Ear Pressure and Headaches: Causes and Solutions - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Miss, your issue may be related to Eustachian tube obstruction and tinnitus.
Here is a reference article.
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"Local Surrounding the Central" – Correct Concepts for Treating Tinnitus
Mr.
Chang Jun-Hong 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'." In it, he discusses how the opposition party, the DPP, could first gain local governance through elections of county and city mayors in Taiwan, and then push towards central governance and even the presidential election.
This strategy of surrounding the central authority 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 to rule out earwax or otitis media, doctors often arrange for hearing tests.
If hearing loss is observed and is of a neurological nature, the doctor can only advise 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 attributed to purely psychological factors.
The concept of "local surrounding the central" suggests that tinnitus is rarely a singular event; patients often have other underlying conditions, and tinnitus may simply be one clinical manifestation of these diseases.
If treatment can be approached from the perspective of other clinical symptoms, and if these objective symptoms (like the "local") improve, leading to the disappearance of the subjective tinnitus (the "central"), 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 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 onset of deafness," and "if tinnitus persists, it may lead to deafness." These ancient phrases highlight the potential severity of tinnitus.
The English term for tinnitus comes from the Latin word meaning "ringing." Scholars typically classify tinnitus based on its underlying causes as follows:
1.
Inner Ear Tinnitus: As the name suggests, this type of tinnitus arises from inner ear disorders.
The most notable examples are Meniere's disease and the increasingly common sudden sensorineural hearing loss.
I have discussed this in my article "A Discussion on Dizziness," and I will reiterate it here.
- Meniere's Disease: When the general public thinks of dizziness, they often think of Meniere's disease, and even general practitioners may diagnose it as such.
However, 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 presents with dizziness, tinnitus, and hearing loss, the physician will consider this disease.
The renowned Japanese physician Ichiro Kitabatake even described it as a "7 points disease" due to its 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 can occur suddenly without any triggers.
3.
Recurrent dizziness: Patients with Meniere's disease often experience repeated episodes, rarely just one.
4.
Reversible dizziness: There are periods of complete normalcy between episodes; it does not last for days.
5.
Dizziness accompanied by cochlear nerve symptoms: Patients often experience fluctuating hearing, severe tinnitus during acute episodes, and sometimes perceive sounds at different frequencies.
6.
Hearing loss is often observed in the low-frequency range.
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 a detailed medical history and basic physical examination crucial.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a feeling of fullness in the ear, 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 as long as vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, only to have another episode weeks later.
Many elderly patients report having recurrent dizziness since their youth, eventually leading to gradual hearing loss 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 neurotrophic 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 three months.
If pharmacological treatment 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 identify 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.
Typically, it only presents with dizziness once, lasting for a day or several days without recurrence, but with persistent hearing loss and tinnitus.
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, and treatment has shifted from a "shotgun" approach to targeting the specific underlying cause.
- Inner Ear Circulatory Disturbances: This occurs when the blood vessels supplying the inner ear become obstructed or spasmodic, leading to hypoxia and hearing impairment.
It is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Therefore, treatment focuses on plasma expanders (e.g., Dextran) to improve blood flow, which is a glucose polymer with a molecular weight of 40,000 that reduces blood viscosity and prevents thrombosis.
- Viral Infections: Many viruses can infect the inner ear, such as the rubella virus and cytomegalovirus, which can cause congenital deafness in fetuses; mumps virus, measles virus, varicella-zoster virus, and the recently prevalent influenza virus can lead to acquired deafness.
Treatment typically involves corticosteroids, starting with a dose of 60 mg for six days, then tapering over two weeks.
- Autoimmune Diseases: Patients often have systemic autoimmune diseases such as lupus erythematosus or rheumatoid arthritis, and typically present with bilateral hearing loss.
Diagnosis involves medical history, physical examination, and electronystagmography (ENG) to differentiate between central and peripheral causes.
Hospitalization for at least a week is generally recommended; if hearing does not improve, the patient is discharged; if there is improvement, they may be hospitalized for an additional week.
Daily hearing assessments and recording of eye movement changes are conducted during hospitalization, with follow-up every two weeks after discharge for three months.
Prognostic indicators include: 1) earlier treatment correlates with better outcomes; 2) high-frequency hearing loss indicates a poorer prognosis; 3) patients with dizziness have a worse prognosis, while those with tinnitus still have cochlear nerve function, indicating a better prognosis; 4) older age correlates with poorer outcomes.
3.
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 such as explosions, gunfire, fireworks, or the current trend of rock concerts and personal music devices.
- Chronic Noise-Induced Hearing Loss: The modern industrialized society has brought prosperity but also a noisy environment, with many workplaces potentially leading to occupational injuries, such as railways, factories, airports, auto repair shops, DJs, gaming employees, and stockbrokers.
Noise levels below 80 decibels are less likely to cause hearing damage, but exposure to noise levels above 100 decibels for more than 8 hours can easily lead to temporary threshold shifts.
If individuals can avoid noisy environments quickly, their hearing may recover.
However, if permanent threshold shifts occur, hearing cannot be restored.
