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

Objective To investigate the etiology,clinical characteristics,diagnosis,and treatment strategies and efficacy of pulsatile tinnitus(PT)caused by vascular anatomy abnormality.Methods The clinical data of 45 patients with PT in our hospital from 2012 to 2019 were collected and retrospectively analyzed.Results 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.Conclusion 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.

Surgical treatment of pulsatile tinnitus related to the sigmoid sinus

Objective: Tinnitus-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.Methods: We conducted a retrospective review of 4 patients who underwent surgery for sigmoid sinusassociated PT via the transmastoid approach at Nanjing Drum Tower Hospital from January to December2020. Of these, 2 patients had sigmoid sinus wall defect and 2 had sigmoid sinus diverticulum. Postoperative tinnitus grading and surgical efficacy were determined.Results: After 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 3patients 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.Conclusion: Surgical repair of sigmoid sinus-associated PT via the transmastoid approach deserves clinical promotion as it exhibited better efficiency while being relatively less invasive.

Bone remodeling in sigmoid sinus diverticulum after stenting for transverse sinus stenosis in pulsatile tinnitus: A case report

BACKGROUND Pulsatile tinnitus(PT)is a potentially disabling symptom that has received increasing attention.Multiple causes of PT have been confirmed by targeted treatment.However,dynamic changes of related structures in PT patients with multiple causes after stenting for ipsilateral transverse sinus stenosis(TSS)have not been previously reported.We report such a case and present postoperative computed tomography venography(CTV)follow-up findings to demonstrate the decreased sigmoid sinus diverticulum and bone remodeling.CASE SUMMARY A 45-year-old man suffered from left-sided PT for 15 years that was occasionally accompanied by headache and dizziness.Pre-operative CTV revealed left-sided sigmoid sinus wall anomalies(SSWAs),TSS,outflow dominance,large posterior condylar emissary vein,and an empty sella turcica.A cerebrospinal fluid pressure of 270 mmH2O was further detected.The sound disappeared immediately after stenting for ipsilateral TSS,with no recurrence during 2 years of follow-up.After the procedure,the patient underwent four consecutive CTV examinations.The diverticulum decreased 6 mo after the procedure with new bone remodeling.The density of the remodeled bone was further increased 1 year later,and a hardened edge was formed 2 years later.CONCLUSION PT associated with SSWAs,TSS,and idiopathic intracranial hypertension can be cured by stenting for TSS alone.And bone remodeling around SSWAs is a more significant finding.

Diploic vein as a newly treatable cause of pulsatile tinnitus: A case report

BACKGROUND Pulsatile tinnitus(PT)is an annoying sound that can be eliminated with targeted treatment of the cause.However,the causes of PT have not been fully elucidated.CASE SUMMARY A 38-year-old woman with right-sided objective PT underwent preoperative computed tomography arteriography and venography(CTA/V).A 3.8 mm vine diploic vein(DV),which passed through the mastoid air cells posteriorly in a dehiscent canal and was continuous with the transverse-sigmoid sinus,was thought to be the causative finding.Four-dimensional flow magnetic resonance(4D flow MR)imaging showed that the blood in the DV flowed toward the transverse-sigmoid sinus.The closer the blood was to the transverse-sigmoid sinus,the higher the velocity.No vortex or turbulence was found in the DV or adjacent transverse sinus.The sound was eliminated immediately after ligation of the DV with no recurrence during a three-month follow-up.No flow signal of the DV was noted on postoperative 4D flow MR.CONCLUSION A DV may be a treatable cause of PT.CTA/V and 4D flow MR could be utilized to determine the morphological and hemodynamic characteristics of the DV.

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.

Treatment of Pulsatile Tinnitus Associated with Multiple Factors

Numerous factors may lead to pulsatile tinnitus （PT）, including atherosclerosis, benign intracranial hypertension, glomus tympanicum tumor, dural arteriovenous fistulas （dAVFs）, abnormalities of the sigmoid sinus （dehiscence and diverticulum）, and jugular bulb anomalies （glomus jugular tumor, diverticulum, high-riding or dehiscent jugular bulb）. However, exact causes often cannot be found in many patients even after a detailed physical examination and extensive auxiliary examinations. Moreover, no effective treatment is available for these patients. Patients with PT associated with multiple factors are seldom reported, and the condition is essentially intractable. Here, we reported three cases with PT involving multiple factors.

