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392 Disorders of the Auditory System
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frequencies. Vernon and Meikle (1988)
reported that tinnitus in their subjects was
matched to frequencies above 3000
83% of the time. Similar findings have
been reported by others (Nageris et al.,
2010). It is important to note that the pitch,
quality, and loudness of tinnitus may vary
together or they may vary independently,
which can complicate the pitch-matching
procedure. Also, many patients with tinnitus experience more than one tinnitus
sound. In these cases, efforts to determine the perceived pitch of the tinnitus
may require multiple assessments to fully
appreciate the nature of the tinnitus that
the patient is experiencing. This type of
information can have important implications for treatment decisions, especially if
sound maskers, hearing aids, or tinnitus
instruments (i.e., devices that combine both
of these technologies) are being considered
(see Meikle, Creedon, & Griest, 2004).
Sometimes the frequency of the tinnitus is related to particular otologic
problems. For example, the tinnitus experienced by patients with Ménière’s disease is often matched to a low-frequency
stimulus and is occasionally pulsatile in
nature, whereas the tinnitus experienced
by patients with noise-induced loss is
more commonly matched to a highfrequency stimulus (Douek & Reid, 1968).
Even the more recent report from Nageris
et al. (2010) reflected this trend in individuals with noise-induced hearing losses.
However, from the present authors’ view,
the strength of these relationships has not
always been highly reliable or specific.
Therefore, it is important that one does
not limit testing to a particular frequency
range when assessing patients, even if one
anticipates a likely match within a specific
frequency range based on the patient’s
presenting symptoms and/or otologic
diagnosis.
Hz
The masking of a patient’s tinnitus
has been discussed for many years, both
as a diagnostic procedure and as a management tool. In most cases, tinnitus can
be effectively masked using a broadband
noise stimulus. In fact, 91% of the patients
in an investigation conducted by Vernon
and Meikle (1988) achieved complete
masking of the tinnitus. If a patient’s tinnitus can be easily masked with a broadband stimulus, it may indicate that a
masking device may work well as a management option for that patient. In a large
number of subjects with tinnitus, Savastano (2008) reported that slightly more
than 50% of the patients had their tinnitus
masked by a broadband noise in the 31 to
60 dB range, whereas slightly more than
30% required levels in excess of 60
(although not specified in this study, these
levels were assumed to be effective masking levels and not SL measures). Savastano (2008) also related that individuals
with hearing loss required higher levels
of noise to mask their tinnitus than those
with normal hearing (see qualifying comment offered earlier).
In assessing tinnitus, perhaps one of
the most interesting measures is that of
residual inhibition (RI). This measure is
accomplished by using a masking noise
(usually a broadband noise, but narrowband noise or tones can also be used)
that is presented above the intensity level
needed to mask the tinnitus (usually
dB higher) for a period of time (usu-
10
ally 1 min). After the exposure time has
lapsed, patients are asked if they still hear
the tinnitus, and if they do, they are asked
if the tinnitus sounds as loud as it did
before the presentation of the masker, or
whether it appears that the intensity of the
tinnitus has been reduced. If the patients
report hearing no tinnitus, it is considered
positive or complete RI, and the period
dB
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of time required for the tinnitus to return
is measured. If the tinnitus is the same
after the presentation of the masker, it is
considered a negative result; and if the
tinnitus is present but reduced in loudness, it is classified as a partial RI (Meikle
et al., 2004).
Residual inhibition (the time period
with complete or partial tinnitus relief)
can last from seconds to several minutes.
Most people with tinnitus have some
degree of RI (Meikle et al., 2004), but some
(10% to 15%) note complete abolition of
the tinnitus signal (Savastano, 2008). In a
large data set, between 2% and 3% of individuals who experienced RI had durations
of greater than 10 min (Meikle et al., 2004).
Residual inhibition does not have strong
implications for routine clinical application at this time, but it is a phenomenon
of great interest and should be studied
more. Therefore, the authors believe that
measures of RI should be included in the
evaluation of tinnitus.
