Cause Of Pulsatile Tinnitus Research Articles

Non-invasive imaging modalities for diagnosing pulsatile tinnitus: a comprehensive review and recommended imaging algorithm.

Pulsatile tinnitus (PT) is a challenging diagnostic condition arising from various vascular, neoplastic, and systemic disorders. Non-invasive imaging is essential for identifying underlying causes while minimizing risks of invasive diagnostic angiography. Although no consensus exists on the primary imaging modality for PT and currently CT, ultrasound, and MRI are used in the diagnostic pathway, MRI is increasingly preferred as the first-line screening test for its diagnostic efficacy and safety. MRI protocols such as time-of-flight, magnetic resonance angiography, diffusion-weighted imaging, and arterial spin labeling can identify serious causes, including vascular shunting lesions, venous sinus stenosis, and tumors. In this narrative review of the current literature we discuss the benefits and limitations of various non-invasive imaging modalities in identifying the characteristic imaging findings of the most common causes of PT and also provide an algorithm that clinicians can use to guide the imaging evaluation.

Outcomes of Pulsatile Tinnitus After Cerebral Venous Sinus Stenting: Systematic Review and Pooled Analysis of 616 Patients

Pulsatile tinnitus (PT) is a debilitating condition with substantial morbidity related to quality of life. Cerebral venous sinus stenosis has recently emerged as a noninfrequent cause of PT, either in the setting of concurrent idiopathic intracranial hypertension (IIH) or due to primary venous stenosis. Venous sinus stenting (VSS) is an endovascular technique that can be used to treat venous stenosis. However, it is unclear if outcomes are different between patients with primary venogenic PT and IIH associated PT. A systematic literature review and pooled analysis was completed to evaluate the clinical outcomes of PT in patients undergoing cerebral VSS. Outcome measures included: Improved PT, complete resolution of PT, and PT recurrence at follow-up. Subgroup analysis between patients with IIH and primary PT was completed. In total, 28 studies were identified with 616 patients. The proportion of improved PT symptoms after VSS had an overall pooled rate of 91.7% (confidence interval [CI]:88.1%-95.2%; I2= 65%) and no difference between subgroups (P= 0.12). Complete resolution after VSS had an overall pooled rate of 88.6% (CI: 84.0%-93.3%; I2= 68%) and no significant difference between subgroups (P= 0.35). Recurrent PT after stenting occurred in 6.5% of cases (CI: 1.7%-11.3%; I2= 62%). Furthermore, subgroup analysis demonstrated that IIH patients had a significantly higher recurrence rate (10.6%; CI: 5.2%-16.1%; I2= 26%) compared to patients treated with venous stenting for PT as the primary indication (2.0%; CI: 0.8%-4.7%; I2= 0%) (P < 0.0001). Venous stenting in patients with PT results in a substantial decrease and often complete resolution of symptoms. PT is more likely to recur in patients with IIH-associated PT.

Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review.

Sigmoid sinus diverticulum (SSD) has been increasingly reported as a cause of pulsatile tinnitus (PT). While both endovascular and surgical treatments have been used, there is a lack of consensus on the treatment modality to treat SSD. We conducted a systematic review of the available literature to compare the clinical outcomes and safety of endovascular versus surgical approaches for treating SSD. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify studies encompassing the management of SSD. Studies reporting the clinical outcomes and safety of endovascular or surgical treatments for SSD between January 2000 and January 2023 were included. Results were characterized using descriptive statistics. Endovascular treatment (EVT) was reported by 17 articles, yielding 26 patients with 27 diverticula. Surgical treatment was reported by 20 articles, yielding 105 patients with 107 diverticula. EVT led to complete or near-complete resolution in all patients with SSD and PT. Complications occurred in 3.7% (1/27) with a return to baseline after 2 months. There were no permanent complications from EVT. Surgical treatment resulted in complete resolution in 77.6% (83/107) of cases, incomplete resolution in 11.2% (12/107), and no resolution in 11.2% (12/107). Significant complications occurred in 9.3% (10/107) of the surgical-treated patients. EVT in patients with PT and venous diverticulum appears more effective and safer than surgical treatment, but large studies are lacking. Studies directly comparing endovascular and surgical treatment are needed.

Hemodynamic assessments of unilateral pulsatile tinnitus with jugular bulb wall dehiscence using 4D flow magnetic resonance imaging.

