Objective vibratory tinnitus aurium of vascular origin is an unusual clinical entity which was involved with much speculation. 2 -4 ,l1 Objective vibratory tinnitus aurium of nonvascular origin-'' is not considered in this report. Although other rare types of arteriovenous communications with objective tinnitus occur, such as between the middle meningeal artery and the greater petrosal sinus,6,13 those which primarily connect the occipital or greater auricular arteries with the transverse sinus are more common 7,10,16,17; eleven such cases have been reported in the literature. The present report concerns three additional cases of arteriovenous malformation between the occipital artery and the transverse sinus. REPORT OF CASESCase 1. A 69-year-old woman was admitted because of a pulsating "hissing" noise in the left ear. This tinnitus began suddenly 14 months earlier. No history of trauma or ear disease was obtained. Physical and neurologic examination was normal except for some memory loss and objective tinnitus determined by auscultation. This objective tinnitus was demonstrated over the left carotid artery bifurcation with a loud grade III/VI systolic bruit, which was loudest over the left mastoid bone and the distribution of the occipital artery. The tinnitus could be obliterated, both subjectively and objectively, by com-pression of the left carotid artery or by pressure on the left occipital artery. Routine laboratory studies were normal.Radiology. Skull x-rays were normal. A left carotid arteriogram showed a large arteriovenous malformation involving the occipital artery (Figs. 1 and 2). The occipital artery was considerably larger than normal. There was early filling of the left sigmoid sinus (Fig. 1), jugular vein, and some dilated posterior cervical veins. There were numerous vascular channels between the occipital artery and the transverse sinus. A left vertebral arteriogram, performed via the axillary artery, showed no communication of the vascular malformation with the vertebral or basilar circulations.Surgery and Follow-up. Through an anterior sternocleidomastoid muscle incision, the external carotid artery was mobilized with a DeBakey clamp. The objective tinnitus could be obliterated by clamping the external carotid artery. After repeated testing, the external carotid artery was doubly ligated and left in continuity. The postoperative course was uneventful. At one year her condition remained improved. After surgery and at follow-up one year later, she stated that she occasionally heard a noise; but no objective tinnitus was observed.Comments. This was the simplest type of dural arteriovenous malforma-
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