Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Clin J Sport Med. 2022 Mar 1;32(2):82–85. doi: 10.1097/JSM.0000000000000874

Concussion Management Guidelines Neglect Auditory Symptoms

SM Theodoroff 1,2,*, M Papesh 1,2, TC Duffield 3, M Novak 3, FJ Gallun 1,2, L King 1,3,4, J Chesnutt 3,4, R Rockwood 3, M Palandri 3, TE Hullar 1,2
PMCID: PMC7956904  NIHMSID: NIHMS1606329  PMID: 32941367

Abstract

Tinnitus, noise sensitivity, and hearing difficulties are commonly reported secondary to head injury. These auditory deficits have been shown to negatively impact daily functioning, and yet, often go unnoticed by health care professionals. The purpose of this editorial is to explain why it is essential for clinical practice guidelines that address the management of patients who have experienced a head injury to incorporate assessment and rehabilitation of auditory symptoms.

Keywords: Hearing Disorders, Tinnitus, Noise, Practice Guideline

Background

Evidence-based guidelines are essential to promote and provide best practices. They present a logical framework for clinicians to find established criteria for diagnostic purposes and treatment recommendations. Unfortunately, many published guidelines for the assessment and management of patients with traumatic brain injury (TBI) or concussion fail to synthesize current knowledge pertaining to the occurrence of auditory symptoms at the time of injury, or the recovery timeline for these symptoms (Gómez & Hergenroeder, 2013; Doperak et al, 2019; Harmon et al, 2019; Rebbeck et al, 2019; Scorza et al, 2019; Silverberg et al, 2019).

The underlying mechanisms for many auditory symptoms following head injury are poorly understood, which complicates classifying these symptoms as either “post-TBI-related” or in the case of mild TBI (mTBI), “post-concussive-related.” Identifying auditory symptoms that manifest secondary to head injury will aid in the assessment and treatment of these conditions. Most importantly, and the main issue addressed in this editorial, is that there are a number of auditory deficits besides vestibular injury that occur secondary to head injury, and yet, often go unnoticed by health care professionals.

Auditory Symptoms

The primary auditory symptoms associated with head injury are tinnitus, noise sensitivity, and difficulty understanding speech in complex listening environments (i.e., auditory processing deficits; Papesh et al, 2018). There is a growing body of literature reporting these auditory symptoms following sports-related head injuries, blast-injuries, falls, and motor vehicle accidents (Bergemalm & Borg 2005; Turgeon et al., 2011; Gallun et al, 2012; Saunders et al, 2015; Białuńska & Salvatore, 2017; Gallun et al, 2017; Hiploylee et al, 2017; Papesh et al., 2018).

Despite many attempts to create symptom profiles and subtypes to assist in the management of concussion patients, a clinical consensus on this subject does not currently exist (Reynolds et al, 2014). While many concussion subtypes include a vestibular category, rarely do they include an auditory category. Often, meta-analytic approaches are used to identify subtypes, but this effort is hindered by poor documentation of auditory symptoms in the majority of studies. Emphasizing this point, Lumba-Brown et al (2020) acknowledge an auditory subtype of concussion exists, but is not commonly assessed. Due to the heterogeneity of concussion symptom profiles, persistence of auditory symptoms post-head injury beyond expected physiologic recovery thresholds (i.e., three months) could refine classification processes of TBI and concussion subtypes. Taking this into consideration, screening for common auditory symptoms as part of the clinical interview might greatly assist with the clinical management of TBI and concussion patients (see Table 1).

Table 1.

Common auditory symptoms associated with concussion defined and suggested screening questions.

