Tinnitus and Hyperacusis

• Primary tinnitus has no identified cause other than hearing loss.
• Pulsatile tinnitus is characterized by a noise that is rhythmic and resembles the heartbeat.
• Secondary tinnitus has a specific known cause.
• Somatic tinnitus is caused or influenced by sensory input in the body—for example, muscle spasms.

Hyperacusis is an exaggerated response to ordinary sounds in the environment that are tolerated well by those without hyperacusis. Hyperacusis may result in a range of reactions and emotional responses to sound, varying by individual. Categories of hyperacusis include loudness, annoyance, fear, and pain? (Tyler et al., 2014). As with tinnitus, hyperacusis varies in severity. The negative responses to sound may be strong enough to cause avoidance of normal interactions and situations and may significantly alter a person’s life. Related terms found in descriptions of hyperacusis include the following examples:

• Decreased sound tolerance refers to various disorders involving intolerance to and avoidance of sound.
• Misophonia is characterized by a strong dislike of certain sounds, unique to the individual, that results in negative emotions and reactions.
• Phonophobia is characterized by a persistent and abnormal fear of sound.

Tinnitus and hyperacusis may exist independently or in comorbidity.

Incidence refers to the number of new cases of a disorder identified within a specified period. Because there is no national registry in the United States tracking newly identified patients with tinnitus, published incidence rates stem from population-based community studies. Most notably, a 10-year prospective study performed in Beaver Dam, Wisconsin, followed 2,922 participants who self-identified as having no tinnitus at the start of data collection. The 10-year cumulative incidence of tinnitus in the study population was 12.7%. Significant associations were found with pain?, swelling?, stiffness?, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।" data-rx-term="arthritis" data-rx-definition="Arthritis means joint inflammation causing pain, swelling, stiffness, or reduced movement. সহজ বাংলা: জয়েন্টের প্রদাহ।">arthritis?, head injury, smoking, and, among women only, hearing loss. Alcohol consumption was associated with a decreased risk, along with age for women and obesity for men (Nondahl et al., 2010).

Prevalence refers to the number of individuals with a disorder in a specified period. The prevalence of tinnitus is estimated by the National Center for Health Statistics (a division of the Centers for Disease Control [CDC]) from data collected in the National Health and Nutrition Examination Survey (NHANES). Since 1999, the NHANES includes questions about ringing, roaring, or buzzing in the respondent’s ears or head. In 2005, the tinnitus question was refined to adult participants (ages 20–69 years) reporting that they were “bothered by ringing, roaring or buzzing” that lasts for more than 5 minutes. The prevalence has ranged from 7.1% (2007–2008; National Center for Health Statistics, 2016) to 14.6% (2011–2012; National Center for Health Statistics, 2016). This is consistent with findings in other countries, which reported a range of 10.2% to 15.1% in earlier studies (Møller, 2011).

It is notable that in the 2011–2012 NHANES findings, 9.3 % of those reporting bothersome tinnitus reported it as a big or very big problem, and 39.3% reported that they were bothered when going to sleep. Additionally, 81.5% indicated that they had the tinnitus for 3 months or longer, and 39.3% noted that they experience tinnitus almost always or at least once a day.

A review of the literature reveals inconsistent and broad ranges of prevalence for children with tinnitus, varying from 4.7% to 62.2%. This disparity is likely due to differences in describing the tinnitus, the question posed, response options, age, and study design (Rosing, Schmidt, & Baguley, 2016).

The signs and symptoms of tinnitus and hyperacusis may vary in description and severity across individuals. Both tinnitus and hyperacusis may be symptoms of other disorders or diseases and/or may be associated with other conditions.

Tinnitus may be

• acute? or chronic?;
• bothersome or non bothersome;
• centered in the head or localized? outside the head;
• constant, pulsing, or intermittent;
• high or low in pitch;
• present in one or both ears; and/or
• of variable loudness.

Hyperacusis is characterized by an intolerance to, or a response of discomfort (physical and/or emotional) to, sounds that would be considered acceptable or tolerable to the average listener with normal hearing.

