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American Journal of Audiology logoLink to American Journal of Audiology
. 2023 Nov 2;32(4):950–961. doi: 10.1044/2023_AJA-23-00118

Hyperacusis Diagnosis and Management in the United States: Clinical Audiology Practice Patterns

Kelly N Jahn a,b,✉, Chelsea E Koach a,b
PMCID: PMC11001428  PMID: 37917915

Abstract

Purpose:

Hyperacusis often leads to debilitating psychosocial consequences, but there is no standard protocol for its diagnosis and management in the United States. In this study, we surveyed U.S. clinical audiologists to understand their education and clinical practices surrounding the evaluation and treatment of hyperacusis.

Method:

An online survey was distributed to clinical audiologists across the United States. Survey responses were quantified using descriptive statistics and inductive content analysis.

Results:

Hyperacusis definitions and clinical practice patterns varied widely across the 102 respondents. Respondents cited a lack of education and training as the primary barrier to effective audiological diagnosis and management of hyperacusis, with most respondents reporting ≤ 5 hr of hyperacusis education. Other primary barriers to effective audiological management of hyperacusis included time constraints, reimbursement, poor sensitivity and specificity of available diagnostic tools, and poor efficacy of available treatments and management strategies. Most respondents (82.5%) agreed that audiologists are the primary professionals who are responsible for implementing hyperacusis interventions. However, 63.3% of respondents reported that their clinic does not have a hyperacusis management protocol, and 80.0% routinely recommend treatment that is outside their scope of practice to implement (cognitive behavioral therapy).

Conclusions:

Clinical audiologists in the United States do not receive uniform education on hyperacusis, and they report multiple barriers to its evidence-based diagnosis and management. Effective hyperacusis management necessitates a multidisciplinary approach. The information obtained via this survey will pave the way toward the refinement of interprofessional education programs and the development of systematic, evidence-based clinical protocols for hyperacusis.

Supplemental Material:

https://doi.org/10.23641/asha.24431188

As many as 15.2% of adults (Fabijanska et al., 1999) and 17.1% of children (Rosing et al., 2016) experience hyperacusis. In broad terms, hyperacusis represents a reduced tolerance to sounds that are well-tolerated by individuals who do not have hyperacusis (Adams et al., 2020). An individual's ability to tolerate sound depends on a variety of physical, emotional, and perceptual factors. From a psychoacoustic perspective, hyperacusis is often conceptualized as a disorder of loudness perception, where moderately intense sounds are judged to be very loud or uncomfortable relative to what a person without hyperacusis would perceive (Fowler, 1965; Tyler et al., 2014). Individuals with hyperacusis can also report negative emotional reactions to sound (e.g., annoyance, fear, distress) that may occur independent of the loudness percept (Baguley & Andersson, 2007; Tyler et al., 2014; Urnau & Tochetto, 2011). Some individuals experience physical pain at sound levels much lower than individuals who do not report hyperacusis (Baguley & Andersson, 2007; Tyler et al., 2014). Those with bothersome hyperacusis who seek clinical intervention can present with any combination of these symptoms to varying degrees of severity.

Despite the high estimated prevalence of hyperacusis (Andersson et al., 2002; Fabijanska et al., 1999; Rosing et al., 2016) and the profound negative impact that it can have on an individual's quality of life (Jüris et al., 2013), its diagnosis remains largely subjective (Jahn, 2022) and there are no universally effective treatments (Baguley & Hoare, 2018). Aside from a standard hearing evaluation (Jahn & Polley, 2023), uncomfortable loudness level (ULL) testing is the only auditory assessment that the American Speech-Language-Hearing Association (ASHA) recommends to assist in the differential diagnosis of hyperacusis (ASHA, 2018). In general, a ULL represents the lowest intensity level that an individual judges to be uncomfortably loud for a given stimulus. Although ULLs are often abnormally low in adults who report hyperacusis, the range of ULLs varies widely across studies and patient populations (Aazh et al., 2018; Aazh & Moore, 2017; Jahn, 2022; Sheldrake et al., 2015), and they are not sensitive or specific enough to be taken as a sole diagnostic indicator of hyperacusis (Jahn, 2022). Moreover, clinicians must rely on patient self-report and questionnaires to evaluate and monitor sound tolerance symptoms that are not captured by psychoacoustic tests of loudness perception, such as emotional reactions or physical pain (ASHA, 2018; Jahn, 2022).

Given the lack of sensitive, evidence-based protocols for the diagnosis and management of hyperacusis, there is a pressing need to understand what audiologists typically do when individuals who report hyperacusis seek evaluation and treatment. In this study, we aim to understand current trends in the audiological diagnosis and management of hyperacusis in the United States. To address this goal, we developed a targeted questionnaire based on a review of similar published surveys of clinical audiology practice patterns (Emanuel et al., 2011; Flores & Gustafson, 2022; Stoup et al., 2022). This information will provide a crucial step toward improving hyperacusis education and training and in developing standard clinical protocols for working with patients who have hyperacusis and difficulty tolerating sound.

Method

This study was approved by the institutional review board of The University of Texas at Dallas. An anonymous online survey was developed in REDCap (Harris et al., 2019) and distributed to U.S. clinical audiologists via e-mail, local and national professional organizations, social media, and the university website. Specifically, the survey was shared via e-mail with one professional audiology organization from each state (e.g., Texas Academy of Audiology). In cases where the state did not have a dedicated audiology organization, the survey was shared with the state's speech-language-hearing association. The survey was also posted on professional discussion forums within the ASHA website, within three large professional Facebook groups (two for clinical audiologists and one for faculty in communication sciences and disorders), and via the laboratory's website and Twitter account. A snowball sampling technique was used, wherein respondents were encouraged to pass the survey on to others who might be interested or eligible to participate. Note that the use of a snowball sampling method precludes the ability to estimate a survey return rate. The data collection period ran from June 2022 through November 2022.

