White Spots on Tonsils: Causes and Treatments - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Mr.
K,
1.
Regarding the issue of tinnitus, I have provided an article for your reference.

2.
As for the tonsils, if there is no pain, it may be due to the natural secretions of the tonsils, which is a normal phenomenon.

3.
For the issue of nasal congestion, I have also provided an article for your reference.
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"Local Surrounding Central" – Correct Concepts for Treating Tinnitus
Mr.
Chang Chun-Hong from the Democratic Progressive Party wrote a small book years ago titled "The Path to Governance – The Theory and Practice of 'Local Surrounding Central'." In it, he discussed how the opposition party could first gain local governance through elections for county and city mayors in Taiwan, and then push towards central governance and even the presidential election.
This strategy of using local governance to surround the central government can also be applied to the diagnosis and treatment of the bothersome condition of tinnitus.
Tinnitus is a very subjective experience; after a basic local examination by an otolaryngologist, which rules out earwax or otitis media, the doctor often arranges for a hearing test.
If there is hearing loss due to nerve damage, the doctor can only prescribe medication to prevent further deterioration of hearing, but there is no specific remedy for tinnitus.
If the hearing test shows normal results, it is often considered purely a psychological issue.
The concept of "local surrounding central" suggests that tinnitus is rarely a singular event; patients often have other underlying conditions accompanying their tinnitus, and it is likely that tinnitus is just one clinical manifestation of these conditions.
If treatment can be approached from the perspective of other clinical symptoms, and if these objective symptoms (like "local") improve, leading to the subjective tinnitus (like "central") disappearing, we can consider the treatment successful.
With the prosperity of the economy, there has been a corresponding increase in patients with hypertension and hyperlipidemia; changes in entertainment among younger populations, such as KTV, concerts, and portable music players, are also major causes of noise-induced tinnitus.
The intense competition in industrial society has led to vascular spasms in the cochlea, and 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 loss of hearing," and "if tinnitus persists, it may lead to deafness." These ancient phrases highlight the serious possibility that tinnitus can cause 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:
- Inner Ear Tinnitus: As the name suggests, this type of tinnitus is caused by lesions in the inner ear.
The most well-known conditions include Meniere's disease and increasingly common sudden sensorineural hearing loss.
I have discussed this in my article "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 may 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.
If the number of Meniere's cases is disproportionately high among patients in a neurotology clinic, the physician's competence may be questioned.
In simple terms, if a patient has dizziness, tinnitus, and hearing impairment, the physician will consider this disease.
The renowned Japanese physician Ichiro Kitamura even described it as a "7 points disease" due to the following characteristics:
1) Severe dizziness: It feels as if the world is spinning and can last for several hours, with the first episode being the most intense.
2) Spontaneous dizziness: It occurs without any triggers and can happen 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, and dizziness does not last for several days.
5) Dizziness accompanied by cochlear nerve symptoms: Patients often have fluctuating hearing, severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6) Hearing loss is often evident in 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, so a detailed medical history and basic physical examination are crucial.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a feeling of ear fullness, and hearing loss.
These episodes do not occur daily, and their duration is not as brief as in "benign paroxysmal positional vertigo," nor as prolonged as in "vestibular neuritis." Most patients experience dizziness for about 3 to 4 hours before it gradually subsides, but it may recur weeks later.
Many elderly patients report having experienced recurrent dizziness since their youth, with gradually worsening hearing and persistent tinnitus.
This condition typically occurs between the ages of 20 and 40 and has a maternal inheritance pattern.
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 neuroprotective agents, vasodilators, and mild sedatives.
If episodes occur once a month, 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 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" means that the patient can clearly indicate a specific day or even a moment when they suddenly lost hearing or experienced severe ringing.
This is considered 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.
It typically involves dizziness only once, lasting for a day or several days, after which it does not recur, but hearing loss and tinnitus persist.
Meniere's disease, on the other hand, involves recurrent dizziness, but hearing often recovers more quickly after episodes.
A small number of acoustic neuroma cases may also present as sudden hearing loss, requiring a CT scan for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disorders, viral infections, and autoimmune diseases, and treatment has shifted from a "shotgun approach" to targeting the specific underlying cause in each case.
1) Inner Ear Circulatory Disorders: These occur due to obstruction or spasm of the blood vessels supplying the inner ear, leading to hypoxia and hearing impairment.
This is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Therefore, treatment focuses on plasma expanders (e.g., Dextran), which is a glucose polymer that reduces blood viscosity and prevents thrombosis.
2) Viral Infections: Many 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 recently prevalent influenza viruses can cause acquired deafness.
Treatment involves corticosteroids, starting with 60 mg per day for six days, then tapering over two weeks.
3) Autoimmune Diseases: Patients often have systemic autoimmune diseases such as lupus or rheumatoid arthritis, and bilateral hearing impairment is common.
Before treatment, a medical history, physical examination, and electronystagmography (ENG) can help determine whether the condition is central or peripheral.
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 is conducted every two weeks after discharge for three months.
Prognostic indicators include: 1) earlier treatment leads to better outcomes; 2) high-frequency loss has a poorer prognosis; 3) those with dizziness have a poorer prognosis, while those with tinnitus still have cochlear nerve function, leading to better outcomes; 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 can occur from events like explosions, gunfire, or loud concerts.

