by hearing loss related damage in the inner ear. The mechanism behind hyperacusis is not currently known, but it is suspected to be caused by damage to the inner ear and cochlea. It is theorized that type II afferent fibers become excited after damage to hair cells and synapses, triggering a release of ATP in response. This release of ATP results in pain, sound sensitivity, and cochlear inflammation. Diagnosis The basic diagnostic test is similar to a normal audiogram. The difference is that additionally to the hearing threshold at each test frequency also the lowest uncomfortable sound level is measured. This level is called loudness discomfort level (LDL), uncomfortable listening level (UCL), or uncomfortable loudness level (ULL). In patients with hyperacusis this level is considerably lower than in normal subjects, and usually across most parts of the auditory spectrum. Treatment Avoidance and Hearing Protection Setback prevention and reduction of pain symptoms are high priorities among those with hyperacusis and noxacusis, which is often managed through a combination of controlling the environment so as to avoid loud sounds, soundproofing, and wearing hearing protection, such as earplugs and/or safety earmuffs, such as the type used at firing ranges or industrial applications Diet Diet may play a role in symptom management in some cases of hyperacusis, with response to a migraine diet, low-histamine diet, or low sodium diet. Sound Therapy Sound therapy is sometimes recommended for those with hyperacusis, though its application among those with pain (noxacusis) should be used with caution. Tinnitus retraining therapy, a treatment originally used to treat tinnitus, uses broadband noise to treat hyperacusis. Pink noise can also be used to treat hyperacusis. By listening to broadband noise at soft levels for a disciplined period of time each day, some patients can rebuild (i.e., re-establish) their tolerances to sound. More research is needed on the efficacy of sound therapy techniques when hyperacusis is the primary complaint, rather than a secondary symptom, indicating that "no strong conclusions can be made" about its efficacy at this time. Cognitive Behavioral Therapy Another possible treatment is cognitive behavioral therapy (CBT), which may also be combined with sound therapy. However, randomized controlled trials with active control groups are still needed to establish the effectiveness of CBT for hyperacusis and the usefulness of CBT for noxacusis (pain hyperacusis) is not yet demonstrated in the scientific literature. Society and culture Notable cases Musician Jason DiEmilio, who