Working with Tinnitus Is More Than Masking

Robert Traynor
January 30, 2019

All of a sudden there is lots of talk and ads by audiologists about tinnitus on television and in the mailbox, where did that come from? 

Audiology is highly competitive these days and in the 2019 US marketplace the treatment of hearing loss alone is no longer a lucrative business in many areas.  As the competitive climate for new patients becomes greater from new government regulations, big box stores, corporate encroachment, and over the counter hearing aids, more audiology clinics are turning to the treatment of tinnitus as another component of their clinical services. 

Tinnitus and hyperacusis treatment, however, is significantly more complex than the mere selling of hearing devices for masking, it involves some serious issues that may require medical treatment or surgery by not only ENT but other physicians, and therapy with mental health professionals as well as  audiologists that have taken the time to learn about tinnitus, sound therapy and sound therapy by earning special training in tinnitus.  While there are other credentials for tinnitus, the CH-TM offered by the American Board of Audiology is a 7 module online program available to all audiologists that prepares clinicians for their clinical journey treating tinnitus and hyperacusis patients.   


Incidence of Tinnitus: How Common is it?


Davis and El Refaie (2000)  have estimated that 10% to 15% of the US population experience chronic or persistent tinnitus (eg, ringing in the ears or internal head noises). About half of the people with tinnitus are bothered by it, and it is reported that about 1% indicate that tinnitus substantially affects their lives.  Thus, there are 30+ million individuals suffering from tinnitus in the United States and these patients offer a virtually untouched source of patients for audiologists. 

While Hall (2017) and others indicate that approximately 70-80% of these tinnitus patients can be treated with counseling, hearing aids, smart phones and sound therapy, Bhatt et al (2016) estimate that 7.5% to 9.3% have debilitating tinnitus. While these may be huge numbers of patients to add to a practice the following is a sample of the treatment complexity and a reason to seek special training before offering routine tinnitus and hyperacusis services within the practice.  


Tinnitus and Hallucinations


One of those compounding factors with tinnitus treatment is contrasting tinnitus and auditory hallucinations. Musiek et al (2007) define tinnitus as a humming, tonal-type sound of any pitch and, in some cases, more than one pitch. It may also be a pulsing, clicking, or frying (noisy) type of sound. Tinnitus may be subjective (i.e., only the person with the tinnitus can hear it) or objective (i.e., others can hear it).

Auditory hallucinations can be easily differentiated from objective tinnitus in that they are heard only by the person who has them. While subjective tinnitus is usually some form of tonal sensation, Blom (2015) formally contrasts auditory hallucinations (or paracusia) as a phenomenologically rich group of endogenously mediated percepts associated with psychiatric, neurologic, otologic, and other medical conditions.

Musiek et al (2007) and Blom (2015) both call attention to the fact that auditory hallucinations are usually associated with psychiatric illness but that many individuals without psychiatric disorders also experience them. Further complicating the differentiation between these disorders is that Bloom (2015) feels that auditory hallucinations or paracusia is also experienced by 10–15% of healthy individuals and may be verbal, musical, echo of reading, exploding-head syndrome, and numerous other types.

Sheikh (2017) reports that clinical experience indicates that healthy people with hallucinations are often taking prescription drugs, experiencing sleep deprivation and migraines that trigger the illusion of sounds or sights that are not present. In these cases, the treatment usually involves the management of the extenuating illness but there are some other causes that should be considered as the audiologist moves toward rehabilitative treatment of what could either be severe debilitating tinnitus or auditory hallucinations requiring referral and/or a multidisciplinary approach.


Causes of Auditory Hallucinations


While mental illness, such as schizophrenia, is the most common cause of auditory hallucinations, a collection of references document that there may be several other causes for auditory hallucinations. There may be as many as 11 different underlying causes for auditory hallucinations that audiologists should aware as they find these patients with severe tinnitus.

