From first tone
to confident masking.

Initial AC: 1000, 2000, optional 3000, 4000, optional 6000, 8000, 500 and 250 Hz. Retest 1000 Hz on the first ear before switching ears. Better-ear choice is reviewed using mean AC at 500, 1000 and 2000 Hz; the checker does not penalise an initially unknown better ear.

With no prior result, the checker expects AC familiarisation at 40 dB HL. With a reference, it expects reference + 30 dB, capped at 80. Familiarisation rises by 10 dB up to 80, then by 5 dB until a response, within output limits. Retests use the same-frequency result; new frequencies use the preceding available result in the prescribed sweep, with 1000 as the reference for 500 and 500 for 250.

Initial BC: 1000, 2000 and 500 Hz on one side, chosen by the worse AC mean at these frequencies (either side on a tie). Its familiarisation reference is the better AC at the test frequency + 30 dB, capped at 80. These describe this simulator’s teaching checks; follow your tutor’s instructions for the exercise.

Present tones for 1–3 seconds and vary their duration and spacing. ISI is measured from one tone ending to the next starting. Gaps below one second are flagged; longer thinking pauses are distinguished from rhythm sequences. Duration variation is assessed across the session, excluding familiarisation tones, so short threshold searches can contribute to the same check. Longer searches are also checked for limited variation within their own block. Timing feedback is a teaching heuristic.

Shortcuts work outside editable fields and settings dialogs. Tab reaches controls. After editing a main dropdown, Enter or Escape returns to testing. Touch and pointer users can use the same buttons and selectors. Opening a settings dialog or losing window focus stops a held tone; showing a helper dock does not.

Delete point removes the selected ear/frequency/category, including its no-response variant, regardless of current tone level. Delete curve clears the selected ear’s current curve and applicable shadows. Delete all clears both ears’ PTA points and PTA annotations. Patient settings, the presentation log, ISO overlays and the separate masking chart remain.

AC curve deletion clears AC and its not-masked shadow; in NZ mode, not-masked AC deletion clears only the not-masked series. Masked BC deletion also clears its not-masked BC shadows; not-masked BC deletion clears only not-masked BC. A masker value of OFF selects the not-masked category even if the masking switch is on.

Select Visual helper to open a live dock. Compare the tone and masker reaching each cochlea with its apparent threshold, then observe which cochlea responds. The main patient response light combines responses; it cannot tell you which cochlea heard the tone.

With zero conductive loss and 40 dB AC interaural attenuation, a 40 dB HL tone in the right ear reaches the right cochlea at 40 and the left at 0. A 50 dB EML masker in the left ear reaches the left at 50 and crosses to the right at 10. Actual patient settings may differ.

Ascending trials shows responses/presentations by level. Only a tone higher than the preceding presentation in the same context counts; first, equal-level and descending presentations do not. Green counts highlight 2/2, 2/3 and 2/4. Delayed responses can contribute. Start level records the first presentation in that context.

With both BC attenuation settings at their default 0 dB, the same BC tone level reaches both cochleae regardless of the selected test side. Independent BC attenuation can change those levels. A conductive component reduces an AC tone or masker reaching the same-side cochlea; the cross pathway is controlled separately by AC IA. Apparent threshold reflects the cochlear baseline raised by any effective masking at that cochlea.

Changing ear, AC/BC, frequency or masker state/level resets these displays. Counts accumulate while the dock is hidden and never store a threshold automatically. This tool is disabled in assessment mode.

Select Masking helper, choose a rule and add/edit worksheet rows. Record frequency, ear under test and relevant plotted thresholds, then enter Masker Start level, dB EML. The helper reads the audiogram, not hidden patient thresholds.

Add missing entries adds outstanding rows for the selected rule and fills new starting masker values from opposite-ear AC at the same frequency, using masked AC if available. Existing answers stay intact. Check entries checks existing rows and reports missing requirements for the selected rule. Delete individual/selected rows or clear the worksheet as needed.

For every rule, the expected start is the non-test ear’s effective AC threshold in dB EML. Blank and no-response points cannot supply a numeric start. Completed masked results remove matching outstanding rows. Not-masked BC can belong to either cochlea; masked BC helps resolve that ambiguity. These fixed rule checks do not replace a plateau search or cover every patient-specific IA. The worksheet is session-only and disabled in assessment mode.

1. Obtain an initial threshold and a full masker-off recheck.
2. Set the first masker to the opposite ear’s effective plotted AC threshold. Turn Masking on and select a numeric level: OFF is not effective masking.
3. Find and confirm the tone threshold at that masker level. Set Channel 1 to the result and press Store masking plot in Channel 2.
4. Increase masker by 10 dB, perform a full threshold search, and store a chart point at each level. The checker expects at least four masker-level measurements, with the final three thresholds within 5 dB.
5. Once you establish a plateau, record the final PTA threshold separately using Store.

