Dr. Nagler's Tinnitus Corner
Latest Topics
 
 
 


Reply
  Author   Comment  
Ric

Member
Registered:
Posts: 4
 #1 
Hi Dr. Nagler,

I have been experiencing an acute period where my tinnitus, which had always been low, suddenly spiked concomitant with a bacterial sinus infection (not sure if any connection). I've been receiving as much treatment as possible for things, and at the moment am on a prednisone taper and antibiotic (again, to ensure full healing of the sinus condition).

There is also the belief that TMJ could be playing an issue -- clicking/popping/tension in jaw, neck pain. Recently received a bite guard for sleep.

The tinnitus has thankfully subsided to a level that, while not quite where it was before, I consider manageable. However, it's been replaced by some very significant hyperacusis which is affecting my professional and personal life quite significantly.

It's only been about 6 days since onset of hyperacusis, during which time it has gradually gotten worse. Though never officially diagnosed (am seeing another ENT in 2 days), I also believe I have a myoclonus, which has been around my entire adult life, only at a low level. Basically, any sounds that I hear through my right ear, create a physical flutter in my left ear a split second after. It has always been only an annoyance, but now I can feel that flutter on overdrive, and it is this hyperactivity that I suspect is at least partly responsible for the hyperacusis.

I am in the Bay Area where the choices seem pretty slim. It's basically the UCSF program or nothing, although the first thing the new patient coordinator said is that they can't cure H, they only offer management advice -- and it's very expensive for just advice. 

My question then, is how long should I wait for this acute period to perhaps do its thing before I seek therapy for the hyperacusis? I do (like many of us here) have an underlying anxiety condition and have been meditating and increasing self-care (just began cognitive behavioral therapy last week), and the jaw tension is very real. Is it worthwhile to give things a chance to resolve first? If there is indeed a middle ear myoclonus causing the problems, would an institutional "management" program even make an attempt at determining a potential relationship? If the tinnitus settled down (hopefully on its own and not because of just the prednisone), is it possible the H could as well?

Thanks for all you do here.

Ric


Dr. Nagler

Owner
Registered:
Posts: 1,759
 #2 
Hi Ric -

Hard to know what's going on with a thorough evaluation, and it seems that you are in the process - so good for you.

My only recommendation for hyperacusis in what you refer to as the "acute period" is to resist the temptation to "give your ears a rest" by avoiding sound or overprotecting. Sure, you want to avoid excessively loud sound - but overprotecting just compounds the problem.

There used to by a wonderful audiologist in the Bay Area named Malvina Levy, who is very knowledgeable in tinnitus and hyperacusis. Not sure if she is still in practice - but if she is, you might want to make an appointment.

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

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Ric

Member
Registered:
Posts: 4
 #3 
Thank you so much for your guidance Dr. Nagler. You'll be pleased to hear Ms. Levy is indeed still in practice here at the Hearing and Speech Center, and I've been in contact with her. She's advised me to complete the tests and doctor visits I have planned (an audiogram with loudness levels, which I have tomorrow, as well as a TMJ specialist in a month), and then meet with she and her colleagues.

If you don't mind, I'd love to ask a couple of follow-up questions.

1) I've found that tylenol helps a bit for the hyperacusis discomfort. Is there anything that would suggest this to be an unwise medication to take? (I'm avoiding ibuprofen entirely from now on if I can help it.)

2) The tinnitus has been gradually "spreading" (for lack of a better term) to my right ear over the past few days, and by this point is only slightly less loud than the noise in my left ear. I admit this development feels troubling. I have asymmetrical hearing loss on the left side (which we're investigating), but newly I do have high frequency loss on the right side as well, which would certainly account for the new tinn on that side. My question is, is this likely a natural part of my brain adjusting to its new state after this sudden hearing loss, or is there something I'm doing that might be exacerbating things? My thoughts (as always) go to the soft foam earplugs which I pretty much need in order to sleep -- all the ENTs I've seen so far say that while they themselves sleep without earplugs, there's no reason to suggest that use of soft earplugs for sleeping would exacerbate tinnitus, provided there's no wax buildup. One ENT told me that the ears get plenty of auditory stimulus during the day.

As per your advice I'm avoiding earplug use during the day whenever possible so as not to make the hyperacusis worse, for what that's worth.

I suppose in general, my question would be with this nature of the T growing gradually worse on one side, rather than the very sudden worsening I experienced on the left. In your experience is it common for tinnitus to suddenly get louder on one side, followed by a gradual increase on the other?

Pardon the wordiness, I try my best to be concise but as I'm sure you know, the urge to overanalyze and overthink (and overshare) is strong amongst those with these issues!

