Managing Chronic Liver Issues and New Ear Symptoms: A Neurology Perspective

Long-term liver function abnormalities and bronchial sensitivity have recently led to increased ear ringing and worsening headaches?

Hello, Doctor.
Here is a summary of my pre-existing conditions and the issues that have arisen this past week.
I have been a carrier of hepatitis B since childhood and have resumed regular medication treatment in recent years.
However, I have only had periodic blood tests, which indicate abnormal liver function.
Due to the COVID-19 pandemic, abdominal ultrasound examinations have not been possible, leaving me uncertain about potential fatty liver issues.
About two years ago, after having the flu in winter, my airways became more sensitive.
Especially in the past year, with poor air quality, I have been coughing severely, sometimes making it difficult to speak.
Currently, I can only manage moderate persistent asthma without complications, using medication along with inhalers for control.

I have had headaches for many years; they used to occur occasionally or more frequently over a few days, typically unilateral, sometimes on the left and sometimes on the right, usually resolving after a few days with minimal use of painkillers.
I also experience a noticeable swelling sensation in the scalp above both ears, which feels sore and numb when pressed.
More than two years ago, before I started treatment for hepatitis B, I suddenly experienced numbness in my right hand, which gradually spread from the fingertips to my upper arm.
An orthopedic evaluation revealed a very mild, impending herniated disc in my cervical spine.
After a period of rehabilitation treatment (including heat therapy, electrical stimulation, and cervical traction), there was improvement.

Chronic shoulder and neck stiffness has been an ongoing issue.
This year, I have felt deep pain and weakness in my left lower back, and I often find myself needing to support my left waist with my hand when changing positions, fearing sudden severe pain.
In May of this year, I began seeing a traditional Chinese medicine practitioner for acupuncture to help with structural adjustments, which has led to significant improvement over the past month.

However, starting last Sunday, I began experiencing new symptoms.
I have a bubbling sound in my left ear, which occurred two to three times on the first day, culminating in a sudden high-pitched tinnitus during dinner.
On Monday morning, the bubbling sensation in my ear was quite pronounced, lasting for several minutes, stopping for about ten minutes, and then repeating, only in the left ear.
I later managed to ignore it while working in the afternoon.
When I got home for dinner that evening, the intermittent bubbling returned.
On Tuesday, the bubbling in my left ear decreased, but I experienced sharp pain on the right side of my head, which was different from my usual mild, dull pain.
The pain was intense enough to cause me to frown deeply.
On Wednesday, the bubbling in my left ear continued, sometimes present and sometimes absent, with some headache, but it was slightly better than Tuesday.

On Thursday, the bubbling sensation seemed to last longer, and the sound variations felt increasingly irregular, resembling a mix of low-frequency noise and bubbling sounds, with high-pitched tinnitus occurring only two or three times.
On Friday morning, I woke up with a persistent bubbling sensation in my left ear, but after a deep sleep that night, I still felt very fatigued and stayed in bed.
After getting up in the afternoon, I felt fine temporarily, but after dinner at 7 PM, I still felt very tired and went to lie down.
At 8:30 PM, I suddenly felt a dull pain in my heart area.
Over the past few days, I have also felt a persistent urge to cough, with my tonsils feeling itchy and rough (I have been testing negative for COVID-19 for the past four to five days).

Due to the pandemic, some clinics seem unable to perform further examinations, and some advanced tests lack the necessary equipment.
My symptoms seem to require consultations with several specialties, but with the current pandemic situation, is it advisable to visit a hospital? Will it not affect resources for other patients with severe conditions? Since I have just moved, I would like to change my healthcare providers for my liver and respiratory issues.
Otherwise, I may need to visit at least two or three clinics.

I would like to ask you, Doctor, whether the sounds in my ears and headache symptoms are more related to bodily changes or to autonomic nervous system dysregulation.
Which specialty should I start with for appointments and what tests would be most efficient? (Family medicine? ENT? Neurology?) Would you recommend going directly to the hospital to address my needs for examination and treatment? Thank you for taking the time to respond to my lengthy message.

