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montana

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 #1 
Hi Dr. Nagler,

I am about three weeks into high pitched persistent tinnitus in my right ear (started January 2, 2016).  

Background:  I have had my hearing tested and appear to have a small amount of high frequency hearing loss in the affected ear, in one "notch."  It may have been noise induced (I fired two shots lefthanded from a shotgun outdoors on December 12th, 2015).

Prior to the tinnitus, I had a difficult molar extraction on the right side followed by a skin infection and 5 weeks of hives and swelling all over my body.  I was prescribed Amoxicillin, then Bactrim and Prednisone.  The hives, though improved, are still coming in, mostly on hands and feet. 

On January 18, I was looked at by an ENT's PA.  It seemed rather cursory, only about half an hour.  He looked up my nose and in my ear. No sign of infection, and he indicated the Eustachian tube didn't appear inflamed.  He advised me to try Claritin D and Flonase, and that if it's still here in six months it's probably permanent.  Since beginning these meds, the intermittent feelings of fullness, pain, and itchiness in the afflicted ear have mostly disappeared. And the hives and swelling are mostly gone.  But the ringing remains.  

Should I get an MRI? After some research, I am surprised the ENT PA didn't bring up the possibility of acoustic neuroma, vestibular schwannorma, AIED, SSHL, etc.  I suppose he figures the ringing was caused by NIHL, and I can't really blame the guy for given it seems the simplest cause.  That said, given the other health problems I have had recently, are there any other tests I ought to consider at this point or over the next few months?  I am terrified of losing more hearing or my tinnitus worsening.

Thanks for any guidance you may provide.  At this point, I just want to eliminate as many underlying medical issues as I can, particularly those that may worsen my condition.  I reviewed "Tinnitus for Newbies" and some of your other materials, and found them helpful.  I truly appreciate the time and care you have put into helping those afflicted with this problem.

Best wishes,

S
Dr. Nagler

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 #2 
Hi montana -

So there are lots of issues and sub-issues in your post, but here are the things that immediately come to mind ...

In terms of your initial question: "What constitutes a thorough ENT exam?" if we are talking about a tinnitus evaluation, the ENT should (a) rule out the (unfortunately rather rare) causes of tinnitus that can be fixed an in-so-doing ablate the tinnitus or at least lastingly diminish its intensity and (b) rule out the (fortunately even rarer) causes of tinnitus that represent a threat to health or life. How the ENT goes about accomplishing those tasks can vary depending on the circumstances but at the least should include taking a careful history, performing a thorough head and neck examination (including, of course, looking in the ears), and arranging for an audiogram (to measure hearing thresholds) and tympanometry (to assess middle ear pressures).

Regarding the question of an MRI, in my opinion that test should be performed in the case of unexplained unilateral (i.e., one-sided) tinnitus lasting more than six weeks and/or unexplained asymmetrical hearing hearing loss. If an MRI is indicated, the specific test to be ordered is an "MRI of the brain and IAC's with and without gadolinium." And if you do have the test, be sure to wear earplugs since the machine itself can be rather loud. Please understand that such studies are almost always unremarkable, but I feel nevertheless that they should be performed under the above-mentioned circumstances.

In your case, with tinnitus and a slight threshold shift in your right ear after shooting a shotgun left-handed (i.e., with your left ear tucked near your shoulder while your right ear is exposed to the noise), one should try to determine whether or not the tinnitus in your right ear is indeed "unexplained" before going ahead with an MRI. If there is any doubt, then it is probably better to go ahead with the exam - if for no reason other than peace of mind.

But here's the thing, my new friend. And it is something we often tend to lose sight of. Medicine is a service industry. You (or your insurance carrier on your behalf) are paying for a service. My first step would be to make another appointment with your ENT, specifying that you wish to see the ENT and not the PA. Come with a written list of questions (preferably no more than three or four), and if you are still dissatisfied with the quality of the service at the conclusion of your visit, then fire your ENT and go see another one!

Hope this helps!

Dr. Stephen Nagler
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.
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David McCullough quoting Wilbur Wright
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