Use the previous threshold + 30 dB, capped at 80, for familiarisation at the next masker level. Confirm thresholds through ascending trials rather than simply copying a previous result.

Select Masking chart to view the graph: x is masker level (dB EML), y is tone level (dB HL). Curves are separate by ear, frequency and AC/BC. The curve selector reviews earlier work without changing instrument controls. Repeating a masker level replaces its point; Undo point can reverse replacements and clears.

Annotate using freehand, line, arrow or text. Enter text then choose Add text at centre for keyboard placement. Point and annotation undo/clear controls are separate. Export PNG saves the selected curve and notes. The chart is available in assessment mode; curves and annotations are session-only.

Some patients have no achievable plateau because of cross-masking or output limits. Do not substitute a no-response threshold for a masking dilemma. Method review can explain supported limitations after the available masker range is exhausted; stopping earlier may leave the series incomplete. Loudness comfort is not modelled.

Plot patient thresholds replaces existing AC/BC results with ideal values for the selected mode, retaining ULL. It is an answer/review tool, not a measurement. It also works with manually edited Patient settings. Save your own plot first.

AC is plotted at all eight testing frequencies; BC at 500, 1000 and 2000 Hz. Initial not-masked BC stays on the side with the worse mean initial AC at those three frequencies (right on a tie). Masked mode adds required results under Rules 1–3 only where an achievable plateau exists and retains not-masked shadows. Ideal levels round up to the next 5 dB; values above 120 use NR at 120. Actual measurement output limits still apply during testing.

• General audiometry: choose a young, typical-for-age baseline, no additional losses and no conductive component. Practise the frequency sequence, 1000 Hz retest and ascending confirmation; review timing and search steps.
• Cross-hearing: add a large flat sensorineural component to one ear. Measure not-masked, then inspect Visual helper to explain why the worse ear can appear better than its own cochlea.
• Conductive loss and BC: add a unilateral conductive component. Compare AC and not-masked BC, use Masking helper to identify outstanding requirements, then document a BC masking series.
• Cross-masking: create bilateral conductive components. Inspect how masker transmission limits the plateau; compare the chart, Visual helper and method feedback.
• More complex patterns: explore high/low-frequency loss, cookie bite, NIHL and BC notches. Inspect the actual generated patient values.

Not every generated case requires every rule or permits a plateau. Inspect the resulting case rather than assuming a preset guarantees a particular masking exercise.

Review one patient per attempt. Editing the patient midway creates mixed-patient evidence. The log records a patient revision identifier without revealing thresholds. Results present before the first tone are treated as supplied information; their original measurement method was not observed. Later plotted but unlogged points also cannot prove a procedure. Resetting the log removes the evidence available to Check method.

Open Annotation, choose freehand, line, arrow or text, and draw over either ear. Enter text before placing it; keyboard users can choose Add text at centre for the selected ear. Choose colour, undo the last annotation or clear annotations independently of masking-chart notes.

View mode or hiding the panel stops drawing while finished annotations remain visible. Notes follow the plot through redraws, resizing and layout changes. Both audiogram PNG controls include completed notes and omit the live crosshair. Notes are not saved in links.

In Plot settings, toggle the ISO 7029 age-related overlay and set age, male/female reference and interval. For ISO 1999 noise/age, set LEQ8h and years of exposure and choose age display options. Shaded regions describe model reference ranges, not measured responses.

1. Age reference: enable Presbyacusis ISO7029, enter age, select the male/female reference and choose the displayed interval (75%, 80% or 95%). Select a colour to distinguish the shaded range.
2. Noise and age: enable NIHL+AGE ISO1999 and enter LEQ8h, the noise exposure level referenced to an eight-hour working day, plus years of exposure. The age and male/female settings above also apply.
3. Compare age with age plus noise: select Also plot age alone to show the age-only shading alongside the combined prediction. This helps illustrate the additional modelled effect of noise exposure.
4. Keep the comparison: export the audiogram PNG, or use Save image (new window) and your browser’s save/copy image commands to place it in a report or teaching document.

For an example, compare a 50-year-old male reference with 25 years of exposure at LEQ8h 90 dB, then switch the age-only comparison on and off. The shaded ranges are reference predictions, not an individual diagnosis or proof of the cause of a measured loss.

Overlays change the display, not the patient’s cochlear thresholds. Tutorial age/NIHL generation is a separate action. The full-page layout includes the symbol legend; toggle back for the compact display.

