Patient guide · Audiology · 6 min read
Acoustic reflex threshold testing, a painless test of the middle-ear and auditory-nerve reflex arc.
An objective test measuring the stapedius muscle contraction to loud sound. Used alongside tympanometry and audiometry to characterise conductive, cochlear and retrocochlear hearing pathology.
Key facts
- 01
Definition
An objective measurement of the stapedius muscle reflex in response to loud sound.
- 02
Painless, 5–10 minute test
A soft probe sits in the ear canal — no needles, no radiation, no recovery.
- 03
Part of a full audiology work-up
Read alongside audiometry and tympanometry — not in isolation.
- 04
Normal threshold 70–100 dB
Above the pure-tone hearing threshold at each test frequency.
- 05
Absent or elevated thresholds
Point to middle-ear or retrocochlear pathology and prompt further work-up.
- 06
Differentiates hearing loss types
Helps separate conductive, cochlear and neural (VIII nerve) pathology.
How it’s done
From preparation to report — what happens, in order.
A short, painless test done alongside tympanometry and audiometry. Same-day report from the audiologist.
- 01
Before
No preparation required
Eat, drink and take medication as normal. No fasting, no sedation.
- 02
On the day
Probe placed in the ear canal
A soft silicone tip forms an airtight seal — mildly snug, never painful.
- 03
On the day
Contralateral or ipsilateral stimulation
Loud tones are delivered to the same or opposite ear to trigger the reflex.
- 04
On the day
Threshold measured at 500, 1000, 2000 Hz
The lowest sound level that elicits a stapedius contraction is recorded per frequency.
- 05
On the day
Reflex decay over 10 seconds
A sustained tone is held for 10 seconds — decay of the reflex flags retrocochlear pathology.
- 06
On the day
Combined with tympanometry and audiometry
The three tests together characterise the middle-ear and auditory-nerve arc.
- 07
After
Audiologist reports the same day
You leave with results, an interpretation, and — if needed — an onward plan.
Total time in the clinic: around 30 minutes with the full audiology battery.
What it shows
The patterns the reflex threshold reveals.
Read in context with the audiogram and tympanogram, the reflex threshold points to where the pathology sits along the middle-ear and auditory-nerve pathway.
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Normal stapedius reflex arc
Confirms an intact middle-ear, cochlear and VIIth/VIIIth nerve reflex loop.
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Absent reflex with conductive hearing loss
Suggests ossicular fixation, effusion or perforation on the tested side.
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Absent reflex with severe cochlear loss
Where hearing thresholds exceed the level needed to trigger the reflex.
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Elevated threshold in cochlear pathology
Reduced dynamic range narrows the gap between hearing and reflex thresholds.
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Positive reflex decay
Half-amplitude decay within 10 seconds — a classical retrocochlear (VIII nerve) sign.
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Facial-nerve integrity
The stapedius branch of the VIIth nerve is tested by the presence of a reflex.
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Ossicular chain disruption
Post-traumatic or post-surgical disruption abolishes the reflex on the affected side.
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Red flag: unilateral absent reflex + reflex decay + asymmetric SNHL — MRI IAM to exclude vestibular schwannoma
This triad demands cross-sectional imaging of the internal auditory meatus.
Next steps
What follows the result.
The next step depends on the pattern — reassurance, imaging, referral, aid trial or surgery. Here’s the map.
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Reassurance if normal
A normal ART alongside normal audiometry and tympanometry usually needs no further action.
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Correlate with audiogram and tympanogram
Interpretation is always in the context of the full audiological battery.
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MRI internal auditory meatus (IAM)
The definitive next test where retrocochlear pathology — including vestibular schwannoma — is suspected.
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ENT referral for asymmetric SNHL
Asymmetry between the ears is a mandatory ENT referral regardless of severity.
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Hearing aid trial
For confirmed sensorineural loss of a degree that affects communication and quality of life.
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Middle-ear surgery
Ossiculoplasty, stapedectomy or tympanoplasty for structural conductive causes.
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Follow-up audiology
Serial testing to track progression, response to intervention or post-operative recovery.
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Multi-disciplinary neuro-otology review
For complex, syndromic or ambiguous cases — audiology, ENT and neurology together.
Red flags
When the result changes what happens next.
Certain patterns and clinical pictures demand escalation — usually MRI IAM, ENT review, or both. These are the ones we don’t sit on.
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Unilateral SNHL with absent reflex + reflex decay
A classical retrocochlear triad — MRI IAM without delay.
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Vestibular schwannoma
A benign VIIIth nerve tumour that this pattern can be the first clue to.