1) Chronic Noise-Induced Hearing Loss: Modern industrial society has brought prosperity but also a noisy environment.
Many work environments can lead to occupational injuries, such as railroads, factories, airports, auto repair shops, DJs, arcade workers, and stockbrokers.
Noise levels below 80 decibels are less likely to cause hearing damage, but levels exceeding 100 decibels for over eight hours can lead to temporary threshold shifts.
If one avoids loud noise quickly, hearing can recover.
However, if permanent threshold shifts occur, hearing loss is irreversible due to pathological changes in the inner ear, such as outer hair cell degeneration and stereocilia fusion or loss, which is an irreversible tissue injury.
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: This refers to inner ear damage caused by a sudden loud noise.
Young people often frequent rock concerts, karaoke, and pubs, and may experience tinnitus, hearing loss, and ear fullness the next day, which can be termed "disco deafness," "karaoke deafness," or "portable music player deafness." After the presidential election, several patients presented with ear fullness, ear pain, and tinnitus after exposure to loudspeakers at campaign headquarters, which could be termed "election deafness." Additionally, the high-pressure shock waves from events like the explosion on Wall Street last longer than 1.5 milliseconds, while gunfire shock waves last less than 1.5 milliseconds.
Unlike irreversible hearing loss from long-term noise exposure, these situations are due to transient acoustic trauma, and medication treatment is very effective.
It is strongly recommended to seek prompt treatment to restore hearing.
However, exposure to noise levels exceeding 130 decibels for prolonged periods (such as continuous firecrackers at weddings or funerals) can lead to fatigue and decreased tolerance to noise, similar to the irreversible damage caused by chronic noise exposure.

