Plenty of people arrive for a hearing test with no idea what is about to happen, and leave holding a printed graph nobody explained. Others never get that far: they run one of the free hearing checks on their phone, get a score, and have no way to judge whether it means anything at all. This is what the appointment actually involves, and how to read the chart at the end of it.
An online or phone hearing screening is not a diagnosis
Screening tools have a real use. They are quick, they cost nothing, and they prompt people to act who might otherwise have waited years. What they cannot do is diagnose.
The World Health Organization says so plainly about its own hearWHO screening app, which it describes as a check rather than an assessment: it “is not a formal hearing test and does not replace the need to consult a health professional”. Where a result suggests a problem, the WHO’s advice is to “have a formal hearing test with a health professional”.
The reasons are practical rather than mysterious. A screening app plays sound through whichever earphones you happen to own, in whichever room you happen to be sitting in, at an output level the app has no way to verify. Diagnostic pure tone audiometry is done in a sound treated booth, using equipment calibrated to a recognised national standard, so that the softest sound you respond to can be recorded as a real number that means the same thing next year as it does today.
A screening also cannot tell you why. It cannot separate a blockage or a middle ear problem from a change in the inner ear, and that distinction is the one that shapes everything that follows. A free online check can reasonably tell you that something is worth looking at. It cannot tell you what.
What a diagnostic hearing test involves
A full assessment is a sequence of short tests rather than one long one. None of them hurt, and none of them require you to know anything in advance.
The case history
It starts with a conversation: when you first noticed a change, whether one ear is worse than the other, whether there is ringing, whether you struggle more in restaurants than in quiet rooms, your noise exposure, and any relevant medical background. This is not small talk. It shapes which tests are prioritised and how the results are read. If you are unsure what to bring up, our guide on how to prepare for your first audiologist visit covers it.
Looking in the ear
Before any sound is played, the audiologist examines the ear canal and eardrum. Observation of the outer ear followed by pneumatic otoscopy is generally enough to detect outer and middle ear abnormalities that may contribute to a diagnosis. It is a few seconds per ear, and it matters, because something as ordinary as an obstructed canal will change every measurement taken afterwards.
Pure tone audiometry
This is the part most people picture. You sit in a sound treated booth wearing headphones or insert earphones, and press a button, raise a hand or say yes each time you hear a tone, however faint.
The audiologist is not testing whether you can hear a comfortable sound. They are finding your threshold, which is defined as the softest ascending presentation you respond to at least half the time. That is why the tones get frustratingly quiet, and why guessing is unhelpful. A standard audiogram measures thresholds across octaves and most inter-octaves from 250 Hz to 8000 Hz, a range slightly broader than human speech, usually including 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz.
Bone conduction
A small vibrating device, a bone conduction oscillator, is then placed against the bone behind your ear, on the mastoid. It sends sound waves directly to the cochlea through vibration.
The point of doing both is that they measure different stretches of the same pathway. Air conduction measures sound travelling from the outer ear, through the middle ear, into the inner ear and on to the central nervous system. Bone conduction measures only the part from the inner ear onwards. Comparing the two is what separates a mechanical problem in the outer or middle ear from a change in the inner ear or the nerve.
Masking
If one ear hears considerably better than the other, the good ear can pick up a sound intended for the weaker one and answer on its behalf. To prevent this, a masking noise is introduced into the non-test ear to raise that ear’s threshold temporarily. It sounds like a rushing or hissing sound and it is a sign the test is being done properly, not a sign something is wrong.
Tympanometry
Tympanometry assesses how easily acoustic energy transfers through the middle ear system as air pressure changes. A soft probe seals the ear canal, a tone is played, and the pressure is varied, typically across a range from about +200 daPa to -400 daPa. In a normally functioning middle ear, energy transfer is greatest at atmospheric pressure, meaning 0 daPa, and falls away at pressures well above or below that.
You will feel a brief change of pressure, similar to a lift or an aeroplane descending. It takes seconds per ear and requires nothing from you but stillness.
Speech testing
Hearing tones is not the same as understanding words, which is why speech testing is done alongside the tones. The speech recognition threshold measures the lowest level at which speech can be identified at least half of the time. A word recognition score then assesses how well you recognise and repeat words at a comfortable listening level, above that threshold.
