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Objective To describe the effect of sinusitis on Weber test lateralization which normally lateralizes toward the ear of a conductive hearing loss and away from the ear of a sensorineural hearing loss; to investigate whether the presence of an extra-aural condition might affect Weber test results. Study design Descriptive study. Setting Tertiary referral center. Subjects and methods Consecutive adult patients with maxillary and/or frontal sinusitis were included (study group), as well as patients with normal sinus structure and function (control group) were enrolled between February and September 2019. Presence or absence of paranasal disease and middle ear aeration was confirmed by computerized tomography. Subjects with otologic condition were excluded. The physical examinations, tympanograms, and audiograms were unremarkable. The Weber test consisted of 512, 1024, and 2048 Hz tuning forks that were applied on the central incisors and frontal midline, and lateralization patterns were compared with the extent of paranasal pathology. Results There were 44 participants (M:F=26:18), age 19 to 63 years (average 51). The cohort included 39 patients with sinusitis, affecting the frontal and/or maxillary sinus(es), as well as 5 controls without evidence of paranasal disease. There was a match between the extent of paranasal disease and the results of all 3 Weber test frequencies in 35 patients (80%). Omission of the 2048 and 1024 Hz tuning forks from the analysis yielded a match in 40 (91%) and 43 (98%) patients, respectively. No Weber test lateralized to the nondiseased sinus in any subject. Weber test lateralization was observed in 11% of patients, after the sinonasal pathology was successfully addressed. Conclusion Weber test lateralization in the absence of aural pathology may be explained by asymmetry related to paranasal disease and may alert to its presence.

Recent guidelines encourage the use of Webet test (WT) as a part of the physical examination of a newly suspected sudden sensorineural hearing loss (SSNHL) patient. However, the most sensitive tuning-fork frequency has never been identified.To identify the most sensitive frequency for initial WT of patients with suspected SSNHL.Medical records of patients with confirmed SSNHL, who underwent formal audiometry in which the WT was carried out with different frequencies were analyzed.319 medical records were identified. The most sensitive WT frequency was 500 Hz, with a sensitivity of 94.49% (223/236. confidence interval 90.76-97.03). There was a non-significant difference between 1000 Hz EBO and 500 Hz EBO (The most sensitive WT frequency for SSNHL diagnosis is 500 Hz. However, the sensitivity of this frequency is 94.49%.512 or 1024 Hz should be used to better identified SSNHL. Even WT lateralization to the affected ear, does not preclude the diagnosis of SSNHL. Formal audiometry should be used in any case of medical history suspected for sudden hearing loss with normal otoscopy.

Objective: The aim of this paper was to compare the accuracy of a smartphone-based Weber test (SPWT) with the traditional tuning fork Weber test (TFWT) in identifying and differentiating between sensorineural hearing loss (SNHL) and conductive hearing loss (CHL). Study Design: We conducted a prospective, noncontrolled clinical study. Methods: Sixty patients referred to the emergency department due to unilateral hearing loss (HL) were enrolled. They were asked to press a single uncovered smartphone on their forehead and conduct a Weber test by means of the smartphone’s vibration application. The results were compared to the TFWT. Results: Twenty-six (43%) patients were diagnosed with a SNHL, and 34 (57%) with a CHL. The SPWT was in agreement with the TFWT (at a frequency of 512 Hz) in 55 (92%) patients. The sensitivity and specificity of the TFWT were 84.6 and 94.1%, respectively. The sensitivity and specificity of the SPWT were 76.9 and 97.1%, respectively. Conclusion: SPWT can serve as an auxiliary diagnostic tool in the absence of a 512-Hz tuning fork to assist in the identification of the type of HL and to potentially hasten the diagnosis and provision of treatment when indicated.

The skull vibration-induced nystagmus test (SVINT) is a global vestibular test stimulating otoliths and semicircular canals at a frequency of 100Hz, not modified by vestibular compensation, which may reveal vibration-induced nystagmus (VIN). Bone-conducted vibration applied to the mastoid processes and the vertex instantaneously induces predominantly low-velocity (∼10°/s) horizontal nystagmus, with rapid phases beating away from the affected side in patients with unilateral vestibular loss (UVL). VIN starts and stops immediately with stimulation, is continuous, reproducible, beats in the same direction irrespective of which mastoid process is stimulated, with no or little habituation. The SVINT acts like a vestibular Weber test. In peripheral UVL, the SVINT is a good marker of vestibular asymmetry and demonstrates pathological nystagmus beating towards the healthy side in 90% of cases of vestibular neuritis, 71% of cases of Meniere's diseases and 44 to 78% of vestibular schwannomas. In superior semicircular canal dehiscence, VIN usually beats towards the affected side due to facilitation of bone conduction related to the presence of a third window. Stimulation of the vertex is more effective than in UVL patients, with sensitivity extending to higher frequencies, up to 700Hz. Observation of vibration-induced nystagmus then reveals equally represented vertical, torsional, and horizontal components beating towards the affected ear, suggesting dominant, but not exclusive, stimulation of the dehiscent superior semicircular canal.