Auditory Symptom Definition Screening Question
Tinnitus Perception of sound in the absence of an external [acoustic] source. Do you experience ringing in the ears (tinnitus) that lasts for at least 5 minutes?
Noise Sensitivity General intolerance to everyday sounds that encompasses a range of psychological attributes that contribute to the degree an individual is reactive to noise. Do you have a problem tolerating sounds because they often seem too loud or bother you for other reasons?
Hearing difficulty Trouble understanding speech or other sounds in quiet or noisy environments. Do you have any difficulties understanding speech or other sounds? Do you feel like you have more difficulties hearing in noise compared to others?
Open in a new tab

Treatment Considerations

Screening patients for tinnitus, noise sensitivity, and hearing difficulty following head injury will aid the clinician in providing targeted rehabilitation to best meet the patient’s needs. When patients screen positive for one or more of these issues, it is important to determine if the auditory symptom(s) occurred pre- or post-head injury, and for any symptoms that were pre-occurring, to ask if they became exacerbated. Referral to an audiologist or otologist is recommended for these patients as these healthcare professionals are uniquely trained to diagnose and treat auditory conditions. For example, hearing loss is not uncommon following closed head injury (Bergemalm, 2003; Tambs et al, 2003) and both structural and functional changes that occur in the peripheral and central auditory system post-head injury contribute to many of the auditory symptoms reported by patients. In these instances, provision of hearing aids may improve patients’ symptoms and ability to communicate. However, many patients will experience symptoms in the absence of hearing loss (Bergemalm & Borg, 2005; Vander Werff, 2016). For these patients, additional testing may be recommended to aid with a differential diagnosis, such as tests of speech-in-noise comprehension or other tests of auditory processing (Tepe et al, 2020).

Many of the auditory symptoms reported following head injury have subtypes and identifying these features can help to guide treatment protocols. For example, when tinnitus occurs secondary to head injury, the perceptional attributes (i.e., loudness, pitch, timbre) may change following head and neck maneuvers, forceful muscle contractions or jaw movements. This clinical phenotype is classified as somatosensory tinnitus (Michiels et al, 2016; Ralli et al, 2017). Patients with somatosensory tinnitus often have an underlying biomechanical deficit, such as temporomandibular joint dysfunction, or injury to their cervical spine, that may trigger or exacerbate the tinnitus. In these instances, patients may benefit from individualized physiotherapy to address both the tinnitus and underlying musculoskeletal issue simultaneously (Sanchez & Rocha 2011; Cherian et al, 2013; Cote et al, 2019).

Among patients describing decreased sound tolerance, which includes noise sensitivity and hyperacusis, it is important to differentiate if the primary complaint is related to the “loudness” of everyday sounds, suggestive of hyperacusis, or a broader issue involving multiple factors that contribute to being overwhelmed by all the “noise.” Hyperacusis is an intolerance of sounds at low-to-moderate intensity levels that may include physical discomfort, stress, and anxiety (Aazh et al, 2016). Noise sensitivity addresses an individual’s reactivity to noise, theorized to be a manifestation of a state of hyperarousal resulting in negative attitudes to sound including annoyance and feelings of being overwhelmed (Shepherd et al, 2019). However, because distinguishing auditory signals such as speech from background noise is a particularly challenging task for the central auditory system, patients may also endorse symptoms of noise sensitivity stemming from poorer auditory functioning in environments with competing noise sources following head injury (Tepe et al., 2020). Thus, asking the patient to give examples is necessary to distinguish hyperacusis from noise sensitivity and hearing difficulties related to background noise. There are multiple types of decreased sound tolerance conditions and they are not mutually exclusive (Theodoroff et al, 2019).

Patients with noise sensitivity should consistently use hearing protection when exposed to loud sounds (e.g., band practice, concerts), but using hearing protection in quiet environments (e.g., classrooms) can result in the auditory system becoming more sensitive, not less (Formby et al, 2003). In some instances, it may be appropriate for patients to initially use hearing protection sparingly in quiet environments and slowly reintroduce listening to sounds at tolerable levels. When patients reacclimate to environmental sounds in this fashion, it is essential to monitor that using hearing protection in this way does not exacerbate their auditory symptoms.

