Acoustic Reflex Threshold (ART) Patterns: An

Interpretation Guide for Students and Supervisors:

Course Material and Exam Questions
Course Material

Introduction
Students studying audiological testing enter the clinic with
varying degrees of competency regarding the interpretation
of acoustic reflex threshold (ART) test results. If a student
clinician becomes lost in the maze of right and left, ipsilateral
and contralateral boxes often associated with the fairly
common, but rather ghastly, 2x2 ART table, then clinical
speed may be compromised as a student tries to recall the
connection between pathology location and memorized
tables. This tutorial reviews the basics of ART pattern
interpretation with a clear, simple model for use as a
teaching/learning tool for supervisors and students. This
model is also shown as it relates to the traditional 2x2 table
for cross reference. Students should be aware that the actual
anatomical structures and real life clinical interpretations
are more complex than those shown with this simple model,
but this tutorial is intended as an approachable introduction.
What follows are six introductory pieces of information and
then a step-by-step illustrated guide to simple ART
interpretation.
Six Introductory Pieces of Information
First, students must study the anatomy and physiology
associated with the ART including the outer, middle, and
inner ear structures, the vestibulocochlear nerve (VIII cranial
nerve), and structures in the central auditory nervous system
(CANS); specifically, auditory structures located at the level
of the lower brainstem including the cochlear nuclei, superior
olivary complex and facial nerve (VII nerve) nuclei. For this
tutorial, students must be aware that the facial nerve
innervates the stapedius muscle and that the stapedius
muscle contraction is responsible for the acoustic reflex
threshold in humans.
Second, the nature of a reflex must be understood. A reflex
occurs when a signal is transmitted along a sensory neuron

to an interneuron to a motor neuron causing a contraction of

the muscle tissue innervated by the motor neuron. This is
below the level of cognitive control; in other words, patients
do not have to think about it. This is why one pulls a hand
quickly away from a hot pot without thinking first, Wow, my
hand is burning (that comes later) and this is why the
stapedius muscle contracts in response to a loud sound, even
though the patient does not consciously control the action.
When a loud sound enters a normal ear, the stapedius muscle
will contract on both sides regardless of which ear is
stimulated. Therefore, the ART is a bilateral (two side)
reflex.
Third, the word ipsilateral (ipsi) means same side and
contralateral (contra) means opposite side. These terms
refer to where the ART is measured relative to where the
loud sound is presented. If the ART is measured on the same
side in which a loud sound is presented, then it is an
ipsilateral ART. If the signal is measured on the opposite side
to that in which the loud sound is presented, then it is a
contralateral ART. One additional way to remember this is: if
the tone is presented on the probe side, then it is an
ipsilateral ART. If the tone is presented on the earphone side,
it is a contralateral ART.
Forth, right and left in ART testing refer to the ear that is
stimulated by the loud sound. If the signal goes into the right
ear and the ART is measured in the right ear, it is called a
right ipsilateral ART. If the signal goes into the right ear and
ART is measured in the left ear, it is called the right
contralateral ART. Note that some audiologists reverse this
and use a non-standardized method, which can be confusing
(see Emanuel (2004) for more details).
Fifth, the response pattern can suggest a site of lesion, but
other tests are necessary for confirmation. One can suspect,
but cannot diagnose, site of lesion based solely on the results
of ART testing.
Sixth, commercially available diagnostic bridges for testing
ARTs are capable of producing high intensity stimuli (e.g.,
120 dB HL and higher) and there is documentation in the
literature that ART testing can cause permanent hearing loss
and tinnitus (e.g. Hunter, Ries, Schlauch, Levine, & Ward,
2000). Although some authors have recommended a
maximum presentation level of 110 dB SPL (Wilson &
Margolis, 1999), there are no standards for safe presentation

