Sudden Onset Tinnitus Secondary to Nitroglycerin

[VitaminBike]

I have officially lurked here for 5 months and decided it was time to share my story and seek input from the community. I am 38, would describe myself as fit and healthy but was unfortunate enough to wake up randomly on July 29th in the middle of the night to ringing in ears.

Despite my baseline norms I have juggled for years (stressful job, bruxism etc), life was business as usual and particularly low stress the night of onset.

I have only four theories of onset with one of highest consideration as it was the only "new" thing and a rare scenario wherein I was actually taking a medication.

A dental crown had been placed 1 month prior but that process was fairly uneventful.

I had fairly severe COVID-19 in 2020 and vaxed in 2021 but seemed to do OK. With the COVID-19 I did lose my sense of smell and only regained that sense about 70% over the course of 2 years (!) which we assume means some CNS component of COVID-19 for me back then.

Absolutely no hearing loss, ear infections, loud noise, tinnitus or anything otologic of any kind in my lifetime before onset.

The biggest suspicion for my onset was Nitroglycerin (RECTIV) ointment I had been taking for 6 days to deal with a colorectal issue. This medication is infamous for producing immediate headaches which I certainly experienced. Nitroglycerin being the only thing 'new' and having caused severe headaches for 6 days, it seemed an obvious trigger for tinnitus, so I stopped the medication as of the next morning with hope the ringing would just stop... of course it did not.

I have researched Nitroglycerin extensively and what is interesting is that the drug comes up more often as a potential TREATMENT for hearing loss than as a cause of it. I have gone as far as contacting the FDA and referencing the FAERS to see if other Nitroglycerin-related hearing loss or tinnitus has been reported and there exist fairly few cases. The tricky part here is that most people take Nitroglycerin for angina and WILL be on other cardiac medications that are more traditional causes of ototoxicity (e.g., Lasix) and hence attributing the tinnitus to Nitroglycerin and not Lasix could be missed. Interestingly, the drug is a nitric oxide donor thought to be protective to the cochlea, HOWEVER, at high enough doses nitric oxide converts from protective to harmful to the cochlea, combined with central hypotension, I can theorize a pathogenesis for cochlear injury. Why I struggle with my own theory as I would expect that an ototoxic SSNL would have been detectable on an audiogram and/or clinically, and/or be noticeably asymmetrical.

My tinnitus is biased to the left but is more or less a "head noise" that can range from reactive and 7/10 to a mild and almost non-existent 1-2/10 (yesterday for NYE which was a nice gift). I am clinging on to Audiology Online's favorable 'most cases will resolve in 6-12 months' data but am not naive enough to think things will really be that simple.

I am already enrolled in a program of CBT and TRT but otherwise have taken a step back from doctors after experiencing the obligatory disappointment.

I wanted to put this out there as it appears that if my theory is true (Nitroglycerin triggered my tinnitus), I might be able to help protect others from taking this medication and/or find someone for whom the cause was not known and the onset may have coincided with the use of Nitroglycerin. Additionally, it should be an important consideration in the continued investigation of Nitroglycerin as a potential treatment for hearing loss.

Thanks guys. Let's all "keep going!"

 

[Joe Cuber]

Hey there @VitaminBike, just wanted to welcome you to the forum. I'm not familiar with Nitroglycerin, but I hope you're able to piece together a theory well enough. What I've learned is that there are so many factors that could cause a sudden onset. I suppose you've done the usual--sought out the advice of an ENT and/or audiologist to see whether you've experienced sudden hearing loss. The thing that stands out to me in your description is your years of stressful job and bruxism. In my experience, those types of things slowly build up over time and could plausibly tip you over the threshold into experience tinnitus.

I have a friend who has bruxism, which he strongly suspects is his cause. Like you, his is intermittent, ranging from not hearing it at all on some days to hearing it loudly on other days. Incidentally, mine is daily intermittent as well--ranging from non-existent to loud, over-everything hiss depending on the day. I suspect mine is caused by neck issues (like muscle and/or skeletal). I wanted to ask you whether yours is somatic--can you modulate the pitch/volume by moving your neck or jaw?

 

[VitaminBike]

Hey there @VitaminBike, just wanted to welcome you to the forum. I'm not familiar with Nitroglycerin, but I hope you're able to piece together a theory well enough. What I've learned is that there are so many factors that could cause a sudden onset. I suppose you've done the usual--sought out the advice of an ENT and/or audiologist to see whether you've experienced sudden hearing loss. The thing that stands out to me in your description is your years of stressful job and bruxism. In my experience, those types of things slowly build up over time and could plausibly tip you over the threshold into experience tinnitus.

I have a friend who has bruxism, which he strongly suspects is his cause. Like you, his is intermittent, ranging from not hearing it at all on some days to hearing it loudly on other days. Incidentally, mine is daily intermittent as well--ranging from non-existent to loud, over-everything hiss depending on the day. I suspect mine is caused by neck issues (like muscle and/or skeletal). I wanted to ask you whether yours is somatic--can you modulate the pitch/volume by moving your neck or jaw?

