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Year : 2017  |  Volume : 23  |  Issue : 4  |  Page : 264-266

A rare complication of tuning fork test

1 Department of Otorhinolaryngology Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
2 Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Kuala Krai, Kelantan, Malaysia

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Rajinder Singh Hardyal Singh
Department of Otorhinolaryngology Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_107_17

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Incidence of tuning fork-related complication is extremely rare. Here, we report a case of an 18-year-old gentleman who presented with a recurrent left ear discharge with a central perforation for the past 7-year duration. Left myringoplasty was performed after the ear condition was permissible. One week after surgery, he presented with an erythematous lesion over his forehead secondary to a tuning fork test which was done prior discharge.

Keywords: Allergy, complication, tuning fork

How to cite this article:
Hardyal Singh RS, Hashim HZ, Mohamad I. A rare complication of tuning fork test. Indian J Otol 2017;23:264-6

How to cite this URL:
Hardyal Singh RS, Hashim HZ, Mohamad I. A rare complication of tuning fork test. Indian J Otol [serial online] 2017 [cited 2020 Jul 7];23:264-6. Available from: http://www.indianjotol.org/text.asp?2017/23/4/264/231639

  Introduction Top

Tuning fork test is a routine clinical test. It is a part of the ear examination procedure which is performed in the outpatient clinics. The Rinne and Weber tests give the clue for the type of hearing impairment either conductive or sensorineural hearing loss. It also detects the laterality of the problem. In the setting of a patient undergoing myringoplasty, the tuning fork tests performed should show a pure conductive deafness at the affected ear.

  Case Report Top

An 18-year-old man complained of recurrent left ear discharge for 7-year duration. The discharge was mucopurulent in nature and not foul smelly. He complained of itchiness, on-and-off tinnitus, and slight reduced hearing on the right ear. There was no otalgia or any nasal or throat symptoms.

Examination noted a left tympanic membrane 50% central perforation with minimal dried mucopus. Otoscopy of the right ear was normal. Tuning fork test done using the tuning fork [Figure 1] showed left conductive hearing loss. Pure-tone audiometry was consistent with left mild conductive hearing loss with right normal hearing.
Figure 1: The tuning fork used in the preoperative hearing test

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Left myringoplasty was performed. On the next day before discharge, the routine postoperative tuning fork test done using a different tuning fork [Figure 2] revealed the expected left conductive hearing loss. He was discharged well.
Figure 2: The tuning fork used in the postoperative test

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On the next follow-up after a week, he complained of wound on the forehead secondary to tuning fork test. He claimed that area became inflamed with signs of redness and itchiness, which developed after few hours after the last tuning fork test. Blister developed on the subsequent day. The condition worsened after he kept scratching on that area. He was treated with chloramphenicol ointment for topical application. After 2 months, the lesion healed with scar [Figure 3].
Figure 3: The scar at the area of placement of tuning fork for the Weber test

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  Discussion Top

The tuning fork test has been routinely practiced by specialists, medical officer, medical students, and health-care personnel to determine the type of hearing loss in patients who presented with reduced hearing. The tuning fork was first used as a musical instrument and was designed by John Shore an English trumpeter in 1711.[1] In 1855, Rinne used the tuning fork to diagnose deafness by comparing hearing by air and bone conduction.[2]

There is a variety of hearing test being carried out using the tuning fork to diagnose hearing loss. Out of which, the Rinne and Weber tests are subjective tests, which are routinely performed clinically using a tuning fork to assess a person's hearing level. A tuning fork with the frequency range of 512 Hz or 1024 Hz is used to carry out the Weber and Rinne tests to detect whether the hearing loss is conductive or sensorineural.[3]

The tuning fork consists of a handle and two prongs with various frequencies available. The tuning fork is usually made up of stainless steel containing a mixture of alloy nickel and chromium. In Rinne test, the base of the vibrating fork is placed on the mastoid bone, behind the ear to assess bone conduction. Air conduction is tested by placing the fork immediately in front of the ear canal with the “U” of the fork facing forward to maximize the sound produced by the vibrating prongs.[4] The patient is asked to compare the loudness of the sound by bone conduction or by air conduction. In normal hearing, the air conduction is louder than bone conduction.[4] The Weber test is conducted by placing the base of the vibrating fork on the vertex. The patient is asked if the sound is heard and whether it is heard in the center of the head (or in both ears equally), toward the left, or toward the right. In a patient with normal hearing, the tone is heard centrally. In asymmetric/unilateral hearing impairment, the tone lateralizes to one side.[4]

