A case of severe pulsatile tinnitus cured with surgery

 

Tinnitus is an extraordinary disease in some ways. It affects 1/5 Americans (that’s 60+ million people) yet it is poorly understood and still, for the most part, untreatable. I cannot think of any other affliction that is at the same time so pervasive, yet so poorly managed. The most common form of tinnitus is non-pulsatile tinnitus, which is often described as a constant buzzing or ringing tone. This type of tinnitus is most often related to high frequency hearing loss, which can be diagnosed with a formal hearing test. Aside from recommending hear aids and white-noise, there is little else that’s been proven to work. It’s a frustrating diagnosis for both me and the patient.

So when a patient came to me complaining of several months of “roaring” tinnitus from his right ear, I was gearing myself up for the same disappointing conversation. But as I listened to this patient describe his tinnitus, several key points were elucidated that caught my attention: 1) his tinnitus was pulsatile, meaning it sounded like a heartbeat rather than a constant hum 2) certain positions seemed to make the noise better or worse 3) the patient felt that his hearing was more or less intact. The noise was so severe that the patient has only been able to sleep 3-4 hours a night. When the noise first started, he spent several hours searching his house for the source of the sound because he couldn’t believe it was coming from inside his own head.

On my physical exam, I was able to match the patient’s tinnitus to hear heartbeat, indicating this was most likely caused by a vascular anomaly. Furthermore, when I compressed his neck on the right side, his tinnitus magically disappeared. I counseled the patient that in situations like this, there is about a 10% chance we may find a specific abnormality on a CT scan. Furthermore, only a fraction of these abnormalities would actually be treatable, and would usually involve a moderately complex surgery. Most patients at this point would resign to just living with their tinnitus, but understandably, this young man was so affected by his tinnitus that he wanted to pursue every option available.

With expectation tempered, we obtained several scans designed to look for vascular anomalies near his ear. And there it was – an abnormal sigmoid sinus, which is a large vein that runs behind the ear. Turbulent flow caused by a defect in the bony covering of this vein was causing blood to become turbulent as it passed behind the ear. Long story short, the patient underwent surgery and has been tinnitus free for a month. It’s a small win in a long and frustrating battle against tinnitus and it gives me hope that future medical advances will one day allow me to better help every patient that comes into my office with all forms of tinnitus.

 

Headache and facial pain from a deviated septum

When something touches our skin, it’s generally very easy for our brains to pinpoint the exact location of stimulation due to the dense forest of nerves that cover the outside of our bodies. On the contrary, the insides of our bodies have a much less developed sensory system which often makes it hard to describe and locate a potential source of discomfort. Nowhere is this more of a problem than the head, neck, and face. For example, ear pain can be referred from the back of the tongue, the tonsils, the back of the nose, and even deep muscles of the neck.

In this post, I want to touch on a very specific type of referred pain called Sluder’s neuralgia which are contact headaches caused by a severely deviated nasal septum. I’ll begin by summarizing the clinical course of a recent patient. The patient had been suffering from more than 15 years of predominantly right sided headaches. Her headaches weren’t constant but when they struck, they kept her out of work for days at a time. She didn’t have any blurry vision or visual auras that are typical of migraine headaches. By the time she was referred to me, she had already seen 2 different neurologists and had a MRI of the head and neck area ruling out any intracranial abnormalities. She went to physical therapy to try to improve her posture and even took migraine medications for 6 months without any improvement.

Her headaches were strongly associated with nasal congestion and responded well to decongestants such as Afrin. While not a smoking gun, this certainly raised the possibility that her headaches were somehow related to her nose. On nasal endoscopy in my office, this is what I saw:

 

The tip of my instrument is pointing at a bone spur that likely formed when the patient was struck by a basketball during her high school years. Every time her nasal passage became congested, the spur literally stabbed into the side of her nose, causing her left sided headaches. When I touched the area of the bone spur in clinic, it perfectly recreated the sensations that had plagued her for years.

After a simple 30 minute procedure to remove the bone spur, the patient has been pain free. Here’s an after picture:

I have seen patients with eye pain, cheek pain, tooth pain, and even ear pain depending on where the bone spur erupts. While it’s not a common cause of facial pain, I do think Sluder’s neuralgia should be considered especially when more common pathologies such as migraines, trigeminal neuralgia, sinusitis, and dental issues have been ruled out. If it is diagnosed, I am generally very optimistic for a complete cure after surgery.

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