Overuse of Hearing Protection - What Do Professionals Say?

What do professionals say about the overuse of hearing protection as a strategy to deal with tinnitus and hyperacusis? Have a look.

“People with sound super-sensitivity tend to overprotect their ears, which is understandable since everyday noises seem almost painful. But the result of overprotection is actually a worsening of the condition. Hyperacusis patients need to protect their ears from truly loud sounds. (We all do.)”

Tinnitus Questions and Answers – Jack Vernon and Barbara Sanders (2001)


“These data reveal that most (93%) of the hyperacusis patients who responded to the survey [conducted by the American Tinnitus Association of 104 patients who indicated they had hyperacusis] were thwarting their own recovery by overprotecting their ears.”

Tinnitus Questions and Answers – Jack Vernon and Barbara Sanders (2001)


“[Patients] need to understand, however, that inappropriate use of hearing protection can greatly enhance the tinnitus problem. Some patients use earplugs or earmuffs because of their belief that certain sounds, or sound in general, will cause their tinnitus to become worse. They need to be educated that overuse of hearing protection can result in heightened sensitivity to sound, as well as the perception that the tinnitus is louder due to the occlusion effect. If such overuse has already occurred, then it is important that the patient take steps to “undo” the process by gradually reducing the use of hearing protection. These patients must progress to the point that they only use hearing protection when exposed to sounds that can cause damage to the auditory system.”

Tinnitus Retraining Therapy Clinical Guidelines – James Henry, Dennis Trune, Michael Robb, and Pawel Jastreboff (2007)


“Many patients with troublesome hyperacusis attempt to reduce the intensity of environmental sound by the use of hearing protection devices. This can range from the use of earplugs, to earmuffs designed for industrial hearing protection, and more recently to active noise-cancelling headphones. The prevalence of the use of hearing protection devices in troublesome hyperacusis has not been quantified, but anecdotally it is commonly observed among clinicians in this field. Furthermore, it has been noted that consistent use of such devices is likely more common in severe cases. For example, the present authors have seen many patients who never go anywhere without bringing hearing protection with them…. Both this observation and conceptual reflection lead to an argument that the consistent use of hearing protection in troublesome hyperacusis can lead to a worsening of the symptom. Given the consensus that hyperacusis is essentially a phenomenon of abnormally high central auditory gain, the reasoning is that reducing the intensity of environmental sound, and introducing an element of having to strain to hear, can further increase central auditory gain. This would have the effect of increasing the severity of hyperacusis, which would be reinforced by the associated apprehension and fear.

The outworking of this argument is that the use of hearing protection devices in everyday contexts is contraindicated, and that it runs the risk of exacerbating hyperacusis. Thus, patients should be counseled against the use of such devices, and encouraged to wean themselves off their use. For some patients this is a lengthy process, and the clinician must be emphatic about this, while still continuing to help the patient out of the trap of protection when it is not justified by the sound environment (though obviously there can be circumstances in the life of a hyperacusis patient when hearing protection can be justified).”

Hyperacusis – Mechanisms, Diagnosis, and Therapies – David Baguley and Gerhard Andersson (2007)


“Work by Craig Formby and colleagues provides emergent evidence that loudness perception can change, and that it is influenced by the presence/absence of sound stimulation. Experiments where volunteers consistently wore earplugs, or wideband sound generators (at a stable intensity) have respectively demonstrated reduction or increase in the ability to tolerate intense sound. Work by Munro and Blount corroborates these findings by indicating that stapedial reflex thresholds can reduce when earplugs are consistently worn. The idea that the human auditory brain exhibits adaptive plasticity, and can adapt on the basis of learning, injury and sound stimulation is now widespread. “

Definitions, Epidemiology and Possible Mechanisms of Hyperacusis – David Baguley [published in ENT and Audiology News, Volume 21 No 6, January/February 2013]


“… patients with severe hyperacusis often present with a distinct pattern of avoidance behaviours, which can be sorted into three different categories. The first relates to avoidance of sound due to actual pain in the ears and severe discomfort. This avoidance can be very specific and associated with certain environments. A form of avoidance relating to this is to use ear protection to ‘avoid’ the risk of feeling discomfort when being exposed to unexpected sounds. I would argue that this discomfort/pain-related avoidance is the main problem for many people with hyperacusis. The second form of avoidance is less driven by pain and discomfort, but rather avoidance of sounds and environments that can lead to irritation and annoyance. This is similar to the construct of misophonia, which is a term used by advocates of Tinnitus Retraining Therapy. The third form of avoidance, perhaps being more common among persons with tinnitus and hearing loss, is fear of sound that might damage hearing and lead to worse hyperacusis (and tinnitus). While this avoidance can be motivated by environments that might damage hearing it is often exaggerated (even to the extent that patients have catastrophic beliefs about what sound can do to their hearing). I need to stress that beliefs regarding the consequences of being exposed to sounds is always a part of the symptom profile of adults with hyperacusis. With children and persons with neurological dysfunctions, it is less clear that they have any thoughts and beliefs about sound.”

