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Author: admin | 27.09.2015 | Category: Homeopathic Treatment For Tinnitus

We present four documented cases of objective pulse synchronous tinnitus due to focal narrowing (acquired and developmental) of the mid-portion of the transverse dural sinus. Transverse sinus stenosis is an unappreciated cause of objective pulsatile tinnitus, and we believe that this mechanism may underlie many cases of "essential" or venous etiology tinnitus not otherwise anatomically explained.
Roughly half of the patients with vascular tinnitus are presumed to have a venous etiology of sound production.
A 45-year-old-African-American female with chronic depression and headaches presented with a "swishing" sound in her left ear of 18 months duration.
Next, the catheter was directed into the contralateral right jugular vein and then into the right sigmoid sinus. Considering the clear relationship of the audible bruit to the underlying venous stenosis, possible treatment options were discussed, including ligation, attempted dilatation, or close observation. One year after the onset of the tinnitus, and shortly after angiography and venography, the tinnitus and bruit disappeared. Two months later, the tinnitus returned at a lower volume; however, the objective bruit could not be heard. A 30-year-old female presented with a two and one-half year history of increasing right-sided pulsatile tinnitus, beginning during pregnancy. MR scans revealed post-operative changes with surgical clips seen in the retromastoid region.
Four vessel angiography performed in July 1993 revealed no evidence of vascular tumor or arteriovenous fistula. We considered that a hyperdynamic state derived from the severe anemia accentuated flow-related sounds through the stenotic segment of the sinus and recommended re-evaluation after treatment. Venous tinnitus may be clinically confirmed based on response to specific physical maneuvers.
Our cases generally fit the pattern described first by Graf,14 who in 1947 and 1952 first described the entity of essential tinnitus. However, in cases where the noise is debilitating, treatment can be considered to lessen the bruit. Despite extensive prior investigations into the source of sound in cases of venous tinnitus, and all currently available testing, a specific anatomic explanation for the source of the sound has not and is often still not obtained, either by clinical methods or by imaging techniques. The circumstances observed bring into question the etiology of the acute onset of tinnitus in patients who may have a fixed developmental sinus stenosis. Despite the ability of special MR techniques to visualize the dural sinuses with excellent resolution, and even permit the distinction of sinus hypoplasia from thrombosis in some patients,21 we believe that current routine MR imaging strategies may fail to diagnose a narrowed transverse sinus as the cause of objective tinnitus.
Concerning angiography, investigation is based on the premise that many causes of objective tinnitus, such as DAVF, have potentially neurological sequelae and are treatable. It appears from our experience, that segmentation or stenosis of the dural sinuses may be responsible for a portion of the previously termed "idiopathic" cases of objective pulsatile tinnitus.
The article was presented in January 1994 at the Middle Section meeting of the Triological Society, Mayo Medical Center, Rochester, MN. This patient presented with headaches, pulse synchronous tinnitus, and transient visual obscurations of 1 week duration, and was found to have grade 4 disc edema with prominent peripapillary hemorrhages. Cerebral venous sinus thrombosis must be evaluated for in patients with signs and symptoms of increased intracranial pressure.
Modulator converts information from digital mode to analog mode at the transmitting end and demodulator converts the same from analog to digital at receiving end. When an analog facility is used for data communication between two digital devices called Data Terminal Equipment (DTE), modems are used at each end. The modem at the transmitting end converts the digital signal generated by DTE into an analog signal by modulating a carrier. The transmission medium between the two modems can be dedicated circuit or a switched telephone circuit. To begin with the Data Terminal Equipment or DTE (better known as a computer) sends a Ready To Send or RTS signal to the Data Communication Equipment or DCE (better known as a modem). Alternatively, for anyone confused by what the entire Internet industry dubs TLA's which means Three Letter Acronyms, the following diagram should help. By way of completeness, these signals are all sent through different pins in the plug which is why the handbooks for all modems and printers carry a pin diagram somewhere in the section on troubleshooting. Of course, that still leaves the question of exactly how data is transferred from one computer to another; something that is more of a problem than might first appear mainly because the phone lines are analogue while computers are digital. Without going into technical details this is done by superimposing different frequencies onto the analogue signal (which then becomes known as the carrier wave). From this it becomes obvious that the more frequencies that can be superimposed on the carrier wave the faster data can be transmitted.
Unfortunately it is only possible to send a limited number of frequencies at the same time, known as the bandwidth, which means communication takes that much longer as the size of the signals steadily increases. Finally, as the whole process comes down to sending binary digits or bits over a phone line the speed of the system is expressed as Bits Per Second or BPS which is a figure quoted by all the modem manufacturers. Unfortunately when it comes to data communications there is a lot more involved than just how fast bits can be sent down a phone line. Connect Us On FaceBook and Google+Dinesh Thakur is a Technology Columinist and founder of Computer Notes and Technology Motivation. Objective tinnitus, in which the sound is perceived by both the patient and the examiner, is less common.