Objectives: To compare the diagnostic performance of the Hum Test against the Weber Test using pure tone audiometry (PTA) as the “gold standard” comparator. Methods: 29 participants with normal hearing of ages 18 to 35 without any history of hearing abnormalities or otologic conditions were enrolled. Subjects underwent three tests (Hum Test, Weber Test, and PTA) across two conditions: with an ear plug in one ear (side randomized) and without ear plugs. Results: When examining the ability of the Hum Test to detect simulated conductive hearing loss (CHL), the test had a sensitivity of 89.7% and specificity of 100% with high pitched humming and 93.1% and 100%, respectively, with low pitched humming. The Weber Test had a sensitivity and specificity of 96.6% and 100%, respectively. McNemar’s test demonstrated agreement between the Hum Test, performed with either high pitched ( P = .32) or low pitched ( P = .56) humming, and the Weber Test. Receiver operating characteristic (ROC) curves for the Hum Test (both high and low pitched) and Weber test were compared and demonstrated no statistically significant difference. Conclusion: The Hum Test is comparable to the Weber Test with regards to its sensitivity, specificity, and diagnostic accuracy in assessing new onset unilateral CHL in previously normal hearing subjects.

Mondini dysplasia is a developmental disorder of the inner ear structures and it is a rare cause of recurrent bacterial meningitis in children. A 10-year-old boy presented with acute febrile encephalopathy and right ear pain. In the past, he had suffered from two distinct episodes of pyogenic meningitis. On examination, he had signs of meningeal irritation and right ear sensorineural deafness. Magnetic resonance imaging of the brain and computerized tomography of the temporal bone was suggestive of Mondini dysplasia in the right ear. Our case highlights the need for (a) screening of hearing loss at the bedside by Rinne and Weber test in case of recurrent bacterial meningitis (b) searching for an underlying inner ear malformation if there is a hearing loss. Keywords: Recurrent meningitis, Mondini dysplasia, Cerebrospinal fluid, Sensorineural hearing loss

Objectives Analyze reasons for unilateral conductive hearing loss (CHL) with unknown etiology in children. Introduction Unilateral conductive hearing loss (HL) without known etiology can be undiagnosed despite of hearing screening programs. It can be difficult to find the reason for HL and to make a treatment plan. Middle ear endoscopy gives hard-evidence diagnosis and basis for an individual treatment plan. Methods and material Prospective clinical follow-up study for a cohort of generally healthy elementary school age children with unilateral conductive HL with unknown etiology. The study population was 192 children, of which 46 had a HL of at least 25 dB with more than 10 dB conductive component. Mean age was 8.7 years. Preoperative tests included otomicroscopy, bone- and air-conduction audiogram, tympanometry, stapes reflex tests, Rinne and Weber test and Otoacoustic emissions. The children underwent endoscopy of the middle ear with an individual treatment plan and long-term follow-up. The aim was to explore etiology and to give a treatment plan for hearing loss. Follow-up included air- and bone conduction hearing tests annually or every other year. Mean follow-up was 5.2 years. Results A clear etiological finding was found in 36 (78%) ears, stapes anomaly (23) as the most common (64%) finding. Other findings were two cholesteatomas, 2 status after trauma, 5 middle ear anomalies, 5 incus fixations and one incus erosion. Air conduction hearing improved spontaneously during follow-up in 81% (17/21, 2 dropouts) of the stapes anomaly ears (mean 11,3 dB, range 4–32 dB), and none of these ears showed hearing deterioration. In the incus fixation group, one ear showed hearing deterioration. There were no major complications for exploration, and 5 minor postoperative infections. Conclusions The most common reason for pediatric unilateral conductive hearing loss was stapes anomaly/fixation. The HL does not deteriorate. Hearing loss in stapes anomalies shows a tendency for spontaneous recovery. Stapes surgery can be postponed or avoided.

When bone is exposed, fingertip defects may require a flap procedure. Many types are available, with little consensus about which one is best. But each one has its own disadvantages: esthetic (claw nail deformity), neurological (sensory disorders) or functional (stiffness). The purpose of this study was to evaluate a palmar bipedicular island flap (our modification of the Tranquilli-Leali flap) for fingertip reconstruction. We retrospectively analyzed the prospective data of 42 patients with a mean follow up of 16.4 months (6–30 months) operated in two hospital facilities. Thirty-three patients were men. Mean age was 39.5 years (12–83 years) and 24 (57.1%) were smokers. In 23 cases (54.8%), the trauma was work-related. A crush mechanism was identified in 29 patients (69%). According to Allen's classification of fingertip injuries, there were 26 cases of stage II, 14 cases of stage III and 2 cases of stage IV. All procedures were performed on an emergency basis, within 24 hours of the trauma. No claw nail deformity was observed. The mean discrimination in the Weber test was 3.8 mm (2–6 mm). The mean Total Active Motion (TAM) was 268.3 ° (255–275 °). The patient satisfaction was graded at 8.7 on a 10-point scale. Results were considered as excellent in 15 cases and good in 23 cases. The modified palmar bipedicular island flap makes the old Tranquilli–Leali flap – which has a poor reputation in the hand surgeon community—simpler and safer to use. This flap restores proper balance between skin, bone and nail in Allen stage II and III fingertip amputations.

Despite advances in microsurgery, digital nerve repair remains a challenge due to the lack of reproducible procedures with satisfactory functional results. The aim of this study was to compare the sensory and functional results of direct microsurgical sutures protected by a Revolnerv(®) nerve regeneration conduit, with results of a series of direct sutures without a protective conduit in the literature. From November 2009 to April 2010, 35 patients were treated by direct epiperineural suture for digital nerve injury, protected by a Revolnerv(®) nerve regeneration conduit at the FESUM centre "SOS-mains Lesquin/CHRU de Lille". Sensory recovery was assessed by the static two-point discrimination Weber test (WS) and the Semmes-Weinstein (SW) test at postoperative months 1, 3, and 6. The final evaluation was performed after a minimum follow-up of 6 months. Statistical analysis of sensory results (WS and SW) was mainly performed with non-parametric tests (Wilcoxon, Mann and Whitney). P

Background: The aim of the study was to analyze the possible effects of eyeglasses and palatal prostheses on the results of the Weber tuning fork test.Methods: We enrolled 96 patients diagnosed with unilateral conductive-type hearing loss. All were aged between 18 and 65 years. Group 1 was composed of 48 patients with eyeglasses and group 2 included 48 patients with palatal prostheses. All patients underwent the weber tuning fork test with and without their eyeglasses and prostheses, and the results were compared. Weber tests were performed using 256 Hz and 512 Hz tuning forks. Results: No significant between-group difference was apparent (both p>0.05).Conclusions Neither eyeglasses nor palatal prostheses significantly affected the results of the Weber test.

