Article-At-A-Glance
- A comprehensive hearing evaluation may include several different tests rather than a single pass-or-fail screening.
- An audiogram shows hearing thresholds across different frequencies and can help identify the degree and pattern of hearing loss.
- Speech testing provides information about how well a person detects and recognizes spoken words under controlled conditions.
- Comparing air- and bone-conduction thresholds helps clinicians distinguish conductive, sensorineural, and mixed hearing loss.
- Hearing-test results should be interpreted as a whole rather than relying on one number, category, or test result.
Many people picture a hearing test as sitting in a booth, wearing headphones, and responding whenever they hear a beep.
Pure-tone testing is an important part of hearing evaluation, but a comprehensive assessment can involve much more. Depending on the reason for testing, an evaluation may include a health and hearing history, examination of the ear canal and eardrum, middle-ear testing, pure-tone testing, and speech testing.
The goal is not simply to determine whether hearing loss is present. Testing can help identify its degree, configuration, type, possible need for medical evaluation, and potential options for hearing rehabilitation.
What a Hearing Test Can Tell You
A hearing evaluation provides information about how the auditory system responds to sound.
Depending on the tests performed, results may help determine:
- The softest sounds you can detect at different frequencies
- Whether hearing differs between the two ears
- Whether a hearing loss has conductive, sensorineural, or mixed components
- How well you recognize speech under specific test conditions
- Whether middle-ear findings may be contributing to hearing difficulty
- Whether additional medical or audiological evaluation may be appropriate
A hearing evaluation cannot always determine the exact cause of hearing loss by itself. Medical history, physical examination, additional audiological testing, imaging, laboratory testing, or specialist evaluation may sometimes be needed.
Common Parts of a Comprehensive Hearing Evaluation
There is no universal rule that every full hearing examination must contain exactly five tests. The components used depend on age, symptoms, medical history, clinical setting, and the reason for evaluation.
However, the following are common components of an adult diagnostic hearing evaluation.
1. Case History
The evaluation commonly begins with questions about hearing concerns and relevant health history.
Topics may include:
- When hearing difficulty began
- Whether one or both ears are affected
- Noise exposure
- Tinnitus
- Dizziness or balance symptoms
- Ear pain, pressure, drainage, or infections
- Family history of hearing loss
- Medications and relevant medical conditions
- Previous ear surgery or injury
- Listening situations that are particularly difficult
This information helps the clinician interpret test results in the appropriate context.
2. Otoscopy
Otoscopy is visual examination of the external auditory canal and tympanic membrane, commonly called the eardrum.
An otoscope can help identify findings such as:
- Earwax that may obstruct the canal
- Foreign objects
- Inflammation or drainage
- Possible eardrum perforation
- Other visible abnormalities
Otoscopy is generally quick and should not normally be painful, although an inflamed or injured ear may be sensitive.
3. Tympanometry
Tympanometry evaluates the acoustic and mechanical behavior of the middle-ear system while air pressure in the ear canal is varied.
A probe is placed in the ear canal, and the resulting measurement is displayed as a tympanogram.
Tympanometry can provide useful information about middle-ear function and may help identify patterns consistent with fluid, abnormal middle-ear pressure, tympanic-membrane perforation, or other conditions.
Common tympanogram classifications include:
- Type A: A peak occurring within a generally expected pressure range. Additional subtypes may describe unusually shallow or deep compliance.
- Type B: A relatively flat tracing. Interpretation depends importantly on ear-canal volume and other findings; possible explanations include middle-ear fluid, perforation, or an open pressure-equalization tube.
- Type C: A peak occurring at negative middle-ear pressure, which may occur with Eustachian-tube dysfunction or related conditions.
A tympanogram does not establish a diagnosis by itself. It is interpreted together with otoscopy, symptoms, hearing results, and other clinical information.
4. Pure-Tone Air- and Bone-Conduction Testing
Pure-tone audiometry measures the softest tones a person can detect across selected frequencies.
During air-conduction testing, sounds are delivered through headphones or insert earphones. The listener responds when a tone is heard, even when it is very soft.
Bone-conduction testing uses a bone oscillator, typically placed on the mastoid area behind the ear. It stimulates the cochlea through skull vibration while reducing the contribution of the outer and middle ear.
Comparing air- and bone-conduction thresholds helps determine whether a hearing loss is conductive, sensorineural, or mixed.
