Pulsatile Tinnitus: Differential Diagnosis and Approach to Management

PURPOSE OF REVIEW

The purpose of this review is to provide an updated approach to the evaluation and management of pulsatile tinnitus (PT), an uncommon but often treatable subtype of tinnitus.

RECENT FINDINGS

Secondary PT can be due to either vascular or non-vascular etiologies, including, but not limited to: neoplasm, arteriovenous malformation or fistula, idiopathic intracranial hypertension, dural venous sinus stenosis, otoacoustic etiologies (e.g., otosclerosis, patulous eustachian tube) and bony defects (e.g., superior semicircular canal dehiscence). Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies. If initial vascular imaging is negative and a vascular etiology is strongly suspected, digital subtraction angiography (DSA) may further aid in the diagnosis. Many vascular etiologies of PT can be managed endovascularly, often leading to PT improvement or resolution. Notably, venous sinus stenting is an emerging therapy for PT secondary to idiopathic intracranial hypertension with venous sinus stenosis. Careful history and physical exam can help establish the differential diagnosis for PT and guide subsequent evaluation and management. Additional studies on the efficacy and long-term outcome of venous sinus stenting for venous stenosis are warranted.

Tensor Tympani and Stapedial Tendon Reconstruction for Postoperative Hyperacusis after Tendon Lysis for Middle Ear Myoclonus

OBJECTIVE

To present a method for repair of the stapedial and tensor tympani tendons in a patient with hyperacusis after a tendon lysis procedure.

PATIENTS

A 71-year-old professional musician who presented to clinic with debilitating hyperacusis following a tensor tympani and stapedial tendon lysis procedure to treat middle ear myoclonus.

INTERVENTIONS

A novel procedure for reapproximation of the tensor tympani and stapedial tendons into their native insertion points using periosteal grafts and nitinol wire.

MAIN OUTCOMES MEASURES

Stapedial reflex measurements, uncomfortable loudness level, and subjective patient experience.

RESULTS

Postoperatively, the patient had objective improvement in hyperacusis with return of acoustic reflexes in the affected ear and durable improvements in their frequency-specific uncomfortable loudness levels.

CONCLUSIONS

This case describes the debilitating complication of hyperacusis following tendon lysis and highlights the importance of maximizing behavioral and medical measures prior to undergoing surgical intervention for middle ear myoclonus.

Treatment of Stapedial Myoclonus as a Migraine-Related Phenomenon

OBJECTIVE

To describe a case series of patients with stapedial myoclonus (SM) whose conditions improved after prophylactic migraine treatment.

PATIENTS

We present seven cases of SM reported from a tertiary care neurotology clinic. All seven patients reported SM triggers similar to those of migraine headaches and suffered from concomitant headaches and/or vertigo, and were thus treated with a standard migraine protocol used at this neurotology clinic.

INTERVENTION

Prophylactic migraine treatment.

MAIN OUTCOME MEASURES

Reduction or resolution of SM.

RESULTS

In this series, seven patients with SM were included. Six of seven subjects were male (86%), with a mean age at presentation of 44 years. Four patients noted significant improvement in their symptoms, with a reduced frequency, duration, and intensity of their symptoms with the migraine regimen. Three patients experienced complete resolution of SM with their migraine treatment.

CONCLUSION

We report that treatment with prophylactic migraine treatment can provide long-term relief for patients with SM, which may suggest an etiological association between migraine and SM as well as a possible treatment for SM.

Tinnitus Related to Forceful Eyelid Closure: A Case Report

Tinnitus is a common complaint in the clinical setting and can be classified into sensorineural and objective tinnitus. The sources of objective tinnitus may either come from para-auditory structures, such as myogenic or vascular structures, or the middle ear muscles. One type of objective tinnitus of muscular origin is known as forceful eyelid closure syndrome (FECS). We present an additional case of a 22-year-old woman with unilateral FECS. The auricles and external auditory canals were normal bilaterally; we examined her tympanic membrane under an endoscope, the left tympanic membrane was retracted simultaneously with the closure of her eyelids. Both tympanograms were of type A. However, small cut trace associated with tympanic membrane movement were obtained during blinking. The patient was managed by behavioral therapy and medication treatment conservatively, and the condition became well-controlled. Here, we present this rare case and review the literature.

Intratympanic Botulinum Toxin Injection as a New Therapeutic Modality for Middle Ear Myoclonic Tinnitus

OBJECTIVE

Middle ear myoclonic tinnitus (MEMT) is a disease caused by myoclonus or abnormal contractive movement of middle ear muscles (MEMs). This translational study was conducted to propose intratympanic botulinum toxin (IT-BTX) injection as a new therapeutic modality to treat MEMT.