Pulsatile tinnitus (PT) is a type of tinnitus characterized by a rhythmic sound that is synchronous with the heartbeat. One of the possible causes of PT is the jugular bulb wall dehiscence (JBWD). However, the hemodynamics of this condition are not well understood. To elucidate this issue, the present study aimed to compare the blood flow of PT patients with JBWD, PT patients with sigmoid sinus wall dehiscence (SSWD), and volunteers. A retrospective case-control study was conducted, which enrolled patients with unilateral PT who had undergone both computed tomography angiography (CTA) and four-dimensional (4D) flow magnetic resonance imaging (MRI) examinations at the Department of Otolaryngology-Head and Neck Surgery of Beijing Friendship Hospital affiliated to Capital Medical University between January 2019 and July 2023. After excluding the possible causes of PT, the patients were divided into the JBWD group and SSWD group according to the presence or absence of JBWD and/or SSWD. Finally, 11 female unilateral PT patients with JBWD (JBWD group, 11sides), 22 age- and side-matched female patients with SSWD (SSWD group, 22 sides), and 22 age-matched female volunteers (volunteer group, 36 sides) were enrolled. The area, maximum voxel velocity (Vv-max), maximum velocity (Vmax), average velocity (Vavg), and average blood flow rate (Q) were measured in the transverse sinuses (TSs), sigmoid sinuses (SSs), and jugular bulb (JB). The vortex flow pattern was also assessed. Fisher's exact test and Bonferroni correction were used for count data, with P<0.017 was considered statistically significant. Shapiro-Wilk test, one-way analysis of variance (ANOVA), Kruskal-Wallis H test, paired-samples t-test, and Wilcoxon matched-pairs signed-rank test were used for continuous variables depending on the distribution and variance of the data. The P<0.05 and corrected P<0.05 was considered statistically significant. The area and Q of TSs and JB on the symptomatic side were higher than those on the contralateral side in the JBWD group (TSs: Parea=0.004, Pflow=0.002; JB: Parea=0.034, Pflow=0.018). The area was larger and velocities were lower in the JBWD group at the TSs than the SSWD group (Parea=0.004, PVv-max=0.009, PVmax=0.021, PVavg=0.026), and velocities were higher at the distal TSs and SSs than the volunteer group (TSs: PVv-max=0.042, PVmax=0.046, PVavg=0.040; SSs: PVv-max=0.007, PVmax=0.001, PVavg=0.001). At the JB, the JBWD group also had higher Vv-max than the volunteer group (P=0.012). The occurrence rate of vortex at JB in the JBWD group was higher than both the JBWD and the volunteer groups (P=0.002<0.017 and P=0.009<0.017, respectively). The blood flow of the intracranial venous sinus was different between the JBWD group and the SSWD group. The indicators that can differentiate include Vv-max, Vmax, Vavg, vortex, and TSs cross-sectional area.

Ringing in the Ears: Approaches to Imaging and Management of Tinnitus

ABSTRACT Tinnitus is a condition in which patients perceive sound without an external stimulus. It can be classified into either pulsatile or nonpulsatile tinnitus. This condition affects around 14% of the global population, and the severity of tinnitus can range from barely noticeable to devastating. In most cases, tinnitus is benign and nonpulsatile in nature. The diagnostic role of imaging is to detect treatable and specific pathology. Therefore, a comprehensive clinical assessment, which includes a meticulous examination for associated symptoms like hearing loss, vertigo, or headaches, along with a thorough physical examination, otoscopy, and audiologic testing, is imperative before considering any imaging studies as the choice of imaging will depend on various factors. Nonpulsatile or continuous tinnitus is most commonly associated with presbycusis but can also be caused by functional injuries due to ototoxic medications or exposure to loud noise and usually requires no imaging evaluation. Unlike nonpulsatile tinnitus, imaging patients with pulsatile tinnitus typically reveals perceptible findings. The cause of pulsatile tinnitus is usually a vascular tumor, vascular malformation, or vascular anomaly. Other causes of tinnitus include idiopathic intracranial hypertension, otosclerosis, Paget’s disease, and Meniere’s disease. One of the main challenges is that the underlying cause of tinnitus is often unknown. Another challenge is that tinnitus can have a significant effect on a person’s quality of life, yet the condition is not life-threatening and there is no cure. We present a clinical review of the most prevalent causes of tinnitus along with an emphasis on the diagnostic imaging workup and management of common presentations.

