CC BY-NC-ND 4.0 · Semin Hear 2023; 44(01): 084-092
DOI: 10.1055/s-0043-1763296
Review Article

Wideband Acoustic Reflex Measurement

M. Patrick Feeney
1   VA Portland Health Care System, National Center for Rehabilitative Auditory Research, Portland, Oregon
2   Department of Otolaryngology, Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon
Kim S. Schairer
3   Hearing and Balance Research Program, James H. Quillen VA Medical Center, Mountain Home, Tennessee
4   Department of Audiology & Speech Language Pathology, East Tennessee State University, Johnson City, Tennessee
Daniel B. Putterman
1   VA Portland Health Care System, National Center for Rehabilitative Auditory Research, Portland, Oregon
2   Department of Otolaryngology, Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon
› Author Affiliations


Acoustic reflex thresholds (ART) obtained using pure-tone probe stimuli as part of a traditional immittance test battery can be used to evaluate site of lesion and provide a cross-check with behavioral results. ARTs obtained as part of a wideband acoustic immittance (WAI) test battery using a click as the probe stimulus can be used in the same way with the added benefit that they may provide lower ARTs than those obtained using a pure-tone probe. Another benefit of the WAI ART test is that it can be completed without requiring a hermetic seal or pressurizing the ear canal. A new adaptive method of obtaining ARTs using WAI techniques may cut test time in half, thus making this an attractive option for future clinical use. More advanced uses of WAI ART tests include the measurement of AR growth functions. These may be used to investigate the possible effects of synaptopathy related to high levels of noise exposure and possible auditory deficits related to ototoxicity.


The content of this manuscript does not represent the views of the U.S. government or the Department of Veterans Affairs.

