- Email: [email protected]
The implications of variability in the instruction and practice of the Rinne test
Translational Research in Anatomy 18 (2020) 100053
Contents lists available at ScienceDirect
Translational Research in Anatomy journal homepage: www.elsevier.com/locate/tria
The implications of variability in the instruction and practice of the Rinne test
T
Shauna Matya,∗, Kristen Salanaa,∗∗, Robert Hageb a b
St. George's University, School of Medicine, St. George, Grenada, West Indies St. George's University, Department of Anatomical Sciences, St. George, Grenada, West Indies
A R T I C LE I N FO
A B S T R A C T
Keywords: Rinne test Weber test Hearing test Medical education Audiometry
Purpose: Prior to graduation, all medical students are expected to master the delivery of two basic hearing examinations: the Rinne and Weber tuning fork tests. Throughout basic science years, these tests are routinely examined to determine student competency in clinical skills. However, there exists a high level of variation between practitioners in their modes of implementing these examinations. Materials and methods: Utilizing online databases, YouTube and PubMed, the phrases “Rinne tuning fork test” and “Weber tuning fork test” were searched to find instructional guidelines on how to perform these hearing examinations. Each medium was assessed on five different parameters related to clinical implementation of the hearing exam. In total, 31 of 35 videos met inclusion criteria with views ranging from 1,000 to 1,100,000 and were subsequently assessed for data collection. Results: Through our research investigating instructional video resources of the Rinne test, as well as guidelines in textbooks and journal articles, we were able to determine the major source of incongruity in the instructional process. Of the 31 videos analyzed, bone conduction was tested prior to air conduction in 30 of the 31 videos, while 20 of 31 practitioners held the fork tines parallel to the axis of hearing with the point of reference being the external auditory canal. Only 3 of 31 videos provided guidance regarding the distance the tuning fork should be held away from the patient. A high level of variability exists concerning the purported best approach to testing air and bone conduction in the educational materials available. Conclusion: After reviewing and cross-referencing multiple sources from different mediums, the conclusion was drawn that specific parameters of delivery did not impact the diagnostic reliability of the Rinne test. The major commonality amongst these educational sources was that patients must be able to identify air conduction being louder that bone conduction in order to have a “positive” Rinne test. Given the high level of discrepancy that exists and the likelihood that these examinations will be replaced by audiometry, are these screening tests necessary to teach medical students?
1. Introduction The basic 512 Hz tuning fork hearing examinations medical students are taught in their basic science years are the Rinne and Weber tests [1]. Performance of the Rinne test is an easily testable skill in an Objective Structured Physical Exam (OSPE) that allows instructors to assess the competence of students [2]. How frequently students will utilize these tests in clinical rotations and in their future practice will vary based on the specialty they pursue. However, based on extensive research, students may be exposed to conflicting techniques on how to perform the test by clinicians and academic faculty (see Table 1). Although the Rinne test appears to be a simple and straightforward ∗
hearing exam, many experts maintain diverging opinions on the most efficacious method of implementation with minimal tolerance for deviation from their preferred approach. A survey distributed among Canadian otolaryngologists revealed confusion amongst these specialists in regards to the reference point of the tuning fork tines when asked if they held it parallel or perpendicular relative to the external auditory canal when performing the Rinne test [3]. 2. Materials and Methods Initial research on the gold standard method to perform the Rinne and Weber tests yielded varying results. An attempt to create uniform
Corresponding author. Corresponding author. E-mail addresses: [email protected] (S. Maty), [email protected] (K. Salana), [email protected] (R. Hage).
∗∗
https://doi.org/10.1016/j.tria.2019.100053 Received 12 September 2019; Accepted 14 November 2019 Available online 20 November 2019 2214-854X/ © 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
2
1,059,171
595,496
532,433 379,167
366,302 168,381 154,023
149,142
105,978 96,526 89,721 67,852
48,734 38,067 35,248
33,459
Views
30,889
28,870
https://www.youtube.com/watch?time_continue=4&v=sJBpai74tlU
https://www.youtube.com/watch?v=RVH4K4EcsiA
https://www.youtube.com/watch?v=vU8-PLsdJ-w
https://www.youtube.com/watch?v=CU5Mz18U3jQ
https://www.youtube.com/watch?v=kNLBAuOQlhc https://www.youtube.com/watch?v=GeC0A-cDx9w https://www.youtube.com/watch?v=2js72BYjZAw
https://www.youtube.com/watch?v=FNy7dgOwu30
https://www.youtube.com/watch?v=7BQFKnP-7Qg https://www.youtube.com/watch?v=FgF91K7dU8Y
https://www.youtube.com/watch?v=_ZKPrYLKY-Y
https://www.youtube.com/watch?v=8UFmMIm9kZs
https://www.youtube.com/watch?v=uI6_nPCkdK4
https://www.youtube.com/watch?v=9PH1xjefjpo
https://www.youtube.com/watch?v=2uDriyP9PwE
https://www.youtube.com/watch?v=AdiUYCn7r_M
Website
https://www.youtube.com/watch?v=ybqWpp5AKbA
https://www.youtube.com/watch?v=8c_E9vzcZNk
Cranial Nerve Examination: OSCE Guide Hearing Test (Rinne and Weber Examinations) – ENT Examination of the Cranial Nerves: Explanation UBC Medicine Neurology Clinical Skills - Cranial Nerves Examination Rinnes and Webers Test Rinne Test AAO-HNSF The ENT Exam Episode 1: The Ear Exam Cranial Nerve VIII Auditory Acuity, Weber & Rinne Tests 20 Rinne Test Weber and Rinne Test Clinical Examination Ear Examination with Weber and Rinne Test Target USMLE: Abnormal hearing - Rinne/Weber test Performing the weber and rinne tests Clinical skills: doing the Rinne test in English ENT: Clinical Physical Examination Hearing Tests Rinne's Weber' Test Professor Abnormal Cranial Nerve VIII - Auditory Acuity, Weber & Rinne Name of Video
Rinne & Weber Tests Cranial Nerve VIII examination evaluating loss of hearing Hearing Tests
Views
Website
Name of Video
Table 1 Video sources analyzed with corresponding Rinne test methodology.
