Hanyang Med Rev.  2016 May;36(2):99-108. 10.7599/hmr.2016.36.2.99.

Objective Tinnitus

• Park SN

• KMID: 2164667
• DOI: http://doi.org/10.7599/hmr.2016.36.2.99

Abstract

Objective
tinnitus originates from the para-auditory structures of the head and neck and can be heard or documented by examiner. Three representative forms of objective tinnitus, according to the causal organs are myoclonic tinnitus, vascular tinnitus and tinnitus caused by the patulous Eustachian tube. Etiologies, pathologic mechanisms, diagnostic approaches, and proper treatment methods of objective tinnitus are comprehensively discussed with a review of literatures. Objective tinnitus can be cured in many cases. Clinicians need to be well aware of the clinical characteristics of objective tinnitus since early, correct diagnosis with proper management are mandatory for its cure.

Keyword

Tinnitus; Objective; Myoclonic; Vascular; Patulous Eustachian Tube

MeSH Terms

Diagnosis
Eustachian Tube
Head
Neck
Tinnitus*

Figure

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  Fig. 1 The pre-injection electromyogram of the the tensor veli palatini muscle showed the bursts of electrical activity with different frequencies and amplitudes (A). Botulinum toxin injection to the tensor veli palatini muscle was accomplished through an EMG-guided external approach (B).

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  Fig. 2 Diagnostic methods of middle ear myoclonic tinnitus. Direct observation of To-and-fro, or inward-and-outward motion, mostly in the posterior part of the tympanic membrane by otoendoscopic examination (A, arrows), sound evoked tremor-like motion of tympanic membrane which is also frequently observed in acoustic reflex decay test (B) are useful tools. Strong inward-and-outward motion of tympanic membrane in middle ear myoclonic tinnitus associated with a forceful eyelid closure syndrome can be documented even in a static compliance test (C).

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  Fig. 3 Vascular tinnitus diagnosed by imaging studies (arrows). High jugular bulb detected in temporal bone computed tomogram (A), intracranial aneurysm in 3D-reconstructed Brain CT angiogram (B), arteriovenous fistula in magnetic resonance arteriography (C), and glomus tympanicum in Gd-enhanced temporal bone magnetic resonance imaging (D).

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  Fig. 4 Diagnosis of the patulous Eustachian tube. Otoendoscopic examination of the tympanic membrane during forceful inspiration and expiration with the contralateral nostril blocked demonstrates the inward-and–outward motion of the total tympanic membrane according to the respiratory status. Outward buldging of tympanic membrane during expiration is shown in this otoendoscopic finding (A). It can also be documented by tympanogram in accordance with forceful respiration which shows severe and irregular perturbation (B).

Reference

1. Yoo HJ, Park SN, Kim DK, Park KH, Kim MJ, Kim JE, et al. Incidence and clinical characteristics of patients with tinnitus according to diagnostic classification. Korean J Otorhinolaryngol-Head Neck Surg. 2011; 54:392–398.

2. Duschel G, Mischeke G, Schenk E, Shulte-Monting J, Luking CH. Symptomatic and essential rhythmic palatal myoclonus. Brain. 1990; 113:1645–1672.

3. Saeed SR, Brookes GB. The use of clostridium botulinum toxin in palatal myoclonus. A preliminary report. J Laryngol Otol. 1993; 107:208–210.

4. Penney SE, Bruce IA, Saeed SR. Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature. J Neurol. 2006; 253:857–860.

5. Park SN, Park KH, Kim do H, Yeo SW. A case of palatal myoclonus associated with orofacial buccal dystonia. Clin Exp Otorhinolaryngol. 2012; 5:44–48.

6. Park SN, Park KH, Lee DH, Yeo SW. A Case of Palatal Myoclonus Tinnitus Treated with Botolinum Toxin Injection . Korean J Otolaryngol-Head Neck Surg. 2005; 48:1177–1180.

7. Park SN. Treatment f objective tinnitus. In : Kyung Hee Tinnitus Seminar 7th; Tinnitus treatment in special situation;2015.

