Hearing and sound issues: Sound sensitivity, autophony, misophonia

Ross Hauser, MD

I have written at length about the many problems that atlantoaxial or upper cervical instability can cause. Among these problems are the problems of sounds and hearing.  In this article and video I will discuss sound sensitivity or what I call hypersensitivity sound syndrome meaning that someone is hypersensitive to sound.

This article and video will continue the discussions found in my other articles:

The sounds in one head

The problems of sound are well known and documented in the medical literature:

A September 2022 paper in the American journal of audiology (3) gives a description of Sound Tolerance Conditions.

  • Hyperacusis is a physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people.
  • Misophonia refers to intense emotional reactions to certain sounds (this can be the sound of chewing or sniffing) not influenced by the perceived loudness of those sounds. Explanatory note: Misophonia is any strong dislike for certain sounds, most of us have a strong dislike for the scratching of fingernails on a chalkboard. There are many different hypersensitivity sound syndromes. This is one of the keys to this:
  • Noise sensitivity refers to increased reaction to sounds that may include general discomfort. “It’s too noisy in here” regardless of the actual volume of noise.
  • Phonophobia, is a fear of sound and can create an emotional response such as anxiety that the sound itself will result in discomfort or pain.

It is very rare that someone will reach out to our center with the main symptoms being the sounds that they now hear. Typically sound disorder is one of many symptoms. For example this email which ahs been edited for clarity. “I have been hearing a swishing sound in my head over a year now. I have back problems at my L5 and S1 which is causing compression on my nerves causing my feet to cause my a lot of pain and limited my daily activities. I have also been treated for TMJ in the past.” Initially with someone like this with a history of TMJ and nerve compression in the lower spine, we would look at possible compression in the cervical spine and a problem in the neck. I explore the connection between TMJ and sound and hearing disorders in my article: TMJ and Tinnitus: Should we explore the ligament chain from the cervical spine through the neck to the jaw to the ear?

Another email describes: “Meniere’s disease (vertigo, tinnitus, pulsating tinnitus, sensitivity to sounds, hearing loss), IBS (please see may article Cervical spine instability and digestive disorders: Indigestion and irritable bowel syndrome caused by cervical spondylosis), my heart often skips beats (please see my article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations and blood pressure problems?).  My neck is a constant pain, especially in the upper part of the neck.”

Here again we see someone with a myriad of symptoms including the hearing and sound problems and a link to the upper cervical spine.

I was in a car accident when I was 14 and over the years developed different symptoms. One of the very odd symptoms I developed is that on rare occasions I’ll wake up and I’ll have an echoing of my own voice. I hear my voice like it is in an echo chamber. The echoing sensation is a component of the diagnosis autophony and is a symptom shared by many patients. Autophony is when one’s own voice is too loud or echoing. A diagnosis of Autophony can also be suggested in patients who “hear their blood flow through their arteries” or the sound of their breathing takes on a a deep, loud noise.

Autophony can also be transient in nature. It can come and go with ear infections or otitis media, blockage or occlusions in the ear canal, or Eustachian tube dysfunction. For the purpose of this article we will examine autophony and the other hearing and sound disorders as a chronic, long-term problem.

Autophony and malnutrition

We do see many patients with sound disorders and digestive disorders. Rarely are connections made with weight loss and sound disorders expect in cases of anorexia nervosa. Many of the patients we see have severe digestive disorders because they cannot move food down the digestive tract. Please see my article How neck pain and cervical spine instability cause nausea, gastroparesis and other digestive problems. Weightloss, malnutrion, and sound disorders are among the many problems they have to face.

Let’s take a brief trip over forty years of medical research in understanding autophony, In 1981 doctors presented a description in the journal Laryngoscope (6). They described autophony and the patulous (remains open) Eustachian tube as a real but rare clinical entity often misdiagnosed because the symptoms so mimic those of middle ear effusion. The diagnosis is made by the history of fullness or blockage and hearing ones own voice and breath sounds in the ear. . . .The usual past history is of weight loss. The 1981 treatments included silver nitrate and teflon injections. WEhat they doctors also noted was that some patients had very severe symptoms and others did not “remains a mystery that needs further study.”

