Tinnitus and Nasal Issues: Seeking ENT Guidance - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Mr.
Wenzi,
1.
A detailed examination is necessary to determine the cause.
For your reference, "Local Surrounding the Central" – The Correct Concept of Treating Tinnitus.
Mr.
Chang Junhong from the Democratic Progressive Party wrote a small book years ago titled "The Path to Governance – The Theory and Practice of 'Local Surrounding the Central'," where he discussed how the opposition DPP could first gain local governance through elections of county and city mayors in Taiwan, and then push towards the central government and even the presidential election.
This strategy of surrounding the central authority with local power can also be applied to the diagnosis and treatment of the bothersome condition known as tinnitus.
Tinnitus is a highly subjective experience.
After a basic local examination by an otolaryngologist, which rules out earwax or otitis media, doctors often arrange for hearing tests.
If hearing loss is present and is of a neurological nature, the doctor can only prescribe oral medications to prevent further deterioration of hearing, but there are no specific remedies for tinnitus.
If the hearing test shows normal results, it is often considered purely psychological.
The concept of "Local Surrounding the Central" suggests that tinnitus is rarely a singular event; patients often have other underlying conditions alongside tinnitus, and it is likely that tinnitus is merely one clinical manifestation of these conditions.
If treatment can be approached from the perspective of other clinical symptoms, and if these objective symptoms (like the "local") improve, leading to the subjective tinnitus (like the "central") disappearing, we can consider the treatment successful.

With the prosperity of socioeconomic development, there has been a corresponding increase in patients with hypertension and hyperlipidemia; changes in entertainment among younger populations, such as KTV, concerts, and personal music devices, are major causes of noise-induced tinnitus; and the intense competition in industrial society has led to vascular spasms in the cochlea, while the aging population has resulted in more cases of age-related vascular tinnitus.
These are all factors that an otolaryngologist must consider when treating tinnitus.
Below is an introduction to diseases related to tinnitus.
● Classification of Tinnitus
"Tinnitus is a gradual onset of deafness," and "if tinnitus persists, it may lead to deafness," these ancient phrases highlight the serious possibility that tinnitus can lead to significant hearing loss.
The English term for tinnitus comes from the Latin word meaning "ringing." Scholars generally classify tinnitus based on its causes as follows:
○ Cochlear Tinnitus
Cochlear tinnitus, as the name suggests, is caused by lesions in the inner ear.
The most well-known conditions include Meniere's disease and the increasingly common sudden sensorineural hearing loss.
I have previously discussed Meniere's disease in "A Discussion on Dizziness," and I will reiterate it here.
1.
Meniere's Disease
When the general public thinks of dizziness, they often think of "Meniere's," and even general practitioners tend to diagnose it as such.
In reality, there are not as many cases of Meniere's disease as one might think; many patients complain of dizziness and are overdiagnosed by physicians as having Meniere's disease.
Therefore, if the number of Meniere's cases is disproportionately high among patients in a neurotology clinic, the physician's competence in managing dizziness may be called into question.
Simply put, if a patient experiences dizziness, tinnitus, and hearing loss, the physician will consider this disease.
The renowned Japanese physician Ichiro Kitahara even described it as a "7 points disease," due to the following characteristics:
1) Severe dizziness: The sensation is akin to the world spinning, often lasting for several hours, with the first episode being the most intense.
2) Spontaneous dizziness: It occurs without any apparent trigger and can strike suddenly.
3) Recurrent dizziness: Patients with Meniere's disease often experience repeated episodes, rarely having just one.
4) Reversible dizziness: There are periods of complete normalcy between episodes; dizziness does not last for several days.
5) Dizziness accompanied by cochlear nerve symptoms: Patients often have fluctuating hearing, with severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6) Hearing loss typically manifests at low frequencies.
7) There is a "reverberation phenomenon," where patients often complain of discomfort in noisy environments like markets or stations.
To date, no laboratory tests can definitively diagnose Meniere's disease, making detailed medical history and basic physical examination crucial.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a sensation of ear fullness, and hearing loss.
These episodes do not occur daily and last longer than the brief episodes seen in benign paroxysmal positional vertigo, nor do they last for days like vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, but episodes may recur weeks later.
