Portuguese Version

Year:  2004  Vol. 70   Ed. 2 - (5º)

Artigo Original

Pages: 178 to 181

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The venous hum as a cause of vascular pulsative tinnitus

Author(s): Gabriel Cesar Dib 1,
Ektor Onishi 2,
Norma de Oliveira Penido 3

Keywords: tinnitus, pulsative, venous hum

Abstract:
Tinnitus is one of the most common complaints in medical practice. The venous hum is described as an uncommon cause of vascular tinnitus, seldom remembered or recognized as a clinical entity. Aim: The aim of this paper is to identify the venous hum cases at Tinnitus Ambulatory at UNIFESP-EPM and compare them to literature. Material and Method: retrospective research of venous hum cases identified at UNIFESP-EPM from April 1997 to April 2003, analyzing the following parameters: age of appearance, frequency, affected side, presence of associated hearing loss and dizziness, improvement and worsening factors, audiometry results, vestibular exam and computadorized tomography of temporal bones, evolution and treatment performed. Results: pulsative tinnitus happened in 7,5% and venous hum in 3% of total cases of the patients with tinnitus, all in women, with no preference for age of appearance, most common at left ear. All patients have improved with clinical treatment and surgery was not needed in any case. Conclusion: The venous hum is not an uncommon cause of tinnitus (39% of pulsative tinnitus) as described in literature. Treatment should be performed by acting in responsible and decurrente factors caused by tinnitus. In great number of cases venous hum spontaneously disappears, needing no treatment. Surgical treatment is rarely indicated and must be reserved only in cases with no improvement with clinical treatment.

INTRODUCTION

Tinnitus is one of the most common otological complaints faced by Otorhinolaryngologists in daily clinical practice and there are innumerous etiologies to explain it. It can be characterized as objective (from arterial, venous or muscular origin) or subjective, but the former is less common 1. Venous hum is described as an uncommon cause of vascular originated tinnitus, many times neglected by specialists. Patients may spend years without complaints and it may appear and disappear spontaneously many times throughout life 2, 3. It is normally found in children and adolescents and disappears as years go by 1.

Pathophysiology of venous hum may derive from jugular vein pathologies (such as increase in lumen diameter, high jugular bulb, wide sigmoid sinus with narrow jugular bulb, compression of the jugular vein at high neck region caused by transversal process of the second cervical vertebra), be secondary to systemic diseases (such as intracranial pressure increase and hyperkinetic circulation status, such as anemia, pregnancy, thyrotoxicity, and fever) and be idiopathic 1, 4-6.

The resulting tinnitus is pulsatile, rhythmic, synchronous with heartbeat, of increasing-decreasing type, continuous or intermittent, and it can be present or absent for months or years during life. One of the most important characteristics of this type of tinnitus is its elimination by digital compression of the internal jugular vein pathway at the neck region on the same side of the tinnitus, with Valsalva's maneuver and when patients lie their head on the pillow or place the hand on the same side of the tinnitus 2, 7, 8. There may be worsening of tinnitus by turning the head to the contralateral side, by compression of the jugular vein on the affected side by the transversal process of the second cervical vertebra, and flow goes from laminar to active, perceived by the patient as pulsatile tinnitus 9.

Diagnosis is quite easily made through the characteristics of the clinical history and physical and complementary examinations. Differential diagnosis should be made with non-pulsatile tinnitus in addition to arterial, venous and muscular-originated ones, including: persistence of stapedial artery, glomus tumors, aberrant carotid artery, arterial-venous malformations, myoclonus (elevator and tensor veli palatini and tensor tympani) 1, 9-11.

The purpose of the present study was to identify among patients with pulsatile tinnitus seen by the Ambulatory of Tinnitus, Discipline of Otorhinolaryngology, UNIFESP-EPM, those that were of vascular origin and had venous hum etiology to compare data with the literature.

