Tinnitus Presentasi

7/25/2019 Tinnitus Presentasi

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MANAGEMENT OFTINNITUS

By : Dina Riana

Supervised : dr. Sally Mahdiani, Mes, Sp.T!T. "# ,

$

#ITERATUR READINGAUDIO#OGI

DE%ARTEMEN I#MU "ESE!ATAN TE#INGA !IDUNG TENGGORO"BEDA! "E%A#A DAN #E!ER RS!S & F" UN%AD BANDUNG

'($)Sa*al+, TR. Sa*al+,-. !asha,

M. Tinni*us. In Sa*al+, TR.Sa*al+,-. !earin/ #+ss. 0*h ed.Mar1el Deer In1, Ne 2+r. $330.


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Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.

Tinni*us, +r *heper1ep*i+n +6s+und in *he

a7sen1e +6 ane8*ernal audi*+ry

s+ur1e

A 1+99+npa*ien*

1+9plain* in+*+laryn/+l+/i1

pra1*i1es.

up *+ )( 9illi+nadul*s in *he US,i*h $ 9illi+n

e8perien1in/6re;uen* +r

1hr+ni1 *inni*usin *he pri+r $'

9+n*hs

N+n pulsa*ile &pulsa*ile *inni*us

< su7=e1*ive &+7=e1*ive *inni*usare 1ri*i1al in *he

appr+pria*edia/n+sis and9ana/e9en*

INTRODU>TION


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Sa*al+, TR. Sa*al+,-. !asha,


0


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>ara1*eris*i1s

*inni*uspulsa*il

n+npulsa*ile

4Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.


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)

Tinni*

uspulsa*i6

F+ll+in/hear*7ea*

?en+us i*h

@h++sin/s+und

Rhy*9i1i*h *hepa*ien*s

pulse

M+died 7ye8*ernal

9+ve9en*s,+r1han/e inp+si*i+n



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*inni*us

+7=e*i6

A7le *+ 7e

heard 7ypa*ien* ande8a9iner

?as1uar7rui*s,vas1ular*u9+r,pala*al*ens+r *i9pani

9y+1l+nus

su7=e*i6

!ard +nly

7y *hepa*ien*s




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!+ *+ dia/n+sedC



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!is*+ry




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%!2SI>A#EAMINATION

3




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DIAGNOSTI> E?A#UATION

Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544. $(


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SUB-E>TI?E NON%U#SATI#E

TINNITUS

Noise-induced hearing loss, presbyacusis,

ototoxic medications, labyrinthitis, herpes zoster

oticus, Meniere's disease, and genetic hearing losses cause

inner ear hair cell damage resulting in hearing loss, which

can lead to nonpulsatile tinnitus. Chronic otitis media.

cholesteatoma, canal occlusion, and otosclerosis can cause

a conductive hearing loss that ultimately may result in tinnitus.

Lesions that aect the cochlear nerve and central

nervous system !CN"# such as acoustic neuroma, meningioma,

multiple sclerosis, and Charcot-Marie-$ooth disease

can also induce tinnitus, typically along with a coincident

hearing loss !%ig. &&.&, $able &&..Sa*al+, TR. Sa*al+,-. !asha,


$$


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Ris 6a1*+r

The 9+s* prevalen* ris 6a1*+r 6+rsu7=e1*ive, n+npulsa*ile *inni*us ishearin/ l+ss.

Fre;uen*ly *his hearin/ l+ss in1ludessi/ni1an* sens+rineural l+sses a*hi/her 6re;uen1ies

' +6 pa*ien*s i*h pr+6+undsens+rineural hearin/ l+ss HSN!# illn+* have *inni*us.

Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544. $'


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Su7=e1*ive N+npusa*ile*inni*us

The+ries +6 /enera*i+n +6 n+npulsa*ile*inni*us: (( speciically the role o certaincochlear structures such as outer hair cells.

observations that sub)ective nonpulsatile tinnitusis re*uently seen in individuals with measurable

hearing loss or ollowing +nown ototoxic in)uries.

!such as ototoxic medication exposure. noiseexposure,head in)ury#.

Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544. $0


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E*i+l+/i 1+1hle+/eni1 J %ersis*en1e +6*inni*us 6+ll+in/ *run1a*i+n +6 *he audi*+rynerve +r a7la*i+n +6 *he 1+1hlea

Many studies have noted a decrease in inhibitory neural

input at multiple sites along the central auditory

pathways,including the dorsal cochlear nucleus .

