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

2. 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.

3. 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.

4. 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 

5. Eagle syndrome
Watt Weems Eagle in 1937

7. 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.

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

9. 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

10. 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.

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

14. 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.

15. 2 traditional surgical approaches to styloidectomy
intraoral approach (or transpharyngeal)
extraoral approach

16. 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.

17. 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.

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

19. 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

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

21. 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.

22. Take home message
Diagnosis depends on examiner awareness

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

24. Surgical treatment is feasible and easy but should be retained to resistant casesIF
Still in debate

25. Thank You