The Treatment of Hyperacusis with Cognitive Behaviour Therapy – Gerhard Andersson [published in ENT and Audiology News, Volume 21 No 6, January/February 2013]


“For many patients the first reaction to hyperacusis is to use earplugs, ear muffs or other hearing protection devices in order to protect them. As most of the theories of hyperacusis suggest that it is a disorder of central gain, the use of such devices, which decrease the intensity of sound entering the auditory system, may actually increase central gain further, and thus exacerbate the problem rather than improve it, as would be indicated by the findings of Formby et al.”

Tinnitus A Multidisciplinary Approach (second edition) – David Baguley, Don McFerran, Gerhard Andersson, and Laurence McKenna (2013)

here2help

 

This is provides good info and support to many as the question is often raised, or promotion of overprotection is given.
I couldnt help but to giggle a bit at

Going to many clinicians in the first place is a trap on this field, so it's truly appreciative that you gather this information for us, thank you

 

I can't imagine any clinician worth his/her salt would recommend overprotection. The dangers of this practice has been known for some time, as @here2help's fine compilation points out.

 

Thank you. I have often worried that I hadn't protected my ears enough - but this reassures me. I always think that H is the worst of the two. Perhaps you should post this in the H section?

 

hearing protection didn't cause my condition and has never made my ear pain worse, but noise did and has.

 

My personal experience is that balance is the key. Constant masking led to an increase in my awareness of tinnitus, my anxiety at and because of the tinnitus, and a tendency to have VERY bad spikes if I got caught in a quiet room without masking sounds. I felt that I was exhausting my ears and thus my CNS.

On the other hand, I believe overprotecting will eventually have the same effect. When I do wear earplugs, I'm very conscious of the sounds in my head and listen for them (can't help it!) above any masking sounds. Personally I only use earplugs on a regular basis when driving my wife's car for decent-sized trips, because the engine is very loud, and it's always a relief to remove them and get some environmental sounds back into the mix.

I've found it helpful to "unmask" as well -- lying down with a good book in a very quiet room, soaking in a warm tub with my ears under the water -- as this seems both to provide some rest to my ears/nerves and a chance to habituate to the sounds. My best experiences have been reading material that calls for lots of imaginary sound effects, especially comics. I get so wrapped up in imagining voices and sounds, the real-to-me sounds in my head go away.

DC's New 52 Justice League vol. 1 deserves a special mention here. Not only does it introduce a hero with tinnitus (and built-in masking) but panel-for-panel it is easily one of the loudest comics ever written. At one point, the cacophony of the final battle rose to such a fever pitch, it completely suppressed my tinnitus. I heard nothing but BOOM! BOOM! BOOOOM! Then silence. When I realized this, I had a few seconds where I honestly wondered if I'd been cured. Not permanent, but not bad for a funny book, eh?

 

Of course they do, why would I ever be willing to subject myself to that kind of pain?

Define "worsening." I've experienced permanent worsening as a result of sound exposure, but my increased sensitivity caused by hearing protection goes away within minutes of removing it.

What about people who cite lengthy periods of quiet and time as the sole reasons for their recovery and improved sound tolerance? Such people do exist.

I use hearing protection quite a lot and it has not hindered my habituation whatsoever. Tinnitus is currently one of my lesser problems. I use hearing protection because of my experience that certain sounds HAVE worsened my tinnitus and ear pain, not my belief that they will.

"Damage" needs to be defined. Is it defined as hearing loss? Is it possible that damage is occurring that isn't hearing loss? How can we measure such damage? Hyperacusis and tinnitus are frequently referred to as non-damage, so if tinnitus and hyperacusis are not damage, why is it relevant which sounds cause or don't cause damage?

The consensus among whom, and based on what evidence? I know of another consensus among highly regarded professionals that nobody knows how hyperacusis works or why it happens.

Were these experiments performed on people with hyperacusis/tinnitus or people of normal hearing? How much did their sound tolerance decrease? How quickly did sound tolerances return to normal after use of hearing protection was discontinued? We all know that when you take out your ear plugs, things sound mildly louder for a little while. This happens to me and it always goes back to baseline within 10 minutes or so. We don't need a study to tell us this. The issue that is unclear to me is whether or not use of hearing protection causes severe, prolonged, and continual worsening, not mild and transient worsening with a plateau.

Again, if tinnitus and hyperacusis are not damage, why would the level of sound that causes damage be relevant to a person whose primary complaint is tinnitus and hyperacusis? If hyperacusis and tinnitus are not damage, why would it be unreasonable to believe that a non-damaging sound could potentially worsen tinnitus or hyperacusis?

