Eustachian tube dysfunction
If you have ever had to pop your ears while flying in an airplane or driving in the mountains, you have had firsthand experience with your Eustachian tubes. If you have ever felt ear pain or severe pressure in these situations, you have experienced Eustachian tube dysfunction, or ETD.
The Eustachian tube (diagram, with more information on ETD) connects the middle ear with the back of the throat. The middle ear is an air-filled space, and the air pressure in this space under ideal circumstances is the same as the ambient (outside) air pressure. When the ambient air pressure changes rapidly, as it does while driving through the mountains, there is a difference in pressure between the outside air and the air in your middle ear. If this pressure difference is great enough, you will feel pressure, or even pain, in your ears. When people pop their ears they typically swallow or open and close their jaws. These actions tend to open the Eustachian tube, allowing the air pressure to equalize between the outside world and your middle ears.
Most of the time, the Eustachian tubes are not open; it takes active muscle movement to open them (1). Unfortunately, many things can inflame the tubes, causing the tissue lining the tube to swell. Under such circumstances it becomes difficult or impossible to actively open the tubes. This is very similar to the problem we have all experienced breathing through a congested nose: as the tissues lining the nasal cavity swell, it becomes progressively more difficult to pull air through the nose.
Air within the middle ear is gradually absorbed by the blood flowing through the lining of the middle ear space. Periodically, we open our Eustachian tubes in order to replenish this lost air. If the Eustachian tubes function poorly, the air cannot be replenished, and thus the air pressure drops within the middle ear space. Since the ambient air pressure is higher than the middle ear air pressure, there is a net force on the ear drum. If the pressure is low enough, the walls of the middle ear space exude fluid which can collect in the middle ear space, compromising hearing.
The Eustachian tubes open into the throat immediately behind the nasal cavity. Many nasal problems may lead to inflammation of the Eustachian tube openings. Allergies, sinusitis, and the common cold primarily affect the nose and sinuses; because drainage from the nose passes by the Eustachian tube openings, these nasal/sinus problems can lead to Eustachian tube dysfunction. Similarly, throat infections (viral or bacterial) can also cause Eustachian tube dysfunction (2).
The symptoms of Eustachian tube dysfunction are fullness and pain in the ears, and hearing loss in more severe cases. if persistent, you may also experience ringing in the ears, and dizziness or unsteadiness. Your doctor may have noted fluid behind your ear drums, or that the ear drums appear retracted (sucked in).
The treatment for this problem depends upon the root cause. Your doctor will need to determine whether your ETD is due to a throat, nose, or sinus problem. The treatment will vary depending upon the root cause, but may involve antibiotics, nasal sprays, decongestants and/or antihistamines. Unfortunately, not all cases of ETD are due to a treatable cause; some folks have Eustachian tubes which are dysfunctional all the time.
Only occasionally is surgical treatment required. This involves making a small cut in the ear drum and placing a tiny plastic grommet tube into the cut. The hole in the grommet tube allows air to pass into the middle ear, thus functionally “replacing” the Eustachian tube. This procedure is usually performed under local anesthesia.
The tube is called a “ventilation tube,” which is a reflection of its function, but it is also frequently referred to as a “PE tube” for pressure equalization or polyethylene (the material from which the first such tubes were made.)
References:
1. Otitis media, atelectasis, and Eustachian tube dysfunction. C.D. Bluestone and J.O. Klein. In: C.D. Bluestone, S.E. Stool and M.A. Kenna, eds. Pediatric Otolaryngology, Vol. 1. Philadelphia, WB Saunders, 1996, pp 412-414.
2. Otitis media, atelectasis, and Eustachian tube dysfunction. C.D. Bluestone and J.O. Klein. In: C.D. Bluestone, S.E. Stool and M.A. Kenna, eds. Pediatric Otolaryngology, Vol. 1. Philadelphia, WB Saunders, 1996, pp 431-443.
D.
By any chance could the Eustachian tube come loss and hang loss in the throat?
Physically impossible. Even if you could go up there with a little scalpel and cut all the various attachments (very nearly an impossible operation, by the way), you would still have to figure out a way to evert the tube so that it hung down into the throat.
If you’re feeling something dangling in your throat, chances are it’s a swollen uvula.
IT’s not there anymore, my ENT Dr. cut it off. He said it was a palet.
A couple of years ago, my right ear started clicking occasionally, when swallowing or yawning. My physician said this would eventually go away which it did. More recently, I experienced a whistling sound in the same ear but only when lying in a certain position. My physician said there was some water in the ear and that it was almost certainly Eustachian Tube Dysfunction and that it would go away in time, which indeed it did. A couple of weeks on, the clicking sound has reappeared. Should I wait and see if this disappears, or go back to my GP again, whom I am loath to trouble during this swine flu period? I have tried all the usual over-the-counter meds to no great effect. Thanks, KKW, London, UK
Clicking, if it’s a regular, repetitive sound, usually indicates something called “myoclonus,” which is the medical term for a muscle twitch. Yes, there are muscles in the middle ear. Very. Tiny. Muscles. And when they twitch, you can hear them twitch, because they’re attached to your middle ear bones.
If the clicking sound is the only thing bothering you and you have no other symptoms, you could probably wait this one out. BUT:
The usual caveat: I’m basing this on the small amount of information you’ve given me, and I haven’t had the opportunity to take a history or examine your ears myself. My opinions are merely educated guesses, no more than that.
I notest that when my sinest is running, i can fell it on the righ side but not on the left side. could it be the tube that runs from the sinises could be the tube that was hanging in my throat?
Afew years ago my wife put bleach an water in my ear to clean the wax out, ive been having problums every since.
Thank You for your comments.
Richard
Hi.
Over a year ago I had a cosmetic rhinoplasty. Ever since then I have experienced a strong sensation of ear pressure or ear clogging or ear fullness.
I also couldn’t breathe at all after the rhinoplasty (nose job).
