Vascular tinnitus: Role of the undiscovered Eagle syndrome Mosaad Soliman, Khaled Mowafy; Ahmed Magdy; Reem Soliman Mansoura University

Types of tinnitus Pulsatile tinnitus continuous tinnitus originates within the blood vessels inside the head or neck region when disturbed blood flow occurs. continuous tinnitus results from damage to the cochlea and/or hearing nerve.

Pulsatile Tinnitus  vascular tinnitus because in the majority of cases, it is related to disturbances in the blood flow. 3% of tinnitus patients experience this type of tinnitus perceived as a rhythmic pulsing that is often in time with the heartbeat. experienced as a thumping or whooshing sound.

Vascular tinnitus-Causes 1 – Benign Intracranial Hypertension 2 – Glomus Tumor 3 – Atherosclerotic Carotid Artery Disease 4 – Intracranial Vascular Lesions 5 – Middle Ear Effusion 6 – Venous Hum 7 – Hypertension 8 – Twisted Arteries 9- Arnold-Chiari malformation 10- Muscle spasm in the soft palate 

Eagle syndrome Watt Weems Eagle in 1937

Also termed stylohyoid syndrome styloid syndrome,  styloid- stylohyoid syndrome, or styloid–carotid artery syndrome Approximately 4% of the general population have an elongated styloid process, and of these about 4% give rise to the symptoms of Eagle syndrome. Therefore, the incidence of stylohyoid syndrome may be about 0.16%. Typically between 30 and 50 years of age It is more common in women, with a male:female ratio ~ 1:2.

Classic eagle syndrome is present on only one side, however, rarely, it may be present on both sides

Sharp, shooting pain in the jaw, back of the throat, base of the tongue, ears, neck, and/or face Difficulty swallowing Sensation of having a foreign object in throat Pain from chewing, swallowing, turning the neck, or touching the back of the throat Ringing or buzzing in the ears

the tip of the styloid process is palpable in the back of the throat neurological symptoms occur upon head rotation. Symptoms tend to be worsened on bimanual palpation of the styloid through the tonsillar bed.

Medical management includes the following: Analgesics Anticonvulsants Antidepressant Local infiltration with steroids or long-acting local anesthetic agents 

In both the classic and vascular form, the treatment is surgical A partial styloidectomy is the preferred approach. Repair of a damaged carotid artery is essential in order to prevent further neurological complications.  Regrowth of the stylohyoid process and relapse are a common occurrence.

2 traditional surgical approaches to styloidectomy intraoral approach (or transpharyngeal) extraoral approach

Intraoral approach locates the styloid process by digital palpation of the tonsillar fossa. performing tonsillectomy first split the muscles, elevate the mucoperiosteum, fracture and excise the styloid process.

intraoral approach The advantages The disadvantages safe, simple, less time consuming, and an external scar is avoided. The disadvantages possible infection of deep neck spaces, risk of injury to major vessels, poor visualization.

Not recommended with bilateral intervention at the same surgery, because of possible great discomfort postoperatively

Extraoral approach cervical incision at the upper two thirds of the anterior margin of the sternocleidomastoid muscle to the hyoid bone. the parotid fascia is reflected anteriorly and the carotid sheath and the sternocleidomastoid posteriorly in order to reach the posterior belly of the digastric muscle and the vascular-nervous bundle of the neck. The styloid process can now be palpated. Aponeurotic and muscular insertions are separated from the styloid process. Styloidectomy is then performed. Ceylan et al reported a 93.4% of success after external resection

Complications Deep space neck infection Injury to main neurovascular structures Hemorrhage Temporary alterations of speech and swallowing Injury of the facial nerve

Main presentation was tinnitus increased by rotation of the neck 7 female patients Age 19-35 Main presentation was tinnitus increased by rotation of the neck decreased by pressure in the neck 2 had palpable styloid in the tonsillar bed 4 treated intraorally 3 exraorally All followed uneventful course with immediate improvement of tinnitus Extraoral approach was more feasible If pulsatile tinnitus is caused by turbulent flow in arteries, pressure applied to the upper neck on the side of the tinnitus should alter or reduce it. If it is venous in origin, the Valsalva maneuver may improve it. This is performed by forcibly exhaling against closed lips and pinched nose, forcing air into the middle ear, provided the Eustachian tube is open. Neither of these is a fool-proof way of identifying or alleviating the problem but positive results may lead to a better diagnosis by a physician.

Take home message Diagnosis depends on examiner awareness

Tinnitus does not mean referral to otolaryngologist but means Lat view Plain x-ray

Surgical treatment is feasible and easy but should be retained to resistant cases IF Still in debate

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