Sigmoid Sinus Diverticulum Research Articles

Clinical analysis of 50 patients with abnormal pulsatile tinnitus in sigmoid sinus

Objective: To analyze the disease characteristics, diagnosis and treatment methods of venous pulsatile tinnitus treated by intervention of sigmoid sinus. Methods: Fifty patients (from Shandong Provincial ENT Hospital, Shandong University between February 2014 and July 2020) with venous pulsatile tinnitus treated by sigmoid sinus surgery were analyzed retrospectively. The tinnitus characteristics, imaging findings, surgical methods, intraoperative findings and postoperative tinnitus changes were recorded. The patients were followed up for 6-12 months. The sign rank sum test was used to analyze the difference in tinnitus grading before and after surgery. There were 50 patients with unilateral venous pulsatile tinnitus, including 49 females and 1 male. The age ranged from 17 to 67 years, with a median age of 44 years. There were 45 cases of right tinnitus and 5 cases of left tinnitus. The degree of tinnitus before operation was grade Ⅱ or above, including 4 cases of gradeⅡ, 11 cases of grade Ⅲ, 22 cases of grade Ⅳ and 13 cases of grade Ⅴ. Results: Thirty-seven cases were cured, 8 cases were ineffective (no change in tinnitus), 3 cases were markedly effective (tinnitus grade decreased by 3 in 2 cases, 4 in 1 case), and 2 cases were effective (tinnitus grade decreased by 1). The difference of tinnitus grade before and after operation was statistically significant (Z=-5.70,P<0.05). Temporal bone CT showed 36 cases of sigmoid diverticulum (including 17 cases with sigmoid sinus dehiscence), 12 cases of sigmoid sinus dehiscence and 2 cases of absence of the temporal bone cortex abutting to sigmoid sinus. Thirty-five cases were performed with closure of sigmoid sinus diverticulum, 4 cases were performed with resurfacing of the sigmoid plate, 5 cases were performed with narrowing of sigmoid sinus, 4 cases were performed with simple opening of pre sigmoid mastoid air chamber, 1 case of opening was performed with pre sigmoid mastoid air chamber combined with narrowing of sigmoid sinus, and 1 case was performed with opening of pre sigmoid mastoid air chamber combined with closure of sigmoid sinus diverticulum. Conclusions: Venous pulsatile tinnitus is common in women. The common causes may be sigmoid sinus wall abnormalities such as sigmoid sinus diverticulum and perisigmoid bone defect. Imaging examinations are helpful for diagnosis. Venous pulsatile tinnitus can be treated with surgery.

Flow Analysis of Central Venous Outflow Tract: A New Approach to Understanding Pulse-Synchronous Tinnitus.

Pulse-synchronous tinnitus (PST) has been linked to multiple anatomical variants of the central venous outflow tract (CVOT) including sigmoid sinus (SS) dehiscence and diverticulum. This study investigates flow turbulence, pressure, and wall shear stress along the CVOT and proposes a mechanism that results in SS dehiscence and PST. Case series. Tertiary Academic Center. Venous models were reconstructed from computed tomography scans of 3 patients with unilateral PST. Two models for each patient are obtained: a symptomatic and contralateral asymptomatic side. A turbulent model-enabled commercial flow solver was used to simulate the pulsatile blood flow over the cardiac cycle through the models. Fluid flow through the transverse and SS junction was analyzed to observe the velocity, pressure, turbulent kinetic energy (TKE), and shear stress over a simulated cardiac cycle. Fluid flow on the symptomatic side showed increased vorticity in the presence of an SS diverticulum. Higher TKE with periodicity following the cardiac cycle was observed on the symptomatic side, and a sharp increase was observed if SS diverticulum was present. Shear stress was highest near the narrowest segments of the vessel. Pressure was observed to be lower on the symptomatic side at the transverse-SS junction for all 3 patients. Computational fluid dynamics modeling of blood flow through the CVOT in PST suggests that low pressure may be the cause of dehiscence, and tinnitus may result from periodic increases in TKE.

Tailored re-roofing technique for pulsatile tinnitus caused by sigmoid sinus dehiscence or diverticulum.

