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Naunton's Masking Dilemma Revisited

Seneviratne, Sheran*; McNeill, Celene†,‡; Greenberg, Simon L.§; Kong, Jonathan||

doi: 10.1097/MAO.0000000000002043
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Background: Pure-tone audiometry is essential in diagnosing clinical hearing loss. Masking of the nontest ear is mandatory for determining accurate hearing thresholds in the presence of asymmetrical levels between the two ears and for ascertaining the presence of a conductive hearing loss. Paradoxically, over masking occurs when the intensity of the required masking noise to the contralateral ear is such that it exceeds interaural cranial attenuation by an amount sufficient to mask the test ear. Ralph F Naunton was the first to describe this phenomenon, which has since been known as “Naunton's masking dilemma.”

Methods: A formula was derived mathematically to predict when Naunton's masking dilemma might occur in air and bone conduction. Review of Ralph F Naunton's primary works and related publications was performed.

Results: Our derived mathematical formulae predict when “Naunton's masking dilemma” may occur. During air conduction testing, a masking dilemma may occur when the sum of the air/bone gaps is greater than or equal to twice the interaural attenuation minus 15 dB (Σ ABGNTE+TE ≥ 2 × IA – 15 dB). During bone conduction testing, a masking dilemma may occur when the air-bone gap of the nontest ear is greater than or equal to the interaural attenuation minus 15 dB (ABGNTE ≥ IAAIR 15 dB).

Conclusion: Naunton's masking dilemma imposes a significant limitation to conventional audiometric testing. To the best of our knowledge, we think this is the first time that Naunton's masking dilemma has been represented in a simplified mathematical equation.

*Department of Ear, Nose and Throat Surgery, St George Hospital, Kogarah

Department of Otolaryngology Head and Neck Surgery, Royal Prince Alfred Hospital

Hearing and Balance Centre, St. Vincent's Hospital Sydney

§University of Sydney

||Macquarie University, Sydney, Australia

Address correspondence and reprint requests to Sheran Seneviratne, M.B.B.S., M.S., Ear Nose and Throat Surgery, St George Hospital, Kogarah, NSW 2217, Australia; E-mail:

ORCID No: 0000-0002-4898-7452.

Institution where work was performed: St George Hospital, Kogarah, Sydney, NSW, Australia.

The authors disclose no conflicts of interest.

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