The scope of this page includes both tinnitus and hyperacusis in both pediatric and adult populations.
See the Tinnitus evidence map for summaries of the available research on this topic.
Tinnitus is the perception of noise (e.g., ringing, buzzing, hissing) in the absence of an external sound source. It may be perceived in one or both ears, centered in the head, or localized outside the head. Objective tinnitus is a rare condition in which the perceived noise is generated within the body—for example, from a muscle spasm or a vascular disorder. Sound from objective tinnitus may be detected/heard by an examiner (i.e., not only by the individual with the symptom). Subjective tinnitus, which is far more common, is perceived only by the individual with the symptom. As the impact of tinnitus on one's quality of life can vary (from minimal to severe), there is a difference between bothersome tinnitus and nonbothersome tinnitus. Several other terms are used to differentiate tinnitus within the literature, including the following examples:
Hyperacusis is an exaggerated response to ordinary sounds in the environment that are tolerated well by those without hyperacusis. Hyperacusis may result in a range of reactions and emotional responses to sound, varying by individual. Categories of hyperacusis include loudness, annoyance, fear, and pain (Tyler et al., 2014). As with tinnitus, hyperacusis varies in severity. The negative responses to sound may be strong enough to cause avoidance of normal interactions and situations and may significantly alter a person's life. Related terms found in descriptions of hyperacusis include the following examples:
Tinnitus and hyperacusis may exist independently or in comorbidity.
Incidence refers to the number of new cases of a disorder identified within a specified time period. Because there is not a national registry in the United States tracking newly identified patients with tinnitus, published incidence rates stem from population-based community studies. Most notably, a 10-year prospective study performed in Beaver Dam, Wisconsin, followed 2,922 participants who self-identified as having no tinnitus at the start of data collection. The 10-year cumulative incidence of tinnitus in the study population was 12.7%. Significant associations were found with arthritis, head injury, smoking, and, among women only, hearing loss. Alcohol consumption was associated with a decreased risk, along with age for women and obesity for men (Nondahl et al., 2010).
Prevalence refers to the number of individuals with a disorder in a specified time period. The prevalence of tinnitus is estimated by the National Center for Health Statistics (a division of the Centers for Disease Control [CDC]) from data collected in the National Health and Nutrition Examination Survey (NHANES). Since 1999, the NHANES includes questions about ringing, roaring, or buzzing in the respondent's ears or head. In 2005, the tinnitus question was refined to adult participants (ages 20–69 years) reporting that they were "bothered by ringing, roaring or buzzing" that lasts for more than 5 minutes. The prevalence has ranged from 7.1% (2007–2008; National Center for Health Statistics, 2016) to 14.6% (2011–2012; National Center for Health Statistics, 2016). This is consistent with findings in other countries, which reported a range of 10.2% to 15.1% in earlier studies (Møller, 2011).
It is notable that in the 2011–2012 NHANES findings, 9.3 % of those reporting bothersome tinnitus reported it as a big or a very big problem, and 39.3% reported that they were bothered when going to sleep. Additionally, 81.5% indicated that they had the tinnitus for 3 months or longer, and 39.3% noted that they experience tinnitus almost always or at least once a day.
Review of the literature reveals inconsistent and broad ranges of prevalence for children with tinnitus, varying from 4.7% to 62.2%. This disparity is likely due to differences in describing the tinnitus, the question posed, response options, age, and study design (Rosing, Schmidt, & Baguley, 2016).
The signs and symptoms of tinnitus and hyperacusis may vary in description and severity across individuals. Both tinnitus and hyperacusis may be symptoms of other disorders or diseases and/or may be associated with other conditions.
Tinnitus may be
Hyperacusis is characterized by an intolerance to, or a response of discomfort (physical and/or emotional) to, sounds that would be considered acceptable or tolerable to the average listener with normal hearing.
Conditions that may co-occur or that may be associated with the presence of tinnitus and/or hyperacusis include
Individuals with tinnitus and/or hyperacusis may also experience functional limitations, including
In many cases, the etiology of tinnitus and hyperacusis remains unknown. However, hearing loss of any etiology increases the likelihood of tinnitus and can also contribute to some forms of hyperacusis.
Causes and risk factors for objective tinnitus may include
Causes and risk factors for subjective tinnitus may include
Causes and risk factors for hyperacusis may include
Audiologists play a central role in the assessment, diagnosis, and management of persons with tinnitus and/or hyperacusis. Professional roles and activities in audiology include clinical/educational services (diagnosis, assessment, planning, intervention, and management), prevention and advocacy, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2018) and ASHA's Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006).
Appropriate roles for audiologists include the following:
As indicated in ASHA's Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
Speech-language pathologists may encounter individuals with complaints of tinnitus and/or hyperacusis within the populations that they serve. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for speech-language pathologists include the following:
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 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.