Abstract 095: Pulsatile Tinnitus from An Enlarged Mastoid Emissary Vein: Successful Management with Endovascular Embolization

Introduction Tinnitus is a prevalent condition, affecting approximately 10% of the population. It can be categorized into vascular (pulsatile) and nonvascular (non‐pulsatile) based on its rhythmic quality in sync with the heartbeat (1). Recent literature identifies venous etiologies as the most common cause of pulsatile tinnitus, including venous sinus stenosis, venous diverticula, and the less common enlarged mastoid emissary vein (MEV). Emissary veins are residual connections between the extracranial venous system of the head and the intracranial venous system. Although rare, pathologically enlarged MEVs have been recognized as a cause of pulsatile tinnitus. Endovascular treatment is a novel approach for these patients, offering a safe and quicker recovery compared to traditional open surgical options (2). Here, we present a case of a young woman with debilitating pulsatile tinnitus due to an enlarged MEV, with technically successful treatment via endovascular embolization. Methods A 42‐year‐old female presented with left pulsatile tinnitus, imbalance, and headaches following a motor vehicle collision two years prior. Her symptoms included a persistent “whooshing” sound at rest, exacerbated by strenuous physical activity. A tinnitus handicap inventory score of Grade 4‐5 (severe to catastrophic) confirmed the severity of her condition. After ruling out other malignant causes through extensive imaging, a CT scan revealed an enlarged 4.4mm left mastoid emissary vein. Diagnostic suspicions were confirmed by physical examination with superficial compression of the vein along the mastoid region, effectively eliminating the tinnitus. A cerebral angiogram subsequently confirmed an enlarged 5.2mm left MEV, while excluding other malignant arterial or arteriovenous etiologies. After discussing surgical options with neurosurgery and ENT specialists, the patient chose to pursue endovascular intervention. Using a transvenous approach, a coaxial construct of a guide catheter with microcatheter was navigated into the emissary vein, with technically successful coil embolization/sacrifice of the MEV. Post embolization angiogram demonstrated complete occlusion of the MEV with preserved arterial, parenchymal, and venous phases on cerebral angiogram. No procedural complications were reported. Results Following the procedure, the patient reported complete resolution of her symptoms. At one‐month follow‐up, she experienced an occasional pulsatile sensation in the left ear, lasting less than one hour per day. The post‐procedural tinnitus handicap inventory scoring was 1, indicating significant improvement in her quality of life, and she resumed an essentially normal daily routine. Conclusion This case highlights the successful management of pulsatile tinnitus caused by an enlarged MEV through endovascular intervention, offering a new and safe alternative to traditional surgical treatments. Although emissary veins have been implicated as a venous cause of pulsatile tinnitus, reports of this specific etiology (mastoid emissary vein) and endovascular treatment remain limited (3),(4). The considerable improvement in the patient’s quality of life, rapid post‐procedural recovery, and minimally invasive nature of the procedure makes this approach a promising alternative for the management of pathologically enlarged MEVs as a cause of pulsatile tinnitus.

More than just noise: Association of pulsatile tinnitus with anxiety, depression, and reduction of quality of life.

While many of the causes of pulsatile tinnitus (PT) are treatable with endovascular approaches, the risks of treatment must be balanced with the risks of the underlying cause and the psychological impact of symptoms on patients. While many physicians have anecdotal experience, the comorbid relationship of depression and anxiety with PT is unknown. The objectives of this study are to quantify the prevalence of depression and anxiety, and, to identify the demographic risk factors for impactful depression and anxiety in patients with PT. Subjects recruited from online PT groups filled out secure online questionnaires that included demographic questions, validated Tinnitus Functional Index (TFI) as well as PHQ-9 and GAD-7 questionnaires to assess the prevalence of concurrent depression and anxiety, respectively. Sample included 515 surveys (84% female, 65% unemployed, mean(sd) age = 46.4 years (14.2)). Median symptom duration was 1.9 years. Data showed 46% and 37% of patients with moderate to severe depression and anxiety, respectively. Higher TFI scores were associated with moderate to severe depression (OR 1.07; 95% CI 1.06-1.09, p < 0.001) and anxiety (OR 1.05, 95% CI 1.04-1.06, p < 0.001), with TFI subscores also independently being associated in a univariate analysis. The prevalence of moderate to severe depression and anxiety in the PT population, which was previously unknown, is estimated in our study to be 46% and 37%, respectively. Significant association of TFI score with increased depression and anxiety scales adds further evidence of the impact of PT on the psychological health of these patients.

