Definition 1: at least 1 negative or equivocal response in the test orientation; definition 2: any combination of negative or equivocal responses in the test orientation; definition 3: 2 negative responses in the test orientation. Sensitivity and specificity were determined by comparison to a 2-frequency pure tone audiometric masked air-bone gap of 20 decibels (dB) gold standard.
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Butskiy O, Nunez DA. Diagnostic Accuracy of Parallel vs Perpendicular Orientation of the Tuning Fork in the Identification of Conductive Hearing Loss. JAMA Otolaryngol Head Neck Surg. 2018;144(3):275–276. doi:10.1001/jamaoto.2017.3004
One hundred sixty-two years after its description, the Rinne test continues to be widely used by primary care and specialist physicians to detect conductive hearing losses. On acoustic anechoic chamber evidence,1 audiology society recommendations,2 medical student texts,3 and peer reviewed publications, placing the vibrating tines parallel as opposed to perpendicular to the auditory meatus is recommended when testing air conduction of sound with the Rinne test.4 We report a real-world clinical experiment comparing patients’ responses to the Rinne test when performed with the tuning fork positioned parallel vs perpendicular to the external auditory meatus.
Written informed consent was obtained from adult patients prospectively recruited with institutional ethical approval from Vancouver General Hospital. Patients were recruited at a tertiary care academic otology clinic between February 2016 and February 2017. Patients’ eligibility was identified by a screening Rinne test with a 512 Hz tuning fork, in which the allocation of tuning fork tines’ orientation (parallel vs perpendicular) was determined by a random number sequence. Patients with a negative (bone conduction louder than air) or equivocal (bone conduction equal to air) Rinne result (suggesting conductive hearing loss) in at least 1 ear were recruited. Enrolled patients underwent 4 further Rinne tests with a 512 Hz tuning fork presented to each ear: 2 with the tines parallel and 2 with the tines perpendicular to each ear canal. The test orientation sequence was block randomized, and the experimenter blinded to the screening results.
A tuning fork identified conductive hearing loss was predefined as at least 1 negative or equivocal response in the test orientation (definition 1). In the exploratory analyses, 2 alternative definitions of conductive hearing loss were considered: any combination of negative or equivocal responses in the test orientation (definition 2); and 2 negative responses in the test orientation (definition 3). Sensitivity and specificity of tuning fork identified conductive hearing loss were determined by comparison with the following reference standard: 20 decibels (dB) average air-bone gap at 500 Hz and 1000 Hz. Audiometric measurements were performed on the same day as the tuning fork testing.
Of 57 eligible patients, 50 were recruited for a sample of 100 ears. The Table demonstrates the results and agreement between the 2 Rinne test tuning fork presentations. A Cohen κ of 0.83 (95% CI, 0.72-0.94) demonstrated a high level of intertest agreement. The sensitivity and specificity of the 2 Rinne test tuning fork presentations were nearly identical compared with the reference standard.
Exploratory analyses showed that Cohen κ was 0.74 (95% CI, 0.55-0.85) and 0.63 (95% CI, 0.44-0.81) for the conductive hearing loss definition 2 and 3, respectively. Receiver operating curve demonstrates that the sensitivity and specificity of the 2 Rinne test tuning fork presentation for alternate conductive loss definitions remained similar (Figure).
We found good agreement and nearly identical intertest diagnostic accuracy in identifying conductive hearing loss with tuning fork positions parallel and perpendicular to the external auditory meatus during the Rinne test. Hence, in the real-world environment parallel or perpendicular orientation of the tuning fork when testing air conduction with the Rinne test will not alter the test result. These results should not be extrapolated to other variations, such as a 45% angled tuning fork presentation to the external auditory meatus.
Corresponding Author: Oleksandr Butskiy, MD, Gordon & Leslie Diamond Health Care Centre, 4th Flr, 4299B-2775 Laurel St, Vancouver, BC V5Z 1M9 Canada (email@example.com).
Accepted for Publication: November 11, 2017.
Published Online: February 1, 2018. doi:10.1001/jamaoto.2017.3004
Author Contributions: Dr Butskiy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Butskiy.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Administrative, technical, or material support: Nunez.
Study supervision: Nunez.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank Dr Li Qi, Department of Audiology, Vancouver General Hospital, for facilitation of bone conduction audiograms for the study. He was not compensated.
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