pulstaile tinitus radiology

BY DR AHMED HAMDY

A LECTURER - ASWAN SCHOOL OF MEDICINE

TINNITUS

TINNITUS Introduction Classification

Pulsatile tinnitus Imaging findings Checklist Quiz

IntroductionThe perception of sound in the absence of external stimuliTinnire = ldquoringingrdquo in Latin

Unilateral or bilateral First or only symptom of a disease process or auditorypsychological

annoyance 40 million affected in the United Stateshellip 10 million severely affected

hellip Suicide Most common in 40-70 year-olds The evaluation of a patient with tinnitus requires a detailed history

neurootologic physical examination with otoscopy a comprehensive audiologic evaluation with hearing thresholds and imaging studies

Classification

SUBJECTIVE TINNITUS sound is only perceived by the patient (most common)

OBJECTIVE TINNITUSsound produced by paraauditory structures which may be heard by

an examiner often PULSATILE

Subjective TinnitusSubjective Tinnitus

bull Most common type of tinnitusbull Only heard by the patientbull Associated symptoms depend on cause

bull Vertigo ndash superior semicircular canal dehiscence amp Menierersquos disease

bull Conductive hearing loss ndash otosclerosis amp superior semicircular canal dehiscence

bull Sensorineural hearing loss ndash vestibular schwannoma presbyacusis amp noise induced hearing loss

Objective TinnitusObjective Tinnitus

bull An actual sound made by the human bodybull Physical explanation for perceived noisebull Often due to a vascular processbull Can be due to other physiologic sounds

bull Muscular contractions (palatal myoclonus ndash clicking)

bull Respiration (patulous Eustachian tube)bull Venous hum (flow murmurs)

bull Frequently can be perceived by an observer

PulsatilePulsatile TinnitusTinnitus

bull Can be altered with compression of arterial or venous structuresbull Can be perceived by the examiner if stethoscope placed in the

right locationbull Can be venous or arterialbull Tends to produce whooshing soundbull Cardiac rhythm synchronous

Pulsatile Tinnitus Pulsatile Tinnitus CausesCauses1- CONGENITAL VASCULAR MALFORMATIONS

A- Arterial- Aberrant internal carotid artery (ICA) persistent stapedial artery lateralised internal carotid artery Fibromuscular dysplasia

B- Venous- High-riding jugular bulb Dehiscences jugular bulb Jugular venous diverticula laterally placed sigmoid sinus Abnormal mastoid emissary veins

2- ACQUIRED VASCULAR ABNORMALITIES Petrous carotiud aneursm Carotico-cavernous fistula Dural Artero-venous Malformation Vascular loop syndrome Carotid artery dissection occlusion atherosclerosis

stenosis

Sigmoid sinus wall anomalies

Pulsatile Tinnitus Pulsatile Tinnitus CausesCauses

3- VASCULAR TUMORS Paragangliomas (glomus tympanicum or glomus jugulare) Metastasis

4- NARROWING OF THE TRANSVERSE SINUS Pseudotumor cerebri Transverse sinus Jugular thrombosis

5- MISCELLANEOUS Superior semicircular canal dehiscence Otospongiosis Inflammatory hyperemia diseases (mastoiditis - Pagetrsquos

disease)

Collins RD Algorithmic diagnosis of symptoms and signs a cost-effective approach 2d ed Philadelphia Lippincott Williams amp Wilkins 2003568-9

ENT Referral

ENT Referral

Imaging Findings Associated Imaging Findings Associated withwith

Pulsatile Tinnitus Pulsatile Tinnitus

Imaging OptionsImaging Optionsbull Overall radiologic imaging is effective in detecting

causes of pulsatile tinnitus in approximately 70 of cases

bull High-resolution contrast-enhanced CT or MRI are reasonable options and are regarded as the imaging modalities of choice

bull In the absence of objective pulsatile tinnitus CTA or MRA are appropriate initial exams

bull If there is suspicion for arterio-venous fistulas angiography should be performed

A variant of the internal carotid artery (ICA) Involution absence of the normal cervical portion

(first embryonic segment) of the ICA

Enlargement of the usually small collaterals passes lateral to the cochlear promontory and appears during otoscopic examination as a retro-tympanic vascular mass

