About the ear

How the ear works

The ear is divided into three parts: the outer, middle, and inner ear. Each part performs an important function in the hearing process.

The outer ear consists of the pinna (the part you see on the outside) and the ear canal. The outer ear serves to collect sound and funnel it to the middle ear. The tympanic membrane (eardrum) divides the outer from the middle ear. When sounds reach the eardrum, it to vibrates.

The middle ear consists of an air-filled cavity containing the three middle ear bones, called ossicles. These three bones are the malleus, incus, and stapes. The ossicles are connected and move together in a lever action to amplify sounds. The vibration of the eardrum moves these bones, which are also connected to the inner ear by the stapes.

The inner ear contains two parts, the cochlea (hearing part) and the vestibular (balance) part. The cochlea is a fluid filled organ that contains tiny hair cells. When the stapes moves, it puts the fluid in the cochlea in motion. The motion of this fluid stimulates the cochlea's hair cells at particular points, which stimulates nerve endings and converts the signal into an electrical impulse. The nerves transmit these impulses to the brain via the acoustic nerve. The brain interprets these signals as sound.

The cochlea is considered a tonotopic organ; this means that it consists of pitch-specific regions. Depending on where within the cochlea the stimulation occurs, a person will perceive different sounds.'

What is hearing loss?

Hearing loss affects 28 million Americans of all ages. It is categorized by the degree of loss, which can be mild, moderate, moderate-severe, severe, or profound. These categories are typically used to describe the amount of hearing loss in each frequency (pitch) region.

The tones used for testing hearing vary in frequency (Hertz or Hz) and intensity (decibels or dB). The softest level or intensity of sound that you respond to at each frequency (pitch) is referred to as a threshold. Threshold results are plotted on a graph called an audiogram.

Hearing levels on the audiogram between -10dB and 25dB are considered to be within the range of normal hearing. Someone with thresholds within normal range should be able to hear all speech sounds and most environmental sounds without much difficulty, especially when it is quiet.

  • Mild hearing loss range is 26-40dB. With hearing at this level, a person will only hear some of the speech sounds when spoken at a normal conversational volume. Many of the speech sounds will be missed if whispered or if background noise is present.
  • Moderate hearing loss is within the range of 41-55dB. A hearing loss of this level will result in most speech sounds being missed when spoken at a normal conversational volume.
  • Moderate-severe hearing loss is from 56-70dB, and results in the inability to hear any speech sounds when spoken at a normal conversational level. Many sounds will missed when shouted as well.
  • Severe hearing loss is from 71-90dB. Persons with this degree of hearing loss will not hear any speech sounds, and few environmental sounds, without amplification.
  • Profound hearing loss range is 91dB or more. At this level, a person will not hear speech sounds and very little environmental sounds, even with traditional amplification.

Signs of hearing problems in children and adults

Adults Children
  • Straining to understand conversations
  • Problems hearing/understanding over the telephone
  • Trouble following conversations when two or more people are talking at the same time
  • Others complain that the television volume is up too high
  • Frequently asking people to repeat themselves
  • Others seem to mumble or not speak clearly
  • Using “what?” or “huh?” frequently
  • Intently watching the faces of speakers
  • Sitting too close to the television
  • Not being startled by loud sounds
  • Lack or delay in speech and language development


Tinnitus is the perception of sound by a person when no external sound source is present. It can be perceived/heard in one or both ears, or somewhere in the head (not localized to a specific ear). It is often described as a ringing or buzzing sound, but other descriptions include hissing, chirping, clicking, whistling, roaring, or crickets. It is estimated that 40-50 million Americans have some degree of tinnitus. Roughly 75% of those with tinnitus are not significantly bothered by it, while the other 25% are bothered enough to seek medical treatment.

While the causes of tinnitus are often unknown, it does tend to occur with hearing loss, and with damage to the inner ear that may not have yet manifested as hearing loss. It frequently can occur as a result of loud noise exposure, such as a gun blast or a loud concert. Many medications and medical conditions have a possible side effect of tinnitus that can be either temporary or permanent. Additionally, there are several medical conditions whose symptoms include tinnitus—that is, tinnitus may be an early sign of a problem. If you suffer from tinnitus, it is important that you discuss it with your medical professional to rule out any possible treatable sources.

While there is generally no cure for tinnitus, there are many treatments available. Please speak to your medical professional before trying any treatment. For more information on tinnitus, please visit the American Tinnitus Association.