Licensed audiologists who had worked clinically within the previous 12 months were eligible to participate. Individuals whose primary professional responsibilities included teaching, research, and/or administration were not eligible to participate.

The survey was designed to address five primary research questions:

  1. How do audiologists define hyperacusis?

  2. What formal education and training on hyperacusis do audiologists receive? Where do they receive that training?

  3. Do audiologists employ a hyperacusis test battery in their clinics? If so, what tests do they routinely administer as part of that test battery?

  4. Do audiologists routinely recommend interventions for hyperacusis? If so, what types of interventions do they recommend?

  5. What are the limitations, if any, to the audiological diagnosis and management of hyperacusis in the United States?

Additional survey questions collected relevant demographic information including age, sex and gender identity, education level, clinical specialties, years of professional experience, employment setting, and self-reported hearing status.

The full survey is available in the enhanced online content associated with this article (Supplemental Material S1). Before beginning the survey, the respondents confirmed their eligibility by indicating that they were older than age 18 years and that they had practiced as a clinical audiologist within the previous 12 months. The main survey consisted of 46 questions (40 multiple-choice questions and six free-response questions). Seven of the multiple-choice questions had a conditional follow-up question that appeared depending on the respondent's answer to the previous question (as denoted in Supplemental Material S1). Most of the multiple-choice questions had an “Other” option, which allowed respondents to define their own answer choice. At the end of the survey, respondents had the opportunity to provide open-ended feedback.

Here, we summarize the data most relevant to the primary research questions. Note that not all respondents answered every question. Thus, all percentages are based on the number of respondents who answered the respective question. For any question that was not answered by all 102 participants, the number of respondents (n) is indicated along with the percentage of respondents that selected each answer choice. Responses to multiple-choice questions were quantified via descriptive statistics. Open-ended responses were characterized via inductive content analysis (Elo & Kyngäs, 2008), wherein the written material was reviewed and coded to identify recurring themes. Specifically, the authors read each open-ended response several times to familiarize themselves with the overall trends in the data. Then, depending on the question being analyzed, words that described either symptoms or comorbid conditions associated with hyperacusis were identified within each open-ended response. The extracted content words were sorted into higher order categories based on common themes and meanings. For example, words such as “uncomfortable” and “discomfort” were grouped together into the same higher order category because they represented similar underlying constructs (see Table 1). Each category was then named using words that described the content of the category (see Table 1). The number of respondents that included each content word in their answer was tallied to calculate the percentage of responses that incorporated each theme. To enhance reliability and validity of the inductive content analysis, each author independently reviewed the open-ended statements and agreed on the final groupings and category names.

Table 1.

Themes, definitions, and representative quotes in response to the open-ended questions: “What is your current understanding/definition of hyperacusis?” and “What do you observe to be the main presenting features of hyperacusis?”

Themes Definitions Quotes
Sensitivity Included terms such as sensitivity, hypersensitivity, increased sensitivity, abnormal sensitivity “Sensitivity to sounds that are not bothersome to other people.”
“An elevated sensitivity to loud sounds.”
“Decreased tolerance/increased sensitivity to sounds—most often includes sounds considered average (or soft sometimes like misophonia) sounds that do not bother others. Just disliking the siren of a fire truck does not automatically equal hyperacusis.”
Loudness Included terms such as loudness discomfort levels, loudness growth, loudness perception “An abnormal perception of loudness compared to ‘typical’ loudness perception, or an abnormal perception of loudness growth with actual loudness growth.”
“When loudness discomfort levels (LDLs) are obtained outside of the normal range (< 80 dB HL) for speech and/or pure-tones.”
Intolerance Included terms such as intolerance, decreased tolerance, abnormal tolerance “A condition involving decreased sound tolerance.”
“Intense intolerance and disliking of sound(s).”
“Hyperacusis is a condition where a patient has abnormally low tolerance for loudness. They experience pain or discomfort when presented with sound levels that are below where typical loudness discomfort occurs.”
Emotion and mental health Included terms describing emotional reactions and mental health such as anxiety, fear, and distress “The sensitivity of certain sounds or frequencies that an individual finds distressing.”
“It is a negative emotional response or reflexive response of intense discomfort or pain to specific acoustic stimuli.”
“‘Average’ or ‘moderate’ intensity sounds are uncomfortable. One with hyperacusis thinks sounds that others are unphased by are too intense. They may be more anxious and uncomfortable with being out in public places or noisier places.”
Discomfort Included terms such as uncomfortable and discomfort “Discomfort associated with loud/certain sounds.”
“Abnormal perception of certain sounds which can cause discomfort to the person experiencing the problem.”
Pain Included terms that described physical or undefined pain “Hyperacusis is a disorder of perceived loudness with heightened sensitivity or awareness, where noises/sounds can be painful and unbearably loud.”
“Sensitivity or hypersensitivity to average and high intensity sounds, usually resulting in pain or discomfort when exposed to such sounds.”
Avoidance Included terms that described avoidant behaviors. “Inability to tolerate loud sounds, if possible, child will remove self from situation.”
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Results