Medical and Audiologic
Treatment
As outlined previously, numerous disorders are associated with tinnitus and treatment of these associated disorders varies significantly. Perhaps one of the most
common medical approaches to tinnitus is
pharmacologic management. This is partially related to the strong psychological
component associated with tinnitus, which
is discussed in the following section.
Psychological Treatment
When a nonotologic or nonaudiologic etiology for tinnitus is uncovered, referrals
to other specialists, such as dentists, neurologists, and/or psychologists may be
necessary. Psychological treatment plays
a critical role for many patients with tinnitus as there is a high comorbidity between
tinnitus and associated psychological
disorders. These often include anxiety,
depression, sleep disturbance, and general social impairment. As a result, tinnitus is often diagnosed as a psychological
disorder with psychological consequences
(Wilson & Henry, 2000). In conjunction
with audiologic management, cognitive
behavioral therapy may prove beneficial
for patients with significant tinnitus. Tinnitus is often compared to and treated in a
manner similar to chronic pain (Tonndorf,
1987). Patients with tinnitus, not unlike
patients with chronic pain, have extreme
difficulty coping with the symptom and
often feel as though they have no control
over the tinnitus itself. As a result, several treatment approaches have been suggested to help alleviate the psychological
impact of tinnitus on the patient’s life. In
addition to pharmacologic agents, these
include approaches such as biofeedback,
cognitive behavioral therapy, and relaxation training.
There are numerous assessments
related to the psychological impact of
tinnitus. Examples of these include the
Tinnitus Functional Index (Henry et al.,
2016), the Tinnitus Reaction Questionnaire
(Wilson, Henry, Bowen, & Haralambous,
1991), the Tinnitus Handicap Inventory
(Newman, Jacobson, & Spitzer, 1996), the
Tinnitus Effects Questionnaire (Hallam,
1996), the Tinnitus Severity Scale (Halford
& Anderson, 1991), the Tinnitus Handicap
Questionnaire (Kuk, Tyler, Russell, & Jordan, 1990), and the Tinnitus Coping Style
Questionnaire (Budd & Pugh, 1996). These
types of questionnaires have proven to be
very beneficial to clinicians as they can
be used to determine the psychological
impact of tinnitus on a patient’s everyday
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functioning. In addition to providing an
initial assessment of the impact of the tinnitus on the patient’s functioning, these
questionnaires can be used to monitor the
efficacy of treatment as well.
Relaxation methods are a form of biofeedback that have been employed with
patients who have chronic tinnitus. Some
of the first psychological approaches to
the treatment or management of tinnitus used similar techniques. The most
common form of training is progressive
muscular relaxation as described by Bernstein and Borkovec (1973). Through a
series of exercises, the patient learns to
tense and relax muscle groups. Although
this approach alone may not demonstrate
significant benefit, it may prove beneficial when used in conjunction with other
therapeutic techniques. It also may be
effective in treating or managing some of
the other disorders/symptoms that are
often experienced by the tinnitus sufferer.
For example, many patients with tinnitus
suffer from severe sleep disturbance, and
this particular approach has proven to
be helpful in assisting patients with general sleep disorders (Morin, Culbert, &
Schwartz, 1994).
Due to the strong psychological component associated with tinnitus, cognitive
behavioral therapy (CBT) for use with tinnitus patients was first recommended by
Sweetow in the 1980s (see Sweetow, 2000).
More recently, the American Academy of
Otolaryngology-Head and Neck Surgery
(AAO-HNS) published their clinical practice guidelines on tinnitus in which they
recommend CBT as a treatment approach
for persistent, bothersome tinnitus (see
Tunkel et al., 2014). The CBT approach
aims to provide patients with the skills
needed to change negative associations
and behaviors by restructuring their
thoughts to be more accurate and posi-
tive (Tunkel et al., 2014). The following
systematic 10-step approach is the recommended procedure for implementing CBT
with tinnitus patients (Sweetow, 2000).
1. Define the problem in terms of a
framework that allows for amenable
solutions.
2. Identify the behaviors and thoughts
affected by the tinnitus.
3. List the maladaptive strategies
and cognitive distortions currently
employed.
4. Distinguish between the tinnitus
experience and the maladaptive
behavior.
