with hyperacusis. normal hearing threshold is generally defined as 0–20 decibels (db). normal loudness discomfort levels are 85–90+ db, with some authorities citing 100 db. a dynamic range of 55 db or less is indicative of hyperacusis. severity tinnitus is often rated on a scale from "slight" to "severe" according to the effects it has, such as interference with sleep, quiet activities, and normal daily activities. assessment of psychological processes related to tinnitus involves measurement of tinnitus severity and distress, as measured subjectively by validated self-report tinnitus questionnaires. such questionnaires measure the degree of psychological distress and handicap associated with tinnitus, including effects on hearing, lifestyle, health, and emotional functioning. a broader assessment of general functioning, such as levels of anxiety, depression, stress, life stressors, and sleep difficulties, is also important in the assessment of tinnitus due to higher risk of negative well-being across these areas, which may be affected by or exacerbate the tinnitus symptoms. current assessment measures aim to identify levels of distress and interference, coping responses, and perceptions of tinnitus to inform treatment and monitor progress. however, wide variability, inconsistencies, and lack of consensus regarding assessment methodology are evidenced in the literature, limiting comparison of treatment effectiveness. developed to guide diagnosis or classify severity, most tinnitus questionnaires have been shown to be treatment-sensitive outcome measures. pulsatile tinnitus if examination reveals a bruit (sound due to turbulent blood flow), imaging studies such as transcranial doppler (tcd) or magnetic resonance angiography (mra) should be performed. differential diagnosis other potential sources of the sounds normally associated with tinnitus should be ruled out. for instance, two recognized sources of high-pitched sounds might be electromagnetic fields common in modern wiring and various sound signal transmissions. a common and often misdiagnosed condition that mimics tinnitus is radio frequency (rf) hearing, in which subjects hear objectively audible high-pitched transmission frequencies that sound similar to tinnitus. prevention safety sign from the uk government regulations requiring ear protection prolonged exposure to loud sound or noise levels can lead to tinnitus. custom made ear plugs or other measures can help with prevention. employers may use hearing loss prevention programs to help educate and prevent dangerous levels of exposure to noise. government organizations set regulations to ensure employees, if following the protocol, should have minimal risk to permanent damage to their hearing. certain groups are advised to wear ear plugs to avoid the risk of tinnitus, such as that caused by overexposure to loud noises like wind noise for motorcycle riders. this includes military personnel, musicians, djs, agricultural workers, and construction workers as people in those occupations are at a greater risk compared to the general population. several medicines have ototoxic effects, which can have a cumulative effect that increases the damage done by noise. if ototoxic medications must be administered, close attention by the physician to prescription details, such as dose and dosage interval, can reduce the damage done. management if a specific underlying cause is determined, treating it may lead to improvements. otherwise, the primary treatment for tinnitus is talk therapy, sound therapy, or hearing aids. there are no effective drugs that treat tinnitus. psychological the best-supported treatment for tinnitus is cognitive behavioral therapy (cbt). it decreases the stress those with tinnitus feel. this appears to be independent of any effect on depression or anxiety. acceptance and commitment therapy (act) also shows promise in the treatment of tinnitus. relaxation techniques may also help. a clinical protocol called progressive tinnitus management has been developed by the united states department of veterans affairs. sound-based interventions the application of sound therapy by either hearing aids or tinnitus maskers may help the brain ignore the specific tinnitus frequency. although these methods are poorly supported by evidence, there are no negative effects. there are several approaches for tinnitus sound therapy. the first is sound modification to compensate for the individual's hearing loss. the second is a signal spectrum notching to eliminate energy close to the tinnitus frequency. there is some tentative evidence supporting tinnitus retraining therapy, which aims to reduce tinnitus-related neuronal activity. an alternative tinnitus treatment uses mobile applications that include various methods including masking, sound therapy, and relaxation exercises. such applications can work as a separate device or as a hearing aid control system. neuromonics is another sound-based intervention. its protocol follows the principle of systematic desensitization and involves a structured rehabilitation program lasting 12 months. neuromonics therapy employs customized sound signals delivered through a device worn by the patient, which aims to target the specific frequency range associated with their tinnitus perception. medications as of 2018 there were no medications effective for idiopathic tinnitus. there is not enough evidence to determine if antidepressants or acamprosate are useful. there is no high-quality evidence to support the use of benzodiazepines for tinnitus. usefulness of melatonin, as of 2015, is unclear. it is unclear if anticonvulsants are useful for treating tinnitus. steroid injections into the middle ear also do not seem to be effective. there is no evidence to suggest that the use of betahistine to treat tinnitus is effective. botulinum toxin injection has succeeded in some of the rare cases of objective tinnitus from a palatal tremor. caroverine is used in a few countries to treat tinnitus. the evidence for its usefulness is very weak. neuromodulation in 2020, information about clinical trials indicated that bimodal neuromodulation may reduce the symptoms of tinnitus. it is a noninvasive technique that involves applying an electrical stimulus to the tongue while also administering sounds. equipment associated with the treatments is available through physicians. studies with it and similar devices continue in several research centers. some evidence supports neuromodulation techniques such as transcranial magnetic stimulation, transcranial direct current stimulation, and neurofeedback. alternative medicine ginkgo biloba does not appear to be effective. the american academy of otolaryngology recommends against taking melatonin or zinc supplements to relieve symptoms of tinnitus, and reported that evidence for the efficacy of many dietary supplements (such as lipoflavonoids, garlic, traditional chinese/korean herbal medicine, honeybee larvae, and various other vitamins and minerals, as well as homeopathic preparations) did not exist. a 2016 cochrane review also concluded that evidence was not sufficient to support taking zinc supplements to reduce symptoms associated with tinnitus. prognosis while there is no cure, most people with tinnitus get used to it over time; for a minority, it remains a significant problem. epidemiology adults tinnitus affects 10–15% of people. about a third of north americans over 55 experience it. it affects one third of adults at some time in their lives, whereas 10–15% are disturbed enough to seek medical evaluation. 70 million people in europe are estimated to have tinnitus. children tinnitus is commonly thought of as a symptom of adulthood, and is often overlooked in children. children with hearing loss have a high incidence of pediatric tinnitus, even though they do not express the condition or its effect on their lives. children do not generally report tinnitus spontaneously and their complaints may not be taken seriously. among those who do complain, there is an increased likelihood of associated otological or neurological pathology such as migraine, juvenile meniere's disease, or chronic suppurative otitis media. its reported prevalence varies from 12–36% in children with normal hearing thresholds, and up to 66% in children with a hearing loss. approximately 3–10% of children have been reported to be troubled by tinnitus.