STUDY DESIGN

Animal experiment and nonrandomized controlled clinical trial.

SETTING

Laboratory and medical center of an academic tertiary medical institution.

METHODS

For the animal study, male Sprague-Dawley rats were divided into 4 subgroups according to the sacrificing day after IT-BTX injection. After initial hearing tests, randomly assigned experimental ears were intratympanically injected with 1 unit/100 μL of BTX-A, whereas control ears were injected with normal saline. Changes in the hearing thresholds, morphometry of the cochleae, electron microscopy study, and immunofluorescence analysis of MEMs were evaluated. For the human study, 10 intractable MEMT patients were enrolled. The hearing thresholds and the degree of tinnitus distress were observed for changes after IT-BTX injection. All patients were followed up for 3 months.

RESULTS

As for the animal study, there were no significant changes in hearing thresholds and cochlear morphologies in all 4 subgroups of the rats. Significant MEM degenerations and immuno-detection of cleaved synaptosome-associated protein of 25 kDa (cSNAP-25) indicated the efficacy of IT-BTX. MEMT patients enrolled for the pilot clinical trial showed statistically significant improvement in tinnitus after IT-BTX injection. No major complications were noted.

CONCLUSION

The new therapeutic modality of IT-BTX injection for the treatment of MEMT seems highly promising with an excellent result.

Middle ear myoclonus: Systematic review of results and complications for various treatment approaches

OBJECTIVE

To perform a systematic review of the diagnosis and treatment of patients with pulsatile tinnitus secondary to middle ear myoclonus.

DATABASES REVIEWED

PubMed, EMBASE, and Scopus.

METHODS

A systematic review was performed using standardized methodology. Computerized and manual searches were performed to identify studies of all ages (patients) who had middle ear myoclonus (intervention). All study designs were assessed. Extracted data included demographics, clinical features, duration of followup as well as the diagnosis and reversibility of symptoms with medical or surgical intervention. Studies were included if they included subjects with middle ear myoclonus. Exclusion criteria included letters/commentaries and reviews.

RESULTS

Twenty articles representing 115 subjects with middle ear myoclonus were included. The mean age was 29.7 (range 6-67). The follow-up period ranged from 5 weeks to 36 months. Primary treatment consists of medical therapy utilising anxiolytics, antiepileptics, botulinum toxin and surgical treatment involving division of middle ear muscular tendon(s). In total, 60 patients underwent middle ear muscular tenotomies, with division of both stapedius and tensor tympani tendons being the most prevalent (88%). Limitations in the data arose from study design, related comorbidities such as palatal myoclonus, and concomitant drug administration. No study provided any objective criteria to diagnose this condition or evaluate post-treatment outcome.

CONCLUSION

Middle ear myoclonus is an entity that is poorly assessed in the literature. There is a lack of consensus regarding the criteria and strategies for both diagnosing and treating this condition. Although level of evidence of current studies remains modest, it is felt that a stepwise approach is deemed best, with therapeutic decisions being made on an individual basis, evaluating each patient's specific circumstances and priorities.

Low inter-rater consistency in semantic profiles of tinnitus-like sounds rated by tinnitus patients

Characterizations of the tinnitus sound percept are always based on a subjective description by the person affected. Since the experimenter cannot have access to the tinnitus percept, it is not possible to verify whether individuals use the adjectives describing the sound in the expected way, i.e., whether a label given to the tinnitus percept corresponds to the label that the experimenter or another individual would give to the same sound percept. However, if it is assumed that tinnitus patients can reliably describe their own tinnitus, then they should also be able to reliably describe tinnitus-like sounds, presented acoustically. In this study, 26 tinnitus patients used a tablet computer to rate 18 pre-defined adjectives on their level of descriptiveness for their own tinnitus percept as well as 17 tinnitus-like sounds presented via headphones. The main interest of the current study was to calculate intraclass correlation (ICC) and Krippendorff's alpha coefficients for the rating profiles of the acoustically-presented sounds, in order to quantify how well the individuals agreed on the ratings of known sounds, i.e., whether the adjectives would receive similar ratings from all participants for a specific tinnitus-like sound. The results show that the level of agreement was low for all adjectives and sounds, meaning that the different individuals did not use the adjectives in a consistent manner. The conclusion is that subjective tinnitus descriptions should be interpreted with great caution, and that the inherent variability involved in the characterization of sounds by naïve listeners can contribute to the observed heterogeneity in tinnitus symptoms and treatment outcomes.

