What Is Reactive Tinnitus?

[Michael Leigh]

What is Reactive Tinnitus?

A word often used in tinnitus forums these days is: "Reactive" tinnitus. People affected will say something like: " I have habituated but my tinnitus is reactive to certain sounds" or " I have reactive tinnitus". I believe there is some confusion here and will explain.

Someone that has tinnitus especially when caused by loud noise exposure hyperacusis (sensitivity to certain sounds) is often present. If hyperacusis isn't treated the auditory system will always be sensitive to certain sounds even after habituation has been reached. It is for this reason the use of white noise generators (wngs) is recommended to help desensitize the auditory system. White noise generators are used as part of TRT (tinnitus retraining therapy) and must be adjusted correctly as not to irritate the inner ear (cochlear) when wearing them. This treatment is best done under the care of a Hearing Therapist.

When a person says they have "reactive tinnitus" in my opinion, they are not aware they have hyperacusis, which is causing their tinnitus to spike when they hear certain sounds. Although hyperacusis can improve by itself with time, without treatment there is no guarantee. For this reason I often recommend a person to use sound enrichment (sound therapy) as it helps to desensitize the auditory system.

Inside the human body is noisy place but our brain has learned to filter out much of this sound so it doesn't focus on it. Anyone with tinnitus that sleeps in a quiet room, risks making their tinnitus more intrusive as the brain and auditory system never switch off. If the brain hears silence while we sleep, it has the ability to increase its background activity, and at the same time increasing the tinnitus making it louder and more intrusive. A person might not notice this immediately as it's usually a gradual process.

When we are in deep sleep a sound machine supplies the brain and auditory system with sound enrichment. Over time, the tinnitus is pushed further into the background making it less intrusive and will help make the path to habituation easier. It is usually best to have the sound machine playing in the background at a low level (slightly below the tinnitus) without drawing attention to itself unlike a radio. For this reason music is not the best source to use at night as it draws attention to itself.

Michael

 

[foryourinfo]

A word often used in tinnitus forums these days is: "Reactive" tinnitus. People affected will say something like: " I have habituated but my tinnitus is reactive to certain sounds" or " I have reactive tinnitus". I believe there is some confusion here and will explain.

I think the only confusion there is might reside inside your own head. Subsequently, you might be adding to the confusion here on the board because of your outdated regurgitated knowledge. There is in fact a term called "reactive tinnitus" - and no, it is not the same as hyperacusis. You might want to check out some of the literature such as the article below (and also some of the material by Dr. Salvi):

www.health24.com/Medical/Hearing-management/Tinnitus/An-overview-of-Tinnitus-patient-management-20120721

One must be aware that a small percentage of patients report "reactive" tinnitus; that is, tinnitus that seems to be louder with external sounds.

I seem to have found quite a few mistakes regarding your knowledge in just one day. I hope I didn't over-complicate the plot for you.

 

[Ed209]

@foryourinfo, it's interesting that it says to stay off the Internet, which is standard audiological advice (usually). It's also a firmly held belief of mine that when one is in the acute stage, the Internet can be a bit of a double edged sword. It can offer immediate support, but it's usually at the cost of increased anxiety and behavioural obsession.

The scientific community does not have a complete understanding of tinnitus. What we have is a scattered picture of different pathologies, representing a broad spectrum of symptoms, and believed mechanisms behind them. No two peoples tinnitus is the same which highlights the complexity of it all.

Most of us here are well read when it comes to this condition, but that still doesn't make us experts (although we have a deep understanding because we have it). In fact, the experts aren't really experts, because they also don't fully understand it yet. All we can do is try to help each another, and to be honest that's all Michael is trying to do whether you agree with him or not. You have to bear in mind that he uses his free time to try and help people.

I don't agree with everyone here, and I know for sure that everyone doesn't agree with me, but that's how it should be. We are free to express our thoughts and opinions based on our real life experiences.

 

[foryourinfo]

You have to bear in mind that he uses his free time to try and help people.

