Hyperacusis, or sensitive hearing, describes a problem in the way the brain’s central auditory processing center perceives noise, often leading to pain and discomfort. People with hyperacusis have a hard time tolerating sounds that are typically not loud to others, such as noise from running water, traffic or riding in a car, walking on leaves, shuffling papers, running the dishwasher or other machines, and more. Although all sounds may be perceived as too loud, high frequency sounds may be particularly troublesome.

Many people experience sensitivity to sound, but true hyperacusis is rare, affecting approximately one in 50,000 individuals. It can affect people of all ages in one or both ears, and is often associated with tinnitus, or ringing in the ears. Nearly 36 million Americans suffer from tinnitus; an estimated one in every thousand also has hyperacusis. People can have tinnitus and hyperacusis at the same time.

It’s no surprise that hyperacusis can have a big impact on quality of life for people living with this condition. For those with a severe intolerance to sound, it’s difficult and sometimes impossible to function in ordinary environments with all of today’s ambient noise. That’s why hyperacusis can lead to withdrawal, social isolation, fear of normal sounds (called phonophobia), and depression.

What Are the Symptoms of Hyperacusis?

Symptoms of hyperacusis can include:

• Sensitivity to everyday sounds, often beginning in one ear then progressing to both ears
• Difficulty tolerating ordinary environments and situations
• Isolation
• Pain, or physical discomfort with sounds

What Causes Hyperacusis?

People are not born with hyperacusis, but some can develop an increased sensitivity to sound later in life. While a clear cause is commonly unidentifiable, possible causes include:

• Head injury
• Exposure to loud noise(s)
• Ear damage from toxins or medication
• Lyme disease
• Air bag deployment
• Viral infections involving the inner ear or facial nerve (Bell's palsy)
• Temporomandibular joint (TMJ) syndrome

There are a variety of neurologic conditions that may be associated with hyperacusis, including:

• Post-traumatic stress disorder (PTSD)
• Chronic fatigue syndrome
• Tay-Sach’s disease (a rare, inherited disorder that destroys nerve cells in the brain and spinal cord)
• Some forms of epilepsy
• Valium dependence
• Migraine headaches
• Depression
• Anxiety, mood swings, with increased heart rate, sweating

Hyperacusis can be seen in children with brain injuries (often with other sensory sensitivities), some autistic children, and some children with cerebral palsy.

If you think you or a loved one may have hyperacusis, you should seek an evaluation by an ENT (ear, nose, and throat) specialist, or otolaryngologist. The initial consultation is likely to include a full audiologic evaluation (with hearing test), medical history review, and a medical evaluation. Your doctor should also provide counseling about their findings, as well as possible treatment options.

What Are the Treatment Options?

There are no specific surgical or medical treatments to correct hyperacusis. However, sound therapy may be used to retrain the auditory processing center of the brain to accept everyday sounds. Your doctor may have you wear a noise-generating device on the affected ear, or both ears. The device produces a gentle, static-like sound (white noise) that is barely audible. Sound therapy can take up to 12 months to complete, and often improves sound tolerance.

Hearing tests for hyperacusis may indicate normal hearing sensitivity, but this does not mean that someone with hyperacusis can hear better than others. “Recruitment” is another type of sound sensitivity, a condition where soft sounds cannot be heard, and loud sounds are distorted or intolerable. For example, a person with Recruitment may have hearing loss below 50 decibels. At the same time, sound above 80 decibels may be intolerable, resulting in a narrow range of comfortable hearing.

What Questions Should I Ask My Doctor?

1. What are my treatment options for hyperacusis?
2. Can using a cotton ball or ear plug be effective in treating hyperacusis?
3. What tests should I have performed?
4. Do I need to get an MRI to rule out common causes of hyperacusis?
5. Are there any effective, available medications?
6. Can treating my anxiety help my condition?

Hoarseness (also called dysphonia) is an abnormal change in the quality of your voice, making it sound raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, fatigued, or shaky, often making it harder to talk. This usually happens when there is a problem in the vocal cords (or folds) of your voice box (larynx) that produce sound. Your vocal cords are separated when you breathe, but when you make sound, they come together and vibrate as air leaves your lungs. Anything that alters the vibration or closure of the vocal cords results in hoarseness.

You can read recently published recommendations on the evaluation of hoarseness in this “Plain Language Summary for Patients: Hoarseness (Dysphonia).” ^1,2

What Are the Symptoms of Hoarseness?

If you have any of these symptoms for hoarseness, you should see an ENT (ear, nose, and throat) specialist, or otolaryngologist, as soon as you can:

• Hoarseness that lasts more than four weeks, especially if you smoke
• Severe changes in voice lasting more than a few days
• Voice changes, such as raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, fatigued, or shaky voice
• Difficult breathing
• Pain when speaking
• Vocal professionals (singer, teacher, public speaker) who cannot do their job

What Causes Hoarseness?

Acute laryngitis—The most common cause of hoarseness is acute laryngitis. A cold, viral infection in your breathing tract, or voice strain can make your vocal cords swell. You can seriously damage your vocal cords if you talk while you have laryngitis.

