01Purpose and principlesWhat the assessment is for and the core concepts behind it.
Weber and Rinne tests are useful when a rapid bedside assessment can help localise a hearing complaint before formal audiometry is available. Their strength is speed and their weakness is limited resolution. They compare perceptions rather than measure calibrated ear-specific thresholds. A clear result can support a provisional explanation, but a normal pattern cannot establish normal hearing across the frequency range, and an inconsistent result should prompt caution rather than an increasingly elaborate bedside diagnosis.
Air-conducted sound travels through the ear canal and middle-ear apparatus before stimulating the cochlea. Bone-conducted vibration reaches the cochleae through the skull and is less dependent on the ordinary transmission route. This distinction explains why a sizeable conductive deficit can reverse the usual preference for an air-conducted tone. It also explains a major trap: the patient may respond to bone vibration using the opposite, better cochlea, particularly when one ear has very poor sensorineural function.
The British Society of Audiology recommends a 512 Hz fork because it offers a useful balance of tone persistence, limited overtones and reduced confusion with felt vibration. Inspect the instrument for damage and hold the stem. Activate a tine against a padded surface or the examiner's elbow or hand rather than a hard object. Excessive force and an unsuitable striking surface can introduce unwanted frequencies, making the patient's comparison less meaningful.
Prepare the person before generating the tone. Establish how they will respond and ensure that your explanation itself is accessible. A child may point to the side on which the sound is heard. Reduce background noise and avoid leading questions such as asking whether the sound is louder in the ear already believed to be affected. Observe the patient's confidence and consistency; an uncertain response is a finding to record, not an error to conceal.
Key points
- Use a 512 Hz audiometric fork in a quiet setting and explain the listening task before testing.
- Perform Weber first, asking where the midline tone is perceived without suggesting a preferred side.
- For the BSA Rinne method, compare a brief air-conduction presentation with an immediate mastoid presentation and ask which sounded louder.
- Air louder than bone is Rinne positive; this occurs in normal hearing and sensorineural loss.
- Bone louder than air suggests a significant conductive component, but severe unilateral sensorineural loss can produce a false-negative result.
- Interpret both tests together and confirm clinically important findings with audiological assessment.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
Ask about onset, laterality, prior ear disease and the ear the patient considers better. Otoscopy identifies an obstruction or abnormal membrane that may help explain a conductive pattern. A normal view does not exclude cochlear disease, and a small amount of wax may be incidental.
A midline tone is usually perceived centrally with symmetrical hearing, including symmetrical sensorineural impairment. In asymmetric sensorineural loss it tends towards the better-hearing ear; with an asymmetric conductive component it tends towards the affected ear. Mixed or bilateral unequal disease can complicate this interpretation.
A positive result describes air conduction perceived louder than bone conduction. A negative result describes the reverse and usually suggests a significant conductive element. State the actual comparison and the side tested rather than recording only a symbol that may be misunderstood.
Weber towards the better ear despite a negative Rinne on the profoundly impaired side can reflect a false-negative Rinne. Longstanding unilateral sensorineural impairment can also produce less typical lateralisation. These patterns require formal assessment rather than an assumption that every response fits a simple diagram.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Weber using a 512 Hz forkFirst step - Why
- Assess the perceived location of bone-conducted sound before undertaking Rinne.
- Interpretation and limitations
- Place the footplate on the midline forehead, vertex or another suitable midline site. Support the head to maintain gentle firm contact, allow up to four seconds of listening, then ask whether the sound is central, in both ears or towards one side. Record the patient's response without converting it prematurely into a diagnosis.
- 02
Rinne using the BSA comparison method - Why
- Compare perceived loudness through air and bone in each ear.
- Interpretation and limitations
- Start with the ear towards which Weber lateralised. Hold the vibrating fork about 25 mm from the canal with its acoustic axis directed at the opening for approximately two seconds, then immediately place the footplate firmly on the mastoid for about two seconds, avoiding intervening hair. Ask which presentation was louder.
- 03
Appropriately masked pure-tone audiometry - Why
- Resolve uncertain localisation and quantify hearing sensitivity by frequency.
- Interpretation and limitations
- Formal masking can prevent the better cochlea from answering for the ear under test. This is particularly important when severe asymmetry makes a bedside bone response unreliable. Record whether the patient appeared to hear the mastoid presentation in the opposite ear and pass that observation to the audiologist.
