What an Audiogram Measures (and What It Misses)
The standard hearing test (audiogram) shows the softest sounds you can hear at different pitches. But real-world hearing involves more than that. This guide explains what the audiogram does measure—and what it misses—so you can understand your hearing better.
- The audiogram is the graph of your hearing test results. It plots the quietest sounds you can hear at different frequencies (pitches) in each ear, which helps determine the degree and type of your hearing loss.
- An audiogram alone doesn’t tell the whole story. It doesn’t measure how well you understand speech in noise, how clear sounds are to you, or issues like tinnitus and listening fatigue. You might have trouble following conversations even if your audiogram is “normal.”
- “Hidden hearing loss” can explain normal tests with hearing trouble. Some people struggle to hear in noisy places despite a normal audiogram, often due to inner ear nerve damage that standard tests can’t detect.
- Other tests can fill in the gaps. Special assessments (like speech-in-noise tests, otoacoustic emissions, or auditory brainstem response) can uncover issues that a basic audiogram might miss.
What an audiogram measures
An audiogram is essentially a map of your hearing sensitivity. During a standard hearing test, you wear headphones and listen for very soft tones. The audiologist marks the quietest sound (threshold) you can hear at each frequency (pitch). This results in a chart with frequency along the x-axis (bass to treble) and sound level in decibels along the y-axis. The audiogram shows your hearing thresholds across the range of pitches most important for speech (typically 250–8000 Hz for adults).
By looking at an audiogram, professionals can determine the degree of hearing loss (if any) and whether it’s the same across frequencies or worse in certain pitches (like a high-frequency loss). Hearing loss is often categorized as mild, moderate, severe, or profound based on how loud sounds need to be before you detect them. The audiogram also differentiates types of hearing loss. For example, testing with both headphones (air conduction) and a small bone vibrator behind the ear (bone conduction) can tell if loss is conductive (due to middle or outer ear issues) or sensorineural (due to inner ear or nerve issues) by comparing the results.
Example: If your audiogram shows a 30 dB threshold at several frequencies, that is considered a mild loss at those pitches. If bone conduction results are much better than headphone results, it suggests a conductive component (like ear fluid or wax). This way, the audiogram measures your baseline hearing sensitivity and helps pinpoint the nature of any hearing loss.
Myth: “Mild” hearing loss isn’t a big deal.
Reality: Even a mild hearing loss can have significant effects. For example, one study found that a person with a mild 30 dB loss might miss about half of the words in a normal conversation if they’re not using hearing aids or other help. In other words, “mild” doesn’t mean insignificant—it means you may still struggle to hear soft speech, especially with background noise.
What an audiogram does not measure
The audiogram is very useful, but it has limitations. It focuses on the threshold of hearing tones in a quiet setting. It does not measure how well you can understand speech once it’s above your hearing threshold. Real-life listening is usually more complex than pure tones in silence. Many people with hearing difficulties complain that they “can hear but can’t understand” speech—especially in noisy environments or when multiple people are talking.
The standard audiogram doesn’t capture those suprathreshold processing abilities, such as your ability to filter out background noise, distinguish similar sounds, or comprehend rapid speech. It also doesn’t assess the clarity of sound (whether speech sounds distorted to you) or the effort it takes for you to listen.
Because of these gaps, two individuals with the same audiogram can experience very different real-world hearing. For instance, if you have trouble understanding speech in a busy restaurant, a basic hearing test might still come out “normal.” Conversely, if you have hearing loss, the audiogram’s degree (e.g. mild vs. moderate) doesn’t always predict your communication difficulty. Some people with relatively mild loss struggle a lot, while others with a worse audiogram may get by better than expected. The audiogram alone cannot tell how well you hear in complex situations or how hard your brain has to work to make sense of sounds.
Myth: If my audiogram is normal, my hearing is normal.
Reality: Not necessarily. You could pass a basic hearing test (meaning you hear soft tones in a quiet room) and still have trouble understanding speech in everyday conditions. This is sometimes called “hidden hearing loss”—hidden because a standard test can’t detect it. In noisy places or echoey rooms, you might find yourself missing words or needing repetition, even though your audiogram looked normal. That’s a real hearing difficulty, just one the audiogram doesn’t measure.
The controversial zone: Hidden hearing loss and synaptopathy
Researchers use the term hidden hearing loss to describe hearing difficulties that aren’t reflected on the audiogram. If you have normal hearing thresholds but struggle to hear conversation in noise or have other listening issues, hidden hearing loss could be an explanation. The leading theory is something called cochlear synaptopathy—damage to the connections (synapses) between the delicate inner ear hair cells and the auditory nerve fibers that send sound signals to the brain. You can lose a substantial portion of these synapses (for example, due to loud noise exposure or aging) without affecting your tone thresholds on an audiogram.
