Chapter 1

An Analogy for Beginners; Abbreviations, Definitions, and Rules; Formulae Quick Reference Summaries

This chapter is a reference guide for those who want to quickly access a formula, or need a reminder of what the many abbreviations stand for in this e-book or the associated games.

For first time readers, there is an analogy that may be of interest, but after that, the remainder is quick references for those who have already completed the book, so you would then skip to Chapter 2

Show Me the Masking Analogy Take Me to Chapter 2

Introduction and an Analogy

Masking is one of the more challenging topics for first year audiology students. There are some fundamental concepts of crossover and crossback that have to be understood. Perhaps an analogy will help. Perhaps not, but it probably won’t hurt, so let’s try.

Sarah, age 3, is in the kitchen with her father who is keeping her busy making cookies. Sarah’s mother is in the next room, behind a closed door, talking to Sarah’s grandmother who wants to know what to buy Sarah for her upcoming birthday.

Conversation Overheard

Uh oh! Sarah’s father can hear bits of the phone conversation from the other room; the “what to get Sarah” conversation has “crossed over” to the kitchen, which means risk that Sarah’s birthday gift won’t be a surprise.

Masking Crossover

In hearing testing, some of the test ear signal can spill over to the non-test ear. Just as we want only the grandmother to hear the birthday gift suggestions, not Sarah, we want only the test ear to hear the tone (or speech testing material). We don’t want the response to come from the non-test ear. When the sound is conveyed from the test ear to the non-test ear, it is said to have “crossed over”.

Masking During Cookie Making

Sarah’s father quickly turns on some music, which is louder than the faint murmur of the conversation in the other room. He has masked the “crossover”.

Masking During Masking

To prevent the non-test ear from detecting the crossed-over tone, noise will be put into the non-test ear.

Insufficient Masking

Sarah complains that she doesn’t like that song and changes it, alas to one that is quieter. Dad can hear bits of the conversation, so he asks Sarah to turn up the volume.

Undermasking

Just putting some noise in the non-test ear doesn’t mean it’s enough noise. We will consider if we may be undermasking.

Crossback – the Radio is Audible in the Room Next Door

Not unexpectedly, the radio may be heard in the room where grandmother and mother are talking by phone. If the radio is lower than the conversation, it’s not a problem.

Crossback in Masking

In masking, if the noise that is meant to keep the non-test ear from hearing the test ear tone is loud enough, it can cross back to the test ear cochlea. If some of the masking noise sent to the non-test ear sneaks over to the test ear, that’s not necessarily a problem. As long as the crossed back noise is less intense than the signal level (reaching the test ear cochlea), then it won’t alter the test results.

Crossback Interfering with (Masking) the Phone Conversation

A favorite song comes on and Sarah turns up the volume considerably and stops her cookie making to dance to the music. The grandmother complains “Can you turn down the radio you have in the background? It’s louder than you are and I’m having trouble understanding you.” Problematically, Sarah’s tunes have crossed from the kitchen back to the room where the all-important conversation about gift choices is taking place.

Overmasking

When the masking noise interferes with hearing of the test ear signal, then “crossback” is “overmasking”. (We want to mask -- prevent the hearing of the crossover -- but we don’t want so much masking that it crosses back to the test ear and interferes with hearing of the signal in the test ear.) Sometimes the solution is to turn down the masker noise.

I’ll Have to Phone You Later!

But what if the mother’s cell phone was lousy and/or the grandmother’s phone had low volume and the only way for them to converse is if the mother speaks very loudly? The mother’s loud voice reaches the kitchen, so the father has to have the radio that loud to keep Sarah from hearing. This is a no-win situation. The radio is interfering with the phone conversation, so Grandmother can’t hear Sarah’s mother, but the mother needs to speak loudly.

Masking Dilemmas

Sometimes we need a lot of masking noise to mask the crossover, but that crosses back and keeps the test ear from hearing the tone. If adjustments cannot be made to prevent audible crossover (keep non-test ear from hearing) without having the confounding problem of cross back causing overmasking (noise interfering with test ear hearing), then that is called a masking dilemma. It’s only a dilemma if there is no solution. If you have to work at adjusting the noise level but can find a level that works, then it’s not a true dilemma.

