Medicine:Hyperacusis

From HandWiki
Hyperacusis
Other namesHyperacousis
SpecialtyOtolaryngology, neurology, psychiatry
Differential diagnosisSensory processing disorder, Autism

Hyperacusis is an increased sensitivity to sound and a low tolerance for environmental noise. Definitions of hyperacusis can vary significantly, but it is often categorized into four subtypes: loudness, pain, annoyance, and fear.[1][2] It can be a highly debilitating hearing disorder.[3]

There are a variety of causes and risk factors, with the most common being exposure to loud noise.[1] It is often coincident with tinnitus.[1] Proposed mechanisms in the literature involve dysfunction in the brain, inner ear, or middle ear.[4][5][6][7][8][9]

Little is known about the prevalence of hyperacusis, in part due to the degree of variation in the term's definition.[1][10] Reported prevalence estimates in the literature vary widely, and further research is needed to obtain strong epidemiological data.[11] While there are no exact numbers, several people have died by suicide due to the severe consequences of the disease.[12]

Signs and symptoms

Hyperacusis symptoms can include an increased perception of the loudness of sounds (loudness hyperacusis), pain (noxacusis/pain hyperacusis/sound-induced otalgia), annoyance, and/or fear in response to sounds by which most people are unaffected. It may affect one or both ears.[13] The majority of patients experience bilateral symptoms but often have one ear that is more affected than the other. Annoyance hyperacusis is often considered synonymous with misophonia. Fear hyperacusis is often considered synonymous with phonophobia. Many researchers more narrowly define hyperacusis to only include loudness hyperacusis and pain hyperacusis.[13]

Hyperacusis can also be accompanied by tinnitus. The latter is more common[14] and there are important differences between their involved mechanisms.[3]

Hyperacusis can result in anxiety and stress. Avoidant behavior is often a response to prevent the effects of hyperacusis and this can include avoiding social situations.[15]

Loudness hyperacusis

Loudness hyperacusis is characterized by an increased perception of the loudness of sounds.[13] It is often associated with certain volumes and/or frequencies. It can occur in children[16] and adults,[17] and can be either "short-term" in a duration of weeks to less than a year before recovery, or, less commonly, "long-term," spanning years and in some cases becoming permanent. Sensitivity is often different between ears.[18]

Noxacusis (pain hyperacusis)

In some instances, hyperacusis is accompanied by pain, which is known as noxacusis.[19] Noxacusis is characterized by pain resulting from sounds, often initiated at certain volumes or frequencies.[20] Pain can be immediate or delayed, and it sometimes persists for an extended period of time following exposure.[18] Pain can be acute or chronic, and is often described as stabbing, burning, throbbing, or aching. In healthy listeners, pain from sound is not typically experienced until the volume exceeds approximately 120 decibels.[13]

Individuals experiencing noxacusis report less improvement over time and fewer benefits from sound therapy compared to individuals with loudness hyperacusis.[21]

Loudness discomfort level (LDL)

The threshold of sound at which discomfort is initially experienced; measured in decibels (dB).[22]

Setback

A setback is a temporary exacerbation of symptoms, a worsening of the perception of loudness or pain from sound, often due to a particular noise exposure.[13] Setback prevention is an important focus among those affected. Efforts to avoid setbacks commonly include using hearing protection and avoiding loud noises.[18] Pain hyperacusis patients experience setbacks more frequently than patients with loudness hyperacusis.[13]

Associated conditions

Some conditions that are associated with hyperacusis[23] include:


Causes and risk factors

The most common cause of hyperacusis is overexposure to excessively high decibel (sound pressure) levels, which can cause acoustic trauma.[1] An acoustic shock, which can lead to symptoms such as hyperacusis and ear pain, can also occur after exposure to an unexpected moderately loud to loud noise, even if this does not necessarily result in permanent cochlear damage.[7]

Some affected people acquire hyperacusis suddenly as a result of taking ototoxic drugs (which can damage the cells responsible for hearing), Lyme disease, Ménière's disease, head injury, or surgery. Others are born with sound sensitivity or develop superior canal dehiscence syndrome.[33] Bell's palsy can trigger hyperacusis if the associated flaccid paralysis affects the tensor tympani, and stapedius, two small muscles of the middle ear.[25] Paralysis of the stapedius muscle prevents its function in dampening the oscillations of the ossicles, causing sound to be abnormally loud on the affected side.[34] Age may also be a significant factor, with younger patients exhibiting more severe hyperacusis.[11]

