Archives of
Arch. Otorhinolaryngol. 222, 229-234 (1979)
Oto-Rhino-Laryngology 9 Springer-Verlag 1979
Tinnitus Caused by Bilateral Shunts from the Occipital Arteries to the lntracranlal Veins A Case Report Magnus G. Lind and Per-G. Lundquist Department of Otolaryngology,Karolinska Hospital, S-104 01 Stockholm60, Sweden
Summary. A patient with objective tinnitus and a pulse synchronous murmur over both left and right sides of the mastoid regions is described. Microphones placed over the mastoid regions recording "phonomastoidograms" clearly demonstrated the pulse synchronous tinnitus. Arteriovenous shunts from the occipital arteries to the sigmoid sinus were later demonstrated with angiograms. After bilateral surgical removal of the arteriovenous shunts the incapacitating tinnitus disappeared. The importance of thorough examination of pulse synchronous tinnitus is discussed.
Key words: Objective tinnitus - Tinnitus registration -- Arterio-venous shunts - Occipital artery
A slight tinnitus is a common symptom. It is most often explained by presbyacusis but also by slight inner ear changes caused by noise trauma, medication and many types of diseases affecting the inner ear (Sexton 1888; Fowler, 1944; Goodhill, 1952). Some patients complain of tinnitus intense enough to seriously affect their psychic stability. Generally, the etiology of the tinnitus cannot be elucidated even after extensive examinations. However, in a few cases it is possible to demonstrate arteriovenous aneurysms or shunts as the causing factor by careful clinical evaluation, including sophisticated audiological methods and angiographic techniques. As a complete relief of the incapacitating symptoms sometimes can be achieved with minor surgery, we would like to make a comment on how rewarding a careful clinical examination can be.
Case Report Patient History Woman aged 52. No earlier diseases of importance. Since 1 year she has suffered from tinnitus synchronouswith the heart rate and increasingin intensitywhen exercising.The tinnitus appearedto be
0302-9530/79/0222/0229/$ 01.20
230
M.G. Lind and P.-G. Lundquist
Fig. 1. A Line I: Electrocardiogram, Line I I - V I : Phonomastoidogram, registration at different frequences. B Line I: Electrocardiogram, Line II, I V - V I : Phonomastoidogram, registration at different frequences. Line Ill: Blood pressure in the carotid arery
equally strong in both ears. By accidence the patient found out that the noise disappeared if she pressed the finger against the tissues behind the mastoid regions. The noise in the head had under the last year increased to a degree where it interferred seriously with sleep and with psychic harmony.
Clinical Findings Examination of the mastoid regions, the external ear and ear drums could not reveal any signs of pathology. Listening with a stetoscope over the mastoid regions revealed a puls synchronous tinnitus from time to time. However, at a special examination by a senior audiologist in the audiologic centre
Fig. 2A--C. (Legend see page 232)
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M.G. Lind and P.-G. Lundquist
Fig. 3. Carotid angiography demonstrated a shunt from the occipital artery to intracranial veins (white arrows)
the murmur could not be heard and nothing abnormal was demonstrated by audiometry or by tympanometric methods. Radiographic examination of the ears and temporal bones did not reveal any abnormal conditions. Due to the persistence of the patient and her clear subjective finding of disappearance of the tinnitus when compression over the mastoid regions was applied, microphones used for phonocardiography were placed over the mastoid regions and the noise was registered using an ink recorder. An electrocardiogram as well as the arterial pressure in the ipsilateral carotid artery were registered simultaneously by use of external detectors. A clear objective pulse synchronous tinnitus could be demonstrated and recorded (Fig. 1). The recordings proved that compression of the carotid artery as well as compression in the occipital artery region made the murmur disappear and that it returned after releasing the pressure (Fig. 2). Carotid angiography was then performed but an angiographic demonstration of vascular abnormality was not obtainable by routine examination. Because the phonomastoidogram proved the existence of an arterial blood flow abnormality, a special examination by a very well trained neuroradiologist was asked for and an arteriovenous shunt from the occipital arteries to the sigmoid sinus, could finally be demonstrated (Fig. 3).
Summary of Findings The objective systolic murmurs of the mastoid regions of both sides were thus caused by bilateral shunts from the occipital artery to the sigmoid sinus.