5. Identify alternative thoughts, behaviors, and strategies.
6. Encourage the patient to formulate
and prioritize attainable target goals.
7. Collaboratively devise and rehearse
strategies that can be measured.
8. Regularly assess success or failure of
coping strategies.
9. Question and challenge unsubstantiated statements.
10.
Lay a framework for maintenance of
positive change.
Research findings have documented that
CBT is an effective approach to tinnitus
management (see Aazh & Moore, 2018).
In addition, a recent study showed that
CBT can be an efficacious management
approach even through the use of an Internet delivery system (Beukes, Andersson,
Allen, Manchaiah, & Baguley, 2018). This
management approach (whether audiologist-guided or Internet provided) also has
been shown to have long-term efficacy
with respect to tinnitus relief (Beukes,
Allen, Baguley, Manchaiah, & Andersson,
2018). Although CBT has been found to
be a helpful management approach for
the tinnitus patient, care must be taken to
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counsel the patient that tinnitus generally
is an incurable condition. As is the case
in many of the current therapies and/or
interventions for tinnitus, CBT is designed
to help in the management of the condition but will not result in the elimination
of the tinnitus.
Pharmacologic Treatment
While not the recommended first line of
treatment in the management of tinnitus,
numerous drugs have been investigated
for the treatment of tinnitus (Elgoyhen
& Langguth, 2010). These drugs include
antiarrhythmics, anticonvulsants, anxiolytics, glutamate receptor antagonists,
antidepressants, and other miscellaneous
pharmaceuticals or homeopathic agents,
including both controlled and over-thecounter medications. However, it should
be noted that there are no standardized
protocols for the use of these medications
to treat tinnitus at this time.
Perhaps the most routinely prescribed drugs are antidepressants (Darlington & Smith, 2007). This is likely a
result of the high comorbidity between
tinnitus and psychological involvement.
Additionally, anxiolytics have been prescribed with success in managing tinnitus in some patients. Both antidepressants and anxiolytics have been shown to
result in statistically significant improvements in tinnitus patients when evaluated
using a double-blind, placebo-controlled
investigational approach (Johnson, Brummett, & Schleuning, 1993; Sullivan, Katon,
Russo, Dobie, & Sakai, 1992). Intravenous
lidocaine also has proven to be somewhat
effective; however, the effect is shortlived, and there can be notable side effects
(Dodson & Sismanis, 2004). Hence, the
use of intravenous lidocaine is not a practical approach to the treatment of tinnitus.
Although a number of pharmacologic
treatments are available, no one drug has
proven to be effective in treating all tinnitus patients. In most cases, the drugs prescribed do not treat the tinnitus itself, but
rather are used to manage many of symptoms that accompany tinnitus (i.e., depression, stress, and anxiety). It should also be
noted that there currently are no medications that the Food and Drug Administration (FDA) has approved specifically for
the treatment of tinnitus. The use of pharmacologic treatments, if employed, should
be closely monitored by a physician and
will likely prove most beneficial if used in
conjunction with other nonpharmaceutical management strategies.
Sound Generators and Maskers
One of the earliest forms of treatment for
tinnitus was the use of sound generators
and maskers. This form of management
can be dated to the early 1820s when
the famous French physician Jean Itard
described trying to “cover up the internal
noise” by using various environmental
noises. The first attempt to use ear-level
devices to mask the tinnitus was initiated
in the early to mid-1970s (see Vernon,
1975). These devices have been termed
tinnitus maskers and tinnitus instruments and are officially classified by the
Food and Drug Administration as therapeutic devices. Tinnitus maskers can be
worn as both behind-the-ear and in-theear devices.
Nonwearable devices are often used
to assist in masking tinnitus, particularly in an effort to improve sleep disturbance. Reports indicate that nearly 70%
of patients with tinnitus suffer from sleep
disturbance (Meikle et al., 2004). As a
result, many patients use items such as
fans, televisions, radios, commercially
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available sound generators, and cell
phone applications to “mask” their tinnitus and promote sleep.
