Rinne’s Test, Weber’s Test & Whisper Test
Hearing assessment is a core clinical skill tested in pharmacy OSCEs, particularly in ear examination stations. Three tests make up a complete hearing assessment: the whisper test, Rinne’s test, and Weber’s test. Each answers a different clinical question, and together they allow you to determine whether a patient has a hearing problem and, if so, what type.
Understanding not just how to perform these tests, but why they work and how to interpret the results, is what separates a passing OSCE from a strong one.
Consider using Geeky Medics video➚ for a supplement to your learning
Types of Hearing Loss – What You Are Trying to Identify
Before performing any hearing test, it helps to understand what you are looking for. There are two distinct mechanisms by which hearing can be lost:
| Type | What Goes Wrong | Example Causes |
|---|---|---|
| Conductive | Sound cannot travel efficiently from the outer or middle ear to the inner ear | Ear wax impaction, otitis media, perforated tympanic membrane, foreign body, grommet |
| Sensorineural | The inner ear, cochlea, or auditory nerve fails to transmit signals to the brain | Age-related hearing loss, noise damage, ototoxic drugs, acoustic neuroma, infection |
Why does this matter for pharmacy? Several commonly prescribed medications are ototoxic – meaning they can directly cause sensorineural hearing loss as an adverse effect. These include aminoglycosides (e.g. gentamicin), loop diuretics (e.g. furosemide), and platinum-based chemotherapy agents.
Recognising sensorineural loss and considering drug causes is a pharmacy-specific skill that can set you apart in an OSCE discussion.
Step 1 – The Whisper Test
The whisper test is the starting point for any hearing assessment. It is a quick, equipment-free screening tool. If the whisper test suggests hearing impairment, you then proceed to Rinne’s and Weber’s tests.
How To Perform The Whisper Test
- Always start with the better ear (or the ear the patient reports as better)
- Stand 30 cm directly behind the patient on the side of the ear being tested – behind, not in front, to prevent lip reading
- Ask the patient to cover the opposite ear by pressing down on the tragus
- Whisper a sequence of equally accented numbers or syllables (e.g. “three-five-two”) and ask the patient to repeat them back
- Move to 1 metre behind the patient and repeat the same process
- Repeat both distances for the other ear
Interpreting The Whisper Test
| Distance | Outcome | Interpretation |
|---|---|---|
| 30 cm | Patient repeats correctly | Normal hearing at close range |
| 1 metre | Patient repeats correctly | Normal hearing – no further tests required |
| 1 metre | Patient cannot repeat correctly | Hearing impairment likely → proceed to Rinne’s and Weber’s |
Step 2 – Rinne’s Test
Rinne’s test uses a tuning fork to compare two routes by which sound reaches the inner ear:
- Air conduction – sound travels via the ear canal, tympanic membrane, and ossicles
- Bone conduction – sound vibrations travel directly through the skull to the cochlea
In a healthy ear, air conduction is more efficient than bone conduction. Rinne’s test checks whether this relationship holds – or whether it has been disrupted.
Equipment
A 512 Hz tuning fork – this frequency offers the most reliable balance between decay time and avoiding tactile vibration interference.
How To Perform Rinne’s Test
- Activate the tuning fork by striking it firmly against the base of your palm or your thigh – never on a hard surface
- Place the flat base of the fork firmly against the mastoid process (the bony prominence behind the ear) and ask the patient to tell you when they can no longer hear the sound – this tests bone conduction
- As soon as they indicate the sound has gone, move the fork to just outside the external auditory meatus (the ear canal opening) and ask whether they can now hear it again – this tests air conduction
- If sound is heard again at the ear canal, air conduction is better than bone conduction – this is a Rinne’s positive result
- If sound is not heard at the ear canal (bone conduction outlasts air conduction), this is a Rinne’s negative result
Interpreting Rinne’s Test
| Result | What It Means |
|---|---|
| Positive (AC > BC) | Normal, OR sensorineural hearing loss |
| Negative (BC > AC) | Conductive hearing loss in that ear |
| False negative | Sensorineural loss so severe that bone vibrations are picked up by the opposite cochlea – this is why Weber’s is essential |
Step 3 – Weber’s Test
Weber’s test assesses the symmetry of hearing between both ears. Where Rinne’s tests one ear at a time, Weber’s tests both simultaneously by placing the tuning fork on the midline of the skull.
How To Perform Weber’s Test
- Activate the same 512 Hz tuning fork
- Place the flat base against the centre of the forehead in the midline
- Ask the patient: “Which ear does the sound feel louder in, or does it sound equal in both?”
