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dr.g

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 #1 
Hello Dr. Nagler,

First of all, thank you for providing this wonderful resource for those of us who are struggling. I, like many here I imagine, immediately implored Dr. Google for answers and became incredibly confused, hopeless and scared. I am following your recommendation and avoiding other online tinnitus sites for my own sanity. My ENT and audiologist completely concur with you on that.

Apologies in advance for my lengthy note. My tinnitus and sound hypersensitivity started rather acutely last Thursday afternoon while playing acoustic guitar. I felt some ringing, fullness and hissing sound, with some degree of garbling/distortion mainly from my right ear. The garbling and distortion has resolved some but now my left ear is also ringing. The quality is a very high pitched constant hissing sound in both ears and a sharp ringing in my right ear. This has caused me incredible grief in the short time I have experienced it. I have no prior history of tinnitus other than occasional 1-2 days after a concert 20+ years ago. I am a lover of peace and quiet, and this has ruined that for me. I have been experiencing multiple panic attacks and lack of sleep. Trying to use white noise to mask it which helps but is annoying in it's own right and can even exacerbate my tinnitus. On the flip side, noisy environments also seem to aggravate it. I love music and haven't been able to play or listen to it since this started. The fridge, the shower, the air conditioning, the dishwasher, conversation with others all are painful to hear. I am having a very hard time finding some middle ground here.. feel trapped in this ringing hell. 

I have been on sudafed, nasal steroids and antihistamine since outset with no effect. I saw a very experienced ENT in town (major west coast city) today who said my ears look fine. No fluid in middle ears. Normal pressures. No redness except in my nose and throat. My hearing is "excellent" after an audiogram. I was apparently hearing well above normal in all frequencies. He has put me on a short course of prednisone is see if, in the case this is inflammatory, he can get it to calm down. I feel comforted in being fully evaluated and ruling out the usual suspects. I will follow up with him in 2 weeks. He emphasized how difficult it can be to figure this problem out.

Naturally, as a physician/diagnostician and one who is suffering, I want to figure out the WHY so I can determine WHAT to do. My ENT was really unsure as to the cause. He thought it might be allergic but less likely viral infection or drug ototoxicity. My symptoms came on about 24 h after being around my house during mold remediation. I wasn't in the house but was outside. I also had the indoor air treatment with ozone/hydrogen peroxide while the house was vacated. I had a flare of sinus symptoms and headache the night of, but no ear problems until 24 hrs later. No lung issues. My first instinct was whether this was an allergic response to all the crap that was kicked up during the work. I would expect more fluid in the ears (ETD-type symptoms) which I don't have. Could it be neurotoxin related damage or oxidative damage from air treatment? Possible.. but yet impossible to determine really. There is so much unsubstantiated mold-related information on the internet.. it's frightening. Its clear some molds produce toxins, but it is unclear as to how much exposure would be necessary to develop symptoms. Virtually every house in my part of the country has some degree of mold in it and our house wasn't by any means the worst case. Do you have any experience with allergy-related or mold/environmental toxin-related tinnitus? 

I also wonder if it could be related to my medications -- I have been taking meloxicam (Mobic) 7.5 mg qd daily and gabapentin 1200 mg daily for the past 2 months. These drugs have helped immensely with my reactive arthritis and cervical myelopathy nerve pain, respectively, more so than any other medication or treatment. The mobic has a 20 h half-life, so wondering if my continual use of it over the past few months has led it to build up to levels high enough to produce tinnitus. I stopped taking it 4 days ago, so has been about 4 half lives. I'm really not sure how long to be off it, honestly, to determine whether it is a culprit or not. I imagine it takes time for the hair cells to repair? From what I have read, NSAID toxicity tends to be reversible. Is this your impression as well? My arthritis is flaring back up, crying out for more medication, and making everyday life uncomfortable again. It doesn't seem like there is any good evidence Gabapentin causes injury to ears, but thought i'd just raise that remote consideration with you as well.

