Loudness Discomfort Level Research Articles

Occurrence and suppression effect of Otoacoustic Emissions in normal hearing adults with tinnitus and hyperacusis

The association between tinnitus and hyperacusis is common according to the literature. AimTo verify the occurrence and the suppression effect of transient otoacoustic emissions (TEOAE), the existence of association between tinnitus degrees and hyperacusis degrees, and between the suppressive effect of TEOAE and laterality, tinnitus and hyperacusis degrees in normal hearing adults with complaints of tinnitus and hyperacusis. Materials and Methods25 normal hearing subjects with complaints of hyperacusis and tinnitus were studied in this cross-sectional study. The Tinnitus Handicap Inventory (THI) was used for the classification of tinnitus degrees, and the Loudness Discomfort Level (LDL) for the hyperacusis classification. ResultsThe occurrence of TEOAE ranged from 33 to 88%. We observed the presence of TEOAE suppression effect on 63.7% in the right ear and 81.7% in the left ear. There was no significant correlation between the degrees of tinnitus and hyperacusis in both ears. No statistically significant associations between the TEOAE suppression effect and laterality, tinnitus degrees and hyperacusis degrees were found. ConclusionThe occurrence of TEOAE was lower than that found in normal hearing adults. A higher percentage of the presence of TEOAE suppression effect has been found in both ears. No association between the variables was observed.

Accuracy and Reliability of a Real-Ear-to-Coupler Difference Measurement Procedure Implemented within a Behind-the-Ear Hearing Aid

Measurement of the real ear response of a fitted hearing aid allows matching of the frequency response to prescriptive targets, as well as comparison of the response to both threshold and loudness discomfort level (LDL). These processes are recommended procedures for hearing aid fittings. The real ear aided response (REAR) is often predicted based on the coupler response of the device, the real-ear-to-coupler difference (RECD), and the microphone location effect (MLE). Individualized measurement of the RECD tends to increase the accuracy of this prediction. A commercial hearing aid has been developed that measures the individual RECD and incorporates the data into the software-assisted fitting process. This study evaluated the test-retest reliability and predictive validity of this particular method for measuring the RECD. A repeated measures design was used to evaluate differences between subsequent measures of the RECD in the same ear, and prediction differences associated with using the RECD (and other information) to predict the REAR. Fifteen ears, on a convenience sample of ten adults (45-86 yr) and five children (6-15 yr) were tested. All participants were hearing aid users. Predicted and measured REARs were collected using normal clinical procedures, on an Audioscan Verifit VF-1 for two test signals/levels. Reliability, mean differences between predicted and measured REARs, and 95% confidence intervals of the prediction accuracy are reported. The RECD procedure had test-retest reliability within 2.5 dB for 14 out of 15 ears between 500 and 4000 Hz, and had predictive accuracy within 5 dB between 500 and 4000 Hz for 14 out of 15 ears. However, errors associated with earhook misalignment were discovered. Also, the RECD values measured using this hearing-aid-specific procedure differ somewhat from the normative data available from insert earphone RECDs. This procedure, when measured according to recommendations, provides a reasonably accurate prediction of the REAR. Functionally, this procedure does not replace the range of measures offered by modern real ear measurement systems. However, given the inaccuracy of software-assisted fittings without a measure of individual ear canal acoustics, use of this procedure may have the potential to improve the accuracy of fittings versus fittings completed without real ear measurement.

