28 November 2022: Articles
Tinnitus Triggered by a Cerebellopontine Arachnoid Cyst in an Adolescent
Challenging differential diagnosis, Diagnostic / therapeutic accidents, Rare coexistence of disease or pathologySofia E. Olsson1AEF, Seckin O. Ulualp23ABCDEF*, Yann-Fuu Kou24ADEF
Am J Case Rep 2022; 23:e938294
BACKGROUND: Tinnitus can be a symptom of a wide range of disorders. The identification and treatment of the underlying condition is essential for management of tinnitus in children. Tinnitus can occur with medical conditions other than sensorineural hearing loss. Cerebellopontine arachnoid cysts are rare and can cause tinnitus and hearing loss in adults. Tinnitus caused by an arachnoid cyst has not been reported in an adolescent. We report clinical and radiological features of a teenager with bothersome tinnitus caused by an arachnoid cyst.
CASE REPORT: A 14-year-old girl with unilateral tinnitus for 10 months presented to the Pediatric Otolaryngology Clinic. The loudness and duration of tinnitus had progressed gradually. Turning the head to the right induced right otalgia and tinnitus. The patient denied hearing loss, vertigo, exposure to loud noise, feeling of fullness in ear, otorrhea, facial weakness, numbness, dysphagia, changes in smell or taste, and problems with the jaw or temporomandibular joint. The focused neurological examination and head and neck examination were within normal limits. The patient had normal hearing on audiometry. T1-weighted, T2-spin-echo, T2-FLAIR, and diffusion-weighted magnetic resonance imaging sequences were obtained, revealing a right cerebellopontine angle arachnoid cyst. After arachnoid cyst marsupialization, the patient’s tinnitus and otalgia resolved.
CONCLUSIONS: This case highlights the importance of suspecting identifiable nonauditory system disorders as causes of tinnitus in children. Thorough analysis of clinical findings and timely use of imaging is critical to prevent delay in diagnosis and treatment of children with bothersome tinnitus caused by rare medical conditions.
Keywords: Adolescent, Arachnoid Cysts, Tinnitus
Tinnitus is the perception of sound without an external source . The sound perceived is typically described as buzzing, ringing, clicking, pulsating, and other noises [1,2]. While subjective tinnitus is perceived only by the patient, objective tinnitus can be perceived by others. Subjective tinnitus is more common than objective tinnitus. The prevalence of tinnitus in children ranges from 6% to 46% . Children rarely spontaneously report tinnitus, and persistent and bothersome tinnitus has been found to occur in 0.6% to 3.1% of children [3,4]. The prevalence of tinnitus is higher in children with any type of hearing loss . Tinnitus can cause behavioral changes, poor concentration, and difficulty sleeping. Early detection and treatment of tinnitus is essential to diminish the distress it causes.
Tinnitus can be a symptom of a wide range of disorders, such as cerumen impaction of the external auditory canal, Eustachian tube dysfunction, otosclerosis, Ménière’s disease, vestibular schwannoma, vascular anomalies, myoclonus, and intracranial hypertension. Tinnitus is classified as idiopathic in the absence of an underlying cause. Identification and treatment of the underlying condition is essential for the management of tinnitus in children.
Intracranial arachnoid cysts are cerebrospinal fluid-filled cysts, which occur in adults and children . Intracranial arachnoid cysts are mostly asymptomatic; however, patients can develop symptoms specific to the location [6,7]. The most common location of intracranial arachnoid cysts is the middle cranial fossa [8,9]. Cerebellopontine arachnoid cysts are rare and can cause tinnitus and hearing loss in adults [8–11]. To the best of our knowledge, isolated tinnitus caused by an arachnoid cyst has not been reported in an adolescent. We report the clinical and radiological features of a teenager with isolated tinnitus caused by an arachnoid cyst.
A 14-year-old girl with no medical or surgical history presented to the Pediatric Otolaryngology Clinic because she had been hearing an intermittent soft buzzing sound in her right ear for 10 months. The tinnitus would only last a few minutes initially. The adolescent eventually presented to otolaryngology clinic because the loudness and duration of the tinnitus gradually became more severe, with loud and frequent episodes of tinnitus affecting her concentration at school. The patient developed right otalgia during episodes of tinnitus. Turning the head to the right induced right otalgia and tinnitus. The tinnitus did not interfere with sleep. The patient denied hearing loss, vertigo, exposure to loud noise, feeling of fullness in the ear, otorrhea, facial weakness, numbness, dysphagia, changes in smell or taste, and problems with the jaw or temporomandibular joint.
