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Two categories based on whether observer can hear the tinnitus (objective) or not (subjective).

  • Objective—much less common than subjective

    1. Vascular—typically corresponds to pulse (aka, pulse synchronous tinnitus); may be venous, arterial, or combination (arteriovenous) source or secondary to high-output cardiac state, tumors, other; (pulse synchronous tinnitus may be subjective also)

      • Pathogenesis:

        • – Venous sources

          • Jugular bulb: high riding and large, turbulent flow, dehiscent jugular plate at level of middle ear

          • Sigmoid sinus: diverticulum, turbulent flow, dehiscent sigmoid plate

          • Other venous structures: aberrant condylar vein, superior petrosal sinus, inferior petrosal sinus; aberrant vein contacting labyrinthine structures

        • – Arterial sources

          • Carotid artery: cervical carotid dissection, aneurysm, or stenosis; aberrant carotid artery; carotid body tumor; dehiscent carotid plate within the middle ear

          • Persistent stapedial artery: derived from internal carotid artery, passes through obturator foramen of stapes superstructure

        • – Arteriovenous (AV) malformations and dural AV fistulas

          • May be associated with venous drainage leading to enlarged cortical veins (high rate of bleeding)

          • Often associated with sigmoid/transverse sinus and prior craniotomy

        • – Tumors

          • Paraganglioma, middle ear adenoma, choristoma, facial nerve neuroma, hemangioma

          • Any tumor (or encephalocele) contacting the ossicular chain or TM may lead to pulse synchronous tinnitus (subjective or objective)

        • – High cardiac output states: anemia, thyrotoxicosis, pregnancy, beriberi, etc.

      • Diagnosis: Auscultation with stethoscope, Toynbee tube, palpation of peri-auricular tissue

        • – CT angiography

        • – Magnetic resonance angiography (MRA)/magnetic resonance venography (MRV)

        • – Formal cerebral angiography (small risk of stroke)

      • Treatment: based on etiology and severity of symptoms

        • – Selective embolization, surgical resection/clipping, and radiosurgery are options for dural AV fistulas and malformations.

        • – Surgical excision or combination of surgery and radiosurgery may be used for tumors.

        • – High output states should be medically corrected.

        • – Anatomic vascular abnormalities may or may not be amenable to intervention.

    2. Nonvascular—typically presents as clicking sensation

      • Palatal myoclonus—rapid (50-200 beats/min) irregular clicking caused by eustachian tube opening and closing from palatal musculature contraction.

        • – Symptoms often worse during times of stress

        • – Diagnosed by prolonged tympanogram showing movement with palatal contraction; may visualize palate with nasopharyngoscope as well; Toynbee tube may be used to auscultate rhythmic sound

        • – Treated with muscle relaxants or botox in refractory cases

        • – Often associated with central nervous system disease; MRI of posterior fossa should be performed to assess

      • Stapedial or tensor tympani muscle spasm

        • – Can be heard as clicking or crackling noise

        • – Diagnosis similar to above, but without observed palatal muscle contractions

        • – Treated with muscle relaxants or sectioning of tendons if refractory

      • Patulous eustachian tube—symptoms worsen with respiration and are often described as roaring sensation; autophony

        • – Can be diagnosed by TM movement with respiration, but not always visualized. Prolonged tympanometry may also be helpful

        • – Placement of head in dependent position for relief of symptoms

      • May be associated with temporomandibular joint disorders, normal swallowing that leads to TM movement (latter may be heard as single click with Toynbee tube)

  • Subjective

    1. Incidence: 10% of population

    2. Can arise due to ...

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