Is My Tinnitus "Pulsatile" Because It's Often Rhythmic?

Hi Everyone,

I have some questions about whether or not my Tinnitus is truly "pulsatile", and I'm hoping you can help me answer it.

On November 2nd, I awoke in the morning to find myself with constant, bilateral Tinnitus - the kind where both ears hears a consistent high-pitched frequency, similar to the sound that older electronics or CRTs would make. It's typically louder on my left ear than in my right ear, though it changes amplification volume frequently - and I'm also able to change the volume (and almost silence it in one of the two ears) by moving my lower jaw. I also can cause additional Tinnitus and/or make it louder by clenching my teeth/jaw or straining. I've long suspected that I have Eustachian Tube or TMJ issues (something that I shared with @engineerLA after learning of his hopeful experience curing his own Tinnitus), and an ENT recently diagnosed me with TMJ as the primary cause of my Tinnitus last week.

As you can tell, I've been on a mission since introducing myself last month to try and understand what might be causing my tinnitus, so that I can at least treat or manage it. But it's been lately unpredictable - some days it's a lot better, other days it's a lot worse, and I can't seem to find any correlation. So I'm trying to figure out if it's really pulsatile as a way of hopefully narrowing down the aggravating factors. So far, my journey has looked like this:

• In the month prior to my sudden onset of Tinnitus, I had some G.I. issues when laying flat that also caused premature ventricular contractions in my heart (around ~200 a day) which my electrophysiological cardiologist ruled benign and on the whole "unconcerning." I was subsequently diagnosed with gastritis and dyspepsia, which are being treated using PPIs and a very mild cardiac beta blocker for now. Doctors "think" that this condition, which is continuing, and started in October has nothing to do with my Tinnitus.
  
  
• As soon as my Tinnitus began, I had a Brain MRI (showing only minor dehiscence in my maxillary sinuses and some possible retention in the sphenoid sinus, which doctors said was "unconcerning and non-specific"), a Brain MRA (which came back as "normal" and "unremarkable"), Chest CT w/Contrast (came back "normal"), and Abdominal CT w/Contrast (also came back generally normal, with only gastric-specific findings). I haven't had any tests done on my neck (carotid dopplers) or heart (echocardiogram) to further explore circulatory disturbance issues, though I am inclined to ask for these tests soon - even though my expectations are that they won't find anything of substance.
  
  
• In the past couple of weeks, I've noticed that the whistling has a rhythmic sensation to it - directly in synch with my heartbeat. It sort of "comes" and "goes" with each pulse.
  
  
• My Tinnitus is worse with exertion or strain, especially after working out. The volume becomes louder and more sustained in both ears, though it subsides some time afterwards.
  
  
• Originally, I had dizziness, headaches, and cold or tingling sensations that accompanied many of my G.I. symptoms, though those have generally dissipated as I have managed my G.I. symptoms separately as per above.
  
  
• I went to a leading ENT and an audiological exam determined that I had some hearing loss in both ears in the high ranges, near the frequency of my T. The Audiologist opined that the T may or may not be distorting the results of my hearing exam, but in most cases, T is caused by hearing loss, and so the former is a reaction to the latter's presence, and not the other way around.
  
  
• After my ENT diagnosed me with TMJ as the cause, I went to see a maxillofacial surgeon to have this evaluated (today). He conducted an X-Ray and performed a full physical exam. He found that I have some moderate TMJ inflammation in both sides of my upper jaw, but he didn't want to classify it as a "disorder" or something truly severe. He suggested a regimen of anti-inflammatories and to start wearing a night guard to see if there's improvement over the next couple of weeks.

So, here are my questions:

1. Does anything about my case strike you as particularly telling about possible causes of my T, or vectors of investigation, that I should investigate?
   
   
2. Is the fact that I have noticed that the whistling of my T has a "rhythmic" sensation that's synched with my heartbeat a "smoking gun" that tells me that this is definitely pulsatile?

Thanks for your thoughts and advice! I greatly appreciate it!

 

Karen,

Thanks so much for your warm and welcoming response. I'm not going to give up on further tests. The biggest mystery to me is why some days, I notice a dramatic improvement -- and other days, significant deterioration. It's like a see-saw effect, and it all starts at the beginning of the morning. I'm wondering if, whether it's TMJ or something else, there's something with how I am sleeping at night that is having a musculoskeletal impact.

