A Critique of the Stenger Test.

Introduction: Most audiometers have an in-built "Stenger test" setting. The test is sometimes applied in cases of single-sided deafness as an indicator of malingering. Although textbooks have been written about it, the underlying conditions remain enigmatic. The literature usually points to psychological problems, pointing to the patient as having "nonorganic hearing loss", "malingering", "false and exaggerated hearing loss", "hysterical hearing loss", or "pseudohypoacusis". These are all non-objective features without a sound scientific base, and the test tends to blame the patient for providing non-repeatable hearing thresholds.

Methods: This opinion piece looks at the literature surrounding the Stenger test and the factors that might cause hearing threshold variability and concludes that the test has a subjective basis that makes it unscientific. In our opinion, we also think it is ethically questionable to blame the patient for malingering when there are non-repeatable findings. In order to make the test scientifically valid, we frame a testable hypothesis: that the Stenger effect could be due to unrecognised contraction of the middle ear muscles in response to stimulation of the contralateral (worse-hearing) ear. That is, we suppose that bilateral contraction impairs thresholds in both the good and poor ear, so the subject can no longer hear a tone in their good ear which they previously could when their audiogram was established monaurally. Thus, we make the case that the subject is not malingering-they genuinely cannot hear the test tones in either ear.

Discussion and conclusions: We believe it is incorrect to blame the patient when the problem may lie with incomplete understanding of how the auditory system functions bilaterally. The test needs to be objectively investigated and perhaps reinterpreted in terms of hearing sensitivity in one ear being reduced by sound levels in the contralateral ear. If this is not possible, we suggest it would be better if the Stenger test were abolished.