Participant Demographics

Respondents were 102 clinical audiologists between the ages of 25 and 70 years (M = 37.6 years, SD = 10.4 years). They were representative of the gender, racial, and ethnic makeup of the audiology field at large (ASHA, 2022), with 83.5% identifying as female, 86.6% identifying as White, and 4.2% identifying as Hispanic or Latino. All respondents held doctoral degrees (88.2% doctor of audiology [AuD], 5.9% PhD) and/or master's degrees (22.5%) in audiology. Most respondents (57.4%) had between 2 and 10 years of experience working as an audiologist. About one third of respondents (32.7%) had more than 10 years of experience, and 9.9% of respondents had less than 1 year of experience working as an audiologist. Respondents were employed in a variety of clinical settings, including hospitals (37.3%); ear, nose, and throat clinics (35.3%); private practice (20.6%); university clinics (20.6%); outpatient facilities (14.7%); and community clinics (5.9%). Respondents (n = 95) represented all regions of the United States as defined by the U.S. Department of Commerce in the delineation of the U.S. Census Bureau: 50.5% from the South, 17.9% from the West, 17.9% from the Midwest, 12.6% from the Northeast, and 1% from the Pacific. Most respondents (75.3%) had caseloads that included both pediatric and adult patients; 10.8% of respondents reported that they only see adult patients, whereas 13.9% reported that they only see pediatric patients. Of the respondents who self-reported their hearing status, 86.5% (n = 83) experience constant or intermittent (frequent or occasional) tinnitus, 18.6% (n = 18) experience hearing loss, and 15.6% (n = 15) experience sensitivity or intolerance to everyday sounds.

Education and Training on Hyperacusis

We asked several questions to characterize respondents' formal education and training related to hyperacusis. The vast majority of respondents (n = 85, 83.4%) have received ≤ 10 hr of formal education or training in the evaluation, diagnosis, and/or management of hyperacusis. Moreover, 63.8% (n = 65) of respondents have received ≤ 5 hr of formal education or training in hyperacusis, with 42.2% (n = 43) reporting 2–5 hr and 21.6% (n = 22) reporting < 1 hr of education or training. In a follow-up question, 10.8% (n = 11) indicated that they have received no formal training at all.

Approximately one third (n = 33, 32.7%) of respondents indicated that they sought most of their hyperacusis education and training on their own (e.g., via continuing education courses, conferences, seminars, workshops, and/or specialty certification programs). Another one third (n = 32, 31.7%) of respondents indicated that most of their hyperacusis education or training was provided by their clinical training program (i.e., master's or AuD program). About one fifth (n = 22, 21.8%) of respondents indicated that the amount of hyperacusis education and training that they have received has come equally from their own efforts and from their clinical training program.

Definition of Hyperacusis and Related Conditions

Respondents were asked to reply to a series of open-ended questions that probed their current beliefs about hyperacusis and related conditions. Table 1 summarizes data from the 94 open-ended responses that were obtained when respondents were asked to explain their current understanding or definition of hyperacusis and its main presenting features. Respondents provided a variety of definitions that encompassed seven main themes (see Table 1, Figure 1). The top two themes included language related to “sensitivity” (n = 63) and “loudness” (n = 59). Additional themes included, in descending order of frequency, terms describing “intolerance” (n = 35), “emotion and mental health” (n = 29), “discomfort” (n = 25), “pain” (n = 20), and “avoidance” (n = 11). Some definitions contained terms related to multiple themes, whereas others only contained terms relevant to a single theme. Representative quotes are provided in Table 1.

Figure 1.

The words in the word cloud in the order of decreasing font sizes are Sensitivity, loudness, intolerance, discomfort, pain, emotion and mental health, and avoidance.

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Word cloud depicting the primary themes that respondents used to define hyperacusis. The size of each word represents the proportion of responses that contained the respective theme.

Respondents mentioned a variety of stimuli that they believe patients with hyperacusis are sensitive to, have difficulty tolerating, or that cause discomfort, including loud sounds (n = 34), sounds deemed “normal” to those without hyperacusis (n = 23), “certain” or “specific” sounds (n = 21), everyday or environmental sounds (n = 20), average or moderate intensity sounds (n = 12), soft-intensity sounds (n = 2), speech stimuli (n = 2), “many” sounds (n = 2), and pure tones (n = 1). Approximately one fifth (n = 18, 19.4%) of respondents did not mention specific sounds or stimuli that they believe can trigger hyperacusis symptoms.

It was noted that only seven responses to this question included specific diagnostic criteria, all of which related to ULLs, but none of which were identical to one another. For example, one respondent indicated that an average of 77 dB HL for pure-tone ULLs indicated hyperacusis, whereas a different respondent indicated that ULLs < 80 dB HL for speech and/or pure tones indicated hyperacusis. Four respondents provided ULL diagnostic criteria of 70 dB HL, 85 dB HL, 90–95 dB HL, and 90–100 dB HL, but did not indicate methods of obtaining those values (e.g., type of stimuli or procedures).

Respondents were also asked to describe which conditions they think commonly occur alongside hyperacusis (n = 94 total responses). Figure 2 shows a word cloud depicting the comorbid conditions that participants cited, with the size of each word representing the proportion of responses that contained the respective theme. The most common co-occurring conditions reported, in descending order of frequency, were mental health concerns and diagnoses (e.g., anxiety, depression, posttraumatic stress disorder; n = 79), tinnitus (n = 52), hearing loss (n = 37), other audiological or vestibular concerns (e.g., noise injury, phonophobia, superior semicircular canal dehiscence; n = 44), sensory processing disorders (e.g., autism spectrum disorder; n = 27), misophonia (n = 12), head injury (n = 12), and migraine (n = 12). Other responses included poor quality of life, viral infections, neurologic concerns and diagnoses, and social isolation.

Figure 2.

The words in the word cloud in the order of decreasing font sizes are A S D, tinnitus, depression, head injury, P T S D, S S C D, emotional trauma, acoustic trauma, eighth nerve pathology, decreased sound tolerance, sound aversion isolation, stress, A P D, O C D, phonophobia, neurologic disorders, lyme disease, neurodivergence, panic, age, psychosomatic psychological reaction, dizziness, viral infection, recruitment, perseverance, tensor tympani syndrome, H P D overuse, behavioral concerns, tensor tympani syndrome, development delay, autophonia, agoraphobia, poor Q O L, stapes footplate hyperfunction, abnormal acoustic reflex thresholds, metabolic disorders, various syndromes, and pain related disorders.