Complications resulting from the use of tuning fork are extremely rare. Up to date, there are no available literatures explaining tuning fork-related injuries. We believe that the complication suffered by the patient following the test is due to an allergic reaction to the material in which the tuning fork is made up of.

Allergic contact dermatitis from external exposure to metals is a well-established medical fact. All stainless steel material contains mostly iron and a small amount of chromium and nickel. Both nickel and chromium could generate an allergic reaction in a certain group of people. Exposure to these metal products could trigger a hypersensitivity reaction, dermatitis, and asthma.[5] Usually, a delayed type IV hypersensitivity reaction is triggered, and T-lymphocytes are the key to patient's reaction.[6] During sensitization, CD8+ and CD4+ T-cells are activated resulting in cytotoxic and inflammatory aspects of tissue damage, respectively.[6]

Women are usually more susceptible to nickel-related allergic contact dermatitis compared to men. In a study by Blanco-Dalmao et al., who studied the incidence of nickel hypersensitivity in relation to sex involving 121 men and 282 women, the author concluded that of all women tested, 31.9% showed positive reaction to nickel while 20.7% of men tested showed the same reaction.[7] The reason being is probably women have contact nickel more by wearing jewelry that contains this metal.[7]

Metal-related allergy usually developed as a result of repeated or prolonged skin contact with metal ions. When ions from a metal gain access to a viable epidermis, an immune response is initiated. Usually, all body parts can be involved in allergic contact dermatitis. The formation of erythema, edema, papules, vesicles, and weeping are the characteristic features of acute dermatitis while chronic dermatitis usually present as scaly, dry, and fissured.[8] In this case, the patient developed similar symptoms as was described above. When the symptoms of acute inflammation subside, it will result in scar formation. We also observed that while the patient did not develop any allergy reaction to the tuning fork used in the preoperative hearing test, he did develop an allergy reaction with the tuning fork that was used in the postoperative hearing test. This could be due to the fact that the preoperative tuning fork had a plastic covering on its base, preventing direct contact of its metal part with the patient.

In conclusion, tuning fork test is considered a safe and effective screening test to detect hearing loss. However, there are a small number of individuals that are sensitive to metal product and may develop an allergy reaction. Therefore, before the commencement of the test, a history of recent allergies should be asked to prevent unwanted allergy-related complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pearce JM. Early days of the tuning fork. J Neurol Neurosurg Psychiatry 1998;65:728, 733.  Back to cited text no. 1
Huizing EH. The early descriptions of the so-called tuning-fork tests of weber, rinne, schwabach, and bing. II. The “Rhine test” and its first description by polansky. ORL J Otorhinolaryngol Relat Spec 1975;37:88-91.  Back to cited text no. 2
Rabinowitz PM. Noise-induced hearing loss. Am Fam Physician 2000;61:2749-56, 2759-60.  Back to cited text no. 3
Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA 2006;295:416-28.  Back to cited text no. 4
Kocadereli L, Ataç PA, Kale PS, Ozer D. Salivary nickel and chromium in patients with fixed orthodontic appliances. Angle Orthod 2000;70:431-4.  Back to cited text no. 5
Noble J, Ahing SI, Karaiskos NE, Wiltshire WA. Nickel allergy and orthodontics, a review and report of two cases. Br Dent J 2008;204:297-300.  Back to cited text no. 6
Blanco-Dalmau L, Carrasquillo-Alberty H, Silva-Parra J. A study of nickel allergy. J Prosthet Dent 1984;52:116-9.  Back to cited text no. 7
Thyssen JP, Menné T. Metal allergy – A review on exposures, penetration, genetics, prevalence, and clinical implications. Chem Res Toxicol 2010;23:309-18.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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