• Deafness and Tinnitus Clinic

  • Assessment of hearing function by Pure Tone Audiometry and Middle ear pressures by Acoustic Impedance Bridge. Suggestion on treatment of conductive deafness and sensori neural hearing loss. Treatment by different types of hearing aid with pictures.

    Anatomy and Physiology of the ear

    Anatomy and Physiology of the Ear

     

     The ear consists of 3 parts

     

    The outer ear consists of the ear canal which extends to the eardrum. It directs sound vibrations to the ear drum and sets it into vibrations.

    The middle earBehind the eardrum lies the middle ear. It is an air-filled space situated between the ear drum and inner ear. It has a chain of the body’s three smallest bones – the Hammer (Malleus), the Anvil (incus) and the Stirrup (stapes). The ear drum vibrations are conducted to the internal ear by this small chain of bones.

    For the ear drum to vibrate freely, there has to be air on both sides of the drum. Nature has made a clever provision for air on the inner aspect of the ear drum to come from the back of the nose through a tube (Eustachian tube) which is responsible for maintaining air in the middle ear and the inner aspect of the ear drum. Unfortunately, for this reason, all diseases of the nose have an effect on ventilation of the middle ear. Common colds, sinus infections, nasal tumours, adenoids can all affect the function of the Eustachian tube and cause a middle ear type of deafness (conductive deafness).

    The internal ear – Deeper inside is situated the inner ear with the organs of hearing and balance, which are filled with fluid and surrounded by fluid.

    The hearing portion is a coiled tube shaped like a snail shell (cochlea). From the tiny hair cells of the inner ear, the sound waves are converted into electrical impulses, which are transmitted to the brain’s hearing centre by the nerve of hearing.

    The balance portion has three semi circular canals and the vestibule.

    The semicircular canal systems of the two sides convey information of angular acceleration of the head to the brain in the three planes of space – horizontal, vertical and oblique.

    The vestibule consists of the Utricle and Saccule which inform the brain of head position head in space in the yaw and pitch planes.

    These impulses are transmitted by the nerve of balance as electrical impulses to be conveyed to the brain stem nucleii and finally to the cerebellum and other brain centres.

    Computerized Audiogram and Computerized Impedance test results of a normal hearing individual

    Anatomy and Physiology of the Ear Click here

    Examination of a patient with a hearing loss

    It is important to determine the type of hearing loss – Conductive, Sensori-neural or Mixed
    The level of hearing – HTL (Hearing Threshold Level) has to be determined.
    Whether the high frequencies or low frequencies are affected
    Whether speech discrimination is affected or not

    A physical exam, using a ear microscope or endoscope, will evaluate the ear canal and tympanic membrane. The nose, nasopharynx, paranasal sinuses, throat, larynx and neckand upper respiratory tract will also be examined as the ear and nose has close anatomical relationship and disease conditions in one often affects the other ( eg one becomes temporarily deaf during a “cold”.

    Primary tests done in a hard of hearing patient

    Pure Tone Audiometry – Pure tones are presented to each individually via head phones at frequencies of 0.128 KHz to 10 KHz. The patients responses are recorded as a graph.

    Acoustic Impedance Audiometry (Immitance Audiomety)– Tests the Acoustic Reflex the contraction of a tiny ear muscle that responds to sounds at different volumes. Also Tympanometry measures the impedance of the middle ear to sound. Tympanometry is useful in distinguishing between types of conductive deafnes – due to middle effusions, disruption or fixation of the small chain of bones, negative middle ear pressure in the middle ear.

    A graphical computerized report of hearing function (Audiogram) and pressure within the middle ear and measurement of reflex movements of tiny muscles in the middle ear (Acoustic Impedance) are the basic tests for diagnosis of hearing disorders.

    This information is the first step to diagnosis. Once a correct diagnosis is made, proper treatment is instituted.

    Basic types of Deafness – Conductive and Sensori –neural deafness

    Conductive Deafness – When deafness is caused by disease of the outer (external) ear, ear drum or mddle ear, it is referred to as a conductive deafness.

    Sensori neural Deafness – When deafness is caused by disease of the inner ear, nerveof hearing or brain centres, it is referred to as a Sensori neural Deafness.

