Hyperacusis: major research questions

Difference in characteristics between tinnitus patients with and without hyperacusis according to three different definitions of hyperacusis

OBJECTIVE

To evaluate the phenotypic differences between patients with tinnitus only and patients with tinnitus and hyperacusis, based on three different definitions of hyperacusis.

DESIGN AND STUDY SAMPLE

A retrospective analysis was conducted on 199 adult patients visiting the tinnitus clinic at Ghent University Hospital. Patients were categorised into two groups: those with tinnitus only and those with tinnitus and hyperacusis, based on three definitions of hyperacusis: anamnesis, Hyperacusis Questionnaire (HQ), and dynamic range (DR). Phenotypic differences between both groups were compared.

RESULTS

Among all patients with tinnitus, 19.6% exhibited hyperacusis based on HQ or DR, whereas 63.8% demonstrated hyperacusis according to anamnesis. Total scores for the Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI) were significantly higher among patients presenting with both tinnitus and hyperacusis, in comparison to those with tinnitus alone. Various other characteristics either displayed no discernible differences between the two groups or exhibited differences depending on the definition of hyperacusis employed.

CONCLUSION

Patients experiencing both tinnitus and hyperacusis reported higher levels of annoyance (based on a higher THI and TFI total score) in comparison to those solely dealing with tinnitus. Nonetheless, discrepancies in various other characteristics were frequently influenced by the specific definition of hyperacusis employed.

Clinical phenotype and management of sound-induced pain: Insights from adults with pain hyperacusis

Pain hyperacusis, also known as noxacusis, causes physical pain in response to sounds that do not bother most people. How sound causes excruciating pain that can last for weeks or months is not well understood, resulting in a lack of effective treatments. To gain insight into the underlying mechanisms of the condition, 32 adults attended a virtual focus group to describe their sound-induced pain. Focus group data were used to develop three follow-up surveys that aimed to identify the most common symptoms of pain hyperacusis as well as the participants' use of therapies for pain relief. All participants endorsed negative effects of pain hyperacusis on psychosocial and physical function. Most reported sound-induced burning (80.77%), stabbing (76.92%), throbbing (73.08%), and pinching (53.85%) sensations that occur either in the ear or elsewhere in the body. Participants have used numerous pharmaceutical and non-pharmaceutical interventions to alleviate their pain with varying degrees of pain relief. Benzodiazepines and nerve blockers emerged as the most effective analgesic options while non-pharmaceutical therapies were largely ineffective. Symptoms and therapeutic approaches were generally consistent with peripheral mechanistic theories of pain hyperacusis (e.g., trigeminal nerve involvement). An interdisciplinary approach to clinical studies and the development of animal models are needed to identify and treat the pathological mechanisms of pain hyperacusis. PERSPECTIVE: This article presents the physical and psychosocial consequences of debilitating sound-induced pain (i.e., pain hyperacusis) and the interventions that sufferers have sought for pain relief. The results are largely consistent with peripheral mechanistic theories (e.g., trigeminal nerve involvement) and will guide future work to investigate neural mechanisms and effective therapies.

Audiometric Profiles Across a Clinical Population of Children With Hyperacusis

PURPOSE

Hyperacusis (sound sensitivity) is well documented among adults, but little is known about hyperacusis in children. Here, we assess relationships among the presence of hyperacusis, audiometric profiles, and nonauditory factors in a pediatric clinical population.

METHOD

A retrospective review of clinical records from 329 children, ages 2-17 years, was performed to assess the prevalence of hyperacusis and correlations among hearing status, behavioral or communication concerns, and the presence of hyperacusis.

RESULTS

In 329 study participants, 18% reported hyperacusis (58% male and 42% female). No significant sex or age differences were found. Hyperacusis was more likely to occur alongside normal hearing or with unilateral hearing loss relative to bilateral hearing loss. Among children with hyperacusis, there was a high prevalence of audiovestibular problems, mental health concerns, speech and language delays, difficulty in school, and behavioral problems. Tinnitus was also found to be comorbid with hyperacusis, but the comorbidity was less than that reported in adults.

CONCLUSIONS

This study identified common hearing profiles and critical comorbidities in a large clinical cohort of children with hyperacusis. These results demonstrate the urgent need for standardized multidisciplinary assessment and treatment protocols for pediatric hyperacusis.

Dissociable effects of hyperacusis and misophonia severity imply different mechanisms of decreased sound tolerance

OBJECTIVE

It is thought that decreased sound tolerance can be subdivided into distinct types including misophonia (involving specific trigger sounds) and hyperacusis (broader in profile). However, there are few established methods for differentially assessing these disorders and this is complicated by the fact that some measures (e.g. the HQ Hyperacusis Questionnaire) were developed before the concept of misophonia was accepted.

DESIGN/STUDY SAMPLE

We took a group of N = 119 participants with misophonia (varying in severity) and asked them about the presence of hyperacusis (based on a scoping review definition).

RESULTS

Scores for some items on the HQ were correlated with scores for misophonia severity (e.g. social impact of sound) and others with scores for hyperacusis (e.g. ability to concentrate in noise). Similarly, some trigger sounds were more indicative of hyperacusis (e.g. dishes being stacked) and others were more indicative of misophonia in the absence of hyperacusis (e.g. chewing).

CONCLUSIONS

These double dissociations provide compelling evidence for separable forms of sound intolerance. Moreover, our research suggests that a single-item question about hyperacusis is associated with other characteristics of hyperacusis, even when assessed 18 months later.

Current Recommendations for the Use of Sound Therapy in Adults with Hyperacusis: A Scoping Review

Hyperacusis is a condition that is characterized by hypersensitivity to normal everyday sounds or reduced sound tolerance and can affect patients in distressing ways. Sound therapy is a treatment intervention that is used to desensitize patients. However, as yet, there is a lack of understanding on how it is used in clinical practice, the different types of devices, or how to use them. The aim of this scoping review was to establish the current use of sound therapy in adults with hyperacusis and identify any factors that may influence treatment. Methodology: An established methodological framework was used to formulate the research question and guide the search strategy and reporting. The inclusion criteria were studies reporting adult (>18 years) populations with hyperacusis and sound therapy treatments which were published in any language. Searches of electronic databases (CINAHL, Cochrane Library, Medline (EBSCO), Scopus, PsycINFO) identified 31 studies that met the inclusion criteria (completed in April 2024). Data from included records were collated and summarized descriptively.

Estimation of Prevalence of Hyperacusis in High School Students of Mysore District

Objective

Hyperacusis, characterized by an abnormal sensitivity to everyday sounds, is a condition associated with subjective distress and physiological changes in the auditory system. Prevalence rates have varied significantly worldwide, emphasizing the need for standardized criteria. This study aimed to determine the prevalence of hyperacusis among high school students in Mysore district and explore gender differences.

Methods

A diverse cohort of 597 high school students participated in this cross-sectional study. The Modified Khalfa Hyperacusis Questionnaire assessed hyperacusis symptoms. Demographic data included age, gender, and educational status. A cut-off score of 28 on the questionnaire identified hyperacusis cases. Data were analyzed descriptively.

Results

The study revealed a substantial hyperacusis prevalence of 17.25% among high school students in the Mysore district. Out of 103 identified cases, 43.69% were females, and 56.31% were males. These results suggest a potential gender disparity in hyperacusis prevalence. The study's findings highlight the high prevalence of hyperacusis among Indian high school students, emphasizing the need for attention to this issue in adolescent health. Gender differences observed in this study align with previous research, indicating a higher prevalence among males.

Conclusions

Hyperacusis is a prevalent condition among Indian high school students, warranting further research on its causes and co-occurrence across different age groups. These findings underscore the significance of addressing hyperacusis as a critical health concern among adolescents and emphasize the need for tailored interventions and increased awareness.