Not All Doors Are Created Equal

Sarah’s mother wouldn’t have much luck at keeping the phone conversation secret if a glass bead curtain separated the two rooms – the decorative curtain provides no sound attenuation. (Sarah’s mother would have known that other sound needs to mask her conversation right from the start.) The hollow-core interior doors in most homes provide pretty minimal sound attenuation; if the door is solid wood, the attenuation would be better.

Different Transducers Have Different Interaural Attenuation Values

Attenuation is a loss of sound – the glass curtain offered no attenuation. In audiologic testing we are concerned with the between-ears attenuation, which is termed the interaural attenuation.

Bone vibrators are the glass curtain of the audiology world. If you put the oscillator on the right ear, the bones of the head are all vibrating together and you send the entire signal over to the left ear.

Supra-aural earphones are akin to the hollow-core door. Insert earphones have the best interaural attenuation – they convey the least sound from test ear to non-test ear, or noise from non-test ear back to the test ear.

Figure 1-1

Figure 1-1 lower. Bone oscillator (left) testing has no interaural attenuation, supra-aural earphones, such as this TDH-50P style shown at center, offer modest interaural attenuation. The earphone with the best (greatest) interaural attenuation is the insert earphone (right).

The Home with Only Glass Bead Interior Doors

Let’s imagine that Sarah’s parents are "new-age" types who believe that family should not be separated by solid doors. And since it’s raining outside, the mother is not inclined to go outside to make the phone call. Mom will be easily heard, any music that is in the kitchen will readily cross back to Mom and interfere with the Grandmother’s hearing about what gifts Sarah would like.

Solution: have Sarah wear earphones to listen to the music while baking the cookies. Now, for this analogy to work, the earphones have to be the foam type that sit on top of the ear and don’t block sound out – they just present the music directly to Sarah, which allows masking. Sarah’s wearing of earphones has the advantage of less chance of cross-back. Imagine how loud the music presented via earphones would have to be to be heard by Grandmother.

When Testing via Bone-Conduction, Present the Masking with Earphones

Since bone-conducted sound all crosses to the non-test ear, we have an inherent problem. The non-test ear is always stimulated. If you were to try to put masking noise into the non-test ear by bone conduction, it would cross right back and overmask. The solution is to put the masking noise in by air-conduction – using an insert earphone or supra-aural earphone. The insert earphones are not preventing the crossover, they are not creating any attenuation (just as the foam earphones sitting in Sarah’s conchas would not mask her mother’s conversation if the music is off). It just means that we can mask (Sarah won’t hear) – and the noise won’t immediately overmask (won’t interfere with the phone conversation).

Sarah and Her Father Potentially Hear Mom Better than Grandmother Does

This part of the analogy is a bit weak, but let’s try it. Could there ever be a time when the mother’s voice (through the glass curtain) is more audible in the kitchen than over the phone? Sure, how about if phone Grandmother was using had insufficient volume? Well, that doesn’t make for a good analogy for bone-conduction testing, so we are going to have to create a far-fetched scenario. I’ll have to make Sarah an official Hamill for a moment, though I have no such niece. Hamills don’t give the extended family real Christmas gifts, we exchange gag gifts. The person who gives the best gag gift wins the coveted fish slippers, which are … slippers shaped like fish. The winner displays the fish slippers but never wears them, as they must be surrendered to the next year’s winner without toe jam contamination. Sarah’s Aunt Mary gave Sarah a pair of earphones that have giant dog ears attached, as shown in Figure 1-2. Now Sarah can hear sounds better than average so long as she’s looking in that direction of the sound source, and the cookie-cutting Sarah is indeed looking at the glass beaded door, wondering who her mother is talking to on the phone. (And Aunt Mary once again has custody of the fish slippers. Hey, I warned you the analogy was weak.)

Figure 1-2

Figure 1-2. Sarah’s foam earphones are mounted inside fur-covered giant plastic dog ears that enhance sounds from the direction in which she is looking.

Bone-Conduction Occlusion Effect

Wearing earphones causes bone-conducted sound to increase in loudness, though it’s not related to a resonance effect like Sarah’s dog earphones. How that works will be covered in Chapters 6 and 9. The phenomenon of sound increasing in loudness when an earphone is in place is called the occlusion effect – the crossed over bone-conduction sound is actually louder in the non-test ear, just as Sarah could hear her mother better than her grandmother can – unless Sarah has the (masking) music on.

