Abstract

Tonic tensor tympani syndrome (TTTS) is an involuntary, anxiety-based condition where the reflex threshold for tensor tympani muscle activity is reduced, causing a frequent spasm. This can trigger aural symptoms from tympanic membrane tension, middle ear ventilation alterations and trigeminal nerve irritability. TTTS is considered to cause the distinctive symptoms of acoustic shock (AS), which can develop after exposure to an unexpected loud sound perceived as highly threatening. Hyperacusis is a dominant AS symptom. Aural pain/blockage without underlying pathology has been noted in tinnitus and hyperacusis patients, without wide acknowledgment. This multiclinic study investigated the prevalence of TTTS symptoms and AS in tinnitus and hyperacusis patients. This study included consecutive patients with tinnitus and/or hyperacusis seen in multiple clinics. Data collected: Symptoms consistent with TTTS (pain/numbness/burning in and around the ear; aural "blockage"; mild vertigo/nausea; "muffled" hearing; tympanic flutter; headache); onset or exacerbation from exposure to loud/intolerable sounds; tinnitus/hyperacusis severity. All patients were medically cleared of underlying pathology, which could cause these symptoms. 60.0% of the total sample (345 patients), 40.6% of tinnitus only patients, 81.1% of hyperacusis patients had ≥1 symptoms (P < 0.001). 68% of severe tinnitus patients, 91.3% of severe hyperacusis patients had ≥1 symptoms (P < 0.001). 19.7% (68/345) of patients in the total sample had AS. 83.8% of AS patients had hyperacusis, 41.2% of non-AS patients had hyperacusis (P < 0.001). The high prevalence of TTTS symptoms suggests they readily develop in tinnitus patients, more particularly with hyperacusis. Along with AS, they should be routinely investigated in history-taking.

Keywords: Acoustic shock, hyperacusis, tensor tympani, tinnitus, tonic tensor tympani syndrome

How to cite this article:

Westcott M, Sanchez TG, Diges I, Saba C, Dineen R, McNeill C, Chiam A, O'Keefe M, Sharples T. Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: A multi-clinic prevalence study. Noise Health 2013;15:117-28

How to cite this URL:

Westcott M, Sanchez TG, Diges I, Saba C, Dineen R, McNeill C, Chiam A, O'Keefe M, Sharples T. Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: A multi-clinic prevalence study. Noise Health [serial online] 2013 [cited 2020 Sep 18];15:117-28. Available from: http://www.noiseandhealth.org/text.asp?2013/15/63/117/110295

Introduction

Symptoms consistent with TTTS

Symptoms consistent with TTTS developing or being exacerbated by intolerable sound exposure

AS aetiology triggering the onset of their tinnitus and/or hyperacusis.

Methods

Age and gender

The presence of tinnitus and/or hyperacusis in each ear

The degree of severity of tinnitus and/or hyperacusis in each ear. The participating clinics routinely used either the tinnitus reaction questionnaire (TRQ) or the tinnitus handicap inventory (THI) to evaluate tinnitus in their patients. Because different questionnaires were being used, each clinician was asked to categorize their patient's tinnitus and hyperacusis as mild or moderate or severe. All the clinicians involved in this study were experienced in tinnitus/hyperacusis evaluation and therapy, so it was considered reasonable to assume there would be consistency in these severity judgements, and in most cases the TRQ/THI score was also provided.

Whether the tinnitus/hyperacusis onset had been triggered by exposure to an acoustic incident (a loud/sudden/unexpected/intolerable sound perceived as highly threatening) and if so, whether the acoustic incident was near one or both ears.

The presence of symptoms consistent with TTTS in each ear or side of the head (except for the symptoms of subjective vertigo and nausea, which could not be lateralized, and headache, if central): Sharp pain in the ear Dull ache in the ear A sensation of aural fullness or "blockage" A sensation of tympanic flutter A sensation of numbness around the ear A burning sensation around the ear Pain in the cheek Pain in the TMJ area Numbness/burning/pain along the side of the neck "Disordered" balance/mild vertigo (often described as 'sway'- like being on a boat) Nausea "Muffled" hearing (when the patient reports a subjective, often fluctuating, hearing loss, but their test results indicate normal or stable hearing) Subjective "distorted" hearing (includes any fluctuating change in clarity of hearing, e.g., diplacusis) Headache.

If symptoms consistent with TTTS were present, further data was recorded: Whether the symptoms were intermittent or constant Whether the symptoms developed with loud/intolerable sound exposure or, if constantly present, were exacerbated by loud/intolerable sound exposure.

Hearing assessment results, recorded in each ear as a 4 frequency average of hearing thresholds at 500 Hz, 1 kHz, 2 kHz and 4 kHz. A hearing loss was considered to be present if the 4 frequency average exceeded 20 dB. A hearing loss was further categorized as sensorineural, conductive, or due to noise damage.

Results

49.3% (170/345) of patients had tinnitus only (T group)

42.3% (146/345) of patients had tinnitus plus hyperacusis (T + H group)

8.4% (29/345) of patients had hyperacusis only (H group).

46.2% (146/316) had tinnitus plus hyperacusis (T + H group)

53.8% (170/316) had tinnitus only (T group).

83.4% (146/175) had tinnitus plus hyperacusis (T + H group)

16.6% (29/175) had hyperacusis only (H group).

Figure 1: Prevalence of symptoms consistent with tonic tensor tympani syndrome in patients with and without an acoustic incident trigger



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Table 1: Acoustic incident trigger and symptoms consistent with TTTS



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19.7% (68/345) of patients in the total sample

26.3% (47/179) of patients in the clinics from Australia/New Zealand

13.2% (7/53) of patients in the clinic from Spain

12.4% (14/113) of patients in the clinics from Brazil.

