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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. How to cite this article Cevette MJ, Barrs DM, Patel A, Conroy KP, Sydlowski S, Nelson BNNGA, Stepanek J, et al. Background: Recent studies in noise-induced and idiopathic sensorineural hearing loss have suggested that magnesium supplementation may lessen both hearing loss and the severity of tinnitus in patients.
Descriptions of tinnitus date back to the time of ancient Egypt, yet science has failed to unravel the mysterious underlying mechanisms that produce these subjective auditory perceptions of sound.
Despite these encouraging findings, no controlled study has examined the effect of magnesium supplementation for patients with moderate to severe tinnitus. Between March 6 and December 10, 2008, patients aged 18 years or older who were seen for an audiological evaluation at Mayo Clinic in Scottsdale, Arizona, and who had a Tinnitus Distress Rating (TDR) scale score from 3 through 8 (Figure 1) were eligible for the study. Participants were given a daily magnesium supplement, 532 mg (Mg Plus Protein, 133-mg tablets; Miller Pharmacal Group, Carol Stream, Illinois). The primary outcome measures were comparisons of TDR scale scores and THI scores as converted to TSS grades at baseline and the end of the study. The present study indicated that subjects showed significant improvement in their self-rating of tinnitus with a magnesium supplement of 532 mg daily for 3 months.
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. Further epidemiological evidence indicates that all age groups of Americans fall short of the recommended daily allowance for magnesium by 100 mg daily. These perceptions may be manifestations of damage resulting from noise exposure, ototoxicity, or other abnormal conditions of the auditory system.
Additionally, no study to date has examined self-reported tinnitus severity before and after magnesium supplementation. The TDR was adapted from an existing pain scale, with the subject rating him- or herself between 0 (no tinnitus) to 10 (worst possible tinnitus). The Tinnitus Handicap Inventory is a 25-item self-report questionnaire that the patient can complete in about 10 minutes.
A review by the Division of Cardiovascular Diseases indicated that daily magnesium supplementation at the level of 532 mg was benign for heart patients whose kidney function was normal.
After beginning magnesium supplementation, the participants rated themselves daily for 3 months using the TDR.
The data collected for each participant included informed consent, sex, date of birth, hearing threshold at 8 frequencies (250, 500, 1,000, 2,000, 3,000, 4,000, 6,000, and 8,000 Hz), weekly diaries of daily TDR ratings of tinnitus, THI questionnaires at baseline and the end of the study, dates of first and last dose of magnesium, number of tablets used, reason for discontinuation, and adverse events.
Of these, 2 patients (8%) discontinued the study because of adverse events and subsequently had no follow-up data.
Change in tinnitus rating in 26 patients from baseline to 3 months after treatment with magnesium. In fact, significant improvement in the TDR occurred as early as 1 month into the study, suggesting that benefit of magnesium supplementation occurred early in treatment and was sustained throughout the 3 months of the study. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. PhD, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - AC - United States. MD, Department of Otolaryngology, Head and Neck Surgery - Mayo Clinic - Scottsdale - United States.
AuD, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - United States.
AuD, Section of Audiology - Cleveland Clinic Head and Neck Institute - Cleveland - United States. BS, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - United States.
MD, Division of Preventive, Occupational and Aerospace Medicine - Mayo Clinic - Scottsdale - United States. 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. Purpose: The purpose of this study was to examine any potential benefit in lessening the severity of tinnitus in patients taking supplemental magnesium. However, many individuals have idiopathic tinnitus for which no specific cause can be determined. For example, the putative magnesium mechanism within the auditory system involves a metabolic cellular cascade of events. The purpose of this study was to examine any potential lessening of the severity of tinnitus in patients receiving magnesium supplementation.
The Tinnitus Handicap Inventory (THI) and Tinnitus Severity Scale (TSS) (Table 1), developed by McCombe et al. A review by the Mayo Pharmacy indicated that there were no major drug interactions with magnesium at the levels of the current protocol.
