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Tinnitus is the perception of an insistent, unpleasant ringing, buzzing or other consistent noise, located in or near the skull but without a definable external source. Tinnitus is often perceived as a ringing or persistent high tone very close to or within the ear. Tinnitus is often regarded as a symptom of auditory conditions, such as damage to the tissues in the ear that control the perception of tones and frequencies. An increasing number of researchers argue that tinnitus is a disorder of the connections between the inner ear and certain areas of the brain. Some scientists had developed a theory that tinnitus was associated with deficiencies in vitamin B12. Chronic inflammation of the middle ear (otitis media) may also be associated with some cases of tinnitus. Tinnitus related to otitis media may be improved by surgery to correct damage caused by this inflammation. The MM1 Sound Generator fits neatly into the ear canal, making it discreet and easy to use. AbstractBackground: Arachnoid cysts most frequently occur in the middle cranial fossa and when they are symptomatic, patients present with central nervous symptoms.
Arachnoid cysts are rare cerebrospinal fluid (CSF) collections within the arachnoid membrane and subarachnoid space1. We report the cases of two adults with middle fossa arachnoid cysts referred to our department with nonspecific inner ear symptoms. A previously asymptomatic 56-year-old male was referred to the ENT Department of Chania General Hospital with the complaints of mild headache, nausea, vertigo, unsteadiness and tinnitus on the left ear. Figure 2: Case 1 pathologic video-oculography recordings of A) smooth pursuit with low symmetric gain and continuous “catch-up” saccades B) saccades showing overshoot dysmetria.
Figure 3: Coronal and axial T1- weighted brain MRI brain MRI of case 1 showing a large arachnoid cyst occupying the left cranial fossa on the left.
A 48-year-old male was admitted to the ENT department of Chania General Hospital with the main complaint of tinnitus on the left ear lasting for a week.
Figure 5: Axial T1-weighted brain MRI of case 2 showing a left anterior temporal arachnoid cyst.
Arachnoid cysts most frequently occur in the middle cranial fossa, followed by the posterior fossa, convexity and suprasellar regions. Arachnoid cysts, as in our cases, have a predilection for males and the left temporal fossa14. The second patient’s main complaint was tinnitus, which showed aggravation during his completion of audiological and electrophysiological evaluation while he was receiving ?-histine. Spansdahl and Solheim in their quality of life study in adult patients with primary intracranial arachnoid cysts, concluded that patients with atypical symptoms have a low employment status, decreased quality of life scores and prevalent symptoms of anxiety. With the advent of imaging studies, there has been an increased incidence of detection of incidental asymptomatic or with atypical symptoms arachnoid cysts. Asymptomatic patients are not operated on, while symptomatic patients are candidates for surgical intervention via several methods, including cystoperitoneal shunt placement, craniotomy, endoscopic fenestration and stereotactic aspiration2,7. Literature review shows that it is often difficult to interpret the relationship between inner ear symptoms and intracranial arachnoid cysts.
It is not considered to be a condition in its own right, but a syndrome or symptom related to many forms of auditory damage or disorder. Age-related hearing impairments, or disorders of the circulatory system around the ear, may also be related to this complaint. Some scientists conclude that tinnitus is in fact related to damage of the nervous tissue in or around the auditory cortex of the brain. A recent study including 100 patients with tinnitus found that 63 of these had low vitamin B12 levels. As the natural molecule histamine is associated with the regulation of both inflammation and some auditory nervous tissue, drugs that block its receptors in the brain are currently proposed as treatments for tinnitus.
Darius Kohan is renowned for his otology expertise and has been highlighted on several outlets such as a CBS spotlight on tinnitus and is often cited in WEB MD and other medical outlets. Symptoms of primary arachnoid cysts usually appear during infancy, but delayed presentation until adolescence has also been reported7. Despite the possible presenting symptoms, a large proportion of arachnoid cysts are incidentally diagnosed during neuroimaging.
Clinical examination revealed normal otoscopy and endoscopy of the upper respiratory system. In a recent histopathologic study, the rare cases of arachnoid cysts confined in the internal auditory canal and facial nerve canal have been reported11.