    “Mixed” Deafness – Both Conductive and Sensori-neural components are present

    Computerised Audiogram and Computerised Impedance test results of a normal –hearing individual

     

     

    Approximate sound levels in decibels (dB) of common daily experiences amongst 21st century “civilized” people

    Values for   (Patient Name) - Date -
    Event Approx. levelin dB
    Ordinary breathing (barely audible) 0 – 10
    Rustle of leaves. Quiet country side 10 – 20
    Whisper 20 – 30
    Average quiet household. Singing birds 40 dB = Borderline level for Socially Adequate Hearing 30 – 40
    Ordinary conversation. 40 – 50
    Average restaurant. Crying infant.  General office. Classroom 50 – 60
    Loud voice. Average air conditioner. Vacuum cleaner.  T.V. 60 – 70
    Inside a motor car. Barking dog. Printing press. Piano. Doorbell 70 – 80
    Street traffic. Shouted speech. Food mixer 80 – 90
    Railway train. Power tools. Pneumatic drills 90 – 100
    Helicopter. Rock bands. Motor cycles. Large orchestra 100 – 110
    Jet aircraft taking off.  Fire cracker 110 – 120
    Artillery. Rifles. Gunfire at close range. 120 – 130
    Explosions. Machine guns. Nearby thunder 140 & above

    Conductive Deafness

    Conductive Deafness

    Anatomy and Physiology of the Ear Click here

    Conductive Hearing Loss: Conductive hearing loss occurs when sound waves are prevented from passing from the air to the fluid-filled inner ear. This may be caused by a variety of problems including buildup of earwax (cerumen), infection, fluid in the middle ear, a perforated eardrum, or fixation of the ossicles, as in otosclerosis . Other causes include scarring, narrowing of the ear canal, tumors in the middle ear etc. Once the cause is found and removed or treated, hearing usually is restored.

    Deafness due to disease of the external ear, ear drum or mddle ear.

    Causes


    Causes for Conductive Deafness :

    Audiogram and Impedance test results of a patient with Conductive Deafness

    Evaluating Hearing Loss
    Your Ear Nose Throat Surgeon will perform a number of examinations to determine the presence, extent, location, magnitude, and qualities of any hearing loss.

    A physical exam, using an otoscope or ear microscope, will evaluate the ear canal and tympanic membrane. The nose, nasopharynx, and upper respiratory tract will also be examined as the ear and nose has close anatomical relationship and disease conditions in one often affects the other ( eg one becomes temporarily deaf during a “cold”.

     

    Audiometry involves the presentation of pure tones each ear via headphones or through a bone conductor transducer. A range of frequencies is used, and the patient’s pattern of response is analyzed.

     

    Acoustic Reflex testing measures the contraction of a tiny ear muscle that responds to sounds at different volumes. The loudness at which the reflex occurs, or the absence of the acoustic reflex, provides important information.

     

    Tympanometry measures the impedance of the middle ear to sound. It uses an airtight seal and a microphone to deliver sound into the ear canal. The amount of sound that is absorbed or reflected from the middle ear is measured at the microphone at normal, positive, and negative air pressures. Tympanometry is useful in identifying middle-ear effusions in children. It is often used as a confirmatory test when microscopic examination is inconclusive.

     

    Other tests: patients with conductive hearing losses may require computed tomography (CT) scans of the temporal bones. Those with unilateral or asymmetric sensorineural hearing loss should have magnetic resonance imaging (MRI) of the head. Many specialized centres do Electro-Nystagmography (ENG) for assessment of vertigo

     

    Treatment of  Conductive deafness

    Treatment of  Conductive deafness depends on the cause and can be medical,surgical or by hearing aid.

    Medical treatment of Conductive deafness:

    Surgical treatment of Conductive deafness:

    Myringotomy – Incision and Drainage of fluid from middle ear

    Myringotomy and insertion of ventilation tube (grommet) for drainage

    Myringotomy and insertion of ventilation tube (grommet) with Adenoidectomy.

    Myringoplasty – Fashioning a new ear drum

    Tympanoplasty – Removal of ear middle ear disease and fashioning a new ear drum

    TympanoMastoidectomy – Removal of disease in middle ear and mastoid bone (usually cholesteatoma) with reconstruction of the ossicular chain.

    Stapedectomy and Stapedotomy for Otosclerosis.

     

    Hearing aids: In selected cases of Conductive deafness not remediable by surgical means.

    While a hearing aid is an effective help – it is not a cure for hearing impairment.

