Abnormal sounds in bl ear dd not tinitus 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

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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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