Rinne test: does the tuning fork position affect the sound amplitude at the ear?

The Expression Levels of MicroRNAs Differentially Expressed in Sudden Sensorineural Hearing Loss Patients' Serum Are Unchanged for up to 12 Months after Hearing Loss Onset

Sudden sensorineural hearing loss (SSNHL) is an acquired idiopathic hearing loss. Serum levels of small, non-coding RNAs and microRNAs (miRNAs) miR-195-5p/-132-3p/-30a-3p/-128-3p/-140-3p/-186-5p/-375-3p/-590-5p are differentially expressed in SSNHL patients within 28 days of hearing loss onset. This study determines if these changes persist by comparing the serum miRNA expression profile of SSNHL patients within 1 month of hearing loss onset with that of patients 3-12 months after hearing loss onset. We collected serum from consenting adult SSNHL patients at presentation or during clinic follow-up. We matched patient samples drawn 3-12 months after hearing loss onset (delayed group, n = 9 patients) by age and sex to samples drawn from patients within 28 days of hearing loss onset (immediate group, n = 14 patients). We compared the real-time PCR-determined expression levels of the target miRNAs between the two groups. We calculated the air conduction pure-tone-averaged (PTA) audiometric thresholds in affected ears at the initial and final follow-up visits. We undertook inter-group comparisons of hearing outcome status and initial and final PTA audiometric thresholds. There was no significant inter-group difference in miRNA expression level, hearing recovery status and initial and final affected ear PTA audiometric thresholds.

Dorsal Column Bedside Examination Test: Tips for the Neurosurgical Resident

The dorsal column medial lemniscus (DCML) system is a sensory pathway of the central nervous system; it carries sensations of soft touch, vibration, proprioception, two-point discrimination, and pressure from the skin and joints. The clinical signs of the DCML pathway lesions include loss of soft touch, vibratory sense, proprioception, discrimination sense, and a positive Rhomberg test. Diseases that affect this pathway are usually degenerative, for example, spinal cord degeneration due to vitamin B12 deficiency; it can also be affected by trauma or infarction of the posterior spinal artery causing posterior cord syndrome. This video manuscript provides a step-by-step examination technique of the dorsal column examination, specially catered for Malaysian medical students and trainees. A series of videos show the techniques for soft touch sensation examination, examination of the vibratory sense, examination of the joint position sense, examination of two-point discrimination and the Rhomberg test. We hope that students can adhere to these techniques and apply them in their daily neurological assessments.

Rinne Test Results: How Badly Can We Be Mistaken?

Objective

To establish the extent to which sound amplitudes delivered by a vibrating tuning fork change around its long axis and to evaluate whether such differences in amplitude might change the results of the Rinne test.

Study Design

Experimental measurements.

Setting

Laboratory setting.

Methods

Setup I: a vibrating tuning fork was handheld and manually rotated around its long axis next to a sound recording device (the simulated ear) in order to record sound amplitude data at a full range of angles relative to the device; files were split into segments in which sound amplitude changed: A (from a maximum to a minimum) and B (from a minimum to a maximum). Setup II: a vibrating tuning fork was machine-rotated, and the angle of rotation, along with the sound amplitude, was automatically recorded through a single full rotation.

Results

The angles of 0° and 180° (which equate to the established best practice in Rinne testing) were associated with the highest sound amplitudes. All other angles decreased sound amplitude. The greatest decrease in amplitude was recorded at 51° and 130°. This difference ranged from 9.8 to 34.7 dB, depending on the initial amplitude.

Conclusion

The outcome of a Rinne test can be affected if attention is not paid to the precise angle at which the tuning fork is held relative to the ear. The potential of this effect will be greater when high background noise or patient hearing loss requires that the tuning fork be vigorously excited to obtain high sound amplitudes.

Validation of a smartphone-based Rinne test to detect an air-bone gap

Objective

To validate a smartphone-based Rinne test employing the vibration application of mobile telephones.

Study design

Prospective controlled clinical study.

Setting

Tertiary referral medical center.

Methods

Twenty consecutive patients hospitalized in the otolaryngology department of a tertiary medical center due to unilateral hearing loss (HL study group), and 30 consecutive inpatients on the same ward who had no otological history (controls) were enrolled. Each participant underwent the traditional 512 Hz tuning fork-based Rinne test, as well as a smartphone-based Rinne test by means of a single uncovered smartphone with a vibration application. The test results were compared to those of formal audiometry.

Results

The overall agreement between the traditional Rinne test and the smartphone-based test was 98%. The Sensitivity was 85% for both tests, specificity was 90% and 93% for smartphone and tuning fork tests, respectively. The smartphone-based Rinne test could correctly discriminate between patients with an air–bone gap ≥ 25 dB at 512 Hz from patients with a lower or no air–bone gap at 512 Hz. The smartphone-based Rinne could not evaluate two patients with a moderately severe/severe sensorineural hearing loss due to their inability to detect the vibrations.