Aberrant Internal Carotid Aberrant Internal Carotid Artery Artery

If mistaken for a paraganglioma and biopsied theresults can be FATAL

C2= three sections vertical the genu bendhorizontal portion

Normal Caro

tid canal

Aberrant ICA

Radiographic features

A deficient bony plate along the tympanic portion of the ICA (aberrant ICA) is a normal variant and can be mistaken with glomus jugulare

Left aberrant ICA entering the middle ear cavity through an enlarged inferior tympanic canaliculus (arrows)

Failure of regression of the embryonic stapedial arteryThe stapedial artery is an embryological vessel arising from the primitive second aortic arch that divides into a dorsal branch (the future middle meningeal artery) and a ventral division (future maxillary and mandibular arteries) These divisions link with branches developing from the external carotid artery during the third fetal month causing the stapedial artery to regressIf the stapedial artery persists in postnatal life the middle meningeal artery arises from it thus the foramen spinosum (normally containing the middle meningeal) is absent

Radiographic featuressmall canaliculus origniating from petrous segment of internal carotid artery linear soft tissue density crossing over cochlear promontoryenlarged facial nerve canal or separate canal parallel to facial nerveaplastic or hypoplastic foramen spinosummay be normal variant or in instances where middle meningeal artery arises from ophthalmic artery

The vessel is important to recognize as it can be confused on examination with vascular tumours such as glomus tympanicum It should not be biopsed as it will bleed profusely

The persistent stapedial artery The persistent stapedial artery (PSA)(PSA)

Related pathologymay be associated with aberrant ICA which is formed when inferior tympanic artery anastomosis with the caroticotympanic artery enlarged inferior tympanic canaliculus is then seenmay be associated with other middle ear anomales

Coronal CT image shows the left internal carotid artery within the

hypotympanum (arrow)

Aberrant Carotid Artery amp Aberrant Carotid Artery amp Persistent Stapedial ArteryPersistent Stapedial Artery

Axial CT image shows the stapedial artery passing through the obturator

foramen (arrow)

Lateralised internal carotid Lateralised internal carotid arteryarteryThe lateralised internal carotid artery is an anatomic variation of the course

of the horizontal internal carotid artery (ICA) It can be visualised on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum It may result in pulsatile tinnitus

Radiographic features CTa lateralised ICA passes underneath the cochlea in the hypotympanumfocal thinned or dehiscent lateral wall of the carotid canalTHE INFERIOR TYMPANIC CANALICULUS IS NOT AFFECTED

Differential diagnosis aberrant internal carotid artery usually courses across the middle ear along the cochlear promontory and shows an enlarged inferior tympanic canaliculus

the lateralised internal carotid artery is an anatomic variation of the course of the horizontal internal carotid artery (ICA) It can be visualized on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum It may result in pulsatile tinnitus

Radiographic features CT a lateralised ICA passes underneath the cochlea in the hypotympanum focal thinned or dehiscent lateral wall of the carotid canal the inferior tympanic canaliculus is not affected

Heterogeneous group of vascular lesions characterized by an idiopathic non-inflammatory and non-atherosclerotic angiopathy of small and medium-sized arteriesFibromuscular Dysplasia is an arteriopathy that may lead to stenosis aneurysm and dissection most common in young females Pulsatile tinnitus is a presenting symptom in approximately one-third of patients and is associated with a pattern of multi-vessel involvement increased involvement of the cervical carotid andor vertebral arteries and cervical artery dissectionThe characteristic finding is alternating stenoses and dilatations causing a string of beads appearance

Fibromuscular dysplasia Fibromuscular dysplasia (FMDFMD)

Beaded appearance of the internal carotid arteries at the C1 to C2 level greater on the left than the right Finding is typical of fibromuscular dysplasia

Coronal MRA MIP image shows a beaded appearance of the right internal carotid artery (arrow) Axial MRA MRIP images shows narrowing of the right petrous internal carotid artery (arrow) due to dissection

The jugular bulb is often asymmetric with the right jugular bulb usually being larger than the left If it reaches above the posterior semicircular canal or IAM high jugular bulb

If the bony separation (sigmoid plate) between the jugular bulb and the middle ear is absent Dehiscent jugular bulb

