Tinnitus and TTTS? Post-Traumatic Brain Injury

[PLips]

Dear Dr Nagler,
After consultation with 2 ENT surgeons and an audiologist I'm not any wiser to what exactly is causing my tinnitus and (self diagnosed) tonic tensor tympanic membrane syndrome. It's wonderful that with your wealth of experience and knowledge that you serve to help those suffering from these problems.

I'm a 42yr old doctor living in Australia working as an emergency physician. Unfortunately, emergency medicine training doesn't include a lot of training in hearing loss nor neurology.

In November 2014 I had a syncopal episode which caused me to fall suffering a severe head injury. I had a basal skull fracture through my L temporal bone with a small extradural and contracoup injury to my R frontotemporoparietal lobes.

Thankfully I didn't suffer any obvious longterm consequences besides my hearing problems.

I had partial deafness in my L ear immediately after the accident which I thought was due to an occlusive blood clot in my L ear canal. I did have some vertigo which improved after 2 days of otolith repositioning exercises. Amazing!

There was an uncomfortable feeling of fullness in my L ear which I had put down to having a blood clot in my canal. I also had some tinnitus.

I saw an ENT specialist where I work who suggested just waiting and giving it time which I was happy to do.

Eventually the blood clot had partly cleared and later the ENT specialist removed residual clot. Unfortunately my hearing did not return to normal and since the fracture extended longitudinally along the ear canal there was a suspicion of sensorineural injury.

One thing I did notice was that my hearing improved when I did manoeuvres equalizing my L ear such as yawning and swallowing.

Over the course of 3 months my L ear gradually improved to the point of almost feeling back to normal. However quite acutely over the course of 3 days my R ear which had been completely fine started to feel deaf. As this had been my good ear this was obviously of great concern to me. I spoke to and saw my ENT as well as spoke to a friend who is also an ENT specialist. My otoscopy was normal. They weren't sure how it was related to my head injury however they diagnosed me with sudden onset sensorineural hearing loss and both recommended prednisolone which I took for 3 wks. My R ear improved gradually I think just on it's unrelated to the steroids over 4wks.

I had trouble believing that I would suddenly develop an uncommon syndrome after what had happened recently and thought it more likely that it was somehow related to my brain injury.

I had an MRI scan which showed some residual injury to my R temporal lobe particularly to the inferior and middle gyrus. The 8th and 7th nerves appeared okay.

I had audiometry which interestingly showed minor hearing loss on both sides and interestingly showed that my tympanic reflex was present on my R side but absent on my L.

What I noticed was that on awakening and in quiet places my symptoms settled however any amount of background noise not necessarily loud would bring on symptoms of fullness, sometimes discomfort, numbness on the R side of my head and a feeling of deafness particularly the inability to distinguish conversation in a noisy environment. Working in emergency makes this difficult!

Stress definitely brings on these symptoms (particularly my kids fighting and screaming). Driving in the car also, talking and chewing.

After some internet research it seemed that I had symptoms similar to tonic tensor tympanic membrane sydrome and I believe I had it in my L ear and for some reason it's moved to my R ear. In the last month it has to my L ear again and has become quite bad, intrusive making it hard to hear people talking at work.

My theory is that I've injured part of my auditory cortex causing the tinnitus and has somehow affected my acoustic reflexes.

I'd be interested to hear your opinion on all of this and is there any treatment you think would help? I've tried various things I could find over the internet but wonder if many of the treatments are designed to work for a peripheral cause (ear apparatus/cochlear) rather than auditory cortex.

Kind regards,
Dr Andre

 

[Dr. Nagler]

I'd be interested to hear your opinion on all of this ...

Goodness, Dr. Andre, that's quite a history. I can absolutely understand your frustration.

You know, we doctors like to analyze and compartmentalize. I guess that's what gets folks like you and me through medical school. We are cause-and-effect sorts of people, yes? We want explanations ... and we want to take action based upon those explanations. Such a philosophy in the main serves our patients well. But in tinnitus, it can lead to one huge kerfuffle - because in tinnitus often you cannot figure out the cause part; and even if you can, often you cannot figure out the effect part; and even if you can, often it does not contribute to a workable explanation-based action. So with tinnitus you have to go about things a bit differently.

Let me give you an example of what I mean ...

You have had a closed-head injury affecting your left ear, which you say is now pretty much back to normal. And you recently experienced an acute threshold shift in your right ear that is now also pretty-much back to normal. You were told by a couple of ENTs that the right-sided threshold shift was likely due to SSHL rather than being related to the closed head injury. You were treated with steroids, and the threshold shift resolved. You are not sure whether or not the steroids played any role in that resolution, nor are you even sure that the ENTs were correct in their analysis.

So, yea, I get where you are coming from.

But here's the thing. You cannot prevent a closed-head injury that has already happened. And whether or not your (now resolved) threshold shift in your right ear was related to it is similarly largely irrelevant. That's why with tinnitus I prefer to look at things from a strictly pragmatic point of view ... and set the cause-and-effect stuff (that has served us so well in other areas) aside.

Now as I understand from your post, one of your main concerns is whether or not you have TTTS - and if you do, what are its implications in terms of therapeutic options. The remainder of your current concerns sort of stem from that one.

So if I were in your shoes, I'd find out ...

Myriam Westcott is an audiologist in Melbourne who has written a number of papers on TTTS and is very-well regarded by her colleagues in the field. In addition to being quite knowledgeable and experienced when it comes to TTTS and related entities, Myriam also happens to be a thoroughly delightful lady. And she is moreover a good friend of mine, which may be one of her less-redeeming qualities. Anyway, what I would do is call her, tell her you are doing so at my suggestion, explain your situation, and ask if she thinks it would be beneficial for you to go to Melbourne to see her!

All the best -

stephen nagler