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:
See ASHA's Cultural Responsiveness Practice Portal page for information on gathering a case history.
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 in Adults 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 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 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 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 refers to the level of broadband or narrowband noise required to mask or alleviate bothersome tinnitus for a given patient.
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 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:
Assessment of hyperacusis may include one or more of the following measures (see subsections below).
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:
See ASHA's Cultural Responsiveness Practice Portal page for information on gathering a case history.
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 in Adults 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 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.
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 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:
See the Treatment section of the Tinnitus evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
Assessment of tinnitus and/or hyperacusis may result in recommendations for management options and/or referral to medical professionals, as appropriate. Management of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). Intervention may address a patient's concerns regarding thoughts and emotions, sleep, concentration, and hearing.
See the ASHA resource titled Person-Centered Focus on Function: Tinnitus Management [PDF] for an example of functional goals that are consistent with the World Health Organization's (WHO) ICF framework (WHO, 2001).
In general, there is no cure for tinnitus. Some individuals with tinnitus do not find it bothersome. For others it can be debilitating, causing emotional distress and negatively impacting quality of life. Tinnitus management may include one or more of the following options.
Patients presenting with tinnitus that is bothersome and persistent will require educational and informational counseling. The AAO-HNSF guidelines provide a recommendation for education and counseling (Tunkel et al., 2014). It may be helpful to include the patient's support system (e.g., family, significant others) in the counseling portion of tinnitus management.
The audiologist or related practitioner may provide information related to the patient's specific case of tinnitus and potential management strategies. The patient may also be made aware of unverified claims and "cures" that may mislead them as they research tinnitus online. See ASHA's page on Health Literacy for more information on communicating with patients and family members. Audiologists and related practitioners may also consider professional referrals to address the psychosocial aspects of tinnitus.
Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. CBT may be applicable to patients with tinnitus to help reduce negative responses and improve quality of life (Hesser, Weise, Westin, & Andersson, 2011). CBT may be used in combination with other tinnitus management strategies. The AAO-HNSF guidelines provide a recommendation for CBT (Tunkel et al., 2014).
Some individuals with hearing loss also complain of tinnitus. A properly fitted hearing aid may alleviate bothersome tinnitus through amplification and/or masking effects (Kochkin & Tyler, 2008; McNeill, Távora-Vieira, Alnafjan, Searchfield, & Welch, 2012; Shekhawat, Searchfield, & Stinear, 2013). The AAO-HNSF guidelines on tinnitus provide a recommendation for hearing aid evaluation (Tunkel et al., 2014). Hearing aids may be beneficial when used independently or in combination with a sound generator as an optional programmable feature (Henry, Frederick, Sell, Griest, & Abrams, 2015). Hearing aids that are fit specifically for amelioration of tinnitus may require individualized programming.
See ASHA's Hearing Aids For Adults Practice Portal page for more detailed information on hearing aid fitting.
Sound therapy refers to the use of sound to relieve bothersome tinnitus. It is inclusive of several strategies and products (e.g., wearable devices, external devices, accessories to hearing aids). Sound therapy uses external noise to distract, mask, habituate, or neuromodulate (i.e., reduce neural hyperactivity that may be an underlying cause of tinnitus) the perceived subjective tinnitus. A secondary benefit of sound therapy is to provide a relaxation effect, which may aid in habituation. Sound therapy may be considered as an important component of a comprehensive tinnitus management plan (Hoare, Searchfield, El Refaie, & Henry, 2014).
Wearable masking devices may be used alone or in combination with hearing aids. Several different styles are available, and some offer frequency adjustment for the patient to use as needed. Some wearable devices are worn for a prescribed number of hours each day and introduce sounds that have been customized for the patient and their tinnitus.
Nonwearable devices include any environmental device that provides background sound that can be used by patients to reduce their perception of bothersome tinnitus. Examples include
Nonwearable masking devices may be especially helpful for those individuals who have difficulty sleeping due to bothersome tinnitus.
There are several management programs specific to tinnitus, including those described below.
Pawel J. Jastreboff (1990) wrote about the neurophysiological model of tinnitus. Based on this model, tinnitus retraining therapy (TRT) is a habituation-based intervention that includes a combination of directive counseling and sound therapy. The TRT protocol involves a structured case history followed by assignment of the patient into one of five categories differentiated by their specific type of tinnitus. Category assignment directs intervention. All patients receive directive counseling and education specific to tinnitus and auditory physiology, among other topics. Some type of sound input/enriched sound is often included.
The progressive tinnitus management (PTM) approach focuses on the patient learning to self-manage their negative reactions to tinnitus. PTM uses a clinical service structure in which a patient progresses to higher (more intensive) levels of intervention only as needed. A significant aspect of PTM involves educating the patient on the use of individualized coping skills as well as some elements of CBT. The five levels of PTM have been described in detail (Henry, Schechter, Zaugg, & Myers, 2008; Henry, Zaugg, Myers, Kendall, & Turbin, 2009).