Appreciate your time and thoughts on this very early-on case. I pursued treatment as fast as I could as the symptoms were literally driving me crazy and I wanted to try and reverse any damage, if possible.  I am hoping things will calm down and resolve soon as I am trying to maintain my sanity. I certainly can keep you posted if you are interested in follow up.

Best,
Dr. G

Dr. Nagler

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Posts: 1,078
 #2 
Hello Dr. G ... and welcome.

I am sorry that you have a need for a site like this, but I am very glad it could be here for you.

Your post has many layers and conveys many questions and concerns. It will take a while to unpack, but I will do my best within the constraints of the medium.

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Originally Posted by dr.g
First of all, thank you for providing this wonderful resource for those of us who are struggling.

You are welcome.

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I, like many here I imagine, immediately implored Dr. Google for answers and became incredibly confused, hopeless and scared.

I completely understand. You wouldn't believe how many times a week I hear the same story, virtually without exception the specific culprit's being the Tinnitus Talk site.

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I am following your recommendation and avoiding other online tinnitus sites for my own sanity. My ENT and audiologist completely concur with you on that.

Good to know.

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Apologies in advance for my lengthy note.

Not a problem save for the fact that my remarks will likely not do it justice.

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My tinnitus and sound hypersensitivity started rather acutely last Thursday afternoon while playing acoustic guitar. I felt some ringing, fullness and hissing sound, with some degree of garbling/distortion mainly from my right ear. The garbling and distortion has resolved some but now my left ear is also ringing. The quality is a very high pitched constant hissing sound in both ears and a sharp ringing in my right ear.

Since you were playing acoustic guitar (presumably without amplification), it is safe to assume that whatever caused your tinnitus it did not involve noise-induced auditory damage. Acoustic guitars typically do not produce enough dB over enough time to cause physical damage to the auditory system.

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This has caused me incredible grief in the short time I have experienced it.

Sure, because you feel you have lost control and you feel that you have lost your silence. People who truly suffer from severe intrusive tinnitus know the incredible grief you describe only too well.

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I have no prior history of tinnitus other than occasional 1-2 days after a concert 20+ years ago.

OK.

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I am a lover of peace and quiet, and this has ruined that for me.

You can have your peace and quiet back. You might need to recalibrate a bit, but you can have it back. In fact, I bet that before any of this happened, you didn't like peace and quiet as much as you now claim you did. A normally hearing person with no tinnitus typically gets very agitated after spending several minutes in a totally soundproof room. The auditory system needs sound. The auditory system thrives on sound. Sound is the raison d’être of the auditory system. You are not a lover of peace and quiet, my friend. What you love is where you put your "zero" on the continuum of sound - and that locus can be shifted.

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I have been experiencing multiple panic attacks

Right. Likely due to your loss of control and what you consider to be your inability to "get quiet."

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and lack of sleep.

Possibly related to your autonomic nervous system's excessively monitoring your tinnitus amidst the silence of the night as it tries to protect you from The Guest from Hell that has taken up residence in your head.

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Trying to use white noise to mask it which helps but is annoying in it's own right and can even exacerbate my tinnitus.

That can sometimes happen with masking as your ANS cannot protect you from an enemy it cannot detect - so your auditory system "turns up the gain" to allow your ANS to do its job. The unfortunate byproduct is a temporary increase in tinnitus loudness.

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On the flip side, noisy environments also seem to aggravate it. I love music and haven't been able to play or listen to it since this started. The fridge, the shower, the air conditioning, the dishwasher, conversation with others all are painful to hear. I am having a very hard time finding some middle ground here.. feel trapped in this ringing hell.

I am having a bit of trouble following you. Is it that these "noisy environments" make your tinnitus louder ... or is that that sounds well-tolerated by others sound too loud to you ... or is it both? And if it's both, which is the greater problem for you?

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I have been on sudafed, nasal steroids and antihistamine since outset with no effect. I saw a very experienced ENT in town (major west coast city) today who said my ears look fine. No fluid in middle ears. Normal pressures. No redness except in my nose and throat. My hearing is "excellent" after an audiogram. I was apparently hearing well above normal in all frequencies.

OK. Nothing unusual there.

Quote:
He has put me on a short course of prednisone is see if, in the case this is inflammatory, he can get it to calm down.

