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Author: admin | 27.08.2014 | Category: Ringing Of The Ears Treatment

Axial 3 D FIESTA study show a Vascular loop in Internal Auditory Canal around 7-8th CN complex on right side. Is there any correlation between pulsatile tinnitus and a vascular loop in internal auditory canal ?
Tinnitus is a common disorder of sound in ear occurring without external stimulus and the etiology remains mostly unclear. With advent of 3D-FIESTA MR imaging which elegantly demonstrates the anatomy at IAC, more and more cases are mentioned with presence of a vascular loops in IAC around 7-8 CN complexes.
Therefore, the presence of vascular loops within the IAC may not be a definite indication of vascular compression syndromes. Tinnitus can be defined as a sound that a patient can hear and relates it to the ear, head or both the ear and the head, while there is no such sound outside theear of tinnitus patient head (in a subjective tinnitus), or a structure inside the head is generating a noise (in objective tinnitus). Subjective tinnitus may be heard as a sound that come from a source that is located outside the head.
When the sound can be heard or recorded by someone else (usually pulsatile sound) it is called objective tinnitus. The patient may tell about sounds of sea waves, high voltage cables, electric engine such as the engine of a refrigerator, discharge of air under pressure, sounds of birds or insects.
The objective tinnitus can be heard by another person with or without instruments for amplification of the sound. The pulsations can have the same rate as the heart beats or have a different counts per minutes than the heart beats of the patient.
Insomnia (disturbance to sleep), irritability, inability to concentrate on intellectual activities, fatigue, exhaustion, deterioration in ability to work, disturbance to family life, detachment from social life, anhedonia (inability to derive pleasure from life), anxiety, depression, hyperacusis (sensitivity to noise), palpitations, hypertension and hearing impairement.
Psychotropic medications, H2-Blockers, Psychotherapy (hypnosis, cognitive behavioral therapy, bio-feedback, relaxation exercises), sound therapy (Tinnitus Maskers, TRT, hearing aids). Surgery for tumors, surgery for blood vessels abnormality, drainage of abscesses, Drainage of infection, antibiotic therapy for bacterial infections, removal of Otto-Toxic medication and Metabolic Intervention which is the main part in my medical approach. July 1, 2009The aim of this presentation is to demonstrate imaging findings of common diseases of the temporal bone. CT is the imaging modality of choice for most of the pathologic conditions of the temporal bone, especially for those of the middle ear. Disease processes in the pontine angle and in the internal acoustic meatus are not discussed.
There are several normal variants which may simulate disease or should be reported because they can endanger the surgical approach.
A cochlear cleft is a narrow curved lucency extending from the cochlea towards the promontory. On the left an example of bilateral cochlear cleft in a one-year old boy with congenital hearing loss. The petromastoid canal or subarcuate canal connects the mastoid antrum with the cranial cavity and houses the subarcuate artery and vein. If this patient would be a trauma victim, the canal could easily be confused with a fracture line (arrow). The cochlear aqueduct is a narrow canal which runs towards the cochlea in almost the same direction as the inner auditory canal, but situated more caudally.
The jugular bulb is often asymmetric, with the right jugular bulb usually being larger than the left. It can be accidentally lacerated during a mastoidectomy and therefore should be mentioned in the radiological report when present. The vestibular aqueduct is a narrow bony canal (aqueduct) that connects the endolymphatic sac with the inner ear (vestibule). This progression is reportedly associated with minor head trauma, which exposes the inner ear to pressure waves via the large vestibular aqueduct. The large vestibular aqueduct is associated with an absence of the bony modiolus in more than 90% of patients.
In external ear atresia the external auditory canal is not developed and sound cannot reach the tympanic membrane.
The extent of ossicular chain malformation can vary from a fusion of the mallear head and incudal body to a small clump of malformed ossicles, which is often fused to the wall of the tympanic cavity. The mastoid portion of the facial nerve canal can be located more anteriorly than normal and this is important to report to the ENT surgeon in order to avoid iatrogenic injury to the nerve during surgery. Early developmental arrest leads to an inner ear that consists of a small cyst, the so-called Michel deformity. Developmental arrest at a later stage leads to more or less severe deformities of the cochlea and of the vestibular apparatus. Instead of the normal two-and-one-half turns, there is only a normal basal turn and a cystic apex. A minor deformity of the cochlear apex is visible – there is no separation of the second and third turn and the bony modiolus is absent.
Malformations of the vestibule and semicircular canals vary from a common cavity to all these structures to a hypoplastic lateral semicircular canal. During embryogenesis the lateral semicircular canal is the last structure to form, thus in malformations of the semicircular canals the lateral canal is most commonly affected. On the left a 16-year old boy, examined preoperatively for a cholesteatoma of the right ear.
