tinnitus and other symtoms

[dcrespe]

Male
37 yo

Hi there,

It's been 7 months now that I have got tinnitus that I can hear when it's quiet. My ears hurt. My nose is blocked and my throad is a little painful. Sometimes, I wake up at night because I can hardly breathe. In the day, I am easily exhausted. I also have some pain through my head going back and forth. My eyes itch.

I had a head scanner, nothing weird. We tested my hearing too, no loss.

I have no idea where all these symptoms come from. My health was good before.

Thanks for you help,
Denis

[Enoch Choi, MD]

I'm so glad you're healed.  And that you're willing to help people here in the ENT forum.  So many people here are looking for help with their vertigo.

[Nancy T]

PT is a physical therapist; there are some who have special training in helping patients with dizziness or balance problems, and these are known as vestibular physical therapists. You can find lists of them at www.vestibular.org. I don't know your history, but you could see if your ear doctor thinks this might help you. For some patients it's a great help, if they don't have "unstable" dizziness, in other words if they don't have ongoing, uncontrolled inner-ear damage.

I honestly don't know the cause of my dizziness, which began slowly for the most part about 20 years ago. After it got worse when I sneezed hard in 1999 (instantly losing the hearing in my left ear), many things were ruled out including inner-ear tumor, membrane break, vascular loop, etc. Personally I suspect (but truly don't know) that migraine, very mild autoimmune disease (I've had numerous other odd symptoms over the years plus highly abnormal auditory evoked potentials, which test the hearing nerve pathways), or maybe both of these have something to do with it, exacerbated by some kind of damage to my inner ear when I sneezed. But the doctors have never been able to find out why I'm dizzy. Not their fault; they tried.

In any case, an attention-deficit disorder medication called Strattera (atomoxetine) allows me to concentrate normally instead of having the dizziness-induced "fog" that was my big problem. I have also gotten allergy shots the last two years, as my ear doctor believes allergy can make ear problems worse (although I never believed I had allergies until I was tested!). I have had some overall improvement in my dizziness, whether due to the shots or other reasons is hard to prove, but they probably have helped. I still have wooziness, motion sensitivity, and just plain dizziness which fluctuates, but I function really well now.

However, Strattera is NOT a medication anyone would think would be prescribed for dizziness. It just happens to help me, a LOT. I tried it after a neurologist had me try Provigil and then Ritalin, both stimulant type meds, both of which helped me a lot too. Anti-anxiety medications (such as Xanax and Ativan) and vestibular suppressants (such as meclizine) did nothing for me, but they are very commonly prescribed for dizziness and do help many people.

Nancy T.

[sirjoseph]

whats a pt? and what was the cause of your dizziness and the meds you took?

[Nancy T]

Thanks Dr. Choi--both the docs I saw were very good, one was affiliated with the med school, and they did help as much as they could--and now thanks mostly to the right medication, the dizziness is no longer a problem in my life.

[Enoch Choi, MD]

If neither ENT nor neurologist offered help, i'd go see another, in a university setting, a tertiary care referral center.

[Nancy T]

W/a/J says: "Because of this, a lot of dizzy patients fall through cracks, get frustrated, give up..."

I definitely agree with that! Good point. People get bounced around and don't know where to turn. The ENT says it's not an inner ear problem, must be brain. The neurologist says it's not a neurological problem, it's your inner ear. That never really happened to me (they both just said "don't know," but both did try to help me)--but I see that complaint SO MANY times on the dizziness list that I read. Often, no one really wants the dizzy patient except a PT (IF the patient is lucky enough to be referred to a real expert PT).

I remember seeing some presentation by a dizziness-expert doctor that started out by saying something to the effect of how physicians presented with a dizzy patient often get a sinking feeling and just want to bolt out of the room, BUT (says this doctor) you don't have to feel that way if you take this rational approach! Which just goes to show how difficult dizziness can be,how frustrating it can be for the doctor as well as the patient. But from the patient's point of view, it's really awful to realize that a doctor hates dealing with you.

Nancy T.

[Wear/a/Jimmy]

Nany,

Of course there are people that specialize. Again that is the point, academically there is really no one prepared right out of college for balance. Especially if you consider all the things that a PT has to learn in essentially 2 years....  no way.  Knowledge in the balance system is aquired, picked up etc after college through various programs as you mentioned.

That is why you will find PT, audiologist, Chiroprators, ENTs, OTs, yoga instructors, massage therapists, and the list can go that have a self proclamation of being an expert in balance, and every one of from this group can argue that neither one is prepared to be an expert or has the proper training to be an expert in balance.

We like to call it a Team Approach, trouble is, who does what, who reports to who?  Because of this, a lot of dizzy patients fall through cracks, get frustrated, give up, fall down, fracture a hip, and it is all down hill from that point.

[Nancy T]

W/a/J, I'm not sure exactly what you mean by "via academic training," but I certainly think there are real balance experts out there in various fields.

