speech recognition test definition

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Training in Speech Audiometry

• Why Perform Functional Hearing Tests?
• Performing aided speech testing to validate pediatric hearing devices

Speech Audiometry: An Introduction

Description, table of contents, what is speech audiometry, why perform speech audiometry.

• Contraindications and considerations

Audiometers that can perform speech audiometry

How to perform speech audiometry, results interpretation, calibration for speech audiometry.

Speech audiometry is an umbrella term used to describe a collection of audiometric tests using speech as the stimulus. You can perform speech audiometry by presenting speech to the subject in both quiet and in the presence of noise (e.g. speech babble or speech noise). The latter is speech-in-noise testing and is beyond the scope of this article.

Speech audiometry is a core test in the audiologist’s test battery because pure tone audiometry (the primary test of hearing sensitivity) is a limited predictor of a person’s ability to recognize speech. Improving an individual’s access to speech sounds is often the main motivation for fitting them with a hearing aid. Therefore, it is important to understand how a person with hearing loss recognizes or discriminates speech before fitting them with amplification, and speech audiometry provides a method of doing this.

A decrease in hearing sensitivity, as measured by pure tone audiometry, results in greater difficulty understanding speech. However, the literature also shows that two individuals of the same age with similar audiograms can have quite different speech recognition scores. Therefore, by performing speech audiometry, an audiologist can determine how well a person can access speech information.

Acquiring this information is key in the diagnostic process. For instance, it can assist in differentiating between different types of hearing loss. You can also use information from speech audiometry in the (re)habilitation process. For example, the results can guide you toward the appropriate amplification technology, such as directional microphones or remote microphone devices. Speech audiometry can also provide the audiologist with a prediction of how well a subject will hear with their new hearing aids. You can use this information to set realistic expectations and help with other aspects of the counseling process.

Below are some more examples of how you can use the results obtained from speech testing.

Identify need for further testing

Based on the results from speech recognition testing, it may be appropriate to perform further testing to get more information on the nature of the hearing loss. An example could be to perform a TEN test to detect a dead region or to perform the Audible Contrast Threshold (ACT™) test .

Inform amplification decisions

You can use the results from speech audiometry to determine whether binaural amplification is the most appropriate fitting approach or if you should consider alternatives such as CROS aids.

You can use the results obtained through speech audiometry to discuss and manage the amplification expectations of patients and their communication partners.

Unexpected asymmetric speech discrimination, significant roll-over , or particularly poor speech discrimination may warrant further investigation by a medical professional.

Non-organic hearing loss

You can use speech testing to cross-check the results from pure tone audiometry for suspected non‑organic hearing loss.

Contraindications and considerations when performing speech audiometry

Before speech audiometry, it is important that you perform pure tone audiometry and otoscopy. Results from these procedures can reveal contraindications to performing speech audiometry.

Otoscopic findings

Speech testing using headphones or inserts is generally contraindicated when the ear canal is occluded with:

• Foreign body
• Or infective otitis externa

In these situations, you can perform bone conduction speech testing or sound field testing.

Audiometric findings

Speech audiometry can be challenging to perform in subjects with severe-to-profound hearing losses as well as asymmetrical hearing losses where the level of stimulation and/or masking noise  required is beyond the limits of the audiometer or the patient's uncomfortable loudness levels (ULLs).

Subject variables

Depending on the age or language ability of the subject, complex words may not be suitable. This is particularly true for young children and adults with learning disabilities or other complex presentations such as dementia and reduced cognitive function.

You should also perform speech audiometry in a language which is native to your patient. Speech recognition testing may not be suitable for patients with expressive speech difficulties. However, in these situations, speech detection testing should be possible.

Before we discuss speech audiometry in more detail, let’s briefly consider the instrumentation to deliver the speech stimuli. As speech audiometry plays a significant role in diagnostic audiometry, many audiometers include – or have the option to include – speech testing capabilities.

Table 1 outlines which audiometers from Interacoustics can perform speech audiometry.

Table 1: Audiometers from Interacoustics that can perform speech audiometry.

Because speech audiometry uses speech as the stimulus and languages are different across the globe, the way in which speech audiometry is implemented varies depending on the country where the test is being performed. For the purposes of this article, we will start with addressing how to measure speech in quiet using the international organization of standards ISO 8252-3:2022 as the reference to describe the terminology and processes encompassing speech audiometry. We will describe two tests: speech detection testing and speech recognition testing.

Speech detection testing

In speech detection testing, you ask the subject to identify when they hear speech (not necessarily understand). It is the most basic form of speech testing because understanding is not required. However, it is not commonly performed. In this test, words are normally presented to the ear(s) through headphones (monaural or binaural testing) or through a loudspeaker (binaural testing).

Speech detection threshold (SDT)

Here, the tester will present speech at varying intensity levels and the patient identifies when they can detect speech. The goal is to identify the level at which the patient detects speech in 50% of the trials. This is the speech detection threshold. It is important not to confuse this with the speech discrimination threshold. The speech discrimination threshold looks at a person’s ability to recognize speech and we will explain it later in this article.

The speech detection threshold has been found to correlate well with the pure tone average, which is calculated from pure tone audiometry. Because of this, the main application of speech detection testing in the clinical setting is confirmation of the audiogram.

Speech recognition testing

In speech recognition testing, also known as speech discrimination testing, the subject must not only detect the speech, but also correctly recognize the word or words presented. This is the most popular form of speech testing and provides insights into how a person with hearing loss can discriminate speech in ideal conditions.

Across the globe, the methods of obtaining this information are different and this often leads to confusion about speech recognition testing. Despite there being differences in the way speech recognition testing is performed, there are some core calculations and test parameters which are used globally.

Speech recognition testing: Calculations

There are two main calculations in speech recognition testing.

1. Speech recognition threshold (SRT)

This is the level in dB HL at which the patient recognizes 50% of the test material correctly. This level will differ depending on the test material used. Some references describe the SRT as the speech discrimination threshold or SDT. This can be confusing because the acronym SDT belongs to the speech detection threshold. For this reason, we will not use the term discrimination but instead continue with the term speech recognition threshold.

2. Word recognition score (WRS)

In word recognition testing, you present a list of phonetically balanced words to the subject at a single intensity and ask them to repeat the words they hear. You score if the patient repeats these words correctly or incorrectly.  This score, expressed as a percentage of correct words, is calculated by dividing the number of words correctly identified by the total number of words presented.

In some countries, multiple word recognition scores are recorded at various intensities and plotted on a graph. In other countries, a single word recognition score is performed using a level based on the SRT (usually presented 20 to 40 dB louder than the SRT).

Speech recognition testing: Parameters

Before completing a speech recognition test, there are several parameters to consider.

1. Test transducer

You can perform speech recognition testing using air conduction, bone conduction, and speakers in a sound-field setup.

2. Types of words

Speech recognition testing can be performed using a variety of different words or sentences. Some countries use monosyllabic words such as ‘boat’ or ‘cat’ whereas other countries prefer to use spondee words such as ‘baseball’ or ‘cowboy’. These words are then combined with other words to create a phonetically balanced list of words called a word list.

3. Number of words

The number of words in a word list can impact the score. If there are too few words in the list, then there is a risk that not enough data points are acquired to accurately calculate the word recognition score. However, too many words may lead to increased test times and patient fatigue. Word lists often consist of 10 to 25 words.

You can either score words as whole words or by the number of phonemes they contain.

An example of scoring can be illustrated by the word ‘boat’. When scoring using whole words, anything other than the word ‘boat’ would result in an incorrect score.

However, in phoneme scoring, the word ‘boat’ is broken down into its individual phonemes: /b/, /oa/, and /t/. Each phoneme is then scored as a point, meaning that the word boat has a maximum score of 3. An example could be that a patient mishears the word ‘boat’ and reports the word to be ‘float’. With phoneme scoring, 2 points would be awarded for this answer whereas in word scoring, the word float would be marked as incorrect.

5. Delivery of material

Modern audiometers have the functionality of storing word lists digitally onto the hardware of the device so that you can deliver a calibrated speech signal the same way each time you test a patient. This is different from the older methods of testing using live voice or a CD recording of the speech material. Using digitally stored and calibrated speech material in .wav files provides the most reliable and repeatable results as the delivery of the speech is not influenced by the tester.

6. Aided or unaided

You can perform speech recognition testing either aided or unaided. When performing aided measurements, the stimulus is usually played through a loudspeaker and the test is recorded binaurally.

Global examples of how speech recognition testing is performed and reported

Below are examples of how speech recognition testing is performed in the US and the UK. This will show how speech testing varies across the globe.

Speech recognition testing in the US: Speech tables

In the US, the SRT and WRS are usually performed as two separate tests using different word lists for each test. The results are displayed in tables called speech tables.