As a coincidental finding, there is a plump lateral semicircular canal (yellow arrow) and an absence of the superior canal (blue arrow).
For the ENT-surgeon the differentiation between chronic otitis media and cholesteatoma is important. Erosion of the lateral wall of the epitympanum and of the ossicular chain is common in cholesteatoma (around 75%).


Cholesteatoma can present with a non-dependent mass while chronic otitis shows thickened mucosal lining. However, in both diseases the middle ear cavity can be completely opacified, obscuring a cholesteatoma.
A small amount of soft tissue (arrow) is visible between the scutum and the ossicular chain but no erosion is present. There is calcification of the eardrum (white arrow) and calcific deposits on the stapes and the tendon of the stapedius muscle (black arrow).
CT shows a tympanostomy tube (yellow arrow) and almost opacification of the tympanic cavity and mastoid air cells with soft tissue.
CT shows the tympanostomy tube (yellow arrow) and complete opacification of the tympanic cavity and mastoid air cells with soft tissue.
Large cholesteatomas can erode the auditory ossicles and the walls of the antrum and extend into the middle cranial fossa. CT demonstrates a soft tissue mass between the ossicular chain and the lateral tympanic wall, which is eroded. Pars flaccida cholesteatomaThe lesion starts anterosuperiorly in 'Prussaks space', the area just below the scutum, which is limited by the tympanic membrane, the malleus, and the lateral ligament of the malleus. A cholesteatoma will then extend laterally towards the ossicular chain and into the epitympanum.
The cholesteatoma begins posterosuperiorly and extends posteriorly towards the facial recess and tympanic sinus, and medially towards the ossicular chain. On the left a large cholesteatoma in the right middle ear with destruction of the lateral wall of the tympanic cavity. On the left images of a cholesteatoma, which has eroded the ossicular chain and the wall of the lateral semicircular canal (arrows). A large cholesteatoma has resulted in a so called 'automastoidectomy', with severe erosion of the lateral tympanic cavity wall and destruction of the ossicular chain. On the left images of a 50-year old man who presented with a left- sided retraction pocket and otorrhoea. All these findings favor the diagnosis of a cholesteatoma, but at surgery, chronic mastoiditis was found and no cholesteatoma was identified. The CT shows erosion of the wall of the lateral semicircular canal (arrow) due to cholesteatoma.
The right ear shows a soft tissue mass medial to the ossicular chain with lateral displacement of the incus with erosion of its lenticular process and of the stapes, compatible with a pars tensa cholesteatoma (arrow). Cholesteatomas are of mixed intensity on T1-weighted pulse sequences and of high intensity on T2-weighted pulse sequences. After intravenous contrast MRI can distinguish granulation tissue from effusions.Diffusion weighted MR can differentiate between a cholesteatoma, which has a restricted diffusion, and other abnormalities - especially granulation tissue - which have normal diffusion characteristics (figure). It is sometimes called otospongiosis because the disease begins with an otospongiotic phase, which is followed by an otosclerotic phase when osteoclasts are replaced by osteoblasts and dense sclerotic bone is deposited in areas of previous bone resorption.
When this process involves the oval window in the region of the footplate, the footplate becomes fixed, resulting in conductive hearing loss. Conductive hearing loss develops early in the third decade and is considered to be the hallmark of the disease. However, involvement of other portions of the otic capsule can result in mixed sensorineural hearing loss. The process starts in the region of the oval window, classically at the fissula ante fenestram, i.e.
There is a subtle otosclerotic focus in the characteristic site: the fissula ante fenestram (arrows). On CT the detection of otosclerosis can be difficult to the inexperienced eye because the spread of the disease is often symmetrical.
Sometimes the whole otic capsule is surrounded by these 'otospongiotic' foci, forming the so-called fourth ring of Valvassori. There is a lucency anterior to the oval window (arrow) and between the cochlea and the internal auditory canal. On the left a patient with a well-positioned metallic stapedial prosthesis: medially it touches the oval window and laterally it connects with the long process of the incus. Notice the lucency between vestibule and cochlea as a manifestation of otosclerosis (arrow). On the left images of a 68-year old woman who experienced a traumatic head injury 50 years ago. The consequences of the intracranial injuries dominate in the early period after the trauma. A temporal bone fracture can manifest itself with acute signs like bleeding from the ear or acute facial paralysis.
Longitudinal fractures generally spare the inner ear, which is more often breached by transverse fractures.
However, many temporal bone fractures are neither longitudinal nor transverse and a comprehensive description of the structures which are crossed by the fracture is needed.