Fig. 2. A Line I: Electrocardiogram, Line II--VI: Phonomastoidogram, registered at different frequenees. An increasing pressure was applied against the occipital artery at the registered side with starting point indicated by the arrow. B Line I--VI as in Figure 2A. The pressure against the occipital artery inhibits the blood flow through the arteriovenous malformation. No murmur was registered. C Line I--VI as in Figure 2A. The pressure against the occipital artery was released as indicated by the arrow. The murmur reappeared
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233
Fig. 4. Line I: Electrocardiogram, Line II-VI: Post operative phonomastoidogram, registered at same frequences, as in Figures 1 and 2. No pulse correlated murmur could be found
Surgery Due to the patient's feeling of slightly more discomfort on the right side the mastoid region was here explored. In the region of the emissary vein of the mastoid, comparatively large arterio-venous shunts were present. These were ligated and cut. After surgery the tinnitus of the operated side disappeared as could be demonstrated by postoperative phonomastoidograms (Fig. 4). The patient was so satisfied with this reduction in tinnitus that she did not at that time want a second operation on the left side. However, half a year later she wanted also this side to be operated. A surgical exploration was made on the left side and small arteriovenous shunts were found penetrating the cortex of the mastoid surface in the region of the emissary veins.
Discussion The most c o m m o n cause of objective tinnitus is an arteriovenous malformation in the posterior fossa (Arenberg and McCreary, 1971). Usually collaterals of the occipital artery and transvere sinus are involved. According to Stoll and K u h n e r (1975) three different arterial origins of arteriovenous shunts in the posterior fossa region should be considered. 1. Perforants from the occipital artery, superficial temporal artery, and posterior auricular artery. 2. Meningeal communicants from the middle meningeal artery and posterior meningeal artery. 3. The medial and lateral tentorial arteries. In most cases these shunts are intracranially located and have to be explored by neurosurgical methods as described by Hugosson and Bergstr6m (1974). In m a n y cases advanced diagnostic methods and neurosurgery are necessary in treating objective tinnitus.
234
M. G. Lind and P.-G. Lundquist
However, extracranial vascular malformations as a cause of the tinnitus should first be excluded by careful clinical examination. In this patient the commonly used clinical methods for examination of possible objective tinnitus, such as auscultation with a stetoscope and tympanometric recordings did not reveal the objective tinnitus in a reproducible and reliable way. Therefore, the indication for carotid angiography was doubtful and surgery could not be performed. However, the simple method of placing microphones over the mastoid region and using standard electrophonographic recording techniques were sufficient to clearly demonstrate the pulse synchronous tinnitus. It was also possible to record the disappearance of the murmur when he blood flow through the external and occipital arteries, respectively, was diminished by external pressure. The arterial vascular abnormality was thus proven and carotid angiography was indicated. The initially negative angiographic findings were contradictionary to the clinical picture. As the phonomastoidogram proved the arterial abnormality it was found reasonable to ask for a special examination by a very well trained neuroradiologist who had experienced similar cases before (Newton and Greitz, 1969). He finally demonstrated the shunts and their exact location. This made surgical intervention and ultimate cure possible. Such simple methods as palpation and compression of the carotid artery or the jugular vein together with the use of well known phonocardiographie techniques giving recordings of "phonomastoidograms" should be considered in the otoneurological examination of tinnitus patients.
References Arenberg, I. K., McCreary, H. S.: Objectivetinnitus aurium and dural arteriovenous malformationsof the posterior fossa. Ann. Otol. Rhinol. Laryngol. 80, 111-120 (1971) Fowler, E. P.: Head noises in normal and in disordered ears. Arch. Otolaryngol. 39, 498-503 (1944) Goodhill, V.: A tinnitus identification test. Ann. Otol. Rbinol. Laryngol. 61, 778 (1952) Hugosson, R., Bergstr6m, K.: Surgical treatment of dural arteriovenons malformation in the region of sigmoid sinus. J. Neurol. Neurosurg. Psychiatry 37, 97-101 (1974) Newton, T. H., Greitz, T.: Arteriovenous communicationsbetween the occipital artery and the transverse sinus. Radiology 87, 824--828 (1969) Sexton, S.: The ear and its diseases. New York: William Wood and Co. 1888 Stoli, W., Uhner, A.: Objective tinnitus caused by arteriovenous malformationsin the region of transverse and sigmoid sinus. Laryngol. Rhinol. Otol. (Stuttg.) 54, 388--398 (1975) Received July 10, 1978/Accepted October 4, 1978
Arch. Otorhinolaryngol. 222, 229-234 (1979)
Oto-Rhino-Laryngology 9 Springer-Verlag 1979
Tinnitus Caused by Bilateral Shunts from the Occipital Arteries to the lntracranlal Veins A Case Report Magnus G. Lind and Per-G. Lundquist Department of Otolaryngology,Karolinska Hospital, S-104 01 Stockholm60, Sweden
Summary. A patient with objective tinnitus and a pulse synchronous murmur over both left and right sides of the mastoid regions is described. Microphones placed over the mastoid regions recording "phonomastoidograms" clearly demonstrated the pulse synchronous tinnitus. Arteriovenous shunts from the occipital arteries to the sigmoid sinus were later demonstrated with angiograms. After bilateral surgical removal of the arteriovenous shunts the incapacitating tinnitus disappeared. The importance of thorough examination of pulse synchronous tinnitus is discussed.
