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Pulsatile or pulsating tinnitus

Q: What causes the sound of your pulse to be heard in your ears?

A: This is known as pulsating, pulsatile or vascular tinnitus. Here is a list of the possible causes of pulsatile tinnitus:

1. Chronic inflammation and/or infection of the middle ear. Chronic inflammation is almost always accompanied by increased blood flow to the inflamed tissue; since this tissue is in the ear, some people are able to hear the increase in blood flow.

2. Eustachian tube dysfunction. For reasons which are unclear to me, ETD can sometimes result in pulsating tinnitus.

3. Middle ear effusion (fluid.) The middle ear is normally an air-filled space. If, due to infection, inflammation or Eustachian tube dysfunction fluid accumulates behind the middle ear, pulsating tinnitus may result. It would be accompanied by decreased hearing and a pressure sensation, and may also be accompanied by pain. Treatment may be medical (with antibiotics, decongestants, nasal steroid sprays and so forth) or surgical.

4. Vascular tumors. Such tumors in the middle ear go by a variety of names, but are most commonly referred to as glomus tumors or paragangliomas. They are benign (not cancerous), but due to their location and vigorous blood supply, they can be very troublesome. Treatment is surgical.

5. Arteriovenous malformations (AVMs.) AVMs are abnormal collections of arteries and veins that sometimes occur within the cranial cavity near the auditory nerve. AVM pulsation against the auditory nerve stimulates the nerve, resulting in a pulsating tinnitus. AVMs can also occur outside of the cranial cavity. AVMs can develop as a result of trauma, but can also occur due to abnormal development in the womb– the individual is born with a small AVM which enlarges later in life. Treatment is usually surgical.

6. Carotid artery-cavernous sinus fistula. A fistula is an abnormal connection; thus, carotid artery-cavernous sinus fistula is an abnormal connection between a very large artery and a very large venous "lake" (not really a "sinus" in the sense of facial sinuses) within the cranial cavity. It is usually the result of severe head trauma. Treatment is nonsurgical, requiring the services of an interventional radiologist.

7. Venous hum. Patients who are pregnant, anemic, or have thyroid problems may develop increased blood flow through the largest vein in the neck, the jugular vein. The jugular vein carries blood from the brain back to the heart; in so doing, it traverses the middle ear. Turbulent blood flow anywhere in the course of the jugular vein can be heard in the middle ear as a "hum" which may or may not fluctuate with the pulse. Correction or resolution of the underlying problem often results in improvement.

There are other, less common, causes of vascular tinnitus, but these are the "biggies." I recommend that you see an ear, nose and throat specialist for a comprehensive evaluation, because (as you can see from this list) many of the possible explanations are NOT trivial!


Q: Is it necessary to see a doctor for tinnitus? It began after firing weapons in the military 15 years ago. Can acupuncture help?

A: If you are absolutely certain that you know the cause of the tinnitus (also known as "head noise," or "ringing in the ears") then you are right, it is not necessary to see a doctor. If there is some doubt as to the origin of this noise, then it would be a good idea to see a doctor. Tinnitus can be a symptom of more serious illness– even brain tumor. Nevertheless, if his tinnitus has existed unchanged for 15 years, it is improbable that this symptom signifies anything serious.

Before you completely toss the doctor visit aside, here is what it could possibly accomplish:
1. Verify the diagnosis. In other words, you would have a doctor’s statement that your tinnitus, and any associated hearing loss, is due to noise exposure in the military. You may not need a hearing aid now, but you may need one in 10, 20, or 30 years. This is impossible to predict. If you can get the Veteran’s Administration to acknowledge responsibility for his problem, then the VA may pick up part of the cost of hearing aid(s) in the future. (I am assuming you are a US citizen. Other countries may have similar policies, however.) If this interests you, you ought to see a VA doctor, since his/her opinion will carry more clout than that of a non-VA doctor.

2. Establish the level of hearing loss. For this, you will either need to see an audiologist, or see an ear, nose and throat physician who can do hearing tests in his/her office. This is the best way to determine if you need a hearing aid now, or may need one in the future.

This is also an important point if you work in a noisy environment. If you do, you needs to wear noise protection (plugs, muffs, etc.) in order to prevent further hearing loss. Also, if you think you may have a workman’s compensation case for occupational hearing loss, a "base-line" hearing test is critical. Otherwise, your hearing loss could be attributed entirely to your time in the army.

