Understanding Your Audiogram: A Comprehensive Guide to Deciphering Hearing Test Results

The moment of truth arrives: you’ve had your hearing tested, and now you’re holding a strange-looking graph – an audiogram. For many, it appears to be a cryptic jumble of lines, symbols, and numbers, offering little insight into something as personal and vital as their hearing. Yet, this single sheet of paper holds the key to understanding your auditory health, pinpointing the nature and degree of any hearing loss, and guiding the path toward effective solutions.

This in-depth guide is designed to demystify the audiogram, transforming it from an intimidating document into a clear, actionable roadmap of your hearing abilities. We’ll break down every element, from the axes and symbols to the various types and configurations of hearing loss, providing you with the knowledge to interpret your results confidently and engage in meaningful discussions with your audiologist.

The Foundation: What Exactly is an Audiogram?

Before we dive into the specifics, let’s establish a foundational understanding. An audiogram is a visual representation of your hearing thresholds across a range of frequencies (pitches) and intensities (loudness). It’s the standard tool used by audiologists to diagnose hearing loss, providing objective data about how well you hear pure tones.

Think of it like an eye chart for your ears. Just as an optometrist uses a Snellen chart to measure your visual acuity, an audiologist uses an audiogram to map your auditory sensitivity. The test itself involves presenting tones at different frequencies and intensities, and you indicate when you can just barely hear them. These “thresholds” are then plotted on the audiogram.

Decoding the Axes: Frequency and Intensity

The first step in deciphering an audiogram is understanding its two fundamental axes:

The Horizontal Axis: Frequency (Pitch)

The horizontal axis of the audiogram represents frequency, measured in Hertz (Hz). This is the “pitch” of a sound.

Left Side (Lower Frequencies): As you move from left to right, the frequencies increase. The far left typically starts around 125 Hz or 250 Hz, representing very low-pitched sounds. These are the deep rumblings, the bass notes in music, or the hum of a refrigerator. Vowel sounds in speech often fall into these lower frequencies.
Middle (Mid Frequencies): In the middle, you’ll find frequencies like 500 Hz, 1000 Hz, and 2000 Hz. These are crucial for understanding speech, as many consonant sounds and the nuances of human voice fall within this range.
Right Side (Higher Frequencies): The far right extends to 8000 Hz or even higher (16000 Hz in some specialized tests). These are high-pitched sounds, like birdsong, the rustle of leaves, or the sibilant “s” and “f” sounds in speech. Hearing loss often begins in these higher frequencies.

Why is frequency important? Different frequencies carry different information. Losing the ability to hear high frequencies, for example, makes it difficult to distinguish certain speech sounds, even if you can hear overall loudness.

The Vertical Axis: Intensity (Loudness)

The vertical axis represents intensity or loudness, measured in decibels (dB HL – Hearing Level). This axis works counter-intuitively for many:

Top (Softer Sounds): The top of the audiogram, typically starting at -10 dB HL or 0 dB HL, represents very soft sounds – sounds that a person with normal hearing can just barely perceive.
Bottom (Louder Sounds): As you move down the axis, the decibel levels increase, indicating progressively louder sounds. Values like 80 dB HL, 100 dB HL, or even 120 dB HL represent very loud sounds.

Why is intensity important? The higher the number on the vertical axis where a symbol is plotted, the louder a sound needs to be before you can hear it. This directly correlates to the degree of hearing loss. For instance, if your symbol is plotted at 60 dB HL for a specific frequency, it means you need that sound to be 60 decibels loud to hear it, whereas someone with normal hearing might hear it at 10 dB HL.

Understanding the Symbols: Your Hearing Thresholds

The core of the audiogram lies in the symbols plotted on the graph. Each symbol represents the softest sound (your hearing threshold) you could hear at a specific frequency for a specific ear and type of sound presentation.

Air Conduction Testing: How You Hear with Your Outer and Middle Ear

Air conduction tests assess the entire hearing pathway, from the outer ear, through the middle ear, and into the inner ear (cochlea) and beyond. This is how we typically hear sounds in our daily lives.

Right Ear: Represented by a red circle (O).
Left Ear: Represented by a blue ‘X’ (X).

These symbols indicate the softest sound you can hear through headphones (or inserts) for each ear at each tested frequency. If these symbols are plotted high on the graph (closer to 0-20 dB HL), your air conduction hearing is good for that frequency. If they are plotted lower down (higher dB HL values), it indicates a hearing loss.

Bone Conduction Testing: Bypassing the Outer and Middle Ear

Bone conduction testing bypasses the outer and middle ear and directly stimulates the inner ear (cochlea) via vibrations transmitted through the skull. A bone conduction oscillator is placed on the mastoid bone behind the ear or on the forehead.