Many elderly patients report having recurrent dizziness since their youth, with gradually worsening hearing and persistent tinnitus.
This condition commonly occurs between the ages of 20 and 40 and has a maternal hereditary component.
The cause is believed to be endolymphatic hydrops in the inner ear, leading to a sensation of ear fullness.
Treatment primarily involves medical management, including neurotropic agents, vasodilators, and mild sedatives.
If episodes occur monthly, treatment should last at least four months; if they occur every two months, treatment should last at least five months, which is the interval between episodes plus an additional three months.
If medication is ineffective or the patient cannot tolerate long-term medication, endolymphatic sac decompression surgery may be considered.
2.
Sudden Sensorineural Hearing Loss
"Sudden" implies that the patient can clearly identify a specific day or even moment when they suddenly lost hearing or experienced significant ringing.
This is an otolaryngological emergency, and patients are generally advised to seek immediate hospitalization.
Some patients may also experience dizziness and vomiting, necessitating differentiation from Meniere's disease.
Typically, dizziness occurs only once and lasts for a day or several days without recurrence, but hearing loss and tinnitus persist.
In contrast, Meniere's disease involves recurrent dizziness, but hearing often recovers more quickly after episodes.
A small number of acoustic neuroma cases may also present with sudden hearing loss, requiring a CT scan for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disturbances, viral infections, and autoimmune diseases.
Treatment has shifted from a "shotgun" approach to targeting the potential causes for each case:
1) Inner ear circulatory disturbance: Blockage or spasm of the blood vessels supplying the inner ear leads to hypoxia and hearing impairment.
This often occurs in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Treatment primarily involves plasma expanders (e.g., Dextran), which is a glucose polymer that reduces blood viscosity and prevents thrombosis.
2) Viral infections: Various viruses can infect the inner ear, such as the rubella virus and cytomegalovirus, which can cause congenital deafness; mumps virus, measles virus, varicella-zoster virus, and the currently circulating influenza virus can lead to acquired deafness.
Treatment involves administering corticosteroids, starting with 60 mg daily for six days, then tapering over two weeks.
3) Autoimmune diseases: Patients often have systemic autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, frequently presenting with bilateral hearing loss.
Diagnosis is based on medical history, physical examination, and electronystagmography (ENG) to differentiate between central and peripheral causes.
Patients are generally advised to be hospitalized for at least a week; if hearing does not improve, they may be discharged; if there is improvement, they may stay for another week.
During hospitalization, daily hearing tests and eye movement changes are recorded, and follow-up appointments are scheduled every two weeks for three months after discharge.
Prognostic indicators include: 1) earlier treatment leads to better outcomes; 2) high-frequency loss indicates poorer prognosis; 3) dizziness correlates with poorer prognosis, while tinnitus suggests preserved cochlear nerve function and better prognosis; 4) older age correlates with poorer prognosis.
○ Noise-Induced Tinnitus
Generally, noise-induced tinnitus can be divided into chronic noise exposure and acute trauma-induced tinnitus.
The former results from long-term exposure to noisy environments, while the latter may arise from events like explosions, gunfire, or the loud music at concerts that are popular among today's youth.
1.
Chronic Noise-Induced Hearing Loss
The modern industrialized society has brought prosperity but also created a noisy environment.
Many workplaces can lead to occupational injuries, such as those in railways, factories, airports, auto repair shops, DJs, gaming employees, and securities traders.
Noise levels below 80 decibels are less likely to cause hearing damage, but exposure to noise levels above 100 decibels for more than eight hours can easily lead to temporary threshold shifts.
If one avoids noisy environments promptly, hearing may recover.
However, if permanent threshold shifts occur, hearing loss becomes irreversible.
Pathologically, the outer hair cells in the inner ear may degenerate, and stereocilia may fuse or disappear, resulting in irreversible tissue damage.
Labor safety regulations have established permissible noise exposure limits to protect workers' hearing, which can serve as a reference for daily life and work.
In principle, the maximum allowable industrial noise level is 90 decibels, and exposure should not exceed eight hours per day.
2.
Acute Trauma-Induced Hearing Loss
Acute trauma-induced hearing loss refers to inner ear damage caused by intense external sound stimuli over a short period.
This is a direct physical injury from mechanical waves.