1. Prepare the patient. In PTA Patient settings, choose a tympanogram type and enter ECV, Comp and MEP for the ear where the Ipsi probe will sit. These fields must be set before measurement; see the patient settings below.
2. Select TYMP and the ear. Insert the Ipsi probe in the intended ear and use the RIGHT / LEFT button to select that ear's result set. The Contra probe is not needed for tympanometry.
3. Press START. The pressure sweep runs from right to left across the plot. Wait for the completed ECV, compliance and MEP readout. Frequency, level and PRESENT controls are inactive in TYMP mode.
4. Compare the display. With Compensated checked, the canal-volume contribution is subtracted. Uncheck it to include ECV in the plotted compliance. NP in Comp or MEP produces a flat trace in this simulator.
5. Test the other ear. Remove and insert the Ipsi probe on the other side, select that ear and press START. Each selected ear retains its latest tympanogram; another START replaces that ear's display while the journal keeps earlier measurements.

STOP interrupts the sweep and releases pressure. An interrupted run remains in the journal. Completed results survive switching to REFLEX mode.

1. Prepare the ART settings. Set Reflex setting, the relevant Ipsi/Contra thresholds and Middle ear status in PTA Patient settings. Normal middle ear permits a response; Abnormal Middle ear on the measurement-probe side produces no measured reflex in this model. The stimulus ear's PTA conductive component reduces the effective stimulus level.
2. Select REFLEX, ear and route. Fit Ipsi in the measurement ear. IPSI uses that same probe for the stimulus; CONTRA uses the separately fitted Contra probe. A missing Ipsi probe blocks START; a missing Contra probe gives a flat underlying response during CONTRA testing.
3. Select stimulus and level. Use the − / + buttons for 500, 1000 or 2000 Hz and levels from 0 to 115 dB HL in 5 dB steps.
4. Press START and observe the baseline. A clean fit briefly wobbles, then settles to zero. The vertical line in the horizontal bar shows live change in compliance on a fixed −0.10 to +0.10 mmho scale. With a noisy fit it continues moving; PRESENT becomes available after the brief initial preparation even if the baseline remains unstable.
5. Click PRESENT once for each measurement. One click records one trace at the selected level. The bar follows the same instantaneous signal as the plot. A clean reflex produces a negative dip and returns to zero. At the simulated threshold its peak change is −0.020 mmho; larger responses or artefacts may exceed the visible scale. Adjust the level and repeat as instructed by your tutor.
6. Review the stored set. Results are separate for each selected ear, IPSI/CONTRA route and frequency. Changing these selections displays that set's earlier traces rather than deleting them. Click a tile to enlarge; click again or press Escape to return.

The plot area keeps a fixed height. Tiles shrink in steps as the set fills; they remain clickable to enlarge. At the minimum size, Results full blocks another measurement. Download the journal if needed, then use Clear measurement to make room in that set.

STOP releases pressure and stops the live bar, including noise between recordings. Probe fitting changes, switching mode/ear/route, clearing results and losing window focus also stop monitoring. Press START to resume; it does not change the existing fit state.

When probe-fit problems are enabled for the patient, insertion can produce one of three simulated conditions:

These state names explain the model; the testing screen does not announce which fit was drawn. Noise continues between measurements and is added to the reflex signal, so an irregular dip may be an artefact or a reflex obscured by noise. The peak readout describes the recorded signal, including noise.

To try to resolve noise: remove the Ipsi probe, reselect its intended ear if needed, insert it again and press START. Each insertion draws a new fit using that actual ear's settings. STOP/START, clearing results and repeated Insert clicks while already fitted do not draw a new state. Refitting may still produce a problem; at 100% probability it always will. Contra probe fit does not generate noise in this simulator.

Noise in a saved tile stays the same when you enlarge it or revisit the set. Noisy ART results show Unclear in the journal and CSV, rather than revealing the underlying reflex response.

Tutors can set the probability and severity in PTA Patient settings. Both ears default to 0%, preserving clean recordings for existing cases.

Presentation log in the immittance simulator records both TYMP and ART runs. It includes selected ear and the actual Ipsi/Contra probe placements at onset. ART rows also include frequency, level, route, stimulus ear, probe ear and response; TYMP rows include ECV, compliance and MEP. Interrupted runs are retained. This journal is separate from the PTA tone journal and does not record tone duration or ISI.

Select Download CSV before Clear session, reload or closing the tab. Patient links retain the patient settings, including noise probability and severity; they do not retain measured tympanograms, ART traces, probe placements, fit states or this journal.

