Pulsatile Tinnitus From a Spontaneous Carotid-Jugular Fistula

Abstract

We describe a patient who presented with unilateral objective pulsatile tinnitus (PT) from an unusual spontaneous fistula between the internal carotid artery (ICA) and the internal jugular vein (IJV). The 56-year-old woman presented with unilateral PT without antecedent trauma. A blowing bruit, synchronous with the pulse, was audible with stethoscopic examination of the right carotid, mastoid, and orbital regions. The duplex ultrasound showed high velocity flow over the right ICA. Right carotid angiography demonstrated a high-flow fistula between the ICA and the IJV. The patient received treatment with endovascular embolization, with coils, and the PT disappeared. Unilateral objective PT should be carefully evaluated for arteriovenous communications within the head and neck region. Although a fistula between the ICA and the IJV is rare, this arteriovenous fistula should be included in the differential diagnosis of pulsatile tinnitus. Noninvasive color duplex ultrasonography, rather than conventional angiography or CT arteriography, and venography, could be the primary diagnostic tool of choice with the suspicion of carotid artery abnormality in patients with normal otoscopic and neurologic examinations.