Sigmoid sinus diverticulum/dehiscence (SSD) is one of the treatable causes of venous pulsatile tinnitus. It can be diagnosed using temporal bone computed tomography (CT) or magnetic resonance angiography/venography (MRA). In cases where patients find their symptoms intolerable, surgical treatment is typically preferred. Here, we have presented a novel surgical technique involving sigmoid sinus re-roofing and have analyzed its feasibility. Between January 2020 and July 2023, approximately 150 patients with pulsatile tinnitus were evaluated at two different tertiary hospitals. Of these, 12 patients were diagnosed with SSD, and seven underwent surgical treatment. Five patients were treated with tailored reroofing (TRR) of the sigmoid sinus and two with transmastoid resurfacing (MRS) of the sigmoid sinus. We compared the Korean tinnitus handicap inventory (K-THI) score, pure tone audiogram (PTA) threshold, and CT findings before and a month after surgeries for these two techniques. The operation time was also analyzed. In TRR cases, the K-THI score reduced from 55.0 ± 31.4 preoperatively to 4.0 ± 3.0 postoperatively, and the SSD was well-repositioned and covered by a bone chip postoperatively. In MRS cases, the K-THI score reduced from 41.0 ± 9.9 preoperatively to 15.0 ± 21.2 postoperatively, and the SSD was well-covered with bone cement postoperatively. The average surgical time of five TRR and two MRS cases were 77.5 ± 32.5 and 174.0 ± 75.0 min, respectively. No complications were noted. Despite the insufficient number of cases, we noted that TRR requires a reasonable amount of time, involves a smaller incision, and may provide favorable outcomes compared to conventional MRS in cases of pulsatile tinnitus associated with SSD. IV.

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.

Surgical Management of Pulsatile Tinnitus due to Sigmoid Sinus Diverticulum and Dehiscence - A Technical Note.

Pulsatile tinnitus (PT) is the perception of an auditory sensation without an external source and in synchrony with the heartbeat. One of the most common cases of PT is bony anomalies of the sigmoid sinus, including dehiscence or diverticula. This case report describes a 26-year-old female patient who presented with pulsatile tinnitus caused by sigmoid sinus diverticula and dehiscence, which was successfully treated with cortical mastoidectomy with diverticula closure using pedicled temporalis fascia and resurfacing of the dehiscence with autogenous bone pate along with bone cement. We recommend thorough clinical and radiological workup to rule out other possible causes of PT before surgical intervention. In addition, we would like to highlight the surgical technique using pedicled temporalis fascia that we have used in our patient, which is easily reproducible and offers successful outcomes.

Analysis of Etiology, Diagnosis, and Treatment Strategy and Efficacy of Pulsatile Tinnitus Caused by Abnormal Vascular Anatomy.

To investigate the etiology, clinical characteristics, diagnosis, and treatment strategies and efficacy of pulsatile tinnitus (PT) caused by vascular anatomy abnormality. The clinical data of 45 patients with PT in our hospital from 2012 to 2019 were collected and retrospectively analyzed. All 45 patients had vascular anatomical abnormalities. The patients were divided into 10 categories according to the different locations of vascular abnormalities: sigmoid sinus diverticulum (SSD), sigmoid sinus wall dehiscence (SSWD), SSWD with high jugular bulb, pure dilated mastoid emissary vein, aberrant internal carotid artery (ICA) in the middle ear, transverse-sigmoid sinus (TSS) transition stenosis, TSS transition stenosis with SSD, persistent occipital sinus stenosis, petrous segment stenosis of ICA, and dural arteriovenous fistula. All patients complained of PT synchronous with heartbeat rhythm. Endovascular interventional therapy and extravascular open surgery were used according to the location of the vascular lesions. Tinnitus disappeared in 41 patients, was significantly relieved in 3 patients, and was unchanged in 1 patient postoperatively. Except for one patient with transient headache postoperatively, no obvious complications occurred. PT caused by vascular anatomy abnormalities can be identified by detailed medical history and physical and imaging examination. PT can be relieved or even completely alleviated after appropriate surgical treatments.