We (my current doctor and I) thought that that the air deficiency might be causing my ear pressure dysfunction problem. But when my current Dr. fixed my breathing mostly with a functional rhinoplasty, my ears were only minimally improved. They got better, but not nearly enough.
We now think the operating doctor scarred my Eustachian tubes from inside my nose in some way, and the lack of air only aggravates, not causes, the problem.
Can you recommend someone or a hospital who specializes in treating Eustachian tubes scarred by surgery or otherwise scarred from inside the nose
or any group /hosptial/ expert group to visit that might give me help with my problem?
I am satisfied with my current dr and will continue seeing him for now, but I’d like as much insight and expertise attached to this problem as possible
Also could you educate me about what exactly could have been scarred to be causing the problem?
For example, is their a muscle that might have been knicked or could the scarring have webbed over the Eustachian tube openings themselves?
thank you
Candice, looks like my reply above was to a different question (about exostoses) — I’m not sure how that happened, some sort of WordPress glitch. Sorry about the confusion. To answer your first question, it would be very unlikely for a cosmetic rhinoplasty to cause Eustachian tube dysfunction — at least not directly. Perhaps the rhinoplasty aggravated an existing nasal inflammatory condition (rhinitis) or caused a spike in sinusitis? There’s really no way that a rhinoplasty could have scarred the ET openings — they’re quite far from the area your doctor would have been working.
Did the rhinoplasty improve your airway? Sometimes when we improve an airway, we inadvertently cause a spike in allergy symptoms. The nose is pulling more air, and thus more particulate matter (pollen, dust, etc). Allergy can definitely cause a spike in ET dysfunction. Your first letter, however, suggests that your ETD began even before the airway was improved, so this scenario may not be plausible.
ETD is easily diagnosed with a tympanogram and/or an appropriate examination by an ENT. No super-specialist necessary — this is a bread-and-butter problem for an ENT. You merely need an ENT who is willing to take the time to listen carefully to your history and examine you just as carefully.
Hope this helps.
Very strange — my reply got shifted higher in the list. I have no idea why.
Hello.
2 days after flying in from Savannah, my right ear felt clogged. Within a few days, I used a home remedy ear-wax cleaning kit. A week later, I felt no releif, so I saw my ENT. He wasn’t sure what was going on. He prescribed prednisolone. It didn’t work. A week later, hearing tests and pressure checks, the ENT said he didn’t know what was going on and he was sure there was no fluid in the middle ear.
Here I am, three weeks later and I feel like there something’s behind my ear drum that interfering with my hearing. I made another appt with a different ENT to get some relief. I want to fly next month but have been told not to.
Any ideas?
i am absolutely am so upset about my clogged ear. 2 weeks ago i woke up with pain in my rt. ear and my left side of throat sore aboutAbsolutely felt fine before that, laid on heating pad and pain went away in about a day but ear was still clogged up and throat still abit soar. Went to doctor and he said i had infection and prescribed a new kind of antiobiotic, throat started feeling okay but ear still clogged about a week and half later ear still clogged and right side of throat sore, doctor sent me to ent. he said ear was completely clogged caused by fluid and eustachain tube clogged and this was causing my throat to be sore too, told me to take musinex. still nothing, it is still totally closed, tried steam, perioxide, heat. Its driving me nuts and now I worry is something really wrong. I kept asking ent is something really wrong and he assured me that was not, needless to say I am an extreme worrier. Any recommendations thanks
ENTs vary in what they will or will not offer people in your position. I’m assuming from what you have written that you do, indeed, have fluid behind the ear drum. If this is the case, I usually offer such patients a choice between observation and more aggressive intervention. This problem almost always resolves on its own, given enough time, but that may take weeks. Some folks are willing to wait weeks, some are not. For those who want a faster approach, I offer a myringotomy — a procedure where I make a small incision in the ear drum and then suck out the fluid (DON’T try this at home!) It’s fast, it’s easy, it gives immediate results, and the risks are relatively minor. Risks include but are not limited to the pain of the procedure itself, persistent nonhealing perforation, or some fairly devastating and permanent damage if the patient moved suddenly during the procedure. (None of my patients has ever moved!)
Your ENT has learned that if he does nothing, his patient will still get better in time. There’s something to be said about being a minimalist, but that’s not my philosophy. I prefer to give the patient a choice in the management of his condition.
Hi Hoffmand, I am very interested in what you’re doing, I have had the fluids behind my eardrum since more than 2 months and I am now on antibiotic and prednisolone, short course though, steroid nasal spray to minimal improvement. Could you tell me how long does it take for the fluids take to eliminate by itself if ever? Also where are you located ? I live in Canada, in a city called Mississauga? Are you licensed to do this?
Many thanks
Rawdha
I’m licensed to practice medicine in the State of California. As for “this,” if you mean blogging and providing folks with information, that does not require a license
Everything here is strictly informational. Read the disclaimer.
Middle ear fluid can take weeks to months to resolve on its own. Folks who don’t want to wait for months can try a variety of medications (none of which are terribly effective in my experience) or find an ENT who can offer a myringotomy (a procedure in which a small incision is made in the ear drum). It’s at least worth talking to an ENT about the medication options and myringotomy. However, myringotomy is a purely elective procedure, so I’m not sure whether it’s an option for you in the Canadian health care system. Best of luck.
I have had eustachian tube disfunction for more than 2 years now, it has gotten slightly better over time but not much. It started after a trip to costa rica, about a week after I got back. The only thing of found and I’ve tried everything but surgery is taking an occaisional valium. Do you have any other suggestions? Any help would be greatly appreciated.