3. Receive information regarding treatment. True enough, there is no cure for noise-induced tinnitus, but there are a variety of simple techniques which may make the tinnitus more tolerable. Occasionally, medication may be prescribed to help with tinnitus. Devices (such as "tinnitus maskers") may also be extraordinarily helpful for the "tough cases." More information on tinnitus treatment options can be found at the American Tinnitus Association website. 

I’m sorry to say that I have no experience with acupuncture for the treatment of tinnitus. Since there is no cure for tinnitus, many alternative treatments have been attempted. Meditation, biofeedback and herbal medicine are especially popular. As a general rule, however, when multiple treatments exist for an ailment, it is unlikely that any of the treatments are routinely successful. (But that doesn't mean they are never successful!) 

Acute otitis media and middle ear fluid in adults

Q: A young man reports that he was diagnosed with acute otitis media and an effusion. He thought that this sort of thing usually only happened to children.

A: Acute otitis media is a short term (acute) middle ear inflammation (otitis media.) It is almost always due to a bacterial infection. You are correct that this sort of infection is much more common in children than in adults, but adults do, occasionally, get acute otitis media. 

The middle ear (the space behind the eardrum) is normally an air-filled space. In the early days of your infection, this space was filled with dead white blood cells and bacteria– pus, in other words. Gradually, the pus was replaced by a clear, yellow fluid; days to weeks later, the yellow fluid (the medical term is serous effusion) will be replaced by air. 

You probably have a serous effusion at present; this may take 1 to 4 weeks to resolve. Occasionally, the fluid does not go away, even after several weeks. An ear, nose and throat specialist could treat this problem by making a very small cut in your ear drum, suctioning out the fluid, and placing a tiny plastic tube into the hole to help ventilate the middle ear space. The tube could be removed at a later date, or you could wait for it to fall out all by itself, 6 to 18 months after it is inserted.

The underlying cause of most middle ear infections is Eustachian tube dysfunction. The Eustachian tubes are muscular/cartilaginous tubes that extend from each middle ear space to the top of the throat (nasopharynx.) The tubes are normally closed, but can "pop" open as needed to ventilate your middle ear spaces. That’s what the tubes are for– they allow air up into the middle ear spaces.

If you had a very long, skinny finger, you could pass it down one nostril and tickle the opening of one of your Eustachian tubes. Anything that happens to drain from your nose goes down the back of your throat, right past these openings. This explains why acute otitis media is often preceded by cold, flu, or sinusitis. In each case, a nasty mix of mucus and pus drains past the Eustachian tube openings, inflaming them and thereby making it difficult for the tubes to do their job.

Rarely, Eustachian tube dysfunction is due not to inflammation (from sinusitis, allergy or cold/flu) but to obstruction from a tumor. Tumor should be suspected when the infection is recurrent, when the serous effusion fails to resolve after several weeks, or when there are large lymph nodes in the patient’s neck. Since the Eustachian tube openings are difficult to examine by standard methods, the ear, nose and throat specialist will need to examine you by passing a flexible fiberoptic scope down a nostril to view the nasopharynx. Occasionally, further studies (such as a CT scan) may be necessary. 

Eustachian Tube Dysfunction
Douglas Hoffman, M.D., Ph.D.

This is an instructional pamphlet that I give to patients whom I have diagnosed with Eustachian tube dysfunction. The information in this pamphlet is current (last checked 11/1/98) and all factual statements are based on the medical literature. For this Web version, I have provided literature citations for statements that I feel need attribution. These citations are hyperlinked to a reference list at the end of this article.  Other practitioners are welcome to copy and use this material, but by permission only please.

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 discomfort in these situations, you have experienced Eustachian tube dysfunction.

The Eustachian tube 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.

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; if persistent, you may experience hearing loss, 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. Dr. Hoffman will need to determine whether your Eustachian tube dysfunction 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. 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 performed using 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.)

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.

These letters originally appeared in Dr. Hoffman's column on
Copyright (c) 1998 - 2000, Douglas Hoffman, MD all rights reserved
Reprinted with permission from The Medical Consumer's Advocate  

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