Recently, it has been discovered that individuals with one copy of the GJB2 (Cx26) genetic mutation exhibit hearing that is more sensitive than average, akin to hyperacusis. These individuals appear to be at greater risk for damage from noise.[35]

Some psychoactive drugs such as LSD, methaqualone, benzodiazepines, or phencyclidine can cause hyperacusis.[11][36] An antibiotic, ciprofloxacin, has also been seen to be a cause, known as ciprofloxacin-related hyperacusis.[37] Benzodiazepine withdrawal syndrome is also a possible cause.[38][39]

Epidemiology

Prevalence estimates for hyperacusis vary widely in the literature, and further epidemiological data is needed. No gender differences have yet been established among hyperacusis patients. Hyperacusis appears to be more severe in younger patients.[11]

Possible mechanisms

Loudness hyperacusis

As one possible mechanism, adaptation processes in the auditory brain that influence the dynamic range of neural responses are assumed to be distorted by irregular input from the inner ear. This is mainly caused by hearing loss related damage in the inner ear.[4] The mechanism behind hyperacusis is not currently known, but it is suspected to be caused by damage to the inner ear and cochlea.

Noxacusis (pain hyperacusis)

Inner ear theory

Type II afferent fibers of the cochlear nerve are not responsible for hearing like the type I afferent fibers. They are thought to be cochlear pain neurons. Gain of function of these type II afferent fibers may be caused by a flood of ATP after hair cell damage.[5][6] Now sensitized, they react to the small amount of ATP released during the normal process of hearing. This may result in pain.[5][6]

Middle ear theory

Noreña et al. (2018) propose a model that may account for sound-induced pain and a constellation of other symptoms often experienced after an acoustic shock, acoustic trauma, and potentially other mechanisms of auditory damage. Symptoms may include a sense of fullness in the ear, tinnitus, and dizziness.[7][8]

The model details how symptoms may be initiated by tensor tympani muscle damage or overload due to acoustic shock or trauma. Hypercontraction or hyperactivity of the muscle may cause an "ATP energy crisis." The muscle is then forced to create energy without sufficient oxygen, which results in the release of lactic acid into the middle ear space. This acidity can activate pain-sensing neurons. Muscle relaxation requires energy in the form of ATP. In the setting of low ATP, it is more difficult for the muscle to relax, which causes the cycle to continue. Via a cascade of events, the activated pain neurons can cause neurogenic inflammation, which may lead to additional pain. In this way, a "vicious circle" is created.[7][9]

Pain from sound sometimes radiates to the face, scalp, and neck. This may be due to the trigeminocervical complex in the brainstem, which integrates input from and output to various regions of the head and neck, including the middle ear. Of note, the tensor tympani muscle is innervated by the trigeminal nerve. The model also explains how whiplash injuries, temporomandibular joint dysfunction, and other conditions affecting the head and neck regions may influence the function of the tensor tympani muscle and contribute to ear symptoms such as pain hyperacusis.[7][8][9]

Diagnosis

Loudness discomfort levels (LDLs): group data of hyperacusis patients without hearing loss. Upper line: average hearing thresholds. Lower long line: LDLs of this group. Lower short line: LDLs of a reference group with normal hearing.[40]

The basic diagnostic test is similar to a normal audiogram. The difference is that, in addition to the hearing threshold at each test frequency, the lowest uncomfortable sound level is also measured. This level is called loudness discomfort level (LDL) or uncomfortable loudness level (ULL). In patients with hyperacusis this level is often considerably lower than in normal subjects, and usually across most parts of the auditory spectrum.[1][40] However, there is not a consensus regarding what constitutes a normal LDL. The relationship between LDL's and self-reported ability to tolerate sounds in everyday life in unclear.[41]

In addition to self-report questionnaires, audiologists may employ a variety of other techniques to evaluate auditory function in patients experiencing noise sensitivity. When conducting testing that involves the presentation of sounds, which may cause the patient discomfort or pain, it is vital to inform the patient of the volume and duration of sounds to be presented prior to testing. Care should be taken to begin with sounds of low volume, and volume should be increased gradually. The audiologist and patient should both be prepared to stop testing at any time, depending on the patient's symptoms.[41]