Conclusion

A smartphone-based Rinne test was validated for the detection of an air–bone gap ≥ 25 dB at 512 Hz in the clinical setting. The validity of patient-operated smartphone-based Rinne test awaits further study.

Level of evidence

2B.

Contralateral occlusion test: The effect of external ear canal occlusion on predicting conductive hearing loss

INTRODUCTION AND OBJECTIVES

The contralateral occlusion test (COT) has the potential to allow the quantitative evaluation of unilateral conductive hearing loss. The purpose of this study was to determine the accuracy of the test in predicting the degree of hearing loss.

MATERIALS AND METHODS

Fifty-three subjects with unilateral conductive hearing loss were recruited from an otolaryngology department of a tertiary hospital. The COT was performed using 128, 256, 512, 1024 and 2048Hz tuning forks with the non-affected ear canal totally occluded to determine lateralization. Pure-tone audiometry was performed to establish the presence and degree of the air-bone gap (ABG) and the pure-tone average (PTA). The tuning fork responses were correlated with the ABG and the PTA to determine their accuracy.

RESULTS

The COT showed a better association between hearing loss and the lateralization response using the 512Hz tuning fork (p=0.001). The sensitivity of the 512Hz fork in detecting a PTA of at least 35.6dB was 94.6% and the specificity was 75.0% for a positive predictive value of 89.7% and a negative predictive value of 85.7%, assuming a pretest prevalence of 69.8%.

CONCLUSIONS

The overall accuracy of the COT in predicting the degree of unilateral conductive hearing loss was significant. The COT had significant power in one direction: if lateralization to the affected ear occurred, it was almost certain evidence of a moderate or severe conductive hearing loss.

Diagnostic Accuracy of Tuning Fork Tests for Hearing Loss: A Systematic Review

Objective

(1) To determine the diagnostic accuracy of tuning fork tests (TFTs; Weber and Rinne) for assessment of hearing loss as compared with standard audiometry. (2) To identify the audiometric threshold at which TFTs transition from normal to abnormal, thus indicating the presence of hearing loss.

Data Sources

PubMed, Ovid Medline, EMBASE, Web of Science, Cochrane, and Scopus and manual bibliographic searches.

Review Methods

A systematic review of studies reporting TFT accuracy was performed according to a standardized protocol. Two independent evaluators corroborated the extracted data and assessed risk of bias.

Results

Seventeen studies with 3158 participants, including adults and children, met inclusion criteria. The sensitivity and specificity of the Rinne test for detecting conductive hearing loss ranged from 43% to 91% and 50% to 100%, respectively, for a 256-Hz fork and from 16% to 87% and 55% to 100% for a 512-Hz fork. The audiometric thresholds at which tests transition from normal to abnormal ranged from 13 to 40 dB of conductive hearing loss for the Rinne test and from 2.5 to 4 dB of asymmetry for the Weber test. Significant heterogeneity in TFT methods and audiometric thresholds to define hearing loss precluded meta-analysis. There is high risk of bias in patient selection for a majority of the studies.

Conclusion

Variability exists in the reported test accuracy measurements of TFTs for clinical screening, surgical candidacy assessments, and estimation of hearing loss severity. Clinicians should remain mindful of these differences and optimize these techniques in specific clinical applications to improve TFT accuracy.

Incidence of Discomfort During Pure-Tone Audiometry and Measurement of Uncomfortable Loudness Levels Among People Seeking Help for Tinnitus and/or Hyperacusis

PURPOSE

The aim of this study was to assess the proportion of patients seen in a tinnitus and hyperacusis therapy clinic for whom presentation levels based on the British Society of Audiology (BSA)-recommended procedures for pure-tone audiometry and determination of uncomfortable loudness levels (ULLs) exceed ULLs, leading to discomfort during administration of these procedures.

METHOD

This was a retrospective cross-sectional study of 362 consecutive patients who attended a National Health Service audiology clinic for tinnitus and/or hyperacusis rehabilitation.

RESULTS

For 21% of the patients, presentation levels based on the BSA procedure for pure-tone audiometry exceeded the ULL for at least 1 of the measured frequencies (excluding the first frequency tested, 1 kHz): 0.25, 0.5, 2, 3, 4, 6, and 8 kHz. For 24% of patients, the starting presentation level of 60 dB hearing level recommended for determination of ULLs exceeded the ULL for at least 1 frequency.

CONCLUSION

The starting presentation levels used for pure-tone audiometry and measurement of ULLs should be lower than those recommended by the BSA for people with tinnitus and hyperacusis.