Hyperacusis vs Tinnitus: Questions, Symptoms and Next Steps

No, hyperacusis and tinnitus are not the same thing, though they can show up together. Hyperacusis is sensitivity to everyday sounds: a noise most people tolerate can feel painful, uncomfortable or frightening to you. Tinnitus is hearing a sound, such as ringing, buzzing or hissing, when no sound from outside is causing it. The American Speech-Language-Hearing Association (ASHA) notes that the two may exist on their own or together.

How do hyperacusis and tinnitus differ?

The easiest way to separate them is to ask where the sound comes from. Tinnitus is a sound with no outside source. Hyperacusis starts with an ordinary outside sound, and the problem is how loud or unpleasant that sound feels to you. The table sets out the main differences as the sources describe them.

What is sound sensitivity?

Sound sensitivity is another way of describing hyperacusis. ASHA defines hyperacusis as an intolerance to, or a discomfort (physical, emotional or both) with, sounds that the average listener with typical hearing finds acceptable. The reactions can be strong enough to make people avoid routine situations, and they can significantly change a person’s life. ASHA also says hyperacusis varies in severity.

What does it feel like?

London paediatric ENT surgeon Daniel Tweedie describes hyperacusis on his tinnitus and hyperacusis page as discomfort or pain from everyday loud noises. His examples include hairdryers, hand dryers, noisy classrooms, roadworks and police sirens. He notes that some children find hairdryers upsetting but have no difficulty in a noisy playground.

ASHA says the reactions can be physical, emotional or both, and it groups them into four categories: loudness, annoyance, fear and pain.

What are the symptoms of hyperacusis?

The main sign is discomfort or intolerance with ordinary sounds. ASHA also lists the problems that can come with it, which apply to tinnitus or hyperacusis: difficulty concentrating, difficulty following conversations, difficulty resting and relaxing, difficulty sleeping, emotional distress, social isolation and avoidance.

What causes hyperacusis?

ASHA says that in many cases the cause is not known. ASHA says hearing loss of any cause can contribute to some forms of hyperacusis. Tweedie’s page adds that some people with underlying stress or anxiety find certain sounds more distressing than others do. It also says hyperacusis is seen in some people with a degree of hearing loss, such as children with glue ear and older people with age-related loss at high frequencies.

Does hyperacusis come and go?

Yes, it can. ASHA says hyperacusis can fluctuate, so it may help to repeat some loudness measurements. Its severity also varies from person to person.

What is tinnitus, and what can cause it?

Johns Hopkins Medicine describes tinnitus as the sound of ringing, roaring, buzzing, hissing or clicking inside the head. The sounds range from a mild distraction to a disabling condition. Hopkins says tinnitus may be caused by many things, including various types of hearing loss, exposure to loud noise, ear and sinus infections, head or neck injury, reaction to certain medicines, wax buildup and jaw misalignment. Cleveland Clinic’s tinnitus service describes two types: somatosensory tinnitus, which is sound you perceive when you move your jaw or neck muscles, and subjective tinnitus, which only you can hear.

Harvard Health reports that Harvard Medical School scientists are finding evidence of “hidden” hearing loss. This is damage to the auditory nerve, which carries sound signals from the ear to the brain, that conventional hearing tests do not pick up. In the tinnitus research, the nerve in focus is therefore the auditory nerve.

Can hyperacusis and tinnitus occur together?

Yes. ASHA says tinnitus and hyperacusis may exist independently or together. It reports that people with associated diagnoses such as Williams syndrome, autism spectrum disorder or tinnitus have higher rates of hyperacusis, from 4.7% to 95%, than the general population. For comparison, ASHA cites the 2014 National Health Interview Survey, in which 5.9% of adults aged 18 and older described sensitivity to day-to-day noises.

Hearing loss is another link. ASHA says hearing loss of any cause makes tinnitus more likely and can also contribute to some forms of hyperacusis. For people with bothersome tinnitus, ASHA says a properly fitted and objectively verified hearing aid has been shown to help in some individuals.

Is hyperacusis dangerous?

ASHA says hyperacusis can be debilitating for some people, causing emotional distress and negatively affecting quality of life. Tweedie’s page says exposure to most everyday loud sounds is unlikely to damage the ears. He lists exceptions such as unmuffled car or motorcycle exhausts, firearms, power tools and construction or DIY work.

Why should advice about ear protection be individualized?

Whether to use ear protection depends on how loud the sound is and why you are using it. ASHA says some people with hyperacusis find that hearing protection helps them avoid disturbing sounds. It adds that this is not generally advisable when environmental sound levels are safe. Avoiding sounds can make the auditory system more sensitive to them, which can make hyperacusis worse, according to research ASHA cites from 2003.

Tweedie’s page makes the same point from another angle. It says that, in most cases, building up exposure to loud sounds in non-threatening settings is better than shielding yourself from them, which can make things worse.

In practice, protect your hearing from sounds loud enough to damage it, and ask your audiologist whether protection in everyday situations is helping or adding to the problem.

What does a hyperacusis test involve?

ASHA describes an assessment that starts with your history. This covers other health results, how the hyperacusis shows up, any history of posttraumatic stress disorder or exaggerated startle response, balance problems, tinnitus, difficulty concentrating and pain. Otologic and audiologic assessment follows, to help tell hyperacusis apart from other causes.

