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