Somatosensory (Sometimes) Pulsatile Tinnitus — Would You Have an Angiogram?

Hello good people. My first post here. Thanks for all you do and contribute.

Today an interventional radiologist suggested that I consider an Angiogram, which has prompted this post. Although this is a decision only I can make, your read of my circumstances would be gold at this point. Full disclosure: I am reticent to pursue further investigations after CTs and MRIs were all clear, and when the only symptom is hearing my heart rhythm layered over the high pitched tinnitus. Here's a quick intro which may help you understand the dilemma:

If you asked me to describe myself a year ago, I would have said "I'm a healthy, very fit 51 year old guy, with not a care in the world". But that has changed rather unexpectedly. Physically I am a big guy, 6 ft 4, with a big skull, heavy bones and a high pulse pressure (not blood pressure, which is 122/58). I am in good shape, eat clean and have very few vices. I have battled to sleep for most of my life, and have been on one Zopiclone tab at night for many years.

Symptoms: For the past 7 months I have had high pitched tinnitus which, around half the time, sounds like a wave that tracks my heart beat. The rest of the time it is constant. It was initially unilateral (left ear only), but is now also audible in my right ear. I can modulate it by (i) clenching my jaw or (ii) putting pressure on the bone behind my ear. These symptoms have been constant and beyond tormenting, except for about three non-consecutive days where it was barely audible. I am not an anxious person, but it feels like I have remained in fight-or-flight mode, or in sympathetic nervous system activation space, to the extent that I now have significant digestive issues (these were investigated and put down to IBS). Could tinnitus even cause nausea and pain? I don't know, but I do not have a better explanation.

Triggering event?: During a routine test I was informed that my free Testosterone level was very low. A Depo Testosterone injection was administered. Within a week I had severe heart palpitations. I exercise at high intensity and this was a concern. A CT Angiogram (which involved dilation)was done and I was given the all clear. The heart palpitations lasted for about 6 weeks. A month later in, August 2021, the tinnitus ensued.

Medical tests: An ENT suggested that it is probably linked to neck/muscle/TMJ issues and high-frequency hearing loss, but could not explain the pulsatile component which occurs at times. 2 x Audiograms confirmed low-moderate hearing loss in the higher frequencies (quite a steep drop at 4000 Hz which seems noise induced). Three MRIs were clear (head, ears and blood flow from neck).

The simple answer: ...was that I had hearing loss related tinnitus, but somehow my heavy heart beat was layered over this. I have no idea whether that is even a thing, whether the somatic component was just a random part of this etc., so, I forged on...

The dilemma: I wanted to exhaust my functional options. The scans will were thus sent to an interventional radiologist. He has been very kind, has listened, and has reviewed the scans in detail, but found nothing aside from a high-riding jugular bulb on the opposite side (right). His suggestion is that I have an Angiogram if I wish to go with the gold standard of eliminating anything which could be treated. I know I went looking for this, but am now doubting whether the risks make this a good decision, at the risk of sounding spoilt. Or even whether I could make this all worse by pushing too hard. Or what the likelihood is of finding anything that could be treated, especially since it is now bilateral. Most of you reading here know the torment of constant tinnitus, especially when coupled with uncertainty.

Thanks for reading. Your wisdom and thoughts regarding my many questions is received with much gratitude.

 

Hi @Wern, how were your digestive issues investigated - what tests were performed so I can comment more on your pulsatile tinnitus? Also do you have tight neck muscles - soreness?

It appears that you have hearing loss tinnitus as well.

Me too. I have unfixable somatic tinnitus, unfixable hearing loss tinnitus and unfixable pulsatile tinnitus.

 

Great hearing from you @Greg Sacramento. Thanks for reading, and for your questions. I am so sorry to hear that you have not found a resolution to your barrage of tinnitus. How you have coped in terms of psychological distress and the emotional components would be a topic I would love to touch at some point. But, back to your questions:

The digestive issues started a few months pre tinnitus with significant lower abdominal discomfort and pain. It was investigated via colonoscopy in March - got the all clear. It resolved after about two months. Then, three months into the tinnitus journey I started experiencing upper abdominal pain, right up under my ribcage, coupled with nausea on and off. If I eat, the pain refers to my back and chest. It calms down when I sleep, but within a minute of waking up the "active tummy" and pain sets in (as soon as my digestive system gets an awake signal). I have had a gastroscopy - all healthy, ultrasound - no gallstones etc., stool sample - no HP or blood detected. It was put down to IBS and something that will resolve by itself. PPIs have just made me more nauseous, and did nothing for the pain, although I do have a strange taste in my mouth when the pain sets in.

I'm generally mentally strong, have a great family support network and am spiritually anchored. But it feels as if the tinnitus has gradually worn me down. Especially the stop start journey of trying to come to peace with it and setting myself to habituate, and then having more medical examinations. Of course I'd like to be able to say that I did all I could to rule out a treatable/functional cause, but I have doubts regarding the risk/reward of the catheter-based Angiogram, given my symptoms and the results of previous tests. As mentioned, I did relentlessly push to get to the point where the scans were scrutinised post the first "all clear"... and got another "we can see nothing wrong" with a "but let's do an Angiogram". I would have said the same in their shoes, so I totally get it. And appreciate the level of care I am receiving very much.

I exercise a lot and do most of my work in front of a computer screen, so a stiff neck is generally part of what I live with. I did have significant whiplash 30 years ago (it knocked me out cold), and concussion three years before that (2 x auto accidents in my reckless youth). I have had some adjustment and physio treatments over the past few months in the hope that it may help, but it has not. The most significant somatic events are clenching my jaw and pushing, with some force, on the bone behind my ear. Both give me a 100% increase in loudness of the 8000 Hz tone. Neck rotation and pressing on the jugular does not seem to affect the tone or intensity.

