I am a researcher of cerebrovascular diseases, but most of the patients or family members who consult and seek help on my webpage are about tinnitus; this indicates a problem that there are few doctors in China who do research on tinnitus, and the treatment effect is poor. In this regard, I would like to communicate with the patients.
A patient once lamented on the Internet: There are more than 1 billion people in China, but is there not a doctor who can treat tinnitus? This is not only the patient’s demand, but also reflects the helplessness of many doctors. Today, with the rapid development of science and technology, people can send spacecraft out of the galaxy, assemble supercomputers with billions of times per second, build high-speed railroad networks of tens of thousands of kilometers, etc. But for the simplest single-celled animal in the biological world, we still do not know how it grows, not to mention how the human tissue cells are composed and grow; this is the huge unknown space in the medical field. .
Therefore, it can be associated that in the current medical process of dealing with human diseases, only about 30% of the diseases can be cured (such as fractures, cholecystitis, appendicitis, etc.), 50% of the diseases cannot be cured but can be alleviated or prolonged (such as arteriosclerosis, hypertension, diabetes, early stage of tumors, etc.), and 20% or more of the diseases cannot be cured or treated at all (such as advanced tumors, severe trauma, brain hemorrhage, etc.). In the case of tinnitus, most pulsatile tinnitus is in the 30% group, while neurological tinnitus may fall into the 50% range; this is a reality that both doctors and patients must face, not because doctors are not trying, but because the medical profession has a long way to go.
(a) Since tinnitus is a functional impairment of the sense of hearing, the symptom is only a sensation.
It is not yet medically possible to obtain visually visible evidence, such as MR or CT films to diagnose tumors, or electrophysiological profiles like those used to diagnose heart disease; this is especially true in the case of neurological tinnitus and partial pulsatile tinnitus.
This is especially true for neurological tinnitus and some pulsatile tinnitus. Therefore, it is easy for some people to see this as “depression and anxiety” in their lives and in the process of seeking medical treatment, and even suggest that patients go to psychiatry and psychiatric departments. As a result, many tinnitus patients not only suffer from the constant noise and disturbance day and night, but also do not receive any understanding and comfort from their families and friends. I would like to ask society and everyone to recognize the suffering of tinnitus patients and give them the right help they need in their daily lives as much as possible.
The basic pathological mechanism of pulsatile tinnitus, which is the sensation of a sound in one or both sides of the ear that is the same as the rhythm of the beating heart, is related to abnormal vascular structures inside and outside the skull, and the location of the lesion is mostly not in the ear. Electrical auscultation is predominantly low frequency, usually not exceeding 800 Hz; the loudness of tinnitus varies according to the severity of the lesion. There may be venous, arterial, and other vascular abnormalities in the classification, with the first two predominating; the vast majority are permanently curable.
First of all, arterial tinnitus is most commonly caused by arteriovenous fistulas caused by meninges, hemangiomas, or trauma at the base of the skull, commonly known as “vascular short circuits”.
The narrowing of the arteries in the neck and skull base, or the formation of clips in the arterial walls due to trauma and atherosclerosis, can produce a murmur consistent with the pulse beat due to changes in the blood flow rate. In clinical examination, the murmur can generally be heard around the eyes, behind the ears, and in the neck with a stethoscope, but squeezing the neck by oneself cannot diminish or disappear this murmur; therefore, this kind of tinnitus can be identified as arterial.
In addition, venous tinnitus is basically caused by the structural variation of the cerebral venous sinuses.
Commonly, there is a narrowing of the junction area between the transverse sinus and the sigmoid sinus, a narrowing of the jugular venous foramen segment of the sigmoid sinus combined with a high or thick jugular venous bulb, and a larger diverticulum of the sigmoid sinus. When these structural abnormalities cause accelerated blood flow and create turbulence, a local murmur is formed, which is then transmitted to the cochlea via the bony structures at the base of the skull, and pulsatile tinnitus occurs. Because of the slow venous blood flow, even if there is a murmur, its loudness is not too loud, so it cannot be heard locally with a stethoscope; however, by squeezing the jugular vein in the neck, the murmur (or tinnitus) is significantly reduced or disappears; this is the most typical feature of venous pulsatile tinnitus.
What tests are done after suffering from pulsatile tinnitus?
1. first go to the otolaryngologist and first listen for murmurs with a stethoscope in the neck, in front of and behind the ears, and around the eyes; if you can hear it, it is basically an arterial murmur.
2. squeeze the position of the internal jugular vein under the jaw, and if the tinnitus disappears, it is a venous murmur.
