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Tinnitus can cause unpleasant symptoms such as intolerance to loud sounds, which can cause significant emotional distress. Thank you for posting this article, it provides a solid overview of tinnitus, its causes and treatments. MIXED HEARING LOSS Whenever the hearing loss of a patient includes a mixture of both conductive and sensorineural characteristics, is said to have a mixed hearing loss.
Superior ventral cochlear nucleus (SVCN) Erythroblastosis typically causes hearing loss that centers around 3000–4000 Hz. Central Auditory Processing Disorders (CAPD) CAPD characterized by decreased understanding of speech in the presence of background noise. FUNCTIONAL HEARING LOSS Functional or psychogenic hearing loss is the customary diagnosis when there is no organic basis for the patients apparent deafness. Functional Overlay It is entirely possible for hearing loss of functional origin to be superimposed on true organic hearing impairment. History: A 34-year-old woman with otosclerosis and hearing loss for over 10 years Refuse to use hearing aids She often says, What? Audiometric Patterns in Functional Hearing Loss There is no characteristic audiometric pattern in functional hearing loss, but the consistent inconsistencies serve to alert the physician. Malingering Malingering is the deliberate fabrication of symptoms that the patient knows do not exist. In the past, a persistent stapedial artery was frequently cited as a reason to discontinue stapes surgery, however, several authors have had success operating on the oval window despite the presence of a persistent artery.
The stapedial artery is an important vessel in the developing embryo, supplying most of the nonneural structures of the head and neck; however, with maturation this vessel takes on much less importance and by ten weeks gestation the external carotid system becomes the primary arterial supply of the head and neck. Diagnostic considerations included otosclerosis with Schwartze's sign, a vascular tumor, persistent stapedial artery, or possibly granulation tissue. Exploratory tympanotomy was performed by one of the senior authors (MDS) under general anesthesia with continuous facial nerve monitoring (Silverstein Facial Nerve Monitor, Weigand; Minneapolis, MN). The stapedial artery is a second branchial arch derivative that develops from the dorsal end of the hyoid artery. The diagnosis of a persistent stapedial artery was usually made during surgery for otosclerosis and when it was encountered it was generally recommended to abort the procedure.5,6 The primary reasons cited, were concern of uncontrollable hemorrhage and the possibility of causing distal ischemia of neural or cochlear structures.
Individual consideration for the patients problem including the degree of hearing loss and severity of the tinnitus must be carefully assessed prior to recommending surgical removal of a persistent stapedial artery. Our report represents a unique case of a persistent stapedial artery causing conductive hearing loss and pulsatile tinnitus.
Also, it is appreciated that you mentioned hypnotherapy, I have assisted people in coping with the stress of tinnitus and it can be an effective component of a comprehensive treatment plan. Hearing deficiency may have started originally as a conductive failure (otosclerosis) and later developed a superimposed sensorineural component. In clinical practice, most cases with an original sensorineural etiology remain in that classification without an added conductive element. In chronic otitis media some toxic inflammatory metabolite produces a cochleitis or labyrinthitis. This example a warning to physicians to avoid assuring any patient that his hearing loss can be corrected merely by removing cerumen, because mixed hearing loss may be found subsequently.
In every case of mixed hearing loss one should determine how much of the deficit is conductive and how much is sensorineural. If the patient does not understand any better with a hearing aid or when the voice is raised, hearing is not improved even if the conductive portion of the mixed hearing loss is corrected.
17 The auditory pathway consists of a series of transducers that repeatedly change the speech stimulus so that it can be handled effectively by the cortex. Characteristic Features of central hearing loss : Hearing tests do not indicate peripheral hearing impairment. This may be caused by injury to SVCN spheroid cells, the second-order neurons of the ascending auditory pathway, even in the presence of normal hair cells in the organ of Corti. Common complaints include inability to study or read in the presence of noise, slowing of reading speed caused by noise(vacuum cleaners or air conditioners ) and suspicion by family members that the patient has a hearing loss. The inability to hear results entirely or mainly from psychological or emotional factors, and the peripheral hearing mechanism may be essentially normal. Psychogenically induced hearing loss usually is a uniform flat- tone loss in all frequencies, suggestive of a well-marked conductive impairment.
Usually, the hearing impairment is bilateral, and the bone conduction level is the same as the air conduction level.
We present a case of a patient with conductive hearing loss and tinnitus successfully treated with removal of a persistent stapedial artery that was filling the obturator foramen.
The diagnosis of a persistent stapedial artery is haphazard and usually only discovered by direct observation during tympanotomy which explains why it is commonly seen with otosclerosis.
Laboratory testing was normal including tests for urine and serum norepinephrine and metanephrines. A large persistent stapedial artery was identified and was seen to completely fill the obturator foramen (Fig.
Stapes mobility was only slightly reduced and it was felt to be due to the large size of the persistent vessel. In this area superior to the oval window and inferior to the facial nerve, cautery was set at 7 watts.