Hearing tests

Audiometric evaluation (hearing test)

You will be seated in a sound-treated booth and wear headphones or small insert earphones. You will be instructed to indicate repeatedly, by raising your hand or pushing a button, whether you hear a sound/beep/tone in your ear. The sounds will vary by pitch (frequency) and by loudness (intensity). Using this method, the audiologist is able to establish the softest level of sound you are able to hear (threshold). The threshold at each frequency is recorded on a graph called an audiogram.

You will then be asked to complete other tasks as part of the evaluation, including repeating words at soft and comfortable listening levels to determine your speech understanding. Bone conduction testing will be performed using a special headphone that is placed behind the ear. Thresholds for tones/beeps will be determined using the same methods as with standard headphones. This test assesses the function of the inner ear bypassing the effects of outer or middle ear problems, such as fluid. These results are used to determine the type of hearing loss (conductive vs. sensorineural vs. mixed).

A test of middle ear function (tympanometry) will likely be conducted. This test requires a small, soft probe tip to be inserted into the outer portion of the ear canal. You will feel a slight pressure change in your ear while this is being performed. You are not required to do anything during this test other than to sit very quietly. This test measures how well the eardrum (tympanic membrane) moves in response to slight pressure change, and the results are printed on a graph called a tympanogram. This test is very sensitive in detecting anything that may inhibit normal movement of the eardrum, such as fluid, infection, Eustachian tube dysfunction, or perforation. In addition to the pressure test, additional tests may be performed to assess the function of the muscles and nerves within the ear. These tests use the same probe tip inserted into the outer portion of the ear canal, but this time will produce some loud tones. With this test as well, you are asked to sit very quietly and do not need to respond to the tones.

A test called Otoacoustic Emissions (OAE) test may be performed during your visit. This test is used to assess the health and function on the inner ear (nerve fibers called hair cells). This is a fast, simple, and painless procedure. The test entails placing a small foam earplug into the outer portion of the ear canal. This foam plug contains a probe tip that will produce a series of sounds and record the ear’s response to these sounds. You do not need to respond in any way to these sounds, but it is necessary that you be very quiet for this test.

Following your hearing evaluation, the audiologist and/or physician will explain the results. They will identify the type and degree of hearing loss, if any, and will make recommendations to you based on those results.

Testing children

Children of any age can have their hearing evaluated. Older children (5 years and older) can be tested in the same manner as adults. Children between the ages of 2 and 5 will be asked to place a block or ball into a basket when they hear a sound (conditioned play), rather than raise their hand. Children under the age of 2 will likely be testing using a method referred to as Visual Reinforced Audiometry (VRA) or Conditioned Oriented Response (COR) testing. This involves the child sitting on the parent’s lap in the middle of the sound booth. Sounds will be presented through speakers placed on either side of the room. The child will be conditioned to look towards the sound when it is heard and this action will be reinforced by a toy lighting up as a reward. This method will be used to assess hearing at several frequencies (pitches) and for speech awareness.

The specific testing method used will vary based upon the child’s age, cognitive ability, and cooperation level (i.e. if a 3 year old child will not wear headphones, they may be tested using a “younger” level test).

In most cases, tympanometry will be performed as well. The instructions for a child tympanometry are the same as above. An OAE test may also be performed on children.

An additional test may be requested by your physician, particularly if results are questionable, or if the child is not able to cooperate for traditional testing. This test is referred to by several names, including ABR (Auditory Brainstem Response), BSER (Brainstem Evoked Response), and BAER (Brainstem Auditory Evoked Response). This is a non-invasive test, but for some children may require sedation.

Who will test my hearing?

Your hearing will be evaluated by a state licensed and nationally certified (by the American Speech-Language-Hearing Association) audiologist. An audiologist is a professional who evaluates, diagnoses, and provides prevention and rehabilitation to individuals with hearing loss and balance problems. Audiologists must have received a master’s and/or doctoral degree from an accredited university graduate program. In addition, they must complete a fellowship year of supervised clinical experience and must be licensed by the state in which they work. In order to maintain both New York State licensure and national certification, audiologists must complete annual, ongoing continuing education.

Please view our Staff page for detailed information.

Auditory brainstem response (ABR)

Your physician or physician’s assistant may request that you have an Auditory Brainstem Response (ABR) test. ABR testing measures the neural activity that occurs when the auditory system is stimulated. Sound normally travels from the beginning of your ear up to the auditory cortex in the brainstem. The nerves in the body responsible for responding to sound stimuli will be activated, and electrodes placed on your skin during the test record this neural activity. This neural response is represented by a series of waves that the audiologist can see on a computer screen.