Dynamic Volume Computed Tomography for Characterizing Pulsatile Tinnitus Caused by Sigmoid Sinus Diverticulum with Bone Defects: Clinical Implications.

The objective of this study is to investigate the diagnosis of dynamic volume computed tomography (CT) for pulsatile tinnitus caused by sigmoid sinus diverticulum (SSD) and bone defects. Data obtained by dynamic volume CT from 35 patients with SSD were retrospectively collected. Then the ear morphological parameters, including bone defect, transverse sinus stenosis, position of the jugular bulb, jugular bulb diverticulum, defect of the jugular bulb wall, gross venous sinus thrombosis and SSD, and blood perfusion parameters, including cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT), were evaluated and compared between the tinnitus side and the asymptomatic side of the ear. The maximum diameters of the bone defects on the tinnitus side were greater than those on the asymptomatic side (Horizontal 6.36±2.35mm vs. 1.12±0.78mm; Longitudinal 4.87±1.25 vs. 0.88±0.06mm). Dynamic volume CT visually displayed the SSD herniated into the adjacent mastoid via the bone defect. Transverse sinus stenosis, high position of the jugular bulb, jugular bulb diverticulum, defect of the jugular bulb wall, and gross venous sinus thrombosis were present more frequently on the tinnitus side than on the asymptomatic side (P < 0.05). Moreover, CBF, CBV, and MTT were significantly greater on the tinnitus side than on the asymptomatic side (P < 0.05). Dynamic volume CT examination is an effective method for the diagnosis of pulsatile tinnitus caused by SSD with bone defects.

Surgical treatment of pulsatile tinnitus related to the sigmoid sinus

ObjectiveTinnitus—a common clinical symptom—can be categorized into pulsatile tinnitus (PT) and non-PT. Among these, PT is usually associated with sigmoid sinus symptoms, such as sigmoid sinus wall defect or diverticulum, for which various surgical treatments are available. We have discussed the clinical efficacy of surgery for sigmoid sinus-associated PT via the transmastoid approach in this study. MethodsWe conducted a retrospective review of 4 patients who underwent surgery for sigmoid sinus-associated PT via the transmastoid approach at Nanjing Drum Tower Hospital from January to December 2020. Of these, 2 patients had sigmoid sinus wall defect and 2 had sigmoid sinus diverticulum. Post-operative tinnitus grading and surgical efficacy were determined. ResultsAfter surgery, PT dissolved in 3 patients, while tinnitus significantly decreased in 1 patient. During the follow-up period of 12–18 months, none of the 4 patients showed complications related to increased intracranial pressure or venous sinus thrombosis, and tinnitus symptoms disappeared in 3 patients without recurrence, although 1 patient occasionally developed tinnitus. Postoperative thin-slice CTA of the temporal bone indicated that the sigmoid sinus bone wall defect or diverticulum was completely repaired with a thick soft tissue coverage. ConclusionSurgical repair of sigmoid sinus-associated PT via the transmastoid approach deserves clinical promotion as it exhibited better efficiency while being relatively less invasive.

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.

Sigmoid Sinus Diverticulum-A Unique Case of Pulsatile Tinnitus.

Sigmoid sinus diverticula are relatively rare but typically cause pulsatile tinnitus (PT) in the involved ear. Occasionally, symptoms produced by blood flowing through the diverticulum are severe enough to necessitate recontouring the sigmoid sinus. Recently, a 59-year-old female was evaluated after years of worsening unilateral PT. CT angiography identified a 5 mm sigmoid sinus diverticulum near the sinodural angle. Given the severity of symptoms, the patient's diverticulum was surgically decompressed and recontoured using hydroxyapatite bone cement.

