Paroxysmal tinnitus and nystagmus accompanied by facial spasm

Microvascular decompression of the cochleovestibular nerve for treatment of tinnitus and vertigo: a systematic review and meta-analysis of individual patient data

OBJECTIVE Microvascular decompression (MVD) is regarded as a valid treatment modality in neurovascular conflicts (NVCs) causing, for example, trigeminal neuralgia and hemifacial spasms. An NVC of the cochleovestibular nerve might cause tinnitus and/or vertigo; however, general acceptance of MVD for this indication is lacking. The aim of this study was to investigate the effectiveness, safety, and prognostic factors for success of MVD of the cochleovestibular nerve. METHODS A systematic review and meta-analysis of individual patient data (IPD) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Individual Patient Data (PRISMA-IPD) guidelines. By a comprehensive search (conducted in January 2016) in MEDLINE, EMBASE, and Google Scholar, eligible studies were identified. The collected outcome was a global measurement of improvement of 1) tinnitus, 2) vertigo, and 3) tinnitus combined with vertigo. For the meta-analysis, IPD were collected from the papers and/or from the authors. IPD were analyzed with logistic regression analysis while accounting for study clustering. RESULTS Thirty-five studies (572 patients) were included. The level of evidence provided by these studies was low. In 28% of patients with tinnitus and 32% of patients with vertigo, complete relief following MVD was reported. Patients with both tinnitus and vertigo had complete relief in 62% of cases. In 11% of patients, ≥ 1 complications were reported. Meta-analysis of IPD (165 patients) demonstrated that patients with both tinnitus and vertigo had a higher chance of success (OR 3.8, 95% CI 1.45-10.10) than patients with tinnitus alone. No other variables were significantly related to success. CONCLUSIONS Due to low success rates, MVD cannot be considered as a standard treatment method for tinnitus or vertigo. Moreover, a substantial complication rate was found. However, patients with combined symptoms had a higher chance of success. When combined symptoms occur, it is more likely that an NVC is the underlying pathology and MVD might be appropriate. Due to the low level of evidence in the included studies, this conclusion must be taken with caution. Further validation is necessary to evaluate whether patients with combined symptoms are indeed better candidates for MVD.

Idiopathic tinnitus concomitant with eye closure

OBJECTIVE

To describe 2 patients presenting with idiopathic tinnitus concomitant with eye closure.

STUDY DESIGN

Clinical capsule report.

SETTING

University hospital.

PATIENTS

Two patients presented with intermittent tinnitus synchronous with eye closing or blinking. Otoscopic examination revealed inward movement of tympanic membranes concomitantly with eye blinking or eye closure in 1 patient. Neither patient had facial nerve disease or myoclonus.

INTERVENTIONS

Compliance in impedance audiometry was recorded.

RESULTS

Compliance in impedance audiometry was reduced during eye blinking and eye closure in both cases. The tinnitus was attributed to muscular tinnitus via stapedial muscle contraction during eye closure.

CONCLUSION

These are the rare 2 reported patients presenting with idiopathic muscular tinnitus concomitant with eye closure. The reductive change of compliance in impedance audiometry during tinnitus coincident with eye closure is a feature of this form of tinnitus. We suggest evaluation of compliance change in impedance audiometry to be a key examination in patients with stapedial muscular tinnitus concomitant with eye closure.

Gabapentin responsive audiovestibular paroxysmia

Trigeminal neuralgia and hemifacial spasm are well-documented vascular compression syndromes involving the 5th and 7th cranial nerves. Drugs that stabilize the irritated nerves and vascular decompression surgery are accepted treatments. By contrast, the diagnosis and treatment of a comparable syndrome involving the 8th cranial nerve is controversial. We describe two patients with brief, spontaneous, recurrent attacks of tinnitus and vertigo that responded to low dose gabapentin and we argue that this clinical presentation represents the prototypical 8th nerve vascular compression syndrome.

Typewriter tinnitus: a carbamazepine-responsive syndrome related to auditory nerve vascular compression

Six subjects with similar unilateral tinnitus that was fully suppressed by carbamazepine have been identified. Their ages at the time of the sudden onset of their tinnitus ranged from 39 to 87 years (mean 67). The 3 men had right ear tinnitus. Two of the 3 women had left ear tinnitus. All 6 described a staccato quality of their intermittent tinnitus ('like a typewriter in the background, pop corn, Morse code'). Five of the 6 subjects had no other hearing or vestibular complaints; their audiograms were symmetric and consistent with their ages. Vascular compression of the auditory nerve ipsilateral to the tinnitus was detected in 4 of the 5 subjects imaged. The similarities between typewriter tinnitus and other cranial nerve syndromes associated with vascular compression (trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia) suggest that surgical decompression of the auditory nerve can relieve medication-refractive cases of typewriter tinnitus.

Paroxysmal tinnitus due to a meningioma in the cerebellopontine angle

A 44 year old woman presented with frequent paroxysms of unilateral tinnitus and ataxia which were abolished by treatment with carbamazepine. Hearing was normal and initially there were no other symptoms or signs between paroxysms. Brain stem evoked responses from the affected left ear were absent and MRI showed a large tumour in the left cerebellopontine angle. This was completely removed and histologically proved to be a meningioma. There were striking similarities to trigeminal neuralgia and other paroxysmal brain stem symptoms which occasionally occur in multiple sclerosis and diseases of the cerebellopontine angle. Possible mechanisms are discussed.