How do you properly use a tuning fork for hearing assessment?

How to Use a Tuning Fork for Hearing Assessment

Strike the tuning fork on your covered elbow or knee (never on hard surfaces), then perform both Weber and Rinne tests using a 256 or 512 Hz fork to distinguish between conductive and sensorineural hearing loss. 1

Proper Striking Technique

• Always strike the tuning fork on a protected elbow or knee to avoid generating nonharmonic frequencies that occur when struck against wooden or metal surfaces 1
• Use a 256 or 512 Hz tuning fork specifically for hearing assessment 1

Weber Test Procedure

Step 1: Activate and Position

• After striking the fork on your covered elbow/knee, place the vibrating tuning fork at the midline of the forehead or on maxillary teeth (avoid false teeth) 1

Step 2: Patient Response

• Ask the patient where they hear the sound 1
• Normal response: sound heard at midline or "everywhere" 1

Step 3: Interpretation

• If sound lateralizes to one ear: either conductive hearing loss (CHL) in that ear OR sensorineural hearing loss (SNHL) in the opposite ear 1

Rinne Test Procedure

Step 1: Bone Conduction

• Strike the fork on your covered elbow/knee 1
• Place the vibrating tuning fork over the mastoid bone of one ear 1

Step 2: Air Conduction

• Move the tuning fork to the entrance of the ear canal without touching the ear, with tines directed toward the ear 1

Step 3: Patient Response

• Ask where the sound is louder 1
• Normal (positive Rinne): sound heard better via air conduction at the ear canal entrance 1

Step 4: Interpretation

• If bone conduction > air conduction in the same ear: CHL in that ear 1
• If bone conduction > air conduction but in the opposite ear: SNHL in the test ear 1
• Repeat for the other ear 1

Combined Interpretation Pattern

Conductive Hearing Loss Pattern:

• Weber: lateralizes to affected ear 2
• Rinne: negative (bone > air) in affected ear 2

Sensorineural Hearing Loss Pattern:

• Weber: lateralizes to unaffected ear 2
• Rinne: positive (air > bone) in both ears 2

Critical Pitfalls to Avoid

• Never strike on hard surfaces: This creates nonharmonic frequencies that invalidate results 1
• Do not substitute formal audiometry: Tuning fork tests provide preliminary information only and do not replace audiometric testing 1
• Ensure quiet environment: Testing should occur in a quiet, relaxed setting to minimize interference 2
• Watch for misdiagnosis: Assuming CHL without considering SNHL can delay critical treatment for sudden sensorineural hearing loss 1

Alternative When Tuning Fork Unavailable

• The "hum test" can substitute for Weber: Ask the patient to hum; if they hear their own hum louder in the affected ear, this suggests CHL in that ear with similar accuracy to the Weber test 1
• Note: The hum test cannot replace Rinne testing 1

Clinical Context

The total examination duration (approach, contact, removal) should be approximately 2 seconds per application 1, and combining both Weber and Rinne results greatly aids in distinguishing between CHL and SNHL 1. This distinction is essential because these conditions have markedly different management strategies and prognoses, with CHL often having treatable causes like cerumen impaction 1.