This leads to a net increase in excitatory signaling in

the auditory pathway and hasbeen proposed as the

neurophysiologic basis or sub)ective tinnitus.Sa*al+, TR. Sa*al+,-. !asha,


$4


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Meniere disease

>+ndu1*ive +r 9i8ed hearin/ l+ss 1anals+ 7e ass+1ia*ed i*h *inni*us,in1ludin/ *ha* 1aused 7y +*+s1ler+sis,+ssi1ular dis1+n*inui*ies, +r+7s*ru1*i+n +6 *he e8*ernal audi*+ry

1anal 7y 1eru9en +r +*her 6a1*+r. caeine, aspirin, ibuproen, and nicotine can

cause tinnitus and head in)ury.Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1, Ne

2+r. $330. p400544. $)


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$

Sa*al+, TR. Sa*al+,-. !asha,M. Tinni*us. In Sa*al+, TR.

Sa*al+,-. !earin/ #+ss. 0*h ed.Mar1el Deer In1, Ne 2+r. $330.


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$




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E*i+l+/i1 6a1*+rs in su7=e1*ive *inni*us

Neurologic abnormalitiesSull 6ra1*ure +r 1l+sed head

*rau9aKhiplash in=uryMul*iple s1ler+sisMenin/i*i1 ee1*s

Pharmacologic factorsAspirin 1+9p+undsNSAIDA9in+/ly1+sides!eavy 9e*als

Psychologic factors Depressi+n

An8ie*y

MeniereLs diseaseO*+s1ler+sis

Otologic factors%res7y1usisN+ise5indu1ed hearin/ l+ss

Metabolic function!yp+*hyr+idis9!yper*hyr+idis9!yperlipide9ia

in1 de1ien1y?i*a9in de1ien1y

Dental factorsTM- syndr+9e

$. Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h

ed. Mar1el DeerIn1, Ne 2+r. $330. p400544. $


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Dia/n+s*i1 Evalua*i+n

Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,

Ne 2+r. $330. p400544. $3


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'(

pa*ien*s i*h unila*eral *inni*us 9ay have aves*i7ular s1hann+9a +r +*her in*ra1ranialan+9aly re;uirin/ 6ur*her *rea*9en* HFi/.

$$.$ .


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TREATMENT

AM%#IFI>ATION

Use +6 a ell5**ed hearin/ aid, *ha* in1lude a ide,hi/h56re;uen1y a9pli1a*i+n 7and and +pen ear 9+ld.

Open 9+uld de1rease +1lusi+n ee1* and e8*end

a9pli1a*i+n a* hi/er 6reen1ies. Ideal hearin/ aid se**in/ 6+r pa*ien*s i*h hearin/ l+ss

and *inni*us !earin/ aid in1rese *he a97ien* n+ise per1eived 7y *he

pa*ien*s,*hus 9asin/ *he *inni*us.

TINITUS

MAS"ING

N+npulsa*ile and pulsa*ile *inni*us s+unds 1an

s+9e*i9es 7e 1+vered H+r 9ased 7y e8*ernal s+unds,*hus 7l+1in/ *he *inni*us per1ep* and *he unpleasan*sensa*i+ns ass+1ia*ed i*h *hese s+unds.

F+r 9any pa*ien*s, use +6 envir+n9en*al s+unds su1has a n+ise /enera*+r +r radi+ 1an ee1*ively andine8pensively 9as *heir *inni*us.

The addi*i+n +6 9asin/ *+nes *+ a9pli1a*i+ns 6r+9 ahearin/ aid 1an 9as *inni*us s+unds 9+re ee1*ivdy*han a hearin/ aid al+ne.

Residual inhi7i*i+n is hyp+*hesied *+ resul* 6r+9inhi7i*i+n +6 syn1hr+n+us a1*ivi*y i*hin *he audi*+*ypa*hay


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TINITUS RETRAININGTERAP!"at meminimalisir

TRT is base# on the conce"tthat habituation to theun"leasant stimulus canminimi$e the reactions thatthese "atients e%"erience&TRT #oes not see' tore#uce "ro#uction of thetinnitus soun# but instea#attem"ts to change thelin'age bet(een thetinnitus "erce"tion an#

autonomic an# limbic systemsusing e%tensi)e counselingan# soun# thera"i&



''


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NEUROMONI*S Uses soun# thera"y& e%tensi)etinnitus e#ucation+ an# cogniti)ethera"y to treat "atients (ithtinnitus& Patients begin their

thera"y by listening to"re"rocesse# mi%e# ,calmingmusic- .a combination of baro/uean# ne( age0 combine# (ith noisemi%e# by "ro"rietary algorithm for1 to 2 hours #aily&