BC
BC
Air Conduction (AC) or Bone Conduction (BC)
BC
BC
BC
BC
BC
BC
BC BC
BC
BC BC BC
BC
BC
AC
BC
Air Conduction (AC) or Bone Conduction (BC)
✓ ✓
-
Parallel to axis of hearing
✓ ✓
-
✓a -
✓
N/A
Patient asked which sound is louder -
-
✓ N/A
✓
✓ ✓a ✓ ✓
✓ ✓ -
✓
Patient alerts practitioner when sound ends
✓
✓
✓
✓
✓
✓
✓ ✓
-
-
-
-
-
-
-
-
-
✓
✓ -
-
-
-
-
-
-
-
-
-
-
-
-
✓ ✓
✓
-
✓
N/A
1-2 cmb
Distance of tuning fork from ear
N/A
N/A
N/A
1-2 cmb
N/A
N/A
N/A N/A
N/A
N/A N/A N/A
N/A
N/A
N/A
N/A
Distance of tuning fork from ear
(continued on next page)
Head supported
Perpendicular to axis of hearing
✓ ✓
-
✓
✓
-
✓
✓
-
✓
✓
✓
✓
✓
-
-
✓
Head supported
-
Perpendicular to axis of hearing
✓
Parallel to axis of hearing
Patient asked which sound is louder
Patient alerts practitioner when sound ends
S. Maty, et al.
Translational Research in Anatomy 18 (2020) 100053
3
13,548
13,013 12,261 8,225 7,506 7,333
2,765 1,775
https://www.youtube.com/watch?v=LhcW0OAYrqk
https://www.youtube.com/watch?v=QUv7YAeOVSY https://www.youtube.com/watch?v=rZSubCKg4QI
https://www.youtube.com/watch?v=IAqD84jYuZE
https://www.youtube.com/watch?v=6jKktrjng0A
https://www.youtube.com/watch?v=NshiaiR-jng
https://www.youtube.com/watch?v=B37pgI-OHSM https://www.youtube.com/watch?v=aGgF5Mlqolk
b
a
15,431
https://www.youtube.com/watch?v=VcTdFAavYXs
BC BC
BC BC
BC
BC
BC
BC BC
BC
BC
BC
Air Conduction (AC) or Bone Conduction (BC)
✓ ✓ ✓a
-
✓ ✓ ✓ ✓a
✓ ✓
✓ -
-
-
✓
✓
✓
-
✓
✓
✓
✓
-
✓
-
-
-
✓
Parallel to axis of hearing
Patient asked which sound is louder
Patient alerts practitioner when sound ends
✓ -
✓ -
-
✓
-
✓ ✓
-
N/A
✓
Perpendicular to axis of hearing
✓
-
-
-
✓
✓
-
-
-
Head supported
N/A N/A
N/A N/A
N/A
N/A
N/A
N/A N/A
N/A
2 cmb
N/A
Distance of tuning fork from ear
The practitioners in the videos referenced instructed that both of these methods were clinically valid: telling a patient to alert them when the sound ended, or to verbalize which sound was louder (AC or BC). Distance from opening of external auditory canal
1,144 N/A
25,888
https://www.youtube.com/watch?v=MxnhFM0Fwos
ENT - Hearing tests - Rinne and Weber's examinations Tuning Fork Tests - For Medical Students Weber's and Rinne's Tests Explained in 3 Minutes | Medic in a Minute UW, Rinnes test ENT Examination 3 - Clinic Based Hearing Tests 08.Hearing evaluation -Rinne Test.avi Otoscopy/Rinne and weber test Assessment - Cranial Nerves - Cranial Nerve 8 – Auditory Acuity, Weber & Rinne Tests How to do Rinne's Test How to Perform the Rinne Hearing Test Rinne's and Weber's Test Rinne's Tuning Fork Test
https://www.youtube.com/watch?v=e-hdkzKaJe0 https://simbrazil.mediviewprojects.org/index.php/hearing/tuning-forktests/rinnes-test
Views
Website
Name of Video
Table 1 (continued)
S. Maty, et al.
Translational Research in Anatomy 18 (2020) 100053
Translational Research in Anatomy 18 (2020) 100053
S. Maty, et al.
4.2. Should the bone conduction part of the test be performed before or after the air conduction part of the test?
guidelines to perform these tests has previously been attempted by the British Society of Audiology with their publication of “Recommended Procedure Rinne and Weber Tuning Fork Tests.” However, the widespread variation uncovered throughout this research indicated the published guidelines are not universally adhered to Refs. [4,5]. To find the most disseminated instructional videos and documents on these hearing tests, the phrases “Rinne tuning fork test” and “Weber tuning fork test” were searched. This allowed access to numerous instructional videos and academic guidelines from YouTube and PubMed. To ensure reliability and accuracy, YouTube videos assessed were limited to being instructional in nature, with views ranging from at least 1,000 to over a million views, and/or were from a reputable source such as an academic university, audiological society, or an ENTaudiology entity. A collection of entries from students, fellows, physicians, audiologists, and exam preparation agencies were also entered for comparison. Under these criteria, 35 videos were assessed on five different parameters: was bone or air conduction tested first, is the patient asked which sound is louder or are they instructed to alert the physician when they stop hearing the sound, are the fork tines held parallel or perpendicular to the axis of hearing, and at what distance was the tuning fork held.