Key words: Objective tinnitus - Tinnitus registration -- Arterio-venous shunts - Occipital artery
A slight tinnitus is a common symptom. It is most often explained by presbyacusis but also by slight inner ear changes caused by noise trauma, medication and many types of diseases affecting the inner ear (Sexton 1888; Fowler, 1944; Goodhill, 1952). Some patients complain of tinnitus intense enough to seriously affect their psychic stability. Generally, the etiology of the tinnitus cannot be elucidated even after extensive examinations. However, in a few cases it is possible to demonstrate arteriovenous aneurysms or shunts as the causing factor by careful clinical evaluation, including sophisticated audiological methods and angiographic techniques. As a complete relief of the incapacitating symptoms sometimes can be achieved with minor surgery, we would like to make a comment on how rewarding a careful clinical examination can be.
Case Report Patient History Woman aged 52. No earlier diseases of importance. Since 1 year she has suffered from tinnitus synchronouswith the heart rate and increasingin intensitywhen exercising.The tinnitus appearedto be
0302-9530/79/0222/0229/$ 01.20
230
M.G. Lind and P.-G. Lundquist
Fig. 1. A Line I: Electrocardiogram, Line I I - V I : Phonomastoidogram, registration at different frequences. B Line I: Electrocardiogram, Line II, I V - V I : Phonomastoidogram, registration at different frequences. Line Ill: Blood pressure in the carotid arery
equally strong in both ears. By accidence the patient found out that the noise disappeared if she pressed the finger against the tissues behind the mastoid regions. The noise in the head had under the last year increased to a degree where it interferred seriously with sleep and with psychic harmony.
Clinical Findings Examination of the mastoid regions, the external ear and ear drums could not reveal any signs of pathology. Listening with a stetoscope over the mastoid regions revealed a puls synchronous tinnitus from time to time. However, at a special examination by a senior audiologist in the audiologic centre
Fig. 2A--C. (Legend see page 232)
232
M.G. Lind and P.-G. Lundquist
Fig. 3. Carotid angiography demonstrated a shunt from the occipital artery to intracranial veins (white arrows)
the murmur could not be heard and nothing abnormal was demonstrated by audiometry or by tympanometric methods. Radiographic examination of the ears and temporal bones did not reveal any abnormal conditions. Due to the persistence of the patient and her clear subjective finding of disappearance of the tinnitus when compression over the mastoid regions was applied, microphones used for phonocardiography were placed over the mastoid regions and the noise was registered using an ink recorder. An electrocardiogram as well as the arterial pressure in the ipsilateral carotid artery were registered simultaneously by use of external detectors. A clear objective pulse synchronous tinnitus could be demonstrated and recorded (Fig. 1). The recordings proved that compression of the carotid artery as well as compression in the occipital artery region made the murmur disappear and that it returned after releasing the pressure (Fig. 2). Carotid angiography was then performed but an angiographic demonstration of vascular abnormality was not obtainable by routine examination. Because the phonomastoidogram proved the existence of an arterial blood flow abnormality, a special examination by a very well trained neuroradiologist was asked for and an arteriovenous shunt from the occipital arteries to the sigmoid sinus, could finally be demonstrated (Fig. 3).
Summary of Findings The objective systolic murmurs of the mastoid regions of both sides were thus caused by bilateral shunts from the occipital artery to the sigmoid sinus.