Management and treatment

There are currently no evidence-based guidelines regarding the treatment of patients with hyperacusis. The majority of audiologists report insufficient formal education in this area, likely due in part to the current lack of consensus in the literature regarding definitions and treatment of hyperacusis.[42]

Avoidance and hearing protection

Setback prevention and reduction of pain symptoms are high priorities among those with hyperacusis and noxacusis, which is often managed through a combination of controlling the environment so as to avoid loud sounds, soundproofing, and wearing hearing protection, such as earplugs and safety earmuffs. Preliminary research has shown that individuals with pain hyperacusis can experience an exacerbation of their symptoms when not adequately protecting themselves against loud sounds.[18]

There are diametrically opposing views on avoiding overuse of hearing protection and silence. Some audiologists may advise against using hearing protection in normal sound environments, claiming it can cause or worsen hyperacusis. This is based on a study in healthy volunteers and not individuals with preexisting loudness or pain hyperacusis.[43]

Diet

Diet may play a role in symptom management in some cases of hyperacusis, with response to a migraine diet, low-histamine diet, or low sodium diet.[44][45]

Sound therapy

Sound therapy is sometimes recommended for those with hyperacusis, though its application among those with pain (noxacusis) should be used with caution. Tinnitus retraining therapy, a treatment originally used to treat tinnitus, uses broadband noise to treat hyperacusis. Pink noise can also be used to treat hyperacusis. By listening to broadband noise at soft levels for a disciplined period of time each day, some patients can rebuild (i.e., re-establish) their tolerances to sound.[2][46][47][48] More research is needed on the efficacy of sound therapy techniques when hyperacusis is the primary complaint, rather than a secondary symptom, indicating that "no strong conclusions can be made" about its efficacy at this time.[16] Importantly, individuals with pain hyperacusis are more likely than individuals with loudness hyperacusis to report worsening of their condition after the use of sound therapy.[21]

Cognitive behavioral therapy

Another possible treatment is cognitive behavioral therapy (CBT), which may also be combined with sound therapy.[23][49] However, randomized controlled trials with active control groups are still needed to establish the effectiveness of CBT for hyperacusis[50] and the usefulness of CBT for noxacusis is not yet demonstrated in the scientific literature.

Surgery

Studies have shown improved loudness discomfort levels in patients with hyperacusis after round and oval window reinforcement.[16]

A case of chronic ear pain associated with hyperacusis after exposure to loud noise at a concert was successfully treated with tympanic neurectomy.[51]

Treatment for suicidal thoughts

Suicidal ideations are a risk factor in hyperacusis patients. Hashir et al. (2019) interviewed 292 patients and found that 15.75% had expressed suicidal ideations in the previous two weeks of the study. They recommend screening for these issues.[52]

