Dr- Ebtessam Nada Audiology step by step

Tuning fork and tuning fork tests:

Definition: A tuning fork is an acoustic resonator in the form of a two-pronged fork with the
prongs (tines) formed from a U-shaped bar of elastic metal (usually steel). It resonates at a
specific constant pitch when set vibrating by striking it against a surface or with an object, and
emits a pure musical tone once the high overtones have died out.
Parts of the tuning fork:
1. Foot piece.
2. Stem.
3. Prong.

Resonance: In physics, resonance is the tendency of a system to oscillate with greater amplitude
at some frequencies than at others. Frequencies at which the response amplitude is a relative
maximum are known as the system’s resonance frequencies, or resonance frequencies.
How to use tuning fork?
1. Hold the stem of the tuning fork between the index finger and thumb of your right hand
without touching the prongs.
2. Strike the junction of superior 1/3 and inferior 2/3 of the prongs (area of maximum
vibration) on a rubber pad or elbow.
3. When a tuning fork or bone oscillator is overdriven and made so loud it deviates from its
fundamental frequency, it will produce distortion.
Characteristics of tuning forks:
 The pitch that a particular tuning fork generates depends on the length and mass of the
two prongs.

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  The frequency of sound from a tuning fork will decrease when the temperature increases.
As the temperature of the tuning fork increases, the atoms inside the fork will gain
kinetic energy and vibrate more. This will cause the fork to expand and become longer.
As can be seen from the following formula the frequency of the tuning fork is inversely
proportional to the square of the tuning fork length. Therefore any slight increase in the
tuning fork length will cause a reduction in the sound frequency produced. Thus a
characteristic frequency of a tuning fork is in a standard atmospheric temperature.

 A tuning fork will always vibrate at a specific frequency when struck. The difference
that you can hear is that when you hit with a hard object, more energy is transferred in
the impact, making it ring louder, but with the same frequency. With a soft object like
rubber, some energy is dissipated by the rubber. This makes the fork ring softer but still
at the same frequency. The change that you can hear is the amplitude of the wave.
 Damaging the fork could change its natural frequency or damping the vibration to
prevent resonance. That is the reason you hit a tuning fork with a rubber mallet (or your
knee).
 The predominant frequency of motion of all tuning forks was their expected fundamental
frequency. Additional non-harmonic frequencies were recorded when striking the 256
Hz and the 512 Hz tuning forks against metal or wood. The aberrant frequencies were of
lower intensity relative to the fundamental frequency of the tuning fork.
Overtones:
 Overtones are the "hidden" sounds of music.
 Normally we think of a sound made by a musical instrument as "one note". For example,
if you play C on the flute and the same C on the violin; they are both the same note C.
 Our ears know that the two C's sound different even though they are the same note.
 It is the sounding of different overtones above the note C that gives each instrument its
distinct sound or tonal color.
 The fork shape is the shape that is usually clear of overtones "producing pure tone" the
reason for this is that the frequency of the first overtone is about 52/22= 25/4 = 6 1⁄4
times the fundamental (about 2 1⁄2 octaves above it).
  While, by comparison, the first overtone of a vibrating string or metal bar is only one
octave above (twice) the fundamental, so when the string is plucked or the bar is struck,
its vibrations tend to be a mixture of the fundamental and overtone frequencies.
 When the tuning fork is struck, little of the energy goes into the overtone modes; they
also die out correspondingly faster, leaving a pure sine wave at the fundamental
frequency. It is easier to tune other instruments with this pure tone.
 The handle motion is small, allowing the fork to be held by the handle without damping
the vibration, but it allows the handle to transmit the vibration to a resonator, which
amplifies the sound of the fork.
 Tuning fork material:
o Rinne tests using steel tuning forks are more sensitive than with aluminum in
detecting the presence of an air-bone gap. This is substantiated by significant
differences in the relative acoustic versus mechanical outputs of steel versus
aluminum forks.
o Aluminum tuning forks have more potential to ring overtones.