Hemodynamic mechanism of pulsatile tinnitus caused by venous diverticulum treated with coil embolization

Background and objectiveCoil embolization has become a new treatment method for pulsatile tinnitus (PT) caused by sigmoid sinus diverticulum (SSD). Although this therapy has achieved good results in clinical reports, the hemodynamic mechanism of coils in the treatment of PT in SSD remained unclear. MethodsFinite element method (FEM) and computational fluid dynamics (CFD) were combined to explore the hemodynamic mechanism of coil embolization in SSD treatment. Three personalized geometric models of sigmoid sinus were established according to the CTA data of patients. Coil model were established by FEM, and the hemodynamic differences of SSD before and after coiling were compared by transient CFD method. ResultsVelocity streamlines disappeared in the SSD after coiling. At the peak time (t1 = 0.22 s), the SSD-average velocity decreased in every patient. The average value of the decreased in three patients was 0.154 ± 0.028 m/s (mean ± SD). Wall average pressure (Pavg) also showed a decline in every patient. Average of decrements of three patients was 17.69 ± 4.91 Pa (mean ± SD). Average WSS (WSSavg) was also reduced in every patient. The average value of WSS drop was 9.74 ± 3.02 Pa (mean ± SD). After coiling, the proportion of low-velocity region in the sigmoid sinus cortical plate dehiscence (SSCPD) area increased. Average of increments was 22.1 ± 5.36% (mean ± SD). ConclusionsA reduction in SSD-average velocity, wall pressure, and WSS were the short-term hemodynamic mechanism of coil embolization for PT. Coil embolization increased the proportion of low-velocity region in the SSCPD area, thereby creating a hemodynamic environment that easily produced thrombus and protects blood vessels from the impact of blood flow. This phenomenon was the long-term effect of coil embolization.

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.

Multiphysics coupling numerical simulation of flow-diverting stents in the treatment of patients with pulsatile tinnitus.

Patients with pulsatile tinnitus (PT) have unstable treatment effects after resurfacing surgery. Flow-diverting stents (FDS) are proposed as a potential method for the treatment of PT, but the therapeutic effect is not clear. This study aimed to investigate the efficacy of FDS in the treatment of patients with PT induced by sigmoid sinus diverticulum (SSD) and sigmoid sinus wall dehiscence (SSWD). In addition, we aimed to explore the treatment mechanism of PT. Transient-state multiphysics coupling numerical simulation method based on computed tomography angiography of five patients was used to clarify the biomechanical and acoustic states before and after FDS placement. FDS was placed to prevent the blood flow from impacting the vessel wall in the SSD and SSWD areas. Low blood flow velocity (<0.0391 m/s), high relative residence time (>10Pa-1 ), and low wall shear stress of SSD might lead to thrombosis after FDS placement. The average pressure on the SSWD area of each patient decreased by 13.77%, 18.82%, 29.23%, 19.03%, and 11.20%. The average displacement of the vessel wall on the SSWD area showed acute pulsation and decreased by 15.29%, 14.64%, 30.22%, 41.03%, and 21.28%. The average sound pressure level at the tympanum decreased by 14.01%, 9.33%, 17.66%, 18.88%, and 25.18%, respectively. In brief, FDS was placed to avoid blood flow impacting vessels and reduce the vibration of vessels in the short term, thereby attenuating the degree of PT. The long-term prognosis was that the SSWD area was blocked after SSD thrombosis. Therefore, FDS might be an effective method for the treatment of PT induced by SSD and SSWD. This study would provide a theoretical basis for the treatment of PT and an exploration of FDS design in the treatment of PT.

Etiopathology and Prevalence of Pulsatile Tinnitus in a Tertiary Care Referral Hospital.

The diverse etiopathogenesis of pulsatile tinnitus (PT) makes it a difficult condition to diagnose and treat. To describe the clinical features, investigations and diagnosis of patients presenting with pulsatile tinnitus (PT). Retrospective chart review in an otology unit of a tertiary care referral centre. All medical records of patients who had a complaint of pulsatile tinnitus during the period 1st January 2014-1st May 2020 were included in the study. Data regarding history, characteristics of tinnitus, examination findings, investigations and diagnosis were collected and analyzed. Sixty-four patients with complaints of PT presented to our clinic during this time period and were included in the study giving a prevalence of 0.09%. Definite diagnosis was made in 62 (96.8%) cases with a detailed history, clinical examination and tailored investigations. Pathologies diagnosed were paraganglioma (25%), superior semicircular canal dehiscence (20.3%), anterior inferior cerebellar artery loop (7.8%), sigmoid sinus wall dehiscence (10.9%), sigmoid sinus diverticulum (6.25%), jugular bulb anomalies (7.8%) and hyperpneumatised petrous apex (3.1%) among others. Rare causes encountered were IgG4 disease, far advanced otosclerosis, vestibular aqueduct dehiscence and idiopathic intracranial hypertension. Pulsatile tinnitus is a rare complaint in the Otology clinic. Almost all cases of PT can be diagnosed correctly and appropriate treatment initiated with a logical approach to investigations.

