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02.03.2014

Pulsatile tinnitus venous hum, stress induced tinnitus symptoms - .

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Tinnitus is a very common symptom and is classified as the perception of a sound in the absence of an external auditory stimulus. People often describe the sensation of subjective tinnitus as a sound of ringing, hissing, machinery or cicadas, among many others, coming from one or both ears. As tinnitus is a subjective symptom, quantification of its severity is based on a patient’s description of its effect on their daily functioning and quality of life.
The natural history of most cases of tinnitus is that the patient gets used to the sound or habituates to it.
Sudden onset of tinnitus and hearing loss or a blocked ear can occasionally represent what is termed the sudden sensorineural hearing loss syndrome. When a patient presents with asymmetric hearing loss or singlesided tinnitus, imaging of the brain and cerebellopontine angle is indicated to exclude the unlikely presence of central pathology, the most common of which is a vestibular schwannoma (acoustic neuroma).
Meniere’s disease is a disorder affecting inner ear homeostasis, classically manifested by episodic vertigo lasting hours, fluctuating hearing loss, tinnitus and aural fullness. When a patient describes the sound of tinnitus resembling pulsation, clicking or related to breathing or swallowing, a mechanical or structural lesion is more likely and must be ruled out. The most common underlying cause of pulsatile tinnitus is the most benign and relates to a degree of Eustachian tube dysfunction. True pulsatile tinnitus originates from vascular structures within the head, skull base, neck and thoracic cavity, and is transmitted to the cochlea by bony or vascular structures. Usually both a CT scan of the skull base and magnetic resonance imaging, angiography and venogram are required.
Conductive hyperacusis of the superior semicircular canal dehiscence syndrome is a rare condition that causes pulsatile tinnitus. Myoclonic contractions of the tensor veli palatini, levator veli palatini, salpingopharyngeus, superior pharyngeal constrictor and the stapedius muscles are another uncommon cause of tinnitus. About 15% of the adult population report some degree of tinnitus with less than 2% of people describing it as a distressing symptom. There are a number of wellvalidated questionnaires that can be used in this regard such as the Tinnitus Handicap Inventory (figure 1). This is commonly used in people who only notice their tinnitus when there is no or minimal background sound.
The aim is to use a specific sound program to assist in habituation of the tinnitus and sensibly focuses on the aberrant central connections that have been established. Because of the presumed pathophysiological connection with alternate neural tinnitus pathways and the limbic system, any physiological or emotional stress has the capacity to exacerbate tinnitus. Often patients notice the tinnitus and a full or blocked feeling but do not appreciate that their hearing is also impaired. This often occurs after a head cold and is related to pulsations being transmitted down a partially blocked Eustachian tube to the middle ear. It is due either to increased blood flow or stenosis, and can be classified as arterial or venous.
The tinnitus is usually a clicking sound ranging between 10 and 240 clicks per minute, which can occasionally be confused with a pulsatile sensation. Most cases of tinnitus are subjective, but occasionally the tinnitus can be heard by an examiner. Occasionally severe noise exposure, especially of an impulsive nature can leave one with permanent tinnitus. It is in those with more severe tinnitus and associated symptoms that a range of management options should be considered. Another diagnosis to consider in bilateral pulsatile tinnitus is benign intracranial hypertension, although this can also cause unilateral symptoms (figure 5). Otologic problems, especially hearing loss, are the most common causes of subjective tinnitus. Age, genetic susceptibility, accumulated noise exposure, infections, trauma, Meniere’s disease, otosclerosis (especially with cochlear involvement), and more serious pathology such as a vestibular schwannoma can all be causes of auditory damage and thus tinnitus.


During the initial assessment it is important to spell out that the initial aim is to rule out any serious underlying causes (which are very rare) and then to minimise the intrusiveness of tinnitus.
While some of these could be classified as alternative, anything that can minimise the feedback loop to the accessory tinnitus pathways is helpful. A number of studies have shown that many people will experience tinnitus when placed in an anechoic environment or after using occlusive earplugs. The initial injury leads to generation of the tinnitus, which is then modified by central connections to the limbic system and trigeminal nucleus. Therefore any abnormalities in these areas can act as non-ear exacerbating factors to the tinnitus. It is very important to say that there are many things that can be done, but it is also important to state that the quest to completely get rid of the tinnitus is counterproductive. The usual management of tinnitus begins with an explanation of the underlying pathophysiology of tinnitus as previously described. Essentially one should have the volume of the masking noise just below that of the tinnitus and over a period of time reduce the volume of the masking noise.
In significantly intrusive tinnitus with any more than mild hearing loss, consideration of hearing aids need be made, even if patients do not identify that their hearing is a problem. This process is thought to facilitate the brain’s ability to habituate to the underlying tinnitus as opposed to removing it entirely.
This situation often leads to a vicious feedback loop where, as the tinnitus becomes more intrusive and distressing, further activation of the limbic system leads to further exacerbation of the same system and so on and so forth. If the severe hearing loss is accompanied by significant tinnitus, cochlear implantation has recently been shown to be a very efficacious management option. When symptoms are severe, consideration of direct venography is made, allowing more accurate diagnosis and measurement of trans-stenotic pressure gradients. Subjective tinnitus is a sound that cannot be detected externally, and is by far the most common form, while objective tinnitus is a sound that an examiner can hear. Almost all medications have at some stage been associated with tinnitus but usually this is coincidental.
Often patients will feel that it is their tinnitus causing a degree of hearing loss but it is the other way around.
Most of what we think of as objective tinnitus is related to transmission of sound to an otherwise normal ear; however, this externally derived sound is not always audible to the examiner.
The modern approach to tinnitus often parallels the management of chronic pain and as a way of explanation can be likened to phantom limb pain following amputation. It is interesting that even when the hearing aids are removed the degree of tinnitus is still improved.
Clues as to the cause of the tinnitus can be gained by otoscopy and auscultation of the chest, neck and skull.
Objective tinnitus usually is caused by vascular abnormalities of the carotid artery or jugular venous systems. It is, presumably, almost impossible to experience tinnitus without some degree of damage to the hearing mechanism. A large component of this is cognitive behavioural therapy and aims to minimise the link between the tinnitus and the central activation of the limbic system.
If occlusion of the internal jugular vein minimises the sound then a venous cause is more likely. Initial evaluation of tinnitus should include a thorough history, head and neck examination, and audiometric testing to identify an underlying etiology. This article will focus on subjective tinnitus, with objective tinnitus being dealt with more briefly at the end. The combination of severe tinnitus and severe hearing loss is difficult to manage, as a standard hearing aid is unable to amplify sound adequately to impart a benefit.
While there are few centres dedicated to specific tinnitus retraining therapy, most psychologists with an interest in cognitive behavioural therapy can make a big difference.