Abstract Number ‐ 119: Stent‐Coil Embolization Of A High Riding Jugular Bulb For Symptomatic Pulsatile Tinnitus

Introduction Tinnitus affects millions of people worldwide and in a significant number of people, tinnitus can be severe enough to impact day‐to‐day life. Various diseases can manifest with tinnitus, including atherosclerotic disease, AVMs, Meniere’s disease, IIH, medication toxicity, and neoplasms. Jugular bulb diverticula are a significant contributor to the incidence of persistent tinnitus. One study of 1579 temporal bone specimens, 8.2% were found to have high‐riding jugular bulbs. Other sources demonstrate a prevalence of 6% in the population. Another study demonstrated a high‐riding jugular bulb in 2.4‐7% of temporal bones, a 5 times higher prevalence of a high‐jugular bulb in patients with ear related symptoms, and tinnitus in 22% of patients in a 730 cohort who presented to otolaryngology. We present 3 cases of jugular bulb diverticula causing debilitating tinnitus and their subsequent treatment with stent‐assisted coiling. Methods Retrospective chart review of patients who presented with symptoms of pulsatile tinnitus, noted to have a jugular bulb diverticulum on cerebral venogram, who underwent stent‐assisted coil embolization. Results A 71‐year‐old male with a history of migraines presented with nausea and right‐sided tinnitus that worsened on lying down. The persistence of symptoms prompted further investigation with a catheter venogram which demonstrated a high‐riding right jugular bulb measuring 10.37 mm x 8.61 mm. The patient underwent stent‐assisted coiling and embolization with improvement in his symptoms. A 57‐year‐old male with recent history of right ischemic infarct secondary to intracranial atherosclerosis had worsening left sided pulsatile tinnitus over one year to the point where it prevented sleep, waking him hourly. A CT‐Venogram revealed a left jugular bulb diverticulum measuring 5.33×5.02 mm. A cerebral angiogram and venogram confirmed this diagnosis and ruled out an AVM/dAVF. Stent‐assisted coiling resulted in immediate relief. The above patients were treated with a Zilver stent (Cook Medical, Bloomington, IN) and Target Coils (Stryker Neurovascular, Kalamazoo, MI). A 40‐year‐old woman presented with severe abrupt‐onset pulsatile right‐sided tinnitus and associated hearing loss, without any associated relieving factors. Due to the severity of her symptoms, she goes to counseling. A cerebral venogram revealed a right internal jugular diverticulum measuring 6.73 mm x 14.5 mm, without any associated dural sinus stenosis. She is scheduled for stent assisted coil embolization. Conclusions High‐riding jugular bulb or jugular diverticulum should be suspected as a potential and treatable cause of pulsatile tinnitus when other diagnoses have been ruled out. Our case series demonstrates that stent assisted coil embolization is safe and effective in relieving tinnitus and hearing loss, which can be debilitating in many cases.

Analysis of Revision Surgery Following Surgical Reconstruction of the Sigmoid Sinus Wall in Patients with Pulsatile Tinnitus.

Background:To explore potential causes leading to the failure of the surgical reconstruction of sigmoid sinus wall in patients with pulsatile tinnitus.Methods:This study retrospectively analyzed pulsatile tinnitus patients with sigmoid sinus wall dehiscence and/or sigmoid sinus diverticulum, who underwent revision surgeries following the surgical reconstruction of the sigmoid sinus wall.Results:A total of 7 pulsatile tinnitus patients were included. After the first surgery, 5 of 7 patients showed varying degrees of remission in pulsatile tinnitus, but pulsatile tinnitus gradually recurred. The other 2 patients experienced no change in pulsatile tinnitus. Images after the first surgeries revealed that the surgical failure of Patients 1-5 was caused by incompleted elimination of sigmoid sinus wall dehiscence and sigmoid sinus diverticulum. Following revision surgeries, they all acquired great or complete resolution of pulsatile tinnitus. In Patient 6, an abnormal diploic vein entering the sigmoid sinus was overlooked during the first surgery for repairing sigmoid sinus wall dehiscence. As soon as the diploic vein was blocked during the revision surgery, the patient’s pulsatile tinnitus was alleviated significantly. Patient 7 had a recurrence of pulsatile tinnitus after transient improvement following the first surgery, and still experienced no change in pulsatile tinnitus after the revision surgery. However, after venous sinus stenting in the stenosis of transverse-sigmoid sinus junction, she got complete resolution of pulsatile tinnitus. It suggested that the unresolved stenosis of the venous sinus was the cause of the surgical failure.Conclusions:Both sigmoid sinus diverticulum and sigmoid sinus wall dehiscence are recommended to be resolved during surgery. Abnormal diploic veins and venous sinus stenosis are potential causes of pulsatile tinnitus.