No. He uses he his free time on Tinnitus Talk because he has nothing else to do with it. Which tells me all I need to know.

 

[PaulBe]

I actually have what I would call "reactive" tinnitus some days, and I also have hyperacusis. They are easily separated in my experience as two quite distinct entities. I've thought about this more than I'd like to and that's how it seems.

 

[Tinker Bell]

I actually have what I would call "reactive" tinnitus some days, and I also have hyperacusis. They are easily separated in my experience as two quite distinct entities. I've thought about this more than I'd like to and that's how it seems.

What do you feel are the differences between your hyperacusis and reactive tinnitus? I'd appreciate the opinion of someone dealing with both.

 

[Michael Leigh]

No such thing as reactive tinnitus. It was a term made up in tinnitus forums. Reactive tinnitus is in fact Hyperacusis. Hyperacusis comes in different levels of severity. If hyperacusis isn't treated and cured tinnitus will always be a problem and often manifests itself by "spikes" or sensitivity to sound.
Michael

 

[Ed209]

Some audiologists today are starting to recognise reactive tinnitus as a seperate issue to hyperacusis. I know a few years back there wasn't any real 'official' recognition for it; it was deemed an invention of the forums. I did have some reactive components to my T at the beginning; I probably still do but it's subtle, and I've got some hyperacusis since my ETD/glue ear got out of control.

I'm no expert, so I'm going to stay out of the official definition of what's really going on, and leave it for you all to make your own minds up. However, I'll post an excerpt below (along with a link) which may help:


Reactive Tinnitus
Reactive tinnitus is a smaller subset of the overall tinnitus population. It is a type of tinnitus that is worsened after exposure to mild to moderate levels of sound. Typical tinnitus, if there is such a thing, is made worse by loud music, loud yard tools, loud traffic, street noise, et cetera. However, a patient with reactive tinnitus will tell you that their tinnitus is worse after they get out of the car or the shower. Most tinnitus patients find a lot of refuge in the shower; they like that constant sound. These patients do not. This increase in sensitivity tends to last for more than one day. It is a subset of the overall tinnitus patient, but one of which you need to be aware and know how to identify.

The best test for identifying reactive tinnitus is the Residual Inhibition test that you will do as a part of your overall tinnitus evaluation. The procedure for that test is presenting narrowband noise at the tinnitus frequency for about one minute at a sensation level of about 15 dB over the threshold at that pitch. You will then turn the noise off and ask the patient if their tinnitus has changed any. Some will say it is the same. There are those that will say that it has increased or it is worse. That can be a red flag of the presence of reactive tinnitus.

Also on the patient history, you will find a report of overuse of hearing protection when not indicated. These people are wearing hearing protection to the grocery store or at the gas station, or during times when they otherwise would not need to be protecting their hearing. They have also found that nothing will reduce their awareness of their tinnitus, and they may have had other trials with acoustic-based treatments that have aggravated their tinnitus. They may have tried hearing aids unsuccessfully and needed another option instead.

The Neuromonics Oasis product has a two-stage protocol. We have a reactive tinnitus protocol for these patients where you would begin the patient in Phase 2 and complete their treatment using just that phase of the therapy.

Hyperacusis
Another difficult tinnitus patient can be one who has decreased sound tolerance or hyperacusis in conjunction with their tinnitus. Decreased sound tolerance is discomfort from sounds at a level which most people would not find uncomfortable. The guideline is loudness discomfort levels below 90 dB. Hyperacusis is when the patient experiences sounds that would normally be considered loud, but easy tolerated by other patients. This patient would perceive sound to be painful or very loud. There is some physical discomfort that many of these patients experience. As a guideline, LDLs are typically below 70 dB across all frequencies. We recommend testing 500, 1000, and 4000 Hz in the tinnitus frequency to give you a good basis for their discomfort levels.