Furthermore, clinical outcome for these patients seems to be worse than those with plausible symptoms because of late referral and delayed diagnosis7. On CT scan, arachnoid cysts are well circumscribed, with an imperceptible wall displacing adjacent structures. In fact there is a debate whether arachnoid cysts are associated with these symptoms in most cases7,13,15. The 22MA+ is available in beige or brown skin tones, with either a standard earhook or with open fitting eartips. Other cases may be related to exposure to very loud or destructive levels of noise, such as from an explosion, industrial equipment or farming equipment. Others have found associations between increased activity in further brain regions, age of tinnitus onset and distress caused by the syndrome.
However, treating this deficiency had no significant effects on the complaint in these patients. Other new and emerging treatments for tinnitus focus on the potential indicated by the studies into its links with abnormal brain activity, as mentioned earlier. The first patient presented with mild headache, nausea, vertigo, unsteadiness, and tinnitus on the left ear while the second patient’s main complaint was left sided tinnitus.Both patients (initially managed for peripheral disorders) underwent a thorough clinical and electrophysiological evaluation. In children arachnoid cysts occur more frequently in males, while in the elderly they are equally distributed2,8. He was treated by his general practitioner with a five-day course of vestibular suppressants with no clinical improvement. He did not report history of imbalance and clinical evaluation of the vestibular system was uneventful.
Prevalent hypothesis for primary arachnoid cysts formation is arachnoid tearing after complete differentiation in 15th week of gestation or during separation between arachnoid membrane and dura mater12.
Although his gait was characterized as ataxic, in the absence of any focal neurological deficits or cerebellar pathological signs, we concluded that it reflected an uncompensated vestibular disorder in which, the signals from inner ear were unable to reach brainstem and cerebellum for balance and gait adjustment.  The pathologic findings of the vestibular system evaluation (abnormal smooth pursuit and saccades) and in ABR (prolonged absolute latency of wave III on the left) imposed brain imaging. ?-histine has been reported for tinnitus treatment although, its effectiveness has not been established with prospective controlled studies21. Tinnitus may have a significant negative impact on the life quality of those affected by it.
Different research groups have concluded that chronic tinnitus may be associated with an impaired connection between the cerebral cortex, which controls advanced functions such as memory, perception of the environment and cognition, and the thalamus, which supplies the cortex with sensory information. A recent study, including 974 patients, indicated that hearing aids were preferable and more effective in treating blast-related tinnitus compared to noise generators.
Presuming further research confirms the findings of these studies, deep brain stimulation (a form of implant placed in the brain to correct this activity) may be a viable option for severe treatment-resistant tinnitus. Because of the patients’ persistent clinical symptoms, and indications of CNS disorder in the first case, neuroimaging by brain MRI was performed revealing a middle cranial fossa arachnoid cyst in both patients. Pure tone audiogram revealed a symmetric high frequency hearing loss (Figure 4), while ABR was normal with an interaural latency difference (ILD) for wave V of 0.13 ms at stimulus intensity 90 dBnHL. Although these lesions present symptoms during childhood, they may give symptoms later in adulthood, or remain asymptomatic.
Tunes et al suggest that dizziness and vertigo is the pressure effect of temporal arachnoid cysts on the vestibular cortex15. We prefer to prescribe a short course of ?-histine in patients with tinnitus until their final evaluation, prior other treatment modalities. Otorhinolaryngologists should be aware of the fact that atypical, recurrent or intermittent symptoms may masquerade a CNS disorder. Conclusion: Occasionally, patients with arachnoid cysts may present with mild, atypical or intermittent and irrelevant symptoms which can mislead diagnosis. Symptoms might be caused by a space occupying effect with pressure on surrounding structures, a change in CSF dynamics, or dysgenesis of the brain13. In the central vestibular system secondary vestibular afferents relay signals from vestibular nuclei to the extraocular motor nuclei, the spinal cord, or the flocculus of the cerebellum.
We believe that a pressure effect following a spontaneous cyst enlargement might also be the reason of tinnitus, as tinnitus is an active physical process occurring in multiple neural substrates in response to peripheral or central stimulus. Complete clinical and electrophysiological examination is needed and any pathological finding should be carefully evaluated for a prompt diagnosis.