Thank,
Martin McCurdy
Most important thing is to make sure you’ve been correctly diagnosed. Certain conditions can masquerade as ETD — low frequency sensorineural hearing loss, and patulous ETD (which is treated differently than garden variety ETD). For true ETD, we usually start by treating any underlying sinus conditions or nasal allergies. If that doesn’t work and I’m sure of the diagnosis of ETD, I’ll offer a myringotomy (a small cut in the ear drum) to see if this relieves the patient’s symptoms. If the diagnosis is correct, a myringotomy should relieve the symptoms. Myringotomies almost always heal within a few weeks or less, so I consider it a nice test to see if the patient might benefit from a ventilation tube, which is a longer lasting solution.
Needless to say, you need an ENT to guide you through this.
Hello,
I have had constant non-stop, high-pitch ringing in both ears since this past April which has gotten louder. In April, my ears had fluid in them and I had to go on antibiotics, Flonase and Afrin to clear up the fluid.
I have bad allergies..allergic to 39 out of 50 testings I had done. I take Allegra and Flonase daily.
Now, its October and for two weeks, both of my ears are in alot of pain, have alot of pressure…loud ringing…and VERY sensitive to noise. I went to family doctor today and he said my ear drums are retracted..and to take Flonase twice a day…Afrin 3 times a day..and wear ear plugs for the noise. The only thing that has changed for me is Im around people who smoke now…alot. Is this agitating?
What can be going on with my ears? Im scared….
Any help or suggestions would be greatly appreciated..
Thank you!
Hi Pamela,
Your symptoms could be related to Eustachian tube dysfunction (you’ll find lots of other information on ETD on this site) which is common in people with allergies. Cigaret smoke would tend to make this worse. This is the most likely explanation, but is not the only possible explanation. It’s also possible that you might have sustained a more permanent type of hearing loss, what is called sensorineural hearing loss, last April. Either way, this is not the sort of thing that I would recommend you leave to your family doctor. Ask for a referral to an ENT (demand it if necessary). A hearing test with an audiologist would be an excellent idea, too.
Four months ago I started having extreme fullness in my ear and my lungs and throat felt inflammed. The throat and lung issue got better within a few weeks. The other symptoms did not. I have ear fullness and pressure. My vision seems off. It doesn’t feel like my contact prescription is wrong, my vision just feels different than normal. Every now and then it seems to get a little better. It gets worse towards the end of the day and when I’m driving.
I have intermittent pressure in my face and in my temples. Also, and the most disturbing symptoms, is difficulty concentrating and a disconnected feeling. I’ve heard some people call it “brain fog.” It almost feels like I’m a bit intoxicated.
I had sinus surgery a week ago. My symptoms have not gotten better though. Could this all be related to a sinus issue or does it sound more like an inner ear issue?
I’m afraid that either are possible (and Eustachian tube dysfunction is a possibility as well). This is one of those questions that I can’t be much help on, since there is too much missing data (not least of which, I can’t examine you). I’m hoping that you’ve asked your ENT this question, but if not, that’s clearly the next step. Also, give the sinus surgery a bit more time — it typically takes SEVERAL weeks to fully recover (and see the benefit from) a sinus operation.
I have been taking a calcium channel blocker for BP, for several months. I developed pulsatile tinnitus about two months into taking the drug (Norvasc). I am absolutely sure that this is the cause of my tinnitus, which is so very distracting, drives me bonkers and makes it very difficult to sleep, as well as to carry on certain other activities. My doctor will *not* believe me regarding my interpretation of its cause, nor will an ENT specialist (all tests negative, so far, scans, Dopplers, etc.). When researching calcium channel blockers, it clearly states that side effects from these can be tinnitus. I feel *so* frustrated. It has been difficult to find a drug to control my BP easily but Norvasc does the trick – hence, my doctor states that all drugs produce side effects of some sort, so I am expected to learn to tolerate this noise.
Frustrating situation . . . What you really need, I think, is for your doctor to show the flexibility to allow you to go off Norvasc for a couple of days in order to test out the theory. You might need to be on something different in the meantime, so that’s why your primary care doctor’s cooperation is essential. Best of luck on this. Worst case scenario, you might have to find a different primary care doctor if your present one won’t help — but hopefully it will not come to that.
i have had ear fullness for about 2 years. i believe it first started coming home from a trip from Mexico where i had sinus infection and ear ache after. i am also experiencing neck & head pain, shoulder pain, jaw pain, ear fullness and pain that will not go away. i also grind my teeth. i have been to ent and there was no fluid in my ear, hearing was fine. she said i was feeling ear fullness due to grinding. is there anything i can do? it is so discomforting to have the ear fullness constantly. it has not stopped and it feels full all the time. i appreciate any advice you have to offer.
Your ENT may be right. Did she check a tympanogram? That would be the definitive test to determine if the fullness was related to a true pressure imbalance (Eustachian tube dysfunction) or something else. Of the “something else” variety, your grinding could easily have led to TMJ dysfunction, which in turn could have led to myofascial pain disorder. The latter condition, as it relates to the TMJs, manifests as pain in the jaw and/or cheekbone and/or temple. The ear can feel full and/or painful. The neck and shoulder pain is a little unusual — it might be related, or it might be due to something else entirely.
Do a little research on line about TMJ and myofascial pain disorder. If these seem like probable diagnoses, discuss them further with your dentist, your ENT, and your primary care doctor (if the first two aren’t helpful).
If you’re grinding your teeth, your first priority should be to have your dentist fashion something for you to wear at night to prevent it. (Your dentist, by the way, should be able to take one look at your teeth and tell you if you grind at night. It’s often obvious from the wear pattern on your teeth.) Don’t chew ice or gum. Try to soften up your diet as much as possible. Warm compresses can help, too. Ask your ENT or your dentist if an NSAID (nonsteroidal anti-inflammatory drug) like ibuprofen might help. But the grinding issue really is way at the head of the priority list. Ask your dentist for more advice on TMJ — this is a very abbreviated version of a much longer speech!
Best of luck!
