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Enhancing Auditory Physiology: Simulating Unilateral Conduction Defects to Improve Understanding of Rinne's and Weber's Tests

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Title: Enhancing Auditory Physiology: Simulating Unilateral Conduction Defects to Improve Understanding of Rinne's and Weber's Tests
Language: English
Authors: Raju Suresh Kumar (ORCID 0000-0002-9561-6208), M. Ganesh Kamath (ORCID 0000-0002-2439-6068), Rekha Prabhu (ORCID 0000-0003-3018-9628), Mohamed Eldigire Ahm (ORCID 0000-0003-0326-7926)
Source: Advances in Physiology Education. 2025 49(3):689-695.
Availability: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
Peer Reviewed: Y
Page Count: 7
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Physiology, Auditory Perception, Auditory Tests, Simulation, Medical Students, Teaching Methods, Medical Education, Deafness, Experiential Learning, Instructional Effectiveness, Foreign Countries
Geographic Terms: Malaysia
DOI: 10.1152/advan.00058.2025
ISSN: 1043-4046
1522-1229
Abstract: Tuning fork tests, particularly the Rinne and Weber tests, are fundamental in assessing hearing loss. However, medical students often struggle with key auditory physiology concepts, such as the auditory masking effect and sound lateralization. This study evaluated a simulation-based teaching method to enhance first-year medical students' understanding of these concepts. A prospective educational intervention was conducted with 123 first-year Bachelor of Medicine, Bachelor of Surgery (MBBS) students using a pretest and posttest design with a validated questionnaire. During laboratory sessions, students performed tuning fork tests on peers while instructors demonstrated a novel method to simulate unilateral conductive deafness by closing the external auditory meatus with a finger. Students replicated this method before completing posttest evaluations. Pretest data showed that 66.66% of students were uncertain or disagreed with their understanding of the auditory masking effect, and 60.16% were unsure about sound lateralization. Posttest results demonstrated significant improvement: 79.67% strongly agreed they understood the auditory masking effect, and 91.05% strongly agreed they comprehended sound lateralization (P < 0.001). Additionally, student engagement increased, with 96.74% reporting they enjoyed the session compared to 26.01% before the intervention. This study demonstrates that a simple, reproducible simulation-based approach enhances medical students' understanding of auditory physiology concepts. By actively experiencing a simulated unilateral conduction defect, students gain deeper conceptual insight and greater confidence in performing tuning fork tests. This innovative method holds promise for broader adoption in medical education.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1475552
Database: ERIC
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  Value: &lt;anid&gt;AN0187950961;apu01sep.25;2025Sep16.05:05;v2.2.500&lt;/anid&gt; &lt;title id=&quot;AN0187950961-1&quot;&gt;Enhancing auditory physiology: simulating unilateral conduction defects to improve understanding of Rinne&#39;s and Weber&#39;s tests&#160;&lt;/title&gt; &lt;p&gt;Tuning fork tests, particularly the Rinne and Weber tests, are fundamental in assessing hearing loss. However, medical students often struggle with key auditory physiology concepts, such as the auditory masking effect and sound lateralization. This study evaluated a simulation-based teaching method to enhance first-year medical students&#39; understanding of these concepts. A prospective educational intervention was conducted with 123 first-year Bachelor of Medicine, Bachelor of Surgery (MBBS) students using a pretest and posttest design with a validated questionnaire. During laboratory sessions, students performed tuning fork tests on peers while instructors demonstrated a novel method to simulate unilateral conductive deafness by closing the external auditory meatus with a finger. Students replicated this method before completing posttest evaluations. Pretest data showed that 66.66% of students were uncertain or disagreed with their understanding of the auditory masking effect, and 60.16% were unsure about sound lateralization. Posttest results demonstrated significant improvement: 79.67% strongly agreed they understood the auditory masking effect, and 91.05% strongly agreed they comprehended sound lateralization (P &amp;lt; 0.001). Additionally, student engagement increased, with 96.74% reporting they enjoyed the session compared to 26.01% before the intervention. This study demonstrates that a simple, reproducible simulation-based approach enhances medical students&#39; understanding of auditory physiology concepts. By actively experiencing a simulated unilateral conduction defect, students gain deeper conceptual insight and greater confidence in performing tuning fork tests. This innovative method holds promise for broader adoption in medical education. NEW &amp;amp; NOTEWORTHY: This study introduces a novel, hands-on simulation to teach auditory physiology concepts. Students gain direct experiential learning by simulating unilateral conductive hearing loss, significantly improving their understanding of auditory masking and sound lateralization. The method is simple, cost-effective, and highly engaging, with strong potential for integration into medical curricula to enhance conceptual learning and clinical skills.&lt;/p&gt; &lt;p&gt;Keywords: auditory perception; hearing loss; teaching methods; tuning fork tests; undergraduate&lt;/p&gt; &lt;hd id=&quot;AN0187950961-2&quot;&gt;INTRODUCTION&lt;/hd&gt; &lt;p&gt;According to the World Health Organization (WHO), over 1.5 billion individuals, representing nearly 20% of the global population, experience hearing loss ([&lt;reflink idref=&quot;bib1&quot; id=&quot;ref1&quot;&gt;1&lt;/reflink&gt;]). The prevalence of hearing loss is projected to rise due to noise exposure, poorly managed chronic conditions, and an aging population ([&lt;reflink idref=&quot;bib2&quot; id=&quot;ref2&quot;&gt;2&lt;/reflink&gt;]). Hearing loss is typically classified into three types: conductive, sensorineural, or mixed ([&lt;reflink idref=&quot;bib2&quot; id=&quot;ref3&quot;&gt;2&lt;/reflink&gt;]). Tuning fork tests are commonly used to identify conductive and sensorial deafness. ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref4&quot;&gt;3&lt;/reflink&gt;]). The Rinne&#39;s and Weber&#39;s tests, in particular, help differentiate between the location and type of hearing loss ([&lt;reflink idref=&quot;bib4&quot; id=&quot;ref5&quot;&gt;4&lt;/reflink&gt;]). Despite advancements in computer-based hearing assessments, tuning fork tests remain essential for evaluating hearing ([&lt;reflink idref=&quot;bib5&quot; id=&quot;ref6&quot;&gt;5&lt;/reflink&gt;]). One of the primary advantages of these tests is their simplicity; they require only a tuning fork, which is both affordable and widely available ([&lt;reflink idref=&quot;bib5&quot; id=&quot;ref7&quot;&gt;5&lt;/reflink&gt;]). Tuning fork tests compare the efficacy of air conduction and bone conduction in each ear, helping the examiner differentiate between the types of hearing loss experienced by the patient. Bone conduction involves conveying vibrations from the skull bones to the fluid within the cochlea ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref8&quot;&gt;3&lt;/reflink&gt;]). Air conduction in a healthy ear is more effective than bone conduction due to the impedance-matching process in the middle ear after sound waves hit the tympanic membrane. This process requires the involvement of the ossicular system, located in the middle ear, and the tympanic membrane. Sound waves that hit the tympanic membrane are amplified before they generate vibrations in the fluid within the cochlea ([&lt;reflink idref=&quot;bib6&quot; id=&quot;ref9&quot;&gt;6&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Conductive hearing loss is a common condition managed by otolaryngologists and general practitioners ([&lt;reflink idref=&quot;bib7&quot; id=&quot;ref10&quot;&gt;7&lt;/reflink&gt;]). This hearing impairment occurs when sound waves cannot travel efficiently through the outer or middle ear. This may result from factors such as earwax buildup, fluid accumulation, or issues with the ossicular chain that disrupt sound conduction ([&lt;reflink idref=&quot;bib7&quot; id=&quot;ref11&quot;&gt;7&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;In patients with unilateral hearing impairment, the sound tends to lateralize toward one ear due to an ipsilateral conduction defect or a contralateral sensory neural defect. In unilateral conduction deafness, when Weber&#39;s test is performed, the sound is lateralized and heard better in the affected ear. In contrast, the sound is lateralized towards the healthy ear in the contralateral sensory neural defect. The Weber test effectively identifies unilateral conductive and sensorineural hearing loss ([&lt;reflink idref=&quot;bib4&quot; id=&quot;ref12&quot;&gt;4&lt;/reflink&gt;]). When the Weber test is performed, the sound is conducted through bone rather than air. When Weber&#39;s test is performed in subjects with no hearing loss, the vibrating sounds of the tuning fork are equally perceived by both ears. When a Weber test is performed in unilateral conductive hearing loss, the sound will be louder in the affected ear because the masking effect of environmental noise is absent in that ear ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref13&quot;&gt;3&lt;/reflink&gt;], [&lt;reflink idref=&quot;bib8&quot; id=&quot;ref14&quot;&gt;8&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Rinne&#39;s and Weber&#39;s tests are essential skills that first-year undergraduate medical students must master during their physiology laboratory, which is part of the clinical examination of the eighth cranial nerve in our medical school. First-year medical students often find it challenging to grasp the concepts of auditory masking effects and sound lateralization. Despite the availability of laboratory manuals and clinical videos that describe tuning fork tests, students frequently struggle to grasp the concept of sound lateralization. Many find it particularly challenging to visualize how sound lateralizes in cases of unilateral conductive hearing loss. Currently, there are no laboratory teaching methods in Physiology that enable students to experience unilateral conductive deafness, highlighting a significant gap in the existing literature.&lt;/p&gt; &lt;p&gt;Therefore, this study aimed to evaluate the effectiveness of a simulation-based method in enhancing medical students&#39; understanding of auditory masking and sound lateralization in Rinne and Weber&#39;s tests.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-3&quot;&gt;Tuning Fork Tests and Their Physiological Basis&lt;/hd1&gt; &lt;p&gt;The perception of sound through air and bone conduction was well-established by scientists early in the 17th century ([&lt;reflink idref=&quot;bib9&quot; id=&quot;ref15&quot;&gt;9&lt;/reflink&gt;]). Knowledge of air conduction and bone conduction is essential for the differential diagnosis of bone and air conduction deafness. For the clinical evaluation of VIIIth cranial nerve function, tuning forks with a frequency of 512 Hz are traditionally preferred because they provide an appropriate balance between tone decay and tactile vibratory sensations ([&lt;reflink idref=&quot;bib4&quot; id=&quot;ref16&quot;&gt;4&lt;/reflink&gt;]). Tuning fork tests are designed based on the principle that, when the vibrating tuning forks are placed on the skull surface, the sounds can also stimulate the hair cells within the cochlea through the route of bone conduction (direct stimulation of the inner ear), other than the regular route of air conduction through the external auditory meatus ([&lt;reflink idref=&quot;bib10&quot; id=&quot;ref17&quot;&gt;10&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-4&quot;&gt;Concept of Air Conduction and Bone Conduction in Hearing&lt;/hd1&gt; &lt;hd1 id=&quot;AN0187950961-5&quot;&gt;Air conduction (a conductive mechanism).&lt;/hd1&gt; &lt;p&gt;During normal hearing, the pinna collects sound waves from the external environment, which travel through the external auditory meatus (as shown in Fig. 1). It sets the tympanic membrane into vibration. The lever mechanism of the three tiny bony ossicles (malleus, incus, and stapes), the difference in the surface area of the tympanic membrane in comparison with the surface area of the foot plate of stapes amplifies are the two factors responsible for the amplification of sound to ∼22 times before it strikes the hair cells of the cochlea (in the inner ear). This phenomenon is called impedance matching ([&lt;reflink idref=&quot;bib6&quot; id=&quot;ref18&quot;&gt;6&lt;/reflink&gt;]). It is essential to overcome the inertia of fluids inside the cochlea. Conductive hearing loss can result from defective middle ear ossicles or a head injury that could result in ossicular discontinuity. It could also be due to conditions like otosclerosis ([&lt;reflink idref=&quot;bib11&quot; id=&quot;ref19&quot;&gt;11&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;DIAGRAM: Figure 1. Schematic diagram depicting both air conduction (&lt;reflink idref=&quot;bib1&quot; id=&quot;ref20&quot;&gt;1&lt;/reflink&gt;) and bone conduction (&lt;reflink idref=&quot;bib2&quot; id=&quot;ref21&quot;&gt;2&lt;/reflink&gt;).&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-6&quot;&gt;Bone conduction (sensory neural mechanism).&lt;/hd1&gt; &lt;p&gt;The cochlea is located within the bony cavity called the bony labyrinth in the temporal bone. Vibrations picked up from the skull surface can directly stimulate the hair cells inside the cochlea of the inner ear (Fig. 1). This, in turn, stimulates the vestibulocochlear nerve, resulting in the perception of hearing by the individual ([&lt;reflink idref=&quot;bib10&quot; id=&quot;ref22&quot;&gt;10&lt;/reflink&gt;]). This route is referred to as bone conduction via the sensory neural mechanism. It is the physiological basis for the individual&#39;s ability to perceive sounds when a vibrating tuning fork is placed on the mastoid process, as in the Rinne test, or when it is placed on the midline of the forehead, as in the Weber test.