How can I differentiate between conductive and sensorineural hearing loss during a clinical examination?

To differentiate between conductive and sensorineural hearing loss during a clinical examination, start with otoscopy and tuning fork tests followed by audiometry.

Otoscopy helps identify external or middle ear causes such as impacted earwax, otitis externa, or middle ear effusion, which suggest conductive hearing loss ¹.

Tuning fork tests, specifically the Rinne and Weber tests, are practical bedside tools: a Rinne test showing bone conduction greater than air conduction (negative Rinne) indicates conductive hearing loss, whereas air conduction greater than bone conduction (positive Rinne) suggests sensorineural loss. The Weber test lateralizes to the affected ear in conductive loss and to the better ear in sensorineural loss ¹.

Pure tone audiometry is the definitive test, measuring air and bone conduction thresholds. Conductive hearing loss is characterized by impaired air conduction with normal bone conduction thresholds, while sensorineural hearing loss shows impairment in both air and bone conduction thresholds without an air-bone gap ¹.

Tympanometry may be used to assess middle ear function, supporting the diagnosis of conductive loss if abnormal.

Clinical history is also important: conductive loss often presents with a history of ear infections, trauma, or obstruction, whereas sensorineural loss may be associated with noise exposure, ototoxic drugs, or neurological symptoms ¹.

Recent literature emphasizes the importance of combining clinical examination with audiometric testing for accurate differentiation and notes that while tuning fork tests are useful, audiometry remains the gold standard for diagnosis (Esser and Lüers, 2025).