A 35-year-old male presents with a claim of sudden severe unilateral hearing loss in the left ear following a workplace noise exposure incident. He is pursuing a compensation claim. Audiometry shows a claimed left ear threshold of 80 dB HL across frequencies, with a normal right ear threshold of 10 dB HL. During testing, the structure marked **A** in the diagram is performed: a 1000 Hz tone is presented simultaneously at 90 dB HL to the left ear (10 dB above his claimed threshold) and 0 dB HL to the right ear (10 dB below his claimed threshold). The patient does not respond to this stimulus pair. What does this finding most strongly suggest about the nature of this patient's hearing loss?

Explanation

## Why "The hearing loss is non-organic (functional) in nature, consistent with malingering or conversion disorder" is right The **Stenger test** (marked **A**) is the gold-standard bedside test for detecting unilateral non-organic hearing loss. The test is based on the Stenger principle: when two tones of identical frequency are presented simultaneously to both ears, the listener perceives only the *louder* tone and lateralizes to that ear. In this case, the 90 dB tone in the claimed "bad" left ear is louder than the 0 dB tone in the right ear. If the patient truly had severe hearing loss in the left ear (threshold 80 dB), he would not perceive the 90 dB tone in that ear and would instead hear and respond to the soft 0 dB tone in the normal right ear. However, the patient *did not respond*—a **negative response to the bilateral stimulus pair = positive Stenger test**. This indicates the patient is consciously or unconsciously aware of the loud tone in the left ear, assumes it is a test of that ear alone, and suppresses his response (false expectation of fooling the examiner). This non-response proves the left ear threshold is better than claimed and confirms non-organic hearing loss. Per Cummings Otolaryngology and Dhingra, a positive Stenger test is pathognomonic for functional/non-organic hearing loss in the unilateral setting. ## Why each distractor is wrong - **The patient has true bilateral sensorineural hearing loss with left ear predominance**: A truly deaf or severely hearing-impaired left ear would still perceive the 90 dB tone and respond to it (or respond to the 0 dB tone in the right ear via the Stenger principle). The patient's failure to respond despite the loud stimulus in the claimed bad ear is inconsistent with organic loss and indicates non-organic pathology. - **The patient has conductive hearing loss in the left ear with normal bone conduction thresholds**: Conductive hearing loss does not explain the Stenger test result. Moreover, conductive loss would not account for the inconsistency between claimed air-conduction thresholds and the patient's actual perceptual response during the Stenger test. Conductive loss also would not be expected in a noise-exposure claim. - **The patient has central auditory processing disorder with intact peripheral hearing**: Central auditory processing disorder affects the interpretation and integration of sound, not the detection of pure tones at threshold. A patient with CAPD would still respond to a 90 dB tone presented to either ear. The Stenger test specifically detects non-organic hearing loss, not CAPD. **High-Yield:** Positive Stenger test (no response to bilateral simultaneous tones when the loud tone is in the claimed bad ear) = pathognomonic for unilateral non-organic hearing loss; confirms malingering or conversion disorder. [cite: Cummings Otolaryngology - Head and Neck Surgery 7e, Chapter 134 (Non-Organic Hearing Loss); Dhingra Diseases of Ear Nose and Throat 7e]