Traditional hearing aids also have
been used in the management of tinnitus
patients. In general, the literature indicates that the majority of patients with tinnitus receive relief of this symptom from
hearing aids as well as sound generators
(Berberian et al., 2017; Park et al., 2018). In
fact, the AAO-HNS recommends a hearing aid evaluation as one of the primary
approaches for patients with persistent,
bothersome tinnitus who have comorbid
hearing loss (Tunkel et al., 2014). Amplification devices such as hearing aids have
proven successful because when these
devices are worn by the tinnitus sufferer, ambient noise in the environment
is amplified, and the patient’s tinnitus is
masked. Kochkin and Tyler (2008) have
reported that approximately 60% of individuals with tinnitus who were fitted with
hearing aids have reported improvement
in their tinnitus symptoms.
There have been many significant
developments in signal processing since
the time that tinnitus maskers were first
introduced. At the present time, devices
that combine both a traditional hearing
aid and a tinnitus masker in one unit are
commercially available. These instruments are appropriate for patients who
may need additional tinnitus masking
beyond that provided by a hearing aid
alone (see Folmer, Martin, Shi, & Edlefsen,
2006, and Searchfield, 2006, for additional
discussion).
Although ear-level maskers continue
to be used, they are limited as a management approach in that, when they are not
being worn, the tinnitus typically continues to be problematic for the patient. It
is important for the clinician fitting such
devices to be keenly aware of the impor-
tance of appropriate fitting techniques.
This includes assessments of the patient’s
tinnitus — including pitch and loudness
matching, minimum masking level, and
residual inhibition as outlined previously. Additionally, one must understand
that there is a distinct difference between
an effective versus an acceptable level of
masking (Vernon & Meikle, 2000). Effective masking or “complete masking”
refers to the ability to successfully cover
the tinnitus so that the patient can no longer hear it, whereas an acceptable level of
masking or “partial masking” refers to a
situation in which the patient is provided
a masking sound which offers some relief
from the tinnitus. In the latter situation,
the tinnitus is still present but is perceived
by the patient to be of lower intensity and
less of an annoyance. There are a number
of factors that determine whether complete masking can be achieved for a given
patient. These include such variables as
the level of the tinnitus, the frequency of
the tinnitus (e.g., if the tinnitus is matched
to a speech frequency, it may be difficult
to provide sufficient masking without
affecting speech understanding), and
the presence of multiple tinnitus sounds
(for additional information, see Vernon &
Meikle, 2000).
Neurophysiologic Rehabilitation
Neurophysiologic rehabilitation relies on
the plasticity of the brain to create neural
changes, which can alleviate the tinnitus.
Plasticity can be defined as the alteration
of nerve cell pathways to better conform
to immediate environmental influences,
with this alteration often associated with
behavioral change (Musiek & Berge,
1998). It has been theorized that tinnitus
is driven not only by a dysfunction of the
auditory system, but also by involvement
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of the limbic and autonomic nervous systems (Jastreboff, 2000). The strong emotional and often physical response exhibited by many tinnitus sufferers would
suggest that there are nonauditory areas
within the central nervous system that
contribute to tinnitus. The limbic system
is responsible for behavioral responses
including mood state and emotion. The
autonomic nervous system, on the other
hand, provides for motor innervations.
As many patients report issues associated with sleep, anxiety, and tension, this
would suggest that both systems may
somehow play a role in tinnitus. The theory behind the neurophysiologic rehabilitative approach is that if both the audiologic (central auditory nervous system)
and the psychological (limbic system)
aspects can be addressed, improvement in
symptoms will be observed. In the most
simplistic terms, it is theorized that the
“central gain” produced within the brain
is enhanced because of lack of inhibitory
neural control, which leads to enhanced
excitatory activity. In essence, the loss of
sensory input results in enhanced central
auditory activity (Auerbach, Rodriques, &
Salvi, 2014). Tinnitus (as well as hyperacusis) is believed to be a result of such activity. Neurophysiologic rehabilitation theoretically aims to decrease the central gain
by reorganizing the auditory inhibitory
and excitatory balance within the brain
(Hanley, Davis, Paki, Quinn, & Bellekom,
2008). One such approach has been Tinnitus Habituation Therapy (THT), which
was introduced on a theoretical basis by
Hallum and colleagues (Hallam, Rachman, & Hinchcliffe, 1984). The goal of this
therapy is not to cure tinnitus but rather
to filter and block tinnitus-related activity within the brain, thus reducing awareness and disturbance (Jastreboff, 2000).