This syndrome may also have deleterious effects on the emotional, psychological and functional status of the patient. Neurotologic examination revealed a low-amplitude nystagmus, with Frenzel glasses, that was not seen during visual fixation.
Late symptoms presentation is attributed to intracystic bleeding and subdural hematoma following head trauma, or to spontaneous cyst expansion9.

Many vestibular reflexes are controlled by processes that exist primarily within the brainstem. As their wall is very thin it only occasionally can be seen, and their presence is implied by displacement of surrounding structures. The nystagmus was conjugate and predominantly horizontal with the fast component beating to the right only at the right gaze position (1st degree nystagmus according to the Alexander’s law). Tracing techniques have identified extensive connections between the vestibular nuclei and reticular formation, thalamus and cerebellum. There was a torsional component with the upper poles of the eyes beating towards the right ear. Brain MRI revealed an arachnoid cyst at the anterior part of the temporal lobe (Galassi type I) on the left (Figure 5). No focal neurological deficit was found, while Romberg’s test was positive and patient had wide-based gait, with slow cadence. The patient did not report history of CNS inflammation or any neurosurgical procedure and has been followed-up by the neurosurgical department of the hospital with brain imaging at regular intervals. Recent studies in humans confirm the parietal and insular regions as the cortical location for processing vestibular information16.
Pure tone audiometry revealed mild sensorineural hearing loss on the left (Figure 1), while tympanometry was normal. Furthermore, a vestibular area has been identified in the temporal cortex, which could be linked to the perception of self-motion17. Patient was treated with a second course of vestibular suppressants as well as steroids in a tapering manner. The pursuit pathway starts at the retina and runs to the magnocellular portion of the lateral geniculate nucleus, the striate cortex, the dorsolateral pontine nucleus, cerebellum, vestibular nuclei, brainstem reticular formation and the ocular motor nuclei18. CT scan and metrizamide CT cisternography in arachnoid cyst of middle cranial fossa: classification and pathophysiological aspect. Saccades are produced and controlled via the occipitoparietal cortex, the frontal lobes, the basal ganglia, the superior colliculus, the cerebellum and the brainstem19. Evaluation of the vestibular system was performed on a scheduled appointment after patient’s discharge, with video-occulography and video-nystagmography revealing pathologic smooth pursuit test and saccades (Figure 2). Central auditory afferent pathway includes cochlear nucleus, superior olivary complex, lateral lemniscus, inferior colliculus, medial geniculate body and auditory cortex20.
Smooth pursuit eye movements were elicited by means of a projected yellow- colored circular target with a width of 10, moving in a sinusoidal pattern in horizontal plane. In the first patient electrophysiologic evaluation showed a delay of the signal transmission from the distal part of cochlear nerve to the superior olivary complex, probably due to the compression of the acoustic pathway structures along the brainstem. A projected yellow- colored circular target with 0.30 width, moving randomly in horizontal and vertical planes, was used eliciting saccade eye movements. Imaging was decided due to the intermittent patient’s symptoms, as well as, the findings of auditory brainstem response and video-oculography. Brain MRI revealed a large cystic lesion occupying the left middle fossa causing ventricle asymmetry (Figure 3). The diagnosis was middle fossa arachnoid cyst (Galassi type III) probably of congenital origin, as the patient did not report history of CNS inflammation or any neurosurgical procedure. The patient has been informed for the possible complications of his condition, as well as, for the need of follow-up and the several treatment modalities. A year after his admission, the patient is free of vestibular symptoms with unchanged hearing thresholds. Intracranial arachnoid cysts in children: a review of pathogenesis, clinical features, and management.
Arachnoid cysts in the middle cranial fossa: cause and treatment of progressive and non-progressive symptoms. Location, sidedness, and sex distribution of intracranial arachnoid cysts in a population-based sample. Pre- and post-operative dizziness and postural instability in temporal arachnoid cyst patients. Human vestibular cortex as identified with caloric stimulation in functional magnetic resonance imaging.

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