Hyperacusis in Tinnitus Individuals Is Associated with Smaller Gray Matter Volumes in the Supplementary Motor Area Regardless of Hearing Levels

Recent evidence suggests a connection between hyperacusis and the motor system of the brain. For instance, our recent study reported that hyperacusis in participants with tinnitus and hearing loss is associated with smaller gray matter volumes in the supplementary motor area (SMA). Given that hearing loss can affect gray matter changes in tinnitus, this study aimed to determine if the changes reported in our previous findings of smaller SMA gray matter volumes in hyperacusis persist in the absence of hearing loss. Data for this study were gathered from four prior studies conducted between 2004 and 2019 at the University Medical Centre Groningen (UMCG). A total of 101 participants with tinnitus and either clinically normal hearing (normal hearing with tinnitus or NHT, n = 35) or bilateral sensorineural hearing loss (hearing loss with tinnitus or HLT, n = 66) were included across four studies. Hyperacusis was determined by a score of ≥22 on the Hyperacusis Questionnaire (HQ). In the NHT group, 22 (63%) participants scored ≥22 on the HQ (NHT with hyperacusis: mean age 44.1 years, 12 females), while in the HLT group, 25 (38%) participants scored ≥22 on the HQ (HLT with hyperacusis: mean age 59.5 years, 10 females). The 2 × 2 between-group ANOVAs revealed that hyperacusis is associated with smaller SMA gray matter volumes, regardless of hearing levels. Notably, the smaller SMA gray matter volumes in hyperacusis were primarily influenced by the attentional subscales of the HQ. The association between hyperacusis and the motor system may indicate a constant alertness to sounds and a readiness for motor action.

Clinical phenotype and management of sound-induced pain: Insights from adults with pain hyperacusis

Pain hyperacusis, also known as noxacusis, causes physical pain in response to everyday sounds that do not bother most people. How sound causes excruciating pain that can last for weeks or months in otherwise healthy individuals is not well understood, resulting in a lack of effective treatments. To address this gap, we identified the most salient physical and psychosocial consequences of debilitating sound-induced pain and reviewed the interventions that sufferers have sought for pain relief to gain insights into the underlying mechanisms of the condition. Adults (n = 32) with pain hyperacusis attended a virtual focus group to describe their sound-induced pain. They completed three surveys to identify common symptoms and themes that defined their condition and to describe their use of pharmaceutical and non-pharmaceutical therapies for pain relief. All participants endorsed negative effects of pain hyperacusis on psychosocial and physical function. Most reported sound-induced burning (80.77%), stabbing (76.92%), throbbing (73.08%), and pinching (53.85%) that occurs either in the ear or elsewhere in the body (i.e., referred pain). Participants reported using numerous pharmaceutical and non-pharmaceutical interventions to alleviate their pain with varying degrees of pain relief. Benzodiazepines and nerve blockers emerged as the most effective analgesic options while non-pharmaceutical therapies were largely ineffective. Symptoms of pain hyperacusis and therapeutic approaches are largely consistent with peripheral mechanistic theories of pain hyperacusis (e.g., trigeminal nerve involvement). An interdisciplinary approach to clinical studies and the development of animal models is needed to identify, validate, and treat the pathological mechanisms of pain hyperacusis.

Background and Rationale for a Transitional Intervention for Debilitating Hyperacusis

PURPOSE

This report provides the experimental, clinical, theoretical, and historical background that motivated a patented transitional intervention and its implementation and evaluation in a field trial for mitigation of debilitating loudness-based hyperacusis (LH).

BACKGROUND AND RATIONALE

Barriers for ameliorating LH, which is differentiated here from other forms of hyperacusis, are delineated, including counterproductive management and treatment strategies that may exacerbate the condition. Evidence for hyper-gain central auditory processes as the bases for LH and the associated LH-induced distress and stress responses are presented. This presentation is followed by an overview of prior efforts to use counseling and therapeutic sound as interventional tools for recalibrating the hyper-gain LH response. We also consider previous efforts to use output-limiting sound-protection devices in the management of LH. This historical background lays the foundation for our transitional intervention protocol and its implementation and evaluation in a field trial.

CONCLUSIONS

The successful implementation and evaluation of a transitional intervention, which we document in the outcomes of a companion proof-of-concept field trial in this issue, build on our prior efforts and those of others to understand, manage, and treat hyperacusis. These efforts to overcome significant barriers and vexing long-standing challenges in the management and treatment of LH, as reviewed here, are the pillars of the transitional intervention and its primary components, namely, counseling combined with protective sound management and therapeutic sound, which we detail in separate reports in this issue.

Bridging the Gap between Psychophysiological and Audiological Factors in the Assessment of Tinnitus: An EEG Investigation in the Beta Band

BACKGROUND

Despite substantial progress in investigating its psychophysical complexity, tinnitus remains a scientific and clinical enigma. The present study, through an ecological and multidisciplinary approach, aims to identify associations between electroencephalographic (EEG) and psycho-audiological variables.

METHODS

EEG beta activity, often related to stress and anxiety, was acquired from 12 tinnitus patients (TIN group) and 7 controls (CONT group) during an audio cognitive task and at rest. We also investigated psychological (SCL-90-R; STAI-Y; BFI-10) and audiological (THI; TQ12-I; Hyperacusis) variables using non-parametric statistics to assess differences and relationships between and within groups.

RESULTS

In the TIN group, frontal beta activity positively correlated with hyperacusis, parietal activity, and trait anxiety; the latter is also associated with depression in CONT. Significant differences in paranoid ideation and openness were found between groups.

CONCLUSIONS

The connection between anxiety trait, beta activity in the fronto-parietal cortices and hyperacusis provides insights into brain functioning in tinnitus patients, offering quantitative descriptions for clinicians and new multidisciplinary treatment hypotheses.

Analysis of Loudness Discomfort Level Tests in Tinnitus Patients

INTRODUCTION

We aimed to investigate the clinical significance of the loudness discomfort level (LDL) test in tinnitus patients and its relationship with pure-tone audiometry, tinnitogram, and questionnaires.

METHODS

We retrospectively reviewed the medical records of 320 tinnitus patients who visited a tertiary university hospital's tinnitus clinic and completed LDL tests between March 2020 and December 2022. Epidemiological data and psychoacoustic test results were collected.

RESULTS

The LDL showed no significant differences between frequencies for both ears. The mean LDL did not correlate with mean pure-tone average or hearing thresholds at each frequency. The hearing loss group had a higher LDL at 8 kHz compared to the normal hearing group (p < 0.01). Objective sound intolerance was found in a quarter, correlating with subjective hyperacusis, anxiety, and depression. Weak negative correlations were found between most of questionnaire's scores and LDL on the left side. Tinnitus loudness weak negatively correlated with LDL at most frequencies, except 8 kHz.

DISCUSSION/CONCLUSION

Our findings suggest a notable association between LDL levels and emotional factors in tinnitus patients, rather than with auditory thresholds. While lateralized differences in LDL responses were observed, specifically on the left side, these preliminary results do not confirm a causal link and thus do not warrant changes to current clinical testing protocols without further research.

Confirmatory Factor Analysis of the Hyperacusis Impact Questionnaire, Sound Sensitivity Symptoms Questionnaire, and Screening for Anxiety and Depression in Tinnitus, Including Preliminary Analyses of the Parent Versions for Use with Children

BACKGROUND

 We previously reported the results of exploratory factor analysis (EFA) of the Hyperacusis Impact Questionnaire (HIQ), the Sound Sensitivity Symptoms Questionnaire (SSSD), and the Screening for Anxiety and Depression in Tinnitus (SAD-T). Confirmatory factor analysis (CFA) is necessary to confirm the latent constructs determined using EFA. CFA should use different samples but with similar characteristics to those used for EFA.

PURPOSE

 The aim was to use CFA to confirm latent constructs derived using EFA of the HIQ, SSSQ, and SAD-T. We further evaluated the psychometric properties of parent versions of these questionnaires (indicated by -P), which are intended for use with children.

RESEARCH DESIGN

 This was a retrospective cross-sectional study.

STUDY SAMPLE

 Data for 323 consecutive adults and 49 children who attended a Tinnitus and Hyperacusis Therapy Clinic in the United Kingdom within a 6-month period were included.

DATA COLLECTION AND ANALYSIS

 Data were collected retrospectively from the records of patients held at the Audiology Department. CFA with the weighted least-squares mean and variance-adjusted estimator was applied to assess the previously proposed factor structures of the HIQ, SSSQ, and SAD-T. The internal consistency of the scales was assessed via Cronbach's α (α). The items of the HIQ, SSSQ, and SAD-T were tested for measurement invariance regarding age and gender using the multiple indicator multiple cause (MIMIC) model.

RESULTS

 All questionnaires showed good to excellent internal consistency, with α = 0.93 for the HIQ, 0.87 for the SSSQ, and 0.91 for the SAD-T. The parent versions showed acceptable to good internal consistency, with α = 0.88 for the HIQ-P, 0.71 for the SSSQ-P, and 0.86 for the SAD-T-P. CFA showed that the HIQ, SSSQ, and SAD-T were all one-factor questionnaires and the factors generally were similar to those obtained for the EFA. The MIMIC model showed that all three questionnaires can be considered as measurement invariant, with scores similar across genders and ages.

