Original Article SMJ

Re – evaluation of Rinne Test with Aluminum Alloy

Tuning Fork 256 Hz and 512 Hz

Patcharaporn Phonpornpaiboon, M.D., Kanokrat Suvarnsit, M.D., Sarun Prakairungthong, M.D.

Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

ABSTRACT
Objective: To study the sensitivity, specificity and accuracy of the 256 Hz and 512 Hz aluminum tuning fork in
the detection of conductive hearing loss by quick Rinne test.
Methods: The patients with hearing problems recruited from out-patient unit were tested with the 256 Hz and 512
Hz aluminum quick Rinne test. The audiometry was performed on the same day and the results were compared.
Results: During the study period, 246 ears with conductive hearing loss and 246 ears with non-conductive hearing
loss were recruited. The 256 Hz Rinne test had higher sensitivity than the 512 Hz Rinne test (93.83% and 71.95%
respectively). The specificity and accuracy of the 512 Hz Rinne test was markedly greater than the 256 Hz Rinne
test (91.18 % vs. 26.7% specificity and 83.57% vs. 61.85% accuracy). The 512 Hz Rinne test had sensitivity over 80%
when the air-bone gap was equal to or greater than 20 dB. The sensitivity was even higher (more than 90%) if the
air-bone gap was equal to or greater than 30 dB.
Conclusion: This study demonstrated that the 512 Hz Rinne test had better accuracy than the 256 Hz Rinne test
for the diagnosis of conductive hearing loss. The 512 Hz Rinne test can detect the air-bone gap of 30 dB or greater
which indicates the surgical role with the sensitivity more than 90%. We recommend that 512 Hz Rinne test should
be used as a screening tool for the detection of conductive hearing loss.

Keywords: Rinne; tuning fork; accuracy; conductive hearing loss; air-bone gap (Siriraj Med J 2019;71: 127-130)

INTRODUCTION hearing loss, pre-and post- operative evaluation of middle

The tuning fork test for hearing evaluation has ear surgery1 and detection of the air-bone gap. Even
long been widely used. Various techniques for tuning fork though, several researches have tried to evaluate the
usability were developed; for instance, Weber test, Bing value of tuning fork since 1980s2, the results had wide
occlusion test, Schwaback test and Rinne test. However, variation. One study3 suggested that a 512 Hz tuning fork
the Rinne test is primarily used as one of the bedside should be used for screening patients with conductive
tools in the evaluation of patients with hearing problem. hearing loss. However, another study advised to use 256
Despite the easily accessibility of the audiometry which Hz tuning fork instead.3 Also, the tuning fork material is
is considered as a gold standard for hearing diagnosis, another issue to consider for the various results. Many
tuning fork 256 Hz and 512 Hz were still recommended studies didn’t mention tuning fork material.2,3,4 Also, one
for general practitioners and otoneurologists for several study used uncommon material such as metal tuning
circumstances; for example, screening for conductive fork which is rarely used in ordinary practice.5

Coresponding author: Sarun Prakairungthong

E-mail: tiktono99@gmail.com, tiksarun99@yahoo.com
Received 24 July 2018 Revised 17 January 2019 Accepted 20 January 2019
OCID ID: http://orcid.org/0000-0002-2098-5199
http://dx.doi.org/10.33192/Smj.2019.20

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Phonpornpaiboon et al.