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, with a daily exposure limit of 8 hours.
- Acute Trauma-Induced Hearing Loss: This refers to inner ear damage caused by intense external sound stimuli over a short period.
Young people often frequent rock concerts, karaoke, and pubs, experiencing tinnitus, hearing loss, and a feeling of fullness in the ear the following day, which can be termed "disco deafness," "karaoke deafness," or "personal music device deafness." After the presidential election, several patients presented with symptoms of 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 year typically last more than 1.5 milliseconds, while the shock waves from gunfire last less than 1.5 milliseconds.
Unlike irreversible hearing loss caused by long-term noise exposure, the aforementioned 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, 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 adaptability to noise, resulting in irreversible damage similar to chronic noise-induced hearing loss.
4.
Metabolic Tinnitus: The most common cause of metabolic tinnitus among the population is hyperlipidemia.
Due to the 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 suffer from this condition.
These patients often complain of feeling "dizzy, dull-headed, and ringing in the ears," with an indescribable discomfort.
The mechanisms leading to 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 in the inner ear and embolism.
Patients with hyperlipidemia often present with other conditions such as hypertension, diabetes, vascular sclerosis, 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 systemic 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 maintain a proper diet, the condition can easily recur.
However, once treated, patients often feel a sense of relief, akin to seeing the light after a storm.
Blood tests will show lipid levels returning to normal, supporting our hypothesis.
5.
Vascular Tinnitus: The vertebral arteries supply blood to the brain and inner ear through the transverse foramina of the cervical vertebrae.
If the arteries supplying the inner ear become obstructed or spasmodic, 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 due to insufficient blood supply to the posterior cranial fossa, 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, or hyperlipidemia.
For vascular tinnitus, which arises from poor blood circulation, traditional treatments often involve vasodilators to achieve therapeutic effects.
However, in cases of vascular stenosis due to atherosclerosis, vasodilators cause systemic vasodilation and do not selectively dilate the inner ear vessels.
It is now widely accepted that treatment should focus on improving hemodynamics, increasing the deformability of red blood cells, and reducing blood viscosity to ensure the inner ear receives adequate oxygen and nutrients.
"Vascular active agents," which are designed based on this concept, include both natural extracts from ginkgo biloba and synthetic options.
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 more easily through hardened vessels; they can also act on blood vessels to reduce spasms and prevent platelet aggregation, thereby promoting smooth blood flow.
6.
Tumor-Related Tinnitus: In the field of otolaryngology, unilateral tinnitus raises suspicion for two types of tumors: nasopharyngeal carcinoma and acoustic neuroma.
I have previously mentioned this in "A Discussion on Dizziness," and I will reiterate it 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, known as the cerebellopontine angle (CPA).
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 acoustic neuroma is confined to the internal auditory canal and is less than 1 cm, it may be difficult to detect on a CT scan.
Some have attempted to perform a lumbar puncture to introduce air into the ventricles, allowing the patient to lie on their side so that air enters the internal auditory canal; if an acoustic neuroma is present, the air will not fill the internal auditory canal.
This is known as "air CT," but it has the drawback of causing patients to experience headaches for about a week due to the air in the skull.
With the advent of MRI, tumors smaller than 1 cm can now be easily diagnosed.
If the tumor grows larger and extends towards the cerebellum or brainstem, it can 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 Cure
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 increasing 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 workplace.
Early treatment of acute trauma-induced hearing loss is very effective, 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 greasy foods can help maintain normal cholesterol levels.
Self-Assessment for Tinnitus
Through some carefully designed questions, we can often determine the possible causes of a patient's tinnitus.
Here are some simple questions:
1.
Is the tinnitus accompanied by dizziness? Does it become louder during dizziness? Tinnitus associated with dizziness suggests the possibility of "inner ear tinnitus." Meniere's disease, sudden sensorineural hearing loss, and anterior inferior cerebellar artery obstruction are often unilateral; vertebrobasilar insufficiency tends to be bilateral.
In Meniere's disease, tinnitus often becomes 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 injuries from fireworks? As mentioned earlier, the human ear can tolerate noise levels up to 90 decibels for a maximum of 8 hours a day.
If tinnitus occurs, it is essential to leave the noisy environment to prevent 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.
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 disorders often present with high-pitched tinnitus, while Meniere's disease or middle ear disorders typically present with low-pitched tinnitus.
Inner ear tinnitus is often unilateral, while central vascular tinnitus is usually bilateral.
6.
Is the tinnitus synchronized with your heartbeat? If the tinnitus is synchronized with your heartbeat or pulse, it may indicate a vascular malformation or venous anomaly.
If the tinnitus diminishes or disappears when the neck is turned towards the affected side, it may be due to excessive pulsation of the neck vessels.
7.
Is the tinnitus related to your breathing? General respiratory infections or Eustachian tube obstruction caused by flying can lead to tinnitus, while excessive opening of the Eustachian tube can also cause tinnitus, often accompanied by a sensation of ear vibration during breathing.
If the body bends down to tie shoelaces, increased blood flow to the brain can immediately alleviate symptoms.

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Reply Date: 2005/09/27