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Tinnitus and hyperacusis: types, the neurophysiological model, assessment and management
Tinnitus is a sound perceived with no external source (subjective) or a real sound in the body that can sometimes be heard from outside (objective). The distress it causes depends not on its loudness but on the emotional reaction to it — so effective treatments target the reaction, not the sound.
Why it matters in the exam
Tinnitus is common — about 10–15% of adults — and only a minority are significantly bothered. In both types it is an involuntary perception. Tinnitus that pulses with the heartbeat, especially if the examiner can hear it, points to a vascular source and needs work-up and imaging; one-sided tinnitus with asymmetric loss also needs work-up. Somatic tinnitus is modulated by movement or pressure in the head, neck and jaw (somatosensory system). In Jastreboff's neurophysiological model, the limbic and autonomic nervous systems drive the emotional reaction — so tinnitus that grows with strong emotions involves the limbic system. Measured tinnitus loudness or pitch bears little relation to distress. Residual inhibition is a temporary fading or disappearance of tinnitus after masking.
Assessment: history, an audiogram and a distress questionnaire (for example the THI) — to establish how much the tinnitus disturbs sleep, concentration and mood, which is what decides management. Management: under the US guideline, no drug has been shown to treat chronic tinnitus, so drugs and supplements are not recommended; CBT has the best evidence for reducing distress; hearing aids help when there is hearing loss; sound therapy and TRT (counselling with background sound) are options. Hyperacusis is increased sensitivity to sounds of ordinary loudness; testing avoids acoustic reflexes and high-level tests that may make it worse, and the UCL is measured with care.
Key points
- About 10–15% of adults; a minority bothered.
- Pulsatile — vascular; one-sided — MRI.
- Jastreboff: limbic and autonomic.
- CBT has the best evidence; no proven drug.
- Hyperacusis — no acoustic reflexes.
Summary table
| Topic | The fact | Meaning |
|---|---|---|
| Prevalence | About 10–15% of adults | Most people are not significantly bothered |
| Objective versus subjective | A real body sound versus a perception with no source | Both — involuntary perception |
| Pulsatile | With the heartbeat, sometimes audible to the examiner | Vascular source; work-up and imaging |
| Somatic | Modulated by head, neck and jaw | Somatosensory input |
| Jastreboff model | Limbic and autonomic systems | Distress does not depend on loudness |
| Management | CBT, hearing aids, sound therapy | No proven drug |
| Hyperacusis | Sensitivity to ordinary sounds | Avoid acoustic reflexes; UCL with care |
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Sources
- Tunkel et al., Otolaryngology–Head and Neck Surgery, 2014 — Clinical Practice Guideline: Tinnitus
- Jastreboff, Neuroscience Research, 1990 — Phantom auditory perception (tinnitus): mechanisms of generation and perception
- Baguley, McFerran & Hall, The Lancet, 2013 — Tinnitus
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.