Objective Tinnitus Aurium and Dural Arteriovenous Malformations of the Posterior Fossa

Abstract

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-

Role of Angiography in the Evaluation of Patients With Pulsatile Tinnitus

“…Systemic disorders of high output (i.e., anemia, thyrotoxicosis, valve heart disease), arteriovenous malformations, DAVFs, arterial wall diseases (i.e., dissection, atherosclerosis, aneurysm), skull base tumors, and intracranial hypertension may all cause pulsatile tinnitus with normal findings on otoscopy. 1,4,7,11,[15][16][17] In patients with normal findings on otoscopy and pulsatile tinnitus, experience from this study suggests that CT scan is less sensitive in diagnosis of vascular abnormalities. Only 16% (1 of 6) of the CT studies correctly diagnosed the lesion (excluding the 10 patients CT ϭ computed tomography; MRI ϭ magnetic resonance imaging; MRA ϭ magnetic resonance angiography; SAH ϭ subarachnoid hemorrhage; TS DAVF ϭ transverse/sigmoid sinus dural arteriovenous fistula; SA ϭ selective angiography.…”

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

“…Venous hum can be defined as an idiopathic vascular tinnitus of venous origin [ 15 , 16 , 17 ]. It is common in patients between 20 and 40 years with a marked female preponderance.…”

Pulsatile tinnitus —a review of 84 patients

“…Therefore the causes of pulsatile tinnitus are multiple. They include systemic disorders with high cardiac output (anaemia, thyrotoxicosis, valvular heart disease) [9, 111, circumscribed vascular variations [ 1,8,19,20,25,27,28,37,49], arteriovenous malformations, dural arteriovenous fistulas [2,3,10,12,13,23,24,34,38,42,55,58] or arterial wall diseases causing stenosis such as dissections, fibromuscular displasias or atherosclerosis [7, 16-18, 30, 33, 35, 44, 50, 56], skull base tumours [26,36,48, 511, intracranial hypertension [31,32,45,46] and rare diseases such as Paget's disease [14] or histiocytosis X of the petrous bone [5].…”

“…The 12 patients with a nonvascular pathology were investigated by CT (8), MRI (7), arteriography (6) and ultrasonography (2). The diffuse metastases on the skull base in 1 patient were seen by MRI only; in all of the other patients, either CT or MRI was able to show the underlying pathology.…”

“…None of these investigations showed an abnormality that could explain pulsatile tinnitus. [58] Dural arteriovenous fistula [2,13,23,24,34,38,55] Carotid cavernous fistula [42] Aneurysm of the ICA [3,12] Fibromuscular dysplasia of the ICA [ 17,56] Dissection of the ICA [33,50] Atherosclerosis [7,16,30,44] Occlusion of the contralateral CCA [35] Vascular anomalies of the ear [8,20,28,49] Vascular compression of the VIII nerve [27,37] Migraine [52] Jugular bulb anomalies [1,391 Abnormal condylar and mastoid emissary veins [19,25] Glomus tumor [26,36,48] Paget's disease [14] Cavernous haemangioma [51] Histiocytosis X [5] Intracranial hypertenison of various causes [14,31,32,45,46] Anaemia, high cardiac output [9,11] Palatal myoclonus [4,22] Abnormally paten...…”