How to manage tinnitus, hyperacusis, and associated ear pain?

Management of Tinnitus, Hyperacusis, and Associated Ear Pain

Patients with tinnitus, hyperacusis, and ear pain should receive prompt audiologic examination, education and counseling, sound therapy, and cognitive behavioral therapy as the primary management approach, while avoiding medications that lack evidence of benefit.

Initial Evaluation

A targeted evaluation is essential to identify potential underlying causes and guide management:

• Audiologic examination: A comprehensive audiologic examination should be obtained promptly for this patient with persistent tinnitus, hyperacusis, and ear pain 1. This is particularly important given the patient's description of sound sensitivity and ear pain, which suggests possible hyperacusis.

• Characterize the tinnitus: Determine if the tinnitus is:

  • Unilateral or bilateral
  • Pulsatile or non-pulsatile
  • Constant or intermittent
  • Recent onset or persistent (≥6 months)
  • Bothersome or non-bothersome 1, 2

• Imaging considerations: Imaging studies should NOT be obtained unless the patient has one or more of the following: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1, 2.

Diagnosis and Classification

The patient's symptoms suggest a combination of:

1. Tinnitus: The ringing sensation described by the patient
2. Hyperacusis: Increased sensitivity to sounds that would not bother most people
3. Possible Tonic Tensor Tympani Syndrome (TTTS): The ear pain and sensitivity to specific sounds like clapping may indicate TTTS, which is common in patients with both tinnitus and hyperacusis 3

Research shows that 81.1% of hyperacusis patients have symptoms consistent with TTTS, including pain/numbness/burning in and around the ear and aural "blockage" 3. The patient's description of certain noises causing pain (clapping, shoes dragging) is consistent with this syndrome.

Management Strategy

1. Education and Counseling (First-line)

• Provide clear explanation about the mechanisms of tinnitus and hyperacusis
• Reassure that while these conditions can be distressing, they are manageable and rarely indicate serious underlying disease
• Explain the relationship between anxiety, stress and worsening of symptoms 1, 2

2. Sound Therapy (Recommended)

• Sound generators: White noise machines or ear-level sound generators to provide background noise that can help mask tinnitus and gradually desensitize the auditory system 2, 4
• Environmental sound enrichment: Recommend using background sounds (fans, soft music) to reduce the contrast between tinnitus and silence
• Hearing aids: If hearing loss is identified during audiologic examination, hearing aids can help by amplifying environmental sounds to mask tinnitus 1, 2

Sound therapy has been shown to reduce auditory gain (hypersensitivity) in patients with hyperacusis and can help desensitize the auditory system over time 4.

3. Cognitive Behavioral Therapy (CBT)

• CBT is the most effective evidence-based intervention for tinnitus and hyperacusis with proven benefits for quality of life 1, 2
• Helps patients develop coping strategies and change negative thought patterns about their symptoms
• Addresses the anxiety and irritability that the patient reports as associated with their symptoms

4. Stress Management Techniques

• Progressive muscle relaxation has shown benefit for patients with hyperacusis 5
• Mindfulness meditation and deep breathing exercises can help reduce the stress response that often exacerbates symptoms

What to Avoid

• Medications: Do not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for treating persistent, bothersome tinnitus as they lack evidence of benefit 1, 2
• Dietary supplements: Ginkgo biloba, melatonin, zinc, or other dietary supplements are not recommended as they lack evidence of efficacy 1
• Transcranial magnetic stimulation: Not recommended for routine treatment 1

Follow-up and Monitoring

• Schedule follow-up within 4-6 weeks to assess response to initial management
• If symptoms persist or worsen, consider referral to specialized tinnitus/hyperacusis clinic
• Monitor for signs of depression or severe anxiety, as patients with tinnitus and hyperacusis have increased risk of psychological distress 1

Special Considerations

• The combination of tinnitus, hyperacusis and ear pain can significantly impact quality of life and may lead to social isolation and avoidance behaviors
• Women are affected by the combination of tinnitus and hyperacusis significantly more often than men 6
• There is not always a direct correlation between the severity of tinnitus and hyperacusis, though they frequently co-occur 6

Key Pitfalls to Avoid

• Dismissing symptoms: These symptoms significantly impact quality of life and should be taken seriously
• Focusing only on tinnitus: Hyperacusis and ear pain require specific management approaches
• Overmedication: Avoid prescribing medications with limited evidence and potential side effects
• Delayed intervention: Early management may prevent symptom progression and psychological complications

By implementing this comprehensive approach focusing on audiologic evaluation, education, sound therapy, and CBT, most patients will experience improvement in their symptoms and quality of life.