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The Clinical Audiogram

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The Clinical Audiogram The Clinical Audiogram Its History and Current Use Donald A. Vogel, Au.D. Hunter College, City University of New York Patricia A. McCarthy Rush University Medical Center Gene W. Bratt, Vanderbilt University Carmen Brewer National Institutes of Health This article documents the historical development and evolution of the audiogram through a litera- ture review and describes how audiologists currently use the audiogram. Issues of electronic data collection, privacy, and future developments are briefly discussed. Introduction ing the auditory receptive communication skills of their patients. Audiologists base habilitative and rehabilitative The audiogram has been the banner of the clinical programs on information obtained from the audiogram. audiologist’s work since the profession gained recog- Considering the variety of ways that hearing sensitivi- nition after World War II. Without the data contained ty of an individual can be recorded, a widespread ac- on the audiogram, physicians could not properly docu- ceptance of established standards has enabled the au- ment pathologic conditions of the ear, nor prepare for diogram to be universally understood despite variables otological surgeries. Speech-language pathologists have such as patient-related historical data, types of tests per- utilized the audiogram for the purposes of understand- formed, and test conditions/components. Communicative Disorders Review Volume 1, Number 2, pp. 81–94 81 Copyright © 2007 Plural Publishing, Inc. 82 cOMMUnicativE DISORDERS REVIEW, VOL. 1, NO. 2 As facilities and practices grow in a technologically fluid field, the audiologist must remain current in every aspect of his or her practice. Similarly, the audiogram must periodically change to reflect current advances or modifications in clinical protocols and state of the art equipment. The purpose of this paper, therefore, is to document the historical development and evolution of the audio- gram through literature review and to describe how au- diologists currently use the audiogram and briefly raise issues about privacy, electronic data collection, and fu- ture applications. An Audiometry Time line in Appendix A highlights the landmarks of hearing measurement. The History of the Audiogram Since the invention of the audiometer over 100 years ago, the audiogram has become the graphic and/ Figure 1. Recreation of Hartmann’s Auditory Chart, first or numerical record of hearing sensitivityFigure for1. Recreation the oto- of Hartmann’s Auditory Chart, first conceived in 1885. This was used to logic and audiologic specialties in health care. The au- conceived in 1885. This was used to document tuning diogram was born out of necessity asdocument the signature tuning tool fork responsesfork responses to the to leftthe andleft andright right ears. ears. specific to the hearing scientist’s ability to observe, mea- sure, and record hearing behavior (Hedge, 1987). With- out the ability to record information retrieved from the cording forms for hearing testing. It was finally accepted test environment, data collection would be circumspect in 1909 during the 8th International Congress of Otol- and haphazard. Interestingly, this indispensable tool has ogy in Budapest, Hungary. Called an “Acumetric Sche- received little more than cursory attention throughout ma,” this attempt at hearing record standardization was the years. never universally accepted (Feldmann, 1970). From a historical perspective, as audiology grew in- Unfortunately, hearing loss in the eras of Hartmann to a profession, the audiogram reflected the technolo- and Wien could not be specified in quantitative values gies developed and used in the clinical environment. relative to normal hearing. The tester arbitrarily selected (See the Audiometry Time Line in Appendix A for an intensity steps. It was not until 1922 that Fletcher, Fowl- overview of the historical development of these tools.) er, and Wegel first employed frequency at octave inter- In 1885, Arthur Hartmann designed an “Auditory Chart” vals plotted along the abscissa and intensity downward which included left and right ear tuning fork represen- along the ordinate as a degree of hearing loss. Fletch- tation on the abscissa and percent of hearing along the er et al. also coined the term “audiogram” at that time ordinate (Figure 1) (Feldmann, 1970). (Feldmann, 1970). Although Hartmann’s “Auditory Chart” does show Throughout the years, the audiogram has reflected similarities to today’s pure-tone grid, the standard for re- the growth of audiometry from air conduction in the cording hearing sensitivity gradually evolved from Max early 1920s (Jacobson & Northern, 1991) to otoacoustic Wien’s “Sensitivity Curve” first presented in 