Intervention for restricted dynamic range and reduced sound tolerance: Clinical trial using a Tinnitus Retraining Therapy protocol for hyperacusis
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Hyperacusis is the intolerance to sound levels that normally are judged acceptable to others. The presence of hyperacusis (diagnosed or undiagnosed) can be an important reason that some persons reject their hearing aids. Tinnitus Retraining Therapy (TRT), a treatment approach for debilitating tinnitus and hyperacusis, routinely gives rise to increased loudness discomfort levels (LDLs) and improved sound tolerance. TRT involves both counseling and the daily exposure to soft sound from bilateral noise generator devices (NGs). We implemented a randomized, double-blind, placebo-controlled clinical trial to assess the efficacy of TRT as an intervention for reduced sound tolerance in hearing-aid eligible persons with hyperacusis and/or restricted dynamic ranges. Subjects were assigned to one of four treatment groups (2x2): Devices: NGs or placebo NGs and Counseling: Yes or No. They were evaluated at least monthly on a variety of audiometric tests, including LDLs, the Contour Test for Loudness for tones and speech, and word recognition measured at each session's comfortable and loud levels. Eighty percentage of the participants who received full treatment benefited significantly; whereas the other treatment groups demonstrated ≤ 45% treatment efficacy. Treatment dynamics and examples of improved word recognition post-treatment will be described. [Work supported by NIH R01 DC04678.]Keywords:
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Hyperacusis, as defined here, is a relatively rare condition in which the patient, with or without hearing loss, experiences severe loudness discomfort to everyday environmental sound levels. The case studies of 14 patients with severe hyperacusis are described; all wore passive attenuators (earplugs and/or earmuffs) in an attempt to alleviate their discomfort, frequently producing communication difficulties. These subjects were fitted binaurally with experimental electronic loudness suppression devices housed in in-the-ear casings. The devices supplied low-level amplification followed by an extreme form of amplitude compression for moderate or high-level inputs in an attempt to reduce loudness discomfort without reducing audibility. Many of the subjects were found to function with a wider dynamic range with the active devices compared with passive attenuators or the unoccluded ear, and most reported that they benefited from the devices in at least some listening situations.
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Patients visiting the department of Otorhinolaryngology-Head and Neck Surgery often recite tinnitus as the primary complaint. Frequently, tinnitus is accompanied by other symptoms such as hyperacusis and hearing loss. The present study is a cross-sectional study analyzing the relationships between tinnitus, hearing loss, and hyperacusis by the use of the audiologic measurements performed in a clinical practice.All patients visiting the Otorhinolaryngology-Head and Neck Surgery department of the University Hospital Antwerp with complaints of tinnitus (sometimes accompanied by hyperacusis) during the year of 2012, were looked up (n = 588). All patients underwent audiometry and filled out the Tinnitus Questionnaire (TQ) and Hyperacusis Questionnaire (HQ), and tinnitus analysis was performed. The relationships between all measurements were examined by use of correlations, multinomial logistic regression analyses, and descriptive statistics.Scores on the TQ and HQ were significantly positively correlated (r = 0.5, p < 0.001). In general, patients with a combination of tinnitus and hyperacusis showed significantly higher TQ scores (p < 0.001) and higher ratings on the VAS for loudness and distress (p < 0.001) compared with tinnitus patients without hyperacusis. Furthermore, an age-dependent influence on the audiometric configuration and tinnitus type was found.Tinnitus and hyperacusis are two frequent symptoms recited at a consultation. The present study found that patients with a high TQ grade more often also perceive hyperacusis compared with patients with a low TQ grade.Tinnitus and hyperacusis are two frequent symptoms recited at a consultation. We have to point out that also other issues, such as additional health problems and stress, may influence tinnitus severity. In addition, tinnitus type seems to be age dependent as younger patients more often experience a pure tone tinnitus and older patients more often experience a noise-like tinnitus.