Hi,
I am absolutely desperate and hoping you can shine some light on my symptoms and where i should go from here with your knowledge in this area. I am only up right now, because once again my symptoms have woke me up, causing anxiety because I do not know what is wrong with me or how to find out. I have been to four or five medical doctors over the past two years trying to figure out the physiological cause, and have had MRI’S, cat scans, and ear pressure test but everything looks normal. But every single night when i lay down i get intense rumbling sensations in my ears, almost like wind trapped in them or the rumble of thunder that I can hear and feel. When it is really bad it also feels like my ear is spasming in and out rapidly inside, and that is what often wakes me up after I am asleep. The unique thing about it is that it is only triggered by position (laying down). I also have thick post nasal drip that I feel in my throat almost every night as well, and am beginning to wonder if this is related. I have been told it may be stapedial myoclonus causing this but with the drainage and the ear fullness/popping i also get at night I am starting to think it may be more eustachian tube related? I have noticed that when the rumbling/spasming is really bad that it is greatly reduced or even stopped when i try the valvasa maneuver or apply firm pressure at the top of my neck/back of my ear…..anyways, I know this is alot of information but i am trying to be very thorough in case one piece of it may help solve the mystery that is causing so much anxiety not knowing what is wrong with my body. I have worried often that it may be blood flow related which is scary. I am a 33 year old mother of 3 and want to stay healthy for them! The only other thing that could be important information is that when I was 15 my brother who was a navy diver took me deep sea scuba diving without giving me much training (stupid now that i look back on it!) however, after all my reading I wonder if not equalizing correctly or coming to surface way too fast (which i know I did when i panicked) could have damaged something and could be causing problems this much later??
I would appreciate any help and guidance as I do not know what steps to take next medically to get answers. Feels like I am chasing my tail lately.
Thank you so very much
Beth Floyd
Some of your symptoms really do fit the picture for middle ear myoclonus (“When it is really bad it also feels like my ear is spasming in and out rapidly inside”) — aside from the stapedius muscle, there’s another one called the tensor tympani which could be to blame. But the rumbling sensation sounds a lot more like jugular venous hum — particularly in the way that you can shut off the noise with direct pressure.
Middle ear myoclonus could be related to ETD. It wouldn’t surprise me. Jugular venous hum, though? Not much connection there, I suspect.
If you do have either or both conditions, I’d like to stress that they’re potentially treatable, especially middle ear myoclonus. Jugular venous hum (JVH) can be difficult to treat depending on the cause. JVH is thought to be due to turbulent blood flow through one or both jugular veins. It can be a sign of increased cardiac output, which can be due to anemia, certain thyroid conditions, and certain heart problems too.
If you haven’t seen an ENT yet, see one; if you have and that ENT didn’t mention JVH, find another. If you can find an otologist (an ENT who has specialized in ear problems) so much the better. Good luck to you.
Also, I doubt whether the diving incident caused any lasting damage, but anything is possible.
is irradiation affect eustachian function e.g.postlaryngectomy?
Well, it depends. Ordinarily, the radiation field for a typical patient with laryngeal cancer will not go high enough to include the Eustachian tubes. If for some reason the patient received radiation that high (if he had suspicious lymph nodes that high in the neck), then yes, the Eustachian tubes would be adversely affected.
Hi, I’ve had various Eustachian tube problems for over a year now. At first my ears were clogged for several weeks. I occasionally experienced tinnitus over this time. I was on intranasal steroids, alternately oral antihistamines, decongestants, the whole bit, for several months. I finally had an allergy test and found out I’m allergic to basically everything (never had an allergy problem before ETD, and no other symptoms bother me but this one).
Anyway, I was given prednisone to attempt to knock out the swelling (I had also received tubes in both ears). I had done prednisone once before and it had only worked temporarily, but the hope was the combination of intrasal antihistaimines and intranasal steroids would make the benefit more lasting that time and get it under control.
Anyway, in the midst of this prednisone series, which was a few months ago, I started hearing my heartbeat. I was worried I had “gone patulous,” and so I called a doctor (my ENT was unreachable) who said I should just stop the prednisone, there were no risks in a short series. Anyway, the withdrawal was one of the worst experiences of my life despite the doctor’s confidence (was completely useless for several days, could barely stay awake and my blood sugar and pressure seemed way off, just awful).
Anyway, the hearing my heartbeat has persisted, but this seems more like pulsatile tinnitus than a persistently patulous tube.
Now, I occasionally had symptoms that seemed patulous in the past (that my case is by no means textbook has made me a difficult case for the doctors I’ve seen). I would sometimes get autophonia when talking, making regular speech really uncomfortable for me, and exercise became hit or miss in terms of aggravating my ear situation. However, these symptoms became dominate after the prednisone, so I really do think my tubes started being at least intermittently patulous, while I have persistent pulsatile tinnitus in addition to the other tinnitus that developed especially in my right ear (the one with the worst overall ETD symptoms as well).
It got to a point where if I used even just nasonex I could predict a few hours, a little after noon the next day, my ear would open up, I would get really uncomfortable autophony, and would have to stop hanging out with friends, not participate in class, whatever it was, because I just couldn’t stand talking. It’s a really awful condition as you must know!
So now I’ve gone down to just a claritin a day, and I get these bad cases less frequently, though almost always when talking my right ear feels uncomfortable like it’s just about to go wonky — and I have horrible problems with mucus/snot in my nose, and I feel like it’s gunking up my right ear all the time though I don’t know if that’s the right explanation for the sensations. Even worse, I had to completely give up exercise because any time I raise my heart rate (running, even just hiking moderately uphill) my ear will “go patulous” and I won’t be able to talk, and if I am breathing at all heavily it is just the worst sensation. Like air is rushing in and out of a place of my head it’s not supposed to be in.