Mercifully, this is nearly the end of the analogy, which I hope is some aid in remembering the crossover, crossback, interaural attenuation terminology.

Overview of Masking and Review of Terms

Masking is a difficult topic to fully comprehend. This brief text, and its accompanying games, attempt to make masking easier to understand. We need to mask because sometimes when testing one ear, the signal could “cross over” to the non-test ear. We will always put masking in by air-conduction, and preferably using an insert earphone to produce that masking noise. If we aren’t using loud enough noise to mask the crossover, then we are “undermasking.” There are times when the masking noise is so loud it can “cross back” to the test ear and cause erroneous results – this is called overmasking.

Bone-conduction testing is especially challenging. All of the signal crosses to the non-test ear, and if you insert an earphone to start the masking process, for the low-frequency stimuli, you create a sound enhancement, called the occlusion effect. This means you will need even more masking noise in the non-test ear to nullify the occlusion effect. And… unfortunately that added noise makes cross back more likely.

There are two fundamental approaches to masking: plateau masking and formula masking. Plateau masking is akin to Sarah’s father putting on some music, checking that he can’t hear the phone conversation, then turning up the music a bit more to be sure. In plateau masking, you make incremental noise adjustments. In formula masking, you know how your masking is calibrated, and you can calculate how much noise is enough. You’ll double check your math – was that really enough (not undermasking), not too much (not overmasking)? This would be like the experienced father knowing that the soundtrack to Nemo (does Nemo have a soundtrack?) at volume 20 will mask the conversation if Sarah’s Mom is speaking at 50 dB HL behind a door.

You need to understand plateau masking well before learning about formula masking.

I’ll try to make this learning as fun as possible for you – or if that’s too high a bar then hopefully this e-book, the games, and the audiometer simulator will make the learning less painful.


 Abbreviations and Definitions

AC
air conduction
BC
bone conduction
Central masking effect
The elevation of the test ear threshold when masking is heard in the opposite ear, which occurs not because the masking has eliminated the cross hearing, but because the listening task has been made more difficult. It is harder to attend to a very low intensity test signal when hearing noise in the opposite ear, so thresholds increase. Central masking effects are small with low noise levels, and increase as the noise in the non-test ear increases in intensity.
Conservative
most cautious, careful
Crossback (CB)
The amount of masking noise that crosses from the non-test ear to the test ear and potentially interferes with hearing of the test ear signal. It is equal to the noise level at the non-test ear minus the air-conduction interaural attenuation.
Crossover (CO)
The amount of signal that is present in the non-test ear. It is equal to the presentation level of the signal in the test ear minus the interaural attenuation for that transducer.
False Negative Response
Occurrence of a patient failing to respond to the presentation of a test signal, even though it is above threshold. Occurs due to patient uncertainty, distraction, or presence of increased ambient noise.
False Positive Response
Occurrence of a patient responding that a tone was heard, when the tone is inaudible. The patient guesses a tone is present when it was not. Some patients are more prone to giving false positive responses than other patients.
Interaural Attenuation (IA)
The amount of sound energy reduction as a signal crosses from the test ear to the non-test ear cochlea (or in the case of overmasking, the noise signal reduction as it crosses from the NTE to the TE cochlea). For pure-tone testing, the minimum interaural attenuation is assumed to be 50 dB for insert earphones, 40 dB for supra-aural earphones and 0 dB when testing via bone-conduction. For speech testing (and speech noise), the minimum insert earphone IA is 60 dB, it is 50 dB for supra-aural earphones.
Masking Dilemma
A situation where masking is needed, but using masking causes overmasking. The test needs masking, but using masking will immediately cause overmasking. This is a “no win” situation – I need to mask, I cannot mask. It happens with maximum or near maximum bilateral conductive losses.
Maximum Conductive Loss
A conductive loss of a magnitude that is equal to the interaural attenuation value for the air-conduction transducer being used. (Confusing point: most conductive losses are not more than about 50-60 dB, which is sometimes called a “maximum conductive loss”, but for the purposes of a book on masking, we reserve this term for a loss that is so great the stimulus is heard only because the air-conduction signal causes the skull to oscillate, creating a bone-conducted sound that goes to both the test- and non-test ear cochleas.
Non-test ear (NTE)
Ear that is opposite from the one that should be receiving the test stimulus.
Non-test ear air-bone gap (NTE ABG)
The air-conduction threshold minus the bone-conduction threshold for the test ear, which indicates the size of the non-test ear conductive impairment.
Occlusion effect (OE)
Enhancement in the sound received at the cochlea when the external ear is occluded (covered/blocked).
Overmasking (OM)
When the noise presented to the non-test ear crosses back to the test ear, and prevents the hearing of the test ear signal, overmasking is occurring.
Reduced Plateau Width
A normal masking plateau occurs when three consecutive 5-dB increases in masking intensity do not change the hearing threshold. The plateau width is said to be reduced when only one or two 5-dB increases occur before the overmasking portion of the plateau begins.
Sensorineural hearing loss (SNHL)
Hearing loss due to cochlear and/or retrocochlear site of lesion.
Test ear (TE)
Do I really need to define this? Just making sure you can look up the acronym.
Test ear air-bone gap (TE ABG)
The air-conduction threshold minus the bone-conduction threshold for the test ear, which indicates the size of the test ear conductive impairment.
Transducer
In this book, an earphone, headphone or bone oscillator. A transducer converts energy from one form (e.g. electrical) to another form (e.g. acoustic). (Microphones are also transducers.)
Undermasking (UM)
When the noise presented to the non-test ear is not sufficiently intense to mask the crossed-over signal. If the audiologist undermasks, then the non-test ear is being stimulated; the response does not necessarily reflect the hearing of the test ear.


