250 Hz to 8000 Hz, with lower decibel hearing level (dB HL) values signifying better hearing. Normal hearing is generally defined as thresholds of 25 dB HL or better across tested frequencies in both ears.^[1]^[21] Next, calculate the pure-tone average (PTA), a key metric summarizing mid-frequency hearing loss severity, by averaging the air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz for each ear. For example, if thresholds at these frequencies are 10 dB HL, 15 dB HL, and 20 dB HL, the PTA is (10 + 15 + 20) / 3 = 15 dB HL. This average helps gauge overall hearing ability for speech comprehension, as these frequencies carry most conversational sounds.^[22]^[3] Assess for asymmetry by comparing thresholds between the right and left ears at the same frequencies; significant asymmetry, such as a difference of 15 dB or more at two or more frequencies, may suggest a unilateral hearing issue requiring further investigation. Masking is applied when interaural differences exceed approximately 40 dB to isolate responses from the test ear.^[1]^[23] Evaluate the air-bone gap (ABG) to differentiate conduction pathways, calculated as the difference between air conduction and bone conduction thresholds at each frequency using the formula:

\text{ABG} = \text{AC threshold} - \text{BC threshold}

A normal ABG is less than 10 dB across frequencies, indicating no significant conductive component; larger gaps highlight potential middle ear involvement.^[1]^[3] Finally, analyze the overall configuration or shape of the threshold lines to understand the pattern of hearing sensitivity. Common shapes include a U-shaped (cookie-bite) curve, where thresholds are elevated in the mid-frequencies compared to low and high frequencies, often associated with sensorineural patterns such as genetic hearing impairments; or a high-frequency drop, showing relatively preserved low-frequency hearing that declines sharply above 2000 Hz, as seen in age-related changes. These configurations provide initial insights into the distribution of hearing loss without implying specific causes.^[1]^[24]

Relating to Hearing Loss Types

Audiograms provide diagnostic insights into the type of hearing loss by comparing air-conduction and bone-conduction thresholds, revealing patterns that distinguish conductive, sensorineural, and mixed impairments. The air-bone gap (ABG), calculated as the difference between air and bone thresholds at each frequency, is a key indicator: an ABG of 15 dB or greater typically signifies a conductive component, while an ABG less than 10 dB suggests sensorineural involvement with no significant conductive overlay.^[1]^[25] Conductive hearing loss arises from issues in the outer or middle ear that impede sound transmission, resulting in elevated air-conduction thresholds while bone-conduction thresholds remain normal or near-normal, producing an ABG of at least 15 dB across two or more frequencies. The audiogram pattern is often flat or emphasizes low-frequency elevation, reflecting the mechanical blockage rather than inner ear damage. Common causes include otitis media, which temporarily obstructs the middle ear, leading to such configurations that are usually reversible with medical intervention.^[1]^[26]^[27] Sensorineural hearing loss, stemming from damage to the cochlea, auditory nerve, or central pathways, elevates both air- and bone-conduction thresholds with an ABG typically under 10 dB, indicating the impairment lies beyond the outer and middle ear. Patterns often show a high-frequency sloping configuration, where thresholds worsen progressively from low to high frequencies, as seen in presbycusis—an age-related loss affecting the basal turn of the cochlea first—or noise-induced hearing loss, which may exhibit a characteristic notch around 4 kHz due to damage from acoustic trauma. These irreversible losses distort speech perception, particularly for consonants.^[1]^[13]^[28] Mixed hearing loss combines elements of conductive and sensorineural types, featuring a partial ABG (often 10-15 dB or more) alongside elevated bone-conduction thresholds, signaling both transmission issues and inner ear or neural damage. Audiograms display air-conduction thresholds worse than bone but with the latter shifted upward, commonly from conditions like chronic otitis media superimposed on presbycusis. Distinctions between unilateral (affecting one ear, potentially indicating asymmetric etiologies like acoustic neuroma) and bilateral losses are evident by comparing the two sides on the graph, aiding in localization of the problem.^[1]^[27]^[29] Severity of hearing loss is graded based on the pure-tone average (PTA), calculated from air-conduction thresholds at 500, 1000, and 2000 Hz, providing a metric for overall impairment degree across types. Classifications include mild (26-40 dB PTA), moderate (41-55 dB), moderately severe (56-70 dB), severe (71-90 dB), and profound (91+ dB), guiding prognostic and rehabilitative decisions.^[27]^[30]^[6] Specific audiogram configurations further refine diagnosis within these types. A cookie-bite pattern, with greater loss in mid-frequencies (1-2 kHz) and relative sparing at lows and highs, often indicates genetic hearing impairments. In contrast, a corner or sharply dropping high-frequency pattern may signal ototoxicity from agents like aminoglycosides, causing broad cochlear damage. These shapes, alongside type and severity, help pinpoint etiologies without relying on additional tests.^[1]^[28]

