Two Cases of Idiopathic Pulsatile Tinnitus Successfully Treated with Kampo Medicine / 日本東洋医学雑誌

In cases of pulsatile tinnitus, the presence of organic disease should be suspected, and many of them can be treated once the cause is identified. However, there are idiopathic cases in which the cause cannot be identified, and there is no established treatment for them. Here, we report 2 cases in which Kampo medicine was effective for idiopathic pulsatile tinnitus. Case 1 was a 50-year-old man. He had been stressed for half a year due to the change of job title in his workplace, and he had left pulsatile tinnitus a month ago. We administered saikokaryukotsuboreito, and his tinnitus disappeared in a week. Case 2 was a 30-year-old woman. She gave birth 4 months ago, and after giving birth, she had less sleep and was tired and stressed. She started to notice right pulsatile tinnitus and dizziness from a month ago. We administered nyoshinsan, and her tinnitus and dizziness disappeared in 2 months. In both cases, they were aware of hot flashed on their face as a symptom of qi counterflow, and Kampo treatment improved the symptom together with pulsatile tinnitus. It is possible that blood flow in the head increased with qi counterflow, causing relative stenosis of the blood vessels in the head, leading to turbulence in the lumen of the blood vessels, and hearing pulsatile tinnitus.

Etiología del acúfeno pulsátil. Caso clínico / Etiology of pulsatile tinnitus. Case report

Resumen El acúfeno es un síntoma relativamente frecuente en una consulta de otorrinolaringología. Se han descrito interacciones en las células ciliadas externas o internas, desequilibrios en el balance de las fibras aferentes y fenómenos de reorganización cortical tras lesiones periféricas que están involucrados en un 90%-95% de las causas del acúfeno. El restante 5%-10% está constituido por un tipo de acúfenos llamados objetivos, que no comparten estos mecanismos fisiopatológicos, sino que se originan en alguna estructura del organismo generalmente ajena a la vía auditiva y estimulan el aparato auditivo igual que lo haría un sonido del exterior. Presentamos el caso de un varón de 52 años remitido al Servicio de Otorrinolaringología de nuestro hospital por acúfeno pulsátil de meses de evolución, sin asociar hipoacusia, ni vértigo, ni otra sintomatología.

Abstract Tinnitus is a relatively frequent symptom in an otolaryngology consultation. Interactions in external or internal hair cells, imbalances in the afferent fiber balance and cortical reorganization phenomena after peripheral injuries have been described in 90%-95% of the causes of tinnitus. The remaining 5%-10% is comprised of a type of tinnitus called objective, which do not share these pathophysiological mechanisms, but originate from some structure of the body generally external to the auditory pathway and stimulate the auditory apparatus just as a sound from the exterior. We present the case of a 52-year-old man referred to the Otolaryngology service at our hospital for pulsatile tinnitus of months of evolution, with no hearing loss, vertigo, or other symptoms associated.

Carotid-artery cochlear dehiscence

Changes in course of the internal carotid artery (ICA) are uncommon, and dehiscence of the carotid canal with cochlea may occur. A 48-year-old female individual with pulsatile tinnitus. No other otologic symptoms observed. Otolaryngologic examination and audiometric test with normal results. Computed tomography (CT) scan of the mastoid bones showed dehiscence of cochlea with ICA on the right side. An option for monitored observation was made after analysis of the risks and undefined results of surgery. Patient maintained clinical and audiometric profile. Carotid-artery cochlear dehiscence is a condition that must be known, remembered and investigated, because it may mimic other otologic pathologies. Knowledge about it prevents serious complications that can be difficult to reverse.

An in vitro Experiment on Relationship Between Pulsatile Tinnitus and Temporal Bone Pneumatization Grade / 医用生物力学

Objective To study the relationship between pulsatile tinnitus and temporal bone pneumatization grade. Methods Through the in vitro experiment, the generation and transmission pathways of the venous sound were simulated. The sound signals at the position of eardrum were recorded and analyzed. Results In case of cortical plate dehiscence, the high pressure and pulse-synchronous venous sounds were received at eardrum. The highest sound pressure occurred in the normal pneumatization case. In case of cortical plate intactness, the non-pulsatile venous sounds with pressure close to the background control sound were received at eardrum. Temporal bone air cells (TBAC) with different pneumatization grades would transmit venous sound in different frequency ranges. Conclusions Normal pneumatization TBAC exhibited the highest amplification on venous sound, while hypopneumatization TBAC exhibited the lowest amplification on venous sound. The pneumatization grade of TBAC is neither the sufficient nor essential condition of pathogenic venous sound, while the cortical plate dehiscence is the sufficient or necessary condition of pathogenic venous sound.

