Concussions and traumatic brain injuries (TBIs) affect millions of Americans each year, with impacts extending far beyond the initial injury. While headaches and cognitive difficulties often receive focus, effects on sensory systems, particularly hearing and vision, remain critically overlooked yet essential to treat.

To better understand the connection between concussion and audiology, we spoke with Dr. Melissa Kokx-Ryan, an audiologist at the National Intrepid Center of Excellence (NICoE), the Defense Health Agency’s center for TBI clinical care, research, and education at Walter Reed National Military Medical Center.

The Relationship Between TBIs and Sensory Impairments

When evaluating a concussion or TBI patient, Dr. Kokx-Ryan watches for several key symptoms. “Ear pain, pressure or fullness in your ears, ringing in your ears, oversensitivity to sounds, and of course, hearing loss are some of the most common ones,” she says. “Sometimes, we’ll have patients tell us that it feels like they’re listening through a blown-out speaker.”

The impact of a TBI can damage not only physical ear structures but also disrupt the neural pathways that process sensory information. “Beyond damage to auditory structures causing hearing loss or tinnitus, concussion can also affect how the brain processes auditory information,” Dr. Kokx-Ryan explains. “The brain’s ability to filter relevant sounds from background noise—what we call ‘auditory processing’—can be significantly affected following head trauma.” Because a concussion often results in global diffuse axonal injury from synaptic shearing—damage to the brain’s nerve fibers caused by forceful movement or impact—it can cause harm beyond the auditory structures that isn’t always visible on an MRI.

Dr. Kokx-Ryan notes that because balance and hearing are interconnected, audiologists also evaluate dizziness symptoms, which can include vertigo. “Your temporal bone houses your inner ear structures—and it’s connected to your peripheral vestibular system, which provides balance information to your body,” she says.

Evaluating Sensory Impairments After Concussion

Dr. Kokx-Ryan recommends assessment as soon as the patient is medically stable. “Ideally, we want to establish a baseline within the first week following injury,” she says. “But there are often more pressing concerns to rule out—temporal bone fractures, ENT (ear, nose, and throat) referrals. Audiology tends not to be the biggest alligator closest to the canoe, so to speak.”

Certain symptoms warrant immediate attention: “Anything with sudden onset hearing loss, or anything painful in your ear, you’ll want to be evaluated by an ENT specialist immediately,” Dr. Kokx-Ryan says.

Many sensory symptoms become apparent when patients return to normal environments and activities. “If a patient continues to experience symptoms after six months, we recognize that as a chronic condition, which requires long-term management,” she says.

Treating Concussions and TBIs Holistically

NICoE’s integrated approach to TBI management distinguishes it from other treatment centers. “When a patient experiences symptoms after a concussion or TBI, they’re often sent separately to speech pathology, neuropsychology, audiology, imaging, and physical therapy,” Dr. Kokx-Ryan explains. “Depending on the context, there might not be another option—but the hard part is that these disciplines will often function in silos due to the nature of the clinics.”

At NICoE, traumatic brain injuries receive holistic treatment from an interdisciplinary team, recognizing how interconnected symptoms can be. What might present as a memory problem could stem from undiagnosed hearing difficulties. “If you can’t hear information clearly, you certainly can’t recall it later,” Dr. Kokx-Ryan points out.

“All of a person exists in a particular environment,” she continues. “How well they slept, headaches, anxiety, PTSD—hearing can be a component of all this. My job is to isolate audition to determine if it’s contributing to difficulties, or if we can rule it out so other specialists can rehabilitate in the right areas.”

Effective Rehabilitation Strategies

Dr. Kokx-Ryan tailors rehabilitation to specific deficits. For tinnitus management, she recommends ambient sound therapy: “Put yourself in an environment with sound you control, helping the tinnitus fade into the background like refrigerator noise.” Smartphone apps and Bluetooth devices can provide low-cost, immediate relief. For persistent cases, NICoE combines these approaches with cognitive behavioral therapy.

For vestibular issues where there are balance concerns, audiologists diagnose the condition before partnering with vestibular physical therapists for specialized exercises. Hearing difficulties receive a combination of traditional hearing aids, assistive devices, and communication strategies.

When patients show “normal” hearing on standard tests but struggle in complex environments, Dr. Kokx-Ryan often recommends “low-gain” hearing aids. “We’re not necessarily turning up the volume because they don’t have hearing loss. We’re ‘cleaning up’ the sound and putting them more in control.” This emerging approach shows promising results among TBI patients with auditory processing challenges.

Self-Advocacy for TBI Patients

Dr. Kokx-Ryan emphasizes that patients should persist when something feels wrong, even when initial tests appear normal. “I cannot tell you the number of patients who say, ‘I feel like I don’t hear well in background noise, but they test my hearing and keep telling me I have normal hearing.’” Many struggle for years before receiving an appropriate diagnosis.

If you’ve experienced a TBI and notice difficulty hearing in noisy environments, trouble following conversations, or fatigue after social interactions, Dr. Kokx-Ryan suggests specifically requesting evaluation for auditory processing disorder. A standard hearing test showing normal results doesn’t necessarily mean normal hearing function.

“Don’t be afraid to continue bringing up symptoms if they’re not improving or changing,” Dr. Kokx-Ryan advises. “There are treatments we can try. You don’t have to grin and bear it.”

Guidance for Healthcare Professionals

Dr. Kokx-Ryan notes that hearing and balance issues can exacerbate other symptoms. For example, when patients experience difficulty hearing or struggle with dizziness, it often combines with PTSD, depression, and anxiety, leading to social withdrawal or reduced self-advocacy.

She recommends that healthcare providers include audiology screening in initial and follow-up TBI evaluations, avoid dismissing patients who pass standard tests but report difficulties in complex environments, offer immediate relief strategies for tinnitus, make appropriate referrals for comprehensive auditory processing evaluations, and understand the connection between hearing difficulties and other symptoms like fatigue and apparent memory problems.

“I understand that when first assessing someone with a concussion or TBI, audiology isn’t the priority,” she acknowledges, “but as you work through that treatment plan, bring us in.”

By addressing sensory challenges through comprehensive evaluation and appropriate interventions, patients can experience significant improvements in their quality of life, demonstrating why an interdisciplinary, holistic approach remains essential for effective TBI care.