In all cases, a bruit was audible directly over a focal constriction in the sinus, demonstrated by cerebral angiography or direct catheter venography. Non-invasive testing, computed tomography (CT) and MR and non-directed angiography may overlook it.
Obstruction of retrograde flow of contrast in left sigmoid sinus during selective catheter venography. Demonstration of stenotic left transverse sinus by contralateral right catheter venography. The temporal relationship with the procedure suggests the possibility that the sinus thrombosed, perhaps due to local catheter trauma or contrast effect. This may represent partial recanalization, or venous rerouting around a thrombosed transverse sinus.
The noise began with a faint sound and became progressively louder over the course of several months. Mid (a) and the late (b) venous phase images from right carotid angiogram reveals marked narrowing of the dominant right transverse sinus (arrows, b), with a jet of contrast (long arrow) traversing this segment to impact a diverticulum of the more distal sigmoid sinus (open arrow, b).
Venous phase of carotid arteriogram reveals moderate narrowing of the mid-right transverse sinus, (arrows), just beneath the audible bruit observed clinically. Follow-up six months later revealed no interval change in the noise, which remained loud enough to interfere with hearing in the right ear, to the point that the patient would turn her head to the opposite side to hear better.
In the venous phase of the left carotid injection, a large patent right transverse sinus and jugular were seen.


Frontal view of the venous phase of carotid angiogram reveals metallic surgical clips adjacent to the narrowed mid-portion of the left transverse sinus (open arrow).
Lateral view of venous phase showing narrowed left transverse sinus (arrows), and normal contralateral right transverse sinus (single arrow). The most recent follow-up, four months after angiography, revealed that the noise persisted, although it had significantly diminished and that with iron therapy the HCT has risen to 13 from 8.
An elevated position of the jugular bulb in relation to the floor of the hypotympanum has been cited as a potential cause of pulsatile tinnitus.8 So-called high or dehiscentjugular bulbs may protrude into the middle ear and cause an audible and characteristic "white noise" turbulence. Venous tinnitus is usually eliminated by ipsilateral jugular pressure or turning the head toward the uninvolved side, resulting in cervical venous narrowing and a decrease in flow. If a specific diagnosis could be made, further expensive and potentially invasive diagnostic testing would become unnecessary. The distensibility of the "stenotic" segment in Case 1 may indicate the presence of a weak dural interface between the lumen of the sinus and the intracranial compartment, allowing the intracranial contents to "sag" on the sinus, producing reversible narrowing. This well known phenomenon has also been proven to be associated with the production of transverse sinus dural arteriovenous fistula (DAVF),4-6 where sinus stenosis and occlusion often precedes the development of the fistula. In essence, since tinnitus is often relatively acute in onset, and the presumed anatomic substrate relatively static, noise is likely to be related to an increase in local or systemic blood flow from a variety of possible conditions. If the tympanic membrane is abnormal (vascular), high resolution CT should be performed first, since it is effective at differentiating jugulotympanic paraganglioma from aberrant carotid artery and jugular dehiscence.19 With a normal tympanic membrane, MR should be the first study, because of its improved contrast resolution. The variable resolution of MRA also limits its accuracy for the reliable detection of a narrowed sinus segment, although detection may improve with a high index of suspicion, and perhaps slow velocity encoded MR venography. Therefore considering this and the lack pitfalls of MR and MRA, selective arteriography should be performed when the source of objective tinnitus is not found with non-invasive imaging. Increased awareness of this condition should permit a firm diagnosis to be made in such cases, halting further pointless and expensive diagnostic workup, and allowing appropriate therapeutic options to be fully addressed.
Ward PH, Babin R, Calcaterra TC, Konrad HR: Operative treatment of surgical lesions with objective tinnitus.
Arenberg IK, McCreary HS: Objective tinnitus aurium and dural arteriovenous malformations of the posterior fossa. House OW, Campbell JK, Campbell RJ, et al: Arteriovenous malformation affecting the transverse dural sinus-an acquired lesion. Nishijima M, Takaku A, Endo S, et al: Etiological evaluation of dural arteriovenous malformations of the lateral and sigmoid sinuses based on histopathological examinations.
Dora F, Zileli T: Common variations of the lateral and occipital sinuses at the confluens sinuum.
Mas JL, Meder JF, Meary E, Bousser MG: Magnetic resonance imaging in lateral sinus hypoplasia and thrombosis.
Modems are used for data transfer from one computer network to another computer network through telephone lines. The process of converting analog signals of one computer network into digital signals of another computer network so they can be processed by a receiving computer is referred to as digitizing. This modem at the receiving end demodulates the carrier and hand over the demodulated digital signal to the DTE.
