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dave2

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Posts: 96
Reply with quote  #1 
Most websites, including the Hyperacusis Network, state that H can come on gradually or occur suddenly. Most of the histories I have read on this message board and elsewhere seem to fall into the "suddenly" category - because they involve specific incidents that triggered H, usually a noise injury. I wonder if anyone has insights on various questions about gradual versus sudden onset:

1. Is there data on percentage of people who acquire H suddenly versus gradually?

2. What causes gradual onset?

3. Does sudden versus gradual suggest any differences in treatment approach? For example, does gradual suggest it is not noise-induced, but rather something like an underlying medical condition, an ototoxic drug accumulation, or even a vitamin or mineral deficiency? Meaning that first the underlying issue should be identified before TRT? or at least in conjunction with TRT?

4. For people on this message board, has anyone had gradual, unexplained onset? If so, did you ever figure out an explanation?

For me, H has set in very gradually over the last 18 months. I have always worked in a quiet office environment so no loud work noise, and have not experienced any loud noise incidents such as concerts for several years, so nothing like that would seem to be an explanatory factor. So, I am trying to figure out if TRT is the way to go right away or if I should do more work on looking for an underlying condition (for example, since I spend a lot of time in a high-risk Lyme area, I got tested, and it was negative).

Many thanks in advance for any thoughts!
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briann

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Posts: 141
Reply with quote  #2 
Hi Dave,

I hope you get responses for your questions 2-4. I'm interested in the answers too. I have an answer for question 1:

Hypersensitivity to sound--questionnaire data, audiometry, and classification
http://informahealthcare.com/doi/abs/10.1080/010503999424653?journalCode=saud
This study of 100 hyperacusis patients found 30% had a gradual onset of hyperacusis

Hyperacusis: Clinical Studies and Effect of Cognitive Behavioral Therapy
http://uu.diva-portal.org/smash/get/diva2:648834/FULLTEXT01.pdf
This study of 62 hyperacusis patients found 33.9% had a gradual onset of hyperacusis.
There is a typo in the chart that has gradual and sudden inverted. The text clarifies that 33.9% is the right number for gradual.

I recommend people look through these surveys. They are interesting. The second one is free.

-Brian
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briann

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Posts: 141
Reply with quote  #3 
Actually you may want to work through these for question 2. It's from the literature review on hyperacusis in the recent news section of hyperacusis.net.
Screen Shot 2015-04-21 at 7.59.50 PM.jpg

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Rob

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Posts: 4,049
Reply with quote  #4 
dave2 -

What are your symptoms?

Has a hearing healthcare professional diagnosed you with hyperacusis?  If so, were any tests administered to you to help the clinician reach the diagnosis? 

Hyperacusis can be caused by other things in addition to exposure to loud noise such as head injury, migraine, Williams Syndrome, Lyme disease, autism, Bell's palsy, benzo withdrawal, and post stapedectomy.   

Rob
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dave2

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Posts: 96
Reply with quote  #5 
Brian,

Thanks very much, I downloaded the second report and read through it, very interesting. I gather from an earlier posting that a similar survey is being developed by Stanford under commission from Hyperacusis Resesarch, so hopefully they will take the Uppsala work to greater depth and understanding.

Also thanks on the extract from the literature review, I had not noticed that before. I think I have come across most of those condition associations and ruled them out. But helpful to have a reputable list in one place.

- Dave
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dave2

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Posts: 96
Reply with quote  #6 
Rob,

Starting about 18 months ago, I gradually started finding that some sounds were painful at the time of hearing them and also could leave my ears aching for a couple hours or days afterwards. It started with things like sirens, car horns, screeching buses that need brake jobs, loud subway trains, and toddler screams. Then progressed gradually to things like dishes clattering, weights clanging at the gym, some checkout beeps, and even certain adult voices. 

About 6 months prior to the start of the H, I developed very mild unilateral T. A couple months ago, I developed a new T sound, bi-lateral this time, and quite a bit more irritating than the first sound, but still relatively mild and manageable. I have no other symptoms.

I met with a neuro-otologist who provided a diagnosis of hyperacusis. In preparation for that appointment, an audiologist conducted a pure tone audiometry up to 8k and an LDL test. The audiometry was normal. Interestingly, the LDLs were normal, averaging about 95, the worst one being about 88. This was a bit of a puzzle. A couple months later, I had my LDLs tested again by an entirely different audiological practice. They were a little lower this time, low 80s to mid 90s, but still considered normal. I seem to be okay when the sound is gradually turned up in an LDL test but when it is an immediate loud noise I find it excruciatingly painful.

Dave


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Aplomado

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Posts: 711
Reply with quote  #7 
The "cause" of my H was almost certainly gunshot noise, but it took some weeks to develop.

I highly recommend you don't torture yourself trying to figure out why you have it, just start TRT and sound therapy.  I waited six months of agony before I started, for no good reason.
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Paulbe

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Posts: 176
Reply with quote  #8 
I agree with Aplo in principle.  There may be some diseases you need to have ruled in or out, but most likely you'll be left with symptoms without a cause that still need to be addressed.

Did your neuro-otologist discuss possible causes at all? 
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briann

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Posts: 141
Reply with quote  #9 
Hi Dave,

LDLs in the 80s or 90s does not guarantee your sound tolerance is normal. Your main complaint seemed to be pain from sound and not loudness from sound. On average, sensations were normal people feel a tickle in their ear is around 125 dB and pain comes around 135 dB. It is likely your pain thresholds are much lower than 135 dB. 

