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Functional hearing loss (pseudohypacusis): signs, the Stenger test and objective tests
In functional hearing loss the admitted thresholds are worse than the person's true hearing — sometimes on purpose (malingering) and sometimes without awareness (especially in children). It is spotted by inconsistency between tests, confirmed with the Stenger test when the problem is one-sided, and with objective tests when it is bilateral.
Why it matters in the exam
Warning signs: an SRT much better than the pure-tone average (more than about 10–15 dB), no "shadow curve" in a severe one-sided loss (without masking we would expect the good ear to respond at a high level), half-word answers on the SRT, very high recognition at a low level above threshold, thresholds that change on retest, and normal OAEs or acoustic reflexes at or below the admitted threshold. The Stenger test uses a quirk of two-ear listening: identical tones in both ears are perceived only on the side where the tone sits further above that ear's threshold.
The procedure: present a tone some 10 dB over the good ear's threshold while simultaneously presenting the same tone some 10 dB under the threshold claimed for the "poor" ear. A person who truly cannot hear in the poor ear hears the tone in the good ear and keeps responding — a negative Stenger, the loss is real. A person who exaggerates hears the tone only in the "poor" ear and, so as not to admit it, stops responding — a positive Stenger, the loss is functional. The test suits only a one-sided or asymmetric loss (a difference of at least about 20 dB). When the suspicion is bilateral and symmetrical, objective tests are used: OAE, acoustic reflexes and ABR or ASSR threshold, which gives a reliable threshold estimate. Talk to the person without accusing; in children there is sometimes emotional distress or secondary gain worth exploring.
Key points
- Inconsistency: SRT versus average, no shadow curve, a different retest.
- Stenger: 10 above in the good ear, 10 below the admitted threshold in the poor ear.
- Positive — stops responding — functional; negative — keeps responding — real.
- Bilateral: OAE, reflexes, ABR or ASSR.
- Talk without accusing; in children look for distress.
Summary table
| Tool | What is seen in functional loss | Note |
|---|---|---|
| SRT versus pure-tone average | SRT much better than the average | A difference of more than about 10–15 dB |
| Shadow curve | Missing in a severe one-sided loss without masking | The good ear should respond |
| Stenger | Positive: the person stops responding | Only for one-sided or asymmetric loss |
| OAE | Normal despite an admitted moderate or worse loss | Contradicts the admitted threshold |
| Acoustic reflex | At or better than the admitted threshold | Not possible with such a real loss |
| ABR or ASSR | Objective threshold better than admitted | The main tool when bilateral |
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Sources
- Austen & Lynch, International Journal of Audiology, 2004 — Non-organic hearing loss redefined
- Katz (ed.), Handbook of Clinical Audiology, 7th edition (2015) — Pseudohypacusis
- Martin, Champlin & Chambers, Ear and Hearing, 2000 — Pseudohypacusis: seventy years later
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.