Dr. Shyam Kalyan. N
Otolaryngology (E.N.T)
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
About a year ago, I noticed mild clicking in my right ear, only in the early morning. It was triggered mostly by sound and rarely started on its own. This pattern continued for several months and then stopped. About eight months ago, I developed eustachian tube dysfunction following flying with a cold. It did not improve on its own, and the ear popper helped a bit. About two and half months ago, the clicking problem returned but was not limited to the morning hours. It was on-and-off throughout the day and mostly sound-triggered, but the sensitivity was much higherin the late night, overnight and early morning. Six weeks ago, I had two surgeries- a balloon dilation procedure to deal with the eustachian tube dysfunction and the cutting of the tendons to the stapedius and tensor tympani muscles to deal with the clicking. My ETD got better, but much to the shock my both neurotologists, the clicking did not got resolved. Please suggest. Thank you.
Hello,
Welcome to icliniq.com.
I have read your query and thoroughly reviewed your reports and history. I believe the current issues you face are likely due to the surgery on the tube. One of the side effects of eustachian tube dilatation is an excessively patent tube. The nasopharyngeal end becomes open throughout; we call this condition a patulous eustachian tube. As a result, you hear constant noises, and your voice is heard differently. Another reason could be due to the cutting of tendons. The tensor tympani and stapedial tendons work to reduce the vibration and conduction of sounds. That way, your inner ear is protected from unwanted and extra loud sounds. These tendons and their respective muscles also function for usual sounds and modulate the intensity transmitted into the inner ear. Your audiometry and impedance studies are more or less normal. The immediate post-op period of about a few months may not show complete improvement. You should wait for a few months from now to appreciate the changes that are to happen. Meanwhile, besides the medicines you told me you are on, are you taking any nasal drops, sprays, or ear drops? When is your review date? Do they feel that these complaints will get taken care of with time? Did you ask them about excessive patency of the eustachian tube is one of the reasons for your current issues? Is the clicking likely due to your age (64 years), and is more a sensorineural problem than to do with tendons of the middle ear? Have they ruled out acoustic neuroma or any retro cochlear lesion as a cause for your problems? Was any imaging done, like an MRI brain? Is there any complaint with the other non-operated ear? Lastly, do you smoke? Was the ear surgery done endoscopically or using a microscope? Please revert back to me with all details. I shall guide you. I must say that your problem is not something we encounter on a routine basis. Regards.
Patient's Query
Hello doctor,
Thank you very much for the response. To answer your questions: (1) I am no longer taking any drops. (I was given some post-op, but assumed they were only to be used until the eardrum healed.) (2) I am returning after I receive an MRI (presently scheduled for next week). (3) At the moment, the people at Clinic cannot figure out why the clicking is continuing after the surgery. If you look at the third page of my audiometry or impedence report, you will see on page 3 that the reflex decay charts showing that there was a movement of the eardrum when I heard the clicking. (The circles show where I raised my finger during the test, indicating I was hearing the clicking sound.) However, I am told that the next report showed no such movement and yet, I was still hearing the clicking. (4) I have discussed the patulous issue with my doctor, but more concerning was the ETD, not the clicking. (5) As to the possibility of a sensorineural problem, I suspect that might explain the reduction in the quality of hearing, but I am not sure how it would cause the clicking. (6) As stated above, I will have an MRI in a couple of weeks. (I did have a CT scan done back when my only complaint was ETD, and they told it was fine. That, I assume, will answer the acoustic neuroma issue, although my doctor said he thought it was doubtful that the MRI would indicate a problem. (7) I am not having problems with the other ear. I hear clearly through it and do not have the same clicking problems. (Once in a long while, I might listen to a single click, but it does not appear to be the same thing.) (8) I do not smoke and never have, although I was surrounded by significant secondhand smoke during my childhood and early teen years. (9) I do not know the answer to your question regarding endoscopically versus microscope. I am also attaching a fairly long summary of my symptoms that I prepared a few days ago. It will give more detail. Thanks.
Hello,
Welcome back to icliniq.com.
I have gone through all the details of the reports. The sound of vibration and static sound in that ear can be explained due to the patulous nature of the eustachian tube post-dilatation. The clicking sound needs an MRI (magnetic resonance imaging). MRI and CT (computerized tomography) show different structures. MRI shows soft tissue better, and CT shows bony structure better. Acoustic neuroma and retro cochlear lesions get better in MRI, whereas mastoid disease or facial canal dehiscence gets picked by CT better. Can you attach the CT films and report so that I can have a look? This will not prevent the need for MRI but can provide me with some points on the ear condition. Endoscopic and microscopic surgeries have some relative advantages and disadvantages, but majorly it is in the surgeon's convenience. One may be better in one than the other, and so he may prefer one over the other. I hope this helps, and please attach the CT reports for further investigation. Regards.
Patient's Query
Hello doctor,
Thank you again. I do not presently have the CT report, unfortunately. Is it possible to hear clicking or cracking associated with an acoustic neuroma? I have heard that in the surgery to remove a neuroma, and frequently all hearing is lost. Even if it is recovered, it will never improve. So this means I will always have the clicking, right? Please resolve my doubt. Thank you.
Hello,
Welcome back to icliniq.com.
Clicking and crackling are not associated with acoustic neuroma usually. But stapedial reflex decay is a sign of a retro cochlear lesion like a neuroma. Therefore, we want to rule it out. I hope this helps. Regards.
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Otolaryngology (E.N.T)
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