CONCLUSION

The HIQ, SSSQ, and SAD-T are internally consistent one-factor questionnaires that can be used in clinical and research settings to assess the impact of hyperacusis, the severity of sound sensitivity symptoms, and to screen for anxiety and depression symptoms. Future studies should further explore the psychometric properties of the parent versions of the HIQ, SSSQ, and SAD-T.

Hyperacusis Diagnosis and Management in the United States: Clinical Audiology Practice Patterns

PURPOSE

Hyperacusis often leads to debilitating psychosocial consequences, but there is no standard protocol for its diagnosis and management in the United States. In this study, we surveyed U.S. clinical audiologists to understand their education and clinical practices surrounding the evaluation and treatment of hyperacusis.

METHOD

An online survey was distributed to clinical audiologists across the United States. Survey responses were quantified using descriptive statistics and inductive content analysis.

RESULTS

Hyperacusis definitions and clinical practice patterns varied widely across the 102 respondents. Respondents cited a lack of education and training as the primary barrier to effective audiological diagnosis and management of hyperacusis, with most respondents reporting ≤ 5 hr of hyperacusis education. Other primary barriers to effective audiological management of hyperacusis included time constraints, reimbursement, poor sensitivity and specificity of available diagnostic tools, and poor efficacy of available treatments and management strategies. Most respondents (82.5%) agreed that audiologists are the primary professionals who are responsible for implementing hyperacusis interventions. However, 63.3% of respondents reported that their clinic does not have a hyperacusis management protocol, and 80.0% routinely recommend treatment that is outside their scope of practice to implement (cognitive behavioral therapy).

CONCLUSIONS

Clinical audiologists in the United States do not receive uniform education on hyperacusis, and they report multiple barriers to its evidence-based diagnosis and management. Effective hyperacusis management necessitates a multidisciplinary approach. The information obtained via this survey will pave the way toward the refinement of interprofessional education programs and the development of systematic, evidence-based clinical protocols for hyperacusis.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24431188.

Hyperacusis: Focus on Gender Differences: A Systematic Review

BACKGROUND

While gender differences of several diseases have been already described in the literature, studies in the area of hyperacusis are still scant. Despite the fact that hyperacusis is a condition that severely affects the patient's quality of life, it is not well investigated; a comprehensive understanding of its features, eventually including gender differences, could be a valuable asset in developing clinical intervention strategies.

AIM

To evaluate gender differences among subjects affected by hyperacusis.

METHODS

A literature search was conducted focused on adult patients presenting hyperacusis, using the MedLine bibliographic database. Relevant peer-reviewed studies, published in the last 20 years, were sought. A total of 259 papers have been identified, but only 4 met the inclusion criteria. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

The four selected papers included data from 604 patients; of these, 282 subjects resulted as affected by hyperacusis (125 females and 157 males). Questionnaires for analyzing factors affecting the attentional, social and emotional variance of hyperacusis (such as VAS, THI, TSCH, MASH) were administered to all included subjects. The data suggest that there are no hyperacusis gender-specific differences in the assessed population samples.

CONCLUSIONS

The literature data suggest that males and females exhibit a similar level of hyperacusis. However, in light of the subjective nature of this condition, the eventual set up of further tests to assess hyperacusis features could be very helpful in the near future.

Hyperacusis Assessment Questionnaire-A New Tool Assessing Hyperacusis in Subjects with Tinnitus

Hyperacusis, a kind of decreased sound tolerance, is difficult to measure objectively. It often co-occurs with tinnitus. There is a need for valid and reliable patient-reported outcome measures to capture this subjective phenomenon. The aim of the study was to create a questionnaire capturing hyperacusis in terms of loudness, fear, and pain and to evaluate its psychometric properties. The study sample consisted of 106 adult patients with hyperacusis and tinnitus with a mean age of 45.2 years. A medical interview, an audiological examination, and several questionnaires (the Tinnitus Handicap Inventory, the Hyperacusis Questionnaire, the State-Trait Anxiety Inventory, and Visual Analog Scales) were applied. The final 14-item Hyperacusis Assessment Questionnaire showed an appropriate three-factor structure with 70.5% of the variance explained. Convergent and divergent validity were confirmed by correlations with other measures of hyperacusis, anxiety, tinnitus severity, misophonia, and hearing thresholds. The internal consistency assessed with Cronbach's alpha was excellent (α = 0.91), as was reproducibility (intraclass correlation, ICC = 0.96). The new Hyperacusis Assessment Questionnaire is a psychometrically sound and brief tool assessing the severity of hyperacusis in terms of loudness, fear, and pain. It can be used in clinical practice and scientific research for patients with hyperacusis and tinnitus.

Asymmetric hearing thresholds are associated with hyperacusis in a large clinical population

Hyperacusis is a debilitating auditory condition whose characterization is largely qualitative and is typically based on small participant cohorts. Here, we characterize the hearing and demographic profiles of adults who reported hyperacusis upon audiological evaluation at a large medical center. Audiometric data from 626 adults (age 18-80 years) with documented hyperacusis were retrospectively extracted from medical records and compared to an age- and sex-matched reference group of patients from the same clinic who did not report hyperacusis. Patients with hyperacusis had lower (i.e., better) high-frequency hearing thresholds (2000-8000 Hz), but significantly larger interaural threshold asymmetries (250-8000 Hz) relative to the reference group. The probability of reporting hyperacusis was highest for normal, asymmetric, and notched audiometric configurations. Many patients reported unilateral hyperacusis symptoms, a history of noise exposure, and co-morbid tinnitus. The high prevalence of both overt and subclinical hearing asymmetries in the hyperacusis population suggests a central compensatory mechanism that is dominated by input from an intact or minimally damaged ear, and which may lead to perceptual hypersensitivity by overshooting baseline neural activity levels.

Persian Version of the Hyperacusis Questionnaire: Psychometric Evaluation and Prevalence Determination

PURPOSE

Hyperacusis is an uncommon hearing disorder, known as increased sensitivity to daily surrounding sounds. This disorder can profoundly affect people's daily activities. The studies conducted about hyperacusis are very limited in Iran. The purposes of this study are the psychometric evaluation of the Persian version of the Hyperacusis Questionnaire (PHQ) and the investigation of its prevalence.

METHOD

This cross-sectional study was accomplished on 203 young university students with normal hearing sensitivity. After translating the questionnaire, the psychometric properties of the PHQ were evaluated by content validity ratio (CVR) and index (CVI) and exploratory factor analysis (EFA). Students were evaluated by clinical audiology tests, the loudness discomfort level (LDL) measurement, and answering the PHQ. The research data collection was done from April to November 2022. Otoscopy, clinical and speech audiometry, and LDL were all executed, respectively. The participants directly answered the PHQ. All statistical analyses were performed using SPSS software Version 26.

RESULTS

The PHQ demonstrated acceptable validity and reliability, Cronbach's alpha (.81), CVI (> 0.88), and CVR (> 0.98). EFA revealed four dimensions of the questionnaire. Of the participants, four (2%) were identified as suffering from hyperacusis. The PHQ showed the possibility of differences between genders.

CONCLUSIONS

The psychometric evaluations of the PHQ were found to be acceptable and can be used in future studies. The prevalence of hyperacusis in our sample was 2%, and estimated to be higher in females. These findings suggest the need for further research on hyperacusis in Iranian population and specified studies to compare the two genders.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Hyperacusis is associated with smaller gray matter volumes in the supplementary motor area

Hyperacusis is a disorder in loudness perception characterized by increased sensitivity to ordinary environmental sounds and associated with otologic conditions, including hearing loss and tinnitus (the phantom perception of sound) as well as neurologic and neuropsychiatric conditions. Hyperacusis is believed to arise centrally in the brain; however, the underlying causes are unknown. To gain insight into differences in brain morphology associated with hyperacusis, we undertook a retrospective case-control study comparing whole-brain gray matter morphology in participants with sensorineural hearing loss and tinnitus who either scored above or below the threshold for hyperacusis based on a standard questionnaire. We found that participants reporting hyperacusis had smaller gray matter volumes and cortical sheet thicknesses in the right supplementary motor area (SMA), independent of anxiety, depression, tinnitus burden, or sex. In fact, the right SMA volumes extracted from an independently defined volume of interest could accurately classify participants. Finally, in a subset of participants where functional data were also available, we found that individuals with hyperacusis showed increased sound-evoked responses in the right SMA compared to individuals without hyperacusis. Given the role of the SMA in initiating motion, these results suggest that in hyperacusis the SMA is involved in a motor response to sounds.