In 97% of the videos analyzed, the practitioner performed bone conduction before air conduction during the Rinne test. In a recent article published by Kong and Fowler (2019), it is explicitly stated that the bone conduction be examined before air conduction for the purpose of evaluating whether air conduction can still be heard even after the sound of bone conduction has gone [1]. Guidelines published by Oxford Medical School emphasize bone conduction should be tested prior to air conduction when performing the Rinne to establish a longer time frame in which air conduction is occurring, thus producing a positive or negative test for the patient [6]. 4.3. Should the Rinne test be done before the Weber test? The current guidelines from the British Society of Audiology state that the Weber test should be performed first, and that the Rinne test should start with whichever ear the Weber lateralized to if appropriate [6]. The method of using the Weber test before Rinne test is purported to allow a quick determination of whether a unilateral hearing loss is conductive or sensorineural [7]. Amongst videos included, there was a clear majority of practitioners performing the Weber test before the Rinne test. However, there was one video that instructed Rinne first without specifying a clinical significance for this choice. Overall, the order in which the tests are given is up to the discretion of the physician who is examining the patient. Ultimately, the sequence in which they are performed does not greatly impact the results of the tests. Rather, it is more important they are conducted together to ensure a proper screening exam [8].
3. Results A total of 35 Rinne Test videos were assessed with views ranging from approximately 1,000 views to 1,100,000 views. Of the 35 videos analyzed, 31 educational videos were able to address all the questions the authors were seeking to answer. Exclusion criteria included nonEnglish language videos and videos that had less than 1,000 views. Bone conduction was tested before air conduction in 30 of the 31 videos (97%), while only 1 video tested air conduction before bone conduction. Of the videos, 22 of 31 (71%) instructed patients to alert the practitioner when the vibratory sound ended from the tuning fork, while in 7 videos (23%) the practitioners queried which sound was louder: air or bone. Also of note, 2 videos (6%) instructed that either method was acceptable. The manner of holding the tuning fork for air conduction varied considerably: 20 of 31 (65%) practitioners held the fork tines parallel to the axis of hearing (external auditory canal), 10 (32%) practitioners held the fork perpendicular to the axis of hearing, and 1 video did not specify in their instructions. Head support during bone conduction was performed by 8 (26%) of the 31 practitioners. Only 3 of 31 videos (10%) provided guidance regarding the distance the tuning fork should be held away from the patient. Typically, they reported the tuning fork should be held 1–2 cm away from the external auditory canal.
4.4. In what position should the tines of the tuning fork be held in front of the ear canal? Analysis of the videos revealed that nearly every video instructed the tuning fork be held either parallel or perpendicular, but the point of reference is rarely defined and the specific distance is not made clear. Parallel and perpendicular have very different meanings when referring to the position in relation to either the ear canal or the eardrum. In regards to positioning, there was also considerable variability in whether the tuning fork was held at the side of the head at an angle or straight up and down. In a majority of videos, the explanation of distance was referred to as “close to” or “in front of” followed by a visual example without specifying a direct measurement or position. However, 1 video did have specific instruction on holding the tines 1–2 cm from the auditory ear canal. Further, there are very few articles that mention a specific distance. For example, a chapter on the ear and auditory system in the Turner handbook (1990) states that the tuning fork should be held 2.5 cm away from the ear during these examinations [9]. Based on the high level of variation between instructional videos on the “correct” position of the tines of the tuning fork, the position is not imperative to the accuracy of the exam as a screening assessment. Butskiy and Nunez (2018) revealed further evidence surrounding the idea that tuning fork positioning does not impact the validity of the test [10]. Using 100 pairs of ears as their sample, the researchers demonstrated that identifying conductive hearing loss using the Rinne test was not affected by the position of the tines of the tuning fork. Holding the tines of the tuning fork parallel or perpendicular to the external auditory meatus did not result in a difference in diagnostic accuracy. The most important aspect of these screening tests is the ability of a patient to hear the air conduction portion of the test with better quality than the bone conduction. With regard to position, it is recommended that the tines be held in the same way on both sides to promote consistency and a professional aesthetic.
4. Discussion 4.1. How should the test procedure be explained? Based on our data collection, there were two categories in which there was a clear majority: bone conduction being performed before the air conduction test, and waiting for the sound of the tuning fork to end before switching versus asking the patient to simply identify which sound was louder. In 71% of the videos the practitioner instructed the patient to alert them when the sound of the tuning fork subsided before switching to the alternate position for the test. Some sources instruct that in a normal or “positive” exam, the sound heard through air conduction should be at least twice the duration of the sound heard via the bone conduction part of the exam [1]. Time can be lost in a busy clinic by asking the patient to indicate when the sound is no longer heard. Patients may not understand what is expected of them or may forget to adhere to the physician's instructions. The ability to hear either the air or bone conduction louder forms the basis of a positive or negative Rinne test outcome, not the time difference. 4
Translational Research in Anatomy 18 (2020) 100053
S. Maty, et al.
4.5. Does the composition of the tuning fork affect the accuracy of the test?
Ethical statement
The Rinne and Weber hearing tests are typically performed with a 512 Hz tuning fork made of aluminum or steel. The kind of metal used is not considered to be as clinically significant as the frequency of the tuning fork, and is often omitted from methodology [4]. The frequency of 512 Hz has been shown to have the least overtones and best performance if struck against a bony prominence.
