Otoscopy and the Rinne and Weber tests !

Maneuver

Looking into the ear with an otoscope and using a tuning fork to tell whether hearing loss is conductive or sensorineural.

Updated 2026-11-01

See it in 3D: Eardrum · Cochlea · Vestibulocochlear nerve (VIII) · Ear canal · Malleus · Incus · Stapes · Auricle

What it is

Otoscopy shows the external ear canal and the tympanic membrane. The Rinne and Weber tests, with a 512 Hz tuning fork, compare air with bone conduction and help classify hearing loss as conductive (outer or middle ear) or sensorineural (cochlea or nerve). They guide the cause and the urgency, but do not replace audiometry.

The anatomy it tests

Air conduction: sound travels down the canal, vibrates the eardrum and the ossicles (malleus, incus, stapes) and reaches the cochlea.
Bone conduction: vibration of the skull stimulates the cochlea directly, bypassing the middle ear.
Normally the middle ear amplifies, so air conduction is heard louder and longer than bone conduction.
In conductive loss, background noise is lost in the affected ear, so the Weber sounds louder on that side.
The cochlea and the vestibulocochlear nerve (VIII) turn vibration into nerve signals; damage to them reduces both routes.

How to do it

Otoscopy: choose the largest speculum that fits comfortably; in adults pull the auricle up and back; in children, down and back.
Brace the hand holding the otoscope against the patient's cheek to avoid injury if they move, and examine the healthy ear first.
Look at the canal (wax, swelling, discharge) and the eardrum: colour, translucency, position, light reflex and handle of the malleus.
Strike the 512 Hz fork on the elbow or knee so it vibrates without a metallic ring.
Weber: place the fork in the midline (vertex, forehead or incisors) and ask in which ear it sounds louder, or whether equal in both.
Rinne: place the fork on the mastoid process until the patient no longer hears it (bone conduction).
Without striking it again, hold the prongs about 2 centimetres from the ear canal and ask whether it is still heard (air conduction).
Repeat on the other ear and record each test result on each side.

How Weber and Rinne are read (in the affected ear)

Finding	Normal hearing	Conductive hearing loss	Sensorineural hearing loss
Weber	Heard in the middle or equally in both ears	Lateralises to the affected ear	Lateralises to the healthy ear
Rinne	Positive: air louder than bone	Negative: bone louder than air	Positive: air louder than bone, both reduced
Otoscopy	Pearly grey drum with a light reflex	Wax, foreign body, perforation or fluid behind the drum	Usually normal
Where the problem is	None	Canal, drum or ossicles (outer or middle ear)	Cochlea or vestibulocochlear nerve

What a positive result means

Weber towards the worse ear with a negative Rinne in that ear: conductive loss (wax, otitis media with effusion, perforation, otosclerosis).
Weber towards the healthy ear with a positive Rinne in the affected ear: sensorineural loss (presbycusis, noise, Ménière disease, acoustic neuroma).
Acute otitis media: bulging, red, opaque drum with poor mobility. Otitis externa: severe pain on pulling the auricle or pressing the tragus.
Sudden sensorineural loss in one ear is an otological emergency: refer to otolaryngology without delay.
A 'negative' Rinne can be false in profound unilateral sensorineural deafness: the other ear picks up the vibration through bone.

Usefulness and limits

They have low sensitivity, especially for mild loss; audiometry is needed to confirm and quantify.
A 512 Hz fork is the right one; lower frequencies are felt as vibration more than heard as sound.
Interpretation depends on patient cooperation; in young children it is unreliable.
Pneumatic otoscopy (eardrum mobility) improves the diagnosis of middle-ear fluid.

Test yourself

Think of the answer, then tap the question to see it.

A patient has impacted wax in the right ear. Where does the Weber lateralise and what is the right Rinne?

The Weber lateralises to the right (affected ear) and the right Rinne is negative: bone conduction beats air conduction.

In left sensorineural hearing loss, what do Weber and Rinne show?

The Weber lateralises to the right (healthy ear) and the left Rinne is positive, with both conductions reduced.

Which tuning fork frequency is used for these tests?

512 Hz, which balances sound duration against little felt vibration.

What does the eardrum look like in acute otitis media?

Bulging, red, opaque, without a light reflex and with poor mobility on pneumatic otoscopy.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

← All of the clinical exam

Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: Hearing Loss in Adults: Differential Diagnosis and Treatment (American Family Physician (American Academy of Family Physicians), 2019); Hearing loss: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); Audiometry: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026).

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