Improvement in Hyperacusis with Tinnitus Retraining Therapy

Objective: Decreased sound tolerance and hyperacusis are frequently found in patients who complain of tinnitus. This study aims to investigate the efficacy of Tinnitus Retraining Therapy (TRT) in patients with hyperacusis. Method: Prospective study of patients with hyperacusis presenting to the tinnitus clinic in a tertiary referral otorhinolaryngology unit. Hyperacusis was confirmed with loudness discomfort level (LDL) measurements. Audiometry was performed in all patients. Improvement of hyperacusis following TRT was measured by structured interview with aid of questionnaires and visual analogue scores. Results: A total of 197 patients were studied. Improvement was achieved in 39%. Environmental sound (70%), Viennatone broadband noise generator (18%) and Marsona sound generator (5%) were used. 18% had hearing aids (HA) fitted even though 73% had hearing loss. Patients who opted for HA complained of worse effects of hyperacusis on life. Age, gender, and presence of hearing loss were similar in patients who did and did not improve. Duration of treatment was longer in patients that improved ( P < .01). Improvement with Viennatone was significantly higher than with environmental sounds alone (49% vs 35%, P < .05), especially when used in presence of hearing loss (61%). Conclusion: Modest proportion of patients with hyperacusis improved with TRT. Use of broadband noise generators and longer duration of therapy appear to give better success rates. Overall success of TRT in patients with hyperacusis may also be related to underlying medical problems such as thyroid conditions and multiple sclerosis.

Intervention for restricted dynamic range and reduced sound tolerance

Hyperacusis is an abnormal condition of sound intolerance that may cause some persons to reject amplified sound from their hearing aids. A significant secondary benefit reported for many patients receiving Tinnitus Retraining Therapy (TRT) is increased Loudness Discomfort Levels (LDLs). TRT involves both counseling and sound therapy (i.e., daily exposure to soft sound from bilateral noise generators (NGs)). We implemented a randomized, double-blind, placebo-controlled clinical trial to assess the efficacy of TRT as an intervention to improve sound tolerance in hearing-aid eligible persons with hyperacusis and/or restricted dynamic ranges. Subjects were assigned to one of four treatment groups: 1) full treatment, both counseling and NGs, 2) counseling and placebo NGs, 3) NGs without counseling, and 4) placebo NGs without counseling. They were evaluated at least monthly, typically for five months or more, on a variety of audiometric tests, including LDLs, the Contour Test for Loudness, and word recognition measured at comfortable and loud levels. Over 80% of the subjects assigned to full treatment achieved significant benefit (defined as shifts of greater than 10 dB in LDLs or the Contour Test uncomfortable level); whereas, most subjects assigned to a partial treatment group did not benefit from their treatment. [Supported by NIH].

Predicting Hyperacusis in Tinnitus Patients

The goal of this study was to develop a model that predicts whether tinnitus patients would report hyperacusis based upon their audiometric thresholds and loudness discomfort levels (LDLs), measured at 1000, 2000, 4000, and 8000 Hz. Follow-up LDLs subsequent to tinnitus retraining therapy (TRT) were used to predict hyperacusis subsequent to treatment. Pretreatment and TRT follow-up audiometric thresholds and LDLs were analyzed for a group of 68 tinnitus patients who self-reported sound tolerance complaints and a group of 58 tinnitus patients who denied sound tolerance problems. A logistic regression model was implemented to determine which of the eight audiological measures (i.e., four threshold and four LDL measures) were essential in predicting the hyperacusis or tinnitus-only categorization. Predictions from the logistic regression model are compared with three versions of a published categorization scheme. The success of each model varied depending on the hearing-loss configuration, with poorest performance for sloping hearing losses. The logistic regression model was the best model overall. The logistic regression model predicted improvement for 54 of 68 (79%) self-reported hyperacusis patients following TRT treatment. The logistic regression model improves the prediction of hyperacusis in tinnitus patients and successfully predicts improvement in the majority of tinnitus patients following TRT treatment.