Summary

Due to the complex clinical presentation of patients with head injuries, auditory symptoms may not receive equivalent attention as other clinical signs and symptoms. This fact, along with the lack of familiarity regarding these auditory symptoms, results in many missed opportunities to delineate the type and nature of auditory symptoms relevant for treatment triage. Additionally, because patients may find it difficult to articulate their complaints and experiences, many symptoms and their negative consequences often go unaddressed (Landon et al, 2012). Further, a lack of consistent terminology used to describe auditory symptoms associated with head injury (e.g., hearing difficulty, auditory processing deficits, noise sensitivity, phonophobia, hyperacusis) contributes to this problem. Due to various terms being used in different disciplines and the lack of a gold standard to diagnose many of these conditions, it is challenging to estimate the prevalence of auditory symptoms in this patient population.

In contrast to the sports medicine literature, there are many accounts of auditory symptoms documented for military service-related head injuries, most likely because of the inherent co-occurring noise exposure with those events (Theodoroff et al, 2015). This is also evident in the joint Department of Veterans Affairs (VA) and Department of Defense (DoD) clinical practice guidelines for the management of mTBI, which uses an algorithm-based stepped-care approach to derive appropriate assessment and management plans for each patient. Auditory symptoms are listed in the category of physical symptoms post-head injury, but specific management recommendations are not made due to a lack of published scientific findings. Therefore, to provide the necessary evidence to inform clinical care decision-making, research is critically needed to address the auditory symptoms and deficits that are caused or exacerbated by head injury.

Although the mechanism of injury might vary for mTBI associated with blasts compared to sports-related injuries, both types of exposures result in auditory symptom reporting (Knoll et al, 2020; O’Connor et al, 2017; Wasserman et al, 2016). It is noteworthy that 92% of a cohort with non-blast mTBI (e.g., motor vehicle accident, falls, sports-related, etc.) endorsed auditory symptoms (Knoll et al, 2020). In comparison, an ongoing chart review of over 1000 patients seen at the Oregon Health & Science University Concussion Clinic has similarly revealed that over 50% of those diagnosed with concussion endorsed one or more auditory complaint at their intake appointment. These data suggest auditory symptoms occur secondary to a variety of head injuries and are not particular to a specific mechanism of injury. This work highlights the need to develop an auditory subtype to complement the other more established subtypes mentioned in clinical practice guidelines to date.

It is essential to increase the research and clinical efforts to address the taxonomy of auditory symptoms associated with head injury, as well as the temporal recovery gradient of specific symptoms or clusters of symptoms, and how auditory symptoms may or may not relate to other injury/individual characteristics. Research is needed to better isolate the mechanism of injury that gives rise to auditory symptoms associated with head injuries. Identifying the separate peripheral versus central auditory deficits that result in these symptoms will also help to explain patient-specific characteristics and risk factors for these conditions. Additionally, it is likely a combination of peripheral, subcortical, and cortical maladaptive changes that result in the persistence of these auditory symptoms months after the head-injury.

Addressing these unanswered questions will help fill the gaps in our knowledge of the etiology, clinical manifestation, and associated risk factors for post-head injury auditory symptoms. In addition to our goal of highlighting and characterizing the auditory consequences associated with head injury, immediate next steps are to (1) further develop a model-based auditory subtype of concussion and (2) involve the scientific and clinical community to gain consensus on how this information will assist with patient assessment and recovery from injury. These efforts are necessary to inform best practices and update clinical practice guidelines for the management of patients with TBI and concussion.

Acknowledgements

This work was supported by a VA RR&D Small Projects in Rehabilitation Research Award (SPiRE; #C3181-P) and National Institutes of Health (NICHD R03 HD 094234). The project described involving chart reviews was supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (UL1TR002369). This material is the result of work supported with resources and the use of facilities at the VA Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research (Center Award #C9230C) at the VA Portland Health Care System in Portland, Oregon. These contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health, U.S. Department of Veterans Affairs, Department of Defense, or the United States Government.

Footnotes

Disclosure statement: The authors declare no competing interests, neither financial nor non-financial.