While this paper is over 40 years old it is still being cited today. The link to weight loss was cited in a 2022 paper lead by the Department of Otolaryngology Head and Neck Surgery University of Colorado School of Medicine. (7) Here the doctors noted: “transient autophony in severe severe anorexia nervosa patients is due to patulous eustachian tube, and was present in at least 8% of patients within our cohort.” A March 2022 paper wrote: “Autophony is a commonly reported, albeit rarely discussed, symptom in individuals with severe eating disorders and correlates with degree of malnutrition.”(8)

Autophony and a clogged ear

Another problem we see in people at our clinic is the problem of ear fullness or chronically clogged ears. The people we see as mentioned, have many severe symptoms and their problems are typically not transient in nature. However, many of them have in the past received from other health care providers different treatment recommendations. They may get steroid treatments to reduce inflammation in the ear, they may use steam inhalation therapy, and they are told to not use sprays such as anti-histamines which may increase fluid in the ears.

Hyperacusis

Hyperacusis is when there’s a hypersensitivity to sound. I have seen patients who wear earplugs because they are so sensitive to sound. Any sound could become horrifically loud to a patient. Hyperacusis is also a symptom that we see in patients that have a lot of symptoms and rarely, if ever, is it the dominating symptom. More typically is the person who reaches out to us with a medical history filled with diagnosis surrounding hearing issues. For instance a history may go like this:

I am currently diagnosed with Eustachian Tube Dysfunction, ear pain and fullness on the right side. I have ringing in both ears, occasional hyperacusis both ears, dizziness, nasal passage closures depending on how I turn my head. (Please see my article Neck Pain Chronic Sinusitis and Eustachian Tube Dysfunction). Lying flat alleviates symptoms. Lying with my head on a pillow causes me to shake. I also get eye pain along with back, neck and shoulder pain.

And another history:

I suffer from excruciating loud tinnitus, it started a few years back. My tinnitus is so loud that masking sounds need to be so loud they would cause hearing damage. I also have hyperacusis, I cannot endure a loud room or noises. Ear fullness, painful eustachian tubes. Headaches every day, some are migraine level. Light sensitivity. (Please see my article Cranial Neuralgias – Symptoms of pain, smell, vision, hearing, taste and talking.) Brain fog, disorientation, depersonalization. Please see my article (Dissociation, Anxiety, Personality Disorders and Depression – Uncontrolled emotion in cervical spine instability patients.)

Had two prior cervical fusions. X-rays show a lack of proper curvature from the fusions, very straight neck.

Hearing and sound issues: Sound sensitivity, autophony, misophonia: Cervical spine lordosis and kyphosis
Hearing and sound issues: Sound sensitivity, autophony, misophonia: Cervical spine lordosis and kyphosis

Hyperacusis is linked to more than twenty non-auditory medical disorders

The challenges of hearing disorders are that they do fall within the scope of sharing many of the characteristics found in other diseases. Generally a diagnosis of hyperacusis means that the doctors and patient’s hunt is on for a cause.

A December 2022 study from doctors at the University at Buffalo write (9) “Although the auditory system seems to be the “central” player, hyperacusis is linked to more than twenty non-auditory medical disorders such as Williams syndrome (pediatric disorder of mild to moderate delays in cognitive development or learning difficulties. A characteristic feature is a child who seems “always happy” and smiling), autism spectrum disorder, fibromyalgia, migraine, head trauma, lupus and acoustic shock syndrome (exposure to a loud noise). Neural models suggest that some forms of hyperacusis may result from enhanced central gain, a process by which neural signals from a damaged cochlea are progressively amplified as activity ascends rostrally (towards the front of the brain) through the classical auditory pathway as well as other non-auditory regions of the brain involved in emotions, memory and stress.” Here again are the possibilities of cervical spine disorders being present as many symptoms are those found in cervical instability.

Traditional understanding of hyperacusis in relation to tinnitus

A November 2022 study in the American journal of audiology (5) explored sound therapy has the potential to suppress or eliminate hyperacusis and tinnitus. The authors write: “Because hyperacusis and tinnitus occur together so often, it has been theorized that they have a common neural mechanism. A leading contender for that mechanism is enhancement of auditory gain (simply an over-activation of sound). In this paper researchers reviewed the evidence that sound/acoustic therapy can reduce auditory gain and, thereby, can increase loudness tolerance for people with hyperacusis and/or suppress the perception of tinnitus. Their findings led them to suggest “Based on results from numerous studies, sound therapy clearly has application as a method of desensitization for hyperacusis. Enhanced auditory gain might be responsible for tinnitus, but other mechanisms have been theorized. A review of the relevant literature leads to the conclusion that some form(s) of sound therapy has the potential to suppress or eliminate tinnitus on a long-term basis.”