Not applicable. Funding This research did not receive any specific grant from funding agencies. Financial disclosure
4.6. What is the utility of the Rinne and Weber screening in modern clinical medicine?
There are no conflicts of interest or funding sources to disclose. The majority of medical students in their clinical rotation years rarely perform the Rinne and Weber tests. If these tests are observed, it is typically during a very brief encounter with ENT specialists during a surgical rotation. Additionally, due to the low sensitivity of these screening tests, a negative result should not be considered diagnostic and should always be followed up with a pure tone audiogram [11]. In another study, Burkey et al. (1998) also conclude that the Rinne test is most effective as a screening tool, rather than a diagnostic one [12]. A recent meta-analysis by Bagai et al. (2006) assessing the current screening and diagnostic hearing tests in practice came to the conclusion that the wide range of error within the Rinne and Weber tests should preclude them from use in general practice [13]. Therefore, in the basic science years, emphasis on how to perform the Rinne test can become a strictly ‘academic’ and testable skill rather than clinically relevant. In other words, the “correct” form of the Rinne test is entirely up to the examiner's discretion whether or not the student receives full points.
Declaration of competing interest We declare that there is no conflict of interest. References [1] E.L. Kong, J.B. Fowler, Rinne Test. StatPearls [Internet], (2019) [cited 2019 Jun]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431071/. [2] J.H. Sim, Y.F. Aziz, A. Mansor, A. Vijayananthan, C.C. Foong, J. Vadivelu, Students' Performance in the Different Clinical Skills Assessed in OSCE: what Does it Reveal? Medical Education Online [Internet], [cited 2019 Jun]; 20(1) (2015), p. 26185. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25697602. [3] O. Butskiy, D. Ng, M. Hodgson, D.A. Nunez, Rinne test: does the tuning fork position affect the sound amplitude at the ear? [cited 2019 Jun], J. Otolaryngol. Head Neck Surg. 45 (1) (2016) Available from: https://www.ncbi.nlm.nih.gov/pubmed/ 27013057. [4] E.A. Kelly, B. Li, M.E. Adams, Diagnostic accuracy of tuning fork tests for hearing loss: a systematic review, [cited 2019 May], Otolaryngol. Head Neck Surg. (Tokyo) 159 (2) (2018) 220–230. Available from: https://www.ncbi.nlm.nih.gov/pubmed/ 29661046. [5] L. Turtoney, S. Batty, Recommended Procedure: Rinne and Weber Tuning Fork Tests, 2016. [cited 2019 May] British Society of Audiology, 2016, pp. 1–11. Available from: https://www.thebsa.org.uk/wp-content/uploads/1987/04/ Recommended-Procedure-Tuning-Forks-2016.pdf. [6] Rinnes and Webers Tests, Tuning Fork [Internet], (2018) [cited 2019 Jun]. Available from: http://www.oxfordmedicaleducation.com/clinical-examinations/ tuning-fork-rinnes-webers-test/. [7] M.P.A. Francis, Pure tone audiogram for students, J. Otolaryngol. ENT Res. 5 (1) (2016) Available from: https://medcraveonline.com/JOENTR/JOENTR-05-00132. php. [8] N.W.B. Wahid, M. Attia, Weber Test. StatPearls, (2019) StatPearls PMID: 30252391. [9] J.S. Turner, The ear and auditory system, in: H.K. Walker, W.D. Hall, J.W. Hurst (Eds.), Clinical Methods: the History, Physical, and Laboratory Examinations, third ed., Butterworths, Boston, 1990, pp. 609–611. [10] O. Butskiy, D.A. Nunez, Diagnostic accuracy of parallel vs perpendicular orientation of the tuning fork in the identification of conductive hearing loss, JAMA Otolaryngol. Head Neck Surg. 144 (3) (2018) 275–276. [11] G.G. Browning, I.R.C. Swan, Sensitivity and specificity of Rinne tuning fork test, BMJ 297 (6660) (1988) 1381–1382. [12] J. Burkey, W. Lippy, A. Schuring, F. Rizer, Clinical utility of the 512-Hz Rinne tuning fork test, Am. J. Otol. 19 (1) (1998) 59–62. [13] A. Bagai, P. Thavendiranathan, A. Detsky, Does this patient have hearing impairment? J. Am. Med. Assoc. 295 (4) (2006) 416–428.
5. Conclusion The analysis of multiple instructional videos yielded a considerable amount of ambiguity in regards to the positioning of the tuning fork and the general explanation of a simple hearing exam. However, the common factor in all videos was ensuring that the patient could identify that air conduction was louder than bone conduction. In regards to the proper positioning, the way the tuning fork should be held is dependent on two things: consistency and explanation. If the tuning fork tines are held perpendicular to the ear canal on the left side, the same should preferably be done on the right side. This method will promote consistency and a professional aesthetic. Instructional videos and educational materials must provide further explanation on the reference point for the tuning fork tines when using the phrases “parallel” and “perpendicular.” Given the high level of discrepancy that exists in the dissemination as well as practice of the Rinne test, it may not be the most necessary tool in the student clinician's skillset, and will likely be fully replaced by audiometry in the future.
