The auditory brainstem response test is an objective assessment that records the electrical activity produced by the hearing nerve and brainstem in response to sounds delivered to the ear. Small sensors are placed on the forehead and behind the ears, an insert or headphone presents the sound, and the equipment records and analyses the resulting waveforms. Its central advantage is that it needs no cooperation and no answers from the patient, which makes it suitable for newborns, young children, and anyone whose behavioural responses cannot be relied upon. The test is usually requested for two purposes: estimating hearing thresholds in people who cannot respond to conventional testing, and checking the integrity of the nerve pathway when loss affects one ear, is asymmetric, or comes with one-sided tinnitus or dizziness. In newborns its role follows initial screening: when a refer result is repeated, this is the test that converts uncertainty into a clear decision. The test is painless and nothing is introduced into the body, but it requires stillness and full relaxation, because muscle movement, neck tension and crying add electrical noise that masks the response being sought. Children are therefore tested in natural sleep after a feed, or with a specific medical sleep arrangement when necessary and only by the doctor's decision. Adults are asked to lie down, close their eyes and relax the jaw and neck, and falling asleep during the recording is welcome rather than a problem. The limits of the test matter greatly, to prevent it being misread. This test **estimates** hearing thresholds; it does not produce a complete behavioural hearing profile, and it does not measure speech understanding or the ability to separate sound from background noise. It is also not a brain scan, does not measure intelligence, and does not diagnose autism, attention disorders or cognitive delay. A normal result does not exclude a central auditory processing difficulty, and an abnormal result must be interpreted together with the rest of the assessment rather than in isolation. Interpreting the result and deciding the next step are done through clinical examination and assessment by the audiologist and ear specialist, not by personally reading waveforms or figures in the report.
Procedure steps
- 1
Preparation and explanation
Hearing history, symptoms and medicines are reviewed, and the sensor sites on the forehead and behind the ears are cleaned to ensure good contact. It is explained that the test is painless and that the only requirement is stillness and relaxation. For children, the best natural sleep timing after a feed is agreed rather than trying to settle them in the clinic.
- 2
Placing sensors and earphones
Surface sensors are attached to the skin with no needles involved, and a small insert is placed in the canal or a headphone over the ear. The equipment checks contact quality and skin impedance before starting, because poor contact produces a noisy recording that is hard to interpret and forces a repeat.
- 3
Recording responses at different levels
Repeated clicks or short tones are presented to each ear separately, and responses are recorded at descending intensities down to the lowest level at which a clear waveform appears. Each level is recorded at least twice to confirm the waveform is reproducible, and this repetition is what makes the test reliable.
- 4
Analysing waveforms and latencies
The audiologist assesses the presence, shape and timing of the main waveforms and the differences between ears. Threshold estimation is based on the lowest intensity that produced a reproducible response, while latencies and inter-ear differences indicate the integrity of the nerve pathway and guide whether further investigation is needed.
- 5
Reporting and integration with other tests
The result is reported with a clear statement that it estimates hearing thresholds, and it is read alongside middle ear tests, otoacoustic emissions and behavioural audiometry where possible. The next step is then defined: monitoring, repeating the test later, starting hearing intervention, or referral to the ear specialist for further assessment.
Before the procedure
Wash your hair before the test and do not apply oil, gel or hairspray, since these prevent the sensors from making contact and add noise to the recording. For children: schedule the appointment to match your child's sleep time, delay the nap slightly before the visit, and feed the child at the clinic so that natural sleep follows. Bring comfortable clothing, a familiar blanket and toy, and spare nappies. Tell the audiologist about any medicines you or your child take, and about any current cold or ear infection, as the test may be postponed for a few days. Do not clean inside the ear with cotton buds and do not use oils or drops, because this pushes wax deeper and obstructs sound. For adults: avoid excess caffeine beforehand, wear clothing that allows you to lie down and relax your neck, and note that no fasting is needed. Tell the clinic in advance if the patient is very anxious or finds it hard to stay still.
After the procedure
There are no restrictions afterwards: work, school, feeding and eating can resume immediately, and any residue from the sensor gel on skin or hair washes off with water. If a medical sleep arrangement was used, follow the doctor's instructions precisely regarding monitoring, eating and drinking, and how the child is positioned in the car, and do not compare your child's recovery with another's. Keep the report in a permanent file and bring it to every visit, because the value of this test multiplies when compared with a later one. Do not interpret the figures or waveforms yourself and do not accept an interpretation from a non-specialist; ask for the next step and its date in writing. Seek care immediately if there is: **a sudden drop or loss of hearing in one ear**, **severe dizziness or imbalance**, **discharge or blood from the ear, or pain with fever**, **unusual heavy drowsiness or breathing difficulty in a child who was given a medical sleep arrangement**, or marked skin irritation at the sensor sites.
Expected duration
The test usually takes about 30 to 60 minutes for threshold estimation in both ears, and may be as short as 15 to 20 minutes when the aim is only to check the nerve pathway. It takes longer if a child needs time to fall asleep or if movement forces sections to be repeated, so the visit should be scheduled with more time than the recording itself.
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