Does Your Doctor Listen to Your Ears?

[Dr. Nagler]

Hi All -

In another thread I posted a story about a patient of mine:

The third patient is a female in her mid-30s who lived in the Midwest. She presented with a six-month history of increasingly loud ringing in her left ear. She had been to three ENTs, all of whom told her that she had tinnitus and had to learn to live with it. She became distracted, distraught, and depressed. She tried a number of different medications and treatment protocols all to no avail. In desperation she flew all the way to Atlanta to see me. (Talk about scraping the bottom of the barrel!) I took a history and reviewed all of her records. The next thing I did was examine her (which is sort of what doctors do!) I looked in her ears, and then I listened to her ears with a stethoscope. I also listened to her neck and all over her head with a stethoscope. Nothing particularly noteworthy in any of that. Finally I inserted a small electronic amplifier into both ear canals and listened again. It was at that point that I was able to detect a sound in her left ear similar to the sound she was describing. It was a venous hum, the sound of turbulent blood flow coursing through the low-pressure venous system (as opposed to a bruit, the sound of turbulent blood flow in the high-pressure arterial system). I turned my attention again to her neck and in a very quiet room was able to trace the origin of the sound to a point high up in her left jugular system. I asked one of my colleagues in vascular radiology to do a selective venous jugular study. He found a tight stenosis, which he gently dilated up over two sessions. And she was cured! Although she had been told by three different ENTs that she had tinnitus, as it turned out she did not have tinnitus at all. What she had was a somatosound emanating from her distal jugular venous system. (And the very last thing she needed was the TRT that she came to me for originally!)​

Almost everybody on this board has been to an ENT at one time or another because of tinnitus. I would like to know how many of those ENTs actually took the time to listen to your ears as part of your examination.

Thank you.

 

[Nucleo]

None. Only visual inspection.

 

[Ricky81]

None.. ENT only looked down my ears via some flashlight but I do have mri results and ent said it looks ok.

Dr. Nagler.. maybe I should come visit you in atlanta. In a quite room.. I hear a heartbeat sound in my left ear.. if I twist my head it goes away.

My T does not change with Head movement.

 

[Telis]

Been once, visual inspection only.

 

[marqualler]

@Dr. Nagler, I have visited a couple of different ENTs and neither have actually "listened" to my ears like that. Would be an interesting request to make and perhaps I will ask my ENT to do this when I make a new appointment in the near future. Going generally to get fitted with musicians' earplugs--I've found that the ones you buy are OK but to a limited degree because my ear canals are slightly different sizes and my ear canals seem to point "up" as opposed to vertical--very strange indeed.

Thanks for the interesting conversation starter!

 

[Beth]

No, I paid £125 (it had to be cash) for a 10 minute maximum visit with ENT, just a torch shone in ears and a quick hearing test, not even proper equipment. Session ended with me being told to get used to it as I'd probably have it for life.

 

[Dr. Nagler]

Dr. Nagler, I have visited a couple of different ENTs and neither have actually "listened" to my ears like that. Would be an interesting request to make and perhaps I will ask my ENT to do this when I make a new appointment in the near future.

I think it's really pitiful when the patient has to tell the doctor how to perform a proper examination.

 

[lapidus]

I didnt even know it was a thing.

 

[Dr. Nagler]

I located a wav file with the amplified recording from patient to whom I was referring at the start of this thread and will attach it to this post. I first recorded from her right ear canal (which was normal) and then from her left ear canal (with the venous hum).

 

[skoupidis]

I wish we had doctors like you in my country. I have been to about 20 doctors and all came to the conclusion that I have to live with this without listening to my ears. Nobody. There were also those that didn't even bother to look properly...

 

[tinnitussufferer]

i have not had mine listened to. People need to be made more aware of what it is they are experiencing. I have seen numerous people on here posting that they have tinnitus when in fact it turned out to be caused by blood vessels or something similar.

 

[Dr. Nagler]

Interesting survey results so far. And sad. Of the 26 people who have responded so far to my little survey here, not even one reports that an ENT listened to his or her ears.

You go the doc because you have ringing in your ears ... and the doc doesn't bother to check to see if it's your ears that are actually ringing!

 

[LadyDi]

Very interesting, @Dr. Nagler I have been to quite a few ENTs/otolaryngology experts since my tinnitus came along, including two well-regarded inner ear surgeons/specialists that I had to travel a ways to see. No one ever has put a stethoscope to my ears. I always assumed because I was told I have subjective tinnitus, no one else could hear it. Thank you for this post.

