11

Multi-Frequency and Multi-Component Tympanometry

INTRODUCTION
Middle ear admittance can be measured at multiple frequencies, and has typically been measured at
226 Hz, 678 Hz, and 1000 Hz. Tympanometry using 226 Hz probe tones was discussed in Chapter 10;
in this chapter we will focus on tympanometry using 678 Hz and 1000 Hz probe tones. In addition,
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total middle ear admittance (Y) can be broken down into the contributions of mass and stiffness (B)
and conductance (G). The sensitivity and specificity of multi-frequency and multi-component
tympanometry can, in some cases, exceed that of conventional 226 Hz tympanometry (Harris,
Hutchinson, & Moravec, 2005).
In this chapter we discuss how to conduct and interpret multi-frequency and multi-component
tympanometry. More specifically, the following tests are covered in this chapter:
• Y1000 Hz tympanometry
• B/G 678 and/or B/G1000 Hz tympanometry
• Resonant frequency evaluation

Y1000 HZ TYMPANOMETRY
Researchers have shown that for infants, Y1000 Hz tympanometry gives more reliable and valid
findings than Y226 Hz tympanometry (Shanks & Shohet, 2009). That tympanometry for adults and
infants differs should not be surprising considering that infants’ ears differ from adults’ in many ways,
including immature anatomy, and at times the presence of middle ear mesenchyme. Accordingly, the
American Academy of Family Practice guidelines (Rosenfeld et al., 2004) suggested the use of Y1000
Hz up to age 4 months, after which Y226 Hz is appropriate.

Procedure
The procedure is the same as for Y226 Hz tympanometry, except 1000 Hz probe tones are
recommended.

Norms and Interpretation

Classification patterns have been proposed but it is often sufficient to make judgments based on Y1000
Hz tympanogram shape. Normal shape is single peaked; if one were to draw a line from the negative
tail to the positive tail, that line should angle upward, and the single peak should be above the line.
Abnormal shape is one peak below that line, flat and/or wide tympanograms, or multi-peaked
tympanograms (Figure 11–1).
Copyright 2017. Plural Publishing, Inc.

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 Figure 11–1. Neonate normal Y1000 Hz tympanogram.

B/G 678 AND/OR B/G 1000 HZ TYMPANOMETRY IN CHILDREN AND ADULTS

Probe Tone Frequency
For adults, Y226 Hz tympanometry provides information regarding middle-ear stiffness, just as
middle-ear disorders causing stiffness can manifest as low-frequency stiffness tilt audiograms
(low-frequency hearing loss). In contrast, higher frequency tympanometry, including 678 and 1000 Hz
tympanometry, provides information regarding middle-ear mass characteristics (Fowler & Shanks,
2002; Lilly, 2005), just as middle ear disorders adding mass can manifest as high-frequency mass tilt
audiograms (high-frequency hearing loss).

Measurement Components
In addition, admittance Y can be broken down into component parts, susceptance B and conductance
G. Conductance has to do with how middle-ear friction affects admittance, whereas susceptance has to
do with how middle-ear mass and stiffness affects admittance. Though the details are beyond the scope
of this text, suffice it to say that in mass-controlled middle ears susceptance, admittance lags sound
pressure because of middle-ear inertia. In contrast, in stiffness-controlled middle ears, susceptance

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 admittance leads sound pressure, much as a spring initially admits energy before tightening. Therefore,
mass and stiffness susceptance are in opposition, allowing for scientific plotting of admittance as a
vector.

Procedure
Select desired frequency and components; for example, the Grason Stadler Tympstar can be set to test
both B and G by selecting B/G. The frequency can be set either to 678 Hz or 1000 Hz. Recording Y678
and Y1000 Hz are optional.

Norms and Interpretation

Mass and stiffness tympanograms have been classified by the number of upward peaks plus the number
of downward peaks (Fowler & Shanks, 2002; Vanhuyse, Creten, & Van Camp, 1975). Some of the
possible shapes are shown in Figure 11–2 on a vector plot from 1B1G stiffness controlled to 5B3G
mass controlled. Table 11–1 contains verbal summaries.

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 Figure 11–2. Four multicomponent tympanogram shapes. From Acoustic immittance measures (Page 70, Figure 5–5) by
L. Hunter & N. Shahnaz, 2014, San Diego, CA: Plural Publishing, Inc. Reprinted with permission.