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Facial nerve palsy
An absent stapedius reflex on the affected side helps localise the lesion.
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Sudden sensorineural hearing loss
An ENT emergency — assessment within 24–48 hours to preserve hearing.
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Post-op stapedectomy dysfunction
A newly absent reflex after ear surgery raises the concern of prosthesis displacement.
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Ossicular chain disruption
Post-traumatic or cholesteatoma-related disruption of the middle-ear conduction path.
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Hyperacusis with absent reflex
Loss of the acoustic reflex removes the ear’s natural loud-sound damping.
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Central auditory processing disorder
Abnormal reflex patterns can indicate a central rather than peripheral cause.
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Congenital retrocochlear pathology
Present from birth — pattern recognition and paediatric neuro-otology input required.
Sources
The guidelines that shape this guide.
Reviewed by Pulse Atlas Editorial Board (). Published 2026-07-30. Next review 2027-07-30.
A quiet reminder
This is a patient guide — not a substitute for clinical advice.
If your symptoms are new, sudden or worsening, speak to your audiologist or GP.
- 01 Reference
British Society of Audiology. Recommended procedures — acoustic reflex threshold testing.
British Society of Audiology. Recommended procedures — acoustic reflex threshold testing. - 02 Reference
NICE CKS. Hearing loss in adults — assessment and management.
NICE CKS. Hearing loss in adults — assessment and management. - 03 Reference
American Speech-Language-Hearing Association. Acoustic immittance measures.
American Speech-Language-Hearing Association. Acoustic immittance measures. - 04 Reference
European Federation of Audiology Societies. Diagnostic audiology guidelines.
European Federation of Audiology Societies. Diagnostic audiology guidelines.
Frequently asked
Everything we get asked about acoustic reflex threshold testing.
Quick answers on what it feels like, how long it takes, how it fits with other audiology tests, and what an abnormal result means.
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What is an acoustic reflex threshold test?
An objective audiological test that measures the softest sound level at which the stapedius muscle in the middle ear reflexively contracts. It’s used to characterise the middle-ear and auditory-nerve reflex arc.
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Is it painful?
No. A soft probe sits in the ear canal and delivers loud tones for a fraction of a second at a time. It can feel briefly loud, but it is not painful and there is no recovery.
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How long does it take?
Between 5 and 10 minutes per ear, and it is usually done back-to-back with tympanometry and pure-tone audiometry — the full battery is around 30 minutes.
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What does an absent reflex mean?
It depends on context. With conductive loss, it usually reflects middle-ear pathology; with sensorineural loss, it may reflect severity or a retrocochlear cause; with reflex decay it prompts an MRI of the internal auditory meatus.
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Do I need it if I’ve already had an audiogram?
Audiometry tells you the level of hearing loss; ART helps tell you where the problem is. The two answer different questions and are typically read together.
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What happens if the test is abnormal?
The audiologist correlates the result with your audiogram and tympanogram. Depending on the pattern, the next step is often an ENT referral and, for suspected retrocochlear pathology, an MRI IAM.
Related tests
Looking for a different test?
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Tympanometry & hearing
Middle-ear pressure and compliance — the natural partner to ART.
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Audiometry
Pure-tone hearing thresholds — the anchor of every audiology work-up.
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MRI brain
Cross-sectional imaging when retrocochlear pathology is suspected.
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Cochlear Implants
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Cholesteatoma Surgery
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In practice, in London
Why private acoustic reflex threshold moves differently in London
With acoustic reflex threshold, the London question is usually about report turnaround and the radiologist reading it — not whether the scan is available. Public provision for acoustic reflex threshold is competent but constrained by capacity. Private London clinics tend to have shorter diaries and longer appointment slots, so you get the same specialists with more time. For people who’ve been going round in circles with primary care, that first proper conversation is often what shifts things.
A private acoustic reflex threshold pathway in London usually looks like this: an initial consultation, any diagnostics booked at a nearby facility (most within Zone 1 or 2), and a written report sent to you and your GP within a few days. The consultants we work with hold NHS posts alongside their private lists, which keeps the standards consistent across both settings. For acoustic reflex threshold specifically, the difference between a routine report and a sub-speciality read is where private care earns its keep.
Where a good concierge earns its keep is in the matching. There are dozens of consultants in London who see acoustic reflex threshold — but not all of them are the right fit for every case. We narrow it down based on subspecialty, insurer coverage, the specific question being asked, and whether continuity into treatment matters. The right first appointment saves you from repeating yourself later.