Society and culture

  • Musician Jason DiEmilio, who recorded under the name Azusa Plane, had hyperacusis and ultimately went on to die by suicide due in part to his sensitivity to noise.[53]
  • Dietrich Hectors, a hyperacusis sufferer in Belgium, took his life in 2009, after years of struggling with catastrophic hyperacusis and tinnitus.[12][54] A local government in Belgium made a short film based on his life to warn others of the dangers of hyperacusis and tinnitus.[55]
  • Musician Stephin Merritt has monaural hyperacusis in his left ear, which influences the instrumentation of his band, The Magnetic Fields, leads him to wear earplugs during performances and to cover his affected ear during audience applause.[56]
  • Vladimir Lenin, the Russian communist revolutionary, politician, and political theorist, was reported seriously ill by the latter half of 1921, having hyperacusis and symptoms such as regular headache and insomnia.[57]
  • Musician Peter Silberman of The Antlers had hyperacusis and tinnitus which put his musical career on hold, until the conditions reduced down to a "manageable level".[58]
  • Racing driver Wolfgang Reip developed severe hyperacusis after several noise traumas during his racing career.[59]
  • Beethoven possibly suffered from hyperacusis alongside his hearing loss. In a letter, he wrote: "As soon as anybody shouts, I can't bear it. Heaven alone knows what is to become of me."[60]
  • British writer Linda Stratmann suffers from hyperacusis and reports noises "cut through her like a scalpel."[61]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 "A review of hyperacusis and future directions: part I. Definitions and manifestations". American Journal of Audiology 23 (4): 402–419. December 2014. doi:10.1044/2014_AJA-14-0010. PMID 25104073. 
  2. ↑ 2.0 2.1 "A review of hyperacusis and future directions: part II. Measurement, mechanisms, and treatment". American Journal of Audiology 23 (4): 420–436. December 2014. doi:10.1044/2014_AJA-13-0037. PMID 25478787. https://pdfs.semanticscholar.org/a5ed/91aa23c1d830720013b3d2b8e41958345f01.pdf. 
  3. ↑ 3.0 3.1 "Advances in the neurobiology of hearing disorders: recent developments regarding the basis of tinnitus and hyperacusis". Progress in Neurobiology 111: 17–33. December 2013. doi:10.1016/j.pneurobio.2013.08.002. PMID 24012803. 
  4. ↑ 4.0 4.1 "Pump up the volume: could excessive neural gain explain tinnitus and hyperacusis?". Audiology & Neuro-Otology 20 (4): 273–282. 2015. doi:10.1159/000430459. PMID 26139435. 
  5. ↑ 5.0 5.1 5.2 "Unmyelinated type II afferent neurons report cochlear damage". Proceedings of the National Academy of Sciences of the United States of America 112 (47): 14723–14727. November 2015. doi:10.1073/pnas.1515228112. PMID 26553995. Bibcode: 2015PNAS..11214723L. 
  6. ↑ 6.0 6.1 6.2 Flores, Emma N.; Duggan, Anne; Madathany, Thomas; Hogan, Ann K.; Márquez, Freddie; Kumar, Gagan; Seal, Rebecca; Edwards, Robert et al. (2015-03-02). "A Non-canonical Pathway from Cochlea to Brain Signals Tissue-damaging Noise". Current Biology 25 (5): 606–612. doi:10.1016/j.cub.2015.01.009. ISSN 0960-9822. PMID 25639244. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Noreña, Arnaud (2018). "An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock". Trends in Hearing 22. doi:10.1177/2331216518801725. PMID 30249168. 
  8. ↑ 8.0 8.1 8.2 Fournier, Philippe; Paleressompoulle, Dany; Esteve Fraysse, Marie-José; Paolino, Fabien; Devèze, Arnaud; Venail, Frédéric; Noreña, Arnaud (2022-09-01). "Exploring the middle ear function in patients with a cluster of symptoms including tinnitus, hyperacusis, ear fullness and/or pain". Hearing Research 422: 108519. doi:10.1016/j.heares.2022.108519. ISSN 1878-5891. PMID 35644108. 