The SRT is the first speech test which is performed and typically uses spondee words (a word with two equally stressed syllables, such as ‘hotdog’) as the stimulus. During this test, you present spondee words to the patient at different intensities and a bracketing technique establishes the threshold at where the patient correctly identifies 50% of the words.

In the below video, we can see how an SRT is performed using spondee words.

Below, you can see a table showing the results from an SRT test (Figure 1). Here, we can see that the SRT has been measured in each ear. The table shows the intensity at which the SRT was found as well as the transducer, word list, and the level at which masking noise was presented (if applicable). Here we see an unaided SRT of 30 dB HL in both the left and right ears.

Once you have established the intensity of the SRT in dB HL, you can use it to calculate the intensity to present the next list of words to measure the WRS. In WRS testing, it is common to start at an intensity of between 20 dB and 40 dB louder than the speech recognition threshold and to use a different word list from the SRT. The word lists most commonly used in the US for WRS are the NU-6 and CID-W22 word lists.

In word recognition score testing, you present an entire word list to the test subject at a single intensity and score each word based on whether the subject can correctly repeat it or not. The results are reported as a percentage.

The video below demonstrates how to perform the word recognition score.

Below is an image of a speech table showing the word recognition score in the left ear using the NU‑6 word list at an intensity of 55 dB HL (Figure 2). Here we can see that the patient in this example scored 90%, indicating good speech recognition at moderate intensities.

Speech recognition testing in the UK: Speech audiogram

In the UK, speech recognition testing is performed with the goal of obtaining a speech audiogram. A speech audiogram is a graphical representation of how well an individual can discriminate speech across a variety of intensities (Figure 3).

In the UK, the most common method of recording a speech audiogram is to present several different word lists to the subject at varying intensities and calculate multiple word recognition scores. The AB (Arthur Boothroyd) word lists are the most used lists. The initial list is presented around 20 to 30 dB sensation level with subsequent lists performed at quieter intensities before finally increasing the sensation level to determine how well the patient can recognize words at louder intensities.

The speech audiogram is made up of plotting the WRS at each intensity on a graph displaying word recognition score in % as a function of intensity in dB HL. The following video explains how it is performed.

Below is an image of a completed speech audiogram (Figure 4). There are several components.

Point A on the graph shows the intensity in dB HL where the person identified 50% of the speech material correctly. This is the speech recognition threshold or SRT.

Point B on the graph shows the maximum speech recognition score which informs the clinician of the maximum score the subject obtained.

Point C on the graph shows the reference speech recognition curve; this is specific to the test material used (e.g., AB words) and method of presentation (e.g., headphones), and shows a curve which describes the median speech recognition scores at multiple intensities for a group of normal hearing individuals.

Having this displayed on a single graph can provide a quick and easy way to determine and analyze the ability of the person to hear speech and compare their results to a normative group. Lastly, you can use the speech audiogram to identify roll-over. Roll-over occurs when the speech recognition deteriorates at loud intensities and can be a sign of retro-cochlear hearing loss. We will discuss this further in the interpretation section.

Masking in speech recognition testing

Just like in audiometry, cross hearing can also occur in speech audiometry. Therefore, it is important to mask the non-test ear when testing monaurally. Masking is important because word recognition testing is usually performed at supra-threshold levels. Speech encompasses a wide spectrum of frequencies, so the use of narrowband noise as a masking stimulus is not appropriate, and you need to modify the masking noise for speech audiometry. In speech audiometry, speech noise is typically used to mask the non-test ear.

There are several approaches to calculating required masking noise level. An equation by Coles and Priede (1975) suggests one approach which applies to all types of hearing loss (sensorineural, conductive, and mixed):

• Masking level = D S plus max ABG NT minus 40 plus E M

It considers the following factors.

1. Dial setting

D S is the level of dial setting in dB HL for presentation of speech to the test ear.

2. Air-bone gap

Max ABG NT is the maximum air-bone gap between 250 to 4000 Hz in the non‑test ear.

3. Interaural attenuation

Interaural attenuation: The value of 40 comes from the minimum interaural attenuation for masking in audiometry using headphones (for insert earphones, this would be 55 dB).

4. Effective masking

E M is effective masking. Modern audiometers are calibrated in E M , so you don’t need to include this in the calculation. However, if you are using an old audiometer calibrated to an older calibration standard, then you should calculate the E M .

You can calculate it by measuring the difference in the speech dial setting presented to normal listeners at a level that yields a score of 95% in quiet and the noise dial setting presented to the same ear that yields a score less than 10%. 

You can use the results from speech audiometry for many purposes. The below section describes these applications.

1. Cross-check against pure tone audiometry results

The cross-check principle in audiology states that no auditory test result should be accepted and used in the diagnosis of hearing loss until you confirm or cross-check it by one or more independent measures (Hall J. W., 3rd, 2016). Speech-in-quiet testing serves this purpose for the pure tone audiogram.

The following scores and their descriptions identify how well the speech detection threshold and the pure tone average correlate (Table 2).

Table 2: Correlation between speech detection threshold and pure tone average.

If there is a poor correlation between the speech detection threshold and the pure tone average, it warrants further investigation to determine the underlying cause or to identify if there was a technical error in the recordings of one of the tests.

2. Detect asymmetries between ears

Another core use of speech audiometry in quiet is to determine the symmetry between the two ears and whether it is appropriate to fit binaural amplification. Significant differences between ears can occur when there are two different etiologies causing hearing loss.

An example of this could be a patient with sensorineural hearing loss who then also contracts unilateral Meniere’s disease . In this example, it would be important to understand if there are significant differences in the word recognition scores between the two ears. If there are significant differences, then it may not be appropriate for you to fit binaural amplification, where other forms of amplification such as contralateral routing of sound (CROS) devices may be more appropriate.

3. Identify if further testing is required

The results from speech audiometry in quiet can identify whether further testing is required. This could be highlighted in several ways.

One example could be a severe difference in the SRT and the pure tone average. Another example could be significant asymmetries between the two ears. Lastly, very poor speech recognition scores in quiet might also be a red flag for further testing.

In these examples, the clinician might decide to perform a test to detect the presence of cochlear dead regions such as the TEN test or an ACT test to get more information.

4. Detect retro-cochlear hearing loss

In subjects with retro-cochlear causes of hearing loss, speech recognition can begin to deteriorate as sounds are made louder. This is called ‘roll-over’ and is calculated by the following equation:

• Roll-over index = (maximum score minus minimum score) divided by maximum score

If roll-over is detected at a certain value (the value is dependent on the word list chosen for testing but is commonly larger than 0.4), then it is considered to be a sign of retro-cochlear pathology. This could then have an influence on the fitting strategy for patients exhibiting these results.

It is important to note however that as the cross-check principle states, you should interpret any roll-over with caution and you should perform additional tests such as acoustic reflexes , the reflex decay test, or auditory brainstem response measurements to confirm the presence of a retro-cochlear lesion.

5. Predict success with amplification

The maximum speech recognition score is a useful measure which you can use to predict whether a person will benefit from hearing aids. More recent, and advanced tests such as the ACT test combined with the Acceptable Noise Level (ANL) test offer good alternatives to predicting hearing success with amplification.

Just like in pure tone audiometry, the stimuli which are presented during speech audiometry require annual calibration by a specialized technician ster. Checking of the transducers of the audiometer to determine if the speech stimulus contains any distortions or level abnormalities should also be performed daily. This process replicates the daily checks a clinicians would do for pure tone audiometry. If speech is being presented using a sound field setup, then you can use a sound level meter to check if the material is being presented at the correct level.

The next level of calibration depends on how the speech material is delivered to the audiometer. Speech material can be presented in many ways including live voice, CD, or installed WAV files on the audiometer. Speech being presented as live voice cannot be calibrated but instead requires the clinician to use the VU meter on the audiometer (which indicates the level of the signal being presented) to determine if they are speaking at the correct intensity. Speech material on a CD requires daily checks and is also performed using the VU meter on the audiometer. Here, a speech calibration tone track on the CD is used, and the VU meter is adjusted accordingly to the desired level as determined by the manufacturer of the speech material.

The most reliable way to deliver a speech stimulus is through a WAV file. By presenting through a WAV file, you can skip the daily tone-based calibration as this method allows you to calibrate the speech material as part of the annual calibration process. This saves the clinician time and ensures the stimulus is calibrated to the same standard as the pure tones in their audiometer. To calibrate the WAV file stimulus, the speech material is calibrated against a speech calibration tone. This is stored on the audiometer. Typically, a 1000 Hz speech tone is used for the calibration and the calibration process is the same as for a 1000 Hz pure tone calibration.

