oto tinnitus

Question 1

Describe the differential diagnosis of pulsatile
“fluttering” tinnitus that is not synchronous with
arterial pulse.

Answer 1

Myoclonus of the tensor tympani, stapedius, or palatal

musculature

Question 2

Provide a differential diagnosis for pulsatile

tinnitus.

Answer 2

● Arterial: Aberrant internal carotid artery, carotid athero-
sclerosis, persistent stapedial artery, arteriovenous mal-
formations, aneurysm, carotid artery dissection, vascular compression of cranial nerve eight, vascular tumors
(glomus)
● Venous: Jugular bulb abnormalities (high-riding, dehis-
cence, diverticulum), idiopathic intracranial hypertension, idiopathic pulsatile tinnitus (venous hum)
● Nonvascular: Palatal, stapedial, and tensor tympani
myoclonus

Question 3

What is the prevalence of carotid artery dehiscence within the middle ear?

Answer 3

Approximately 10%, but rarely does it follow an aberrant

course placing it at risk during myringotomy

Question 4

What otoscopic findings might make you suspect

a dehiscent or high riding jugular bulb?

Answer 4

The most likely area to visualize a dehiscent jugular bulb in
the middle ear is behind the posterior inferior quadrant of
the tympanic membrane, where a dark blue and possibly
pulsatile structure may be seen.

Question 5

What is the clinical significance of an empty sella

in a patient with pulsatile tinnitus?

Answer 5

Associated with elevated intracranial hypertension (idiopathic intracranial hypertension)

Question 6

Describe the clinical manifestations of idiopathic

intracranial hypertension syndrome.

Answer 6

The most common symptoms are headache (~ 90%) and
then pulsatile tinnitus (~ 70%). Other signs and symptoms
including extremity paresthesias, generalized weakness,
hyposmia, abducens palsy, facial paresis, and incoordination
are reported more rarely.

Question 7

What constellation of symptoms is commonly

associated with patulous eustachian tube?

Answer 7

Tinnitus, aural fullness, autophony, audible respiratory

sounds, and vertigo

Question 8

List common medications that may cause tinnitus.

Answer 8

Aspirin-containing products (most common), other non-steroidal anti-inflammatory drugs (or NSAIDs), aminoglycosides, proton pump inhibitors (omeprazole,
esomeprazole), and certain antidepressants

Question 9

What device (nonmedicinal) options are available
for patients with subjective nonpulsatile idiopathic
tinnitus?

Answer 9

Hearing aids, masking devices (deliver constant narrow-
band white noise to “cover up” ringing), and tinnitus retraining therapy (pitch matched to the patient’s tinnitus
to theoretically habituate the central auditory system to the
noise and eventually neglect it). Cochlear implants improve
tinnitus in some patients, but tinnitus itself is not an
indication for implantation.