Discuss the causes ,radiological evaluation and findings in a 60yr. Old man presenting with tinnitus.

Presentation by Dr. Omatiga A.Gabriel Radiology Dept. OAUTHC ILE-IFE

outline
Introduction Epidermiology Types Causes Radiological evaluation Radiological findings

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

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

types
Pulsatile otherwise called vascular Non-pulsatile or non vascular

or
Unilateral Bilateral

TYPES
OBJECTIVE ; SOUND PRODUCED BY PARAAUDITORY STRUCTURES THAT CAN BE HEARED BY THE EXAMINER SUBJECTIVE; IN WHICH CASE THE SOUND IS ONLY HEARED BY THE PATIENT

CAUSES
Causes of pulsatile tinnituswill include

 Pulsatile Tinnitus Neoplasms (typically vascular in nature) Glomus tumors or paragangliomas (chemodectoma,paragangliomas) Glomus tympanicum, glomus jugulare, glomus jugulotympanicum

Hemangioma
Facial nerve hemangioma, cavernous hemangioma Other less vascular neoplasms Meningioma, adenoma

Vascular lesions
Acquired arterial lesions Atherosclerotic plaque (carotid or intracranial) Vascular malformations (intracranial, dural; maybe sequel to trauma) Aneurysm Carotid artery dissection (spontaneous or traumatic)

congenital
Congenital arterial abnormalities Aberrant internal carotid artery Persistent stapedial artery

Jugular bulb abnormality

high position, diverticulum, dehiscence , enlargement

Miscellaneous vascular abnormalities

Fibromuscular dysplasia of carotid artery Vascular compression of cochlear or auditory nerve at root entry zone

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

Nonpulsatile Tinnitus
Palatal myoclonus Spasm, fasciculations, or fibrillations of tensor tympani or stapedius muscles Spontaneous otoacoustic emissions Patulous eustachian tube

Drugs that cause tinnitus

Antinflammatories Antibiotics (aminoglycosides) Antidepressants (heterocyclines) Aspirin Quinine Loop diuretics Chemotherapeutic agents (cisplatin, vincristine)

RADILOGICAL EVALUATION
The approach to radiological evaluation is teken from the point of the possible etiology History and physical examination audiometry are very important

IMAGING MODALITIES
MAGNETIC RESONANCE IMAGING MRA FMRI GADOLINIUM ENH.MRI COMPUTED TOMOGRAPHIC SCAN CECT/NCECT/CTA COVENTIONAL ANGIOGRAPHY PET SCANS VASCULAR ULTRASONOGRAPHY

 Pulsatile tinnitus raise the consideration of a vascular cause, malfomations and other congenital and acquired causes as enumerate earlier, Contrast enhanced CT of temporal bones, skull base, brain, calvaria as first-line study

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 erosion within and around the ear cavity, rcommended for retrotympanic masses The draw back however is that small lesions may be missed

MRI
In otherwise normal otoscopy and an unremarkable CT scan MRI/MRA with its better soft tissue resolution is the next imaging modality being able to show very small 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 in dynamic brain activity studies And also its poor delineation of bony affectation/invovement

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 attendant reduction in the complication. It demonstrates malformatios ,stenoses, ectopic vessel It also has the advantage of being used for interventional procedures

 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

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 on MRI

GLOMUS TYMPANICUM
Glomus tympanicum tumors arise from Glomus tympanicum tumors range at presentation from millimeters in diameter to a mass that fills the middle ear. The tumor is usually visible otoscopically as a reddish, pulsatile mass behind an intact tympanic membrane. Small tumors are best seen on a thin-section (1-mm) bone algorithm CT scan

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

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 lesion over the signal void promontory
Glomus tympanicum tumors

Glomus jugulare
Usually arise from the paraganglia of the adventitia of jugular bulb where the sigmoid sinus become internal jugular 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 jugular vein and tumor because of their intense enhancement with contrast on ct Enhance with T1-weighted MRI with gadolinium and on T2weighted images Characteristic salt and pepper appearance on T1W ENHANCED MRI

 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 may cause slow flow ) or completely

Glomus jugulare tumor

T1 weighted MRI with gadolinium showing a large bell shaped enhancing lesion with areas of flow voids giving the salt and pepper appearance

SALT AND PEPPER APPEARANCE OFGLOMUS JUGULARE TUMOR ON T1W GADOLINIUM ENHANCED MRI

AV-MALFORMATION
These are congenital lesion Involving abnormal communication between the venous and arterial systems which may involveany of the following Occipital artery and transverse sinus, internal carotid and vertebral arteries, middle meningeal and greater superficial petrosal arteries Mandible Brain parenchyma Dura

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

AVMs
The transverse,sigmoid, and cavernous sinuses are the most frequent locations of dural AVMs transverse and sigmoid sinus involvement causes pulsatile tinnitus Branches of the external carotidartery supply these dural AVMs; venousdrainage may be extracranial, intracranial,or both all these features are demonstrated on angiography

The Other contrast enhanced CT diagnoses Aberrant carotid artery Dehiscent carotid artery Dehiscent jugular bulb Persistent stapedial artery

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

Dehiscent jugular vein

Contrast enhanced cranial CT coned view 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

Dissection of internal carotid artery

Difficult to diagnose on CT Transverse T1-weighted MR images shows hyperintense oval shaped mass in the false lumen surrounding the narrowed true lumen of the artery MR angiography and CT angiography both demonstrate the narrowed true lumen of the artery. Conventional angiography is not necessary to make the diagnosis.

Dissection of ICA

Transverse T1-weighted MR images shows hyperintense oval shaped mass in the false lumen surrounding the narrowed true lumen of the artery

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

Radiological evaluation
Carotid angiogram showing stenois of A segment of the carotid artery causing tinnitus

ACOUSTIC NEUROMAS
usually in the cerebellopontine angle, unilateral Acoustic Neuroma
Unilateral tinnitus, asymmetric sensorineural hearing loss or speech descrimination scores T1-weighted MRI with gadolinium enhancement of CP angle is study of choice Thin section T2-weighted MRI of temporal bones and IACs may be acceptable screening test

Mri of acoustic neuroma