Many people with sound sensitivity have great apprehension about any testing that involves presenting noise or tones or other sounds to the ears. They have been tested before, using methods that may have caused discomfort or even pain, and these experiences have created a fear of future testing.
Hyperacusic patients require special care and considerations. Many times, testing that may be perfectly acceptable to the vast majority of people, will cause discomfort to this group. Many people with sound sensitivity find that presentations louder than quiet normal conversational levels are difficult to tolerate. This means that many standard tests completed by audiologists and often physicians may create problems for this population.
Understandably, we must assess the physiology of the person to discover any conditions that may be underlying the condition of hyperacusis. Sometimes, we simply must cause some discomfort to find out what the situation really is, and to also see what can be done in the way of treatment or therapies.
However, there are many audiologic tests that can be avoided or changed a bit to lessen the impact of the sound upon the person's fragile physique. All presentations of tone or noise should begin at sub threshold levels and increase from there, for example. Sudden sound tests should begin at the lowest possible levels to avoid excessive noise levels.
Patients should be warned in advance of sound tests and carefully informed about what is to come in the procedure, and why it is happening. Armed with information, i.e., this sound will last about 3 seconds, most patients can complete the test sequence.
All people who suspected of hyperacusis should consult an otologist and an audiologist. The audiologist would find the baseline thresholds for air and bone conduction, and measure the discomfort levels using 1 tone at a time, gradually walking up the loudness levels of the tone presentations. Patients who fall below the average tolerance level of 90 dB for tones, and 90-95 dB for monitored live voice, should be regarded as having sensitivity to sound.
At this point in time, there are NO objective tests for confirming hyperacusis. The most common subjective behavioral test administered by audiologist is the Loudness Discomfort Level Tests (LDL) that can be given using tones, speech, or recorded voices. A normal LDL will extend up to 90 dB or greater across the range of pitches, from low to high.
An abnormal LDL test will show reduced or collapsed ranges of tolerance, often more severe in the higher pitches. It is important to administer the LDL test in a particular way to obtain the most accurate results, and to inform the person being tested as to the protocol for the test. One important aspect is to be sure the sound is turned off, then on, between each gradually louder tone presentation. This elicits a strong response from the outer hair cells in the cochlea, and provides a more accurate measurement of the person's loudness tolerance levels.
Hyperacusis can fluctuate as well depending on state of mind, fears, other conditions present such as pain or anxiety. Several measurements should be obtained over time to create a realistic picture of a person's LDL average (also known as the Johnson Hyperacusis Quotient).
To calculate your Johnson's Hyperacusis Quotient, obtain your audiogram. Note the auditory threshold for each ear at these frequencies: 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz. Note the level of the LDL test (loudness discormfort test) at each of these pitches. Now, find the dynamic range of each ear at those five pitches, i.e., Left ear, 1000 Hz, threshold was 15 dB, LDL was 55 dB, range is 40 dB. Calculate the range for each pitch for each ear. Add up all the left ear ranges and divde by 5, and you will have the average range or quotient for that ear. Do the same for the right ear. Now you will see your average quotient for each ear.
If you have perfect hearing or close to it, your thresholds will be close to zero across the pitches and the normal hearing ear can tolerate to 90 dB at each pitch without discomfort. That would result in a quotient of 85-90 per ear. If you have hearing within normal limits for adults in this country, i.e., up to 25 dB at all pitches per year, and normal LDLs up to 90 dB at each pitch, then your dynamic range is going to be around 70 dB. People with dynamic ranges of 70 dB or less are likely to have either hyperacusis or recruitment. Severe cases will have a quotient of 20 dB or less.
People who have significant hearing loss may also have a type of sensitivity known as recruitment. People can have a combination of hyperacusis and recruitment, or one of these conditions all by itself. People with recruitment often find that they can improve their sound tolerance by using the hearing aid for a period of time (3-6 months).
Evaluations for the severe-profound hyperacusis require special training and professionalism by the audiologists. There is a fine list of approved clinicians at Dr. Pawel Jastreboff's website.
Here is a Recent Article Written by Dr. Marsha Johnson
THE VISIT TO THE EAR DOCTOR FOR THE CONDITION OF HYPERACUIS
Ok let us consider what the ear physician is thinking perhaps when you enter into the clinic, this might help you a bit:
Number 1) examine your body for physical damage. To accomplish this, the MD is going to look into the ear canal. What one can see in the ear canal is the canal itself, the eardrum sitting at the end of the canal, a vague blurry visual of the outermost bones of the middle ear, and that is about it. If the drum is red or there is fluid in the middle ear space, the MD can see that. If the drum is fluttering or tensing, the MD can also see that, in many cases. However, the inner ear, most of the middle ear area including the tiny ligaments that are attached to the bones, the vestibular system, and all of the nerves, are not visible to the eye of the MD. No one can 'see' tinnitus or 'see' hyperacusis.