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Word cloud depicting the conditions that respondents reported commonly occur alongside hyperacusis. The size of each word represents the proportion of responses that contained the respective theme. ASD = autism spectrum disorder; PTSD = posttraumatic stress disorder; SSCD = superior semicircular canal dehiscence; APD = auditory processing disorder; OCD = obsessive compulsive disorder; HPD = hearing protection device; QOL = quality of life; ADHD = attention-deficit/hyperactivity disorder.

Similar responses were obtained when participants were asked to identify characteristics or conditions that were commonly mistaken for hyperacusis (n = 87 total responses). Mental health concerns and diagnoses (n = 38), misophonia (n = 36), recruitment (n = 20), sensory processing disorders (n = 16), tinnitus (n = 13), hearing loss (n = 6), and migraine (n = 6) were the top conditions cited. Other conditions included head injury, audiological concerns (e.g., auditory processing disorder, tonic tensor tympani syndrome, superior semicircular canal dehiscence), specific personality characteristics (e.g., “high-strung,” “dramatic,” “antisocial”), age, and dementia.

Case History and Self-Report Questionnaires

We asked respondents if they routinely inquire about hyperacusis or sound tolerance symptoms during a standard case history. More than one quarter (n = 27, 27.8%) of respondents indicated that they only ask about hyperacusis or sound tolerance symptoms if the patient mentions it themselves. Another one quarter (n = 22, 22.7%) indicated that they ask about hyperacusis or sound tolerance “most of the time” (12.4%) or “always” (10.3%). The remaining respondents reported, in descending order of frequency, that they ask about hyperacusis or sound tolerance symptoms “some of the time” (n = 22, 26.8%), “rarely” (n = 21, 21.6%), or “never” (n = 1, 1%).

We also asked respondents if they routinely administer hyperacusis or sound tolerance self-report questionnaires to their patients. Most respondents (n = 58, 59.8%) reported that they never administer hyperacusis or sound tolerance questionnaires, and 17.5% (n = 17) indicated that they only administer questionnaires if the patient reports issues with hyperacusis or sound tolerance. The remaining respondents reported, in descending order of frequency, that they administer questionnaires “some of the time” (n = 9, 9.3%), “rarely” (n = 5, 5.2%), “always” (n = 5, 5.2%), or “most of the time” (n = 3, 3.1%). Those who selected any response other than “never” received a follow-up question to determine which questionnaires they utilize. The most commonly used instruments were the Modified Khalfa Hyperacusis Questionnaire (n = 11, 32.4%; Khalfa et al., 2001), the Inventory of Hyperacusis Symptoms (IHS; n = 8, 23.5%; Greenberg & Carlos, 2018), the Hyperacusis Questionnaire (HQ; n = 6; 17.6%; Khalfa et al., 2002), the Noise Avoidance Questionnaire (n = 6; 17.6%; Blaesing & Kroener-Herwig, 2012), the Multiple Activities Scale of Hyperacusis (n = 3; 8.8%; Dauman & Bouscau-Faure, 2005), and the Questionnaire on Hypersensitivity to Sound (n = 2, 5.9%; Nelting et al., 2002). Eleven respondents indicated that they administer other questionnaires not listed, with four specifying that they use the Tinnitus and Hearing Survey (n = 4; Henry et al., 2015).

Loudness Perception Testing

Respondents were asked how often they conduct loudness perception testing with their patients. To minimize differences in reporting based on personal definitions of loudness perception, respondents were provided with the following guidance before viewing the loudness perception questions: “We are using the term ‘uncomfortable loudness level (ULL)’ to refer to a single-point measure of loudness discomfort. We are using the term ‘loudness growth’ to refer to measures of loudness perception that are made at multiple intensity levels in-between an individual's audiometric threshold and ULL.”

Most respondents reported that they never measure ULLs (n = 26, 26.8%) or that they only measure ULLs if the patient reports issues with sound tolerance or hyperacusis (n = 23, 23.7%). The remaining respondents reported, in descending order of frequency, that they measure ULLs “some of the time” (n = 22, 22.7%), “rarely” (n = 12, 12.4%), “always” (n = 7, 7.2%), or “most of the time” (n = 7, 7.2%). Those who selected any response other than “never” received two follow-up questions to determine (a) the types of stimuli they use to measure ULLs, and (b) the testing method(s) that they use to measure ULLs. Respondents indicated that they most often use frequency-specific stimuli (n = 50, 71.4%) to measure ULLs, but many respondents reported that they also use broadband stimuli such as speech or noise (n = 43, 61.4%). The most common methods for measuring ULLs, in descending order of frequency, included categorical loudness scaling (n = 49, 74.2%), magnitude estimation/production (n = 14, 21.2%), equal loudness matching (n = 12, 18.2%), and cross-modality matching (n = 1, 1.5%). Instead of selecting a particular method, four respondents commented that they tell the patient to respond when the sound becomes uncomfortably loud or when the sound reaches a level that they can no longer tolerate.

Similar to ULL testing, most respondents reported that they never conduct loudness growth testing (n = 62, 63.9%) or that they only measure loudness growth if the patient reports issues with sound tolerance or hyperacusis (n = 14, 14.4%). The remaining respondents reported, in descending order of frequency, that they conduct loudness growth testing “some of the time” (n = 10, 10.3%), “rarely” (n = 9, 9.3%), or “always” (n = 2, 2.1%). Those who selected any response other than “never” received a follow-up question to determine what testing method(s) they routinely use to measure loudness growth. The most common methods for measuring loudness growth included, in descending order of frequency, categorical loudness scaling (n = 23, 65.7%), magnitude estimation/production (n = 10, 28.6%), equal loudness matching (n = 9, 25.7%), and cross-modality matching (n = 1, 2.9%).

