title: Air conduction, bone conduction, and soft tissue conduction audiograms in normal hearing and simulated hearing losses.
abstract: BACKGROUND
  In order to differentiate between a conductive hearing loss (CHL) and a sensorineural hearing loss (SNHL) in the hearing-impaired individual, we compared thresholds to air conduction (AC) and bone conduction (BC) auditory stimulation. The presence of a gap between these thresholds (an air-bone gap) is taken as a sign of a CHL, whereas similar threshold elevations reflect an SNHL. This is based on the assumption that BC stimulation directly excites the inner ear, bypassing the middle ear. However, several of the classic mechanisms of BC stimulation such as ossicular chain inertia and the occlusion effect involve middle ear structures. An additional mode of auditory stimulation, called soft tissue conduction (STC; also called nonosseous BC) has been demonstrated, in which the clinical bone vibrator elicits hearing when it is applied to soft tissue sites on the head, neck, and thorax.
  
  
  OBJECTIVE
  The purpose of this study was to assess the relative contributions of threshold determinations to stimulation by STC, in addition to AC and osseous BC, to the differential diagnosis between a CHL and an SNHL.
  
  
  METHODS
  Baseline auditory thresholds were determined in normal participants to AC (supra-aural earphones), BC (B71 bone vibrator at the mastoid, with 5 N application force), and STC (B71 bone vibrator) to the submental area and to the submandibular triangle with 5 N application force) stimulation in response to 0.5, 1.0, 2.0, and 4.0 kHz tones. A CHL was then simulated in the participants by means of an ear plug. Separately, an SNHL was simulated in these participants with 30 dB effective masking.
  
  
  METHODS
  STUDY SAMPLE consisted of 10 normal-hearing participants (4 males; 6 females, aged 20-30 yr).
  
  
  METHODS
  AC, BC, and STC thresholds were determined in the initial normal state and in the presence of each of the simulations.
  
  
  RESULTS
  The earplug-induced CHL simulation led to a mean AC threshold elevation of 21-37 dB (depending on frequency), but not of BC and STC thresholds. The masking-induced SNHL led to a mean elevation of AC, BC, and STC thresholds (23-36 dB, depending on frequency). In each type of simulation, the BC threshold shift was similar to that of the STC threshold shift.
  
  
  CONCLUSIONS
  These results, which show a similar threshold shift for STC and for BC as a result of these simulations, together with additional clinical and laboratory findings, provide evidence that BC thresholds likely represent the threshold of the nonosseous BC (STC) component of multicomponent BC at the BC stimulation site, and thereby succeed in clinical practice to contribute to the differential diagnosis. This also provides evidence that STC (nonosseous BC) stimulation at low intensities probably does not involve components of the middle ear, represents true cochlear function, and therefore can also contribute to a differential diagnosis (e.g., in situations where the clinical bone vibrator cannot be applied to the mastoid or forehead with a 5 N force, such as in severe skull fracture).
authors.affiliation: Speech & Hearing Center, Hadassah University Hospital, Jerusalem, Israel; Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel.
authors.forename: Cahtia
authors.initials: C
authors.lastname: Adelman
authors.affiliation: Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel.
authors.forename: Adi
authors.initials: A
authors.lastname: Cohen
authors.affiliation: Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel.
authors.forename: Adi
authors.initials: A
authors.lastname: Regev-Cohen
authors.affiliation: Department of Communication Disorders, Sackler Faculty of Medicine, Tel Aviv University, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
authors.forename: Shai
authors.initials: S
authors.lastname: Chordekar
authors.affiliation: Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel.
authors.forename: Rachel
authors.initials: R
authors.lastname: Fraenkel
authors.affiliation: Department of Medical Neurobiology (Physiology), Hebrew University-Hadassah Medical School, Jerusalem, Israel.
authors.forename: Haim
authors.initials: H
authors.lastname: Sohmer
mesh_terms: D000161:Acoustic Stimulation / Q000379:methods; D000328:Adult; D001299:Audiometry / Q000379:methods*; D001309:Auditory Threshold / Q000502:physiology*; D001844:Bone Conduction / Q000502:physiology*; D016057:Evoked Potentials, Auditory, Brain Stem / Q000502:physiology*; D005260:Female; D006314:Hearing Loss, Conductive / Q000175:diagnosis / Q000503:physiopathology*; D006319:Hearing Loss, Sensorineural / Q000175:diagnosis / Q000503:physiopathology*; D006801:Humans; D008297:Male; D055815:Young Adult