Number 2) Examine the auditory-vestibular system. Here the MD will defer to the Audiologist who is the expert in the AV system. The audiologist has many tools at hand to examine the inner workings of the ear, including probing the middle ear space with tympanometry, the inner ear with electrophysiological testing, the vestibular system with VNG or other tests, to examine the neural firing and timing of various cells, right up past the brainstem area and into the central nervous system. The audiologist will determine which tests are needed in order to complete a full examination of the 'unsee-able' portions of the auditory-vestibular system and send a report to the MD. Sometimes the Audiologist is located in the MD office, more often, these days, is located nearby in their own office. There are specialty audiology clinics coming along that will focus on areas like tinnitus or hyperacusis, balance or dizziness, cochlear implants, or other fields.
Number 3) the MD will consider all the results and determine if there is any method within his scope of practice that will help. The neuro otologist is often well trained in surgery, and to date, there are only rare cases when hyperacusis or tinnitus warrants or benefits from, surgery. There seems to be a bit of an increase in looking at Decompression of a Vascular Loop (located inside the head near the opening of the internal ear-canal that forms a channel for the major nerves that lead from the inner ear to the brainstem area). Decompression surgeries though, at least as far as I can tell, from the research, do not have uniform predictable outcomes, and many medical providers feel, rightly, that the risks of brain surgery far outweigh potential benefit! I agree. So the MD is going to consider surgery for patients with tinnitus, perhaps, but never for hyperacusis, as hyperacusis, for one thing, has no single focal point, it is a SYSTEM wide problem, in a sense, and in any case, despite any fantasies, the structures we are speaking about are so incredibly small, surgery is simply not even conceivable. It would be like asking a giant to tiptoe through a bed of violets without crushing any. Literally an impossibility.
So, the MD is unable to use his primary skill here, which is surgery.
Number 4 ) the MD at least the otologist, has seen hundreds of patients with tinnitus and a few less with hyperacusis. He or she has done their research well, they are usually very bright people with good memories and ability to recall lots of information, and they are going to be in a position of having to say, I cannot do much for you. If they are 'nice' they will listen a while, and try to recommend what IS known to be ongoing available treatments or options, but these fall outside their specialty area, so to speak, many times, and perhaps we might say, most otologists do not devote a lot of time to educate themselves as to the most current rehabilitation modes in the world of T & H, because it is simply not their 'thing'.
A nicer MD will listen to the critical information you are providing, refer to the Audiologist for examination, review the information, and conclude that there is no part of her or him to play in your recovery. This can happen in a matter of seconds. But remember that the otologist has seen many people before and you are simply one in a long line of people who went to ask the wedding cake baker, to fix your car engine! Ok. The GOOD thing is the the MD and the Audiologist can rule out or rule in some fairly serious potential medical conditions that could be the basis for your problems: tumors, inner ear fluid imbalance, serious neural defects including MS, fractures, ossicular chain breakage, middle ear problems, etc. etc. so you really should be thankful that the minds of the MD and the Audiologist are working to pan through a huge database of possible medical conditions, and you came up: ZERO!
That is good news! Oh yes, it is! Trust me, you do not WANT those medical conditions....nope.
Number 5 ) At the end of the visit, no matter how brief, the MD may do 2 things: the first is more common, which is to simply reassure the patient, you are fine, give it time, you will learn to live with it, you will be ok, use earplugs (by the way, that is not a good idea) , don't worry, etc. MDs say this because they is what they have been trained to say. If you look in their medical training books, the big texts for otologists and otolaryngologists, it says: REASSURE THE PATIENT. So MDs vary in personality and some are better than others. Like my black lab, a particular scent may be either extremely interesting, or not worth a sniff! And to the surgical MD, a person with hyperacusis is hardly worth a sniff! And yet, the nice ones will spend some time reassuring you. And with good intentions and all due respect, what happens next is the part that is really needed!
The 2nd option for the MD is this: to whom can I refer this person who needs something I cannot provide? This is a very grey area in medicine and in auditory science and in otology. Hyperacusis for many decades was considered a psychiatric illness and in many minds of MDs, it still is. Not physiological, but mental. An emotional condition like depression or whatever. And of course, the person with hyperacusis is going to present themselves with plenty of emotions: Hyperacusis can be HELL to live with, we here know that, it can change your entire life! It can make you tearful, angry, emotional, adrift, affect your cognition and your anxiety level, it can have a severe impact on your joie de vivre! And when you communicate this to the MD, and the test results (this is the real crux, even the Audiologist may not do any tests for hyperacusis!) show zip nada zero, the MD may decide at that moment, you are a nut-case, and mention counseling or refer to the psychologist! Or psychiatrist. Or the MD may decide, ah, I will give this person a prescription for a psychotropic medication that will address the 2ndary complaints: insomnia, anxiety, depression..etc...MDs often hand out prescriptions for some pills that can help with those, but most specialists do not want to be the primary provider of those pills, so many will refer back to the primary care physician or hope that the mentioning of the psychiatrist will lead to that end, without the otologist taking charge of the pills.