Emergence of Venous Stenosis as the Dominant Cause of Pulsatile Tinnitus

Background The role of arteriovenous shunts such as dural fistulas, arterial steno‐occlusive states, anatomic variants, and hypervascular tumors in the genesis of pulsatile tinnitus (PT) has long been recognized. On the venous side, diverticula, high‐riding jugular bulb, and sinus wall dehiscence have also been implicated. However, the overall most common cause—venous sinus stenosis (VSS)—continues to be underrecognized. Its clinical importance, separate from venous stenosis association with intracranial hypertension, also requires emphasis. Methods A retrospective review of the last consecutive 208 cases of PT seen at our institution was performed and cause determined, when possible, based on clinical and radiographic data. Results VSS was the common cause of PT (34% of overall cohort). Over 90% are women. Typical clinical presentation was a unilateral whoosh‐like sound in sync with heartbeat that could be completely or nearly completely abolished by ipsilateral jugular compression. This clinical scenario virtually guaranteed the presence of VSS, with very high sensitivity, specificity, positive, and negative predictive values. About two thirds of patients with VSS also harbored other venous anatomic variations such as a high‐riding jugular bulb or sinus diverticulum, that should not be misinterpreted as the primary cause of PT. Most did not have signs or symptoms of intracranial hypertension, even though cerebrospinal fluid and venous pressures are frequently elevated. Conclusions VSS appears to be the most common identifiable cause of PT. Judicious attention to this finding can be immensely helpful in prompt and accurate diagnosis.

Endovascular Management of Brain Arteriovenous Malformation (AVM) Presenting with Contralateral Morbid Tinnitus: A Case Report

Brain arteriovenous malformations are type of intracranial high-flow vascular malformation that can present with incidental finding in asymptomatic patients, seizures, headache, ischemic events due to vascular steal from normal brain, hemorrhage. Pulsatile tinnitus is the result of blood flow related sounds transmitted to the inner ear and coincides with heartbeat. AVMs are a rare cause of pulsatile tinnitus which contributes to less than 1% of published cases in the literature. We report a case of morbid tinnitus due to brain AVM which was resolved completely by endovascular embolization of the lesion. J Bangladesh Coll Phys Surg 2022; 40: 128-131

Vascular abnormalities - a true cause of pulsatile tinnitus?

Pulsatile tinnitus can be a symptom of vascular pathology. However, many of these pathologies present as incidental findings on scanning for unrelated symptoms. This study investigated whether the pathologies attributed to pulsatile tinnitus could instead be considered incidental findings. This retrospective study evaluated imaging results of 272 pulsatile tinnitus cases for clinically relevant pathologies, and examined correlations between the site of symptoms and the imaging findings. Of 272 patients, 238 (88 per cent) had normal scans, 17 (6 per cent) had clinically insignificant incidental findings, and 18 (7 per cent) had findings requiring further investigation or intervention; regarding these latter 18 patients, findings for 8 patients (42 per cent) did not correlate with the symptomatic side. The rates of intracranial aneurysm and arteriovenous malformation in the pulsatile tinnitus group were comparable to those in normal populations. The comparable rates of vascular abnormalities within the symptomatic pulsatile tinnitus group, plus clinically relevant findings contralateral to symptoms, suggest that vascular pathologies could be incidental findings rather than causes of pulsatile tinnitus. Evaluation is recommended of the effectiveness of the new National Institute for Health and Care Excellence guidelines for pulsatile tinnitus investigation.

