In a study published in the JAMA Otolaryngol Head Neck Surgery, researchers found good agreement and nearly identical intertest diagnostic accuracy in identifying conductive hearing loss with tuning fork positions parallel and perpendicular to the external auditory meatus during the Rinne test.

The Rinne test continues to be widely used by primary care and specialist physicians to detect conductive hearing losses. On acoustic anechoic chamber evidence, audiology society recommendations, medical student texts, and peer-reviewed publications, placing the vibrating tines parallel as opposed to perpendicular to the auditory meatus is recommended when testing air conduction of sound with the Rinne test.

The team reports a real-world clinical experiment comparing patients’ responses to the Rinne test when performed with the tuning fork positioned parallel vs perpendicular to the external auditory meatus.  Patients were recruited at a tertiary care academic otology clinic. Patients’ eligibility was identified by a screening Rinne test with a 512 Hz tuning fork, in which the allocation of tuning fork tines’ orientation (parallel vs perpendicular) was determined by a random number sequence.

Patients with a negative (bone conduction louder than air) or equivocal (bone conduction equal to air) Rinne result (suggesting conductive hearing loss) in at least 1 ear were recruited. Enrolled patients underwent further Rinne tests with a 512 Hz tuning fork presented to each ear: 2 with the tines parallel and 2 with the tines perpendicular to each ear canal. The test orientation sequence was block randomized, and the experimenter blinded to the screening results.

A tuning fork identified conductive hearing loss was predefined as at least 1 negative or equivocal response in the test orientation. In the exploratory analyses, 2 alternative definitions of conductive hearing loss were considered: any combination of negative or equivocal responses in the test orientation; and 2 negative responses in the test orientation. Sensitivity and specificity of tuning fork identified conductive hearing loss were determined by comparison with the following reference standard. Audiometric measurements were performed on the same day as the tuning fork testing.

Of 57 eligible patients, 50 were recruited for a sample of 100 ears. The results and agreement between the 2 Rinne test tuning fork presentations. A Cohen κ of 0.83 demonstrated a high level of interest agreement. The sensitivity and specificity of the 2 Rinne test tuning fork presentations were nearly identical compared with the reference standard. Receiver operating curve demonstrates that the sensitivity and specificity of the 2 Rinne test tuning fork presentation for alternate conductive loss definitions remained similar.

The study showed good agreement and nearly identical intertest diagnostic accuracy in identifying conductive hearing loss with tuning fork positions parallel and perpendicular to the external auditory meatus during the Rinne test. Hence, in the real-world environment parallel or perpendicular orientation of the tuning fork when testing air conduction with the Rinne test will not alter the test result. These results should not be extrapolated to other variations, such as a 45% angled tuning fork presentation to the external auditory meatus.