On physical examination, the auricles were of a normal shape, size, and location, without scars, lesions, or masses and no mastoid swelling, tenderness, or erythema. The ear canals were free of cerumen, otorrhea, debris, and foreign bodies, and the tympanic membranes were of normal color with good mobility. There was no audible tinnitus when the patient reported having tinnitus induced by turning the head to the right. The head and neck examination and focused neurological examination were within normal limits. The patient had normal hearing on audiometry (Figure 1). Magnetic resonance imaging (MRI) of the temporal bones and internal auditory canals was obtained owing to the history of unilateral tinnitus. T1-weighted, T2-spin-echo, T2-FLAIR, and diffusion-weighted MRI sequences were obtained. This revealed a right cerebellopontine angle arachnoid cyst with superior displacement of the cisternal segments of the right 7th and 8th cranial nerves and anterior displacement of the cisternal segments of the right 9th, 10th, and 11th cranial nerves (Figure 2). The patient was referred to the Neurosurgery Department. After she underwent arachnoid cyst marsupialization, the tinnitus and otalgia resolved.
Tinnitus can occur with medical conditions other than sensori-neural hearing loss (ie, secondary tinnitus), or without an identifiable cause (ie, primary tinnitus). Tinnitus is described as “bothersome tinnitus” in distressed patients, patients seeking active therapy, and patients with degraded quality of life and/or functional health status. We describe the clinical presentation and management of a 14-year-old girl with bothersome tinnitus due to a cerebellopontine angle arachnoid cyst. The present case illustrates the critical role of thorough analysis of clinical assessment findings and timely use of imaging in the management of children with tinnitus caused by rare medical conditions.
Tinnitus is reported in 34% of children when specifically questioned; however, bothersome tinnitus occurs in up to 3.1% of children [3,4,12]. Tinnitus in children is commonly ignored; hence, children seek medical care more than 12 months after the first appearance of symptoms . Bilateral tinnitus is more common than unilateral tinnitus . Most children experience intermittent and soft tinnitus . Tinnitus can degrade patient quality of life owing to social isolation, depression, sleep disorders, and poor concentration . Similar to patients in previous studies, the adolescent in this study experienced soft and intermittent tinnitus in the right ear. As the tinnitus progressed, our patient developed more frequent and loud episodes. The time between the first appearance of tinnitus and presentation to the Pediatric Otolaryngology Clinic was 10 months. As a consequence of the worsening nature of the tinnitus, our patient experienced poor concentration. Timely recognition of tinnitus and initiation of diagnostic tests are critical to prevent adverse consequences of unrecognized tinnitus.
Tinnitus can be caused by auditory and nonauditory system disorders. In children with bothersome tinnitus, triggers for tinnitus include hearing loss, jaw misalignment/malocclusion, noise trauma, tension of the neck, and middle ear aeration . Nonauditory system tinnitus can occur after cerebellopontine angle tumor removal and can be gaze-modulated . The loudness of the tinnitus varies by ocular movements. Atrophy of the flocculus on the surgical side has been suggested to modulate tinnitus [15,16]. Functional MRI revealed that tinnitus is associated with activities of the Heschl’s gyrus, angular gyrus, cerebellar, and limbic system . Arachnoid cysts are a benign malformation of the arachnoid layer of the meninges. Surgery is recommended when the arachnoid cyst is associated with hydrocephalus, seizure, increased intracranial pressure, or focal neurologic deficits [18,19]. In the present study, displacement and compression of the vestibulocochlear nerve by a cerebrospinal fluid-filled right arachnoid cyst triggered tinnitus. Tinnitus and otalgia were completely resolved upon treatment of the arachnoid cyst, confirming its role in the tinnitus experienced by our patient.
The most effective diagnostic and treatment strategies for children with tinnitus have not been established. Clinical practice guidelines for adults with bothersome and persistent tinnitus assist clinicians in managing primary tinnitus . Guidelines recommend obtaining a targeted history and examination at the initial evaluation of tinnitus. Audiologic examination is obtained in the presence of tinnitus, regardless of laterality, duration, or perceived hearing status. Imaging studies of the head and neck are recommended in the presence of unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss. Imaging studies used for evaluation of the head and neck in patients with tinnitus include computerized tomography angiography of the brain or temporal bone, or MRI angiography of the brain or internal auditory canals. In the present study, a symptom-directed history, physical examination, and hearing test were used to determine the need for imaging. MRI is recommended in the presence of uni-lateral tinnitus present for more than 6 months. The management of tinnitus in our patient was in accordance with clinical practice guidelines recommended for adults with tinnitus. Further studies are needed to establish clinical practice guidelines to manage cases of tinnitus in children.
This case highlights the importance of suspecting identifiable nonauditory system disorders as the cause of tinnitus in children. Thorough analysis of clinical findings and timely use of imaging are critical to prevent delay in diagnosis and treatment of children with bothersome tinnitus caused by rare medical conditions.
