{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:42:56Z","timestamp":1760060576255,"version":"build-2065373602"},"reference-count":59,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2025,9,9]],"date-time":"2025-09-09T00:00:00Z","timestamp":1757376000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Institute of Physiology and Pathology of Hearing, Warsaw"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Audiology Research"],"abstract":"<jats:p>Introduction: Most audiometers have an in-built \u201cStenger test\u201d 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 \u201cnonorganic hearing loss\u201d, \u201cmalingering\u201d, \u201cfalse and exaggerated hearing loss\u201d, \u201chysterical hearing loss\u201d, or \u201cpseudohypoacusis\u201d. 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\u2014they 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.<\/jats:p>","DOI":"10.3390\/audiolres15050115","type":"journal-article","created":{"date-parts":[[2025,9,9]],"date-time":"2025-09-09T19:16:17Z","timestamp":1757445377000},"page":"115","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Critique of the Stenger Test"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7737-2801","authenticated-orcid":false,"given":"Andrew","family":"Bell","sequence":"first","affiliation":[{"name":"Eccles Institute of Neuroscience, John Curtin School of Medical Research, Australian National University, Canberra, ACT 2601, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Myriam","family":"Westcott","sequence":"additional","affiliation":[{"name":"DWM Audiology, Heidelberg, VIC 3084, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8404-0672","authenticated-orcid":false,"given":"W. Wiktor","family":"Jedrzejczak","sequence":"additional","affiliation":[{"name":"Institute of Physiology and Pathology of Hearing, ul. Mochnackiego 10, 02-042 Warsaw, Poland"},{"name":"World Hearing Center, Ul. Mokra 17, 05-830 Kajetany, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,9]]},"reference":[{"key":"ref_1","unstructured":"Hussain, S.A.S., and Hohman, M.H. (2025, September 08). Nonorganic Functional Hearing Loss, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK580555."},{"key":"ref_2","unstructured":"Peck, J.E. (2011). Pseudohypacusis: False and Exaggerated Hearing Loss, Plural Publishing."},{"key":"ref_3","first-page":"179","article-title":"Introduction and research plan. Multidiscipline study of functional hearing loss","volume":"5","author":"Chaiklin","year":"1965","journal-title":"J. Audit. Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1016\/j.anl.2007.11.012","article-title":"Non-organic hearing loss in Chinese teenagers","volume":"35","author":"Zhao","year":"2008","journal-title":"Auris Nasus Larynx"},{"key":"ref_5","unstructured":"Dobie, R.A. (2015). Audiologic evaluation for exaggerated hearing loss. Medical-Legal Evaluation of Hearing Loss, Plural Publishing."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"970","DOI":"10.1055\/s-0029-1203124","article-title":"Simulation und Dissimulation von Ohr-krankheiten und deren Festellung","volume":"33","author":"Stenger","year":"1907","journal-title":"Dtsch. Med. Wochenschr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/0021-9924(70)90001-8","article-title":"The Stenger phenomenon","volume":"3","author":"Altshuler","year":"1970","journal-title":"J. Commun. Disord."},{"key":"ref_8","unstructured":"Katz, J. (1975). The pseudohypacusic. Handbook of Clinical Audiology, Williams and Wilkins. [3rd ed.]."},{"key":"ref_9","first-page":"196","article-title":"The efficiency of audiometric measures used to identify functional hearing loss","volume":"5","author":"Chaiklin","year":"1965","journal-title":"J. Audit. Res."},{"key":"ref_10","first-page":"38","article-title":"The terminology of false and exaggerated hearing loss","volume":"31","author":"Peck","year":"2019","journal-title":"Audiol. Today"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1016\/S0165-5876(98)00069-X","article-title":"Suggestion audiometry for non-organic hearing loss (pseudohypoacusis) in children","volume":"47","author":"Hosoi","year":"1999","journal-title":"Int. J. Pediatr. Otorhinolaryngol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"149","DOI":"10.3109\/05384916509074125","article-title":"Clinical application of the Reger modification of the Stenger test","volume":"4","author":"Watson","year":"1965","journal-title":"Int. J. Audiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1034","DOI":"10.1121\/1.1908886","article-title":"Studies on the aural reflex. I. Contralateral remote masking as an indicator of reflex activity","volume":"33","author":"Ward","year":"1961","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_14","first-page":"15","article-title":"Central masking: Fact or artifact?","volume":"9","author":"McQueen","year":"2011","journal-title":"New Sch. Psychol. Bull."