Question
Occasionally I get a patient whose tinnitus worsens with the use of amplification. Why is this? How should I manage these patients?
Answer
Management depends, to a great extent, on the cause of the problem. Following is an overview of the most common causes behind a patient’s tinnitus getting worse with the addition of amplification – and tips for management.
1. Decreased sound tolerance, or hyperacusis – While most tinnitus evaluation protocols include loudness discomfort level testing, the standard hearing aid evaluation usually does not. It can be easy to overlook this condition as the patient has altered his/her environment to avoid encountering sounds that are uncomfortable. Amplification can serve to further compound this problem in patients with hyperacusis and tinnitus. With a decreased dynamic range, hearing aids set prescriptive levels that can easily cross these levels, leaving the patient over-amplified. MPO levels must also be set with great care.
2. Auditory fatigue – While little data exists, we know of many patients who experience an increase in their tinnitus perception following periods where there are greater demands on their auditory system. The sound does not need to be loud; it can be a situation where there is competing noise present while trying to process auditory information. This creates a greater strain on the system and can cause the tinnitus perception to be worse. In these cases, it may be appropriate to limit hearing aid use to a certain number of hours per day.
3. Reactive tinnitus – Rarely, some individuals with tinnitus report that moderately low intensity sounds aggravate their tinnitus, and that this exacerbation tends to continue for more than a day. Some ways to identify this “reactive tinnitus” may be a case history identifying prolonged tinnitus perception after exposure to moderately low level sounds, the presence of decreased sound tolerance, and a worsening of tinnitus after residual inhibition testing. Treatment for reactive tinnitus is multi-faceted, but from the standpoint of acoustic stimulation needs, requires a very soft-intensity level sound that emphasizes maximal comfort and relaxation.