Hyperacusis Evaluation and Diagnosis

Respondents were asked to indicate who they believe is qualified to diagnose hyperacusis. The majority (n = 90, 90.9%) selected “audiologist.” Other responses included “otolaryngologist” (n = 60, 60.6%), “psychologist” (n = 37, 37.4%), and “neurologist” (n = 27, 27.3%). Four respondents selected “Other,” with two writing that occupational therapists are qualified to diagnose hyperacusis.

Respondents were asked about the test battery that they use when a patient comes in for a hearing evaluation and mentions problems with hyperacusis or sound tolerance. Those who work with both children and adults answered this question separately for their pediatric versus adult patients. When selecting the pediatric options, respondents were asked to consider only patients who are old enough to complete a conventional audiometric test battery (e.g., school-aged and older). Eighty-eight respondents answered the question relative to adult patients, and 85 respondents answered the question relative to pediatric patients. To determine how testing protocols may differ for patients with and without hyperacusis, respondents also indicated which tests they routinely administer during a standard audiometric evaluation.

Figure 3 shows the percentage of respondents who administer each test during a standard audiometric evaluation and when a patient reports hyperacusis. Only the tests that were selected by at least 10% of respondents are shown (except for loudness growth testing). Overall, audiologists tend to administer fewer tests to patients who they suspect have hyperacusis than to their average patient, with three notable exceptions. Respondents are more likely to measure ULLs and loudness growth for patients who have hyperacusis than they are during a standard hearing evaluation. Specifically, 70.5% of respondents reported testing ULLs for adults who have hyperacusis and 36.5% of respondents reported testing ULLs for children who have hyperacusis. In contrast, only 20.6% of respondents routinely include ULL testing in their standard audiometric test battery. Similarly, although loudness growth is rarely measured in general, 25.0% of respondents assess loudness growth for adults who have hyperacusis and 9.4% assess loudness growth for children who have hyperacusis. In contrast, only 3.9% of respondents routinely include loudness growth testing in their standard audiometric test battery. It was also noted that respondents more often assess extended high-frequency (> 8 kHz) thresholds in adults who have hyperacusis (31.8%) than they do during a typical hearing evaluation (18.6%). This trend was not observed for children who have hyperacusis.

Figure 3.

The bar graph depicts the percentage of respondents who administer each auditory test with respect to three types of test batteries: standard, adult hyperacusis, and pediatric hyperacusis. The legend shows that the standard test battery is depicted by black bars, the adult hyperacusis test battery is depicted by dark gray bars, and the pediatric hyperacusis test battery is depicted by light gray bars. The data are as follows. Otoscopy. Standard: 95%. Adult Hyperacusis: 96%. Pediatric Hyperacusis: 72%. Standard pure tone thresholds. Standard: 95%. Adult Hyperacusis: 92%. Pediatric Hyperacusis: 78%. Speech recognition thresholds. Standard: 91%. Adult Hyperacusis: 93%. Pediatric Hyperacusis: 80%. Word recognition scores, quiet. Standard: 90%. Adult Hyperacusis: 92%. Pediatric Hyperacusis: 77%. Tympanometry. Standard: 92%. Adult Hyperacusis: 90%. Pediatric Hyperacusis: 72%. Acoustic reflex thresholds. Standard: 58%. Adult Hyperacusis: 42%. Pediatric Hyperacusis: 29%. Speech in noise. Standard: 53%. Adult Hyperacusis: 48%. Pediatric Hyperacusis: 33%. Otoacoustic emissions. Standard: 51%. Adult Hyperacusis: 42%. Pediatric Hyperacusis: 47%. Uncomfortable loudness levels. Standard: 22%. Adult Hyperacusis: 70%. Pediatric Hyperacusis: 37%. Extended high frequency thresholds. Standard: 18%. Adult Hyperacusis: 32%. Pediatric Hyperacusis: 15%. Acoustic reflex decay. Standard: 14%. Adult Hyperacusis: 13%. Pediatric Hyperacusis: 11%. Loudness Growth. Standard: 4%. Adult Hyperacusis: 25%. Pediatric Hyperacusis: 9%.

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Percentage of respondents that routinely administer each auditory test (y-axis) during a standard conventional hearing evaluation (black), when evaluating adult hyperacusis patients (dark gray), and when evaluating pediatric hyperacusis patients (light gray).

When asked how they selected their hyperacusis test battery, 42.7% (n = 41) of respondents indicated that they do not use a preset or predetermined test battery for hyperacusis. Those who do use a predetermined hyperacusis test battery indicated that they developed their protocol based on their clinical experience (n = 51, 53.1%), consultations with other audiologists (n = 27, 28.1%), literature review (n = 21, 21.9%), recommendations from professional organizations (n = 20, 20.8%), seminars or workshops (n = 18, 18.8%), recommendations from professional mentors (n = 18, 18.8%), and formal education or coursework on hyperacusis (n = 15, 15.6%).

Finally, respondents were asked what evaluations from other disciplines they prefer or require for patients whom they suspect have hyperacusis. The majority selected “otolaryngology” (n = 69, 72.6%), “psychology/psychiatry” (n = 66, 69.5%), and “neurology” (n = 27, 28.4%). Of the 12 respondents who selected “Other,” five wrote that they refer hyperacusis patients to occupational therapy, and two indicated that they refer them to another audiologist who specializes in tinnitus and hyperacusis.