A phenomenological cartography of misophonia and other forms of sound intolerance

People with misophonia have strong aversive reactions to specific "trigger" sounds. Here we challenge this key idea of specificity. Machine learning was used to identify a misophonic profile from a multivariate sound-response pattern. Misophonia could be classified from most sounds (traditional triggers and non-triggers) and, moreover, cross-classification showed that the profile was largely transferable across sounds (rather than idiosyncratic for each sound). By splitting our participants in other ways, we were able to show-using the same approach-a differential diagnostic profile factoring in potential co-morbidities (autism, hyperacusis, ASMR). The broad autism phenotype was classified via aversions to repetitive sounds rather than the eating sounds most easily classified in misophonia. Within misophonia, the presence of hyperacusis and sound-induced pain had widespread effects across all sounds. Overall, we show that misophonia is characterized by a distinctive reaction to most sounds that ultimately becomes most noticeable for a sub-set of those sounds.

Impact of comorbidity on symptomatology in various types of environmental intolerance in a general Swedish and Finnish adult population

Comorbidity with various health conditions is common in environmental intolerances (EIs), which restricts understanding for what symptoms that are associated with the intolerance per se. The present objectives were to study (i) prevalence of a broad range of specific symptoms in chemical, building-related, electromagnetic field- (EMF) related, and sound EI, irrespective of comorbidity, (ii) prevalence of symptoms in body systems in exclusive EIs, and (iii) increased risk of symptoms in body systems in exclusive EIs that cannot be referred to functional somatic syndromes, inflammatory diseases or mental disorders. Cross-sectional data (n = 4941) were used from two combined population-based surveys, the Västerbotten (Sweden) and Österbotten (Finland) Environmental Health Studies. Categorization of EI cases and controls were based on self-reports. Symptoms were assessed with the Environmental Hypersensitivity Symptom Inventory, and these were converted to 27 symptoms of the International Classification of Primary Care, 2nd edition, in eight chapters of body systems. The results showed, with few exceptions, that all assessed specific symptoms were significantly more prevalent in all four EIs than in referents. Although a large overlap between EIs, characteristic body system symptoms were eye and respiratory symptoms in chemical and building-related intolerance, skin symptoms in EMF-related intolerance, and general and unspecified, digestive, eye, cardiovascular, neurological, and psychological symptoms in sound intolerance. After controlling for various comorbidities, all studied body system symptoms were positively associated with chemical intolerance, fewer with sound intolerance, only one with building-related intolerance, and none with EMF-related EI. In conclusion, a broad range of symptoms are reported in all four EIs implying common mechanisms, but symptoms of certain body systems are more likely to be reported in a certain EI that cannot be explained by comorbidity.

Validity and reliability study of the Khalfa's hyperacusis questionnaire with using ULL in tinnitus patients

PURPOSE

This study aims to investigate the validity and reliability of the Khalfa's hyperacusis questionnaire (HQ) in Turkish tinnitus patients with hyperacusis using uncomfortable loudness levels (ULLs) and to determine a cutoff score for tinnitus patients specifically.

MATERIALS AND METHODS

One hundred and forty subjects with a mean age ± SD of 45.27 ± 14.43 years ranging from 18 to 75 participated in the study. HQ and ULLs were used as measures of hyperacusis. The participants were divided into two groups due to ULLs ≤ 90 dB in one or both ears (Group 1) and 56 participants have ULLs > 90 dB (Group 2).

RESULTS

The mean HQ score of the participants was 19.55 ± 7.18 points, Group 1 (n = 84) HQ mean score was 21.97 ± 7.08, and Group 2 (n = 56) 15.91 ± 5.56 points, and the cutoff point was found 16.50. Statistically significant differences were found between the groups in total HQ (p < 0.001), attention, social, and emotional subscales of HQ.

CONCLUSIONS

Hyperacusis questionnaire using with ULLs is a precise tool for the steps of identifying, categorizing, and managing the hyperacusis in patients with tinnitus. However, the effect of the tinnitus on hyperacusis should be considered, because it causes additional problems.

Pilot study on the role of somatic modulation in hyperacusis

BACKGROUND

Hyperacusis is a reduced tolerance to sounds that often co-occurs with tinnitus. Both symptoms have convergent as well as divergent characteristics. Somatic modulation, changes in pitch or loudness during certain movements, is common in patients with a primary complaint of tinnitus. However, thus far, this is not documented in patients with hyperacusis.

OBJECTIVES

This study aimed to examine the influence of somatic manoeuvres on the perception of external sounds in patients with a primary complaint of hyperacusis.

METHODOLOGY

In this prospective cross-sectional pilot study, 18 patients with a primary complaint of hyperacusis were recruited at the Tinnitus Treatment and Research Center Antwerp (TINTRA). While patients listened to a 1 kHz broadband noise of 30 dB sensation level, six neck manoeuvres (flexion, extension, lateroflexion left/right, traction and compression), three jaw manoeuvres (protrusion, laterotrusion left/right) and one placebo manoeuvre (hand on head) were performed. The primary outcome measure was the change in the perception of the presented sound in terms of loudness and intrusiveness between baseline and each modulation measured by a visual analogue scale (VAS).

RESULTS

No overall significant changes were found; however, individual results indicated that five patients presented a clinically relevant change of more than three points out of ten on VAS in terms of hyperacusis after at least one of the executed somatic manoeuvres.

CONCLUSIONS

This pilot study did not demonstrate an overall significant change in hyperacusis after somatic manoeuvres but does not rule out the possibility of somatic modulation in some hyperacusis patients.

TRIAL REGISTRATION

The protocol of this prospective cross-sectional pilot study was registered on clinicaltrials.gov with registration number NCT04693819.

Combined evaluation of audiology examination and self-reported symptoms in patients with hyperacusis

To investigate the application of combined audiological examination and a self-reported symptoms survey in the evaluation of hyperacusis. Patients who visited the outpatient department of Otolaryngology Head and Neck Surgery and Otological medicine, Affiliated Hospital of Southwest Medical University, from January 2019 to March 2021 were divided into a hyperacusis group and a normal control group. We measured the loudness discomfort level (LDL) and hearing threshold (HT) of the subjects and investigated their self-reported symptoms. We compared the demographic characteristics, loudness discomfort level, and hearing threshold of the two groups and analyzed the self-reported symptoms and audiological characteristics of hyperacusis. We considered 87 subjects, comprising 40 patients with hyperacusis and 47 healthy individuals. Among the hyperacusis patients, bilateral disease was predominant. Among them, 33 were females, 23 had hearing loss, and 20 had tinnitus. Patients are mainly in the 21-60 age group. Patients with hyperacusis had low discomfort thresholds at all frequencies except 500 Hz (P ≤ 0.05, mean LDL decreased by 6.14-1.37 dB HL for all frequencies). The incidences of feeling upset, pain, and anxiety or fear were 95%, 65%, and 82.5%, respectively, in patients with hyperacusis. The severity of symptoms varies between patients with hyperacusis and healthy individuals. A combination of LDL measurements and self-reported symptom surveys allows for an accurate and comprehensive assessment of hyperacusis.Trial registration: This study was retrospectively registered (TRN: ChiCTR2100047391) on June 13, 2021.

Psychological Profile and Social Behaviors of Patients with Hyperacusis

Increased noise sensitivity refers to the abnormal subjective response to external sounds, with a prevalence of between 8% and 15.2% in the adult population as suggested by epidemiological studies. The basic neural mechanism of hyperacusis still remains obscure, so therapies for this often-devastating symptom remain elusive. The aim of this study was to assess psychological profiles in patients with presbycusis without tinnitus in a perspective case-control design. All subjects were initially submitted to audiological evaluation (tympanometry, recordings of the acoustic reflex thresholds, pure tone audiometry) and subsequently were administered the following questionnaires: the hyperacusis questionnaire (HQ), the brief symptom inventory (BSI), and the modified somatic perception questionnaire (MSPQ). Patients with hyperacusis reported a total score and subscales (attentional, social, and emotional) of the HQ significantly higher than controls. They also reported higher scores of the MSPQ and significantly higher mean values with concern to the somatization, obsessive-compulsive, interpersonal sensitivity, depression, and anxiety subscales of the BSI. These results show that psychological distress, as expressed by higher level of somatic attention, somatization, anxiety, and depression, is a significant factor to consider for a complete diagnosis and effective treatment of hyperacusis. For a correct diagnosis of patients seeking help for hyperacusis, their psychological distress should also be assessed, regardless of their hearing abilities. Further studies are required to investigate the pathological mechanisms that are involved in the onset of hyperacusis in patients with normal hearing and those with sensorineural hearing loss.

