Hidden hearing loss is described as auditory neuropathy believed to contribute to speech discrimination and intelligibility deficits in people with normal audiograms. •The individual complains of difficulties in understanding speech in the presence of background noise, but has normal hearing thresholds on pure tone audiometry (PTA).

Noise exposure causes damage to both the presynaptic ribbons and postsynaptic nerve terminals of the ribbon synapses. The damaged synapses exhibit various degrees of swelling of the terminals, resulting in disruption of the synaptic connections between IHCs and SGNs.The mechanism for the damage to the postsynaptic terminal is glutamate-mediated excitotoxicity. However, it is unclear how the presynaptic ribbons are damaged. Mechanism of ribbon loss is the loss of cell-cell contact that is required for the maintenance of the pre- and postsynaptic complexes. Ribbon loss results from a breakdown of ribbon building units.

Evaluation of these patients includes pure-tone audiometry, immittance testing, electrocochleography, ABR, and speech-in-noise tests.

The prevalence of synaptopathy increases with age. Children often listen to music or play video games at high volumes through earphones and attend noisy school dances, concerts, sporting events, etc. , making them potentially vulnerable to noise-induced synaptopathy,  Hidden hearing Loss as well.