Lastly, if the speech is being presented through the sound field, a calibration professional should perform an annual sound field speaker calibration using an external free field microphone aimed directly at the speaker from the position of the patient’s head.

Coles, R. R., & Priede, V. M. (1975). Masking of the non-test ear in speech audiometry .  The Journal of laryngology and otology ,  89 (3), 217–226.

Graham, J. Baguley, D. (2009). Ballantyne's Deafness, 7th Edition. Whiley Blackwell.

Hall J. W., 3rd (2016). Crosscheck Principle in Pediatric Audiology Today: A 40-Year Perspective .  Journal of audiology & otology ,  20 (2), 59–67.

Katz, J. (2009). Handbook of Clinical Audiology. Wolters Kluwer.

Killion, M. C., Niquette, P. A., Gudmundsen, G. I., Revit, L. J., & Banerjee, S. (2004).  Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal-hearing and hearing-impaired listeners . The Journal of the Acoustical Society of America , 116 (4), 2395–2405.

Stach, B.A (1998). Clinical Audiology: An Introduction, Cengage Learning.

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What Is A Speech Test? Why You Might Need One

Speech testing evaluates your ability to detect speech and understand words and sentences. This guide will tell you the basics of speech testing.

According to the American Speech-Language-Hearing Association, trouble understanding everyday speech is typically one of the first signs of losing hearing.

That’s why speech testing is crucial to every screening test for hearing loss .

Speech audiometry is one of a battery of tests you will take during a standard hearing exam but is not a part of online hearing tests . The test is about 10 to 15 minutes, and it’s usually done right after pure tone audiometry.

While pure tone testing determines the type and severity of hearing loss, speech testing evaluates your speech-language abilities.  

A hearing aid specialist can use the test results to measure how much gain the hearing aid has to provide to make sounds clear.

An audiologist can also determine if there’s a significant difference between ears by mapping the results on “critical difference tables.”

Why Speech Testing Is Done

Speech testing is primarily used to understand the impact of hearing loss on a person’s speech levels.

Here are some reasons speech testing is commonly used in hearing exams:

• It confirms the pure tone audiometry results which are read on an audiogram.
• It measures speech intelligibility and hearing loss’s effect on an individual’s communication skills.
• It monitors loud speech and the efficacy of hearing aids over time.
• Speech recognition predicts the likelihood of treatment success.
• It helps diagnose certain underlying conditions.
• The test results provide helpful information for hearing aid fitting and programming.

How Is Speech Testing Done

Speech testing is typically performed by a licensed hearing care professional after the audiologist measures hearing thresholds using pure tones.

Environment

The speech testing environment has two soundproof rooms: the equipment and testing rooms.

The ambient noise levels in the testing environment should meet American National Standards Institute (ANSI)  specifications.

Audiologists manipulate the audiometers from the equipment room and the patient takes the test in the testing room, which has speakers, headphones, and other transducers.

Speech audiometry is performed using a speech audiometer built into the same device used for pure tone testing. Sounds are transmitted via headphones and speakers, and a microphone is used for instructing the patient and live voice testing.

The examiner may also play a set of wave files using an external sound player instead of live voice testing.

The diagnostic audiometers also come with a talk-back and talk-forward microphone for communication between the patient and the tester.

The test material needed for speech testing includes a list of monosyllabic words.

Generally, speech testing follows this process:

• The examiner will instruct the patient to repeat back the words presented.
• The audiologist will turn the volume to a level the patient can hear.
• The tester will present a list of 50 single-syllable words and record the patient’s correct and incorrect responses. Each ear may be tested separately.
• The tester calculates the word recognition score, which is the percentage of words repeated correctly.

Speech Audiometry Subtests

Speech testing consists of subtests that will yield a set of metrics the audiologist uses to evaluate your speech-language abilities.

Speech Recognition Threshold Tests

The speech recognition threshold refers to the minimum sound intensity level at which a person can detect the presence of speech at least 50 percent of the time.

It’s also known as speech awareness or speech detection threshold.

It is widely used to double-check the results of tone testing. Ideally, the speech recognition threshold should closely agree with the average pure tone threshold levels obtained at 500 Hz, 100 Hz, and 2,000 Hz.

Did you know you can also measure the range of frequencies you can hear using a sound frequency test ? Read more about it in our guide.

This test only requires the patient to detect the presence of speech. In other words, you don’t need to understand what is being said.

In speech recognition threshold tests you don’t need to understand what is being said, you just need to raise your hand or press a button when you hear a speech signal.

Speech Reception Threshold Tests

The speech reception threshold refers to the lowest volume at which an individual can identify speech at least half of the time.

During the speech reception test, the examiner will present a list of disyllabic words with equal stress placed on each syllable (E.g., football, hotdog, sidewalk). The patient will be instructed to repeat back the words heard.

SRT is also used to validate pure tone thresholds as the reception threshold should be very close to the average of pure tone thresholds obtained at 500 Hz, 1000 Hz, and 2000 Hz.

Word Recognition Testing

Speech discrimination testing checks a person’s ability to understand and repeat single-syllable words.

The tester presents a list of 50 single-syllable words (E.g. cat, dog, pool) at an audible level. The patient will be asked to repeat the words.

After the test, the hearing specialist will calculate the speech discrimination score, which is the percentage of words repeated correctly versus those incorrectly repeated.

A normal score would be between 85 to 100 percent.

An individual with a score below 85 percent will benefit from hearing aids.

Though it’s not common, an audiologist may administer a hearing-in-noise test (HINT) to test word recognition in background noise.

However, this is usually only given for hearing-critical and potentially life-threatening occupations where the ability to communicate clearly is essential, such as aviation, law enforcement, and the armed forces.  

Accuracy of Speech Testing

Speech testing is essential to planning your treatment, but the accuracy of tests can vary with factors such as patient cooperation and test procedure.

Typically the word list used in a speech discrimination test contains 50 monosyllabics. However, some examiners may use a half list to save time. This can affect the accuracy of the score.

For instance, if you correctly repeat 10 out of 20 words, your score would be 50 percent, whereas if you repeat 10 out of 50 words, your score would be 20%.

When administering speech discrimination tests, the tester can use recorded wave files or read the list aloud through a microphone.

Live voice tests are generally less accurate than tests that use recordings because the patient’s ability to understand the tester can vary with the voice quality or dialect used.

Therefore, the use of recorded speech would yield more accurate scores.

Speech audiometry is a subjective hearing test. This means the patient has to cooperate and follow the tester’s instructions to get accurate test results.

If a patient isn’t motivated enough to listen carefully and repeat back words, the score may not reflect the individual’s actual hearing ability.

Speech testing is a valuable part of the audiologist’s toolkit. It includes tests of a person’s ability to detect the presence of speech and repeat back individual words. Speech testing validates the results of tests that use pure tones and provides information that helps hearing professionals effectively treat your condition. Individuals with mild or moderate hearing loss but relatively high word recognition scores benefit the most from using hearing devices.

What is a Good Speech Discrimination Score?

A person with normal hearing should be able to hear 85 to 100 percent of the words that the tester presents.

Do I Need Speech Testing to Purchase Hearing Aids?

According to the American Speech-Language-Hearing Association, you can buy hearing devices online by taking an online screening test. However, these tests are less reliable than a professional audiological exam and cannot tell you the cause of your impairment. If you have difficulty hearing, you should consult an audiologist.

https://www.youtube.com/watch?v=mSTMGdqJrC0&lc=Ugwfu7U3qmrSVYSMk4V4AaABAg

https://www.interacoustics.com/guides/test/audiometry-tests/speech-audiometry

http://www.cochlea.eu/en/audiometry/subjective-measure/speech-audiometry

https://www.audiologyonline.com/articles/word-recognition-testing-puzzling-disconnect-11978

https://www.hopkinsmedicine.org/health/conditions-and-diseases/hearing-loss/speech-audiometry#:~:text=Your%20audiologist%20will%20ask%20you,also%20called%20word%20recognition%20ability .

https://www.asha.org/public/hearing/speech-testing/

https://www.entltd.com/throat-speech/speech-swallowing/speech-audiometry/#:~:text=What%20Is%20Speech%20Audiometry%3F,speech%20discrimination%20(SD)%20abilities

https://www.sciencedirect.com/topics/medicine-and-dentistry/speech-audiometry

https://emedicine.medscape.com/article/1822315-overview

https://www.audiologyonline.com/articles/back-to-basics-speech-audiometry-6828

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Understanding Your Audiogram

The audiogram is a chart that shows the results of a hearing test. It shows how well you hear sounds in terms of frequency (high-pitched sounds versus low-pitched sounds) and intensity, or loudness. The audiogram shows results for each ear and tells the audiologist the softest sound you can hear at each specific frequency.