Introduction Hand wounds are a common cause of emergency department admission. Digital nerve lesions are found in 5% of palm wounds. Early diagnosis reduces the risk of morbidity, sequelae and litigation. Screening for digital nerve injury by the usual tests is difficult in an emergency context. We assessed the diagnostic value of the simple “compress test” to screen for pulp sensibility disorder and the factors that may influence the value of this examination, with a view to validating routine use. Material and method A retrospective study included 821 palm wounds treated between January 2014 and May 2016. There were 605 male and 216 patients; mean age, 42.8 years (range: 18–90 years). The dominant hand was involved in 307 cases (37.4%). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the compress test were calculated. Diagnostic value was also calculated according to age, gender, affected digit, dominant side and examiner's experience. Results Clinical deficit was found in 412 cases (50.2%). A digital nerve lesion was found intraoperatively in 277 cases (33.6%). Test sensitivity was 87.3%, specificity 68.6%, positive predictive value 58.5%, negative predictive value 91.4%, positive likelihood ratio 2.78 and negative likelihood ratio 0.18. The test was more effective for thumb wounds and for examination by a junior surgeon. There were no differences according to injured side, innervation territory or gender. Conclusion This clinical test is reliable, with very good negative predictive value and good sensitivity, allowing its use in routine clinical practice. Nevertheless, surgical exploration of deep palm injuries should remain the rule.

SummaryMit den Stimmgabelprüfungen nach Rinne und Weber können Sie Schallleitungsstörungen und Schallempfindungsstörungen unterscheiden.

This study analyzes permanent paresthetic disorders regarding the inferior alveolar nerve (IAN) after mandibular ramus sagittal osteotomy procedures. Fifty patients (ie, 100 nerves) who underwent mandibular bilateral sagittal split osteotomy between 2003 and 2007 were evaluated to detect sensorial disorders of the IAN. The evaluation was performed for each patient at least 1 year after surgical intervention. The sagittal osteotomy of the mandible ramus was performed according to Epker-Hunsuk technique. The method of fixing through titanium plates and monocortical screws and the displacement width of the osteotomized stumps were also considered. The evaluation of the IAN functionality was performed both subjectively, by means of a questionnaire, and clinically, by using 4 types of tests: light-touch sensation, pinprick sensation, Weber test, and Dellon test.The clinical test analysis revealed that no nervous lesion was detected in 52% of the tested sites, whereas 24% reported significant nervous lesions. In the subjective evaluations, 74% of the patients described the discomfort related to the neurologic alteration as "absent to mild" or "mild to moderate," 10% as "moderate to serious," and 4% as "serious."We observe that the percentage of significant nervous lesions is relatively low and that it matches the mean described in literature. The central nervous system capacity to hide or compensate for functional deficits due to peripheral nervous lesions was confirmed by the comparison between the results of the clinical tests and the patients' subjective evaluations.

Should the palmar digital artery be repaired in the pedicular section of the finger? This repair is discussed in the case of a unilateral pedicular lesion on a vascularised finger, and often neglected in current surgical practice. The problem is knowing the role of a permeable artery in sensory recovery and cold intolerance. The author presents a retrospective study on palmar digital nerve reinnervation after section with or without palmar digital artery section. Artery permeability was studied by doppler ultrasonography. Forty nerves in 35 patients were studied after at least 3 years had passed. Twenty-five nerves were associated with a permeable artery, 15 with a non permeable artery. The functional result was evaluated with the Weber test (S2PD) and by the presence or absence of cold intolerance. This work demonstrates the statistically significant role of the palmar digital artery in sensitive recovery quality and cold intolerance appearance. Its permeability ensures a better sensitive result with an 8.84 mm S2PD versus 13.47 mm with a non permeable artery. The benefit of the systematic repair of palmar digital artery is thus demonstrated for the first time. This repair is all the more justified if local conditions are unfavorable, in particular in contuse wounds with associated lesions (tendinous or bone).

