Russell EJ, Wiet R, Meyer J
Departments of Radiology and Otolaryngology/Head and Neck Surgery, Northwestern Memorial Hospital and Northwestern University Medical School, Chicago, Illinois, USA.
Int Tinnitus J. 1995;1(2):127-137.
Subjective tinnitus is a common problem with many etiologies. Objective tinnitus, in which the sound is perceived by both the patient and the examiner, is less common. Objective tinnitus of the vascular type, in which a pulse synchronous bruit is heard by an independent observer, is frequently related to an underlying arterial or arteriovenous malformation, most commonly a dural arteriovenous fistula (DAVF) involving the transverse and sigmoid sinuses. The remaining cases are usually termed "essential" vascular tinnitus, and are presumed to have a venous etiology. In these cases, the audible noise is generally assumed to be produced within the sino-jugular connection, or within an enlarged jugular bulb. We present four documented cases of objective pulse synchronous tinnitus due to focal narrowing (acquired and developmental) of the mid-portion of the transverse dural sinus. In all cases, a bruit was audible directly over a focal constriction in the sinus, demonstrated by cerebral angiography or direct catheter venography. In one case, selective venography revealed a distensible sinus narrowing, associated with a jet of contrast marking fast flow within a developmental sinus segmentation. In another case, a loud pulse synchronous bruit was heard directly over a focal transverse sinus stenosis, which was detected by angiography at the site of a vascular surgical clip. In this case, magnetic resonance (MR) falsely predicted sinus occlusion. In two other cases, an audible bruit was also heard directly overlying a narrowed transverse sinus, seen in the venous phase of angiography. Transverse sinus stenosis is an unappreciated cause of objective pulsatile tinnitus, and we believe that this mechanism may underlie many cases of "essential" or venous etiology tinnitus not otherwise anatomically explained. Non-invasive testing, computed tomography (CT) and MR and non-directed angiography may overlook it. Conventional catheter arteriography or venography should be performed in such cases, with attention to the dural sinuses, if other tests fail to define the anatomic basis of the audible bruit.
主观性耳鸣是一种病因众多的常见问题。客观性耳鸣（即患者和检查者都能感知到声音）则较为少见。血管型客观性耳鸣（独立观察者可听到与脉搏同步的杂音）常与潜在的动脉或动静脉畸形相关，最常见的是累及横窦和乙状窦的硬脑膜动静脉瘘（DAVF）。其余病例通常被称为“特发性”血管性耳鸣，推测其病因与静脉有关。在这些病例中，可闻及的噪音通常被认为是在颈静脉连接部或扩大的颈静脉球内产生的。我们报告了4例因横窦硬脑膜中段局灶性狭窄（后天性和发育性）导致的客观性脉搏同步性耳鸣病例。在所有病例中，通过脑血管造影或直接导管静脉造影显示，在窦内的局灶性狭窄处可直接闻及杂音。在1例病例中，选择性静脉造影显示为可扩张性窦狭窄，伴有造影剂喷射，表明在发育性窦节段内血流速度加快。在另一例病例中，在局灶性横窦狭窄处可直接闻及响亮的脉搏同步性杂音，血管造影在血管外科夹子部位检测到该狭窄。在该病例中，磁共振成像（MR）错误地预测为窦闭塞。在另外2例病例中，在血管造影静脉期也可见横窦狭窄处直接闻及可闻及的杂音。横窦狭窄是客观性搏动性耳鸣未被认识的病因，我们认为这种机制可能是许多“特发性”或静脉性病因耳鸣（在解剖学上无法用其他原因解释）的基础。无创检查、计算机断层扫描（CT）、MR和非定向血管造影可能会忽略它。如果其他检查未能明确可闻及杂音的解剖学基础，在此类病例中应进行传统的导管动脉造影或静脉造影，并注意硬脑膜窦。