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-7&quot;&gt;Auditory masking effect.&lt;/hd1&gt; &lt;p&gt;The auditory masking effect is a phenomenon observed in healthy ears. It is characterized by one sound raising the hearing threshold to other sounds ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref23&quot;&gt;3&lt;/reflink&gt;]). Everyone may have experienced the presence of an interfering background sound, making it difficult for us to pay attention to someone who is talking or listening while trying to hear a musical piece ([&lt;reflink idref=&quot;bib12&quot; id=&quot;ref24&quot;&gt;12&lt;/reflink&gt;]). This phenomenon occurs because of the relative or absolute refractoriness of the previously stimulated auditory receptors and nerve fibers to other stimuli.&lt;/p&gt; &lt;hd id=&quot;AN0187950961-8&quot;&gt;MATERIALS AND METHODS&lt;/hd&gt; &lt;hd1 id=&quot;AN0187950961-9&quot;&gt;Population and Sample&lt;/hd1&gt; &lt;p&gt;This study was conducted on first-year students (&lt;emph&gt;n&lt;/emph&gt; = 123) enrolled in the Bachelor of Medicine, Bachelor of Surgery (MBBS) program at Manipal University College Malaysia (MUCM), Melaka, Malaysia.&lt;/p&gt; &lt;p&gt;The study included all first-year students enrolled in the MBBS program, using a census method to collect complete data from the entire population. The study lasted for 3 weeks. The medical physiology curriculum for first-year students at this medical school is organized into four blocks. Additionally, students do not have any clinical exposure during their first year in the MBBS program.&lt;/p&gt; &lt;p&gt;The physiology block system was divided as follows:&lt;/p&gt; &lt;p&gt;&lt;/p&gt; &lt;ulist&gt; &lt;item&gt; Block 1: Basic Concepts and Blood, Nerve, and Muscle Physiology;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; Block 2: Cardiovascular, Respiratory, and Gastrointestinal Physiology;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; Block 3: Endocrine, Reproductive, and Renal Physiology; and&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; Block 4: Central Nervous System and Special Senses.&lt;/item&gt; &lt;/ulist&gt; &lt;p&gt;This study was conducted during &lt;emph&gt;block 4&lt;/emph&gt;, which focused on the central nervous system and the special senses. In this block, students first attended didactic lectures on anatomy and physiology, covering the anatomy of the ear and the detailed physiology of hearing. Laboratory sessions followed this.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-10&quot;&gt;Study Design&lt;/hd1&gt; &lt;p&gt;This study was a prospective educational intervention conducted among first-year MBBS students enrolled in the Physiology course. It employed a pretest and posttest design, using a structured questionnaire to assess the effectiveness of a simple simulation method for teaching Rinne&#39;s and Weber&#39;s tests. Laboratory sessions were held during the regular laboratory periods allocated for the physiology course, each lasting 2 hours. Students participating in this study were randomly divided into subgroups of five to six members each. Each subgroup was assigned a specific area within the laboratory, which was equipped with tables, chairs, and tuning forks tuned to 512 Hz. One student from each subgroup volunteered to be the subject for their peers while performing the hearing tests. The instructor demonstrated Rinne&#39;s and Weber&#39;s tests to the students, following the clinical protocol recommended in Macleod&#39;s Clinical Examination ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref25&quot;&gt;13&lt;/reflink&gt;]). First, Rinne&#39;s test was demonstrated, followed by Weber&#39;s test.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-11&quot;&gt;Validation of the Questionnaire&lt;/hd1&gt; &lt;p&gt;After reviewing relevant literature on tuning fork tests and auditory physiology, the principal investigator developed the questionnaire used in this study. The validation process included the following key steps:&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-12&quot;&gt;Content validity.&lt;/hd1&gt; &lt;p&gt;This was established by a panel of independent subject matter experts in physiology, who assessed the relevance, clarity, and appropriateness of the items for evaluating students&#39; understanding of the concepts. Additionally, medical education experts reviewed the questions, and their feedback was incorporated to refine the final version.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-13&quot;&gt;Face validity.&lt;/hd1&gt; &lt;p&gt;This was examined through a pilot test with 27 students from a different batch who were not part of the main study. Their feedback helped ensure the questionnaire was clear, understandable, and relevant to the intended audience.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-14&quot;&gt;Reliability testing.&lt;/hd1&gt; &lt;p&gt;Reliability was assessed using Cronbach&#39;s alpha, which yielded a score of 0.91, indicating that the items consistently measured the intended constructs.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-15&quot;&gt;Distribution of the Questionnaire&lt;/hd1&gt; &lt;p&gt;The pre- and posttest questionnaires were entered into a Google document, and separate QR codes were generated using the link. This QR code was displayed during the laboratory session, allowing students to quickly scan and complete the questionnaires. This approach also helped maintain anonymity, and participation was voluntary.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-16&quot;&gt;Tuning forks.&lt;/hd1&gt; &lt;p&gt;This study utilized tuning forks with a frequency of 512 Hz (Care &amp;amp; Cure Surgico, Sialkot, Pakistan). Two sets of pre- and posttest questionnaire surveys were conducted using a five-point Likert scale, which included four items related to students&#39; opinions on laboratory sessions for hearing tests, as detailed in Tables 1 and 2.&lt;/p&gt; &lt;p&gt;Table 1. Values represent the number of respondents, with percentages in parentheses&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;table&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;thead&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;th align=&quot;center&quot; colspan=&quot;5&quot; rowspan=&quot;1&quot;&amp;gt;Pretest Questionnaire&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Survey Questions&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Strongly Disagree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Disagree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Not Sure&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Agree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Strongly Agree&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/thead&amp;gt;&amp;lt;tbody&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I could perform Weber&#39;s and Rinne&#39;s tests with great ease.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;123 (100%)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I was able to experience and correlate the concept of the auditory masking effect after this laboratory session.