1903 (Fig- emissions of the 1990s. Virtually every population served ure 2). Wien’s graph documented results from tuning by the audiologist, at some point, has its hearing sensitiv- fork stimuli. Physical sensitivity was indicated along the ity recorded on the audiogram. As mid and late 20th cen- ordinate and the chart was the first to show the relation- tury hearing technologies grew, the audiogram moved ship between hearing thresholds and frequency (Feld- into a position not only as the standard for displaying mann, 1970). recorded data, but also as a counseling tool among au- It was not until some 20 years later that a different diologists. Its value is currently emphasized by clinical type of record of hearing measurement was presented doctoral audiology courses as an important application for recognition as a standard by Politzer, Gradenigo, and used to illustrate degrees and types of hearing losses for Delsaux (Figure 3). Their proposal, given in 1904 during patients and caregivers (Chial, 1998). Outside the pro- the 7th International Congress of Otology in Bordeaux, fession of audiology, otologists and speech-language pa- France, was intended to standardize nomenclature such thologists continue to receive training in audiometrics as “auditory horizon” and “auditory area” along with re- so they may understand hearing loss (Nodar, 1997). 4 THE CLINICAL AUDIOGRAM 83 Figure 2. Re-creationFigure of Wien’s2. Re-creation sensitivity of curve,Wien’s first sensitivity conceived curve, in 1903. first The con -graph was the first ceived in 1903. The graph was the first attempt to mark hear- attempt to mark hearinging sensitivity sensitivity in relationin relation to tofrequency frequency (Feldmann, (Feldmann, 1970). 1970). AD 1 1 4 W S a M a A c A R H P V v LI LS AS Figure 3. Recreation of the Acumetric Schema submitted by Politzer et al. in 1904. Although Figure 3. Recreation of the Acumetric Schema submitted by Politzer et al. in 1904. Although intended to document hearing sensitivity, the schema failed in its attempt at standardize nomenclature. Key: W = We- intended to document hearing sensitivity, the schema failed in its attempt at standardize ber test; AD = auris dextra (right ear); S = Schwabach test; AS = auris sinistra (left ear); a1M = duration of 1 4 4 thenomenclature. auditory sensation Key: with W = a Weberfork placed test; AD on the= auris mastoid; dextra a (rightA = same ear); forS = air Schwabach conduction; test; c ASA = = same auris for a c fork and air conduction; R = Rinne test; H = horlogium (distance that a watch may be heard); P = results of Politzer’s acumeter; V1 = vox (distance to which conversational speech is understood); v = same1 for whis- sinistra (left ear); a M = duration of the auditory sensation with a fork placed on the mastoid; a A = same pered voice; LI = limes inferior (lower frequency limit); LS = limes superior (upper frequency limit). 4 4 for air conduction; c A = same for a c fork and air conduction; R = Rinne test; H = horlogium (distance thatThe a watchAudiogram may be heard); and P the = results First of Politzer’s acumeter;sented a V tone = vox or a(distance click; it tohad which an attenuator conversational set in a scale Commercially Produced Audiometer of 40 steps (Seashore, 1899). Although Seashore’s audi- speech is understood); v = same for whispered voice; LIometer = limes was inferior not the (lower first frequencyattempt to limit); create LS an = instrument for hearing testing, its ability to attenuate intensity log- Any limesdiscussion superior of the(upper audiogram frequency must limit). include a dis- arithmically6 made it a landmark invention. This device cussion of the development of the audiometer. In 1899, initiated early forms of hearing testing standards, and Carl E. Seashore introduced the audiometer as an instru- consequently the otologist’s understanding of the need ment to measure the “keenness of hearing” whether in for evaluation protocols and the construction of sound- the laboratory, schoolroom, or office of the psychologist treated test rooms. The decade of the 1920s propelled or aurist. The instrument operated on a battery and pre- hearing testing into a more exacting science with the 8 84 cOMMUnicativE DISORDERS REVIEW, VOL. 1, NO. 1 introduction of audiometers capable of producing pure It may be surmised that the advent of the audiogram tones via air conduction and bone conduction, and, to did not result from any preconceived design born out of a limited extent, even speech testing capabilities. In the scientific necessity; rather, it became the sum of hear- early 1920s, Western Electric developed the first com- ing technology’s evolutionary parts. Scientists in the ear- mercially produced electronic audiometer. This instru- ly years were focused on exploring diseases of the ear, ment was
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