Qiu Xiaojie, 40~49 year old female. Ask Date: 2022/06/04

Dr. Jiang Junyi reply Neurology

Dear Miss Chiu,
You mentioned that "the frequency of the popping sound in my left ear has decreased, but there are sudden sharp pains on the right side of my head, which are not the usual occasional dull aches.
The pain is severe enough to furrow my brow and make my expression quite unpleasant...
Is this related to autonomic nervous system dysfunction?" Your symptoms may need to be evaluated for migraine.
Common prodromal symptoms of migraine include visual disturbances, such as seeing stars or flashes of light, as well as blurred or distorted vision.
Following the onset of these prodromal symptoms, you may experience tingling, weakness, or numbness in the face, hands, or legs.
During the attack, symptoms such as nausea, vomiting, photophobia, phonophobia, and pallor may accompany the pain.
After the prodromal phase subsides, you may experience intense, unilateral throbbing pain that can last for several hours, or even up to 2-3 days.
You mentioned, "If I need to visit clinics, I might have to go to at least two or three." It seems your symptoms may require a multidisciplinary approach.
I recommend seeking care at a nearby hospital with an emergency department to consolidate your medical information in one place.
If you have received two or more doses of the COVID vaccine, you may have less concern about severe illness.
Please ensure to practice self-protection and hygiene before and after your medical visits.
Thank you for your inquiry, and feel free to discuss any related questions!
Wishing you good health and peace,
Dr.
Jiang Junyi, Taoyuan Medical Center

Reply Date: 2022/06/04

More Info

Managing chronic liver issues alongside new ear symptoms can be complex, and it's essential to approach this situation with a comprehensive understanding of both the liver condition and the neurological implications of your new symptoms. Given your history of hepatitis B and the recent onset of ear-related symptoms, it is crucial to consider how these factors may interrelate.

Firstly, chronic liver disease can lead to various systemic effects, including neurological manifestations. Hepatic encephalopathy, for instance, is a condition that arises from liver dysfunction, leading to the accumulation of toxins in the bloodstream that can affect brain function. Symptoms can include confusion, altered consciousness, and even changes in sensory perception, which may explain some of your neurological symptoms, such as headaches and ear noises. However, your symptoms seem to be more localized to the ear and head, which may suggest a different underlying issue.

The ear symptoms you describe—such as the "popping" sounds and tinnitus (ringing in the ears)—could be related to several conditions. Eustachian tube dysfunction is a common cause of such symptoms, where the tube that connects the middle ear to the back of the throat fails to open properly, leading to pressure changes and discomfort. This dysfunction can be exacerbated by respiratory issues, which you mentioned have been problematic for you, especially with your history of asthma and sensitivity to air quality.

Moreover, the presence of headaches, particularly if they are unilateral (on one side), could indicate a migraine or tension-type headache, which can sometimes be associated with ear symptoms. Migraines can cause auditory disturbances, including tinnitus, and may be influenced by stress, hormonal changes, or environmental factors.

Given your complex medical history, including chronic liver disease, respiratory issues, and the recent onset of ear symptoms, it is advisable to take a multidisciplinary approach to your care. Here are some recommendations on how to proceed:
1. Ear, Nose, and Throat (ENT) Specialist: Start with an ENT specialist to evaluate your ear symptoms. They can perform a thorough examination, including audiometry tests and tympanometry, to assess the function of your eustachian tubes and overall ear health. They can also rule out any structural issues or infections that may be contributing to your symptoms.

2. Neurologist: If the ENT evaluation does not reveal a clear cause for your symptoms, consider consulting a neurologist. They can assess your headaches and any neurological symptoms you may be experiencing. Given your history of hand numbness and cervical spine issues, a neurologist can evaluate for any potential neurological conditions that may be contributing to your symptoms.

3. Primary Care Physician (Family Medicine): Your primary care physician can coordinate your care and help manage your chronic liver condition. They can also assist in monitoring your overall health and refer you to specialists as needed. They can perform routine blood tests to monitor liver function and assess for any complications related to your hepatitis B.

4. Pulmonologist: Given your history of asthma and respiratory sensitivity, a pulmonologist may be beneficial to evaluate your lung function and manage your asthma more effectively, especially if you are experiencing increased respiratory symptoms.

5. Considerations for COVID-19: Given the ongoing pandemic, it is essential to consider telehealth options for initial consultations, especially if you are concerned about exposure in a clinical setting. Many specialists offer virtual appointments, which can be a safe way to begin your evaluation.

In summary, your ear symptoms and headaches may be interconnected and warrant a thorough evaluation by specialists in ENT and neurology, alongside ongoing management of your liver condition. It is crucial to address these symptoms promptly, as they can significantly impact your quality of life. Don't hesitate to seek care, as hospitals and clinics are equipped to handle patients with chronic conditions, even during the pandemic. Your health and well-being should always be a priority.

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