What Should Be Considered When Assessing Hyperacusis? A Qualitative Analysis of Problems Reported by Hyperacusis Patients

Hyperacusis (decreased sound tolerance) is a prevalent complaint. Yet, to date, no research has qualitatively evaluated the types of problems experienced by adults with hyperacusis. Our service evaluation aims to determine the hyperacusis-related problem domains reported by patients and the degree to which these domains were reported together. Retrospective analysis was conducted on an anonymised clinical dataset from 306 patients who attended a UK tinnitus and hyperacusis treatment centre between 1994 and 2017. Conventional content analysis was used to categorise responses to the question 'Why is hyperacusis a problem?' into domains which were then subjected to a cluster analysis. Twenty-five problem domains were identified, of which 12 were further classified into three overarching categories. 'Fear', 'Reduced quality of life' and 'Physical reaction to sound' were most frequently reported problems. Cluster analysis revealed that 'Sleep difficulties' and 'Despondency', were commonly reported together. Adults with hyperacusis face many challenges in their everyday lives. The nature of these problems indicates the need to develop complex interventions and assessments to aid management of hyperacusis. Current hyperacusis questionnaires may be useful in identifying some problem domains, but further assessment thorough patient interviews is required to fully explore all potential problems and make informed decisions about treatment.

Sound Therapy to Reduce Auditory Gain for Hyperacusis and Tinnitus

Purpose:

Hyperacusis is the most common of the different types of sound tolerance conditions. It has been defined as physical discomfort or pain when any sound reaches a certain level of loudness that would be comfortable for most people. Because hyperacusis and tinnitus occur together so often, it has been theorized that they have a common neural mechanism. A leading contender for that mechanism is enhancement of auditory gain. The purpose of this tutorial is to review the evidence that sound/acoustic therapy can reduce auditory gain and, thereby, can increase loudness tolerance for people with hyperacusis and/or suppress the percept of tinnitus.

Method:

The scientific literature was informally reviewed to identify and elucidate relationships between tinnitus, hyperacusis, sound therapy, and auditory gain.

Results:

Evidence exists, both in animal and human studies, that enhanced auditory gain is associated with hyperacusis and tinnitus. Further evidence supports the theory that certain forms of sound therapy can reduce neural hyperactivity, thereby reducing auditory gain. The evidence for sound therapy reducing auditory gain is stronger for hyperacusis than it is for tinnitus.

Conclusions:

Based on results from numerous studies, sound therapy clearly has application as a method of desensitization for hyperacusis. Enhanced auditory gain might be responsible for tinnitus, but other mechanisms have been theorized. A review of the relevant literature leads to the conclusion that some form(s) of sound therapy has the potential to suppress or eliminate tinnitus on a long-term basis. Systematic research is needed to evaluate this premise.

Clinical Findings That Differentiate Co-Occurrence of Hyperacusis and Tinnitus from Tinnitus Alone

PURPOSE

We aimed to assess the characteristics of patients with concurrent tinnitus and hyperacusis, determine the best audiological criteria for predicting hyperacusis, and confirm whether objective evidence of changes in the brain exists.

MATERIALS AND METHODS

The medical records of patients with tinnitus who visited the hospital between March 2020 and December 2021 were reviewed. Data on accompanying hyperacusis, audiological profiles, and questionnaires including the Tinnitus Handicap Inventory (THI), Beck Depression Inventory, and numerical rating scale were analyzed. Resting-state quantitative electroencephalography (qEEG) using power spectral density (PSD) and event-related spectral perturbation (ERSP) were performed to objectively quantify changes in the brain.

RESULTS

A total of 194 patients were analyzed. Among them, 51 (26.3%) reported combined subjective hyperacusis with tinnitus. However, the proportions widely varied from 7.4% to 68.4% based on three audiological criteria for assessment. A higher score on the THI questionnaire was independently associated with the co-occurrence of tinnitus and hyperacusis. Fair agreement was observed between subjective hyperacusis and the audiological criterion based on a loudness discomfort level (LDL) of ≤90 dB at two or more frequencies for the diagnosis of hyperacusis. An increased beta-PSD and decreased levels of gamma-PSD, all-ERSP, and delta-ERSP were observed in patients with hyperacusis (p<0.05).

CONCLUSION

Patients with co-occurring tinnitus and hyperacusis had more severe tinnitus distress. An LDL of ≤90 dB at two or more frequencies may be applicable to predict accompanying hyperacusis in subjects with tinnitus, and qEEG also provides more objective information.

Auditory affective processing, musicality, and the development of misophonic reactions

Misophonia can be characterized both as a condition and as a negative affective experience. Misophonia is described as feeling irritation or disgust in response to hearing certain sounds, such as eating, drinking, gulping, and breathing. Although the earliest misophonic experiences are often described as occurring during childhood, relatively little is known about the developmental pathways that lead to individual variation in these experiences. This literature review discusses evidence of misophonic reactions during childhood and explores the possibility that early heightened sensitivities to both positive and negative sounds, such as to music, might indicate a vulnerability for misophonia and misophonic reactions. We will review when misophonia may develop, how it is distinguished from other auditory conditions (e.g., hyperacusis, phonophobia, or tinnitus), and how it relates to developmental disorders (e.g., autism spectrum disorder or Williams syndrome). Finally, we explore the possibility that children with heightened musicality could be more likely to experience misophonic reactions and develop misophonia.

Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management

Purpose: For some people, exposure to everyday sounds presents a significant problem. The purpose of this tutorial was to define and differentiate between the various sound tolerance conditions and to review some options for their clinical management.

METHOD

We informally reviewed the literature regarding sound tolerance conditions. The terminology and definitions provided are mostly consistent with how these terms are defined. However, many inconsistencies are noted. Methods of assessment and treatment also differ, and different methodologies are briefly described.

RESULTS

Hyperacusis describes physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people. Misophonia refers to intense emotional reactions to certain sounds (often body sounds such as chewing and sniffing) that are not influenced by the perceived loudness of those sounds. Noise sensitivity refers to increased reactivity to sounds that may include general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness. Phonophobia, as addressed in the audiology profession, describes anticipatory fear of sound. Phonophobia is an emotional response such as anxiety and avoidance of sound due to the "fear" that sound(s) may occur that will cause a comorbid condition to get worse (e.g., tinnitus) or the sound itself will result in discomfort or pain. (Note that phonophobia is a term used by neurologists to describe "migraineur phonophobia"-a different condition not addressed herein.) Conclusions: The literature addresses sound tolerance conditions but reveals many inconsistencies, indicating lack of consensus in the field. When doing an assessment for decreased sound tolerance, it is important to define any terms used so that the patient and all health care professionals involved in the care of the patient are aligned with the goals of the treatment plan. Treatment generally involves gradual and systematic sound desensitization and counseling.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20164130.

Tinnitus and the triple network model: a perspective

Tinnitus is defined as the conscious awareness of a sound without an identifiable external sound source, and tinnitus disorder as tinnitus with associated suffering. Chronic tinnitus has been anatomically and phenomenologically separated into three pathways: a lateral “sound” pathway, a medial “suffering” pathway, and a descending noise-canceling pathway. Here, the triple network model is proposed as a unifying framework common to neuropsychiatric disorders. It proposes that abnormal interactions among three cardinal networks—the self-representational default mode network, the behavioral relevance-encoding salience network and the goal-oriented central executive network—underlie brain disorders. Tinnitus commonly leads to negative cognitive, emotional, and autonomic responses, phenomenologically expressed as tinnitus-related suffering, processed by the medial pathway. This anatomically overlaps with the salience network, encoding the behavioral relevance of the sound stimulus. Chronic tinnitus can also become associated with the self-representing default mode network and becomes an intrinsic part of the self-percept. This is likely an energy-saving evolutionary adaptation, by detaching tinnitus from sympathetic energy-consuming activity. Eventually, this can lead to functional disability by interfering with the central executive network. In conclusion, these three pathways can be extended to a triple network model explaining all tinnitus-associated comorbidities. This model paves the way for the development of individualized treatment modalities.

Clinical and investigational tools for monitoring noise-induced hyperacusis

Hyperacusis is a recognized perceptual consequence of acoustic overexposure that can lead to debilitating psychosocial effects. Despite the profound impact of hyperacusis on quality of life, clinicians and researchers lack objective biomarkers and standardized protocols for its assessment. Outcomes of conventional audiologic tests are highly variable in the hyperacusis population and do not adequately capture the multifaceted nature of the condition on an individual level. This presents challenges for the differential diagnosis of hyperacusis, its clinical surveillance, and evaluation of new treatment options. Multiple behavioral and objective assays are emerging as contenders for inclusion in hyperacusis assessment protocols but most still await rigorous validation. There remains a pressing need to develop tools to quantify common nonauditory symptoms, including annoyance, fear, and pain. This review describes the current literature on clinical and investigational tools that have been used to diagnose and monitor hyperacusis, as well as those that hold promise for inclusion in future trials.