Factor in the background issues of my pulsatile tinnitus, where my heartbeat sounds like a giant billows huffing and puffing inside my ear and my normal tinnitus, it’s really hard just to LIVE any more. I’m a student and, given my back pain issue that preceded all these ear issues, it’s harder and harder to live even the cushy life of a college student whose wallet is fat with loans. Concentration is a problem, the lack of physical exercise and resultant weight gain (I used to be a really avid runner and in quite good shape, and a very important part of my life has been taken away) is another huge element of stress. I’ve also gone through the whole cycle of being afraid of noise (from my normal tinnitus), which is super stressful, and still have an abnormal relationship to music (music was the other incredibly important part of my life, outside of exercise and my history scholarship, and that has largely been taken away from me too). I cannot sing at all since this started (quickly became unbearably uncomfortable on my right ear), or yell, converse as freely/expressively/confidently as I used to, etc. So I guess communication, a basic human faculty, is compromised as well. My life is just in the dumps since these things have started, and it’s hard to be at all hopeful about the future.
I don’t mean to tell you my life story! But my question is is it possible that someone who has had Eustachian problems as long as I have could have them resolved? Can you think of any treatments or questions I should as an ENT about? Can you think of a reason at all (the prednisone? Allergies?) for my pulsatile tinnitus (this comes pretty randomly, on both sides though usually not at the same time, and while it seems to be predictably caused by a raise in heart rate as during exercise or sex, it can come sometimes just from lying down to go to sleep at night)? Any advice or insight at all would be deeply appreciated. I’ve been very underwhelmed by the quality of treatment I’ve received, and no matter how many “second” opinions I get, I never get to be taken totally seriously by my doctors. It’s as if they think there’s no way any one can have this many symptoms, especially as they apparently don’t match textbook cases. The end result is I’m suffering and get very little relief or even consolation from my doctors.
Thanks so much in advance for your time and any help!
Hmm. You may not like this answer, but here goes. There may be a clue to the underwhelming quality of care you received in the length of your letter. Doctors are only human, and can get overwhelmed by a patient who throws too many things at them all at once. I certainly found your letter overwhelming.
My advice: when you talk to your doctor, focus on your symptoms. Doctors like to hear the basics: how long have you had this? Is it constant or intermittent? Does anything make it better, does anything make it worse? Only sometimes is it useful to focus on the treatments you’ve had that haven’t worked.
I would suggest that you pick your pulsatile tinnitus as the first thing to investigate, since this symptom is the most potentially serious. It can be a symptom of a vascular malformation in the head or neck, a vascular tumor near the ear or near the hearing nerve, or a heart condition. It can also be completely innocent (though annoying), but this is something the doctor needs to figure out. The workup depends a great deal on the specifics of your exam, but could include anything from a cardiac echocardiogram to a CT angiogram — impossible for me to tell what you’ll need based on an email.
Autophony, by the way, seems to occur only in two conditions — patulous eustachian tube dysfunction and semicircular canal dehiscence syndrome. So if you’re having autophony, you’ve already narrowed things down quite a bit.
By the way, if you’re at a university . . . is your university affiliated with a medical school? If so, you may be lucky enough to have an otolaryngology department, and if you do, they probably have an otologist (ear specialist) on staff. That’s who you want to see.
Thanks for your letter. Naturally I don’t recite this thing in the office. I’ve gone to several doctors specifically for the pulsatile tinnitus — of course I give them background, especially when they ask (they have access to my records) — and then the conversation always veers. But I’ve had at least two doctors look me straight in the eye and tell me pulsatile tinnitus is not even potentially serious and that there’s nothing that can be done. One mocked me and said, “Of course, I can hear my heart if I tilt my head a certain way too!” This is what I mean by underwhelming care. When I tell them that it has affected my life, in that I cannot exercise anymore etc., they tell me I am young and that, consequently, my impairment is fictitious and the solution to being inhibited in physical activity is to do that physical activity. According to them I cannot have problems, because I am 24. :/ I suppose the reason I went out of my way to prove that these conditions are affecting the quality of my life in my letter to you is that I’m expecting the same sort of apathy from every one in the medical profession (though, I’m starting to believe this is something peculiar to Kaiser Permanente-type care).
The really curious thing about this is that it started IMMEDIATELY after I took prednisone, and persisted since (it is intermittent). I guess I was hoping you can tell me if you can think of any mechanism for that. I know I’m engaging in post hoc ergo propter hoc reasoning here, but the pulsatile tinnitus followed so closely in time after the prednisone that I can’t help but believe there might be some causation there.
I apologize for writing such an overwhelming letter. But the longer these issues have gone on, the longer my case history has become. When it started it was quite simple, but several set backs and new symptoms later it’s getting really difficult to untangle. The only constant has been the dismissiveness of doctors, so I guess I wrote to you in something like a state of pleading despair. I probably should’ve not done that, haha.
I’ve consistently lowered my expectations for how good my life can be. I’ve resigned myself to “normal” tinnitus, and recognize not much can be done for that. But I know that pulsatile tinnitus can be treated, and I know that Eustachian tube dysfunction often resolves though my question is whether it is too late for mine to resolve, whether I can now expect to have problems for the rest of my life.
Aside from asking my doctors about semicircular canal dehiscience syndrome (which I’m sure they won’t know much about or will dismiss, but I’ll give it a shot), is there any other line of reasoning I can take with my doctors to coerce some kind of real investigation or care from them?
(Unfortunately, I go to UC Berkeley and we don’t have a medical school).
Thanks a lot for your help, I’ll try not to bother you after this message!
The good news is I’m a Berkeley grad. The bad news is I’m a Kaiser doc. You know, the group you just slammed. Honestly, I was going to suggest you join Kaiser if it was an option in your area, since I think we are (on average) a more caring group than your average private practice ENTs. I’m sorry you’ve had such slapdash care — I really am. Particularly since your symptoms do merit a better workup than what you’ve received thus far. If you’re interested, email me privately (malmerkin at gmail dot com) and I’ll send you the phone number. I think it’s okay to cross regions like that, but I’m not 100% certain . . . it may be limited to emergency care.
It’s probably not too convenient for you, but if you ever come down to Bakersfield, I promise to at least try harder than your other doctors. Can’t promise I’ll figure anything out — no one can — but I would give it my best.