8. Golz A, Fradis M, Martzu D, Netzer A, Joachims HZ. Stapedius muscle myoclonus. Ann Otol Rhinol Laryngol. 2003; 112:522–524.

9. Marchiando A, Per-Lee JH, Jackson RT. Tinnitus due to idiopathic stapedial muscle spasm. Ear Nose Throat J. 1983; 62:8–13.

10. Park SN, Nam IC, Shin JH, Yeo SW. A case of objective tinnitus due to middle ear myoclonus treated by surgical therapy. Korean J Otolaryngol-Head Neck Surg. 2007; 50:73–75.

11. Lee GH, Bae SC, Jin SK, Park KH, Yeo SW, Park SN. Middle ear myoclonus associated with forced eyelid closure in children: diagnosis and treatment outcome. Laryngoscope. 2012; 122:2071–2075.

12. Park SN, Bae SC, Lee GH, Song JN, Park KH, Jeon EJ, et al. Clinical characteristics and therapeutic response of objective tinnitus due to middle ear myoclonus: a large case series. Laryngoscope. 2013; 123:2516–2520.

13. Abdul-Baqi KJ. Objective high-frequency tinnitus of middle-ear myoclonus. J Laryngol Otol. 2004; 118:231–233.

14. Badia L, Parikh A, Brookes J. Management of middle-ear myoclonus. J Laryngol Otol. 1994; 108:380–382.

15. Abdul-Baui KJ. Objective high-frequency tinnitus of middle-ear myoclonus. J Laryngol Otol. 2004; 118:231–233.

16. East CA, Hazel JW. The suppression of palatal (or intra-tympanic) myoclonus by tinnitus masking devices. J laryngeal Otol. 1987; 101:1230–1234.

17. Liu HB, Fan JP, Lin SZ, Zhao SW, Lin Z. Botox transient treatment of tinnitus due to stapedius myoclonus: case report. Clin Nuerol Neurosurg. 2011; 113:57–58.

18. Zipfel TE, Kaza SR, Green JS. Middle ear myoclonus. J Laryngol Otol. 2000; 114:207–209.

19. Stouffer JL, Tyler RS. Characterization of tinnitus by tinnitus patients. J Speech Hear Disord. 1990; 55:439–453.

20. Liyanage SH, Singh A, Savundra P, Kalan A. Pulsatile tinnitus. J Laryngol Otol. 2006; 2. 120(2):93–97.

21. Hardison JE, Smith RB, Crawley IS. Self heard venous hums. JAMA. 1981; 245:1146–1147.

22. Bae SC, Kim DK, Yeo SW, Park SY, Park SN. Single-center 10-year experience in treating patients with vascular tinnitus: diagnostic approaches and treatment outcomes. Clin Exp Otorhinolaryngol. 2015; 8:7–12.

23. Sismanis A. Pulsatile tinnitus: a 15-year experience. Am J Otol. 1998; 19:472–477.

24. Radhakrishnan K, Thacker AK, Bohlaga NH, Maloo JC, Gerryo SE. Epidemiology of idiopathic intracranial hypertension: a prospective and case-control study. J Neurol Sci. 1993; 5. 116:18–28.

25. Reid A, Marchbacks RJ, Bateman DE, Martin AM, Brihgtwell AP, Pickard JD. Mean intracranial pressure monitoring by a non-invasive audiological technique: a pilot study. J Neurol Neurosurg Psychiatry. 1989; 52:610–612.

26. Kim DK, Shin YS, Lee JH, Park SN. Pulsatile tinnitus as the sole manifestation of an internal carotid artery aneurysm successfully treated by coil embolization. Clin Exp Otorhinolaryngol. 2012; 5:170–172.

27. Austin JR, Maceri DR. Anterior communicating artery aneurysm presenting as pulsatile tinnitus. ORL. 1993; 55:54–57.

28. Park SN, Park KH, Lim DJ, Lee JH. A case of pulsatile tinnitus with high jugular bulb treated by ligation of internal jugular vein. Korean J Otorhinolaryngol-Head Neck Surg. 2007; 50:1152–1156.