Right Ear (Unmasked): Represented by a red ‘<‘ symbol (pointing left).
Left Ear (Unmasked): Represented by a blue ‘>’ symbol (pointing right).
Right Ear (Masked): Represented by a red square bracket ‘[’ symbol.
Left Ear (Masked): Represented by a blue square bracket ‘]’ symbol.

What is masking? Masking is a technique used during bone conduction (and sometimes air conduction) testing to prevent the “non-test” ear from hearing the sound when the “test” ear is being evaluated. This ensures that the results accurately reflect the hearing of the ear being tested. The presence of brackets ([ or ]) indicates that masking was used.

Why is bone conduction important? Comparing air conduction thresholds to bone conduction thresholds is crucial for determining the type of hearing loss.

The Speech Banana: A Visual Aid for Speech Understanding

You might see an area on your audiogram shaded or outlined, resembling a banana. This is the “Speech Banana.” It represents the approximate range of frequencies and intensities at which most human speech sounds occur.

Low Frequencies/High Intensities: Vowel sounds (e.g., “ooh,” “ahh”) tend to be louder and lower in pitch, falling towards the bottom-left of the speech banana.
High Frequencies/Low Intensities: Consonant sounds (e.g., “s,” “f,” “th”) are generally softer and higher in pitch, located towards the top-right.

How does the speech banana help? If your hearing thresholds (your plotted symbols) fall below or outside the speech banana, it suggests you’ll have difficulty hearing and understanding those specific speech sounds. For example, if your high-frequency hearing is poor, you might miss the “s” or “f” sounds, making words like “cat” and “cats” sound identical, or making speech sound muffled and unclear, especially in noisy environments.

Interpreting Degrees of Hearing Loss

The vertical axis also dictates the degree of hearing loss. While precise ranges can vary slightly between clinics, the general classifications are as follows:

Normal Hearing: -10 dB HL to 20 dB HL
- You can hear very soft sounds, including whispers and most speech sounds without effort.
Slight Hearing Loss: 20 dB HL to 25 dB HL
- Difficulty hearing very soft speech or speech in noisy environments. Often noticeable in children, impacting language development.
Mild Hearing Loss: 26 dB HL to 40 dB HL
- Difficulty hearing soft speech, especially consonants, and understanding conversations in background noise. You may frequently ask people to repeat themselves.
Moderate Hearing Loss: 41 dB HL to 55 dB HL
- Significant difficulty hearing normal conversation. You’ll miss much of what’s said without hearing aids or other amplification.
Moderately Severe Hearing Loss: 56 dB HL to 70 dB HL
- Very difficult to hear normal speech. Requires significant amplification to understand conversation.
Severe Hearing Loss: 71 dB HL to 90 dB HL
- Only very loud sounds are audible. Communication without amplification is extremely challenging.
Profound Hearing Loss: 91 dB HL and greater
- You may only hear extremely loud sounds (e.g., a jackhammer). Communication relies heavily on visual cues (lip-reading, sign language) or cochlear implants.

Example: If your ‘O’ symbol for 1000 Hz is at 45 dB HL, it indicates a moderate hearing loss at that specific frequency in your right ear. If your ‘X’ for 4000 Hz is at 65 dB HL, it indicates a moderately severe hearing loss at that frequency in your left ear.

Identifying Types of Hearing Loss

Comparing the air conduction thresholds (circles/Xs) with the bone conduction thresholds (chevrons/brackets) is critical for determining the type of hearing loss. This distinction is crucial because it informs treatment options.

1. Sensorineural Hearing Loss (SNHL)

What it is: Damage to the inner ear (cochlea) or the auditory nerve. This is the most common type of permanent hearing loss.
Audiogram appearance: Both air conduction symbols (O, X) and bone conduction symbols (<, >, [, ]) are plotted at similar levels, and both show a hearing loss (i.e., they are below 20 dB HL). There is typically no significant “air-bone gap” (a difference of less than 10 dB between air and bone conduction thresholds at any given frequency).
Analogy: Imagine a radio where the speakers are working fine, but the internal circuitry (the receiver or amplifier) is damaged. The sound isn’t being processed correctly.
Causes: Aging (presbycusis), noise exposure, genetics, ototoxic medications, certain infections, Meniere’s disease.
Treatment: Often managed with hearing aids, which amplify sounds to compensate for the damaged inner ear. In severe to profound cases, cochlear implants may be an option.

Concrete Example:

Right Ear Air Conduction (O): 40 dB HL at 2000 Hz
Right Ear Bone Conduction (<): 40 dB HL at 2000 Hz
Interpretation: Both air and bone conduction show a moderate hearing loss at 2000 Hz in the right ear, with no significant air-bone gap. This indicates sensorineural hearing loss.