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3109\/03005368709077767","article-title":"The conceptual problem of \u2018functional hearing loss\u2019","volume":"21","author":"Noble","year":"1987","journal-title":"Br. J. Audiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1016\/B978-0-12-801772-2.00032-1","article-title":"Functional auditory disorders","volume":"Volume 139","author":"Hallett","year":"2016","journal-title":"Handbook of Clinical Neurology"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1080\/14992020400050057","article-title":"Non-organic hearing loss redefined: Understanding, categorizing and managing non-organic behaviour","volume":"43","author":"Austen","year":"2004","journal-title":"Int. J. Audiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2027","DOI":"10.1121\/1.400897","article-title":"A review of otoacoustic emissions","volume":"89","author":"Probst","year":"1991","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"4006","DOI":"10.1007\/s12070-024-04763-z","article-title":"Single-sided deafness at a tertiary care rehabilitation centre: A cross-sectional retrospective study","volume":"76","author":"Shetty","year":"2024","journal-title":"Indian J. Otolargyngol. Head Neck Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1159\/000259252","article-title":"Estimation of the pure-tone audiogram by the auditory brainstem response: A review","volume":"2","author":"Stapells","year":"1997","journal-title":"Audiol. Neuro Otol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"146","DOI":"10.3766\/jaaa.23.3.3","article-title":"Auditory steady-state responses","volume":"23","author":"Korczak","year":"2012","journal-title":"J. Am. Acad. Audiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1055\/s-0035-1570334","article-title":"Summary of the N1-P2 cortical evoked potential to estimate the auditory threshold in adults","volume":"37","author":"Lightfoot","year":"2016","journal-title":"Semin. Hear."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"43S","DOI":"10.1097\/AUD.0b013e31829c70d9","article-title":"Acoustic reflex measurement","volume":"34","author":"Schairer","year":"2013","journal-title":"Ear Hear."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Gibson, W.P. (2017). The clinical uses of electrocochleography. Front. Neurosci., 11.","DOI":"10.3389\/fnins.2017.00274"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.1121\/1.2949505","article-title":"Measuring distortion product otoacoustic emissions using continuously sweeping primaries","volume":"124","author":"Long","year":"2008","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Simpson, M.J., Jennings, S.G., and Margolis, R.H. (2020). Techniques for obtaining high-quality recordings in electrocochleography. Front. Syst. Neurosci., 14.","DOI":"10.3389\/fnsys.2020.00018"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"111862","DOI":"10.1016\/j.ijporl.2024.111862","article-title":"Neonatal hearing screening using a smart-phone based otoacoustic emission device: A comparative study","volume":"177","author":"Madzivhandila","year":"2024","journal-title":"Int. J. Pediatr. Otorhinolaryngol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"345","DOI":"10.3109\/00016488009127147","article-title":"Puretone threshold estimation from acoustic reflex thresholds: A myth?","volume":"89","author":"Hyde","year":"1980","journal-title":"Acta Otolaryngol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"97","DOI":"10.3109\/00206097209072585","article-title":"Some static characteristics of the stapedial muscle reflex","volume":"11","author":"Peterson","year":"1972","journal-title":"Int. Audiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"33","DOI":"10.17430\/1002944","article-title":"A fast, \u201czero synapse\u201d acoustic reflex: Middle ear muscles physically sense eardrum vibration","volume":"7","author":"Bell","year":"2017","journal-title":"J. Hear. Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"9","DOI":"10.17430\/882057","article-title":"How do middle ear muscles protect the cochlea? Reconsideration of the intralabyrinthine pressure theory","volume":"1","author":"Bell","year":"2011","journal-title":"J. Hear. Sci."},{"key":"ref_32","first-page":"141","article-title":"Theories on otic symptoms in temporo mandibular disorders: Past and present","volume":"23","year":"2005","journal-title":"Int. J. Morphol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1620\/tjem.200.129","article-title":"Effects of contralateral noise on the measurement of auditory threshold","volume":"200","author":"Kawase","year":"2003","journal-title":"Tohoku J. Exp. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2628","DOI":"10.1121\/10.0004217","article-title":"Click evoked middle ear muscle reflex: Spectral and temporal aspects","volume":"149","author":"Boothalingam","year":"2021","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e142","DOI":"10.1097\/AUD.0000000000000399","article-title":"Normative wideband reflectance, equivalent admittance at the tympanic membrane, and acoustic stapedius reflex threshold in adults","volume":"38","author":"Feeney","year":"2017","journal-title":"Ear Hear."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1007\/s10162-006-0028-9","article-title":"Simultaneous measurement of noise-activated middle-ear muscle reflex and stimulus frequency otoacoustic emissions","volume":"7","author":"Goodman","year":"2006","journal-title":"J. Assoc. Res. Otolaryngol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1121\/1.4883361","article-title":"Wideband detection of middle ear muscle activation using swept-tone distortion product otoacoustic emissions","volume":"136","author":"Henin","year":"2014","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1001\/archotol.1972.00770090791004","article-title":"Studies in impedance audiometry. I. Normal and sensorineural ears","volume":"96","author":"Jerger","year":"1972","journal-title":"Arch. Otolaryngol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1001\/archotol.1943.00670040383010","article-title":"Audiometric effects of voluntary contraction of the tensor tympani muscles","volume":"38","author":"Smith","year":"1943","journal-title":"Arch. Otolaryngol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Reger, S.N., Menzel, O.J., Ickes, W.K., and Steiner, S.J. (1962, January 7\u20138). Changes in air conduction and bone conduction sensitivity associated with voluntary contraction of middle ear musculature. Proceedings of the Middle Ear Function Seminar, Fort Knox, KY, USA.","DOI":"10.1037\/e426842004-001"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1121\/1.1908156","article-title":"Influence of loud contralateral stimulation on the threshold and perceived loudness of low-frequency tones","volume":"32","author":"Loeb","year":"1960","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1080\/14992027.2023.2174455","article-title":"Acoustic reflexes: Should we be paying more attention?","volume":"63","author":"Prendergast","year":"2024","journal-title":"Int. J. Audiol."