An otoneurosurgical approach to non-pulsatile and pulsatile tinnitus

Most treatments proposed for tinnitus are non-surgical, to such an extent that it is sometimes forgotten that a certain number of patients with tinnitus may benefit from a surgical solution. The aim of this paper is to review the possible otoneurosurgical approaches in tinnitus treatment, treating the tinnitus causally or symptomatically.

A Pubmed search on the words "surgery", "tinnitus" and "pulsatile" was performed and compared to the authors' personal experience with surgical approaches for alleviating tinnitus. The most relevant different pathologies presenting as pulsatile and non-pulsatile tinnitus are given and possible otoneurosurgical approaches for these identities summarised.

Non-pulsatile tinnitus can be the clinical expression of vestibular schwannomas and other cerebellopontine angle lesions, arachnoid cysts, Ménière's disease, otosclerosis, brain tumours along the auditory pathways, Chiari malformations and microvascular compressions of the vestibulocochlear nerve. Symptomatic improvement of non-pulsatile tinnitus can also be obtained by electrical stimulation of the cochlea, auditory nerve or cortex. Pulsatile tinnitus can present as a venous hum resulting from benign intracranial hypertension, Chiari malformation and a high jugular bulb. Arterial-pulse-synchronous tinnitus can be caused by benign intracranial hypertension, arteria carotid stenosis, glomus tumours, vascular lesions of the petrous bone and skull base, ateriovenous malformations, aneurysms, and vascular loops inside the internal auditory canal.

Before people are told "to learn to live with their tinnitus" a thorough exploration of possible cause and potential surgical treatments should be provided for patients presenting with incapacitating tinnitus.