Differences in TDR scores before and after supplementation were compared to determine any effect of supplementation on a participant's self-rated tinnitus.
The adverse event data included the date of onset and whether the adverse event led to premature discontinuation of the intervention. The THI was measured at the time of discontinuation if a patient discontinued the study before 3 months. 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.
Research Design: The study was a single-arm, open-label, before-and-after study of oral magnesium (532 mg per day) in 26 patients for 3 months. Although often presenting in conjunction with hearing loss, the magnitude of hearing loss does not necessarily correspond with the severity of tinnitus.
Specifically, magnesium deficiency leads to increased permeability of the calcium channel in the hair cells with a consequent over-influx of calcium, an increased release of glutamate via exocytosis, and overstimulation of N-methyl-D-aspartate receptors on the auditory nerve fibers. In addition, all participants completed another THI after 3 months of magnesium supplementation. The mean hearing thresholds and mean TDR scores before and after treatment were assessed using a paired t test.
For the subjects lost to follow-up, we assumed for the purposes of this analysis that there was no benefit from treatment. Effect of various serotoninergically induced manipulations on audiogenic seizures in magnesium-deficient mice. Influence of dietary magnesium on the amplitude of wave V of the auditory brainstem response.
Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. 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. Tinnitus severity was evaluated and recorded daily by the patient using the Tinnitus Distress Rating (TDR) scale of 0 (no tinnitus) to 10 (worst possible tinnitus). Recent studies of both noise-induced hearing loss and idiopathic sensorineural hearing loss have suggested that magnesium supplementation may lessen the severity of tinnitus in patients. The THI scores were converted to the grades of the TSS for the purpose of categorizing the numeric values of the THI into a reliable 5-item grading scheme.
These participants were included because if noncompleters doing poorly enough to drop out were not analyzed, then selection bias would be likely. 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. The Tinnitus Handicap Inventory (THI) was administered before and at the end of the study, and scores were converted to the grades of the 5-item Tinnitus Severity Scale (TSS).
This relationship suggests these processes may be linked by underlying imbalances at the level of the hair cell. Magnesium improved hearing recovery and lessened tinnitus in patients with idiopathic sudden hearing loss (Gordin et al., 2002). Therefore, subjects with no follow-up were treated as though they had no improvement and were included in the analysis.
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.
The purpose of this phase 2 study was to investigate whether the treatment was effective at all, and, as such, a placebo control was not performed. The possible influence of magnesium and its antagonist, calcium, has been discussed in the literature as a contributing factor in the mitigation of noise-induced hearing loss, ototoxicity, and the hyperexcitability of the auditory system (Cevette et al., 2003). Upon withdrawal of the catheter, the sinus again collapsed to its original diameter, implying the presence of a pliable stenosis. All data were collected at Mayo Clinic in Scottsdale, Arizona, between March 6 and December 10, 2008. Permanent and temporary changes in auditory function have been linked to nutritional deficiencies of magnesium.
Based on the results of the present study, the authors have initiated a Phase 3 study using a placebo and double-blinding to control for factors unrelated to the magnesium supplementation.
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. There was no significant change in hearing thresholds from 250 Hz through 8,000 Hz for either ear during the duration of the study (Table 2). Data Collection and Analysis: The main outcome measures were mean TDR scale scores and THI scores as converted to TSS grades. There was a significant decrease in the severity of tinnitus for subjects on the basis of their THI responses (P=.03).
Those patients whose THI scores translated to "slight" or greater grade on the TSS before the intervention showed a significant decrease in the severity of their tinnitus (P=.008) (Table 3).
Figure 3 graphically represents the change in TDR in 26 patients from baseline to 3 months after treatment with magnesium.
Conclusion: The results suggest that magnesium may have a beneficial effect on perception of tinnitus-related handicap when scored with the THI. After supplementation, by intention-to-treat analysis, 14 of 26 patients (54%) continued to have more than slight impairment; by analysis of patients who completed the study, only 7 of 19 patients (37%) had more than slight impairment.

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