• Age and ISO 7029 reference: a shared left/right baseline at 18–80 years. Better/typical/poorer for age means the 25th/50th/75th percentile. Random selects within the IQR (middle 50%). These are age-relative positions, not absolute loss severity labels.
• Additional sensorineural loss: choose one/both ears and a flat, high-frequency, low-frequency or cookie-bite shape. Cookie bite peaks at 2 kHz, adding no loss at 250 Hz or 8 kHz; the age baseline remains at the endpoints.
• NIHL (ISO 1999): optionally combines median noise loss with the age baseline in both ears using age + noise − age × noise / 120. Set LEQ8h and exposure years. Noise covers 500–6000 Hz; shaped SNHL is added afterwards.
• Conductive components: independent left/right minimum and maximum (0–60 dB). Equal shapes keep both equal; slopes span the limits. 2/3 kHz notched conductive shapes have their minimum at that frequency and maximum at 250 Hz and 8 kHz.
• BC notch: separately choose None, 2 kHz or 3 kHz and peak attenuation (0–30 dB) for each cochlea. The broad profile applies only at frequencies with a non-zero conductive component. None or zero peak clears generated BC attenuation.
• Headphone IA: select 40–80 dB or random. Generation clamps the chosen value to each frequency’s limits. View IA ranges by frequency shows the limits; inspect the actual generated values in Patient settings.
• BC occlusion effect: defaults to zero at all frequencies. Choose the 25th, 50th, 75th or 90th percentile, or Random, to generate a shared left/right frequency profile from the TDH-39 means and standard deviations reported by Wallaert et al. (2024). Percentiles are normal-distribution estimates; negative values are set to zero. Random uses one randomly sampled percentile across frequencies. No 8000 Hz data are available, so that setting remains zero. View TDH-39 occlusion by frequency shows the source table.

These frequency shapes are teaching presets. Generation overwrites earlier manual cochlear, conductive, BC attenuation, BC occlusion and IA values. Links save the generated patient, not the builder selections. Response variation settings remain as they were.

The Tympanometry and acoustic reflex thresholds section contains separate settings for each ear for immittance test simulation. These settings do not change PTA responses or calculations. When a tympanogram type or reflex setting is set for either ear, a Tymp/ART link appears beneath the existing links in Patient settings. It opens the immittance simulator in a new tab with the same patient settings; the adjacent Copy link button copies its address.

Auto set uses the supplied Gelfand et al. (1990) contra 10th–90th percentile ranges. Applying these ranges to ipsi thresholds is a teaching approximation. Cochlear thresholds are rounded to the nearest 5 dB table row; values below 0 use the 0 dB row and values of 90 dB or higher use the ≥90 row. Where the normative upper limit is NR, cochlear auto-setting retains numeric choices through 125 dB HL plus 200 (NR); the feedback explains that ART cannot distinguish cochlear and retrocochlear patterns at that frequency.

Prepare a noise exercise: under ART Ipsi probe fit, set the desired ear's problem probability and choose severity. For example, 40% with Moderate severity gives a problem on roughly four in ten insertions over many attempts; a single refit may be clean or noisy. For a guaranteed noisy exercise choose 100%; set 0% for clean practice. A problem draw chooses Unstable or Poor with equal probability.

Open the updated Tymp/ART link after editing patient settings. To apply those odds, remove and reinsert the Ipsi probe in the intended ear, then press START. The fit is drawn at insertion, so repeated START does not reroll it. Follow the measurement instructions to observe the baseline, record traces and try refitting.

These values are included in saved patient links. Older links leave the original immittance fields Not set or blank and default both probe-fit probabilities to 0% with Moderate severity. Values already entered are retained when their fields are disabled.

At 1000 Hz, right cochlear threshold 20 dB and right conductive component 20 dB give ideal right AC 40 dB. With right BC attenuation 0, ideal ear-specific BC is 20; with BC attenuation +10, BC becomes 30 while AC remains 40.

Those are ear-specific values. If the left cochlea has lower effective BC threshold, not-masked BC may reveal it instead. Mask to establish which cochlea is responsible.

Carhart’s-notch-style pattern: enter positive BC attenuation centred at 2 kHz to worsen BC transmission without increasing the cochlear threshold. Tutorial BC notch/peak controls generate a broad profile where conductive loss is present. Use Patient settings for an exact frequency pattern.

SSCD-style teaching pattern: set the cochlear thresholds to the intended sensitive BC baseline and use the AC conductive component to create the desired AC/BC separation. Leave BC attenuation at 0 where no BC transmission loss is intended. Do not enter a negative value in the attenuation box to represent an amount of attenuation.

These illustrate audiometric patterns, rather than modelling the full pathology. Check cross-hearing and masking before treating not-masked BC as ear-specific. Testing and plotting limits still apply, including the −10 dB plot floor.

1. Inspect all parameters, especially IA, BC attenuation and response variation.
2. Use Plot patient thresholds and Check current audiogram to inspect the ideal pattern and whether masking is measurable.
3. Try the intended testing and masking sequence. Ideal plots exclude variability and direction effects.
4. Clear answer plots you do not intend to supply. Existing plot data is included in patient links; supplied points are treated as prior information by method review.
5. Create the appropriate links and test them in a fresh tab. Keep your tutor editing link for revisions.