New to Pulsatile Tinnitus — It Seems to Be Highly Correlated to Blood Pressure

[WIllyC]

Hi all -

In the last few weeks I developed PT (left ear). @tiniturtle, I have read your thread on getting a proper diagnosis and I will follow your advice. I am in Canada and so access to specialists is gated by GPs but your post is valuable and has helped arm me for my appointment.

I'm writing this post primarily to share my specifics and see if anyone has a similar situation. I will do my best to come back and update on my status, so if I receive treatment I'll come back and update the community.

I'm in my mid 40s and have had 'regular' tinnitus for a long time but it doesn't bother me that much. In my case my PT seems to be highly correlated to blood pressure. I have had blood pressure problems in the past and so I have a BP meter at home. My BP is fairly well controlled these days (no medication)- not perfect but not considered hypertension (135/90 ish). Of course during the day one's BP changes quite a bit. When I wake up it is lower, and I can't hear the PT at all (also during the night it is rarely heard). Once I get up to my normal operating BP I can start to hear what is like the sound of water through a tap in the distance. Over the day it tends to build and eventually will sound like one of those sprinklers they have on golf courses that pulse (and the pulse matches my HR). If I exercise it actually seems to go away temporarily, which doesn't match the rest of my hypothesis here but that's the facts. I can also make it go away if I rest in a quiet room for a while (presumably reducing my BP).

Also strangely it seems to scale with sound a bit - in that if I am watching TV it will seam louder than when I'm in a quiet room, but still very much tied to my HR. This, along with it reducing during exercise, seems strange. It is possible that my BP is higher for some reason while watching TV. Not sure. I don't like to measure my BP constantly as it isn't good for my BP!

I have sinus issues but use Flonase to help and in general that isn't a big problem these days.

I have tried a variety of pushing various parts of my head and that doesn't seem to make any difference. If I turn my head to the right quite a bit it seems to subside, but otherwise movement and position don't seem to make much difference.

Anyway, as I have a clear course of action before me for now, thanks in part to @tiniturtle, I am writing this partially just for catharsis, but also in case my specific symptoms (which don't seem to match the rest of the group well) are indicative of any particular cause that I should focus more on.

Thanks.

Addendum:

I should also mention that I had an Achilles rupture about 10 weeks ago and for much of that my leg was immobilized below the knee. I mention this only because I've seen some information around leg immobilization causing some of the problems related to PT but I'm not sure what the details of the relationship is.

Added here only for additional information.

 

[WIllyC]

Well, got back from the initial visit with a GP and he thought talk of an MRA and a neurointerventionalist was crazy talk. Was not open to vascular source. Sent to ENT. We will see how that goes and if I can make progress from there.

 

[WIllyC]

@Greg Sacramento Hi Greg - thanks for the message in the conversation you started but for the life of me I haven't been able to find any reply button or any means to add to the conversation.

Is there a limitation on new accounts that might prevent me from participating in a two way conversation?

 

[tiniturtle]

Well, got back from the initial visit with a GP and he thought talk of an MRA and a neurointerventionalist was crazy talk. Was not open to vascular source. Sent to ENT. We will see how that goes and if I can make progress from there.

Maybe they can refer you out if they don't find anything.

 

[WIllyC]

Hopefully. It will likely be quite a while before I am able to see the specialist just due to how it works here. If you have an immediately obvious problem our health system is pretty good, but for this kind of stuff it can be slow.

I'll update after I get my appointment but I expect that to take a month minimum.

I do have a bit of an update though - at some point (separately) each of my ears kind of had a sensation of release and then the sound that was like running water was gone and replaced with just the typical sound of your heart beating in your head (that I assume everyone experiences after a cardio workout for example). The problem is it is still audible even this morning when my BP was reading 128/86. Also it no longer present more on one side than the other.

So an improvement from a quality of life perspective but a I'm a bit concerned about the situation none the less.

 

[WIllyC]

Ok spoke too soon. Sprinkler back in left ear. Not as bad but it's there.

 

[WIllyC]

Well, got the ENT appointment- 2 months from now. Not even with the ENT I requested and no where near where I live.

For a condition that I believe @tiniturtle said should be addressed in days or weeks.

This is the Canadian medical system.

 

[WIllyC]

Hi Greg - thanks for all your work on this site helping people. It's a great thing you do.

Two questions of you don't mind - when you were still diagnosing your issue, was your pulsate tinnitus relatively high pitched and in sync with your heartbeat or was it lower, like you'd expect to hear after a hard sprint?