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;82 (66.66%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;41 (33.33%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session helped me correlate the concept of the sound lateralization phenomenon.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;49 (39.83%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;74 (60.16%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session was enjoyable.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;54 (43.90%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;37 (30.08%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;32 (26.01%)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/tbody&amp;gt;&amp;lt;/table&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt;1 A total of &lt;emph&gt;n&lt;/emph&gt; = 123 students participated in the survey. Likert scale responses: 1: strongly disagree; 2: disagree; 3: not sure; 4: agree; and 5: strongly agree.&lt;/p&gt; &lt;p&gt;Table 2. Values represent the number of respondents, with percentages in parentheses&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;table&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;thead&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;th align=&quot;center&quot; colspan=&quot;5&quot; rowspan=&quot;1&quot;&amp;gt;Posttest Questionnaire&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Survey Questions&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Strongly Disagree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Disagree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Not Sure&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Agree&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Strongly Agree&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/thead&amp;gt;&amp;lt;tbody&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I could perform Weber&#39;s and Rinne&#39;s tests with great ease.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;123 (100%)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I was able to experience and correlate the concept of the auditory masking effect after this laboratory session.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;25 (20.32%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;98 (79.67%)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session helped me correlate the concept of the sound lateralization phenomenon.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;11 (8.9%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;112 (91.05 %)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session was enjoyable.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;4 (3.25%)&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;119 (96.74%)&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/tbody&amp;gt;&amp;lt;/table&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt;2 A total of &lt;emph&gt;n&lt;/emph&gt; = 123 students participated in the survey. Likert scale responses: 1: strongly disagree; 2: disagree; 3: not sure; 4: agree; and 5: strongly agree.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-17&quot;&gt;Rinne&#39;s test.&lt;/hd1&gt; &lt;p&gt;The purpose of this test was to compare bone conduction with that of air conduction. To test the bone conduction, the prongs of the tuning fork were struck and then placed on the subject&#39;s mastoid process. This was done to assess the subject&#39;s bone conduction. The subject was asked to respond by saying &quot;yes&quot; when they heard the vibrations in their ears ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref26&quot;&gt;13&lt;/reflink&gt;]). When the vibrating sound was no longer audible, the prongs of the tuning fork were held parallel to the acoustic axis near the subject&#39;s pinna to perceive the vibrating sound again ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref27&quot;&gt;13&lt;/reflink&gt;]). This was to test air conduction. In a healthy subject, air conduction will be better than bone conduction (Rinne positive). When bone conduction is perceived better than air conduction, it is termed Rinne negative. This could be due to a suggestive air conduction defect ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref28&quot;&gt;3&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-18&quot;&gt;Weber&#39;s test.&lt;/hd1&gt; &lt;p&gt;Weber&#39;s test was demonstrated by placing a 512-Hz vibrated tuning fork on the midline of the subject&#39;s forehead ([&lt;reflink idref=&quot;bib7&quot; id=&quot;ref29&quot;&gt;7&lt;/reflink&gt;]), equal to the subject&#39;s ears, as shown in Fig. 2.&lt;/p&gt; &lt;p&gt;PHOTO (COLOR): Figure 2. Weber&#39;s test involves placing a vibrating tuning fork on the midline of the subject&#39;s forehead. The subject is then asked whether they can hear the vibrations equally in both ears.&lt;/p&gt; &lt;p&gt;To carry out the Weber test, position the base of the vibrating tuning fork at the center of the person&#39;s forehead. Inquire from the subject, &quot;Which side do you hear the sound on?&quot; Note the direction the sound lateralizes to or indicates if they perceive it equally in both ears ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref30&quot;&gt;13&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;A normal individual should be able to perceive the sounds equally in both ears. In patients with unilateral hearing impairment, sound tends to lateralize toward one ear due to either an ipsilateral conduction defect or a contralateral sensory neural defect ([&lt;reflink idref=&quot;bib3&quot; id=&quot;ref31&quot;&gt;3&lt;/reflink&gt;]). In the case of unilateral conduction deafness, when Weber&#39;s test is performed, the sound is lateralized and heard better in the affected ear. Conversely, in the case of a contralateral sensory neural defect, the sound is lateralized toward the healthy ear. When Weber&#39;s test is performed on subjects with normal hearing, the vibrating sounds of the tuning fork are equally perceived by both ears ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref32&quot;&gt;13&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;The students were given 30 minutes to practice Rinne&#39;s and Weber&#39;s tests. Following this, students who volunteered to participate in the research were requested to scan the QR code, and the pretest questionnaire, as listed in Table 1, was available for them to complete.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-19&quot;&gt;Simulating unilateral conduction deafness while performing Weber&#39;s test.&lt;/hd1&gt; &lt;p&gt;All students were again instructed to gather at their designated spots inside the laboratory. To simulate unilateral conduction deafness, the instructors demonstrated a simple innovation during the Weber test. Wearing disposable gloves, the instructors tightly sealed the external auditory canal of their right ear using their right index finger, as illustrated in Fig. 3, while placing a vibrating tuning fork on the midline of the subject&#39;s forehead. The tuning fork was vibrated and positioned in the center of the forehead. In this scenario, the external auditory meatus of the right ear, which was closed tightly with the index finger, appeared to hear better, effectively simulating unilateral conduction deafness.