Pulsatile tinnitus secondary to sigmoid sinus diverticulum: A case report

Sigmoid sinus diverticulum (SSD) has been recently recognized as a cause of pulsatile tinnitus (PT). The cause of the SSD and tinnitus caused by a sinus diverticulum is unknown. Numerous cases have reported successful treatment with surgical or radiological intervention. We report the first case of SSD in our region that was treated surgically with a successful outcome. A 40-year-old female presented to the Ear Nose Thorat (ENT) clinic with the chief complaint of right ear ringing for three years. The symptoms were relieved on compression of the ipsilateral internal jugular vein during clinical examination. Computed tomography showed a bony defect and sigmoid sinus diverticulum. Surgical excision was performed under general anaesthesia using the trans-mastoid approach. The diverticulum was identified and obliterated. Temporalis fascia and conchal cartilage were used as grafts. No postoperative complications were noted. A 3-year follow-up showed no signs of recurrence. Tinnitus is a relatively common condition. SSD should be investigated as a probable cause. A successful outcome is governed by the surgeon’s expertise.

Dilated MMA sign in cDAVF and other arterial feeders on 3D TOF MRA.

BackgroundAmong the varied causes of pulsatile tinnitus, the condition that can cause severe mortality and morbidity is a cranial dural arteriovenous fistula (cDAVF). This study aimed to assess the diagnostic accuracy of the dilated middle meningeal artery on three-dimensional time-of-flight magnetic resonance angiography in cranial dural arteriovenous fistula and to identify other feeders that can aid in the detection of these lesions.MethodMagnetic resonance angiography and digital subtraction angiography data of all patients with cranial dural arteriovenous fistula treated in a single tertiary referral center between 2007–2020 were included. The middle meningeal artery and other feeders recorded from digital subtraction angiography were assessed on magnetic resonance angiography.ResultsThe overall agreement between readers in identifying the dilated middle meningeal artery was substantial (κ = 0.878, 95% confidence interval: 0.775–0.982). The dilated middle meningeal artery indicated the presence of a cranial dural arteriovenous fistula with a sensitivity of 79.49% (95% confidence interval: 66.81–92.16), specificity of 100% (95% confidence interval: 100.00–100.00), and negative predictive value of 94.56% (95% confidence interval: 90.89–98.02). An area under the curve of 0.8341 was observed for the ipsilateral middle meningeal artery, with a sensitivity of 92.2% and a specificity of 75.0% at a cut-off of 0.30 mm for identifying a cranial dural arteriovenous fistula. Of 73 other feeders, the occipital, meningohypophyseal trunk, ascending pharyngeal, and posterior meningeal arteries contributed to a large proportion visualized on magnetic resonance angiography (83.6% (41/49)).ConclusionThe dilated middle meningeal artery sign is useful for identifying a cranial dural arteriovenous fistula. Dilatation of the occipital and ascending pharyngeal arteries and meningohypophyseal trunk should be assessed to facilitate the detection of a cranial dural arteriovenous fistula, particularly in the transverse-sigmoid and petrous regions.

The association between pulsatile tinnitus and degree of carotid stenosis

Background A pulsatile tinnitus may be the first and sole manifestation of carotid artery atherosclerosis and stenosis. The objective of this study was to detect the association between pulsatile tinnitus and degree of carotid stenosis by carotid Doppler ultrasound parameters. Patients and methods This prospective cross-sectional analytical study has been conducted on 40 selective cases complaining from pulsatile tinnitus. Carotid duplex ultrasonography scanning was done. Research has been approved by the Research Ethical Committee of Otolaryngology Department, Faculty of Medicine for Girls, AL-Azhar University. Results Carotid artery atherosclerosis and stenosis were diagnosed as a cause of pulsatile tinnitus in five patients (12.5%). The internal carotid artery (peak systolic velocity and end diastolic velocity) values were significantly higher in patients whose intima-media thickness was greater than 1 mm and the lumen diameters were smaller. Conclusion A pulsatile tinnitus may be the first, unusual, and sole manifestation of carotid artery atherosclerosis and stenosis. So, early screening and accurate diagnosis of atherosclerosis will prevent stroke and other central nervous system complications.