levels for pure tone stimuli. OSHA (1983) recommends a limit

of 115 dBA for brief duration noise, but a pure tone results in
a greater amount of energy concentrated over a smaller area
of the basilar membrane compared with noise. In addition,
some individuals are uniquely sensitive to the effects of loud
sound. Therefore, clinicians should exercise caution in the
presentation of loud sounds as well as be familiar with the
literature in this regard.
With these six pieces of information in mind, students are
ready to proceed to this ART model.
Acoustic Reflex Threshold (ART) Model
Figure 1 provides a model of the acoustic reflex pathway. It
bears just about no resemblance to the actual anatomical
structures which are extremely small, three dimensional and
much more complex in terms of the nerve projections.
However, this figure illustrates the main ART pathways and
most of the key structures.
Figure 1. A simple model of the acoustic reflex pathway. The
acronyms are as follows: ME = middle ear, IE = inner ear,
VIII = vestibulocochlear nerve, CN = cochlear nucleus, SOC
= superior olivary complex, VII = facial nerve. Note: (1) two
of the structures in the pons (SOC and VII nucleus) are
shown together for simplicity. They are actually separate
structures. (2) A branch of the facial nerve ends at the
stapedius muscle and the stapes is shown as a stirrupshaped stick figure. (3) Some nerve projections are omitted
for simplicity.

Imagine first a normal right ear and trace the pathway of a

loud signal. The signal enters the right ear, travels through
the outer, middle (ME) and inner ear (IE), along the VIII
nerve, to the brainstem. When the signal reaches the

brainstem, the signal arrives first at the cochlear nucleus

(CN). From here, the signal travels to both right and left
superior olivary complexes and both right and left facial
nerve (VII) nuclei. The signal is sent from both facial nerve
nuclei to both facial (VII) nerves, which results in a
contraction of both stapedius muscles. Thus, both stapes
bones are pulled outward and downward, in a direction away
from the inner ear. This action makes it harder for energy to
travel through the middle ear (increase in
impedance/decrease in admittance). The lowest intensity
level at which this contraction is measurable is the ART.
The Four Reflex Categories
Highlighted in red (right ear) and blue (left ear) in the
following four diagrams are the pathways taken by the signal
for right ipsilateral (Figure 2), right contralateral (Figure 3),
left ipsilateral (Figure 4) and left contralateral (Figure 5)
pathways.
Figure 2. Right ipsilateral pathway.

Figure 3. Right contralateral pathway.

Figure 4. Left ipsilateral pathway.

Figure 5. Left contralateral pathway.

The information from this ART model can be translated into

the traditional 2 x 2 ART table (Table 1) for ease of
comparison with other textbooks. A normal ear should yield
present ARTs from 500 to 2000 Hz at normal levels. This is

shown with Normal or N, Present (or P), or Within Normal

Limits (WNL) in all of the boxes in the table. The exact
notation will depend on the clinical site. For the remainder
rest of this tutorial, Normal (N) will be used. Normative
values can be found in a number of sources (e.g., Gelfand,
Schwander, & Silman, 1990; Silman & Gelfand, 1981; various
audiology textbooks) and will not be discussed here. With the
normal model and 2x2 table in mind, next examine what
happens to the ART pattern for various auditory pathologies.
Table 1. Bilateral normal ART results.

Cochlear Pathology
Imagine first a right cochlear pathology. The signal will affect
the ART once the damage to the cochlea has reached a
certain degree. For a cochlear hearing loss with air
conduction thresholds below about 50 dB HL, the ART should
resemble a normal ear. As the hearing threshold increases,
the chances of an elevated or absent reflex increase.
Notice in Figure 6 that a right cochlear pathology is
highlighted. Any pathway that crosses the damaged area will
be affected by the cochlear pathology. So the ART will be
absent or elevated whenever the signal is presented to the
right ear, regardless of where it is measured. A signal
entering the normal left ear will be unaffected, so ARTs will
be present for stimuli to the left ear. Thus a pattern of
elevated/absent responses on the right side (both ipsilateral
and contralateral) and present/normal responses on the left
side (both ipsilateral and contralateral) would be the pattern
associated with a cochlear pathology on the right side. Table
2 shows this finding in a standard ART table.
Figure 6. Cochlear pathology, right ear. Note that right
ipsilateral and right contralateral ARTs are elevated/absent
and left ipsilateral and left contralateral ARTs are present.