Frequency or pitch is measured in Hertz (Hz). Frequencies range from low pitch to high pitch and read from left to right on the audiogram. Each vertical line represents a different frequency, such as 250, 500, 1000, 2000, 4000 and 8000 Hz.

The intensity is measured in decibels (dB). The intensity relates to how loud or soft a sound is. Each horizontal line represents a different intensity level. The softest sounds are at the top of the chart and the loudest sounds at the bottom. Each mark on your audiogram shows the softest sounds you can hear. The softest intensity tested is typically 0 dB and the loudest is 120 dB.

Right Ear vs Left Ear

For the part of the hearing test when you used headphones, results for your right ear appear on the audiogram as either a circle or triangle. The left ear is graphed with an X or a square. These responses represent the air conduction results of either the right or left ear.

Results for the part of the hearing test when you are listening through speakers or in the sound field are marked with “S.” This line on the audiogram represents the response of at least one ear, or the response of the better hearing ear.

Other symbols seen on the audiogram may show responses for the bone conduction testing. The right ear is graphed with < or [, and the left ear with > or ]. These responses can help determine whether a hearing loss is sensorineural or conductive .

Frequently Asked Questions About Hearing Aids

Speech Testing

Part of the speech test involves listening to spoken words through headphones, at a comfortable volume and with no background noise. Speech discrimination or word recognition ability is scored as a percentage and shows how often words need to be repeated for you to recognize them.

Degrees of Hearing Loss

Hearing loss ranges from none to profound, depending on your hearing threshold — the softest a sound was heard at a specific frequency.

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The Hidden Risks of Hearing Loss

Speech Audiometry

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Speech Audiometry

• Author: Suzanne H Kimball, AuD, CCC-A/FAAA; Chief Editor: Arlen D Meyers, MD, MBA  more...
• Sections Speech Audiometry
• Indications
• Contraindications
• Pediatric Speech Materials

Speech audiometry has become a fundamental tool in hearing-loss assessment. In conjunction with pure-tone audiometry, it can aid in determining the degree and type of hearing loss. Speech audiometry also provides information regarding discomfort or tolerance to speech stimuli and information on word recognition abilities.

In addition, information gained by speech audiometry can help determine proper gain and maximum output of hearing aids and other amplifying devices for patients with significant hearing losses and help assess how well they hear in noise. Speech audiometry also facilitates audiological rehabilitation management.

The Technique section of this article describes speech audiometry for adult patients. For pediatric patients, see the Pediatric Speech Materials section below.

Speech audiometry can be used for the following:

Assessment of degree and type of hearing loss

Examination of word recognition abilities

Examination of discomfort or tolerance to speech stimuli

Determination of proper gain and maximum output of amplifying devices

Speech audiometry should not be done if the patient is uncooperative.

No anesthesia is required for speech audiometry.

In most circumstances, speech audiometry is performed in a 2-room testing suite. Audiologists work from the audiometric equipment room, while patients undergo testing in the evaluation room. The audiometric equipment room contains the speech audiometer, which is usually part of a diagnostic audiometer. The speech-testing portion of the diagnostic audiometer usually consists of 2 channels that provide various inputs and outputs.

Speech audiometer input devices include microphones (for live voice testing), tape recorders, and CDs for recorded testing. Various output devices, including earphones, ear inserts, bone-conduction vibrators, and loudspeakers, are located in the testing suite. [ 1 ]

Tests using speech materials can be performed using earphones, with test material presented into 1 or both earphones. Testing can also be performed via a bone-conduction vibrator. In addition to these methods, speech material can be presented using loudspeakers in the sound-field environment.

Speech-awareness thresholds

Speech-awareness threshold (SAT) is also known as speech-detection threshold (SDT). The objective of this measurement is to obtain the lowest level at which speech can be detected at least half the time. This test does not have patients repeat words; it requires patients to merely indicate when speech stimuli are present.

Speech materials usually used to determine this measurement are spondees. Spondaic words are 2-syllable words spoken with equal emphasis on each syllable (eg, pancake, hardware, playground). Spondees are used because they are easily understandable and contain information within each syllable sufficient to allow reasonably accurate guessing.

The SAT is especially useful for patients too young to understand or repeat words. It may be the only behavioral measurement that can be made with this population. The SAT may also be used for patients who speak another language or who have impaired language function because of neurological insult.

For patients with normal hearing or somewhat flat hearing loss, this measure is usually 10-15 dB better than the speech-recognition threshold (SRT) that requires patients to repeat presented words. For patients with sloping hearing loss, this measurement can be misleading with regard to identifying the overall degree of loss.

If a patient has normal hearing in a low frequency, the SAT will be closely related to the threshold for that frequency, and it will not indicate greater loss in higher frequencies.

Speech-recognition threshold

The speech-recognition threshold (SRT) is sometimes referred to as the speech-reception threshold. [ 2 ] The objective of this measure is to obtain the lowest level at which speech can be identified at least half the time.

Spondees are usually used for this measurement. Lists of spondaic words commonly used to obtain the SRT are contained within the Central Institute for the Deaf (CID) Auditory List W-1 and W-2.

In addition to determining softest levels at which patients can hear and repeat words, the SRT is also used to validate pure-tone thresholds because of high correlation between the SRT and the average of pure-tone thresholds at 500, 1000, and 2000 Hz.

In clinical practice, the SRT and 3-frequency average should be within 5-12 dB. This correlation holds true if hearing loss in the 3 measured frequencies is relatively similar. If 1 threshold within the 3 frequencies is significantly higher than the others, the SRT will usually be considerably better than the 3-frequency average. In this case, a 2-frequency average is likely to be calculated and assessed for agreement with the SRT.

Other clinical uses of the SRT include establishing the sound level to present suprathreshold measures and determining appropriate gain during hearing aid selection.

Suprathreshold word-recognition testing

The primary purpose of suprathreshold word-recognition testing is to estimate ability to understand and repeat single-syllable words presented at conversational or another suprathreshold level. This type of testing is also referred to as word-discrimination testing or speech-discrimination testing.

Initial word lists compiled for word-recognition testing were phonetically balanced (PB). This term indicated that phonetic composition of the lists was equivalent and representative of connected English discourse.

The original PB lists were created at the Harvard Psycho-Acoustic Laboratory and are referred to as the PB-50 lists. The PB-50 lists contain 50 single-syllable words in 20 lists consisting of 1000 different monosyllabic words. Several years later, the CID W-22 word lists were devised, primarily using words selected from the PB-50 lists. Another word list (devised from a grouping of 200 consonant-nucleus-consonant [CNC] words) is called the Northwestern University Test No. 6 (NU-6). Recorded tape and CD versions of all these word-recognition tests are commercially available.

The PB-50, CID W-22, and NU-6 word lists each contain 50 words that are presented at specified sensation levels. Words can be presented via tape, CD, or monitored live voice. Patients are asked to repeat words to the audiologist. Each word repeated correctly is valued at 2%, and scores are tallied as a percent-correct value.

Varying the presentation level of monosyllabic words reveals a variety of performance-intensity functions for these word lists. In general, presenting words at 25-40 dB sensation level (refer to the SRT) allows patients to achieve maximum scores. Lowering the level results in lower scores. For individuals with hearing loss, words can be presented at a comfortable loudness level or at the highest reasonable level before discomfort occurs.

When words are presented at the highest reasonable level and the word-recognition score is 80% or better, testing can be discontinued. If the score is lower than 80%, further testing at lower presentation levels is recommended. If scores at lower levels are better than those obtained at higher presentation levels, "roll over" has occurred, and these scores indicate a possible retrocochlear (or higher) site of lesion.

Another use of suprathreshold word-recognition testing is to verify speech-recognition improvements achieved by persons with hearing aids . Testing can be completed at conversational levels in the sound field without the use of hearing aids and then again with hearing aids fitted to the patient. Score differences can be used as a method to assess hearing with hearing aids and can be used as a pretest and posttest to provide a percent-improvement score

Sentence testing

To evaluate ability to hear and understand everyday speech, various tests have been developed that use sentences as test items. Sentences can provide information regarding the time domain of everyday speech and can approximate contextual characteristics of conversational speech.

Everyday sentence test

This is the first sentence test developed at the CID in the 1950s.

Clinical use of this test is limited, because its reliability as a speech-recognition test for sentences remains undemonstrated.

Synthetic-sentence identification test

The synthetic-sentence identification (SSI) test was developed in the late 1960s. SSI involves a set of 10 synthetic sentences. Sentences used in this test were constructed so that each successive group of 3 words in a sentence is itself meaningful but the entire sentence is not.