How does decreased sound tolerance or hyperacusis affect treatment? The literature reports that anywhere from 8% to 50% of these tinnitus patients will report decreased sound tolerance or hyperacusis. If you do not address this issue first, it will be very difficult to achieve any headway in managing their tinnitus. For example, let's say you are providing sound therapy as a tinnitus therapy for decreased sound tolerance and the idea there is to give them relief, relaxation, and sense of control. If they are not able to tolerate that sound therapy at a volume loud enough to get relief from the tinnitus, you will not be able to effectively treat the tinnitus. You need to effectively address the hyperacusis first, and then you can begin to address the tinnitus goals.

In terms of expectation management, you need to lay out realities for the patient; they must be on board with those and understand the process of treatment. Then they can follow recommendations, and you will be on the same page. That can be a frustrating exercise if you begin what you think is treatment for their tinnitus, and then you run into brick walls when it comes to their decreased sound tolerance. These are my favorite patients to treat, because many times they have become withdrawn and disconnected from a lot of things they enjoy and love. To give them the ability to go back and experience those things again is very powerful and rewarding.


http://www.audiologyonline.com/articles/your-role-in-treating-tinnitus-12792

 

[Michael Leigh]

Thank you for the information @Ed209 Most people that have noise trauma also have some sensitivity to sound. If this sensitivity doesn't cure naturally or isn't treated and cured the sensitivity remains and will always be a problem even after someone habitutes to the tinnitus. The auditory system needs to be desensitized as the report you've supplied says. It is something that I've always said. A lof of people that experience this "reactive tinnitus" which I still have doubts about, will go once the auditory system is desensitized. This is best done using sound enrichment or preferably white noise generators.

 

[Tinker Bell]

Some audiologists today are starting to recognise reactive tinnitus as a seperate issue to hyperacusis. I know a few years back there wasn't any real 'official' recognition for it; it was deemed an invention of the forums. I did have some reactive components to my T at the beginning; I probably still do but it's subtle, and I've got some hyperacusis since my ETD/glue ear got out of control.

I'm no expert, so I'm going to stay out of the official definition of what's really going on, and leave it for you all to make your own minds up. However, I'll post an excerpt below (along with a link) which may help:


Reactive Tinnitus
Reactive tinnitus is a smaller subset of the overall tinnitus population. It is a type of tinnitus that is worsened after exposure to mild to moderate levels of sound. Typical tinnitus, if there is such a thing, is made worse by loud music, loud yard tools, loud traffic, street noise, et cetera. However, a patient with reactive tinnitus will tell you that their tinnitus is worse after they get out of the car or the shower. Most tinnitus patients find a lot of refuge in the shower; they like that constant sound. These patients do not. This increase in sensitivity tends to last for more than one day. It is a subset of the overall tinnitus patient, but one of which you need to be aware and know how to identify.

The best test for identifying reactive tinnitus is the Residual Inhibition test that you will do as a part of your overall tinnitus evaluation. The procedure for that test is presenting narrowband noise at the tinnitus frequency for about one minute at a sensation level of about 15 dB over the threshold at that pitch. You will then turn the noise off and ask the patient if their tinnitus has changed any. Some will say it is the same. There are those that will say that it has increased or it is worse. That can be a red flag of the presence of reactive tinnitus.

Also on the patient history, you will find a report of overuse of hearing protection when not indicated. These people are wearing hearing protection to the grocery store or at the gas station, or during times when they otherwise would not need to be protecting their hearing. They have also found that nothing will reduce their awareness of their tinnitus, and they may have had other trials with acoustic-based treatments that have aggravated their tinnitus. They may have tried hearing aids unsuccessfully and needed another option instead.

The Neuromonics Oasis product has a two-stage protocol. We have a reactive tinnitus protocol for these patients where you would begin the patient in Phase 2 and complete their treatment using just that phase of the therapy.

