What Are Potential Treatments for Hyperacusis?

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Patient Presentation
A 3 year-old male came to clinic for his health supervision visit. His mother complained that he was very sensitive to loud noises. “He’s almost toilet trained now but every time we go into a public bathroom his eyes get big. I actually put my hands over his ears so he can do his business and he won’t be scared if a toilet flushes,” she reported. “He also likes planes so we took along some ear protectors to the airshow at the airport. He still didn’t like the loud noises but he had fun seeing all the planes. Anything surprising like an alarm going off makes him really upset,” she continued. He usually calmed down quickly after the noise and didn’t seem to avoid activities. His mother had no concerns about his hearing, language development, or problems with other sensations. She and his daycare providers had no concerns about his development. The past medical history was non-contributory and he had 1 ear infection around 2 years of age.

The pertinent physical exam showed a chatty male with growth parameters in the 10-25%, and normal vital signs. His examination was normal.

The diagnosis of a healthy male was made who was sensitive to loud noises. The doctor explained that this was common and that the mother was right to try to help him when he had to be in settings where they could occur. “Putting your hands over his ears is a good option and as he gets more used to public toilets and gets a bit older, this should improve. If this seems to be getting worse, or it is causing him more stress or anxiety or even avoiding places or activities, that may need more help. Just let me know and we can talk about it again,” she said. At his 4 year-old checkup, his mother reported that he still didn’t like the public restrooms, but would use them without her help now. He also still doesn’t like the dogs or sirens but said he realizes that they just happen and stop pretty quickly too.

Discussion
Hearing is functional in human fetuses at approximately 25-27 weeks gestation.. The aural anatomical structures are developed by ~32 weeks gestation.

Hyperacusis does not have a specific definition but in general is an increased sensitivity to sounds (either intensity or loudness). Some authors describe it as “…decreased sound tolerance where there is a negative reaction to the physical characteristics of the sound,” and other authors use “…increased sensitivity to sound in levels that would not trouble a normal individual.” Phonophobia is a true fear of sounds with anticipation causing anxiety at the sight or thought of the object generating the sound. Misophonia is distress caused by certain sounds or patterns of sounds (e.g. chewing, scratching of chalkboards) rather than the sound loudness. Tinnitus can be a ringing or buzzing sound and in general practice means any perceived sound that is not generated externally. Tinnitus usually does not arise to the level of distress but could. A tinnitus review can be found here.

Hyperacusis has a reported prevalence of 3.2-17.1% in the general population but is markedly increased in other populations. For example children with autism spectrum disorder and William’s syndrome have an 18-63% and 95% prevalence rate respectively. In one study the commonest age of presentation was 3-4 years but ranged from 1-15 years. It is not uncommon for young children to be sensitive to sounds but over time to become tolerant.

Possible mechanisms for hyperacusis include:

  • Normally developing but immature auditory system – example is normally developing children who are sensitive for a period of time
  • Auditory deprivation that is temporary – example is child with persistent middle ear fluid may habituate to needing louder sounds, but when fluid diminishes the brain does not appropriately recalibrate and the patient perceives these sounds as “too loud” or distressing in some manner
  • Auditory system disorder – example are patients with neurodevelopmental problems such as autism spectrum disorder, etc, but can also be acquired such as traumatic brain injury
  • Sensory processing disorder – example is children with “…difficulty in regulating or integrating sensory information (visual, touch, sounds, smells, proprioception) which can lead to patterns of hyper-sensitivity to sensory stimuli or a ‘sensory overload’ effect.”

Learning Point
Common troublesome noises triggering hyperacusis include:

  • Household appliance – vacuum cleaner, hair dryers, blender, washing machines, radio or television, lawn mowers
  • Community sounds – toilets, hand dryers, doorbells, telephones, airplanes, sirens
  • Gathering noises – classroom, lunchroom and playground noise, music class, restaurants, sports events
  • Unexpected noises – school bell, balloon popping, dog barking, clapping, sneezing, laughing, babies crying

Also remember that a child is often closer to the sound generator (e.g. toilet, vacuuum, dog, etc.) than an adult and therefore the sound can be louder for them. Also some of these objects also have additional potential threats such as a dog could bite, or a child could be splashed with toilet water which can lead to additional wariness of the object.

Hyperacusis for most children is developmental with improved tolerance with maturation and/or habituation, but other patients may need additional assistance.
Possible treatments include:

  • Reassurance, support, watch and wait
  • Avoidance – doing the vacuuming when patient is not around
  • Allowing control – patients often are more comfortable with sounds they generate or have control over. Child can do the vacuuming, using ear protection to decrease sounds, or sit in different location to mitigate the sound or be able to escape it temporarily
  • Focus on the good part of the activity – help child to focus on playing games with friends rather than the loud sounds the children are making
  • Various specific therapies
    • Desensitization
    • Sensory integration therapy – clinic-based intervention where activities increase the child’s ability to integrate sensory information
    • Sensory based intervention therapy – adult-directed activities to help improve behaviors associated with the sensation, such as using a white noise generator

Questions for Further Discussion
1. How can portable listening devices affect hearing? A review can be found here
2. What are the current recommendations for hearing screening?
3. What are potential choices for hearing amplification?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Hearing Disorders and Deafness and Child Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. 2015;19(2):133-148. doi:10.1177/1362361313517762

Clark-Gambelunghe MB, Clark DA. Sensory Development. Pediatric Clinics of North America. 2015;62(2):367-384. doi:10.1016/j.pcl.2014.11.003

Myne S, Kennedy V. Hyperacusis in children: A clinical profile. International Journal of Pediatric Otorhinolaryngology. 2018;107:80-85. doi:10.1016/j.ijporl.2018.01.004

Rosing SN, Schmidt JH, Wedderkopp N, Baguley DM. Prevalence of tinnitus and hyperacusis in children and adolescents: a systematic review. BMJ Open. 2016;6(6):e010596. doi:10.1136/bmjopen-2015-010596

Potgieter I, Fackrell K, Kennedy V, Crunkhorn R, Hoare DJ. Hyperacusis in children: a scoping review. BMC Pediatrics. 2020;20(1):319. doi:10.1186/s12887-020-02223-5

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published