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Tinnitus is a symptom of abnormal sense of sound at ear or head. The most common neurosurgical causes of tinnitus are: 


● A lesion compressing on nerves or spinal cord at our neck, for example a herniated cervical intervertebral disc.


● A vascular lesion, either congenital or acquired, at our brain or neck, for example a cerebral arteriovenous malformation (congenital), a cerebral aneurysm or a dural arteriovenous fistula (both are acquired lesions).


● A brain tumor, for example an acoustic neuroma that arise from our  cranial nerve that serves the function of hearing and balance.

Image by Franco Antonio Giovanella

After excluding other common causes, such as lesions in ear, nose and throat, neurosurgeon will proceed to detailed examinations at patient's brain and neck, so as to exclude structural lesions as mentioned above. 

Case 1: A herniated cervical intervertebral disc impinging at spinal nerves and cord at neck to cause tinnitus

Mr. Lam, a 33-year-old clerk, though had always been in a healthy lifestyle, he occasionally sensed mild tightness at neck and also nerve pain at arms during work.


Few years ago, Mr. Lam suffered from abnormal sense of sound at both ears, i.e. bilateral tinnitus, for three months.  He visited his family doctor and an otolaryngologist.  Despite after detailed examinations and trials of medications, the tinnitus was still disturbing and haunted Mr. Lam days and nights.  Upon a friend’s referral, Mr. Lam consulted a neurosurgeon for further investigations of his symptom.  Subsequent detailed MRI (Magnetic Resonance Imaging) showed that there were herniated discs at Mr. Lam’s neck at the C5/6 and C6/7 levels of his cervical spine.  The herniated discs were compressing on his spinal nerves and cord, and that caused the disturbing tinnitus. 


As the compression on nerves and cord was only mild to moderate degree, thus not severe enough to justify a surgery.  The neurosurgeon thus treated Mr. Lam with drugs and referred him for six months’ course of COX chiropractic treatment.  While on treatment, Mr. Lam’s disturbing tinnitus disappeared gradually. 


After six months of COX chiropractic  treatment, a follow-up MRI revealed that Mr. Lam’s herniated discs had been significantly reduced and the compressions on nerve and cord was much lessened. 

Case 2: Vascular tinnitus caused by an acquired arteriovenous fistula at dural of brain


Ms. Cheung, a 46 housewife, with her daughter’s companion visited neurosurgery clinic for her 3 months history of disturbing tinnitus at left ear.  While using a stethoscope for ascultation at Ms. Cheung’s head, neck and chest, the neurosurgeon found that the tinnitus was with pulsatile nature and it was synchronized with her heart beat.


Subsequent MRA (Magnetic Resonance Angiography) with 3D images confirmed a dural arteriovenous fistula at the dural of brain near the back of Ms. Cheung’s left ear.  The fistula was an abnormal vascular lesion with high blood flow that was caused by direct communications of arteries and veins, with bypassing the pathway capillaries, as normal it should be.  


With Minimally Invasive Endovascular Neurovascular Surgery lasting for 2 hours, the neurovascular surgeon used titanium coils of extremely fine  size as the shafts of hair, to block the abnormal vascular communications.  With the abnormal high blood flow across the fistula being stopped, Ms. Cheung’s disturbing pulsatile tinnitus disappeared immediately.  Besides tinnitus, her future risk of hemorrhagic stroke that wound be caused by the fistula was also being eliminated.  One day after the surgery, Ms. Cheung was discharged home with daughter’s companion in happy mood.

Case 3: Tinnitus caused by brain tumour: Acoustic Neuroma


Mr. Leung, a 56-year-old businessman, has been annoyed by a day and night tinnitus at his right ear for six months.  MRI examination ordered by an otolaryngologist revealed a small tumor of 5mm size at the right acoustic nerve of Mr. Leung’s brain.  Though hearing test still showed normal hearing function at the moment, the doctor predicted that there would be a gradual tumour growth and that would cause deafness in future.  Mr. Leung was thereafter, referred to a neurosurgeon. 


The neurosurgeon advised Mr. Leung for three treatment options which were: 

(1) conservative observation; 

(2) radiosurgery with using Cyberknife; 

(3) minimally invasive neurosurgery with the aim of hearing preservation.


With consideration of the 3 treatment options with reference to their risks, pros and cons, Mr. Leung eventually opted for the minimally invasive neurosurgery.  Under 4 hours of surgery under microscope, and  with continuous nerve function monitoring, the neurosurgeon carefully used extremely fine instruments of  1-2mm size to separate the 5mm tumor from the acoustic nerve.  


After surgery, Mr. Leung’s hearing was preserved.  Besides, the function of facial nerve remained intact.  Most importantly, Mr. Leung felt no more disturbing tinnitus at his ear.

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