>O>!#EAR IM%#ANTATION 9+dera*e *+ severe *inni*us 1+1hleari9plan*

%!ARMA>OT!ERA%!2 in1ludin/ anes*he*i1 a/en*s HI?lid+1aine, an*i1+nvulsan*s,an*idepressan*s, an*ihis*a9ines,

7en+diaepines, diure*i1, GABAa/+nis*s HBa1l+6en, Gin+ 7il+7a,e8*ra1*s, his*a9ine,. s*er+ids, andvi*a9ins.

MI>RO?AS>U#ARDE>OM%RSION

9i1r+vas1ular de1+9pressi+n +6 *heves*i7ul+1+1hlear nerve su//es* sur/i1al

*rea*9en* +6 vas1ular l++p syndr+9e '0




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'4


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PU3SATI3E TINNITUS

')




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Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544. '


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A

'Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.

4ascular anomalies


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4ascular anomalies

An+9ales +6 *he=u/ular7ul7

*he =u/ular 7ul7represen*s *he =un1*i+n7e*een *he pr+8i9alin*ernal =u/ular vein and

*he si/9+idsinus a* *he sull 7ase.

+7se99+n *+ s/i1al+r end+vas1ularin*erven*i+n. %u7lishedrep+r*s desai7e

su11e6ull i9pr+ve9en*+r eli9ina*i+n +6pulsa*ile *inni*us i*h9iddle ear ++rre1+ns*ru1*i+n, =u/ularvein li/a*i+n, and

endO2asO-iar ++ilE97+lia*i+n

Sigmoid SinusDiverticulum

'(+6 1ases +6 pulsa*ile*innis +ri/ina*in/ 6r+9a ven+usS+ur1e. hyp+*hesied*ha* *u:r7ulen*7l++d i*hin *he si/9+idsinus 9ay lead *+er+si+n +6 *he+verlyin/ 9as*+id 7+nei*h devel+p9en* +6 a

Su11ess6ul eli9ina*i+n +6pulsa*ilesy9p*+9s has 7eenrep+r*ed i*h*rans9as*+idre1+ns*ru1*i+n+6 *he si/9+id all andi*h end+vas1ular 1+ile97+lia*i+n ands*en*in/.


'


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Dural ArteriovenousMalformation/F'IStula

A?M&F 9ay 7e1+n/eni*al +r a1;uired,i*hsy9p*+9s pre1ipi*a*ed

7y *rau9a, in6e1*i+n,pu7er*y,+r pre/nan1y , pulsa*ile*inni*us, heada1he,neur+l+/i11+9pr+9ise, +r

in*ra1ranial he9+rrha/e

Trea*9en* 9+dali*iesin1lude end+vas1ulare97+lia*i+n, s/i1ale8.1isi+n +6 *he :s*ula .

Atherosderotic CarotidArtel)' Disease

Tinnis 9ay resul* 6r+9i9pair9en* +6 *he innerear9i1r+1ir1ulla*i+n due *+a*her+s1ler+*i1 disease+r 6r+9 *here6erred s+und +6*ur7ulen* + *hr+u/hs1ler+*i1 1ar+*idar*eries. In*ravas1ular*u:r7ulen1e due *+ a*+r*ur+us 1ar+*id ar*6ery

1ar+*id s*en+ses*ypi1ally res+lve6+ll+in/ 1ar+*idendar*ere1*+9y+r in*ravas1ular s*en*in/

'3Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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Congenital CarotidAnomalies

in*rape*r+us 1ar+*idar*eiy is repla1ed 7yan enla*/edin6eri+r *y9pani1

ar*ery Ha 7ran1h +6*he as1endin/pharyn/eal.Ra*her *han en*erin/*he sull 7ase *hr+u/h*he

in6eri+r *y9pani11anali1ulus, *hein6eri+r *y9pani1ar*eryanas*+9+ses i*h *he1ar+*i1+*y9pani1

ar*ery in *he 9iddleear here i* is visi7le

li/a*i+n, ei*her viadire1* s/i1al+7li*era*i+n +re97+lia*i+n, 9us* 7e

pre1eded7y an/i+/raphy *+delinea*e anyin*ra1ranial *erri*+rysupplied 7y *hepersis*en* s*apedial

ar*ery and ensure*here is redundan*7l++d supply *+ *ha*re/i+n.