Secondary Benefits from Tinnitus Retraining Therapy: Clinically Significant Increases in Loudness Discomfort Level and Expansion of the Auditory Dynamic Range

In this report, the authors highlight clinically significant improvements in sound tolerance observed over the past decade among patients who were enrolled in tinnitus retraining therapy (TRT) at the University of Maryland Tinnitus and Hyperacusis Center. Pretreatment and TRT follow-up audiometric threshold, loudness discomfort level (LDL), and dynamic-range (DR) data are documented for (1) a group of 68 tinnitus patients who presented with primary complaints of sound intolerance, and (2) a second group of 70 patients who reported only tinnitus (and no sound tolerance problems). TRT-related increases in sound tolerance are (1) due to increases in LDLs and occur independently of changes in audiometric threshold, which were invariant with treatment; (2) statistically significant in tinnitus patients with and without sound tolerance problems, and with and without hearing loss; (3) observed among 81% of the patients with sound tolerance complaints and 44% of the patients who reported primary tinnitus; (4) independent of audiometric frequency over the range 1000 to 8000 Hz; and (5) seemingly independent of TRT treatment duration, which is consistent with recent experimental evidence of a rapid treatment effect (within the first month of TRT). The TRT treatment effects were clinically meaningful, offering new opportunities for expanding the auditory DR and improving sound tolerance in the general hearing-impaired population. The mechanism responsible for the plasticity underlying these treatment effects is uncertain, but appears consistent with a centrally mediated auditory gain control process. Sound tolerance problems were overpredicted among the authors' sample of tinnitus-only patients when existing objective audiometric criteria were used. This finding promoted the development of a new predictive model for sound tolerance problems, which is described in a companion report.

Secondary Treatment Benefits Achieved by Hearing-Impaired Tinnitus Patients Using Aided Environmental Sound Therapy for Tinnitus Retraining Therapy: Comparisons with Matched Groups of Tinnitus Patients Using Noise Generators for Sound Therapy

Tinnitus patients with hearing loss may use amplified environmental sound from hearing aids (HAs) for the sound therapy (ST) component of tinnitus retraining therapy (TRT). Sizable secondary treatment benefits, namely, incremental shifts in loudness discomfort levels (LDLs) and expansion of the auditory dynamic range (DR) for loudness, have been reported for tinnitus patients who use noise generators (NGs) for ST in TRT. The primary questions addressed in this study are (1) Then hearing-impaired tinnitus patients using amplified environmental sound for their ST also achieve significant secondary treatment benefits and, if so, (2) are these secondary effects of similar magnitude to those measured for tinnitus patients using NGs for their ST? An analysis of patient records in the University of Maryland Tinnitus and Hyperacusis Center (UMTHC) revealed TRT treatment-related changes in the LDL averaged 2.70 dB for a group of 25 aided hearing-impaired tinnitus patients. Corresponding treatment effects for four matched groups of tinnitus patients, who used NGs for their ST, ranged from 5.91 to 10.10 dB. The associated incremental changes in the DR averaged 0.60 dB for the aided tinnitus patients and from 4.10 to 9.23 dB for the matched groups of tinnitus patients who used NGs for their ST. These findings indicate that hearing-impaired tinnitus patients using aided environmental sound for TRT achieve smaller secondary treatment benefits than do tinnitus patients who use NGs for their ST.

Evidence for adaptive plasticity in elderly monaural hearing aid users

Hearing aids can induce perceptual changes in some elderly listeners but few studies have investigated physiological changes in this population. Loudness discomfort levels and acoustic reflex thresholds were measured in long-term users of a single hearing aid. The results show an asymmetry of +2 to +9 dB between ears in the sound level that (i) causes loudness discomfort and (ii) elicits a reflex contraction of the middle ear muscles. The elevation of the acoustic reflex threshold occurs in the ear with hearing aid experience, irrespective of the ear of stimulation. Therefore, there is evidence of adaptive plasticity and this can be measured at the level of the auditory brainstem.

Hearing Aid Maximum Output and Loudness Discomfort: Are Unaided Loudness Measures Needed?