Psychiatric and audiologic features of misophonia: Use of a clinical control group with auditory over-responsivity

OBJECTIVE

This cross-sectional study was designed to add to the emerging empirical literature characterizing the psychiatric and audiologic features of misophonia. Because most research to date has not compared misophonia to clinical control groups, the present study used both participants who did not report any sound intolerance problems and a clinical control group of participants with auditory over-responsivity not formally meeting criteria for a diagnosis of misophonia using proposed diagnostic criteria by Schroeder et al. (2013). Severity of misophonia symptoms, frequency of current or lifetime psychiatric disorders, loudness discomfort, and hearing loss were compared across groups.

METHODS

Structured interviews, questionnaires, and objective measures of audiologic functioning were administered to a sample of adult participants (N = 156). Measures included an interviewer-rated diagnostic assessment of misophonia, the MisoQuest, (Siepsiak et al., 2020), M.I.N·I (Sheehan et al., 1998), loudness discomfort level (LDL), and hearing loss (PTA).

RESULTS

Group differences in misophonia symptom severity among all three groups were observed: FWelch (2,50.57) = 149.92, p < .001, n2 = 0.64, validating group assignment. Psychiatric disorders were significantly more frequent in the misophonia group (71%) than in the auditory over-responsivity group (40%) and control group (40%): X² (2, N = 142) = 14.3; p = .001; V = 0.317. A wide range of psychiatric disorders were observed in the misophonia group, (e.g., major depressive episode, suicidality and panic disorder were the most common). There were no significant differences between groups with regards to audiologic functioning.

CONCLUSION

Misophonia co-occurs with a variety of psychiatric disorders but does not appear to be associated with loudness discomfort or hearing impairments.

Hyperacusis: demographic, audiological, and clinical characteristics of patients at the ENT department

PURPOSE

To document whether patients with and without hyperacusis differ from each other on demographic, audiological, and clinical characteristics.

METHODS

Based on the Hyperacusis Questionnaire's (HQ) cut-off (HQ > 28), a total of 2301 participants were divided into patients with and without hyperacusis. Demographic data, scores on self-reported questionnaires [Tinnitus Functional Index (TFI), Visual Analogue Scale of tinnitus loudness (VAS_loudness), Hospital Anxiety Depression Scale (HADS)], and audiological parameters were retrospectively analysed to determine differential factors between the two groups.

RESULTS

In total, 10.9% of the patients was classified as hyperacusis patients (n = 251). They reported a significant, higher tinnitus severity (mean difference of 19 points on TFI) and mental distress (mean difference of 4 points on the HADS subscales) (p < 0.001) than patients without hyperacusis. Moreover, this group consisted of more women (45% % in hyperacusis group vs. 35% in non-hyperacusis group) and women scored significantly higher on the HQ (p < 0.001) and TFI (p < 0.01).

CONCLUSION

Patients with hyperacusis have distinctive characteristics. The presence of hyperacusis in combination with tinnitus can indicate a higher need for psychoeducation. Patients that present themselves with hyperacusis without tinnitus complaints remain a minority, yet might be underdiagnosed. Hence, future studies should disentangle tinnitus from hyperacusis. In clinical practice, greater efforts are required to increase knowledge about hyperacusis as a primary or secondary complaint and to provide individualized treatment for these patients.

Hyperacusis in Children: A Thematic Analysis of Discussions in Online Forums

PURPOSE

Hyperacusis is commonly defined as reduced tolerance to everyday sounds leading to avoidance behavior and disrupting normal functioning. Hyperacusis is prevalent in children. However, the literature on the manifestation and impact of hyperacusis on children is scant. This qualitative study examined online discussion forums to understand the lived experiences of hyperacusis in children from a parent or carer perspective.

METHOD

Posts from publicly available online discussion forums were thematically analyzed. Online searching identified 219 potentially relevant conversation threads across 18 forums and involving 1,436 forum users. A total number of 170 eligible conversation threads, containing 1,834 messages, were used in the analysis.

RESULTS

Thematic analysis of the data generated six themes: personal and health information about the child, onset and prognosis, bothersome sounds and characteristics, reactions, coping strategies, and impact. Hyperacusis onset was associated with loud noise, physical trauma, or stress. Bothersome sounds were categorized in terms of appliances, vehicles, public places, nature, and very loud sounds. Children's reactions included panic, shaking, and screaming. Strategies to manage hyperacusis included ear defenders, building up tolerance, and school adaptations. Hyperacusis had an impact on various aspects of the child's life including academic performance and social development.

CONCLUSIONS

This is the first study to account for the lived experiences of children experiencing hyperacusis from a parent/carer perspective using online forum data. These findings expand on existing research on the manifestation of hyperacusis in children and provide a basis for further work improving clinical assessment and management.

Measurement of Loudness Discomfort Levels as a Test for Hyperacusis: Test-Retest Reliability and Its Clinical Value

Objectives

The aims of this study were to investigate the test-retest reliability of measurements of loudness discomfort levels (LDLs), to suggest cut-off values for diagnosing patients with hyperacusis, and to evaluate the clinical value of-LDL measurements as a test for monitoring hyperacusis.

Methods

For the test-retest reliability of LDL measurements (study 1), a total of 68 patients who sought consultations at our clinic were subcategorized into four groups: patients with tinnitus (group 1), tinnitus and hearing loss (group 2), hyperacusis (group 3), and normal controls (group 4). Inter-hour and inter-day test-retest reliability values using different stimuli were investigated. For study 2, the clinical value of LDL measurements using pure tone stimuli was analyzed by comparing changes after sound generator use in patients with hyperacusis.

Results

In study 1, the group 3 patients showed significantly lower LDLs than the other groups. High test-retest reliability of LDL tests was demonstrated, regardless of the type of stimulus used. The cut-off values for screening patients with hyperacusis were 90 dB HL using pure tone stimuli and 62 dB HL using white-band noise stimuli. In study 2, significantly increased LDLs were correlated with improved symptoms and improved scores on tinnitus questionnaires after sound generator use, indicating that LDL measurement is a reliable test for monitoring hyperacusis during an intervention.

Conclusion

LDL measurement is a reliable diagnostic tool to reflect the condition of hyperacusis, especially during the course of treatment.

Prevalence of Decreased Sound Tolerance (Hyperacusis) in Individuals With Autism Spectrum Disorder: A Meta-Analysis

OBJECTIVES

Hyperacusis, defined as decreased tolerance to sound at levels that would not trouble most individuals, is frequently observed in individuals with autism spectrum disorder (ASD). Despite the functional impairment attributable to hyperacusis, little is known about its prevalence or natural history in the ASD population. The objective of this study was to conduct a systematic review and meta-analysis estimating the current and lifetime prevalence of hyperacusis in children, adolescents, and adults with ASD. By precisely estimating the burden of hyperacusis in the ASD population, the present study aims to enhance recognition of this particular symptom of ASD and highlight the need for additional research into the causes, prevention, and treatment of hyperacusis in persons on the spectrum.

DESIGN

We searched PubMed and ProQuest to identify peer-reviewed articles published in English after January 1993. We additionally performed targeted searches of Google Scholar and the gray literature, including studies published through May 2020. Eligible studies included at least 20 individuals with diagnosed ASD of any age and reported data from which the proportion of ASD individuals with current and/or lifetime hyperacusis could be derived. To account for multiple prevalence estimates derived from the same samples, we utilized three-level Bayesian random-effects meta-analyses to estimate the current and lifetime prevalence of hyperacusis. Bayesian meta-regression was used to assess potential moderators of current hyperacusis prevalence. To reduce heterogeneity due to varying definitions of hyperacusis, we performed a sensitivity analysis on the subset of studies that ascertained hyperacusis status using the Autism Diagnostic Interview-Revised (ADI-R), a structured parent interview.