To answer your question:

No, that's not it. I don't hear any "whooshing" - the rhythmic pulsing sound is really almost that of the same high-pitched whistle just getting a little bit louder and then a little bit softer, all in the same tune to my heartbeat. It's pretty constant, but I don't notice it all the time - I have to strain to listen to hear that pulse happening. It's similar to a heat lamp on a cold subway or train platform in the winter - that rhythmic oscillation of energy pulsing through it. Doctors think it's muscular, but can't rule out a pulsatile experience. But it sounds like from what you're telling me, I should be able to hear viscous whooshing sounds - something that's much more circulatory in nature, with possible vibrating side-effects elsewhere in my head. I definitely don't have that.

Part of me is tempted to just discontinue all of my various medications to see if any of these (most of which I began taking before the sudden onset in November) might be having an ototoxic effect or causing inflammation. Omeprazole (Prilosec) for example has tinnitus as a side effect in approx. 1-2% of all people who take it; perhaps I've hit the lottery?

Thanks again for your warm welcome and positivity - I truly appreciate it!

 

Thanks, Karen.

This is fascinating. You and I have been on similar drugs. I have been on Lisinopril w/Hydrochlorothiazide (20/25 mg, respectively) since September 2010, with no real problems; I was switched in April to just plain old Lisinopril due to a low sodium count in one of my blood tests -- around the same time that my GI problems started, but were quickly addressed with Omeprazole Magnesium (20.6 mg). When my October episodes began, doctors switched me off of Omeprazole and onto Ranitidine which has known otoxocity. I took it for a couple of weeks, and then discontinued it. I was also on Carafate Sucralfate solution 4x a day -- again, like the Omeprazole, ostensibly to treat the G.I. Finally, I was placed on Ativan to help sleep through the G.I. pain/pulsing that I was having at nights.

It was 6 days into taking the Ativan (1 mg once a night) that the Tinnitus started. Doctors, and even many posters on TinnitusTalk, maintain that Ativan couldn't have really been the cause since Tinnitus is a more common side effect over the long-haul use of drugs like Ativan instead of the super-low dosage that I had for ~6 days. Even so, I haven't touched Ativan since then - it's been now more than 5 weeks that I've had Tinnitus and been generally Ativan free.

I had long opined that taking Omeprazole might be causing my Tinnitus, and so, I discontinued it a couple of days ago. I've still been having the yo-yo effect (yesterday was a relatively good day, today was a bit worse - this pattern generally continues). I am also having significant variation within the same day. For example, my left ear continues a steady pulse at the high-pitched frequency. My right ear started at a lower tone earlier this afternoon. I even had a momentary dip in my hearing / clogged feeling with a spike in my Tinnitus in my right ear. Really very strange -- what is going on? -- considering that it's usually my left ear that is consistently worse.

For the past couple of days, I've only been taking Atenolol (a cardiac-selective beta-blocker) to help with my heart's overreaction to my G.I. symptoms, something doctors indicate is extremely benign and unconcerning, 12.5mg nightly (along with ibuprofen to help with inflammation). No real change in my tinnitus to speak of, but I understand that it takes ~4-5 days for Omeprazole to really exit the system, and up to 2 weeks for Lisinopril to bottom out.

At ~5 weeks with Tinnitus, I worry that I'm running out of time to do something truly curative and I fear that the Tinnitus is really starting to "set in." I'm tempted to take a steroid tonight to help lower inflammation; I've been taking natural supplements, including vitamins, all designed to lower inflammation to see if this generally helps - especially since inflammation is generally considered a primary culprit in both pulsatile and non-pulsatile subjective tinnitus.

Any thoughts on what else I should be doing?

Thanks again!

 

Hi @Kaelon your tests have gone beyond what I feel I can comment on intelligently, but I did want to offer one bit of knowledge that I hope will give you a little bit of a sense of calm.

I know everyone talks about the 3 month rule, or running out of time to do something curative - but unless your T is from a direct and obvious acoustic trauma, that 3 month line doesn't apply, it was made because by that time someone assumed that the new neuro pathway had been "solidified" after the loss of auditory input had happened from the acoustic trauma. Even if you do have acoustic trauma it can go away long after 3 months, I've spoken to people for whom that happened.

A month, three months etc. it's all just something someone made up to have a line to talk about - you are not bound to it. Don't set an arbitrary timeline for yourself or adhere to someone else's, you don't need to add to the worry, anxiety and trauma of this situation in that way. Don't put that pressure on yourself. Just know that you're doing all that you can, and try to take some peace from that. You're doing a LOT, and as Karen said, just try one thing, see if it works, and then pursue another option. You have time, and you don't have to do everything at once, in fact, I do not think that will serve you. I did that too in the beginning, and I didn't have time to really see what worked and what didn't. Ears are delicate machinery. They can take months to go back to normal (ever if a drugs is out of your system that caused it for example.)

