What causes a stamping sound in my left ear?

Stamping Sound in Left Ear

Direct Answer

A stamping sound in your left ear that occurs synchronously with external sounds (like hammer strikes) is most likely caused by abnormal middle ear muscle contraction, specifically tensor tympani or stapedius muscle spasm, which can be successfully treated with selective muscle tenotomy if conservative management fails. 1

Understanding the Symptom

This "stamping" or clicking sound represents objective tinnitus that may be audible to you alone or potentially to an examiner, distinguishing it from the more common subjective tinnitus. 2 The key diagnostic feature is whether this sound:

• Occurs synchronously with your heartbeat (pulsatile) 2, 3
• Occurs in response to external sounds or movements 1
• Occurs spontaneously as clicking or fluttering sensations 4

Most Likely Diagnosis: Middle Ear Muscle Spasm

Tensor Tympani or Stapedius Muscle Dysfunction

The description of a "stamping" sound strongly suggests tonic tensor tympani syndrome (TTTS) or stapedius muscle spasm, particularly if the sound occurs in response to external noises or movements. 1, 4

• TTTS involves involuntary muscle spasms with a reduced reflex threshold, causing tympanic membrane tension and distinctive clicking or fluttering sounds 4
• This condition has a prevalence of 60% in patients presenting with tinnitus complaints, and 81.1% in those with hyperacusis 4
• A case report documented successful cure of hammer-strike-synchronous tinnitus through stapedial tenotomy 1

Clinical Features to Assess

Determine if you experience any of these associated TTTS symptoms:

• Pain, numbness, or burning sensation in or around the ear 4
• Sensation of aural "blockage" or fullness 4
• Mild vertigo or nausea 4
• "Muffled" hearing sensation 4
• Tympanic flutter or clicking 4
• Headache 4
• Symptoms triggered or worsened by loud or intolerable sounds 4

Alternative Diagnoses to Exclude

Pulsatile Tinnitus (Vascular Causes)

If the stamping sound is synchronous with your heartbeat, this represents pulsatile tinnitus requiring urgent imaging evaluation because over 70% of cases have identifiable vascular or structural abnormalities. 3

Life-threatening causes that must be ruled out include:

• Dural arteriovenous fistula (8% of pulsatile tinnitus cases, can cause hemorrhagic stroke) 3
• Arterial dissection (requires urgent identification) 3
• Atherosclerotic carotid artery disease (17.5% of pulsatile tinnitus cases) 3

Other vascular causes include:

• Paragangliomas or glomus tumors (16% of cases) 3
• Idiopathic intracranial hypertension (second most common cause) 3
• Jugular bulb abnormalities 3
• Sigmoid sinus diverticulum or dehiscence 3

Structural Abnormalities

• Superior semicircular canal dehiscence (allows transmission of vascular sounds) 3
• High-riding jugular bulb or sigmoid plate dehiscence 3

Diagnostic Approach

Initial Clinical Evaluation

Perform otoscopic examination to assess for:

• Vascular retrotympanic masses (paragangliomas appear as reddish masses behind tympanic membrane) 3
• Tympanic membrane abnormalities 2
• Middle ear pathology 2

Assess the temporal pattern:

• Does the sound occur with your heartbeat? (suggests vascular cause) 2, 3
• Does it occur in response to external sounds? (suggests middle ear muscle spasm) 1
• Is it continuous or intermittent? 5
• Can you or others hear it? (objective vs subjective) 2, 5

Test for venous etiology:

• Apply gentle compression to the ipsilateral jugular vein or carotid artery 3
• Relief with compression suggests venous etiology or arterial dissection 3

Imaging Strategy

If pulsatile (synchronous with heartbeat):

• Order high-resolution CT temporal bone (non-contrast) as first-line for suspected paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 3
• Order CT angiography (CTA) of head and neck with contrast when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, or sigmoid sinus abnormalities 3
• Reserve MRI/MRA with contrast for cerebellopontine angle lesions or when CT/CTA are negative but clinical suspicion remains high 3

If non-pulsatile, unilateral, without focal neurologic abnormalities:

• Imaging is generally not recommended unless associated with asymmetric hearing loss or other concerning features 2
• Consider audiometric examination to assess for asymmetric hearing loss 2

Treatment Algorithm

For Middle Ear Muscle Spasm (Most Likely)

Initial conservative management:

• Avoid triggering sounds or situations when possible 4
• Consider anxiolytic therapy, as TTTS is an anxiety-based condition with reduced reflex threshold 4
• Auditory, behavioral, or cognitive therapies may provide symptom relief 2

Definitive surgical treatment if conservative measures fail:

• Selective stapedial tenotomy has demonstrated complete cure in documented cases of sound-triggered tinnitus 1
• This procedure involves transection of the stapedius tendon 1

For Confirmed Vascular Causes

• Paragangliomas: surgical resection, radiation therapy, or observation depending on size and symptoms 3
• Superior semicircular canal dehiscence: surgical repair if symptoms are debilitating 3
• Sigmoid sinus diverticulum: surgical repair or stenting in severe cases 3
• Dural arteriovenous fistulas: endovascular treatment to prevent hemorrhagic stroke 3

Critical Pitfalls to Avoid

• Do not dismiss unilateral clicking or stamping sounds as benign without proper evaluation, as they may represent treatable middle ear muscle dysfunction 1, 4
• Do not miss pulsatile tinnitus, which requires imaging in nearly all cases due to identifiable causes in >70% of cases and potential life-threatening etiologies 3
• Do not overlook dural arteriovenous fistula, which can present with isolated pulsatile tinnitus before catastrophic hemorrhage 3
• Do not perform inadequate otoscopic examination, as vascular retrotympanic masses (paragangliomas) can be identified on direct visualization 3

When to Seek Urgent Evaluation

Immediate evaluation is warranted if:

• The sound is synchronous with your heartbeat 3
• You have associated neurologic symptoms 2
• You have asymmetric hearing loss 2
• You are older than 50 years, smoke, drink alcohol, or have diabetes 6
• You have severe anxiety or depression (increased suicide risk in tinnitus patients with psychiatric comorbidity) 2, 7