Because the sentences are deemed insufficiently challenging in quiet environments, a recommendation has been made that sentences be administered in noise at a signal-to-noise (S/N) ratio of 0 dB, which presents both sentences and noise at equal intensity level.

Speech perception in noise test

The speech perception in noise (SPIN) test is another sentence-identification test. The SPIN test was originally developed in the late 1970s and was revised in the mid 1980s.

The revised SPIN test consists of 8 lists of 50 sentences. The last word of each sentence is considered the test item. Half of listed sentences contain test items classified as having high predictability, indicating that the word is very predictable given the sentence context. The other half of listed sentences contain test items classified as having low predictability, indicating that the word is not predictable given sentence context. Recorded sentences come with a speech babble-type noise that can be presented at various S/N ratios.

Speech in noise test

The speech in noise (SIN) test, developed in the late 1990s, contains 5 sentences with 5 key words per test condition. Two signal levels (70 and 40 dB) and 4 S/N ratios are used at each level. A 4-talker babble is used as noise. This recorded test can be given to patients with hearing aids in both the unaided and aided conditions.

Results are presented as performance-intensity functions in noise. A shorter version of the SIN, the QuickSIN, was developed in 2004. The QuickSIN has been shown to be effective, particularly when verifying open-fit behind-the-ear hearing aids.

Hearing in noise test

The hearing in noise test (HINT) is designed to measure speech recognition thresholds in both quiet and noise. The test consists of 25 lists of 10 sentences and noise matched to long-term average speech.

Using an adaptive procedure, a reception threshold for sentences is obtained while noise is presented at a constant level. Results can be compared with normative data to determine the patient's relative ability to hear in noise.

Words in noise test

The Words-in-Noise Test (WIN), developed in the early 2000s, provides an open set word-recognition task without linguistic context. The test is composed of monosyllabic words from the NU-6 word lists presented in multitalker babble. The purpose of the test is to determine the signal-to-babble (S/B) ratio in decibels for those with normal and impaired hearing. The WIN is similar to the QuickSIN in providing information about speech recognition performance.

The WIN is used to measure performance of basic auditory function when working memory and linguistic context is reduced or eliminated. This measure, by using monosyllabic words in isolation, evaluates the listener's ability to recognize speech using acoustic cues alone and by eliminating syntactical and semantic cues founds in sentences. The WIN materials allow for the same words to be spoken by the same speaker for both speech-in-quiet and speech-in-noise data collection.

Bamford-Kowal-Bench speech in noise test

Bamford-Kowal-Bench Speech-in-Noise Test (BKB-SIN) was developed by Etymotic Research in the early to mid 2000s. The primary population for this test include children and candidates or recipients of cochlear implants .

Like the HINT, the BKB-SIN uses Americanized BKB sentences. [ 3 ] These words are characterized as short, and the sentences are highly redundant; they contain semantic and syntactic contextual cues developed at a first grade reading level. Compared to the HINT, which uses speech-spectrum noise, the BKB-SIN uses multitalker babble. Clinicians can expect better recognition performance on the BKB-SIN and HINT in comparison to the QuickSIN and WIN because of the additional semantic context provided by the BKB sentences.

Selecting proper speech in noise testing

QuickSIN and WIN materials are best for use in discriminating those who have hearing loss from normal hearing individuals. The BKB-SIN and HINT materials are less able to identify those with hearing loss. [ 4 , 5 ] Therefore, the QuickSIN or WIN is indicated as part of the routine clinical protocol as a speech in noise task. The choice of QuickSIN or WIN is strictly a matter of clinician preference; however, the clinician must also consider whether or not the patient can handle monosyllabic words (WIN) or needs some support from sentence context (QuickSIN).

The BKB-SIN and HINT materials are easier to recognize because of the semantic content, making them excellent tools for young children or individuals with substantial hearing loss, including cochlear implant candidates and new recipients.

Most comfortable loudness level and uncomfortable loudness level

Most comfortable loudness level

The test that determines the intensity level of speech that is most comfortably loud is called the most comfortable loudness level (MCL) test.

For most patients with normal hearing, speech is most comfortable at 40-50 dB above the SRT. This sensation level is reduced for many patients who have sensorineural hearing loss (SNHL). Because of this variation, MCL can be used to help determine hearing aid gain for patients who are candidates for amplification.

MCL measurement can be obtained using cold running or continuous speech via recorded or monitored live-voice presentation. Patients are instructed to indicate when speech is perceived to be at the MCL. Initial speech levels may be presented at slightly above SRT and then progressively increased until MCL is achieved. Once MCL is achieved, a speech level is presented above initial MCL and reduced until another MCL is obtained. This bracketing technique provides average MCL.

Uncomfortable loudness level

One reason to establish uncomfortable loudness level (UCL) is to determine the upper hearing limit for speech. This level provides the maximum level at which word-recognition tests can be administered. UCL can also indicate maximum tolerable amplification.

Another reason to establish UCL is to determine the dynamic speech range. Dynamic range represents the limits of useful hearing in each ear and is computed by subtracting SRT from UCL. For many patients with SNHL, this range can be extremely limited because of recruitment or abnormal loudness perception.

UCL speech materials can be the same as for MCL. The normal ear should be able to accept hearing levels of 90-100 dB. Patients are instructed to indicate when presented speech is uncomfortably loud. Instructions are critical, since patients must allow speech above MCL before indicating discomfort.

While the use of speech testing in general has not necessarily been shown to predict hearing aid satisfaction, [ 6 ] the use of loudness discomfort levels (UCLs) has been shown to be useful in successful hearing aid outcomes. [ 7 ]

The Acceptable Noise Level (ANL) test is a measure of the amount of background noise that a person is willing to tolerate. [ 8 ] In recent years it has gained interest among researchers and hearing-care professionals because of its ability to predict, with 85% accuracy, who will be successful with hearing aids. [ 9 ]

For very young children with limited expressive and receptive language skills, picture cards representing spondaic words can be used to establish the SRT. Before testing, the tester must ensure that the child understands what the card represents. Once the child has been taught to point to the correct picture card, 4-6 cards are chosen and presented to the child. Then, the softest level at which the child can select the correct card at least half the time is established.

For children with typical kindergarten or first-grade language skills, the Children's Spondee Word List can be used instead of adult word lists. The CID W-1 list is appropriate for use with older children.

Word-recognition testing for children can be classified as open-message response testing or closed-response testing. Closed-response testing uses the picture-pointing technique.

Word intelligibility by picture identification test

One of the more popular closed-response tests is the word intelligibility by picture identification (WIPI) test. This test consists of 25 pages; on each page are 6 colored pictures representing an item named by a monosyllabic word. Four pictures represent a test item, while the other 2 serve to decrease probability of a correct guess.

WIPI was developed for use with children with hearing impairment and can be used for children aged 4 years and older.

Northwestern University children's perception of speech test

Another popular closed-response test is the Northwestern University children's perception of speech (NU-CHIPS) test. NU-CHIPS consists of 50 pages with 4 pictures per page.

This test was developed for use with children aged 3 years and older.

Pediatric speech intelligibility test

The pediatric speech intelligibility (PSI) test uses both monosyllabic words and sentence test items. The PSI test consists of 20 monosyllabic words and 10 sentences. Children point to the appropriate picture representing the word or sentence presented.

Test materials are applicable for children aged as young as 3 years.

Phonetically balanced kindergarten test

One of the more popular open-message response tests for children is the phonetically balanced kindergarten (PBK) test, which contains 50 monosyllabic words that the child repeats.

The PKB test is most appropriate for children aged 5-7 years.

Bamford-Kowal-Bench Speech-in-Noise Test

As mentioned prior, the BKB-SIN materials are easier due to the amount of semantic content utilized which makes it an excellent tool for use with young children. [ 10 ]

Lewis MS, Crandell CC, Valente M, Horn JE. Speech perception in noise: directional microphones versus frequency modulation (FM) systems. J Am Acad Audiol . 2004 Jun. 15(6):426-39. [QxMD MEDLINE Link] .

Harris RW, McPherson DL, Hanson CM, Eggett DL. Psychometrically equivalent bisyllabic words for speech recognition threshold testing in Vietnamese. Int J Audiol . 2017 Aug. 56 (8):525-537. [QxMD MEDLINE Link] .

Bench J, Kowal A, Bamford J. The BKB (Bamford-Kowal-Bench) sentence lists for partially-hearing children. Br J Audiol . 1979 Aug. 13(3):108-12. [QxMD MEDLINE Link] .

Wilson RH, McArdle RA, Smith SL. An Evaluation of the BKB-SIN, HINT, QuickSIN, and WIN Materials on Listeners With Normal Hearing and Listeners With Hearing Loss. J Speech Lang Hear Res . 2007 Aug. 50(4):844-56. [QxMD MEDLINE Link] .

