Pulsatile tinnitus dizziness headache,ears ringing dehydration,ringing in the ear medications - Step 3

03.12.2015
Inner ear disorders that increase hearing sensitivity (such as SCD) can cause pulsatile tinnitus.
There are some very large blood vessels -- the carotid artery and the jugular vein -- that are very close to the inner ear (see diagram above).
This is a congenital anomaly in which the internal carotid can present as a middle ear mass. Dural Arteriovenous fistulae (DAVF) cause loud noises, synchronous with the pulse, that can often be heard by others with a stethescope, or sometimes by simply putting one's ear next to the person's head. To be certain there is no DAVF at all, 6 vessel DSA is suggested by the interventional radiologists.
Radiosurgery is mainly reserved for cases that persist after embolization, but some authors use the opposite order -- radiosurgery first, followed by a clean up embolization (e.g.
Recurrence of fistulae may appear, possibly due to release of growth factors associated with local tissue hypoxia, following occlusion of the DAVF. It may seem silly to say this, but in our opinion, it is generally not worth taking on a significant risk of having a stroke to attempt to get rid of a noise in one's head with embolization. If the carotid fails to develop correctly during fetal life, the inferior tympanic artery enlarges to take it's place.


DAVF recieve blood through meningeal arteries or meningeal branches of cerebral arteries and drain directly through a dural sinus or venous channel tributary of a venous sinus through dilated deep veins (Signorelli et al, 2014). The Cognard states that type I and II DAVFs drain directly into dural sinuses, the difference being antegrade flow in the type I, and retrograde flow in the type II.
Successful treatment requires occlusion of the venous recipient, as occlusion of the arteries alone can be associated with recruitment of more venous drainage (Adamczyk et al, 2012).
Surgery is sometimes preferred for fistulae draining into the superior sagittal or dominant transverse sinus when embolization might result in an undesirable sacrifice of the dural venous sinus. Accordingly, other possibilities for vascular tinnitus include dehiscence (missing bone) of the jugular bulb -- an area in the skull which contains the jugular vein, and an aberrantly located carotid artery.
It enters the skull through it's own foramen, courses through the medial part of the middle ear, and then rejoins the petrous ICA (Branstetter and Weissman, 2006). DAVF are thought to be acquired and are associated with intracranial surgery, ear infection, tumor, hypercoagulability, puerperium, and trauma. According to De Keukeleire et al (2011), Type I DAVs are low risk and need be treated only if symptoms are intolerable.
The reason for this order is that embolization might obscure the target for the radiosurgery if performed first.


An enlarged jugular bulb on the involved side is common in persons with venous type pulsatile tinnitus. Radiosurgery by itself has a low succes rate as the only treatment (Signorellli et al, 2014).
To avoid conflicts of interest, ideally the expert should work for another medical insitution. Trans venous embolization is a good option when arterial feedrs are too numerous, and when the venous drainage of the DAVF can be sacrifised.
It is also a poor choice for those with hemmorage, because it is slow acting (1-3 years), and more hemmorage might occur while waiting for the blood vessels to close.
The risk of hemmorage increases with direct drainage into cortical veins (Signorelli et al, 2014). On the other hand, radiosurgery is likely a more durable long term treatment than embolization alone.



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