FiguresFigure 1.. The pure-tone audiogram revealed hearing threshold levels ranging from 10 dB to 20 dB in the right ear and 5 dB to 15 dB in the left ear. Figure 2.. Magnetic resonance imaging demonstrating the right arachnoid cyst’s (white arrow) association with 7th and 8th cranial nerves (black arrow)
1.. Tunkel DE, Bauer CA, Sun GH, Clinical practice guideline: Tinnitus: Otolaryngol Head Neck Surg, 2014; 151(2 Suppl.); S1-S40
2.. Langguth B, Kreuzer P, Kleinjung T, De Ridder D, Tinnitus: Causes and clinical management: Lancet Neurol, 2013; 12(9); 920-30
3.. Humphriss R, Hall AJ, Baguley DM, Prevalence and characteristics of spontaneous tinnitus in 11-year-old children: Int J Audiol, 2016; 55(3); 142-48
4.. Park B, Choi HG, Lee HJ, Analysis of the prevalence of and risk factors for tinnitus in a young population: Otol Neurotol, 2014; 35(7); 1218-22
5.. Piotrowska A, Raj-Koziak D, Lorens A, Skarzynski H, Tinnitus reported by children aged 7 and 12 years: Int J Pediatr Otorhinolaryngol, 2015; 79; 1346-50
6.. Caudron Y, Sterkers O, Bernardeschi D, Kalamarides M, Objective improvement in adults with cerebellopontine angle arachnoid cysts after surgical treatment: Acta Neurochir (Wien), 2021; 163(3); 753-58
7.. Al-Holou WN, Terman S, Kilburg C, Prevalence and natural history of arachnoid cysts in adults: J Neurosurg, 2013; 118(2); 222-31
8.. Helland CA, Lund-Johansen M, Wester K, Location, sidedness, and sex distribution of intracranial arachnoid cysts in a population-based sample: J Neurosurg, 2010; 113(5); 934-39
9.. Giordano M, Gallieni M, Samii A, Surgical management of cerebellopontine angle arachnoid cysts associated with hearing deficit in pediatric patients: J Neurosurg Pediatr, 2018; 21(2); 119-23
10.. Kessler P, Bodmer D, Arachnoid cyst of the cerebellopontine angle causing tinnitus and hearing loss: Otology & Neurotology, 2011; 32; e1-e2
11.. Makhchoune M, Coneys U, Triffaux M, Reversible hearing loss after 3D video-assisted marsupialization of several posterior fossa arachnoid cysts: A case report: Ann Med Surg (Lond), 2022; 75; 103468
12.. Savastano M, Marioni G, de Filippis C, Tinnitus in children without hearing impairment: Int J Pediatr Otorhinolaryngol, 2009; 73; S13-S15
13.. Szibor A, Jutila T, Mäkitie A, Aarnisalo A, Clinical characteristics of troublesome pediatric tinnitus: Clin Med Insights Ear Nose Throat, 2014; 35(7); 1218-22
14.. Aksoy S, Akdogan Ö, Gedikli Y, Belgin E, The extent and levels of tinnitus in children of central Ankara: Int J Pediatr Otorhinolaryngol, 2007; 71; 263-68
15.. Mennink LM, Van Dijk JMC, Van Der Laan BFAM, The relation between flocculus volume and tinnitus after cerebellopontine angle tumor surgery: Hear Res, 2018; 361; 113-20
16.. Mennink LM, Koops EA, Langers DRM, Cerebellar gray matter volume in tinnitus: Front Neurosci, 2022; 16; 862873 29
17.. Zenke JK, Rahman S, Guo Q, Central processing in tinnitus: fMRI study outlining patterns of activation using an auditory discrimination task in normal versus tinnitus patients: Otol Neurotol, 2021; 42(8); e1170-e80 1
18.. Cincu R, Agrawal A, Eiras J, Intracranial arachnoid cysts: Current concepts and treatment alternatives: Clin Neurol Neurosurg, 2007; 109; 837-43
19.. Choi JW, Lee JY, Phi JH, Stricter indications are recommended for fenestration surgery in intracranial arachnoid cysts of children: Childs Nerv Syst, 2015; 31(1); 77-86
05 Jun 2023 : Case reportSuccessful Treatment of Recurrent Colonic Adenocarcinoma with Metastatic Tumor Thrombus in the Superior Mes...
Am J Case Rep In Press; DOI: 10.12659/AJCR.939156
05 Jun 2023 : Case reportDelayed Right Ventricular Pacemaker Lead Perforation 9 Years After Implantation
Am J Case Rep In Press; DOI: 10.12659/AJCR.940291
05 Jun 2023 : Case reportAn 81-Year-Old Man Presenting with Asthenia and Anorexia After an Alcohol-Induced Hypoglycemic Coma and a D...
Am J Case Rep In Press; DOI: 10.12659/AJCR.939840
02 Jun 2023 : Case reportSingle Pterional Burr Hole Coupled with Coagulation of the Middle Meningeal Artery for Management of a Chro...
Am J Case Rep In Press; DOI: 10.12659/AJCR.940045
Most Viewed Current Articles
06 Dec 2021 : Case reportLipedema Can Be Treated Non-Surgically: A Report of 5 Cases
Am J Case Rep 2021; 22:e934406
13 Jul 2022 : Case reportWhistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound
Am J Case Rep 2022; 23:e936441
07 Dec 2021 : Case reportEdwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Fac...
Am J Case Rep 2021; 22:e934347
23 Feb 2022 : Case reportPenile Necrosis Associated with Local Intravenous Injection of Cocaine
Am J Case Rep 2022; 23:e935250