5. Speech Testing
Speech testing provides information that pure-tone thresholds alone cannot provide.
Depending on the evaluation, speech measures may include a speech reception threshold and word-recognition testing. Some clinics also use speech-in-noise testing when difficulty understanding speech in background noise is an important concern.
Speech testing is not simply a direct measurement of how well “the brain processes language.” Performance can be influenced by hearing sensitivity, presentation level, test materials, language, cognition, attention, auditory function, and other factors.
How to Read an Audiogram
An audiogram is a graph showing hearing thresholds across tested frequencies.
Frequency
The horizontal axis represents frequency, measured in Hertz (Hz). Lower frequencies appear toward the left side of the graph and higher frequencies toward the right.
Adult conventional audiometry commonly tests frequencies from approximately 250 through 8,000 Hz, although the exact test range can vary.
Hearing Level
The vertical axis represents hearing level in decibels hearing level, written as dB HL.
Values near the top of the audiogram represent softer test levels. As the marks move downward, louder sound is required for detection.
Importantly, 0 dB HL does not mean an absence of sound. It is a standardized audiometric reference level based on expected hearing thresholds in people with normal hearing.
Right and Left Ear Symbols
Standard audiograms commonly use an O for unmasked right-ear air-conduction thresholds and an X for unmasked left-ear air-conduction thresholds.
Additional symbols are used for masked testing and bone-conduction thresholds.
Why Audiogram Shape Matters
Clinicians consider both the degree and configuration of hearing loss.
Examples include flat, sloping, rising, notched, and other configurations.
Age-related hearing loss often affects higher frequencies more than lower frequencies. Noise exposure can also produce high-frequency hearing loss and may sometimes be associated with an audiometric notch.
However, an audiogram pattern alone does not prove the cause of a hearing loss. Similar configurations can occur for different reasons.
Understanding Hearing-Loss Categories
Hearing thresholds are often described using categories such as normal or within expected limits, mild, moderate, severe, and profound.
There is not one universally used classification system. Cutoffs vary somewhat among professional organizations, clinics, research studies, and age groups.
One commonly used adult classification is approximately:
| General Description | Approximate Hearing Level |
|---|---|
| Within commonly used adult normal limits | About 0–25 dB HL |
| Mild | About 26–40 dB HL |
| Moderate | About 41–55 dB HL |
| Moderately severe | About 56–70 dB HL |
| Severe | About 71–90 dB HL |
| Profound | About 91 dB HL and above |
These categories are useful shorthand, but they should not be treated as complete descriptions of a person’s communication ability.
Two people with similar pure-tone thresholds may function differently because of speech-recognition ability, listening environment, cognitive factors, language, hearing history, and other individual differences.
Speech Reception Threshold
The speech reception threshold (SRT) is the lowest level at which a person can correctly recognize approximately 50% of familiar speech materials under standardized conditions.
Spondee words — two-syllable words with roughly equal stress on each syllable — are commonly used.
The SRT is often compared with the pure-tone average as a cross-check on test consistency.
A discrepancy does not automatically indicate a particular disorder. The clinician considers the size and nature of the discrepancy along with the rest of the evaluation.
Word-Recognition Testing
Word-recognition testing measures how accurately a person identifies standardized speech materials at a specified presentation level.
The result is usually reported as the percentage of words correctly repeated.
Interpretation depends on factors such as:
- The word list used
- Presentation level
- Recorded versus monitored-live-voice presentation
- Hearing sensitivity
- Language and familiarity with the test materials
- Whether masking was required
- Other audiological and medical findings
There is no universal rule that a score below a particular percentage proves auditory-nerve damage.
Unexpectedly poor or asymmetric speech-recognition results may prompt additional evaluation, but they must be interpreted in clinical context.
Speech-in-Noise Testing
Many people report that their greatest difficulty occurs in restaurants, family gatherings, meetings, or other environments with competing sound.
Standard word-recognition testing in quiet may not fully represent those real-world challenges.
Speech-in-noise tests can provide additional information about how well a person recognizes speech when competing noise is present. These results may help guide counseling, hearing-aid programming, assistive technology, and communication strategies.
Air Conduction vs. Bone Conduction
The relationship between air- and bone-conduction thresholds helps classify hearing loss.
Conductive Hearing Loss
A conductive component occurs when sound transmission through the outer or middle ear is reduced.