We're all here to help you, you have time and support. I'm so sorry you're going through this terrible, difficult time, but we're all here for you and I'll keep you in my thoughts for good things and healing.

 

@awbw8 - Thanks so much for your positive and encouraging thoughts.

I'm feeling more and more confident that acoustic trauma had nothing to do with my Tinnitus, and that despite my moderately-low hearing loss (only in the expressed high tones) that was caused probably by long-term over-exposure, the sudden onset of my Tinnitus -- which is pulsatile in nature -- is probably being caused by some yet-to-be-determined neuromuscular complication, neuro-vascular conflict, or some sort of circulatory problem that, I hope, can be diagnosed and treated.

Even so, at 6 weeks in, because things continue to get worse, I cannot help but feel that there's something more I can/should be doing to expose what's going on. I guess returning to my ENT is the next step. I'm just wondering what imaging I should request/insist. Would that be a CVA/T? MRI and MRA of the neck and ears with contrast? I'm truly hopeful that there is a solution here that involves something more than just "waiting it out" for it to go away, or for me to habituate to it over time.

Out of curiosity, what have you learned about your own T, and how have you managed it since April of last year?

 

You're very welcome! We're all here for support : )

It doesn't sound like acoustic trauma (not the kind I was talking about) is the cause from all you've written. If it is from a build up of damage over time, then that 3 month timeline still doesn't apply.

I think you're trying a lot of things right now, and it's complex because you have numerous health issues. I think the best course is to talk to your ENT, yes, but just keep being your own advocate. If you want a certain test, feel it's important and it's not going to put you in the poor house, get it. If you think your meds are poisoning you - talk to your doctors to make sure you are not going to harm yourself by going off them, and then go off them and see what you see. I really think talking to someone is important (a psychologist or psychiatrist - one you trust and like.) No, they wont cure your T, but, especially since your T is seeming to get worse, that's putting a lot of stress on you. It's good to just have someone to vent to if nothing else, truly. I've been seeing someone for over a year since I got my T and it. is. awesome.

As for my own T, I went to a loud concert, I got T. I had never had it before, I didn't know about the necessity of hearing protection. I know it was from that event because I had it when I walked out and it's been with me since. I dealt with it very, very poorly at first, I considered rather seriously the most permanent solution, but thankfully made it onward and away from that. I tried a million things at once, like you, and eventually I habituated *phew.* That's the short version, my success story is in that section here: https://www.tinnitustalk.com/threads/the-light.5969/

I also wrote a blog from about month 2 on with things I tried, books I read and just my personal thoughts as I went through the whole thing. I like to write, so that was cathartic for me. It was mostly for myself, but I think a few like-minded people found comfort and information in it. If you want to give it a read at all, here it is: http://hopeblog.org/

Thanks for asking the question, Kaelon. I think the very central lesson I took away from my personal battle with T is that we are so much stronger than we think we are, we can survive, adapt to and live (happily) with so much more than we think we can. Secondary lesson is how important it is to take care of your whole body and mind. Everything is interconnected, which seems obvious, but when you're dealing with multiple issues, you find out how true that is. When I got T, I really started taking extremely good care of myself in every way - healthy food, exercise, meditation, minimum 7 hours of sleep nightly etc. When I was doing that, my T bothered me least. Sometimes you don't know what part to take care of, so you take care of everything and something works itself out. Tertiary lesson, the people you have in your corner matter, doctors, family, nurses, friends etc. You may not see until you're out of the woods what a difference they made, but you'll look back and realize you wouldn't have made it without them.

My T is very different from yours, but some things are the same for all of us here, trauma is trauma. I think you should try everything you can, so you can say you did. You're in the beginning, it may still go away, just allow yourself some self-love while you're moving along, even though this is hard. You will get through this, it is very hard right now, but I do feel, one way or another, it will not be this bad forever.

If you're in or near NYC, I know a doctor you might like, PM me if you're interested : )

 

Thanks, @awbw8 - that's very kind and generous of you.

I definitely suspect that all of my various health issues -- my gastritis combined with a sudden onset of premature ventricular contractions, the dizziness and cold sensations I've had for the past few months, and now my Tinnitus -- are all somehow interconnected. I've been eating much better and have lost ~20 pounds since starting on this adventure (I suspect it's been mostly stress/water related brought on by the anxiety), but I struggle with exercise because my Tinnitus becomes significantly louder with exertion (and I've read that this is a fairly common circumstance).

My bigger problem is the fact that it seems to get substantially better one day, only to be unpredictably worse the next. Is this typical? Is it unique to pulsatile Tinnitus, or do all Tinnitus sufferers contend with this abnormal behavior?