&lt;/p&gt; &lt;p&gt;PHOTO (COLOR): Figure 3. Simulating a unilateral conduction defect: The vibrated tuning fork was placed on the midline of the subject&#39;s forehead. As depicted, the subject was instructed to close the right external auditory canal tightly using their right index finger.&lt;/p&gt; &lt;p&gt;All students in the subgroups were instructed to replicate the instructor&#39;s method by closing their right ear with their index finger. This effectively simulated real-life conductive deafness, specifically unilateral air conduction deafness in the right ear for each participant. After completing this activity, all students could scan the QR code to access the posttest questionnaire, as shown in Table 2. Below the four items with a five-point Likert scale, the questionnaire also included a comment box for students to reflect on their experience in the laboratory session.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-20&quot;&gt;Ethical Approval&lt;/hd1&gt; &lt;p&gt;The Human Ethics Committee (HEC) at Manipal University College Malaysia (MUCM), Melaka, Malaysia, reviewed and approved the study proposal, questionnaire, and consent form, with approval number MUCM-REC-02FOM/02/2025. Before administering the questionnaires, all students provided informed consent to ensure their voluntary participation and the confidentiality of their responses. They were given clear instructions emphasizing that participation is entirely voluntary, and any student who chose not to participate would have their decision fully respected. The students&#39; names and IDs were not collected to preserve anonymity. The data collected in this research were stored on a password-protected computer and were restricted to the study&#39;s principal investigator.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-21&quot;&gt;Statistical Analysis&lt;/hd1&gt; &lt;p&gt;All statistical analyses were conducted using IBM SPSS version 29.0 (IBM Corp, Armonk, NY). The data collected from pretest and posttest questionnaire surveys were analyzed to assess the impact of the intervention on students&#39; understanding of Weber&#39;s and Rinne&#39;s tests. Descriptive statistics were used to summarize the Likert scale responses, with the median and interquartile range (IQR) reported to describe central tendency and variability, respectively. Since the data were ordinal, the Wilcoxon signed-rank test was employed to compare pretest and posttest scores. A &lt;emph&gt;P&lt;/emph&gt; value of less than 0.05 was considered statistically significant.&lt;/p&gt; &lt;hd id=&quot;AN0187950961-22&quot;&gt;RESULTS&lt;/hd&gt; &lt;p&gt;The study aimed to evaluate the effectiveness of a simulation-based teaching method in enhancing first-year medical students&#39; understanding of the auditory masking effect and sound lateralization during tuning fork tests, specifically Rinne&#39;s and Weber&#39;s tests. The results from the pretest and posttest questionnaires (Tables 1 and 2) revealed significant improvements in students&#39; comprehension, confidence in performing these tests, and their understanding of the underlying physiological concepts. In the pretest questionnaire, all students (100%) strongly agreed that they could efficiently perform Rinne&#39;s and Weber&#39;s tests, indicating high confidence in executing them (see Table 1). However, when it came to understanding the auditory masking effect, 66.66% of students disagreed, and 33.33% were unsure, suggesting a lack of clarity on this concept despite prior instruction. Similarly, 39.83% of students disagreed, and 60.16% were uncertain about their understanding of sound lateralization, highlighting a gap in their knowledge of this phenomenon. Additionally, 54% of students were unsure whether they enjoyed the laboratory sessions, indicating a need for more engaging and effective teaching methods.&lt;/p&gt; &lt;p&gt;Following the intervention, which included a simulation of unilateral conduction deafness by closing the external auditory meatus with the index finger, the posttest results (see Table 2) showed a marked improvement in students&#39; understanding. The Wilcoxon signed-rank test revealed statistically significant changes (&lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001) in all measured outcomes. Expressly, 79.67% of students strongly agreed, and 20.32% agreed that they could experience and correlate the concept of the auditory masking effect after the intervention, compared to 66.66% who disagreed in the pretest. This indicates that the simulation exercise significantly enhanced their understanding of the masking effect. Similarly, the knowledge of sound lateralization improved dramatically, with 91.05% of students strongly agreeing and 8.9% agreeing that they could correlate the concept after the laboratory session, compared to 39.83% who disagreed and 60.16% who were unsure in the pretest. This suggests that the simulation method effectively clarified the concept of sound lateralization for the students.&lt;/p&gt; &lt;p&gt;Furthermore, the intervention had a positive impact on students&#39; enjoyment of the laboratory sessions. In the posttest, 96.74% of students strongly agreed that they enjoyed the sessions, compared to only 26.01% who strongly agreed in the pretest. This increase in enjoyment likely reflects the effectiveness of the simulation-based approach in engaging students and making the learning experience more interactive and meaningful.&lt;/p&gt; &lt;p&gt;The median values for the Likert scale item (see Table 3) also demonstrated significant improvements. For example, the median score for understanding the auditory masking effect increased from 2 (disagree) in the pretest to 5 (strongly agree) in the posttest. Similarly, the median score for understanding sound lateralization increased from 3 (unsure) to 5 (strongly agree), and the median score for enjoyment of the laboratory sessions increased from 4 (agree) to 5 (strongly agree).&lt;/p&gt; &lt;p&gt;Table 3. Results of the Wilcoxon signed-rank test comparing pre- and posttest responses to Likert scale items assessing students&#39; perceptions of auditory physiology concepts&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;table&amp;gt;&amp;lt;col align=&quot;left&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;col align=&quot;char&quot; span=&quot;1&quot; /&amp;gt;&amp;lt;thead&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;2&quot; colspan=&quot;1&quot;&amp;gt;Likert Items&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; colspan=&quot;2&quot; rowspan=&quot;1&quot;&amp;gt;Median&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;2&quot; colspan=&quot;1&quot;&amp;gt;&amp;lt;italic&amp;gt;Z&amp;lt;/italic&amp;gt; Value&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;2&quot; colspan=&quot;1&quot;&amp;gt;&amp;lt;italic&amp;gt;P&amp;lt;/italic&amp;gt; Value&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Pretest&amp;lt;/th&amp;gt;&amp;lt;th align=&quot;center&quot; rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;Posttest&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/thead&amp;gt;&amp;lt;tbody&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I could perform Weber&#39;s and Rinne&#39;s tests with great ease.