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 Table 11–1. High Frequency Y, B, and G Shapes (Vanhuyse, Creten, & Van Camp, 1975; Fowler & Shanks, 2002)

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 Simplified clinical decision rules are offered below:

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 • Number of peaks rules: <5B peaks and/or <3G peaks are seen with normal middle ears (Harris, Hutchinson, &
Moravec, 2005); in fact over 90% of normal middle ears show 1B1G or 3B1G patterns (Wiley, Oviatt, & Block, 1987).
More peaks suggest mass affect, which can result from many disorders.
• Reliability rule: Middle ears should show no increase in the number of peaks at annual or other re-tests. Change is
abnormal, even if the retest results are <5B peaks and/or <3G peaks.
• The 3B3G tympanograms with outermost maxima separated by <75 daPa is seen with normal middle ears or with
monomeric/dimeric tympanic membranes. Wider maxima separation is seen with ossicular disarticulation. Results
from both monomeric/dimeric tympanic membranes and ossicular disarticulations will also show high static
admittance.
• The 5B3G tympanograms with outermost maxima separated by <100 daPa is seen with normal middle ears or with
monomeric/dimeric tympanic membranes. Wider maxima separation is seen with ossicular disarticulation. Results
from both monomeric/dimeric tympanic membranes and ossicular disarticulations will also show high static
admittance.
• Flat with B > G is seen with outer ear or middle ear occlusion.
• Flat with G < B is seen with tympanic membrane perforation or PE tube.

RESONANT FREQUENCY EVALUATION

The resonant frequency of the normal adult middle ear varies depending on measurement procedures;
audiologists should consult their tympanometers manual or manufacturer for normative data.

Procedure
Procedures are equipment specific, consult your equipment manual. For example, the Grason Stadler
Tympstar measures middle ear resonance using the multi-frequency procedure based on (Funasaka,
Funai, & Kumakawa, 1984; Funasaka & Kumakawa, 1988) in which tympanograms are measured in
50 Hz probe tone intervals. As probe tone frequency approaches a normal middle ears’ resonant
frequency, tympanograms manifest peaks, and at the resonant peak the middle-most peak is neither
higher nor lower than the tympanogram tails.

Norms and Interpretation

• Mass effect: Added mass might lower middle ears’ resonant frequency near to or even below 800 Hz. In unilateral
disorder, look also for asymmetry when comparing right and left ears. Pathologies that could add mass to the middle
ear include middle ear effusion (Lai, Li, Xian, & Liu, 2008), and disarticulated ossicular chains, which can mimic
added mass (Hunter & Margolis, 1992).
• Stiffness effect: Added stiffness might raise middle ears’ resonant frequency near to or even above 1200 Hz. In
unilateral disorder, look also for asymmetry when comparing right and left ears. Pathologies that could stiffen the
middle ear include ossicular fixation (Hunter & Margolis, 1992), Eustachian tube dysfunction, and otitis media.
• Large Vestibular Aqueduct (LVA): Long-standing LVA tends to yield low resonant frequencies in the presence of
stable sensory/neural hearing loss and low-frequency air-bone gaps (Bilgen, Kirkim, & Kirazli, 2009; Mimura et al.,
2005; Rosowski, Songer, Nakajima, Brinsko, & Merchant, 2004; Sato, Nakashima, Lilly, Fausti, and Ueda, 2002). The
lower resonant frequency is due to LVA opening a “third window,” which could lower inner ear pressure. Because the
middle ear interfaces with the inner ear, the middle-ear resonance can manifest as low. Hypothetically, superior canal
dehiscence could similarly manifest (Rosowski, et al., 2004).

CAVEATS
Several disorders can cause either a mass effect or a stiffness effect. Therefore it would be a mistake to
expect that a multi-peak mass pattern necessarily indicates a “mass” or “growth.” For example, otitis
media with effusion can manifest as either a mass pattern or a stiffness pattern, perhaps depending on
the amount and viscosity of the effusion. Finally, as is always true with tympanometry, different
disorders might manifest with similar immittance results, and lateral pathologies obscure medial
pathologies.

EXHORTATION
We find many audiologists balk at the notion of conducting multi-frequency tympanometry, even as

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 they accept conducting many other tests at multiple frequencies, including air conduction thresholds,
acoustic reflex thresholds, acoustic reflex decay, auditory brainstem response, and VNG/rotary chair.
Moreover, we have heard audiologists say they would conduct tympanograms at frequencies other than
226 Hz if shown that testing at those frequencies is better. Evidently, only tympanometry is subject to
that requirement. We urge audiologists to consider conducting high frequency tympanometry in
addition to low-frequency tympanometry, not because it is better but because it is different;
low-frequency tympanometry is more sensitive to changes in stiffness, whereas high-frequency
tympanometry is more sensitive to changes in mass. The artful use of a tympanometric test battery can
result in improved sensitivity and/or sensitivity.

REFERENCES
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