- Metabolic Tinnitus: The most common cause of metabolic tinnitus in the population is hyperlipidemia.
Due to the economic prosperity of modern society, there is a widespread phenomenon of nutritional excess, leading to a dramatic increase in hyperlipidemia cases.
In neurotology clinics, up to 10% of patients may have this condition.
These patients often complain of feeling "dizzy, sluggish, 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, arteriosclerosis, or heart disease, requiring several months of medication before seeing effects.
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 normalizing their lipid levels but do not maintain a proper diet, recurrence is likely; however, once they resume medication, they feel immediately relieved.
Blood tests can show lipid levels returning to normal, supporting our hypothesis.
- Vascular Tinnitus: The vertebral arteries supply blood to the brain and inner ear through the transverse foramen of the sixth cervical vertebra, 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 obstructed or spasm, it can easily lead to ischemia in the inner ear, causing abnormal discharges in 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.
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 expand blood vessels for therapeutic effect.
However, in cases of atherosclerosis leading to vessel narrowing, vasodilators cause systemic vasodilation and do not selectively target the inner ear vessels.
It is now believed that improving hemodynamics, 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 designed based on this concept, derived from natural ginkgo biloba or synthesized.
Red blood cells are approximately 7 micrometers in diameter, while the true diameter of capillaries is only 3 to 4 micrometers.
These medications can enhance the deformability of red blood cells, allowing them to pass through hardened vessels more easily; they can also act on blood vessels to reduce spasms and prevent platelet aggregation, thereby promoting smooth blood flow.
- Tumor-Related Tinnitus: In otolaryngology, unilateral tinnitus should raise suspicion for two types of tumors: nasopharyngeal carcinoma and acoustic neuroma.
This was also mentioned in my article "A Discussion on Dizziness," and I will post it again.
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, known as the cerebellopontine angle (CP angle).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so even if it compresses the vestibular nerve, central compensation may prevent dizziness.
As the tumor enlarges and compresses blood vessels, it can lead to sudden hearing loss or dizziness, and symptoms can become very diverse as the disease progresses.
If the tumor is confined to the internal auditory canal and is less than 1 centimeter, it is difficult to detect on a CT scan.
Therefore, some have performed lumbar punctures to inject air into the ventricles, allowing patients to lie on their side so that air enters the internal auditory canal.
If there is an acoustic neuroma, the air will not fill the internal auditory canal, known as "air CT." Its drawback is that patients may experience continuous headaches for about a week due to the air in the skull.
With the advent of "magnetic resonance imaging" (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
After classifying the causes of tinnitus, we learn that many of the causes 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 the development of civilization and lifestyle stress.
Occupational noise injuries are often untreatable, so it is crucial to monitor noise levels in the work environment.
Early treatment of acute trauma-induced hearing loss is very effective, and it is even more important to avoid potentially harmful situations.
For metabolic tinnitus, in addition to controlling internal diseases, appropriate exercise and avoiding greasy foods can help maintain normal cholesterol levels.
Self-Assessment for Tinnitus
Through some carefully designed questions, we can often determine the potential causes of a patient's tinnitus.
Here are some simple questions:
1.
Is the tinnitus accompanied by dizziness? Does it get louder during dizziness? Tinnitus accompanied by dizziness raises the possibility of "inner ear tinnitus." Meniere's disease, sudden sensorineural hearing loss, and anterior inferior cerebellar artery obstruction are often unilateral; vertebrobasilar insufficiency is usually bilateral.
In Meniere's disease, tinnitus 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 been exposed to gunfire? Have you experienced injury from firecrackers? As mentioned above, the human ear can tolerate noise levels up to 90 decibels, and exposure should not exceed eight hours per day.
If tinnitus occurs, it is essential to leave the noisy environment to prevent irreversible damage to the cochlear hair cells.
General ear protection can only block 30 to 40 decibels of noise and is ineffective against high-decibel noises 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 arteriosclerosis? Tinnitus caused by systemic vascular diseases is often bilateral, so it is essential to rule out these internal diseases in tinnitus patients.
4.
Are you taking 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 long-term use.
Therefore, if tinnitus occurs after an injection, it is advisable to stop the injection to prevent irreversible damage.
5.
Is the tinnitus high-frequency or low-frequency? Is it unilateral or bilateral? Auditory nerve lesions often present as high-frequency tinnitus, while Meniere's disease or middle ear lesions often present as low-frequency tinnitus.
Inner ear 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 turning the neck toward the affected side reduces or eliminates the tinnitus, it may suggest excessive pulsation in the neck vessels.
7.
Is the tinnitus related to breathing? Common respiratory infections or Eustachian tube obstruction from flying can cause tinnitus.
Overactive Eustachian tubes can also lead to tinnitus, often accompanied by a sensation of ear vibration during breathing.
If bending down to tie shoes causes a sudden reduction in symptoms due to increased blood flow to the brain, it may also be related.
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This article will be organized in the future on the Yeh Da-Wei Otolaryngology Clinic website / Health Education.
Articles on this website are welcome to be cited, but please indicate the source.

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Reply Date: 2004/11/21