12Bedside Hearing and Speech Checks

FWhy screen hearing at the bedside at all

Hearing loss is the single commonest correlate of tinnitus, so even a crude bedside estimate of hearing changes the conversation: it supports the diagnosis, hints at the likely tinnitus pitch, and — crucially — flags asymmetry that needs investigation [2013]. These tests cost nothing, need no equipment, and can be done anywhere, which makes them ideal triage before formal audiometry.

They are screens, not measurements. A failed screen earns an audiogram; a passed screen in a patient with bothersome unilateral tinnitus still earns one. Their value is in directing urgency, not replacing the audiometer.

TThe whispered-voice test, done properly

The whispered-voice test is the best-validated free-field screen. Stand at arm’s length (about 60 cm) behind or to the side of the patient so they cannot lip-read, mask the non-test ear by gently rubbing the tragus, exhale fully, then whisper a combination of three numbers and letters. The patient repeats them; a second set is used if some are missed.

Performed this way it is a genuinely useful screen, with sensitivity and specificity high enough to triage adults for formal testing [2003]. Its accuracy depends on technique — failure to mask the other ear or to truly whisper inflates both false passes and false fails [2007].

TFinger rub and conversational speech

The finger-rub test is even quicker: rub finger and thumb together a set distance from each ear and ask whether the patient hears it, comparing sides. Calibrating the rub by intensity and distance (the CALFRAST approach) turns a rough gesture into a reproducible screen with good accuracy for detecting significant high-frequency loss [2009].

Free-field conversational and lowered-voice speech adds another dimension: noticing that a patient struggles to follow normal speech, or watching them turn one ear toward you, hints at the degree and laterality of loss. Like the whispered voice, these are bedside hearing checks whose error rate is acceptable for triage but not for diagnosis [2007].

CTurning a screen into a triage decision

Read the results together with the tinnitus history. Symmetric reduced hearing fits the common, benign noise- or age-related picture and supports routine audiology referral [2013]. A clearly asymmetric bedside result — the patient hears your whisper or finger rub on one side but not the other — alongside unilateral tinnitus raises the possibility of retrocochlear pathology and should be escalated to prompt audiometry and, if confirmed, imaging [2003].

Combine the screens with the tuning-fork tests covered earlier: whispered voice or finger rub estimates how much is lost, while Weber and Rinne classify the type. Together they let you triage in minutes — reassure-and-refer-routinely, or fast-track — without waiting for the booth [2009].