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;5&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;5&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot; /&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;I was able to experience and correlate the concept of the auditory masking effect after this laboratory session&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;2&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;5&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;9.941&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;&amp;amp;#60;0.001&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session helped me correlate the concept of the sound lateralisation phenomenon.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;3&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;5&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;10.082&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;&amp;amp;#60;0.001&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;This laboratory session was enjoyable.&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;4&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;5&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;8.559&amp;lt;/td&amp;gt;&amp;lt;td rowspan=&quot;1&quot; colspan=&quot;1&quot;&amp;gt;&amp;amp;#60;0.001&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/tbody&amp;gt;&amp;lt;/table&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt;3 Median scores, &lt;emph&gt;Z&lt;/emph&gt; values, and &lt;emph&gt;P&lt;/emph&gt; values are reported, demonstrating statistically significant improvements in students&#39; understanding and experience of auditory masking, sound lateralization, and enjoyment of the session. &lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001 indicates a highly significant improvement in students&#39; responses between the pretest and posttest.&lt;/p&gt; &lt;p&gt;In summary, the simulation-based teaching method significantly improved students&#39; understanding of the auditory masking effect and sound lateralization, as well as their confidence in performing Weber&#39;s and Rinne&#39;s tests. The intervention also enhanced students&#39; enjoyment of the laboratory sessions, suggesting that this approach is effective and engaging for teaching complex physiological concepts.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-23&quot;&gt;Qualitative Insights: Student Perspectives on the Intervention&lt;/hd1&gt; &lt;p&gt;&lt;/p&gt; &lt;ulist&gt; &lt;item&gt; &quot;I never thought I would enjoy a physiology lab this much! When I closed my ear with my finger and noticed the sound shift to that side, it was such a cool experience!&quot;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; &quot;It helped me understand the concept of sound lateralization clearly. Now, I finally grasp why sound moves to the affected ear in cases of conductive deafness!&quot;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; &quot;This was the most interactive lab session I&#39;ve had so far. Mimicking the conduction defect made everything click for me. I could feel the difference in sound perception, and it was so much fun to do it with my classmates. I wish all labs were as engaging as this one!&quot;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; &quot;At first, I was confused about the auditory masking effect, but after the simulation, it all made sense. Hearing the sound louder in the closed ear was a simple yet effective way to understand the concept. I enjoyed this hands-on approach!&quot;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; &quot;I usually find it hard to stay focused during labs, but this session was different. The simulation was so interesting. I&#39;m glad we did this!&quot;&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; &quot;I loved how we got to experience the concept ourselves instead of just reading about it. Closing my ear and hearing the sound shift was a simple but effective learning method. It was fun!&quot;&lt;/item&gt; &lt;/ulist&gt; &lt;hd id=&quot;AN0187950961-24&quot;&gt;DISCUSSION&lt;/hd&gt; &lt;p&gt;The findings of this study demonstrate that a simple, simulation-based teaching method significantly enhances medical students&#39; understanding of auditory physiology, particularly about the auditory masking effect and sound lateralization in Rinne&#39;s and Weber&#39;s tests. Pretest responses indicated that many students struggled to grasp these concepts despite prior instruction. However, posttest results demonstrated a marked improvement in comprehension and confidence after participating in a hands-on simulation of unilateral conductive hearing loss. Statistical analysis revealed a highly significant difference between pre- and posttest scores (&lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001), confirming the effectiveness of experiential learning in reinforcing theoretical knowledge. By actively engaging in the simulation, students could experience sound lateralization firsthand, making abstract physiological principles more tangible and accessible.&lt;/p&gt; &lt;p&gt;In the present study, when the external auditory meatus of the right ear was tightly closed with the index finger, the ambient background noise and its ability to create an auditory masking effect in the right ear were eliminated. When Weber&#39;s test was performed, bone conduction was better in the right ear than in the left ear due to the absence of an auditory masking effect. The test subjects responded that they could better perceive sounds in the right ear, which was closed by the index finger, than in the left ear. This improvement in sound perception was due to the lack of masking effect in the right ear. As evidenced by the posttest questionnaire survey results, all students appreciated this simple and innovative method of simulating unilateral conduction defects during standard Weber testing.