The purpose of this study was to evaluate a clinical protocol for setting hearing aid maximum output (MPO) in adult users. The protocol consisted of matching prescriptive targets for MPO followed by aided loudness validation and adjustment. Twenty-eight adults fit with multichannel hearing aids during the previous two years were recalled for unaided loudness measures. During the recall visit, unaided frequency-specific loudness discomfort levels were measured for frequencies between 250 and 3000 Hz. These values were converted to real-ear levels by adding individually measured real-ear dial differences. Real-ear saturation responses (RESR) were measured using a 90 dB pure-tone sweep and compared to the real-ear loudness discomfort levels. All participants completed the APHAB Aversiveness scale and Munro-Patel loudness questionnaire. A subset of participants (n = 20) completed the Profile of Aided Loudness. The average RESR-UCL difference was -5.7 dB, and the maximum difference was 15 dB. For all but one participant, the average RESR values (.5-3 kHz) were either less than or no more than 5 dB above the LDLs, and the aided APHAB Aversiveness scores were below the 80th percentile. There were no significant correlations between the scores on the loudness questionnaires and the differences between RESR and LDL values. Results suggest that unaided LDL measures may be redundant if aided loudness validation measures are completed.

Short-Term and Long-Term Hearing Aid Benefit and User Satisfaction: A Comparison between Two Fitting Protocols

Currently published hearing aid fitting protocols recommend speech-in-noise testing and loudness measures, but it remains unclear how these measures affect hearing aid benefit and user satisfaction. This study compared two protocols in their effects on benefit and satisfaction. Protocol A included an electroacoustic analysis, real-ear measures, and hearing aid adjustments based on users' comments. Protocol B included all of Protocol A and a speech-in-noise test, loudness discomfort levels, and aided loudness. Thirty-two participants completed the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Satisfaction with Amplification in Daily Life (SADL) at 45 days and three months post-initial fitting. Fewer hearing aid adjustments were made to the hearing aids for participants fitted with Protocol B than participants fitted with Protocol A, but final gains were similar for both groups. Although similar APHAB scores were obtained for both protocols, SADL scores decreased between 45 days and three months for Protocol A.

Intervention for restricted dynamic range and reduced sound tolerance

Hyperacusis is an abnormal condition of sound intolerance that may cause some persons to reject amplified sound from their hearing aids. A significant secondary benefit reported for many patients receiving Tinnitus Retraining Therapy (TRT) is increased Loudness Discomfort Levels (LDLs). TRT involves both counseling and sound therapy (i.e., daily exposure to soft sound from bilateral noise generators (NGs)). We implemented a randomized, double‐blind, placebo‐controlled clinical trial to assess the efficacy of TRT as an intervention to improve sound tolerance in hearing‐aid eligible persons with hyperacusis and/or restricted dynamic ranges. Subjects were assigned to one of four treatment groups: 1) full treatment, both counseling and NGs, 2) counseling and placebo NGs, 3) NGs without counseling, and 4) placebo NGs without counseling. They were evaluated at least monthly, typically for five months or more, on a variety of audiometric tests, including LDLs, the Contour Test for Loudness, and word recognition measured at comfortable and loud levels. Over 80% of the subjects assigned to full treatment achieved significant benefit (defined as shifts of greater than 10 dB in LDLs or the Contour Test uncomfortable level); whereas, most subjects assigned to a partial treatment group did not benefit from their treatment. [Supported by NIH].