There are many different hypersensitivity sound syndromes. This is one of the keys to this:

There are many different hypersensitivity sound syndromes. This is one of the keys to this: You have the malleus bone that connects to your tympanic membrane. You also have the external auditory canal, which sound enters it and the sound then reaches your tympanic membrane which vibrates. The vibration of your tympanic membrane vibrates the malleus, the incus, the stapes, and then that vibration causes an electrical current in your cochlear vestibular nerve, the cochlea is the organ of hearing, the translation of sound into electric current is then transferred to your brain for processing and you have the sensation of hearing.

Most autophony, hyperacusis, misophonia and hypersensitivity to sound can be caused by dysfunction of the muscles that are suppose to regulate or dampen the volume of sound. You may ask why aren’t these muscles working correctly? One explanation is that the nerve supply to those muscles is being hampered so that muscles aren’t able to contract like they should. We have muscles that dampen the sound of our own voice, if they are not functioning properly your own voice can be too loud, even deafening, for you.

Muscles involved in the attenuation (hearing) of sound. The tensor tympani and stapedius muscles, innervated by the trigeminal and facial nerves respectively contract to help us tolerate loud sounds. When these muscles contract, vibrations are lessened to the cochlea of the inner ear. When a person has atlantoaxial instability, affecting these muscles, the person can be sensitive to any noise, even the sound of their own voice.

Tonic Tensor Tympani Syndrome?

The muscles of the middle ear are not without their controversies, A May 2022 study in the journal Hearing research (4) explores these controversies. In this paper the authors write: “Middle ear muscle abnormalities have been proposed to be involved in the development of ear-related symptoms such as tinnitus, hyperacusis, ear fullness, dizziness and/or otalgia. This cluster of symptoms have been called the Tonic Tensor Tympani Syndrome because of the supposed involvement of the tensor tympani muscle. The researchers point out that dysfunction of the muscles of the middle ear and symptoms such as tinnitus, hyperacusis, ear fullness, dizziness and/or otalgia have not been proven yet.

However the research team notes that a “sudden loud sound (acoustic shock) may impair the functioning of the muscles of the middle ear, specifically the tensor tympani muscle, after an excessive contraction. This would result in inflammatory processes, activation of the trigeminal nerve and a change of the tensor tympani muscle state into a hypersensitive one, that may be associated to the cluster of symptoms listed above.”

Other items to note is the tensor tympani muscle dysfunction relationship to Eustachian Tube dysfunction. The tensor tympani muscles could be evoked to contract by acoustic stimulation, somatic maneuvers (opening the mouth, or clenching the teeth or sticking the jaw out), or pressure changes in the ear canal.

Proper eustachian tube dunction vs. dysfunction. The proper opening of the eustachian tube requires the action of the levator veli palatine and tensor veli palatine muscles innervated by the vagus and trigeminal nerves respectively. When these muscles do not operate properly, fluid builds up in the middle ear potentially causing ear discomfort, fullness, pressure, pain, dizziness and even partial or complete hearing loss.

Traditional understanding of misophonia

A November 2022 paper in the Journal of affective disorders (2) lead by doctors at the Baylor College of Medicine assessed patient outcomes in the various treatment approaches for misophonia.

The researchers write: “While there is no uniformly accepted treatment to date, different intervention approaches are being investigated. Individual’s perceptions of different misophonia treatment methods may affect compliance and satisfaction with treatment options.” The problem is in the patients not believing the treatments would help them. This was study in both adults (252 patients) and children (141 patients) with misophonia.

Here are the summary findings: “Most respondents were not satisfied with misophonia treatments that they or their children had previously received. Audiologic interventions including active and passive noise cancelling and lifestyle modifications were rated as most appropriate for treatment of misophonia by both parent and adult respondents.” However, the researchers concluded: “Most interventions are considered inappropriate by parents of youth with misophonia and by adults with misophonia. This should be interpreted in the light of a general lack of misophonia-specific interventions. (Treatments specifically geared at misophonia).