The distal stapedial artery branches develop into the supraorbital, frontal, anterior ethmoid, lacrimal, inferior orbital and inferior alveolar arteries. The intracranial dural branch substitutes for the middle meningeal artery, and thus explains the absent foramen spinosum. Glasscock,7 Jackson,7 Brackrnann,12 Silverstein,13 Graham14 and Kartushl5 raises doubts about the previously reported concerns regarding stapedial artery electrocauterization.

The fact that this patient did not have complete resolution of her conductive hearing loss suggests that she may indeed have a component of otosclerosis.
Fisch UP, Oldring DJ, Sennig A: Surgical Therapy of Internal Carotid Artery Lesions of the Skull Base and Temporal Bone.
Bergdahl B, Vallfors B: Studies on coagulation and the Development of an Automatic Computerized Bipolar Coagulator. Johnson JH, Jensen DM, Auth D: Experimental Comparison of Endoscopic Yttrium-Aluminum-Garnet Laser, Electrosurgery, and Heater Probe for Canine Gut Arterial Coagulation. Harrison JD, Morris DL: Artery Weld Strength After Bipolar Electrocoagulation is Affected by Electrolyte Solutions Around the Artery. Tinnitus is defined as abnormal perception of sounds or noises in the ear, in the absence of external sound stimulus. In patients with tinnitus, quality of life is changed in a negative way, can cause irritation, loss of attention and memory. Studies to date suggest that such therapy administered per os (oral) for a long time, brings no real benefit. The difficulty may have been sensorineural in the beginning ( presbycusis ), and a conductive defect (middle-ear infection ) may have developed subsequently. In contrast, most cases that start as conductive hearing impairment later develop some sensorineural involvement. The sensorineural deficit may be caused by penetration of the oval window with exposure of the perilymph.
Prognosis: In mixed hearing loss the prognosis depends on the relative proportion of conductive and sensorineural pathology. There is no characteristic audiometric pattern, except that the disparity between the hearing level and the speech interpretation is quite marked. Central pathology must be included in the differential diagnosis of the hearing loss producing a 4000-cycle dip on the audiogram.
If people talk to a person with CAPD while he or she is involved in auditory concentration such as listening to a television program, the person will often not hear.
The basis for functional hearing loss in most patients is psychogenic, the product of emotional conflict, ( neurotic anxiety ). Hysterical blindness and paralysis are other examples of the same type of somatization or conversion reaction.
In a patient with unilateral functional deafness there may be complete absence of bone conduction on the side of the bad ear, though the good ear has normal acuity. If the patient claims he has one good and one bad ear, and the examiner obstructs his good ear with a finger, then shouts into it loudly enough to be heard easily by bone conduction alone, the malingerer claims he hears nothing. This experience, in conjunction with a review of the literature and a discussion with several neurotologic colleagues, leads us to suggest that a stapedial artery can be safely removed allowing unhindered access to the oval window.
In the patient, to be discussed, removal of a stapedial artery led to resolution of the pulsatile tinnitus and hearing improvement.
Otoscopic examination demonstrated a small pulsatile red mass in the posterior-superior quadrant of the middle ear. Preoperative audiogram; note the 20 dB speech reception threshold with a 15-20 dB air-bone gap.
High resolution computed tomographic scan with 1.5 mm axial and coronal cuts with contrast was obtained, and initially was interpreted as normal. Axial CT scan of the temporal bone with the arrows indicating normal foramen ovale anteriorly on both sides, a normal foramen spinosum on the left with no foramen spinosum on the right. Although there was no evidence of otosclerotic plaque, mild otosclerosis could not be entirely ruled out.
The cauterized segment was excised and removed from the obturator foramen and middle ear exposing a 2 mm area of bone erosion in the promontory which extended inferiorly from the oval window (Fig.4). Demonstrates the appearance of the middle ear following removal of the persistent stapedial artery. The cartilage of the developing stapes, at ten weeks gestation, limits further growth of the artery while the external carotid artery anastomosis with the distal stapedial artery leads to eventual atrophy of the stapedial vessel.
Cautious extension of these findings indicates that planned surgical ligation will not likely effect any distal neural or cochlear structures.
Additionally, in the presence of otosclerosis with a small persistent stapedial artery we would consider ablating the vessel and completing the stapedotomy. We are also aware of the possibility that manipulation near the stapes during removal of the artery may have led to a partial mobilization, and caused some hearing improvement. The patient may perceive auditory sensations in various forms: rustling, crackling, hissing, ticking, etc. In some cases the conductive and the sensorineural elements may have started simultaneously ( severe head injury affecting both the inner ear and the middle ear ). Despite meticulous surgical care, the inner ear also can be traumatized readily and made more susceptible to infection. The best way to approximate the conductive and the sensorineural components of a hearing loss is to perform all possible tests for estimating the patients sensorineural potential or cochlear reserve. If the sensorineural component is slight, the surgical prognosis is good, and under favorable circumstances the hearing may approximate the level of the bone conduction. In certain cases, central hearing loss may mimic peripheral causes of deafness, including occupational deafness.