Neuromonics Tinnitus Treatment: Third Clinical Trial

The Neuromonics Tinnitus Treatment combines the use of a novel approach to acoustic stimulation with a structured program of counseling and support by a clinician specifically trained in tinnitus rehabilitation. The distinctive acoustic component has been designed to provide stimulation to auditory pathways deprived by hearing loss, engage positively with the limbic system, and allow intermittent, momentary tinnitus perception within a pleasant and relaxing stimulus, thereby facilitating desensitization to the tinnitus signal. The purposes of this study were (1) to demonstrate the efficacy of the treatment, when enhanced with various modifications since previously reported trials and (2) to test the relative clinical effectiveness of two variations of the approach. In the first, intermittent tinnitus perception was facilitated throughout treatment through the use of a stimulus in which intensity peaks allowed the patients' tinnitus perception to be completely covered up, whereas in the intensity troughs their tinnitus was briefly discernible. In the second, subjects experienced little tinnitus perception while listening to the treatment for the first 2 mo, then experienced intermittent perception. Thirty-five subjects with a predominantly moderate to severe level of tinnitus-related distress before treatment were randomly allocated into one of two treatment groups, corresponding to the two stage-based variations of the Neuromonics Tinnitus Treatment. Participants were provided with a high-fidelity personal sound player with earphones and an acoustic stimulus that had been spectrally modified according to their individual audiometric profile. They were instructed to use the acoustic stimulus for at least 2 hr per day, particularly at those times when their tinnitus was usually disturbing. Each group had equal amounts of clinician time for education, monitoring, and support. At 2, 4, 6, and 12 mo after commencing treatment, both groups displayed clinically and statistically significant improvements in tinnitus distress, awareness, and minimum masking levels as well as loudness discomfort levels. Improvements increased with time over the first 6 mo of therapy, at which time 91% of all subjects across the two groups reported an improvement in tinnitus disturbance (as measured by the Tinnitus Reaction Questionnaire) of at least 40%, with a mean improvement of 65%. Also, 80% of subjects at 6 mo reported a level of tinnitus disturbance that was no longer clinically significant. There was some indication of a more consistent benefit over 12 mo for the group that was provided initially with a high level of tinnitus interaction; however, inter-group differences were not statistically significant. A relation between reported treatment usage (hours per day) and clinical outcomes was observed, suggesting that a "dosage effect" may apply with the stimulus provided. This study found that the Neuromonics Tinnitus Treatment provides rapid and profound improvements to the severity of tinnitus symptoms and their effect on the subject's quality of life. This was a consistent effect, provided by a treatment that subjects reported as being pleasant to use. Both of the stage-based variations of the treatment that were tested in this study were shown to be successful in achieving these outcomes.

NIDCD/VA Hearing Aid Clinical Trial and Follow-Up: Coupler and Real-Ear Measurement

A total of 190 individuals participated in a clinical visit during the Cooperative Studies Program (CSP) 418-A Long Term Follow-Up Study. Of this cohort, 158 participants were considered current hearing aid users, and 32 were non-hearing aid users. Of the current hearing aid users, 81 were still using their original 418 study devices, and 77 had acquired new hearing aids. Coupler and real ear measurements were completed on all available hearing aids. Results showed that study aids had remained relatively stable over the six years between CSP 418 and CSP 418-A. On average, these hearing aid wearers preferred use gain settings that were 6-9 dB less than current NAL-RP insertion gain targets. Mean real ear insertion gain (REIG) was comparable to the mean real ear insertion gain of the same participants in the original study, and users did not tend to increase gain as hearing decreased. Real ear saturation responses (RESR) remained unchanged. Loudness discomfort levels (LDL) obtained during 418-A were significantly lower than LDLs obtained on those same participants at both the initial and final visits in the previous study.

Audiological Evaluation of Affected Members from a Dutch DFNA8/12 (TECTA) Family

In DFNA8/12, an autosomal dominantly inherited type of nonsyndromic hearing impairment, the TECTA gene mutation causes a defect in the structure of the tectorial membrane in the inner ear. Because DFNA8/12 affects the tectorial membrane, patients with DFNA8/12 may show specific audiometric characteristics. In this study, five selected members of a Dutch DFNA8/12 family with a TECTA sensorineural hearing impairment were evaluated with pure-tone audiometry, loudness scaling, speech perception in quiet and noise, difference limen for frequency, acoustic reflexes, otoacoustic emissions, and gap detection. Four out of five subjects showed an elevation of pure-tone thresholds, acoustic reflex thresholds, and loudness discomfort levels. Loudness growth curves are parallel to those found in normal-hearing individuals. Suprathreshold measures such as difference limen for frequency modulated pure tones, gap detection, and particularly speech perception in noise are within the normal range. Distortion otoacoustic emissions are present at the higher stimulus level. These results are similar to those previously obtained from a Dutch DFNA13 family with midfrequency sensorineural hearing impairment. It seems that a defect in the tectorial membrane results primarily in an attenuation of sound, whereas suprathreshold measures, such as otoacoustic emissions and speech perception in noise, are preserved rather well. The main effect of the defects is a shift in the operation point of the outer hair cells with near intact functioning at high levels. As most test results reflect those found in middle-ear conductive loss in both families, the sensorineural hearing impairment may be characterized as a cochlear conductive hearing impairment.