  9. ↑ 9.0 9.1 9.2 Fournier, Philippe; Paquette, Sébastien; Paleressompoulle, Dany; Paolino, Fabien; Devèze, Arnaud; Noreña, Arnaud (July 2022). "Contraction of the stapedius and tensor tympani muscles explored by tympanometry and pressure measurement in the external auditory canal". Hearing Research 420: 108509. doi:10.1016/j.heares.2022.108509. ISSN 1878-5891. PMID 35568596. 
  10. ↑ "Prevalence of tinnitus and hyperacusis in children and adolescents: a systematic review". BMJ Open 6 (6): e010596. June 2016. doi:10.1136/bmjopen-2015-010596. PMID 27259524. 
  11. ↑ 11.0 11.1 11.2 11.3 Musumano, Lucia Belen; Hatzopoulos, Stavros; Fancello, Virginia; Bianchini, Chiara; Bellini, Tiziana; Pelucchi, Stefano; Skarżyński, Piotr Henryk; Skarżyńska, Magdalena B. et al. (2023-10-21). "Hyperacusis: Focus on Gender Differences: A Systematic Review". Life 13 (10): 2092. doi:10.3390/life13102092. ISSN 2075-1729. PMID 37895473. Bibcode: 2023Life...13.2092M. 
  12. ↑ 12.0 12.1 "Noise Kills: When Everyday Sound Becomes Torture" (in en). https://medium.com/buzzfeed-collections/when-everyday-sound-becomes-torture-1082367f24c0. 
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Williams, Zachary J.; Suzman, Evan; Woynaroski, Tiffany G. (2021-06-14). "A Phenotypic Comparison of Loudness and Pain Hyperacusis: Symptoms, Comorbidity, and Associated Features in a Multinational Patient Registry". American Journal of Audiology 30 (2): 341–358. doi:10.1044/2021_aja-20-00209. ISSN 1059-0889. PMID 33877881. PMC 8642094. http://dx.doi.org/10.1044/2021_aja-20-00209. 
  14. ↑ "Hyperacusis" (in en). https://www.tinnitus.org.uk/hyperacusis. 
  15. ↑ Henry, James A.; Theodoroff, Sarah M.; Edmonds, Catherine; Martinez, Idalisse; Myers, Paula J.; Zaugg, Tara L.; Goodworth, Marie-Christine (September 2022). "Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management". American Journal of Audiology 31 (3): 513–527. doi:10.1044/2022_aja-22-00035. ISSN 1059-0889. PMID 35858241. http://dx.doi.org/10.1044/2022_aja-22-00035. 
  16. ↑ 16.0 16.1 16.2 Potgieter, I. (June 29, 2020). "Hyperacusis in children: a scoping review". BMC Pediatr 20, 319 (1): 319. doi:10.1186/s12887-020-02223-5. PMID 32600446. 
  17. ↑ Fackrell, Kathryn; Potgieter, Iskra; Shekhawat, Giriraj S.; Baguley, David M.; Sereda, Magdalena; Hoare, Derek J. (2017). "Clinical Interventions for Hyperacusis in Adults: A Scoping Review to Assess the Current Position and Determine Priorities for Research". BioMed Research International 2017: 1–22. doi:10.1155/2017/2723715. ISSN 2314-6133. PMID 29312994. 
  18. ↑ 18.0 18.1 18.2 18.3 Pollard, Bryan (October 2019). "Clinical Advancements for Managing Hyperacusis with Pain". The Hearing Journal 72 (10): 10, 12. doi:10.1097/01.HJ.0000602900.16223.0e. https://journals.lww.com/thehearingjournal/Fulltext/2019/10000/Clinical_Advancements_for_Managing_Hyperacusis.4.aspx. 
  19. ↑ Auerbach, Benjamin (January 1, 2019). "Physiological mechanisms of hyperacusis: an update". https://www.entandaudiologynews.com/features/audiology-features/post/physiological-mechanisms-of-hyperacusis-an-update. 
  20. ↑ Sheldrake, Jacqueline (May 15, 2015). "Audiometric Characteristics of Hyperacusis Patents". Frontiers in Neurology 6: 105. doi:10.3389/fneur.2015.00105. PMID 26029161. 
  21. ↑ 21.0 21.1 Williams, Zachary J.; Suzman, Evan; Woynaroski, Tiffany G. (2021-06-14). "A Phenotypic Comparison of Loudness and Pain Hyperacusis: Symptoms, Comorbidity, and Associated Features in a Multinational Patient Registry" (in en). American Journal of Audiology 30 (2): 341–358. doi:10.1044/2021_AJA-20-00209. ISSN 1059-0889. PMID 33877881. 