Based on the quality of the waveforms and at what time interval they occur within, the audiologist will determine the test results to be normal, abnormal or inconclusive. The ABR test is typically recommended if there is suspicion that a growth may be present in the auditory system. On some occasions, a threshold ABR may be utilized if results from the hearing test (audiogram) are not reliable.

This test is performed in our Albany office and typically lasts about one hour (occasionally, a person may be scheduled for a “threshold ABR” which could take upwards of two hours). The test itself typically lasts 20 to 45 minutes while the remainder of the hour allows for time to set up the test and possibly go over the results. This test is scheduled by appointment only.

Instructions for ABR test

The ABR test is a non-invasive test to make sure that the auditory nerve (the nerve for hearing) is spontaneously sending impulses to the brain as a person detects sound. This test has several names, including brainstem evoked response (BSER), brainstem auditory evoked response (BAER).

To prepare for the test, please remove any make-up from the forehead and/or earrings from your earlobes prior to the test. It is also helpful if you avoid caffeinated beverages the day of the test.

When you arrive for the test, the audiologist will scrub the skin on your forehead and behind each ear lobe to remove oils, dead skin cells, etc. from your skin. Electrodes are placed on these sites and earphones are placed in each ear canal. You will be asked to lie down and keep your eyes closed for the entire test.

You will hear a rapid clicking sound and a static noise in each ear throughout the majority of the test. You do not need to respond to any sounds during the test and you will be encouraged to relax and remain still.

This test should take approximately one hour. If you are unable to keep this appointment, please notify our office as soon as possible. The practice reserves the right to charge patients for the visit if this specialized test is cancelled within 48 hours of your appointment or if a patient does not show for an appointment.

The ABR is performed in our Albany office only.

Balance function

The inner ear contains two organs of balance: the vestibule (which consists of the utricle and saccule) and the semicircular canals. The organs of the vestibule are responsible for the sensation of gravity. The semicircular canals provide information on head rotation.

The vestibule contains fluid and nerve endings. Within the fluid are calcium particles that have a greater density relative to the fluid that they are immersed in. This causes the particles to “fall” because of the effects of gravity. As the head moves the particles exert pressure on the nerve endings, sending signals to the brain about head position relative to gravity.

There are three semicircular canals in each ear: the superior, lateral, and posterior semicircular canals. These are at roughly right angles to each other, each one corresponding to one dimension in three dimensional space. The canals are filled with a fluid called endolymph. As the head turns the endolymph rotates within the canal and stimulates nerve endings within the end of the canal. These nerve endings then send information to the brain about how quickly and in what direction the head is moving. The fluid in the lateral semicircular canal can be artificially stimulated as part of the caloric test of the ENG/VNG test battery in order to help diagnose balance problems.

Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common form of peripheral vestibular disorders. It is most commonly characterized by episodic vertigo that is often provoked by specific head movements. BPPV typically occurs spontaneously, but can follow head trauma or labyrinthitis.

In the case of BPPV tiny particles, called otoconia, are floating in the fluid within the canals. When the head is moved it causes the particles to move as well, and stimulate receptor cells inappropriately or disproportionally. This causes vertigo.

Diagnosis is made by provoking and observing an abnormal nystagmus response of the semicircular canals. This can sometimes be done with a simple in test in the office. More complicated cases may require a more technical and diagnostic exam to be performed called an ENG. This test may also be necessary to determine the type of BPPV. Spontaneous remission of BPPV is common, but if it persists treatment is often necessary.

Treatments are safe and simple, and often provide immediate relief of symptoms. There are several simple maneuvers that can be done by your physician in the office to try to reposition those particles. The goal of these maneuvers is to prevent the particles from freely moving within fluid in the canals.

Vestibular/balance testing

The inner ear is comprised of two sections, the hearing portion (cochlea) and the balance portion (semicircular canals and vestibule). The semicircular canals and vestibule are sensitive to head movement and rotation as well as gravity. The interaction of these, along with our eyes and sense of touch, gives us our understanding of where we are and what positions we are in. When any of these components are not functioning properly, it can result in vertigo (spinning sensation), dizziness (off-balance), or a feeling of lightheadedness. There is a connection between the balance portion of the inner ear and the eyes and eye muscles. When dizziness occurs, a specific type of eye movement, called nystagmus, often results. Vestibular/balance testing records and measures these eye movements to assess the status of the vestibular system.

