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.
Hearing-related terminology may vary depending upon context and a range of factors. See the American Speech-Language-Hearing Association (ASHA) resource on hearing-related topics: terminology guidance for more information.
Tinnitus is the perception of sound (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 of the head. Objective tinnitus is a rare condition in which the perceived sound 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., as opposed to being heard 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 a heightened sensitivity to ordinary sounds in the environment that are tolerated well by those without hyperacusis. Hyperacusis may result in a range of reactions to sound, including both physiologic and emotional responses. Categories of hyperacusis include loudness, annoyance, fear, and pain (Tyler, Pienkowski, et al., 2014). As with tinnitus, hyperacusis varies in severity. The negative responses to sound may be strong enough to cause avoidance of routine 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.
The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.
Epidemiological measures of tinnitus and hyperacusis vary substantially due to factors such as variable and fluctuating presentation of characteristics; subjective classification of symptoms (Jarach et al., 2022); inconsistent methods of assessment and diagnosis (Baguley & Hoare, 2018; McCormack et al., 2016); and underreporting, particularly in children and adolescents (Mahboubi et al., 2013).
Globally, tinnitus impacts more than 740 million adults (Jarach et al., 2022), with prevalence estimates ranging from 4.1% to 42.7% (Jarach et al., 2022; McCormack et al., 2016; World Health Organization, 2021). Longitudinal studies have reported tinnitus incidence rates ranging from 54 to 3,914 per 100,000 person-years (Jarach et al., 2022). One meta-analysis calculated a pooled prevalence of chronic tinnitus in 9.8% of adults. Although prevalence rates show no significant difference by biological sex, increased prevalence of tinnitus is associated with age (Jarach et al., 2022). In school-age children, international tinnitus prevalence estimates range from 4.7% to 46% of the general pediatric population and from 23.5% to 62.2% of children with hearing loss (Rosing et al., 2016).
In the United States, approximately 25 million adults, or 10% of the population, report that they experienced tinnitus for at least 5 minutes in the past year (National Institute on Deafness and Other Communication Disorders, 2021). On the 2014 National Health Interview Survey, 11.2% of adults, aged 18 years and older, reported ringing in the ears (i.e., tinnitus). Older adults, aged 70 years and older, were more than twice as likely to report symptoms of tinnitus compared with younger adults, aged 18–39 years (Zelaya et al., 2015). Based on results from the National Health and Nutrition Examination Survey, 7.5% of adolescents (approximately 2.5 million), aged 12–19 years, reported ever experiencing symptoms of tinnitus, whereas 4.7% described chronic tinnitus (Mahboubi et al., 2013).
Limited research is available on the prevalence of hyperacusis. Sensitivity to noise has been self-reported at rates ranging from 8.6% to 11.5% of adults across international survey studies (Paulin et al., 2016). On the 2014 National Health Interview Survey, 5.9% of adults, aged 18 years and older, described experiencing sensitivity to day-to-day noises (i.e., hyperacusis; Zelaya et al., 2015). Individuals with associated diagnoses such as Williams syndrome, autism spectrum disorder, or tinnitus demonstrate increased rates of hyperacusis (4.7%–95%) as compared to the general population. Individuals in certain occupational groups (e.g., musicians, teachers) also demonstrate higher prevalence rates of hyperacusis (3.8%–67%; Ren et al., 2021). In children aged 5–19 years, hyperacusis prevalence estimates vary from 3.2% to 17.1% (Rosing et al., 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 and 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 typical hearing.
Diagnoses that may co-occur or be associated with the presence of tinnitus and/or hyperacusis include audiologic diagnoses (e.g., Ménière’s disease, noise-induced hearing loss, otosclerosis, sudden sensorineural hearing loss). Other associated or co-occurring diagnoses include the following examples:
Individuals with tinnitus and/or hyperacusis may also experience functional limitations such as
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.
