Rinne and Weber without second-guessing

What each test asks

Use a 512 Hz fork (256 Hz gives too much vibrotactile artefact, 1024 Hz decays too fast).

• Rinne compares air conduction (AC) — fork at the meatus — with bone conduction (BC) — fork on the mastoid, in one ear.
  • Rinne positive = AC > BC = normal, because air conduction should win.
  • Rinne negative = BC > AC, and that only happens when the conductive pathway is blocked → conductive loss in that ear.
• Weber puts the fork on the midline (forehead/vertex) and asks which side is louder — it lateralises.
  • Conductive loss → Weber lateralises TO the affected (worse) ear (the blocked ear is shielded from room noise, so bone-conducted sound seems louder).
  • Sensorineural loss → Weber lateralises AWAY, to the better ear (the diseased cochlea/nerve simply hears less).

The scenarios as one table

The one rule to hold

Weber goes toward a conductive ear and away from a sensorineural ear. Combine it with Rinne:

• Rinne negative + Weber to that ear → conductive loss (e.g. otosclerosis, wax, effusion).
• Rinne positive bilaterally + Weber to opposite ear → sensorineural loss on the quieter side.

False-negative Rinne — the exam trap: in severe/dead unilateral sensorineural loss, the fork on the mastoid is heard by the opposite (normal) cochlea by transcranial transmission, so the patient reports "BC > AC" and Rinne looks falsely negative (mimicking conductive). Weber saves you — it lateralises to the good ear, exposing the truth. Confirm with a masked (Barany box) test.

Anchor: Rinne classifies the ear you are testing (negative = conductive there); Weber points — toward conductive, away from sensorineural. Read them together, never alone.