Tinnitus pulsátil: caso clínico y revisión de la literatura / Pulsatile tinnitus: clinical case and review

RESUMEN El tinnitus pulsátil es un síntoma otológico infrecuente pero requiere un estudio acabado. Una historia y examen físico detallados, son primordiales para orientar el estudio imagenológico posterior, con lo que se llega al diagnóstico en gran parte de los casos. El tratamiento debe ser dirigido a corregir la causa subyacente. En este trabajo, se presenta un caso clínico de tinnitus pulsátil, revisión del tema y orientación al enfoque diagnóstico.

ABSTRACT Pulsatile tinnitus is an infrequent otologic symptom but requires a thorough study. A detailed history and physical examination are essential to guide the subsequent imaging study, with which the diagnosis is reached in a large number of cases. The treatment should be aimed at correcting the underlying cause. In this study, a clinical case of pulsatile tinnitus, review of the subject and orientation to the diagnostic approach is presented.

Caso de desafío diagnóstico: fístula dural / Diagnostic challenge case: dural fistula

Se presenta el caso de una paciente de sexo femenino, de 69 años, que refiere tinnitus pulsátil de dos meses de evolución percibido en la región retroauricular derecha. Se presentan los hallazgos en estudios de imágenes, diagnóstico y se presenta una corta revisión del tema.

We present the case of a female patient, 69 years old, who reported pulsatile tinnitus since two months ago perceived in the right retroauricular region. We present the findings in image studies, diagnosis and a short review about the topic.

Glomus tympanicum

Glomus tympanicum is a tumour classified under the group glomus tumours, and is also knownas paragangliomas. It is thought to commonly occur in women in the fifth to sixth decades of life.Here, we report a case of a 77-year-old lady with multiple co-morbids and a diagnosis of glomustympanicum presenting to us. Her symptoms included pulsatile tinnitus, and reduced hearing,and the management of the case was done with consideration for her underlying multiple comorbidities.This paper also describes the best modality of treatment for this patient with regardto her background history. The treatment goal was to improve her quality of life and control thedisease.

Petrous Carotid Aneurysm Causing Pulsatile Tinnitus: Case Report and Review of the Literature

We present the case of a patient who developed pulsatile tinnitus that was found to be associated with a petrous carotid aneurysm. The aneurysm was successfully obliterated using stent-assisted coiling, after which the patient was symptom-free. Although aneurysms arising from the petrous segment of the internal carotid artery are rare, this pathology must be considered as a causative factor in patients with pulsatile tinnitus. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Pulsatile Tinnitus Related with Prominent Venous Plexus: Case Report and Literature Review / 대한이비인후과학회지

Pulsatile tinnitus coexists with patient's heartbeat and objective tinnitus is audible to other persons such as examiner. It can be disagreeable for the patient and can also be the only clue to a potentially devastating and life-threatening disease. Pulsatile tinnitus with a normal otoscopic examination often presents a diagnostic challenge, and its differential diagnosis includes a wide range of conditions. Evaluation of a patient with tinnitus requires a detailed history, a comprehensive audiological evaluation with hearing thresholds, neuro-otological physical examination with otoscopy and imaging studies. We recently experienced a case of a 28-year-old male complaining of right-sided pulsatile tinnitus. The tinnitus was objectively audible at the left side of the posterior neck. Non-contrast enhanced computed tomography of temporal bone showed a high jugular bulb on the left side. A 6-vessel angiography showed prominent left paravertebral venous plexus and prominent venous plexus around the skull base.

Multiple Dural Arteriovenous Fistulas Presenting as Pulsatile Tinnitus Treated with External Manual Compression

Dural arteriovenous fistula (DAVF) have been treated by transarterial or transvenous embolization, surgery, and radiosurgery. Besides these treatment options, the external compression technique is a non-invasive, low-cost form of treatment. This article reports that a 60-year-old man with DAVF between multiple arterial branches and transverse/sigmoid sinus was treated by repeated external manual compression method.

Multiple Dural Arteriovenous Fistulas Presenting as Pulsatile Tinnitus Treated with External Manual Compression

Dural arteriovenous fistula (DAVF) have been treated by transarterial or transvenous embolization, surgery, and radiosurgery. Besides these treatment options, the external compression technique is a non-invasive, low-cost form of treatment. This article reports that a 60-year-old man with DAVF between multiple arterial branches and transverse/sigmoid sinus was treated by repeated external manual compression method.