Various theories regarding the biomechanics of tinnitus suggest that tinnitus generators lie within the central auditory systems, with potential contributions from both the peripheral auditory pathway and nonauditory related structures. Current research on the mechanics of tinnitus focuses on increased central activity in response to decreased or compromised information from the peripheral auditory system. More in-depth explanations of the underlying mechanisms of tinnitus can be found in the literature (Auerbach et al., 2014; Han et al., 2009; Henry et al., 2014).
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/treatment of individuals with tinnitus and/or hyperacusis. The professional roles and activities in audiology include clinical and educational services (e.g., diagnosis, assessment, planning, counseling, management, and intervention); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
The following roles and responsibilities are appropriate for audiologists:
As indicated in the ASHA Code of Ethics (ASHA, 2023), 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 they serve. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
It is appropriate for speech-language pathologists to provide referrals (e.g., otolaryngologist, audiologist) for patients who complain of tinnitus and/or hyperacusis.
See the Assessment section of the Tinnitus Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
For guidance and considerations on infection control practices during the assessment process, see the ASHA page on infection control resources for audiologists and speech-language pathologists.
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 on interprofessional education/interprofessional practice (IPE/IPP) for more information.
ASHA’s resource, Person-Centered Focus on Function: Tinnitus Management [PDF], provides an example of assessment data that are consistent with the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).
The assessment of tinnitus may include one or more of the measures described below. It is essential 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. A case history specific to tinnitus may include the following items:
It is important to consider that children may be less able to describe bothersome tinnitus verbally and that they may use actions or emotional gestures instead (e.g., covering ears with hands, crying). Some children may be able to use a visual analog scale or draw a picture of their tinnitus as a way to communicate their understanding and perception of their tinnitus (Kentish, 2014).
See the ASHA Practice Portal page on Cultural Responsiveness for information on gathering a case history.
Otologic and audiologic assessment is vital for an accurate differential diagnosis of tinnitus. An otologic evaluation may help identify or rule out injury or disease processes causing the tinnitus. Audiologic assessment will identify associated hearing loss.
In some cases, acoustic reflex testing is not recommended (Henry et al., 2002) as 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.
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 a medical referral for more specific testing. See the ASHA Practice Portal page on Balance System Disorders for more information.
Additional testing may be performed 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 the 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 et al., 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 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 even longer for some individuals.
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.
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:
It is important to consider that children may be less able to describe hyperacusis verbally and that they may use actions or emotional gestures instead (e.g., covering ears with hands, crying).
See the ASHA Practice Portal page on Cultural Responsiveness for information on gathering a case history.
Otologic and audiologic assessment may assist in the accurate differential diagnosis of hyperacusis. Audiologic tests may be chosen 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.
Balance testing may be added to the comprehensive assessment when patients present with hyperacusis and balance complaints. See the ASHA Practice Portal page on Balance System Disorders for more information.
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) or an uncomfortable loudness level (ULL) may be achieved using a variety of acoustic stimuli. An abnormal LDL/ULL result will demonstrate a reduced sound tolerance range when compared to LDL/ULL results of individuals without hyperacusis. It may be beneficial to take this measurement several times because an individual’s hyperacusis can fluctuate. For some patients, LDL/ULL testing may prove to be difficult to complete. Consideration of this and other test limitations is important when including LDL/ULL 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 and publications:
See the Treatment section of the Tinnitus Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
For guidance and considerations on infection control practices during the treatment process, see the ASHA page on infection control resources for audiologists and speech-language pathologists.
Assessment of tinnitus and/or hyperacusis may result in recommendations for management/treatment options and/or referral to medical professionals. Management of tinnitus and/or hyperacusis is often an interdisciplinary endeavor (e.g., audiologist, otolaryngologist, psychiatrist, psychologist, primary care physician). See the ASHA resource on interprofessional education/interprofessional practice (IPE/IPP) for more information. Intervention may address a patient’s concerns regarding thoughts and emotions, sleep, concentration, and hearing. See the ASHA resource on person-centered care in audiology. The Ida Institute offers tools and resources for counseling both adults and children regarding tinnitus and other hearing concerns.
ASHA’s resource, Person-Centered Focus on Function: Tinnitus Management [PDF], provides an example of functional goals that are consistent with the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).