When To Mask – Pure-Tone Testing

When to Mask for Air-Conduction Testing – Summary of Chapter 2

  • 1 If the test ear air-conducted threshold is 50 dB or more (for insert earphones; or 40 dB or more for supra-aural earphones) above the non-test ear air-conduction threshold at the same frequency, then masking is needed.
  • 2 If the test ear air-conduction threshold is 50 dB or more (for insert earphones; or 40 dB or more for supra-aural earphones) above the non-test ear bone-conduction threshold at the same frequency, then masking is needed.

When to Mask for Bone-Conduction Testing – Summary of Chapter 3

  • 1 If there is a 15 dB or more difference between an air-conduction threshold and the unmasked bone-conduction threshold at the same frequency, then use contralateral masking.

Plateau Masking Steps

Air-Conduction -- Summary of Chapter 5

  • Recognize the need for masking.
  • Set the initial masking level at 10 dB above the non-test ear threshold. Re-obtain threshold, or check that threshold has not changed
  • Increase the masking in 5 dB steps, reobtaining the threshold if threshold shifts.
  • Continue increasing the masking in 5 dB steps until three consecutive increases in the masking level occurs with no change in hearing threshold.
  • If unmasked testing shows bilateral loss, and masked testing shows both ears are 'dead', then it is a masking dilemma

Bone-Conduction - Summary of Chapter 6

  • Recognize the need for masking.
  • Set the initial masking level at the non-test ear air-conduction threshold, plus 10 dB, plus the occlusion effect size. This book recommends using 20 dB at 250, 10 dB at 500 Hz, and 5 dB at 1000 Hz).
    • If the non-test ear has conductive loss that is larger than the occlusion effect size, you can omit the occlusion effect. The conductive loss will eliminate it.
  • Increase the masking in 5 dB steps, re-obtaining threshold if threshold shifts.
  • Continue increasing the masking in 5 dB steps until three consecutive increases in the masking level occur with no change in hearing threshold.
  • If unmasked testing shows bilateral loss, and masked testing shows both ears are 'dead', then it is a masking dilemma

The Masking Formulae

Pure-Tone Air-Conduction Formula Masking – Summary of Chapter 8

The masking signal must be at or above the minimum, and that minimum level must not be at or above the maximum that protects from overmasking. If the minimum is equal to or greater than maximum, then use plateau masking.

For these formulae, 'TE signal level' is your estimate of the eventual masked threshold.

Minimum Masking Level:
TE signal level – IA + significant NTE ABG + 10 dB

For insert earphones:
TE signal level – 40 dB + NTE ABG

For supra-aural earphones:

TE signal level - 30 dB + NTE ABG

It is recommended that you use the highest “reasonably possible” AC threshold in this calculation. This way, if your threshold comes in a bit higher than anticipated, you do not need to increase the noise and recheck threshold.


