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# Tuning fork tests: Rinne, Weber and absolute bone conduction

- Examination

Three quick tuning fork tests tell a conductive from a sensorineural hearing loss at the bedside, before the audiogram.

Updated Nov 5, 2026

## Key points

- Use a 512 Hz fork.
- Rinne negative (bone louder than air) means a conductive loss of roughly 25 dB or more in that ear.
- Weber goes to the ear with a conductive loss and away from the ear with a sensorineural loss.
- A dead ear can give a false-negative Rinne, because the healthy cochlea hears the bone-conducted sound; Weber to the good ear unmasks it.
- Tuning forks do not replace audiometry and are of little help in bilateral symmetric loss.

## What it is

Tuning fork tests compare hearing by air conduction (through the canal and middle ear) with bone conduction (straight to the cochlea through the skull). Weber shows which ear the sound goes to, Rinne compares air and bone in each ear, and absolute bone conduction compares the patient's cochlea with the examiner's. Together they classify a one-sided loss as conductive or sensorineural in a minute. They are a screening and orientation tool: every abnormal or doubtful result goes to pure-tone audiometry. The basic technique is on the Rinne and Weber semiology page; this page focuses on interpretation and pitfalls.

## Findings and interpretation

- Normal hearing: Weber central, Rinne positive on both sides, absolute bone conduction the same as the examiner's.
- Right conductive loss: Weber to the right, Rinne negative on the right, absolute bone conduction normal.
- Right sensorineural loss: Weber to the left, Rinne positive on both sides (air and bone are both reduced on the right), absolute bone conduction reduced.
- Right profound sensorineural loss: Rinne may be falsely negative on the right; Weber to the left and reduced bone conduction give it away.
- Mixed loss and bilateral loss: tuning forks mislead; only audiometry with air and bone thresholds separates the components.
- A sudden one-sided sensorineural pattern is an emergency: the fork findings support it, the audiogram confirms it.

## How it is done

- Examine both canals first: wax, a foreign body or an effusion changes the result.
- Strike the 512 Hz fork on a firm but soft surface such as the elbow or knee.
- Weber: place the base on the vertex, forehead or upper incisors and ask whether the sound is louder on the right, the left or in the middle.
- Rinne: place the base on the mastoid until the sound stops, then hold the prongs about 2 cm from the canal and ask whether it is still heard.
- Absolute bone conduction: close the canal by pressing the tragus, place the fork on the patient's mastoid until the sound stops, then on the examiner's.
- Repeat Rinne and absolute bone conduction on the other ear.
- Record Weber (midline, right or left), Rinne (positive or negative) for each ear and absolute bone conduction (normal or reduced).

## Interpreting the three tests (affected ear)

| Pattern | Weber | Rinne | Absolute bone conduction |
| --- | --- | --- | --- |
| Normal | Midline | Positive (air louder than bone) | Same as the examiner |
| Conductive loss | To the affected ear | Negative (bone louder than air) | Normal |
| Sensorineural loss | To the better ear | Positive (both reduced) | Reduced |
| Profound one-sided sensorineural loss | To the better ear | False negative (heard by the other cochlea) | Reduced |

## Common mistakes

- Reading Rinne without Weber: a false-negative Rinne in a dead ear is then mistaken for a conductive loss.
- Testing over wax or an effusion that was not noted on otoscopy.
- Using a normal tuning fork result to rule out hearing loss: a mild loss can pass; send for audiometry when in doubt.

## Next step / Initial management

- Any hearing loss found or suspected: pure-tone audiometry with tympanometry.
- Conductive pattern: otoscopy guides care (wax removal, otitis treatment); a conductive loss with a normal drum suggests otosclerosis: routine ENT referral.
- Sudden sensorineural pattern (Weber to the good ear, Rinne positive) developing within 72 hours: refer the same day; corticosteroids work best when started early.
- One-sided or asymmetric sensorineural loss, or loss with other cranial nerve signs: refer to ENT for audiometry and MRI of the internal auditory canals.

## Test yourself

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

## Weber lateralises to the left; Rinne is negative on the left and positive on the right. What type of hearing loss is this?

Left conductive hearing loss.

## Weber goes to the right and Rinne is positive on both sides. Where is the problem?

Left sensorineural hearing loss: Weber moves away from the sensorineural ear.

## Why can a totally deaf ear give a negative Rinne?

Bone-conducted sound crosses the skull to the healthy cochlea, so it is «heard» on the mastoid but not by air: a false-negative Rinne.

## Roughly how large must a conductive loss be before Rinne turns negative?

About 25 dB or more; smaller air–bone gaps can leave Rinne positive, which is why audiometry is needed.

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## Elsewhere in DurgiPedia

- [Otoscopy and the Rinne and Weber tests](https://durgical.com/en/clinical-exam/otoscopy-and-the-rinne-and-weber-tests/)

## Connections

## Related 1

- [Pure-tone audiometry: how to read an audiogram](https://durgical.com/en/ent/pure-tone-audiometry-how-to-read-an-audiogram/)

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Hearing Loss](https://www.msdmanuals.com/professional/ear-nose-and-throat-disorders/hearing-loss/hearing-loss) (MSD Manual Professional Edition, 2026); [Sudden Deafness](https://www.nidcd.nih.gov/health/sudden-deafness) (NIDCD, National Institutes of Health, 2018); [Deafness and hearing loss (fact sheet)](https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss) (World Health Organization, 2026).

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Representative model, for educational purposes only.

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