2. Conductive Hearing Loss (CHL)

What it is: Problems in the outer or middle ear that prevent sound from reaching the inner ear effectively. The inner ear itself is usually healthy.
Audiogram appearance: Air conduction thresholds (O, X) show a hearing loss, but bone conduction thresholds (<, >, [, ]) are within normal limits (20 dB HL or better) or significantly better than air conduction. There is a significant “air-bone gap” (a difference of 15 dB or more between air and bone conduction thresholds at a given frequency).
Analogy: Imagine a radio with perfectly working internal components, but the volume knob is broken, or something is blocking the sound from reaching the speakers (e.g., a cloth over the speakers).
Causes: Earwax blockage, middle ear fluid (otitis media), eardrum perforation, ossicular chain discontinuity (disruption of the tiny bones in the middle ear), otosclerosis (abnormal bone growth in the middle ear).
Treatment: Often medically or surgically treatable, as the issue is usually a physical blockage or structural problem. Examples include earwax removal, antibiotics for ear infections, eardrum repair, or surgery to fix ossicular problems. Hearing aids can also be used, but addressing the underlying medical cause is often the first step.

Concrete Example:

Left Ear Air Conduction (X): 50 dB HL at 1000 Hz
Left Ear Bone Conduction (>): 10 dB HL at 1000 Hz
Interpretation: A significant air-bone gap (40 dB) exists, with normal bone conduction and moderate air conduction hearing loss. This points to a conductive hearing loss in the left ear at 1000 Hz.

3. Mixed Hearing Loss (MHL)

What it is: A combination of both sensorineural and conductive hearing loss. Both the outer/middle ear and the inner ear/auditory nerve are affected.
Audiogram appearance: Both air conduction (O, X) and bone conduction (<, >, [, ]) thresholds show a hearing loss (below 20 dB HL), AND there is a significant air-bone gap (15 dB or more).
Analogy: The radio has both damaged internal circuitry AND a broken volume knob or something blocking the speakers.
Causes: Can be complex, involving multiple contributing factors. For example, an elderly person (sensorineural) who also develops a middle ear infection (conductive).
Treatment: Often involves addressing the conductive component medically or surgically first, followed by amplification (hearing aids) to manage the remaining sensorineural component.

Concrete Example:

Right Ear Air Conduction (O): 60 dB HL at 500 Hz
Right Ear Bone Conduction (<): 30 dB HL at 500 Hz
Interpretation: Both air and bone conduction show hearing loss, AND there’s a significant air-bone gap (30 dB). This indicates a mixed hearing loss in the right ear at 500 Hz.

Understanding Hearing Loss Configurations (Shapes of the Audiogram)

Beyond the type and degree, the shape of the plotted thresholds on the audiogram provides further diagnostic clues and predicts how someone might experience hearing.

1. Flat Hearing Loss

Appearance: Hearing thresholds are similar across all frequencies (the plotted symbols form a relatively straight line).
Implication: Sounds are perceived as uniformly softer across the entire pitch range. Speech might simply sound quieter rather than distorted.
Common with: Some genetic hearing losses, certain conductive losses, or early stages of some sensorineural losses.

2. High-Frequency Hearing Loss (Sloping Hearing Loss)

Appearance: Normal or near-normal hearing in the low frequencies, with progressively worse hearing in the higher frequencies (the plotted line slopes downward towards the right). This is the most common configuration.
Implication: Difficulty hearing high-pitched sounds like “s,” “f,” “th,” “sh,” “ch” sounds, bird song, and the higher registers of music. Speech may sound muffled, and understanding conversations in noisy environments is particularly challenging.
Common with: Presbycusis (age-related hearing loss), noise-induced hearing loss.

Concrete Example: Your audiogram shows ‘O’ at 10 dB HL for 250 Hz, 15 dB HL for 500 Hz, but then drops to 40 dB HL for 2000 Hz, and 60 dB HL for 4000 Hz, with similar patterns for ‘X’ in the left ear. This indicates a high-frequency sloping hearing loss.

3. Low-Frequency Hearing Loss (Rising Hearing Loss)

Appearance: Hearing thresholds are worse in the low frequencies and improve in the higher frequencies (the plotted line slopes upward towards the right).
Implication: Difficulty hearing low-pitched sounds like the hum of a refrigerator, deep voices, or the rumble of traffic. Vowel sounds may be missed.
Common with: Meniere’s disease (often fluctuating), some conductive losses, or rare genetic conditions.

4. Notched Hearing Loss

Appearance: A distinct dip in hearing thresholds, typically around 3000 Hz, 4000 Hz, or 6000 Hz, with better hearing on either side of the notch.
Implication: A strong indicator of noise-induced hearing loss, often seen in individuals with a history of occupational noise exposure (e.g., factory workers, musicians, military personnel) or recreational noise exposure (e.g., shooting, loud concerts). The notch represents the frequency where the most damage has occurred.