Case presentation. A 51-year-old right-handed woman was admitted to the hospital because of two syncopal episodes. Both events had similar features with sudden onset of loss of consciousness. There were no preceding symptoms. They lasted only few seconds and were not accompanied by any abnormal movements, incontinence, or tongue biting. There was no confusion following the events. A feeling of vertigo, which gradually dissipated over the following 2 days, was the only residual symptom following both episodes. The patient also had a history of hypertension. She was on no medications. She consumed alcohol occasionally but denied tobacco or drug abuse. Her family history was positive only for heart disease in her mother. ### Question for consideration: 1. What is the differential diagnosis of syncope in this case? GO TO SECTION 2 Syncope is a sudden and brief loss of consciousness, associated with a loss of postural tone, with spontaneous recovery. It results from transiently decreased or interrupted cerebral blood flow. Frequently, the etiology remains unknown. Among diagnosed cases, neurocardiogenic syncope (including vasovagal attack, situational syncope, and carotid sinus syncope) is the most frequent cause. It stems from reflex-mediated changes in the vascular tone or heart rate. Other causes include cardiac (organic heart disease or arrhythmia) or neurologic diseases (concussion or seizure), orthostatic hypotension, medications, or psychiatric disorders.1,2 In this patient, based on the history, both reflex-mediated and primary cardiac causes were contemplated. On admission, the patient reported 3 years of right hearing defect without tinnitus or ear pain. She denied dysphagia or hoarseness of her voice. She was otherwise asymptomatic. On neurologic examination, cranial nerves I–VII were intact. There were multiple lower cranial neuropathies (VIII–XII) on the right side. There was sig-nificant right ear hearing loss. The tuning fork tests were equivocal: the Weber test lateralized to the affected ear (suggesting a conductive hearing loss in …

A 35-year-old woman presented for evaluation of slowly progressive right-sided hearing loss. For the past 6 months, she noted when lying on her left side an inability to hear the television or her baby crying. She also noted right-sided aural fullness and occasional right-sided headache. She had no facial weakness, tinnitus, vertigo, otorrhea, or otalgia; and no history of prior ear surgery, ear infections, noise exposure, or ear or head trauma. She currently takes no medications. Otoscopic examination results were normal. A 512-Hz tuning fork examination showed a left-sided lateralization when the vibrating tuning fork was placed on the center of her forehead (Weber test) and bilateral air greater than bone conduction with the vibrating tuning fork placed in front of her ear canal vs her mastoid tip (Rinne test). Facial motor and sensory function were intact and symmetric. The rest of the head and neck examination was unremarkable. An audiogram was ordered (Figure).

Problem statement: Ramsay Hunt syndrome is characterized by peripheral facial palsy and eruptions in external ear reportedly due to the reactivation of latent varicela zoster virus in the sensory ganglia of facial nerve. Our purpose is to describe a case of this syndrome accompanied by the Neurology Service of Nova Iguacu General Hospital. Approach: A 60-year old female patient sought the emergency room due to a complaint because she was not able to close her left eye, followed by a drift of the labial fold to the right as well as a sensation of &#34burning eyes&#34 for the last three days. She also referred vertigo and bilateral hypoacusis, more intensely felt on the left side. Results: Physical examination showed a left facial palsy with a vesicular eruption in the left external auditory canal, ear lobe and neck on that side. Her taste sensation was decreased on the anterior 2/3 of the tongue, a negative rinne test, a positive weber test indicating a neurossensorial hearing loss, ataxia in walking, a Romberg sign and an abnormal fukuda pace test, however the CT scan was normal. Conclusion: The diagnosis is basically clinical, in turn, treatment is controversial. In addition to clinical findings, the diagnosis is confirmed by the presence of viral DNA in the involved tissue and vesicular exudate, as assessed by polymerase chain reaction. Ramsay Hunt syndrome involves severe dysfunction, with poorer facial nerve prognosis than in Bell’s palsy. Some studies suggest that treatment with prednisone and acyclovir may improve outcome, although a prospective randomised treatment trial remains to be undertaken.

International audience; The skull vibration-induced nystagmus test (SVINT) acts as a vestibular Weber test and reveals a vibration-induced nystagmus (VIN), elicited mainly on the vertex location, with a horizontal or torsional component beating more often toward the side of the lesion in superior canal dehiscence (SCD) than in otosclerosis (OS). In SCD, the VIN vertical component is most often up-beating. These results suggest more a global vestibular contribution than the sole stimulation of the superior semicircular canal. Objectives: This study aimed to evaluate the possible occurrence of nystagmus during SVINT in unilateral conductive hearing loss related to SCD or OS. Methods: The slow-phase velocities (SPVs) of the VIN horizontal, torsional, and vertical components were recorded in patients with a unilateral otologic lesion (17 SCD, 38 OS) and 12 control subjects. Vibratory stimulations (60 Hz, 100 Hz) were applied on the vertex and on each mastoid. Results: In SCD, VIN was observed in 82% of patients with a primarily torsional, horizontal, and vertical (up-beating) component in 40%, 30%, and 30%, respectively. Horizontal and torsional components beat toward the side of the lesion more often than in OS. Higher SPVs were observed after vertex stimulation. In OS, VIN was sparse with low amplitude and was not systematically lateralized to a specific side.

Introduction This objective structured clinical examination (OSCE) case was created for use with standardized patients (SPs), for teaching and/or evaluation purposes. Methods The case follows Dana Jones, a new patient coming in for a work physical. S/he is about to start working as a substitute teacher for the local school district, teaching middle school math and science. Dana's only complaint is that s/he recently started to miss hearing the doorbell and sometimes does not hear the phone ringing. Recommended length of the session is 15–45 minutes for the learner in the patient room, 10 minutes for the patient note (if required), and at least 30 minutes for debriefing with the faculty observer (for teaching purposes only). Results The case has been successfully implemented with 40 MS 1 students at the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. Interrater reliability was assessed on a continuous basis and, for 20 consecutive cases, was above 80%. Additionally, a case study was completed to review the interrater reliability between SPs and faculty observers in a multiple-station high-stakes OSCE examination; results indicated faculty and SPs matched in scoring. Discussion The case is intended for teaching/examination of medical students in years 1–4 (depending on a medical school's type of curriculum). The case could also be used for resident entry-level testing and faculty development in teaching.