If a switched telephone circuit is used, then the modems are connected to the local telephone exchanges. This is sometimes known as a wakeup call and results in the modem sending a Data Carrier Detect or DCD signal to the receiving modem.
They are also standardized after the industry leaders met to agree standards for a whole range of peripheral equipment.
Different frequencies can then represent different groups of binary digits in a process which is known as modulation when it is being transmitted and demodulation when it is decoded at the receiving end. Alternatively, to take a different point of view, the more data there is to be transmitted so the more frequencies are needed. Now that pictures, sound and even video sequences are transmitted over the Internet on a regular basis, and as these all call for massive data files, the amount of available bandwidth is likely to be a problem for some time. There is also the problem of what those bits mean and how they can be assembled into something intelligible at the far end. If a carrier is detected on the line by the modem, I gives an indication of the incoming carrier to the DTE through a control signal of its digital interface.
As long as they camel' IS being received; the modem does not give permission to the DTE to transmit data.
Any system whether simplex, half duplex or full duplex requires a modem at the transmitting as well as the receiving end. Objective tinnitus of the vascular type, in which a pulse synchronous bruit is heard by an independent observer, is frequently related to an underlying arterial or arteriovenous malformation, most commonly a dural arterio enous fistula (DAVF) involving the transverse and sigmoid sinuses. In one case, selective venography revealed a distensible sinus narrowing, associated with a jet of contrast marking fast flow within a developmental sinus segmentation. Conventional catheter arteriography or venography should be performed in such cases, with attention to the dural sinuses, if other tests fail to define the anatomic basis of the audible bruit. Our four cases illustrate a previously unappreciated cause of objective tinnitus: stenosis or segmentation of the transverse dural sinus.
Prompted by the objective findings and the venous phase of the angiogram, a femoral venous puncture was performed and a selective catheter was placed through the jugular vein into the distal left sigmoid sinus A selective retrograde injection into the sigmoid sinus revealed the presence of a sigmoid diverticulum; however, the contiguous transverse sinus was narrowed and could not be filled by reflux (Fig. The catheter was repositioned within the left sigmoid sinus, and carefully advanced over a guide wire, into the stenotic segment of the transverse sinus.
Over the following six years the subjective tinnitus persisted with much less severity and the objective bruit has not reappeared. Upon admission, the patient complained of a recent increase in sound intensity, with occasional pain in the right ear, which was intermittently severe. In the venous phase, the right transverse and sigmoid sinuses were dominant and there was moderate narrowing of the mid-right transverse sinus (Fig. Three years previously she had undergone resection of a left acoustic schwannoma by retrosigmoid approach.
The sinus is slender, and is further narrowed by the clips (arrow), which were placed to control intraoperative hemorrhage at the site of entrance of the superior petrosal sinus.
After medical treatment for anemia (hematocrit level from 25 to 33), the subjective noise improved but did not fully disappear.
Graham13 cites both expansion and diverticulation of the jugular bulb as causes for pulsatile venous tinnitus.
Turning the head toward the involved side, Valsalva maneuver, and deep inspiration may increase flow, and the noise.11 Our first patient had several of these responses. Except for our Case 4, in which a surgical procedure likely played a role in generating the noise, our patients were 30, 33 and 45-years-old, and all were women.
Our current cases illustrate an etiology of pulsatile tinnitus which has previously gone unrecognized. In other cases, this segment of the sinus may be developmentally hypoplastic or segmented, a common condition given the tremendous variations known to occur in this region.17,18 Huang,17 fully described narrowing and atresia of the transverse sinus, while observing that the proximal portion of the sinus was more frequently affected.


Cyclical changes in vascular resistance, blood viscosity and oxygen carrying capacity may playa role, such as in Case 4, where the noise abated with correction of anemia. However, unless careful attention is paid to the venous circulation or subsequent venography is performed, dural sinus stenosis may still go undetected without a high index of suspicion.
The computer network works in digital mode, while analog technology is used for carrying massages across phone lines. Whenever data transmission is required connection between the modems is established through telephone exchanges.
There then follows a series of signals passed between the two until the communication channel has been established.
The Recommended Standard for cable was number 232 which explains that one technical term probably everybody has heard of: RS 232.
Naturally two way communication is achieved by having a single device being capable of both modulation and demodulation, from which the unit takes its name: the modem. Here a whole range of issues need to be addressed and so it might be a good idea to briefly look at the first of these which are the transmission protocols. The remaining cases are usually termed "essential" vascular tinnitus, and are presumed to have a venous etiology. In another case a loud pulse synchronous bruit was heard directly over a focal transverse sinus stenosis, which was detected by angiography at the site of a vascular surgical clip. We believe that this entity may be commonly related to noise production in cases of pulse synchronous tinnitus, and that its previous lack of description is due to the difficulty of making the diagnosis with non-invasive imaging.