Applications and Limitations

Clinical Uses

Audiograms play a central role in the diagnostic evaluation of hearing disorders within ear, nose, and throat (ENT) practices, providing an objective measure of hearing thresholds to identify the type, degree, and configuration of loss for initial assessments.^[1] In newborn screening programs, automated auditory brainstem response (ABR) testing serves as an early diagnostic tool to detect congenital hearing loss, often followed by confirmatory behavioral audiometry once feasible.^[31] For occupational health, audiograms establish baseline hearing levels and monitor noise-induced changes, as mandated by OSHA standards requiring annual testing for workers exposed to excessive noise.^[32] Serial audiograms are essential for monitoring treatment effects and disease progression in various clinical scenarios. They track hearing changes during administration of ototoxic medications, such as cisplatin in chemotherapy, enabling early detection of drug-induced sensorineural loss.^[33] Post-surgical audiometry, for instance after stapedectomy for otosclerosis, evaluates improvements in air-bone conduction gaps typically 3 to 4 weeks postoperatively.^[34] In conditions like Meniere's disease, repeated audiograms document the fluctuating and progressive nature of low-frequency sensorineural hearing loss over time.^[35] Audiogram results directly inform intervention planning by quantifying hearing deficits and guiding device selection. For hearing aid fitting, the pure-tone average (PTA) across key frequencies determines amplification needs, while word recognition scores (WRS) assess speech understanding to optimize device performance.^[16] Cochlear implant candidacy is evaluated using audiometric thresholds, typically requiring bilateral severe-to-profound sensorineural hearing loss with limited benefit from conventional amplification.^[36] These data also shape auditory rehabilitation strategies, such as tailored speech therapy or environmental modifications to enhance communication outcomes.^[16] Adaptations in audiometric testing address developmental and age-related challenges in specific populations. In pediatrics, conditioned play audiometry engages children aged 2 to 5 years by incorporating game-like responses to tones, facilitating reliable threshold measurement in young patients unable or unwilling to respond conventionally.^[37] For geriatric individuals, audiograms must account for cognitive factors, as age-related hearing loss correlates with accelerated cognitive decline, necessitating integrated assessments to distinguish sensory from central processing impairments.^[38] Emerging technologies are expanding audiogram applications as of 2025. Artificial intelligence (AI)-enhanced pure-tone audiometry analyzes patterns in large datasets to improve diagnostic accuracy, particularly in complex cases.^[39] Tele-audiology enables remote testing and monitoring, increasing access for underserved populations through smartphone-based or web-delivered protocols.^[40]

Constraints and Influences

Patient factors significantly impact the accuracy and reliability of audiograms, particularly in vulnerable populations such as children and the elderly. In children, unreliable responses often arise from attention deficits or difficulty understanding instructions, leading to false alarms or inconsistent signaling of tone detection. Similarly, elderly individuals may exhibit cognitive impairments or reduced concentration, compromising their ability to provide consistent responses during testing. Middle ear conditions, such as otitis media with effusion, can elevate pure-tone thresholds by 10-30 dB due to fluid accumulation impairing sound transmission to the inner ear.^[41]^[42] Methodological constraints inherent to standard audiometric procedures further limit the comprehensiveness of audiograms. Conventional pure-tone audiometry typically assesses frequencies from 250 Hz to 8000 Hz, potentially missing ultra-high frequency losses above 8000 Hz that are critical for monitoring ototoxicity from chemotherapy or noise exposure. Additionally, audiograms do not evaluate central auditory processing disorders, which affect sound interpretation in the brain rather than peripheral hearing sensitivity, necessitating supplementary tests for a full diagnostic picture.^[43]^[44] Environmental and technical influences introduce variability that can undermine audiogram precision. Ambient room noise, even at low levels, may mask test tones, resulting in threshold elevations of 5-10 dB, while uncalibrated equipment or improper placement of transducers (e.g., supra-aural headphones) can similarly introduce errors in this range. In speech audiometry, cultural or language biases may affect patient comprehension and responses, leading to skewed results if test materials do not align with the individual's linguistic background.^[45]^[21]^[46] For remote audiometry, additional constraints include device variability and internet connectivity issues, potentially affecting reliability in telehealth settings.^[40] To ensure validity, audiograms should demonstrate high repeatability, with test-retest differences typically within 5 dB across frequencies. Red flags for non-organic overlay, such as inconsistent air-bone gaps exceeding 10 dB without corresponding middle ear pathology, signal potential response unreliability and warrant further investigation. Masking techniques can help mitigate interaural influences during testing to improve result integrity.^[21]^[47]^[48]

References

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