Objectives/Hypothesis The objective of this study were to present an assessment of a new theory to explain lateralization during the Weber test using an animal model. This theory is based on the discovery that a major pathway in bone conduction stimulation to the inner ear is through the skull contents (probably the cerebrospinal fluid [CSF]). The placement of a bone vibrator or tuning fork on the skull excites the inner ear by the classic osseous pathway and by the suggested CSF pathway. We assume that there is a phase difference between the stimulation mediated by the ossicular chain (inertial and occlusion mechanisms) and the one mediated by the CSF. The presence of a conductive pathology will decrease the magnitude of the sound energy mediated by the ossicular chain. Thus, the out-of-phase signal arriving through the bony pathways will be decreased, hence increasing the resultant sound intensity stimulating the cochlea. Study Design Prospective animal study. Methods The experiment was performed on 10 fat sand rats, which had undergone unilateral cochleostomy and a small craniotomy. The auditory nerve brainstem response (ABR) thresholds were measured to air-conducted stimulation, to stimulation with the bone vibrator applied to the skull, and to stimulation with the bone vibrator applied directly to the brain through the craniotomy. The ossicular chain of the second ear was then fixed to the middle ear walls with cyanoacrylate glue to induce a conductive hearing loss. The ABR thresholds to the same three stimuli were then measured again. Results After ossicular chain fixation, the ABR threshold to air-conducted stimulation increased, to bone vibrator stimulation on the bone decreased (hearing improvement), and to bone vibrator stimulation directly on the brain remained unchanged. Conclusions This experiment confirms the proposed theory. During clinical bone conduction stimulation, there is a phase difference between sound energy reaching the inner ear through the middle ear ossicles and from the CSF. A middle ear conductive pathology removes one of these components, thus increasing the effective sound intensity in the affected ear. On the other hand, when the bone vibrator is applied on the brain, the inner ear is stimulated only through the CSF, so ossicular chain fixation does not change the ABR threshold. Moreover, this study proves that lateralization during the Weber phenomenon is the result, at least in part, of an intensity difference between sound energy reaching the two cochleae.

West Nile virus (WNV), is an emerging virus [1]. Most human infections are subclinical or manifest as a mild febrile illness, while fewer than 1% develop a neuroinvasive disease (WNND), including meningitis, encephalitis, and/or an acute flaccid paralysis (AFP) [2–4]. We describe a case of sensorineural hearing loss (SNHL) secondary to WNV infection. A 55 year-old previously healthy and normoacousic man, was admitted (in September 2010) for bilateral hearing loss and leg weakness. He complained, about 2 weeks before, of malaise, fever, generalized fatigue, and diffuse myalgias, initially attributed to a flu-like syndrome. After a few days he noted a mild weakness in both of his legs evolving over a week into a flaccid paraparesis. At the same time, he also developed a sudden bilateral hearing loss. He was afebrile, with stable vital signs. Routine and immunological laboratory data were within the normal range. Neurologic examination was remarkable for a flaccid areflexic paraparesis, weakness being more pronounced in the right leg and proximally (3/5 strength in the right leg, 4/5 strength in the left leg), with flexor plantar responses. No cranial nerve involvement, vestibular, cerebellar, brainstem or meningeal signs were noted. MRI of the brain and whole spine was normal without meningeal, parenchymal or ventral nerve root enhancement. Audiological tests, including the Weber and Rinne tuning fork tests, pure tone and speech audiometry, tympanic admittance, auditory evoked potentials (ABRs) and a screening test for acoustic emissions (OAEs), demonstrated a bilateral, down-sloping SNHL—mild on the left side, severe on the right—with normal acoustic admittance, and impaired OAEs, which were absent in the right ear. Weber test was lateralized to the left side, and the Rinne test was not significant. ABR with click at maximum output level (125 dB SPL) was not evocable by stimulating the right ear and normal for the left ear after latencies correction for the hearing threshold elevation. On the whole, the data were compatible with a bilateral asymmetric cochlear damage. Electrodiagnostic studies showed normal sensory and motor nerve conductions, and moderate decrease of compound motor action potential amplitudes. Late responses were normal. Concentric needle electromyography showed active denervation with a neurogenic recruitment pattern in all four limbs, with a clear predominance in legs. The findings fulfilled the diagnostic criteria for WNV AFP [4, 5]. Neurophysiological examination of cranial nerves and brainstem reflexes studies gave normal results. Since the symptoms began during a work-related stay in Romania where a WNV infection outbreak was occurring [6, 7], we considered the above infection in the differential diagnosis. Serum IgM and low-avidity IgG WNV-specific antibodies were detected (titre:1:1,600; 1:51,200, respectively). The presence of IgMand low avidity IgG WNV-specific I. Casetta (&) E. Cesnik Section of Neurology, Department of Medical and Neurological Sciences of Communication and Behaviour, University of Ferrara, Corso della Giovecca 203, 44121 Ferrara, Italy e-mail: cti@unife.it