Table 2: Hyperacusis in AS and non-AS patients



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66.7% (22/33) had one or more unilateral symptoms consistent with TTTS only on that side

30.3% (10/33) had one or more bilateral symptoms to a greater degree of severity on that side

3.0% (1/33) had one or more bilateral symptoms of equal severity.

Table 3: AS patients with a unilateral acoustic incident trigger



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Table 4: AS patients with a unilateral acoustic incident trigger



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40.0% (138/345) of patients had no symptoms

12.5% (43/345) of patients had 1 symptom

47.5% (164/345) of patients had ≥2 symptoms.

Figure 2: Prevalence of symptoms consistent with tonic tensor tympani syndrome in the total sample



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Table 5: Independence of symptoms



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59.4% (101/170) of patients had no symptoms

9.4% (16/170) of patients had 1 symptom

31.2% (53/170) of patients had ≥2 symptoms.

Figure 3: Prevalence of symptoms consistent with tonic tensor tympani syndrome in T group and tinnitus plus hyperacusis, H groups



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18.9% (33/175) of patients had no symptoms

15.4% (27/175) of patients had 1 symptom

65.7% (115/175) of patients had ≥2 symptoms.

Table 6: Symptom prevalence in T group and T + H, H groups



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Table 7: Symptom prevalence in T group and T + H, H groups



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63.5% (33/52) of patients had one or more symptoms only on that side

21.2% (11/52) of patients had one or more bilateral symptoms to a greater degree on that side

7.7% (4/52) of patients had one or more bilateral symptoms equally in both ears

1.9% (1/52) of patients had one or more bilateral symptoms to a greater degree on the opposite side

5.8% (3/52) of patients had no symptoms.

Table 8: Unilateral hyperacusis patients



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Table 9: Unilateral hyperacusis patients



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Table 10: Individual symptom prevalence in T group compared to T+H, H groups



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Figure 4: Individual symptom prevalence in T group compared to tinnitus plus hyperacusis, H groups



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57.4% (58/101) of patients had no symptoms

12.9% (13/101) of patients had 1 symptom

29.7% (30/101) of patients had ≥2 symptoms.

Figure 5: Effect of tinnitus severity on the prevalence of symptoms consistent with tonic tensor tympani syndrome



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32.2% (37/115) of patients had no symptoms

13.0% (15/115) of patients had 1 symptom

54.8% (63/115) of patients had ≥ 2 symptoms.

32% (32/100) of patients had no symptoms

10% (10/100) of patients had 1 symptom

58% (58/100) of patients had ≥2 symptoms.

Table 11: Tinnitus severity and prevalence of symptoms consistent with TTTS



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26.6% (17/64) of patients had no symptoms

20.3% (13/64) of patients had 1 symptom

53.1% (34/64) of patients had ≥2 symptoms.

Figure 6: Effect of hyperacusis severity on the prevalence of symptoms consistent with tonic tensor tympani syndrome



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17.5% (11/63) of patients had no symptoms

15.9% (10/63) of patients had 1 symptom

66.7% (42/63) of patients had ≥2 symptoms.

8.7% (4/46) of patients had no symptoms

8.7% (4/46) of patients had 1 symptom

82.6% (38/46) of patients had ≥2 symptoms.

Table 12: Hyperacusis severity and prevalence of symptoms consistent with TTTS



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Figure 7: Patients with symptom, reporting development or exacerbation of the symptom from intolerable sound exposure



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Table 13: Patients with symptom, reporting development or exacerbation of the symptom from intolerable sound exposure



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"Distorted" hearing 80.0% (i.e. 80% of patients with "distorted" hearing reported this symptom developed or was exacerbated by loud/intolerable sound exposure)

Tympanic flutter 35.5%

Sharp pain in ear 30.8%

Aural fullness 22.7%

"Muffled" hearing 21.4%.

"Distorted" hearing 78.6%

"Muffled" hearing 75.9%

Dull ache in ear 74.0%

Sharp pain in ear 66.7%

Tympanic flutter 59.2%

Aural fullness 53.3%.

35.8% (62/173) of patients had no symptoms

11.6% (20/173) of patients had 1 symptom

52.6% (91/173) of patients had ≥2 symptoms.

Figure 8: Prevalence of symptoms in normal hearing and hearing loss



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41.9% (72/172) of patients had no symptoms

12.8% (22/172) of patients had 1 symptom

45.4% (78/172) of patients had ≥2 symptoms.

Table 14: Prevalence of symptoms in normal hearing and hearing loss



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Discussion

The association demonstrated between hyperacusis and the high prevalence of symptoms consistent with TTTS

The prevalence of symptom development/exacerbation following intolerable sound exposure, consistent with a stress/anxiety/threat response

The unilateral preponderance of symptoms in patients with unilateral hyperacusis and those who reported exposure to a unilateral acoustic incident exposure triggering their AS. 84.6% of patients with unilateral hyperacusis had one or more symptoms consistent with TTTS to a greater degree on the affected side (P < 0.001) [Table 8]. 97.0% (32/33) of patients with a unilateral acoustic incident trigger for their AS had one or more symptoms consistent with TTTS to a greater degree on the affected side (P < 0.001) [Table 3].

Conclusion

Acknowledgment

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Correspondence Address:

Myriam Westcott

Dineen and Westcott Audiologists, Melbourne

Australia

Source of Support: None, Conflict of Interest: None Check

DOI: 10.4103/1463-1741.110295







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