What does the Rinne test assess for?

The Rinne Test: Assessment of Conductive vs. Sensorineural Hearing Loss

The Rinne test is a clinical examination that distinguishes between conductive hearing loss (CHL) and sensorineural hearing loss (SNHL) by comparing air conduction to bone conduction of sound. 1

Technique for Performing the Rinne Test

The proper technique for the Rinne test involves the following steps:

1. Preparation: Vibrate a tuning fork (256 or 512 Hz) by striking it on your covered elbow or knee, not on hard surfaces which can create nonharmonic frequencies

2. Bone conduction testing: Place the vibrating tuning fork firmly on the mastoid bone behind one ear

3. Air conduction testing: Move the tuning fork to the entrance of the ear canal (without touching the ear), with the tines directed toward the ear

4. Patient assessment: Ask the patient where the sound is heard better - via bone conduction or air conduction

5. Interpretation:

   • Normal result/SNHL: Sound is heard better via air conduction (positive Rinne)
   • Conductive hearing loss: Sound is heard better via bone conduction in the same ear (negative Rinne)

6. Repeat for the other ear 1

Clinical Significance

The Rinne test is particularly valuable in:

• Distinguishing between conductive and sensorineural hearing loss
• Providing initial diagnostic information before formal audiometric testing
• Guiding appropriate referral and management decisions

Accuracy and Limitations

The diagnostic accuracy of the Rinne test varies based on several factors:

• Tuning fork frequency: 256 Hz forks provide better sensitivity (43-91%) and specificity (50-100%) compared to 512 Hz forks (16-87% sensitivity, 55-100% specificity) 2

• Material of tuning fork: Steel tuning forks can detect smaller air-bone gaps (19 dB) compared to aluminum tuning forks (27 dB) 3

• Force applied: Optimal force for mastoid application is approximately 2400g (23.5 N), which provides better sensitivity, specificity and accuracy compared to lighter pressure 4

• Threshold for detection: The test typically becomes negative (indicating CHL) when the air-bone gap reaches 25-40 dB, depending on frequency 5

Common Pitfalls and Caveats

1. Improper striking technique: Always strike the tuning fork on a protected surface to avoid nonharmonic frequencies

2. Inadequate pressure: Insufficient pressure on the mastoid can lead to false-positive results

3. High-frequency conductive loss: Low-frequency tuning forks may miss conductive losses that primarily affect high frequencies 5

4. Vibrotactile responses: With 128 Hz forks, patients may feel rather than hear vibrations, leading to false interpretations 5

5. Relying solely on tuning fork tests: While useful for initial assessment, tuning fork tests should not replace formal audiometric testing 1

Integration with Other Tests

For optimal diagnostic accuracy, the Rinne test should be combined with:

• Weber test: Helps confirm the type of hearing loss by determining if sound lateralizes to one ear
• Otoscopic examination: Essential for visualizing potential causes of conductive hearing loss
• Formal audiometry: Provides definitive quantification of hearing loss when available 1

By properly performing and interpreting the Rinne test, clinicians can make preliminary distinctions between conductive and sensorineural hearing loss, which guides further diagnostic workup and management decisions to improve patient outcomes.