3. doing a tinnitus matching test to understand the frequency and loudness of the tinnitus.
4. doing MRA or CTA of the brain and neck vessels, and brain MRV or CTV to see if there are any abnormalities in the structure of the blood vessels.
5. an ophthalmology examination of the fundus, preferably with a photographic examination to see if there is edema.
6.When the economy is generous, add MR or CT plain scan plus enhancement examination of brain and neck to exclude the possibility of tumor growth and other diseases.
7.If there are symptoms or discomfort in other parts of the body, then find the relevant professional doctor for examination.
8.If the diagnosis is still difficult, then use invasive cerebrovascular DSA imaging, which is the best way to diagnose.
What should I do after the cause of pulsatile tinnitus is determined? There are only two choices: treatment or conservative.
Therefore, I suggest that treatment should be considered when the following conditions occur.
1. The tinnitus is so loud that it seriously interferes with life and even causes anxiety or depression.
2. The examination confirms that the primary lesion causing the tinnitus is very serious, such as arterial stenosis is so severe that it is about to be blocked causing cerebral infarction; or arteriovenous fistula is about to cause cerebral hemorrhage; if the venous sinus stenosis is too severe, there will be edema in the fundus, which may be secondary to fatal cerebral venous sinus thrombosis and intracranial hypertension.
As far as treatment is concerned, since there are no drugs available for pulsatile tinnitus, if the above two are not available, pulsatile tinnitus can be observed for a long time at least for the time being without threatening life, only the nasty tinnitus will reduce the quality of life; however, it needs to be reviewed regularly at the hospital every year, and when it is serious, it is expected to choose the treatment in time, so as not to delay the disease. When treatment is needed, the most effective way is to do interventional embolization or stenting to shape abnormal blood vessels; secondly, open surgery is also possible, but it requires more advanced technology and is difficult, so it is not recommended.
Interventional treatment mainly involves intravascular stenting of the narrowed artery or vein to restore the shape of the normal vessel lumen so that the murmur will not form and the tinnitus can and will disappear. In the case of arteriovenous fistulas and diverticulae, a special small spiral ring is used to occlude them so that the blood flow cannot pass through these abnormalities and instead flows to the normal channels, and the tinnitus is eliminated and other accompanying symptoms are corrected.
Some patients may have bilateral venous sinus stenosis at the same time, in which case they will have pulsatile tinnitus on one or both sides. Since the transverse sinus is anatomically connected to the sinus sink on both sides, only the more severe side of the stenosis is treated; of course, after the stenting of the more severe side, pressure measurements in the transverse and sigmoid sinuses on the other side are done.
Many internet users are concerned about the effectiveness of interventional treatment of tinnitus with venous sinus pulsation.
The technical problems of interventional stenting have been basically solved, and in nearly 100 cases done, the tinnitus has completely disappeared within a few days after the procedure; the longest follow-up is currently 6 years, and there has been no recurrence. The risks of surgery are theoretically always present, but there have been no adverse events so far. The procedure requires antiplatelet agents for 2-3 months and warfarin anticoagulation for 6 months; there have been no significant drug side effects either. Regarding the cost, the cost of treatment for simple venous pulsatile tinnitus is around 40,000-50,000 RMB; whether the medical insurance can reimburse is mainly determined by the local medical insurance department.
After stentoplasty for venous sinus stenosis, it is advisable to have a lumbar puncture to measure the intracranial pressure if there is any swelling of the head or blurred vision, or at the 3-month review. Normally, the cranial pressure should not be higher than 200 mmH2O; if it is high, the stenosis may recur and a brain DSA is needed to determine whether there is restenosis in the stent.
No stent restenosis or blockage has been encountered; if intracranial hypertension has already occurred before surgery, postoperative recovery will take some time; it is better to do regular lumbar puncture to determine the extent of the condition, and then it is also more accurate to choose the appropriate symptomatic treatment.
Since most doctors are familiar with the treatment of arterial lesions, there are many places to consult. However, most otologists and surgeons are relatively unfamiliar with tinnitus caused by venous lesions, so the statements and explanations are more confusing. I have several professional papers on pulsatile tinnitus that have been published in authoritative journals in China and abroad, and should have considerable recognition. The barcode of the papers is attached to the bottom of this letter, so if you are interested, you are recommended to consult and give corrections; you can also consult with the relevant doctors at your local hospital about the condition and treatment of tinnitus. Of course, you can also approach me directly online and at the hospital, and I will try my best to give you a more satisfactory answer. The purpose is for us to collaborate and deal with our common persistent enemy, pulsatile tinnitus, together.