Loudness growth in individual listeners with hearing loss

Recent research indicates that there are large individual differences in how loudness grows with level for listeners with sensorineural hearing losses of primarily cochlear origin. Studies of loudness discomfort level suggest that loudness for most of these impaired listeners approaches the loudness experienced by the normal listeners at high levels. Loudness growth at low levels is still controversial. Although it is now well established that loudness at threshold is greater than zero, its exact value is unknown. If this value is the same for normal and impaired listeners, then the loudness growth for the impaired listeners must be steeper in order to catch up to normal at high levels. This phenomenon is called recruitment. If the loudness at threshold for impaired listeners is higher than that for normal listeners, then the impaired listeners will no longer be able to perceive sounds as soft. This phenomenon is called softness imperception. Results from two experiments suggest that: (1) individual differences are more important for impaired listeners than for normal listeners; (2) some impaired listeners seem to show recruitment, others softness imperception; and (3) averaging the results across the impaired listeners will mask these differences. [Work supported by NIH/NIDCD grant R01DC02241.]

Nível de desconforto para sensação de intensidade em indivíduos com audição normal

Loudness Discomfort Level (LDL), a test used in the hearing aid fitting process, has also been recommended to evaluate patients with tinnitus and/or suspect of hyperacusis. To determine LDL reference values for normal hearing individuals and to correlate the LDL to the Acoustic Reflex Threshold (ART). LDL was investigated in 64 normal hearing subjects, with ages between 18 and 25 years (53.1% female), in the frequency threshold of 0.5 to 8KHz and for speech (non-recorded, non-standardized connected discourse). Pulsate pure tones were presented for two seconds, with a one-second interval between each presentation. The initial stimulus intensity was at 50dB and was followed by ascending presentations, of 5dB each, until the subject referred initial discomfort with loudness. The testing procedure was performed separately in each ear, and was immediately repeated at the end of the test (test and retest situation). The choice of the ear that would start the testing procedure was alternated for each subject. After that contralateral acoustic reflexes ART were measured. The presence of the ART was indicated by a minimal needle deflection (larger than 0.05ml) on the emittance equipment. Median varied from 86 to 98dBHL, with no statistically significant differences between gender (p > 0.11), between ears (p > 0.36) and between the test-retest situation (p > 0.34). The determination coefficients (r2) of the linear regression model revealed absence of correlation between log(LDL) and log(ART). Normal hearing individuals have LDL between 86 and 98dBHL for all of the tested stimuli. Inter-subject differences and the good reproductivity suggest that the interpretation of the test should be cautious and analyzed considering the patient's history. The test can be an useful instrument go follow-up patients. No correlation was found between LDL and ART.

Evaluación de la hiperacusia: test de hipersensibilidad al sonido

BackgroundHyperacusis is a decreased sound tolerance. The audiological examination includes the loudness discomfort level measurement and the handicap evaluation, so we introduce the Spanish validation of the german sound intolerance questionnaire. ObjectivesTo update the concept of hyperacusis and to evaluate its handicap through a Spanish validation of the Geräuschüberempfindlichkeit (GÜF). PatientsForty patients referred to our Tinnitus and Hyperacusis Clinic in the University Hospital, between October 2004 and February 2005. Outcome MeasuresThe Spanish version of the GÜF was performed after transla-tion and retro-translation. Internal consistency and reliability were established. ResultsSpanish adaptation of the GÜF and its subscales (cognitive, somatic behaviour and emotional reaction) showed a high reliability and internal consistency (Cronbach´s alfa: 0.9007). Higher GÜF scores were statistically demonstrated in hyperacusis patients with hearing loss(p 0.05) or tinnitus(p 0.05). ConclusionsSpanish adaptation of the GÜF is valid, reliable and can be used in a clinical setting to quantify the impact of hyperacusis on patient's quality of life.