Table 2. Cochlear pathology, right ear. Whenever a tone

enters the left ear, the ART is present/normal. Whenever a
tone enters the right ear, the ART is elevated or absent. Note
that the abnormal responses are located in the same row
(both right ear).

Vestibulocochlear nerve pathology

A vestibulocochlear (VIII) nerve pathology (Figure 7, Table 3)
would result in the same pattern as a cochlear pathology;
however it is much more likely that ARTs will be absent or
unusually elevated compared with a cochlear pathology.
Elevated/absent ARTs which do not agree with the hearing
loss (again, consult normative values) are a cause for
suspicion of retrocochlear pathology. Keep in mind the ART
should be tested in combination with a battery approach for
differential diagnosis as it is not a perfect test. For example,
in an analysis of published studies, Turner, Shepard, and
Frazer (1984) found 73% sensitivity and 90% specificity for
prediction of acoustic neuroma (more correctly called a
vestibular schwannoma) using the ART, so there is plenty of
room for error in this test.
Figure 7. Vestibulocochlear nerve pathology, right side. Note
that right ipsilateral and right contralateral ARTs are
absent/elevated and left ipsilateral and left contralateral ARTs
are present/normal.

Table 3. VIII nerve pathology, right ear. Whenever a tone

enters the left ear, the ART is normal. Whenever a tone
enters the right ear, the ART is elevated/absent. The ART
pattern is identical to the cochlear pattern but the response is
more likely to be absent in a vestibulocochlear nerve
pathology or unusually elevated compared with normative
values for cochlear hearing loss.

Facial Nerve Pathology

Facial nerve pathology causes a distinct ART pattern;
specifically, ARTs are missing whenever ART is measured on
the affected side (Figure 8, Table 4). This same pattern can
also be seen if there is a problem with innervation of the
stapedius muscle, dysfunction of the stapedius muscle, or
disconnect between the stapedius muscle and the stapes.
Often, facial nerve pathology is associated with other signs of
facial nerve involvement, including a facial droop or history of
VII nerve palsy (e.g., Bells palsy).
Figure 8. Facial nerve pathology, right side. Note that
anything that is measured on the right side will be affected.
This includes right ipsilateral and left contra.\

Table 4. Facial nerve pathology, right side. Whenever an ART

is measured in the right ear (right ipsilateral and left
contralateral) it is absent. Note the absent responses are in
opposite corners of the box.

Middle Ear Pathology

Middle ear pathology will affect the signal coming and
going. In more useful terms, the middle ear pathology can
decrease the intensity of the signal going into the ear and it
can interfere with the ability to measure the ART. Figure 9
illustrates the location of the pathology and Tables 5 and 6
illustrate two examples of possible ART patterns for middle
ear pathology. Table 5 shows a milder condition causing ARTs
to be elevated and Table 6 shows a more severe condition,
such as that seen in chronic otitis media, in which the entire
middle ear cavity is filled with fluid. Middle ear pathologies
may also cause bizarre ART responses such as an ART
recording that deflects in a direction that is opposite of
normal, which may be seen in stiffening pathologies such as
otosclerosis, or a pulsing on the ART, which may be a result
of a mass growing through the inferior wall of the tympanum
(middle ear cavity). This paper will not cover these more
advanced ART findings.
Figure 9. Middle ear pathology, right side. Note that
anything that goes through the right ear or is measured in
the right ear can be affected, depending on the severity of
the pathology.

Table 5. Mild middle ear pathology, right ear. ART may be

affected for signals traveling through the right ear (right
ipsilateral, right contralateral) or signals measured in the
right ear (right ipsilateral, left contralateral).

Table 6. Severe middle ear pathology, right ear. ART will be

absent for signals traveling through the right ear and signals
measured in the right ear. Left ipsilateral would be
unaffected.