Principle of Air Conduction (AC) and Bone Conduction (BC)

The sound can be transmitted to cochlea in 2 ways:

 Air conduction (AC): Transmission of sound to the cochlea via external air and middle
ear
 Bone conduction (BC): Transmission of sound to cochlea via vibration is skull bone,
bypassing the external and middle ear.
Since, the cochlear mechanism is same for both the routes, Air conduction (AC) tests the whole
ear (conductive and senorineural component) while Bone conduction (BC) tests only the
senorineural component.
Note: Direct transmission of the acoustic signal to the cochlea through the skull vibration is 40
dB to 70 dB less effective than the air conduction pathway. Therefore, in the case of a person
listening to air-conducted sound with open ears, bone conduction has minimal contribution to
auditory perception.
A. Rinne test
Concept: This test aims compare air conduction with bone conduction
Value:
 Rinne’s test has a high sensitivity (0.84) though this varies with the skill of the examiner
  Rinne’s test can only detect a conductive hearing loss of at least 30dB
Principle: Normally, Air Conduction (AC) > Bone Conduction (BC)
Procedure:
1. Testing Air Conduction (AC):
1. This uses a tuning fork of 256 Hz or 512 Hz.
2. A heavy tuning fork is preferable, as a light one can produce a sound that fades
too rapidly.
3. It produces a sound level of 90 dB when struck against the knee or elbow.
4. Hold the vibrating tuning fork 2 cm lateral to the test ear, such that the tuning
fork is directly in line with the external auditory canal and .both the prongs
vibrate parallel to the acoustic axis.
Rinne's test will reliably detect a conduction defect with an air-bone gap of at least 30-40 dB. It
is no substitute for pure-tone audiometry.
When the air-bone gap is less than 17.5 dB or greater than 30 dB, the Rinne is usually negative
(Jacob et al, 1993). Because of this, the Rinne test has limited utility.
2. Testing Bone Conduction (BC):
 Hold the vibrating tuning fork and place the foot piece on the flat surface of mastoid just
above External auditory canal (not the mastoid tip).
 Using firm pressure (loudness varies by up to 15 dB with different pressures).
 Hold the patient's head steady with your free hand.
a. Test for duration:
o Test the BC
o Ask patient to signal as soon as he ceases to hear the sound
o After the patient signals, quickly bring the tuning fork in the position to test AC
o Ask if he can still hear the sound or not?
b. Test for loudness:
o Alternately test AC and BC.
o Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of
the sound
o Then promptly lift the fork off the mastoid process and place the vibrating tips
about 1cm from their external auditory meatus
o Leave it there again for a few seconds before taking the tuning fork away from
their ear
 o Ask the patient if loudness of AC or BC is greater?
What is a positive and negative Rinne’s Test?
 A patient who hears the tuning fork loudest when held 1cm from the external auditory
meatus has a positive Rinne’s test
 A patient who hears the fork loudest when it is held against the mastoid process has a
negative Rinne’s test

Interpretation:

Conductive Hearing Loss Sensorineural Hearing Loss

Normal (CHL) (SNHL)

AC > BC (Rinne
Positive) BC > AC (Rinne Negative) AC > BC (Rinne Positive)

 In a normal ear sound is conducted to the cochlear most efficiently via air conduction.
Sound can also be transmitted to the cochlea, less efficiently, via bone
 If a patient can hear best when the tuning fork is in the air (positive Rinne’s) then air
conduction is better than bone conduction so there is no significant conductive hearing
loss
 If the patient can hear best when the tuning fork is on the mastoid (negative Rinne’s)
bone conduction is better than air conduction, demonstrating a conductive hearing loss
Note: Sometimes, in testing for loudness AC = BC can be noted and this may indicate mild
CHL. Test of duration should be performed to confirm.
False Negative Rinne (BC>AC):
 This is seen when a patient has severe SNHL on test side and normal hearing on non-
test side.
  On application of vibrating tuning fork to deaf side the sound is transmitted to the
non-test ear by bone and patient perceives this bone conduction and presumes that it
is perceived by test ear, thus interpreting it as BC > AC.
 Associated conditions: Congenital causes, Skull fracture, Meningitis, Mumps,
Acoustic neuroma
 Correction:
1. Masking opposite ear with Barany’s noise box to prevent transcranial
transmission of sound
2. Weber test is lateralized to better ear.
Why tuning fork of 512 Hz is ideal for hearing tests?
1. Tuning forks of lower frequency produce more bone vibration.
2. Tuning forks of higher frequency have shorter decay time (how fast the tuning fork loses
vibratory energy) and are difficult to activate for them to be heard with a moderate or
severe sensorineural impairment.
3. Minimal gab necessary for detection according to used tuning fork frequency:
 500 Hz and 1000 Hz are the frequencies that are most affected by middle ear inertia.
 With the Rinne test, at frequencies above 1000 Hz, the air-bone gap has to be larger in
order to observe the fork being louder behind the ear compared to at the opening of the
meatus.
 At frequencies 2 to 3 octaves lower than 2000 Hz, an air-bone gap one-half or less the
size than at 2000 Hz is typically needed to indicate a conductive loss.