Fig. 2. A Line I: Electrocardiogram, Line II--VI: Phonomastoidogram, registered at different frequenees. An increasing pressure was applied against the occipital artery at the registered side with starting point indicated by the arrow. B Line I--VI as in Figure 2A. The pressure against the occipital artery inhibits the blood flow through the arteriovenous malformation. No murmur was registered. C Line I--VI as in Figure 2A. The pressure against the occipital artery was released as indicated by the arrow. The murmur reappeared
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233
Fig. 4. Line I: Electrocardiogram, Line II-VI: Post operative phonomastoidogram, registered at same frequences, as in Figures 1 and 2. No pulse correlated murmur could be found
Surgery Due to the patient's feeling of slightly more discomfort on the right side the mastoid region was here explored. In the region of the emissary vein of the mastoid, comparatively large arterio-venous shunts were present. These were ligated and cut. After surgery the tinnitus of the operated side disappeared as could be demonstrated by postoperative phonomastoidograms (Fig. 4). The patient was so satisfied with this reduction in tinnitus that she did not at that time want a second operation on the left side. However, half a year later she wanted also this side to be operated. A surgical exploration was made on the left side and small arteriovenous shunts were found penetrating the cortex of the mastoid surface in the region of the emissary veins.
Discussion The most c o m m o n cause of objective tinnitus is an arteriovenous malformation in the posterior fossa (Arenberg and McCreary, 1971). Usually collaterals of the occipital artery and transvere sinus are involved. According to Stoll and K u h n e r (1975) three different arterial origins of arteriovenous shunts in the posterior fossa region should be considered. 1. Perforants from the occipital artery, superficial temporal artery, and posterior auricular artery. 2. Meningeal communicants from the middle meningeal artery and posterior meningeal artery. 3. The medial and lateral tentorial arteries. In most cases these shunts are intracranially located and have to be explored by neurosurgical methods as described by Hugosson and Bergstr6m (1974). In m a n y cases advanced diagnostic methods and neurosurgery are necessary in treating objective tinnitus.
234
M. G. Lind and P.-G. Lundquist
However, extracranial vascular malformations as a cause of the tinnitus should first be excluded by careful clinical examination. In this patient the commonly used clinical methods for examination of possible objective tinnitus, such as auscultation with a stetoscope and tympanometric recordings did not reveal the objective tinnitus in a reproducible and reliable way. Therefore, the indication for carotid angiography was doubtful and surgery could not be performed. However, the simple method of placing microphones over the mastoid region and using standard electrophonographic recording techniques were sufficient to clearly demonstrate the pulse synchronous tinnitus. It was also possible to record the disappearance of the murmur when he blood flow through the external and occipital arteries, respectively, was diminished by external pressure. The arterial vascular abnormality was thus proven and carotid angiography was indicated. The initially negative angiographic findings were contradictionary to the clinical picture. As the phonomastoidogram proved the arterial abnormality it was found reasonable to ask for a special examination by a very well trained neuroradiologist who had experienced similar cases before (Newton and Greitz, 1969). He finally demonstrated the shunts and their exact location. This made surgical intervention and ultimate cure possible. Such simple methods as palpation and compression of the carotid artery or the jugular vein together with the use of well known phonocardiographie techniques giving recordings of "phonomastoidograms" should be considered in the otoneurological examination of tinnitus patients.
References Arenberg, I. K., McCreary, H. S.: Objectivetinnitus aurium and dural arteriovenous malformationsof the posterior fossa. Ann. Otol. Rhinol. Laryngol. 80, 111-120 (1971) Fowler, E. P.: Head noises in normal and in disordered ears. Arch. Otolaryngol. 39, 498-503 (1944) Goodhill, V.: A tinnitus identification test. Ann. Otol. Rbinol. Laryngol. 61, 778 (1952) Hugosson, R., Bergstr6m, K.: Surgical treatment of dural arteriovenons malformation in the region of sigmoid sinus. J. Neurol. Neurosurg. Psychiatry 37, 97-101 (1974) Newton, T. H., Greitz, T.: Arteriovenous communicationsbetween the occipital artery and the transverse sinus. Radiology 87, 824--828 (1969) Sexton, S.: The ear and its diseases. New York: William Wood and Co. 1888 Stoli, W., Uhner, A.: Objective tinnitus caused by arteriovenous malformationsin the region of transverse and sigmoid sinus. Laryngol. Rhinol. Otol. (Stuttg.) 54, 388--398 (1975) Received July 10, 1978/Accepted October 4, 1978