Moreover, what do beliefs about sound have to do with things ACTUALLY happening to someone's hearing? It seems to me that within the Jastreboff circle, if you catastrophically worsen from an "ordinary" level of sound, you are given a blanket diagnosis of misophonia or phonophobia based entirely on a hypothesis that normal sounds can't worsen your hyperacusis, tinnitus, or ear pain, and because we kinda sorta think that normal sounds can't worsen you, your problem is necessarily an emotional response. It's almost as if the terms "phonophobia" and "misophonia" are used to conveniently explain the unexplained without actually having to look further into what's really going on.

 

Unfortunately, those professionals are regurgitating the same outdated information. The most recent science, using new laboratory techniques, shows that noise is extremely damaging, and at lower levels than previously thought, though the damage doesn't always appear symptomatically until years after the exposure.
Tinnitus and hyperacusis are not the same disorder, but those professionals are erroneously lumping them together.

 

Given the consensus that hyperacusis is essentially a phenomenon of abnormally high central auditory gain, the reasoning is that reducing the intensity of environmental sound, and introducing an element of having to strain to hear, can further increase central auditory gain.

Let me give a very practical and simple solution to this problem.
When you wear hearing protection - DO NOT try to strain to hear things!
Just imagine you are ignorant to everything that is around you and your brain wont increase any auditory gain. I agree that trying to listen to a conversation thru earplugs will inevitably begin to increase auditory gain. Earplugs aren't meant to have conversations. They are meant for navigating your way thru high levels of noise until such time as you are in a safe noise environment, at which time you shall remove said earplugs.

 

I haven't seen research that shows that the hearing loss occurs "years after the exposure." If you are referring to the talk in Providence, I think they said that damage can occur to the synapse of the auditory nerve fiber and the hair cell. This damage--and the resulting change in hearing--presumably occurs in the days or weeks following exposure. Note that the "change in hearing" is not currently classed as hearing loss by audiologists since it doesn't affect the pure tone audiogram. But it is, of course, damage to hearing all the same.

What occurs months after the exposure is loss of the neuron that used to attach to the hair cell where the synapse was lost. This neuron is in the brainstem. But that neuron's death shouldn't affect hearing, since it was already disconnected.

I have a lot of questions! All hair cells aren't the same, and the pattern of neuron-to-hair cell connections varies also. If anyone was at the talk or has a handout or whatever, please share!

 

jim, i am not referring to hearing loss. i am referring to perceptual abnormalities including tinnitus, hyperacusis, fullness, and pain.
and yes, needles to say, I was referring to Providence.

 

But where does the "years later" bit come from?

 

This sounds like classic psuedoscience. I would love to see a reliable source that proves damage happens "years after exposure" and at "much lower levels" than 85DbA, undoing years of verifiable scientific evidence in the process.

 

Unless Mother Nature was able to predict the noise levels of the future, you can be 100% certain that the noise levels of a modern society are well beyond what our inner ears were originally designed for.

What our ears were intended to be used for in the quiet surroundings of nature: 20-60 db (probably)
What our ears in most cases are subjected to on a daily basis: 60-90 db (for at least 4-8 hours per day)

It takes more than a few generations for evolution to catch up with reality. In fact, as long as everyone equally passes on their genes, evolution will never catch up (by law of biology, needless to say...).

Damage to our ears (from noise) occurs in two ways:

1) Acoustic trauma (very loud sounds) where the sound wave itself is responsible for the damage.
2) Prolonged noise exposure (at so-called "safe levels", < 85 db) - here the damage is done by toxins released into the Perilymphatic liquid due to overactivity of the stereocilia (much like the stress experienced in leg muscles after running); prolonged exposure to toxins damages the hair cells (and this type of damage takes a while to develop...).

Sometimes pictures tell the story better:

https://www.tinnitustalk.com/threads/outdoor-concert-t.5059/#post-50409
https://www.tinnitustalk.com/threads/outdoor-concert-t.5059/#post-50509

Classic Psuedoscience...? Actually it is common sense, if you ask me...

I was on 10-hour intercontinental flights for both of my stem cells treatments. Of course, I used earplugs all the way, but I couldn't help take them out once or twice just to feel how loud an airplane actually is. And that's when I thought to myself: there is no way 85 db of inflight cabine noise can be safe for up to 8-10 hours per day (as per official regulations). And then I thought about how awful it is that the relatively young flight attendants are working in that in environment pretty much every day. The reality is, they are doomed. They just don't know it. Yet...

 

I'm too tired to respond to that, suffice to say I'm not impressed. Simply saying "well i took out my earplugs and gee whiz it seemed too loud" is hardly even worth the time of day as an argument.

Also argument from nature fallacy, which not only ignores scientific evidence that noises in the <85Db range are harmless, but ignores the loud environments nature itself produces.

P.S. just googled "perilymphatic liquid + toxins". Most pages didn't even have both terms in, and those that did used both in unrelated statements. "Toxins" is a favourite of psuedoscientists.