A key measure is the loudness discomfort level (LDL) or uncomfortable loudness level (ULL). This is the point at which a sound becomes uncomfortable for you. ASHA says it may help to take this measurement several times, because hyperacusis can fluctuate. Some people with hyperacusis may not tolerate standard audiologic testing. ASHA also lists questionnaires used in assessment, including the German Questionnaire on Hypersensitivity to Sound, the Modified Khalfa Hyperacusis Questionnaire and the Multiple Activity Scale for Hyperacusis. If you also have balance complaints, balance testing may be added.

For tinnitus, Johns Hopkins Medicine says the diagnosis includes a complete health history and physical exam, and your provider may request an audiological evaluation.

What can an ENT do for hyperacusis?

An ENT is a doctor who works on the ear, nose and throat. ASHA says assessment of tinnitus or hyperacusis may result in recommendations for management and/or referral to medical professionals, and psychosocial referrals are also considered. Cleveland Clinic’s tinnitus service asks people to see an otolaryngologist first, so that any condition needing medical or surgical treatment is ruled out.

How are hyperacusis and tinnitus treated?

There is no single fix. Cleveland Clinic says there is often no one answer on how to make tinnitus go away, and that it can take several treatments done at the same time to find relief.

Hyperacusis treatment

ASHA lists education and counseling, cognitive behavioral therapy (CBT) and sound therapy among the options for hyperacusis. CBT is a type of therapy that focuses on problem emotions, thoughts and behaviors. ASHA lists continuous low-level broadband noise, music or environmental sounds, and gradual increases in the maximum output of a hearing aid or ear-level sound generator as sound therapy options for hyperacusis. ASHA also notes that the general principles of tinnitus retraining therapy (TRT), a habituation-based intervention with counseling and education, may be used for hyperacusis.

What exercises can help with hyperacusis?

The closest things to exercises in these sources are gradual exposure and sound therapy. Tweedie describes building up exposure to loud sounds in non-threatening settings, for example a young child going to a playground or park. ASHA describes the gradual sound therapy described above. Ask your audiologist how to start, and how to progress.

Tinnitus and hyperacusis treatment together

Cleveland Clinic’s tinnitus service lists cognitive behavioral therapy and other behavioral therapies, coping strategies such as auditory distraction, sound therapy, oral appliances for jaw and neck muscle pain, and physical therapy. It says its experts may suggest adjusting certain medications when tinnitus is a side effect. Do not change any medicine on your own; talk with the prescriber first.

Self-help ideas from the sources

• Quiet times (tinnitus). Tweedie notes that tinnitus can be more pronounced at quiet times, such as settling down to sleep. For tinnitus, he says some people find low background noise helpful, from options such as apps, a fan, an air purifier or a white noise generator. This is tinnitus advice, not a hyperacusis treatment; ASHA describes hyperacusis sound therapy as clinician-guided and gradual.
• Don’t avoid everything. Tweedie says avoidance generally makes the apprehension around loud sounds worse. ASHA says avoiding sounds can make the auditory system more sensitive.
• Thoughts and outlook. Tweedie says being aware that serious underlying causes are rare, and being optimistic, will generally make symptoms less intrusive over time. For tinnitus specifically, he also says it usually improves with time, and without specific treatment.
• Stress and anxiety. Tweedie says attention to underlying stresses and anxieties is important in some cases.

What does the research show?

Here is what the main studies found, and where they stop.

The research has real limits. ASHA says there is a lack of consensus and standardization on how tinnitus is defined, measured, assessed and managed. It also says the prevalence figures vary substantially, partly because assessment and diagnosis methods are inconsistent. Much of the mechanism work comes from animal models, and a 2013 review in Hearing Research notes that it is not clear what the various animal tests are reflecting. The studies offer possible explanations. They do not tell you which one is behind your symptoms, so the next step is an assessment, not a guess.

What should I bring to my next appointment?

Johns Hopkins Medicine offers practical tips for getting the most from a visit:

• Write down the reason for your visit and what you want to happen.
• Write down your questions before you go.
• Bring someone to help you ask questions and remember what you are told.
• Write down any new diagnosis, medicine, treatment, test or direction.
• Ask whether your condition can be treated in other ways, and why a test is recommended and what the results could mean.

Also note which sounds bother you most and when they happen. If your ringing is on one side only, read tinnitus in one ear before your visit. Tweedie’s page notes that an MRI may be requested in cases of one-sided symptoms.

What is the next step?

Book a visit with an audiologist or an ENT. ASHA says audiologists conduct a comprehensive assessment of hearing, auditory function, balance and related systems, and refer to appropriate professionals to rule out other conditions. Cleveland Clinic’s tinnitus service asks people to have a hearing test during the six months before the first appointment.

Get checked sooner if your ear hurts, you have trouble hearing, or home remedies do not help. A Cleveland Clinic ear, nose and throat specialist says it is smart to seek medical evaluation in those cases, as explained in the Cleveland Clinic earwax removal guide. If you are unsure whether your ear symptoms need a clinician, read what can be mistaken for an ear infection.

By the Connected Diagnostics Evidence Team

This article is for general information purposes only and does not constitute medical advice. Consult your doctor or qualified healthcare provider before making changes to your health routine.

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