Hyperacusis
Another difficult tinnitus patient can be one who has decreased sound tolerance or hyperacusis in conjunction with their tinnitus. Decreased sound tolerance is discomfort from sounds at a level which most people would not find uncomfortable. The guideline is loudness discomfort levels below 90 dB. Hyperacusis is when the patient experiences sounds that would normally be considered loud, but easy tolerated by other patients. This patient would perceive sound to be painful or very loud. There is some physical discomfort that many of these patients experience. As a guideline, LDLs are typically below 70 dB across all frequencies. We recommend testing 500, 1000, and 4000 Hz in the tinnitus frequency to give you a good basis for their discomfort levels.

How does decreased sound tolerance or hyperacusis affect treatment? The literature reports that anywhere from 8% to 50% of these tinnitus patients will report decreased sound tolerance or hyperacusis. If you do not address this issue first, it will be very difficult to achieve any headway in managing their tinnitus. For example, let's say you are providing sound therapy as a tinnitus therapy for decreased sound tolerance and the idea there is to give them relief, relaxation, and sense of control. If they are not able to tolerate that sound therapy at a volume loud enough to get relief from the tinnitus, you will not be able to effectively treat the tinnitus. You need to effectively address the hyperacusis first, and then you can begin to address the tinnitus goals.

In terms of expectation management, you need to lay out realities for the patient; they must be on board with those and understand the process of treatment. Then they can follow recommendations, and you will be on the same page. That can be a frustrating exercise if you begin what you think is treatment for their tinnitus, and then you run into brick walls when it comes to their decreased sound tolerance. These are my favorite patients to treat, because many times they have become withdrawn and disconnected from a lot of things they enjoy and love. To give them the ability to go back and experience those things again is very powerful and rewarding.


http://www.audiologyonline.com/articles/your-role-in-treating-tinnitus-12792

I was just about to post the same article!

Plus through some quick searching I found the slides of a Mayo Clinic presentation on tinnitus and one of the bullet points was: why do some patients have reactive tinnitus.

I don't know, but if such a highly regarded and ranked hospital in the U.S. is using the term in discussions among doctors, then I think it might be on the way to be a recognized term/condition.

Sometimes terms start online and become part of our society's vernacular. Perhaps doctors are noting that as well as noting minor differences between the two.

 

[Ed209]

I was just about to post the same article!

Plus through some quick searching I found the slides of a Mayo Clinic presentation on tinnitus and one of the bullet points was: why do some patients have reactive tinnitus.

I don't know, but if such a highly regarded and ranked hospital in the U.S. is using the term in discussions among doctors, then I think it might be on the way to be a recognized term/condition.

Sometimes terms start online and become part of our society's vernacular. Perhaps doctors are noting that as well as noting minor differences between the two.

Yea I agree. It's now becoming officially recognised in the literature. This is a fairly recent development, even though people have been complaining about 'reactive tinnitus' for years.

 

[CarloZ]

Yea I agree. It's now becoming officially recognised in the literature. This is a fairly recent development, even though people have been complaining about 'reactive tinnitus' for years.

Do you happen to know anybody who has habituated to reactive tinnitus? I've acquired it recently and I'm so damn scared I'll never get used to it.

 

[Michael Leigh]

@Ed209 Thanks again for the report but I suspect they are promoting their Neurommonics Oasis product and using fancy jargon to fool people. A sales pitch to buy into their treatment to treat and cure "reactive tinnitus" I believe sound enrichment or using white noise generators to desensitize the auditory system will suffice if it doesn't cure naturally. In any event, sensitivity to sound will remain a problem if it is not treated.
Take care
Michael

 

[cantbelieveit]

@Ed209 Thanks again for the report but I suspect they are promoting their Neurommonics Oasis product and using fancy jargon to fool people. A sales pitch to buy into their treatment to treat and cure "reactive tinnitus" I believe sound enrichment or using white noise generators to desensitize the auditory system will suffice if it doesn't cure naturally. In any event, sensitivity to sound will remain a problem if it is not treated.

the Mayo Clinic has got nothing to do with Neuromonics [staff: vulgar language removed].

 

[Michael Leigh]

Do you happen to know anybody who has habituated to reactive tinnitus? I've acquired it recently and I'm so damn scared I'll never get used to it.