 

[Dr. Nagler]

I have been to quite a few ENTs/otolaryngology experts since my tinnitus came along, including two well-regarded inner ear surgeons/specialists that I had to travel a ways to see. No one ever has put a stethoscope to my ears. I always assumed because I was told I have subjective tinnitus, no one else could hear it.

That's backwards (although as a patient, there's no way you would know.) An ENT cannot rightfully tell you that you have "subjective tinnitus" unless he or she has first very carefully listened to your ears to rule out the possibility that you have "objective tinnitus."

Thank you for this post.

You are welcome.

 

[Carm]

The poll goes to show how crooked most doctors are.

What are they doing??

 

[soundmachine]

Nada...zip. Just an audiogram and a patronizing pat on the shoulders that I have to "live with it". Yea...medicine (and all of its deep understanding) to the rescue....NOT!

 

[Dr. Nagler]

The poll goes to show how crooked most doctors are.

Well, that's harsh!

Look, I know far more doctors than you will ever know. Many are ignorant about one thing or another. That's why they take Continuing Medical Education courses. But in my experience relatively few are actually "crooked."

 

[Carm]

Look, I know far more doctors than you will ever know. Many are ignorant about one thing or another. That's why they take Continuing Medical Education courses. But in my experience relatively few are actually "crooked."

Have you read posts by people? Most doctors dismiss tinnitus patients. They know tinnitus is impossible to treat so they don't even bother.

There is no prescription they can write so they give up before even trying anything...

It's sad!

 

[carlover]

They are of course not crooked but when they see you have come in for Tinnitus they want you out their office double quick.......I see from the RNID Forum a while back there are protocols half an inch thick they are supposed to put in practice in the UK,more chance of winning the lottery

 

[marqualler]

I have seen a lot of doctors in my lifetime and I wouldn't say that any of them are "crooked" either, but I think there is something to be said about being an informed and educated patient.

For instance I have been a longtime patient of an ophthalmologist who has treated my chronic inflammation in my eyes caused by Bleferitis, and I recently asked him about using Fish Oil supplements to help as a supplement to my dry eye condition. Much to my surprise, when I asked him about it, he actually cited some studies that showed that there is some link to fish oil supplements and aiding in dry eye relief. Although we agreed that I would stay on my Restasis eye drops, the fish oil supplements have also seemingly given me a slight increase in my vision clarity and dry eye. All because I did some research on my condition and asked him questions.

For the most part I think most doctors will check you and see you "in and out" because of the nature of their schedules. That is probably a debate to be taken up somewhere else, which seems to be more to do with the nature of the health care industry in general, a much bigger and more complex topic.

I have a lot of friends who are med students or residents and soon to be MDs, and not one of them is who I would consider "crooked". But I also do think having a mutual level of trust is extremely important, and doing a little homework before your appointment can help.

 

[skoupidis]

I located a wav file with the amplified recording from patient to whom I was referring at the start of this thread and will attach it to this post. I first recorded from her right ear canal (which was normal) and then from her left ear canal (with the venous hum).

Actually, this sound is quite different than mine: Mine is very high pitched (~15000Hz) and it is not synchronous to heartbeat as this recording of your patient is. So, this is what pulsatile T sounds like..
My sound however, does have certain water flaw sounds at times, like a brief running of liquid that ends quickly and while at it, T seems to be a lot lower. When the liquid flaw ends, T starts up again. And I also get brief loud spikes in every step I take wile walking. A zip zip zip sound.
I don't know if this qualifies as pulsitile tinnitus, somatic tinnitus, or T caused by microvascular compression, as my MRI AC shows I do have...

 

[Dr. Nagler]

Have you read posts by people? Most doctors dismiss tinnitus patients. They know tinnitus is impossible to treat so they don't even bother.

ENT is a surgical discipline. You have a non-surgical problem largely involving the auditory pathways within the brain ... and you go to an ear surgeon for help with it. No wonder you leave frustrated! Likely the doctor is as frustrated as you are!

Why not contact the doctor's office before making that appointment ... and ask whether the doctor has an interest in seeing, evaluating, and treating tinnitus patients. If the answer is no, you have saved both you and the doctor a lot of grief.

I think @marqualler had it exactly right earlier, when he said that as patients we should do a little homework.

 

[Dr. Nagler]

Actually, this sound is quite different than mine:

Everybody's tinnitus is unique.

So, this is what pulsatile T sounds like..

No. What I have recorded is not pulsatile tinnitus. What I have recorded is an example of one type of venous hum.

 

[Nucleo]

ENT is a surgical discipline. You have a non-surgical problem largely involving the auditory pathways within the brain ... and you go to an ear surgeon for help with it. No wonder you leave frustrated! Likely the doctor is as frustrated as you are!