Misophonia and paranoia-like thoughts

A November 2022 paper published in the journal Schizophrenia research (1) examined the relationship between misophonia and paranoia-like thoughts.

The research team from the Institute of Psychology, Polish Academy of Sciences, explained the relationship between misophonia and paranoia-like thoughts in this way: “Misophonia is a complex syndrome in which selective auditory stimuli, such as sounds of breathing, sniffing or eating, trigger an intense, negative emotional response. Previous studies have shown that the symptoms of misophonia coexist with a number of mental disorders, such as OCD, depression and anxiety.” In this study 312 people were examine to see what factors might underlie the potential relationship between misophonia and paranoia-like thoughts. Factors included “difficulties in regulating emotions, anxiety and hostile attributions.

I would like to point out that difficulties in regulating emotions, anxiety and hostile attributions, along with misophonia and paranoia thoughts are also symptoms found in many cervical spine instability patients.

Phonophobia, Photophobia, Hyperacusis

The connection between phonophobia, photophobia, and hyperacusis are well documented and deserve special mention. Photophobia, an abnormal sensitivity to light, is so common with migraine headaches that it is almost synonymous with it. Hyperacusis, as mentioned, a heightened sensitivity to sound, and phonophobia, as mentioned, a fear of sound or better fear of a sound that may cause pain, is common in chronic pain syndromes, and frequently found in children. Since these diagnosis occur together in the patient population seen at clinics that treat upper cervical instability, they must have a common pathophysiology.

First let’s explore the documented connection.

A May 2022 paper in the journal Headache (10) investigate the distribution, clinical associations, and treatment responses for the most bothersome symptoms of migraine in a large sample of patients with migraine in Taiwan. Among the recruited 1188 patients with migraine (female 79.4%, average age 39 years old) the most bothersome secondary symptoms of their migraine were: nausea (61.4%),  phonophobia (23.6%), and photophobia 10.3%). Compared to migraine without aura, migraine with aura was associated with photophobia. Chronic migraine was associated with phonophobia, but there was a lower chance for nausea.

As mentioned, the trigeminal nerve innervates the tensor tympani muscle, which dampens sounds that occur with chewing and talking. The trigeminal nerve is the nociceptive (processes sensation) innervation of the eye, as well as part of the trigemnio-vascular and trigemino-autonomic reflexes and trigeminocervical nucleus, all of which could be involved in photophobia. Hyperacusis can also be from the facial nerve as it innervates the stapedius muscle that is involved in sound dampening also. 

Let’s take a moment to explain this and you will see how these things interact and connect.

The trigeminal nerve is processing stimulation, that can be sight, sound, pain, pressure, etc. It also helps innervation of the trigemnio-vascular reflex which is responsible for blood flow into the cranial arteries. The trigeminal nerve also innervates the trigemino-autonomic reflex is a connection between the brainstem, the trigeminal nerve and the facial cranial nerve. It is often implicated in headaches and migraines. For more of a discussion, please see my article Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves.

The common or “source” of phonophobia, photophobia, and hyperacusis could involve the upper cervical anatomy through the ansa cervicalis, there are connections between the upper cervical nerve roots, vagus nerves and the trigeminal and facial nerves.

What are we seeing in this image? How upper cervical instability can impact the brainstem.

The vast array of hearing and sound dysfunction problems suffered by patients with suspected cervical spine instability can be explained by examining the position of the brain stem in the cervical spine and how instability at the C1 or C2 levels can cause these bones to start wandering around and compressing nerves, arteries, and veins.

The vast array of hearing and sound dysfunction problems suffered by patients with suspected cervical spine instability can be explained by examining the position of the brain stem in the cervical spine

Eustachian tube dysfunction

I cover the problems of eustachian tube dysfunction throughout this website and video article companions. I will offer here a brief review. If you are reading this article, you are probably well aware that that the eustachian tube connects the middle ear to the back of your throat. It is a tube that is normally filled with air. In simplest terms the function of the eustachian tube is to open and close to regulate middle ear pressure and to protect the ear, by closing, from loud sounds or sudden air pressure changes. When a person sneezes, swallows, or yawns, the eustachian tube is supposed to open to help regulate air pressure from building up inside the ear. When the eustachian tube does not function properly we get the symptoms already discussed above and a few more. These symptoms include dizziness, vertigo, tinnitus, ear fullness, hearing loss,  muffled sounds, pain, popping or clicking sensation in ears, plugged feeling, imbalance, and tinnitus.