Associated Conditions

Conditions that may co-occur or that may be associated with the presence of tinnitus and/or hyperacusis include

• autism;
• depression or anxiety;
• Ménière’s disease;
• misophonia;
• noise-induced hearing loss;
• obsessive-compulsive disorder (OCD);
• otosclerosis;
• pain?;
• phonophobia; and
• posttraumatic stress disorder (PTSD).

Individuals with tinnitus and/or hyperacusis may also experience functional limitations, including

• difficulty concentrating or thinking clearly;
• difficulty following conversations;
• difficulty performing work tasks;
• difficulty resting and relaxing;
• difficulty sleeping;
• emotional issues;
• perceived hearing difficulty;
• relationship problems; and
• social isolation and avoidance.

In many cases, the etiology of tinnitus and hyperacusis remains unknown. However, hearing loss of any etiology increases the likelihood of tinnitus and can also contribute to some forms of hyperacusis.

Tinnitus

Causes and risk factors for objective tinnitus may include

• anemia?;
• arterial bruit;
• arteriovenous malformation;
• atherosclerotic carotid arteries;
• benign? intracranial hypertension?;
• changes in blood flow in the vessels near the ear due to
  • pregnancy,
  • strenuous exercise, and/or
  • thyrotoxicosis;
• Eustachian tube dysfunction;
• glomus tumors;
• head or neck trauma or injury;
• microvascular compression of the vestibulocochlear nerve (VIII);
• middle ear muscle spasms; and
• palatomyoclonus (contraction of soft palate muscles).

Causes and risk factors for subjective tinnitus may include

• acoustic trauma;
• barotrauma;
• cerumen blockage;
• ear/sinus infection?;
• endocrine disorder;
• hearing loss;
• hormonal changes;
• medication side effects;
• Ménière’s disease;
• metabolic disorder;
• pain?, nausea?, or light sensitivity. সহজ বাংলা: বারবার হওয়া বিশেষ ধরনের মাথাব্যথা।" data-rx-term="migraine" data-rx-definition="Migraine is a recurring headache disorder often with throbbing pain, nausea, or light sensitivity. সহজ বাংলা: বারবার হওয়া বিশেষ ধরনের মাথাব্যথা।">migraine? headache?;
• mineral and vitamin deficiencies;
• multiple sclerosis?;
• noise-induced hearing loss (See the U.S. Department of Labor Occupational Safety and Health Administration (OSHA) standards for occupational noise exposure, the National Institute for Occupational Safety and Health (NIOSH) criteria [PDF], and the World Health Organization-International Telecommunication Union standard [PDF] for recommendations regarding noise exposure related to personal listening devices);
• otitis media;
• otosclerosis;
• presbycusis;
• temporomandibular joint (TMJ) disorder;
• traumatic brain injury (TBI);
• tumors (e.g., vestibular schwannoma, meningioma);
• viral? infections of the inner ear; and
• whiplash.

Hyperacusis

Causes and risk factors for hyperacusis may include

• autoimmune? disorders;
• endocrine disorders;
• fibromyalgia;
• head or neck trauma or injury;
• Lyme disease;
• medication side effects and withdrawal symptoms;
• Ménière’s disease;
• metabolic disorders;
• pain?, nausea?, or light sensitivity. সহজ বাংলা: বারবার হওয়া বিশেষ ধরনের মাথাব্যথা।" data-rx-term="migraine" data-rx-definition="Migraine is a recurring headache disorder often with throbbing pain, nausea, or light sensitivity. সহজ বাংলা: বারবার হওয়া বিশেষ ধরনের মাথাব্যথা।">migraine? headache?;
• neurologic conditions;
• noise exposure and acoustic trauma;
• ototoxins;
• perilymph fistula;
• PTSD;
• sudden sensorineural hearing loss;
• superior canal dehiscence;
• TMJ disorder;
• TBI;
• viral? infections of the inner ear or facial nerve; and
• Williams syndrome.

Roles and Responsibilities of Audiologists

Audiologists play a central role in the assessment, diagnosis?, and management of persons with tinnitus and/or hyperacusis. Professional roles and activities in audiology include clinical/educational services (diagnosis, assessment, planning, intervention, and management), prevention and advocacy, administration, and research.