Possible causes include:
- Earwax blockage
- Middle-ear fluid
- Eardrum abnormalities
- Problems involving the auditory ossicles
- Otosclerosis
When bone-conduction thresholds are better than air-conduction thresholds by a clinically significant amount, an air-bone gap is present.
Some conductive conditions are medically or surgically treatable, while others may be managed with hearing technology or other approaches.
Sensorineural Hearing Loss
Sensorineural hearing loss generally reflects dysfunction involving the cochlea or auditory neural pathways.
Air- and bone-conduction thresholds are both reduced without a significant conductive air-bone gap.
Common contributors include aging, excessive noise exposure, genetic factors, certain medications, illness, and other inner-ear conditions.
Mixed Hearing Loss
Mixed hearing loss contains both conductive and sensorineural components.
This means there is reduced inner-ear or neural hearing sensitivity along with an additional outer- or middle-ear component.
What Happens After the Hearing Test?
After testing, the clinician should explain the results in understandable terms and relate them to the concerns that brought you to the appointment.
Depending on the findings, next steps may include:
- No immediate intervention
- Monitoring hearing over time
- Medical evaluation
- Hearing aids
- Assistive listening technology
- Communication strategies
- Hearing conservation
- Additional audiological testing
- Cochlear-implant evaluation for appropriate candidates
A recommendation should be based on the overall evaluation and the person’s communication needs rather than a single audiogram category.
Questions to Ask After Your Evaluation
- Do I have hearing loss, and if so, what type?
- Is the hearing loss similar in both ears?
- Which frequencies are most affected?
- How might these results relate to the situations where I have difficulty hearing?
- What do my speech-test results show?
- Do any findings suggest that I should see a physician or ENT specialist?
- Would hearing aids or other hearing technology be appropriate?
- When should my hearing be tested again?
- How can I protect my hearing from additional preventable damage?
Ask for a Copy of Your Results
It can be useful to obtain a copy of your audiogram and other test results for your personal records.
Previous results provide a valuable comparison point if your hearing changes in the future or if you seek evaluation from another provider.
When Hearing Aids May Be Considered
Hearing aids may be appropriate when hearing loss creates communication difficulty and amplification is expected to provide meaningful benefit.
The decision is not based solely on whether an audiogram crosses a particular decibel threshold.
Factors can include:
- Degree and configuration of hearing loss
- Speech-recognition results
- Communication needs
- Listening environments
- Manual dexterity and vision
- Technology preferences
- Medical findings
- Personal goals
- Cost and access
Modern hearing aids may include features such as rechargeable batteries, directional microphones, wireless connectivity, smartphone control, and environmental sound processing.
Features alone do not determine whether a device is appropriate. Proper selection, fitting, verification, counseling, and follow-up are important parts of successful hearing-aid use.
Learn more in Hearing Aids: The Complete Guide.
When Hearing Changes Need Medical Attention
Routine hearing difficulty can usually be evaluated through a scheduled appointment. Certain symptoms deserve more urgent attention.
Seek prompt medical evaluation for:
- Sudden or rapidly developing hearing loss, particularly in one ear
- Hearing changes following significant head or ear trauma
- New hearing loss accompanied by significant neurological symptoms
- Severe ear pain or significant drainage
- Other rapidly worsening or concerning symptoms
Sudden sensorineural hearing loss is time-sensitive and should not be assumed to be earwax, congestion, or a problem that can simply wait for a routine hearing-aid appointment.
Frequently Asked Questions
How Long Does a Hearing Test Take?
The length of a hearing evaluation varies according to the tests required.
A basic hearing screening may take only a few minutes. A comprehensive diagnostic evaluation can take substantially longer, particularly when middle-ear tests, speech testing, counseling, or specialized assessments are included.
Rather than expecting every full evaluation to last exactly 60 to 90 minutes, ask the clinic how much time is scheduled for your particular appointment.
Does a Hearing Test Hurt?
Routine hearing tests are generally noninvasive and should not be painful.
Tympanometry briefly changes pressure in the ear canal and may create a sensation of fullness or pressure. Otoscopy can be uncomfortable when the ear canal is inflamed, injured, or very sensitive.
Tell the clinician if any part of the examination causes pain.
At What Age Should Adults Get Their Hearing Tested?