5
Contents lists available at ScienceDirect
Translational Research in Anatomy journal homepage: www.elsevier.com/locate/tria
The implications of variability in the instruction and practice of the Rinne test
T
Shauna Matya,∗, Kristen Salanaa,∗∗, Robert Hageb a b
St. George's University, School of Medicine, St. George, Grenada, West Indies St. George's University, Department of Anatomical Sciences, St. George, Grenada, West Indies
A R T I C LE I N FO
A B S T R A C T
Keywords: Rinne test Weber test Hearing test Medical education Audiometry
Purpose: Prior to graduation, all medical students are expected to master the delivery of two basic hearing examinations: the Rinne and Weber tuning fork tests. Throughout basic science years, these tests are routinely examined to determine student competency in clinical skills. However, there exists a high level of variation between practitioners in their modes of implementing these examinations. Materials and methods: Utilizing online databases, YouTube and PubMed, the phrases “Rinne tuning fork test” and “Weber tuning fork test” were searched to find instructional guidelines on how to perform these hearing examinations. Each medium was assessed on five different parameters related to clinical implementation of the hearing exam. In total, 31 of 35 videos met inclusion criteria with views ranging from 1,000 to 1,100,000 and were subsequently assessed for data collection. Results: Through our research investigating instructional video resources of the Rinne test, as well as guidelines in textbooks and journal articles, we were able to determine the major source of incongruity in the instructional process. Of the 31 videos analyzed, bone conduction was tested prior to air conduction in 30 of the 31 videos, while 20 of 31 practitioners held the fork tines parallel to the axis of hearing with the point of reference being the external auditory canal. Only 3 of 31 videos provided guidance regarding the distance the tuning fork should be held away from the patient. A high level of variability exists concerning the purported best approach to testing air and bone conduction in the educational materials available. Conclusion: After reviewing and cross-referencing multiple sources from different mediums, the conclusion was drawn that specific parameters of delivery did not impact the diagnostic reliability of the Rinne test. The major commonality amongst these educational sources was that patients must be able to identify air conduction being louder that bone conduction in order to have a “positive” Rinne test. Given the high level of discrepancy that exists and the likelihood that these examinations will be replaced by audiometry, are these screening tests necessary to teach medical students?
1. Introduction The basic 512 Hz tuning fork hearing examinations medical students are taught in their basic science years are the Rinne and Weber tests [1]. Performance of the Rinne test is an easily testable skill in an Objective Structured Physical Exam (OSPE) that allows instructors to assess the competence of students [2]. How frequently students will utilize these tests in clinical rotations and in their future practice will vary based on the specialty they pursue. However, based on extensive research, students may be exposed to conflicting techniques on how to perform the test by clinicians and academic faculty (see Table 1). Although the Rinne test appears to be a simple and straightforward ∗
hearing exam, many experts maintain diverging opinions on the most efficacious method of implementation with minimal tolerance for deviation from their preferred approach. A survey distributed among Canadian otolaryngologists revealed confusion amongst these specialists in regards to the reference point of the tuning fork tines when asked if they held it parallel or perpendicular relative to the external auditory canal when performing the Rinne test [3]. 2. Materials and Methods Initial research on the gold standard method to perform the Rinne and Weber tests yielded varying results. An attempt to create uniform
Corresponding author. Corresponding author. E-mail addresses: [email protected] (S. Maty), [email protected] (K. Salana), [email protected] (R. Hage).
∗∗
https://doi.org/10.1016/j.tria.2019.100053 Received 12 September 2019; Accepted 14 November 2019 Available online 20 November 2019 2214-854X/ © 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
2
1,059,171
595,496
532,433 379,167
366,302 168,381 154,023
149,142
105,978 96,526 89,721 67,852
48,734 38,067 35,248
33,459
Views
30,889
28,870
https://www.youtube.com/watch?time_continue=4&v=sJBpai74tlU
https://www.youtube.com/watch?v=RVH4K4EcsiA
https://www.youtube.com/watch?v=vU8-PLsdJ-w
https://www.youtube.com/watch?v=CU5Mz18U3jQ
https://www.youtube.com/watch?v=kNLBAuOQlhc https://www.youtube.com/watch?v=GeC0A-cDx9w https://www.youtube.com/watch?v=2js72BYjZAw
https://www.youtube.com/watch?v=FNy7dgOwu30
https://www.youtube.com/watch?v=7BQFKnP-7Qg https://www.youtube.com/watch?v=FgF91K7dU8Y
https://www.youtube.com/watch?v=_ZKPrYLKY-Y
https://www.youtube.com/watch?v=8UFmMIm9kZs
https://www.youtube.com/watch?v=uI6_nPCkdK4
https://www.youtube.com/watch?v=9PH1xjefjpo
https://www.youtube.com/watch?v=2uDriyP9PwE
https://www.youtube.com/watch?v=AdiUYCn7r_M
Website
https://www.youtube.com/watch?v=ybqWpp5AKbA
https://www.youtube.com/watch?v=8c_E9vzcZNk
Cranial Nerve Examination: OSCE Guide Hearing Test (Rinne and Weber Examinations) – ENT Examination of the Cranial Nerves: Explanation UBC Medicine Neurology Clinical Skills - Cranial Nerves Examination Rinnes and Webers Test Rinne Test AAO-HNSF The ENT Exam Episode 1: The Ear Exam Cranial Nerve VIII Auditory Acuity, Weber & Rinne Tests 20 Rinne Test Weber and Rinne Test Clinical Examination Ear Examination with Weber and Rinne Test Target USMLE: Abnormal hearing - Rinne/Weber test Performing the weber and rinne tests Clinical skills: doing the Rinne test in English ENT: Clinical Physical Examination Hearing Tests Rinne's Weber' Test Professor Abnormal Cranial Nerve VIII - Auditory Acuity, Weber & Rinne Name of Video
Rinne & Weber Tests Cranial Nerve VIII examination evaluating loss of hearing Hearing Tests
Views
Website
Name of Video
Table 1 Video sources analyzed with corresponding Rinne test methodology.
