Intended for healthcare professionals

Practice Rational Testing

Investigating sudden hearing loss in adults

BMJ 2018; 363 doi: (Published 12 November 2018) Cite this as: BMJ 2018;363:k4347

Re: Investigating sudden hearing loss in adults

I enjoyed reading this review but would take issue with the use of tuning fork tests which has been discussed previously(1).

In brief, Weber’s test can only be reliably interpreted when there is a unilateral hearing loss, but even in this situation an unacceptably high false-negative rate (30% refer to the midline limits its usefulness(2). Of the 70% who do lateralise, about a quarter does so to the ‘wrong’ ear(3). A recent study found a non-lateralising or incorrectly lateralising Weber’s test in over a fifth of 250 patients tested, and the test result did not reliably predict the audiometry results for the whole cohort(4). Rinne’s test is poorly sensitive at low air–bone gaps (50% at 10–20 dB), and the reliability depends markedly on the user’s experience and whether masking was used(5). A normal test result is not useful in ruling out hearing impairment in everyday clinical practice: a systematic review of five studies found low likelihood ratios ranging from 0.01 to 0.85(6).

I suggested (somewhat tongue-in-cheek) that, if it were possible, all the 256 and 512 Hz tuning-forks (for Weber’s or Rinne’s) would be smelted and re-made as (useful) 128 Hz ones (for vibration sense). This has the advantage, for neurologists, of ensuring that the correct-sized tuning-fork is available in clinic (1).

In 1886, Dr McBride expressed his concerns in this same journal that “the time-honoured tuning-fork test must now be considered as uncertain” (7). In 2018, shouldn’t we just drop the tuning fork test for hearing loss and focus on the other more effective modes of assessment, such as pure tone audiometry, as your otherwise excellent review highlighted?


1. McGurgan IJ and Nicholl DJ Weber’s and Rinne’s tests: bad vibrations? Pract Neurol. 2017 Aug;17(4):323-324. doi: 10.1136/practneurol-2017-001611.

2. Browning GG. Clinical otology and audiology. 2nd edn. Oxford: Butterworth-Heinemann, 1998:320.

3. Stankiewicz JA , Mowry HJ. Clinical accuracy of tuning fork tests. Laryngoscope 1979;89:1956–63.doi:10.1288/00005537-197912000-00009

4. Shuman AG , Li X , Halpin CF , et al Tuning fork testing in sudden sensorineural hearing loss. JAMA Intern Med2013;173:706–7.doi:10.1001/jamainternmed.2013.2813

5. Burkey JM , Lippy WH , Schuring AG , et al Clinical utility of the 512-Hz Rinne tuning fork test. Am J Otol 1998;19(1):59–62.

6. Bagai A , Thavendiranathan P , Detsky AS. Does this patient have hearing impairment? JAMA 2006;295:416–28.doi:10.1001/jama.295.4.416

7. McBride P The tuning-fork in diagnosis of lesions of the internal ear. Br Med J 1886;1:688.doi:10.1136/bmj.1.1319.688

Competing interests: No competing interests

13 December 2018
David J Nicholl
Consultant Neurologist
Dept of Neurology, City Hospital, Birmingham