Yes, mine is somatic which I have read has variable meaning. I can modulate it with looking up and specifically to the left (full turn to the left) but interestingly not to the right. I assume this has something to do with transient occlusion/turbulence in carotid blood flow perhaps more so than some sort of clue as to a source of impingement but who knows. Also interesting as it doesn't modulate with jaw movements much at all.

Yes, I have had 3 audiograms about a month apart and all were fairly agreeable only showing a 20 dB "dip at 2 kHz which is still "within range". Unfortunately I have no pre-tinnitus baseline as I am now extremely curious because then I would know! It's certainly the case that my hearing doesn't feel normal but that must be largely due to the distraction of listening energy placed on hearing the tinnitus. I am also unfortunate enough for my tinnitus to be fairly reactive some days. Amazingly I have days where it doesn't react and some where it does.

Now 5 months in, I am starting to set realistic expectations and simply remain hopeful that things may level out to tonal and non-reactive to better facilitate a quicker habituation.

You know, I feel the TMJ night guard theory is a tricky one because when you DO wear a night guard, I find myself biting/clenching the hell out of it like a pacifier because you feel it in there and it pads your teeth when you clench VS. with no night guard, I am conscious not to grind my teeth as I use a lower arcade retainer which feels uncomfortable to clench on. The only thing a night guard will protect are your teeth but if you are clenching, the TMJ is taking the hit. TMJ stuff is as much of a head game as tinnitus itself so who knows!

 

[Joe Cuber]

Hey @VitaminBike, yeah it can be quite tricky trying to pin down exactly how tinnitus came about. Your case is quite similar to mine. I can also modulate by moving my eyes around. Mine really reacts when I stretch my neck by tilting my head to the left but not so much to the right.

I've had mild/moderate hearing loss for years. My audiologist believes that my tinnitus started at a very low volume because of my hearing loss and that an event (in my case I believe stress-induced muscle tension in my neck) caused the tinnitus to become intrusive. She's right in that I've had a rather low volume tinnitus for a while (hard for me to say how long I've had it). Any amount of hearing loss, even a 20 dB dip, can put you at risk of tinnitus. So perhaps your case is similar in that your mild hearing loss put you at risk and something stress-induced or your bruxism caused it to manifest. But, yeah, who knows for certain.

I know what you mean about the night guard. I stopped wearing mine because I was clenching the heck out of it.

Amazingly I have days where it doesn't react and some where it does.

Yep, I know what you mean, same thing happens to me. I have two components to my tinnitus--a unilateral non-reactive hiss in my right ear and a reactive tinnitus in both ears. Both of them are independent and daily intermittent, so I can have one, both, or neither on any given day. I've discovered that how my neck is positioned while I sleep has a big effect on whether I experience them the next day. I'm curious whether your have a similar situation--something physical causing your tinnitus to manifest for any given day.

 

[VitaminBike]

I've had mild/moderate hearing loss for years. My audiologist believes that my tinnitus started at a very low volume because of my hearing loss and that an event (in my case I believe stress-induced muscle tension in my neck) caused the tinnitus to become intrusive. She's right in that I've had a rather low volume tinnitus for a while (hard for me to say how long I've had it). Any amount of hearing loss, even a 20 dB dip, can put you at risk of tinnitus. So perhaps your case is similar in that your mild hearing loss put you at risk and something stress-induced or your bruxism caused it to manifest. But, yeah, who knows for certain.

Joe - how did you discover your hearing loss? Did you discover it before the tinnitus started? I never gave ears or hearing health a second thought before this all happened. Good ears and happy hearing was just a given - that's the most upsetting part for sure.

 

[Joe Cuber]

Joe - how did you discover your hearing loss? Did you discover it before the tinnitus started? I never gave ears or hearing health a second thought before this all happened. Good ears and happy hearing was just a given - that's the most upsetting part for sure.

I've suspected I've had hearing loss for years. I could tell because, in social situations, everyone around me seemed to be able to understand the conversation just fine, but I noticed I couldn't understand what people were saying all the time, especially when there was appreciable background noise, like at a restaurant. I figured it was just me getting older, but my audiogram shows what my audiologist called a classic pattern for age-related hearing loss. Everything normal until around 2-3 kHz where it starts to slope down at the higher frequencies.

 

[VitaminBike]

Take a good read. Our condition is largely a head game for which I truly believe we have more control than we realize.

Another scientific article supporting resolution after longer periods of time is possible. Our brains are amazing, let it do the work.

Resolution is possible:
Tinnitus: Characteristics, Causes, Mechanisms, and Treatments

 

[VitaminBike]

For those of you who have read my introduction post, I felt it was VITAL that I update you on my findings.

I have been down an incredibly complex road with my sudden onset tinnitus I would describe as miserable with no improvement in the 9 months since onset. I initially suspected a topical nitroglycerin cream, then considered TMJ and most recently developed a bad radiculopathy in my arm after a biking accident which doubled as a source of suspicion that I my beck might be the source.

