The Hearing Well Practice

Understanding Hearing Impairments

Hearing impairments can take many forms. Some make sounds quieter, others make them unclear, distorted, or even painfully loud. In certain cases, people notice unusual effects like hearing an echo of their own voice, perceiving sounds in double, or hearing the world with a short delay. The ear is a complex system where sound must travel through the ear canal, eardrum, middle-ear bones, and inner-ear hair cells before reaching the brain. Any disruption along this pathway can change how hearing feels. This section explains the main types of hearing loss and the sound distortions or tolerance problems that some people experience, with clear examples to help you understand what might be happening.

Conductive Hearing Loss

Conductive hearing loss happens when sound cannot pass properly through the external or middle ear. This means the inner ear is healthy, but sound is blocked before it reaches it. Common causes include wax build-up, ear infections, fluid behind the eardrum, or damage to the tiny bones of hearing. Conditions like otosclerosis, where the stapes bone becomes stiff, or growths such as cholesteatoma can also create conductive loss. People usually describe it as sounds being quieter, not distorted, as if they are wearing earplugs. In many cases, medical treatment or surgery can correct the problem. If not, hearing aids can often restore clarity and volume. Conductive hearing loss is one of the most treatable forms of hearing impairment, and early diagnosis makes a big difference.

Sensorineural Hearing Loss

Sensorineural hearing loss occurs when the inner ear (cochlea) or the auditory nerve is damaged. This is the most common type of permanent hearing loss. Causes include ageing, long-term noise exposure, certain medications, viral infections, or genetic conditions. Sometimes the loss can fluctuate, as in Ménière’s disease, where changes in inner-ear fluid make hearing unpredictable. With sensorineural hearing loss, sounds are not only quieter but also unclear, especially speech in noisy places. Patients often say they can hear voices but cannot make out the words. While this type of loss usually cannot be cured medically, hearing aids or cochlear implants provide effective support. Rehabilitation focuses on improving clarity, communication strategies, and preserving the hearing that remains.

Mixed Hearing Loss

Mixed hearing loss is when someone has both conductive and sensorineural loss at the same time. For example, a person may have age-related cochlear damage along with middle-ear fluid or otosclerosis. This combination makes sounds both quieter and less clear. Treatment usually begins with addressing the conductive part, such as removing wax or treating an infection. Once that is managed, the permanent sensorineural part can be supported with hearing aids or implants. Mixed hearing loss can be more complex to manage, but recognising the two components helps ensure the right treatment plan. Patients often benefit from a combination of medical care and hearing technology.

Auditory Processing Disorder (APD)

In auditory processing disorder, the ears themselves may work normally, but the brain has difficulty interpreting the sounds it receives. People with APD often say they can hear but cannot understand, particularly when there is background noise or fast speech. It can affect children, making it harder for them to learn and follow instructions, but it also occurs in adults after head injuries, strokes, or with age. Common signs include trouble following multi-step instructions, mishearing similar words, or finding group conversations overwhelming. Management usually involves listening strategies, environmental adjustments, and sometimes assistive listening devices. With support, people with APD can develop coping strategies that make everyday communication much easier.

Diplacusis (Double Hearing)

Diplacusis means hearing the same sound at two different pitches. This happens when one ear processes sound differently from the other, often because of uneven inner-ear damage. Musicians notice it most, as instruments sound out of tune with themselves. Speech may also seem “off balance,” with one ear hearing higher than the other. Diplacusis often follows sudden hearing loss, noise damage, or inner-ear conditions such as Ménière’s disease. It can be very distressing because it makes music unpleasant and conversations confusing. Hearing aids that rebalance the ears, combined with sound therapy, can sometimes reduce the effect. In some cases, the brain adapts over time, but in others, the sensation remains long term.

Polyacusis (Multiple Hearing)

Polyacusis is the perception of a single sound as multiple overlapping copies, almost like an echo chamber inside the ear. Someone with polyacusis may hear a voice or note from an instrument repeated several times, giving speech and music a blurred or doubled quality. This phenomenon is thought to occur when damaged areas of the cochlea or auditory nerve send irregular signals to the brain. It can also appear in neurological conditions that affect timing of sound processing. Living with polyacusis can be frustrating, as it makes listening effortful and tiring. Management may involve amplification with advanced hearing aids, which help the brain focus on clearer signals, along with auditory training to reduce the sense of duplication.

Distorted Hearing

Distorted hearing happens when sounds are not just softer, but actually changed in quality. Patients may describe voices as robotic, metallic, muffled, or crackling. Unlike conductive hearing loss, where sound is simply quieter, distortion arises from damaged inner-ear hair cells or faulty auditory nerve signals. For example, if the hair cells that carry the fine details of speech are damaged, the brain receives scrambled information. This is why people often say, “I can hear you, but I can’t understand you.” Distorted hearing is common in moderate to severe sensorineural hearing loss. Hearing aids can help by boosting clarity and providing cleaner signals, but they cannot always remove distortion fully. Counselling and listening strategies play an important role in adapting.

Hyperacusis (Sound Sensitivity)

Hyperacusis is when everyday sounds feel uncomfortably loud or even painful, despite being safe for hearing. Running water, clinking dishes, or traffic noise may cause sharp discomfort. This oversensitivity happens when the brain’s loudness control system becomes too reactive. It may present as a standalone condition, arise following noise injury, head trauma, or migraine, or occur in conjunction with tinnitus. People with hyperacusis sometimes avoid social situations or noisy environments, which can affect mental well-being. Treatment usually involves sound therapy and counselling, which help the brain re-adjust its perception of loudness. With therapy, many people experience relief over time as they gradually reintroduce everyday sounds and rebuild their tolerance.

Hearing Echo (Autophony and Echoic Hearing)

Some people experience autophony, where their own voice sounds booming and echoey inside their head, or echoic hearing, where external sounds repeat unnaturally. These problems can result from structural ear issues such as superior semicircular canal dehiscence, a rare condition where a thin area of bone in the inner ear creates a “third window.” Middle-ear conditions, such as eardrum thinning or Eustachian tube dysfunction, can also produce similar effects. The sensation is very disorientating, as it makes normal conversation sound hollow or resonant, and even breathing can feel unusually loud. Diagnosis often requires specialist tests, and treatment depends on the underlying cause. For some, surgical repair is possible, while others benefit from tailored sound management strategies.

Delayed Hearing (Auditory Lag)

Delayed hearing is a rare condition where sounds are perceived slightly later than they actually occur, as if the world is half a beat behind. Patients describe watching someone’s lips move and hearing their words with a noticeable lag. This can happen with auditory neuropathy, where the inner ear detects sound but signals travel inconsistently to the brain. Neurological conditions that affect timing in the auditory system may also cause it. Even a small delay makes conversations confusing and exhausting, as speech feels out of sync. Management usually focuses on treating the underlying condition if possible, and using communication strategies to reduce stress. Although rare, delayed hearing highlights how precise timing in the auditory system is essential for effortless communication.