Thanks again for all your help, and all you do. We are lucky to have you.

Ric
Dr. Nagler

Owner
Registered:
Posts: 1,759
 #4 
Quote:
Originally Posted by Ric
1) I've found that tylenol helps a bit for the hyperacusis discomfort. Is there anything that would suggest this to be an unwise medication to take?

Tylenol is fine if taken as directed.

Quote:
2) The tinnitus has been gradually "spreading" (for lack of a better term) to my right ear over the past few days, and by this point is only slightly less loud than the noise in my left ear. I admit this development feels troubling. I have asymmetrical hearing loss on the left side (which we're investigating), but newly I do have high frequency loss on the right side as well, which would certainly account for the new tinn on that side. My question is, is this likely a natural part of my brain adjusting to its new state after this sudden hearing loss, or is there something I'm doing that might be exacerbating things?

Best I can tell you are not doing anything that might be "exacerbating things."

Quote:
I suppose in general, my question would be with this nature of the T growing gradually worse on one side, rather than the very sudden worsening I experienced on the left. In your experience is it common for tinnitus to suddenly get louder on one side, followed by a gradual increase on the other?

In my experience it is best not to try to "figure out" your tinnitus.

Quote:
Thanks again for all your help, and all you do. We are lucky to have you.

Glad to help.

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

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Ric

Member
Registered:
Posts: 4
 #5 
Hi Dr. Nagler, I had an interesting update.

As part of my latest audiology test, they conducted Loudness Levels tests, and they all came back normal (around 100db, sometimes higher).

That instantly made me feel better, and over the course of the ensuing week, I felt the sound sensitivity subside, perhaps helped by the fact that I was able to work from home that week and didn't encounter any loud noises.

However, after getting back into the world, the hyperacusis came back, and is made worse by exposure to even normal environmental noise. At this point, hearing my partner prepare dinner is very difficult. I wonder just how much of this has close connections to tension and anxiety.

Do the normal LDL's suggest "recruitment"? I know very little about this, and although I'm keen to self-educate, I have found it to be a poor idea to trawl through forum posts that are saturated with negativity. If my issue is recruitment, is the therapy the same as with hyperacusis?

Any thoughts you could offer would be, as always, very much appreciated. Thank you!

Ric
Dr. Nagler

Owner
Registered:
Posts: 1,759
 #6 
Ric, based upon what you have written above, you do not have hyperacusis. I’ll explain why shortly, but first please tell me about your audiogram. Are your hearing thresholds relatively normal - or do you have an appreciable degree of hearing loss?

Stephen M Nagler, M.D.


__________________

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

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Ric

Member
Registered:
Posts: 4
 #7 
Thanks as always for your response Dr. Nagler. The audiometry test is below.

I had what began as asymmetric left-side sensorineural hearing loss for several years. After the onset of whatever this recent event was a couple of months ago, that hearing loss had worsened.

I had another test done 3 weeks later, which showed the right ear having caught up to the left ear considerably over that month, marked by introduction and worsening of tinnitus. The left ear was similar or slightly better than the previous test. 

LDLs are all marked at or above 100 dB. Reflex test levels not as high, but the audiologist says this is somewhat common, as it is a machine administering the test, which can lead some patients to become skittish.

My sound sensitivity symptoms enjoyed a calm week after this test -- I thought perhaps it was all in my head. However, that might just as easily have been due to not working or driving that week. The most common triggers like glass clinking or silverware, as well as low bass noises, were not much of a problem. Once I returned to work, I enjoyed about a half day of relative comfort before noticing a growing discomfort.

At this point the common triggers are as uncomfortable and painful, if not more, than before. Although I've been taking your advice and not overusing my musicians earplugs, I feel I might need to use them much more in order to get through my loud day as a music teacher. (Not to complicate, but a further issue seems to be that use of these musicians earplugs -- comfortable though they are compared to others I've tried -- seem to push against my TMJ and cause discomfort and pain there after a few hours of use.)

I can provide additional info if that'd be of benefit, but I'm wary of overproviding given the complexity of it all. I'm currently seeing a sinus specialist given that this event coincided with a flare-up of a sinus infection, and I have a TMJ appointment for later this month. The sinus specialist seems skeptical of a connection, though perhaps it's worth noting that I do have considerable disease of the sinus. And I'm not prepared to concede that these two events were coincidences.

Very interested in your thoughts given these circumstances, and as always very grateful for your counsel, time, and support.