References

  1. Aazh H, Moore BCJ, Lammaing K, Cropley M. Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments. Int J Audiol. 2016;55(9):514–522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bergemalm PO. Progressive hearing loss after closed head injury: a predictable outcome?. Acta Otolaryngol. 2003;123(7):836–845. [DOI] [PubMed] [Google Scholar]
  3. Bergemalm PO, Borg. Peripheral and central audiological sequelae of closed head injury: function, activity, participation and quality of life. Audiol Med. 2005;3(3):185–198. [Google Scholar]
  4. Białuńska A, Salvatore AP. The auditory comprehension changes over time after sport‐related concussion can indicate multisensory processing dysfunctions. Brain Behav. 2017;7(12):e00874. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Cherian K, Cherian N, Cook C, Kaltenbach JA. Improving tinnitus with mechanical treatment of the cervical spine and jaw. J Am Acad Audiol. 2013;24:544–555. [DOI] [PubMed] [Google Scholar]
  6. Cicerone KD, Kalmar K. Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. J Head Trauma Rehabil. 1995;10(3):1–17. [Google Scholar]
  7. Cote C, Baril I, Morency C, et al. Long-term effects of a multimodal physiotherapy program on the severity of somatosensory tinnitus and identification of clinical indicators for predicting favorable outcomes of the program. J Am Acad Audiol. 2019;30:720–730. [DOI] [PubMed] [Google Scholar]
  8. Doperak J, Anderson K, Collins M, Emami K. Sport-related concussion evaluation and management. Clin Sports Med. 2019;38(4):497–511. [DOI] [PubMed] [Google Scholar]
  9. Michiels S, Van de Heyning P, Truijen S, et al. Does multi-modal cervical physical therapy improve tinnitus in patients with cervicogenic somatic tinnitus? Manual Therapy. 2016;26:125–131. [DOI] [PubMed] [Google Scholar]
  10. Formby C, Sherlock LP, Gold SL. Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background. J Acoust Soc Am. 2003;114(1)55–58. [DOI] [PubMed] [Google Scholar]
  11. Gallun FJ, Lewis MS, Folmer RL, et al. Implications of blast exposure for central auditory function: A review. J Rehabil Res Dev. 2012;49(7):1059–1074. [DOI] [PubMed] [Google Scholar]
  12. Gallun FJ, Papesh MA, Lewish MS. Hearing complaints among Veterans following traumatic brain injury. Brain Injury. 2017;31(9):1183–1187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Gómez JE, Hergenroeder AC. New guidelines for management of concussion in sport: Special concern for youth. J Adolesc Health. 2013;53(3):311–333. [DOI] [PubMed] [Google Scholar]
  14. Harmon KG, Clugston JR, Dec K, et al. American medical society for sports medicine position statement on concussion in sport. Br J Sports Med. 2019;53(4):213–225. [DOI] [PubMed] [Google Scholar]
  15. Hiploylee C, Dufort PA, Davis HS, et al. Longitudinal study of postconcussion syndrome: Not everyone recovers. J Neurotrauma. 2017;34(8):1511–1523. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Knoll RM, Herman SD, Lubner RJ, et al. Patient-reported auditory handicap measures following mild traumatic brain injury. Laryngoscope. 2020;130(3):761–767. [DOI] [PubMed] [Google Scholar]
  17. Landon J, Shepherd D, Stuart S, et al. Hearing every footstep: Noise sensitivity in individuals following traumatic brain injury. Neuropsychol Rehabil. 2012;22:391–407. [DOI] [PubMed] [Google Scholar]
  18. Lumba-Brown A, Teramoto M, Bloom OJ, et al. Concussion Guidelines Step 2: Evidence for subtype classification. Neurosurgery. 2020;86(1):2–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. O’Connor KL, Baker MM, Dalton SL, et al. Epidemiology of sport-related concussions in high school athletes: National athletic treatment, injury and outcomes network (NATION), 2011–2012 through 2013–2014. J Athl Train. 2017;52(3):175–185. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Papesh MA, Theodoroff SM, Gallun FJ. Traumatic Brain Injury and Auditory Processing. In: Fagelson Marc and Baguley David M. (Eds.), Hyperacusis and Disorders of Sound Intolerance: Clinical and Research Perspectives (pp. 149–166), 2018, Plural Publishing; Inc., San Diego, CA [Google Scholar]