Very little downside to that approach, but in the absence of associated sudden sensorineural hearing loss (which you do not have), it would be a long shot. Still, nothing wrong with a short course of steroids given that the onset of your tinnitus was so recent.

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I feel comforted in being fully evaluated and ruling out the usual suspects.

Of course you do. And it is a very important step.

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I will follow up with him in 2 weeks. He emphasized how difficult it can be to figure this problem out.

It's only difficult to figure it out if you try to figure it out. And there is absolutely no reason to try to figure it out! As I have often said, "The first step in overcoming your tinnitus is when you have finally figured out that you cannot figure it out at all!" [For a further explanation please see my response to your very next statement.]

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Naturally, as a physician/diagnostician and one who is suffering, I want to figure out the WHY so I can determine WHAT to do.

I totally understand where you are coming from ... and I could not possibly disagree more. You would be spot on if we were talking about painless hematuria, something you regularly encounter in your medical practice. But we are not talking about painless hematuria; we are talking about tinnitus. With painless hematuria you figure out the cause (infection, tumor, trauma, stone, renal TB, etc.), you treat the cause, and the hematuria resolves. With tinnitus, however, a lot of times you cannot figure out what the cause is ... and even if you can identify the cause, a lot of times you cannot fix it ... and even if you can fix the cause, a lot of times the tinnitus still does not resolve. (Like a snowball that is going downhill; even if you can stop it from snowing at the top of the hill, the snowball continues to roll along!) So with tinnitus, you have to look at it differently. With tinnitus once you have ruled out the very rare causes that can be fixed (which takes at most a week), and once you have ruled out the even rarer causes that represent a health threat (which, again, takes at most a week), then for lack of a better term what you are left with is a nuisance. It can be a HUGE NUISANCE or it can be a little bitty nuisance or it can be anything in between. But what (if anything) you do about it depends solely on how much of a nuisance it is rather than the fact that you have it.

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My ENT was really unsure as to the cause.

... which would be a real problem if it mattered. But I hope you are beginning to realize that it doesn't!

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He thought it might be allergic but less likely viral infection or drug ototoxicity. My symptoms came on about 24 h after being around my house during mold remediation. I wasn't in the house but was outside. I also had the indoor air treatment with ozone/hydrogen peroxide while the house was vacated. I had a flare of sinus symptoms and headache the night of, but no ear problems until 24 hrs later. No lung issues. My first instinct was whether this was an allergic response to all the crap that was kicked up during the work. I would expect more fluid in the ears (ETD-type symptoms) which I don't have. Could it be neurotoxin related damage or oxidative damage from air treatment? Possible.. but yet impossible to determine really.

So if it's impossible to determine, why worry about it!!??

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There is so much unsubstantiated mold-related information on the internet.. it's frightening.

The same can be said for tinnitus-related information on the Internet, most of which is tinnitus-related misinformation!

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Its clear some molds produce toxins, but it is unclear as to how much exposure would be necessary to develop symptoms. Virtually every house in my part of the country has some degree of mold in it and our house wasn't by any means the worst case. Do you have any experience with allergy-related or mold/environmental toxin-related tinnitus?

I tend to concern myself with addressing why the tinnitus that you have affects you the way it does rather than why you have it in the first place. Because, like I said earlier, it takes but one or two ENT visits to rule out the causes of tinnitus that can be fixed with the expectation that in-so-doing the tinnitus will resolve. Dr. G, your tinnitus is going to do what it damned well wants to do, which most certainly includes the possibility of resolving on its own. [And, by the way, if your tinnitus goes away after taking Ginkgo, lipoflavinoids, zinc, or the like ... it would have gone away without that stuff in the same time frame.]