However, if one gets the persons attention by calling his or her name before speaking, the first sentence will not be missed, and hearing is normal. Tinnitus is a characteristic feature of hysterical deafness, and patients often claim that the noise is unbearable. Too spectacular an improvement with a hearing aid, especially when the patient has set the controls at minimal amplification, or a sudden disproportionate improvement in hearing after a simple procedure such as drum massage or insufflating the eustachian tube.

Such a patient even may deny hearing shouts directed at the bad ear in spite of the good hearing in the opposite ear. The Weber lateralized to her right ear and Rinne was equivocal in the right and positive in the left with a 512 Hertz tuning fork, suggesting a right-sided conductive hearing loss. However, on repeat evaluation the classic findings of a widened tympanic segment of the facial nerve as well as an absent foramen spinosum were identified (Figs. Bone covered the facial nerve except for a small dehiscence on the inferior aspect of the nerve where the stapedial vessel turned medially. The facial nerve was stimulated again at the lowest setting, and there was an excellent response, suggesting normal facial function. Preoperative angiogram or magnetic resonance angiography may better address this question, however no studies are available to prove this. In order to optimize coagulation lower heat with increased contact time and slow continuous motion along the vessel is recommended.
Moving the vessel away from the stapedotomy site and then completing the procedure is also still an option.
However, assessment of ossicular chain mobility prior to any middle ear manipulation showed normal malleus mobility and only slightly reduced stapes mobility.
Drug treatment also includes vasodilators, benzodiazepines or other drugs indicated in migraine. In surgical trauma to the inner ear, high-frequency hearing loss often falls below the preoperative level, and the patient may complain of reduced discrimination though his pure-tone threshold is improved. However, the discrimination is not improved much, even after correction of the conductive defect. The chief function of the auditory cortex is to interpret and to integrate these impulses and to provide the listener with the exact meaningful information intended by the speaker, or to permit the listener to react appropriately to the actual implication of the sound.
The spheroid cells of the superior ventral cochlear nucleus (SVCN) show an anatomical frequency gradient, low ventral to high dorsal.
Treatment : altering the listening environment to obtain the best possible signal-to-noise ratio. Hearing acuity usually varies, depending on the patients emotional state at the time of testing. In complete deafness the presence of cochlear nerve reflexes with loud noises indicates either malingering or hysteria. Audiometric analysis revealed a 20 dB right conductive hearing loss with elevated stapedial reflexes (Fig. The facial nerve monitor was adjusted to its lowest setting, 0.05 mAmps, and stimulation of the inferior most portion of the facial nerve led to a response.
A small amount of surgicel (Johnson and Johnson, Texas) was placed over the inferior stump of the vessel and after 15 minutes of observation, hemostasis was assured and the ear was closed (Fig. Uncontrolled hemorrhage is another reason surgeons in the past have recommended discontinuing stapes surgery in the presence of a persistent stapedial artery. Postoperatively, this patient's hearing improved and the pulsatile tinnitus resolved with removal of this artery. The psychotherapeutic approaches are cognitive-behavioral therapy, relaxation, education, information, biofeedback, hypnotherapy. If the patient hears and discriminates well when speech is made louder, then the conductive element probably is a major cause of the hearing difficulty, and there is a good chance that surgery will improve the hearing. A similar adverse effect is noted in the ear opposite the tumor when certain words are interrupted periodically or accelerated. This suggested that cautery near this area could be dangerous, and that any use of the bipolar would have to be performed at a low setting and as far away from the facial nerve as possible.
Additionally, it is routine during vestibular schwannoma surgery to use cautery at even closer distances without harmful effects on facial nerve function.
We were able to safely cauterize this vessel with bipolar cautery, excise it, and remove it from the obturator foramen with no bleeding or postoperative neural sequelae. The inferior portion of the artery was cauterized using a standard bi-polar instrument set at 10-12 watts.
Of the 48 reported cases of a persistent stapedial artery, nine underwent successful stapedotomy near the vessel with good audiologic results.4 Our case extends these findings and demonstrates that a large stapedial artery segment may be safely cauterized and removed giving unhindered access to the oval window. Labyrinthitis Otosclerosis was at one time thought to retain its purely conductive character for years; today it is recognized that this condition develops sensorineural impairment in same cases. The packing was removed one week postoperatively and the Rinne was positive to a 512 Hertz tuning fork. Various lasers may be a suitable alternative to bipolar cautery when ablating small vessels.
Additionally, an artery that completely fills the obturator foramen may also be a cause of conductive hearing loss and pulsatile tinnitus.
We have found that defocusing either the potassium titanyl phosphate (KTP) or CO2 laser allows us to safely ablate smaller vessels less than 1.5 mm in diameter.
It is clear from current thinking that complications such as faci al paralysis or hemiparesis secondary to vessel disruption are not likely.
A postoperative audiogram at four weeks and six months showed improvement of the air-bone gap.

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