In recent years, several THT approaches
have been relatively successful in achieving this goal.
Tinnitus Retraining Therapy (TRT) is
a multicomponent program that utilizes
sound therapy along with counseling to
achieve habituation of tinnitus. Tinnitus
patients are categorized along a 4-point
scale, with 0 suggesting a low impact
on life and 4 suggesting a high impact
on life with significant hyperacusis and
prolonged sound-induced exacerbation
(Jastreboff, 2000). The intent of TRT is to
remove the negative association attached
to tinnitus perception and to help the
patient to habituate to the tinnitus so that
it becomes less aversive (Jastreboff, 2007).
This is achieved by presenting low-level,
broadband acoustic stimulation, which
is used to initiate and encourage tinnitus habituation. The effectiveness of TRT
has been reported to be significant, with
improvement in symptoms reported for
up to 80% of patients (Jastreboff, Gray, &
Gold, 1996). A large clinical trial of more
than 800 veterans demonstrated benefit
from TRT, particularly for those individuals with significant tinnitus (Henry
et al., 2006).
Another therapeutic technique is
one first described by Davis in the 1990s.
Davis developed a device (Neuromonics Oasis) and a program (Neuromonics
Tinnitus Treatment, NTT) intended to
address the audiologic, psychological,
and neurologic aspects of tinnitus (see
Davis, Wilde, Steed, & Hanley, 2008). With
the recent advances in technology, the
original device has been replaced by an
application (Neuromonics OasisPro),
which when prescribed by an audiologist,
can be downloaded to an Apple iPhone,
iPad, or iPod (Neuromonics, n.d.).
In this treatment approach, the patient is
presented with precisely designed music
that has been tailored spectrally to account
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for the patient’s auditory thresholds and
loudness tolerance. The theory behind
the NTT program is that, over time,
plasticity will occur through which the
negative conscious association with tinnitus will be reduced and its disturbance
decreased. This is a multistage treatment
program that takes approximately six to
nine months for the patient to complete.
Several reports have demonstrated the
efficacy of treatment with this approach
(Davis et al., 2008; Hanley et al., 2008; Jang,
Johnson, & Chandrasekhar, 2010).
A variety of therapeutic tools are
available to assist clinicians with today’s
tinnitus patients. The previous expression, “you’ll just have to live with it”
rarely applies to today’s patients. What is
important to understand is that, although
treatment approaches are available that
may help alleviate the “symptom,” there
are still no cures for the disorder.
hyPeRacusis
Introduction
Hyperacusis is a disorder related to loudness perception. Specifically, it is defined
as the “consistently exaggerated or inappropriate responses to sounds that are
neither threatening nor uncomfortably
loud to a typical person” (Klein, Armstrong, Greer, & Brown, 1990). It is not
to be confused with phonophobia (i.e., a
fear of sounds) or misophonia (i.e., a dislike for particular sounds). Phonophobia
and misophonia differ from hyperacusis
in that they typically have strong emotional links related to particular sounds,
whereas hyperacusis, which also may
have emotional links, tends to be generalized to nearly all loud sounds (Baguley &
Andersson, 2007). Hyperacusis also varies from recruitment, which is associated
with an abnormally rapid growth of loudness perception as intensity increases (a
symptom typically found in individuals
with cochlear impairment). For example, a
patient with recruitment typically would
have some degree of sensorineural hearing loss and would perceive a moderately
loud sound as uncomfortable (i.e., sounds
that are not perceived as uncomfortable by
normal hearers are perceived by patients
with recruitment as being uncomfortably
loud), whereas a patient with hyperacusis
often presents with normal hearing and is
disturbed even by low-intensity sounds.
Symptoms
Hyperacusis, like tinnitus, is a symptom
and not a disorder. Patients who experience hyperacusis will often demonstrate
some overt behaviors that reflect their
aversion to sounds that are perceived as
being “too loud.” Such behaviors include
the avoidance of sounds that are perceived to be too loud, covering one’s ears
with the hands when anticipating an aversive sound may occur, and/or grimacing
when exposed to offending sounds.
