The Tinnitus and Hyperacusis Clinic
I received a call from a patient’s husband asking for help. His wife was having significant sensitivity to sounds and it had been worsening over the past several years. At the time, they spoke in whispers in the house; she could not be in the room if he was doing dishes; she could not flush the toilet because it was too loud; she wore earplugs most all the time; and when she had to leave the house to go for doctor visits, she wore earplugs and noise canceling headphones. She could not talk on the phone without having earplugs in her ears. She was essentially shut off from the world in her house. She had lost most of her friends because she could not socialize with them; she could not work as a nurse because of her sound sensitivity; and it was affecting her marriage and every aspect of her life. She was scheduled for consultation and testing in my office. I had to conduct the initial interview in whispers, inside my sound treated booth. She suffered from severe hyperacusis, as well as tinnitus and depression. Although this patient represents a severe manifestation of hyperacusis, I have encountered many patients over the years with varying degrees of hyperacusis that have a significant impact on their lives.
Symptoms of hyperacusis
Hyperacusis is an abnormally strong reaction to sound. Some professionals prefer the term decreased sound tolerance which can refer to hyperacusis, phonophobia (fear of sounds), and misophonia (dislike of certain sounds). Patients with symptoms of hyperacusis can experience physical discomfort because of exposure to sound which would not cause any issue in a normal listener. As a result, people that experience hyperacusis often result in the use of earplugs to avoid the discomfort of sound; however, this can lead to a worsening of the hyperacusis symptoms. Hyperacusis can frequently occur together with tinnitus (ringing or ear noises). Patients with hyperacusis can have normal hearing or varying degrees of hearing loss. It is estimated that 1 to 1.5% of the general population suffers significant hyperacusis.
The cause of hyperacusis is unknown, however, it has been linked to sound/noise exposure (usually short, impulse noises), head injuries, certain medications, stress, Lyme disease, Bell’s Palsy, Addison’s disease, increased cerebral spinal fluid, migraine, depression, and withdraw from benzodiazepines. In the case of my patient, she suffered from Lyme disease infection which caused many body systems issues including hyperacusis and tinnitus. Additionally, she had been heavily medicated with Xanax (a benzodiazepine) and had been trying to wean off for many years.
How is hyperacusis diagnosed?
Diagnosis of hyperacusis is achieved by careful review of hyperacusis questionnaires, case history, hearing testing to determine hearing thresholds, most comfortable listening levels (MCLs), and most importantly the loudness discomfort levels (LDLs). The patient with hyperacusis will show significantly decreased tolerance for louder sounds evidenced by reduced LDLs. Patients with misophonia will show decreased tolerance to specific sounds, regardless of the volume of the sound. Misophonia patients can demonstrate sound tolerance issues with sounds such as chewing or other body sounds that can be quite low in volume, whereas hyperacusis is decreased tolerance to sounds that reach a specific volume.
My patient completed several assessment questions such as the Khalfa Hyperacusis Questionnaire, the Tinnitus Handicap Inventory, and Beck’s Depression Inventory. She also had a complete audiological evaluation including threshold testing, speech in quiet testing, MCL and UCL for speech and for individual frequencies, and tympanometry to assess the middle ear system. Results indicated that she did have severe hyperacusis, severe tinnitus and severe depression. It was important to start treatment as soon as possible. Hyperacusis is the main concern at first and treatment consists of using ear level worn sound generators, use of bedside sound generators when ear level devices are not used, educational/instructional counseling used in Tinnitus Retraining Therapy (TRT), and in this patient’s case Cognitive Behavioral Therapy (CBT).
The patient was instructed to stop using her earplugs at home. I explained that over-protection by using earplugs can make hyperacusis worse, however, she still wanted to use noise canceling earphones when she went out of the house. She was fitted with ear level worn sound generators that are hearing devices that were set with no amplification of sound as she did not have any hearing loss. The devices were programmed to provide a low-level consistent sound that she wore consistently with the aim to increase the volume level of the sound gradually over time to toughen the auditory system. This auditory “toughening” would be like gradually acclimating your eyes to daylight after being in a dark room for many days. If you were to go outside to the bright sun abruptly it would be very difficult to tolerate, however, if you increase the brightness gradually your eyes would accept the changes over time and the bright sunshine would not be as difficult to accept.
What else should I know about hyperacusis?
The hyperacusis patient develops many negative emotions to sound and there are considerable reactions from the limbic system which is our emotional system. Our limbic system is like an “overprotective mother”. It wants to protect us, but often makes things much worse as we tend to become fearful of events and stimuli. The goal of educational/instructional counseling is to learn more about the role of the limbic system in hyperacusis. Concepts and strategies taught in TRT help develop more realistic responses to sounds. Hyperacusis patients have created a conditioned response to sound, much like Pavlov’s dog. They have unwittingly reinforced a pattern of fear to sound. This is like installing faulty software in a computer. It is important to understand that our brain’s software can be modified, overwritten, deleted, and changed throughout our lives. Patients that receive treatment with Cognitive Behavioral Therapy (CBT) train their brains to replace negative responses with positive responses and re-write their cognitive software.
My patient used her sound generators every day. She was never in total silence. She did gradually increase the volume of the sound generators while keeping the volume at safe levels (established by the parameters in our office). She attended regular appointments at my office to receive TRT and worked with her mental health therapist for CBT. After 3 months we recorded that she had stopped using the noise canceling earphones outside of the house. She was able to go to the grocery store. She and her husband can talk in normal volume voices at home. She still is quite fearful of sound but can leave the house and felt like she was on the road to recovery. Reassessment of her Hyperacusis Questionnaire showed she improved from a severe score to a moderate score; the Tinnitus Handicap Inventory improved from a severe score to a normal score, and her Beck’s Depression scale improved from severe to moderate. Repeat testing of LDL’s showed significant improvement as well. At six months’ follow up she reported more improvements at home. She was able to do the dishes; flush toilets without reactions to the sound; and drive by herself to appointments. Follow up eleven months from the start of treatment shows she is no longer homebound; she can go to the horse farm where she encounters loud sounds from horses; she can attend to shopping and caring for her elderly mother; and tinnitus is not a problem for her. The Hyperacusis Questionnaire shows normal range scores; Tinnitus Handicap continues to be at normal values, and her LDL are at normal levels. She continues to use the sound generators but does find that some days she forgets to put them in as she is not as dependent on them.
What is the difference between tinnitus and hyperacusis?
Patients with problematic tinnitus develop negative emotions and reactions to tinnitus due to the limbic system involvement, like hyperacusis. Treatment of tinnitus uses the same concepts as the treatment for hyperacusis. We use sound therapy, TRT and CBT with the goal of reducing the impact of tinnitus on the patient’s life. Problematic tinnitus can occur together with hyperacusis, as it did with this patient, or without hyperacusis. Hyperacusis is a treatable condition, as is problematic tinnitus. Don’t accept it if you are told, “there is nothing you can do about it.” There are audiologists that have specialty training to assess and treat these conditions. Treatment with sound generators should only be attempted under the guidance of audiologists to determine the proper gain levels.