Rarely an outpouching is seen Jugular bulb diverticulum

A HIGH RIDING JUGULAR BULBamp

Dehiscent Jugular bulbamp

Jugular bulb diverticulum

Sigmoid Sinus Wall Anomalies

Pulse-synchronous tinnitus (PST) arises from the abnormal self-perception of onersquos own vascular flow and can arise from a number of venous and arterial abnormalities

Venous PST is more commonly encountered in clinical practice than arterial PST

Sigmoid wall anomalies (SWA) are an increasingly recognized cause of venous PST SWA include sigmoid sinus thinning dehiscence diverticulum and ectasia

Sigmoid wall anomalies include attenuation of the sinus plate frank dehiscence resulting in exposure of the sinus to the air in the mastoid air cells diverticula and segmental sigmoid sinus ectasia

Thin plate of bone between a high riding jugular bulb and the middle ear cavity or more generally as the thin bone separating the sigmoid sinus from adjacent structures (especially mastoid air cells) The wall of the vein can protrude through a defect into the middle ear creating a dehiscent jugular bulb

THE SIGMOID PLATE

IAM include facial nerve vestibulocochlear nerve labyrinthine artery (usually a branch of the AICA or basilar artery)

High jugular bulb

Dehiscent Jugular bulb

Large left jugular bulb It is not a high riding bulb by definition since it does not extend cranial to the IAM But note the deficient sigmoid plate allowing the jugular vein to almost protrude into the middle ear

Both jugular bulbs show dehiscence into medial wall of middle ear with absence of intervening bony plate These bulbs are however not high riding


Venous Sinus Dehiscences amp Venous Sinus Dehiscences amp DiverticulaDiverticula

Axial and coronal CT images show right sigmoid sinus diverticulum and dehiscences involving the mastoid air cells and mastoid cortex

(arrows)


bull Sigmoid sinus diverticulum and dehiscence is perhaps the most common identifiable cause for pulsatile tinnitus of venous origin with a prevalence of 23 in symptomatic patients

bull Dehiscence of the sigmoid sinus can involve erode into the mastoid air cells or the mastoid cortex or both

It passes inferiorly in an S shaped groove posteromedial to the mastoid air-cells to the jugular foramen where it ends in the jugular bulb in the posterior half of the foramen (pars vascularis) It has connections via mastoid and condylar emissary veins with pericranial veins

The jugular foramen courses anteriorly laterally and inferiorly as it insinuates itself between the petrous temporal bone and the occipital bone

The jugular foramen is usually described as being divided into two parts by a fibrous or bony septum called the jugular spine intothe pars nervosa anteromedial and smallerthe pars vascularis posterolateral and larger

Mastoid emissary vein (MEV)

sending or coming out as certain veins that pass through the skull and connect the venous sinuses inside with the veins outside


A three-dimensional volume-rendered image (posterior view) (b) shows the MEV draining into the posterior auricular vein (PAV) and PAV draining into the suboccipital venous plexus on the left side

A posterior condylar vein emerges from its canal on the right side

posterior fossa emissary veins in a patient with a hypoplastic sigmoid sinus and internal jugular vein External connections of emissary veins are indicated by the blue arrows and bold white letters DCV deep cervical vein EJV external jugular vein IJV internal jugular vein JB jugular bulb LCV lateral condylar vein MEV mastoid emissary vein OEV occipital emissary vein PAV posterior auricular vein PCV posterior condylar vein PSS petrosquamosal sinus RMV retromandibular vein SOVP suboccipital venous plexus SS sigmoid sinus SSS superior sagittal sinus TS transverse sinus VAVP vertebral artery venous plexus

Para-GangliomaPara-Ganglioma

A) Glomus TympanicumA) Glomus Tympanicum

Axial CT images shows a soft tissue opacity in the middle ear along the cochlear promontory (arr0w) The coronal post-contrast T1-weighted MRI shows avid enhancement

in the lesion (arrow) Catheter digital subtraction angiography shows marked hypervascularity in the lesion (arrow)

Glomus TympanicumGlomus Tympanicum

bull Often apparent on otoscopic examination as a pulsating reddish mass the role of imaging is to differentiate these from glomus jugulotympanicum

bull Most glomus tympanicum tumors arise on the cochlear promontory

bull CT without contrast is adequate for delineating the extent of the tumor

bull Avid enhancement and a ldquosalt and pepperrdquo appearance can be observed on MRI