What is an ENG (Electronystagmography)/VNG (Videonystagmography)?

ENG/VNG is a non-invasive recording of eye movements to assess the vestibular/balance system. ENG uses recording electrodes placed on the forehead and around the eyes and measures changes in electrical potentials that occur when the eye muscles move the eyes. A newer system, often referred to as VNG, uses infrared video cameras, rather than electrodes, to record these eye movements. The VNG system allows for more precise measurements than the traditional electrode ENG’s. Capital Region Otolaryngology has been using a VNG system since 1998.

Instructions for ENG/VNG test

An ENG is a painless recording of eye movements to investigate possible sources of dizziness/vertigo. The ENG/VNG test battery is composed of three sections:

  • The first portion involves watching and following a series of lights/dots as they move in different patterns. During this test, infrared video cameras will record your eye movements. The computer, along with the audiologist, will analyze these movements.
  • The second portion of the test battery requires that you wear a special set of goggles that also contain infrared cameras. During these tests, you will be asked to place your head and body into different positions while lying on an examination table. Again, the cameras will record eye movements, which are analyzed by the audiologist.
  • Finally, while wearing the special goggles, your ears will be irrigated with cool and warm water. As a result of this test you will likely feel some dizziness. This feeling only lasts a few minutes, but gives us a great deal of information about your vestibular system. As in the early sections, the cameras will record eye movements and the results are analyzed to determine if each ear’s vestibular system is functioning properly.

The test will take approximately 1½ hours. Please allow yourself sufficient time.



  • DO NOT take any of the following types of medication: anti-dizziness, anti-depressant, anti-histamine (allergy), cold medicine, diuretics (“water pills”), tranquilizers or sedatives, or narcotics of any kind, including codeine.
  • DO NOT consume alcohol (e.g. beer, wine, liquor).
  • DO NOT drink caffeinated beverages.

In addition:

  • DO NOT eat for 3 hours before the examination is scheduled.
  • DO NOT use eye make-up—it will interfere with the test recording. You may apply it after the test is completed.
  • If you wear contacts, you will be required to remove them prior to testing.
  • You MUST arrange for someone to accompany you to the test to drive you home. Although you should leave the test feeling the same way as you entered, it is likely that you will become dizzy during the test.

Please contact your physician to determine if it is medically safe for you to be off of your medications for the 48-hour period.

Please contact us if you have any questions or are unsure of any medications you are currently taking.

The VNG/ENG test is performed in our Albany office only.

Surgical procedures for hearing loss

Baha system

Capital Region Otolaryngology offers surgical implantation of the Baha System from Cochlear Americas and has done so since 2002. The Baha System from Cochlear Americas is a surgically implanted system designed to assist those with two distinct types of hearing loss. This system takes advantage of the natural processes of bone conduction to deliver speech and environmental sounds to the cochlea(s) in the inner ear. A titanium post and abutment are surgically placed in the skull bone behind the ear. Approximately 3 months after this outpatient surgical procedure, an external sound processor can be snapped to the abutment. This device detects sound through its microphone. The sound bypasses the outer and middle ear structures and travels to the better-functioning cochlea(s) to be recognized and interpreted in the areas of the brain responsible for processing sound. No part of this system is placed in the ear canal.

Many people with conductive and/or mixed hearing losses as well as those with single-sided deafness are unable to benefit from traditional amplification in the form of hearing aids, but they can benefit from the Baha System. Causes of conductive or mixed hearing losses include chronic ear infections, otosclerosis and congenital anomalies or syndromes. For example, there may be an absence of the ear canal structure due to a congenital anomaly or an enlarged mastoid cavity and chronic ear drainage related to chronic middle ear infections. Causes of single-sided deafness, where one ear hears within normal limits while the other ear has no useable hearing, include sudden hearing loss, vestibular schwanomma removal and viruses. These individuals characteristically have not been able to derive benefit from a CROS hearing aid, an air conduction hearing aid designed for this type of hearing loss.

Cochlear Americas, the sole manufacturer and customer support center for the Baha system, provides a thorough overview of the Baha system at their website.