MATERIAL AND METHOD

We conducted a retrospective study of patients seen between April 1997 and April 2003 in the Ambulatory of Tinnitus, Discipline of Otorhinolaryngology, UNIFESP-EPM, with pulsatile tinnitus caused by venous hum, and we analyzed the following clinical criteria: age of tinnitus onset, affected side, frequency of tinnitus, presence of associated hearing loss or dizziness, improvement and worsening factors, results of audiometry, vestibular exam, temporal bone computed tomography scan (CT), progression and treatment.

The complementary tests performed complied with the following protocol: complete blood count, general blood tests and thyroid hormone test, cervical spine x-ray, cervical doppler ultrasound, fundoscopy, audiometry, impedanciometry, vestibular exam, and skull and temporal bone CT scan.
Patients complied with the following treatment protocol:

 guidance about the disease and wait-and-see approach (if so wanted by the patient);

 treatment of the root cause (if present);

 treatment of anxiety (if present);

 acupuncture if patient did not experience any improvement with previous approaches;

 surgery in case of tinnitus refractory to all treatment approaches.
Data were compared to those reported by the literature.

RESULTS

In the analyzed period, we saw in our ambulatory a total of 306 patients with complaints of tinnitus, being 192 (63%) female and 114 (37%) male. Twenty-three people (7.5%) had pulsatile tinnitus. Out of the total, 19 (6.2%) were female and 4 (1.3%) were male. Nine of them (39% of the patients with pulsatile tinnitus and 3% of the total), all female patients, presented tinnitus whose etiology was venous hum. The data obtained were:

 Onset of tinnitus: 2 patients felt the tinnitus for the first time on the 3rd decade of life, 2 patients on the 4th, 4 on the 5th, and 1 on the 6th decade of life.

 Affected side: 7 patients presented tinnitus on the left ear, 1 on the right, and 1 on both ears.

 Presence of associated hearing loss and dizziness: 2 patients presented hearing loss complaint and 3 had dizziness associated with tinnitus.

 Improvement factors: 7 patients presented improvement or remission of tinnitus by turning the head to the affected side, 5 in the presence of environmental noise, and 2 by digital compression of the cervical region on the same side.

 Worsening factors: 3 patients referred worsening of tinnitus after physical exercise, 2 with anxiety, 4 with head rotation to the contralateral side of tinnitus, and 6 in quiet environments. Two of the patients that experienced improvement by rotating the head to the same side of tinnitus had worsening by rotating the head to the contralateral side.

 Audiological test: 2 patients had mild sensorineural hearing loss on the ear with complaint of tinnitus (the two same patients who had complaints of hearing loss on the same side).

 Vestibular test: 8 subjects had normal test and 1 had irritative peripheral vestibular syndrome on the affected side, being one of the three patients that had referred associated dizziness.

 CT scan: 3 patients presented high jugular bulb on the same side of tinnitus (all on the left) and 6 had the scan within the normal range.

 Progression and treatment: 3 patients presented spontaneous remission of tinnitus, 2 reported improvement by using anxiolytic drugs, 1 with acupuncture, 1 patient by treating hyperthyroidism, and 2 patients reported that tinnitus did not bother them, so they did not want to follow any treatment approach.

DISCUSSION

Venous hum is described as an uncommon disease and there are no literature data available about frequency and incidence. We found in our ambulatory patients who had this kind of tinnitus and they were quite frequent comparing to the total number of patients and those with pulsatile tinnitus. In our opinion, this observation is the result of two facts: it is a reference center for diagnosis and treatment of difficult cases and it is not a frequently considered diagnosis among specialists, since few know about venous hum as a specific clinical entity.

There are no data available about the onset of tinnitus, but we found the highest incidence between 3rd and 5th decades of life leading to no predominance of age ranges. In our sample, we had more female cases, which is in agreement with the literature.

We found higher prevalence of tinnitus on the left ear, contrarily to what the literature brings, that the right side is the most affected one. It can be explained by the fact that the studies showed predominance of high jugular bulb on the right, detected by temporal bone CT scans 12.