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 may benefit from educational and informational counseling. It may be helpful to include the patient’s support system (e.g., family, significant others) in the counseling portion of tinnitus management. Professional referrals to address the psychosocial aspects of tinnitus are also considered.
The audiologist or related practitioner can provide information regarding 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 the ASHA Practice Portal page on Counseling for Professional Service Delivery and the ASHA resource on health literacy for more information on communicating with patients and family members.
Referral to a trained and licensed professional for psychotherapy may be indicated. 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 et al., 2011; Woods & Theodoroff, 2019). CBT may be used in combination with other tinnitus management strategies.
Use of a properly fitted and objectively verified hearing aid has been shown to alleviate bothersome tinnitus in some individuals (Kochkin & Tyler, 2008; McNeill et al., 2012; Shekhawat et al., 2013; Waechter & Jönsson, 2022). Hearing aids may be beneficial when used independently or in combination with a sound generator as an optional programmable feature (Henry et al., 2015). Hearing aids that are fit specifically for amelioration of tinnitus may require individualized programming.
See the ASHA Practice Portal page on Hearing Aids for Adults 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 is often an important component of a comprehensive tinnitus management plan (Hoare et al., 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.
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 et al., 2008, 2009).
Tinnitus activities treatment is an intervention using individualized counseling. Four areas are considered, including “thoughts and emotions, hearing and communication, sleep, and concentration” (Tyler et al., 2007, p. 425). Low-level partial masking sound therapy as well as patient homework activities are also integral to this approach.
Given that tinnitus is associated with hearing loss, it is not uncommon for cochlear implant candidates to report tinnitus. With expanding cochlear implant candidacy, more patients with hearing loss and tinnitus consider using a cochlear implant. Emerging research demonstrates that cochlear implants, while restoring binaural hearing, may also be an effective tinnitus treatment for patients with severely debilitating tinnitus who do not benefit from traditional management approaches (Assouly et al., 2021; Borges et al., 2021; Yuen et al., 2021). See the ASHA Practice Portal page on Cochlear Implants for more information.
At the time of this page’s publication, tinnitus is not an approved indication for cochlear implant use by the United States Food and Drug Administration. The audiologist or surgeon recommending cochlear implantation as a treatment for tinnitus is responsible for maintaining up-to-date knowledge of research associated with cochlear implantation and providing patient counseling on pertinent issues. As indicated in the ASHA Code of Ethics (ASHA, 2023), professionals may practice only in areas in which they are competent, based on their education, training, and experience.
In making prudent recommendations for a patient with bothersome tinnitus, current knowledge of the various management options available and careful review of supporting or opposing scientific evidence (or lack thereof) are essential.
Awareness of and familiarity with the variety of tinnitus management options currently being used and/or studied will allow the audiologist to respond to patient questions and/or concerns. Examples of other tinnitus management options 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 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 for some individuals, causing emotional distress and negatively impacting quality of life. Intervention may include one or more of the following options.
Patients presenting with complaints of hyperacusis may benefit from 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. Professional referrals may also be considered to address the psychosocial aspects of hyperacusis.
Education may include information relating to the patient’s specific case of hyperacusis as well as potential management strategies. See the ASHA Practice Portal page on Counseling for Professional Service Delivery and the ASHA resource on health literacy for more information on communicating with patients and family members.
Referral to a trained and licensed professional for psychotherapy may be indicated. 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 tinnitus retraining therapy (TRT) may also be used successfully in the management of a patient with hyperacusis (Mraz & Folmer, 2003). TRT is a habituation-based intervention involving detailed counseling and education. Some type of sound input and/or enriched sound is often included.
Hyperacusis activities treatment is based on the protocol for tinnitus activities treatment. 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. This is not generally advisable when environmental sound levels are safe. Avoiding 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 hyperacusis (Formby et al., 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 (e.g., neurology, psychiatry, occupational therapy, psychology, primary care professionals). The appropriate referrals may depend on whether a specific cause has been identified.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. www.asha.org/policy/
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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]. https://www.asha.org/Practice-Portal/Clinical-Topics/Tinnitus-and-Hyperacusis/