Weber and Rinne tests together: conductive versus sensorineural loss
Weber's and Rinne's tests, read together, help show whether hearing loss is conductive (outer or middle ear) or sensorineural (inner ear or the nerve carrying hearing to the brain).
Remember
In unilateral loss, Weber's tone is louder in the affected ear if the loss is conductive but in the better ear if it is sensorineural, and a negative Rinne (bone louder than air) points to conductive loss, so read the two tests together.
Hearing loss can be conductive or sensorineural. In conductive loss, the outer or middle ear fails to pass sound on to the cochlea (the coiled hearing organ of the inner ear). In sensorineural loss, the cochlea or the hearing nerve is damaged.
Two tuning fork tests help to separate them. A tuning fork is an instrument that vibrates when struck; a 512 Hz fork, which vibrates 512 times a second, should be used.
Weber's test compares the two ears. The struck fork goes on the centre of the forehead, and the patient says whether it sounds louder in either ear. The vibration travels through the skull straight to the cochlea (this is bone conduction), so it bypasses a fault in the outer or middle ear.
In unilateral conductive loss, the tone is heard louder in the affected ear, because bone conduction is enhanced when air conduction (sound travelling through the ear canal and middle ear) is lost. In unilateral sensorineural loss, the tone is heard louder in the better ear.
Rinne's test compares air conduction with bone conduction in one ear. The fork is held on the mastoid process (the bony lump behind the ear) until the sound fades, then moved in front of the ear. Hearing it better through air is a positive Rinne, which is normal. A negative Rinne means bone conduction is better than air conduction, and it points to conductive loss in that ear. In sensorineural loss both routes are reduced about equally, so Rinne usually stays positive.
Weber alone is ambiguous. A tone heard louder in the left ear could mean conductive loss on the left or sensorineural loss on the right. Rinne in each ear helps decide between them, so the two tests are read together. Neither test replaces formal hearing assessment.
Key facts
- Weber in unilateral conductive loss
- the tone is louder in the affected ear.
- Weber in unilateral sensorineural loss
- the tone is louder in the better ear.
- Rinne in conductive loss
- can be negative, with bone conduction better than air conduction in the affected ear.
- Rinne in sensorineural loss
- usually stays positive, with air better than bone, because both are reduced about equally.
- Normal result
- the Weber tone stays central and equally loud, and Rinne is positive in each ear.
- A positive Rinne
- does not mean that hearing is normal, because Rinne also usually stays positive in sensorineural loss.
- Sudden hearing loss
- needs an urgent GP appointment or NHS 111 contact, whatever the tuning fork shows.
Exam traps
- A Weber tone that is louder in the unaffected ear does not fit unilateral conductive loss, because that is the pattern of unilateral sensorineural loss, where the damaged cochlea or nerve detects the tone less well.
- Weber alone does not separate a right sensorineural loss from a left conductive loss, because both send the tone to the left ear (the better ear in the first, the affected ear in the second); the Rinne in each ear helps decide it.
- Equal sensorineural loss in both ears does not explain a tone heard louder on one side, because it would be expected to give a Weber tone heard equally in both ears.
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