Appropriate roles for audiologists include the following:

• Remaining informed of research in the areas of tinnitus and hyperacusis as related to the audiologist’s contribution to patient management.
• Providing prevention information and promoting hearing wellness.
• Educating other professionals about the role of audiologists in tinnitus and/or hyperacusis management.
• Identifying individuals with bothersome tinnitus and/or hyperacusis.
• Conducting comprehensive audiological evaluations, including otoscopic examination of ear canals.
• Referring the patient to other professionals, as needed, to facilitate access to comprehensive services.
• Participating in multidisciplinary team consultation for the assessment and management of a patient with tinnitus and/or hyperacusis.
• Proceeding with hearing aid evaluation, fitting, and orientation, as appropriate.
• Making recommendations for sound therapy and/or tinnitus maskers, as appropriate.
• Counseling patients and families/caregivers to enhance their understanding of, acceptance of, and adjustment to tinnitus and/or hyperacusis.
• Completing appropriate documentation, including interpretation of data and summary of findings and recommendations.
• Developing and using outcome measures, as appropriate, to measure the efficacy of any intervention provided.
• Advocating for individuals with tinnitus and/or hyperacusis at the local, state, and national levels.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists may encounter individuals with complaints of tinnitus and/or hyperacusis within the populations that they serve.

Appropriate roles for speech-language pathologists include the following:

• Providing appropriate referrals for patients who complain of tinnitus and/or hyperacusis.

Assessment of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). A patient may or may not require a comprehensive assessment as determined by the process of diagnosis?: Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।" data-rx-term="differential diagnosis" data-rx-definition="Differential diagnosis is a list of possible conditions that may explain symptoms. সহজ বাংলা: একই লক্ষণের সম্ভাব্য রোগের তালিকা।">differential diagnosis?.

Assessment of Tinnitus

Assessment of tinnitus may include one or more of the following measures (see subsections below). It is necessary to determine the severity of the tinnitus as well as to distinguish between bothersome and non bothersome tinnitus.

Case History

Accurate assessment and diagnosis? of tinnitus rely partly on the audiologist’s interpretation of tests and assessment measures within the context of the individual’s medical and social history. Performing a targeted case history is within the major recommendations in the Clinical Practice Guideline: Tinnitus published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF; Tunkel et al., 2014).

A case history specific to tinnitus may include the following items:

• Collection of results from other health professionals, as available (e.g., cranial nerve assessment, lab work).
• Patient description of tinnitus (acute?, chronic?, persistent, intermittent) and its presentation (description of pitch, loudness, tonality, duration, maskability) with attention to factors such as
  • unilateral tinnitus, which may be related to serious medical conditions such as vascular tumors; and
  • pulsatile tinnitus, which may be related to vascular lesions or systemic? cardiovascular illness.
• Patient description of provoking or alleviating factors.
• Patient description of functional impact or quality-of-life impact of tinnitus.
• Medical history, including
  • general health status;
  • list of medications (prescription, over-the-counter, alternative, and herbal); and
  • presence of co-morbidities.
• History of noise exposure.
• History of trauma.
• Associated otologic/vestibular concerns such as
  • hearing loss;
  • hyperacusis; and
  • balance problems.
• Other associated concerns such as
  • anxiety;
  • depression;
  • difficulty concentrating;
  • difficulty sleeping;
  • pain;
  • perceived difficulty hearing due to tinnitus; and
  • presence of tenderness (trigger points) on the head or neck muscles.

Audiologic Evaluation

Otologic and audiological assessment is vital for accurate differential diagnosis of tinnitus. Otology may help identify or rule out injury, cerumen impaction, or disease processes causing tinnitus. Audiologic assessment will identify associated hearing loss.

Although performing a comprehensive audiology assessment for patients with persistent tinnitus of 6 months or longer, tinnitus associated with hearing problems, or unilateral tinnitus is within the major recommendations in the recommendations made by AAO-HNSF (Tunkel et al., 2014), performing the comprehensive audiologic assessment at the time of patient report may help to avoid delay in obtaining relevant diagnostics. The AAO-HNSF guidelines also provide an option for routine audiological assessment for other types of tinnitus (Tunkel et al., 2014).