A longitudinal fracture is visible, which courses anteriorly to the cochlea through the region of the geniculate ganglion (arrows).
Posttraumatic conductive hearing loss can be caused by a hematotympanum or a tear of the tympanic membrane.
In persistent conductive hearing loss there is usually a disruption of the ossicular chain. The most common disruption is a dislocation of the incudostapedial joint which is often a subtle finding. Fractures of the long process of the incus or the crura of the stapes are difficult to diagnose.


Longitudinal fracture (yellow arrow) coursing through the mastoid towards the region of the geniculate ganglion.
On the left images of a man who had suffered a traumatic head injury two months previously. There is a longitudinal fracture (yellow arrow) coursing through the mastoid towards the region of the geniculate ganglion.
There is a dislocation of the incus with luxation of the incudo-mallear and incudo-stapedial joint (blue arrow). On the left images of a 54-year old male several years after head trauma, followed by left-sided hearing loss.
The lateral semicircular canal is partially filled with dense material, compatible with labyrinthitis ossificans. In acute posttraumatic paralysis a fracture line through the facial nerve canal - usually in the tympanic part - can be observed, sometimes with a bony fragment impinging on the canal.
In delayed facial paralysis the nerve is probably edematous and fracture lines can be absent.
On the other hand, a fracture line may be seen to cross the facial nerve canal without any associated nerve dysfunction.
A vascular anomaly can be suspected if the patient complains of pulsatile tinnitus or when there is a reddish or bluish mass behind the eardrum. In patients with an aberrant internal carotid artery the cervical part of the internal carotid artery is absent. It is replaced by the ascending pharyngeal artery which connects with the horizontal part of the internal carotid artery. On the right side the internal carotid artery is separated from the middle ear (blue arrow).
Exostoses of the external auditory canal are usually multiple, sessile, and bilateral and can cause severe narrowing of the external auditory canal. On the left images of a 57-year old male with a slowly progressive glomus jugulotympanicum tumor, visible as a mass on the floor of the tympanic cavity (arrow).
At CT, the glomus jugulotympanic tumor manifests as a destructive lesion at the jugular foramen, often spreading into the hypotympanum.
Large tumors have a 'salt and pepper' appearance at MRI due to their rich vascularity with flow voids. On the left angiographic images of the left external carotid artery before embolisation and the common carotid artery after embolisation (blue arrow). Glomus tumors arise from paraganglion cells which are present in the jugular foramen and on the promontory of the cochlea around the tympanic branch of the glossopharyngeal nerve. EndoLymphatic Sac Tumor: destructive process of the dorsal temporal bone, with some calcification (arrow).
At CT a destructive process is seen on the dorsal surface of the petrosal part of the temporal bone with punctate calcifications. Non contrast CTB demonstrates a region of irregular density in the left temporal lobe, slightly hyperdense to adjacent white matter. CTA confirms the presence of a left temporal lobe arteriovenous malformation (AVM) which appears to receive the vast majority of its supply from the left middle cerebral artery. This case demonstrates characteristic CT and CTA appearances of a cerebral arteriovenous malformation (AVM).
Tinnitus may be classified as either Pulsatile (synchronous with an arterial pulse) or Non Pulsatile (Continuous). Represents a normal anatomic variation, needs mention in the report but significance to be given in proper clinical context only and should not be used as a the diagnostic option in the decision of decompressive surgery. Some of the main associated factors are: all types of noise exposure, car crush, work accidents, medications and pathology of the auditory system. In the USA the estimation is that 40 million Americans report of tinnitus, and 10 to 12 millions suffer from severe Tinnitus. The examination shows a mass with mixed intensity on sagittal T1 and high intensity on transverse T2 weighted images.
Dislocation of the incus with luxation of the incudo-mallear and incudo-stapedial joint (blue arrow). In most institutions the next test would be non-invasive and either CT angiography or MR angiography.
Contribution from the posterior cerebral artery is although likely via the lateral posterior choroidal arteries.
Given its location in the dominant (assuming right handed patient) temporal lobe, likely deep drainage and a small (<3cm) nidus, this would have a S-M grade of 3.
Findings analyzed were presence of a vascular loop, vascular contact and the angulation of the eighth CN.
It has a high intensity on diffusion weighted images, which indicates restricted diffusion. Catheter angiography, although usually required eventually, is usually a second step, at which time intervention can also be contemplated. Pulsatile tinnitus is most frequently the result of a vascular abnormality or a vascular tumor. Amir Backman (tinnitus and hyperacusis after Barotrauma) can help to understand the symptoms. However, in some cases, the etiology of tinnitus remains uncertain and most of these patients have no abnormalities on routine imaging like CT or routine MRI protocol used for brain evaluation.



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