0(Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.

?as1ular Ne+plas9s


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?as1ular Ne+plas9s

Paragangliomas /l+9us *u9+rs, are *he9+s* 1+99+nvasallar *u9+r +6 *he*e9p+ral 7+ne. Believed

*+ arise6r+9 para/an/lia +n *he1+1hlear pr+9+n*+rySurr+undin/-a1+7s+nPs nerveH/l+9us *y9pani1u9 +r

6r+9 *headven*i*ia +6 *he =u/ular7ul7 i*hin *he =u/ular6+ra9enH/l+9us =u/ulare, *hesehi/hly vasallaried

*u9+rs *ypi1allypresen* i*h pulsa*ile*inni*us

+7serva*i+n, radia*i+n*herapy, and sur/ery.

0$Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.


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Hemangiomas Te9p+ral 7+nehe9an/i+9as,in1ludin/ 6a1ial nerveand

1avern+ushe9an/i+9as, arerare vas1ular *u9+rs+6 *he*e9p+ral 7+ne *ha*1an +11asi+nally 7e

ass+1ia*ed i*hpulsa*ile *inni*us.

>avern+ushe9an/i+9as arel+1a*edpred+9ina*ely in *he

9iddle ear and 1anrese97le a /l+9us*y9pani1u9 +n7+*h physi1al e8a9and radi+l+/i1i9a/in/.


0'


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Non)ascularEtiologies

Idiopathic IntracranialHpertension

The pa*h+physi+l+/y+6pulsa*ile *inni*us in

II! is 1urren*lyunn+n. %+*en*ially,in1reased I>%1+9presses *hein*ra1ranial ven+ussinuses,

1rea*in/ *ur7ulen1e inn+r9ally la9inar7l++d + *ha*9ay lead *+ unila*eral+r 7ila*eral pulsa*ile*inni*us H

Trea*9en* +p*i+ns 6+rII! in1lude li6es*yle9+di1a*i+ns,

par*i1ularly ei/h*l+ss,A1e*a+la9ide,1+r*i1+s*er+ids, anddiure*i1s ,Sur/i1alin*erven*i+n.

Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,

Ne 2+r. $330. p400544. 00


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Semicircular CanalDehis1en1e

S>D syndr+9e resul*s6r+9 a de1ien1yin *he 7+ny 1+verin/+verlyin/ +ne +6 *he

se9i1ir1ular>anals. pa*ien*s i*hp+s*eri+r 1analdehis1en1e resul*in/in 1+n*a1* 7e*een1+n*en*s +6 *he

p+s*eri+r 1anal and*he =u/ular 7ul7 +rsi/9+id sinus 9ayals+ lead *+ pulsa*ile*inni*us

Mana/e9en* +p*i+nsin1lude +7serva*i+n+r sur/i1al 1+rre1*i+n+6 *he dehis1en1e 7y

plu//in/ +rresur6a1in/ *hedehis1en1e H$$.


04


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Palatal and Middle EarMy+d+nus

Mus1le spas9 +6 *heleva*+rveli pala*ini +r *ens+rveli pala*ini 1ause ET

+penin/leadin/ *+ *inni*us,hi1h 1an 7esu7=e1*ive +r+7=e1*ive.

rea*9en* +p*i+nsin1lude +7serva*i+n,9asin/*e1hni;ues, lysis +6

*he s*apedial +r*ens+r *y9pani*end+n,and use +6 B+*+8 +npled/e*s pla1ed in*+*he 9iddle

ear

0)Sa*al+, TR. Sa*al+,-. !asha, M. Tinni*us. In Sa*al+, TR. Sa*al+,-. !earin/ #+ss. 0*h ed. Mar1el Deer In1,Ne 2+r. $330. p400544.


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Patulous !ustachianTu7e

%ulsa*ile *inni*usarisin/ 6r+9 apa*ul+us ET +ri/ina*es+u*side *he audi*+rypa*hay. N+r9allyd+sed in *heres*in/ p+si*i+n, apa*ul+us ET leads *+sy9p*+9s +6au*+ph+ny, aural6ullness and, in s+9e1ases, pulsa*ile*inni*us.