Incidence and Prevalence
There is a paucity of data related to the
incidence and prevalence of hyperacusis.
European reports suggest incidence rates
in the adult population of anywhere from
8% (Andersson, Lindvall, Hursti, & Carlbring, 2002) to 15% (Fabijan´ ska, Rogowski,
Bartnik, & Skarz˙yn´ ski, 1999), whereas
rates among children have been reported
to be around 3.2%, with 9% of children
experiencing phonophobia (Coelho, San-
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chez, & Tyler, 2007) and 17.2% in adolescents (Olsen Widén & Erlandsson, 2004).
Of note is that there is a high comorbidity of hyperacusis (approximately 40%) in
patients whose primary complaint is tinnitus (Jastreboff & Jastreboff, 2000; Sood
& Coles, 1988). However, according to
Anari, Axelsson, Eliasson, and Magnusson (1999), the comorbidity of these two
conditions is reported to be even higher,
with 86% of the patients in their sample
who presented with hyperacusis as their
primary complaint also reporting experiencing some degree of tinnitus.
Etiology and Pathology
Given the commonality between hyperacusis and tinnitus, one would be
led to speculate that there is a shared
mechanism(s) underlying the etiology
and pathology of the two disorders.
Although in some cases of hyperacusis
an underlying etiology can be found, in
the majority of cases, no specific etiology
can be identified (Baguley, 2003). Several
peripheral and central conditions often
result in hyperacusis. Table 8–1 lists some
of the common peripheral and central
conditions that may be associated with
hyperacusis.
Although the exact mechanism(s)
underlying hyperacusis is unknown, there
are several hypotheses which attempt to
explain this phenomenon. It is believed
that there is a strong link between hyperacusis and the neurotransmitter 5-HT. This
is a serotonin receptor that regulates the
modulation of many neurotransmitters,
including those responsible for aggression, anxiety, appetite, cognition, learning,
memory, mood, nausea, and sleep. Marriage and Barnes (1995) have suggested
that when 5-HT becomes disordered, the
result is not only hyperacusis but also
other disorders as outlined in Table 8–1. It
also has been hypothesized that there are
Table 8 –1. Examples of Peripheral and Central Conditions as well as Other Hormonal
and Infectious Diseases That Can Result in Hyperacusis
Hormonal and Infectious
Peripheral Central
Bell’s Palsy
Stapedectomy
Ramsey Hunt Syndrome
Recruitment
Noise-Induced Hearing
Loss
Acoustic Trauma
Ménière’s Disease
Source: Based on Katzenell & Segal (2001).
Headache
Depression
Minor Head Injury
Williams Syndrome
Learning Disabilities
Tinnitus
Spinal Involvement
Brain Lesions (i.e., Multiple
Sclerosis, Stroke, Tumor)
Stuttering
Diseases
Addison’s Disease
Lyme Disease
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enhanced cortical responses secondary to
poor regulation of GABAergic neurons.
GABAergic neurons are responsible for
inhibition of central activity. Recent studies of hyperacusis have demonstrated a
reduction in neuronal activity in the auditory cortex (see Wang, Luo, Huang, Zhou,
& Chen, 2008). However, a more recent
report has demonstrated that individuals
with hyperacusis have increased amplitude for late auditory evoked potentials
compared to control subjects (Norris &
Ceranic, 2011). Although there are many
theories related to the mechanism(s) underlying hyperacusis, there is no consensus
regarding its etiology or its specific site of
origin at this time.
Site of Lesion
As mentioned previously, many theories have been proposed in an attempt to
define the potential mechanisms underlying hyperacusis, and hyperacusis has
been noted in patients with a variety of
peripheral and central system disorders
(see Table 8–1). Therefore, it is likely that
there may be peripheral and/or central
system involvement; however, as noted
previously, at the present time, there is
no definitive information on the origin(s)
of this symptom and additional research
is needed.