RT middle ear cavity glomus tympanicum paraganglioma (red arrow) located just anterior to the cochlear promontory (blue arrow)


Temporal Bone MetastasesTemporal Bone Metastases

Initial presentation of prostate cancer as pulsatile tinnitus due to a metastasis The CT CTA and post-contrast T1-weighted MRI show a

lytic enhancing mass (arrows) in the left temporal bone with associated compression of the left jugular bulb (oval)

bull Rare cause of pulsatile tinnitus due to vascular impingement or tumor hyperemia

bull The presence of accompanying new cranial nerve deficits should raise the suspicion for a malignancy

bull Serial scanning in patients at high risk of metastatic disease may be warranted


ARTERIOVENOUS MALFORMATIONS AND FISTULAS

bullPetrous carotiud aneursmbullCarotico-cavernous fistulabullDural Artero-venous Malformation

Petrous Carotid AneurysmPetrous Carotid Aneurysm

Coronal CT image shows an expansile lesion of the right petrous

carotid canal (arrow)

Catheter angiogram reveals an aneurysm of the horizontal petrous

carotid artery (arrow)


bull Most petrous aneurysms are large and fusiform and believed to be congenital in origin

bull Other etiologies for petrous aneurysms are radiation injury trauma and infection

bull Otologic manifestations include conductive and sensorineural hearing loss and tinnitus with rupture seen in 25 as initial presentation

bull Endovascular treatment is the mainstay of treatment

Dural Arteriovenous Dural Arteriovenous FistulaFistula

The patient presented with a retroauricular bruit and had a remote history of temporal bone trauma The 3D hybrid CTA image shows a prominent occipital artery (arrow) that drains into the junction of the

left transverse sinus with the sigmoid sinus

Dural Arteriovenous FistulaDural Arteriovenous Fistula

bull Related to trauma prior craniotomy or dural sinus thrombosisbull Classified according to direction of flow and presence or absence

of cortical venous drainagebull Most common locations CAVERNOUS transverse amp sigmoid

sinusesbull Findings may be subtle on cross sectional imaging and requires

high index of suspicion

Pseudotumor CerebriPseudotumor Cerebri

Sagittal T1-weighted MRI shows an enlarged partially empty sella in a young obese female The MRA MIP shows constriction of the bilateral transverse

sinuses (arrows) The axial T2-weighted MRI shows mild bulging of the bilateral optic nerve discs (arrows)

Coronal FIESTA MRI show a vascular structure (arrow) impinging upon the right cranial nerve 7 and 8 complex (arrowhead)

Vascular Loop SyndromeVascular Loop Syndrome


bull Pulsatile tinnitus can be caused by arterial or venous vascular loops and may be accompanied by vertigo

bull Impingement upon the cranial nerve 7 and 8 complex in the cerebellopontine angle cistern or internal auditory canal can best be observed on FIESTACISSDRIVE MRI sequences

bull May be treated successfully by microvascular decompression

Vascular compression syndrome in the cerebellopontine angle cistern

Axial 3D-FIESTA MR images through the eighth CN show the following AICA (Anterior inferior cerebellar artery) loop within the right IAC vascular loop extending into gt50 of the IAC (Type III)

Axial 3D CISS image showing (A) a linear structure originating from the basilar artery corresponding to the left anterior inferior cerebellar artery (white arrow) which loops around the cisternal portion of left VIIth and VIIIth nerve (white arrow) (B) The VIIth nerve is not well-visualized as the vascular loop causes overlapping of the structure

Pseudotumor Cerebri Pseudotumor Cerebri (Idiopathic intracranial hypertension (IIH)(Idiopathic intracranial hypertension (IIH)

( Benign intracranial hypertension)( Benign intracranial hypertension)

Syndrome with signs and symptoms of increased intracranial pressure but where a causative mass or hydrocephalus is not identified

The older term benign intracranial hypertension is generally frowned upon due to the fact that some patients with IIH have a fairly aggressive clinical picture with rapid visual loss

Interestingly as it has become evident that at least some patients present with IIH due to identifiable venous stenosis some authors now advocate reverting to the older term pseudotumour cerebri as in these patients the condition is not idiopathic 15 An alternative approach is to move these patients into a group termed secondary intracranial hypertension 15 Venous pulsatile tinnitus can result from conditions associated increased intracranial pressure