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I also wonder if it could be related to my medications -- I have been taking meloxicam (Mobic) 7.5 mg qd daily and gabapentin 1200 mg daily for the past 2 months. These drugs have helped immensely with my reactive arthritis and cervical myelopathy nerve pain, respectively, more so than any other medication or treatment. The mobic has a 20 h half-life, so wondering if my continual use of it over the past few months has led it to build up to levels high enough to produce tinnitus. I stopped taking it 4 days ago, so has been about 4 half lives. I'm really not sure how long to be off it, honestly, to determine whether it is a culprit or not. I imagine it takes time for the hair cells to repair? From what I have read, NSAID toxicity tends to be reversible. Is this your impression as well? My arthritis is flaring back up, crying out for more medication, and making everyday life uncomfortable again. It doesn't seem like there is any good evidence Gabapentin causes injury to ears, but thought i'd just raise that remote consideration with you as well.

Well, it wasn't the gabapentin. Indeed, gabapentin has actually been studied (unsuccessfully) as a tinnitus treatment. And NSAIDs do not cause hair cell damage - so the question regarding how long it takes hair cells to repair is irrelevant in that regard. Of course, NSAIDs can temporarily cause (or temporarily exacerbate) tinnitus, but the mechanism is not by damaging hair cells any more than the exacerbation of tinnitus caused by stress or fatigue is by virtue of the effect of stress and fatigue on hair cells. My suggestion (likely worth little more than you are paying for it) would be to resume the gabapentin but give yourself a week or two off all NSAIDs. Then - even if your tinnitus has not resolved (as it should if the problem were the meloxicam) - restart an NSAID other than meloxicam. Why "other than meloxicam" if meloxicam didn't play a role? For peace of mind, that's all. Perhaps avoid nabumetone as well (see Drugs To Avoid).

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Appreciate your time and thoughts on this very early-on case.

Not a problem. Glad to help. You might want to take a look at Tinnitus 101 for some general information.

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I pursued treatment as fast as I could as the symptoms were literally driving me crazy and I wanted to try and reverse any damage, if possible.

As far as I can tell, there has been no damage to reverse! And while your symptoms are quite bothersome, they are not "literally driving [you] crazy."

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I am hoping things will calm down and resolve soon as I am trying to maintain my sanity.

You sound quite sane to me. Please stop thinking in terms of craziness and sanity. You feel bad enough as is; why think in terms that serve absolutely no function save for making you feel even worse??!!

All the best -

Stephen M. Nagler, M.D.
Atlanta Tinnitus Consultants, LLC

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi
dr.g

Member
Registered:
Posts: 3
 #3 
Dr. N,

I appreciate the time and thought you invested in your response. A little provision of knowledge and reassurance goes a heck of a long way. Although my tinnitus is certainly still acting as a nuisance, I have more peace about it. There are some great resources to reference here, of which I have merely scratched the surface, and feel confident there are professionals available who can help me down the line, if needed. 

I just happened to read in one of your posts somewhere that the American Tinnitus Association is based in my hometown, and is, in fact, right down the street from my ENT office. How about that for coincidence? I am sure they could provide me with some direction with regard to audiology specialists in the area. That said, do you know of anyone in Portland, OR or region you would recommend if I decided to further pursue professional evaluation and treatment?

You mentioned you were having trouble following my paragraph regarding sound sensitivity. Please forgive me, I am not yet familiar with the nomenclature in this field and also, quite truthfully, am still trying to understand what I am hearing and how to best convey it in words. I am confident that I am not the first person in the world to feel what I am feeling, so there must be appropriate descriptions for such things!! So, to further clarify -- "noisy environments" seem qualitatively louder to my ears than they were before my tinnitus. Sounds that didn't previously bother me, like the whistle of air in the AC registers, the hiss of water from the shower head, the squeak of door hinges, now seem more pronounced. In addition, these same "noisy environments" also cause my tinnitus to temporarily become louder in the background, as if the gain is turned up. The tinnitus will quiet down shortly after exposure. You asked which bothers me more -- I'd have to say the tinnitus bothers me more at this point. I can wear earplugs for the loud noises, not for the ringing. Hopefully this makes a little more sense. Is this hyperacusis with tinnitus that I am describing to you?

Although I am making my best effort to just ignore the "Guest from Hell" and get on with it, I have noticed it is much better right after waking and gets progressively worse throughout the day. Valium also seems to work quite well in pushing it into the background and is allowing me sleep without panic attacks, thank God. My wife also provided me salient advice. That is, set some limits and stop talking about it all the time! I was amused to find this echoes similar advice within your wife's "Tinnitus Spouse Survival" reference.

