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

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 22 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

To differentiate between conductive and sensorineural hearing loss during a routine clinical examination:

  • Begin with otoscopy to exclude impacted earwax and acute infections such as otitis externa, which can cause conductive hearing loss .
  • Perform tuning fork tests (Weber and Rinne tests): In conductive hearing loss, the Weber test lateralises to the affected ear, and the Rinne test shows bone conduction greater than air conduction (negative Rinne). In sensorineural hearing loss, the Weber test lateralises to the unaffected ear, and the Rinne test shows air conduction greater than bone conduction (positive Rinne) .
  • Consider pure tone audiometry and tympanometry for further assessment if indicated; audiometry can help distinguish sensorineural from conductive loss by comparing air and bone conduction thresholds .
  • If hearing loss is not explained by external or middle ear causes, or if there are additional symptoms such as unilateral/asymmetric loss, refer for specialist diagnostic assessment .

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