Diagnosis of Stapedial Myoclonus Using Endoscopic Visualization

BACKGROUND

Stapedial myoclonus is an uncommon condition involving the rhythmic contraction of the stapedial tendon that may result in a host of symptoms, including tinnitus . There is a dearth of robust diagnostic modalities to diagnose stapedial myoclonus, and most patients are treated without definitive diagnosis. Herein, we hypothesize that stapedial myoclonus can be readily diagnosed by awake otoendoscopy (see Video, Supplemental Digital Content 1, http://links.lww.com/MAO/A997).

CASE REPORT

A 21-year-old healthy male professional singer presented with a rhythmic "thumping sound" heard in both ears for 5 years. Symptoms were triggered by singing and were worse on the right side. Work-up, including otologic exam, audiologic testing, and high resolution imaging, was unrevealing. Given symptomatology, stapedial tendon myoclonus was suspected.While awake in the operating room, an inferior myringotomy was made, and both 1.9 mm 0 and 30 degree 3-CCD Hopkins rod endoscopes were used to visualize the middle ear space using a transcanal approach. There was robust movement of the tendon with patient vocalization that corresponded precisely with the timing of tinnitus. The patient subsequently underwent transection of the right stapedial tendon under general anesthesia using otoendoscopic visualization. The pyramidal eminence was also removed to avoid future regeneration. The patient underwent an identical procedure on the contralateral ear 3 months later with complete resolution of symptoms bilaterally.

CONCLUSION

Stapedial myoclonus was diagnosed by transtympanic otoendoscopy in an awake patient. This approach may be readily applied in awake patients suspected of having stapedial myoclonus. Transection of the stapedial tendon in these patients resolves tinnitus.

A Novel Technique for the Diagnosis and Management of Middle Ear Myoclonus

A novel technique for the diagnosis and management of middle ear myoclonus is described. A patient with middle ear myoclonus underwent a trans-canal microscopic middle ear exploration with injection of botulinum toxin into the stapedius and tensor tympani muscles. Postoperatively, the patient noted complete resolution of symptoms. This is the first report of the use of botulinum toxin directly applied to the middle ear musculature via a trans-canal approach for the management of middle ear myoclonus. This approach is both a useful diagnostic and therapeutic tool that allows for temporary muscle paralysis prior to offering definitive surgical management. Laryngoscope, 131:E248-E249, 2021.

Pharmacotherapy of Tinnitus

Tinnitus is a common symptom for which there is in most cases no causal therapy. The search for an improvement of tinnitus through pharmacological interventions has a long tradition. The observation that tinnitus can be transiently suppressed by the use of lidocaine has shown that the symptom is susceptible to pharmacotherapy. So far, however, no medication has been found for either acute or chronic subjective tinnitus that reliably leads to a long-term reduction or even complete disappearance of the symptom for the majority of tinnitus sufferers. Nevertheless, in everyday clinical life, drugs are frequently used, usually off-label, to relieve tinnitus or tinnitus-associated symptoms (e.g. sleep disturbance, depression, anxiety disorder or hearing loss). This chapter shows the different approaches to acute and chronic subjective tinnitus by means of pharmacotherapeutic interventions. Furthermore, this review reports on the scientific studies carried out in this area in recent years and explains the difficulties in finding a suitable medication for most forms of tinnitus. In addition, it reports on the pharmacotherapeutic options for objective tinnitus and describes the development of tinnitus as a side effect of certain drugs. Finally, possible target structures are mentioned, which should possibly be addressed in pharmacological studies in the near future.

An evaluation of magnetic resonance imaging with histogram analysis in patients with idiopathic subjective tinnitus

OBJECTIVE

Tinnitus is defined as the perception of sound in the ears without any acoustic stimulus. It has still not been determined whether tinnitus originates peripherally, centrally, or from several locations. The aim of the study was to determine any possible cochlear pathology in patients with normal hearing and tinnitus of unspecified etiology.

METHODS

The study included 22 patients who presented at the clinic with the complaint of idiopathic subjective tinnitus that had been ongoing for at least 1 year. A total of 44 ears were included; 28 with tinnitus and 16 healthy ears. Unilateral tinnitus was determined in 16 patients and bilateral in six patients. The temporal magnetic resonance imaging (MRI) and audiogram results of the patients were retrieved from the hospital records. The MRI histogram measurement was made automatically and calculated for each ear separately.

RESULTS

Entropy was found to be significantly higher in the control group and distribution was lower (p>0.01). In the tinnitus group, distribution was found to be broader, and kurtosis was statistically significantly greater (p<0.001).