  22. ↑ Deihl, Peter (July 15, 2015). "Abnormal auditory gain in hyperacusis: investigation with a computational model". Frontiers in Neurology 6: 157. doi:10.3389/fneur.2015.00157. PMID 26236277. 
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  27. ↑ Hyperacusis : mechanisms, diagnosis, and therapies. San Diego, CA: Plural Publishing Inc. 2007. p. 59. ISBN 978-1-59756-808-1. 
  28. ↑ Traumatic brain injury: methods for clinical and forensic neuropsychiatric assessment. Boca Raton, Fla. London: CRC Taylor & Francis distributor. 2008. p. 181. ISBN 978-0-8493-8139-3. 
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  30. ↑ "Auditory function in patients with systemic lupus erythematosus". Auris, Nasus, Larynx 38 (1): 26–32. February 2011. doi:10.1016/j.anl.2010.04.008. PMID 20576373. 
  31. ↑ Tay–Sachs disease. San Diego, Calif. London: Academic. 2001. p. 25. ISBN 978-0-08-049030-4. https://archive.org/details/advancesgenetics00desn. 
  32. ↑ "Auditory and visual processing in Williams syndrome". The Israel Journal of Psychiatry and Related Sciences 47 (2): 125–131. 2010. PMID 20733255. 
  33. ↑ Suzuki, Mitsuya; Ota, Yasushi; Takanami, Taro; Yoshino, Ryosuke; Masuda, Hiroaki (2023-08-26). "Superior canal dehiscence syndrome: A review" (in en-US). Auris Nasus Larynx. doi:10.1016/j.anl.2023.08.004. ISSN 0385-8146. PMID 37640595. https://www.sciencedirect.com/science/article/abs/pii/S0385814623001505. 
  34. ↑ Core text of neuroanatomy (3rd ed.). Baltimore: Williams & Wilkins. 1985. p. 151. ISBN 978-0-683-01455-6. 
  35. ↑ Liu, Li-Man; Liang, Chun; Chen, Jin; Fang, Shu; Zhao, Hong-Bo (2023). "Cx26 heterozygous mutations cause hyperacusis-like hearing oversensitivity and increase susceptibility to noise". Science Advances 9 (6): eadf4144. doi:10.1126/sciadv.adf4144. ISSN 2375-2548. PMID 36753545. Bibcode: 2023SciA....9F4144L. 
  36. ↑ Medical Toxicology of Drug Abuse : Synthesized Chemicals and Psychoactive Plants. Hoboken, N.J: John Wiley & Sons. 2012. pp. 457, 507, and 616. ISBN 978-1-118-10605-1. 
  37. ↑ "Ciprofloxacin Related Hyperacusis". FDA Reports. 2017. https://www.druginformer.com/search/side_effect_details/Ciprofloxacin/hyperacusis.html. 
  38. ↑ "Benzodiazepines and tinnitus". BMJ 302 (6790): 1465. June 1991. doi:10.1136/bmj.302.6790.1465. PMID 2070121. 
  39. ↑ "Anxiolytic drugs: dependence, addiction and abuse". European Neuropsychopharmacology 4 (2): 85–91. June 1994. doi:10.1016/0924-977x(94)90001-9. PMID 7919947. 
  40. ↑ 40.0 40.1 "Audiometric characteristics of hyperacusis patients". Frontiers in Neurology 6: 105. 2015. doi:10.3389/fneur.2015.00105. PMID 26029161. 
  41. ↑ 41.0 41.1 Jahn, Kelly N. (July 2022). "Clinical and investigational tools for monitoring noise-induced hyperacusis". The Journal of the Acoustical Society of America 152 (1): 553–566. doi:10.1121/10.0012684. ISSN 0001-4966. PMID 35931527. PMC 9448410. http://dx.doi.org/10.1121/10.0012684. 
  42. ↑ Jahn, Kelly N.; Koach, Chelsea E. (2023-11-02). "Hyperacusis Diagnosis and Management in the United States: Clinical Audiology Practice Patterns". American Journal of Audiology 32 (4): 950–961. doi:10.1044/2023_aja-23-00118. ISSN 1059-0889. PMID 37917915. http://dx.doi.org/10.1044/2023_aja-23-00118. 
  43. ↑ Formby, C.; Sherlock, L. P.; Gold, S. L. (July 2003). "Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background". The Journal of the Acoustical Society of America 114 (1): 55–58. doi:10.1121/1.1582860. ISSN 0001-4966. PMID 12880017. https://pubmed.ncbi.nlm.nih.gov/12880017. 
  44. ↑ Migraine - More than a Headache. Adapted from Michael Teixido MD and John Carey MD Edited by: Hamid Djalilian, MD
  45. ↑ Teixido, Michael (2014). "Migraine - More than a Headache". https://www.hopkinsmedicine.org/otolaryngology/_docs/migraine%20patient%20handout.pdf. 