Also - what were the symptoms that caused you to look into it? Was it only the PT or did you have other issues from the organ damage you experienced?

Mine is high pitched - like regular tinnitus but with a pulse to it that matches my heart beat. Testing with a frequency generator on my phone (which may not be that accurate) it seems to be about 10-11khz.

In the last two weeks I've recovered enough from my Achilles tear that I've been able to do legit cardio again. I cut out all alcohol, coffee, and adhered to a strict low BP diet.

My morning rate today (three reading average at rest) was 118/72. My prior week AM average was 127/74.

I did 40 minutes on the bike and after a 5 minute lower pace cool down I took my rate again (immediately with no rest) and it was 109/81 (although HR was still high at this point - really just adding it to show I have good recovery).

During many of these readings my PT was present, so at the least it doesn't seem to correlate to BP exclusively (although I understand that the underlying cause may have been due to a BP spike).

 

[Greg Sacramento]

@WIllyC Type of tests and specialists to see FIRST might depend on your age and if you smoke? Are you taking any heart meds or any other meds either now or within the last year? Have you ever had a high BP reading? Do you have any physical complaints? Any at all? Since your doctor has a non investigate stand with having PT, we can discuss.

 

[WIllyC]

@Greg Sacramento

43, 180lbs, 5'10", non smoker (although used to smoke a long time ago - even then was not a lot). No heart meds. Maybe 10 years ago my resting BP was more like 145/95. Reduced with diet and exercise but 2 months of Achilles recovery in a pandemic - I drank more, ate more junk food, and wasn't able to exercise. That's turned around now it seems.

Have I ever had a high reading? Sure - I've had cardio stress testing and read high during that but was considered normal. At rest - I was particularly anxious early last week and got a 150/105 but it reduced by evening when I calmed down (I don't have general anxiety but I was anxious about this specific issue). I was also freezing cold at the time and I understand that can increase the reading.

Complaints - Achilles still healing. Neck is often stiff (work at a desk). My jaw clicks but my dentist wasn't overly concerned with it. Allergies so take Flonase and sometimes Allegra. After worrying about this and looking for problems I noticed if I lie down and really relax my belly I can slightly feel my heart beat 3 inches above my belly button, which I guess can point to a problem but I think it's just because I'm looking for it. I have 'regular' tinnitus but nothing dramatic.

 

[WIllyC]

Sorry! Not Allegra - Aerius (desloratadine).

 

[WIllyC]

I read this article recently and it made me think mine might fit with somatosensory. I can't modulate it at all with poking various blood pathways, but neck position and activating various muscles in my neck and jaw can change it or stop it.

I also had what is likely acoustic trauma on aug 22 which did cause my existing tinnitus to spike but this came on over a month later.

https://www.researchgate.net/profil...osensory-System.pdf?origin=publication_detail

 

[Greg Sacramento]

@WIllyC You give informative thoughts today in your posts above and I just saw that you posted this:

I can't modulate it at all with poking various blood pathways, but neck position and activating various muscles in my neck and jaw can change it or stop it.

Are you referring to pulsatile tinnitus or your regular tinnitus?
Do you do sit-ups or jerk your head forward when using your exercise bike? After you answer, I will give thoughts.

 

[WIllyC]

I was referring to my pulsate tinnitus (I can modulate my normal tinnitus doing various things too bit in that case it only makes it louder). I mean, I'm not in medicine or biology so I might not be pressing all the right spots and I'm not testing with massive force but from reading around I've tried the various locations people talk about and it just doesn't seem to make any difference.

What else made me consider this is that, once I was getting BP readings that were fairly low (for me anyway) and I was still getting the PT - I thought - what else is different when I wake up? Posture. I've been lying down all night with my neck supported. When it is worse is when I'm at my desk or watching TV where, admittedly, I have some not so great posture. Rounded shoulders, head slightly forward. My wife also massaged my neck last night and it gave me some relief (of course, it probably lowered my BP as well).

I do situps and various other calisthenics that might strain my neck. I don't tend to jerk around when on the bike - but I also noticed that being on the bike gives me some relief - that's a situation where my BP would (presumably) be higher but my posture is different (different than at a desk or in front of the TV). I use a standard road bike in a trainer so my posture on the bike is primarily with my head forward but my core is engaged.

