Rinne and Weber Tests: two simple tuning fork tests

The Rinne test assesses how well a patient hears sound conducted through air compared to sound conducted through bone. A vibrating tuning fork is first placed on the mastoid bone behind the ear to test bone conduction. When the patient can no longer hear the sound, the fork is moved to a position just outside the ear canal to test air conduction.

If the patient can still hear the sound when the fork is moved next to the ear, meaning air conduction is better than bone conduction, the Rinne test is considered positive (normal finding); it also occurs in sensorineural hearing loss. 

If, on the other hand, the patient hears the sound better through the mastoid bone than through the air, the test is negative; it is a sign that something is blocking or impairing sound transmission through the outer or middle ear, such as earwax, fluid behind the eardrum or otosclerosis.

The Weber test assesses whether sound is perceived equally in both ears or localises to one side. A vibrating tuning fork is placed on the centre of the patient's forehead or the top of the skull, and the patient is asked whether they hear the sound equally in both ears or more strongly in one.

• Sound heard equally on both sides: suggests normal hearing or a symmetrical hearing loss
• Sound lateralises to the worse ear: points to a conductive hearing loss on that side; it reduced background noise entering through the ear canal makes bone-conducted sound seem louder
• Sound lateralises to the better ear: suggests sensorineural hearing loss in the opposite ear, where cochlear or auditory nerve damage reduces bone-conducted sound perception.

The real diagnostic value of these two tests emerges when their results are read together. Each test alone gives a partial picture; combined, they allow clinicians to identify both the type and the location of hearing loss:

1. Negative Rinne + Weber lateralises to the same ear → conductive hearing loss on that side
2. Positive Rinne (both ears) + Weber lateralises to the better ear → sensorineural hearing loss in the opposite ear
3. Negative Rinne (one ear) + Weber lateralises to the opposite ear → mixed hearing loss
4. Positive Rinne (both ears) + no lateralisation → normal hearing or symmetrical loss

These combinations are always interpreted alongside the patient's clinical history. 

The Rinne and Weber tests are typically performed when a patient reports a noticeable difference in hearing between the two ears, or when a clinician suspects hearing loss during a routine examination. Common situations include:

• Sudden or unexplained hearing loss in one ear
• Recurrent ear infections or a history of otitis media
• Ear pain, pressure or fullness that affects hearing
• Following a head or ear trauma

Because they require no equipment other than a tuning fork and take only a few minutes, these tests are routinely performed in both GP and specialist settings.

While the Rinne and Weber tests are useful screening tools, they have limitations:

• They rely on subjective patient responses, which can vary
• They are less accurate in cases of severe hearing loss
• A false negative Rinne result can occur in cases of severe sensorineural hearing loss (where bone conduction is also significantly reduced)
• They do not replace formal audiometric testing, which provides precise, quantitative data across multiple frequencies

For a full hearing assessment, tuning fork tests are typically used alongside pure-tone audiometry and tympanometry.