Surgical Causes Of Tinnitus And Their Management

What is tinnitus?

Tinnitus is the perceived sensation of sound in the absence of a corresponding external acoustic stimulus. Tinnitus sensations are usually of an unformed acoustic nature such as a buzzing, hissing, or ringing. Tinnitus is classified as objective tinnitus if a sound is generated in the body and is also audible by the examiner (myoclonic contractions of the tensor tympani muscle or altered blood flow in vessels near the ear), or as subjective tinnitus, which is much more common, if it does not have a specific inner-body sound source.(1)

What are the causes of tinnitus?

Figure: Problems Causing Tinnitus

The causes of tinnitus vary from simple reason such as impacted wax to skull base tumors. Presentation, experience and causes of tinnitus are numerous and varied. The below chart explains some of the common causes of tinnitus. (2)

Figure: Most Common Causes of Tinnitus

When is surgery a treatment option for tinnitus?

The causes of tinnitus are numerous, in that there are conditions where in an underlying pathology treated surgically can be a cure for tinnitus. These conditions warrant a surgical treatment for tinnitus. We will explore few of these conditions where surgery has a definitive role in management of tinnitus.

1. Surgery is considered if it can improve hearing in cases such as chronic otitis media with tinnitus – where tympanoplasty can resolve the problem.

Patients have complaints of ear discharge, decreased hearing and tinnitus where the treatment to eradicate the middle ear disease and restore the hearing process might benefit the tinnitus symptom.

Figure: Image depicts case of cholesteatoma of left side with tympanoplasty both the pre op image of the HRCT temporal bone and intra op picture.

2. Otosclerosis- where stapes surgery in majority of the patients resolves tinnitus and improves hearing.

Women are commonly affected and have decreased hearing with tinnitus in one or both ear – where the bone metabolism is affected. Here surgery of the stapes to mobilize the ossicular chain can improve hearing and resolve tinnitus.

Figure: Image depicts a case of otosclerosis with pre-op image of HRCT temporal bone and the intra-op image of stapedotomy with piston.

3. Objective tinnitus due to middle ear myoclonus- surgical section of tensor tympani or stapedial tendon can help the patient.

Patients have tinnitus due to repetitive contractions of the middle ear muscles i.e., tensor tympani or stapedius muscle. Here surgical resection of the muscles i.e., tenotomy can resolve the tinnitus.

4. Pulsatile tinnitus due to presence of vascular loop in the vicinity of cochlear nerve- microvascular decompression can benefit the individual.

Patients have tinnitus due to compression of the eight-nerve due to a vascular loop around the nerve intracranially- this needs to be surgically resolved and the nerve decompressed.

5. Pulsatile tinnitus of venous origin- ligation of internal jugular vein, occlusion of sigmoid sinus, closure of Dural fistula.

Patients having tinnitus secondary to any abnormality of the venous system eg. glomus jugular, sigmoid sinus diverticulum, Dural fistulas ect. need treatment of the primary condition for resolving the tinnitus.

Figure: Image depicts a case of left Tympanojugular paraganglioma with OSIA implantation for hearing rehabilitation.

6. Tumors of the eight nerve like Vestibular Schwannoma – Surgical excision by different approaches depending on the individual patient factors.

Vestibular schwannoma is tumor of the CP angle which along with other debilitating symptoms can cause tinnitus – here removal of the tumor through different approaches is the primary treatment.

Figure: Case of giant vestibular schwannoma with pre-op image MRI and intra-op image depicting the tumor excision.

7. Patients with Meniere’s disease can have relief from tinnitus with certain surgical options – endolymphatic sac surgery, labyrinthectomy, vestibular neurectomy.

This is due to an inner ear disorder where patients can have vertigo, hearing loss, fullness along with tinnitus. If the symptoms are persistent even after medical treatment and are severe then destructive procedures like endolymphatic sac surgery, labyrinthectomy and vestibular neurectomy can be considered.

8. Temporomandibular joint disorders- surgical options range from arthroscopy to partial or total TMJ implant.

9. Hearing loss associated with tinnitus with no organic cause can be treated with cochlear implant provided the candidate meets the criteria.

In patients with profound hearing loss and tinnitus cochlear implantation can be considered as a form of treatment provided the candidate meets the strict criteria for the eligibility.

What is the management protocol?

The flow chart below describes the protocol in decision making for surgical management of tinnitus in brief: (3)

References:

1. Langguth B, Kreuzer PM, Kleinjung T, De Ridder D. Tinnitus: causes and clinical management. Lancet Neurol. 2013 Sep;12(9):920-930. doi: 10.1016/S1474-4422(13)70160-1. PMID: 23948178.

2. Wu, Vincent & Cooke, Bonnie & Eitutis, Susan & Simpson, Matthew & Beyea, Jason. (2018). Approach to tinnitus management. Canadian family physician Medecin de famille canadien. 64. 491-495.

3. Soleymani, Teo & Pieton, David & Pezeshkian, Patrick & Miller, Patrick & Gorgulho, Alessandra & Pouratian, Nader & De Salles, Antonio. (2011). Surgical approaches to tinnitus treatment - Review and novel approaches. Surgical neurology international. 2. 154. 10.4103/2152-7806.86834.