Your auditory system needs to be desensitized @CarloZ It can cure naturally or by using "sound enrichment" . In more severe cases, the wearing of white noise generators might be needed.

 

[light rain]

I had H before T so did it cause it somehow since.mine is not noise induced. I know about masking but I also have had long standing auditory processing issues and I really think a sound machine pushed things over the edge. Even if they are nature sounds something drives me nuts listening to it from a device. I've even been annoyed by a gurgling rain gutter because my mind will be trying to "translate" it like I often have to do with regular speech. (I of course know there is nothing to be translated, it just becomes very frustrating.)

I'm also looking up info on vestibular H since my episodes of dizziness don't seem to have a pattern except perhaps noise. I do have nerve damage though so maybe not related. Not looking for medical advice - I'm going back to the ENT this month. Just looking for info to consider if there is any to consider about APD in the mix with the H and T.

 

[Ed209]

There's another reference here (scroll down to page 84):

https://books.google.co.uk/books?id...&q=reactive tinnitus a real condition&f=false

 

[Ed209]

To be fair, it seems to be misunderstood, and experts do contradict each other. However, it does seem to be more 'officially' recognised now.

 

[Michael Leigh]

To be fair, it seems to be misunderstood, and experts do contradict each other. However, it does seem to be more 'officially' recognised now.

@Ed209 I will PM you in a moment.

 

[Tinker Bell]

the Mayo Clinic has got nothing to do with Neuromonics.

Ha, I was trying to figure out what the Mayo Clinic is selling. Health? Academic progress in the medical field? Better identification and treatment of medical conditions?

I can personally attest that the place isn't cheap, but they're certainly worth every penny!

 

[Michael Leigh]

Ha, I was trying to figure out what the Mayo Clinic is selling. Health? Academic progress in the medical field? Better identification and treatment of medical conditions?
I can personally attest that the place isn't cheap, but they're certainly worth every penny!

Anything to do with healthcare isn't cheap Tinker bell when one has to pay for it. Here in the UK we do not pay for healthcare and therefore, I feel a sorry for people in certain parts of the world that do. I believe, these so called health professionals, have found away drum up business by using the term "reative tinnitus" that is so often used in tinnitus forums, and will treat using some new method of treatment, which is no more than using "sound enrichment" to desenstize the auditory sytem. I therefore expect it is going to be quite expensitve.

 

[Tinker Bell]

Anything to do with healthcare isn't cheap Tinker bell when one has to pay for it. Here in the UK we do not pay for healthcare and therefore, I feel a sorry for people in certain parts of the world that do. I believe, these so called health professionals, have found away drum up business by using the term "reative tinnitus" that is so often used in tinnitus forums, and will treat using some new method of treatment, which is no more than using "sound enrichment" to desenstize the auditory sytem. I therefore expect it is going to be quite expensitve.

Is not healthcare in the UK paid through taxation? So in theory, UK residents (at least most I would think) are paying for healthcare via their taxes. I'm okay with paying a very reasonable amount via my private insurance.

And no, the Mayo Clinic does not need to use the term reactive tinnitus to drum up business. It is often regarded as one of the best hospitals in the world and consistently ranks #1 in the U.S. in a variety of specialities.

 

[Michael Leigh]

Is not healthcare in the UK paid through taxation? So in theory, UK residents (at least most I would think) are paying for healthcare via their taxes. I'm okay with paying a very reasonable amount via my private insurance. And no, the Mayo Clinic does not need to use the term reactive tinnitus to drum up business. It is often regarded as one of the best hospitals in the world and consistently ranks #1 in the U.S. in a variety of specialities.

Hmmm I seem to have struck a sensitive chord yesterday. Our health system doesn't quite work the way that you've said. I'll leave it at that.
Michael

 

[Tinker Bell]

Then how does the government cover healthcare costs? It's free at the point of use with the government as the single payer, but everything I've read says the government then pays for it through general taxation. I realize this is a tangent, but it's confusing. Can anyone from the UK address how the government covers healthcare costs?

https://en.m.wikipedia.org/wiki/Healthcare_in_England

It's kind of like how in the US we pay for infrastructure like roads. I do not personally write a check to a road construction company, but the government does and covers those costs through taxes.

