Weber and Rinne tests — The Weber and Rinne tests can help direct the remainder of the evaluation, but should not be used as screening evaluations for hearing loss [5,6]. The tuning fork used should be 512 Hz.

Weber test — The Weber tuning fork test is performed by pressing the handle of the tuning fork to the bridge of the forehead, nose, or teeth and asking the patient if the sound is louder in one ear or the other. The sound is heard equally in both ears in patients with normal hearing or symmetric hearing loss.

Rinne test — The Rinne test allows comparison of sound when the tuning fork is placed on the mastoid bone behind the ear (bone conduction), versus when the tuning fork is held near the ear (air conduction) [7,8]. An abnormal result occurs when sound is at least equally loud or louder when the fork is placed on bone as compared with when it is held next to the ear (bone>air conduction). The Rinne test is considered normal when the vibrating fork placed near the ear is louder than when placed on the mastoid bone (air>bone conduction).

One method for performing the Rinne test is to press the handle of the tuning fork to the mastoid bone and ask the patient to tell the examiner when the sound is no longer audible. At that point, the vibrating end of the tuning fork is placed near the external auditory canal (EAC). If the patient can again hear the tuning fork, the Rinne test is normal.

Interpretation — The Weber and Rinne tests can then be used to help distinguish conductive from sensorineural hearing loss (table 2 and figure 1):

●In patients complaining of a unilateral decrease in hearing, the Weber test suggests sensorineural hearing loss if the sound lateralizes (is louder on) to the “good” side; conductive hearing loss is suspected if the sound lateralizes to the “bad” side.

●An abnormal Rinne test, with bone>air conduction, is consistent with conductive loss, particularly if the Weber test also lateralizes to that side.

●When the Weber test lateralizes to an ear in which the Rinne is normal, the Rinne test in the opposite ear should be performed. A normal Rinne test in the contralateral ear suggests sensorineural hearing loss in this contralateral ear (ie, the Weber lateralized to the normal ear). An audiogram is indicated in this situation.

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