A three finger approach to hyperacusis

Working in a musicians’ clinic means that I see…. musicians.  Hearing loss prevention is the number one request, followed closely by a request for in-ear monitors.  But not far behind are inquiries about tinnitus and about hyperacusis.

I must admit, like most of my audiology colleagues, that I know very little about hyperacusis.  It’s not from lack of trying to learn as much as I can- I read all of the journal articles and attend talks on hypercusis given by leaders in the field (who include Dr. Rich Tyler and Dr. David Baguley to name a few), but hyperacusis is partly defined by its amorphous features.

Loud noises may bother a person sometimes, but not all times; loud noises of varying spectra can be more bothersome than other spectral compositions, but not all the time; for days, people who report hyperacusis are not overly bothered, and then inexplicably they become more bothered by loud sounds.

Given the amorphous and variable nature of hyperacusis I am not sure what to do.  One of the things that seem to exacerbate hyperacusis (and also tinnitus) is stress.  Another is a lack of confidence to go into a noisy situation.  We are just now finding out about the brain biochemistry that underlies reports that some sounds are just too loud, but we are only scratching the surface.

There are two things that I do whenever a musician is booked with a complaint of hyperacusis- I book them for a double appointment (about an hour long) and dust off my trusty piano. (I have an old Picoff upright piano in my Toronto location and a baby grand in my Hamilton office).

The first thing that I can do for a person who reports hyperacusis is to counsel them regarding what we do know.  I usually ask them before they come in to Google the names “Rich Tyler” and “David Baguley” to find some well-written articles on this topic suitable for laypeople. (I am sure that many of my colleagues have other names to suggest, and many of them have done some wonderful work in this area).  My form of counseling is “information provision” (hyperacusis is a “brain phonemenon” and not an “ear phenomenon,” discussion of ‘retraining” techniques, …) and this seems to allay many of their fears.

The second thing that I can do for a person complaining of hyperacusis is to increase their confidence.  One way I have been doing this that appears to help (based on phone calls and emails after the appointment) is to use my piano- something that many musicians have access to.

Let’s take a step back to the wonderful world of critical bandwidths.  Although this is an “ear phenomenon” and not a “brain phenomenon,” we can use loudness summation as a counseling tool.  The critical bandwidth has many definitions but the one that I like to use is “that frequency bandwidth where subjective perception appears to change”.  In school we learned about loudness summation.  If I were to give a single pure tone at, say, 1000 Hz, people would judge this to have a certain ”loudness”.  If I were to give two pure tones spaced only slightly apart in frequency at the same sound level as the first, people would judge them to have roughly the same loudness as the first.  If I were to continue adding pure tones spaced slightly apart, the judgments of the loudness would probably remain similar.  This would continue until I exceeded their critical bandwidth.  When I did that, these people would judge that the sound was now getting louder.

This application of “critical bandwidth” is related to loudness summation.  There are other manifestations  of the critical bandwidth phenomenon, and if this is a new concept to you, I guarantee that reading an introductory audiology book or surfing the Internet on a rainy afternoon would be time well spent.

It turns out that a critical bandwidth is roughly 1/3 of an octave.  This is one reason why engineers and auditory scientists in our field love to look at 1/3-octave band analyses of speech or music..

Well, 1/3 octave is about 2-3 white notes on a piano keyboard, and this is where the “three-finger approach to hyperacusis” comes in. I sit my musicians down at my piano and get them to hit a single note on the keyboard (this isn’t a pure tone, but it works well enough).  Being in the relaxing confines of my clinic (and still being pleasantly surprised that I have a piano in my office- talk about instant credibility!), they are assured that this single note will not cause pain.

Next, they are instructed to hit two adjacent white notes, and then three.  They may find that it’s starting to get a bit louder, but not very much.  At this point we are close to their critical bandwidth (about a 3-note span on the piano keyboard).  I ask them to hit four adjacent white keys and gradually work up (to the limits of their fingers and toes).  This is nothing more that asking them to gradually turn up the volume on their radio.

If you don’t happen to have a piano in your office, at least you can instruct the musician client who reports hyperacusis phenomena how to do this when they get home or to their studio.

Because hyperacusis is a multi-facetted phenomenon and its treatment can be related to stress, confidence, and a multitude of other factors, this three-fingered approach is not a cure- merely a first (but important) step in helping these musicians gain confidence that their life’s work is not at an end.  Having said this, for any audiology students out there, this approach (or a related one) is empirical and would make for an interesting Capstone project.

About Marshall Chasin

Marshall Chasin, AuD, is a clinical and research audiologist who has a special interest in the prevention of hearing loss for musicians, as well as the treatment of those who have hearing loss. I have other special interests such as clarinet and karate, but those may come out in the blog over time.