Carlson ML, Sladen DP, Gurgel RK, Tombers NM, Lohse CM, Driscoll CL. Survey of the American Neurotology Society on Cochlear Implantation: Part 1, Candidacy Assessment and Expanding Indications. Otol Neurotol . 2018 Jan. 39 (1):e12-e19. [QxMD MEDLINE Link] .

Killion MC, Gudmundsen GI. Fitting hearing aids using clinical prefitting speech measures: an evidence-based review. J Am Acad Audiol . 2005 Jul-Aug. 16(7):439-47. [QxMD MEDLINE Link] .

Mueller HG, Bentler RA. Fitting hearing aids using clinical measures of loudness discomfort levels: an evidence-based review of effectiveness. J Am Acad Audiol . 2005 Jul-Aug. 16(7):461-72. [QxMD MEDLINE Link] .

Nabelek AK, Tucker FM, Letowski TR. Toleration of background noises: relationship with patterns of hearing aid use by elderly persons. J Speech Hear Res . 1991 Jun. 34 (3):679-85. [QxMD MEDLINE Link] .

Nabelek AK, Freyaldenhoven MC, Tampas JW, Burchfiel SB, Muenchen RA. Acceptable noise level as a predictor of hearing aid use. J Am Acad Audiol . 2006 Oct. 17 (9):626-39. [QxMD MEDLINE Link] .

Neave-DiToro D, Rubinstein A, Neuman AC. Speech Recognition in Nonnative versus Native English-Speaking College Students in a Virtual Classroom. J Am Acad Audiol . 2017 May. 28 (5):404-414. [QxMD MEDLINE Link] .

• Speech audiogram. Video courtesy of Benjamin Daniel Liess, MD.

Contributor Information and Disclosures

Suzanne H Kimball, AuD, CCC-A/FAAA Assistant Professor, University of Oklahoma Health Sciences Center Suzanne H Kimball, AuD, CCC-A/FAAA is a member of the following medical societies: American Academy of Audiology , American Speech-Language-Hearing Association Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Otolaryngic Allergy , American Academy of Otolaryngology-Head and Neck Surgery , American Auditory Society , American Neurotology Society , American Otological Society , North American Skull Base Society , Society of University Otolaryngologists-Head and Neck Surgeons , The Triological Society Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Arlen D Meyers, MD, MBA Emeritus Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery , American Academy of Otolaryngology-Head and Neck Surgery , American Head and Neck Society Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Neosoma; MI10;<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Cliff A Megerian, MD, FACS Medical Director of Adult and Pediatric Cochlear Implant Program, Director of Otology and Neurotology, University Hospitals of Cleveland; Chairman of Otolaryngology-Head and Neck Surgery, Professor of Otolaryngology-Head and Neck Surgery and Neurological Surgery, Case Western Reserve University School of Medicine Cliff A Megerian, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery , American College of Surgeons , American Neurotology Society , American Otological Society , Association for Research in Otolaryngology , Massachusetts Medical Society , Society for Neuroscience , Society of University Otolaryngologists-Head and Neck Surgeons , Triological Society Disclosure: Nothing to disclose.

Medscape Reference thanks Benjamin Daniel Liess, MD, Assistant Professor, Department of Otolaryngology, University of Missouri-Columbia School of Medicine, for the video contributions to this article.

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Speech Audiometry

Audiometry guides, introduction.

Speech audiometry is an important component of a comprehensive hearing evaluation. There are several kinds of speech audiometry, but the most common uses are to 1) verify the pure tone thresholds 2) determine speech understanding and 3) determine most comfortable and uncomfortable listening levels. The results are used with the other tests to develop a diagnosis and treatment plan.

SDT = Speech Detection Threshold, SAT = Speech Awareness Threshold.   These terms are interchangeable and they describe the lowest level at which a patient can hear the presence of speech 50% of the time.   They specifically refer to the speech being AUDIBLE, not INTELLIGIBLE.

This test is performed by presenting spondee (two-syllable) words such as baseball, ice cream, hotdog and the patient is to respond when they hear the speech.   This is often used with non-verbal patients such as infants or other difficult to test populations.   The thresholds should correspond to the PTA and is used to verify the pure tone threshold testing.    

How to Test:      

Instruct the patient that he or she will be hearing words that have two parts, such as “mushroom” or “baseball.” The patient should repeat the words and if not sure, he or she should not be afraid to guess.

Using either live voice or recorded speech, present the spondee word lists testing the better ear first. Start 20 dB above the 1000 Hz pure tone threshold level. Present one word on the list and, if the response is correct, lower the level by 5 dB. Continue until the patient has difficulty with the words. When this occurs, present more words for each 5 dB step.

Speech Reception Threshold (SRT)

SRT, or speech reception threshold, is a fast way to    help verify that the pure tone thresholds are valid. Common compound words - or spondee words - are presented at varying degrees of loudness until it is too soft for the patient to hear. SRT scores are compared to the pure tone average as part of the cross check principle.   When these two values agree, the reliability of testing is improved.

Word Recognition

Instruct the patient that he or she is to repeat the words presented. Using either live voice or recorded speech, present the standardized PB word list of your choice. Present the words at a level comfortable to the patient; at least 30 dB and generally 35 to 50 dB above the 1000 Hz pure tone threshold. Using the scorer buttons on the front panel, press the “Correct” button each time the right response is given and the “Incorrect” button each time a wrong response is given.

The Discrimination Score is the percentage of words repeated correctly: Discrimination % at HL = 100 x Number of Correct Responses/Number of Trials.

WRS = Word Recognition Score, SRS = Speech Reception Score, Speech Discrimination Score.   These terms are interchangeable and describe the patient’s capability to correctly repeat a list of phonetically balanced (PB) words at a comfortable level.   The score is a percentage of correct responses and indicates the patient’s ability to understand speech.

Word Recognition Score (WRS)

WRS, or word recognition score, is a type of speech audiometry that is designed to measure speech understanding. Sometimes it is called word discrimination. The words used are common and phonetically balanced and typically presented at a level that is comfortable for the patient. The results of WRS can be used to help set realistic expectations and formulate a treatment plan.

Speech In Noise Test

Speech in noise testing is a critical component to a comprehensive hearing evaluation. When you test a patient's ability to understand speech in a "real world setting" like background noise, the results influence the diagnosis, the recommendations, and the patient's understanding of their own hearing loss.

Auditory Processing

Sometimes, a patient's brain has trouble making sense of auditory information. This is called an auditory processing disorder. It's not always clear that this lack of understanding is a hearing issue, so it requires a very specialized battery of speech tests to identify what kind of processing disorder exists and develop recommendations to improve the listening and understanding for the patient.

QuickSIN is a quick sentence in noise test that quantifies how a patient hears in noise. The patient repeats sentences that are embedded in different levels of restaurant noise and the result is an SNR loss - or Signal To Noise ratio loss.   Taking a few additional minutes to measure the SNR loss of every patient seen in your clinic provides valuable insights on the overall status of the patient' s auditory system and allows you to counsel more effectively about communication in real-world situations. Using the Quick SIN to make important decisions about hearing loss treatment and rehabilitation is a key differentiator for clinicians who strive to provide patient-centered care.

BKB-SIN is a sentence in noise test that quantifies how patients hear in noise. The patient repeats sentences that are embedded in different levels of restaurant noise an the result is an SNR loss - or signal to noise ratio loss. This test is designed to evaluate patients of many ages and has normative corrections for children and adults. Taking a few additional minutes to measure the SNR loss of every patient seen in your clinic is a key differentiator for clinicians who strive to provide patient-centered care.

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• Audiology features
• Introduction to speech testing

Introduction to speech testing By Janet R Schoepflin

Let’s get back to basics: Dr Schoepflin introduces the concepts behind speech testing for hearing care professionals.

While pure tone threshold testing is considered the ‘gold standard’ for assessing auditory sensitivity, the results of pure tone testing provide only limited information about how an individual will be able to communicate. To evaluate this, a speech stimulus is required; consequently, speech testing should be included in every audiological evaluation.

In this article, I will present an overview of the considerations involved in speech testing, including its purposes, the methods and materials used, and the conditions under which it is conducted. The tests I will cover are those used in the typical audiological evaluation, including speech threshold testing, suprathreshold speech recognition testing, and the testing of the most comfortable and uncomfortable listening levels; the end of the article will include several additional speech test considerations and applications.

Speech threshold testing

Speech threshold testing is a measure of an individual’s ability to detect or just barely recognise speech. Each ear is tested separately, and the level obtained is used as a crosscheck for pure tone thresholds and to determine a starting level for suprathreshold speech recognition testing. The materials used for speech threshold testing are usually spondees; that is, two-syllable words produced with equal stress on each syllable. The listener is familiarised with the list of test words, and the level of the test words, which can be delivered using a monitored live voice or recording, is manipulated until the listener is able to repeat back about 50% of them. This level (in dB HL) is recorded on the audiogram as the speech threshold, often referred to as the speech recognition threshold or SRT.