Young people often frequent rock concerts, karaoke, and pubs, and may experience tinnitus, hearing loss, and a sensation of ear fullness the following day, which can be termed "disco hearing loss," "karaoke hearing loss," or "personal music device hearing loss." After the presidential election, several patients presented in the clinic with symptoms of ear fullness, ear pain, and tinnitus after exposure to loudspeakers at campaign headquarters, which could be referred to as "election hearing loss." Additionally, the high-pressure shock waves from the recent explosion on Wall Street lasted more than 1.5 milliseconds, while the shock waves from gunfire typically last less than 1.5 milliseconds.
Unlike irreversible hearing loss from long-term noise exposure, these acute situations are due to transient auditory trauma, and medication treatment is very effective.
It is strongly recommended to seek prompt treatment to restore hearing.
However, if noise levels exceed 130 decibels and exposure is prolonged (such as the continuous 250 decibel firecrackers commonly seen at weddings and funerals), it can also lead to a decrease in the ear's adaptation to noise, resulting in irreversible damage similar to chronic noise-induced hearing loss.
○ Metabolic Tinnitus
Among the metabolic causes of tinnitus, hyperlipidemia is the most common.
Due to the economic prosperity of modern society, there is a widespread phenomenon of nutritional excess, leading to a dramatic increase in patients with hyperlipidemia.
In neurotology clinics, up to 10% of patients may have this condition.
These patients often complain of feeling "dizzy, dull-headed, and ringing in the ears," experiencing an indescribable discomfort.
The mechanisms causing tinnitus include: 1.
The blood vessels in the inner ear are very delicate and lack collateral circulation, making it easy for lipids to deposit in the cochlea.
2.
Increased blood viscosity can lead to poor circulation and embolism in the inner ear.
Patients with hyperlipidemia seen in internal medicine often have other conditions such as hypertension, diabetes, atherosclerosis, or heart disease, requiring several months of medication before seeing results.
In neurotology, hyperlipidemia patients often present with tinnitus and dizziness as their initial symptoms, without accompanying internal diseases, and typically feel significantly better after just one week of medication.
Among all symptoms, dizziness responds best to treatment, followed by tinnitus, while hearing loss shows no improvement.
If patients stop medication after their lipid levels normalize but do not pay attention to their diet, recurrence is likely.
However, once they resume medication, they immediately feel relieved.
Subsequent blood tests show lipid levels returning to normal, supporting our hypothesis.
○ Vascular Tinnitus
The vertebral arteries supply blood to the brain and inner ear, merging with the basilar artery and branching into the anterior inferior cerebellar artery, posterior inferior cerebellar artery, and superior cerebellar artery.
If the arteries supplying the inner ear become blocked or spasm, it can easily lead to ischemia in the inner ear, resulting in abnormal discharges from the auditory nerve, clinically presenting as tinnitus.
These patients often experience dizziness, nausea, vomiting, and hearing loss, and may also have systemic symptoms such as occipital headaches, neck and shoulder pain, and numbness in the limbs due to insufficient blood supply to the posterior cranial fossa.
Most patients are elderly and often have comorbidities such as hypertension, diabetes, heart disease, and hyperlipidemia.
For vascular tinnitus, which arises from poor blood circulation, traditional treatment often involves vasodilators to achieve therapeutic effects.
However, for vascular narrowing caused by atherosclerosis, vasodilators cause systemic dilation and do not selectively target the inner ear vessels.
It is now believed that improving blood flow dynamics, increasing the deformability of red blood cells, and reducing blood viscosity are essential for ensuring the inner ear receives adequate oxygen and nutrients.
"Vasoactive agents" are medications developed based on this concept, derived from natural ginkgo biloba extracts or synthetically produced.
Red blood cells are approximately 7 micrometers in diameter, while the true diameter of capillaries is only 3 to 4 micrometers.
These medications enhance the deformability of red blood cells, allowing them to pass through hardened vessels more easily; they can also act on the vessels to reduce spasms and prevent platelet aggregation, promoting smooth blood flow.
○ Tumor-Related Tinnitus
In the field of otolaryngology, unilateral tinnitus raises suspicion for two types of tumors: nasopharyngeal carcinoma and acoustic neuroma.