In agreement with literature data, many patients had remission or improvement of tinnitus by rotating the head to the same side as the tinnitus, in the presence of noisy environment and digital compression of the internal jugular vein pathway, or worsening or resurge of tinnitus in stressful, anxious and physical exercise activities, head rotation to the contralateral side and in quiet environments, especially at night. We should emphasize the importance of mechanisms related with perception of tinnitus, especially the neurophysiological model by Jastreboff, in which the limbic and autonomic systems play key roles in the determination of level of anxiety and bothersome of tinnitus 13.

As to the associated symptoms, 2 patients with complaints of hearing loss on the same side as the tinnitus presented mild sensorineural hearing loss, probably owing to artifacts produced by tinnitus during the conduction of the audiological tests (despite the fact that we used non-continuous stimuli), masking low intensity sound perception and showing that there is no real hearing loss. We did not find venous hum to be related with dizziness as reported in 3 patients, but rather that the symptom is caused by other coexisting vestibular diseases or other affections than venous hum. CT scan alterations such as high jugular bulb are in agreement with literature reports, as well as the nonexistence of affections in most of the cases 10, 11. Differently from the literature, we did not require and do not think it is necessary to conduct invasive tests since the diagnosis can be easily made through clinical history and physical examination, in addition to non-invasive complementary tests, which provide much information about the affection. Invasive tests such as arterial and venous angiography were conducted mainly in the 60's and 70's, when CT scan and ultrasound doppler were not available in clinical practice 3.

In many patients, tinnitus disappears spontaneously, and there is no need to treat the problem, but only after appropriate guidance concerning the nature and prognosis of the disease.

In cases in which there is no spontaneous improvement with age or correction of the factors responsible for clinical picture, it may be necessary to use cervical prosthesis that slightly compress the cervical region, and as last resort, surgical correction such as internal jugular vein ligation can be performed with good results, but there may be recurrence of tinnitus after some months 14. Carotid ligation is not effective in such cases and should not be performed. Our evidence about treatment of venous hum is not in agreement with the literature, in which surgical treatment was described as relatively frequent 8, 14, 15. We believe that this approach should be reserved for cases in which there is no improvement after other clinical treatment attempts and the patient feels he has been affected by the problem. In one patient we detected the presence of hyperthyroidism, which was treated and led to remission of tinnitus. In five patients, after appropriate counseling about the disease, they decided to follow the wait-and-see approach and three cases had spontaneous remission of tinnitus, and the other two reported that the problem was not troublesome to them, meaning they did not want any treatment. In two patients who had significant anxiety, we conducted treatment with anxiolytic drugs and psychotherapy, with improvement of the condition. None of the cases required use of neck prosthesis or performance of vascular ligation.

CONCLUSION

Venous hum is not as uncommon a disease as described. It is relatively easy to diagnose provided that it is remembered by physicians that deal with patients who have tinnitus complaints and submit them to the appropriate complementary tests. We should treat any systemic affection that might have caused tinnitus, and depending on the patient, we should act on probable factors related to the problem (such as stress and anxiety) or wait and see, after guiding the patient about the origin and progression of the disease. Invasive approaches are rarely required and they are reserved only to cases in which there is no improvement after different attempts to minimize the problem.

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1 Specialization in Otorhinolaryngology under course, Federal University of Sao Paulo - Escola Paulista de Medicina.
2 Ph.D. in Medicine, Department of Otorhinolaryngology, Federal University of Sao Paulo - Escola Paulista de Medicina.
3 Affiliated Professor, Department of Otorhinolaryngology, Federal University of Sao Paulo - Escola Paulista de Medicina.
Affiliation: Study conducted at the Discipline of Otorhinolaryngology, Department of Otorhinolaryngology and Human Communication Disorders, Unifesp-EPM.
Address correspondence to: Gabriel Cesar Dib - R. Borges Lagoa 980 ap.12 V.Clementino 04038-002 São Paulo SP.
Tel (55 11) 9937-1212 - E-mail:gcdib@hotmail.com.

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