Characteristic neuroimaging findings for pseudotumor cerebri (Idiopathic intracranial hypertension) include a partially empty sella constriction of the transverse sinuses and optic nerve disc and optic nerve sheath cerebrospinal fluid prominence

Both optic nerves showflattening of the posterior sclera (dashed lines) protrusions of the optic nerve heads (red arrows)prominent subarachnoid space around the optic nerves(yellow arrows)vertical tortuosity of the optic nerves

OPTIC NERVESprominent subarachnoid space around the optic nerves (~45)vertical tortuosity of the optic nerves (~40)papilloedema flattening of the posterior sclera (~80)intraocular protrusion of the optic nerve headenhancement of the prelaminar (intra-ocular) optic nerves (~50)

enlarged arachnoid out-pouchings partial empty sella turcica (~70) enlarged Meckel cave 9

prominent arachnoid pits small meningocoeles typically within the temporal bone and sphenoid wing

bilateral venous sinus stenosislateral segments of the transverse sinusesno evidence of current or remote thrombosis 8

slitlike ventricles (relatively uncommon compared to other findings) 15

acquired tonsillar ectopia (mimicking Chiari I malformation)

Atherosclerotic DiseaseAtherosclerotic DiseaseNew pulsatile tinnitus due to new basilar artery steno-occlusive disease (arrow)

Initial MRI MIP MRI MIP 8 years later

bull Pulsatile tinnitus can be the first manifestation atherosclerotic disease

bull Most commonly associated with significant stenosis of the internal carotid arteries

bull Both the head and neck vasculature should be covered on imaging

Atherosclerotic DiseaseAtherosclerotic Disease

Miscellaneous

Superior Semicircular Superior Semicircular Canal Dehiscence Canal Dehiscence syndromesyndromeA recently described inner ear abnormality where a clinical disequilibrium

phenomenon is associated with absence of the bony covering of the superior semicircular canal (SSC)

Dehiscence of the SSC forms a third window into the inner ear in addition to the round and oval windows This allows motion of the endolymph to be induced by sound and pressure stimuli 2

Pulsatile tinnitus results from transmission of the normal pulse-related pressure changes within the cranial cavity to the inner ear

Temporal bone CT is the modality of choice for diagnosing superior semicircular canal dehiscence by the lack of overlying bone particularly via Stenver and Poumlschl views

Rating of the bone covering the SSC used for the 1-mm-collimated CT scans in the control subjects with normal temporal bones(a)Coronal 1-mm-collimated CT scan through the left temporal bone shows clearly intact bone (arrow) over the left SSC(b) Coronal 1-mmcollimatedCT scan through the left temporal bone demonstrates an area of possible bone dehiscence (arrow) over the SSC (c) Coronal 1-mm-collimated CT scan through the right temporal bone demonstrates a region of bone dehiscence (arrow) over the SSC

The patient presented with dizziness pulsatile tinnitus hyperacusis otalgia and fullness in the right ear Stenver and Poumlschl CT images show deficiency of bone along the apex of the right superior semicircular canal (arrows)

CT scan sagittal projections showed bilateral dehiscence of posterior semicircular canal in right ear (3c) and left ear (3d) and unilateral right dehiscence of the superior semicircular canal (3a white arrow) White arrows in 3b instead show the bone covering the left superior semicircular canal

OtospongiosisOtospongiosis

Axial CT images shows extensive demineralization of the otic capsule (arrows)


bull Otospongiosis contains arteriovenous microfistulas which can lead to pulsatile tinnitus

bull Demineralization in the region of the fissula ante fenestram andor otic capsule can be observed on CT

bull The affected areas display enhancement due to the vascular

nature of otospongiosis

Inflammatory and Inflammatory and Hypermetabolic ConditionsHypermetabolic Conditions

Otomastoiditis The MRI shows enhancement throughout the right mastoid air cells and an epidural

abscess (arrow)

Paget disease Sagittal CT image show diffuse expansion of the skull diplopic space and lucency of the otic capsule

(arrow)

bull Infectious and inflammatory processes in and around the temporal bone including mastoiditis and Paget disease can lead to pulsatile tinnitus due to increased regional blood flow

bull Otomastoiditis appears opacification on CT and associated enhancement of the mucosa and sometimes the bone marrow is apparent on MRI

bull Paget disease has variable imaging manifestations depending upon the stage of disease but can appear as bone marrow expansion and demineralization on CT during the active phase with pulsatile tinnitus cranial nerve deficits and Eustachian tube dysfunction