    Hearing aids can not restore our original hearing ability, but they can help us to make the very most of the hearing ability we have left. Today’s hearing aids are intricate technical instruments, which are individually adjusted to the user’s own specific hearing loss. Even so, it takes time to become used to all the new, amplified sounds ­especially if we have lived with a hearing loss for some time and have forgotten how noisy buses and cars sound.

    Most individuals with hearing loss can bene­fit from amplification. The goal of amplification is to make speech audible. The most common types of hearing aids range in size from fitting behind the ear (BTE), in the ear (ITE), and in the canal (ITC) to completely in the canal (CIC), the small­est. The style of hearing aid can be limited by the degree of loss. For example, an individual with severe to profound hearing loss will require a BTE. A lesser hearing loss should benefit from the smaller styles such as ITE or CIC.

    Audiogram and Impedance testing determines the levels of hearing for hearing aid can be selected.

    The most common types of hearing aids range in size from fitting behind the ear (BTE), in the ear (ITE), in the canal (ITC) and completely in the canal (CIC), the small­est. The style of hearing aid is limited by the degree of loss. For e.g., an individual with severe to profound hearing loss will require a BTE. A lesser hearing loss should benefit from the smaller styles such as ITE or CIC and IIC.

    Sensori neural Deafness

    Sensori neural Deafness

    Deafness due to disease of the inner ear, hearing nerve or brain centres

    Anatomy and Physiology of the Ear Click here

    Sensorineural Hearing Loss: Develops when the auditory nerve or hair cells in the inner ear are damaged. The source may be located in the inner ear, the nerve from the inner ear to the brain, or in the brain. Sensorineural hearing loss, commonly referred to as “nerve deafness,” frequently occurs as a result of the aging process in the form of presbycusis, which is a gradual loss occurring in both ears. Tumors such as acoustic neuromas can lead to sensorineural hearing losses, as can viral infections, Meniere’s disease and meningitis. Sensorineural hearing loss can also be the result of repeated, continuous loud noise exposure, certain toxic medications, or as an inherited condition. Generally, it is non-reversible. Scientists have, however, made great progress in uncovering the genes responsible for a number of forms of congenital hearing impairments/ deafness, and this genetic research may in time lead to therapies for some congenital causes of hearing loss.

    Sensorineural hearing loss may be further differentiated as sensory or neural. Sensory hearing loss refers to loss caused by abnormalities in the cochlea, such as by damage from noise trauma, viral infection, drug toxicity, or Meniere’s disease. Neural loss stems from problems in the auditory (eighth cranial) nerve, such as tumors or neurologic disorders. While tumors in this nerve may be life threatening, they are also often curable.

    Causes

     

     

     

     

     

     

     

     

     

     

     

    Audiogram and Impedance test results of a patient with Sensori Neural Deafness

    Hearing Aids – Treatment of  Sensori-Neural (“Nerve deafness”)  and Click

    The hope for  Deafness due to ageing

    An initial hearing loss manifests when people begin to notice a reduction in their hearing ability.

    1. It becomes difficult to understand what is being said, when three or more people are talking together.

    2. It seems that others – especially young people – have begun to mumble.

    3. Background noise can make it difficult to understand what is being said.

    4. Other sounds, such as bird song, doorbells or a ringing telephone, can recede or simply disappear.

    5. Family and friends of people who have a hearing loss, due to advancing age, also notice this

    Treatment of (“Nerve deafness”) and deafness due to ageing

    Treatment of (“Nerve deafness”) and deafness due to ageing

    An initial hearing loss manifests when people begin to notice a reduction in their hearing ability.
    • It becomes difficult to understand what is being said, when three or more people are talking together.
    • It seems that others – especially young people – have begun to mumble.
    • Background noise can make it difficult to understand what is being said.
    • Other sounds, such as bird song, doorbells or a ringing telephone, can recede or simply disappear.
    • Family and friends of people who have a hearing loss, due to advancing age, also notice this.

    It can be a difficult and confusing time for the hearing affected person, as a simple conversation becomes a struggle and they begin to blame others for mumbling. So it may take some time to realize that hearing capacity is decreasing.

    When the High tones are affected in the range where the important speech sounds, usually the consonant sounds, such as “s”, “t” and “f”, can no longer be clearly heard. This causes speech to sound muddy and slurred, so even though we can hear we are being spoken to, we cannot understand what is being said.

    When our hearing fails us, it can be difficult or impossible to perceive all of the rich nuances of life’s many sounds: the clock ticking, footsteps, water running, food sizzling in a pan. The world around us goes quiet – the melody is lost.

