Ignacio Berdejo GagoAudiometry TechnicianOtolaryngology Service
Miguel Caballero BorregoEar, Nose and Throat SpecialistOtolaryngology Service
Published: 18 May 2018 Updated: 18 May 2018
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Tuning
Fork Tests (Rinne’s and Weber’s tests)
How to do Rinne and Weber tuning fork tests for doctors, medical student finals, OSCEs and MRCP PACES
Background to the tuning fork tests
The tuning fork tests provide a reliable clinical method for assessing hearing loss
They are most useful in patients with unilateral hearing loss which is purely conductive or purely sensorineural
Patients with bilateral loss or
mixed losses are better assessed with formal pure tone audiometry
These tests should be carried out with a full examination of the cranial nerves or the ear
The Rinne and Weber tests help
distinguish between a conductive hearing loss (CHL) and sensorineural Hearing Loss (SHL)
Other tuning fork tests include the Schwabach and Bing tests, though these are not used in routine practice
Video on Rinne and Weber tests by Oxford Medical Education
Introduction (WIIPPPE)
Wash your hands
Introduce yourself (name and position)
Identity of patient (confirm name and date of birth)
Permission (consent and explain examination: “I’m going to examine your hearing using this
tuning fork now, is that OK?”)
Pain (especially over the mastoid)
Position (sitting comfortably)
Exposure
Equipment
A 512 Hz tuning fork
Note you should ideally be in a completely silent room for Rinne and Weber tests
How to do Weber’s Test
To perform Weber’s test strike the fork against your knee or elbow, then
place the base of the fork in the midline, high on the patient’s forehead
It is important to steady the patient’s head with your other hand so that reasonably firm pressure can be applied
Then ask the patient: “Do you hear the sound louder in one ear than the other?”
If so, in which ear is it louder?
If the patient is unclear, you may ask if they hear it “everywhere.” Be careful not to ask the question in a leading
manner
Interpretation of Weber’s test
Weber’s test will ‘lateralise’, i.e. move to one side, with a relatively small amount of hearing loss (5dB)
If a patient has a unilateral conductive hearing loss, the tuning fork sound will be heard louder in the deaf ear
If a patient has a unilateral sensorineural hearing loss, the tuning fork sound will be heard
louder in the normal ear
In bilateral and symmetrical hearing loss of either type Weber’s test will be normal
The various outcomes of Rinne and Weber tests are shown below
Interpretation of Rinne’s and Weber’s tests
Test
Normal
Conductive Hearing Loss
Sensorineural Hearing Loss
Rinne's
Air louder than Bone (Rinne’s Positive)
Bone louder than Air (Rinne’s Negative)
Air louder than Bone (Rinne’s false positive)
Weber's
Sound heard in midline
Sound heard in bad ear
Sound heard in good ear
How to do Rinne’s Test
This test aims compare air conduction with bone conduction
Rinne’s test has a high sensitivity (0.84) though this varies with the skill of the examiner
Rinne’s test can only detect a conductive hearing loss of at least 30dB
Explain the test first:
“I’m going to put this vibrating tuning fork in two positions, one touching the bone near you ear, one a short
distance from the ear. I want you to tell me which position you hear the tuning fork loudest in”
Begin by striking the tuning fork against your knee or elbow
Hold the tuning fork in one hand and place the base against the patient’s mastoid process (see video)
Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of the sound
Then promptly lift the fork off the mastoid process and place the vibrating tips about 1cm from their external auditory meatus
Leave it there again for a few seconds before taking the tuning fork away from their ear
Ask the patient in which of the positions they were able to hear the note the loudest in
What is a positive and negative Rinne’s Test?
A patient who hears the tuning fork loudest when held 1cm from the
external auditory meatus has a positive Rinne’s test
A patient who hears the fork loudest when it is held against the mastoid process has a negative Rinne’s test
Interpretations of Rinne’s Test
In a normal ear sound is conducted to the cochlear most efficiently via air conduction. Sound can also be transmitted to the cochlea, less efficiently, via bone
So…
1) If a patient can hear best when the tuning fork is in the air (positive Rinne’s) then air conduction is better than bone conduction so there is no significant conductive hearing loss
Therefore in sensorineural hearing loss on the right, for example, Rinne’s test should be positive on the right
2) If the patient can hear best when the tuning fork is on the mastoid (negative Rinne’s) bone
conduction is better than than air conduction, demonstrating a conductive hearing loss
False negative Rinne’s Test
The difficulty in interpreting Rinne’s test is in total unilateral sensorineural hearing loss (i.e. a ‘dead’ ear)
For example, imagine the right ear is ‘dead’. On testing bone conduction on the right the sound travels to the good left (i.e. untested) ear and sounds louder than when the fork is
held next to the external auditory meatus on the side being tested
The patient reports that bone conduction is better than air conduction giving a false negative Rinne’s test
Complete the examination
Thank the patient, make sure they’re comfortable and ask if they need any help in getting dressed
Wash your hands
In an exam, then turn to examiner with your hands behind back holding your stethoscope, before saying: “To
complete my examination, I would like to…”
Take a full history
Perform formal pure tone audiometry if there is any concern about hearing loss
Do a cranial nerve examination if any concern of damage to other cranial nerves
Click here for qustions about the auditory nerve (8th nerve)
…and
click here for how to examine the ear
Perfect revision for medical student finals, OSCES and PACES
What test is used for conduction deafness?
The Weber test is a useful, quick, and simple screening test for evaluating hearing loss. The test can detect unilateral conductive and sensorineural hearing loss. The outer and middle ear mediate conductive hearing. The inner ear mediates sensorineural hearing.
What are the names of the two tests to detect hearing problems that require the use of a tuning fork?
A tuning fork is a two-pronged, metal instrument that produces sound when struck. This test may indicate whether hearing loss is caused by damage to the vibrating parts of your middle ear and eardrum, or damage to inner ear nerves or damage to both. The Rinne and the Weber are the two main types of tuning fork tests.