Similarly, when I awaken in the mornings -- for the past three days straight, I've enjoyed brief moments of total silence that lasted only a few seconds while I wake up. I wonder if this is a neurological phenomenon, or if it's somehow connected to my blood pressure and cardiovascular system (since blood pressure and heart rate both increase as people wake up and gain consciousness). It is a momentary joyful respite that reminds me of the silence of which I have been robbed. Have you, or has anyone really, ever enjoyed these spontaneous moments of silence? Have you done anything about them, or learned to explore what might be causing them?

And most of all, do I have any reason to hope that -- habituation aside -- all of these variations in symptoms, including the discovery of pulsatile qualities, the better/worse yo-yo, even the hyper-acoustic sensitivity, are all leading towards some sort of resolution over the next few weeks?

 

@Karen, thanks again for your incredibly thoughtful and supportive response.

A big mystery - one that I hope my ENT over at Mass Eye & Ear Infirmary this Friday can help me resolve - is whether or not my Tinnitus is truly "pulsatile." I suppose in the technical sense, it must be: since the 8060 hertz sound that I hear grows louder and softer in-timing with my heartbeat, exactly. But the major question I have is whether pulsatile tinnitus can even be tonal; I've read it's almost always a whooshing, clicking, or thumping sound. Even so, pulsatile qualities must at the very least indicate some sort of vascular component, as you say.

Then there's the broader question - and one which haunts me, because as a project manager by training, I'm a problem-solver - is whether or not, if it can even be identified, this is something that can be treated or addressed. I certainly know that the vast majority of tinnitus cases are not treatable or curable in the classic sense of the word, but I would hope that there are at the very least methods and techniques hat help me keep the volume of this low and down to a negligible level so that I can live my life without its distraction and enjoy the sights, sounds, and adventures of what the world has in store.

 

@Kaelon

I know this is an old post but I am new here, so am just going through other people's threads. I just wanted to mention that I also had taken about 1 week worth of 0.5mg Ativan when I developed pulsatile tinnitus 4 weeks ago. I was on it for a very short period of anxiety that I was dealing with and I only took one a day. Not sure if it's possible it is the culprit but it's been weeks since I have taken any and I still have the pulsing. And how ironic that now I am anxious about this instead!

 

It's ototoxic, so it could very well be. Sorry to hear you've got PT, I honestly don't know what that's like. Is it worse than normal tinnitus?

 

Pulsatile Tinnitus is definitely a very different beast than non-Pulsatile Tinnitus. The clicking, jumping, pulsing, whooshing sensation is circulatory or neurovascular in origin. I have never had that particular type of Tinnitus -- other than fleeting pulses once in a blue moon (every few months or so), which I understand is quite normal and akin to periodic twitches. I did, however, take Ativan for a few days before my high-pitched Tinnitus started, and the two were largely coincidental.

Ativan is not ototoxic. The FDA has done countless tests on benzodiazepines, and their use does not cause damage of any sort to hearing organs or auditory nerves. However, discontinuing benzo drugs after many months or years of use is known to cause a possible "rebound" effect in the Tinnitus that it was helping treat; generally speaking, benzos like Ativan help reduce, not amplify, Tinnitus due to their peripheral benefits for neurological health and anti-spasmodic effects.

 

That's why you should take Campral if you are discontinuing benzos after awhile...

 

@Kaelon thank you for the information, that is good to know that benzos are not known to cause T or PT. I only took them for a very short time so was unsure if they could be the culprit. You seem like a wealth of knowledge, thank you for being so educating to newbies like myself!

@Danny Boy not sure if PT is worse than T since I don't have regular T. My PT is more of a feeling than a sound. I just have a pulsing sensation, but no other noise.

 

Ah, ok. Wish I could hear what you're hearing just to know what you're going through.

 

Have you done a MRI AC (acoustic canals?). It is useful for finding signs of a possible microvascular compression conflict. I have done one, and guess what, mvc is found on the ear I have the tinnitus. Mine is not heart beat synchronous, it is more of a fluctuating continouous sound, but there is a telegraph sound also there. I don't know if that is pulsatile. I do know the problem started after a loud burglar alarm, but I did have T before, not that troublesome. Since they don't have a clue about tinnitus, I find myself wondering if there is a connection of acoustic traumas and neurovascular conflict. I have opened a topic about it.
https://www.tinnitustalk.com/thread...-vascular-compression-do-most-have-both.7518/
Of course, we are not doctors, but there seem to be a sencitivity connected to acoustic traumas and mvc, since there are other I know of that do have unilateral tinnitus problem with mvc in that exact ear!

