EXERCISE 9:

SENSE OF HEARING

A. Parts of the Ear

The peripheral hearing system consists of three parts which are the outer ear, the middle ear and
the inner ear:
• The outer ear consists of the pinna (also called the auricle), ear canal and eardrum.
• The middle ear is a small, air-filled space containing three @ny bones called the malleus, incus and
stapes but collec@vely called the ossicles. The malleus connects to the eardrum linking it to the
outer ear and the stapes (smallest bone in the body) connects to the inner ear.
• The inner ear has both hearing and balance organs. The hearing part of the inner ear and is called
the cochlea which comes from the Greek word for ‘snail’ because of its dis@nc@ve coiled shape.
The cochlea, which contains many thousands of sensory cells (called ‘hair cells’), is connected to
the central hearing system by the hearing or auditory nerve. The cochlea is filled with special fluids
which are important to the process of hearing.

B. How do we hear?
Sound waves, which are really vibra@ons in the air around us, are collected by the pinna on each
side of our head and are funnelled into the ear canals. These sound waves make the eardrum
vibrate. The eardrum is so sensi@ve to sound vibra@ons in the ear canal that it can detect even the
faintest sound as well as replica@ng even the most complex of sound vibra@on paMerns.
The eardrum vibra@ons caused by sound waves move the chain of @ny bones (the ossicles –
malleus, incus and stapes) in the middle ear transferring the sound vibra@ons into the cochlea of the
inner ear. This happens because the last of the three bones in this chain, the stapes, sits in a
membrane-covered window in the bony wall which separates the middle ear from the cochlea of the
inner ear. As the stapes vibrates, it makes the fluids in the cochlea move in a wave-like manner,
s@mula@ng the microscopically small ‘hair cells’.
Remarkably, the ‘hair cells’ in the cochlea are tuned to respond to different sounds based on
their pitch or frequency of sounds. High-pitched sounds will s@mulate ‘hair cells’ in the lower part of
the cochlea and low-pitched sounds in the upper part of the cochlea. What happens next is even
more remarkable because, when each ‘hair cell’ detects the pitch or frequency of sound to which it’s
tuned to respond, it generates nerve impulses which travel instantaneously along the auditory
nerve.
These nerve impulses follow a complicated pathway in the brainstem before arriving at the
hearing centers of the brain, the auditory cortex. This is where the streams of nerve impulses are
converted into meaningful sound. All of this happens within a @ny frac@on of a second, almost
instantaneously aSer sound waves first enter our ear canals. It is very true to say that, ul@mately, we
hear with our brain.
 C. Part 1: Weber Test

The Weber test is a useful, quick, and simple screening test for the evalua@on of hearing loss. The
test can detect unilateral conduc@ve and sensorineural hearing loss. The outer and middle ear mediate
conduc@ve hearing. The inner ear mediates sensorineural hearing. The Weber test is oSen combined
with the Rinne test to detect the loca@on and nature of hearing loss.

Weber Test Principles

The inner ear is more sensi@ve to sound via air conduc@on than bone conduc@on (in other words, air
conduc@on is beMer than bone conduc@on).

In the presence of a purely unilateral conduc@ve hearing loss, there is a rela@ve improvement in the
ability to hear a bone-conducted sound. This can be explained by the following:
• Masking effect: The sound heard via the affected ear has less environmental noise reaching the
cochlea via air conduc@on (for example, the environmental noise is masked) as compared to the
unaffected ear which receives sounds from both bone conduc@on and air conduc@on. Therefore,
the affected ear is more sensi@ve to bone-conducted sound.
• Occlusion effect: Most of the sound transmiMed via bone conduc@on travels through to the
cochlea. However, some of the low-frequency sounds dissipate out of the canal. A conduc@ve
hearing loss (in other words, when an occlusion is present) will, therefore, prevent external
dissipa@on of these frequencies and lead to increased cochlear s@mula@on and increased
loudness in the affected ear.
Procedures:

1. Obtain a tuning fork, strike it with the reflex hammer, causing it to vibrate.
2. Place the handle of the fork against the subject’s forehead in the midline.
3. Ask the subject to indicate if the sound is equally loud in both ears or if it is louder in one ear.
Check the appropriate box in “Table 1” of the laboratory report.