Two neuro-ophthalmological syndromes due to paramedian pontine infarction have previously been described. The ‘‘one and a half’’ syndrome was first reported and named by Miller Fisher [1], and consists of horizontal gaze palsy combined with an ipsilateral inter-nuclear ophthalmoplegia (INO) resulting in loss of all horizontal eye movements except abduction of the contralateral eye. The causative lesion is usually within the ipsilateral pontine tegmentum and is due to involvement of the abducens nucleus plus the medial longitudinal fasciculus (MLF), or alternatively to involvement of the MLF plus the paramedian pontine reticular formation (PPRF). These structures lie in close proximity to the nucleus and intra-axial fasiculus of the facial nerve. Consequently, ipsilateral fascicular lower motor neurone facial nerve palsy may accompany the ‘‘one-and-a-half’’ syndrome. This situation was named the ‘‘eight and a half syndrome’’ by Eggenberger [2], who reported 3 cases of this syndrome that had occured secondary to ischaemic stroke. In continuation of this concept, we here describe the ‘‘sixteen and a half syndrome’’, which is the ‘‘one and a half’’ syndrome with an additional 7th and 8th cranial nerve (vestibulo-cochlear nerve) palsy. A 78-year-old right-handed man presented with sudden onset of incomplete right upper limb paresis, horizontal diplopia and ataxia. This was shortly followed by complete right lower limb paresis. There was associated nausea and vomiting. Examination revealed a left-sided lower motor neurone facial nerve palsy and dysarthria with loss of conjugate gaze to the left and loss of adduction of the left eye. Abduction of the right eye was accompanied by horizontal nystagmus. Convergence was spared. The patient also complained of new-onset left-sided hearing loss. The patient and his family were certain that his hearing before this event had been normal. Magnetic resonance imaging (MRI) with diffusion-weighted sequences revealed an area of restricted diffusion consistent with an acute infarct. The lesion extended beyond and lateral to the paramedian pontine territory supplied by the anteromedial group of pontine perforating arteries, and dorsally to the fourth ventricle and the region of the facial colliculus (Fig. 1a, b). Pure tone audiometry showed no detectable hearing in the left ear. Brainstem auditory evoked potential testing showed no reproducible wave I, wave III or wave V after left ear stimulation. Waves I, III and V from right ear stimulation were of low amplitude with normal absolute and interwave latencies. Eight months later, the Weber test lateralized to the right ear, and the Rinne test revealed absent air-conducted and bone-conducted sound perception in the left ear. Our patient had an ‘‘eight and a half’’ syndrome plus additional ipsilateral hearing loss. We name this clinical entity the ‘sixteen and a half syndrome’. Hearing loss has not previously been described in association with either ‘‘one and a half’’ or ‘‘eight and a half’’ syndrome. A clinical series of 20 cases of ‘‘one and a half’’ syndrome noted G. Cummins R. Dunne K. O’Rourke (&) T. Lynch Dublin Neurological Institute, Mater Misericordiae University Hospital, 57 Eccles St., Dublin 7, Ireland e-mail: killian.orourke@gmail.com

The Rinne and the Weber tests were carried out using a 256-Hz tuning fork on 687 6- to 15-year-old school children, the majority of whom were normally hearing subjects. The Rinne test was positive in 97% of ears with normal hearing or sensorineural hearing loss and negative in 72% of ears with conductive hearing loss. The Rinne test changed from positive to negative at 13 dB when performed using the normal loudness comparison method. In midline Weber results, the mean value of the air conduction difference at 0.25 kHz between the right and left ear was 1.4 dB. The lateralization in the Weber test occurred at a difference of 2.5 dB between the right and left ear. The Weber test was in midline in 96-98% of ears with bilateral normal hearing or sensorineural hearing loss. It lateralized to the poorer ear in 63% of ears with unilateral conductive hearing loss. The values of the Rinne and Weber tests were not good in the diagnosis of mild conductive hearing loss when the air-bone gap was 5-35 dB.

Objective. To compare the use of the Weber tuning fork test and ‘Scratch test’ in postoperative patients following tympanomastoid surgery. Method. Prospective cohort study with control group. Southampton University Hospitals NHS Trust. Secondary care. 19 patients undergoing routine tympanomastoid surgery for middle ear disease and 18 patients undergoing translabyrinthine surgery for lateral skull base lesions. Main Outcome Measures. Localisation of Weber tuning fork. Positive or negative Scratch test: clinician applies a gentle scratch using index finger to the bandage over the operated ear. Postoperative pure tone audiometry. Results. In the context of diagnosing a hearing or non-hearing ear, the Weber test had a specificity of 78% and sensitivity of 100%. The scratch test had a specificity of 100% and sensitivity of 100%. The Weber was 93% specific and 93% sensitive for diagnosing a unilateral conductive hearing loss. Conclusions. As a means of diagnosing an acute postoperative dead ear the Scratch test is an accurate alternative to the Weber test. References 1 Miltenburg D.M. (1994) The validity of tuning fork tests in diagnosing hearing loss. J Otolaryngol. 23, 254–259 2 Behn A., Laszlo C.A., Black D., et al. (2005) Which is mightier, the tuning fork or the bone oscillator? J Otolarygol. 34, 135–139

A 52-YEAR-OLD MAN WITH HUMAN IMMUNOdeficency virus (HIV), AIDS, chronic hepatitis B, and stage IV Burkitt lymphoma presented to the emergency department with a 2-week history of nausea, vomiting, diarrhea, and lethargy as well as a 2-day history of falls at home. He reported no vertigo, tinnitus, otalgia, or otorrhea; however, he did report a 2-month history of left-sided aural fullness and subjective hearing loss. On physical examination, the left tragus, antitragus, and conchal bowl (Figure1) exhibited nontender purple nodules and plaques extending into the cartilaginous external auditory canal. The external auditory canal was patent but narrowed. The tympanic membrane was intact and there was no otorrhea. There was no trismus or tenderness of the temporomandibular joint. A Weber test demonstrated lateralization to the right, and the results of a Rinne test were positive bilaterally. Relevant laboratory findings included a viral load of 152 000 copies/mL and a CD4 cell count of 8/μL. A skin punch biopsy specimen was obtained for histopathologic evaluation (Figure 2 and Figure 3). What is your diagnosis?