The Effect of Degree of Temporal Bone Pneumatization on Sound Transmission of Pulsatile Tinnitus Induced by Sigmoid Sinus Diverticulum and/or Dehiscence: A Clinical and Experimental Study.

Background: Although many studies have suggested that air cells may play an important role in sigmoid sinus diverticulum and/or dehiscence (SSDD)-induced pulsatile tinnitus (PT), the exact effects remain unclear. This study aims to quantitatively investigate the effect of different degrees of pneumatization of temporal bone on sound transmission from the sigmoid sinus to the tympanic cavity.Methods: In the clinical study, 25 patients were enrolled to measure the sound intensity and frequency of SSDD-induced PT. In the experimental study, sound inputs at different frequencies at the dehiscent sigmoid plate were measured and compared among realistic object models of different degrees of pneumatization, when sound intensity in the tympanic cavity was fixed as the level of the PT sound intensity sensed by patients.Results: The sound intensity sensed by PT patients was 34.0 ± 13.0 dB SPL, which represented the sound intensity in the tympanic cavity transmitted from the dehiscent sigmoid plate. In the experimental study, when sound received in the tympanic cavity was fixed at 34 dB SPL, the mean inputs of sound intensity at the dehiscent sigmoid plate were 46.9, 46.2, 45.2, 47.1, 57, 57.4, and 74.1 dB SPL in a hypo-pneumatized model; 42.6, 43, 41.5, 43.2, 47.3, 58.2, and 78.8 dB SPL in a moderately pneumatized model; 52.6, 52.8, 48.1, 61, 64.2, 82.4, and >87.3 dB SPL in a well-pneumatized model; and 47.2, 46.2, 45.4, 49.4, 54.9, 66.6, and 77.7 dB SPL in hyper-pneumatized model, with increased sound frequencies (125-8000 Hz). The mean sound transmission distances were 41.7 mm, 45.2 mm, 47.6 mm, and 48.4 mm in successively better pneumatized models.Conclusion: Sound reduces while passing through air cells and attenuation is lowest in the moderately pneumatized temporal bone, followed by the hypo- and hyper-pneumatized temporal bones, and the highest in the well-pneumatized temporal bone. Lower-frequency sound attenuation (≤1000 Hz) is less than that of higher-frequency sound (>1000 Hz).

Effects of different morphologic abnormalities on hemodynamics in patients with venous pulsatile tinnitus: A four-dimensional flow magnetic resonance imaging study.

The effects of morphologic abnormalities, including sigmoid sinus wall dehiscence (SSWD), transverse sinus stenosis (TSS), and sigmoid sinus diverticulum (SSD), on hemodynamics in venous pulsatile tinnitus (PT) patients have not been established. The aim of this study was to evaluate the effects of SSWD, TSS, and SSD on the hemodynamics of transverse‐sigmoid sinus in venous PT patients. This was a prospective study with 44 venous PT patients and 12 healthy controls. A 3 T/four‐dimensional (4D) flow magnetic resonance imaging with fast field echo was used. Computed tomography arteriography/venography was used to assess ipsilateral SSWD, TSS, and SSD. Maximum velocity (V max), average velocity (V avg), and average flow (Flowavg) were measured. Blood flow patterns were independently assessed by three neuroradiologists. One‐way analysis of variance or Kruskal–Wallis test was also used. On the symptomatic side, all patients had SSWD, 33 patients had TSS, and 22 patients had SSD. Compared with healthy controls, patients with TSS, without TSS, with SSD, and without SSD all showed higher V max (all p < 0.050), V avg (all p < 0.050), and Flowavg (all p < 0.050). Patients with TSS showed higher V max (p < 0.050) and V avg (p < 0.050) than those without TSS, and no significant difference in Flowavg was found between the two groups (p = 0.408). No significant differences in V max, V avg, and Flowavg were found between patients with and without SSD (all p = 1.000). Jet‐like flow in the stenosis and downstream of the stenosis was observed in all patients with TSS. Vortex in SSD was observed in 15 patients with SSD (68%). High blood velocity and flow may be characteristic markers of venous PT. SSWD may be a necessary condition for venous PT. TSS may further increase the blood velocity and form a jet‐like flow. SSD may be related to vortex formation but had no significant effect on blood velocity and flow.Level of Evidence2Technical Efficacy Stage3