    While many of us will have to accept impaired hearing as part of the ageing process, there is absolutely no reason to accept a poorer quality of life as well. The worst thing we can do, when faced with a hearing loss, is to ignore or try to hide the fact. Those around us will quickly suspect that something is wrong, as we become less and less able to communicate normally.

    People with a hearing loss are often treated as if they were less intelligent than those with normal hearing. Their hearing difficulty can put them in situations where, for example, they do not hear a question correctly and consequently give an unrelated answer. Or perhaps they do not hear the question at all. This can be misunderstood and interpreted as a sign of stupidity.

    While a hearing aid is an effective help – it is not a cure for hearing impairment.

    Hearing aids can not restore our original hearing ability, but they can help us to make the very most of the hearing ability we have left. Today’s hearing aids are intricate technical instruments, which are individually adjusted to the user’s own specific hearing loss. Even so, it takes time to become used to all the new, amplified sounds ¬especially if we have lived with a hearing loss for some time and have forgotten how noisy buses and cars sound.

    Age-related hearing loss is neither an illness nor something to be embarrassed about, but rather a completely natural result of advancing age. Fortunately, this is a problem we can do something about!

    Most individuals with hearing loss can benefit from amplification. The goal of amplification is to make speech audible. The most common types of hearing aids range in size from fitting behind the ear (BTE), in the ear (ITE), and in the canal (ITC) to completely in the canal (CIC), and the smallest being invisible in the canal (IIC). The style of hearing aid can be limited by the degree of loss. For example, an individual with severe to profound hearing loss will require a BTE. A lesser hearing loss should benefit from the smaller styles such as CIC or IIC.

    Tinnitus (Noise in the Ear)

    Tinnitus (Noise in the Ear           

    Anatomy and Physiology of the Ear  Click here

    What is Tinnitus?
    The definition of tinnitus is the perception of a noise in the in the ear, ears or somewhere inside the head in absence of an external cause. Tinnitus is quite common, affecting up to 20 per cent of the population. Probably everyone could hear a noise if placed in a sufficiently quiet background.
    There is a wide variation in the effects of tinnitus. Up to 0.5 per cent of the population find that tinnitus affects their daily life severely, and it is usually these patients who come to medical attention, many times for the psychologi¬cal aspects of tinnitus.

    Tinnitus may manifest as a hum, buzzing, roaring, whistle or a hiss. It may come and go, or may be continuous. The type of tinnitus does not  give a clue to its cause, except with pulsatile tinnitus, which suggests a vascular cause or a conductive hearing loss. The hearing of voices or more complex sounds is not tinnitus, and the cause of such symptoms (auditory hallucinations)  lies within the realm of psychiatry or neurology.

    In many instances there is an initial triggering event like trauma – acoustic or physical as in a head injury, sudden mental stress as loss of a family member. The initial site of generation of the noise is probably the coch¬lea, the sound itself may continue despite severing the cochlear nerve, implying that it must be perpetuated centrally.This suggests that tinnitus be considered to be a functional disorder of the entire auditory system.

    What is the cause of Tinnitus?
    Tinnitus may arise from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is important for acute hearing, and injury to them brings on hearing loss and often tinnitus. In the elderly, advancing age is generally accompanied by increasing weakness of the hearing nerve with tinnitus. In younger people, exposure to loud noise is an important cause of tinnitus, and often hearing loss.

    Middle Ear disease causing tinnitus – Otosclerosis stiffening of the middle ear bone stapes (otosclerosis).
    Inner ear disease – A vila infection, blood vascular affection or tumor of the nerve of hearing or balance (Acoustic schwannoma) can cause tinnitus.
    Medical conditions like allergy, high or low blood pressure (blood circulation problems), diabetes, thyroid problems, injury to the head or neck etc. Medications such as anti-inflammatories, antibiotics, sedatives, antidepressants. If you have tinnitus and are taking aspirin, a dosage adjustment may be required..

    What are the investigations necessary
    Hearing tests for the internal ear (Audiogram) and middle ear pressure tests (Tympanogram) balance test (ElectroNystagmogram)  to ellicit the cause of your tinnitus. An MRI scan of the brain is essential when there is a hearing loss only in the ear affected by the tinnitus.