I have a normal audiogram and no noise exposure so the suspicion of acoustic neuroma was "ruled out". Both my audiologist and two ENTs said an MRI was not indicated and I was afraid of noise and contrast after visiting Tinnitus Talk so I was comfortable assuming odds were in my favor.

Well - when I was for a recheck MRI of my neck yesterday and finally feeling generally fed up with the mounting health problems (I have been healthy and fit for 38 years with the fortune of no health problems before this), I decided to just do the damn brain MRI… and we found a tumor. I have what appears to be a choroid plexus papilloma - a tumor that raises intracranial pressure and as you can read, may present with tinnitus. I see a neurologist at Barrow for my neck and now we will have to chat about this as well.

My wife has been very upset with me for suffering so long and refusing to push harder for the MRI but I was afraid and was told I had no indication by the provider.

For reference, I have a somatic tinnitus affected by head position and it is reactive. I have some really quiet days and many bad days as well. Clearly I have no proof yet that addressing this will be the issue but it is finally looking extremely likely I have a diagnosis and solves the mystery… Because I did the darn MRI. While I wanted a normal scan like any sane person, at least now I feel a little more sane when it comes to understanding my tinnitus.

 

[VitaminBike]

In my case, after 10 months of mystery and being told I didn't need an MRI by two ENTs because my hearing was normal, doing TRT to no avail and letting a TMJ doctor mess with my jaw, I finally did the MRI and we found a CPA tumor which we can assume is the most likely cause.

I'm only 39. Take what you are told on "1% odds" with a grain of salt. I'm a historically healthy as a horse, fit young-middle age successful and (previously) happy professional. Be thorough in your search.

I am sharing so much because I feel my story is important as I had internally ruled-out the chance of a brain tumor early on given the ENTs (I saw the best in my city) declared MRI not indicated and "extremely rare" and I was "apprehensive about a loud MRI" after spending time on tinnitus forums.

 

[Hardwell]

How strange is it that I read you had a brain tumour and my first reaction was 'how lucky is he, he might have a chance of getting rid of tinnitus'? Such is the suffering of tinnitus that the optimism of having a causation for treatment far outweighed the severity of having a brain tumour!

I'm not very clued up in regards to brain tumours as I imagine is the case for most normal people. But what does the prognosis look like for such a finding? And what would the treatment course be?

Thank you for keeping us all updated!

 

[hopefuldede]

I am sorry to read this and also happy and respectful of you that you persevered to find a cause, despite your MRI anxiety. The tinnitus was your warning sign for sure. I hope you are getting the best care you possibly can.

 

[Joe Cuber]

Hey @VitaminBike - I lost track of your updates. I wanted to ask what the next steps are for dealing with your tumor. Also, did you have any other symptoms that led you to believe you had a tumor to begin with? Like maybe inflammation or a sensation of tenderness around your scalp?

 

[VitaminBike]

Hey guys. Sorry for the late reply. Great to hear from you Joe, we exchanged early on and here we are!

Well I had a crash on my mountain bike (I race(d) enduro) in early March and woke up a day after the crash with weakness in my left arm/hand. I'd had a mild whiplash during the crash but must have had some compromised discs from a previous accident because the crash felt benign. I had a cervical MRI and met with a few orthopedic surgeons who couldn't fully make sense of my neurological localization (also some numbness in heels and my right fingers). To me it is/was classic mild myelopathy but I wasn't getting agreement on that theory so I deferred to their expertise. Fed up with my collection of terrible health issues, I decided to pull the trigger on a brain MRI since I was already dealing with neck imaging anyway and it would help localize other factors that might be at play for my spinal injury and preexisting tinnitus. Diagnoses now include ependymoma, subependymoma and CPP.

Unfortunately, unlike a traditional acoustic neuroma, this is not an easy tumor to access so I elected to hold off and monitor. Naturally I was given no assurance it could cure my tinnitus to remove the mass (which I understand well as I am in medicine myself). With no promise of tinnitus resolution and moderately considerable surgical risk, I will repeat the MRI in August and continue to take things from there. This diagnosis has definitely changed my life, in some ways good and others bad, but I am trying to appreciate my family and the good things I have. I will battle all of this until the end.

Cheers.

 

[Joe Cuber]

Thanks for the reply @VitaminBike, it's great to hear from you too. CPP, ependymoma, and subependymoma sound like serious business. Sorry to hear you're having to deal with it. It doesn't surprise me that they told you there's no guarantee that removing the mass will resolve your tinnitus. I probably also would have elected to hold off and monitor. Brain surgery sounds chancy.

Because our symptoms are similar (variable strength) and because my tinnitus is correlated with a sensation of tenderness in the skull/neck region around my bad ear (my right ear), your discovery of having CPP has gotten me intrigued. From what I read about it, it causes blockages in cerebrospinal fluid flow. Now I'm contemplating asking my doctor to get a brain MRI.