BC
BC
Air Conduction (AC) or Bone Conduction (BC)
BC
BC
BC
BC
BC
BC
BC BC
BC
BC BC BC
BC
BC
AC
BC
Air Conduction (AC) or Bone Conduction (BC)
✓ ✓
-
Parallel to axis of hearing
✓ ✓
-
✓a -
✓
N/A
Patient asked which sound is louder -
-
✓ N/A
✓
✓ ✓a ✓ ✓
✓ ✓ -
✓
Patient alerts practitioner when sound ends
✓
✓
✓
✓
✓
✓
✓ ✓
-
-
-
-
-
-
-
-
-
✓
✓ -
-
-
-
-
-
-
-
-
-
-
-
-
✓ ✓
✓
-
✓
N/A
1-2 cmb
Distance of tuning fork from ear
N/A
N/A
N/A
1-2 cmb
N/A
N/A
N/A N/A
N/A
N/A N/A N/A
N/A
N/A
N/A
N/A
Distance of tuning fork from ear
(continued on next page)
Head supported
Perpendicular to axis of hearing
✓ ✓
-
✓
✓
-
✓
✓
-
✓
✓
✓
✓
✓
-
-
✓
Head supported
-
Perpendicular to axis of hearing
✓
Parallel to axis of hearing
Patient asked which sound is louder
Patient alerts practitioner when sound ends
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13,548
13,013 12,261 8,225 7,506 7,333
2,765 1,775
https://www.youtube.com/watch?v=LhcW0OAYrqk
https://www.youtube.com/watch?v=QUv7YAeOVSY https://www.youtube.com/watch?v=rZSubCKg4QI
https://www.youtube.com/watch?v=IAqD84jYuZE
https://www.youtube.com/watch?v=6jKktrjng0A
https://www.youtube.com/watch?v=NshiaiR-jng
https://www.youtube.com/watch?v=B37pgI-OHSM https://www.youtube.com/watch?v=aGgF5Mlqolk
b
a
15,431
https://www.youtube.com/watch?v=VcTdFAavYXs
BC BC
BC BC
BC
BC
BC
BC BC
BC
BC
BC
Air Conduction (AC) or Bone Conduction (BC)
✓ ✓ ✓a
-
✓ ✓ ✓ ✓a
✓ ✓
✓ -
-
-
✓
✓
✓
-
✓
✓
✓
✓
-
✓
-
-
-
✓
Parallel to axis of hearing
Patient asked which sound is louder
Patient alerts practitioner when sound ends
✓ -
✓ -
-
✓
-
✓ ✓
-
N/A
✓
Perpendicular to axis of hearing
✓
-
-
-
✓
✓
-
-
-
Head supported
N/A N/A
N/A N/A
N/A
N/A
N/A
N/A N/A
N/A
2 cmb
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Distance of tuning fork from ear
The practitioners in the videos referenced instructed that both of these methods were clinically valid: telling a patient to alert them when the sound ended, or to verbalize which sound was louder (AC or BC). Distance from opening of external auditory canal
1,144 N/A
25,888
https://www.youtube.com/watch?v=MxnhFM0Fwos
ENT - Hearing tests - Rinne and Weber's examinations Tuning Fork Tests - For Medical Students Weber's and Rinne's Tests Explained in 3 Minutes | Medic in a Minute UW, Rinnes test ENT Examination 3 - Clinic Based Hearing Tests 08.Hearing evaluation -Rinne Test.avi Otoscopy/Rinne and weber test Assessment - Cranial Nerves - Cranial Nerve 8 – Auditory Acuity, Weber & Rinne Tests How to do Rinne's Test How to Perform the Rinne Hearing Test Rinne's and Weber's Test Rinne's Tuning Fork Test
https://www.youtube.com/watch?v=e-hdkzKaJe0 https://simbrazil.mediviewprojects.org/index.php/hearing/tuning-forktests/rinnes-test
Views
Website
Name of Video
Table 1 (continued)
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4.2. Should the bone conduction part of the test be performed before or after the air conduction part of the test?
guidelines to perform these tests has previously been attempted by the British Society of Audiology with their publication of “Recommended Procedure Rinne and Weber Tuning Fork Tests.” However, the widespread variation uncovered throughout this research indicated the published guidelines are not universally adhered to Refs. [4,5]. To find the most disseminated instructional videos and documents on these hearing tests, the phrases “Rinne tuning fork test” and “Weber tuning fork test” were searched. This allowed access to numerous instructional videos and academic guidelines from YouTube and PubMed. To ensure reliability and accuracy, YouTube videos assessed were limited to being instructional in nature, with views ranging from at least 1,000 to over a million views, and/or were from a reputable source such as an academic university, audiological society, or an ENTaudiology entity. A collection of entries from students, fellows, physicians, audiologists, and exam preparation agencies were also entered for comparison. Under these criteria, 35 videos were assessed on five different parameters: was bone or air conduction tested first, is the patient asked which sound is louder or are they instructed to alert the physician when they stop hearing the sound, are the fork tines held parallel or perpendicular to the axis of hearing, and at what distance was the tuning fork held.