Hyperacusis Management

Respondents were asked whether their place of employment has a standard protocol for hyperacusis treatment or management. Most respondents selected “No” (n = 62, 63.3%) or “I don't know” (n = 3, 3.1%). However, when asked who they believe is responsible for recommending a treatment plan or management strategies for hyperacusis, 88.7% (n = 86) selected “audiologist.” Other responses, in descending order of frequency, included “otolaryngologist” (n = 56, 57.7%), “psychologist” (n = 51, 52.6%), and “neurologist” (n = 30, 30.9%). Of the six respondents who selected “Other,” three wrote that occupational therapists are responsible for recommending hyperacusis treatment.

Similarly, when asked who they believe is responsible for implementing a treatment plan or management strategy for hyperacusis, 82.5% (n = 80) selected “audiologist.” Other responses, in descending order of frequency, included “psychologist” (n = 52, 53.6%), “otolaryngologist” (n = 28, 28.9%), and “neurologist” (n = 17, 17.5%). Seven respondents selected “Other,” with three writing that occupational therapists are responsible for implementing treatment, and two indicating that patients are responsible for implementing their own treatment.

Respondents who provide treatment recommendations for hyperacusis were asked to indicate which treatments they routinely recommend. The most common treatment recommendations included cognitive behavioral therapy (CBT; n = 72, 80.0%), no or minimal use of hearing protection devices (except when exposed to dangerous noise levels; n = 64, 71.1%), environmental sound therapy/acoustic enrichment (n = 58, 64.4%), ear-level sound/noise generators (n = 42, 46.7%), tinnitus retraining therapy (n = 28, 31.1%), and amplification (n = 26, 28.9%). Sixteen respondents (17.8%) selected “Other,” and most of them used the open-ended box to expand upon their previous selection (e.g., “Amplification if hearing loss is present”). Eight respondents, however, wrote that they refer the patient for additional testing (e.g., computed tomography scan, surgery consult) or to a different health care professional (e.g., neurologist, otolaryngologist, occupational therapist, psychologist, hyperacusis specialist) for treatment recommendations.

Barriers to Diagnosing and Managing Hyperacusis

Respondents were asked to indicate any limitations on their ability to diagnose and treat hyperacusis. The most common barriers to diagnostic testing included a lack of education or training (n = 52, 59.1%), time constraints (n = 52, 59.1%), reimbursement (n = 33, 37.5%), poor sensitivity/specificity of available diagnostic tools (n = 23, 26.1%), individual clinic policies or procedures (n = 22, 22.7%), and lack of equipment or materials (n = 18, 20.5%). Other barriers included a lack of support from other professionals (n = 10, 11.4%), lack of staff (n = 9, 10.2%), and feeling that other professionals are responsible for evaluating hyperacusis (n = 7, 8%). Three respondents who selected “Other” questioned the value of assessing and diagnosing hyperacusis due to the lack of evidence-based treatment options.

The pattern of results was similar when respondents were asked about barriers to hyperacusis treatment and management. The most common treatment barriers that they selected included a lack of education or training (n = 52, 64.2%), time constraints (n = 37, 45.7%), reimbursement (n = 25, 30.9%), poor efficacy of available treatments or management strategies (n = 23, 28.4%), and lack of equipment or materials (n = 17, 21.0%). Other treatment barriers included individual clinic policies or procedures (n = 15, 18.5%), poor sensitivity/specificity of available diagnostic tools (n = 12, 14.8%), lack of staff (n = 9, 11.1%), lack of support from other professionals (n = 8, 9.9%), and feeling that other professionals are responsible for recommending or implementing hyperacusis treatment (n = 7, 8.6%). Five respondents selected “Other,” with two noting that it is difficult to find professionals who have experience treating hyperacusis and one noting that manufacturers do not provide sufficient support for relevant devices such as ear-level sound generators.

Discussion

This study sought to characterize clinical audiology practice patterns regarding hyperacusis diagnosis and management in the United States. We surveyed 102 U.S. clinical audiologists about their current understanding of hyperacusis, the formal education and training that they have received on hyperacusis, and their clinical diagnostic and treatment protocols for hyperacusis. To our knowledge, this is the largest survey to date that has specifically targeted the audiological assessment and management of hyperacusis in the United States.

Results of this survey showed a lack of consensus among U.S. audiologists regarding how to define and diagnose hyperacusis (see Table 1). This diverse understanding of hyperacusis may be related to the minimal formal education and training that the respondents reported. The vast majority (83.4%) indicated that they have received ≤ 10 hr of formal education and training in hyperacusis. Notably, this education often did not come from required graduate coursework or supervised clinical training. Instead, more than half of respondents sought all or some of their hyperacusis education and training of their own accord (e.g., via continuing education courses, conferences, or on-the-job experiences and mentorship).

In fact, most respondents reported that this lack of education and training is a primary barrier that limits their ability to diagnose and manage hyperacusis. The dearth of formal education in hyperacusis is likely compounded by the varied definitions of sound sensitivity in the extant literature and the limited availability of evidence-based diagnostic criteria. Many research teams have attempted to define hyperacusis, with proposed definitions ranging widely in their specificity. One of the most highly cited definitions of hyperacusis distinguishes between four different subtypes of loudness, annoyance, fear, and pain (Tyler et al., 2014). While these symptom subtypes are defined independently, they often co-occur within the same individual to varying degrees. Others broadly define hyperacusis as a reduced tolerance, discomfort, or hypersensitivity to sounds (Adams et al., 2020; Dauman & Bouscau-Faure, 2005; Formby & Gold, 2002; Khalfa et al., 2004), leaving the specific quality of the symptoms open to interpretation.