Maximum Masking Level:
BC threshold of the TE + IA – 5

For insert earphones:
BC TE + 45 dB

For supra-aural phones:
BC TE + 35 dB

It is recommended that you use the lowest “reasonably possible” BC threshold – so that if you are wrong, and bone-conduction is a bit better than you assumed, you will not be in an overmasking situation.


Checking Your Masking

Once threshold has been established:

  • If the measured threshold comes in better than expected, consider the possibility of overmasking.
    Recheck: BC threshold + 45. If you used masking noise that was louder than this level, you may be overmasking. Lower the masking noise level.
  • If threshold is higher than expected (more hearing loss), consider the possibility of undermasking.
    Recheck: BC threshold – 40 + NTE ABG. If you did not use at least this amount of noise, then increase the masking intensity.

Bone-Conduction Formula Masking – Summary of Chapter 9

BC TE is your estimate of the eventual, masked, bone-conduction threshold for the test ear.

Minimum Masking Level:
BC TE +10 + (larger of: OE or NTE ABG)

It is recommended that you use the highest “reasonably possible” BC threshold in this calculation. This way, if your threshold comes in a bit higher than anticipated, you do not need to increase the noise and recheck threshold.

Recommended OE values:
  250 Hz: 20 dB
  500 Hz: 10 dB
  1K Hz : 5 dB
  2K Hz+: None

Maximum Masking Level:
BC TE + 45

It is recommended that you use the lowest “reasonably possible” BC threshold – so that if you are wrong, and bone-conduction is a bit better than you assumed, you will not be in an overmasking situation.


Checking Your Masking

Check that masking is sufficient – calculate the Minimum Masking Level using the established BC, and calculate the maximum using that same threshold. The masking level you used must be between Min and Max. If Min > Max then plateau mask, you may have a masking dilemma. (Note, this will only “work” if you use the same threshold for min and max, if you base min and max on different scenarios (e.g. setting min to work in case threshold is a little higher than you guessed, and setting max by thinking about bone-conduction coming in a little better than your best guess) – then this rule does not work.

Speech Masking - Summary of Chapter 10

When to Mask

Calculate Signal level – 60 (for insert earphones or 50 for TDH earphones). If that is at or above the NTE BC thresholds for one or more frequency in the 500 to 8k Hz range, then cross hearing may influence your results and masking is warranted.

Masking Formulae

Spondee Threshold

Minimum Masking Level:

Predicted SPONDEE THRESHOLD + 10 dB in case the SPONDEE THRESHOLD is a bit higher than the PTA predicts – IA + largest significant NTE ABG + 10 dB pad

(which gives us)

For insert earphones:
TE estimated SPONDEE THRESHOLD – 40 dB + Largest NTE ABG (500 to 8k Hz)

For supra-aural phones:
TE estimated SPONDEE THRESHOLD – 30 dB + NTE ABG


Word Recognition Testing

Minimum Masking Level:

Presentation level – IA + 10 dB pad

For insert earphones:
TE signal level – 50 dB + Largest NTE ABG (500 to 8k Hz)

For supra-aural phones:
TE signal level – 30 dB + NTE ABG

Maximum Masking Level:

For both spondee threshold and word recognition testing: Best TE BC threshold in the 500-8k Hz range + IA – 5

(which is)

For insert earphones:
Best TE 500-8k Hz + 55 dB

For supra-aural phones:
BC TE + 45 dB

Down 20 Rule:

Estimated spondee threshold or word recognition test level – 20 dB.

  • Ideal for asymmetrical sensorineural loss.
  • If there is test ear conductive loss, this rule can overmask, but the overmasking is usually not consequential – it won’t typically interfere with speech understanding.
  • Non-test ear conductive loss causes this rule to often give problematic undermasking.

Speech Noise Crossback May Not Alter Results

  • Calculate the speech sensation level across frequencies (stimulus level minus TE AC threshold)
  • Calculate the theoretical noise crossback level across frequencies (Crossback level minus TE BC threshold)
  • So long as the speech is 10 dB more intense than the crossback, test results are unlikely to be influenced by the crossback.