lunes, 1 de octubre de 2012

Case Study: Hyperacusis with Phonophobia

Tinnitus Topics
The majority of our tinnitus and loudness sensitivity (LS) patients are adults, but sometimes our patients are children. The incidence of children reporting tinnitus and/or LS is unknown, however in the New England Tinnitus and Hyperacusis Clinic, we see about 5 percent of children under the age of 16.
When dealing with a pediatric patient, just as with adults complaining of tinnitus and/or LS, a thorough audiological assessment by a specially trained audiologist is required. A battery of tinnitus and LS tests is performed. Depending on the age of a child, some of the tasks may need to be explained in more detailed fashion.
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CS, a 12-year-old girl, came to the office accompanied by both her parents. She was pleasant and shy. She covered her ears to some of my voice sounds and to the noise of the traffic coming through the closed windows. Her parents communicated with CS by whispering; since I am a 65-year-old male with a slight high-frequency hearing loss, I struggled to hear them speak. CS was obviously having some issues with the loudness of normal conversational sounds. She also reported constant fatigue and migraine-type headaches accompanying exposure to "louder" sounds. CS and her parents attributed the LS to a sinus infection she had about 18 months before coming to the New England Tinnitus and Hyperacusis Clinic.
Her family adapted their lifestyles to CS for the past year. For example, other members of the family were listening to TV using personal headphones so as not to disturb CS's loudness sensitivity. CS was home-schooled for the past year, spending most of her time in an extremely quiet, controlled environment. She also used ear protectors in "anticipation" of possibly being exposed to louder sounds.
CS has seen many ENT physicians as well as neurology, pain management, acupuncture, chiropractic and hypnosis specialists. She has been on many medications for headaches and sleep.
CS was very cooperative during her audiological testing. Her hearing was within normal limits with few frequencies at -5 dB levels. Her word recognition scores were performed at 40 dB HL, which represent at least 60 dB SPL greater than the level at which her family was conversing with CS. She did not miss a single word nor did she object to the level being too high. Her loudness discomfort levels were 40 dB HL across all tested frequencies of 500, 1000, 2000, 4000 and 8000 Hz. This was somewhat in disagreement with CS allowing us to present the word recognition words at 40 dB HL. CS also did not object to us performing tympanometry with the probe tone of 72 dB SPL at 260 Hz. Her tympanometry was normal and acoustic reflex test was not performed.
Based on the above findings and based on the history reported by CS and her parents, a diagnosis of hyperacusis with phonophobia was made.
Hyperacusis is described as an abnormally strong reaction occurring within the auditory pathways resulting from exposure to moderate sound. Patients express reduced tolerance to suprathreshold sounds (below LDL). Phonophobia is described as an abnormally strong reaction of the autonomic nervous system and the limbic systems without physiological, abnormally high activation of the auditory systems. Patients are afraid of sound.
The results of CS's audiological evaluation were reviewed. CHaTT* (Cognitive Tinnitus Treatment Therapy) protocol was explained with the "hardware/software" approach to help CS understand the mechanisms behind her LS. As the hardware component, a binaural set of sound generators (RITE system) was recommended for CS and, in addition, to listen to her favorite music via her MP3 player. A specific CHaTT regimen of graduated sound exposure was prescribed. The software component consisted of the CHaTT instructional/cognitive sessions. CS fully understood her recommended treatment. She asked some pertinent questions, which were thoroughly reviewed with her. She reported feeling somewhat relieved as she was leaving.
CS returned in a week to be fitted with the sound generators and, using REMs, she was instructed on a correct way of adjusting the volume controls. Additionally, "software" issues were addressed and questions posed by CS were answered.
A week later CS returned for her first follow-up appointment. Her parents were not whispering anymore and CS's voice had almost a normal loudness level. LDLs were assessed and were found to be at 50 dB HLs. Again re-explanation of the "software" component was addressed introducing cognitive distortions present in CS's interpretation of her LS.
This process continued in two-week intervals for four months. At her four-month appointment, LDLs were at 90 to 100 dB HLs. CS was ready to re-enter a normal teenager's life. She was getting ready to return to her school and her friends.
*CHaTT is a tinnitus/loudness sensitivity program that utilizes an eclectic, patient-tailored approach. For more information, contact the Tinnitus Practitioners Association,
Natan Bauman, EdD, MS Eng., FAAA, is director of the New England Tinnitus and Hyperacusis Clinic and founder of the Tinnitus Practitioners Association.

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