Shuman AG, Li X, Halpin CF, Rauch SD, Telian SA. Tuning Fork Testing in Sudden Sensorineural Hearing Loss. JAMA Intern Med. 2013;173(8):706-707. doi:10.1001/jamainternmed.2013.2813
Author Affiliations: Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Shuman); Cooperative Studies Program Coordinating Center, Hines VA Hospital, Hines, Illinois (Dr Li); Department of Otology and Laryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (Drs Halpin and Rauch); and Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, Ann Arbor (Dr Telian).
Sudden sensorineural hearing loss (SNHL) is a condition for which prompt diagnosis and initiation of treatment is of paramount importance.1 Because patients frequently seek initial evaluation in urgent care or primary care settings, audiologic assessment may not be immediately available. As such, tuning forks have the potential to assist with initial treatment and appropriate triage because they are available, inexpensive, and easy to use. However, the role of tuning fork testing in the initial workup of hearing complaints has not been clearly elucidated.2,3
A recent multicenter, randomized controlled clinical trial compared oral and intratympanic corticosteroids for sudden SNHL.4 Tuning fork testing and formal audiometry were performed as part of the baseline assessment of eligible study participants, creating a robust database that facilitates a prospective evaluation of the utility of the Weber test in this setting. We hypothesized that the Weber test would be a useful clinical metric to diagnose unilateral SNHL.
This study uses data that determined whether patients were eligible to participate in a prospective multicenter, randomized, clinical trial that compared different treatments for sudden unilateral SNHL (clinicaltrials.gov NCT00097448).4 The trial was conducted from 2004 through 2009 and was approved by the institutional review boards of all participating sites.
Adult patients who presented with unilateral idiopathic sudden SNHL were included. Audiometric criteria for inclusion were a documented pure tone average (PTA) of at least 50 dB in the affected ear, and at least a 30-dB difference between ears in at least 1 of the 4 PTA frequencies.
The Weber test was administered with a 512-Hz tuning fork at screening or enrollment. To perform the Weber test, 1 tine of the tuning fork was struck forcefully enough for the examiner to perceive sound. The fork was placed firmly on the scalp vertex, forehead, or maxillary dentition. The patient reported whether sound was perceived better in either ear or heard in the midline.5 Audiometric evaluation was performed thereafter; variables for each ear included frequency thresholds and PTA.
The results of the Weber test at the time of study enrollment were compared with the results of the audiogram. The sensitivity of the Weber test was calculated. κ Coefficients were calculated to quantify the magnitude of agreement between the Weber test and the PTA. McNemar test was used to test whether the identification of the affected ear by the Weber test was concordant with the PTA results. These analyses were performed for the entire data set (n = 250), as well as for the subset of patients for whom the Weber test lateralized (n = 198).
The Weber test correctly lateralized to the ear opposite the hearing loss in 196 of patients (78%). Of the remaining 22%, 2 cases (1%) incorrectly lateralized, falsely indicating conductive loss; 38 (15%) were heard in the midline, and 14 (6%) were not heard. Despite good overall agreement between the audiogram results and the Weber test with low discordance, the Weber test did not reliably predict the audiogram results for the entire cohort. Among the subset of patients for whom the Weber test lateralized (n = 198), the Weber test correlated considerably better, and was a reliable predictor of the audiogram results (Table).
Since most patients who experience a sudden SNHL are seen in a primary care setting, and since more common conditions are often difficult to distinguish based on clinical assessment alone, referral for specialty evaluation and audiometry are frequently delayed beyond the ideal therapeutic window.6 This study was undertaken to evaluate whether the Weber test might help identify patients with suspected SNHL who require prompt referral and treatment. The finding that the Weber test did not lateralize or could not be heard in over 20% of study participants was consistent with other reports that conclude that Weber test results can be unreliable.2,3
The high reliability of the Weber test when it lateralized away from the suspect ear confirms that the test retains value in the clinical setting when assessing a patient presenting with acute hearing complaints. Most patients with alternative diagnoses routinely considered by primary care providers, such as cerumen impaction, Eustachian tube dysfunction, or otitis media, will present with a conductive hearing loss. Thus, if a Weber test unexpectedly lateralizes to the asymptomatic, better hearing ear, this finding should prompt immediate audiometric testing, and urgent otologic referral if a sensorineural loss is confirmed.7
In light of these data, clinicians should be alert to the possibility of sudden SNHL being overlooked in patients without the expected tuning fork findings. However, among patients presenting with sudden unilateral hearing loss, lateralization of the Weber test to the contralateral ear very reliably predicts a sensorineural etiology, and such patients should be promptly referred and treated accordingly.
Correspondence: Dr Telian, Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (email@example.com).
Published Online: March 25, 2013. doi:10.1001/jamainternmed.2013.2813
Author Contributions:Study concept and design: Halpin, Rauch, and Telian. Acquisition of data: Halpin, Rauch, and Telian. Analysis and interpretation of data: All authors. Drafting of the manuscript: Shuman, Li, and Telian. Critical revision of the manuscript for important intellectual content: Shuman, Halpin, Rauch, and Telian. Statistical analysis: Shuman, Li, and Halpin. Obtained funding: Rauch and Telian. Administrative, technical, and material support: Rauch and Telian. Study supervision: Rauch and Telian.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by grant U01-DC006296 from the National Institute on Deafness and Communication Disorders.
Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: Domenic J. Reda, PhD, Cooperative Studies Program Coordinating Center, Hines VA Hospital, provided statistical expertise and guidance. We thank all of the clinicians, researchers, patients, and families who participated in this multicentered clinical trial.