Suprathreshold speech testing

Suprathreshold speech testing is conducted in each ear to assess how well an individual can recognise the sounds of speech when presented at a comfortable listening level. It is typically conducted using a recorded list of monosyllabic words (to ensure a standardised presentation), without familiarisation, at a level 25 to 40 dB above the SRT in a quiet background, although other levels are often used. In addition, suprathreshold speech testing in noise can be done to provide further diagnostic information.

The word lists most commonly used clinically in the US are the CID W-22 and NU-6 lists. The original versions contained 50 words, which were created for phonemic balance and simplicity in scoring, with each correctly identified word worth 2%. Time constraints in the clinic have limited the use of 50-word lists, so now it is common to use 25-word, or even shorter, lists to test speech recognition. In that case, following the protocol recommended by Hurley and Sells is recommended [1]. Each test word on the test is preceded by a carrier phrase and the listener’s task is to simply repeat the test word. The response of the listener must match the test word exactly for the response to be judged correct. The percentage of correctly identified words in each ear is recorded on the audiogram as the suprathreshold speech recognition score.

There are traditional classifications of speech recognition ability, which include excellent (90% and above), good (78-88%), fair (66-76%), poor (54%), and very poor (less than 52%). If a listener’s score falls below the range of ‘good’, a second test at another level might be warranted.

Most comfortable listening level

The most comfortable listening level (MCL) test is typically conducted on individuals who are being considered for hearing aids, although it can be completed on anyone. As the name suggests, the test is aimed at finding the intensity level at which the listener finds listening most comfortable. The materials that are used for this are usually narratives, such as the reading of a passage. While reading, the tester manipulates (increasing and decreasing) the level of the voice until the listener indicates a comfortable level. Several trials are usually completed because MCL is generally a range, not a single intensity.

Uncomfortable listening level

The uncomfortable listening level (UCL) test is, as the name indicates, meant to identify the level at which speech is uncomfortably loud for a listener. Like MCL, this test is generally conducted on hearing aid candidates, but can be tested on anyone. The materials used are, again, usually narratives. While reading, the tester gradually increases the intensity level of the voice and the listener is asked to indicate when the voice becomes ‘uncomfortably loud’.  Obviously, the term ‘uncomfortably loud’ can be interpreted differently by different people; therefore, the instructions preceding UCL testing are important. What we are trying to determine is not a preference for listening at softer levels, but rather the point at which speech becomes uncomfortable.

Other considerations and applications

Some speech tests, notably speech thresholds, are conducted at low levels. To ensure that test results are valid and reliable, speech testing should be conducted in settings that meet the ANSI/ASA S3.1-1991 (R2018) [2] maximum permissible noise standards, using equipment that meets the ANSI/ASA S3.6-2018 [3] specifications. In addition, all speech testing should follow a standard protocol, supported by the research literature; deviations or modifications in method or materials should always be noted on the audiogram.

Because suprathreshold testing is administered at a comfortable listening level, masking of the non-test ear is required when the presentation level in the test ear is greater than 35 dB above the best bone conduction threshold at 500 Hz, 1000 Hz, or 2000 Hz in the non-test ear [4]. Masking would also be required for the SRT if the best bone conduction threshold in the non-test ear was more than 35 dB better than the SRT in the test ear.

Figure 1. Example of spondee pictures used for testing SRT in children. 

When testing children, different materials are often used. For the SRT, a closed-set task, which uses picture cards depicting the test words, might be employed (Figure 1). For suprathreshold testing, the selected word list might contain words more familiar to younger listeners or a closed-set task could be used; here, the child would select the test word from among a set of four to six pictures.

It is also important to recognise the influence of language on speech test results. When testing those who are non-English speakers, it is not appropriate to use the English test words to establish speech recognition scores.

Finally, speech testing has other applications: in assessing hearing aids, particularly in noisy backgrounds; in testing auditory processing; in determining patterns of error in speech recognition, and other purposes.

1. Hurley R, Sells J. An abbreviated word recognition protocol based on item difficulty. Ear Hear 2003; 24(2) :111-8. 2. American National Standards Institute (2018). ANSI/ASA S3.1-1991 (R2018). Maximum permissible ambient noise levels for audiometric test rooms. New York, USA: American National Standards Institute. 3. American National Standards Institute (2018). ANSI/ASA S3.6-2018. Specifications for audiometers. New York, USA: American National Standards Institute. 4. Roeser RJ, Valente M, Hosford-Dunn H.  Audiology: Diagnosis (2nd ed.) Thieme; 2007.

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What is Speech Audiometry? 

Speech audiometry is a speech test or battery of tests performed to understand the client’s ability to discriminate speech sounds, detect speech in background noise, understand the signals being presented, and recall the information presented.

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Frequently Asked Questions

When should you do speech audiometry.

Most individuals seeking help with their hearing cite difficulties understanding speech, and more often   speech in noise . While  pure tone audiometry  provides invaluable data regarding the nature and severity of hearing loss at a variety of frequencies – of which speech is made up – it cannot provide data on the individual's understanding of speech. Speech stimuli are used in the audiometric test battery to ascertain this data.  

There are a variety of commonly used speech stimuli and tests that help paint a complete patient picture.

What Is Speech Recognition (Reception) Threshold (SRT)

Speech recognition threshold (SRT) testing is often used to validate your pure tone audiometric results. In other words, does the lowest level an individual can detect speech correlate to the hearing loss obtained through pure tone audiometry? This score is also often used as a starting point in determining your presentation level when performing suprathreshold speech testing like word recognition scores (WRS). 

When obtaining an SRT, spondee words, or phonetically balanced words, like hotdog or baseball, are used. A list of these words is presented to the patient at a comfortable level first – this is called conditioning. Once the patient is familiar with the word list, those same words will be presented in a random order at a decreasing volume level. The patient will be asked to repeat back the words presented. The threshold is defined as the level at which 50% of the words are successfully repeated.  

Words can be presented through monitored live voice or recorded speech. With the   Measure audiometer , clinicians have the flexibility to use whichever they prefer. Recorded spondee word lists can be made available in the testing software for a seamless transition from  pure tones  to speech testing. When using monitored live-voice, a VU meter is clearly displayed so clinicians can observe the level of their voice.  

What is a Speech Detection Threshold (SDT)

A speech detection threshold (SDT) describes the lowest intensity level that an individual can detect speech. An SDT is obtained in the same manner as a speech recognition threshold, but the patient is asked to respond to the words in a developmentally appropriate way, like when performing pure tone audiometry, rather than repeating them back. This is useful when testing young children or individuals with very poor speech discrimination who are unable to repeat back words.

What Is a Word Recognition Score (WRS) and How to Get It

A word recognition score (or a speech discrimination score) provides clinicians with valuable information regarding not only an individual’s hearing loss, but which treatment options will be the most appropriate.  

WRS information not only assists in determining whether an individual is a good candidate for hearing aids or if another device like a cochlear implant may be indicated, but it can also help determine if there is a neural component to the hearing loss. 

Scores are often classified into 1 of 5 categorized; excellent, good, fair, poor, and very poor. 

Excellent or within normal limits = 90 - 100% on whole word scoring

Good or slight difficulty = 78 - 88%

Fair to moderate difficulty = 66 - 76%

Poor or great difficulty = 54 - 64 %

Very poor is < 52%

During speech audiometry, an individual's speech recognition threshold is used to determine an appropriate presentation level for obtaining a word recognition score. Alternatively, clinicians can measure a patient’s most comfortable loudness level (MCL) and present there.  

Testing is most often performed in quiet but can be completed using background noise as well. Standardized word lists, like the W22 or NU-6 lists, are presented and the individual is asked to repeat back the words heard. A carrier phrase, for example “say the word” is often used. Having this phrase presented before the target word helps the patient prepare to listen and respond and helps the clinician adjust their voice to the proper level before the target word during monitored live-voice presentations. 

Note that like with speech reception threshold testing, a recorded word list or live voice can be used derive a word recognition score. When using live voice, a clinician can watch the VU meter included in the   Measure Software  during the carrier phrase to check presentation level.   

Why Use Speech Audiometry?

While pure tones are an invaluable stimulus for measuring hearing loss, they don’t represent what individuals are experiencing day-to-day. Using speech stimuli helps to measure a client’s hearing using words they may encounter in everyday life. 