1. Alcoholism and Drug Abuse. Heavy alcohol use and/or hallucinogenic drugs such as ecstasy, LSD, mescaline and psilocybin (found in ‘magic’ mushrooms) can trigger hallucinations. Cannabis also has some hallucinatory effects; both during use and even many years after use. Alcoholics’ hallucinations tend to be localized in space and have a greater frequency than those of schizophrenics (Alpert & Silvers, 2006) (Walsh, 2007).

2. Alzheimer’s Disease and Other Types of Dementia. Schneider and Dagerman (2004) stated that 40-50% of patients diagnosed with Alzheimer’s disease developed hallucinations in the latter stages of the illness. Neuroimaging studies have documented auditory hallucinations are often seen in these later stages of Alzheimer’s Disease. (Holroyd, Shepherd & Hunter, 2000) (Tsunoda et al (2018).

3. High Fevers and Infections. High fevers and some infections, such as encephalitis and meningitis, cause auditory hallucinations, along with the other symptoms of these disorders (Walsh, 2007).

4. Intense Stress. It’s especially common to hear the voice of a loved one after their recent death. Other stressful situations can also trigger these episodes (Ratcliffe & Wilkinson, 2016).


5. Mental illness. Walsh (2007) indicates that up to 75% of hospital admissions for schizophrenia reported suffering from hallucinations. The voices may come from inside or outside of the head. These voices may be positive or negative and may often argue with the person, tell them what to do, or just describe what is happening. Auditory hallucinations may also occur with other mental illnesses including:

• Bipolar disorder
• Borderline personality disorder
• Major depressive disorder
• Posttraumatic stress disorder (PTSD)
• Schizoaffective disorder

6. Migraines. Auditory hallucinations uncommonly co-occur with migraine and usually feature human voices. Their timing and high prevalence in patients with depression may suggest that they are not necessarily a form of migraine aura, though could be a migraine trait symptom. Auditory hallucinations due to migraines may contribute to phonophobia sometime seen in tinnitus patients.. (Miller, Grosberg & Crystal, 2015).

7. Parkinson’s Disease. Patient are more likely to experience visual hallucinations with Parkinson’s. Some of these patients, however, hear things from the scenes they are visualizing, particularly in patients who are also are cognitively impaired. (Inzelberg, Kippervassera, & Korczyn, 1998).

8. Side Effects of Medicine. Patients may begin to hear things when beginning a new medication or if prescribed a higher dose of medication already taken. This concern most often affects older adults as they usually take more medications. The higher the number of medications taken, the greater the possibility of auditory hallucinations due to the interaction of these various medications. A number of psychiatric medications, sleeping pills, seizure medications and, in some rare cases antibiotics are all are candidates for creating auditory hallucinations. (O’Shea, 2016).

9. Sleep issues. It is normal to hear a sound while falling asleep or waking up but auditory hallucinations are more likely if patients fall asleep randomly, such as in narcolepsy, or if they have difficulty falling asleep, such as in insomnia. (Heavner, 2016).

10. Thyroid disease. The thyroid gland produces hormones that regulate the body’s metabolic rate as well as heart and digestive function, muscle control, brain development, mood and bone maintenance. Myxedema is a rare condition where the thyroid gland is not generating enough hormone resulting in dangerously low levels. This life-threatening condition may also produce auditory hallucinations. (Tareq, Drever & Hasan, 2013).

11. Tinnitus. For audiologists, during tinnitus treatment, many patients may be identified with auditory hallucinations. While typical ringing or hissing tinnitus is not usually considered an auditory hallucination; persistent, bothersome tinnitus can raise the risk for auditory hallucinations, especially in the presence of depression (Musiek et al, 2007) (Wible, 2012).


When establishing the cause of paracusia or auditory hallucinations, it is usually the audiological and medical history that rules out many of these factors. When investigating tinnitus and auditory hallucinations clinically, it is best to use an interdisciplinary approach to rule out medical issues and other psychological concerns. Audiologists concerned about a patient with auditory hallucinations, should refer them to their primary care provider and possibly to a psychologist for further evaluation.  