&lt;/p&gt; &lt;p&gt;The findings of our study are consistent with previous research, which demonstrates that innovative teaching strategies, such as the student-involved demonstration (SID) method, enhance the understanding of complex physiological concepts ([&lt;reflink idref=&quot;bib14&quot; id=&quot;ref33&quot;&gt;14&lt;/reflink&gt;]). Similarly, in our study, students actively engaged in a hands-on simulation mimicking a unilateral conduction defect. This experiential approach allowed them to directly perceive how a patient with conductive hearing loss would interpret sound during the Weber test. The interactive nature of the session not only reinforced key physiological principles but also fostered active participation. Notably, posttest responses indicated that students found the session both educational and enjoyable, highlighting the effectiveness of simulation-based learning in medical education. Simulation-based learning in medical education provides students with a hands-on, experiential approach to understanding complex concepts, thereby eliminating risks to patients ([&lt;reflink idref=&quot;bib15&quot; id=&quot;ref34&quot;&gt;15&lt;/reflink&gt;]). The simple simulation of unilateral conductive deafness significantly improved students&#39; understanding of key concepts, as reflected in the posttest questionnaire results. This finding aligns with research demonstrating that simulation-based medical education (SBME) enhances practical learning skills among medical undergraduates ([&lt;reflink idref=&quot;bib16&quot; id=&quot;ref35&quot;&gt;16&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Likert item four assessed the enjoyment students experienced following the laboratory session. The high agreement rate in the posttest survey (Table 2) suggests that students were actively engaged during the tuning fork test. This finding aligns with research by Kimura et al. ([&lt;reflink idref=&quot;bib17&quot; id=&quot;ref36&quot;&gt;17&lt;/reflink&gt;]), which reported that early exposure to simulation-based programs enhances interest among undergraduate medical students. The simulation-based training scenarios and structured debriefing promoted team reflexivity and peer feedback skills ([&lt;reflink idref=&quot;bib18&quot; id=&quot;ref37&quot;&gt;18&lt;/reflink&gt;]). Additionally, early training through SBME has significantly enhanced medical students&#39; clinical skills, ultimately better preparing them for real-life clinical scenarios ([&lt;reflink idref=&quot;bib19&quot; id=&quot;ref38&quot;&gt;19&lt;/reflink&gt;]). In medical physiology, instructors can enhance student learning by using simulation-based approaches to develop practical skills and reinforce key concepts. Additionally, a report highlighted the effectiveness of SBME in teaching hematological concepts to undergraduate medical students, resulting in a deeper understanding of the theoretical foundations. ([&lt;reflink idref=&quot;bib20&quot; id=&quot;ref39&quot;&gt;20&lt;/reflink&gt;]) Students who participated in this study also provided written feedback after the laboratory sessions, expressing that they all had an enriching experience after being introduced to the simulation of conductive deafness.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-25&quot;&gt;Limitations&lt;/hd1&gt; &lt;p&gt;This study has certain limitations. First, the study was conducted with a single cohort of first-year medical students at a single institution, which limits the ability to generalize the findings to diverse educational settings. Second, while the simulation effectively improved conceptual understanding, it did not evaluate long-term retention of knowledge or its impact on clinical skills in later years of training. Third, the study relied on self-reported measures of comprehension and engagement, which may have been influenced by response bias. Finally, the intervention focused exclusively on simulating unilateral conduction defects, leaving its applicability to more complex auditory pathologies unexamined.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-26&quot;&gt;Future Directions&lt;/hd1&gt; &lt;p&gt;Future studies should investigate the effectiveness of this simulation approach in a multicenter setting involving students from various medical schools and diverse educational backgrounds. Longitudinal studies should assess knowledge retention over time and its impact on students&#39; clinical competency in tuning fork tests for hearing. Additionally, integrating this method with digital simulations or augmented reality could enhance experiential learning. Investigating its effectiveness in teaching sensorineural hearing loss and other auditory pathologies could also broaden its applicability.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-27&quot;&gt;Conclusions&lt;/hd1&gt; &lt;p&gt;This study demonstrates that a simple, simulation-based approach significantly enhances medical students&#39; understanding of auditory physiology, particularly the auditory masking effect and sound lateralization in tuning fork tests. By allowing students to experience a unilateral conduction defect actively, this method promotes deeper conceptual learning and engagement. Given its effectiveness and ease of implementation, this approach has the potential to be widely adopted in medical physiology education, improving the teaching of hearing assessment techniques and fostering better clinical application of these fundamental concepts.&lt;/p&gt; &lt;hd id=&quot;AN0187950961-28&quot;&gt;DATA AVAILABILITY&lt;/hd&gt; &lt;p&gt;The data from this study are available from the principal investigator and will be provided upon reasonable request.&lt;/p&gt; &lt;hd id=&quot;AN0187950961-29&quot;&gt;DISCLOSURES&lt;/hd&gt; &lt;p&gt;No conflicts of interest, financial or otherwise, are declared by the authors.&lt;/p&gt; &lt;hd id=&quot;AN0187950961-30&quot;&gt;AUTHOR CONTRIBUTIONS&lt;/hd&gt; &lt;p&gt;R.S.K. conceived and designed research; M.G.K. and R.P. performed experiments; R.S.K., M.G.K., R.P., and M.E.A. analyzed data; R.S.K., M.G.K., R.P., and M.E.A. interpreted results of experiments; R.S.K. prepared figures; R.S.K., M.G.K., R.P., and M.E.A. drafted manuscript; R.S.K., M.G.K., R.P., and M.E.A. edited and revised manuscript; R.S.K., M.G.K., R.P., and M.E.A. approved final version of manuscript.&lt;/p&gt; &lt;hd1 id=&quot;AN0187950961-31&quot;&gt;ACKNOWLEDGMENTS&lt;/hd1&gt; &lt;p&gt;The authors thank the participants who volunteered for this research. They also thank the officials of Manipal University College Malaysia (MUCM), Melaka, Malaysia, and the College of Science and Health Professions (COSHP), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia, for administrative support in this collaborative research project.&lt;/p&gt; &lt;ref id=&quot;AN0187950961-32&quot;&gt; &lt;title&gt; REFERENCES &lt;/title&gt; &lt;blist&gt; &lt;bibl id=&quot;bib1&quot; idref=&quot;ref1&quot; type=&quot;bt&quot;&gt;1&lt;/bibl&gt; &lt;bibtext&gt; World Health Organization.Deafness and hearing loss (Online). 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Ganesh Kamath; Rekha Prabhu and Mohamed Eldigire Ahmed&lt;/p&gt; &lt;p&gt;Reported by Author; Author; Author; Author&lt;/p&gt; &lt;/aug&gt; &lt;nolink nlid=&quot;nl1&quot; bibid=&quot;bib10&quot; firstref=&quot;ref17&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl2&quot; bibid=&quot;bib11&quot; firstref=&quot;ref19&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl3&quot; bibid=&quot;bib12&quot; firstref=&quot;ref24&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl4&quot; bibid=&quot;bib13&quot; firstref=&quot;ref25&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl5&quot; bibid=&quot;bib14&quot; firstref=&quot;ref33&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl6&quot; bibid=&quot;bib15&quot; firstref=&quot;ref34&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl7&quot; bibid=&quot;bib16&quot; firstref=&quot;ref35&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl8&quot; bibid=&quot;bib17&quot; firstref=&quot;ref36&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl9&quot; bibid=&quot;bib18&quot; firstref=&quot;ref37&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl10&quot; bibid=&quot;bib19&quot; firstref=&quot;ref38&quot;&gt;&lt;/nolink&gt; &lt;nolink nlid=&quot;nl11&quot; bibid=&quot;bib20&quot; firstref=&quot;ref39&quot;&gt;&lt;/nolink&gt;