Transmastoid Hydroxyapatite Resurfacing for Sigmoid Sinus Wall Anomalies Causing Pulsatile Tinnitus.

Comprising 4% of tinnitus, pulsatile tinnitus (PT) can be particularly difficult for affected patients as well as surgeons looking to address their symptoms. Often the cause is not identified but can be secondary to turbulent flow in or near the sigmoid sinus, particularly if there is an identifiable sigmoid sinus dehiscence (SSDe) and/or diverticulum (SSDi). These sigmoid sinus wall anomalies (SSWA) may be treated with transmastoid sigmoid sinus resurfacing; however, this intervention remains relatively novel and its technique, materials used, resolution success, and complications need to be continuously reviewed. A retrospective case series of patients with PT due to SSWA at a tertiary referral center was reviewed. A total of 6 patients (7 ears) treated by transmastoid resurfacing using hydroxyapatite (HA) were retrospectively assessed. Pre-operative demographics and symptoms, pre- and post-operative hearing results, and post-operative outcomes were reviewed. All patients were female with an average BMI of 32.9 (±5.4) and a mean age of 45.5 years (±15.3). Mean follow-up was 648 days. Objective tinnitus was noted in all ears with SSDi (100%); however, no objective tinnitus was noted with purely SSDe. In 100% of ears, PT was diminished with ipsilateral jugular compression and was amplified with contralateral head turn. Pre-operative symptoms of PT resolved in all patients, but delayed recurrence (>1 year) occurred in 1 ear (14%). No patient had pre- or post-operative hearing loss. No major complications were encountered. Transmastoid resurfacing for SSWA with HA bone cement is a safe, reliable intervention in properly identified PT patients.

Surgical efficacy analysis of venous pulsatile tinnitus related to sigmoid sinus diverticulum

Objective:To discuss the outcomes of the surgical treatment of venous pulsatile tinnitus caused by sigmoid sinus diverticulum. Method:Fifty-eight patients with venous pulsatile tinnitus caused by unilateral sigmoid sinus diverticulum were admitted. The patients' tinnitus was graded and treated by sigmoid sinus bone wall reconstruction. The maximum cross-sectional area of sigmoid sinus diverticulum defect was measured in 28 patientsc. All the patients were followed up for 3 to 44 months after operation to analyze the improvement of postoperative tinnitus, the relationship between the size of the sigmoid sinus cross-sectional area and the degree of tinnitus and length of disease statistically. Result:Postoperative tinnitus was cured in 41 cases（70.69%）,markedly effective in 10 cases（17.24%）, effective in 3 cases（5.17%） and ineffective in 4 cases（6.90%）. There was a statistically significant difference in the degree of tinnitus before and after surgery （P<0.05）. Pearson correlation analysis showed thatthe maximum cross-sectional area of the sigmoid sinus diverticulum defect was not significantly correlated with the degree of tinnitus and the length of the disease in 28 patients （P>0.05）. Conclusion:The sigmoid sinus bone wall reconstruction can effectively relieve venous pulsatile tinnitus related to sigmoid sinus diverticulum while ensuring patient safety.

Prevalence, Surgical Management, and Audiologic Impact of Sigmoid Sinus Dehiscence Causing Pulsatile Tinnitus.