Unilateral or pulsatile tinnitus may be caused by more serious pathology and typically merits specialized audiometric testing and radiologic studies.
In patients who are discomforted by tinnitus and have no remediable cause, auditory masking may provide some relief.
This allows direct stimulation of the cochlear nerve itself, vastly improving hearing and in almost all cases significantly improving tinnitus. Not infrequently, all of the investigations are unremarkable and the diagnosis of idiopathic or essential tinnitus is then made.
Similar to subjective tinnitus discussed above, often all that patients are looking for is reassurance that there is no serious pathology.
Epidemiologic data reveal that approximately one fourth of persons with tinnitus are discomforted by it, whereas the remaining three fourths experience the condition without significant symptoms.3Tinnitus takes different forms and has different classification proposals.
One classification system stresses distinctions between vibratory and nonvibratory types, while another system groups the different forms of tinnitus into subjective or objective classes.Vibratory tinnitus is caused by transmission to the cochlea of vibrations from adjacent tissues or organs. Nonvibratory tinnitus is produced by biochemical changes in the nerve mechanism of hearing.Subjective tinnitus, which is more common, is heard only by the patient.
Objective tinnitus can be heard through a stethoscope placed over head and neck structures near the patient's ear.The mechanism that produces tinnitus remains poorly understood. Tinnitus may originate at any location along the auditory pathway from the cochlear nucleus to the auditory cortex. Some leading theories include injured cochlear hair cells that discharge repetitively and stimulate auditory nerve fibers in a continuous cycle, spontaneous activity in individual auditory nerve fibers, hyperactivity of the auditory nuclei in the brain stem, or a reduction in the usual suppressive activity of the central auditory cortex on peripheral auditory nerve activity.4This article discusses the causes of subjective and objective tinnitus, and techniques used for evaluating tinnitus. It is continuous and less disturbing than the tinnitus of Meniere's disease.14Ototoxic medications or substances are another common cause of bilateral tinnitus. Temporomandibular joint disorder has been associated with vertigo and tinnitus, although the exact mechanism is unclear.Various metabolic abnormalities may be associated with tinnitus. These abnormalities include hypothyroidism, hyperthyroidism, hyperlipidemia, anemia, and vitamin B12 or zinc deficiency.Many patients with tinnitus exhibit signs of psychologic disorders. Although tinnitus may be a contributing factor to the development of depression, the common association of tinnitus and depression may be the result when depressed patients, particularly those with sleep disturbances, focus and dwell on their tinnitus more than patients who are without an underlying psychologic disorder.OBJECTIVE TINNITUSObjective tinnitus is rare. Patients with objective tinnitus typically have a vascular abnormality, neurologic disease, or eustachian tube dysfunction.4Patients with vascular abnormalities complain of pulsatile tinnitus.
Venous hums may be heard in patients with hypertension or abnormally high placement of the jugular bulb. This type of tinnitus is a soft, low-pitched venous hum, which can be altered by head position, activity, or pressure over the jugular vein.4Congenital arteriovenous shunts are usually asymptomatic, while the acquired type often are associated with pulsatile tinnitus. The symptoms may disappear with Valsalva's maneuver or when the patient lies down with the head in a dependent position.Evaluation of TinnitusHISTORYThe evaluation of a patient with tinnitus begins by taking a thorough history. Precipitous onset can be linked to excessive or loud noise exposure or head trauma.LocationUnilateral tinnitus can be caused by cerumen impaction, otitis externa, and otitis media.
Tinnitus associated with unilateral sensorineural hearing loss is the hallmark of acoustic neuroma.PatternContinuous tinnitus accompanies hearing loss.
Tinnitus of venous origin can be suppressed by compression of the ipsilateral jugular vein.Specific testing for sensorineural or conductive hearing loss is the next part of the examination.
Patients with unilateral or pulsatile tinnitus are more likely to have serious underlying disease and typically merit referral to an otolaryngologist.2,5 A full clinical evaluation should precede radiologic studies.
Because pulsatile tinnitus suggests a vascular abnormality, the preferred imaging study is contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the brain21 (Figure 2).



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Comments to “Pulsatile tinnitus venous hum”

  1. gynyg:
    Includes guidelines as to how you can customize the and reported that there are differences.
  2. ilkin:
    Trained doctoral-level clinician, psychotherapy can reverse the neurobiologic.