Jill mentioned VEMP testing . . . great if it’s available. Most of us make do with a temporal bone CT with the finest cuts the radiologist can provide. And the doc should talk to the radiologist first to make sure the radiologist is knowledgeable about the diagnosis. Not all of them are.
For “regular” patulous ETD, I like treating patients with a premarin solution as nose drops (this is discussed in Derald Brackmann’s Otology textbook — there’s a whole chapter on patulous ETD causes and treatment). Very much an “off label” usage.
Not sure about the prednisone association. The only idea I have is kind of a stretch: prednisone is a potent anti-inflammatory agent; inflammation of the Eustachian tube mucosa would lead to a more typical ET dysfunction under most circumstances. SO perhaps you had a pre-existing patulous ETD which was not symptomatic due to some sort of inflammatory process. Then you got the prednisone, the inflammation went away, and the patulous ETD was unmasked. Like I said, it’s a stretch, and it doesn’t even explain your pulsatile tinnitus.
Just testing as I’ve left a lengthy reply for Nick but it does show after having clicked on “post comment.” I hope this is because the board monitor checks replies prior to publishing.
No, I’m just slow. It’s just me around here and so this place is subject to whatever my state of exhaustion might be. Which, lately, is kind of high. Thanks for your reply to Nick.
Greetings, Nick:
I would believe the above to be written by me, except that I am not a student. I’ve had this same, infernal problem since the beginning of May. There is no doubt that my mood, social activities, exercise, sleep and general quality of life have completely changed, to be sorely lacking. I feel nearly perpetually terribly crabby, as well. Fortunately, I took early retirement pension from work, as I couldn’t possibly work for a living, under these circumstances. Its symptoms cause me to keep to myself most of the time as doing so is the only way I can manage the stress it causes. There is hardly a physician of any sort, in my case, who does not skirt the issue, which is, by the way, objective, not subjective. My family can very well hear the bruits in my ear as we sit quietly together. Most physicians have thought I have an aneurysm, AVM or a blocked carotid artery and I have had a battery of tests (CT, MRI, Dopper, etc., all to no avail). I can, by the way, feel the artery pulsate strongly under my finger.
I have gone the rounds, including an ENT specialist but about six weeks ago requested an appointment to a University Hospital to see a neurotologist which is to take place on January 11. I have spoken to the specialist who suspects (as does Dr. Hoffman) that I have SCDS, which must be corrected through surgery. I am practically at the end of my rope and empathise with you as I so strongly understand how you feel. I am booked for more tests through the specialist, by the way, specifically a VEMP, which will serve to diagnose SCDS. The problem is often the result of head injury, which has left a pinprick hole in the skull and through which the audible pulse is magnified in the eardrum. I banged my head quite severely early in the year which resulted in a vitreous detachment (the sensation of electric lights and zigzags for several weeks) so naturally wonder whether I am experiencing sequellae from this same injury. It took ages to get to the bottom of the flashing lights and impaired vision, as well.
I found a website for pulsatile tinnitus (not the average ringing) called whooshers.com. The woman who began it keeps a list of specialists who deal with the problem and hopefully she has one in your area. The site is an excellent rescource – interesting, helpful and devoted to people such as me, for which I feel especially grateful. I believe you are going to have to take yourself off somewhere to be diagnosed and fixed so as to be able to welcome back your old life. With best wishes from a like sufferer – Jill
i have a continuously disturbing pain in my right ear it started yesterday after i got involved in a minor car accident ..where i hit the front seat with my head around my mouth what is your take
Hard to know for certain what’s going on without examining you, but the most likely explanation is that you hit you lower jaw, and the impact did some damage to the jaw joint — temporomandibular joint, TMJ. Hard to say how much damage, or whether it’s a long-lasting sort of damage or something you’ll get over soon. The TMJ is so close to the ear canal that pain in the joint is usually perceived as an ear pain. Anyway, there are issues here that can only be addressed by someone who can see you, perhaps take X-rays, etc. If it’s still hurting, see a doc. Hope this helps!
Dr. Hoffman,
Apologize about the Kaiser comment, then! I have no basis for comparison, I just felt that since I’ve been underwhelmed it might have something to do with the particular conditions of Kaiser rather than just bad luck or something.
Amazing coincidence, but I’m from Bakersfield, and am actually here right now (for the next ten-twelve days). In fact, a man who must be your colleague (Dr. Stone) put in one of my ear tubes. Unfortunately, I’m whisked back and forth across the imaginary line separating “Kaiser Northern California” from “Kaiser Southern California,” and this makes treatment difficult, so my primary ENT has been in Oakland but I saw Dr. Stone a few times. He was helpful and actually referred me to my allergist, which I appreciated (I learned that much of what I’m experiencing was due to severe allergies), but unfortunately I don’t think he really believed my pulsatile tinnitus (not bad mouthing him at all, he’s a really nice person I believe, but I think I just had one too many symptoms going on at the same time).
I doubt it would be possible to get in on such short notice, but I’m happy to know that I might have access to your services in the future if they’re still needed (I hope not! But it’s lasted this long…). Unless you think I should try to get in, if there’s something that can be done in such a short amount of time. To be honest, I’d be a little wary of trying the nose drops — I have a complicated history with different treatments sometimes making my situation worse rather than better, and while I’m often very uncomfortable as things are, they have been and could be a lot worse. But I’d be interested in anything that could get to the bottom of my pulsatile tinnitus (if I could knock at least one symptom out, maybe I’d be more cavalier again about new treatments for the others). Though I suppose I should think more about the nose drops, if they would mean I could again do some cardiovascular exercise without my ear freaking out.
Hey Nick, ever think it was meant to be? My only concern about seeing you next week is that I’ll be squeezing you into the schedule, so I may not have much more than 15-20 min to spend with you. You need more than that. But if you can cut me some slack for not being able to take as comprehensive a history as I think you deserve, I could certainly get you in, and we could at least get started working on your problems. I’ll have my office call you Tuesday afternoon (assuming I can find your contact info through our computer system) to offer you an appointment.
