Abnormal sounds in bl ear dd not tinitus not continuous
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Searching for intermittent abnormal sounds in both ears (not tinnitus, not continuous).
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intermittent abnormal sounds both ears bilateral not tinnitus differential diagnosis
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pulsatile tinnitus clicking popping ear sounds causes
Harrison's Principles of Internal Medicine, Twenty First Edition
Page 1030
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Based on the clinical description — intermittent, non-continuous abnormal sounds in both ears, not tinnitus — here is a structured differential diagnosis and approach:
Intermittent Bilateral Ear Sounds (Not Tinnitus)
The key distinction from tinnitus is important: tinnitus is typically a perceived sound (ringing, buzzing, hissing) with no external cause. Intermittent, episodic sounds in both ears suggest a mechanical or vascular etiology.
Primary Differentials
| Condition | Character of Sound | Key Feature |
|---|---|---|
| Patulous Eustachian Tube | Autophony, hollow/echo sound | Worsens with breathing, relieved lying down |
| Tensor Tympani / Stapedius Myoclonus | Clicking, rapid clicking/fluttering | Middle ear muscle spasm; can be bilateral |
| Palatal Myoclonus | Rhythmic clicking | Synchronous with palatal muscle movement |
| Eustachian Tube Dysfunction | Crackling, popping, muffled sound | With swallowing, pressure changes |
| Temporomandibular Joint (TMJ) Disorder | Clicking, popping | Coincides with jaw movement |
| Superior Semicircular Canal Dehiscence | Autophony, sound of own eye movement/footsteps | Bilateral rare but possible |
| Pulsatile sounds (vascular) | Whooshing, pulsing in rhythm with heartbeat | Needs vascular workup if bilateral |
| Acoustic neuroma (vestibular schwannoma) | Usually unilateral; asymmetric hearing loss | Typically not bilateral |
Most Likely Causes for Bilateral, Intermittent Sounds
-
Middle Ear Myoclonus (Tensor Tympani or Stapedius Muscle Spasm)
- Presents as rapid, low-pitched fluttering or clicking — often described as "a moth flapping" or "machine gun" sound
- Can be triggered by loud noise, stress, yawning
- Bilateral occurrence is well documented
- Diagnosis: tympanometry during the episode; may show impedance fluctuation
-
Patulous Eustachian Tube
- Abnormally open Eustachian tube allows autophony and hearing one's own breathing
- Bilateral in cases of significant weight loss, dehydration, pregnancy, or neuromuscular disease
- Hallmark: symptoms improve when lying down or with nasal congestion
-
Eustachian Tube Dysfunction / Dysfunction with Crackling
- Crackling/popping on swallowing, yawning
- Very common, bilateral
- Associated with upper respiratory infections, allergies, barotrauma
-
Palatal Myoclonus
- Rhythmic clicking at ~60–200 clicks/min
- Caused by rhythmic contractions of soft palate muscles (tensor veli palatini)
- Can be essential (idiopathic) or symptomatic (brainstem lesion — MS, stroke)
- Bilateral because muscle anatomy is midline
Red Flag Features Warranting Urgent Workup
- Sounds synchronous with the heartbeat → vascular lesion (glomus tumor, AV fistula, aneurysm) — MRA/MRV or CT angiography indicated (Harrison's, p. 1030)
- Associated with focal neurological signs → central cause (palatal myoclonus from brainstem pathology)
- Progressive hearing loss or vertigo accompanying sounds
- Onset after head trauma
Suggested Workup
- Detailed history: character of sound (clicking vs. whooshing vs. crackling), triggers (breathing, swallowing, jaw movement, posture, heartbeat synchrony), duration of episodes
- Otoscopy — assess tympanic membrane mobility
- Tympanometry — ideally during an episode
- Audiogram with stapedial reflexes
- Nasopharyngoscopy if patulous ET or palatal myoclonus suspected
- MRI/MRA brain if vascular cause or central cause suspected
- TMJ assessment if sounds are jaw-related
Bottom Line
The most common cause of intermittent bilateral ear sounds that are not classic continuous tinnitus is middle ear myoclonus or Eustachian tube dysfunction. The precise character (clicking vs. crackling vs. fluttering), triggers, and whether they sync with the heartbeat or breathing are the most diagnostically useful features to elicit. Vascular and central causes must be excluded if red flags are present.
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