A middle-aged man experiences intense vertigo (a spinning sensation) and nausea a few days after developing an upper respiratory infection. His hearing from the left ear has deteriorated, and he can no longer understand words on the telephone. There is also an intense ringing in his left ear, and it feels as if the ear is underwater.
This patient’s history—the combination of nausea and vertigo, hearing loss, and tinnitus—tells the doctor that the man probably has a disorder of both the hearing and balance parts of the inner ear. The doctor will use this information to focus the medical examination and testing that will help lead to a diagnosis. The patient’s history of symptoms is often the most important part of the medical evaluation.
Ear disorders can cause various symptoms. Each symptom alone can suggest certain problems, but when the indicators are looked at in combination, a clearer picture emerges. Understanding the symptoms is the key to knowing what is triggering ear disorders. In this chapter we discuss some of the more common ear symptoms and their causes.
Hearing Loss
Hearing loss is a reduction in the perception of sound by the brain. This loss can be caused by problems of the outer, middle, or inner ear, the nerve of hearing, or the brain itself. The precise cause is identified by conducting a review of the patient’s medical history, a physical examination, and testing.
Sound can be blocked in the ear canal or middle ear by wax, fluid, infection, or middle ear bone disorders.
When the cochlea (inner ear) is not working, sound waves are not converted (transduced) into nerve signals that can stimulate the brain. Some explanations for cochlear problems include genetic abnormalities, noise exposure, certain antibiotics and anti-cancer drugs, and the process of aging.
The nerve of hearing, which connects the cochlea to the brain, can be damaged by tumors and head trauma. And the brain itself may not function properly as a result of infection, stroke, degeneration, or trauma.
Tinnitus
Tinnitus is any type of sound heard by a person that does not have a source in the outside world. When tinnitus is caused by disorders of the cochlea, auditory nerve, or brain it may be perceived as ringing, roaring, white noise, or even music.
Sometimes tinnitus sounds like the pulse or heartbeat. This kind of tinnitus is the result of turbulent blood flow in the arteries or veins inside the skull and can often be heard by the ear specialist as well as the patient. Pulsatile tinnitus and turbulent blood flow can be caused by high blood pressure, abnormal blood vessels, aneurysms, and tumors. It may also be a byproduct of benign intracranial hypertension (mild hydrocephalus) that is associated with obesity.
Clicking or typewriter-like tinnitus is caused by contraction of muscles near the ear. It may be the result of head trauma, stress, stroke, and rare tumors. Many people describe this kind of tinnitus as sounding like an old-fashioned typewriter.
Vertigo
Vertigo is a feeling of motion when you are holding still. Vertigo is often compared to imbalance and lightheadedness, but there are different root causes. For practical purposes it is generally true that the balance system of the inner ear causes the symptoms of vertigo, while imbalance and lightheadedness are likely to be the result of factors such as low blood sugar, thyroid disorders, circulation issues, drugs, or stroke. (See chapter 10 for more detail.)
The key to identifying the cause of vertigo is how long each episode lasts. Short, five- to ten-second, bursts of vertigo associated with head motion may be a result of benign positional vertigo, caused by dislocation of calcium crystals in the inner ear. Long-lasting vertigo, more than twenty-four to forty-eight hours, that improves slowly over a one- or two-week period is typically caused by vestibular neuritis. Intense, episodic vertigo lasting two minutes to a few hours with associated hearing loss, tinnitus, and ear pressure typically suggests Ménière’s disease (see chapter 21).
Fullness
A common cause of a feeling of fullness or blockage of the ear is wax obstruction of the ear canal or fluid behind the eardrum. However, it can also come from abnormal fluid pressure in the inner ear, in which case a visual examination of the ear appears normal. A pressure sensation can also be referred from other locations.
Ear Pain
Ear pain typically is a sign of inflammation and/or infection. If the ear canal is draining, the fluid usually indicates an infection of the ear canal skin. If the ear canal is normal but yellowish discoloration is seen behind a red eardrum, it suggests that the middle ear is infected.
Ear pain may come from the ear itself or surrounding structures that have the same sensory nerve supply as the ear. Common examples of non-ear problems that feel like ear pain include disorders of the temporomandibular joint (TMJ), the throat, and the voice box. When non-ear disorders cause ear pain, the pain is called referred pain—that is, the source of the pain is elsewhere in the body but it is felt in the ear.
Ear Drainage
Infection of the ear canal or the middle ear usually results in fluid draining from the ear. It is typically yellow to green and smells bad. Your doctor will need to carefully clean and inspect the ear to determine the source. Cleaning the ear canal is also the first step in treatment because it allows antibiotic drops to work and reduces the infection.
Pus from a middle ear infection (called otitis media) may make its way to the ear canal if a perforation of the eardrum occurs. Such a perforation may be painful at first, but quickly becomes less painful—unlike the persistent pain caused by an ear canal infection (swimmer’s ear). Inflammatory conditions such as eczema of the ear canal skin generally have a clear to light yellow drainage and produce more itching than pain. To complicate matters, inflammatory conditions like eczema can lead to recurring infections of the ear canal.
Hearing Your Own Voice
Autophonia, the sense of loudness or echoing of your own voice, may occur when the ear canal is occluded (by wax) or when fluid builds up behind the eardrum. To experience this sensation, place your palm firmly over the outer ear opening and speak a sentence. Your voice will sound louder in the blocked ear. This is called the occlusion effect. Other disorders—such as disruption of the middle ear bones or a too-wide-open Eustachian tube—may also cause autophonia.
Hearing Your Breathing
The Eustachian tube connects the ear to the upper airway, which continues all the way to the lungs (see chapter 1). It is normally a closed structure except when a person is swallowing or yawning. But with rapid weight loss, sometimes the Eustachian tube stays open. The sounds of breathing can then pass into the ear. This can be treated effectively with topical medication or, in severe cases, by partially blocking the tube.