Publication History

Article published online:
14 March 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Metz O. Threshold of reflex contractions of muscles of middle ear and recruitment of loudness. AMA Arch Otolaryngol 1952; 55 (05) 536-543
  • 2 Feeney MP, Keefe DH. Acoustic reflex detection using wide-band acoustic reflectance, admittance, and power measurements. J Speech Lang Hear Res 1999; 42 (05) 1029-1041
  • 3 Feeney MP, Schairer KS. Acoustic stapedius reflex measurements. In: Katz J, Chasin M, English KM, Hood LJ, Tillery KL. eds. Handbook of Clinical Audiology. 7th ed. . Baltimore, MD: Lippincott, Williams and Wilkins; 2015: 165-186
  • 4 Feeney MP, Keefe DH. Estimating the acoustic reflex threshold from wideband measures of reflectance, admittance, and power. Ear Hear 2001; 22 (04) 316-332
  • 5 Feeney MP, Keefe DH, Marryott LP. Contralateral acoustic reflex thresholds for tonal activators using wideband energy reflectance and admittance. J Speech Lang Hear Res 2003; 46 (01) 128-136
  • 6 Feeney MP, Keefe DH, Sanford CA. Wideband reflectance measures of the ipsilateral acoustic stapedius reflex threshold. Ear Hear 2004; 25 (05) 421-430
  • 7 Schairer KS, Ellison JC, Fitzpatrick D, Keefe DH. Wideband ipsilateral measurements of middle-ear muscle reflex thresholds in children and adults. J Acoust Soc Am 2007; 121 (06) 3607-3616
  • 8 Keefe DH, Fitzpatrick D, Liu YW, Sanford CA, Gorga MP. Wideband acoustic-reflex test in a test battery to predict middle-ear dysfunction. Hear Res 2010; 263 (1-2): 52-65
  • 9 Keefe DH, Feeney MP, Hunter LL, Fitzpatrick DF. Aural acoustic stapedius-muscle reflex threshold procedures to test human infants and adults. J Assoc Res Otolaryngol 2017; 18 (01) 65-88
  • 10 Feeney MP, Keefe DH, Hunter LL. et al. Normative wideband reflectance, equivalent admittance at the tympanic membrane, and acoustic stapedius reflex threshold in adults. Ear Hear 2017; 38 (03) e142-e160
  • 11 Schairer KS, Putterman DB, Keefe DH. et al. Automated adaptive wideband acoustic reflex threshold estimation in normal-hearing adults. Ear Hear 2022; 43 (02) 370-378
  • 12 Kujawa SG, Liberman MC. Adding insult to injury: cochlear nerve degeneration after “temporary” noise-induced hearing loss. J Neurosci 2009; 29 (45) 14077-14085
  • 13 Furman AC, Kujawa SG, Liberman MC. Noise-induced cochlear neuropathy is selective for fibers with low spontaneous rates. J Neurophysiol 2013; 110 (03) 577-586
  • 14 Sergeyenko Y, Lall K, Liberman MC, Kujawa SG. Age-related cochlear synaptopathy: an early-onset contributor to auditory functional decline. J Neurosci 2013; 33 (34) 13686-13694
  • 15 Fernandez KA, Jeffers PW, Lall K, Liberman MC, Kujawa SG. Aging after noise exposure: acceleration of cochlear synaptopathy in “recovered” ears. J Neurosci 2015; 35 (19) 7509-7520
  • 16 Bourien J, Tang Y, Batrel C. et al. Contribution of auditory nerve fibers to compound action potential of the auditory nerve. J Neurophysiol 2014; 112 (05) 1025-1039
  • 17 Schmiedt RA, Mills JH, Boettcher FA. Age-related loss of activity of auditory-nerve fibers. J Neurophysiol 1996; 76 (04) 2799-2803
  • 18 Shaheen LA, Valero MD, Liberman MC. Towards a diagnosis of cochlear neuropathy with envelope following responses. J Assoc Res Otolaryngol 2015; 16 (06) 727-745
  • 19 Valero MD, Hancock KE, Liberman MC. The middle ear muscle reflex in the diagnosis of cochlear neuropathy. Hear Res 2016; 332: 29-38
  • 20 Valero MD, Hancock KE, Maison SF, Liberman MC. Effects of cochlear synaptopathy on middle-ear muscle reflexes in unanesthetized mice. Hear Res 2018; 363: 109-118
  • 21 Liberman MC, Kiang NY. Single-neuron labeling and chronic cochlear pathology. IV. Stereocilia damage and alterations in rate- and phase-level functions. Hear Res 1984; 16 (01) 75-90
  • 22 Kobler JB, Guinan Jr JJ, Vacher SR, Norris BE. Acoustic reflex frequency selectivity in single stapedius motoneurons of the cat. J Neurophysiol 1992; 68 (03) 807-817
  • 23 Wojtczak M, Beim JA, Oxenham AJ. Weak middle-ear-muscle reflex in humans with noise-induced tinnitus and normal hearing may reflect cochlear synaptopathy. eNeuro 2017; 4 (06) 4
  • 24 Bramhall NF, Reavis KM, Feeney MP, Kampel SD. The impacts of noise exposure on the middle ear muscle reflex in a veteran population. Am J Audiol 2022; 31 (01) 126-142
  • 25 Westman MR, Putterman DB, Garinis AC, Hunter LL, Feeney MP. Wideband acoustic reflex growth in adults with cystic fibrosis. Am J Audiol 2021; 30 (3S): 825-833
  • 26 Li H, Steyger PS. Systemic aminoglycosides are trafficked via endolymph into cochlear hair cells. Sci Rep 2011; 1: 159
  • 27 Mulheran M, Degg C, Burr S, Morgan DW, Stableforth DE. Occurrence and risk of cochleotoxicity in cystic fibrosis patients receiving repeated high-dose aminoglycoside therapy. Antimicrob Agents Chemother 2001; 45 (09) 2502-2509
  • 28 Cheng AG, Johnston PR, Luz J. et al. Sensorineural hearing loss in patients with cystic fibrosis. Otolaryngol Head Neck Surg 2009; 141 (01) 86-90
  • 29 Liu K, Jiang X, Shi C. et al. Cochlear inner hair cell ribbon synapse is the primary target of ototoxic aminoglycoside stimuli. Mol Neurobiol 2013; 48 (03) 647-654
  • 30 Li S, Hang L, Ma Y. FGF22 protects hearing function from gentamycin ototoxicity by maintaining ribbon synapse number. Hear Res 2016; 332: 39-45
  • 31 Ishikawa M, García-Mateo N, Čusak A. et al. Lower ototoxicity and absence of hidden hearing loss point to gentamicin C1a and apramycin as promising antibiotics for clinical use. Sci Rep 2019; 9 (01) 2410
  • 32 Xu M, Hu HT, Jin Z. et al. Ototoxicity on cochlear nucleus neurons following systemic application of gentamicin. Acta Otolaryngol 2009; 129 (07) 745-748
  • 33 Liberman MC, Guinan Jr JJ. Feedback control of the auditory periphery: anti-masking effects of middle ear muscles vs. olivocochlear efferents. J Commun Disord 1998; 31 (06) 471-482 , quiz 483, 553
  • 34 Lima da Costa D, Erre JP, Pehourq F, Aran JM. Aminoglycoside ototoxicity and the medial efferent system: II. Comparison of acute effects of different antibiotics. Audiology 1998; 37 (03) 162-173
  • 35 Avan P, Erre JP, da Costa DL, Aran JM, Popelár J. The efferent-mediated suppression of otoacoustic emissions in awake guinea pigs and its reversible blockage by gentamicin. Exp Brain Res 1996; 109 (01) 9-16
  • 36 Garinis AC, Cross CP, Srikanth P. et al. The cumulative effects of intravenous antibiotic treatments on hearing in patients with cystic fibrosis. J Cyst Fibros 2017; 16 (03) 401-409
  • 37 Noreña AJ. An integrative model of tinnitus based on a central gain controlling neural sensitivity. Neurosci Biobehav Rev 2011; 35 (05) 1089-1109
  • 38 Cao XJ, Lin L, Sugden AU, Connors BW, Oertel D. Nitric oxide-mediated plasticity of interconnections between t-stellate cells of the ventral cochlear nucleus generate positive feedback and constitute a central gain control in the auditory system. J Neurosci 2019; 39 (31) 6095-6107