As seen in the present data set, clinicians and researchers often cite ULLs as a primary diagnostic tool to characterize hyperacusis. However, there is also a lack of consensus regarding what constitutes a normal versus abnormal ULL. In this study, respondents cited normal ULL cutoff criteria that spanned a 30-dB range (70–100 dB HL). Notably, ASHA recommends utilizing ULL testing to aid in the differential diagnosis of hyperacusis and suggests that patients may have “a reduced sound tolerance range when compared to ULL results of individuals without hyperacusis” (ASHA, 2018). However, ASHA does not provide guidance for how to measure the ULL nor how to determine whether it is within a typical range. It is well-known that the type of stimulus, the test procedure, and the test instructions can have a substantial impact on loudness perception data (Hawkins, 1980a; 1980b; Ricketts & Bentler, 1996).

If we consider pure-tone stimuli, some evidence suggests that adults with normal hearing who do not report sound tolerance problems may be expected to have ULLs greater than or equal to 80, 85, 80, and 75 dB HL at 0.5, 1, 2, and 4 kHz, respectively (Sherlock & Formby, 2005). However, although ULLs can be abnormally low in hyperacusis sufferers, the range of reported ULLs varies widely, and many patients have ULLs comparable to listeners who do not report hyperacusis (Aazh & Moore, 2017, 2018b; Anari et al., 1999; Blaesing & Kroener-Herwig, 2012; Sheldrake et al., 2015). In line with this, recent work has shown a wide range of loudness perception and self-reported sound sensitivity symptoms in young adults with normal hearing who do not report hyperacusis (Jahn et al., 2022). Sound sensitivity may be best described as a spectrum that encompasses a variety of symptoms that are not captured by ULLs in every patient (Jahn et al., 2022; Sheldrake et al., 2015).

Consequently, diagnostic recommendations that are based on ULLs vary widely across studies, ranging from 70 dB HL (Anari et al., 1999) to 95 dB HL (Goldstein & Shulman, 1996) to 77 dB HL in the worse ear (Aazh & Moore, 2017). The lack of consensus across our respondents' descriptions and definitions of hyperacusis reflects the diversity of information available from scientific literature and professional organizations. In many ways, this observation is promising in that it demonstrates the translation of scientific findings to influence patient care. However, this result also highlights the critical need for researchers and U.S. clinicians to work toward establishing a clear definition and standard evaluation protocol for hyperacusis.

In addition to the variability in definition and diagnostic criteria, the present data raise questions regarding the provision of hyperacusis interventions in the United States. The vast majority of our respondents believe that audiologists are responsible for recommending and implementing hyperacusis treatment. With that said, 80% of respondents indicated that they routinely recommend CBT for hyperacusis, which is a type of psychological intervention that falls outside an audiologist's scope of practice in the United States. Although audiologists feel that they should play a primary role in working with hyperacusis patients, most respondents cited the importance of a multidisciplinary team approach. The majority of respondents indicated that other health care providers, especially mental health professionals and otolaryngologists, share responsibility in diagnosing and managing hyperacusis.

Some evidence supports the idea that CBT may be effective in reducing hyperacusis-related handicap (Aazh, Landgrebe, et al., 2019; Aazh & Moore, 2018a; Beukes et al., 2018; Jüris et al., 2014). An important component of the CBT model for hyperacusis involves education about the auditory system and the processes underlying the distress caused by the condition, coupled with psychological counseling and emphatic listening (Aazh, Landgrebe, et al., 2019). Ideally, hyperacusis-oriented CBT would be delivered by a provider who has knowledge of the auditory system and its associated disorders.

Given the limited education and training that U.S. audiologists receive in hyperacusis, this begs the question of how knowledgeable other U.S. health care professionals are about hyperacusis and related conditions. It is not unreasonable to assume that mental health professionals receive much less training in the auditory system than ear specialists. Although little research exists on the topic, some data suggest that school psychologists have insufficient training or experience working with students who have hearing loss and other co-occurring disabilities (Muncy et al., 2019). It is also worth noting that hyperacusis often co-occurs with a variety of conditions such as tinnitus, posttraumatic stress disorder, depression, anxiety, or central auditory processing disorder (see Figure 2), to name a few. If clinicians do not recognize the connection between hyperacusis and other debilitating conditions, the negative psychosocial implications could compound and impact quality of life above and beyond the impact of one condition alone.

Taken together with the present data, these findings emphasize the need for improved interprofessional practice (IPP) and interprofessional education (IPE) across the fields of psychology and audiology in the United States. In the United Kingdom, CBT for tinnitus and hyperacusis is often provided by trained audiologists who screen patients for comorbid psychological conditions and refer to mental health professionals as warranted (Aazh, Landgrebe, et al., 2019). There is evidence that adults with bothersome tinnitus and decreased sound tolerance find it acceptable and beneficial to receive audiologist-guided CBT (Aazh, Bryant, & Moore, 2019; Beukes et al., 2018). While it may be difficult, if not impossible, to expand the scope of practice for U.S. audiologists to include CBT, the present data demonstrate the need for formal IPP/IPE initiatives that would facilitate effective multidisciplinary collaborations for hyperacusis. Of course, collaborations with other health care professionals could extend beyond the provision of CBT. For instance, collaborating with pain management or integrative medicine specialists could lead to innovative management strategies for those who suffer from sound-induced pain. These initiatives would serve not only to improve clinical care for patients and their families but also to provide synergistic educational opportunities for audiologists, mental health professionals, and other health care providers.