In some cases, acoustic reflex testing is not recommended (Henry, Jastreboff, Jastreboff, Schechter, & Fausti, 2002). Some patients with tinnitus are very sensitive to sound and may not tolerate acoustic reflex testing. However, if the audiologist approaches the acoustic reflex testing with caution and provides the patient with proper instruction, valuable diagnostic information may be obtained.

Additional balance testing may be added to the comprehensive assessment when patients present with tinnitus and balance complaints or when initial testing indicates possible vestibular dysfunction (Wackym & Friedland, 2004). Results from these tests may lead to a medical referral for more specific testing.

Additional Testing

Additional testing may be performed in an attempt to quantify various psychoacoustic qualities of a patient’s subjective tinnitus. Results from these tests may be used for patient counseling and education purposes as well as for the provision of baseline information to guide management decisions and for later comparison.

Tinnitus Pitch Matching

Tinnitus pitch matching involves comparing the pitch of the tinnitus that the patient hears to external tones of varying frequencies. The patient identifies which frequency best matches the pitch of their tinnitus. Ideally, the pure tones at all frequencies presented will be similar in loudness to the patient’s tinnitus. Pitch matching is not feasible for those individuals whose tinnitus is not tonal.

It may be beneficial to repeat the pitch-matching measure several times and to document the range of responses provided by the patient. Some patients may not consistently identify the pitch match frequency given multiple trials (Henry, Flick, Gilbert, Ellingson, & Fausti, 2004; Tyler & Conrad-Armes, 1983b).

Tinnitus Loudness Matching

Tinnitus loudness matching involves comparing an external tone or broadband noise to the patient’s perception of the loudness level of their tinnitus in an attempt to quantify the tinnitus at a decibel level. The intensity of the given tone will be increased from the patient’s audiometric threshold in small steps until the patient reports a loudness level that is similar to their tinnitus. The decibel level of the perceived tinnitus can be compared against the decibel level of the patient’s audiometric threshold to find the tinnitus loudness sensation level, which is often found to be 10 dB or less above the hearing threshold.

The tone used during tinnitus loudness matching is that which the patient perceived as closest to their tinnitus during the pitch matching task. In many cases, different tinnitus loudness sensation levels will be found when tinnitus loudness matching is completed at frequencies not matched to the patient’s tinnitus (Tyler & Conrad-Armes, 1983a). A fuller picture of tinnitus loudness as a function of frequency may be obtained by completing loudness matching at multiple frequencies.

Minimum Masking Level

Minimum masking level refers to the level of broadband or narrowband noise required to mask or alleviate bothersome tinnitus for a given patient.

Residual Inhibition Assessment

Residual inhibition refers to a temporary result of tinnitus suppression that some individuals experience after masking. The effect may last for a few seconds or minutes—or, for some, even longer.

Subjective Patient Questionnaires

Subjective patient questionnaires may be used in the identification, assessment, and management of tinnitus. Different questionnaires will address different measures (e.g., severity, disability, functional impact, psychological factors, and quality of life). Although some questionnaires may help determine the impact of tinnitus on the patient, others may assist in assessing the outcomes of intervention. Examples include the following tools and publications:

• Difficulties Experienced by Tinnitus Sufferers (Tyler & Baker, 1983)
• Tinnitus Functional Index (Meikle et al., 2012)
• Tinnitus Handicap Inventory (Newman, Jacobson, & Spitzer, 1996)
• Tinnitus Handicap Questionnaire (Kuk, Tyler, Russell, & Jordan, 1990)
• Tinnitus Primary Function Questionnaire (Tyler et al., 2014)
• Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991)

Assessment of Hyperacusis

Assessment of hyperacusis may include one or more of the following measures (see subsections below).

Case History

Accurate assessment and diagnosis of hyperacusis rely partly on the audiologist’s interpretation of assessment measures within the context of the individual’s medical and social history.

A case history specific to hyperacusis may include the following items:

• Collection of results from other health professionals, as available (e.g., psychiatric assessment, lab work).
• Patient description of hyperacusis and its presentation.
• Patient description of functional impact or quality-of-life impact of hyperacusis.
• Medical history, including
  • general health status;
  • list of medications (prescription, over-the-counter, alternative, and herbal); and
  • presence of co-morbidities.
• History of noise exposure.
• History of PTSD or exaggerated startle response.
• Associated otologic/vestibular concerns such as
  • balance problems; and
  • tinnitus.
• Other associated concerns such as
  • anxiety;
  • depression;
  • difficulty concentrating; and
  • pain.

