Disclaimer: This article is for informational purposes only and does not constitute medical advice. Sound sensitivity conditions are complex and poorly understood. If you have severe symptoms, work with a specialist who has experience treating these conditions.
If you've searched online for help with sound sensitivity, you've probably encountered advice that sounds confident: "Don't avoid sound—that makes it worse!" "Ear protection will increase your sensitivity!" "You need to expose yourself to normal sounds."
For many people with mild hyperacusis, gradual sound exposure does help. But there's a growing clinical recognition that this advice can be dangerous for a subset of patients—particularly those with noxacusis (pain hyperacusis).
The critical distinction: loudness vs. pain
Clinicians and researchers increasingly distinguish between different subtypes of sound sensitivity:
Loudness Hyperacusis
Sounds that others consider normal feel uncomfortably loud. The experience is one of intensity and annoyance.
- • Everyday sounds feel "too much"
- • Discomfort, not physical pain
- • Often responds to graded exposure
- • May improve with desensitization
Noxacusis (Pain Hyperacusis)
Sound causes actual physical pain—sharp, burning, stabbing sensations. This is a different pathophysiology.
- • Sharp, burning, or stabbing ear pain
- • Pain may persist hours/days after exposure
- • "Setbacks" can cause lasting worsening
- • May require protective approach initially
Why this matters
The treatment that helps loudness hyperacusis may actively harm someone with noxacusis. Patients report that following standard "exposure therapy" advice led to significant, sometimes permanent, worsening of their condition.
This is not a fringe concern—it's increasingly recognized in specialized clinical settings.
The controversy: protection vs. exposure
Since Jastreboff and Hazell introduced Tinnitus Retraining Therapy (TRT) in 1993, the dominant clinical narrative has been: "Avoiding sound and using ear protection makes hyperacusis worse."
This advice is based on the theory that the auditory system becomes more sensitive when deprived of input. While there's logic to this for loudness hyperacusis, the evidence for pain-type hyperacusis is far less clear.
What patients are reporting
Patient communities increasingly document cases where:
- Mildly affected individuals followed "continue normal sound exposure" advice and became severely disabled
- A single "setback" from sound overexposure led to months or years of worsened symptoms
- Those who protected early and gradually re-introduced sound had better long-term outcomes
A note on evidence
Hyperacusis—especially noxacusis—remains poorly researched. Much of what we know comes from patient reports and clinical observation, not large randomized trials. Both the "always expose" and "always protect" camps are working with incomplete data.
The wisest approach may be: match your treatment to your subtype and severity.
A framework: matching approach to subtype
Mild-to-moderate loudness hyperacusis
Sounds are uncomfortable but don't cause physical pain or lasting setbacks.
Approach: Graded exposure often helpful
- • Structured sound therapy programs
- • Gradual increase in sound tolerance
- • Limit protection to genuinely loud environments
- • CBT to address anxiety/fear response
Moderate-to-severe hyperacusis (mixed or uncertain type)
Some pain component, setbacks occur but recovery is possible within days.
Approach: Cautious, personalized
- • Know your specific limits before pushing
- • Use protection strategically (not all-or-nothing)
- • Very gradual increases only when stable
- • Work with experienced specialist if possible
Severe noxacusis (pain hyperacusis)
Sound causes physical pain; setbacks can last weeks/months; at risk of progressive worsening.
Approach: Protection and stabilization first
- • Create controlled, predictable sound environment
- • Use ear protection outside safe zones
- • Avoid any sound that causes pain or burning
- • Stabilize before attempting any exposure increases
- • Rule out structural causes (temporal bone CT)
- • Consider specialized interventions (Silverstein procedure, etc.)
Medical interventions for severe cases
For severe noxacusis that doesn't improve with time and conservative management, specialized ENTs may consider:
- High-resolution temporal bone CT: Rule out structural causes like superior semicircular canal dehiscence (SSCD)
- Silverstein round/oval window reinforcement: Surgical intervention showing promising outcomes for some severe cases
- Tensor veli palatini (TVP) Botox: May help cases involving middle ear muscle tension
- Sphenopalatine ganglion (SPG) nerve blocks: Emerging option for pain management
Related phenomena: reactive tinnitus and palinacousis
Many people with hyperacusis also experience:
Reactive Tinnitus
Tinnitus that intensifies immediately in response to sounds that exceed your tolerance threshold. Often temporary, but can become persistent if the triggering exposure continues.
Palinacousis
A sound persists or "replays" internally after the external stimulus has stopped. For example, hearing an ambulance siren continue even after it's passed and the environment is silent.
Bimodal devices: Susan Shore and Lenire
For those whose primary issue is tinnitus rather than pain-based sound sensitivity, bimodal neuromodulation devices may be worth exploring:
Susan Shore Device (University of Michigan)
Uses precisely timed sound + electrical stimulation to face/neck, targeting the dorsal cochlear nucleus. Clinical trials show promising results, especially for somatic tinnitus (tinnitus that changes with jaw or neck movement). Not yet commercially available but FDA review anticipated.
Lenire
FDA-cleared device using tongue stimulation + sound therapy. Mixed independent results, but some patients report significant improvement. Available commercially in the EU and US.
Where does CBT fit?
Cognitive Behavioral Therapy remains valuable regardless of your hyperacusis subtype—but the focus shifts:
- For loudness hyperacusis: CBT can directly help reduce fear-avoidance and anxiety that amplifies the condition
- For noxacusis: CBT supports coping with a chronic pain condition, without necessarily pushing sound exposure
The goal of CBT in severe cases isn't "normalize your relationship with all sound"—it's manage the psychological toll of living with a debilitating condition while pursuing appropriate medical care.
Key takeaways
- 1.Identify your subtype. Loudness discomfort and physical pain are different conditions with different optimal treatments.
- 2.Match your approach to your severity. Standard exposure advice works for mild cases; severe noxacusis may require the opposite approach initially.
- 3.Setbacks matter. A single overexposure can sometimes cause lasting damage. When in doubt, err on the side of caution.
- 4.Find the right specialist. Most ENTs and audiologists have limited experience with severe hyperacusis. Seek out those who do.
- 5.CBT helps—but differently. It manages the brain's alarm response regardless of whether you're pushing sound exposure or protecting.
Focus on what you can control
Regardless of your hyperacusis subtype, managing the brain's threat response is essential. MyPattern's CBT-informed approach helps reduce the emotional amplification—a key factor in quality of life.
For severe hyperacusis or noxacusis, work with a specialist experienced in these conditions. This content does not constitute medical advice.