In 97% of the videos analyzed, the practitioner performed bone conduction before air conduction during the Rinne test. In a recent article published by Kong and Fowler (2019), it is explicitly stated that the bone conduction be examined before air conduction for the purpose of evaluating whether air conduction can still be heard even after the sound of bone conduction has gone [1]. Guidelines published by Oxford Medical School emphasize bone conduction should be tested prior to air conduction when performing the Rinne to establish a longer time frame in which air conduction is occurring, thus producing a positive or negative test for the patient [6]. 4.3. Should the Rinne test be done before the Weber test? The current guidelines from the British Society of Audiology state that the Weber test should be performed first, and that the Rinne test should start with whichever ear the Weber lateralized to if appropriate [6]. The method of using the Weber test before Rinne test is purported to allow a quick determination of whether a unilateral hearing loss is conductive or sensorineural [7]. Amongst videos included, there was a clear majority of practitioners performing the Weber test before the Rinne test. However, there was one video that instructed Rinne first without specifying a clinical significance for this choice. Overall, the order in which the tests are given is up to the discretion of the physician who is examining the patient. Ultimately, the sequence in which they are performed does not greatly impact the results of the tests. Rather, it is more important they are conducted together to ensure a proper screening exam [8].
3. Results A total of 35 Rinne Test videos were assessed with views ranging from approximately 1,000 views to 1,100,000 views. Of the 35 videos analyzed, 31 educational videos were able to address all the questions the authors were seeking to answer. Exclusion criteria included nonEnglish language videos and videos that had less than 1,000 views. Bone conduction was tested before air conduction in 30 of the 31 videos (97%), while only 1 video tested air conduction before bone conduction. Of the videos, 22 of 31 (71%) instructed patients to alert the practitioner when the vibratory sound ended from the tuning fork, while in 7 videos (23%) the practitioners queried which sound was louder: air or bone. Also of note, 2 videos (6%) instructed that either method was acceptable. The manner of holding the tuning fork for air conduction varied considerably: 20 of 31 (65%) practitioners held the fork tines parallel to the axis of hearing (external auditory canal), 10 (32%) practitioners held the fork perpendicular to the axis of hearing, and 1 video did not specify in their instructions. Head support during bone conduction was performed by 8 (26%) of the 31 practitioners. Only 3 of 31 videos (10%) provided guidance regarding the distance the tuning fork should be held away from the patient. Typically, they reported the tuning fork should be held 1–2 cm away from the external auditory canal.
4.4. In what position should the tines of the tuning fork be held in front of the ear canal? Analysis of the videos revealed that nearly every video instructed the tuning fork be held either parallel or perpendicular, but the point of reference is rarely defined and the specific distance is not made clear. Parallel and perpendicular have very different meanings when referring to the position in relation to either the ear canal or the eardrum. In regards to positioning, there was also considerable variability in whether the tuning fork was held at the side of the head at an angle or straight up and down. In a majority of videos, the explanation of distance was referred to as “close to” or “in front of” followed by a visual example without specifying a direct measurement or position. However, 1 video did have specific instruction on holding the tines 1–2 cm from the auditory ear canal. Further, there are very few articles that mention a specific distance. For example, a chapter on the ear and auditory system in the Turner handbook (1990) states that the tuning fork should be held 2.5 cm away from the ear during these examinations [9]. Based on the high level of variation between instructional videos on the “correct” position of the tines of the tuning fork, the position is not imperative to the accuracy of the exam as a screening assessment. Butskiy and Nunez (2018) revealed further evidence surrounding the idea that tuning fork positioning does not impact the validity of the test [10]. Using 100 pairs of ears as their sample, the researchers demonstrated that identifying conductive hearing loss using the Rinne test was not affected by the position of the tines of the tuning fork. Holding the tines of the tuning fork parallel or perpendicular to the external auditory meatus did not result in a difference in diagnostic accuracy. The most important aspect of these screening tests is the ability of a patient to hear the air conduction portion of the test with better quality than the bone conduction. With regard to position, it is recommended that the tines be held in the same way on both sides to promote consistency and a professional aesthetic.
4. Discussion 4.1. How should the test procedure be explained? Based on our data collection, there were two categories in which there was a clear majority: bone conduction being performed before the air conduction test, and waiting for the sound of the tuning fork to end before switching versus asking the patient to simply identify which sound was louder. In 71% of the videos the practitioner instructed the patient to alert them when the sound of the tuning fork subsided before switching to the alternate position for the test. Some sources instruct that in a normal or “positive” exam, the sound heard through air conduction should be at least twice the duration of the sound heard via the bone conduction part of the exam [1]. Time can be lost in a busy clinic by asking the patient to indicate when the sound is no longer heard. Patients may not understand what is expected of them or may forget to adhere to the physician's instructions. The ability to hear either the air or bone conduction louder forms the basis of a positive or negative Rinne test outcome, not the time difference. 4
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4.5. Does the composition of the tuning fork affect the accuracy of the test?
