Audiogram Report - Interpretation

What the Report Shows

Audiogram Symbols Used (Standard)

Reading the Audiogram Grid

• Right ear (red, O symbols): Thresholds appear to fall around 40-70 dB HL across frequencies - this is in the moderate to moderately-severe range
• Left ear (blue, X symbols): Thresholds appear similarly affected, with a sloping or flat configuration
• The bone conduction markers (< and >) appear to roughly track the air conduction values, suggesting minimal or no air-bone gap

Degree of Hearing Loss (WHO/Standard Classification)

Type of Hearing Loss

• No significant air-bone gap = sensorineural (not conductive)
• A large air-bone gap would indicate conductive loss (outer/middle ear problem)
• Both types together = mixed hearing loss

Additional Tests Recorded (Lower Section)

• Rinne test - comparing air vs. bone conduction with a tuning fork
• Weber test - lateralization test
• BING, ABG, WEBER, RINNE columns visible
• Recruitment - testing for abnormal loudness growth (suggests cochlear origin)
• SISI, SSI - speech/sensitivity tests
• LTS (Loudness Tolerance/Stapedius) values noted

• "R2-1-" type notation (likely Rinne results)
• "Special [B?]" notes
• "Hot some" and "14 i/mnd" - possibly treatment/follow-up notes
• "No" under some correction columns, "5G 25" values under SRT/AVE fields
• Referred by Dr. [Nazar/Nazir?], Date visible

Remarks / Handwritten Notes

• "Pr" notation at top left
• "LHI" (possibly Left High-frequency impairment)
• "Courtesy" section with referral information
• "To consider" - likely indicating whether hearing aids are warranted

Clinical Summary

What This Means Practically

• The patient likely has difficulty hearing conversational speech without amplification, especially in noisy environments
• Moderate SNHL in both ears typically warrants bilateral hearing aid fitting
• The noted SRT of ~25 dB suggests speech recognition threshold is borderline-mild, which may reflect the better-tested frequencies
• The "to consider" note in the remarks section likely refers to hearing aid candidacy

Note: This interpretation is based on visual analysis of a photographed audiogram. For precise threshold values and clinical decision-making, the original audiogram should be reviewed by the prescribing audiologist. The handwritten notes contain some details that are partially illegible in this image quality.

• K.J. Lee's Essential Otolaryngology, Chapter 14 - The Audiogram
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 2 - The pure-tone audiogram

Type Ad Tympanogram

What It Looks Like

• Peak pressure: Normal (near 0 daPa, same as Type A)
• Peak compliance (height): Abnormally HIGH / exaggerated - the peak is very tall and sharp, often going off the top of the scale (>2.0 mL, sometimes referred to as >1.75-2.0 mmho)
• The pressure at which the peak occurs is normal, but the amplitude of tympanic membrane movement is excessive

What It Means - Causes

• Type Ad on tympanometry
• Significant conductive hearing loss (30-60 dB air-bone gap) on the audiogram
• Absent or reduced stapedial reflexes

"A type Ad tympanogram may suggest ossicular discontinuity as a cause of conductive hearing loss." - Cummings Otolaryngology Head and Neck Surgery

Jerger Classification - Full Context

Clinical Relevance

• Type Ad alone does not always indicate pathology - it can occasionally occur in normal ears, particularly in children with very compliant eardrums
• When paired with a conductive hearing loss on pure-tone audiogram and an absent stapedial reflex, ossicular discontinuity becomes the most likely diagnosis
• High-resolution CT of the temporal bones is the imaging of choice to confirm ossicular chain integrity
• Scott-Brown's Otorhinolaryngology notes: "A tympanogram may show unusually high compliance, with a high-peaked Type AD tympanogram, although this may occur in normal ears"

Treatment of Type Ad Tympanogram (Ossicular Discontinuity / Hypercompliance)

1. Surgical Treatment - Ossiculoplasty (First-line for Ossicular Discontinuity)

Types of Prostheses Used

• PORP achieves air-bone gap closure within 20 dB in ~49-57% of cases
• Titanium and hydroxylapatite prostheses show equivalent functional results and stability
• Presence of the manubrium, better preoperative hearing, and canal-wall-up technique are positive prognostic factors

Tympanoplasty Type III (Myringostapediopexy)

2. Addressing the Underlying Cause First

3. Non-Surgical Options - Hearing Amplification

• Are not surgical candidates (only hearing ear, poor general health)
• Have mixed hearing loss where the sensorineural component limits surgical benefit
• Are children (defer surgery until age ~10+ to reduce SNHL risk from post-op AOM)
• Prefer non-surgical management

• Conventional air-conduction hearing aid - first choice for bilateral moderate conductive hearing loss
• Bone-Anchored Hearing Aid (BAHA) - ideal when air-conduction aids are unsuitable (chronically draining ear, recurrent otitis externa, canal stenosis); delivers sound via osseointegrated titanium implant directly through the skull
• Bone-conduction hearing aid (non-implantable) - softband BAHA for children too young for implant

4. Pre-operative Workup

• High-resolution CT temporal bones - mandatory to identify ossicular defect type, middle/inner ear anomalies, and plan reconstruction
• Full audiometric evaluation - to assess sensorineural reserve and set realistic expectations
• Eustachian tube function - poor ET function predicts poorer outcomes

Prognosis

• Best results: intact stapes suprastructure, dry ear, no cholesteatoma
• Worst results: total stapes loss, active infection, poor sensorineural reserve
• Overall, ~50-57% of patients achieve the success criteria (dry ear, no extrusion, ABG ≤20 dB)

"Better hearing before surgery, presence of the manubrium, tympanoplasty alone, and canal-wall-up tympanomastoidectomy were factors associated with successful hearing results." - Shambaugh Surgery of the Ear

• Shambaugh Surgery of the Ear - Ossicular Reconstruction Techniques and Results
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 2 - Principles of Management
• Cummings Otolaryngology - Audiometry and Hearing Loss

Type Ad Tympanogram + CHL - Clinical Significance & Approach

Why This Combination Is Diagnostically Critical

• The ossicular chain acts as an impedance matching transformer, efficiently transferring sound energy from the low-impedance air of the middle ear to the high-impedance fluid of the cochlea
• When the chain is broken/discontinuous, this impedance matching is lost - sound energy is no longer efficiently conducted to the inner ear despite the TM moving freely
• Result: maximally compliant TM (Type Ad) + significant CHL = the system is hypermobile but non-functional

"A type Ad tympanogram may suggest ossicular discontinuity as a cause of CHL." - Cummings Otolaryngology

"Type A₀ indicates ossicular discontinuity" (some texts use Ad and A₀ interchangeably for this pattern) - Cummings Otolaryngology

The Diagnostic Triad of Ossicular Discontinuity

Common Causes

Important Differential - Do Not Miss

• Also causes CHL with normal or present acoustic reflexes
• Bone conduction thresholds may be negative (<0 dB) at low frequencies
• Type Ad-like hypercompliance possible
• Key differentiator: acoustic reflexes are PRESENT in SSCD, absent in true ossicular discontinuity

Investigation Pathway

Type Ad + CHL
      |
      ↓
Absent stapedial reflexes?
      |
   YES → High-resolution CT temporal bones (confirm ossicular defect)
      |        → Surgical exploration + ossiculoplasty
      |
   NO  → Consider SSCD / third-window lesion
         → HRCT temporal bones (look for canal dehiscence)
         → VEMP testing (low thresholds → SSCD)

Management Summary

• Cummings Otolaryngology Head and Neck Surgery - Audiometry and Immittance Testing
• Shambaugh Surgery of the Ear - Ossicular Reconstruction