If you have additional questions about the Baha system or you wish to schedule an appointment to discuss this as a treatment option, please contact our office at these phone numbers or at

Cochlear implants

Cochlear implants are electronic devices that provide sound information to individuals with severe to profound hearing loss. A cochlear implant is a surgically implanted device for those with too much hearing loss to benefit from the use of hearing aids. The cochlear implant system consists of two parts: an internal portion and an external portion. The internal portion is surgically implanted under the skin, behind the ear. It consists of a receiver and an electrode array. The electrode array is inserted through the skull and middle ear into the cochlea (inner ear). The external portion of the system consist of a speech processor that is worn behind the ear and resembles a hearing aid, and a transmitting coil that attaches to the head by magnets near the speech processor. A cochlear implant bypasses the damaged parts of the auditory system and stimulates the auditory (hearing) nerve directly with electrical impulses.

How does it work?

The external speech processor contains microphones that pick up sounds. The processor then analyzes and converts these sounds into special codes. These codes are sent to the transmitting coil and through the skin to the implant. The internal implant receives these codes and coverts the signal to an electrical impulse. These electrical impulses are sent through the electrode array and stimulate the hearing nerves at specific locations. The auditory nerve picks up these signals and sends them to the brain where they are interpreted as sound.

Cochlear implants are different from hearing aids. Hearing aids simply amplify sounds. A person with severe to profound hearing loss is not able to process this louder sound normally because it is still going through the damaged part of the inner ear. A cochlear implant does not make sounds louder. It bypasses the damaged parts of the inner ear and sends electrical signals directly to the auditory nerve.

The cochlear implant and speech processor must be programmed by a trained audiologist. This is done several weeks after the surgery, and on an ongoing basis. During a programming session the electrodes are tested to make sure they are functioning properly and measurements are made as to how much electrical stimulation is needed on each electrode for the patient to perceive it as sound. Programs, called maps, are then developed, and multiple maps can be made for different types of listening situations. The amount of electrical stimulation that is required can change over time, requiring re-programming of the processor.

Who is a candidate?

Current FDA guidelines state that candidates must meet the follow general criteria:

  • Infants (12 months to 24 months) with profound bilateral sensorineural hearing loss, and a lack of progress in the development of auditory skills
  • Children (25 months to 17 years and 11 months) with severe to profound bilateral sensorineural hearing loss, with poor speech understanding, and a lack of progress in the development of auditory skills
  • Adults (age 18+) with a moderate to profound bilateral sensorineural hearing loss, with poor speech understanding even with appropriately fit hearing aids
  • All patients must be in good general health and have no medical contraindications.

These guidelines are general, and there are exceptions, as well as more specific criteria to determine candidacy. To determine if you are a candidate, please call to schedule an appointment.

Surgical procedure

The surgery is performed in the hospital under general anesthesia. The procedure takes approximately three hours. Patients are generally able to go home the same day as surgery (outpatient surgery), but do occasionally stay overnight.

The surgical approach used to place a cochlear implant is similar to the surgery that is done for chronic ear infections.

  • The skin incision is made behind the ear.
  • A special instrument is placed on the patient’s face to monitor the facial nerve. The mastoid bone (bone behind the ear) is then removed with a high speed surgical drill. An area of bone above the ear is also removed in order to make room for the internal receiver of the cochlear implant. An area called the facial recess is then uncovered to reveal an area of the inner ear called the round window.
  • A microscope drill is used to open this window and enter the cochlea. The electrode is then inserted through the facial recess into the round window and into the cochlea. The surgeon uses both visual and tactile information to ensure that the electrode is in proper position and that a full insertion of all electrodes has been achieved. The round window and facial recess are then packed with a small plug of muscle to insure that the electrode array stays in place.
  • At this point the skin incision is partially closed to allow the surgical and audiologic team to test the implant. In the unlikely event that a problem with the implant or its placement is detected, it can be remedied.
  • After the incision is closed, a sterile dressing is placed in the incision, and the patient is taken to recovery.

Initial healing takes several days, after which the patient is allowed to get the incision wet. Full healing takes several weeks to months. Initial programming of the implant takes place 4-6 weeks after surgery.

For more information on cochlear implants, please visit the manufacturers’ websites:

Additional audiology services

We offer both custom and non-custom swim plugs, as well as other products to reduce water in the ear when swimming and bathing.

We also offer both custom and non-custom hearing protection. These are available for general noise protection as well as for musicians and those that enjoy loud music venues but wish to protect their hearing.

Please contact our office and ask to speak with an audiologist for more information on these products.

Additional information

To learn more about audiology, please visit our academy website.