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WhatsTheDx publishes a new Audiology case every day. Five clues, one diagnosis, and no account needed to play.
Play today's Audiology caseFive progressive clues
These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 12-year-old is referred to the audiology clinic after failing the hearing screening at school twice. Her parents say that over the last couple of months she has been asking people to repeat themselves at home, and has started turning the television up. Her teachers have moved her to the front of the class.
Clue 2
The history is oddly clean. There was no illness before it, no ear infection, no injury, no loud noise, and no medication. It did not creep in over years — it arrived, and it arrived in both ears at the same time. Otoscopy is entirely normal on both sides: clear canals, healthy drums, nothing to see.
Clue 3
The audiogram appears to confirm the referral. Thresholds sit at around 55 dB HL in both ears in a flat line across the frequencies, a moderately severe loss with no air-bone gap. Tympanometry is normal on both sides — normal peak pressure, normal compliance. On paper this is a symmetrical sensorineural loss of sudden onset in a healthy twelve-year-old, which would be a serious finding.
Clue 4
Repeating the test is where it starts to come apart. Retested at the same frequencies, her thresholds move by more than 15 dB — a real threshold does not wander that far. Two things in the room do not fit either. She watches the speaker’s mouth intently, as someone with a new severe loss would, yet her own voice never rises above a normal conversational volume. And when the clinician makes a quiet remark to a colleague, not directed at her, she answers it.
Diagnosis
Non-Organic Hearing Loss
Why the diagnosis fits
Everything about the referral is legitimate: she really did fail the screening twice, and the audiogram really does show a flat moderately severe loss in both ears. The diagnosis is made by noticing that the results contradict each other. Three inconsistencies stack up. Her thresholds move by more than 15 dB when the same frequencies are retested, whereas a genuine threshold repeats to within a few decibels. Her speech reception threshold is 25 dB HL against a pure-tone average of 55 dB HL, and those two figures should agree to within five to eight decibels — she is repeating words at a level she has just indicated she cannot hear tones at. And in the room she behaves in two incompatible ways at once, lip-reading intently as a newly deafened person would while keeping her own voice at a normal volume and answering a remark not addressed to her. The finding that closes it is the one requiring no cooperation: acoustic reflexes present at normal levels in both ears, triggered well below her reported thresholds. That is an involuntary muscle response, so it demonstrates that sound is reaching the cochlea and brainstem regardless of what the behavioural test recorded. The important thing is what this diagnosis does and does not assert. It runs along a spectrum, from conversion disorder at the unconscious end, through factitious disorder, to consciously motivated malingering, and nothing in this assessment locates a twelve-year-old on that spectrum — the abrupt bilateral onset during a period of academic pressure and disruption at home fits the unconscious end well. Reaching the diagnosis is what protects her: many cases go undetected, and those patients can end up receiving unnecessary and sometimes harmful treatment for a loss they do not have.
Educational reference
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Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.
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