Aslo, I do make my T louder by opening-stretching my mouth wide open...

​

 

Hello,
Was diagnosed with PT in Dec 2012. Just woke up and it was there. Did all the tests you have done and cut out all the meds like others here did and to no avail. The only med I did not stop was my Xanax as I was taking it for anxiety. Since I 've retired from a very stressful job my anxiety is much less so I decided to taper off my Xanax. Needless to say the withdrawal symptoms were very intense but it has now been 2 months and have reduced from 1.5mg/day to .5 /day and I can say my PT has reduced in sound to the point it is barely noticeable unless I try to hear it. Xanax has been well documented to affect your ears and CNS . So anyone with PT and taking Xanax, you might want to try cutting back and see what happens. It does take awhile for you to notice though. Ironic that doctors prescribe Xanax for T.
Good luck! Keep looking for alternatives as my experience with all the doctors was they seldom think outside their box and are so busy to get to their next patient that they don't spend the time with you and listen.

 

Kaelon, I have what you describe, what I call the Triple Play of T: 1. steady high pitch sound, no too far off the frequency you posted above, 2. Pulsatile T, where the sound grows louder and softer in sync with my heartbeat, and 3. Somatic T, where the sound increases (in frequency & loudness) by opening-stretching my mouth, jutting out my jaw, chewing...even driving over a bump in the road in my car. I've been to the T clinic at MGH/Mass Eye & Ear, seen Dr. El Chemali who is the T specialist there. My T started 6 years ago one night after a long dental procedure, where I had my mouth/jaw open for a long period of time. I woke up in the middle of the night with this sound that has stayed with me ever since. A jaw MRI ruled out TMJ. A brain MRI ruled out tumors, vascular issues. Like others, I really don't know what the cause is, and I wonder if it was already there before that dental procedure, maybe at a lower level. I do have some hearing loss at high frequencies, consistent with my >50 age. Of course, not everyone with high frequency hearing loss hears T -- lucky sons of a gun! All of the dietary advice out there has no impact on me: coffee, salt, alcohol, etc. Dr. El Chemali would tell you that none of the dietary theories are substantiated in any studies. I believe there will be an effective treatment someday, and am hanging my hat on that as hope. In meantime, having exhausted the conscious medical battle, I stay focused on the subconscious battle as a measure of control. Yoga/mindfulness, adopting an attitude of gratitude, owning and caring for a loved pet, being kind - all these are proven ways to lower stress, increase seratonin production, release endorphins, and have other beneficial mental and physical health benefits. I even intentionally jut out my jaw from time to time to make my T ring louder so I can take comfort that it could be worse :-(

 

Hi @yeoman,

This Triple Play of T, as you describe it, is symptomatic of neuromuscular inflammation. The dead give-away is steps 2 and 3 -- the oscillation (I don't call it "pulsatile" T, because this has a very specific clinical designation and neither you nor I seem to suffer from any vascular or circulatory issues that would be responsible or a pulsatile Tinnitus), and the somatic nature of it. If you can counter the inflammation, you can also counter (and ultimately, silence) the Tinnitus. Hot showers, hydration, and good sleep provide minor relief -- and if they offer you relief, then, that's a good sign. Powerful anti-spasmodics and anti-inflammatory drugs (namely, prednisone at a minimal 50 mg. daily initial taper down to 10 mg) can almost entirely silence it.

Have you noticed any relief with any of those exercises I've described above? Have you seen an upper cervical chiropractor? Even though TMJ disorders are usually blamed for situations like these, the reality is that the neuromuscular inflammation above-the-head is actually a very complicated scenario involving numerous muscle groups in the head, neck, jaw, and upper back spasming and tightening. So anything that can be done to support muscular health there, and loosen the muscles, can produce tremendous relief.

Have you tried any of that?

 

@Kaelon: Would you be able to inform us what type of tests the clinic did to check for your pulsatile tinnitus?
Was it by audiologist(s) or an ENT?
How did they do an evaluation as I've heard the stethoscope was the only technique? (this seems to be the most basic, rather than a true assessment/work-up for validation of this type of T). Thx!

 

Yeoman,
I too had PT start 2 weeks after a lengthy dental procedure involving a broken tooth and extraction. I also can jut out my jaw and it increases the PT that is present but after doing it 3-4 times it's as if the muscle has been exercised and it doesn't increase it. Also chewing sometimes does make it happen. Does tilting your head back all the way increase the sound and lowering your head decrease the sound? Also are your ears sensitive to sound as mine are? Not painful sensitivity but definitely there when a sharp sound happens.
Thx!