Thanks again for reading, and for your wisdom.

Warmly,
Werner

 

Interesting post Werner.

I have acquired severe pulsatile tinnitus as a result of a COVID-19 vaccine.

It sounds quite similar to yours. At night I can hear every heartbeat against a low drone like someone beating on a drum. Impossible to sleep with.

I have started taking one Zopiclone per night sometimes with 12.5 mg of Promethazine which gives me a good night's sleep. Strangely for 3 or 4 hours after I wake up, the ordinary tinnitus and pulsatile tinnitus are very low. However, when I get up and go to work, the pulsatile tinnitus especially increases and is pretty intolerable by night time.

Have you had any side effects from taking Zopiclone so long?

I am trying to put off any kind of invasive investigations for as long as possible. I have bad experiences from ENT investigations including TTTS.

In the end it will be up to you.

I wish you the best of luck.

 

@Wern, ultrasound is the test I wanted to hear with having digestive issues. This will rule out an abdominal aortic aneurysm which can easily be responsible for pulsatile tinnitus.

You had some good radiological tests and all that was found was a high-riding jugular bulb. Some decide to endure some pulsating when they don't have dizziness with conservative management. Something to discuss with family and your IR.

This article is a case of a patient who presented with debilitating pulsatile tinnitus in association with two jugular bulb diverticula. A comment from article: Anterior-extending diverticula are more often associated with sensorineural hearing loss and tinnitus without vertigo.

Case Report: Endovascular treatment of jugular bulb diverticula causing debilitating pulsatile tinnitus - PMC (nih.gov)

 

@volsung37 - I have great empathy for what you are experiencing. My hope is that this resolves over time for you.

I have had varying experiences with Zopiclone, depending upon the brand. I would stay well away from all the generics - can't emphasise this enough. Imovane is what I would recommend if you can get hold of it. If anything, the tinnitus I experience is lower volume on 7.5 mg at night. Of course it is not ideal to be on any sleep medication on an ongoing basis, but my mother's side of the family are plagued by sleep onset REM and excessive dreaming, and I suffer from the same malady. I settled on Zopiclone as the side effects (in my case) were negligible. I have been taking it for more than a decade keeping the dose constant (1 tab before bed).

I hear you regarding invasive procedures, and am leaning in the same direction, at least for now.

By the way, is your pulsatile tinnitus subjective?

Strength and honour!

 

@Greg Sacramento - thanks for the feedback - and the very interesting link. I have questions (no surprise there!). Your comments regarding abdominal aortic aneurysm got me thinking:

-The ultrasound was ordered by the GE to rule out gallstones. Would normal procedure be to check for AAA? They did work their way around, checking the liver etc., so I imagine they have a standard list of conditions to check for?

-I had the CT coronary angiogram in July 2021 to investigate heart palpitations. The report was quite detailed and included a review of major organs. I imagine this would have shown AAA if it was present?

Speaking of which, and probably way off the mark -- I had a mean headache from the dilation, and actually wondered whether this whole procedure could have contributed to tinnitus developing...

Thanks as always!

P.S. The precursor to pretty much everything seemed to be the testosterone shot. This may just be a coincidence, but I started feeling unwell three days after this, followed by the heart palpitations and eventually tinnitus. Here's a link to a study summary you may find interesting. Especially the one line "Conclusion":

Injection testosterone and adverse cardiovascular events: A case-crossover analysis

I have the full PDF if you are interested in further reading.

 

Thanks Werner.

I’m not sure whether the pulsatile tinnitus is subjective. I haven’t gone to anyone to assess that yet.

Good to hear that you haven’t experienced any bad side effects from the Zopiclone usage over that period of time.

We struggle on!

 

Trying not to use many medical terms.

From your article: Exogenous testosterone administration may affect blood clotting, polycythemia, and may increase atherosclerosis.

Yes, but your radiological neck testing did not show carotid atherosclerosis, but this and pulsatile tinnitus can take years to develop. Your legs probably don't show trauma which is often a first sign from a dilation procedure.

High blood pressure or a hypertension crisis can cause AAA and atherosclerosis and if so, atherosclerosis can travel to carotid and narrow in minutes causing pulsatile tinnitus. Atherosclerosis can also cause high blood pressure. AAA can also be caused from intense exercise or injury. Hypertension crisis is a medical term - HC can happen quick and a high blood pressure change may be only for seconds. Your normal blood pressure is hypotensive and that's not concerning.

Yes, in showing AAA. I really doubt you have AAA.

Has your IR reviewed all mid-section prior tests, including the CT coronary angiogram in July 2021 to investigate heart palpitations. The report was quite detailed and included a review of major organs.

These tests should be reviewed before an Angiogram.

Possible and with what is noted in CT coronary angiogram, but from this, pulsatile tinnitus could take years to develop.

Your IR mentions a high-riding jugular bulb. Some use conservative management for a high-riding jugular vein if pulsatile tinnitus is not severe.

Bottom line: Do you have any problems with legs and feet? Blood vessels and swelling?

 

@Greg Sacramento, thank you for putting all of that together!

Short answer - no, no problem with legs or feet, thankfully.

Your post made me think about how my regular running activities often take me to very high heart rates. As an aside, I had COVID-19 bouts in April 2020 and December 2021. A friend who is a local physician is doing some work with “long COVID-19” cases. Very interesting conversation, albeit that many unknowns remain.

I really appreciate the methodical and scientific way in which you engage these conversations. Pretty rare, thank you.