This disease has also been mentioned in "A Discussion on Dizziness," and I will post it again here.
◎ Acoustic Neuroma
The auditory nerve runs from the inner ear to the brainstem, with tumors most commonly occurring at the opening of the internal auditory canal, specifically at the cerebellopontine angle (CP angle).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so although it may compress the vestibular nerve, central compensation prevents dizziness.
As the tumor enlarges and compresses blood vessels, it can lead to sudden hearing loss or dizziness, and symptoms become increasingly diverse as the disease progresses.
If the acoustic neuroma is confined to the internal auditory canal and is less than 1 centimeter, it may be difficult to detect on a CT scan.
Some have attempted lumbar punctures to introduce air into the ventricles, allowing the patient to lie on their side to see if air can fill the internal auditory canal; if an acoustic neuroma is present, the air will not fill the canal, known as "air CT." The downside is that patients may experience headaches for about a week due to air in the cranial cavity.
With the advent of MRI, tumors smaller than 1 centimeter can now be easily diagnosed.
If the tumor grows larger and extends toward the cerebellum or brainstem, it may pose a life-threatening risk.
Clinically, patients may present with normal hearing but no response in auditory brainstem responses, necessitating consideration of this condition.
● Prevention is Better than Treatment
Through the classification of tinnitus mentioned above, we learn that many causes of tinnitus can be prevented in advance.
Patients with Meniere's disease should pay attention to their diet and avoid excessive salt intake; the increase in cases of sudden sensorineural hearing loss may be related to societal development and lifestyle stress.
Occupational noise injuries are often untreatable, so controlling noise in the work environment is crucial; early treatment of acute trauma-induced hearing loss yields excellent results, and it is even more important to avoid potentially harmful environments.
For metabolic tinnitus, in addition to managing underlying medical conditions, appropriate exercise and avoiding fatty foods can help maintain normal cholesterol levels.
● Self-Questioning for Tinnitus
Through some carefully designed questions, we can often identify potential causes of tinnitus in patients.
Here are some simple questions:
1.
Is the tinnitus accompanied by dizziness? Does it become louder during dizziness? Tinnitus associated with dizziness should raise the possibility of "cochlear tinnitus." Meniere's disease, sudden sensorineural hearing loss, and anterior inferior cerebellar artery obstruction are often unilateral; vertebrobasilar insufficiency tends to be bilateral.
Additionally, tinnitus in Meniere's disease tends to be louder during dizziness.
2.
Is the work environment noisy? Have you worked in a high-noise environment for a long time? Have you experienced gunfire or injury from firecrackers? As mentioned earlier, the human ear can tolerate noise levels up to 90 decibels, and exposure should not exceed eight hours per day.
When tinnitus occurs, it is essential to leave the noisy environment to avoid irreversible damage to the cochlear hair cells.
Standard ear protection only blocks 30 to 40 decibels of noise and is ineffective against high-decibel sounds from sources like airplane engines, trains, or lathes.
3.
Have you had blood tests for cholesterol levels? Do you have anemia, high or low blood pressure, thyroid disease, diabetes, or atherosclerosis? Tinnitus caused by systemic vascular diseases is often bilateral, so it is essential to rule out these underlying medical conditions in tinnitus patients.
4.
Are you taking any long-term medications? Have you received antibiotic injections? Some medications, such as aspirin, quinine, contraceptives, antihypertensives, and antipsychotics, can sometimes cause bilateral tinnitus, which resolves upon discontinuation.
Older physicians sometimes administered streptomycin, kanamycin, or gentamicin, which can also lead to tinnitus with prolonged use.
Therefore, if tinnitus occurs after an injection, it is advisable to stop the injection to prevent irreversible damage.
5.
Is the tinnitus high-pitched or low-pitched? Is it unilateral or bilateral? Auditory nerve lesions typically present with high-pitched tinnitus, while Meniere's disease or middle ear conditions often present with low-pitched tinnitus.
Cochlear tinnitus is usually unilateral, while central vascular tinnitus is often bilateral.
6.
Is the tinnitus synchronized with your heartbeat? If tinnitus coincides with the heartbeat or pulse, it may indicate a vascular malformation or venous anomaly.
If the tinnitus diminishes or disappears when the neck is turned toward the affected side, it may suggest excessive pulsation of the cervical vessels.
