TINNITUS Discuss the Causes ,Radiological Evaluation and Findings
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Transcript of TINNITUS Discuss the Causes ,Radiological Evaluation and Findings
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Discuss the causes ,radiological
evaluation and findings in a 60yr.Old man presenting with
tinnitus.
Presentation by Dr. Omatiga A.Gabriel
Radiology Dept. OAUTHCILE-IFE
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outline
Introduction
Epidermiology
Types Causes
Radiological evaluation
Radiological findings
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introduction
DEFINED as the perception of sound in the
absence of external stimulus
Tinnere means ringing in Latin
The sound include ringing,clicking, buzzing
,whistling all in the absence of any external
stimuli
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epidermiology
40 million affected in the United States
10 million severely affected
Most common in 40-70 year-olds More common in men than women
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types
Pulsatile otherwise called vascular
Non-pulsatile or non vascular
or
Unilateral
Bilateral
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TYPES
OBJECTIVE ; SOUND PRODUCED BY PARA-
AUDITORY STRUCTURES THAT CAN BE HEARED
BY THE EXAMINER
SUBJECTIVE; IN WHICH CASE THE SOUND IS
ONLY HEARED BY THE PATIENT
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CAUSES
Causes of pulsatile tinnituswill include
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Pulsatile Tinnitus Neoplasms (typically vascular in nature)
Glomus tumors or paragangliomas
(chemodectoma,paragangliomas) Glomus tympanicum, glomus jugulare, glomus
jugulotympanicum
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Hemangioma
Facial nerve hemangioma, cavernous
hemangioma
Other less vascular neoplasms
Meningioma, adenoma
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Vascular lesions
Acquired arterial lesions
Atherosclerotic plaque (carotid or intracranial)
Vascular malformations (intracranial, dural;maybe sequel to trauma)
Aneurysm
Carotid artery dissection (spontaneous ortraumatic)
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congenital
Congenital arterial abnormalities
Aberrant internal carotid artery
Persistent stapedial artery
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Jugular bulb abnormality
high position,
diverticulum,
dehiscence , enlargement
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Miscellaneous vascular abnormalities
Fibromuscular dysplasia of carotid artery
Vascular compression of cochlear or auditory
nerve at root entry zone
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Miscellaneous causes
Valvular heart disease (aortic stenosis,
insufficiency)
Benign intracranial hypertension or
pseudotumor cerebri
Hyperdynamic state (eg, anemia, thyrotoxicosis)
Otosclerosis with anastomoses between
haversian
bone and endochondral layer
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Nonpulsatile Tinnitus
Palatal myoclonus
Spasm, fasciculations, or fibrillations of tensor
tympani or stapedius muscles Spontaneous otoacoustic emissions
Patulous eustachian tube
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Drugs that cause tinnitus
Antinflammatories
Antibiotics (aminoglycosides)
Antidepressants (heterocyclines)
Aspirin
Quinine
Loop diuretics
Chemotherapeutic agents (cisplatin,vincristine)
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RADILOGICAL EVALUATION
The approach to radiological evaluation is
teken from the point of the possible etiology
History and physical examination
audiometry are very important
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IMAGING MODALITIES
MAGNETIC RESONANCE IMAGING
MRA
FMRI
GADOLINIUM ENH.MRICOMPUTED TOMOGRAPHIC SCAN
CECT/NCECT/CTA
COVENTIONAL ANGIOGRAPHY
PET SCANS
VASCULAR ULTRASONOGRAPHY
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Pulsatile tinnitus raise the consideration of a
vascular cause, malfomations and other
congenital and acquired causes as enumerate
earlier, Contrast enhanced CT of temporalbones, skull base, brain, calvaria as first-line
study
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CT SCAN
The imaging approach is to start with contrast
enhanced CT SCAN .This shows vascular
anormalies and vascular tumours. It also has
the advantage of demonstrating bony erosionwithin and around the ear cavity,
rcommended for retrotympanic masses
The draw back however is that small lesions
may be missed
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MRI
In otherwise normal otoscopy and an unremarkable CTscan MRI/MRA with its better soft tissue resolution isthe next imaging modality being able to show verysmall lesion and also its non-invasiveness in showing
vascular lesions The draw backs include
non-availability
cost
and the niose which mask the source of tinnitus indynamic brain activity studies
And also its poor delineation of bonyaffectation/invovement
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ANGIOGRAPHY
Conventional angiography was the initial method
of choice for the evaluation of vascular tinnitus ,
but it is has been taken over by the newer
modalities which are less invasive with attendantreduction in the complication.
