A 35-year-old male presents to the audiology clinic with a complaint of sudden hearing loss in the right ear following a workplace injury. Audiometry shows a claimed right ear threshold of 60 dB HL, while the left ear threshold is 10 dB HL. During the Stenger test, a 1 kHz tone is presented at 20 dB HL to the left ear (better ear, 10 dB above its threshold) and simultaneously at 50 dB HL to the right ear (10 dB below his claimed threshold). The patient denies hearing any sound. The finding marked **A** in the diagram—a positive Stenger result—is demonstrated. Which of the following best explains the clinical significance of this finding?
A. The patient has bilateral symmetrical hearing loss with normal middle ear reflexes
B. The patient has genuine organic sensorineural hearing loss in the right ear with normal cochlear function
C. The patient has unilateral functional (non-organic) hearing loss, likely malingering for workers compensation benefits
D. The patient has retrocochlear pathology affecting the right vestibulocochlear nerve
Explanation
Why "The patient has unilateral functional (non-organic) hearing loss, likely malingering for workers compensation benefits" is right
A positive Stenger test (marked A in the diagram) occurs when the patient denies hearing ANY sound despite a clearly audible tone being presented to the better ear. This is pathognomonic for unilateral or asymmetric functional (non-organic) hearing loss. The Stenger phenomenon—binaural suppression of the quieter tone—means a genuinely hearing-impaired patient would still perceive the loud tone in the better ear. By denying all sound, this patient reveals exaggeration or feigning of the hearing loss. In this medicolegal context (workplace injury claim), malingering for secondary gain (workers compensation) is the most likely diagnosis. The anchor A directly identifies this behavioral finding as the gold standard screening test for functional hearing loss (Katz Handbook of Clinical Audiology 7e).
Why each distractor is wrong
"The patient has genuine organic sensorineural hearing loss in the right ear with normal cochlear function": A positive Stenger test explicitly rules out organic hearing loss. A truly hearing-impaired patient would report the loud tone in the better ear, not deny all sound. This contradicts the Stenger principle.
"The patient has bilateral symmetrical hearing loss with normal middle ear reflexes": The Stenger test is designed to detect UNILATERAL or ASYMMETRIC loss. Bilateral symmetrical loss would not produce a positive Stenger result, as the test requires asymmetry to function. Additionally, the clinical presentation here is clearly asymmetric (right 60 dB vs. left 10 dB).
"The patient has retrocochlear pathology affecting the right vestibulocochlear nerve": Retrocochlear lesions (marked D in the diagram—tone decay) are detected by different tests (ABR, tone decay testing). A positive Stenger test is specific for functional loss, not organic retrocochlear disease. Retrocochlear patients would show normal Stenger results (negative Stenger).
High-YieldNEET PG
Positive Stenger = functional unilateral/asymmetric loss; patient denies all sound when loud tone presented to better ear + quiet tone to worse ear = confirms non-organic component.
Katz Handbook of Clinical Audiology 7e
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