Dear Dr. Dandle:
I want to thank you for your po stings, they have answered many questions I have been wondering about for years. The way you have answered people's questions and concerns is a great service you provide. I want to give you information of my tinnitus in hopes you may give some insight.
I went to a doctor who me I had tinnitus that was probably due to nerve damage. I have had tympanometry test, brainstemevoked audiometry, electrocochleography, verstibular function test and vestibular posturography all showing normal. I have been treated with Xanax, Buspar, Nortriptylin, Ginkgo and Meclizine. From the above medications, Xanax and Meclizine are the most effective, for two reasons, it reduces the tinnitus and helps in falling to sleep. Meclizine seems to change the tone of the tinnitus 16 hours after taking it from 500fhz to 8000fhz, so I am afraid of taking too much of it.
I obtained my records from the 1970's to present. In reviewing the hearing tests. It looks from the 1996 tests the hearing loss in the high frequency range is not that much greater that the 1974 tests. In the right ear, the one that has tinnitus, I have on average a 17db hearing loss between air and bone conduction in 250 through the 2000 fhz range and on average a 30 to 35db loss in the high frequency. Air conduction thresholds are normal in the speech range, but in the high frequency range 300 to 8000 fhz the thresholds are at 75 to 80 db. Bone conduction in the same measurable ranges are 45db thresholds.
In 1974 I and surgery on my right ear to remove a Chlesteatoma. I did not experience tinnitus before 1976. In 1976, I had surgery on my right ear to remove another Chlesteatoma. The incus was removed and the malleus was fused to the staples. After that surgery, when I lied down, my right ear would start to ring, when I got up it would stop. This happened anytime and every time I would do this.
In the summer of 1990 I walked by a loud speaker, I noticed the tinnitus both day and night regardless of head position. Two years later, a commercial fire alarm went off over my head in a doppler effect for about two seconds, at that time my tinnitus got worse. In the 1976 surgery report it says my stapes is loose. Could a loud speaker and/or fire alarm, damage the hearing mechanism to produce a ring or could I start hearing otoacoustic emissions when previously I could not as a result of these loud noises? Is it possible the ringing is due to conductive damage or some other factor as opposed to nerve damage?
Now my tinnitus as taken on a different characteristic. At times when my ear has been ringing very little of not at all, I have felt a small sensation of something moving or slipping inside the ear and the ear would start to ring. Do you know why this would happen?
I have tried autoinflation and I feel air in the left ear, but not in the right. I do not tried to hard because I am afraid of damaging the ears. When my right ear has popped on its own, as it has in the passed the tinnitus was reduced.
If you would address the following questions, it would be appreciated:
1. Do you know what causes the slipping sensation in my right and sometime left ear and the ear starts to ring?
2. Is there a test to determine if tinnitus is due to nerve damage, conductive hearing loss or eustachian tube dysfunction?
3. If tinnitus is due to conductive hearing loss due to my surgery or eustachian tube dysfunction, will it cause hearing nerve damage?
4. If a prosthesis was used to replaced the incus that was removed would it correct the conductive hearing loss and reduce the tinnitus. If so, what are the risks and could it make the tinnitus worse?
5. Why would lying down or standing up influence tinnitus?
6. When you autoinflat, do you want to do it hard enough to cause both ears to actually pop and is there a chance of damage or making tinnitus worse by doing this?
7. Is it possible that loud sounds can cause conductive damage as opposed to nerve damage?
8. Should I stop taking Meclizine?
9. In Tinnitus FAQ, it talks about sound therapy, do you know anyone who has tried this therapy and it reduced their tinnitus?
10. What are the disadvantages to the right ear if nothing is done?
I get different answers from ENT doctors when I explain my situation to them. One has said just live with it, one wants to put a tube in ear, three have told me to get a hearing aid, one wants to lift up to lift up the eardrum and look inside my ear to see if he can see anything loose or something wrong. It is confusing and I do not know who to believe or what to do. Any feedback would be most helpful.
Thank you,
Reply: -----------------------------
Before answering your numbered questions I would comment that one does not "hear" otoacoustic emissions. Research has not been able to link otoacoustic emissions with the subjective complaint of tinnitus. As best as I can determine from your post, it sounds as though you have a "mixed" hearing loss in your right ear and a history of 2 operations on your right ear for cholesteatoma. Susequent to your surgeries, you note a history of 2 episodes of significant noise exposures. Finally, you have noted subjective changes in the character of the tinnitus that may be affected by variation in middle ear pressure.
In answer to your questions:
1) This most likely represents a change in middle ear pressure caused
by swallowing, yawning, or valsalva activities or is related to
variation in ambient air pressures. These factors may result in various
tensions on the ear drum which you may be feeling and could result in
changes in subjective tinnitus.
2) There is no test that will definitively determine the cause of tinnitus.
3) Tinnitus does not make hearing objectively worse - ie it does not cause damage to the hearing organ.
4) The use of a prosthesis to reconstruct the ossicular chain in your right ear may have given better hearing results - it depends on many, many other factors such as the condition of your ear drum, the status of the mastoid, eustachian tube function, etc. It is also possible that if better hearing results could have been obtained, that it might have resulted in less tinnitus - this is purely speculative.
5) This may affect middle ear pressures.
6) Autoinflation should not be done forcefully. It should be done in a gradual sustained fashion until the both ears "pop". If the opening pressures differ greatly between the 2 ears - it may not be possible to "pop" both ears comfortably. The main precaution about autoinflation is to stop at once if any vertigo is experienced.
7) Hazardous noise exposure tends to cause damage to the outer aspect of the cochlea where the nerve endings for high frequency hearing are located. Thus the most consistent finding with hazardous noise exposure is high frequency nerve hearing loss. Pre-existent significant conductive hearing loss may tend to have a protective affect in noise exposure by limiting the transfer of sound energy into the inner ear. Noise exposure is unlikely to cause conductive hearing loss unless it were in the form of an explosion or severe enough to cause physical trauma to the ear drum.
8) This would be best answered by your physician
9) I am not familiar with this therapy - unless you are referring to masking strategies such as tinnitus maskers. Tinnitus maskers have variable success.
10) I suppose the main "disadvantage" would be the persistence of tinnitus and hearing loss. The addition of age related hearing loss may result in greater impact on daily communication and symptoms. This would only be considered a "disadvantage" (as opposed to a simple but unfortunate reality) if one could predict a high probability that some type of medical or surgical intervention could change the situation for the better - I am not sure, based on what you have posted that that is likely.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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