  21. Ralli M, Greco A, Turchetta R, et al. Somatosensory tinnitus: Current evidence and future perspectives. J Int Med Res. 2017;45(3):933–947. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Rebbeck T, Evans K, Elliott JM. Concussion in combination with whiplash-associated disorder may be missed in Primary Care: Key recommendations for assessment and management. J Orthop Sports Phys Ther. 2019;49(11):819–828. [DOI] [PubMed] [Google Scholar]
  23. Reynolds E, Collins MW, Mucha A, Troutman-Ensecki C. Establihsing a clinical service for the management of sports-related concussions. Neurosurgery. 2014;75:S71–S81. [DOI] [PubMed] [Google Scholar]
  24. Sanchez TG, Rocha CB. Diagnosis and management of somatosensory tinnitus: Review article. Clinics. 2011;66(6):1089–1094. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Saunders GH, Frederick MT, Arnold M, et al. Auditory difficulties in blast-exposed Veterans with clinically normal hearing. J Rehabil Res Dev. 2015;52(3):343–360. [DOI] [PubMed] [Google Scholar]
  26. Scorza KA, Cole W. Current concepts in concussion: Initial evaluation and management. Am Fam Physician. 2019;99(7):426–434. [PubMed] [Google Scholar]
  27. Shepherd D, Landon J, Kalloor M, Theadomon A. Clinical correlates of noise sensitivity in patients with acute TBI. Brain Inj. 2019;33(8):1050–1058. [DOI] [PubMed] [Google Scholar]
  28. Silverberg ND, Iaccarino MA, Panenka WJ, et al. Management of concussion and mild traumatic brain injury: A synthesis of practice guidelines. Arch Phys Med Rehabil. 2019;Oct 22. pii: S0003–9993(19)31305-X. [DOI] [PubMed] [Google Scholar]
  29. Tambs K, Hoffman HJ, Borchgrevink HM, et al. Hearing loss induced by noise, ear infections, and head injuries: results from the Nord-Trøndelag Hearing Loss Study: Hipoacusia inducida por ruido, infecciones de oído y lesiones cefálicas: resultados del estudio Nord-Trøndelag sobre pérdidas auditivas. International J Audiol. 2003;42(2):89–105. [DOI] [PubMed] [Google Scholar]
  30. Tepe V, Papesh MA, Russell S. et al. Acquired central auditory processing disorder in Service Members and Veterans. J Speech Lang Hear Res. 2020;63(3):834–857. [DOI] [PubMed] [Google Scholar]
  31. Theodoroff SM, Lewis MS, Folmer RL, et al. Hearing Impairment and Tinnitus: Prevalence, Risk Factors, and Outcomes in US Service Members and Veterans Deployed to Iraq and Afghanistan Wars. Epidemiol Rev. 2015;37(1):71–85. [DOI] [PubMed] [Google Scholar]
  32. Theodoroff SM, Reavis KM, Griest SE, et al. Decreased sound tolerance associated with blast exposure. Sci Rep. 2019;9:10204. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Turgeon C, Champoux F, Lepore F, et al. Auditory processing after sport-related concussions. Ear Hear. 2011;32(5):667–670. [DOI] [PubMed] [Google Scholar]
  34. U.S. Department of Veterans Affairs (2019). Veterans Benefits Administration Annual Benefits Report Fiscal Year 2018. https://www.benefits.va.gov/REPORTS/abr/docs/2018-abr.pdf Accessed January 17, 2020 [Google Scholar]
  35. Vander Werff KR. The application of the international classification of functioning, disability and health to functional auditory consequences of mild traumatic brain injury. Semin Hear. 2016;37(3):216–232. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Veterans Affairs/Department of Defense. Management of concussion-mild traumatic brain injury (mTBI) clinical practice guidelines, 2016. https://www.healthquality.va.gov/guidelines/rehab/mtbi/ Accessed November 19, 2019. [Google Scholar]
  37. Wasserman EB, Kerr ZY, Zuckerman SL, Covassin T. Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes From 2009–2010 to 2013–2014: Symptom Prevalence, Symptom Resolution Time, and Return-to-Play Time. Am J Sports Med. 2016;44(1):226–233. [DOI] [PubMed] [Google Scholar]

RESOURCES