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February 21, 2007

Clinical Assessment of Hearing Impairment—Reply

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2007;297(7):695-696. doi:10.1001/jama.297.7.695-c

In Reply: We agree with Drs Kieran and Fenton that sudden unilateral sensorineural hearing loss prompts urgent investigations and may involve immediate commencement of oral steroids. However, we do not agree that the tuning fork tests aid the primary care physician with the diagnosis of this condition or the urgency of referral to an otolaryngologist.

The Weber tuning fork test, which could potentially detect asymmetrical hearing loss, has been evaluated in only 1 study,1 which showed that it is inaccurate and lacks precision. The positive likelihood ratio (LR) is 1.6 (95% confidence interval [CI], 1.0-2.3) and the negative LR is 0.7 (95% CI, 0.48-1.0), so that regardless of the finding, the probability of unilateral hearing loss is neither increased nor decreased, making it the “Homan sign” of hearing tests. The Rinne tuning fork test, which potentially detects only conductive hearing loss, has a large range of reported accuracies. Negative LRs range from 0.01 to 0.85, with most being above 0.3 (poor for ruling out conductive loss). We therefore believe that the tuning fork tests are not useful to diagnose sudden unilateral sensorineural hearing loss, and anyone who is symptomatic should be directly referred for formal audiometry. The urgency for referral should be based on recognizing the suddenness of unilateral hearing loss on history.