Intra-Axial Brainstem Pathology

This is the point when basic ART pattern interpretation is less
straightforward. Textbook intra-axial brainstem pathology
(Figure 10) causes missing contralateral reflexes and present
ipsilateral reflexes (Table 7), but, as the saying goes, very
few patients read the textbooks before coming into the clinic.
This same pattern of missing contralateral reflexes can also
be observed if you test ARTs using supra-aural earphone
cushions for patients with bilateral collapsing ear canals;
thus, be wary of this pattern in patients with unusually small
or narrow, slit-shaped ear canals.
Figure 10. Small intra-axial brainstem pathology. A classical
finding is missing contralateral responses, but this can also
be seen with bilateral collapsing ear canals. One or both

ipsilateral responses may also be missing, depending on the

exact location.

Table 7. Small intra-axial brainstem pathology (small). All

contralateral ARTs are absent. All ipsilateral ARTs are present.
This is a textbook pattern which will actually vary
depending on the exact location and the structures that are
compressed.

In actual practice, ARTs associated with intra-axial brainstem

pathology will vary tremendously depending on exactly where
the pathology is located and how large it is. As brainstem
structures are very small, a small intra-axial pathology can
cause pressure on a number of structures, causing ARTs to
be affected on both sides. Figure 11 and Table 8 illustrate the
ART results for a larger intra-axial pathology.
Figure 11. Larger intra-axial brainstem pathology.
Depending on the location, size, and the extent to which
surrounding structures are compressed, some or all of the
responses will be absent. Due to the large number of nuclei
located in the pons, other non-auditory neurological
symptoms are also expected.

Table 8. Large intra-axial brainstem pathology. All ARTs are

absent, but this is the least of this persons worries.
Significant non-auditory neural symptoms are anticipated.

Extra-Axial Brainstem Pathology

Extra-axial brainstem pathology can result in a variety of ART
patterns depending on the size and location of the lesion. The
lesion may mimic a vestibulocochlear (VIII nerve) pathology
or it could mimic an intra-axial pathology, or it could mimic
facial nerve pathology or it may have a bizarre pattern
depending on size and location. Note in Figure 12, that the
ART pathway will depend on the location.
Figure 12. Extra-axial brainstem pathology may result in a
myriad of ART patterns, depending on the size and location.

Problem Solving with ART Patterns

The following method can be used to teach ART interpretation

to student clinicians. To determine the damaged pathway,

have the student start with the ART model (Figure 1) and
sketch in the pathways for ARTs that are normal. After
obtaining an individual patients ARTs, the pathology should
be localized to the area that is not highlighted.
For example, examine the ART findings from Table 9a and 9b
(note that youll need to synthesize the results from the three
frequencies, as in 9a, into one overall summary, as in 9b).
Ask the student to determine where the pathology is located.
Rather than recall memorized tables, have the student trace
the pathway using the model in order to understand the
pathways.
Table 9. (a) Example ART results for 500 2000 Hz and (b)
Summary table.

Figure 13. Example pathway traced on ART model. Note that

any time the signal enters the left ear, the reflex is present
and any time the signal enters the right ear, the signal is
absent.

Point out to the student that as per Figure 13 the ARTs are
missing whenever the signal goes into the right ear but
present whenever the signal goes into the left ear. This is
regardless of where the signal is measured. Therefore, ARTs
indicate a problem along the right pathway somewhere.
Further examination is required to determine the exact
location along the right pathway. Ask the student to
determine if the ART levels are consistent with cochlear or
retrocochlear pathology based on published normative data.
Point out that as clinicians, we need to combine findings from
the entire audiological test battery to make appropriate
recommendations for further testing, medical referrals,
amplification, and so forth. Always keep in mind when both
teaching ARTs and conducting ART testing, that ARTs are not
meant to be used alone, but as part of a battery of tests to
help in the evaluation process.
References
Emanuel, D.C. (2004, September/October). Probe ear or
stimulus ear? How audiologists report contralateral acoustic
reflex thresholds. Audiology Today, 36.
Gelfand, S. A., Schwander, T., & Silman, S. (1990). Acoustic
Reflex Thresholds in Normal and Cochlear-Impaired Ears:
Effects of no-response rates on 90th percentiles in a large
sample. Journal of Speech and Hearing Disorders, 55, 198205.
Hunter, L. L., Ries, D. T., Schlauch, R. S., Levine, S. C., &
Ward, W. D. (1999). Safety and clinical performance of
acoustic reflex tests. Ear & Hearing, 20, 506-514.
OSHA (1983). OSHA Instruction CPL 2-2.35, Nov. 9, 1983.