Quiz

18-year-old male with right pulsatile tinnitus

34 year-old female with right pulsatile tinnitus


44 year-old female with left pulsatile tinnitus

Axial CT shows ectatic left sigmoid sinus with thinning of the left sigmoid plate without a focal diverticulum

41 year-old female with right tinnitus

38 year-old female with right PST

Case senirohellipTransmastoid approach for sigmoid sinus wall repair Intraoperative findings

(A) Appearance of a right sigmoid sinus diverticulum during transmastoid surgery Yellow lines outline of normal sigmoid sinus Blue oval diverticulum (B) Post-reduction of diverticulum Metal suction tip sitting on the wall of the sigmoid sinus through a hole in the bone after diverticulum reduction (C) Post-repair of sinus wall Tissue graft reinforcing the wall of the sigmoid sinus sitting deep to the bone on the sinus wall through the hole in the bone Following this step the hole itself is repaired with synthetic bone cement (Hydroset) and bone pate made from the patientrsquos own bone

A B C

Postoperative imaging findings CT

Axial CT image of the temporal bone on soft tissue window (A) demonstrates relatively hypoattenuating material (arrows) lateral to the hyperattenuating contrast enhanced sigmoid sinus (B) On bone windows hydroset material is identified as sharply demarcated hyperdense material (asterisk) conforming to the size and shape of dehiscence Bone pate is identified lateral to the hydroset as amorphous ill-defined hyperdensity (arrow)

A B

CHECKLISTS

of imaging findings in various anatomical

compartments

Epicraniumndash Dilatation of branches of the external carotid artery (in dural arteriovenous fistulas)

Neckndash Vascular stenosis (arteriosclerosis fibromusculardysplasia)ndash Vascular dissectionndash Aneurysmndash Carotid or vagal paragangliomandash Jugular vein abnormality

Temporal bonendash Aberrant or dehiscent internal carotid arteryndash Persistent stapedial arteryndash Anatomical variantsabnormalities of the jugular bulbndash Tympanicjugular paragangliomandash Other strongly vascularized tumor of the temporal bonendash Otosclerosisndash Otitisndash Semicircular canal dehiscencendash Labyrinth fistulandash Meningocele meningoencephalocelendash Cholesterol granuloma

Other skullndash Strongly vascularized tumor vessel-rich metastasisndash Pagetrsquos diseasendash Empty sellandash Large emissary veinndash Dilated transossial vascular canals (in dural arteriovenousfistulas)

Dura materndash Dural arteriovenous fistula

ndash Sinuvenous thrombosis

ndash Stenosis or diverticulum of dural sinus

Endocraniumndash Space-occupying lesion

ndash Disturbance of CSF circulation

ndash Craniocervical transition disorder

ndash Vascular loops in the internal auditory meatus

ndash Pial arteriovenous vascular malformation

ndash Venous congestion (in dural arteriovenous fistulas)

Thanks for your time

TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus

Pulsatile Tinnitus Causes

Slide 9

PowerPoint Presentation

Slide 11

Imaging Findings Associated with Pulsatile Tinnitus

Imaging Options

Slide 14

Aberrant Internal Carotid Artery

Slide 16

Slide 17


Slide 23

Failure of regression of the embryonic stapedial artery The stapedial artery is an embryological vessel arising from the primitive second aortic arch that divides into a dorsal branch (the future middle meningeal artery) and a ventral division (future maxillary and mandibular arteries) These divisions link with branches developing from the external carotid artery during the third fetal month causing the stapedial artery to regress If the stapedial artery persists in postnatal life the middle meningeal artery arises from it thus the foramen spinosum (normally containing the middle meningeal) is absent Radiographic features small canaliculus origniating from petrous segment of internal carotid artery linear soft tissue density crossing over cochlear promontory enlarged facial nerve canal or separate canal parallel to facial nerve aplastic or hypoplastic foramen spinosum may be normal variant or in instances where middle meningeal artery arises from ophthalmic artery The vessel is important to recognize as it can be confused on examination with vascular tumours such as glomus tympanicum It should not be biopsed as it will bleed profusely