    How can one cope with Tinnitus?
        The following list of DOs and DON’Ts can help lessen the severity of tinnitus:
    • Avoid exposure to loud sounds and noises.
    • Get your blood pressure checked. If it is high, get your doctor’s help to control it.
    • Avoid stimulants such as coffee, tea, cola, and tobacco. Decrease intake of salt. Adjust dose of aspirin.
    • Exercise daily to improve your circulation.  Get adequate rest and avoid fatigue.
    • Stop worrying about the noise. Recognize it as an annoyance and learn to ignore it as much as possible.

         Diagnosis:

         Imbalance or dizziness are frequently associated with tinnitus or hearing loss,although it is not always easy to establish their relevance. Acute attacks of true rotary vertigo are relevant, but the more common vague feeling of imbal¬ance is less significant.
         Psychological factors are certainly important and should be explored, particularly stress-related aspects or symptoms suggesting de¬pression.

         Use of medicines may cause tinnitus – many drugs. have tinnitus listed as a potential side-effect, although in reality this fortunately appears to be rare. It would be expected that stopping medication should stop the tinnitus, but as in the case of the division of the cochlear nerve, this may not happen. Persistent unilateral symptoms with hearing loss should always be investi¬gated.

         Examination of the ears may suggest a diagnosis.
         Impacted wax can lead to a conductive hearing loss that can then lead to tinnitus.
         A middle-ear effusion following flying or a URTI may precipitate tinnitus, again because of the con¬ductive loss.
         Audiometry establishes whether there is a hearing loss, whether it is ¬unilateral or bilateral, and quantifies any loss.

    Common causes: Most patients will present with tinnitus alone or in combina¬tion with some degree of sensorineural hearing loss, usually as a result of presbyacusis. Examination will be normal, and audiometry will effectively give the diagnosis. Assessing any psychological factors will help. If hearing loss seems to be present, then obtaining a hearing aid may ameliorate the tinnitus.
    The effect of high level of noise is well-recognised, and there are two groups where tinnitus is related to noise exposure. The first consists of patients with a long history of noise exposure. This may be occupational, such as in sheet metal or print workers. Despite awareness of noise risks and occupational health monitoring, Noise-Induced Hearing Loss (NIHL) still occurs, with asso¬ciated tinnitus. Musicians are another group at risk of NIHL. They are not usually subjected to monitoring, but are often very sensitive about their hearing and may find tinnitus quite disturbing. The second, smaller group have a sudden event leading to tinnitus with or without hearing loss. The classic ex¬ample is related to very loud music events. It is common for those attending to come out with both the ears ringing and blocked feeling. This shows as a temporary threshold shift on an audiogram. By the following morning these symptoms usually disappear, but for a small group of people the effects can be permanent. Avoiding further noise trauma is often the only action that can be taken to help ¬with both hearing loss and tinnitus.

    Middle-ear effusions from any cause (infection, barotrauma) act in a similar fashion. If there is conductive loss due¬ to tympanic membrane perforation, surgical correction is not usually offered for tinnitus alone, but it is possible that correcting the associated hearing loss may help.

    Rare causes: It is extremely rare for bilateral tinnitus to be a manifestation of any serious intracranial disease. The only time when imaging should be con¬sidered is when there is co-existing neurological symptoms. Occasionally patient anxiety is such that it necessitates imaging. MRI scans are best.

    Unilateral tinnitus presents more of a dilemma. It is important because it may indicate the presence of an intracranial or retrocochlear lesion. Such lesions are usually benign, and treatment is more successful the smaller the tumour. In many cases, bilateral tinnitus begins as unilateral tinnitus for a variable time. In the absence of any other symptoms, waiting three months is reason¬able.
    Acoustic neuroma, more appropriately called a vestibular schwannoma, is a benign tumour arising in the internal auditory canal or cerebellopontine angle. It occurs in 1:50,000 to 1:100,000 people per year. At least 90 per cent of  cases present with asymmetric hearing loss and possibly tinnitus.  Tinnitus alone as a presenting symptom is rare, although hearing loss may only mani¬fest itself as a blocked feeling. The tumours tend to grow slowly, with periods of no growth. Management options include serial observation by MRI, surgical removal or radiotherapy to control growth. Any patient with unexplained unilat¬eral sensorineural hearing loss (with or without tinnitus) needs an MRI to ex¬clude this condition.