Hoffmand, I’m so sorry you’re so exhausted – I certainly hope the break helps. It’s good of you to take over this project, particularly when most suffering people expect a diagnosis over the internet! I suspect Nick has no interest in hearing from other people who wrestle with the same, dismal symptoms. Empathy certainly doesn’t produce results and perhaps he prefers to self-diagnose, anyway. For anyone who has pulsatile tinnitus, please try whooshers.com. Misery loves company and the time to diagnosis is understandingly long and arduous!
Patient support groups are a double-edged sword. On the one hand, there’s nothing better for addressing the loneliness of feeling like you’re the only person in the world suffering from X, and that no one in your circle of family and friends understands what you’re really going through. On the other hand, these groups can be a source of disinformation. And on the third hand, these groups can sometimes be extremely useful sources of information, suggesting diagnoses to a patient that he can then relay to his doctor. We can’t always think of everything, and especially with a relatively newly characterized illness such as SSCD — first described in 1998 — many doctors, especially non-ENTs, haven’t even heard of it yet.
Thanks for the kind wishes, but I’m on call this weekend . . . hoping for a quiet one, of course.
I’ve been attempting to do a bit of research on the internet. It could be that I have patulous eustachian tube, as well – hopefully, I’ll find out on Wednesday what is causing this prolonged (nine months) symptom of extremely loud heartbeat on one side (it never abates, so is terribly nerve-wracking). I wonder what the treatment is for such, as I can’t seem to find an appropriate answer which likely means there really isn’t one. The most recent finding I have come across is to use either blu tack (a pea-sized dollop) or steristrip against the eardrum (I suppose to cushion the sound), the most recent research from Dalhousie University, in Canada. I strongly suspect it would be a vast improvement to be completely deaf in one ear and question as to whether an ENT surgeon would agree to such procedure, for peace of mind of the patient. It is difficult to imagine being plagued with this symptom, for years on end. I am supposed to go on a cruise, fly to the departure port and wonder whether either mode of travel would be contraindicated. Thanks and sincerely, Jill E.
Perhaps you have patulous Eustachian tube dysfunction, but that is not what you have described. You’re describing pulsatile tinnitus, a condition which can have a variety of causes (anything from the relatively innocent jugular venous hum to the relatively serious vascular tumor or vascular malformation). This requires a careful workup by an ENT with appropriate radiologic studies. The treatments you describe — taping something to the ear drum, eliminating all hearing — are incredibly far from the mainstream.
My son has developed facial twitching within 4 days of having grommets inserted. I need to establish if the operation had anything to do with this. Need advice please as this is distressing.
In 21 years of practice, I’ve never seen this, nor have I ever heard of it. That doesn’t mean it couldn’t be related — we have a saying in medicine, “never say never” — but it certainly means it’s not a common complication, nor even one of the commonly known rare complications.
I have gone to two ENT regarding ETD. The second doctor performed hearing test, pressure and some other test that he said I don’t have ETD. After the hearing test, it determined a below the average hearing and said I suffer from nerve damage from a loud noise.
I remember having sinus issues that caused the soreness in ears and throat. I was in bed one morning planning my day when I felt the left ear plug. I knew at that point, the sinus, throat, and ear issue need a doctor’s care. I went to doctor and was treated with antibiotics for ear infection and allergy nasal spray. After a couple of weeks of antibiotice, allergy and steroid nasal spray, and Sudafed, the sound in the ear is still muffled and pressure with some ringing.
After I use the nasal spray I feel crackling noise and I can move my jaw around to relieve some of the pressure. The sound I hear is not a normal sound and I feel as long as there is this pressure against my inner ear, even with a hearing aid, the sound will have the muffled sound. The only difference is louder muffled noise.
I do not believe for one moment I experienced a loud noise. My hearing was immediate that morning.
I don’t know what to do. I really don’t think a hearing aid is the answer. Just like some of your other messages I read, sometimes it is painful to hear too. I started moving my jaw around to loosen the moisture or whatever is in there causing the sound to muffle. I found by moving my jaw towards my ear, it pops in there and feels like if I continue doing it, it might open.I do not have head aches ever unless the sinuses are acting up before rain. I don’t have TMJ.
Please give me some encouragement that I’m not wrong. I didn’t have gradual hearing loss nor have I been around anything loud.
Hard to comment without actually seeing the hearing test and examining you. I suspect the ENT made the determination of a noise-related hearing loss based on the shape of the audiogram. Just because the audiogram suggests a noise-induced loss doesn’t mean that’s what happened — it could be coincidental that it LOOKS like a noise-related loss.
The question to ask the ENT: is this hearing loss purely a nerve deafness? If so, then no amount of antibiotics, antihistamines, Sudafed, or nasal steroid spray will help you. However: you wrote “My hearing was immediate that morning.” Did you mean to write, “My hearing LOSS was immediate that morning.”? If so, this is a sudden sensorineural hearing loss, and these are potentially treatable. In our group practice, we offer this protocol to most patients: http://www.ncbi.nlm.nih.gov/pubmed/18401285
There’s a whole set of tests sudden hearing loss patients need . . . often involving an MRI, sometimes blood testing. You need to have this discussion with your ENT as soon as possible.
Hello.
I have a clicking in my ears for about 3 weeks now. I believe is it ETD and I am taking a steroid nasal spray. However, it is really affecting my everyday life. I cannot talk to anyone without this clicking noise and I can’t concentrate on anything else all day long. I don’t have ear wax, sore throat or runny nose but only clicking and popping feeling and sound. It is making me depressed as I am reading various comments about it and some people have had it a very long time and I am really worried that it wont go away. I went to a doctor and he said to give it time, but there has been no improvement. Should I go see a ENT specialist or could something else be wrong?
thank you,
Michelle
Hi Michelle,
“Clicking” is much more commonly associated with middle ear myoclonus than with ETD. Check out this blog post I wrote back in 2006 (I think?) The links still work. See if any of that information sounds right to you.