Audiologic Evaluation

Otologic and audiologic assessment may assist in an accurate differential diagnosis of hyperacusis. Audiologic tests may be chosen by the practitioner for each patient and their specific needs and concerns. Patients with hyperacusis may experience pain, discomfort, or fear when exposed to ordinary sounds and may not tolerate standard audiology testing.

Additional Testing

Additional testing may be performed during the differential diagnosis process. Results from these tests may be used for patient counseling and education purposes as well as for baseline information that will guide management decisions and outcome analysis.

Loudness Discomfort Level (LDL)/Uncomfortable Loudness Level (ULL)

A loudness discomfort level (LDL) may be achieved using a variety of acoustic stimuli. An abnormal LDL result will demonstrate a reduced sound tolerance range when compared to LDL results of individuals without hyperacusis. It may be beneficial to take this measurement several times because an individual’s hyperacusis may fluctuate. For some patients, LDL testing may prove to be difficult to complete. Consideration of this and other test limitations is important when including LDL testing in an assessment.

Subjective Patient Questionnaires

Subjective patient questionnaires may be used in the identification, assessment, and management of hyperacusis. Different questionnaires will address different measures (e.g., disability, functional impact, psychological factors, and quality of life). Examples include the following tools:

• German Questionnaire on Hypersensitivity to Sound (GUF; Blasing, Goebel, Flotzinger, Berthold, & Kroner-Herwig, 2010)
• Modified Khalfa Hyperacusis Questionnaire (Khalfa et al., 2002)
• Multiple Activity Scale for Hyperacusis (MASH; Dauman & Bouscau-Faure, 2005)

Assessment of tinnitus and/or hyperacusis may result in recommendations for management options and/or referral to medical professionals, as appropriate. Management of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). Intervention may address a patient’s concerns regarding thoughts and emotions, sleep, concentration, and hearing.

Management Options for Tinnitus

In general, there is no cure for tinnitus. Some individuals with tinnitus do not find it bothersome. For others it can be debilitating, causing emotional distress and negatively impacting quality of life. Tinnitus management may include one or more of the following options.

Informational and Educational Counseling

Patients presenting with tinnitus that is bothersome and persistent will require educational and informational counseling. The AAO-HNSF guidelines provide a recommendation for education and counseling (Tunkel et al., 2014). It may be helpful to include the patient’s support system (e.g., family, significant others) in the counseling portion of tinnitus management.

The audiologist or related practitioner may provide information related to the patient’s specific case of tinnitus and potential management strategies. The patient may also be made aware of unverified claims and “cures” that may mislead them as they research tinnitus online. See ASHA’s page on Health Literacy for more information on communicating with patients and family members. Audiologists and related practitioners may also consider professional referrals to address the psychosocial aspects of tinnitus.

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. CBT may apply to patients with tinnitus to help reduce negative responses and improve quality of life (Hesser, Weise, Westin, & Andersson, 2011). CBT may be used in combination with other tinnitus management strategies. The AAO-HNSF guidelines provide a recommendation for CBT (Tunkel et al., 2014).

Amplification/Hearing Aids

Some individuals with hearing loss also complain of tinnitus. A properly fitted hearing aid may alleviate bothersome tinnitus through amplification and/or masking effects (Kochkin & Tyler, 2008; McNeill, Távora-Vieira, Alnafjan, Searchfield, & Welch, 2012; Shekhawat, Searchfield, & Stinear, 2013). The AAO-HNSF guidelines on tinnitus provide a recommendation for hearing aid evaluation (Tunkel et al., 2014). Hearing aids may be beneficial when used independently or in combination with a sound generator as an optional programmable feature (Henry, Frederick, Sell, Griest, & Abrams, 2015). Hearing aids that are fit specifically for the amelioration of tinnitus may require individualized programming.