Interpreting Weber’s Test
| Finding | Interpretation |
|---|---|
| Sound heard equally in both ears | Normal hearing bilaterally |
| Sound heard louder in the affected ear | Conductive hearing loss on that side |
| Sound heard louder in the unaffected ear | Sensorineural hearing loss on the opposite side |
Why does conductive loss lateralise to the affected side? When the ear canal is partially blocked (as in conductive loss), external background noise is reduced on that side.
This means bone-conducted sound is relatively louder in the affected ear – there is less competing noise to mask it.
Putting It Together – Full Interpretation Table
| Whisper Test | Rinne’s Test | Weber’s Test | |
|---|---|---|---|
| Normal | Passes at 1 metre both ears | AC > BC (Positive) | Midline – equal in both |
| Conductive loss | Fails at 1 metre (affected ear) | BC > AC (Negative) | Lateralises to affected ear |
| Sensorineural loss | Fails at 1 metre (affected ear) | AC > BC (Positive) | Lateralises to unaffected ear |
Worked Example
Scenario: You are assessing a 62-year-old patient, Mrs Patricia Hall, who has attended the pharmacy reporting reduced hearing in her right ear over the past week. She also reports recent nasal congestion following a cold.
Whisper Test:
- Left ear at 1 metre: passes
- Right ear at 1 metre: fails – unable to repeat syllables correctly
Hearing impairment confirmed in the right ear. Proceed to Rinne’s and Weber’s.
Rinne’s Test – Right Ear: Tuning fork placed on right mastoid. Patient hears sound, then it stops. Fork moved to right ear canal. Patient reports she cannot hear the sound.
Result: Negative Rinne’s – bone conduction is better than air conduction in the right ear.
Weber’s Test: Tuning fork placed on forehead. Patient reports the sound is louder in the right ear.
Result: Lateralises to the right – the affected side.
Conclusion: Rinne’s negative on the right + Weber’s lateralising to the right = Right-sided conductive hearing loss. In the context of recent upper respiratory tract infection, acute otitis media or eustachian tube dysfunction would be the most likely cause.
As a pharmacist, your next step would be:
- Assess whether OTC management is appropriate (e.g. decongestants for eustachian tube dysfunction)
- Consider whether the duration and severity warrant referral to a GP
- Counsel the patient on red flag symptoms warranting urgent review (sudden severe loss, pain, blood or discharge, or symptoms persisting beyond 3 weeks)
Ototoxic Drugs – A Pharmacy-Specific Addition
This section is rarely covered in other OSCE guides but is directly relevant to your practice as a pharmacist.
Certain drugs cause sensorineural hearing loss as an adverse effect:
| Drug Class | Examples | Mechanism |
|---|---|---|
| Aminoglycosides | Gentamicin, amikacin | Direct cochlear hair cell damage |
| Loop diuretics | Furosemide | Disrupts ion transport in the cochlea |
| Platinum-based chemotherapy | Cisplatin, carboplatin | Oxidative damage to cochlear hair cells |
| Quinine/antimalarials | Quinine | Cochlear vasoconstriction |
| Salicylates (high dose) | Aspirin | Reversible at high doses, may cause tinnitus |
If a patient presents with new hearing loss and is taking any of the above, this should be flagged and reviewed – particularly for aminoglycosides and cisplatin, where monitoring is a formal clinical requirement.
Common OSCE Mistakes
- Activating the tuning fork on a hard surface – this creates overtones that affect the result; always use your palm or thigh
- Placing the fork at an angle against the mastoid rather than flat – this gives an inconsistent bone conduction reading
- Forgetting to test both ears with Rinne’s – always test both, even if only one ear appears affected
- Misremembering Weber’s lateralisation – remember, conductive loss draws the sound toward the problem; sensorineural loss pushes it away
- Performing Rinne’s and Weber’s without the whisper test first – the whisper test is the starting point, not optional
- Missing drug causes of sensorineural loss in the clinical discussion
OSCE Tips – Hearing Assessment
- Whisper test first, every time – if the patient passes at 1 metre bilaterally, you may not need to proceed to tuning fork tests at all
- Always start with the better ear in every test – it establishes a baseline and is standard clinical practice
- In Weber’s, ask “which ear is it louder in” – not “can you hear it in both ears”, which prompts a yes/no answer rather than a lateralisation
- Know your ototoxic drugs – an examiner asking “what drug-related causes would you consider?” is a gift, not a trick
- The classic OSCE catch: sensorineural loss with a positive Rinne’s – students often assume positive Rinne’s always means normal. It does not.
- Practise out loud with a partner – both the technique and the verbal instructions to the patient are marked separately