To evaluate the prevalence, surgical management, and audiologic impact of pulsatile tinnitus caused by sigmoid sinus dehiscence. Retrospective chart review at a tertiary care hospital. Adults with unilateral pulsatile tinnitus attributable to sigmoid sinus dehiscence who underwent resurfacing between January 2010 and January 2020. Transmastoid sigmoid resurfacing. Resolution of pulsatile tinnitus; audiologic outcomes; complications; tinnitus etiologies. Nineteen patients (89.4% women) had surgery for suspected sigmoid sinus dehiscence. The mean dehiscence size was 6.1 mm (range, 1-10.7 mm). Eight patients had concurrent sigmoid sinus diverticulum and one patient also had jugular bulb dehiscence. Only two patients (10.5%) had the defect identified by radiology. Low-frequency pure-tone average, measured at frequencies of 250 and 500 Hz, showed a significant median improvement of 8.8 dB following resurfacing (18.8 dB versus 10.0 dB, p = 0.02). The majority of patients had complete resolution of pulsatile tinnitus (16/19, 84.2%). Of those without complete resolution, two patients had partial response and one patient had no improvement. There were no significant complications. Of 41 consecutively tracked patients with a pulsatile tinnitus chief complaint, sigmoid pathology represented 32% of cases. Sigmoid sinus dehiscence represents a common vascular cause of pulsatile tinnitus that, if properly assessed, may be amenable to surgical intervention. Sigmoid sinus resurfacing is safe, does not require decompression, and may improve low-frequency hearing. Radiographic findings of dehiscence are often overlooked without a high index of clinical suspicion. Its relationship with transverse sinus pathology and idiopathic intracranial hypertension remain unclear.

CT venography correlate of transverse sinus stenosis and venous transstenotic pressure gradient in unilateral pulsatile tinnitus patients with sigmoid sinus wall anomalies

ObjectivesTo investigate the correlation between transverse sinus stenosis (TSS) and transstenotic pressure gradient (TPG) in unilateral pulsatile tinnitus (PT) patients with sigmoid sinus wall anomalies (SSWA).MethodsFifty-seven patients with unilateral venous PT were retrospectively included. All of them underwent CT venography and catheter manometry, accompanied with SSWA. The degree, length, shape (intrinsic/extrinsic/dysplasia), location (proximal/middle/distal, referring to the relative position of TSS and the Labbé vein junction) of TSS, the types of SSWA (dehiscence/diverticulum), and the degree of transverse sinus outflow laterality were assessed, and the correlations with ipsilesional TPG were analyzed.ResultsThe mean value of ipsilesional TPG was 7.61 ± 0.52 mmHg. The degree and length of ipsilesional TSS were positively correlated with TPG (p < 0.001, p’ < 0.001), respectively. TPG was significantly larger in patients with contralateral transverse sinus dysplasia than those without (p = 0.023) and significantly smaller in patients with ipsilesional sigmoid sinus diverticulum than those with isolated dehiscence (p = 0.001). No statistical difference in TPG was shown between ipsilesional TSSs of different shapes or locations (p > 0.05). No correlation was noted between the degree of ipsilesional transverse sinus outflow laterality and TPG (p = 0.051). Stepwise linear regression indicated that the degree (β = 9.207, 95% CI = 3.558–14.856), length (β = 0.122, 95% CI = 0.025–0.220) of ipsilesional TSS, and contralateral transverse sinus dysplasia (β = 1.875, 95% CI = 0.220–3.530) were significantly correlated with TPG (R2 = 0.471).ConclusionsThe degree, length of ipsilesional TSS, and contralateral transverse sinus dysplasia may be used to predict TPG in unilateral PT patients with SSWA.Key Points• CT venography may act as a screening tool to help low-probability unilateral pulsatile tinnitus (PT) patients with sigmoid sinus wall anomalies (SSWA) avoid invasive catheter manometry.• The degree and length of ipsilesional transverse sinus stenosis (TSS) are positively correlated with transtenotic pressure gradient (TPG) in unilateral PT patients with SSWA.• Ipsilesional TPG is larger in unilateral PT patients with contralateral transverse sinus dysplasia than those without and is smaller in unilateral PT patients with sigmoid sinus diverticulum than those with isolated dehiscence.