Fitting Hearing Aids Using Clinical Measures of Loudness Discomfort Levels: An Evidence-Based Review of Effectiveness

Clinical measurement of the loudness discomfort level (LDL) historically has been part of the hearing aid fitting procedure, and this clinical practice remains popular today. LDL measurements also are recommended in contemporary hearing aid fitting protocols. Yet, surveys show that many hearing aid users are dissatisfied with the loudness of their hearing aids. In this evidence-based review article, we evaluate the effectiveness of clinical LDL measurements. Specifically, we asked the question "Are the clinical measurements of LDL for adult patients predictive of aided acceptance and satisfaction of loudness for high inputs in the real world?" Nearly 200 articles were reviewed; three met the criteria set forth in this review. The evidence supported using unaided LDLs for selecting the maximum real-ear output of hearing aids. No study using aided LDLs or aided loudness verification met the criteria. The level of the evidence for the three articles using unaided LDLs was low; no higher than Level 4. The limited number of studies, the level of evidence, and the statistical power of the studies prevents us from making a strong recommendation concerning the clinical use of LDL measures. Additional research in this area, especially research employing randomized controlled trials would be a useful addition to this body of literature.

Clinical Guide for Audiologic Tinnitus Management I

This article is the first of 2 that present basic guidelines for audiologists to provide clinical management of tinnitus. The method, termed audiologic tinnitus management (ATM), was developed to incorporate management strategies that can be implemented most efficiently by audiologists. Development of ATM has been drawn from the clinical and research experience of the authors and numerous audiologists. Certain elements of ATM are adapted from the methods of tinnitus masking and tinnitus retraining therapy. Procedures are described in the present article for performing the intake assessment, while the companion article (J. A. Henry, T. L. Zaugg, & M. A. Schechter, 2005) describes treatment methodology. Development of ATM has resulted in defined procedures to conduct a basic tinnitus assessment that includes written questionnaires, an intake interview, audiologic evaluation, and a psychoacoustic assessment of tinnitus perceptual characteristics. If patients report a sound tolerance problem (hyperacusis), loudness discomfort levels are measured at audiometric frequencies. There are special procedures for selecting hearing aids, ear-level noise generators, combination devices (noise generator and hearing aid combined), and personal listening devices (i.e., portable radios and tape, CD, and MP3 players). This article explains each of these assessment components in detail. Adoption of the ATM assessment protocol by audiologists can contribute to the establishment of uniform procedures for the clinical management of tinnitus patients.

Estimates of Loudness, Loudness Discomfort, and the Auditory Dynamic Range: Normative Estimates, Comparison of Procedures, and Test-Retest Reliability

The purpose of this series of experiments was to establish normative reference values for absolute and relative judgements of loudness discomfort and for the auditory dynamic range (DR), and to evaluate intersubject variability and intra-subject test-retest reliability for the respective measures of loudness discomfort. To establish the normal auditory DR, audiometric thresholds and loudness discomfort levels (LDLs) were measured from a group of 59 normal-hearing adults without sound tolerance problems. The resulting estimates of the LDL and DR were on the order of 100 dB HL and 95 dB, respectively. A subset (n = 18) of this larger group participated in further studies in which loudness growth functions and the upper limit of the auditory DR were measured by categorical scaling judgments. The findings revealed no significant differences between the test methods for absolute (LDL) and relative (categorical scaling) judgements of loudness discomfort, intersubject variability, or intrasubject test-retest reliability, and suggest that the simple LDL estimate of loudness discomfort is an efficient and valid clinical measure for characterizing the "threshold of discomfort."