4. Repeat steps 1 to 3 with the right ear, and then with leS ear, packed with coMon.
In normal hearing, an individual will hear equally on both sides of the ear. The Weber test is a test of
lateraliza@on and is of most value useful in those with an asymmetrical hearing loss.
Interpreta@on

Normal Hearing
• Weber test does not demonstrate lateraliza@on: In a normal subject, the sound should be heard
in the middle and equally on both sides.
• Rinne test: Normal/posi@ve in both ears (AC greater than BC)
Unilateral Sensorineural Hearing Loss
• Weber test lateralizes to the unaffected ear, in other words, it is heard louder in the beMer ear.
 • Rinne test: Normal/posi@ve on the affected ear (AC greater than BC); normal/posi@ve on the
unaffected ear (AC greater than BC)
Note: An abnormal/nega@ve response on the affected ear (BC greater than AC) can also occur in a severe
sensorineural hearing loss, also called a dead ear. This is termed a "false nega@ve." Rinne "true nega@ve"
only occurs if there is a conduc@ve hearing loss element. However, when tes@ng a dead ear, the bone
conduc@on is perceived to be heard louder than air conduc@on due to cross-over of bone
conduc@on detected by the opposite normal-func@oning cochlear, resul@ng in a Rinne false nega@ve.
Unilateral Conduc@ve Hearing Loss
• Weber test lateralizes to the affected ear, in other words, it is heard louder in the poorer ear.
• Rinne test: Abnormal/nega@ve on the affected ear (BC greater than AC); normal/posi@ve on the
unaffected ear (AC greater than BC)
Symmetrical Conduc@ve Hearing Loss
• Weber test does not demonstrate lateraliza@on
• Rinne test: Abnormal/nega@ve on the affected ear (BC greater than AC)

D. Part 2: Rinne’s Test

The Rinne test used to evaluate the loss of hearing in one ear. The Rinne test differen@ates sounds
transmiMed by air conduc@on from those transmiMed through the mastoid by bone conduc@on. It quick
screens for the conduc@ve hearing loss. A Rinne test should be done with a Weber test to detect
a sensorineural hearing loss.

*The Rinne test is conducted by placing a tuning fork on the mastoid bone.
• Air conduc@on uses the apparatus of the ear (eardrum, pinna, and ossicles) to amplify and direct
the sound.
• Bone conduc@on allows the vibra@on sound to be transmiMed to the inner ear. There is reduced
volume transmiMed by to the bones of the skull to the other ear.

Procedures:
1. Obtain a tuning fork, strike it with the reflex hammer, causing it to vibrate.
2. Place the end of the fork’s handle against the subject’s leS or right mastoid process,
3. When the subject indicates that the sound is no longer audible, hold the s@ll vibra@ng prongs
close to his auditory canal.
4. If the subject hears the fork again when it is moved to that posi@on, the test result is to be
recorded as posi@ve (+). If not, the test result is to be recorded as nega@ve.
5. Repeat the test, but this @me air conduc@on hearing first.
6. ASer the tone is no longer heard by air conduc@on, hold the handle of the tuning fork on the
bony mastoid process.
7. If the subject hears the tone again, the result is recorded nega@ve (-). If not, the result is to be
recorded posi@ve (+).
8. Repeat the sequence for the opposite ear.
 Interpreta@on
• Rinne Posi@ve: The pa@ent is posi@ve on that side (the ossicular chain is doing what it should be
doing, ac@ng as an amplifier). If the bone conduc@on through the mastoid process is heard
louder than through the air, then the pa@ent is Rinne nega@ve. This is always abnormal.
• If the pa@ent has nega@ve or abnormal Rinne nega@ve, air vibra@ons are not being transmiMed
across the external auditory canal, the tympanic membrane, the ossicular chain, or the oval
window.