Thanks. Its really frustrating when my doctor seems unsure as to what it is. What would you recommend for a treatment. It does seem to be getting worse. People standing beside my head can even here the cracking/clicking sound when I block and unblock my nose. The only time it seems to have relief is when I eat, or when I don’t talk at all. Does this sort of thing just go away, or is it a bad sign that it seems to get worse with time? I have tried all the usual, decongestant, antihistamines etc. I do not feel blocked up at all and I feel that the nasal spray is doing more damage than good. What would your recommendations be?
Thank you so much.
Hi…I hope I can still get a response. I see the last question was in January. I have allergies, some sinus issues, and a really bad cold/flu back in Feb that required antibiotics (1st time since a child). I’m 45. This Mar/Apr I’ve been managing allergies pretty well (I thought). I felt under the weather for a day and then wham…sudden earache. Never had one (maybe as a kid). In 4 hrs I was in ER. Nasty infection. Potential for rupture. It ruptured at 1am. On top of inner ear infection and ruptured eardrum (small hole), I now have an outer ear infection…all in 4 days time. I’m on antibiotics, ear drops, nasal spray, antihistimine (and my normal prescription eye drops…pataday). Pain is gone. Still a bit naseous. Energy coming back. But, the fluid behind eardrum hasn’t changed at all in a week…full feeling, whosh/ringing constant. Doc says it could be 1-3 months. How do people live like that? Help…N
You’ve only asked one question. So I’m guessing you want to know what to do about the fluid. Yes, the wait-and-see approach will usually work (but takes time). But if you can find an ENT who will offer you a myringotomy (a small incision in the ear drum to drain the fluid), that’s another option, too. As with any procedure, there are risks, and your ENT would counsel you on these before doing the procedure.
I sometimes experience the sensation of needing to ‘pop’ my ears when exercising, and when i am breathing harder, the noise of my breath is amplified to the point where i can’t hear what other people are saying. Swallowing or trying to pop my ears usualy doesn’t help. It goes away gradually after i stop exercising, but coud it actualy have something to do with ETD?
Sounds like patulous Eustachian tube dysfunction, diagnosis and treatment of which has been discussed here a LOT. PETD = abnormally open Eustachian tubes. There’s an easy test for it. Next time you get that noisy breathing symptom, lie down flat. See if it goes away. You may need to stay flat for 10-20 minutes, but if the symptom resolves, you have your answer.
Thanks….i will definitely look into it! I wasn’t sure if this was a common problem or something serious i should get checked by my GP but since i found this blog i now have somewhere to start and something to go by!
Ok i have this strange problem. Whenever i swallow theres a clicking type of noise in my right and left ear. I went out of country from march to april 2012. Before that, everything was fine. When i came back my right ear had little amount of hearing loss which is exhuasting becasue i feel it helps with my balance. When i wake up in the mornring every day, both of my ears feel plugged. but as the day progesses, my ear slowly starts opening up. And the strange thing is as my ears start opening up, i start thinking more clearly. in the mornring, i feeli can’t concenratte on anything. is there any way the brain is connected to the ear?
This does sound like Eustachian tube dysfunction. That’s a guess, mind you, based on limited information, no actual exam, etc. You need to see a doctor for a REAL diagnosis, of course. There are a number of ways to make this diagnosis; best is with something called tympanometry. Also, a skilled doctor using an otoscope with an insufflating bulb can make the diagnosis, too. It helps to see a specialist, but this isn’t absolutely essential — especially if your primary care doctor has a tympanometer.
You’re wondering also if this problem could be affecting your ability to concentrate. I’m not sure why this happens, but I have seen it before — when the ears are plugged, people will sometimes report that they feel a little dazed, in a dream-like state, etc. I can’t think of a really good mechanism to explain this, but maybe it will help you to know you’re not alone.
I was diagnosed with ETD (left ear only) by an ENT specialist. I detect a slight fullness (intermittent) – also if I hold my nose and pressurise, I hear clicking/bubbling (or even move the muscles for a yawn). I am a musician/audio engineer and would regard ANY reduction in hearing as a disaster (even a few dB) – is myringotomy or insertion of a grommet even an option? I have tried the whole steroid/prednisone approach, with no real improvement. Are there any other alternatives you’ve heard of – infrared light or laser, maybe, or something else circulation/inflammation related?
Best treatment in my opinion is to identify the underlying problem (allergies? sinus infection? reflux?) and treat accordingly. Treat the underlying problem and the ETD should resolve with time. If it’s due to a viral infection (a common cold, flu, etc.) once again time will do the job.
There’s relatively little risk from a myringotomy, but it could well be a short-term fix. Once the myringotomy heals, if the underlying problem has not been treated, the ETD will become apparent once again.
A tube is longer-term solution, but you would likely be a bad candidate. I strongly suspect that the weight of the tube subtly changes the acoustics of the ear drum. Patients I’ve had in the past who are singers, musicians, music teachers etc. usually don’t like tubes, and ask to have them removed within days of placement. Your mileage, of course, may vary, but some of these folks have told me that they just don’t like their hearing post-tube. Best of luck.
thanks for your response.
according to my current dr, i don’t have fluid behind my ears constantly, though i do at some points in time . My ear is at that endpoint of sort of functional where it is always feeling clogged but clears fluid, and can tip into not clearing fluid
I dont know that the dr said that I had exostoses, unless I am misunderstanding you.
I’m at a loss of what to do next.
Ive had mri.s and a scope up my nose
are there any other tests you could recommend?
or any “super” expert?
I am willing to start flying around anywhere.
I am waiting until after I have my next surgery with my current dr and then I’ll try find out about other possible approaches. Would it be worth it to fly out to visit you, do you think? Im at the other side of the country
See above.