Ethical statement
The Rinne and Weber hearing tests are typically performed with a 512 Hz tuning fork made of aluminum or steel. The kind of metal used is not considered to be as clinically significant as the frequency of the tuning fork, and is often omitted from methodology [4]. The frequency of 512 Hz has been shown to have the least overtones and best performance if struck against a bony prominence.
Not applicable. Funding This research did not receive any specific grant from funding agencies. Financial disclosure
4.6. What is the utility of the Rinne and Weber screening in modern clinical medicine?
There are no conflicts of interest or funding sources to disclose. The majority of medical students in their clinical rotation years rarely perform the Rinne and Weber tests. If these tests are observed, it is typically during a very brief encounter with ENT specialists during a surgical rotation. Additionally, due to the low sensitivity of these screening tests, a negative result should not be considered diagnostic and should always be followed up with a pure tone audiogram [11]. In another study, Burkey et al. (1998) also conclude that the Rinne test is most effective as a screening tool, rather than a diagnostic one [12]. A recent meta-analysis by Bagai et al. (2006) assessing the current screening and diagnostic hearing tests in practice came to the conclusion that the wide range of error within the Rinne and Weber tests should preclude them from use in general practice [13]. Therefore, in the basic science years, emphasis on how to perform the Rinne test can become a strictly ‘academic’ and testable skill rather than clinically relevant. In other words, the “correct” form of the Rinne test is entirely up to the examiner's discretion whether or not the student receives full points.
Declaration of competing interest We declare that there is no conflict of interest. References [1] E.L. Kong, J.B. Fowler, Rinne Test. StatPearls [Internet], (2019) [cited 2019 Jun]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431071/. [2] J.H. Sim, Y.F. Aziz, A. Mansor, A. Vijayananthan, C.C. Foong, J. Vadivelu, Students' Performance in the Different Clinical Skills Assessed in OSCE: what Does it Reveal? Medical Education Online [Internet], [cited 2019 Jun]; 20(1) (2015), p. 26185. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25697602. [3] O. Butskiy, D. Ng, M. Hodgson, D.A. Nunez, Rinne test: does the tuning fork position affect the sound amplitude at the ear? [cited 2019 Jun], J. Otolaryngol. Head Neck Surg. 45 (1) (2016) Available from: https://www.ncbi.nlm.nih.gov/pubmed/ 27013057. [4] E.A. Kelly, B. Li, M.E. Adams, Diagnostic accuracy of tuning fork tests for hearing loss: a systematic review, [cited 2019 May], Otolaryngol. Head Neck Surg. (Tokyo) 159 (2) (2018) 220–230. Available from: https://www.ncbi.nlm.nih.gov/pubmed/ 29661046. [5] L. Turtoney, S. Batty, Recommended Procedure: Rinne and Weber Tuning Fork Tests, 2016. [cited 2019 May] British Society of Audiology, 2016, pp. 1–11. Available from: https://www.thebsa.org.uk/wp-content/uploads/1987/04/ Recommended-Procedure-Tuning-Forks-2016.pdf. [6] Rinnes and Webers Tests, Tuning Fork [Internet], (2018) [cited 2019 Jun]. Available from: http://www.oxfordmedicaleducation.com/clinical-examinations/ tuning-fork-rinnes-webers-test/. [7] M.P.A. Francis, Pure tone audiogram for students, J. Otolaryngol. ENT Res. 5 (1) (2016) Available from: https://medcraveonline.com/JOENTR/JOENTR-05-00132. php. [8] N.W.B. Wahid, M. Attia, Weber Test. StatPearls, (2019) StatPearls PMID: 30252391. [9] J.S. Turner, The ear and auditory system, in: H.K. Walker, W.D. Hall, J.W. Hurst (Eds.), Clinical Methods: the History, Physical, and Laboratory Examinations, third ed., Butterworths, Boston, 1990, pp. 609–611. [10] O. Butskiy, D.A. Nunez, Diagnostic accuracy of parallel vs perpendicular orientation of the tuning fork in the identification of conductive hearing loss, JAMA Otolaryngol. Head Neck Surg. 144 (3) (2018) 275–276. [11] G.G. Browning, I.R.C. Swan, Sensitivity and specificity of Rinne tuning fork test, BMJ 297 (6660) (1988) 1381–1382. [12] J. Burkey, W. Lippy, A. Schuring, F. Rizer, Clinical utility of the 512-Hz Rinne tuning fork test, Am. J. Otol. 19 (1) (1998) 59–62. [13] A. Bagai, P. Thavendiranathan, A. Detsky, Does this patient have hearing impairment? J. Am. Med. Assoc. 295 (4) (2006) 416–428.
5. Conclusion The analysis of multiple instructional videos yielded a considerable amount of ambiguity in regards to the positioning of the tuning fork and the general explanation of a simple hearing exam. However, the common factor in all videos was ensuring that the patient could identify that air conduction was louder than bone conduction. In regards to the proper positioning, the way the tuning fork should be held is dependent on two things: consistency and explanation. If the tuning fork tines are held perpendicular to the ear canal on the left side, the same should preferably be done on the right side. This method will promote consistency and a professional aesthetic. Instructional videos and educational materials must provide further explanation on the reference point for the tuning fork tines when using the phrases “parallel” and “perpendicular.” Given the high level of discrepancy that exists in the dissemination as well as practice of the Rinne test, it may not be the most necessary tool in the student clinician's skillset, and will likely be fully replaced by audiometry in the future.
5