The vagus nerve has a major role in sound and hearing issues

The vagus nerve has a major role in the regulation of middle ear pressure by opening the Eustachian tube. Normal opening of the Eustachian tube equalizes atmospheric pressure in the middle ear and clears mucus form the middle ear. The Eustachian tube needs to be open during normal swallowing, as just that noise could damage the sensitive nerve endings and structures in the inner ear. The vagus nerve innervates the levator veli palatini, the other muscle that opens the Eustachian tube is the tensor veli palatine innervated by the trigeminal nerve. If the Eustachian tube on one side of the head were unable to open and close properly then fluids would build up in the middle ear, causing a pressure difference between the middle ears on both sides of the head. When the pressure inside one middle ear cavity is different than the other side it can cause many symptoms including dizziness, hearing loss, ear discomfort, ear fullness, pressure in the ears (as if submerged in water), as well as pain in the ears.

In this video Ross Hauser, MD discusses general problems of ear pain, ear fullness, sound sensitivity, and hearing problems.

Below is the transcript summary and explanatory notes:

  • As the video starts, Dr. Hauser makes a connection between cervical spine/neck instability and cause problems related to the ear and hearing.
  • In many of these patients, their problems of tinnitus, Meniere’s disease, dizziness, ear fullness, decreased hearing, or sensitivity to sound may be traced to problems of cervical spine/neck instability.

We hope you found this article informative and it helped answer many of the questions you may have surrounding your problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

References

1 Bagrowska P, Pionke-Ubych R, Gawęda Ł. Do they make these sounds to hurt me? The mediating role of emotion regulation, anxiety and hostile attributions in the relationship between misophonia and paranoia-like thoughts. Schizophrenia Research. 2022 Dec 1;250:137-42. [Google Scholar]
2 Smith EE, Guzick AG, Draper IA, Clinger J, Schneider SC, Goodman WK, Brout JJ, Lijffijt M, Storch EA. Perceptions of various treatment approaches for adults and children with misophonia. Journal of Affective Disorders. 2022 Nov 1;316:76-82. [Google Scholar]
3 Smith EE, Guzick AG, Draper IA, Clinger J, Schneider SC, Goodman WK, Brout JJ, Lijffijt M, Storch EA. Perceptions of various treatment approaches for adults and children with misophonia. Journal of Affective Disorders. 2022 Nov 1;316:76-82. [Google Scholar]
4 Fournier P, Paleressompoulle D, Fraysse MJ, Paolino F, Devèze A, Venail F, Noreña A. Exploring the middle ear function in patients with a cluster of symptoms including tinnitus, hyperacusis, ear fullness and/or pain. Hearing Research. 2022 May 13:108519. [Google Scholar]
5 Henry JA. Sound Therapy to Reduce Auditory Gain for Hyperacusis and Tinnitus. American Journal of Audiology. 2022 Nov 15:1-1. [Google Scholar]
6 O’Connor AF, Shea JJ. Autophony and the patulous eustachian tube. The Laryngoscope. 1981 Sep 1;91(9):1427-35. [Google Scholar]
7 Mann SE, Hollis J, Frederics T, Watters A, Oakes J, Cass SP, Mehler PS. Transient patulous eustachian tube in severe anorexia nervosa: A prospective observational study. Laryngoscope Investigative Otolaryngology. 2022 Aug;7(4):1143-9. [Google Scholar]
8 Hollis J, Mann S, Watters A, Oakes J, Mehler PS. Autophony in inpatients with anorexia nervosa or avoidant restrictive food intake disorder. International Journal of Eating Disorders. 2022 Mar;55(3):388-92. [Google Scholar]
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10 Tu YH, Wang YF, Yuan H, Chen SP, Tzeng YS, Chen WT, Lai KL, Ling YH, Wang SJ. Most bothersome symptoms in patients with migraine: A hospital‐based study in Taiwan. Headache: The Journal of Head and Face Pain. 2022 Apr 25.

 


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