Additionally, a speech test assesses the client’s full auditory pathway. In other words, the question is, once sound is detected, is the ear able to accurately send that sound to the brain? At times, although able to hear the words presented, individuals may have difficulty processing those words. This is something that can only be detected by using speech audiometry. 

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Audiograms and Functional Auditory Testing to Assess Hearing Speech in Noise: A Review of the Clinical Evidence [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2015 Aug 17.

Audiograms and Functional Auditory Testing to Assess Hearing Speech in Noise: A Review of the Clinical Evidence [Internet].

Appendix 1 functional tests to assess speech in noise.

• The Hearing in Noise Test (HINT)

The HINT is an adaptive test that is composed of 250 sentences that are divided into 25 lists. 8 The test is adaptive in that the signal-to-noise ratio is adjusted based on the performance of the participant. 8 Only the speech level is adjusted whereas the noise level remains constant. 8 For each correct sentence the participant identifies, the following sentence is presented at a lower speech level, and for each sentence incorrectly identified, the following sentence is presented at a higher speech level. 8 The intention of the adaptive test is to ensure each participant approaches the 50% correct response rate. 8 The speech level typically is presented at 55 dB SPL to start, and the noise remains constant at 65 dB SPL. 8 The test is designed to be administered with the participant sitting 1 meter from eight speakers. 8 The speaker directly in front of the individual will present the sentences, whereas the other 7 speakers surrounding the participant will play the background noise. 8

• The Speech Recognition in Noise Test (SPRINT)

The SPRINT was designed by the United States Army to identify hearing loss in active duty soldiers. 9 The test includes 200 monosyllabic words that are pre-recorded with multitalker babble, and are delivered to both ears simultaneously using earphones. 9 The speech-to-babble ratio is 9dB; at this ratio, active duty soldiers with normal hearing are expected to hear at least 95% of the words correctly. 9 The SPRINT is recommended to be administered by an audiologist or a technician with audiologist supervision. 9

• The Words in Noise Test (WIN)

The WIN consists of the administration of 70 monosyllabic words divided into two 35 word lists that are pre-recorded with a noisy background. 10 The test is adaptive in that the loudness of the speech fluctuates during the test while the multitalker babble level remains constant. 10 The test is administered using earphones and is conducted in each ear separately. 10 The 50% correct point, measured in dB signal-to-babble ratio is then calculated for the participant. 10

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• Cite this Page Audiograms and Functional Auditory Testing to Assess Hearing Speech in Noise: A Review of the Clinical Evidence [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2015 Aug 17. APPENDIX 1, Functional Tests to Assess Speech in Noise.
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Speech Recognition

Speech recognition is the capability of an electronic device to understand spoken words. A microphone records a person's voice and the hardware converts the signal from analog sound waves to digital audio. The audio data is then processed by software , which interprets the sound as individual words.

A common type of speech recognition is "speech-to-text" or "dictation" software, such as Dragon Naturally Speaking, which outputs text as you speak. While you can buy speech recognition programs, modern versions of the Macintosh and Windows operating systems include a built-in dictation feature. This capability allows you to record text as well as perform basic system commands.

In Windows, some programs support speech recognition automatically while others do not. You can enable speech recognition for all applications by selecting All Programs → Accessories → Ease of Access → Windows Speech Recognition and clicking "Enable dictation everywhere." In OS X, you can enable dictation in the "Dictation & Speech" system preference pane. Simply check the "On" button next to Dictation to turn on the speech-to-text capability. To start dictating in a supported program, select Edit → Start Dictation . You can also view and edit spoken commands in OS X by opening the "Accessibility" system preference pane and selecting "Speakable Items."

Another type of speech recognition is interactive speech, which is common on mobile devices, such as smartphones and tablets . Both iOS and Android devices allow you to speak to your phone and receive a verbal response. The iOS version is called "Siri," and serves as a personal assistant. You can ask Siri to save a reminder on your phone, tell you the weather forecast, give you directions, or answer many other questions. This type of speech recognition is considered a natural user interface (or NUI ), since it responds naturally to your spoken input .

While many speech recognition systems only support English, some speech recognition software supports multiple languages. This requires a unique dictionary for each language and extra algorithms to understand and process different accents. Some dictation systems, such as Dragon Naturally Speaking, can be trained to understand your voice and will adapt over time to understand you more accurately.

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• Positive 'Rollover'

Robert H. Margolis, PhD

April 11, 2005.

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• Hearing Evaluation - Adults

Speech recognition rollover is one of the special tests that, in the pre-ABR and pre-MRI era, comprised the battery of tests that were helpful for screening for retrocochlear pathology. ABR significantly increased the sensitivity of auditory testing to VIIIth nerve lesions and MRI was found to be significantly more sensitive than ABR. As a result, acoustic neuromas and other lesions of the VIIIth nerve and cerebellopontine angle are now typically under a centimeter in diameter at detection and often under 0.5 cm. Before ABR and MRI, two-, three-, and four-cm tumors at detection were common. Consequently, those special tests represent an important development in the history of diagnostic audiology but are no longer in widespread use. There are two classic papers on speech recognition rollover for detection of retrocochlear pathology. Jerger and Jerger (1971) measured speech recognition rollover for 41 subjects with cochlear hearing loss and 16 subjects with retrocochlear pathologies. Their important observation was that when rollover was expressed as a difference (maximum score - minimum score), there was poor separation between groups. But when the difference was expressed as a proportion of the maximum score, there was nearly complete separation between patients with cochlear hearing loss and those with VIII nerve pathology. Dirks et al. (1977) reported results on 89 ears of 59 subjects with cochlear loss and 8 ears of 7 subjects with retrocochlear loss. Their results agreed closely with those of Jerger and Jerger. In both studies a "rollover index" of 0.45 provided excellent separation of the two groups. References Jerger J, Jerger S (1971). Diagnostic significance of PB word functions. Arch Otolaryng 93, 573-580. Dirks DD, Kamm C, Bower D, Betsworth A (1977). Use of performance-intensity functions for diagnosis. J Speech Hear Dis 42, 408-415. Robert H. Margolis (b. Lorain, Ohio, 29 June 1946) earned bachelor's and master's degrees from Kent State University (1968, 1969) and a Ph.D. degree from the University of Iowa (1974). After a post-doctoral research fellowship at the University of Wisconsin, he joined the faculty of the UCLA Medical School in 1975. In 1980, he was appointed associate professor of communication sciences and disorders and director of the Gebbie Hearing Clinic at Syracuse University. In 1988 he became professor and director of audiology at the University of Minnesota Medical School. Dr. Margolis has over 120 publications in scientific and clinical journals and textbooks. His research has focused on development of methods for evaluating disorders of hearing. He has been awarded research grants from the Deafness Research Foundation, and the National Institutes of Health. He has served as president of the Minnesota Academy of Audiology, the International Hearing Foundation, and the Minneapolis- University Rotary Club. He has been awarded the Honors of the Association by the Minnesota Academy of Audiology, the Humanitarian Award by the American Academy of Audiology, the Editor's Award by the Journal of the American Academy of Audiology, the Rotarian of the Year award by the Minneapolis-University Rotary Club, the Larry Mauldin Award for Excellence in Education in Audiology, and an Honorary Membership by the Vitacura Rotary Club (Santiago, Chile). Margolis lives in Arden Hills, Minnesota with his wife, Janet, and two daughters, Jane and Brittany. He coaches girls' basketball and softball and enjoys tennis and fishing.

Robert H. Margolis earned bachelor's and master's degrees from Kent State University (1968, 1969) and a Ph.D. degree from the University of Iowa (1974). After a post-doctoral research fellowship at the University of Wisconsin, he joined the faculty of the UCLA Medical School in 1975. In 1980, he was appointed associate professor of communication sciences and disorders and director of the Gebbie Hearing Clinic at Syracuse University. In 1988 he became professor and director of audiology at the University of Minnesota Medical School. In 2000 he established AUDIOLOGY INCORPORATED to develop improved hearing tests. Dr. Margolis has over 120 publications in scientific and clinical journals and textbooks. His research has focused on development of methods for evaluating disorders of hearing. He has been awarded research grants from the Deafness Research Foundation, NATO Division of Scientific Affairs, and the National Institutes of Health. He has served as president of the Minnesota Academy of Audiology, the International Hearing Foundation, and the Minneapolis-University Rotary Club. He has been awarded the Honors of the Association by the Minnesota Academy of Audiology, the Humanitarian Award by the American Academy of Audiology, the Editor's Award by the Journal of the American Academy of Audiology, the Rotarian of the Year Award by the Minneapolis-University Rotary Club, the Larry Mauldin Award for Excellence in Education in Audiology, an Honorary Membership by the Vitacura Rotary Club (Santiago, Chile), and the James Jerger Career Research Award by the American Academy of Audiology.

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