It demonstrates malformatios ,stenoses, ectopic
vessel It also has the advantage of being used for
interventional procedures
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Glomus tympanicum bone algorithm CT scan
best shows extent of mass
May not be able to see enhancement of small
tumor
Tumor enhances on T1-weighted images with
gadolinium or on T2-weighted images
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IMAGING FINDINGS
Glomus jugulare
Erosion of osseous jugular fossa
Enhances with contrast, may not be able to
differentiate jugular vein and tumor
Enhances with T1-weighted MRI with gadolinium
and on T2-weighted images
Characteristic salt and pepper appearance onMRI
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GLOMUS TYMPANICUM
Glomus tympanicum tumors arise fromGlomus tympanicum tumors range at
presentation from millimeters in diameter
to a mass that fills the middle ear. Thetumor is usually visible otoscopically as a
reddish, pulsatile mass behind an intact
tympanic membrane. Small tumors arebest seen on a thin-section (1-mm) bone
algorithm CT scan
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Glomus tympanicum
The diagnosis is made on bone algorithm scan
Its usually difficult to appreciate enhancement of
small tumors confined to the middle ear on CT
CT shows the anatomic extent clearer than MRI b
MRI shows better tumor enhancment.and the
tumor usually shows as a small entensely
enhancing mass on gadolinium administration
Most tumor arise on the cochlear primontory
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Bone windqw cranial ct and gadolinium enhnced Ti w
MRI showing a mass over the the promontory of the
cochlear and a highly enhancing oval shaped lesionover the signal void promontory
Glomus tympanicum tumors
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Glomus jugulare
Usually arise from the paraganglia of the adventitia ofjugular bulb where the sigmoid sinus become internaljugular vein
Glomus jugulare Erosion of osseous jugular fossa lateral and anterior wall
Occasionally enlarged inferior tympanic canaliculus may be seen
Enhance with contrast, may not be able to differentiate jugularvein and tumor because of their intense enhancement withcontrast on ct
Enhance with T1-weighted MRI with gadolinium and on T2-
weighted images Characteristic salt and pepper appearance on T1W
ENHANCED MRI
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Both glomus jugulare tumor and
jugulotympanicum tumors may grow into the
neck within the lumen of internal jugular vein
to obstruct the vein partially (which maycause slow flow ) or completely
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Glomus jugulare tumor
T1weighted MRI with gadoliniumshowing a large bell shaped enhancing
lesion with areas of flow voids giving
the salt and pepper appearance
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SALT AND PEPPER APPEARANCEOFGLOMUS JUGULARE TUMOR ON
T1W GADOLINIUM ENHANCED MRI
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AV-MALFORMATION
These are congenital lesion
Involving abnormal communication between thevenous and arterial systems which mayinvolveany of the following
Occipital artery and transverse sinus, internalcarotid and vertebral arteries, middle meningealand greater superficial petrosal arteries
Mandible
Brain parenchyma
Dura
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AVMs
Dural AVM or AVF is also the mostfrequent
cause of objective pulsatile tinnitusin the
patient with a normal otoscopic examination
Symptoms usually include Pulsatile tinnitus
Headache
Papilledema
Discoloration of skin or mucosa
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AVMs
The transverse,sigmoid, and cavernoussinuses are the most frequent locations ofdural AVMs
transverse and sigmoid sinus involvementcauses pulsatile tinnitus
Branches of the external carotidartery supplythese dural AVMs; venousdrainage may beextracranial, intracranial,or both all thesefeatures are demonstrated on angiography
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The Other contrast enhanced CT diagnoses
Aberrant carotid artery
Dehiscent carotid artery
Dehiscent jugular bulb
Persistent stapedial artery
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a
T1W MRI of the skull and lateral
view of common carotid angio
showing cluster of small vessels(arrows) in the left occipital
subcutaneous soft tissues.
andshows a dural AVM.
Dural AV -malformation
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Dehiscent jugular vein
Contrast enhanced cranial CT conedview of the internal acoustic meaTus
shows a dehiscent jugular vein (white
arrow) bulging into the middle ear
through a discontinuity
(black arrows) in the cortex of the
jugular tus
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Dissection of internal carotid artery
Difficult to diagnose on CT
Transverse T1-weighted MR images showshyperintense oval shaped mass in the false lumensurrounding the narrowed true lumen of the artery
MR angiography and CT angiography bothdemonstrate the narrowed true lumen of the artery.
Conventional angiography is not necessaryto make the diagnosis.
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Dissection of ICA
Transverse T1-weightedMR images shows
hyperintense oval shaped
mass in the false lumen
surrounding the narrowed
true lumen of the artery
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ATHEROSCLOROTIC VASCULAR
DISEASE
BOTH atherosclerotic vascular disease and
tinnitus increase in prevalence with age
Stenosis is usually seen on conventional angio
The bifurcation of the carotid is the usual site
Fibromuscular dysplasia may also be seen as
segmental narrowing with pre stenotic
dilatation giving a beaded appeaerance
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Radiological evaluation
Carotid angiogram showing stenois of
A segment of the carotid artery
causing tinnitus
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ACOUSTIC NEUROMAS
usually in the cerebellopontine angle,
unilateral
Acoustic Neuroma
Unilateral tinnitus, asymmetric sensorineuralhearing loss or speech descrimination scores
T1-weighted MRI with gadolinium enhancementof CP angle is study of choice
Thin section T2-weighted MRI of temporal bonesand IACs may be acceptable screening test
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Mri of acoustic neuroma