Rinne Negative
256 Hz 512 Hz 1024 Hz
in

Minimum Air- 30 dB (Mild 45 B (Moderate

15 dB
Bone gap CHL) CHL)

B. Weber test:
Principle:
 This test is useful in identifying unilateral hearing loss.
 A patient with a unilateral conductive hearing loss (CHL) would hear the tuning fork
loudest in the affected ear. This is because the conduction problem masks the
 ambient noise of the room, whilst the well-functioning inner ear picks the sound up
via the bones of the skull causing it to be perceived as a louder sound than in the
unaffected ear.
 Sound lateralizes occurs also with contralateral sensorineural hearing loss.
Procedure:
A. Place the foot piece or base of the vibrating 512 Hz tuning fork on either of midline of
vertex, forehead, chin or upper incisor teeth
B. Ask the patient – which ear hears the sound louder?
Interpretation:

Normal Conductive Hearing Loss Sensorineural Hearing Loss

Not lateralized (Central

Lateralized to poorer ear Lateralized to better ear
Weber)

 Rinne test may provide

further information which will be
useful to distinguish between
these possibilities.
 Weber is a sensitive test
and a difference of even 5 dB is
sufficient to lateralize the Weber.

C. Absolute Bone Conduction (ABC) test

Principle: This is a modified Schwabach’s test where, the bone conduction level of patient is
compared to that of the clinician. It includes occlusion of the External Auditory Canal by
pressing the tragus to reduce the ambient sound in the surrounding, which is not done in
Schwabach’s test.
Pre-requisite: Clinician should have normal bone conduction level or at least he should know
his bone conduction level.
Procedure:
 Examiner closes the test ear by gently pressing the tragus against ear canal.
 Foot piece of vibrating tuning fork is kept over mastoid bone and patient listens to
the fork till sound disappears completely.
 Immediately same fork is transferred over mastoid bone of the clinician
and simultaneously ear canal is closed by pressing the tragus.
 Clinician listens whether he can appreciate the sound stimulus or not.
 If the clinician doesn’t hear the sound after transferring it from mastoid of the
patient, the procedure may be reversed.
Interpretation:

Test details Result Interpretation

Clinician listens longer than patient ABC reduced SNHL

Clinician listens equal to that of ABC normal Normal

patient

Patient listens longer than clinician ABC lengthened CHL

D. Other tests
a. Bing test:
1. This is like ABC test, but the external ear canal is alternately closed and
opened by pressing and releasing the tragus.
2. Positive Bing test (Louder when occluded): Normal or SNHL
3. Negative Bing test (No change): CHL
b. Gelle’s test: Tuning fork is placed on mastoid and the pressure in the ear canal is
increased using the Siegle’s speculum. This increase in pressure in ear canal pushes
the tympanic membrane and ossicles inward, leading to rise in intralabyrinthine
pressure. This causes immobility of basilar membrane of cochlea, resulting in
decreased hearing.
1. Positive gelle test (Decreased hearing): Normal or SNHL
2. Negative gelle test (Normal hearing): Ossicular chain fixation (otosclerosis)
or discontinuation