Test gross hearing by whispering a series of numbers in the patient’s ear and asking the patient to repeat the numbers.

If this shows a deficit, proceed to Rinne and Weber tests.


Hold a vibrating tuning fork next to the external auditory meatus then place the base on the mastoid process. The sound should be louder on holding the tuning fork next to the ear (air conduction), the test is abnormal if louder on bone (implies conductive hearing loss).


The sound from a vibrating tuning fork placed on the centre of forehead is heard loudest in the affected ear if there is a conductive hearing defect.

If there is a hearing deficit look in the ears and arrange formal testing.


Look for nystagmus on testing eye movements.

Nystagmus is described by the physician with reference to the direction of gaze and the direction of the fast beating component. This can be horizontal (right beating, left beating, bidirectional), vertical (upbeating, downbeating) or torsional. Features of nystagmus to discern between central and peripheral causes are given in the table below. Other tests such as Dix-Hallpike manoeuvre and Vestibular-ocular reflex can be employed but will not be discussed here (see Vetigo in the ED learning session)

Clinical FeaturesPeripheral Central
Purely horizontal without torsionRareCommon
Mixed horizontal/torsionalCommonRare
Purely vertical or torsionalRareCommon
Changing direction with gazeRareCommon
Visual fixationDampensUnchanged