In other words, the basic test stays normal, but your inner ear’s “wiring” has been partially frayed, making complex listening much harder. This concept is still an area of active research and a bit of controversy. Not all audiologists agree on how common hidden hearing loss is or how best to test for it. However, evidence is growing.
Studies have found, for example, that people with normal audiograms but difficulty in noise often show reduced auditory brainstem response (ABR) wave amplitudes—an objective sign that fewer nerve fibers are responding. There’s also evidence linking hidden hearing loss to tinnitus (ringing in the ears) in some cases—essentially, noise damage that doesn’t shift your thresholds but does cause nerve fiber loss could lead to tinnitus because the brain “turns up the volume” on missing signals. While there’s currently no clinical cure for this type of nerve damage, knowing it exists can validate the experiences of patients who feel they’re “not hearing right” despite a normal test.
Key point: If you have symptoms of hearing difficulty (needing the TV louder, trouble with phone or in meetings, etc.) but an audiogram shows normal thresholds, you should discuss it with an audiologist. They may perform additional tests geared towards uncovering hidden hearing loss.
What tests can fill the gaps?
When an audiogram doesn’t explain someone’s listening problems, audiologists can use other assessments to get a fuller picture of your hearing. One common option is a speech-in-noise test. For example, the QuickSIN or similar tests play sentences with background noise at various levels, and you repeat back what you hear. These tests measure how much harder you need the speech to be relative to noise compared to a person with normal hearing.
Other specialized tests include:
- Otoacoustic Emissions (OAE): This test measures the echo-like sounds produced by your inner ear’s outer hair cells. Sometimes people with normal audiograms show reduced or absent OAEs, indicating subtle damage to the cochlea’s hair cells even though thresholds are normal.
- Auditory Brainstem Response (ABR): Electrodes measure the electrical activity of your hearing nerve. For suprathreshold issues, audiologists might use high-level or rapid-click ABR protocols to see if the nerve response is weaker than expected (a potential sign of synapse loss).
- Central auditory processing tests: These assess how the brain processes complex sound information. These might involve tasks like recognizing words when parts are missing. Such tests can diagnose Central Auditory Processing Disorder (CAPD)—where hearing is physically normal but the brain has trouble interpreting sounds.
- “Can you explain my audiogram to me?” Have the provider walk you through your hearing chart and what that means for everyday situations.
- “Why am I having trouble even if my audiogram is normal?” Ask if additional tests like speech-in-noise or ABR might shed light on those issues.
- “How can we address the things the audiogram doesn’t cover?” For example, ask about hearing assistive technologies or communication strategies.
- “Do I need a referral or further evaluation?” If your test shows something unusual like hearing loss in one ear much worse than the other, ask if you should see an ENT doctor.
- Sudden hearing loss in one or both ears (developing over hours or a day or two)—this is an emergency.
- Hearing loss with severe dizziness or balance problems—if you suddenly feel intense vertigo or unsteady, seek care immediately.
- New hearing loss with ear pain or drainage—this may be an infection or eardrum issue that needs quick attention.
Early intervention for sudden hearing loss can make a massive difference in recovery.
Next steps
Building on your test results. Now that you understand what your audiogram does and doesn’t show, you can work with your hearing care professional to address any remaining concerns. If your audiogram showed loss, consider a trial of hearing aids early—it keeps your brain socially engaged. If your audiogram was normal but you struggle, ask about hearing training exercises or remote microphones.
Related Guides
References
- Asghar S, et al. (2022). Frequency of hearing loss among medical students. Pak J Med Sci.
- Alanazi AA. (2023). Understanding Auditory Processing Disorder: A Narrative Review. Saudi J Med Med Sci.
- American Academy of Audiology. Hidden Hearing Loss (web page). audiology.org
- Fleser RC, et al. (2025). Hearing Loss in Young Adults: Risk Factors and Mechanisms. Biomedicines.
- Chandrasekhar SS, et al. (2019). Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngol Head Neck Surg.
Further Reading
- Katherine Bouton (2017). How’s Your Hearing? It May Not Be as Great as You Think. AARP Health.
- Hearing Health Foundation (2023). What Is Hidden Hearing Loss? In-depth explanation of research and prevention.
- Sharon Reynolds (2022). Diagnosing Hidden Hearing Loss. NIH Research Matters news.
- Brandon T. Paul (2018). Tinnitus with a Normal Audiogram. Canadian Audiologist article on missed damage.
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UCSF EARS provides educational information and is not a substitute for medical care. If you have sudden hearing loss or balance issues, seek urgent evaluation.