Tinnitus activities treatment (TAT) is an intervention using individualized counseling. Four areas are considered, including "thoughts and emotions, hearing and communication, sleep, and concentration" (Tyler, Gogel, & Gehringer, 2007, p. 425). Low-level partial masking sound therapy as well as patient homework activities (based on the four problem areas outlined above) are also integral to this approach.
In making prudent recommendations for a person complaining of tinnitus, a clinical practitioner should remain current in their knowledge of the various management options available and should carefully review supporting or opposing scientific evidence (or lack thereof).
See the Treatment section of the Tinnitus Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
A variety of other tinnitus management options are currently being used and/or studied. Examples include the following approaches:
Appropriate referrals for a patient with tinnitus may include a variety of health care professionals. In cases where a medically treatable cause is identified, medical, surgical, psychiatric, or dental treatment may be recommended by the appropriate medical professionals (e.g., surgical excision of a tumor, medication for an infection). Based on an audiologist's own knowledge and skills, it may be appropriate to refer out for specific tinnitus management techniques, such as TRT. Psychological referrals may be necessary for counseling and CBT. Effective treatment of depression, anxiety, and insomnia may help to reduce the severity of tinnitus and improve a patient's quality of life (Folmer, 2002).
Tinnitus presents several challenges for clinicians because there is generally no cure, and there is a lack of consensus and standardization regarding definition, objective measurement, assessment, and management. Future responses to these difficulties may include
Hyperacusis can be debilitating, causing emotional distress and negatively influencing an individual's quality of life. Intervention may include one or more of the following options (see subsections below).
Patients presenting with complaints of hyperacusis will require education and counseling. It may be helpful to include the patient's support system (e.g., family, significant others) in the counseling portion of hyperacusis management.
Education may include information relating to the patient's specific case of hyperacusis as well as potential management strategies. See ASHA's web page on Health Literacy for more information on communicating with patients and family members. Professional referrals may also be considered to address the psychosocial aspects of hyperacusis.
Referral to a trained and licensed professional for psychotherapy may be appropriate. Cognitive behavioral therapy (CBT) is a specific type of therapy that focuses on modifying problem emotions, thoughts, and behaviors. Treatment of depression, anxiety, and insomnia may also be necessary.
Sound therapy for hyperacusis requires the patient to listen to low-level sounds for long periods of time to encourage habituation. "Over time, gradual increases of the level and/or duration of the sound treatment should be implemented along with positive reinforcement by the clinician" (Pienkowski et al., 2014, p. 428). Sound therapy options for hyperacusis include the following presentations (Pienkowski et al., 2014):
The general principles of TRT described in an earlier section may also be used successfully in the management of a patient with hyperacusis (Mraz & Folmer, 2003).
Hyperacusis activities treatment is based on the protocol for TAT, described earlier. The approach includes both individualized counseling and sound therapy specific to hyperacusis.
Some individuals with hyperacusis feel that wearing hearing protection to avoid disturbing sounds is helpful; however, this is not advisable when environmental sound levels are safe. Avoiding normal-level sounds in the environment can make the auditory system become more sensitive to these sounds when protection is not used. This increased sensitivity can exacerbate the hyperacusis (Formby, Sherlock, & Gold, 2003). Using hearing protection when exposed to excessive noise is advisable for all individuals.
Appropriate referrals for a patient with hyperacusis may include a variety of health care professionals. These referrals may include neurology, psychiatry, occupational therapy, psychology, and primary care professionals. The appropriate referrals may depend on whether a specific cause has been identified.
It is important to consider that children may be less able to describe bothersome tinnitus or hyperacusis verbally, and they may use actions or emotional gestures instead (e.g., covering ears with hands, crying). Children may have tinnitus, hyperacusis, or both. Underreporting of tinnitus or hyperacusis is a concern in the care of children.
Children who experience tinnitus—much like adults who experience tinnitus—will benefit from general education and information about the condition. Allaying a child's fears may be a significant factor in the management of tinnitus. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and for the specifics of the tinnitus.
Hyperacusis in children may coexist with conditions such as autism. Hyperacusis can be acquired after severe ear infections and head injuries, and through a variety of other causes. A child with hyperacusis may have normal hearing. Pediatric audiology specialists will use the assessment and intervention techniques described above as appropriate for the child and for the specifics of the hyperacusis. Similar to management of hyperacusis in adults, a goal of managing hyperacusis in children is to help children reduce their fear of and aversion to everyday sounds.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Tinnitus and Hyperacusis page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Tinnitus and Hyperacusis. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Tinnitus-and-Hyperacusis/.
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