박동성 이명의 진단과 치료의 최신 지견

Pulsatile tinnitus (PT), in general, is not related to pathology of the auditory system. Although PT is not as common as non-pulsatile tinnitus, the diagnosis and treatment of PT is important as it is reported to be found in as much as 4% of general population and treatable vascular causes are found in 44~91% of subjects with PT. Three types of vascular origins (arterial, arteriovenous, and venous) of pulsatile tinnitus exist and the main causes of pulsatile tinnitus are related to aberrant/ectopic, stenosis, diverticulum, bony wall dehiscence, or other pathologies of blood vessels, either arterial or venous. Brain MRI with angiography, temporal bone high-resolution CT, Doppler ultrasonography, and classical transfemoral cerebral angiography are radiological diagnostic tools for pulsatile tinnitus, but basic findings at the outpatients’ clinic such as subjective psychoacoustic nature of the PT, otoendoscopic findings, and audiologic features are also very important as these can be of great help for the physicians to obtain presumptive diagnostic impression for each subject with PT. Dehiscence/diverticulum of the sigmoid sinus one of the most common surgically correctable venous cause of PT. Additionally, benign intracranial hypertension is also a very common cause of PT that should not be forgotten in obese PT subjects with normal radiologic findings. In this review, diagnostic steps and appropriate surgical- or interventional management options for each cause of PT will be discussed in detail. (J Clinical Otolaryngol 2021;32:26-39)

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy.

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Computational fluid dynamics study of the effect of transverse sinus stenosis on the blood flow pattern in the ipsilateral superior curve of the sigmoid sinus.

To investigate the effect of different types of transverse sinus stenosis on blood flow patterns in the ipsilateral superior curve of the sigmoid sinus. According to the morphology of transverse and sigmoid sinus sections in pulsatile tinnitus patients, ten idealized models with different degrees and positions of transverse sinus stenosis were constructed. Computational fluid dynamics simulations were performed to compare the hemodynamic characteristics among these models. Follow-up images of previous cases were included, which preliminarily confirmed the hypothesis that bone plate erosion of the sigmoid sinus sulcus is related to blood flow impingement. Blood flow impingement on the superior curve of the sigmoid sinus wall intensified with increasing degree of stenosis and decreased with increasing distance between the stenosis and the sigmoid sinus. The impact zone was generally confined to the anterior and lateral walls of the superior curve of the sigmoid sinus. When the stenosis was located far from the middle of the transverse sinus, the blood flow impingement on the sigmoid sinus wall was very weak. When stenosis is located far from the sigmoid sinus, the causes of tinnitus should be comprehensively considered instead of assuming that stenosis is the main cause. Bone plate erosion of the sigmoid sinus sulcus was promoted by blood flow impingement. • Ten idealized models with different degrees and positions of stenosis were constructed. • The causes of pulsatile tinnitus should be comprehensively considered. • Sigmoid sinus plate dehiscence was promoted by blood flow impingement.

Jugular Bulb Diverticulum: A Rare Cause of Pulsatile Tinnitus and Literature Review

Objectives: Pulsatile tinnitus involves a wide spectrum of etiologies. The etiologies include normal vascular variants, temporal bone tumor, acquired vascular lesions and chronic middle ear inflammatory diseases. Jugular bulb diverticulum is a rare cause of pulsatile tinnitus. We report one case of jugular diverticulum presenting with pulsatile tinnitus and its surgical management and outcome. Case Report: A 36-year-old woman with a history of uterine myoma and chronic anemia presented with right pulsatile tinnitus that was worsening in recent one month. Neurological exam was normal. ENT evaluation revealed no abnormalities via otoscopy and physical examination. The CT scan revealed right dominant jugular bulb with diverticulum projecting to posterior ear canal wall. We performed jugular bulb diverticulum resurfacing with temporalis fascia, Surgicel® and Gelfoam®, and bone wax via transmastoid approach. The symptom improved postoperative immediately. No major complications were noted during outpatient clinic follow-up. Conclusion: Transmastoid resurfacing of jugular bulb diverticulum is an effective management of pulsatile tinnitus from this kind vascular anomaly.

Imaging in Pulsatile Tinnitus: Case Based Review.

Tinnitus refers to auditory perception of internal origin. It is a relatively common problem and affects men and women equally. Clinically, it may be divided as pulsatile or non-pulsatile and subjective and objective. Although pulsatile tinnitus (PT) is less common, it is more likely to be associated with underlying vascular tumors, lesions or anomalies. Imaging forms the baseline for evaluation of objective tinnitus, primarily in the form of computed tomography or magnetic resonance imaging. We present a review of common causes of PT, along with emphasis on key imaging findings.