Why not contact the doctor's office before making that appointment ... and ask whether the doctor has an interest in seeing, evaluating, and treating tinnitus patients. If the answer is no, you have saved both you and the doctor a lot of grief.

I think @marqualler had it exactly right earlier, when he said that as patients we have to do our homework.

Well GPs do refer us to ENTs...

 

[Dr. Nagler]

Well GPs do refer us to ENTs...

Then ask your GP to refer you to an ENT who he or she knows to be particularly interested in the evaluation and treatment of tinnitus sufferers.

 

[marqualler]

I think @marqualler had it exactly right earlier, when he said that as patients we should do a little homework.

FWIW--in a separate practice of medicine, the field of psychology, I have been "interviewing" potential therapists who may be able to help me by asking them if they have ever treated patients with tinnitus. Although I consider myself mostly habituated, I would still like to see a therapist who "understands" tinnitus more than the average person so that if it comes up in therapy, it is something he or she might have some background in. As it happens, the first person I contacted had not treated patients with tinnitus before, but she sent a message out to her psychology listserv and had a number of colleagues provide her with information about how it can be managed. Since she has other approaches that I like (including incorporating yoga and Eastern philosophies alongside CBT and Western philosophies) and she has shown herself to be adaptable to other patients' needs by learning about tinnitus, she may have a new long-term patient in me!

Just goes to show that I really do think the doctor-patient relationship is a 2-way street and in order to get the most out of it, one needs to make sure that the 2-way street is established.

 

[undecided]

Very interesting topic and survey.

Not one of the ENTs or neurotologists I have visited (and there were many) actually took the time to listen to my ears.
Visual inspection only.

Out of all of them, one is supposedly an expert in pulsatile tinnitus (Aristides Sismanis) and has publications on the subject. He didn't even bother.
I actually had to ASK him to listen... he looked around for a stethoscope (he had one buried somewhere in his office) and he 'listened'. I don't know what the hell he was listening though because he didn't really seem to know what to listen for and his office wasn't the quietest place to begin with...

He certainly did bother asking for his 100 euros visit fee though. He was quite thorough about that.

 

[Carm]

Just goes to show that I really do think the doctor-patient relationship is a 2-way street and in order to get the most out of it, one needs to make sure that the 2-way street is established.

Many doctors don't listen to patients' wishes or requests.

It's not unusual for a doctor to feel offended if you try to show them something they don't know about...

They are megalomaniacs...

 

[vasil]

Nope. I had and still have some neck troubles and pains, so its worth a try, if I manage to find a good enough doctor to do this.
The first ENT i visited, didnt manage to find that i had eustachian tube inflamation or whatever it is called. And he was the head of the ENT departament in the local hospital. The second one found it for 10 seconds, so its probably not that hard for a specialist.

 

[patwalsh]

Hi All -

In another thread I posted a story about a patient of mine:

The third patient is a female in her mid-30s who lived in the Midwest. She presented with a six-month history of increasingly loud ringing in her left ear. She had been to three ENTs, all of whom told her that she had tinnitus and had to learn to live with it. She became distracted, distraught, and depressed. She tried a number of different medications and treatment protocols all to no avail. In desperation she flew all the way to Atlanta to see me. (Talk about scraping the bottom of the barrel!) I took a history and reviewed all of her records. The next thing I did was examine her (which is sort of what doctors do!) I looked in her ears, and then I listened to her ears with a stethoscope. I also listened to her neck and all over her head with a stethoscope. Nothing particularly noteworthy in any of that. Finally I inserted a small electronic amplifier into both ear canals and listened again. It was at that point that I was able to detect a sound in her left ear similar to the sound she was describing. It was a venous hum, the sound of turbulent blood flow coursing through the low-pressure venous system (as opposed to a bruit, the sound of turbulent blood flow in the high-pressure arterial system). I turned my attention again to her neck and in a very quiet room was able to trace the origin of the sound to a point high up in her left jugular system. I asked one of my colleagues in vascular radiology to do a selective venous jugular study. He found a tight stenosis, which he gently dilated up over two sessions. And she was cured! Although she had been told by three different ENTs that she had tinnitus, as it turned out she did not have tinnitus at all. What she had was a somatosound emanating from her distal jugular venous system. (And the very last thing she needed was the TRT that she came to me for originally!)​

Almost everybody on this board has been to an ENT at one time or another because of tinnitus. I would like to know how many of those ENTs actually took the time to listen to your ears as part of your examination.

Thank you.

I'm due to go and see the ENT consultant on the 2nd of June . My T is in my left ear. Do you think I should mention this to him?