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Increased auditory sensitivity, also called hyperacusis, is a pervasive complaint of people with tinnitus. The high prevalence of hyperacusis in tinnitus subjects suggests that both symptoms have a common origin. It has been suggested that they may result from a maladjusted increase of central gain attributable to sensory deafferentation. More specifically, tinnitus and hyperacusis could result from an increase of spontaneous and stimulus-induced activity, respectively. One prediction of this hypothesis is that auditory sensitivity should be increased in tinnitus compared with non-tinnitus subjects. The purpose of this study was to test this prediction by examining the loudness functions in tinnitus ears (n = 124) compared with non-tinnitus human ears (n = 106). Because tinnitus is often accompanied by hearing loss and that hearing loss makes it difficult to disentangle hypersensitivity (hyperacusis) to loudness recruitment, tinnitus and non-tinnitus ears were carefully matched for hearing loss. Our results show that auditory sensitivity is enhanced in tinnitus subjects compared with non-tinnitus subjects, including subjects with normal audiograms. We interpreted these findings as compatible with a maladaptive central gain in tinnitus.
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Although tinnitus represents a major global burden, no causal therapy has yet been established. Ongoing controversies about the neuronal pathophysiology of tinnitus hamper efforts in developing advanced therapies. Hypothesizing that the unnoticed co-occurrence of hyperacusis and differences in the duration of tinnitus may possibly differentially influence the neural correlate of tinnitus, we analyzed 33 tinnitus patients without (T-group) and 20 tinnitus patients with hyperacusis (TH-group). We found crucial differences between the T-group and the TH-group in the increase of annoyance, complaints, tinnitus loudness, and central neural gain as a function of tinnitus duration. Hearing thresholds did not differ between T-group and TH-group. In the TH-group, the tinnitus complaints (total tinnitus score) were significantly greater from early on and the tinnitus intensity distinctly increased over time from ca. 12 to 17 dB when tinnitus persisted more than 5 years, while annoyance responses to normal sound remained nearly constant. In contrast, in the T-group tinnitus complaints remained constant, although the tinnitus intensity declined over time from ca. 27 down to 15 dB beyond 5 years of tinnitus persistence. This was explained through a gradually increased annoyance to normal sound over time, shown by a hyperacusis questionnaire. Parallel a shift from a mainly unilateral (only 17% bilateral) to a completely bilateral (100%) tinnitus percept occurred in the T-group, while bilateral tinnitus dominated in the TH-group from the start (75%). Over time in the T-group, ABR wave V amplitudes (and V/I ratios) remained reduced and delayed. By contrast, in the TH-group especially the ABR wave III and V (and III/I ratio) continued to be enhanced and shortened in response to high-level sound stimuli. Interestingly, in line with signs of an increased co-occurrence of hyperacusis in the T-group over time, ABR wave III also slightly increased in the T-group. The findings disclose an undiagnosed co-occurrence of hyperacusis in tinnitus patients as a main cause of distress and the cause of complaints about tinnitus over time. To achieve urgently needed and personalized therapies, possibly using the objective tools offered here, a systematic sub-classification of tinnitus and the co-occurrence of hyperacusis is recommended.
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Objective Determine if somatic tinnitus patients with hyperacusis have different characteristics from those without hyperacusis. Patients and methods 172 somatic tinnitus patients with (n = 82) and without (n = 90) hyperacusis referred to the Tinnitus Unit of Sapienza University of Rome between June 2012 and June 2016 were compared for demographic characteristics, tinnitus features, self-administered questionnaire scores, nature of somatic modulation and history. Results Compared to those without hyperacusis, patients with somatic tinnitus and hyperacusis: (a) were older (43.38 vs 39.12 years, p = 0.05), (b) were more likely to have bilateral tinnitus (67.08% vs 55.56%, p = 0.04), (c) had a higher prevalence of somatic modulation of tinnitus (53.65% vs 36.66%, p = 0.02) and (d) scored significantly worse on tinnitus annoyance (39.34 vs 22.81, p<0.001) and subjective hearing level (8.04 vs 1.83, p<0.001). Conclusion Our study shows significantly higher tinnitus modulation and worse self-rating of tinnitus and hearing ability in somatic tinnitus patients with hyperacusis versus somatic tinnitus patients without hyperacusis. These differences could prove useful in developing a better understanding of the pathophysiology and establishing a course of treatment for these two groups of patients.