Guidelines for Noise Enforcement. Occupational Safety and

Health Administration, U.S. Department of Labor,
Washington, DC.
Silman, S., & Gelfand, S. A. (1981). The relationship between
magnitude of hearing loss and acoustic reflex threshold
levels. Journal of Speech & Hearing Disorders, 46, 312-316.
Turner, R. G., Shepard, N.T., & Frazer, G. J. (1984). Clinical
performance of audiological and related diagnostic tests. Ear
& Hearing, 5, 187-194.
Wilson, R. H., & Margolis, R. H. (1999). Acoustic reflex
measurements. In Musiek, F.E., & Rintlemann, W.F. (Eds.).
Contemporary Perspectives in Hearing Assessment. Boston:
Allyn & Bacon, 131-165.

Exam Questions
Question 1: Which of the following anatomical
structures is/are included in the acoustic reflex
pathway?
Answer A Vestibulocochlear nerve
Answer B Cochlear nucleus
Answer C Facial nerve nucleus
Answer D All of the above
Question 2: Which of the following nerve types is/are
involved in a reflex?
Answer A Sensory neuron
Answer B Interneuron
Answer C Motor neuron
Answer D All of the above
Question 3: What cranial nerve innervates the
stapedius muscle?
Answer A Vestibulocochlear nerve
Answer B Trigeminal nerve
Answer C Facial nerve
Answer D Vagus nerve
Question 4: In a normal human auditory system, a loud
sound directed to the right ear will cause the

contraction of which muscle?

Answer A Right stapedius
Answer B Left stapedius
Answer C Both right and left stapedius muscles
Answer D Left tensor veli paletini muscle
Question 5: The word ipsilateral means:
Answer A Same side
Answer B Opposite side
Answer C Both sides
Answer D Superior
Question 6: The acoustic reflex involves the
contraction of the middle ear muscles, which causes
the following change to occur in the middle ear
system:
Answer A An increase in admittance
Answer B A decrease in impedance
Answer C An increase in impedance
Answer D No change occurs in admittance or impedance
Question 7: Based on the model shown in this article,
which of the follow results from a right
vestibulocochlear pathology?
Answer A Both blue lines stop at the left vestibulocochlear
nerve
Answer B Both red lines stop at the right vestibulocochlear
nerve
Answer C Both blue and red lines stop when they reach
their respective vestibulocochlear nerve
Answer D None of the above
Question 8: If a patient has bilateral collapsing ear
canals and the ART is tested with supra-aural
earphones, the results may mimic which pathology?
Answer A Unilateral middle ear pathology
Answer B Unilateral cochlear pathology
Answer C Unilateral facial nerve pathology
Answer D Intra-axial brainstem pathology
Question 9: The ART pattern seen as a result of a right
cochlear pathology is most likely to resemble the ART
pattern associated with pathology at which other
location?
Answer A Left middle ear
Answer B Right vestibulocochlear nerve
Answer C Intra-axial

Answer D Right facial nerve

Question 10: If all ARTs are absent except left
ipsilateral, which of the following is the most likely
cause?
Answer A Right side vestibulocochlear pathology
Answer B Right side facial nerve pathology
Answer C Severe right side middle ear pathology
Answer D Right side cochlear pathology