The one piece of information that I can't explain well (that I think I mentioned in my original post) is that - once I am already experiencing PT, then sounds seem to aggravate it. Like the PT will be there either way but louder sounds cause the PT to get louder. The effect lingers on even when the sound is gone, and it causes a tired sensation in that ear (which I realize is a symptom of hearing loss). That being said, if it isn't there I don't have this problem. My completely non-medical education guess would be that, maybe, is that once my auditory nerve is aggravated by whatever posture issue I have, it is then further aggravated by having to transmit sound information. Like a short circuit (likely poor analogy). That might biased thinking though based on what I want and don't want this to be.

 

[Greg Sacramento]

@WIllyC It appears that you added high-pitched somatic (neck and jaw), cardiac-synchronous tinnitus. When cases of pulsatile tinnitus are both induced and suppressed by activation of the somatosensory system of the head or upper lateral neck, then this syndrome can be influenced from (a) cardiac synchronous somatosensory activation of the central auditory pathway (b) failure of the somatosensory-auditory central nervous system interactions to suppress cardiac somatosensory sounds or (c) from a vein or artery in neck.

So you first developed auditory tinnitus from probably noise. Then the peripheral nervous system which is a channel for the relay of sensory and motor impulses between the central nervous system and the body, skeletal muscles around jaw joint and C spine) kicked in. So from this, rising blood pressure from quick and very brief hypertension- (lasting a few minutes) may had happened.


You have no other complaints and you should not have any hypertension crisis problems. Hypertension Crisis is a medical term, but I doubt that your blood pressure ever increased to this level, but 150/105 BP is somewhat high.

You PT seems to be influenced by blood pumping thru heart, but your heart is probably fine. You probably don't have much atherosclerosis. but with any hypertension blood pressure, atherosclerosis can travel or develop in neck arteries, but I doubt any serious blockage would be present. This can happen easier from also having a c- spine injury ((muscle spasms in neck) that can then cause jaw problems as well as from any hypertension.

I don't think that you have any real serious problems - echocardiogram - from heart to neck, examinations of neck arteries and veins - all of them -MRA and X rays of c-spine. CBC blood test.

 

[WIllyC]

@Greg Sacramento thank you so much for taking the time to read my posts and provide your insight.

I've read it is normal for systolic BP to rise to 200-220 during intense physical exercise and that this is normal. ...but a hypertensive crisis is systolic over 180 (from memory).

...so presumably it is normal at times to have a BP that would otherwise be deep into crisis territory, no? So does strenuous exercise pose all the same risks or is the situation different in some way?

 

[Greg Sacramento]

I've read it is normal for systolic BP to rise to 200-220 during intense physical exercise and that this is normal. ...but a hypertensive crisis is systolic over 180 (from memory).
...so presumably it is normal at times to have a BP that would otherwise be deep into crisis territory, no?

Correct

So does strenuous exercise pose all the same risks or is the situation different in some way?

Strenuous exercise is not a concern. You didn't have a hypertension crisis. Blood pressure could also tense arteries, veins, cranial nerves, muscles, nerves in the neck and jaw, ears - sensory and motor impulses. You don't seem to have an ongoing blood pressure problem, but even small blood pressure cardiac function can play into what I mention in paragraph one (stress) and paragraph two (physical) in post above.

s I noticed if I lie down and really relax my belly I can slightly feel my heart beat 3 inches above my belly button

With this, I would ask your doctor again to order a MRA of neck. X ray of c-spine - that will also help exclude pressure to the vertebral artery and also to your jaw. Again, your heart is most likely fine, but an echocardiogram can examine blood flow from heart into neck. Your blood pressure appears to react a bit to sound. ENT visit for this, but interventional radiology would exam for a reason why.
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I fought with doctors in the ER more than once for the following to be examined.
https://cdn.intechopen.com/pdfs/25108/InTech-Evaluation_of_tinnitus_in_the_emergency_department.pdf

 

[WIllyC]

With this, I would ask your doctor again to order a MRA of neck. X ray of c-spine - that will also help exclude pressure to the vertebral artery and also to your jaw. ... but interventional radiology would exam for a reason why.

Thanks for the advice.

So just so people in the US understand how it is here - arranging for all of that is very difficult. Because the state pays for it all, there's a bias towards not performing these scans unless certain conditions are met. The GP is the gatekeeper to essentially all specialists, so if they are unfamiliar with your problem, it is unlikely you will get referred to a given specialist. I've been referred to an ENT and if I'm really lucky that ENT will have heard of this and maybe I can get other referrals. More than likely he'll just tell me to live with it and I'll have to find a different GP who will refer me to a different ENT and I'll play the lottery again (each "play" will take a few month as there's a shortage of almost all specialists).