There is a whole industry of balance courses for PTs (see, e.g., www.vestibular.org and click on "For Health Professionals," then "Conferences and training"). The most respected seems to be Susan Herdman's courses, but there are many other good ones too, I'm sure. I imagine you were talking about basic PT training not teaching much about balance.

I would consider the otoneurologist (neurologist specializing in dizziness--a rare breed) that I saw an expert in balance, as well as the PT he referred me to. Some PTs do a very large percentage of their work with vestibular patients and really know their stuff.

There really are academic centers with a lot of scientists working on balance, and patients can benefit from this if they find the right place.

When you say that ENTs don't know how to interpret balance-testing results, do you mean they can't interpret an ENG?? Maybe you are referring to "ordinary" ENTs? Surely neurotologists can interpret balance testing. But again, neurotologists aren't exactly in every city, easily available to dizzy patients.

Thanks for your info and perspectives!

Nancy T.

[Wear/a/Jimmy]

I do not contend that all ENTs operate without Audiologist or anoint some one without any training for their hearing & balance diagnostic work.

Some ENTs would never do so, just out of pride & in order to maintain a level of competitiveness in the area. But again, they do not have to have an audiologist if they do not want to. (one of the reasons why salaries are so low)

So I guess the point is, regarding a person in your position, is when you do refer out to an ENT, just make sure they staff a licensed audiologist.

Then of course find out what equipment that have available such as:

Tympanometer
OAE
ABR
ASSR
ENG/VNG

If they have all of that, you can feel secure that this ENT runs a good office and is concerned about getting good diagnostic information in order to determine a Dx/Rx & prognosis.

Let me know when you are coming to Phuket, I may make a trip just to meet you. I go there routinely for work related things. Our office is located right next door to an ENT group...  yep, we like to try to help each other.

[Enoch Choi, MD]

Wear/a/Jimmy, thanks for opening my eyes to all of this.  That's very informative...

[Wear/a/Jimmy]

But what about all those places that place full-page newspaper advertisements for hearing aids? You know, the kind with pictures of Grandpa and his grandkids whom he wants to hear at the holidays. I presume audiologists can work there (without an ENT) because these places don't bill an insurance company but just take cash from the customer?

Currently in the US, the federal law is anyone can sell a hearing aid. Just go to e-aby if you want proof.

Like I said, anyone can sell a hearing aid. A hearing aid is a 510K exempt Class 1 medical device. That places it right up there with tooth brushes, Q-tips and band aids.

Now the federal law states to FIT AND DISPENSE hearing aids you have to have a license.

State laws say that you have to have a license to sell, fit and dispense, and just recently the Fed govt stated that the states can not upsurp federal law.

Regardless:

3 Individuals can fit and dispense hearing aids

1) A licensed physician (that means any physician)
2) A licensed Audiologist
3) A licensed Hearing aid dealer  (BCHIS) Board Certified Hearing Instrument Specialist


1) Qualifications of a physian in the realm of hearing, hearing aids etc....  little to none.
2) Qualifications of an Audiologist, at least a Doctorate degree in audiology.
3) Qualification of a Hearing aid dealer, No recorded felony, High School diploma or its equivalancy, and the passing of a hearing aid dealers test. They aslo have an aprenticeship program too. ,& no college courses required specifically in the field of audiology or auditory sciences.

Of course you the public is not aware of this.

Yes, to sell a hearing aid an ENT is not required, and yes this is because hearing aids are for the greater part not covered by Insurance. Now if there is coverage, most of the insurance companies I have worked with either demand a physicians rx of a hearing aid or an audiologist to fit and dispense the hearing aid. So at least insurance companies do show some awareness of the situation.

Balance experts:  In my opinion, there are none via academic training. PT really have little to no education regarding balance, and I think to be a PT a bachelors degree is the requirement. For that short amount of time, becoming an expert by academics would be very difficult. ENTs... they have a good handle on things, but they would not know how to perform or interpret the tests associated with balance testing. Then the therapy needed, would also be beyond an ENT. Audiologist, yes they do have probably the most training regarding balance testing, but have really no training in physical therapy....  so you can see Balance is out there floating around...  with no one individual really being a bonified expert.  In my humble opinion, I think PT, with the proper amount of training are more apt at balance therapy than anyone. They are trained to perform therapy and create therapy plans etc.

Audiologist, no, they are trained for testing, diagnostics, hearing aid fittings, imediate results. ENT again, imediate results via a pill or surgery.

[Nancy T]

Interesting... that makes sense why everyone wants to sell hearing aids! (Although no one has ever tried to sell me one; in fact they said they didn't think a hearing aid would do me any good.)

But what about all those places that place full-page newspaper advertisements for hearing aids? You know, the kind with pictures of Grandpa and his grandkids whom he wants to hear at the holidays. I presume audiologists can work there (without an ENT) because these places don't bill an insurance company but just take cash from the customer?

I guess I'm not sure about ALL the people who've ever tested my hearing, but on the occasions when I saw a report, I'd see their credentials by their signature, or maybe on the doctor's Web site under the staff bios. I do know that the person who did my first ENG was not an audiologist--she is an RN. But she had worked there forever and by all accounts did it right.