    Meniere’s disease classically presents a triad of symptoms: attacks of ver¬tigo, hearing loss and tinnitus. This presentation is usually easy to diagnose, but the diagnosis may be more difficult if; in particular, the attacks. of vertigo are infrequent but the tinnitus and hearing loss is always present.
    The manage¬ment of these symptoms is along conventional lines. Vertigo is usually treated with drugs such as betahistine, diuretics and salt restriction. Refractory cases are now usually offered intratympanic gentamicin injections.

    Management: Some people have an identifiable and correctable cause, but most patients will have tinnitus either as a sole complaint or in association with sensorineural hearing loss. They may be concerned about the implica¬tions of tinnitus and their future; establish exactly what bothers them first. Patients must be told that there is no magic pill, but there are many treatments that can help.
    Treating hearing loss with an appropriate aid, may be beneficial. It may not improve the tinnitus directly, but may help any disability and handi¬cap secondary to the hearing loss. Tinnitus is usually most disturbing during night. A simple strategy is to increase background environment noise by lis¬tening to radio when going to sleep. Patients who are not satisfied with the initial explanation, express interest in further treatmetifs or have co-existing anxiety or depression require further intervention. Disordered mood may ben¬efit from drug treatment, tricyclic antidepressants may benefit selected pa¬tients. Empowering the patient to self-treat is worth while, but sometimes more specific interventions are needed. Specific treatments include counselling, re¬laxation therapy, cognitive behavioural therapy, masking and sound therapy. Most people are helped, but a few need psychiatric assessment, especially if suicide is a possibility.

    What  is the treatment of Tinnitus?

    Medical treatment Combinations of various drugs which nourish the delicate nerves of the inner ear may be tried. Initially, a mild tranquiliser should be taken. As adjustment to the noise occurs, the dose of this may be decreased. 

    Concentration and relaxation exercises and Yoga can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation can reduce the intensity of tinnitus in many patients.

    Masking. Tinnitus is usually more bothersome in quiet surroundings. A competing sound at a constant low level, such as a ticking clock or soft music from a Walkman set may mask the tinnitus and make it less noticeable. Products that generate white noise are also available through catalogs and specialty stores.

    Hearing Aids. If you have a hearing loss, a hearing aid(s) may reduce head noise while you are wearing it and sometimes cause it to go away temporarily. It is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.

    Tinnitus maskers combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.

     In tinnitus without definable cause     Learn to realize that –

     Tinnitus is a very common complaint.

     Tinnitus usually lessens over a period of time.

     Medical treatment works in many cases – if it does not, one has to learn to cope up with tinnitus without the help of medicines.

     Most people learn to live with it without much difficulty. Time is the best healer.

     Many methods are available in helping you to adapt to the noise, which while not curing it, would certainly assist in coping with it.

     Remember, tinnitus sounds are not in fact very loud by comparison with many everyday sounds.
                                                    
     They can be irritating and frustrating like traffic noise, the dripping tap at night or the next door baby’s cry.
     
     It is therefore a matter of learning to control reactions to these irritations or to ignore them and not let them take control.

             Your present check up results show that there is no disease of the ears or suspicion of  brain disease like tumour or degeneration to explain the noise in the ears.

    However, it is essential to assess the condition from time to time.

    Do report for assessment if the tinnitus increases or symptoms like giddiness, vertigo, develop in which case, further investigations like a head and brain scan like  a C. T. or  M. R. I. Scan would be required.

    Differential Diagnosis of Pulsatile Tinnitus

    Cardiovascular disease
    Vascular disease Arteriovenous fistula Caroticocavernous fistula ICA atheroma
    ICA thrombosis
    ICA dissection
    Ectasia or stenosis Fibromuscular dysplasia Intrapetrous carotid aneurysm Intracranial aneurysm

    Cardiac valvular disease

    Cardiac high-output states Anemia
    Thyrotoxicosis
      Beri-beri

    Vascular tumor of temporal bone or cranium
    Paraganglioma (Glomus jugulare tumor)
    Meningioma
    Hemangioma
    Vestibular schwan noma
    Vascular metastatic carcinoma
    Parenchymal A VM

    Other disorders of the temporal bone Paget’s disease
    Otosclerosis (osteolytic phase)

     Congenital or developmental anomalies
         Anomalous ICA of middle ear
         Congenital arterial shunts
          Persistent stapedial artery
          Primitive otic artery
          Primitive hypoglossal artery
          Eagle syndrome
          Jugular megabulb
          Dehiscent jugular bulb
          Posterior condylar emissary vein

     Other conditions
           Benign intracranial hypertension