We also rarely get access to the scans. The doctor will show them to us but where I read others being sent away with a copy of the scans to do with as they will is not normal here. I'm not saying it is forbidden- just that it isn't the norm.

To overcome the problem of access to certain diagnostics, a reasonably common practice is to go to the ER and fake the symptoms of what might require the desired scan. Since this doesn't often result in you getting a copy of the scan, you just have to hope that whoever reads it is a specialist familiar with your real problem. You have no input on this. This technique has even been recommended to me by family members who are doctors (retired though, unfortunately, as the other angle is using connections to get a referral as a favour). I am not very comfortable using this technique.

The GP can be resistant to referring you on your request because if it seems a frivolous referral it damages their reputation and may lead to their patients being de-prioritized for future referrals. The individual specialists own their practice and are private businesses who bill the state so, within limits, they run their business as they like and are really under no obligation to see anyone. They can only Bill the state though.

There are specialists outside of the single payer system - such as dentists. I suspect this operates more like the US. I can go to my dentist and he'll happily do whatever I like and just bill me for it - he'll also do his best to help my insurance pay for it as he's incentivized to do so.

It's always a bit shocking when I take my cat to the vet. My local vet has Xray machines, ultrasound, and various other scanners (MRI even I think - it is truly amazing what they have in that one building). My cats have top notch private insurance so when I'm there the vet will do it all if I ask. I'll be invited back to participate if I like (prior to COVID anyway). I'll be given copies of anything I like.

If I suspect my cat has a problem that requires blood work and scans I can take them there and have the whole thing done in days. The same for me would take many months.

I wanted to explain this as I see a lot of other people from countries that have similar systems and I empathize with how difficult access is. I also empathize with how difficult it is in the US if you can't pay for services. The two are very different problems.

...but what I can tell you is this - my cats have access to faster problem resolution with newer equipment than I do - by orders of magnitude.

 

[Roughseas]

Did you ever get an answer from your ENT?

I'm also in Canada and can absolutely empathize with the lack of access to specialists, testing, and results.

I was weirdly lucky enough to have an ENT appointment for an unrelated issue already booked before my tinnitus started. But did it help me? No. Because the ENT basically did a cursory exam, didn't really listen to my descriptions of my tinnitus, and told me to learn to live with it.

I'm still learning about what triggers spikes in my tinnitus, but what I do know so far is that it's pulsatile unilateral somatosensory. It seems like when I eat the jaw movements cause a spike. It's worse (more pulsatile and louder) after each meal.
I had a sinus issue that was causing me eye pressure and dizziness for a few days and I decided to chew a massive amount of gum to try to clear out my ears. Maybe that was the instigating factor. Inflammation and jaw tension combined into this feedback loop of high pitched pulsatile ringing.

It seems to be settling down a tiny bit though. Maybe it's wishful thinking that it'll ever go away.

 

[Greg Sacramento]

@Roughseas, possible Eustachian tube/sinus dysfunction caused a stiff or retracted eardrum. This would be primary to secondary jaw tension.

Not all retracted or stiff eardrums require treatment. Mild cases often improve as pressure in your ear returns to its usual level. This can take up to several months, so your doctor may just recommend keeping an eye on your symptoms before starting any treatment.

 

[WIllyC]

@Roughseas, so just FYI I learned that in Canada when you go to have your test, you ask to file a freedom of information request for the results right there. They will have a form available (at least in BC) and you'll be mailed the results. In each case I saw mine before the doctor contacted me.

Eventually I received a number of scans (the process probably took 8 months end to end) and the ENT felt it was SCDS. That finding actually came up again later in a scan for something else, so seems like there's some validity to it.

There are a lot of ways this ends up making sense now that I understand what it is and how it might be triggered, including the things I can do to temporarily suppress it - like pressing down hard on the top of my head.

It is not a vascular cause though (it's a hole in your inner ear - you can end up hearing various sounds inside your head. So the sound has a vascular source but the problem is the hole, not the fact your heart is beating. )

Here's the thing - the percentage of people who have pulsatile tinnitus and that source is SCDS is small, and most of those people have some additional, non-auditory symptoms. So this probably isn't you, by the numbers anyway.

That being said I am also being treated for jaw problems, but they had been with me for a long time.

Also I do experience the same sort of reactive tinnitus as you - usually just kindling and not winding up.