A varie*y +6 9edi1al*rea*9en* +p*i+nshave 7een pr+p+sed,in1ludin/ ei/h* /ain,dis1+n*inua*i+n+6 de1+n/es*an*s ands*er+id nasal sprays,9u1+us*hi1enin/ a/en*s,and nasal es*r+/endr+ps. Sur/i1alin*erven*i+nsin1lude 9yrin/+*+9yand *u7e inser*i+n,end+s1+pi1peri*u7alau/9en*a*i+n +6 ETvalve. and sur/i1al1l+sure +6 *he ETlu9en



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0


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03Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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4(




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4$


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Tinni*us !andi1ap Inven*+ry s1+res:

I. Sli/h* T!I (Q$

II. Mild T!I $Q0

III. M+dera*e T!I 0Q)

I?. Severe T!I )Q

?. >a*as*r+phi1 T!I Q $((

4'Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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Trea*9en*

Av+idan1e : Aspirin51+n*ainin/ 1+9p+unds, NSAID

Av+id dis*ur7in/ n+ise

N+ise pr+*e1*i+n

!+9e59asin/ *e1hni;uesBedside 9aser

%sy1h+l+/i1 *es*in/





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In a**e9p*in/ *+ *rea* pa*ien*s disa7led 7y *heirsy9p*+9s, 9easure9en* +6 *he *inni*us isi9p+r*an*. F+ur aspe1*s +6 *inni*us are 9easured in*he s*andard *inni*us pr+/ra9:

-Pitch

-Loudness

-Minimum masking level

-Residual inhibition

Tinni*us %r+/ra9





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%i*1h Masin/

Tinnitus synthesi$er

*+nal, hissin/, his*lin/ and 1ri1e*5lie

#+udness Ma*1hin/

Tinni*us is n+* usually l+ud

) less *han a 5dB sensa*i+n level

Tinni*us is 9a*1hed and *he 9a*1hin/ s+und is

in1reased 6r+9 *hresh+ld *+ *he level a* hi1h *hes+und is per1eived *+ 7e e;ual *+ *he *inni*us

4)Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**

Killia9s < Kilins. '($4..



Mini9al Masin/ #evel


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Mini9al Masin/ #evel

The nu97er +6 de1i7els +6 s+und re;uired

*+ 1+ver *he *inni*us

Residual Inhi7i*i+n

%hen+9en+n +6 pa*ien*s e8perien1in/peri+ds +6 de1reased +r n+ *inni*us a6*erhavin/ 7een e8p+sed *+ 9asin/

S+9e pa*ien*s a1*ually have l+n/ *inni*us56ree in*ervals a6*er vari+us 9asin/e8p+sures.





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)(Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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!IG!#IG!T

>+9plain*s +6 *inni*us sh+uld 7e dividedin*+ su7=e1*ive versus +7=e1*ive andn+npulsa*ile versus pulsa*ile 1a*e/+ries

*+ 6a1ili*a*e dia/n+sis and 9ana/e9en*. All pa*ien*s i*h *inni*us sh+uld have

a 1+9ple*e audi+/ra9 as par* +6 *heirevalua*i+n. I9a/in/ and +*her s*udies9ay 7e indi1a*ed 7ased +n ndin/s +nhis*+ry and physi1al e8a9ina*i+n.

)$Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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!IG!#IG!T

N+npulsa*ile *inni*us 1an resul* 6r+9 avarie*y +6 1auses, in1ludin/ SN!#, >!#.in/es*i+n +6 s*i9ulan*s, head *rau9a, and

psy1hia*ri1 disease. Khen p+ssi7le,*rea*9en* +6 *he underlyin/ 1ause 1anallevia*e *inni*us.

Khen e*i+l+/y5spe1i1 9ana/e9en* +6

n+npulsa*ile *inni*us 6ails +r is n+*p+ssi7le. n+nspe1i1 9ana/e9en* +6*inni*us sh+uld 7e a**e9p*ed.

)'Maura ", %a9ela >.. Tinni*us. In Bailey, -B. -+hns+n, T-. !ead and Ne1 O*+laryn/+l+/y. )*h ed. ?+l '. #ippin1+**Killia9s < Kilins. '($4..




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%ulsa*ile *inni*us 1an 7e /enera*ed 7ya varie*y +6 ar*erial and ven+us 1auses,vas1ular *u9+rs, uid i*hin *he 9iddle

ear, +*+s1ler+sis, and *u9+rs +6 *he lA>.In up *+ +ne5*hird +6 *hese 1ases, n+e*i+l+/i1 a/en* ill 7e iden*ied.

Trea*9en* +6 *he underlyin/ 1ause +6pulsa*ile *inni*us, hen p+ssi7le. 1anres+lve *his 1+9plain*.


Tinnitus Presentasi

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