Clinical Implications

Despite the observed variability in clinical definitions of hyperacusis and the few sensitive diagnostic tools and treatments for the condition, the present data shed light on clinical practice patterns that can be modified in the near-term to improve audiological care for hyperacusis. Hyperacusis is relatively common, with prevalence estimates ranging from 9% to 15% of adults (Andersson et al., 2002; Fabijanska et al., 1999) to 17% of children (Rosing et al., 2016). However, many respondents in this study indicated that they do not routinely ask about hyperacusis or sound tolerance during an audiological case history. Given the subjective nature of hyperacusis and the lack of objective clinical tools, audiologists should make it a priority to inquire about sound tolerance in the same way that we routinely ask patients about their hearing and health history, communication difficulties, or tinnitus. In fact, patient self-report is considered a valuable and sensitive indicator of disease severity and progression across several health domains (Bourgeois et al., 2007; Gifford & Dorman, 2019). Within the field of audiology, for instance, asking the patient whether they think they need a second cochlear implant is a highly sensitive metric of candidacy (Gifford & Dorman, 2019). Simply asking about sound tolerance symptoms during case history would be a great start. Audiologists could also consider administering a validated hyperacusis questionnaire such as the HQ (Khalfa et al., 2002) or the IHS (Greenberg & Carlos, 2018).

Many respondents conceptualize hyperacusis as a disorder of loudness perception, and they often mentioned ULLs as part of the diagnostic test battery. However, most respondents never measure ULLs during a standard hearing evaluation, and many only measure ULLs if a patient reports issues with sound tolerance or hyperacusis. If respondents do not routinely ask their patients about hyperacusis or sound tolerance, then they are likely only measuring ULLs on patients who self-report the most severe sound intolerance symptoms. Audiologists should consider routinely measuring ULLs in all patients who can tolerate the procedure in order to characterize the range of sound tolerance among their clinical population. Although our respondents cited time constraints and reimbursement as major barriers to hyperacusis diagnosis, regularly assessing ULLs would benefit multiple domains of their clinical practice. For instance, the audiologist would be able to establish normative ULL data for their patient population, stimuli, and procedures, allowing them to interpret each data point more accurately within the context of the expected ULL variability at their clinic. Moreover, ULL data can be used not only to quantify loudness perception and to monitor changes over time but also to select appropriate word recognition levels (Guthrie & Mackersie, 2009), to optimize hearing aid fittings (Formby et al., 2017), and to counsel patients on multiple topics (e.g., hyperacusis burden, hearing aid acclimatization).

When they do perform ULL testing, most respondents indicated that they use a categorical loudness scaling procedure. During categorical loudness scaling, the intensity of the sound is gradually increased until the patient reports that the sound is uncomfortable (Cox et al., 1997). It is recommended that the starting level for ULL testing be equal to the individual's audiometric threshold at the test stimulus (Aazh & Moore, 2017). This implies that, during a ULL test, most audiologists are presenting stimuli across the patient's full dynamic range of hearing. However, the vast majority of respondents indicated that they never measure loudness growth. To obtain a rich understanding of the patient's psychoacoustic impression of loudness without adding substantial time to the test battery, the audiologist should consider documenting the patient's response to each sound that they present while completing ULL testing using a categorial loudness scaling procedure (Jahn, 2022).

Of course, it is important to proceed with care when presenting sounds to individuals who have hyperacusis. As discussed in the work of Jahn (2022), clinicians and researchers should obtain a patient's informed consent and thoroughly explain the planned test procedure, including the levels and duration of sounds that will be presented. The tester should be prepared to cease testing at any time to avoid causing discomfort or pain. Regardless of the type of test administered, sounds should be presented at very low intensity levels and increased gradually as needed.

Conclusions and Future Research Directions

Hyperacusis definitions and clinical practice patterns vary widely among the U.S. audiologists surveyed in this study. This variability is likely related, in part, to the lack of consensus on definitions and diagnostic criteria for hyperacusis disseminated via scientific publications and professional organizations. The vast majority of respondents feel that audiologists are responsible for hyperacusis diagnosis and management, and we note that the ASHA Audiology Certification Standards (Standard II-C, C6) indicate that applicants must demonstrate knowledge of and skills in “providing assessment of tolerance problems to determine the presence of hyperacusis” (ASHA, 2020). However, our respondents indicated that the primary barrier to proper hyperacusis diagnosis and management is a lack of education and training. Additionally, respondents often cited time constraints, reimbursement, poor sensitivity and specificity of available diagnostic tools, and poor efficacy of available treatments and management strategies as key barriers to effective audiological management of hyperacusis.

Most respondents agree that the diagnosis and management of hyperacusis should be a multidisciplinary endeavor, but it is unclear whether health care professionals who do not specialize in the auditory system are equipped with the knowledge base to optimally address hyperacusis-related burden. Increased IPP/IPE in the United States regarding hyperacusis (and likely hearing loss in general), especially among audiologists and mental health professionals, is required. Additionally, the field at large would benefit from consistent, widespread training in hyperacusis and in the methods and utility of loudness perception testing in clinical settings. Researchers and clinicians should continue to work toward identifying sensitive diagnostic tools, evidence-based treatments, and a multidisciplinary consensus definition of hyperacusis that considers input from all stakeholders including patients, families, clinicians, and researchers.

Data Availability Statement

Data are available from the corresponding author upon reasonable request.

Supplementary Material

Supplemental Material S1. Participant survey.
AJA-32-950-s001.pdf (124.9KB, pdf)

Acknowledgments

This work was supported by National Institute on Deafness and Other Communication Disorders Grant K01 DC019647 (awarded to K.N.J.).

Funding Statement

This work was supported by National Institute on Deafness and Other Communication Disorders Grant K01 DC019647 (awarded to K.N.J.).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material S1. Participant survey.
AJA-32-950-s001.pdf (124.9KB, pdf)

Data Availability Statement

Data are available from the corresponding author upon reasonable request.

Articles from American Journal of Audiology are provided here courtesy of American Speech-Language-Hearing Association

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