29. Sesmanis A. Otologic manifestations of benign intracranial hypertension syndrome: diagnosis and management. Laryngoscope. 1987; 97:1–17.

30. Executive committee for the asymptomatic carotid atherosclerosis study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995; 273:1421–1428.

31. O'Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope. 1981; 91:1427–1435.

32. DiBartolomeo JR, Henry DF. A new medication to control patulous eustachian tube disorders. Am J Otol. 1992; 13:323–327.

33. Plate S, Johnsen NJ, Nodskov Pedersen S, Thomsen KA. The frequency of patulous eustachian tubes in pregnancy. Clin Otolaryngol Allied Sci. 1979; 4:393–400.

34. Pulec JL. Abnormally patent eustachian tubes: treatment with injection of polytetrafluoroethylene (teflon) paste. Laryngoscope. 1967; 77:1543–1554.

35. Ikeda R, Oshima T, Oshima H, Miyazaki M, Kikuchi T, Kawase T, et al. Management of patulous eustachian tube with habitual sniffing. Otol Neurotol. 2011; 32:790–793.

36. Oshima T, Kikuchi T, Kawase T, Kobayashi T. Nasal instillation of physiological saline for patulous eustachian tube. Acta Otolaryngol. 2010; 130:550–553.

37. Boudewyns A, Claes J. Acute cochleovestibular toxicity due to topical application of potassium iodide. Eur Arch Otorhinolaryngol. 2001; 258:109–111.

38. Chen DA, Luxford WM. Myringotomy and tube for relief of patulous eustachian tube symptoms. Am J Otol. 1990; 11:272–273.

39. Boedts M. Paper patching of the tympanic membrane as a symptomatic treatment for patulous eustachian tube syndrome. J Laryngol Otol. 2014; 128:228–235.

40. Brace MD, Horwich P, Kirkpatrick D, Bance M. Tympanic membrane manipulation to treat symptoms of patulous Eustachian tube. Otol Neurotol. 2014; 35:1201–1206.

41. Boudewyns A, Claes J. Acute cochleovestibular toxicity due to topical application of potassium iodide. Eur Arch Otorhinolaryngol. 2001; 258:109–111.

42. Yu BJ, Kim HM, Jin SK, Park SN. Therapeutic efficacy of angiocatheter insertion surgery in the bony orifice of patulous Eustachian tube. Korean J Otorhinolaryngol-Head Neck Surg. 2014; 57:54–60.

43. Bluestone CD, Cantekin EI. "How I do it"-otology and neurotology. A specific issue and its solution. management of the patulous eustachian tube. Laryngoscope. 1981; 91:149–152.

44. Sato T, Kawase T, Yano H, Suetake M, Kobayashi T. Trans-tympanic silicone plug insertion for chronic patulous eustachian tube. Acta Otolaryngol. 2005; 125:1158–1163.

45. Takano A, Takahashi H, Hatachi K, Yoshida H, Kaieda S, Adachi T, et al. Ligation of eustachian tube for intractable patulous eustachian tube: a preliminary report. Eur Arch Otorhinolaryngol. 2007; 264:353–357.

46. Doherty JK, Slattery WH 3rd. Autologous fat grafting for the refractory patulous eustachian tube. Otolaryngol Head Neck Surg. 2003; 128:88–91.

47. Oh SJ, Lee IW, Goh EK, Kong SK. Endoscopic autologous cartilage injection for the patulous eustachian tube. Am J Otolaryngol. 2016; 37:78–82.

48. O'Connor AF, Shea JJ. Autophony and the patulous eustachian tube. Laryngoscope. 1981; 91:1427–1435.

49. Robinson PJ, Hazell JW. Patulous eustachian tube syndrome: the relationship with sensorineural hearing loss. J Laryngol Otol. 1989; 103:739–742.

50. Yanez C, Pirron JA, Mora N. Curvature inversion technique: a novel tuboplastic technique for patulous eustachian tube—a preliminary report. Otolaryngol Head Neck Surg. 2011; 145:446–451.