Station 10 — Hearing and Balance Assessment: Tuning Forks, Vestibular Tests and Audiology
🎯 Candidate Task
Demonstrate appropriate tuning-fork and bedside balance tests on the patient. Interpret the supplied audiogram and tympanometry findings, distinguish peripheral from central balance dysfunction where appropriate, and state the relevant investigation request.
⚡ Model Station Answer
Hearing: I would perform Rinne testing on both ears and Weber testing in the midline using a 512-Hz tuning fork.
Interpretation: Rinne is normally positive with air conduction better than bone conduction. Weber is central normally; it lateralizes to the affected ear in conductive loss and to the better ear in sensorineural loss.
Balance: I would assess stance and gait and perform an appropriate vestibular bedside test. Peripheral dysfunction usually produces a vestibular pattern without focal neurological signs, whereas central dysfunction may produce atypical nystagmus, marked gait or limb ataxia, or other neurological abnormalities.
Audiology: An air–bone gap suggests conductive loss; similar reduction of air and bone thresholds suggests sensorineural loss. Tympanometry should be interpreted from the tracing and middle-ear pressure/compliance pattern.
Investigations: I would request the investigation relevant to the suspected ear disorder and document patient details, side, clinical indication, relevant findings and authentication clearly.
🔎 How to Perform / Approach
- Step 1 — Prepare the patient.
Introduce yourself, confirm identity, explain the assessment, obtain consent and position the patient comfortably. - Step 2 — Perform the Rinne test.
Vibrate a 512-Hz tuning fork, place its base firmly on the mastoid process to assess bone conduction, then hold the vibrating tines just outside the external auditory meatus to assess air conduction. Compare both ears. - Step 3 — Perform the Weber test.
Place the base of the vibrating tuning fork on the midline of the forehead and ask whether the sound is heard centrally or louder in either ear. Interpret Weber together with Rinne. - Step 4 — Assess balance.
Observe standing posture and gait and perform an appropriate test such as Romberg or tandem gait. Where clinically indicated, assess vestibular signs such as nystagmus and other bedside vestibular findings. - Step 5 — Look for peripheral versus central features.
Peripheral dysfunction commonly produces a vestibular pattern such as vertigo with predominantly horizontal or rotational nystagmus. Vertical or direction-changing nystagmus, severe gait or limb ataxia, or additional focal neurological signs should raise concern for a central cause. - Step 6 — Interpret the audiology.
On pure-tone audiometry compare air- and bone-conduction thresholds: an air–bone gap supports conductive loss; comparable reduction of both supports sensorineural loss; reduction of both with an additional air–bone gap suggests mixed loss. Interpret tympanometry by assessing the configuration, peak pressure and compliance. - Step 7 — Select and request the investigation.
Choose the investigation according to the clinical problem, such as pure-tone audiometry, tympanometry or appropriate imaging when indicated. On the requisition include correct patient identifiers, affected side, clinical indication, relevant examination findings, requested test, date and authentication.
🖼️ Visual Learning
Rinne, Weber and Bedside Balance Testing
Pure-Tone Audiogram and Tympanometry Interpretation
🎥 Practical Demonstration
Rinne & Weber Test — OSCE Demonstration
A concise practical demonstration of gross hearing assessment, Weber testing and Rinne testing from Geeky Medics.
📝 Important Viva Questions
1. What tuning-fork frequency is commonly used for Rinne and Weber tests?
Answer: A 512-Hz tuning fork is commonly used because it provides a useful balance between sound duration and minimal tactile vibration.
2. How do Rinne and Weber findings differ in unilateral conductive and sensorineural hearing loss?
Answer: Conductive loss typically gives a negative Rinne on the affected side and Weber lateralization toward that ear. Sensorineural loss usually has a positive Rinne with Weber lateralization toward the better ear.
3. Which findings during balance assessment suggest a central rather than peripheral disorder?
Answer: Vertical or direction-changing nystagmus, marked gait or limb ataxia and accompanying focal neurological signs are important central features.
4. What is an air–bone gap on pure-tone audiometry?
Answer: It is a significant difference between poorer air-conduction and better bone-conduction thresholds and supports a conductive component to hearing loss.
5. What do Type A, Type B and Type C tympanograms broadly indicate?
Answer: Type A represents a normal middle-ear pressure/compliance pattern, Type B is a flat tracing commonly associated with middle-ear effusion, and Type C demonstrates abnormally negative middle-ear pressure.