This document discusses tinnitus and hyperacusis. It defines tinnitus as any perceived sound that does not come from an external source. The most common causes are hearing loss and changes in the auditory system. Treatments include counseling, sound therapy like masking, and Tinnitus Retraining Therapy. Hyperacusis causes sounds to seem too loud and is often comorbid with tinnitus. Precautions must be taken when fitting hearing aids for patients with hyperacusis. Referral to an ENT is recommended if tinnitus or hyperacusis seems worse than the measured hearing loss.

1. Tinnitus & Hyperacusis
Ozarks Technical Community College

2. What is tinnitus?
 Any sound that is perceived by the listener that does
not originate from an external sound source
 May be perceived in one or both ears (peripheral)
and/or in the head (central)
 60% bilateral
 30% unilateral
 10% central
 From latin word, tinniere, which means “to ring”

3. Descriptive Labels
 Ringing
 Hissing
 Buzzing
 Roaring
 Clicking
 Ocean sound
 Cicadas
 Pulsing
 Heartbeat

4. Causes of Tinnitus
 Most commonly caused by some sort of change
to the auditory system
 80% of patient’s with SNHL have tinnitus
 Hearing loss results in changes in the neural
activity of the auditory system, which the
auditory cortex interprets as sound
 Much like phantom limb syndrome. Areas of the
cochlea where there is hair cell damage can no
longer amplify sounds where damage has
occurred so a phantom sound is interpreted by the
brain.

5. Other Causes of Tinnitus
 Hearing loss, especially in cases of noise-induced
hearing loss (NIHL)
 External or middle ear issues (wax, fluid)
 Acoustic neuroma (UNILATERAL tinnitus)
 Medications
 Sinus/allergy issues
 Dental issues (TMJ-temporal-mandibular joint
syndrome)
 Cardiovascular
 Neurological (MS)
 Stress/anxiety

6. Medications that cause tinnitus
 Anti-inflammatories
 Antibiotics
 Antidepressants
 Aspirin
 Quinine
 Loop diuretics
 Chemotherapy drugs

7. Some musician’s consider it a badge of
honor…
 Peter Frampton
 “I wonder how you’re feeling. There’s ringing in my ears.
And no one to relate to, ‘cept the sea.”
 Bob Seger
 “With the echoes of amplifiers ringing in your head.”

8. Prevalence of Chronic Tinnitus
NIDCD.NIH.GOV
•~22 Million Americans
•10% of adult population

9. Types
 Subjective
 Can only be perceived by the patient
 Most common type (95%)
 Objective
 Can be heard by others
 Rare (<5% of all tinnitus cases)
 Usually pulsatile (in sync with heartbeat)
 Causes: vascular or muscular

10. Causes of Objective Tinnitus
 Vascular
 Arteriorvenous aneurysm
 Glomus jugulare tumor
 Muscular
 Patent eustachian tube
 Palatal myoclonus: involuntary muscle jerk of the roof of
the mouth
 Spasm of stapedius or tensor tympani muscles

11. Bothersome/Uncompensated Tinnitus
 Only about 20% of people with tinnitus are bothered
by it
 The tinnitus itself isn’t the problem. The person’s
REACTION to it is what is problematic.
 Tinnitus may result in irritability, fatigue/sleep disturbance,
depression, suicidal thoughts
 These patient’s need to be referred to a mental health
professional

12. A Viscious Cycle
 Attentional Factors (patient chooses to attend to
tinnitus)
 Emotional reaction
 Limbic system: negative emotional labeling of the tinnitus
 Autonomic system: activation of the fight-or-flight
mechanism (Can this tinnitus harm me?)
 Stress
 Amplification of tinnitus signal (louder)

13. Tinnitus Treatment
 Surgery (uncommon option)
 Medication (usually xanax, valium,
antidepressants)
 Dietary restrictions (caffeine, alcohol, salt,
MSG)
 Masking
 Counseling
 Cognitive Behavioral Therapy
 Tinnitus Retraining Therapy
 Sound treatment
 Neuromonics

14. Masking
 Use of noise to temporarily mask or “cover up” the
tinnitus so it cannot be perceived
 This is often successfully accomplished when patients
with hearing loss use traditional hearing aids. The
amplification of environmental noises often reduces or
completely masks tinnitus.
 Our newest generation hearing aids have optional tinnitus
maskers built-in for when hearing aids aren’t enough to
mask tinnitus. This may benefit that 20% of patients with
tinnitus that are truly bothered by their tinnitus.

