Medical Mysteries: That Noise Was Not Tinnitus
Tuesday, July 7, 2009
The noise, an incessant loud whooshing in his left ear, was driving Roger Luchs crazy -- literally.
For six months the real estate lawyer who lives in Bethesda had struggled to cope with a problem relieved only by sleep. The emergency room physician who examined him shortly after the problem surfaced in August 2000 had assured him that the noise, inaudible to everyone but Luchs, would probably clear up on its own. Three otolaryngologists had told Luchs he had tinnitus, a harmless but annoying condition typically characterized by a ringing sound, less often by the pulsating noise Luchs heard.
That was not reassuring. To Luchs, then 49, the prospect of living with his own private version of "The Telltale Heart," the classic Edgar Allan Poe story about a man who cannot escape the relentless sound of a phantom beating organ, had caused him intense anxiety and depression, driving him to see a psychiatrist.
All his doctors gave him the same advice: There's no cure for tinnitus, nothing else is wrong, find a way to live with it.
Which is why Luchs was shocked when a Richmond ear, nose and throat specialist, after listening with a stethoscope, informed Luchs that he, too, could hear the noise, which had a much more ominous cause than simple tinnitus.
"It was very impressive," recalled Aristedes Sismanis, formerly chair of the department of otolaryngology at Virginia Commonwealth University's School of Medicine. A constant barrage of noise, Sismanis adds, can be very distressing; some tinnitus sufferers have committed suicide because they could not bear the constant din.
Luchs vividly remembers feeling a rush of gratitude so intense it initially trumped his fear about its underlying cause. "I can't believe no other doctors thought to put a stethoscope on the source of the problem," he said. "But they didn't."
His problem began one morning while he was taking a large dose of tetracycline to treat the bacteria that causes stomach ulcers. Luchs awoke shortly before 6 a.m. and began vomiting violently, a probable reaction to the antibiotic.
Suddenly he felt a sharp pain in his neck and a loud noise inside his left ear that sounded like a pulse. A few hours later, the pain began to subside; the noise did not. Alarmed, Luchs went to a Maryland emergency room.
A physician took his blood pressure, ran a CT scan and told Luchs she could find nothing wrong. She assured him that although she wasn't sure what was causing the noise, the sound would probably go away in a few hours.
It didn't. A day or so later Luchs consulted an otolaryngologist. He couldn't find anything wrong, either, and told Luchs the vomiting and pulsing noise were unrelated. A second ENT thought the problem might be a blocked eustachian tube, which the doctor cleaned out. When that failed to diminish the noise, the physician prescribed a corticosteroid, which helped briefly. But soon the noise returned as loud as ever.
Next stop was a third ENT. He suggested Luchs try a low-salt diet; that sometimes diminishes tinnitus, which can be caused by exposure to loud noise, aging or medication. The diet had no effect, nor did the over-the-counter remedies the doctor prescribed. Because imaging studies, including CT scans and MRIs, had ruled out a stroke, bleeding in the brain, atherosclerosis or malformed blood vessels, the otolaryngologist, who Luchs said had started avoiding his calls, told him he would need to learn to live with the condition that might be pulsatile tinnitus.
Dissatisfied, Luchs said that at his request the third ENT referred him to Sismanis, a prominent tinnitus expert whose name Luchs had found in a medical book.
Although he had bought a "white noise" machine that enabled him to sleep, Luchs said, he was constantly aware of the whooshing sound while awake. "I could maybe forget it for five minutes if I got involved in work," he said. "It's a horrible thing to have to listen to." He was acutely aware that other people thought he was imagining or exaggerating the noise audible only to him.
Sismanis asked the third ENT to order an MRI angiogram, called an MRA, to check Luchs's head for blocked blood vessels or other problems. Records show that the radiologist reported that the exam, performed two weeks before Luchs saw Sismanis, was normal -- a finding that would soon be called into question.
On Feb. 1, 2001, Luchs drove to Richmond to see Sismanis. The first thing the doctor did was take him into a quiet exam room and place a specially amplified stethoscope against Luchs's head, just below the left ear. The sound, recalled Sismanis, who has retired from VCU and now practices in his native Athens, Greece, was unmistakable: Luchs had been listening to his own heartbeat.
After telling Luchs he could hear the noise, Sismanis told him "most likely it was a vascular problem in his head. It's an alarming thing for a doctor to find. But the moment you can tell a patient you can hear it, that relieves their anxiety."
Sismanis suspected that the cause of the noise was a dissecting left carotid artery. The large vessel that brings blood to the brain had somehow torn, causing the area to fill with blood and resulting in a dangerous narrowing of the artery, which placed Luchs at high risk for stroke.
A 2008 article in eMedicine, an online medical textbook, reports that dissection can occur as a result of trauma from a high-speed motor vehicle accident, sports injuries or even after yoga or overhead painting. Such dissections are among the most common causes of stroke in people younger than 50; a quarter of patients with a dissecting artery report pulsatile tinnitus.
One of the best ways to detect a dissection is through an MRA. Although the first MRA was found to be normal, an angiogram performed a few weeks later at VCU clearly showed the problem.
What caused it?
Sismanis said he believes Luchs suddenly hyperextended his neck while vomiting, tearing the artery. The neck pain he reported to the ER physician is characteristic of such an injury, as is pulsatile tinnitus.
Once the diagnosis was confirmed, Luchs faced the daunting task of sorting out conflicting recommendations from specialists. Some thought the best treatment involved placing one or more stents to open the nearly closed artery, while others worried such a procedure might trigger a stroke.
Two months after meeting Sismanis, Luchs underwent a cerebral angioplasty at Inova Fairfax Hospital. A neuroradiologist inserted two stents in his carotid artery, which fixed the problem. The noise disappeared.
A month after his operation, Luchs wrote to the Washington ENT who had told him he had done all he could and urged the lawyer to learn to live with the constant whooshing.
"Unfortunately you never treated my case as a vascular problem," he wrote, "and did not do the simplest test that would have revealed that, i.e., placing the stethoscope behind my ear to determine if you could hear an unusual pulsation."
A few weeks later he received a form letter from the doctor.
"I appreciate you bringing this information to my attention and also appreciate your viewpoint on the subject," the letter said. "I hope that all goes well with you on your disorder."