Sound Therapy

Sound therapy refers to the use of sound to relieve bothersome tinnitus. It is inclusive of several strategies and products (e.g., wearable devices, external devices, and accessories to hearing aids). Sound therapy uses external noise to distract, mask, habituate, or neuromodulate (i.e., reduce neural hyperactivity that may be an underlying cause of tinnitus) the perceived subjective tinnitus. A secondary benefit of sound therapy is to provide a relaxation effect, which may aid in habituation. Sound therapy may be considered as an important component of a comprehensive tinnitus management plan (Hoare, Searchfield, El Refaie, & Henry, 2014).

Wearable Devices

Wearable masking devices may be used alone or in combination with hearing aids. Several different styles are available, and some offer frequency adjustments for the patient to use as needed. Some wearable devices are worn for a prescribed number of hours each day and introduce sounds that have been customized for the patient and their tinnitus.

Nonwearable Devices

Nonwearable devices include any environmental device that provides background sound that can be used by patients to reduce their perception of bothersome tinnitus. Examples include

• bedside devices providing white noise/nature sounds;
• digital downloads of relaxing music/noise/nature sound delivered through headphones or pillow speakers;
• fans; and
• radios.

Nonwearable masking devices may be especially helpful for those individuals who have difficulty sleeping due to bothersome tinnitus.

Tinnitus-Specific Management Programs

There are several management programs specific to tinnitus, including those described below.

Tinnitus Retraining Therapy (TRT)

Pawel J. Jastreboff (1990) wrote about the neurophysiological model of tinnitus. Based on this model, tinnitus retraining therapy (TRT) is a habituation-based intervention that includes a combination of directive counseling and sound therapy. The TRT protocol involves a structured case history followed by the assignment of the patient into one of five categories differentiated by their specific type of tinnitus. Category assignment directs intervention. All patients receive directive counseling and education specific to tinnitus and auditory physiology, among other topics. Some type of sound input/enriched sound is often included.

Progressive Tinnitus Management (PTM)

The progressive tinnitus management (PTM) approach focuses on the patient learning to self-manage their negative reactions to tinnitus. PTM uses a clinical service structure in which a patient progresses to higher (more intensive) levels of intervention only as needed. A significant aspect of PTM involves educating the patient on the use of individualized coping skills as well as some elements of CBT. The five levels of PTM have been described in detail (Henry, Schechter, Zaugg, & Myers, 2008; Henry, Zaugg, Myers, Kendall, & Turbin, 2009).

Tinnitus Activities Treatment (TAT)

Tinnitus activities treatment (TAT) is an intervention using individualized counseling. Four areas are considered, including “thoughts and emotions, hearing and communication, sleep, and concentration” (Tyler, Gogel, & Gehringer, 2007, p. 425). Low-level partial masking sound therapy as well as patient homework activities (based on the four problem areas outlined above) are also integral to this approach.

Other/Alternative Tinnitus Management Options

In making prudent recommendations for a person complaining of tinnitus, a clinical practitioner should remain current in their knowledge of the various management options available and should carefully review supporting or opposing scientific evidence (or lack thereof).

A variety of other tinnitus management options are currently being used and/or studied. Examples include the following approaches:

• Biofeedback training—learning to monitor one’s physiological response to tinnitus in an attempt to gain some voluntary control of the response.
• Hypnotherapy—introducing an altered state of consciousness to allow for positive suggestions to bring about subconscious change.
• Myofascial trigger point therapy—working with a skilled practitioner to release muscle contraction at trigger points (for patients with tinnitus and chronic pain in areas around the ear).
• Neuromodulation—introducing specific therapeutic sound presentations and sequences, often administered through a neuromodulation device.
• Psychotherapy, such as
  • mindfulness training—learning to attend to thoughts and feelings that one is having in the current moment without judgment and with acceptance, and
  • relaxation training—developing skills and techniques for relaxation and stress management.
• Self-help options—using resources such as Internet-guided programs providing CBT or mindfulness and stress management for tinnitus.
• Transcranial magnetic stimulation—a noninvasive procedure using magnetic fields to stimulate nerve cells in the brain.
• Vagus Nerve Stimulation—stimulation of the vagus nerve with an electrical stimulator implanted under the skin and used in conjunction with audio tone therapy.