15. Masking
 There are companies that manufacture tinnitus
maskers for those with normal hearing. May be in-
the-ear with a very large vent or a
behind-the-ear, open-ear device
www.ata.org www.siemens.com

16. Masking
 The use of a sound machine or external noise
source (i.e. ceiling fan) can be very helpful at night
 Different types of noise are utilized in masking: white
noise, pink noise, brown noise, grey noise (all have
varying complexity based on frequency components)

17. Tinnitus Handicap Inventory
 Patient self-survey
 Sample questions
 Do you feel you have no control over your tinnitus?
 Because of your tinnitus do you feel tired?
 Because of your tinnitus do you feel depressed?
 Does your tinnitus make you feel anxious?
 Quantifies the severity of tinnitus
 Rates degree of handicap from slight to catastrophic

18. Tinnitus Retraining Therapy
 Jastreboff created TRT
 Combines counseling with use of noise generators
 Counseling: reclassify tinnitus to a category of neutral
signals
 Sound therapy: weaken the tinnitus-related neural activity
 Goal: Habituation to the tinnitus (no longer pay
attention to it)

19. Neuromonics
 Six to eight month therapy protocol
 Uses spectrally modified music that has been
tailored according to each patient’s hearing and
tinnitus characteristics
 Combined with an underlying neural stimulus
 Retrains the brain to filter out
tinnitus disturbance
Very expensive~$5000 for treatment that lasts less
than a year

20. Other Sound Disorders-Hyperacusis
 Everyday sounds seem “too loud” or “uncomfortable”
 About ½ of those with tinnitus, also have
hyperacusis
 Affects 1 in 50,000

21. Hyperacusis Causes
 Hearing loss
 Noise Injury
 Head injury (i.e air bag deployment)
 Ototoxicity
 Lyme disease
 Viral infections involving the inner ear or facial nerve
(Bell’S palsy)
 TMJ
 PTSD (post-traumatic stress disorder)
 Chronic fatigue syndrome
 Epilepsy
 Depression
 Migraine headaches

22. Hearing Aids in Patients with Hyperacusis
 The measurement of LDLs is very important to ensure
that the maximum output of the hearing aids (MPO)
never exceeds the patient’s comfort level
 Real-ear-to-coupler difference (RECD) should be performed to
convert the patient’s LDLs in dB HL (audiometer) to dB SPL
 Real-ear measurements are VERY important to confirm that the
MPO of the hearing aid in the patient’s ear is below the patient-
specific LDLs (in dB SPL)

23. Hearing Aids in Patients with Hyperacusis
 It may be beneficial to perform a closed ear fitting (rather
than a completely open fit)
 Using a closed dome, custom earmold, or custom aid will
prevent environmental noise from naturally entering the ear
canal
 This will allow you to better control the sounds that are allowed
through the hearing aid to make the patient as comfortable as
possible
 On the other hand, patients with hyperacusis AND tinnitus may
find that a closed fitting makes their tinnitus seem louder.
 As you can see, we walk a very fine line with hyperacusis and tinnitus
patients

24. Other sound disorders
 Misophonia
 Dislike of sound
 Phonophobia
 Fear of sound
 Often these patients come in reporting that they use
earplugs in everyday circumstances. This is NOT
recommended. It will actually worsen problem.

25. When in doubt…
 If you have a patient with bothersome tinnitus
and/or hyperacusis, it is important to refer them to an
ENT physician for medical evaluation and treatment
 A good indicator that a patient needs to be referred
for medical evaluation is when they report that the
tinnitus and/or hyperacusis is worse than their
hearing loss
 Use the Tinnitus Handicap Inventory as a guide