RESULTS

A total of 7783 nonduplicate articles were screened, of which 67 were included in the review and synthesis. Hyperacusis status was ascertained in multiple ways across studies, with 60 articles employing interviews or questionnaires and seven using behavioral observations or objective measures. The mean (range) age of samples in the included studies was 7.88 years (1.00 to 34.89 years). The meta-analysis of interview/questionnaire measures (k(3) = 103, nASD = 13,093) estimated the current and lifetime prevalence of hyperacusis in ASD to be 41.42% (95% CrI, 37.23 to 45.84%) and 60.58% (50.37 to 69.76%), respectively. A sensitivity analysis restricted to prevalence estimates derived from the ADI-R (k(3) = 25, nASD = 5028) produced similar values. The estimate of current hyperacusis prevalence using objective/observational measures (k(3) = 8, nASD = 488) was 27.30% (14.92 to 46.31%). Heterogeneity in the full sample of interview/questionnaire measures was substantial but not significantly explained by any tested moderator. However, prevalence increased sharply with increasing age in studies using the ADI-R (BF10 = 93.10, R2Het = 0.692).

CONCLUSIONS

In this meta-analysis, we found a high prevalence of current and lifetime hyperacusis in individuals with ASD, with a majority of individuals on the autism spectrum experiencing hyperacusis at some point in their lives. The high prevalence of hyperacusis in individuals with ASD across the lifespan highlights the need for further research on sound tolerance in this population and the development of services and/or interventions to reduce the burden of this common symptom.

Development of Tinnitus and Hyperacusis in a Mouse Model of Tobramycin Cochleotoxicity

Aminoglycosides (AG) antibiotics are a common treatment for recurrent infections in cystic fibrosis (CF) patients. AGs are highly ototoxic, resulting in a range of auditory dysfunctions. It was recently shown that the acoustic startle reflex (ASR) can assess behavioral evidence of hyperacusis and tinnitus in an amikacin cochleotoxicity mouse model. The goal of this study was to establish if tobramycin treatment led to similar changes in ASR behavior and to establish whether ebselen can prevent the development of these maladaptive neuroplastic symptoms. CBA/Ca mice were divided into three groups: Group 1 served as a control and did not receive tobramycin or ebselen, Group 2 received tobramycin (200 mg/kg/s.c.) and the vehicle (DMSO/saline/i.p.) daily for 14 continuous days, and Group 3 received the same dose/schedule of tobramycin as Group 2 and ebselen at (20 mg/kg/i.p.). Auditory brainstem response (ABR) and ASR hearing assessments were collected at baseline and 2, 6, 10, 14, and 18 weeks from the start of treatment. ASR tests included input/output (I/O) functions which assess general hearing and hyperacusis, and Gap-induced prepulse inhibition of the acoustic startle (GPIAS) to assess tinnitus. At 18 weeks, histologic analysis showed predominantly normal appearing hair cells and spiral ganglion neuron (SGN) synapses. Following 14 days of tobramycin injections, 16 kHz thresholds increased from baseline and fluctuated over the 18-week recovery period. I/O functions revealed exaggerated startle response magnitudes in 50% of mice over the same period. Gap detection deficits, representing behavioral evidence of tinnitus, were observed in a smaller subset (36%) of animals. Interestingly, increases in ABR wave III/wave I amplitude ratios were observed. These tobramycin data corroborate previous findings that AGs can result in hearing dysfunctions. We show that a 14-day course of tobramycin treatment can cause similar levels of hearing loss and tinnitus, when compared to a 14-day course of amikacin, but less hyperacusis. Evidence suggests that tinnitus and hyperacusis might be common side effects of AG antibiotics.

Prevalence of Hyperacusis in the General and Special Populations: A Scoping Review

Objectives: To study the prevalence of hyperacusis in the general population and the special population, and to determine the effect of population differences on hyperacusis. Methods: The two authors followed a scoping review methodology and screened nearly 30 years of English literature in Pubmed, Web of Science, OVID, and EBSCO. Then, the extracted results of each study were discussed in groups and subgroups. Results: The authors selected 42 pieces of scientific literature that met the requirements, studying a total of 34,796 subjects, including the general population (28,425 subjects), the special occupation population (2,746 subjects), and the patients with concomitant diseases (5,093 subjects). The prevalence was 0.2-17.2% in the general population, 3.8-67% in the special occupation population, and 4.7-95% in the patients with special diseases. It was found that in the general population, the high prevalence occurs in adolescents and older adults. The prevalence of hyperacusis in women is significantly higher than in men. In people with hearing disorders, the prevalence of hyperacusis is significantly higher than in people with normal hearing. Various diseases (such as Williams syndrome, tinnitus, and autism), as well as various occupations (musicians, music students, teachers, and others), have been found to be high risk factors for hyperacusis. Conclusion: The high prevalence of hyperacusis and the large differences between reported prevalence in different studies deserves our great attention. Additionally, in order to increase the comparability of the studies, a standardized set of criteria are needed to study the prevalence of hyperacusis.

An online survey study of the association between tinnitus and hyperacusis using validated questionnaires

OBJECTIVE

To investigate the association between the highly comorbid tinnitus and hyperacusis conditions using standard questionnaires.

DESIGN

A cross-sectional internet-based survey consisted of general demographic questions, questions about hearing and emotional status, Tinnitus Primary Function Questionnaire (TPFQ), and Hyperacusis Questionnaire (HQ).

STUDY SAMPLE

Six hundred sixteen completed surveys were obtained primarily from students and staff in a large university.

RESULTS

About 6% of the respondents could be classified as having hyperacusis based on the criterion of HQ scores ≥ 28 and had significantly increased odds of reporting having tinnitus (OR 10.11; 95% CI 3.76-35.3). Tinnitus severity (TPFQ) and HQ scores were correlated regardless of the hearing loss status. When predicting TPFQ scores, after controlling for demographic factors and affective states, hyperacusis status became an insignificant predictor. In contrast, both affirmative answers to having anxiety and depression, together with hearing loss status and tinnitus were significant predictors of HQ scores.

CONCLUSIONS

Having hyperacusis did not appear to contribute significantly to tinnitus severity, but having tinnitus contributed to the likelihood of having hyperacusis. Our findings provide a nuanced view of how tinnitus and hyperacusis conditions co-occur and influence each other, which may be valuable to clinicians and researchers.

Evaluation and Management of Misophonia Using a Hybrid Telecare Approach: A Case Report

Decreased sound tolerance (DST) is a negative reaction to environmental sounds and is estimated to affect 3.5% of the population. This case report presents the evaluation and management of an adult female with severe, longstanding misophonia. Her evaluation included comprehensive audiometric testing (including uncomfortable loudness levels) and a detailed assessment of the impact of DST on her life. She enrolled in tinnitus retraining therapy and began receiving treatment aiming to facilitate habituation of bothersome environmental sounds. This case was complicated by the advent of the coronavirus disease 2019 (COVID-19) pandemic and a telemedicine hybrid approach was employed to increase access to audiologic care. Using this structure, some appointments occurred in person in the clinic and others occurred via a telemedicine video visit format. Telemedicine video visits facilitated in-depth discussions, afforded the opportunity to answer questions, and provided the option of cloud-based remote programming of on-ear devices. Future care will continue to employ a hybrid approach.

Prevalence of Hyperacusis and Its Relation to Health: The Busselton Healthy Ageing Study

Importance

The prevalence of hyperacusis and its relationship with mental and general health is unknown in a nonclinical sample. Therefore, we aimed to determine the prevalence of hyperacusis and its relation with hearing, general and mental health in a population‐based study.

Study Design

Prospective population‐based study.

Material and Methods

This study uses data from the Busselton Healthy Ageing Study (BHAS). A sample of 5,107 eligible inhabitants aged 45 to 70 years completed a detailed questionnaire and a clinical assessment. A positive answer to “Do you consider yourself sensitive or intolerant to everyday sounds” was used to indicate hyperacusis. Logistic regression was used to examine the association between hearing, mental and general health factors, and hyperacusis.

Results

Of 5,107 participants, 775 (15.2%) reported hyperacusis. The majority of participants with hyperacusis reported an occasional effect on daily life (72.0%). Being female, older in age, having a lower income, physical or mental health difficulties, more severe hearing loss, and tinnitus were all associated with the presence of hyperacusis. Individuals who experience hearing impairment, poorer general or mental health have a higher possibility of hyperacusis having an effect on their daily life.

Conclusions

In this community population‐based cohort study, we found a prevalence of hyperacusis of 15.2%. Individuals with hearing loss, mental health problems, and lower physical health have a higher possibility of experiencing effects on their daily life associated with their hyperacusis. Unravelling the relationship between hyperacusis hearing, general and mental health can be of major importance for a better understanding of the condition and its consequences.