-Brian
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dave2

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Posts: 96
Reply with quote  #10 
Aplomado and Paulbe, thanks, I think that is right, start on TRT, after all 85-ish percent odds are pretty good. The neuro-otologist was rather stumped as to possible cause, since there were no suggestive symptoms or specific trigger noise injury events. In light of the unilateral T, he did recommend the obligatory MRI to rule out the unlikely possibility of an acoustic neruoma. I got the MRI and it was clean.
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dave2

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Posts: 96
Reply with quote  #11 
Brian,

Yes, my main complaint is pain. Sounds do not sound any louder to me than before (e.g., a car does not sound like a jet engine to me like it does to some on this board, to me it still sounds like a car), I hear sounds at the same loudness as I always have, but many combinations of frequencies / decibel levels now cause pain where they did not before.

Everything I have read so far references H clinical definition as a function of the difference between threshold and LDL. And the Jastreboffs consider less than 60 to be H, and less than 40 to be severe H. My threshold is about 10 and my LDLs are about 90, that would put my difference around 80. Any thoughts on what this implies, either from a diagnosis or treatment point of view?

Dave




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Rob

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Posts: 4,049
Reply with quote  #12 
dave2 -

Some clinicians would say LDLs at 95 dB HL are normal.  Others, including the Jastreboffs, would say LDLs of approximately 100 dB HL and higher are normal (i.e., exclude the presence of hyperacusis).  My own take is LDLs of 100 and higher are normal. 

If we assume your more recent LDL test is indicative of your sound tolerance (low 80s to mid 90s), that could explain some of what you are describing.  In my view, LDLs in the low 80s to mid 90s indicate you may have some hyperacusis, but not severe or even moderate hyperacusis.  The reason I say "may" is because it is usually not enough to diagnose hyperacusis based on LDLs alone.

I'm not sure how you got the impression the Jastreboffs consider less than 60 to be hyperacusis and less than 40 to be severe hyperacusis.  Having low LDLs alone does not necessarily mean someone has hyperacusis; low LDLs could also be due to misophonia.  In a recently published paper, the Jastreboffs write that "in cases of pure hyperacusis, LDLs are in the 60 to 85 dB HL range.  In cases of pure misophonia, LDL values are as low as 30 dB HL to as high as 120 dB HL."   

Rob


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briann

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Posts: 141
Reply with quote  #13 
Dave,

As someone without any medical credentials whatsoever, I think you have mild hyperacusis. It's not really practical to study differences between loudness and pain thresholds so we work with loudness thresholds. A mild hyperacusis categorization from LDLs might hide the possibility that your pain thresholds have dropped even more. There are many examples of people experiencing pain from sound while posting LDL numbers like yours or even higher. When I first got H mine was mild (it came on worse and sudden but quickly became mild). I got better after a few years without therapy but I also got much worse years later by exposing myself to damaging levels and mild pain a bit too often. Don't forget that although the pain we sense is not necessarily damage, what triggered these lowered thresholds is suspected to be the result of cochlear damage. So for whatever reason we are susceptible and have to make sure we protect from damaging levels without protecting from safe levels.

I think noise therapy couldn't hurt, just don't push up the noise to unsafe volumes. Loudness and pain thresholds can go up from this. Below is a 2007 analysis led by Craig Formby of people who went through TRT. The severe column of the bottom graph can be easily misinterpreted. Most of the severe in this study are so categorized as a result of significant hearing loss eating into their dynamic range. The range of this category is also quite large. In other words, just because people remain in the severe category after treatment does not mean they did not improve. It looks like much of the mild cases improved too.

Screen Shot 2015-04-25 at 4.40.42 PM.jpg

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dave2

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Posts: 96
Reply with quote  #14 
Rob,

Thanks for that clarification. Where I got that impression was from the below link, but I think either I am interpreting "dynamic range" incorrectly or the article may have mixed things up slightly because in reading direct source Jastreboff papers I see that what you have noted is correct:

"Jastreboff and Hazell define "sensitivity to sound/hyperacusis" as a reduced dynamic range of less than 60 dB between threshold and LDL." (Jastreboff PJ, Hazell JWP: A neurophysiological approach to tinnitus: clinical implications. Br. J. Audiol 27:7-17, 1993.)

http://www.tinnitusjournal.com/detalhe_artigo.asp?id=360

Dave
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dave2

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Posts: 96
Reply with quote  #15 
Brian,

Thanks for your thoughtful comments on my situation and for posting the chart, very interesting. Is the full paper available somewhere? I searched briefly but could not find it other than behind a paywall.

Dave
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dave2

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Posts: 96
Reply with quote  #16 
This chart (from the Goldstein and Shulman paper) helps clarify in my mind how to characterize hyperacusis as a function of both dynamic range and absolute LDLs (recognizing this is blending together the approaches of different researchers, Jastreboff and Hazell among them):

Hyperacusis chart 5.jpg

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briann

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Posts: 141
Reply with quote  #17 
Since you don't have hearing loss, you should not be using dynamic range as the criteria for H severity.

Unfortunately most of this research is behind a paywall. I did not see anything regarding progress for gradual vs sudden onset patients though. I believe it is the same to them. I would love to get an answer for this from an experienced provider of this treatment. We need an AMA with one of these people.

The report from a recent TRT Clinical trial is free, also from formby,
http://www.ica2013montreal.org/Proceedings/mss/050083_1.pdf
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