7.
Is the tinnitus related to breathing? General respiratory infections or Eustachian tube obstruction from flying can cause tinnitus, while excessive Eustachian tube opening can also lead to tinnitus, often accompanied by a sensation of ear vibration during breathing.
If the body bends down to tie shoelaces, increased intracranial pressure may immediately alleviate symptoms.
2.
Please come for a detailed examination to rule out the possibility of sinusitis.
For your reference, here is an article titled "The 'Cure-All' Sinus Surgery That Makes One's Nose Tingle." In the otolaryngologist's clinic, symptoms like cough, headache, dizziness, and nasal congestion are very common, yet their complex causes make treatment challenging.
Patients often flock to exaggerated advertisements promising "cure" or "guaranteed treatment." In recent years, many patients have come to the clinic after undergoing "five-minute sinus cure" procedures, resulting in issues like nasal mucosal adhesions, nasal vestibular inflammation, nasal obstruction, and nasal septal perforation, which are truly overwhelming and disheartening.
The causes of nasal congestion typically include "infection," "nasal structural abnormalities," "allergic rhinitis," and "vasomotor rhinitis," each with its pathogenic mechanisms and treatment approaches.
Of course, each condition has its limits in efficacy, which has allowed alternative traditional therapies to gain traction.
Below is a brief introduction to each disease based on this classification.
◎ Infection: The most common cause of nasal congestion is the common cold.
Once the cold resolves, the congestion typically improves.
Bacterial infections leading to sinusitis are more severe and can cause nasal congestion along with post-nasal drip, headaches, difficulty concentrating, and chronic nighttime cough, significantly affecting children's sleep quality and academic performance.
If conservative treatments like medication and irrigation are ineffective, the physician may recommend surgical intervention.
Previously, the most common procedure was Luc's surgery, which involved incising the lip to remove the entire sinus mucosa, but this has been completely replaced by endoscopic sinus surgery.
Endoscopic surgery allows for selective removal of obstructive mucosal tissue under good visualization, restoring normal sinus function.
◎ Nasal Structural Abnormalities: Deviated septum and chronic hypertrophic rhinitis.
A deviated septum can result from natural compression at birth or from trauma causing cartilage distortion.
The degree of deviation does not always correlate with nasal congestion, and surgical correction may be determined based on the patient's subjective experience.
Chronic hypertrophic rhinitis refers to the hypertrophy of normal turbinate tissue, which can cause nasal congestion.
Turbinates, also known as "nasal meat," are normal physiological structures located on the lateral wall of the nasal cavity, and patients may mistakenly believe they have nasal polyps and undergo inappropriate cautery procedures.
◎ Allergic Rhinitis: Currently, there is no definitive cure for allergic rhinitis in medicine.
It is a disease caused by a specific predisposition, leading to nasal mucosal edema and congestion during episodes.
Treatment can be tailored based on the severity of symptoms, including oral medications, nasal sprays, injections, or surgery to alleviate nasal congestion.
◎ Vasomotor Rhinitis: Various factors can cause vasomotor rhinitis, including work stress, hormonal changes during pregnancy, certain antihypertensive medications, and even irritants like perfumes, temperature, humidity changes, or cooking fumes.
These factors can cause the blood vessels in the nasal mucosa to dilate and become congested, leading to nasal congestion symptoms.
Whether it is chronic hypertrophic rhinitis, allergic rhinitis, or vasomotor rhinitis, treatment options include conservative oral medications, nasal sprays, traditional inferior turbinate resection, and advanced laser surgery.
There are now techniques involving thermal probes placed submucosally in the turbinates, using radiofrequency to generate low heat, causing protein coagulation in the submucosal tissue, leading to fibrosis and reduction of the hypertrophied turbinates.
Nasal congestion itself is not a disease but a highly annoying symptom.
It not only makes breathing difficult but can also lead to dizziness, headaches, difficulty concentrating, snoring, insomnia, or sleep apnea.
Consulting a professional otolaryngologist to identify the true cause of nasal congestion and selecting appropriate symptomatic treatment is the right approach.
We sincerely hope not to see any more so-called "cure-all" sinus surgeries in the clinic.

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Reply Date: 2004/01/25