I have another question for you which I could pose as separate topic, however, thought it might make more contextual sense to include in this thread. Before developing tinnitus last week, I was planning to undergo cervical arthroplasty for myelopathy. My new little ringing friend has thrown an unexpected variable into the equation. How concerned should I be going forward with procedure this soon in proximity to developing tinnitus, or does it matter? I am planning to inform my anesthesiologist at pre-op about my tinnitus and sound sensitivity so that he/she can avoid using medications known to be troublesome and can ensure I have ear plugs snuggly placed during the procedure. Is there any risk of worsening tinnitus with general anesthesia that you are aware of? I am leaning towards the conclusion that the risks outweigh the benefits and there is nothing much to be concerned about from the tinnitus front, but again, would appreciate any input you have in this regard. I certainly don't want to bring my life to a halt based on fear of theoretical problems I "could potentially" have or risks I have no control over.

Again, thanks for your sage advice.

Best,
Dr. G


Dr. Nagler

Owner
Registered:
Posts: 1,078
 #4 
Quote:
I appreciate the time and thought you invested in your response. A little provision of knowledge and reassurance goes a heck of a long way.

Glad to help.

Quote:
Although my tinnitus is certainly still acting as a nuisance, I have more peace about it.

If you have more peace about it, then that means it is becoming less of a nuisance. In other words, whether or not your tinnitus is getting better, you are getting better. And in tinnitus that is the only thing that counts. Why? Because your tinnitus is going to do exactly what it wants to do ... and you have precious little to say in the matter. You've only had tinnitus for eight days ... and already you are getting better. Excellent.

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There are some great resources to reference here, of which I have merely scratched the surface,

Please stop scratching. You are getting better. Unnecessarily devoting yourself to all those "great resources" will serve only to delay that process. Devote yourself instead to something more important than your tinnitus - like perhaps the quarter finals of the Southwest Manitoba harmonica championships. Or maybe the nude beach on Sauvie Island. Or a good book? Or kicking back and doing nothing?

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and feel confident there are professionals available who can help me down the line, if needed.

"If needed." Why even think in those terms? I mean, if you have a daughter living in Albuquerque who is thinking about possibly moving somewhere on the East Coast within the next decade, you aren't going to go out and research subway lines in New York City on the chance she just might wind up there. Or are you? [I mean no offense, but I hope you get my point.]

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I just happened to read in one of your posts somewhere that the American Tinnitus Association is based in my hometown, and is, in fact, right down the street from my ENT office. How about that for coincidence?

That is quite a coincidence indeed. Powell's Books is also rather close to your ENT's office. And since you read, I guess that's a coincidence as well? [There I go again, sorry.]

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I am sure they could provide me with some direction with regard to audiology specialists in the area.

You have already seen an ENT, and you have established that whatever is causing your tinnitus, it is not one of the causes that can be fixed and it is not one of the causes that represent a threat to health. Moreover, you are getting better. So why exactly are you thinking in terms of direction with regard to specialists? Plus, even though ATA can provide you with a list, they will not attest to the knowledge, experience, competence, intelligence, and ethics of anybody on that list. It's like looking for a doctor in the Yellow Pages; I am sure you are listed, Dr. G, but your being on that list says nothing about whether you are any good at what you do. Or whether you are honest.

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That said, do you know of anyone in Portland, OR or region you would recommend if I decided to further pursue professional evaluation and treatment?

Well, if you are thinking in terms of the particular qualities I listed directly above (knowledge, experience, competence, intelligence, and ethics), there's Glynnis Tidball in Vancouver (BC), Allen Rohe in Tempe (AZ), Gail Brenner in Philadelphia, and (if you really want to scrape the bottom of the barrel) me in Atlanta.

