Patient: H.L.

Age: 16 years ~9 months

Gender:  Male

H.L. is a nearly 17 year old male seen in the summer months in advance of his senior year in high school. The case is from many years ago when the writer was living in a rural and very conservative area of the country.  He was accompanied by a woman whose age was between what I expected of for his mother or his grandmother, and was inclined to guess grandmother but fortunately did not (“and your are ….?”) : the woman who appeared in her 60′s was his mother.

H.L. is reporting hearing loss bilaterally of recent onset. He was not  a good historian about the onset or its severity.  He denied pain, tinnitus, dizziness and aural fullness.  His mother was doubtful of hearing loss.  Medical history was unremarkable.

Otoscopy revealed clear ear canals. Tympanograms were normal and acoustic reflexes normal. This case predates clinical use of otoacoustic emissions, but let’s “doctor” the case a bit and indicate that emissions were present and normal, which does not rule out mild hearing loss.

While HL was being tested by a graduate student, Mrs L took me aside and volunteered that H had “behavioral issues.”  I inquired further.  She indicated that her family adheres to what I would characterize as strict religious beliefs, including restrictions against dancing, listening to rock and roll music, smoking, drinking and swearing.  The examples of misbehavior cited included attempting to wear a leather motorcycle jacket, smoking and listening to rock music behind her back.

At this point, I excused my self to observe the testing, and the student audiologist informed me that the loss had characteristics of being non-organic. Test/retest reliability was poor, there was a bit of an SRT/PTA discrepancy. Since the loss being feigned was bilateral, Stenger testing could not be used.

• What testing would you do next?
• It is typical to offer a “graceful out” to the patient.  What strategies might you try to get this young man to provide accurate threshold information?
• Given that the patient is still a minor, your duty is to report findings to his mother.  Given the report of family discord, now coupled with the presentation of non-organic loss, how would you approach this?