Level of Evidence

2 Laryngoscope, 131:E2887–E2896, 2021

A Phenotypic Comparison of Loudness and Pain Hyperacusis: Symptoms, Comorbidity, and Associated Features in a Multinational Patient Registry

Purpose Hyperacusis is a complex and poorly understood auditory disorder characterized by decreased tolerance to sound at levels that would not trouble most individuals. Recently, it has been suggested that individuals who experience otalgia in response to everyday sounds (termed pain hyperacusis) may differ clinically from those whose primary symptom is the perception of everyday sounds as excessively loud (termed loudness hyperacusis). Despite this theoretical distinction, there have been no empirical studies directly comparing these two populations of hyperacusis patients. Method Using data from a multinational patient registry (the Coordination of Rare Diseases at Sanford Registry), we examined self-reported demographics, symptoms, comorbidity, and response to treatment in a sample of 243 adults with hyperacusis, 152 of whom were classified as having pain hyperacusis based on reported symptoms. Bayesian statistical tests were used to investigate both the presence and absence of group differences between patients with loudness and pain hyperacusis. Results Individuals with pain hyperacusis presented with a more severe clinical phenotype, reporting a higher frequency of temporary symptom exacerbations (i.e., "setbacks"), less perceived symptom improvement over time, more severe comorbid headache disorders, and reduced benefit from sound therapy. However, the two hypothesized hyperacusis subtypes exhibited more similarities than differences, with the majority of symptoms and comorbidities being equally prevalent across groups. Multiple comorbidities were commonly observed, including tinnitus, primary headache disorders, psychiatric disorders, and functional somatic syndromes. Intolerance of sensory stimuli in other modalities was also frequently reported. Conclusion Although this study provides little evidence that loudness and pain hyperacusis are pathophysiologically distinct conditions, our findings indicate that a pain-predominant phenotype may be a meaningful prognostic marker in patients with hyperacusis.

[Hyperacusis: a mini review]

Hyperacusis refers to the experience of the sound environment being perceived as overwhelmingly loud or painful, and this can severely affect the patient's quality of life. In China little attention has been paid to hyperacusis, and there has been little research undertaken on the topic. Therefore, this article summarizes the recent research on hyperacusis regarding definition, epidemiology, etiology, mechanism, evaluation and treatment to give directions for future research.

A distinct electrophysiological signature for synaesthesia that is independent of individual differences in sensory sensitivity

People with synaesthesia have been reported to show atypical electrophysiological responses to certain simple sensory stimuli, even if these stimuli are not inducers of synaesthesia. However, it is unclear whether this constitutes a neural marker that is relatively specific to synaesthesia or whether it reflects some other trait that co-occurs with synaesthesia, but is not specific to it. One candidate is atypical sensory sensitivity (e.g., strong aversion to certain lights and sounds, 'sensory overload') which is a feature of both synaesthesia and autism and that varies greatly in the neurotypical population. Using visual evoked-potentials (to stimuli varying in spatial frequency) and auditory-evoked potentials (to stimuli varying in auditory frequency), we found that synaesthetes had a modulated visual evoked-potential around P1/N1 (emanating from fusiform cortex), a greater auditory N1, as well as differences in the time-frequency domain (increased alpha and beta induced power for visual stimuli). This was distinct from that found in non-synaesthetes. By contrast, no significant electrophysiological differences were found that were linked to neurotypical variation in sensory sensitivity.

A psychoacoustic test for diagnosing hyperacusis based on ratings of natural sounds

Hyperacusis is defined as an increased sensitivity to sounds, i.e. sounds presented at moderate levels can produce discomfort or even pain. Existing diagnostic methods, like the Hyperacusis Questionnaire (HQ) and Loudness Discomfort Levels (LDLs), have been challenged because of their variability and lack of agreement on appropriate cut-off values. We propose a novel approach by using psychoacoustic ratings of natural sounds as an assessment tool for hyperacusis. Subjects (n = 81) were presented with natural and artificial (tone pips, noises) sounds (n = 69) in a controlled environment at four sound levels (60, 70, 80 and 90 dB SPL). The task was to rate them on a pleasant to unpleasant visual analog scale. The inherent challenge of this study was to create a new diagnostic tool when no gold standard of hyperacusis diagnosis exists. We labeled our subjects as hyperacusic (n = 26) when they were diagnosed as such by at least two of three methods (HQ, LDLs and self-report). There was a significant difference between controls (n = 23) and hyperacusics in the median global rating of pleasant sounds. Median global ratings of unpleasant sounds and artificial sounds did not differ significantly. Then we selected the subset of sounds that could best discriminate the controls from the hyperacusics, the Core Discriminant Sounds (CDS), and we used them to develop a new metric: The CDS score. A normalized global score and a score for each sound level can be computed with respect to a control population without hyperacusis. A receiver operating characteristic analysis showed that the accuracy of our method in distinguishing subjects with and without complaints of hyperacusis (86%, 95% Confidence Interval (CI): 76-93%) is comparable to that of existing methods such as the LDL (77%, CI: 67-86%) and the HQ (80%, CI: 69-88%). We believe that the CDS score is more relevant to subject's complaints than LDLs and that it could be applied in a clinical environment in a fast and effective way, while minimizing discomfort and biases.

The Content and Quality of Information About Hyperacusis Presented Online

Purpose Hyperacusis is a disorder characterized by reduced sound tolerance leading to ear pain, emotional distress, and reduced quality of life. Many people with hyperacusis turn to the Internet for information and support from online communities to discuss their condition. The purpose of this study was to assess the content and quality of hyperacusis information presented online. Method The three most used Internet search engines were used to identify relevant websites using the single search term hyperacusis. Fifteen websites were selected for analysis. Details of the purpose, audience, and content of each website were extracted using a bespoke data extraction form. The quality of the information on each website was rated using the validated DISCERN questionnaire. Results There was a wide disparity in the quality and content of hyperacusis information across websites. The website Hyperacusis Focus achieved the highest overall DISCERN score. Hyperacusis Focus and U.K. National Health Service websites were the most comprehensive online resources for health care professionals and patients, respectively. Wikipedia was judged useful for both health care professionals and patients. In general, hyperacusis-related information was accurate. However, no single website provided a complete account of hyperacusis, and some were judged to be selective in the information they provided. Conclusions The Internet provides an important source of information for those who have hyperacusis and those who care for them. Revisions to the websites reviewed here are needed for each to provide a complete account of hyperacusis. Supplemental Material https://doi.org/10.23641/asha.12869717.

Association between Hyperacusis and Tinnitus

Many individuals with tinnitus report experiencing hyperacusis (enhanced sensitivity to sounds). However, estimates of the association between hyperacusis and tinnitus is lacking. Here, we investigate this relationship in a Swedish study. A total of 3645 participants (1984 with tinnitus and 1661 without tinnitus) were enrolled via LifeGene, a study from the general Swedish population, aged 18-90 years, and provided information on socio-demographic characteristics, as well as presence of hyperacusis and its severity. Tinnitus presence and severity were self-reported or assessed using the Tinnitus Handicap Inventory (THI). Phenotypes of tinnitus with (n = 1388) or without (n = 1044) hyperacusis were also compared. Of 1661 participants without tinnitus, 1098 (66.1%) were women and 563 were men (33.9%), and the mean (SD) age was 45.1 (12.9). Of 1984 participants with tinnitus, 1034 (52.1%) were women and 950 (47.9%) were men, and the mean (SD) age was 47.7 (14.0) years. Hyperacusis was associated with any tinnitus [Odds ratio (OR) 3.51, 95% confidence interval (CI) 2.99-4.13], self-reported severe tinnitus (OR 7.43, 95% CI 5.06-10.9), and THI ≥ 58 (OR 12.1, 95% CI 7.06-20.6). The association with THI ≥ 58 was greater with increasing severity of hyperacusis, the ORs being 8.15 (95% CI 4.68-14.2) for moderate and 77.4 (95% CI 35.0-171.3) for severe hyperacusis. No difference between sexes was observed in the association between hyperacusis and tinnitus. The occurrence of hyperacusis in severe tinnitus is as high as 80%, showing a very tight relationship. Discriminating the pathophysiological mechanisms between the two conditions in cases of severe tinnitus will be challenging, and optimized study designs are necessary to better understand the mechanisms behind the strong relationship between hyperacusis and tinnitus.

Noise: Acoustic Trauma to the Inner Ear

Cochlear damage is often thought to result in hearing thresholds shift, whether permanent or temporary. The report of tinnitus in the absence of any clear deficit in cochlear function was believed to indicate that hearing loss and tinnitus, while comorbid, could arise independently from each other. In all likelihood, tinnitus that is not of central nervous system origin is associated with hearing loss. As a correlate, although a treatment of most forms of tinnitus will likely emerge in the years to come, curing tinnitus will first require curing hearing loss.