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Tinnitus is an auditory sensation in the absence of external sounds; its neural mechanisms remain unclear. An active loudness model suggests that tinnitus is a result of increased central noise while hyperacusis is that of increased central gain. To the extent that loudness reflects the system-level neural activities, this active model predicts that tinnitus increases loudness at thresholds but does not increase the slope of loudness function. To test this prediction, the present study compared loudness growth of various stimuli between tinnitus and non-tinnitus subjects. The stimuli were tested at frequencies without hearing loss and both tinnitus and non-tinnitus subjects had unremarkable hyperacusis. Consistent with the prediction, the loudness at threshold in tinnitus subjects were 2.3 times greater than that in non-tinnitus subjects; there was no significant difference in the slope of loudness growth between these two groups of subjects. The present result shows that traditional psychophysics, originally developed to investigate relationships between subjective sensation and physical stimulation, can also help delineate neural mechanisms underlying tinnitus and other disorders.
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Tinnitus in in-patients at our clinic is evaluated on a five-score scale for each of the following three characteristics:1) subjectively reported loudness; 2) degree of annoyance; and 3) interference with life activities. In the present study we evaluated the influence of these characteristics upon the clinical course and overall condition of our tinnitus patients. Our conclusions were as follows:(1) There was a fair degree of correlation among the scores for the three categories, but individual patients showed various combinations of scores for the three scales. The combined use of all three categories is therefore felt to be important.(2) 73% of the tinnitus patients showed loudness lev e l under 10 dB as measured by the loudness balance method. Subjectively reported loudness levels of patients with measured tinnitus under 10 dB were found to differ from those of patients with measured tinnitus above 10 dB.(3) While evaluation of externally-simulated tinnitus sounds by normal controls and hearing loss patients are uniformly correlated with the actual loudness of the simulated sound, this result was not obtained in tinnitus patients.(4) Investigation of the relationships among the 3 characteristics proved useful in overall assessment of the condition of the tinnitus patients.(5) Tinnitus patients whose scores for the “degree of annoyance” and “interference with life activities” categories were unusually high in relation to the subjective level of loudness tended to have physical or mental problems in addition to their tinnitus.(6) In addition to their scores for the 3 categories described above, patients were evaluated on a scale from 0 to 100 for subjective loudness, with the loudest tinnitus in that patient's experience being rated as 100. This parameter appeared to be broadly influenced by such non-tinnitus factors as lack of sleep and depression.(7) In patients who showed decreases in the d egree of annoyance and/or interference with life activities without any accompanying improvement in tinnitus loudness, it was concluded that the original degree of annoyance or interference with life activities had been exaggerated by the patient. Combined use of the 3-category scale and the 100-point scale yielded the most accurate evaluation of clinical progress.
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The patients with tinnitus and/or hyperacusis undergoing an 18-24 month period of TRT are divided into five categories of treatment. Different types of counselling and sound therapy are used in each category. Selection of patients into a specific category depends on such factors as: hyperacusis, subjective hearing loss and long-lasting effect of noise on tinnitus. The 108 cases were evaluated After 1 year of treatment. The results of therapy of 40 patients with tinnitus and subjective hearing loss (category II) were compared with the results of therapy of patients with tinnitus only (categories 0 and I). A special questionnaire, answered before and during the treatment, was used to assess the results. Our data indicate significant improvement in about 70% of patients with tinnitus only and in about 90% of patients with tinnitus and subjective hearing loss after one year of therapy.
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