Concrete Example: Your audiogram shows normal hearing up to 2000 Hz, then a sharp drop to 50 dB HL at 4000 Hz, before improving again at 8000 Hz. This “notch” at 4000 Hz is highly indicative of noise-induced hearing loss.

5. Cookie Bite (Saucer-Shaped) Hearing Loss

Appearance: Poorer hearing in the mid-frequencies, with better hearing in both the low and high frequencies (resembling a “U” or “saucer” shape).
Implication: Difficulty with a range of speech sounds, as the mid-frequencies are crucial for clarity.
Common with: Often genetic or congenital hearing losses.

The Speech Recognition Score (Word Recognition Score)

While the pure tone audiogram shows what you can hear, the Speech Recognition Score (SRS), also known as the Word Recognition Score (WRS) or Speech Discrimination Score, indicates how clearly you can understand speech when it’s audible. This is often represented as a percentage.

How it’s measured: You listen to a list of single-syllable words presented at a comfortable listening level and repeat them.
Interpretation:
- 90-100%: Excellent speech understanding.
- 75-90%: Good speech understanding, but may miss some words in challenging situations.
- 60-75%: Fair speech understanding, noticeable difficulty, especially in noise.
- 50-60%: Poor speech understanding, significant communication challenges.
- <50%: Very poor speech understanding, even with amplification.

Why is it important? Someone with mild sensorineural hearing loss might still have excellent speech recognition if their inner ear is mostly intact. Conversely, someone with moderate sensorineural hearing loss and significant inner ear damage might have very poor speech recognition, even if sounds are amplified. This score helps determine the potential benefit of hearing aids and the realistic expectations for improved clarity.

Other Important Audiometric Tests

While the pure tone audiogram and speech recognition scores form the core, other tests provide additional diagnostic information:

Tympanometry

What it measures: The function of your middle ear, including the eardrum (tympanic membrane) and the ossicles (tiny bones). It assesses how well your eardrum moves in response to changes in air pressure.
Audiogram connection: Helps differentiate between conductive and sensorineural hearing loss by confirming middle ear status. For example, a “flat” tympanogram could indicate fluid behind the eardrum, explaining a conductive hearing loss.

Acoustic Reflexes

What they measure: The involuntary contraction of a tiny middle ear muscle in response to loud sounds.
Audiogram connection: Can provide information about the integrity of the auditory pathway, from the ear to the brainstem. Absence or elevated reflexes can suggest specific types of hearing loss or nerve damage.

Otoacoustic Emissions (OAEs)

What they measure: Very soft sounds produced by the outer hair cells in the inner ear (cochlea) as they respond to incoming sound. OAEs are an objective measure of cochlear function.
Audiogram connection: If OAEs are absent, it suggests damage to the cochlea. This test is often used for newborn hearing screenings.

Your Actionable Guide to Engaging with Your Audiogram

Now that you understand the components, here’s how to use this knowledge:

Request Your Audiogram: Always ask for a copy of your audiogram after a hearing test. It’s your health information.
Locate Your Ears: Identify the red circles (right ear) and blue Xs (left ear) for air conduction. Note any bone conduction symbols too.
Check for Symmetry: Are the hearing thresholds similar in both ears? If there’s a significant difference (asymmetrical hearing loss), it warrants further investigation.
Identify the Degree of Loss: For each ear, look at where the symbols fall on the vertical (dB HL) axis at different frequencies. Classify your hearing loss (normal, mild, moderate, severe, profound) for each frequency range.
Determine the Type of Loss: Compare your air conduction (O, X) with your bone conduction (<, >).
- No Gap: Sensorineural.
- Significant Gap (Air worse than Bone): Conductive.
- Both Worse, with a Gap: Mixed.
Observe the Configuration: Does your hearing loss slope downwards (high frequency), stay flat, or have a notch? This provides clues about the cause and impact.
Consider the Speech Banana: Are your thresholds below the speech banana? If so, which sounds are you likely missing?
Ask About Your Speech Recognition Score: What percentage did you achieve? This score, combined with the audiogram, gives a full picture of your communication abilities.
Prepare Questions for Your Audiologist:
- “What is the degree of my hearing loss in each ear?”
- “What type of hearing loss do I have?”
- “What caused my hearing loss, if known?”
- “How does this audiogram explain my daily listening difficulties?”
- “What are the recommended solutions based on these results (hearing aids, medical intervention, assistive listening devices, communication strategies)?”
- “What are my speech recognition scores, and what do they mean for understanding speech with amplification?”
- “Will my hearing loss progress, and how often should I be retested?”

Empowering Your Hearing Journey

An audiogram is more than just a graph; it’s a personalized blueprint of your hearing health. By understanding its components and what they signify, you move from passive recipient to active participant in your hearing journey. This knowledge empowers you to ask informed questions, make confident decisions about treatment options, and ultimately, take control of your ability to connect with the world of sound around you. Your audiogram is the first step towards better hearing and a richer life.