Non-cancerous vocal cord lesions—Nodules, polyps, and cysts usually develop after prolonged trauma to the vocal cords from talking too much, too loudly, or with bad technique.

Pre-cancerous or cancerous lesions—Pre-cancer or cancerous lesions on the vocal cords can also cause hoarseness. If it lasts four weeks or more, or if you are at a higher risk of developing throat cancer (i.e., you smoke), you should have your voice box evaluated by an ENT specialist.

Neurological diseases or disorders—Hoarseness can occur with Parkinson’s disease or after a stroke. A rare disorder called spasmodic dysphonia can also create hoarseness or uneasy breathing. A paralyzed vocal cord, usually after surgery, viral illness, or injury, may also cause a weak, breathy voice.

Vocal cord atrophy—As we age, our vocal cords become thinner (decreased bulk) and floppy (decreased tone). This is not due to talking too much or too little, it’s just a fact of life. A raspy voice that changes from day to day with decreased power is common.

Vocal cord hemorrhage—You can lose your voice after yelling or other strenuous vocal activity if a blood vessel/blood blister breaks, filling the vocal cord with blood. This is a vocal emergency and should be treated with complete voice rest and examination by an ENT specialist.

Are There Related Factors or Conditions?

Reflux—Reflux is when acidic or non-acidic stomach contents move from the stomach up into your swallowing tube (the esophagus). Classic heartburn and indigestion are symptoms of gastroesophageal reflux (GERD), which is caused by acid. If the stomach acid travels up the esophagus and spills into the throat or voice box (called the pharynx/larynx), it is known as laryngopharyngeal reflux (LPR).

Smoking—Most importantly, smoking increases the risk of developing throat cancer. Smoking can also cause permanent changes to your vocal cords that can lead to swelling, which lowers the pitch of your voice and can block the airway in severe cases. Smokers who develop hoarseness should see an ENT specialist right away.

Other—Other related factors such as allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation can contribute to hoarseness.

What Are the Treatment Options?

An ENT specialist needs to obtain your medical history and look at the voice box (larynx) with special equipment before they can determine what’s causing your hoarseness and recommend treatment options. They may pass a very small, lighted flexible tube with a camera (called a fiberoptic scope) through your nose to view your vocal cords. Most patients tolerate these procedures well. Sometimes, it helps to measure voice irregularities, how the voice sounds, airflow, and other characteristics to help decide how to treat your hoarseness.

Appropriate treatment depends on the cause of your hoarseness.

Acute laryngitis—Supportive care and voice rest are usually the recommended courses of action for acute laryngitis. Antibiotics and steroids are often not needed, and your primary care physician can manage this. If your hoarseness lasts beyond typical cold symptoms, however, you should see an ENT specialist.

Non-cancerous vocal cord lesions—Treatment for non-cancerous vocal cord lesions includes learning proper voicing technique with voice therapy, adequate hydration, and sometimes surgery.

Pre-cancerous or cancerous lesions—Surgery is needed to diagnose and treat pre-cancerous or cancerous lesions. Sometimes, other cancer treatments are needed, such as radiation therapy or chemotherapy.

Neurological diseases or disorders—Determining why your vocal cords are paralyzed helps your doctor decide the best course of action. Sometimes, vocal cord augmentation is needed. For patients with Parkinson’s disease, special voice techniques can help, but evaluation is also very important. Mumbled speech (called dysarthria) after a stroke or from a degenerative neurologic disorder can be addressed with speech therapy or the use of assistive communicative devices. Other disorders can be treated with botulinum toxin, or Botox®, injections.

Vocal cord atrophy—Treatment for vocal cord atrophy includes voice therapy and, sometimes, vocal cord injection, but reassurance from your doctor that your hoarseness is not due to cancer may be all that you need for peace of mind.

Vocal cord hemorrhage—Treatment usually includes resting your voice and avoiding blood thinners. Surgery is rarely needed.

Are There Potential Dangers or Complications?

Depending on the cause of your hoarseness, long-term concerns range from permanent hoarseness, inability to effectively communicate with others, loss of work for vocal professionals, to major surgery or, in severe cases, death from cancer and cancer-related treatments. That’s why it’s very important to see an ENT specialist to be evaluated for persistent hoarseness.

General vocal wellness tips include:

• Avoid speaking in loud environments.
• Be aware of how much and how loudly you are talking.
• Use a microphone or other type of voice amplification if your job requires a lot of talking (like teaching or public speaking).
• Drink plenty of water, usually around 60 ounces daily. This helps thin out mucus.
• Avoid large amounts of caffeine, such as caffeinated coffee, tea, and soda.
• Stop smoking and avoid secondhand smoke. This is a good idea for all smoked products.

What Questions Should I Ask My Doctor?

1. What is the cause of my hoarseness?
2. Are any of my medications drying me out?
3. When should I see a specialist?

References

1. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018 Mar;158(1_suppl):S1-S42.

2. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update) Executive Summary. Otolaryngol Head Neck Surg. 2018 Mar;158(3):409-426.

Each year, more than 55,000 Americans will develop cancer of the head and neck (most of which is preventable). Nearly 13,000 will die from cancer of the head and neck.

Head and neck cancers are curable if caught early. Fortunately, most of them produce early symptoms. You should know the potential warning signs so you can alert your physician as soon as possible. Successful treatment of head and neck cancer depends on early detection. Knowing and recognizing its signs can save your life.

What Are the Symptoms of Head and Neck Cancer?

Symptoms of head and neck cancer can include:

• A lump in the neck
• Change in the voice
• A growth in the mouth
• Bringing up blood
• Swallowing problems
• Changes in the skin
• Persistent earache

A lump in the neck—Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump(s) in the neck can be the first sign of cancer of the mouth, throat, voice box (larynx), thyroid gland, salivary glands, or of certain lymphomas and blood cancers.

Change in the voice—Most cancers in the voice box cause a change in your voice. An ENT (ear, nose, and throat) specialist, or otolaryngologist, can examine your voice box easily and painlessly. If you are hoarse or notice voice changes for more than two weeks, see a physician.

A growth in the mouth—Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Cancer is often painless. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after two weeks should be evaluated by a physician.

Bringing up blood—This is often caused by something other than cancer. However, tumors in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see a physician.

Swallowing problems—Cancer of the throat or esophagus may make swallowing solid foods, and sometimes liquids, difficult. If you have trouble almost every time you try to swallow something, you should see a physician. A barium swallow X-ray or a direct examination of the swallowing tube with a scope, called an esophagoscopy, can help determine the cause.

Changes in the skin—The most common head and neck cancer is basal cell skin cancer. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, but can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that slowly grows, producing a central dimple and, eventually, an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes.

Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and are usually not dangerous if caught early and treated properly. If there is a sore on the lip, lower face, or ear that does not heal, see a physician. Malignant melanoma typically produces a blue-black or black discoloration of the skin. However, any mole or spot that changes size or color, or begins to bleed, should be seen as soon as possible by a dermatologist or other physician.

Persistent earache—Constant pain in or around the ear when you swallow can be a sign of infection or tumor in the throat. This is particularly serious if you also have difficulty swallowing, a hoarse voice, or a lump in the neck, and should be evaluated by an ENT specialist.

What Causes Head and Neck Cancer?

Head and neck cancers occur due to prolonged exposure to specific risk factors, such as tobacco use (e.g., cigarettes, cigars, chewing tobacco, or snuff), excessive alcohol abuse, or exposure to HPV. Cancer of the lip may be caused by prolonged exposure to sunlight, and is also a major cause of skin cancer.

What Are the Treatment Options?

Treatment options depend on several factors, such as the stage of disease, type and location of the tumor, and the patient’s overall health. Treatment options for cancer are best discussed in a multi-disciplinary setting involving the surgeon, radiation oncologist, oncologist, pathologist, radiologist, speech and swallowing experts, as well as the patient and caregivers. Treatment options may include:

Surgery—The goal of cancer surgery is to remove the cancerous tissue and a ring of normal tissue around it. The surgery may also include removing lymph nodes from the neck. Reconstructive plastic surgery may be needed if the cancer is widespread and requires extensive tissue removal. These may include surgery to the tongue, jawbone, facial skin, pharynx, or larynx. In cases such as this, tissue from other parts of the body, like the forearm or leg, can be transplanted to give patients the best possible cosmetic and functional outcomes.

Radiation therapy—High energy X-rays are used to stop the growth of and kill cancer cells. Depending on the type and stage of cancer, radiation can be used as a stand-alone treatment or given after surgery with or without chemotherapy. A commonly used form of radiation therapy is intensity-modulated radiation therapy (IMRT), which concentrates radiation beams to the tumor while minimizing damage to the surrounding healthy cells.

Systemic therapy—Chemotherapy is the most common type of systemic therapy and destroys cancer cells through the bloodstream using one drug or a combination of drugs. Chemotherapy is often used in combination with radiation therapy either concurrently as primary treatment or after surgery as supplemental treatment. These medications are given in fixed doses as determined by the medical oncologist who monitors the response to treatment and any potential adverse reactions.

Immunotherapy improves the body’s immune system and helps fight cancer cells. This rapidly growing area of treatment options has shown promise in patients with recurrent or widely spread (metastatic) cancers. Pembrolizumab (KEYTRUDA®) and nivolumab (OPDIVO®) are examples of FDA-approved immunotherapeutic drugs for head and neck cancers.

What Questions Should I Ask My Doctor?

1. What is the stage of my cancer?
2. I have heard about HPV causing cancer of the tongue and/or tonsil. Is my cancer related to the virus?
3. Will surgery cause disfiguration?
4. Will I need any additional treatment like radiotherapy or chemotherapy?
5. Will surgery affect my ability to speak or swallow?
6. What are the side effects of this treatment?
7. How long may I have to be in the hospital?
8. What are the chances that the cancer will come back?
9. Should I seek a second opinion?