59 Non-Organic Hearing Loss
Non-organic hearing loss (NOHL) is a condition in which a patient consistently displays an apparent auditory deficit, when no true hearing loss exists, or exaggerates a real hearing loss.
This condition is usually encountered either in an adult, in whom there is an ongoing claim for compensation because of ototrauma (hearing loss from noise exposure, ototoxic drugs or trauma), or in a child with psychological disturbance. In the former group, the patient exaggerates an existing hearing loss to improve any compensatory payment. In the latter group, this psychosomatic symptom represents a cry for help in response to some current stressful event, although it may not always be possible to identify the stressor. The underlying hearing is usually normal.
59.1 Clinical Assessment
The diagnosis of NOHL depends primarily on a high index of clinical suspicion, particularly in those who may achieve a financial gain and in children without obvious pathology. The preliminary clinical investigation may reveal some inconsistencies which suggest the diagnosis:
• The patient appears to hear much better than the subsequent audiogram would suggest (but beware of lip readers).
• The pure-tone audiogram itself may be performed in an erratic and hesitant fashion.
• Patients complaining of a unilateral hearing loss may deny any hearing of a tuning fork placed on the mastoid process of the affected side. A patient with a genuine unilateral hearing loss would perceive the bone-conducted stimulus in the normal cochlea and report the perception of sound in one or both ears.
• Those patients who have some degree of psychological upset often appear completely unconcerned about the hearing loss but are often accompanied by an extremely concerned carer.
Unfortunately, in all patients who are pursuing a financial claim, a non-organic component must be excluded; it has been estimated to occur in up to 25% of cases.