It if the otologist is up to date, then a referral to an Audiologist who focuses on T & H might happen. I would suggest to you that this happens about once in every so many visits: perhaps one MD otologist in every five visits,but it certainly has increased in the 10 years I have been in practice, and in the 20 years since Dr. Jastreboff brought the light to shine on the condition of Hyperacusis, with his single minded dedication to tinnitus and hyperacusis in research and presentations, and books, and articles, and interviews. Dr. Jastreboff alone has raised the shade on the formerly dark area of hyperacusis.
I can testify to this as about ten years ago, the largest T clinic in the country had identified only 4 cases of hyperacusis out of 16,000 patients with T. That rapidly changed once they began 'testing' for it! Now, like Dr. J found, they record that about 40 to 50 percent of people with T will have H. But notice, there are no large centers for H alone. And many people simply have H, not both T and H.
Ok. So the MD has 2 choices there: refer to the mental health people or to the auditory science people. The fact is, when we keep hyperacusis in the medical physiological world, it has a 'real' basis, and is recognized as a 'real' problem, and with a cellular basic or a neural malfunction, and clearly NOT the responsibility of the patient. For many reasons, psychological conditions are most often regarded as the patient's "FAULT" and therefore are assigned back to the patient's circle of responsibility, and this is quite unfair in my point of view, as this takes a medical problem and puts it back into the pocket of the victim........rather than seeing it as a distinct physical condition that requires care, time, healing, rehabilitation, and so on. Imagine taking a spinal cord injury and saying to that person, well, you are to see the mental health people as you are unable to walk and clearly this is is causing anxiety and depression and we need to explore WHY you are having those symptoms!
Please do not misunderstand me here: I value the mental health colleagues and have found over the years that the counseling and psychiatric care to be a very important resource for people with H. In my own clinic, there is a cognitive behavioral therapist who works with many patients so successfully. Of course we need them.
BUT if the Otologist's only referral is to the mental health folks, then they are ignoring the physiological aspects of H that may respond to rehabilitation based on the physical nature of the condition.
I apologize for the length of this point, but if you made it this far, good for you! The fact is, MDs are extremely effective and often very kind people, who have limited resources in the field of hyperacusis and who have extremely limited time to discover IF they can help you or not, for the most part, and once major big horrible things are ruled out, they have literally no tools in their tool boxes (with the lone exception of Michael Robb, practicing in Arizona, who is an otologist who has created a focus on T & H, and dear Dr. John Epley, in Portland, Oregon, who has set his incredible brainpower to work over many decades in the field of vestibular disorders but who with enthusiasm wanders off into the lands of T and H on occasion, in innovative fashion).
Besides those two otologists, the vast majority of medical specialists who dedicate themselves to hyperacusis are Audiologists, there are PhD scientists in the field, and Clinicians with either Master's degrees or like many of us perking along, Clinical Doctoral Degrees, the AuD.
So take heart, go rule out the monsters, and then listen to the referral ideas, gently help that MD or Audiologist to recognize and expand their referral bases, and be glad in a sense, when the MD sends you away. It is a good! Very good NOT to have any of those things that the otologist specializes in.....trust me!
The ENT can be characterized as above, but even more remote from the area of the hyperacusis....much more common than the Otologist, but covering the nose, throat, and ears!
Dr. Marsha Johnson
To learn more about evaluations and testing for hyperacusis, visit the Oregon Tinnitus & Hyperacusis Treatment Clinic.
Here is a recent Research Article Supporting the Use of the LDL test:
J Am Acad Audiol. 2005 Feb;16(2):85-100
Estimates of loudness, loudness discomfort, and the auditory dynamic range: normative estimates, comparison of procedures, and test-retest reliability.
University of Maryland, Baltimore, MD 21201, USA. [email protected]
The purpose of this series of experiments was to establish normative reference values for absolute and relative judgements of loudness discomfort and for the auditory dynamic range (DR), and to evaluate intersubject variability and intra-subject test-retest reliability for the respective measures of loudness discomfort. To establish the normal auditory DR, audiometric thresholds and loudness discomfort levels (LDLs) were measured from a group of 59 normal-hearing adults without sound tolerance problems. The resulting estimates of the LDL and DR were on the order of 100 dB HL and 95 dB, respectively. A subset (n = 18) of this larger group participated in further studies in which loudness growth functions and the upper limit of the auditory DR were measured by categorical scaling judgments. The findings revealed no significant differences between the test methods for absolute (LDL) and relative (categorical scaling) judgements of loudness discomfort, intersubject variability, or intrasubject test-retest reliability, and suggest that the simple LDL estimate of loudness discomfort is an efficient and valid clinical measure for characterizing the "threshold of discomfort."