},{"key":"ref_43","unstructured":"Katz, J., and Gabbay, W.L. (2009). The acoustic reflex. Handbook of Clinical Audiology, Wolters Kluwer."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1121\/10.0016853","article-title":"The middle ear muscle reflex: Current and future role in assessing noise-induced cochlear damage","volume":"153","author":"Trevino","year":"2023","journal-title":"J. Acoust. Soc. Am."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1044\/jshr.0604.315","article-title":"Impedance measurements at the ear-drum as an aid to diagnosis","volume":"6","author":"Feldman","year":"1963","journal-title":"J. Speech Hear. Res."},{"key":"ref_46","first-page":"1","article-title":"Extratympanic manometry in man","volume":"7","author":"Brask","year":"1978","journal-title":"Scand. Audiol. Suppl."},{"key":"ref_47","unstructured":"Klockhoff, I. (1979, January 25\u201328). Impedance fluctuation and a \u201ctensor tympani syndrome\u201d. Proceedings of the Fourth International Symposium on Acoustic Impedance Measurements, Lisbon, Portugal."},{"key":"ref_48","first-page":"E96","article-title":"Tensor tympani muscle: Strange chewing muscle","volume":"12","author":"Ramirez","year":"2007","journal-title":"Med. Oral Patol. Oral Cir. Bucal"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"287","DOI":"10.3109\/00016486409134578","article-title":"Middle ear muscle reflexes elicited by acoustic and nonacoustic stimulation","volume":"188","author":"Djupesland","year":"1964","journal-title":"Acta Oto Laryngol. Suppl."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"108519","DOI":"10.1016\/j.heares.2022.108519","article-title":"Exploring the middle ear function in patients with a cluster of symptoms including tinnitus, hyperacusis, ear fullness and\/or pain","volume":"422","author":"Fournier","year":"2022","journal-title":"Hear. Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"108509","DOI":"10.1016\/j.heares.2022.108509","article-title":"Contraction of the stapedius and tensor tympani muscles explored by tympanometry and pressure measurement in the external auditory canal","volume":"420","author":"Fournier","year":"2022","journal-title":"Hear. Res."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"25","DOI":"10.17430\/JHS.2021.11.2.3","article-title":"The curious \u2018type C\u2019 tympanogram: Contraction of the tensor tympani masquerades as negative middle ear pressure","volume":"11","author":"Bell","year":"2021","journal-title":"J. Hear. Sci."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"S2","DOI":"10.1017\/S0022215114000309","article-title":"Acoustic shock controversies","volume":"128","author":"Hooper","year":"2014","journal-title":"J. Laryngol. Otol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"29","DOI":"10.3109\/03005369309077886","article-title":"Functional components and resolved thresholds in patients with unilateral nonorganic hearing loss","volume":"27","author":"Gelfand","year":"1993","journal-title":"Br. J. Audiol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1080\/03655230600895531","article-title":"Acoustic shock injury (ASI)","volume":"126","author":"Westcott","year":"2006","journal-title":"Acta Otolaryngol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"117","DOI":"10.4103\/1463-1741.110295","article-title":"Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: A multi-clinic prevalence study","volume":"15","author":"Westcott","year":"2013","journal-title":"Noise Health"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"114","DOI":"10.7861\/futurehosp.3-2-114","article-title":"Person-centred care: What is it and how do we get there?","volume":"3","author":"Coulter","year":"2016","journal-title":"Future Hosp. J."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1126\/science.847460","article-title":"The need for a new medical model: A challenge for biomedicine","volume":"196","author":"Engel","year":"1977","journal-title":"Science"},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Bolton, D., and Gillett, G. (2019). The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments, Palgrave Macmillan.","DOI":"10.1007\/978-3-030-11899-0"}],"container-title":["Audiology Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-4349\/15\/5\/115\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:42:47Z","timestamp":1760035367000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-4349\/15\/5\/115"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,9]]},"references-count":59,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["audiolres15050115"],"URL":"https:\/\/doi.org\/10.3390\/audiolres15050115","relation":{},"ISSN":["2039-4349"],"issn-type":[{"type":"electronic","value":"2039-4349"}],"subject":[],"published":{"date-parts":[[2025,9,9]]}}}