The sound changed with position, becoming louder when supine and decreasing with the head turned to the left or right. A "jet" of contrast was seen to traverse the stenotic portion of the transverse sinus, and impact the more distal diverticulated portion of the sigmoid sinus. Contrast injection fills the narrowed left transverse sinus (large arrow) by reflux around the torcula. In view of the presence of an easily heard pulse synchronous bruit in the right post-auricular region, conventional cerebral angiography was performed in October 1989. Note some prominence of scalp branches of the occipital artery (arrows) and relatively rapid flow (high signal) in the right transverse sinus (white arrows).
The procedure was complicated by bleeding at the junction of the transverse and superior petrosal sinuses, requiring the placement of several vascular clips in this region.
The anatomic substrate of noise production in cases of objective venous tinnitus has, however, generally been impossible to pin down. We believe that the transverse sinus may frequently be the source of objective vascular tinnitus, when other etiologies are not found. In other cases, sinus thrombosis may produce relative obstruction and turbulence, or narrowing contralateral to the side of tinnitus may increase flow toward a moderately narrowed ipsilateral sinus segment. This process is known as handshaking and helps to explain why, even now, some companies like CompuServe use the symbol of two hands grasping each other to mean being on-line.
The signal might be constant, but it is constantly changing from positive to negative and back again in a series of smooth curves. In these cases, the audible noise is generally assumed to be produced within the sino-jugular connection, or within an enlarged jugular bulb. No history of trauma, exposure to loud noise, hearing loss, ototoxic medications or hypertension was elicited. In an attempt to further define the nature of the narrowed segment, the catheter was carefully reintroduced into the left jugular bulb, and this time gently advanced, without difficulty, through the left transverse sinus.
Note the jet of contrast (small arrows) existing the stenotic segment, impacting the diverticulum of the sigmoid sinus beyond it (compare to 1a). On physical examination, a loud bruit was clearly audible in the left post-auricular region, centered over the location of the left transverse venous sinus vascular clips. A relatively hypoplastic left transverse sinus filled, and appeared to be further narrowed near the surgical clips at its mid-portion (Figs.
In the two patients with long term study, one experienced a decrease in noise level after several years, and one had no change in severe tinnitus after fi ve years.
Dora and Zileli18 studied 192 retrograde venograms and observed that transverse sinuses were well formed bilaterally in only 47% of their cases, and that an occipital sinus is usually well developed when a transverse sinus is hypoplastic. In either case, changes in flow may increase flow related sounds which may then be sufficient to cross the threshold above which sound becomes noticeable to the patient or an observer.
Of course, after that all it takes is for the second modem to send a Data Set Ready or DSR signal to its computer and wait for the Data Terminal Ready or DTR reply. Computers, on the other hand, can only understand information when it is presented as a string of binary digits so the idea is to map digital output onto an analogue signal. In two other cases, an audible bruit was also heard directly overlying a narrowed transverse sinus, seen in the venous phase of angiography.
Physical examination revealed an easily heard left postauricular bruit, synchronous with systole and obliterated by manual ipsilateral jugular compression. The narrowed segment easily dilated to accommodate the catheter, and injection of contrast outlined a narrowed segment with a wider diameter than could be appreciated from the contralateral injection (Fig. In the venous phase of both the right internal carotid and left vertebral artery injections, a marked constriction of midand-distal portion of a dominant right transverse sinus was appreciated. The pitch increased with Valsalva and the sound level decreased with ipsilateral neck compression.
All patients did however choose not to pursue surgical attempts to obliterate the sound, probably because they were indirectly encouraged not to do so by a full presentation of the possible risks and unproven nature of such endeavors. When that happens the first modem sends a Clear To Send or CTS signal to the computer that started the whole process off and data can then be transmitted. Neurologic exam was normal, and no evidence for hyperdynamic state was found on examination or laboratory investigation. A contrast jet through the stenotic segment more distally impacted a sigmoid sinus diverticulum (Figs. An outside magnetic resonance angiography (MRA) was interpreted to be suspicious for a dural arteriovenous fistula, with prominence of the right transverse sinus and prominent branches of the occipital artery visualized in the scalp (Fig. In most cases of venous tinnitus, the patient is assured of the benign nature of the condition after appropriate workup, and no therapy is recommended. Upon withdrawal of the catheter, the sinus again collapsed to its original diameter, implying the presence of a pliable stenosis.
The diagnosis was objective tinnitus related to constriction ofthe transverse sinus, probably related to turbulent blood flow near a post-operative stricture along the developmentally hypoplastic venous sinus.



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