Tinnitus and Hyperacusis

See the Assessment section of the Tinnitus evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Assessment of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). A patient may or may not require a comprehensive assessment as determined by the process of differential diagnosis.

See the ASHA resource titled Person-Centered Focus on Function: Tinnitus Management [PDF] for an example of assessment data that are consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (WHO, 2001).

Assessment of Tinnitus

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

Case History

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

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

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

See ASHA's Cultural Competence Practice Portal page for information on gathering a case history.

Audiologic Evaluation

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

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

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

See the Joint Audiology Committee Clinical Practice Statements and Algorithms (ASHA, 1999) and ASHA's Hearing Loss Beyond Early Childhood Practice Portal page for more in-depth information regarding comprehensive audiologic assessment.

Additional balance testing may be added to the comprehensive assessment when patients present with tinnitus and balance complaints or when initial testing indicates possible vestibular dysfunction (Wackym & Friedland, 2004). Results from these tests may lead to medical referral for more specific testing. See ASHA's Balance System Disorders Practice Portal page for more information on the assessment of balance system disorders.

Additional Testing

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

Tinnitus Pitch Matching

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

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

Tinnitus Loudness Matching

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

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

Minimum Masking Level

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

Residual Inhibition Assessment

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

Subjective Patient Questionnaires

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

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

Assessment of Hyperacusis

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

Case History

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

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

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

See ASHA's Cultural Competence Practice Portal page for information on gathering a case history.

Audiologic Evaluation

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

See Joint Audiology Committee Clinical Practice Statements and Algorithms (ASHA, 1999) and ASHA's Hearing Loss—Beyond Early Childhood Practice Portal page for more in-depth information regarding comprehensive audiologic assessment.

Additional balance testing may be added to the comprehensive assessment when patients present with hyperacusis and balance complaints. See ASHA's Balance System Disorders Practice Portal page for more information on the assessment of balance system disorders.

Additional Testing

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

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

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

Subjective Patient Questionnaires

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

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

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.