NIHR | Manchester Biomedical Research Centre

Why extended high-frequency hearing testing is important to patients, and why we need to listen to them – World Hearing Day

Melanie Lough

Author: Melanie Lough View Profile

Research Audiologist

On World Hearing Day Melanie Lough, Research Audiologist, discusses her proposed project that aims to widen the use of extended high-frequency hearing testing (audiometry) within NHS hearing services – and how patient and public involvement is helping to shape this research.

In the UK, hearing loss ranks third for years lived with a disability. It causes communication difficulties and impacts on quality of life, cognition and mental health. We therefore need to improve our methods of detecting and managing hearing loss. One test that could be key in achieving this is extended high-frequency audiometry.

Extended high-frequency audiometry explained

Extended high-frequency audiometry is a hearing test that assesses hearing sensitivity in the highest frequency range of human hearing. To understand ‘frequency’, it helps to think of a piano keyboard; the keys of a piano are tuned to different frequencies, which get higher as you go from left to right on the keyboard. One of the main advantages of extended high-frequency audiometry is that it can detect hearing loss before many other diagnostic tests (including the standard hearing test, ’pure-tone audiometry meaning referrals into hearing services can be made earlier, and audiological counselling and treatment can be provided faster.

Our proposed research project

Extended high-frequency audiometry is not performed routinely in the UK, and there are currently no clinical guidelines for audiologists on how to perform the test. Along with my colleagues at the NIHR Manchester Biomedical Research Centre (BRC), I am proposing to tackle this issue with a three-year research project that will answer important questions about how we can perform extended high-frequency audiometry safely and reliably. This will lead to the development of national clinical guidance on this test for audiologists, which should increase the use of extended high-frequency audiometry in NHS hearing services.

Patient and public involvement

Because we understand the priorities of researchers in academic institutions do not always mirror those of patients and the public, it was important to us to involve patients and members of the public right from the start of our research project. In September 2021, with the support of VOCAL (a not-for-profit organisation with expertise in patient and public involvement) Manchester BRC colleagues, Professor Chris Plack, Dr Anisa Visram and I held an online consultation with a group of eight members of the public.

The background of the public contributors included people who have developed hearing loss because of cancer treatment, people with age-related hearing loss, and carers of relatives with hearing loss. They were invited to be involved because cisplatin chemotherapy, head and neck radiotherapy, and advancing age are known causes of extended high-frequency hearing loss.

Key themes from our consultation and their impact

1. The importance of performing a baseline measurement and monitoring hearing regularly, particularly when receiving treatment that can be damaging to hearing (ototoxic).

The group thought that it would be useful to have extended high-frequency hearing tests every year, in the same way that you have eye tests, because hearing is equally as important as sight. However, those in the group that had developed hearing loss through cancer treatments felt that a yearly hearing test would not be frequent enough for monitoring the hearing effects of chemotherapy or radiotherapy. They also agreed that in order for extended high-frequency audiometry to be useful for this purpose. A former radiotherapy recipient said: “you need a baseline [test] to start with”.

Impact: In the United States and South Africa, guidance already exists that recommends a baseline hearing test is performed before ototoxic treatments commence. This makes it easier to determine whether the treatment itself has caused the hearing loss. There is no such guidance in the UK, but we intend to change this with our planned research.

2. Knowing early on that ototoxic treatment can affect hearing would be beneficial, even if the treatment cannot be changed.

A former chemotherapy recipient said: “When I started having chemotherapy, there wasn’t much focus on the hearing loss aspect a lot, and I think if you’re younger and it’s going to impact you for longer in your life, I think there needs to be more emphasis on it, because I didn’t realise you could get hearing loss from chemotherapy until I started having hearing loss investigated…”

This view was also shared by a radiotherapy recipient, who said that she felt extended high-frequency audiometry would be helpful for learning how the cancer treatment can affect your hearing, as well as for the personal benefit of knowing that it has. When asked whether she would still want to know, even if the radiotherapy dose couldn’t be changed to prevent further deterioration in hearing, she said:“Yes, absolutely. It would have been beneficial to know and not thinking I’m going mad, because they don’t tell you that.”

Impact: These views support that chemotherapy and radiotherapy patients would like to be told of the possibility of hearing loss at the start of their treatment, and that hearing effects should not be underestimated. The early confirmation of hearing loss provided by extended high-frequency audiometry would also be appreciated.

3. Standard pure-tone audiometry is comfortable and an extra five to 10 minutes to test the extended high frequencies would be worthwhile.

The majority of the public contributors in the group had personal experience of having a standard hearing test. None of them reported any issues with comfort or background noise during the hearing test, and there was agreement that the additional time it would take to test the extended high frequencies would be worthwhile.

A carer of a relative with hearing loss said: “I personally think it’s definitely worth it to…not leave any stone unturned…to come out knowing you’ve got the full picture”.

Impact: This highlights that, on balance, the additional test time that would be required to complete extended high-frequency audiometry, is likely to be acceptable to (or even welcomed by) patients.

4. Standard audiometry can be difficult due to the concentration required, but for the extended high frequencies "spot frequencies" could be tested.

Although standard audiometry was felt to be comfortable, a couple of the public contributors reported that they (or their relative) had difficulty concentrating during the test. The following solution was suggested:

Former radiotherapy recipients said:

A – “You don’t [need to] do the whole range, you just pick a couple of spot frequencies, maybe.”

B – “I totally agree with you.”

By testing a selection of extended high frequencies, the test time is reduced, meaning the demands on a patient’s concentration are also reduced.

Impact: These findings have informed our planned research in two ways. Firstly, we have scheduled for public contributors to comment on our study protocols so that our test procedures are not likely to cause any concentration difficulties. This will help to ensure our results are accurate, as well as comfortable, for participants. Secondly, we have chosen to perform some of our analyses per individual frequency, as well as across the entire extended high-frequency range.

This will mean we can guide clinicians on which “spot frequencies” to test if a patient’s concentration starts to wane.

5. The need for this work to inform future treatments and rehabilitation.

One public contributor was keen to know how extended high-frequency audiometry could lead to treatments in future. This was important to him as he described his experience of eye tests when he was losing his vision as distressing due to there being no available treatment options.

In the vast majority of cases, a hearing loss that worsens and progresses to the standard frequency range can be treated with hearing devices, such as hearing aids or cochlear implants. However, as this contributor’s experience shows, it is important to think ahead to what extended high-frequency audiometry can offer beyond the detection of hearing loss.

Impact: Although our planned research project will not be focusing on developing treatments, it will help standardise how extended high-frequency audiometry is carried out. This will be valuable for future research into hearing devices for extended high-frequency hearing loss and new drug treatments to prevent hearing loss.

6. Communication to patients about the test is key.

Another volunteer stressed that it is essential that details about the test are properly explained to patients.

A former radiotherapy recipient said: “I think it’s very important if you do [this test], you put the patient at ease and tell them why you’re doing it. Give them communication, communication, communication!”.

Impact: We would expect the hearing test instructions that are already given to patients in clinic to be comprehensive. However, future feedback from our public contributors on our study protocols will help to confirm or inform this.


As an audiologist, I can see a clear benefit for using extended high-frequency audiometry in clinical practice and our public contributors have reinforced my opinion. The end goal of our planned research project is to develop national clinical guidance on extended high-frequency audiometry, and so our public contributors will ultimately be facilitating this. Patient and public involvement has already directly influenced how we plan to conduct our research.

I am really looking forward to getting our research project off the ground and to continuing collaboration with our public contributors as it progresses.