There is no single age at which every healthy adult must begin comprehensive annual hearing testing.
Testing is appropriate whenever a person notices hearing difficulty, tinnitus, communication problems, or other relevant symptoms.
People with occupational or recreational noise exposure, ototoxic medication exposure, previous ear disease, family history, or other hearing-risk factors may also benefit from periodic testing.
Older adults should pay particular attention to gradual hearing changes because age-related hearing loss can develop slowly.
What Is the Difference Between an Audiologist and a Hearing Aid Specialist?
An audiologist is a healthcare professional trained in the evaluation and management of hearing and balance disorders. In the United States, new audiologists generally enter the profession with a Doctor of Audiology degree, although practicing audiologists may hold other qualifying graduate degrees depending on when and how they entered the profession.
A hearing aid specialist, sometimes called a hearing instrument specialist, is licensed according to state requirements to evaluate hearing for the purpose of selecting, fitting, and dispensing hearing aids within the professional’s authorized scope of practice.
Scope-of-practice rules vary by jurisdiction. Medical or diagnostically complex hearing concerns may require an audiologist, physician, or otolaryngologist.
Can You Fail a Hearing Test?
A diagnostic hearing test is not a school examination and does not have a passing or failing grade.
The goal is to measure hearing as accurately as possible. Respond whenever you believe you hear the test signal, even if it is very faint.
If you are unsure whether you heard something, that uncertainty is normal. Audiometric procedures are designed to establish thresholds through repeated responses rather than relying on a single answer.
What Is Considered Normal Hearing on an Audiogram?
For adults, thresholds around 0 to 25 dB HL are commonly described as being within normal or expected limits, although classification systems vary.
Children are often evaluated using more stringent criteria because even relatively small hearing deficits can be important during speech and language development.
Hearing ability should not be reduced to a single category. Frequency-specific thresholds, differences between ears, speech understanding, symptoms, and communication needs all contribute to interpretation.
Does a 4,000 Hz Notch Prove Noise-Induced Hearing Loss?
No.
A high-frequency notch, often involving frequencies around 3,000 to 6,000 Hz, can be associated with noise exposure. However, the presence of a notch does not by itself prove that noise caused the hearing loss.
Noise history, age, medical factors, test reliability, and the complete audiometric configuration should all be considered.
Do I Need a Referral for a Hearing Test?
Whether a referral is required depends on the provider, jurisdiction, insurance plan, and reason for testing.
Many audiology practices accept self-referrals, but insurance coverage may have separate requirements.
Symptoms such as sudden hearing loss, significant ear drainage, severe ear pain, or certain neurological symptoms require medical evaluation rather than simply scheduling a routine hearing screening.
Does Medicare Cover Hearing Tests and Hearing Aids?
Medicare coverage rules can change and depend on the type of service and circumstances.
Original Medicare generally does not cover hearing aids or routine hearing exams for the purpose of fitting hearing aids. Diagnostic hearing and balance evaluations may be covered when Medicare requirements are met.
Because coverage rules, Medicare Advantage benefits, and individual insurance plans can differ, verify current benefits directly with Medicare, your health plan, and the provider before assuming a service is covered.
What Should I Do If My Hearing Test Shows Hearing Loss?
The next step depends on the type, degree, configuration, symptoms, and likely cause of the hearing loss.
Some conductive problems may require medical treatment. Many permanent sensorineural hearing losses can be managed with hearing aids and communication strategies. People with more severe hearing loss and limited benefit from appropriately fitted hearing aids may be evaluated for cochlear implantation or other options.
Your hearing-test results are the starting point for those decisions, not the entire decision by themselves.
Reliable Sources and Further Reading
- National Institute on Deafness and Other Communication Disorders — Hearing, Ear Infections, and Deafness
- National Institute on Deafness and Other Communication Disorders — Hearing Aids
- National Institute on Deafness and Other Communication Disorders — Sudden Deafness
- American Speech-Language-Hearing Association — Hearing and Balance
Apex Provides Education, Not Individual Medical Care
Apex Brain & Hearing Health provides general educational information about hearing tests, audiograms, hearing loss, and hearing technology. This information cannot diagnose the cause of an individual’s hearing difficulty or replace professional evaluation.
Seek prompt medical attention for sudden hearing loss, significant neurological symptoms, serious ear or head injury, or other rapidly developing or concerning symptoms.