As the Weber test evaluates the slowly adapting fiber-receptor system (constant touch), the "moving two-point discrimination test" evaluates the innervation density of the quickly adapting fiber-receptor system which mediates the perception of touch stimuli moving across the hand. Results with this test in 39 hands used as controls and in 63 patients with nerve injuries show it to be a simple, quick, and valid diagnostic tool in nerve compression syndromes and nerve lacerations and an accurate prognosticator and monitor during sensory reeducation following nerve repair.

Author studied the logics of masking bone conduction, and the phenomenon with regard to Weber test, especially from experimental and clinical stand point. Results obtained are as follows :1) In order to mask the ear not to be tested, it is necessary to bear in mind the limitation of effectiveness of masking the ear dependent on the noise level, especially the limitation to the maximum noise level of the audiometer concerning on the three types of cases, i. e. binauraly perceptive. conductive deafness and one ear conductive the other perceptive. These limitation is able to be demonstrated by fomulation.2) Bone conduction measurement under deficiency of masking represents shadow hearing curves which coincide with some limitation curves of masking.3) Over masking cosists of peripheral and central elements, the former is masking opposite ear by the crossed air and bone conduction, the later through the crossed auditory nervous pathways.a) The central masking shows some frequency characteristics which are not remarkable as peripheral masking.b) The degree of effectiveness of the central masking is in proportion to the intensity of noise.c) Peripheral over masking tends to rise in the tested ear suffered from conducrive deafness, central over masking tends to rise at the case of which difference by bone conduction between both ears is large.4) In Weber test a questionable point is that sometimes bone conduction may not be heard in the better ear by bone conduction. To study the etiology of this paradoxical phenomen, placing air conduction receivers on the both ears, either ear was heard tones near the threshold level, and the existence of false judgement on the audible side was proved.5) In the both ears the least differenc between the intensity of two tones from which the feeling to hear in either ear arises is larger at higher intensity level than at lower, then Weber test is reasonable to be made at lower intensity level.6) In one ear, the least intensity differences between two tones being able to differ are larger at the higher intensity level than the lower, and this relation also quantitatively coincides with the former experiment in the both ears.

The Kraus-Weber test of minimum muscular fitness was administered to 38 trainable mentally retarded (TMR) children. The results revealed that: The TMR group was seriously deficient in muscular fitness when compared with four groups of normal children; the TMR group was not necessarily retarded in flexibility when compared with four groups of normal children; the TMR girls tended to be more muscularly fit and more flexible than the boys; the lower back test item caused the greatest percentage of failure for the TMR group; 63.3 percent of the 30 failures were multiple; there was no difference between the TMR boys' and girls' multiple failures.

POSTOPERATIVE serous labyrinthitis is one of the great problems in fenestration surgery today. To reduce or eliminate postoperative serous labyrinthitis, there must be a calibrated method of measuring its type, degree, and duration. To obtain this goal, we have calibrated the Weber test. By adapting the long-proved Weber test to the bone-conduction oscillator of the audiometer, it has been possible to demonstrate the variations in threshold and, with increasing intensity, variations in lateralization of sound. As presented, the calibrated Weber test may be described as a new hearing test; in actuality, it is only an audiometric adaptation of one of the oldest hearing tests. This test has been of value to us in determining the status and prognosis in our recent cases of fenestration. In summary, this article is the report of a study on the behavior of bone conduction in the recently fenestrated ear. As stated, the calibrated Weber

Although the literature consistently refers to Weber [1834] as the originator of the tuning fork test bearing his name, re-reading his Latin text shows that he described only: (1) the effect of occlusion of the external ear canal on bone conduction and (2) the phenomenon of lateralization of bone conduction into the occluded ear. The first to use bone conduction lateralization as a clinical diagnostic means seems to have been Schmalz. He described in 1846 how bone conduction is localized in the better ear in sensory-neural hearing loss, whereas it is heard in the poorer ear in conductive deafness.

In this study, 1,195 elementary school children were tested with the Kraus-Weber test of Minimum Muscular Fitness and compared with other geographical surveys. The Eugene group yielded a 38.1 per cent test failure. They were, by sex and age, superior to those in other published American studies. At no time, however, did any American sample score lower than the European youth. Of the 455 Eugene children who failed the Test, 78.7 per cent failed only one item. The flexibility item not only accounted for the greatest number of these failures, but at every age level caused the girls to appear more “muscularly fit” than the boys.

This paper presents results of the Kraus-Weber Test for Minimum Muscular Fitness which was conducted in East Pakistan. A total of 2325 Pakistani male and female school children were subjects. The results were compared with reports of the original tests in the United States and Europe. The testing program revealed that Pakistani children were less able than European children in passing the six test items. They were, however, more successful than American children included in the original report of the Kraus-Weber Test.

NEURILEMMOEMA of the facial nerve within the temporal bone is rare with a wide range of clinical symptomatology. Three diverse cases have been encountered by the senior author (G.E.S.), and one additional case by Valvassori. Report of Cases CASE 1.—History.—A 60-year-old white woman, referred with a "tumor deep in the right ear," had been diagnosed one week previously as having a neurilemmoma of the facial nerve on the basis of a surgical biopsy performed by the referring physician. Approximately eight months earlier the patient had consulted the referring physician because of "buzzing" and a pounding tinnitus in her right ear, with a slight hearing loss. At this time the Weber test lateralized to her right ear, and the Rinne test was negative on the right at 256 and 512 cycles per second (cps). She had also noted a slight facial asymmetry with decreased movement on the right, which had slowly progressed.