Degree of Sigmoid Sinus Compression and the Symptom Relief Using Magnetic Resonance Angiography in Venous Pulsating Tinnitus

OBJECTIVES: To show that mechanical compression of sigmoid sinus is effective for treatment of pulsatile tinnitus caused by sigmoid sinus enlargement, and to evaluate the relationship between the compression degree of sigmoid sinus and the tinnitus symptom relief using magnetic resonance angiography. METHODS: Medical records of twenty-four patients who were diagnosed with venous tinnitus caused by sigmoid sinus enlargement and underwent mechanical compression of sigmoid sinus were reviewed between April 2009 and May 2013. All these patients received computed tomography and magnetic resonance venography study before undergoing surgery and were followed for at least 4 months. RESULTS: Twenty-three patients felt relief from tinnitus three months after the surgery, and the cross-sectional area of the sigmoid sinus on the tinnitus side was compressed approximately by half (46%-69%) after the surgery. There were 4 patients whose tinnitus suddenly disappeared while lying on the operating table before operation, which may be a result of the patient's emotional tension or postural changes from standing. One of the four patients felt no relief from tinnitus after the surgery, with the cross-sectional area of the sigmoid sinus only compressed by 30%. And two patients of them had a recurrence of tinnitus about 6 months after the surgery. Seven patients had sigmoid sinus diverticula, and tinnitus would not disappear merely by eliminating the diverticulum until by compressing the sigmoid sinus to certain degree. There were 3 minor complications, including aural fullness, head fullness and hyperacusis. The preoperative low frequency conductive and sensorineural hearing loss of 7 subjects subsided. CONCLUSION: Mechanical compression of sigmoid sinus is an effective treatment for pulsatile tinnitus caused by sigmoid sinus enlargement, even if it might be accompanied by sigmoid sinus diverticulum. A compression degree of sigmoid sinus about 54% is adequate for the relief of tinnitus symptom. Cases in which patients' tinnitus suddenly disappeared before the surgery might be excluded to improve the efficacy of surgery.

Single-Center 10-Year Experience in Treating Patients With Vascular Tinnitus: Diagnostic Approaches and Treatment Outcomes

OBJECTIVES: Vascular tinnitus is the most common form of pulsatile tinnitus, particularly when the tinnitus corresponds with the pulse of patients. In this study, we reviewed the 10-year clinical data on vascular tinnitus of our tinnitus clinic to investigate the frequency of the underlying etiologies, to introduce a diagnostic protocol, and to evaluate the treatment outcomes. METHODS: We retrospectively collected the data of 57 patients who were diagnosed as vascular tinnitus between April 2001 and December 2011. Careful history taking, otoscopy, thorough physical examinations, audiometry, laboratory tests, as well as radiologic examinations were performed according to our diagnostic protocol to find the origin of pulsatile tinnitus. Treatment options were individualized based on the specific etiology, and the outcomes were assessed using patient's subjective reports at the follow-up interviews. RESULTS: High jugular bulb was the most common cause (47.4%) of vascular tinnitus, and venous hum was the next (17.5%). Dural arteriovenous fistula, intracranial aneurysm, atherosclerotic carotid artery disease, and hypertension were less common causes. Vascular tinnitus was alleviated in most patients after the appropriate treatment: surgical intervention, tinnitus retraining therapy, reassurance, and medications. CONCLUSION: Vascular tinnitus can be successfully diagnosed by the regular use of the suggested protocol. Many patients with vascular tinnitus have treatable underlying etiologies. Treatment of those etiologies or at least counseling about the tinnitus itself can benefit the patients with troublesome vascular tinnitus.

Analysis of CT and MRI in pulsatile tinnitus / 实用放射学杂志

Objective To investigate the changes of pulsatile tinnitus on HRCT and MRI CE 3D-SPGR image.Methods CT and MRI images of 1 5 pulsatile tinnitus patients were retrospective analysis.All 1 5 patients underwent temporal bone HRCT and MRI CE 3D-SPGR scan.Abnormal changes on CT and MRI image,which caused the pulsatile tinnitus,were compared.Results In 1 5 patients,9 sides (8 cases)showed abnormal sigmoid sinuses including 4 sides of sigmoid sinuses diverticulum,5 sides sigmoid sinu-ses uncovering,8 sides dominant sigmoid sinuses.The high jugular bulb was showed in 10 sides (8 cases),the thick emissaria mas-toidea in 5 sides (4 cases),bilateral semicircular canal dehiscence in one case,glomus tympanicum tumor in one case and the cochle-ar nerve was constricted by small vessel in one case.Conclusion Cranial base vessel abnormity can be visualized more precisely on MRI CE 3D-SPGR image than that on HRCT.On the contrary,the detection of temporal bone abnormalities is superior on HRCT.