- 04
Otoscopy and directed additional assessment - Why
- Relate the physiological clues to visible disease and associated symptoms.
- Interpretation and limitations
- Obstructing wax or middle-ear disease can support a conductive mechanism, but neither the fork nor the otoscope alone gives a complete diagnosis. New neurological findings and the chronology of hearing loss determine urgency independently of a provisional fork classification.
04Clinical next stepsHow the result changes management or prompts escalation.
01A consistent conductive patternFind the lesion and assess residual hearingFirst stepWeber is perceived towards the symptomatic ear and Rinne on that side shows bone louder than air.+
- 1Check for canal obstruction, inflammation, fluid, perforation or relevant ear surgery, and describe the examination rather than assuming one particular cause.
- 2Arrange treatment or ENT assessment appropriate to the observed lesion and the patient's symptoms, using safe ear-care methods.
- 3Confirm persistent hearing difficulty with audiometry after a reversible cause is addressed; a conductive component can coexist with cochlear impairment.
02A pattern suggesting asymmetric sensorineural lossLet the history determine the referral intervalWeber is heard towards the better ear with air louder than bone on the affected side, or the overall findings raise concern despite uncertainty.+
- 1Establish both how rapidly hearing deteriorated and when that deterioration occurred; these separate time measurements determine the NICE referral category.
- 2Arrange assessment within 24 hours for unexplained loss developing over three days or less within the previous 30 days. Older sudden loss and deterioration over four to 90 days require urgent assessment within two weeks.
- 3Communicate examination and fork results as supporting observations and ensure audiological assessment follows without delaying an urgent referral.
03A discordant or unreliable resultAvoid diagnosing from a single manoeuvreResponses conflict, the patient cannot compare reliably or profound unilateral impairment is suspected.+
- 1Recheck instructions, fork position and environmental noise, then repeat only as needed to establish whether the response is reproducible.
- 2Consider cross-hearing if a negative Rinne appears in the ear opposite the Weber lateralisation, especially with severe sensorineural asymmetry.
- 3Arrange appropriate formal testing with masking when indicated; do not use improvised contralateral noise as a substitute for a validated audiological procedure.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Document fork frequency, Weber location and each ear's actual air-versus-bone comparison, including any uncertainty or inability to hear the tone.
- Check that the referral outcome and formal audiogram explain the bedside pattern; a discrepancy may reflect test limitations or mixed disease.
- Review hearing after treatment of a visible conductive cause and reassess any continuing unilateral complaint.
- Ensure the patient has understood the urgency and practical arrangements for an indicated appointment, using written or accessible communication.
- Provide return advice for a further sudden change, new vertigo or neurological symptoms while assessment is pending.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Weber first reduces an important interpretive error
Testing lateralisation before Rinne gives context for a seemingly conductive response in a very poorly hearing ear. If the midline sound is heard in the opposite ear, the examiner should consider whether the later mastoid response is also being detected by that better cochlea.
Loudness comparison differs from sound extinction
The BSA procedure uses brief successive air and mastoid presentations and asks which is louder. Waiting for the mastoid sound to disappear and then moving to the canal is a different technique; avoid blending instructions from the two approaches or presenting the timing as interchangeable.
A small gap may escape the test
Tuning-fork performance varies with the size of the conductive component and the procedure used. A positive Rinne does not reliably exclude a small air-bone gap. When the patient describes persistent hearing difficulty, a near-normal bedside result is a reason to obtain suitable audiometry rather than dismiss the complaint.
The untested frequencies still matter
A 512 Hz response cannot describe high-frequency hearing in someone who struggles with consonants or competing speech. Bilaterally positive Rinne tests and a central Weber can coexist with considerable age-related or noise-related difficulty. Listening needs and a complete audiological assessment remain central.
07Common pitfallsFrequent interpretation and management errors.
- 01
Writing 'Rinne positive therefore normal' and overlooking the same response in sensorineural impairment.
- 02
Performing Rinne alone and missing evidence that a bone response came from the opposite cochlea.
- 03
Striking the fork on metal or furniture and producing distracting overtones.
- 04
Using subjective bedside tests to quantify a precise decibel deficit or to exclude disease at other frequencies.
- 05
Allowing repeated uncertain examinations to delay an urgent referral indicated by the history.