Appropriate Referrals

Appropriate referrals for a patient with tinnitus may include a variety of healthcare professionals. In cases where a medically treatable cause is identified, medical, surgical, psychiatric, or dental treatment may be recommended by the appropriate medical professionals (e.g., surgical excision of a tumor, or medication for an infection). Based on an audiologist’s knowledge and skills, it may be appropriate to refer out for specific tinnitus management techniques, such as TRT. Psychological referrals may be necessary for counseling and CBT. Effective treatment of depression, anxiety, and insomnia may help to reduce the severity of tinnitus and improve a patient’s quality of life (Folmer, 2002).

Future Directions

Tinnitus presents several challenges for clinicians because there is generally no cure, and there is a lack of consensus and standardization regarding definition, objective measurement, assessment, and management. Future responses to these difficulties may include

• standardized training for students, audiologists, and other practitioners;
• collaboration among tinnitus experts to define important outcomes of focus for clinical trials; and
• standardized procedures for the diagnosis, assessment, and management of tinnitus.

Management Options for Hyperacusis

Hyperacusis can be debilitating, causing emotional distress and negatively influencing an individual’s quality of life. Intervention may include one or more of the following options (see subsections below).

Informational and Educational Counseling

Patients presenting with complaints of hyperacusis will require education and counseling. It may be helpful to include the patient’s support system (e.g., family, significant others) in the counseling portion of hyperacusis management.

Education may include information relating to the patient’s specific case of hyperacusis as well as potential management strategies. See ASHA’s web page on Health Literacy for more information on communicating with patients and family members. Professional referrals may also be considered to address the psychosocial aspects of hyperacusis.

Cognitive Behavioral Therapy (CBT)

Referral to a trained and licensed professional for psychotherapy may be appropriate. Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. Treatment of depression, anxiety, and insomnia may also be necessary.

Sound Therapy

Sound therapy for hyperacusis requires the patient to listen to low-level sounds for long periods to encourage habituation. “Over time, gradual increases of the level and/or duration of the sound treatment should be implemented along with positive reinforcement by the clinician” (Pienkowski et al., 2014, p. 428). Sound therapy options for hyperacusis include the following presentations (Pienkowski et al., 2014):

• Continuous low-level broadband noise
• Music or environmental sounds
• Successive approximations of high-level broadband noise
• Successive approximations to troublesome sounds
• Gradual increase of maximum output of hearing aid or ear-level sound generator

Hyperacusis-Specific Management Programs

Tinnitus Retraining Therapy (TRT)

The general principles of TRT described in an earlier section may also be used successfully in the management of a patient with hyperacusis (Mraz & Folmer, 2003).

Hyperacusis Activities Treatment

Hyperacusis activities treatment is based on the protocol for TAT, described earlier. The approach includes both individualized counseling and sound therapy specific to hyperacusis.

Hearing Protection

Some individuals with hyperacusis feel that wearing hearing protection to avoid disturbing sounds is helpful; however, this is not advisable when environmental sound levels are safe. Avoiding normal-level sounds in the environment can make the auditory system more sensitive to these sounds when protection is not used. This increased sensitivity can exacerbate hyperacusis (Formby, Sherlock, & Gold, 2003). Using hearing protection when exposed to excessive noise is advisable for all individuals.

Appropriate Referrals

Appropriate referrals for a patient with hyperacusis may include a variety of healthcare professionals. These referrals may include neurology, psychiatry, occupational therapy, psychology, and primary care professionals. The appropriate referrals may depend on whether a specific cause has been identified.

Considerations for Pediatrics

It is important to consider that children may be less able to describe bothersome tinnitus or hyperacusis verbally, and they may use actions or emotional gestures instead (e.g., covering their ears with their hands, and crying). Children may have tinnitus, hyperacusis, or both. Underreporting of tinnitus or hyperacusis is a concern in the care of children.

Tinnitus

Children who experience tinnitus—much like adults who experience tinnitus—will benefit from general education and information about the condition. Allaying a child’s fears may be a significant factor in the management of tinnitus. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and the specifics of the tinnitus.

Hyperacusis

Hyperacusis in children may coexist with conditions such as autism. Hyperacusis can be acquired after severe ear infections and head injuries and through a variety of other causes. A child with hyperacusis may have normal hearing. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and the specifics of the hyperacusis. Similar to the management of hyperacusis in adults, a goal of managing hyperacusis in children is to help children reduce their fear of and aversion to everyday sounds.

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