Fatal Cataclysmic Otorrhagia and Epistaxis Due to a Ruptured Aneurysm of the Petrous Internal Carotid Artery: A Case Report

Background: Aneurysms of the internal carotid artery within the petrous temporal bone are extremely rare;their true incidence is unknown. The exact cause is unclear: they may be congenital or result from trauma, infection, or radiation. Aim: We report a case of massive otorrhagia and epistaxis from a ruptured aneurysm of the petrous internal carotid artery. Case Presentation: A 34-year-old man presented to our department for the first time with repeated left otorrhagia ongoing for 5 years, left sided pulsatile tinnitus and left conductive hearing loss. In his history, we noted a right hemi-corporeal deficit of sudden onset one month ago and the head-CT showed a left frontoparietal subarachnoid hemorrhage without any visualised vascular malformation. Otomicroscopy showed a pulsatile mass visible at the posterior part of the hypotympanum. There was a right-sided hemiparesis estimated at 2/5 with no disorder of the sensitivity. After hemodynamic stabilization, the patient was discharged from the hospital and treatment was scheduled in interventional radiology and neurosurgery unit. Unfortunately the patient presented at home with a cataclysmic hemorrhage by massive otorrhagia and epistaxis and arrived dead at the emergency unit. Conclusion: The treatment of a petrous carotid aneurysm must be carried out quickly considering the risk of rupture leading to a cataclysmic hemorrhage that can be rapidly life threatening.

Glomus tympanicum removal using transcanal endoscopic assisted surgery:An experience with six cases

Objective:To evaluate an endoscopic approach in the management of glomus tumor,and also to investigate and evaluate its appropriateness and feasibility.Methods:Glomus tumors,also known as paragangliomas,are benign primary tumors of the middle ear.The advent of endoscopic ear surgery has provided new dimensions to the management of this highly vascular tumor.Retrospective analysis of six patients of glomus tympanicum,operated between July 2014 and June 2019,with modified Fisch classification Type A and B1,who were managed by a retroauricular transcanal endoscopic approach.Preoperative and postoperative analysis was done for these patients.Results:The chief complaint was pulsatile tinnitus,which disappeared in five cases and reduced in severity in one of them.Hearing was improved with reduction in air‐bone gap in all the cases.No major complications or recurrence were observed in any of the patients after 12 months of follow‐up.Conclusion:This endoscopic approach serves as a safe and reliable technique for tumor removal.It thus provides postoperative comfort for most of the patients.

Transmastoid Approach for Resurfacing the Superior Semicircular Canal Dehiscence with a Dumpling Structure

Background： Superior semicircular canal dehiscence （SSCD） is gradually recognized by otologists in recent years. The patients with SSCD have a syndrome comprising a series of vestibular symptoms and hearing function disorders which can be cured by the operation. In this study, we evaluated the characteristics of patients with SSCD and determined the effectiveness of treating this syndrome by resurfacing the canal via the transmastoid approach using a dumpling structure. Methods： Patients with SSCD, confirmed by high-resolution computed tomography and hospitalized at Beijing Tongren Hospital between November 2009 and October 2012, were included in the study. All of the patients underwent the unilateral transmastoid approach for resurfacing the canal, and received regular follow-up after surgery. Data from preoperative medical records and postoperative follow-up were comparatively analyzed to evaluate the effect of surgery. Results： In total, 10 patients and 13 ears （three left ears, four right ears, three bilateral ears） were evaluated in the study, which included 7 men and 3 women. Different symptoms and distinctive manifestations of vestibular evoked myogenic potential were found in these patients. Alter surgery, 4 patients had complete resolution, 5 had partial resolution, and 1 patient, with bilateral SSCD, had aggravation. None of the patients suffered from serious complications such as sensorineural hearing loss, facial paralysis, cerebrospinal fluid leakage, or intracranial hypertension. Conclusions： In patients with unilateral SSCD, resurfacing the canal via the transmastoid approach using a dumpling structure is an effective and sate technique. However, more consideration is needed for patients with bilateral SSCD.