CONCLUSION

MRI histogram analysis can be considered as a method to be used in the clinical evaluation of the determination of possible cochlear pathology in ears with tinnitus.

Treatment of objective tinnitus with transpalatal Botox® injection in a pediatric patient with middle ear myoclonus: A case report

We describe a case of bilateral middle ear myoclonus (MEM) that was treated with trans-palatal Botox^® injection after failing surgery to section the tensor tympani and stapedial tendons. MEM is a rare disorder resulting from rhythmic contraction of middle ear muscles. An 8-year old girl presented with audible clicking tinnitus, and resultant inability to focus in school. Her parents declined medical therapy, and she underwent surgeries for tendon lysis, with only temporary relief. She had successful response to trans-palatal Botox^® injection to the tensor veli palatini aponeurosis. Trans-palatal Botox^® injection is a safe and reasonable alternative for treatment of MEM.

[Myoclonus of the middle ear]

The objective of the present study was to overview the foreign literature concerning middle ear myoclonus (MEM) known to be the most common cause of the manifestations of objective tinnitus. The authors reports two typical clinical cases of myoclonus of the middle ear. The present article is aimed at the enhancement of the awareness of the otorhinolaryngologists, audiologists, and neurologists of the condition of interest as a way to promote the further progress in its treatment.

Long-Term Effects of Middle Ear Tendon Resection on Middle Ear Myoclonic Tinnitus, Hearing, and Hyperacusis

Objective: To evaluate the therapeutic effects of middle ear tendon resection (METR) on middle ear myoclonic tinnitus (MEMT) and to investigate its long-term effects on hearing and hyperacusis. Materials and Methods: Thirty-seven patients with MEMT with a mean age of 33.2 ± 11.8 years were included in this study. METR was performed on all 37 MEMT patients (41 ears) between November 2004 and August 2016. The mean follow-up period was 16.1 months. We examined changes in tinnitus and accompanying stress and depression in patients after surgery, and examined the hearing changes and the occurrence of complications including hyperacusis. Results: After surgery, 34 (91.9%) patients exhibited complete resolution of MEMT during their follow-up period, and 3 patients showed a partial response. The mean Visual Analog Scale (VAS) scores for tinnitus severity, the Tinnitus Handicap Inventory (THI), and stress index decreased significantly after surgery (p < 0.05, paired t test). No patient developed hearing loss or hyperacusis following surgery. Preexisting hyperacusis even improved in most of the patients with intractable MEMT after surgery. Recurrence of the symptom occurred in only 1 patient, who underwent revision surgery with improvement. We observed 1 case of postoperative delayed facial palsy with complete recovery in 2 weeks. Conclusions: METR seems to be an effective and safe treatment option for intractable MEMT, considering its high control rate of tinnitus and no long-term harmful effects on hearing and hyperacusis.

Objective Tinnitus Concomitant with Eye Blinking: A Case Report

Tinnitus is a common auditory phenomenon associated with many otological diseases, and is usually subjective. Objective tinnitus can be generated by para-auditory structures, usually derived from vascular or myogenic sources, or the eustachian tube. We present a rare case of intermittent unilateral tinnitus associated with eye blinking. Otoendoscopic examination showed that the external auditory canals and tympanic membranes were normal; however, rhythmic movements of both tympanic membranes, concomitant with the tinnitus, were evident whenever the patient blinked. The tympanometry and stapedial reflexes measured via impedance audiometry exhibited saw-tooth patterns; movement of the tympanic membrane was associated with eyelid blinking. The patient was managed conservatively, with reassurance and medication, and the condition became well-controlled. Here, we present this educational case and review the literature.

Is it necessary to retain the tensor tympani tendon in tympanoplasty?

OBJECTIVES/HYPOTHESIS

To evaluate the acoustic effect after canal wall-down tympanoplasty with sectioning of the tensor tympani muscle (TTM) tendon in patients with chronic otitis media.

STUDY DESIGN

Prospective, controlled clinical trial.

METHODS

From January 2010 to April 2014, 212 patients underwent canal wall-down tympanoplasty with ossicular chain reconstruction in one-stage surgery. For this study, the patients were assigned to two groups. In group 1 (107 patients), the TTM tensor would be removed during the surgery, whereas it would be retained in group 2 (105 patients). Pre- and postoperative air conduction and bone conduction thresholds at 0.5, 1, 2, and 4 kHz were reported, and the air-bone gaps (ABGs) were measured.