Medical and Audiologic
Evaluation
As hyperacusis has been linked to both
neurologic and hormonal pathologies, it is
important to fully examine the patient to
rule out any serious disease process. One
of the most important components of the
examination of the patient with hyper-
acusis is a careful history. As with any
audiologic complaint, a careful description of the presenting complaint along
with any important features and/or characteristics of the reported symptom such
as the degree, length, and frequency of
disturbance are important to obtain and
document. A careful history also includes
any history of otologic (ear pathology, tinnitus, vertigo, etc.), neurologic (migraine,
stroke, muscle numbness or weakness,
head injury, etc.), or audiologic (hearing
loss, noise exposure, etc.) involvement.
Additionally, it is important to determine
the presence of any other medical or psychological condition or conditions.
The physical examination should
include a careful head and neck examination. In addition, general physical health
measurements such as pulse, blood pressure, and weight should be considered.
A neurologic examination should include
a screening of the cranial nerves and both
the motor and sensory systems (Katzenell
& Segal, 2001). Additional laboratory tests
should include a complete blood count
and measurement of electrolyte, cortisol,
and thyroid stimulating hormone levels
(Katzenell & Segal, 2001).
The audiologic evaluation should
be complete and comprehensive. This
should include both pure-tone air conduction (and bone conduction if warranted)
and speech audiometry. Additionally,
loudness discomfort levels for both tones
and speech are important in determining
the degree of involvement. As there have
been reports of abnormal acoustic reflex
measures in hyperacusic patients (Gordon, 1986), the assessment of acoustic
reflex thresholds should also be considered. The sequence of audiologic tests for
patients with hyperacusis is an important
consideration. Tests that require highintensity levels could exacerbate this
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symptom. This in turn may influence test
results. Therefore, it may be prudent to
administer any audiologic tests requiring
high-intensity stimuli (e.g., acoustic reflex
testing) at the end of the test battery.
Results from the patient’s reported
history, otologic examination, and audiologic testing may result in referral to a
variety of other medical professionals.
This may range from neurologists to psychiatrists. It is important for both audiologists and otolaryngologists to have
referral sources who have experience in
working with these types of patients so
that they can readily refer their patients
to these professionals when necessary.
Medical and Audiologic
Treatment
There is no consensus regarding the best
treatment approach for patients who present with hyperacusis. If after the medical
examination the patient is found to present
with an underlying disease, then management of such disease may lead to resolution of the hyperacusis. For many patients
suffering from hyperacusis, an initial
flight response often occurs in which the
patient desires to protect his or her hearing through the use of hearing protection in environments with nonhazardous
noise levels. However, there is no evidence
to support such practice, and many individuals would argue that this may in fact
exacerbate the condition (Baguley, 2003).
It has been suggested that therapeutic approaches to tinnitus may provide
benefit to tinnitus patients who also suffer
from hyperacusis. In this regard, both TRT
(Jastreboff & Jastreboff, 2000) and commercially available programs such as NTT
(as described previously) have been proposed as alternative therapies for hyper-
acusis. The theory behind these therapeutic approaches is that the use of low-level
sound stimulation acts to promote cortical reorganization and desensitization. However, although these therapies
have been proposed as “off-label” uses
for the treatment of hyperacusis, to the
best of the authors’ knowledge, there are
no published data to support the efficacy
of these approaches.
Perhaps one of the best treatment
approaches for many patients with hyperacusis and tinnitus is reassurance that
there are no pathologic clinical conditions
contributing to their symptoms once these
have in fact been ruled out. Both tinnitus
and hyperacusis have a strong psychological component, which must be considered when managing these patients.
In conjunction with the reassurance
approach that was described previously,
CBT has been advocated in the management and treatment of the hyperacusic
patient (with or without tinnitus) using
a multidisciplinary team to address the
sensitivity, annoyance, and fear associated
with the condition. This is a complicated
condition about which we know very little, but perhaps with future research both
at the basic science and clinical levels we
will be able to unravel the etiology and
pathophysiologic mechanisms underlying this auditory condition and uncover
efficacious approaches to the treatment
and/or management of this condition.
auditoRy
hallucinations
Introduction
Auditory hallucinations are auditory perceptions that are experienced in the ab-
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