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You mentioned you were having trouble following my paragraph regarding sound sensitivity. Please forgive me, I am not yet familiar with the nomenclature in this field and also, quite truthfully, am still trying to understand what I am hearing and how to best convey it in words. I am confident that I am not the first person in the world to feel what I am feeling, so there must be appropriate descriptions for such things!! So, to further clarify -- "noisy environments" seem qualitatively louder to my ears than they were before my tinnitus. Sounds that didn't previously bother me, like the whistle of air in the AC registers, the hiss of water from the shower head, the squeak of door hinges, now seem more pronounced. In addition, these same "noisy environments" also cause my tinnitus to temporarily become louder in the background, as if the gain is turned up. The tinnitus will quiet down shortly after exposure. You asked which bothers me more -- I'd have to say the tinnitus bothers me more at this point. I can wear earplugs for the loud noises, not for the ringing. Hopefully this makes a little more sense. Is this hyperacusis with tinnitus that I am describing to you?

OK. So you have DST (Decreased Sound Tolerance, which is a bit of a broader term than hyperacusis) and - unrelated to your DST - you have tinnitus that is somewhat sound-sensitive. You are using earplugs because of your DST, which at this point in time is just about the worst thing you can do, because it deprives your auditory system of the types of sounds it needs to thrive. The end result will be to make the DST worse and make it more difficult for you to overcome your tinnitus. So please resist the temptation to use earplugs to "protect" your ears from sounds that are uncomfortably loud unless those sounds are of such a decibel level that they represent potential auditory damage. And the sounds you describe above (the whistle of air in the AC registers, the hiss of water from the shower head, the squeak of door hinges, etc.) are most certainly not loud enough to cause damage - regardless of how unpleasant they sound to you.

Quote:
Although I am making my best effort to just ignore the "Guest from Hell" and get on with it, I have noticed it is much better right after waking and gets progressively worse throughout the day. Valium also seems to work quite well in pushing it into the background and is allowing me sleep without panic attacks, thank God.

Sounds like you are still trying to "figure out" your tinnitus. You are wasting your time, but everybody does it at first - so go ahead. But please keep in mind that the sooner you get past that point, the better off you will be.

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My wife also provided me salient advice. That is, set some limits and stop talking about it all the time! I was amused to find this echoes similar advice within your wife's "Tinnitus Spouse Survival" reference.

There is nothing at all amusing when two wives agree. It's a sign that their husbands ought to give very serious thought to what they are saying! :-)

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I have another question for you which I could pose as separate topic, however, thought it might make more contextual sense to include in this thread. Before developing tinnitus last week, I was planning to undergo cervical arthroplasty for myelopathy. My new little ringing friend has thrown an unexpected variable into the equation. How concerned should I be going forward with procedure this soon in proximity to developing tinnitus, or does it matter?

It doers not matter; go ahead with your surgery as planned.

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I am planning to inform my anesthesiologist at pre-op about my tinnitus and sound sensitivity so that he/she can avoid using medications known to be troublesome

There are no drugs administered by an anesthesiologist in relation to a cervical arthroplasty that can cause auditory damage. You should be aware of the fact that the lidocaine sometimes administered on induction to decrease cardiac irritability might cause a very brief increase in tinnitus loudness just before you fall asleep (so do not be alarmed if that happens), but it always resolves before you wake up.

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and can ensure I have ear plugs snuggly placed during the procedure.

May I ask why?

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Is there any risk of worsening tinnitus with general anesthesia that you are aware of?

No.

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I am leaning towards the conclusion that the risks outweigh the benefits and there is nothing much to be concerned about from the tinnitus front, but again, would appreciate any input you have in this regard.

Done.

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I certainly don't want to bring my life to a halt based on fear of theoretical problems I "could potentially" have or risks I have no control over.

Excellent attitude.

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Again, thanks for your sage advice.

I am not exactly sure how "sage" it is, but you are welcome nonetheless!

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi
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Dr. Nagler's Tinnitus Corner is provided for education and information only. It is not intended for the purpose of providing medical care and should in no way substitute for appropriate in-person consultations with qualified healthcare professionals. By using this site, participants agree to hold Dr. Nagler and Atlanta Tinnitus Consultants, LLC harmless with respect to any loss, injury, claim, liability, or damage arising from following the postings herein.