RESULTS

Mean postoperative ABG was 16.0 dB in group 1 and 17.0 dB in group 2 and the ABG closure was 11.9 ± 8.5 in group 1 and 11.8 ± 9.7 in group 2. Both were not statistically different (P = .2381 and P = .9625). Overall, 84.1% of patients in group 1 and 75.2% of patients in group 2 attained a postoperative ABG of 20 dB or less. Success rate in group 1 is slightly higher than group 2, but not significant (P = .1255).

CONCLUSIONS

The section of the tensor tympani muscle tendon in canal wall-down tympanoplasty with ossiculoplasty had no statistically significant influence on sound transmission and can be a safe maneuver in middle ear surgery.

LEVEL OF EVIDENCE

4

Feasibility of endoscopic treatment of middle ear myoclonus: a cadaveric study

Stapedius and tensor tympani tenotomy is a relatively simple surgical procedure commonly performed to control pulsatile tinnitus due to middle ear myoclonus and for several other indications. We designed a cadaveric study to assess the feasibility of an entirely endoscopic approach to stapedius and tensor tympani tenotomy. We performed this endoscopic ear surgery in 10 cadaveric temporal bones and summarized our experience. Endoscopic stapedius and tensor tympani section is a new, minimally invasive treatment option for middle ear myoclonus that should be considered as the first line surgical approach in patients who fail medical therapy. The use of an endoscopic approach allows for easier access and vastly superior visualization of the relevant anatomy, which in turn allows the surgeon to minimize tissue dissection. The entire operation, including raising the tympanomeatal flap and tendon section, can be safely completed under visualization with a rigid endoscope.

Tinnitus

Tinnitus is a common medical symptom that can be debilitating. Risk factors include hearing loss, ototoxic medication, head injury, and depression. At presentation, the possibilities of otological disease, anxiety, and depression should be considered. No effective drug treatments are available, although much research is underway into mechanisms and possible treatments. Surgical intervention for any otological pathology associated with tinnitus might be effective for that condition, but the tinnitus can persist. Available treatments include hearing aids when hearing loss is identified (even mild or unilateral), wide-band sound therapy, and counselling. Cognitive behavioural therapy (CBT) is indicated for some patients, but availability of tinnitus-specific CBT in the UK is poor. The evidence base is strongest for a combination of sound therapy and CBT-based counselling, although clinical trials are constrained by the heterogeneity of patients with tinnitus.

Middle ear myoclonus: two informative cases and a systematic discussion of myogenic tinnitus

Background

The term middle ear myoclonus (MEM) has been invoked to explain symptoms of tinnitus presumably caused by the dysfunctional movement of either of the two muscles that insert in the middle ear: tensor tympani and stapedius. MEM has been characterized through heterogeneous case reports in the otolaryngology literature, where clinical presentation is variable, phenomenology is scarcely described, the pathogenic muscle is usually not specified, natural history is unknown, and the presumptive definitive treatment, tensor tympani or stapedius tendon lysis, is inconsistently effective. It is not surprising that no unique acoustogenic mechanism or pathophysiologic process has been identified to explain MEM, one of several descriptive diagnoses associated with the complicated disorders of myogenic tinnitus.

Methods

Here, we explore MEM from the neurologist’s perspective. Following the detailed descriptions of two informative cases from our clinic, we systematically evaluate the different mechanisms and movement disorder phenomena that could lead to a diagnosis of MEM.

Results

From a functional neuroanatomic perspective, we explain how tensor tympani MEM is best explained as a form of peritubal myogenic tinnitus, similar to the related disorder of essential palatal tremor. From a pathogenic perspective, we discuss how MEM symptomatology may reflect different mechanical and neurologic processes. We emphasize the diagnostic imperative to recognize when myogenic tinnitus is consistent with a psychogenic origin.

Discussion

Both individual patient care and further elucidation of MEM will rely on more detailed clinical characterization as well as multidisciplinary input from neurology, otolaryngology, and dentistry.

Tinnitus related to eyelid blinking

Tinnitus can be generated by various causes, including vascular or myogenic factors and sensorineural auditory structures. Tinnitus due to repetitive contraction of the paraauditory muscles is a rare condition. We present a case of bilateral tinnitus concomitant with eyelid blinking. Otoscopy revealed normal tympanic membranes; however, inward movement of the tympanic membrane was visible whenever the patient blinked. Long-time-based tympanometry measuring static compliance revealed a cogwheel or saw-toothed pattern associated with movement of the tympanic membrane related to eyelid blinking. The patient was managed with pharmacological treatment combined with assurance and was relatively well controlled.