The Kraus-Weber Test of muscular fitness was administered to a population of 1456 elementary school children. Results indicate: 1. The Test and Test items are highly reliable. 2. There is no relationship between grip strength and success on the Test. 3. Girls are substantially superior to boys at all levels in passing the Test, and in flexibility. 4. For both sexes, there is a decided decrease in strength item failure as age increases. By the time the children are 11 years of age the percentage of failure on any item is less than 8 per cent, and agrees very closely with the results found for European children.

For ninety years, the condition known as caisson sickness or disease has been studied by many observers. In 1912, Hill 1 published the historic, physiologic, experimental and pathologic facts about caisson sickness. In 1896, Alt 2 reported three severe cases of apoplectiform labyrinthitis in caisson workers. A workman, an hour after being subjected to a pressure of 2.2 atmospheres for more than two hours, experienced a sudden onset of severe pain in the ears, vertigo and absolute deafness. Another workman, within a few minutes after leaving the air lock, experienced the sudden onset of severe pains in the chest, serious collapse and total deafness. A third workman had cyanosis, dyspnea, deafness and marked vertigo. In all of Alt's cases, the Weber test was referred to the ear less affected. The return of hearing was slight, and the tympanic membranes were not ruptured. However, he quoted a case reported

This study extended the Kraus-Weber Tests of Minimum Muscular Fitness in order to provide more differentiating scores at all levels of ability. A pass or fail score, which could be determined from the continuous scoring system, was also obtained. Results indicate that strength and flexibility differ with age and sex and that the standards, even though considered minimal, should also vary with the different ages and sex groups.

The lateralisation of bone-conducted sound from the forehead (Weber test) is discussed. Perception of tones from the handle of a tuning fork in the ear affected with conduction deafness only is due not to better bone-conduction of this ear, but to an effect of veritable perception of sound direction by phase differences. The paper contains notes on the theory of bone-conducted sounds and Mr. Fournier's Faux-Bing test.

Aurists who have taken an acute interest in hearing tests and in their analysis are convinced that most of the tests cannot be considered singly as the sole criterion for a diagnosis. Thus the deductions from the findings in one test must be made only after collecting the data from the others. Findings will, of course, suggest the pathology present, and, vice versa, the pathology diagnosed should explain the test findings. For example, it has long been recognized that the Weber lateralization must be valued in the light of the following possibilities, namely, mixed deafness, unilateral or bilateral, and bilateral deafness of the same or of different types. It can nearly always be predicted what the Weber test will be if each ear is first tested for air conduction and bone conduction independently. For any testing instrument with which it is possible to make the Weber test, the sound

The lateralizing value of the Weber test has been studied in relation to otosclerosis and stapedectomy. Special attention is given to the occurrence of equivocal and paradoxical results whenever the conductive pathology is different on the two sides, a fact that has to be remembered by the clinician during his every day use of the Weber test.

The Weber, Rinne and Bing tests were examined in normally hearing and hearing impaired subjects, using different techniques. The Weber test was found to be most sensitive and reliable with the tuning fork stem placed on the upper incisors. The Rinne tests showed a transition point from Rinne positive to negative at 19 dB when performed using the normal loudness comparison technique and at 24 dB with a threshold comparison technique. The Bing test with the tuning fork placed either on the mastoid or the vertex showed a transition point from Bing positive to negative at approximately 9 dB air-bone gap.

The authors think that in otosclerosis surgery the accurate measurement of cochlear function must be made according to 4 local factors, to which must be added a 5th, general one.The pure-tone audiogram gives the diagnosis of the stage of deafness. Accurate bone conduction (BC) must of course be researched with a contralateral narrow-band masking when there is the slightest difference between 2 air-conduction (AC) diagrams, as well as between the 2 BC diagrams.Speech audiometry gives the functional value of the ear. It must be done in AC and BC; the authors insist on the value of the speech Weber test.The Carhart notch must always be taken into account in forecasting the postoperative result; it explains why part of postoperative BC rises above preoperative BC.A progressive integration of hearing occurs slowly, generally in one year or more, under the influence of treatment to support the cochlea.Finally, a general, cardiovascular, factor must be added to the 4 local factors for measurement of the cochlear...

THE SUBJECT of this communication, a woman of 50 years, was first seen in April, 1948. She then gave a history of one month's duration of attacks of rotational vertigo preceded for some months by increasing deafness of the right ear accompanied, since the onset of vertigo, by a continuous humming tinnitus in the right ear. Examination of the ears, nose, and throat revealed nothing abnormal. Roentgenological examination of the paranasal sinuses showed mucosal thickening within the right antrum, which was washed out with negative results. Pure-tone audiometry, carried out in May, 1949, gave the result shown in Figure 1. Tuning-fork tests showed the deafness of the right ear to be of the perceptive type, the Weber test being referred to the left, with a false negative Rinne test on the right mastoid. There was no spontaneous or positional nystagmus, and the caloric tests gave the results shown in Figure

Prior to the advent of the audiometer, tuning forks and other instruments were used for routine clinical testing of hearing. Tuning fork testing is still performed. Many hearing tests are identified by the names of those who introduced them. The Schwabach test compares the duration of bone conduction of the patient with the duration of the bone conduction of normal hearing. The Weber test is employed to ascertain the lateralization of sound by bone conduction. The Rinne test compares the duration of hearing by air conduction and by bone conduction. The Gelle test was conceived in an effort to determine the mobility of the stapes. The Stenger test is used to expose simulated monaural deafness.