Davis A, El Refaie A. (2000). Epidemiology of tinnitus. In: Tyler RS, ed. Tinnitus Handbook. San Diego: Singular Publishing Group; 2000:1-24.

Henry, J., Zaugg, T., Myers, P., ; Kendall, C., & Michaelides, E. (2010). A triage guide for tinnitus. Journal of Family Practice, Vol 59(7), pp. 389-393.

Kochkin S, Tyler R, Born J. (2011) MarkeTrak VIII: The Prevalence of Tinnitus in the United States and the Self-Reported Efficacy of Various Treatments. Hearing Review, 18(12):10-26.

Hall, J., (2017). Personal Communication. University of Florida Counseling Course, October 2017.

Bhatt, J., Lin, H., & Bhattacharyya, N. (2016). Tinnitus Epidemiology: Prevalence, Severity, Exposures and Treatment Patterns in The United States. JAMA Otolarngol Head Neck Surg, 142 (10),

     pp 959-965.

Musiek, F., Ballingham, T., Liu, B., Paulovicks, J. Swainson, B., Tyler, K., Vasil, K. & Weihing, J. (2007). Auditory hallucinations: An audiological perspective. Hearing Journal, 60 (9), pp 32-52.

Bloom, J. (2015). The Human Auditory System. In KH Levin and P Chauvel, The Handbook of Clinical Neurology, Elsevier, Retrieved September 7, 2018.

Sheikh, K., (2017). Do You Hear What I Hear? Auditory Hallucinations Yield Clues to Perception. Scientific American, Retrieved September 7, 13 2018.

Alpert, M., & Silvers, K. (2006). Perceptual Characteristics Distinguishing Auditory Hallucinations in Schizophrenia and Acute Alcoholic Psychoses. American Journal of Psychiatry, online

     publication, retrieved October 8, 2018.

Walsh, L. (2007). Caring for patients who experience hallucinations. Nursing Times, Vol 103(21), pp 28.

Miller, E., Grosberg, B., & Crystal, S. (2015). Auditory hallucinations associated with migraine: Case series and literature review. Cephalalgia, Vol 35(10), pp 923-930.

Inzelberg, R., Kipervassera, S., & Korczyna, A. (1998). Auditory hallucinations in Parkinson’s disease, Vol 64(4).

Holroyd, S., Shepherd, M., & Hunter, J. (2000). Occipital Atrophy Is Associated with Visual Hallucinations in Alzheimer’s Disease. Journal of Neuropsychiatry and Neurosciences, published

online, retrieved October 8, 2018.

Traynor, RM (2018). Tinnitus and Hallucinations.  ASHA Leader, 23(12), 2018.

Tsunda, N., Hashimoto, M., Fukuhara, R., Yuki, S., Tanaka, H., Hatada, Y., Miyagawa, Y., & Ikeda, M. (2018). Clinical Features of Auditory Hallucinations in Patients with Dementia with Lewy

     Bodies: A Soundtrack of Visual Hallucinations. J Clinical Psychiatry, May/June, Vol 79 (3).

O’Shea, T., (2016). 10 scariest prescription drug side effects. Pharmacy Times, Retrieved October 9, 2018.

Heavner, W. (2016). Why do humans hallucinate on little sleep? Stanford Neurological Institute. Retrieved October 9, 2018.

Tareq, S., Drever, E., & Hasan, F. (2013). Hallucinations as Presenting Complaint in Thyroid Storm: An Uncommon Presentation of Graves’ Disease. The Endocrine Society’s 95th Annual Meeting  

     and Expo, June 15–18, 2013 – San Francisco. Retrieved October 9, 2018.

Ratcliffe, M & Wilkinson, S., (2016). How anxiety induces verbal hallucinations. Consciousness and Cognition, Vol 39(1), pp 48-58.

Wible CG. (2012). The Brain Bases of Phantom Auditory Phenomena—From Tinnitus to Hearing Voices. Seminars in Hearing, Vol 33(3).

Leave a Reply