Related pathology may be associated with aberrant ICA which is formed when inferior tympanic artery anastomosis with the caroticotympanic artery enlarged inferior tympanic canaliculus is then seen may be associated with other middle ear anomales

Aberrant Carotid Artery amp Persistent Stapedial Artery

Lateralised internal carotid artery

Slide 28

Heterogeneous group of vascular lesions characterized by an idiopathic non-inflammatory and non-atherosclerotic angiopathy of small and medium-sized arteries Fibromuscular Dysplasia is an arteriopathy that may lead to stenosis aneurysm and dissection most common in young females Pulsatile tinnitus is a presenting symptom in approximately one-third of patients and is associated with a pattern of multi-vessel involvement increased involvement of the cervical carotid andor vertebral arteries and cervical artery dissection The characteristic finding is alternating stenoses and dilatations causing a string of beads appearance


Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Venous Sinus Dehiscences amp Diverticula


Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52

A) Glomus Tympanicum

Glomus Tympanicum

Slide 55


Temporal Bone Metastases

Slide 58

Slide 59

Petrous Carotid Aneurysm

Slide 61

Dural Arteriovenous Fistula

Slide 63

Pseudotumor Cerebri

Slide 65

Vascular Loop Syndrome


Slide 68

Slide 69

Pseudotumor Cerebri (Idiopathic intracranial hypertension (IIH) ( Benign intracranial hypertension)

Slide 71

OPTIC NERVES prominent subarachnoid space around the optic nerves (~45) vertical tortuosity of the optic nerves (~40) papilloedema flattening of the posterior sclera (~80) intraocular protrusion of the optic nerve head enhancement of the prelaminar (intra-ocular) optic nerves (~50) enlarged arachnoid out-pouchings partial empty sella turcica (~70) enlarged Meckel cave 9 prominent arachnoid pits small meningocoeles typically within the temporal bone and sphenoid wing bilateral venous sinus stenosis lateral segments of the transverse sinuses no evidence of current or remote thrombosis 8 slitlike ventricles (relatively uncommon compared to other findings) 15 acquired tonsillar ectopia (mimicking Chiari I malformation)

Slide 73

Atherosclerotic Disease

Slide 75

Miscellaneous

Superior Semicircular Canal Dehiscence syndrome

Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83

Inflammatory and Hypermetabolic Conditions

Slide 85

Quiz

Slide 87

Slide 88







Case senirohellip Transmastoid approach for sigmoid sinus wall repair Intraoperative findings


CHECKLISTS of imaging findings in various anatomical compartments

Slide 98

Slide 99

Slide 100

Slide 101

TINNITUS Introduction Classification

Pulsatile tinnitus Imaging findings Checklist Quiz






Classification





















stenosis






disease)


ENT Referral

ENT Referral














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101






Classification





















stenosis






disease)


ENT Referral

ENT Referral














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101


















stenosis






disease)


ENT Referral

ENT Referral














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101





disease)


ENT Referral

ENT Referral














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101


ENT Referral

ENT Referral














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101














Normal Caro

tid canal

Aberrant ICA













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101













foramen (arrow)























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101























THE SIGMOID PLATE


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101


High jugular bulb







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101







(arrows)


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101


















































































Miscellaneous


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101


















abscess (arrow)


(arrow)





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101





Quiz










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101










A B C



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101



A B

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101

CHECKLISTS


compartments















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101















TINNITUS

Slide 2

Introduction

Classification

Subjective Tinnitus

Objective Tinnitus

Pulsatile Tinnitus


Slide 9


Slide 11


Imaging Options

Slide 14


Slide 16

Slide 17


Slide 23





Slide 28



Slide 31

Slide 32


Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40



Slide 43

Slide 44

Slide 45

Slide 46

Slide 47


Slide 49

Slide 51

Slide 52


Glomus Tympanicum

Slide 55



Slide 58

Slide 59


Slide 61


Slide 63

Pseudotumor Cerebri

Slide 65



Slide 68

Slide 69


Slide 71


Slide 73


Slide 75

Miscellaneous


Slide 78

Slide 79

Slide 80

Slide 81

Otospongiosis

Slide 83


Slide 85

Quiz

Slide 87

Slide 88










Slide 98

Slide 99

Slide 100

Slide 101

pulstaile tinitus radiology

Science