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Cookie bite or U-shaped audiograms.

Timothy C. Hain, MD Hearing Page Page last modified: November 19, 2016

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There are many patterns of hearing loss. Generally clinicians group them along several axes; sensory vs conductive; the severity axis -- mild vs moderate vs. profound; the time axis -- sudden vs progressive vs chronic, and the frequency spectrum that is affected. Roughly speaking, the frequency patterns of hearing loss are divided up into: Low-frequency, mid-frequency, high-frequency, notches, and flat. The "cookie bite" audiogram is a bilateral mid frequency notch. It is different from the "noise" notch which is generally centered at about 4K, because the "cookie bite" occurs at a lower frequency.

There are also combinations of the above patterns -- mainly the "peaked", which is a mixture of low and high-frequency, sparing mid-frequency.

Some common audiogram shapes are shown below:


Normal audiogram -- threshhold of 0. Noise Notch -- hearing loss centered at 4K


Examples of other abnormal hearing patterns are shown below

low frequency cookie high flat
Low frequency (Meniere's) -- also a low/high (peaked) is common in Meniere's. Middle (or "cookie bite") centered on 1K High-frequency loss, beginning at 8K Flat hearing loss in both ears, R is worse.

Here we are discussing only U-shaped or cookie bite patterns.

As an overview, mid-frequency hearing loss is traditionally attributed to congenital hearing disorders(Wong & Bance, 2004) -- also see below.

Cookie bites have also been described after carbon monoxide intoxication (Baker & Lilly, 1977), in patients with acoustic neuromas (Shah, Blevins, & Karmody, 2005).

Our impression is that "cookie bites" have been very little studied. In our own patients, "cookie bite" hearing loss is usually stable over decades, and often seem ignored by the patient. Cookie bites are nearly always bilateral.


Papers are easy to publish about genetic hearing loss conditions, so the literature is oversupplied with these. If there is a family history you should be thinking about this.

Wong and Bance(2004) discussed causes of cookie bites including non-ocular Stickler’s syndrome(Admiraal, Brunner, Dijkstra, Huygen, & Cremers, 2000) and Waardenberg’s which are autosomal dominant. Also U shaped audiograms are occasionally seen in mutations of connexin 26 (autosomal recessive).




Copyright November 19, 2016 , Timothy C. Hain, M.D. All rights reserved. Last saved on November 19, 2016