Our study aimed to re-assess the accuracy, specificity, RESULTS

and sensitivity of the 256 Hz and 512 Hz aluminum There were 296 cases recruited in this study. Most
tuning fork test by performing quick Rinne test as the of them are women (61.5%). Age ranged between 18 to
primary objective. The secondary objectives were the 87 years with the mean age of 54.4 years (S.D. 15.22).
following; Demographic data are shown in Table 1.
1. To determine how to interpret equivocal Rinne test Data recorded when performing the test with 256
2. To determine the results of tuning fork test in comparison Hz tuning fork was mostly negative Rinne test on both
with the air-bone gap. conductive hearing loss (92.6%) and nonconductive
The findings from this study will guide us for the hearing loss (65.85%) groups. When using 512 Hz tuning
way to evaluate of hearing problem patients in out-patient fork, the negative Rinne test was recorded in 71.95% of
clinic and primary care unit. conductive hearing loss subjects. Whereas, the positive
Rinne test was reported in 86.5% of nonconductive
MATERIALS AND METHODS hearing loss subjects.
This cross-sectional study was approved by the Siriraj The equivocal result was recorded in similar amount
Institutional Ethical Committee (Si 587/2015). Subjects of 5% in both conductive and nonconductive hearing
were recruited from the out-patient otolaryngology loss group either performing with 256 Hz or 512 Hz
clinic during May 2015 to July 2016. Routine history tuning fork. Interestingly this equivocal result lead to
taking and otological examination were performed in nonconductive situation in 256 Hz tuning fork while
individual patients. The patients with the age of 18 years this leads to no clue in 512 Hz tuning fork. All results
and older suspicious for abnormal hearing were recruited.6 from all tests in this study are shown in Table 2.
The exclusion criteria was patients with learning or The data was calculated with the exclusion of
psychological problems. The procedure was started with equivocal results for sensitivity, specificity, accuracy,
the quick Rinne test performed on both ears by a group of positive predictive value and negative predictive value
well-trained doctors in the tightly closed room (estimate of 256 Hz and 512 Hz quick Rinne test. Therefore, the
background noise of 53.2 dBA SPL). The examiners were number of the tested ears decreased to the final of 464
blinded from both patients’ diagnosis and otological ears in 256Hz tuning fork group and 465 ears in 512Hz
examination. The Rinne test was performed using 256 tuning fork group.
Hz and 512 Hz aluminum tuning fork by the loudness As the result, the 256 Hz Rinne tuning fork test has
comparison method (quick Rinne test).7 very high sensitivity (93.83%), low specificity (26.7%),
The vibrating tuning fork was placed firmly behind and moderate accuracy (61.85%). However, all the data
the pinna (BC position) for few seconds then moved to the in 512 Hz tuning fork group was higher than 256 Hz
front of the ear canal approximately 2 to 2.5 centimeters tuning fork group except for the sensitivity. (Fig 1)
from the tragus with parallel position to the skull (AC
position). The examinee would be asked to compare the
loudness of each position. Which site was louder?2 The TABLE 1. Demographic data.
results were recorded in 3 categories: negative Rinne
Data Number (%)
test when the examinee heard louder when placing
tuning fork on the mastoid bone than when holding in Sex
front of the ear (BC>AC), positive Rinne test when the Male 114 (38.5)
examinee heard louder while holding the fork in front Female 182 (61.5)
of the ear than placing on the mastoid bone (AC>BC),
Education
and equivocal Rinne test when the examinee could not
tell the difference between the two positions (AC=BC). Uneducated 2 (0.7)
We classified the examinee into 2 groups: conductive Grade 1-6 75 (25.3)
hearing loss group and nonconductive hearing loss Grade 7-12 56 (18.9)
group. The calculated number for each group was 246 Diploma 24 (8.1)
ears which were collected in order to avoid the bias. The Undergraduate 139 (47%)
profound sensorineural hearing loss ears were excluded
Number of used ear
from the study.
Unilateral 100 (33.8%)
Bilateral 196 (66.2%)

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 Original Article SMJ

TABLE 2. Results of 256 Hz and 512 Hz Rinne tuning fork test.

Conductive hearing loss Nonconductive hearing loss

256 Hz (246 ears) 512 Hz (246 ears) 256 Hz (246 ears) 512 Hz (246 ears)
Number (%) Number (%) Number (%) Number (%)

Rinne negative 228 (92.6) 177 (71.95) 162 (65.85) 19 (7.72)

Rinne positive 15 (6.09) 56 (22.76) 59 (23.98) 213 (86.5)

Rinne equivocal 3 (1.21) 13 (5.28) 25 (10.16) 14 (5.69)

Fig 1. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 256 Hz compare with 512 Hz Rinne tuning
test. (*positive predictive value, **negative predictive value)

In this study authors used the average air-bone gap than 512 Hz tuning fork test (Fig 1). This yield the similar
according to Committee on Hearing and Equilibrium result as previous studies of Burkey et al2 and Chole et al.3
guidelines for the evaluation of results of treatment of Burkey et al2 suggested that the sensitivity of
conductive hearing loss.9 From the results, different equivocal Rinne test in conductive hearing loss can be
frequencies tuning forks had different power to determine improved by applying 512 Hz tuning fork.
conductive hearing loss. The 256 Hz tuning fork had Chole et al3 and Browning et al4 reported that
very high power (92.7%) to detect conductive hearing whether they included equivocal results of tuning fork test
loss even with only 10 dB air-bone gap. Whilst, 512Hz or not, the sensitivity and specificity were not different.
tuning fork would have a high power (91.9%) to detect We found that the equivocal Rinne test comprised of 5%
conductive problem if the air-bone gap is greater than of subjects and our data showed that the results did not
30 dB air-bone gap. (Fig 2) correlate with either positive nor negative Rinne test.3,4
For this reason, we did not include the equivocal Rinne
DISCUSSION test in the calculation for sensitivity and specificity.
Despite the low specificity of 256 Hz tuning fork, Rinne’s sensitivity of detecting conductive hearing
the sensitivity of 256 Hz Rinne tuning fork test is greater loss in each range of air-bone gap is essential for clinical

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Phonpornpaiboon et al.

Fig 2. Sensitivity of air-bone gap detection of 256 Hz and 512 Hz Rinne tuning fork.

appliance. Crowley et al8 studied between the Rinne tuning of 30 dB or greater which indicates surgical role with
fork test 256, 512, 1024, and 2048 Hz in 153 ears and the sensitivity of 92.3%.
air-bone gap detection. He concluded that the air-bone
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130 Volume 71, No.1: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th