Speech in noise testing goes further, measuring how much louder speech needs to be than the background before you can follow it. Combined with pure tone audiometry, speech audiometry gives a fuller picture than thresholds alone, which is exactly why the common complaint of “I can hear you, I just cannot understand you in a restaurant” is a real, measurable thing rather than an excuse.
How to read your audiogram
The two axes
An audiogram is a graph with pitch running one way and loudness the other. The horizontal axis is frequency in hertz, from low pitches on the left to high pitches on the right. The vertical axis is sound intensity in decibels hearing level, and it is inverted: the quietest sounds sit at the top, the loudest at the bottom.
That inversion is the single thing most people get wrong. A mark low on the chart is not good. It means a sound had to be made louder before you could hear it. The further down the page your marks sit, the more volume you needed.
The symbols
Each ear is plotted separately, and the convention is consistent: red for sounds detected by the right ear, blue for the left. Air conduction and bone conduction thresholds use different symbols, so a single chart carries four sets of marks. If your printout is in black and white, the symbol shapes still tell you which is which, and it is entirely reasonable to ask the audiologist to label them for you.
What the numbers mean
Severity is usually described in bands, based on the average of the air conduction thresholds at 500, 1000 and 2000 Hz:
- Normal hearing: -10 to 15 dB HL
- Slight: 16 to 25 dB HL
- Mild: 26 to 40 dB HL
- Moderate: 41 to 55 dB HL
- Moderately severe: 56 to 70 dB HL
- Severe: 71 to 90 dB HL
- Profound: 91 dB HL and above
Two things are worth knowing about these labels. Better than average hearing can produce thresholds below 0 dB HL, so a negative number is not an error. And separately, the World Health Organization defines disabling hearing loss as greater than 35 decibels in the better hearing ear, which is a different measure for a different purpose. A band name on a chart is a description, not a verdict on how you live.
The gap between the lines
The relationship between the air conduction and bone conduction results indicates the type of loss, not just the amount.
Where the air and bone lines sit on top of each other with no air-bone gap greater than 10 dB HL, that pattern indicates a purely sensorineural picture, involving the inner ear or the nerve pathway. An air-bone gap, present when the difference between air and bone thresholds at a given frequency exceeds 15 dB HL, points to a conductive component somewhere in the outer or middle ear. A mixed picture shows features of both.
This is the part that changes the plan, and it is the part no screening app can produce, because a screening app measures nothing by bone conduction at all.
Shape matters as much as depth
Two people can share an average threshold and have completely different experiences. A result that is normal in the low frequencies and drops away in the high ones affects consonants far more than vowels, which is why speech can sound present but indistinct. Where your line falls, across which frequencies, is a large part of what the audiologist is reading.
Questions worth asking before you leave
- May I have a copy of my audiogram for my records?
- Is this conductive, sensorineural or mixed, and what does that mean in my case?
- Which frequencies are affected, and how does that map onto what I struggle with day to day?
- Should this be re-tested, and if so, when?
Asking for the printout is normal and worth doing. A single audiogram is a snapshot. Two taken years apart are a trend, and a trend is far more useful. That is one of the arguments for regular hearing tests rather than a single test at the point of crisis.
Booking a hearing test in George
If an online check has flagged something, or you have simply been aware for a while that conversations are getting harder, the useful next step is a diagnostic assessment rather than another screening. Distinct Hearing provide complete diagnostic hearing tests, hearing aid fitting and hearing loss management from One York Medical Centre in George, serving George and the wider Garden Route.
A hearing test does not commit you to anything. It produces a measurement and an explanation of what that measurement means, and what happens after that is a decision you make with the information in front of you. If you are unsure whether what you are noticing warrants an appointment, the signs of hearing loss page is a reasonable place to start, and it is also worth understanding what an audiologist is and how that differs from a hearing aid acoustician.
To arrange an assessment, get in touch with the practice.
This article is general information about audiological testing and is not a diagnosis or medical advice. An audiogram must be interpreted by a qualified audiologist in the context of your own history and examination.