Dear Dr. Dankle,
I am a 36 year old female classical pianist and piano tuner who was injured on a loading dock on 10-17-95. A 50 lb. metal dock plate was dropped without warning on a metal truck bed in an echoing concrete tunnel, with my right ear only 5 feet away. This sound was like a cannon blast. Although my audiogram had several dips right after the accident to 20 or 30 db, it has stabilized with the left ear reading as "perfect" up to 12 Khz, and the right ear dipping to 5 or 10 db in three different waves, ending at 10 db at 12 Khz. The audiologist said there is now no measurable hearing loss, and I have been able to tune.
The remaining problems are tinnitus and hyperacusis. The tinnitus began as severe. The only 'objective' measurement I have is that when I began wearing earplugs after the accident, I could not hear myself breathing. 3 weeks later, I was shocked to hear myself breathe once I put the earplugs in. I could hear a wide fluctuating band of pitches like bugs and crickets humming and chirping, and also "beats" like planets orbiting the sun at different speeds, seeming to go around in circles. A true nightmare for a piano tuner! Of course, this led to lack of sleep and depression. The tinnitus has changed over time to a hissing, steam escaping sound unless I wear earplugs, in which case I have the summer evening bugs sound.
The hyperacusis is not as bad as some have it. I am bothered by sudden sounds such as dishes clinking, dogs barking, hands clapping, metal on metal sounds, musical instruments :(, and loud laughter. Normal conversation is ok, and papers rattling are fine. I am bothered more when other people initiate the sound. If I am making it, I expect it, and it is not so bad.
The first ENT had me take 150 mg. of Papavarene for 2 months, the second has had me take 100 mg. of Niacin twice per day. for the last month.
I have never ever had any tinnitus until 10-17-95, not even for one minute. I still experience depression and difficulty adjusting, and a part of me hopes it will go away and I won't have to adjust. Sleep is unpredictable; some nights it is only 2 or 3 hours, other nights 6 hours.
Questions:
1. What is the percentage of acoustic trauma tinnitus patients
that recover completely?
2. How long does the improvement continue before tinnitus is
presumed to be relatively permanent?
3. How does acoustic trauma tinnitus differ in treatment or
recovery from other forms of tinnitus? Better, or worse?
4. Is it true that musicians have more sensitive ears that are
more easily damaged? And that their personalities are sensitive and
difficult? (My feelings won't be hurt if you answer yes.)
5. Any treatments that you would suggest I ask my ENT about
pursuing?
6. Do you recommend any particular hearing protection for playing
instruments or tuning? (My ENT said he is thinking about musicians ear
plugs that are molded to the individual ear, and a piano tuner told me
he uses Peltor ear muffs for tuning.)
7. I am seeing a psychologist. Any books on adjustment that you
think would be helpful in conjunction with psychological treatment?
8. I live near UCLA in Los Angeles. I went to their biomed
library yesterday. Any publications you think are helpful?
9. I am in good health, blood pressure 110 over 70, and
cholesterol 116. I never smoked, drank, or used any type of illegal
drug. (Not even a puff of marijuana! I never tried anything because I
was afraid I would like it and become addicted.) I assume all of this
helps, and I will keep eating right, taking a vitamin supplement, and
walking for exercise.
Thank you, and if this did not go to Dr. Dankle, would the recipient please forward this?
Answer ---------
Please refer to previous posts concerning tinnitus. In specific regard to the questions posed above, tinnitus following acoustic trauma is well-known. Tinnitus may occur acutely following short term or limited exposure to high level noise such as blasts, weapons discharge, etc. Tinnitus may also develop more insidiously with long term chronic noise exposure such as that associated with many years of employment in a loud factory.
In many cases such tinnitus will be associated with a discrete loss of hearing in the frequencies between 3000 and 6000 Hz. Generally lower frequency hearing is preserved. Short term exposure to high intensity noise may result in a phenomenon known as a temporary threshold shift whereby the thresholds for hearing are temporarily depressed but eventually recover with noise protection. Anecdotally, it has been my experience that the complaint of tinnitus is often times more severe in patients with short term exposure to high intensity noise such as you describe, as compared with factory workers exposed to chronic noise over many years. Also, the complaint of tinnitus in such short term exposures may be associated with minimal objective hearing loss. Unfortunately, there is little if anything in the literature that provides reference for prognosticating about the likelihood of recovery from tinnitus caused by acoustic trauma. Furthermore, the determination of permanence of tinnitus is likewise a difficult proposition and is often times an arbitrary one - 6 mos to a year.
I am not familiar with any physiologic reason why musicians' ears might be more susceptible to injury from acoustic trauma than others. However, similar to the individual who uses their voice professionally and is therefore much more sensitive to seemingly subtle changes in the voice, a musician is certainly more sensitive to and much more affected by acute hearing disorders than the average individual.
The treatment of tinnitus is difficult and there are few treatments that are consistently successful. The medications listed above have been used variably by many over the years, but the results of such treatment are inconsistent. Often times the best treatment is masking with broad band noise in otherwise quiet surroundings such as at night or bedtime. Often, the use of low dose Xanax can be quite helpful in reducing or eliminating tinnitus for reasons that are unknown. A common recommendation would be 0.25 mg at nighttime. As with any medication, the potential risks, and the use of this medication in the context of your particular health history must be thoroughly discussed with your physician.
Adverse consequences of perisistent tinnitus such as depression and weight loss are well-known and have been reported in the literature. Adjuvant therapies such as psychological intervention, biofeedback, stress reduction techniques, are all potentially beneficial approaches to comprehensive management of tinnitus.
Useful resources on the internet regarding tinnitus can be found - I would suggest the search engine at http://altavista.digital.com and enter the word tinnitus. You can also frequently find useful information on the Usenet newsgroup alt.support.tinnitus including a long "FAQ" document about tinnitus.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
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