Tinnitus; diagnosis and imagingRutger Hofman, MD, PhD

NVA, NijmegenSeptember 30th, 2011

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Contents

Introduction Diagnosis Imaging Pathology; diagnosis and imaging Conclusion; algorithm

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Joseph Toynbee (1815-1866)

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Tinnitus

Definition: ‘a sound perceived for more than fiveminutes at a time, in absence of any externalacoustical or electrical stimulation of the ear and not occurring immediately after exposure to loudnoise’.

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Tinnitus

Objective Subjective Auditory hallucinations

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Diagnosis Medical history

Subjective description of tinnitus (uni-, bilateral) Annoyance daily life/sleep Synchrony of tinnitus with pulse Effect of neck movement Effect of neck compression Effect of respiration Associated auditory or vestibular symptoms Otological/general medial conditions Medication/Drugs Noise exposure, family history Stress conditions, psychological/psychiatrical disorders

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Medication

1. Salicylate, NSAID’s: aspirin (reversible)

2. Mycin-antibiotics3. Antimalaria medication: quinine (reversible)

4. Diuretics: furosemide5. Cytotoxic medication: cisplatin, methotrexate6. Tricyclic antidepressant, benzodiazepine

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Diagnosis

Physical examination Otoscopy Palpation Auscultation

Audiometry Pure tone audiometry Speech audiometry Tympanometry Stapedial reflexes (BERA, OAE’s)

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Otoscopy

External meatus acousticus Tympanic membrane, middle ear cavity

Tympanic sclerosis Glue Schwartze’s sign Myoclonus middle ear muscles Vascular tumours anomalies

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Physical examination

Palpation neck Thyroid gland

Auscultation Peri-auricular Neck (carotid souffle) Cor (transmittid souffle)

Oropharyngeal inspection Palatal myoclonus

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Diagnosis

(Vestibular assessment) (Neurological assessment)

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Imaging

Ultrasound neck (echo duplex) Superficial vascular structures

Computed Tomography (CT/CTA) Bony structures

Magnetic Resonance Imaging (MRI/ MRA) Soft tissue structures

Digital Substraction Angiography Profound vascular structures

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Tinnitus

Objective Subjective

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Objective tinnitus

Vascular (pulsatile) Vascular malformations

Arterioveneus malformationsAneurysmsFistulae

Carotid artery stenosis

Vascular tumours Paragangliomas

Glomus tympanicum

Glomus jugulare Haemangioma

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Arteriovenous malformations

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Arteriovenous malformations

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Stenosis carotid artery

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Paraganglioma

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Paraganglioma

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Paraganglioma

= glomustympanicum

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Haemangioma

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Haemangioma

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Objective tinnitus

Vascular (pulsatile) Increased intracranial pressure Transmitted cardiac murmurs Different hyperdynamic vascular states (‘veneus hum’)

Pregnancy Hyperthyreoidism

Anaemia

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Benign intracranial hypertension(‘pseudo-tumour cerebri’)

Unusual Raised intracranial pressure

headaches, dizziness, visual distubance, pulsatile tinnitus

Associated with obesity Lumbar puncture, MRI

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Objective tinnitus

Myogenic Palatal Middle ear muscles

m. tensor tympani m. stapedius m. levator palatini

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Objective tinnitus

Patulous Eustachian tube; ‘Tuba aperta’ Nasal respiration Tympanic membrane movements

Otocopy tympanometry

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Objective tinnitus

Temporomandibular joint abnormality

Spontanous otoacoustic emissions

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Subjective tinnitus

Conductive hearing loss Sensorineural hearing loss

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Conductive hearing loss

1. Otitis externa2. (chronic) Otitis media3. Otosclerosis

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Otitis externa

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Otitis media

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Otitis media

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Otosclerosis

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Otosclerosis

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Otosclerosis

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Otosclerosis

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Sensorineural hearing loss

1. Noise-induced2. Ménière’s disease3. Congenital/hereditary4. Vestibular schwannoma5. Presbyacusis6. Paget’s disease (osteodystrophia deformans)

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Vestibular schwannoma

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Vestibular schwannoma

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Vestibular schwannoma

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Paget’s diseaseosteodystrophia deformans

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Paget’s diseaseosteodystrophia deformans

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AICA

Anterior inferior carotid artery

Vascular loop with suggested compression orirritation of the auditory nerve equally present in symptomatic and non-symptomatic ears. Makinset al., 1998

Vascular loops significantly more common (p<0.0001) in patients with unilateral pulsatiletinnitus than non-pulsatile tinnitus. De Ridder et al., 2005

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AICA

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Typewriters tinnitus

Levine RA, 2006 n = 6 ‘…a staccato quality of their intermittent tinnitus

('like a typewriter in the background, popcorn, Morse code‘)’.

5 patients symmetric and consistent with theirages audiograms.

4 patients vascular compression of the auditorynerve on MR imaging.

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Typewriters tinnitus

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Conclusion

Extensive medical history Extensive physical examination Imaging Pulsatile tinnitus!

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Algorithm

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Acknowledgements

dr. R.H. Freedrs. J.A. Wachters

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References1. Ceranic B, Luxon LM. Tinnitus and other dyacuses. In: Gleeson

M et al.(eds) Scott-Brown’s Otorhinolaryngology, Head and NeckSurgery 7th edition. London: Hodder Arnold, 2008, 3594-3629

2. Andersson G et al. Tinnitus, a multidisciplinary approach. London, Philadelphia: Whurr publishers, 2005

3. Weismann JL, Hirsch BE. Imaging of tinnitus; a review. Radiology 2000, 216; 342-9

4. Levine RA. Typewriter tinnitus: a carbamazepine-responsivesyndrome related to auditory nerve vascular compression. ORL J Otorhinolaryngol Relat Spec 2006, 68; 43-6

5. De Ridder D et al. Pulsatile tinnitus and the intrameatal vascularloop; Why do we not hear our carotids. Neurosurgery 2005, 57; 1213-7

6. Mijangos SV et al. Case 171: Facial Nerve Hemangioma. Radiology 2011, 260; 296-301

7. Monsell EM. The mechanism of hearing loss in Paget's diseaseof bone. Laryngoscope 2004, 114; 598-606

8. Nam E-C et al. Carbamazepine responsive typewriter tinnitusfrom basilar invagination. J Neurol Neurosurg Psychiatry 2010, 81; 456-458

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City of Groningen