  46. ↑ "Help for Hyperacusis: Treatments Turn Down Discomfort" (in en-US). The Hearing Journal 67 (8): 22. August 2014. doi:10.1097/01.HJ.0000453391.20357.f7. ISSN 0745-7472. 
  47. ↑ "A Sound Therapy-Based Intervention to Expand the Auditory Dynamic Range for Loudness among Persons with Sensorineural Hearing Losses: A Randomized Placebo-Controlled Clinical Trial". Seminars in Hearing 36 (2): 77–110. May 2015. doi:10.1055/s-0035-1546958. PMID 27516711. 
  48. ↑ Hyperacusis and Disorders of Sound Intolerance Clinical and Research Perspectives. Plural Publishing. 2018. pp. C15, C16. ISBN 978-1-94488-328-7. 
  49. ↑ "Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients' evaluations of the effectiveness of treatments". International Journal of Audiology 55 (9): 514–522. September 2016. doi:10.1080/14992027.2016.1178400. PMID 27195947. 
  50. ↑ Aazh, Hashir; Landgrebe, Michael; Danesh, Ali A.; Moore, Brian Cj (2019). "Cognitive Behavioral Therapy For Alleviating The Distress Caused By Tinnitus, Hyperacusis And Misophonia: Current Perspectives". Psychology Research and Behavior Management 12: 991–1002. doi:10.2147/PRBM.S179138. ISSN 1179-1578. PMID 31749641. 
  51. ↑ Ally, Munira; Moinie, Ahmad; Lomas, Joan; Borsetto, Daniele; Mochloulis, George; Bance, Manohar; Boscolo-Rizzo, Paolo; Vijendren, Ananth (2022-09-26). "Aetiology and management options for secondary referred otalgia: a systematic review and meta-analyses". European Archives of Oto-Rhino-Laryngology 280 (1): 47–59. doi:10.1007/s00405-022-07638-7. ISSN 0937-4477. PMID 36163556. http://dx.doi.org/10.1007/s00405-022-07638-7. 
  52. ↑ Aazh, Hashir; Landgrebe, Michael; Danesh, Ali (2019). "Parental Mental Illness in Childhood as a Risk Factor for Suicidal and Self-Harm Ideations in Adults Seeking Help for Tinnitus and/or Hyperacusis". American Journal of Audiology 28 (3): 527–533. doi:10.1044/2019_AJA-18-0059. PMID 31184510. https://pubs.asha.org/doi/full/10.1044/2019_AJA-18-0059. 
  53. ↑ "When Everyday Sound Becomes Torture". Buzz Feed. 15 March 2013. https://www.buzzfeed.com/joycecohen/noise-kills-when-everyday-sound-becomes-torture. 
  54. ↑ "Farewell Letter from Dietrich Hectors" (in en). https://hyperacusiscentral.blogspot.com/2022/11/farewell-letter-from-dietrich-hectors.html. 
  55. ↑ "Minister Schauvliege stelt kortfilm Ruis voor : gehoorschade" (in nl). https://nnieuws.be/artikel/minister-schauvliege-stelt-kortfilm-ruis-voor-gehoorschade. 
  56. ↑ "The return of indie pop's favorite crank". 2012-03-05. https://www.salon.com/2012/03/05/the_return_of_indie_pops_favorite_crank/. 
  57. ↑ Shub 1966, p. 426; Rice 1990, p. 187; Service 2000, p. 435.
  58. ↑ "How Peter Silberman Lost His Hearing, Then Rediscovered Sound" (in en). pastemagazine.com. 24 February 2017. https://www.pastemagazine.com/articles/2017/02/how-peter-silberman-lost-his-hearing-and-rediscove.html. 
  59. ↑ Treworgy, David (2022-02-24). "Champion Racing Driver Wolfgang Reip Announces Battle with Severe Hyperacusis" (in en-US). https://hyperacusisresearch.org/champion-racing-driver-wolfgang-reip-announces-battle-with-severe-hyperacusis/. 
  60. ↑ Huxtable, Ryan (February 2000). "The deafness of Beethoven: A paradigm of hearing problems". Proceedings of the Western Pharmacology Society 43: 1–8. PMID 11056941. https://www.researchgate.net/publication/12269658. 
  61. ↑ "Man does dishes for wife because sound of it is too painful for her" (in en). https://metro.co.uk/2019/08/10/man-does-dishes-for-wife-because-sound-of-it-is-too-painful-for-her-10549473/?fbclid=IwAR2az1izAy1UFfkyXMPquiFnuFOptsjDvZNob8KSk9pXFaqQ5wwZVp3lCA4. 

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