Pulsatile Tinnitus due to Intracranial Dural Arteriovenous Fistula after Head Trauma by a Golf Ball / 대한이비인후과학회지

Diagnosis of traumatic arteriovenous fistula (AVF) is usually delayed because it takes time to be enlarged enough to emerge radiologically or because symptoms occur a few months after the trauma. A 56-year-old woman presented with a newly developed tinnitus immediately after a head trauma. Pulsatile high-frequency tinnitus was heard also by examiner and recorded using a transcanal microphone. Angiography revealed an intracranial dural AVF fed by the middle meningeal artery, draining the superior sagittal sinus on the affected side. After percutaneous transarterial embolization, tinnitus successfully disappeared. The clinical presentation, radiologic and angiographic features, and management are discussed. To our knowledge, this is the first reported case of pulsatile tinnitus caused by AVF developed immediately after a trauma. We emphasize that precise physical examination, laboratory tests, and appropriate radiographic imaging are essential for accurate diagnosis and treatment when a patient presents with pulsatile tinnitus, especially after a head trauma.

Endoscopic Treatment of Middle Ear Myoclonus with Stapedius and Tensor Tympani Section: A New Minimally-Invasive Approach.

Aims: We describe a new, entirely endoscopic surgical technique for treatment of middle ear myoclonus. Case Presentation: In our patient, the stapedius and tensor tympani tendons were sectioned to control chronic middle ear myoclonus. The procedure was performed using endoscopic ear surgery techniques, with the aid of rigid Hopkins rod endoscopes. Control of the pulsatile tinnitus was achieved after endoscopic tenotomy of the stapedius and tensor tympani, without any complications. Discussion and Conclusion: Endoscopic tensor tympani and stapedius tendon section is a new, minimally invasive treatment option for middle ear myoclonus that should be considered as a first line surgical approach in patients who fail medical therapy. The use of an endoscopic approach allows for easier access and vastly superior visualization of the relevant anatomy, which in turn allows the surgeon to minimize dissection of healthy tissue for exposure. The entire operation, including raising the tympanomeatal flap and tendon section can be safely completed under visualization with a rigid endoscope with good control of the pulsatile tinnitus.

Pulsatile Tinnitus Caused by a Dilated Mastoid Emissary Vein

Although pulsatile tinnitus can be audible, objective demonstration of this heartbeat-synchronous sound has rarely been successful. We report a rare case of pulsatile tinnitus in a 44-yr-old female patient, which was induced by a large mastoid emissary vein (MEV) and objectively documented by Doppler sonography of the left posterior auricular region. The tinnitus was intermittent and the patient could adapt to the tinnitus without intervention on the mastoid emissary vein. These findings suggest that a single large MEV can cause pulsatile tinnitus in the absence of other vascular abnormalities, and imaging studies of the posterior fossa and Doppler ultrasonography can aid the diagnosis in such cases.

Pulsatile Tinnitus with a Dural Arterio-Venous Fistula Diagnosed by Computed Tomography-Angiography

A 43 year-old female patient suffered the sudden onset of pulsatile tinnitus in the left ear 2 months ago. The tinnitus did not subside spontaneously and remained unchanged. The patient had no history of head trauma or surgery of the head and neck. The character of the tinnitus was pulsatile, and it was synchronous with the heart beat. Audiologic examinations were performed and all of the results were normal. Computed tomography with angiography was performed and evidence of an arterio-venous fistula (AVF) was found. 4-vessel angiography was performed to confirm the dural AVF between the external carotid artery and sigmoid sinus. Embolization of the feeder-vessels was done under a fluoroscope and 70% of the fistula flow was controlled after embolization and the tinnitus totally subsided during the embolization.

Pulsatile Tinnitus Caused by Arteriovenous Fistula of External Carotid Artery

Isolated pulsatile tinnitus is a rare condition in patients with neurological disorders but can be the only clue to a potentially life-threatening disease such as intracranial vascular malformation. We report a patient with pulsatile tinnitus caused by an arteriovenous fistula of the external carotid artery, which was successfully treated with coil embolization.

Pulsatile Tinnitus Arising from Aberrant Internal Carotid Artery at Nasopharynx

Pulsatile tinnitus arising from an aberrant internal carotid artery at the level of the nasopharynx is rarely found. We present a case of a 74-year-old woman complaining of pulsatile tinnitus in the right ear. The tinnitus was not audible by auscultation. Endoscopic examination revealed pulsating swelling of the nasopharyngeal wall on the right side. Computed tomography angiography of the head and neck region showed medial and superficial transposition of the right internal carotid artery at the level of the nasopharynx. The artery was located right next to the orifice of the Eustachian tube and coursed along the distal portion of the tube. The patient's perception of tinnitus was improved after explaining the cause of the tinnitus and reassuring her about thecondition.