Ric

20190514_005946.jpg 

Dr. Nagler

Owner
Registered:
Posts: 1,759
 #8 
Ric, the operative phrase in your post above is: "given the complexity of it all." There is no way that a response on this sort of web-based platform can possibly do justice to your very good (but highly complex) question. Add to that the fact that I have not evaluated you myself, and I hope you can begin to appreciate the degree to which I am handicapped in trying to address your issues responsibly. I will therefore speak only in very general terms.

I am going to start with a diagram depicting the difference between hyperacusis and recruitment:

recruitment02.jpg  

Hyperacusis is a decreased threshold to discomfort from sound. It can range from a person who is mildly uncomfortable in a restaurant setting wherein all the rest of the people at the table have no discomfort at all ... to a person who has profound discomfort from many of the sounds encountered in daily life. Desensitization techniques (like pink noise files, TRT, etc.) can be highly effective in treating hyperacusis. The sine qua non of hyperacusis is abnormal LDL testing (Loudness Discomfort Level). On your audiogram the LDLs appear towards the bottom of the graph; on the Jastreboff diagram they are depicted towards the top. Your LDLs in this study are in the normal range - so at the time of the study you did not have hyperacusis. Importantly, you wrote [in part]: "over the course of the ensuing week, I felt the sound sensitivity subside," by which I conclude that your sound sensitivity cannot be due to hyperacusis because you were still symptomatic (at the beginning of the ensuing week) in the face of normal LDLs. I hope that makes sense.

Recruitment is something completely different. Recruitment, according to Dr. Jack Vernon, is the rapid growth of perceived loudness for those sounds located in the pitch region of a hearing loss. Let me give you an example. My father had a significant hearing loss for several years before his death at the age of 89. I could say, "Dad." He heard nothing, and he of course did not respond. So I’d say it a bit louder. Still nothing. A bit louder than that. Still nothing. And then ... just a very tiny bit louder. The response: "Stop yelling so loud, Son, I hear you just fine. Tone it down a bit, will you!" So THAT'S recruitment - a rapid growth of perceived loudness in a pitch region containing hearing impairment. [And it is very difficult to convey to a person with significant hearing loss that the time he hears my voice at a level uncomfortable to his ears ... was actually the fourth time I tried to get his attention.] This phenomenon occurs because at some decibel level, the normal hair cells adjacent to the damaged hair cells (corresponding to the frequency of a hearing loss) are "recruited." At the decibel level at which these normal hair cells "kick in," perceived loudness shoots up rapidly, causing discomfort. Desensitization protocols do not help in cases of pure recruitment ... what is required is hearing aids (with compression, if the recruitment is severe).

As you can see from the diagram, LDL levels in recruitment are normal. [Note that the LDLs in the diagram are towards the top, whereas the LDL curve on the audiogram is towards the bottom of the graph.] So, Ric, it would be understandable to conclude that recruitment is the source of your problem, but I don't think it is for two reasons. First, it takes an audiologist who is unusually highly experienced in LDL testing to tease out accurate LDLs in recruitment; most reasonably competent audiologists will find them to be abnormal because of the rapid increase in loudness unless the testing is done in a very slow and meticulous manner. So if your symptoms were due to recruitment, you'd almost always expect to (incorrectly) see abnormal LDL testing results. And second, symptoms in recruitment do not tend to fluctuate.

What are some other possibilities? You may have heard of misophonia - but here, again, the LDL curve should reveal some abnormalities. Also, in misophonia the shape of the LDL curve very often mimics the shape of the audiogram curve. In your case, however, while the audiogram curve slopes downward, the LDL curve is flat. So if misophonia (or some variety thereof) were actually the root cause of your symptoms, it would be a rather atypical case.

You mentioned that you have TMJ and sinus difficulties, but I am unaware of any role of either in sound sensitivity. And as far as tension and anxiety go, I tend to look at those sorts of factors only after absolutely everything else has been ruled out.

So in the paragraphs above, you have some general thinking offered by me from a point of profound disadvantage because I have not actually evaluated you myself.

OK, where does that leave us? Well, your situation is indeed complex. That happens in life. But complex does not mean impossible. All it means is challenging. As to what you should do now? Well that's the easy part. You need help. I mean, you can continue to try to noodle through this on your own and try to pick up what you can from the Internet. But that's apt to make it tougher in the long run. No, what you should do is move from the Bay Area to Atlanta and convince me to come out of retirement, which ain't gonna happen! Or how about this? Make an appointment to see Malvina Levy, whose office is a short drive from your home. You have already been in touch with her, and you have completed the work-up as per her instructions. So go and see her! :-)

All the best with it!

Stephen M. Nagler, M.D.
http://www.atlantatinnitus.com

__________________

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

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Previous Topic | Next Topic
Print
Reply

Quick Navigation:

Easily create a Forum Website with Website Toolbox.



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.