The balance-testing expert/vestibular scientist who posts on our dizziness list is very grumpy about the growing number of "balance centers" who advertise themselves as such but don't have people who really know how to run the equipment, nor proper experts to interpret the results.

How much we the public don't know until we're up to our ears in it, so to speak... thanks W/a/J.

Nancy

[Wear/a/Jimmy]

Also, sorry Nancy you got me started....

A lot of times the person doing the testing is not actually an audiologist. There is no law that states that an audiologist can only perform hearing evaluations. In other words, ENT can hire any one, and under their power & authority of "delegation" they can delegate audiology test work, from balance studies, balance therapy, ABR anything...  Delegation rules specify that the doctor must be present.... present being defined as within the building...  not in the room.  

So technically speaking, it is a "dont ask don't tell" situation. You may think you saw an audiologist.... but did you really?  You may think an Audiologist performed the test that determines if your 5 month old cute bundle of joy with 2 different colored eyes is an audiologist, & you may rely on those results as vallid....  but are they?  Where did this techy get their training? I ask because there is no audiology techy program or associates degree etc?  Did the ENT train the techy?  Oh no, I don't think so.

So basically, you they public are getting rooked, because your insurance company is going to pay for an ENG, ABR study etc, and you don't even know if those test results are vallid.

It is a shame and a sham at the same time. In order to make more money, the ENTs hire up some one, and anoint them as their audio tech. It happens all over the country.  So public... beware.

[Wear/a/Jimmy]

Audiology employed with ENTs etc....  

I could write for days and not even scratch the surface.

Audiology has been a proffession for over 50 years. Currently a doctorate degree is required to inter the field of audiology. BUT out of all the ancillary medicaly profession, audiology is probably the least recognized field. For example, PT (a bachelor degree), OT, SLP, Chiropractioners etc all can bill insurance companies.  Audiologist can not, they most work under the thumb of ENTs. Audiologist know a tremendous amount about hearing, hearing loss, hearing disorders, anatomy & physiology etc. I dare say they no more if not the same amount as ENTs. It is logical really. The ENT studies a wide scope, while audioogist stay with essentially SLP/Deaf Ed & audiology subject matters all through their training.

Job experience forces them to stay within one area, so naturally they know/learn and develop a lot of knowledge about the ear.  

Audiologist represent the last bastion of easy money to ENTs and by that I mean, hearing aids are not covered by insurance. So when a hearing aid is sold inside of an ENT office....  that is cold hard cash. Like, dentists or, plastic surgeons. Big and fast money for the ENTs. So ENTs will fight to the death before audiologist ever gain independence from ENTs.

Any how, audiologist are considered subordinates to, ENTs....  so even if technically they are qualified, most are scared to open their mouth and talk to pateints about their hearing etc.  It kind of depends on their boss/ENT.

I have worked with severak ENTs and I have found the younger ENTs want the audiologist more involved with patients etc. Saves them a lot of time. The older ENTs, I have found them to have more of the "bus boy" mentality. So it is a mixed bag.

Like I said I could write for days....   all the many reasons why, I rarely see patients any more.

[Nancy T]

Question for you two experts--what about the audiologists that ENTs have on their staff, right there in their offices, working for them? Are these audiologists OK?

In 8 years of hearing loss, audiologists have tested my hearing, but none has actually sat down with me and discussed options. They simply pass my audiogram to the doctor, who will say, I don't think this or that would work for you, end of story.

Nancy T. (waiting for my insurance to cover BAHA, i.e., waiting for Godot)

[Enoch Choi, MD]

Wear/a/Jimmy is right, i'm a family doc, and when i refer for audiometry hearing tests, i refer to an audiologist like Wear/a/Jimmy not my ENT buddies.

[Janster]

Sounds like you have some nasal / allergy issues.... or your sinuses in your head are all clogged up.

Have you tried taking any medications for cold/flu/allergies?  

Think about seeing an ear, nose, & throat specialist.

[dcrespe]

Thanks a lot.

[Wear/a/Jimmy]

BTY no physician ENT ect has the proper training to do hearing tests to any degree....

that is an the job of an audiologist. That is not to say there are some physicians that think that they can do ot.....   which is very funny to watch.

[Wear/a/Jimmy]

No, that was not tympanometry.

Further question...  first they should do air conduction. That would be done with a headphone or an insert ear phone. (A sponge plug with wires in it)  Then after that a small black object is placed behind the ear... fits pretty snug, and you listen for beeps.

If this procedure was not done, and tympanometry was not done.....   you got your self pretty cra-ppy care.

[dcrespe]

The doctor did the test at the hospital. I don't know the name of the tests but I can describe : they made me hear different frequencies from 0 db and increasing. At the end, they printed out a graph and told me that it has the correct shape.  Was that tymanometry?

[Wear/a/Jimmy]

Who did the hearing test? Was tymanometry done, where air and bone scores tested?  Because I do not know these answers, I can not tell you if you have a conductive loss or not, which is major sign of an middle ear infection.

If you had an ear infection, I imagine it is only a symtom of a chain of related issues.