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  Data: Enhancing Auditory Physiology: Simulating Unilateral Conduction Defects to Improve Understanding of Rinne&#39;s and Weber&#39;s Tests
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  Data: &lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Raju+Suresh+Kumar%22&quot;&gt;Raju Suresh Kumar&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;https://orcid.org/0000-0002-9561-6208&quot;&gt;0000-0002-9561-6208&lt;/externalLink&gt;)&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22M%2E+Ganesh+Kamath%22&quot;&gt;M. Ganesh Kamath&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;https://orcid.org/0000-0002-2439-6068&quot;&gt;0000-0002-2439-6068&lt;/externalLink&gt;)&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Rekha+Prabhu%22&quot;&gt;Rekha Prabhu&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;https://orcid.org/0000-0003-3018-9628&quot;&gt;0000-0003-3018-9628&lt;/externalLink&gt;)&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Mohamed+Eldigire+Ahm%22&quot;&gt;Mohamed Eldigire Ahm&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;https://orcid.org/0000-0003-0326-7926&quot;&gt;0000-0003-0326-7926&lt;/externalLink&gt;)
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  Data: &lt;searchLink fieldCode=&quot;SO&quot; term=&quot;%22Advances+in+Physiology+Education%22&quot;&gt;&lt;i&gt;Advances in Physiology Education&lt;/i&gt;&lt;/searchLink&gt;. 2025 49(3):689-695.
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  Data: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
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  Data: 7
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  Data: 2025
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  Data: Journal Articles&lt;br /&gt;Reports - Research
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  Data: &lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Physiology%22&quot;&gt;Physiology&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Auditory+Perception%22&quot;&gt;Auditory Perception&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Auditory+Tests%22&quot;&gt;Auditory Tests&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Simulation%22&quot;&gt;Simulation&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Medical+Students%22&quot;&gt;Medical Students&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Teaching+Methods%22&quot;&gt;Teaching Methods&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Medical+Education%22&quot;&gt;Medical Education&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Deafness%22&quot;&gt;Deafness&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Experiential+Learning%22&quot;&gt;Experiential Learning&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Instructional+Effectiveness%22&quot;&gt;Instructional Effectiveness&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Foreign+Countries%22&quot;&gt;Foreign Countries&lt;/searchLink&gt;
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  Data: &lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Malaysia%22&quot;&gt;Malaysia&lt;/searchLink&gt;
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1152/advan.00058.2025
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1043-4046&lt;br /&gt;1522-1229
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Tuning fork tests, particularly the Rinne and Weber tests, are fundamental in assessing hearing loss. However, medical students often struggle with key auditory physiology concepts, such as the auditory masking effect and sound lateralization. This study evaluated a simulation-based teaching method to enhance first-year medical students&#39; understanding of these concepts. A prospective educational intervention was conducted with 123 first-year Bachelor of Medicine, Bachelor of Surgery (MBBS) students using a pretest and posttest design with a validated questionnaire. During laboratory sessions, students performed tuning fork tests on peers while instructors demonstrated a novel method to simulate unilateral conductive deafness by closing the external auditory meatus with a finger. Students replicated this method before completing posttest evaluations. Pretest data showed that 66.66% of students were uncertain or disagreed with their understanding of the auditory masking effect, and 60.16% were unsure about sound lateralization. Posttest results demonstrated significant improvement: 79.67% strongly agreed they understood the auditory masking effect, and 91.05% strongly agreed they comprehended sound lateralization (P &lt; 0.001). Additionally, student engagement increased, with 96.74% reporting they enjoyed the session compared to 26.01% before the intervention. This study demonstrates that a simple, reproducible simulation-based approach enhances medical students&#39; understanding of auditory physiology concepts. By actively experiencing a simulated unilateral conduction defect, students gain deeper conceptual insight and greater confidence in performing tuning fork tests. This innovative method holds promise for broader adoption in medical education.
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  Data: 2025
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  Data: EJ1475552
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    Identifiers:
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        Value: 10.1152/advan.00058.2025
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 7
        StartPage: 689
    Subjects:
      – SubjectFull: Physiology
        Type: general
      – SubjectFull: Auditory Perception
        Type: general
      – SubjectFull: Auditory Tests
        Type: general
      – SubjectFull: Simulation
        Type: general
      – SubjectFull: Medical Students
        Type: general
      – SubjectFull: Teaching Methods
        Type: general
      – SubjectFull: Medical Education
        Type: general
      – SubjectFull: Deafness
        Type: general
      – SubjectFull: Experiential Learning
        Type: general
      – SubjectFull: Instructional Effectiveness
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Malaysia
        Type: general
    Titles:
      – TitleFull: Enhancing Auditory Physiology: Simulating Unilateral Conduction Defects to Improve Understanding of Rinne's and Weber's Tests
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Raju Suresh Kumar
      – PersonEntity:
          Name:
            NameFull: M. Ganesh Kamath
      – PersonEntity:
          Name:
            NameFull: Rekha Prabhu
      – PersonEntity:
          Name:
            NameFull: Mohamed Eldigire Ahm
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1043-4046
            – Type: issn-electronic
              Value: 1522-1229
          Numbering:
            – Type: volume
              Value: 49
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Advances in Physiology Education
              Type: main
ResultId 1