Rinne and Weber Tuning Fork Test Interpreter
Rinne and Weber Tuning Fork Test Interpreter
The twelve possible Rinne and Weber combinations and the pattern each one points to, including the four that are internally inconsistent and the false negative Rinne that produces them.
Rinne and Weber pattern
All twelve combinationsRinne negative on the right, Rinne positive on the left, Weber lateralising to the right
All twelve Rinne and Weber combinations
| Rinne right | Rinne left | Weber | Pattern indicated |
|---|---|---|---|
| Positive | Positive | Central | Normal, or a symmetrical sensorineural loss |
| Positive | Positive | Right | Asymmetrical sensorineural loss, poorer on the LEFT |
| Positive | Positive | Left | Asymmetrical sensorineural loss, poorer on the RIGHT |
| Negative | Positive | Right | Conductive component, right ear — the two tests agree |
| Positive | Negative | Left | Conductive component, left ear — the two tests agree |
| Negative | Positive | Central | Right conductive component the Weber has not detected, or a mixed loss |
| Positive | Negative | Central | Left conductive component the Weber has not detected, or a mixed loss |
| Negative | Positive | Left | Inconsistent — suspect a false negative Rinne on the right from a severe right sensorineural loss |
| Positive | Negative | Right | Inconsistent — suspect a false negative Rinne on the left from a severe left sensorineural loss |
| Negative | Negative | Central | Bilateral conductive component, similar on the two sides |
| Negative | Negative | Right | Bilateral conductive component, greater on the RIGHT |
| Negative | Negative | Left | Bilateral conductive component, greater on the LEFT |
What the tuning fork can and cannot see
| Property | Figure or wording | Consequence |
|---|---|---|
| Fork | “The preferred tuning fork is a 512Hz tuning fork” | Lower frequencies are felt as much as heard; higher ones decay too fast |
| Air-bone gap the Rinne detects | “able to distinguish a conductive hearing loss with an air-bone gap of 17.5 dB – 30 dB” | A gap meeting the published 10 dB or 15 dB audiometric criteria may not turn the Rinne negative at all |
| Rinne performance | Sensitivity estimated at 76.86%, specificity 85.48% | Roughly one conductive loss in four is missed and one normal ear in seven is called abnormal |
| Weber alone, as a screen for sudden sensorineural loss | Sensitivity “likely to be around 78%” | Not a rule-out test |
| Known blind spots | “limited use detecting mild conductive hearing losses or mixed hearing losses”; with longstanding one-sided sensorineural loss “the Weber response can be central and not lateralised” | A normal pair of tuning fork tests does not exclude a hearing loss of any type |
Two crude tests that are only interpretable together
The Rinne and the Weber are the bedside version of the air-bone gap, and they work on the same physics. The Rinne compares air conduction at the ear canal with bone conduction on the mastoid in one ear: if bone is louder, something in the conductive pathway is attenuating the air-conducted sound, and the result is called negative. The Weber puts the fork on the midline and asks where the sound is heard, which detects asymmetry between the ears. Neither is interpretable without the other, because the Weber’s rule reverses depending on the type of loss: in conductive loss the midline fork is heard in the poorer ear, and in sensorineural loss in the better ear. The Rinne is what tells you which rule to apply, and getting that pairing the wrong way round is the commonest error in this examination.
There are only twelve possible combinations, and each one says something different. Four are the straightforwardly consistent patterns. Two more place an asymmetrical sensorineural loss on the side away from the Weber. Two show bilateral conductive loss with an asymmetry. Two show a conductive Rinne with a Weber that has not moved, which means either a gap too small to shift the percept or a mixed loss pulling it back. And two are internally inconsistent — a negative Rinne on one side with the Weber going the other way.
Those last two are the most useful rows in the table, because they are not noise. They are the signature of the false negative Rinne, which BSA describes as occurring when bone conduction crosses the skull and is heard by the better cochlea in the non-test ear, with a severe sensorineural loss on the side being tested. The ear that looked conductive is in fact severely sensorineural, and the Weber, lateralising correctly to the better ear, is the test that catches it. An examiner who treats the inconsistency as a mistake and re-tests until the two agree has thrown away the finding.
The limits are worth stating as plainly as BSA states them. These tests indicate type and never degree. The Rinne is reported as able to distinguish a conductive loss with an air-bone gap of 17.5 to 30 dB, with a sensitivity of about 77% and a specificity of about 85%, which leaves a whole band of criterion-meeting conductive loss below its floor and misses roughly one in four. They are particularly subjective and vulnerable to response bias. A normal pair excludes nothing, and BSA’s own position is that a tuning fork result “should not be the sole indicator on which a decision for further audiological assessment is based”. Audiometric results are equipment- and calibration-dependent: the dB HL scale is defined against the reference equivalent threshold levels of the ISO 389 series for a particular transducer and coupler, so the same ear can read differently on two audiometers, and the BSA recommended procedure puts the uncertainty of any threshold measurement at no better than plus or minus 5 dB. Your own audiogram and the calibration standard it was recorded against govern, not this arithmetic.
Frequently asked questions
What does a negative Rinne mean?
That bone conduction on the mastoid was louder than air conduction at the ear canal, which indicates a significant conductive element in that ear. A positive Rinne — air louder — indicates either normal hearing or a sensorineural loss, so it cannot distinguish those two.
Which way does the Weber lateralise?
It depends on the type of loss, which is why the Rinne has to be done too. With an asymmetrical conductive loss the midline fork is heard in the POORER ear; with an asymmetrical sensorineural loss it is heard in the BETTER ear. With symmetrical hearing, or a symmetrical loss, it is central.
What is a false negative Rinne?
A Rinne that reads negative without any conductive component. BSA describes it as occurring when bone conduction crosses the skull and is detected by the better cochlea in the non-test ear, which happens with a severe sensorineural loss on the side being tested. The giveaway is a Weber that lateralises AWAY from the apparently conductive ear.
How large an air-bone gap does the Rinne detect?
BSA’s procedure reports it as able to distinguish a conductive hearing loss with an air-bone gap of 17.5 to 30 dB, and notes it “has limited use detecting mild conductive hearing losses or mixed hearing losses”. Published audiometric criteria for a significant gap start at 10 to 15 dB, so there is a real band of conductive loss the fork cannot reach.
Which tuning fork should be used?
BSA states that “the preferred tuning fork is a 512Hz tuning fork”. Lower frequencies are increasingly felt as vibration rather than heard, which contaminates the comparison, and higher ones decay too quickly to complete the test.
Related calculators
References
- British Society of Audiology. Recommended Procedure: Rinne and Weber tuning fork tests, OD104-51. Reading: BSA, 2022.
- British Society of Audiology. Recommended Procedure: Pure-tone air-conduction and bone-conduction threshold audiometry with and without masking, OD104-32. Reading: BSA, 2018.
- Repatriation Medical Authority. Statement of Principles concerning conductive hearing loss. Australian Government Department of Veterans’ Affairs (CLIK).
Not medical advice. For healthcare professionals and education. Reference intervals vary by laboratory and assay — always use your own laboratory's. Never base a dose or a treatment decision on this page alone. Full disclaimer at calcengines.com/disclaimer/