 

[GregCA]

Then how does the government cover healthcare costs?

The answer is here. General Taxation mainly.
That's how governments' "free" services are often funded.

 

[Tinker Bell]

The answer is here. General Taxation mainly.
That's how governments' "free" services are often funded.

Thank you! Nice to see that I was in part quite correct.

 

[PaulBe]

What do you feel are the differences between your hyperacusis and reactive tinnitus? I'd appreciate the opinion of someone dealing with both.

I've avoided the term "reactive tinnitus" in the past mainly because I've considered it to be simply a part of the devil's orchestra of phantom sound that is tinnitus. That said though, the term comes up a lot and I actually think its a valid term, not as a diagnostic term but as a descriptive or observational term. (hell, in Cardiology, "fear of impending doom" is a legit subjective descriptive term that they look for...try measuring that with a doom meter, but it means something when it is heard in whatever way it is stated). My version of hyperacusis involves alterations in how normal sound is perceived through particular abnormal loudness and distortion within certain frequency bands, whereas when I have what might be called "reactive" tinnitus it is more when the added tinnitus sound rises and falls alongside normal sound. Basically I can at times have one without the other, and I've never considered them to be any more than incidentally linked. Reactive or not, if the sound is coming in normal and the tinnitus is following the syncopation (jumping about with the rises and falls) of normal sound I would describe it as being reactive, but it is still simply tinnitus because it is an added sound. If the normal sound is coming in abnormally, be it sharp, over-prominent or extra loud then I call it hyperacusis. I see T & H as related but separate entities that possibly arise through different mechanisms within the ear. Micheal's own story of recovery kind of supports this idea as he still has one but not the other. In the end though, it doesn't really help whether its a real term or not, because the bottom line, as Micheal notes, is a hypersensitive auditory system and until someone somewhere finds a convincing model for differential diagnosis of sound perception issues outside of autopsy, then what Michael proposes is really as good as it gets in our current, under-researched reality. It worked well enough for him, and I see no reason to not take him at his word. I still think he was very lucky (?) to hit the National Health at a time when they still seemed interested in such things, and by his account he did indeed get good care, which is more than most of us see. Ours in Australia is shit. They couldn't care less...and as for ENT-owned chain Audiolo-gits (pun intended) hawking Neuromonics for commissions? Don't get me started.

Phew!

 

[Raphael7713]

Background noise just irritates the heck of my T even more. Yesterday I played rain sounds at a very low volume, and you have no idea how irritating my T got. The moment I shut it off I went back to my "regular" T which is nicer.

 

[BuzzyBee]

Okay, so what would this be called? Having a fairly quiet day and barely noticing the usual static buzz and feeling almost normal. Go into Old Navy where they are, as stores do, playing fairly loud music. Leave the store and static is now at a high volume and sounds like a steady flow of air being released from an air mattress. Goes on until I go to a quiet place, then gradually goes down (if I'm lucky).

So is that "reactive tinnitus" or hyperacusis that can be fixed with pink noise? I'm so frustrated. Why can't one of the ten or so people who went to medical school provide an answer? So frustrating.

I put in the Widex zen and it seems to relieve some stress, however hearing aid or not I still have huge spikes when exposed to any kind of noise. Still on the fence about keeping the hearing aid because I don't know if I'm treating regular tinnitus, reactive tinnitus or hyperacusis.

 

[Allan1967]

Hi all,

I'm sure as Hell my Tinnitus is reactive now, in a big way. Crisp packets, plastic bags, paper all seem to make my Tinnitus spike. There's no pain, it just seems to aggravate it.

What do I do for the best? Carry on and NOT protect my hearing as this may make matters worse? Does reactive tinnitus settle down?