Trying to Find a Cause for My Tinnitus

[Kaelon]

Dr. Nagler,

I can use your help determining a cause of my tinnitus, based upon the testing that has been done to me to-date. I feel like I don't have a good explanation as to what is going on, or even why my tinnitus seems to vary widely in amplification (somewhat unpredictably so). I'm a 35 year old male.

On November 2, 2014, I awoke with a case of moderately-loud, constant, bilateral tinnitus with amplification a bit louder on the left side. Like others, I had experienced fleeting moments of tinnitus that came and went within seconds throughout much of my life. I did not experience any particular trauma (no flights, no acoustic disturbances, etc.) leading up to this sudden onset, though I have for several years listened to my music on the subway at a moderately loud volume using in-ear earbuds.

For about 30 days prior to this point (since October 1st), I had been dealing with persistent GI issues (later diagnosed as acute gastritis and esophagitis with GERD) that had been keeping me up at night (and anytime I laid down horizontally flat, whereupon I felt an abdominal pulse/rhythmic pounding). Several tests confirmed that I was experiencing ~150-200 premature ventricular contractions each day, though my cardiologist determined that this was a relatively benign and unconcerning condition. An upper gastroscopy confirmed the gastritis/esophagitis with GERD, and taking 12.5mg of Atenolol helped alleviate these symptoms in mid-November. The general consensus is that my abdominal issues (and corresponding cardiological reactions to laying down horizontally) are unrelated to my Tinnitus.

Following the onset of Tinnitus on Nov. 2, I had a Brain MRA, Brain MRI, Chest CT w/Contrast, and Upper Abdominal CT w/Contrast, all of which came back as entirely normal. I had a slight bony pathology with some minimal retention in my sphenoid sinus, which doctors regarded as "unconcerning" and ultimately "unremarkable."

Afterwards, I met with a leading ENT out of Mass. Eye & Ear Infirmary in Boston who upon examining me found no issues with my Eustachian Tubes, though my audiological examination conducted earlier that day determined I had some hearing loss in both ears in the higher ranges (which was a surprise to me, given that I don't feel like there's anything I'm not hearing). My ENT did a physical examination and discovered that I am suffering from TMJ, and she concluded that a chronic TMJ disorder is the most likely culprit, and she suggested that it can be treated and cured.

A follow-up examination today with a maxillofacial surgeon who conducted x-rays and a muscular exam determined that I had moderate strain to my upper jaw muscles on both sides, but he would not characterize my TMJ as anything more than "mild" and avoided calling it a "disorder" outright. So as you can imagine, I'm a bit confused as to what might be causing this constant bilateral tinnitus with shifting amplifications and intensities across both of my ears (though routinely focused a bit more on the left ear).

Here are the characteristics of my Tinnitus:

• It is a ~13,000 Mhz. whistle, similar to the sounds produced by old CRTs and electronics.
  
  
• It is persistent and continuous, though changing with amplification frequently. Sometimes, one ear is so quiet that it is easily ignored. Other times, within the same day, it reaches a load roar. Some days, I almost feel as if it's entirely manageable - only for the next day, the Tinnitus to return louder with a vengeance. This appears to operate on a 3-5 day cycle (1-2 days of misery, followed by 2-3 days of relatively manageable tinnitus -- but never outright silence).
  
  
• I can change the amplification (though not the pitch) of my Tinnitus by moving my jaw side to side and clenching my jaw. This action causes a second concurrent whistle of the same frequency to join the one that is constantly playing. I can also almost entirely silence my Tinnitus in one of my two ears if I move my lower jaw in the direction of the ear-to-be-silenced.
  
  
• If I listen carefully, the Tinnitus is pulsating; meaning it has an oscillating rhythm that is exactly in sync with my heartbeat. This isn't something that I noticed until the past couple of weeks.
  
  
• I have a "fullness" in my ears that is momentarily cleared when I yawn or perform valsalva maneuvers to "pop" them; sometimes, this fullness is slightly painful (a 2-3 out of 10). This fullness started on or around when the Tinnitus first began.

Considering that my ENT was unwilling to prescribe steroids or antibiotics (feeling that there was no immediate trauma that caused this), but that my condition continues to persist, do you have any thoughts or guesses as to vectors of investigation that I should be pursuing to determine why I am experiencing tinnitus?

Aside from the 12.5mg of Atenolol I take daily, I'm also taking 40 mg of Omeprazole (increased in late October from 20 mg) for GI issues, and 20 mg. of Lisinopril to control high blood pressure. Doctors have routinely told me that none of these drugs should be causing any issues.

Thanks so much for your help.

 

[Dr. Nagler]

Dr. Nagler,
I can use your help determining a cause of my tinnitus, based upon the testing that has been done to me to-date. I feel like I don't have a good explanation as to what is going on, or even why my tinnitus seems to vary widely in amplification (somewhat unpredictably so). I'm a 35 year old male ...

Hi @Kaelon -

Thank you for your excellent question.

It makes perfect sense to do a thorough search for the cause of your tinnitus, the idea being that if you can find the cause and effectively address it, your tinnitus should largely or completely resolve. The problem is that while this logical approach works well for most other conditions, it just does not seem to work for tinnitus.

Why?

Well first of all, in many cases the cause for an individual's tinnitus cannot be found. And even if the cause can be found, in many cases it cannot be fixed. And even if the cause can be fixed, in many cases doing so does not appreciably mitigate the tinnitus, which by that time can sort of be like a snowball headed downhill.

So I suggest a different approach.

Those (relatively few) causes of tinnitus that can be fixed and in-so-doing appreciably mitigate the tinnitus are few in number and are known to most competent ENTs. You have already had a thorough ENT work-up, and the ENT came up with nothing save for her guess that it might be due to a TMJ problem. A TMJ specialist, however, characterized your TMJ condition as mild and (I presume) felt that pursuing it would not likely mitigate your tinnitus. It might seem at first blush, then, that you are sort of back to square one - except you're not, because the ENT has now ruled out those few causes of tinnitus that (like I said) can be fixed and in-so-doing appreciably mitigate your tinnitus. Your ENT has also ruled out the (even fewer) causes of tinnitus that represent a threat to your health or life. (Or she would have very quickly told you otherwise!)

At this point (i.e., when the fixable causes and dangerous causes have been ruled out) what you are left with - for lack of a better term - is a nuisance. It can be a HUGE NUISANCE or it can be a little nuisance or it can be anything in between. Very importantly, however, what (if anything) you decide to do about it now depends not on its cause, but rather on how much of a nuisance it is.

In your case, @Kaelon, the next thing you might consider doing is ... absolutely nothing. You have only had tinnitus for a few weeks. In many cases it just settles down on its own given a bit of time. So other than taking to heart my Doctors' Corner response regarding the obstacles to habituation at https://www.tinnitustalk.com/threads/overcoming-obstacles-to-habituation.6886/ ... perhaps you should just sit tight for the time being. Or as one sage friend of mine once said, "Don't just do something, stand there!"

Hope this helps more than frustrates -

Dr. Stephen Nagler