Pulsatile tinnitus may have many sources. Most commonly it occurs in conductive hearing loss, especially middle ear effusion, due to reduced external hearing and augmented vascular pulsations conducted through the fluid. Persistent and troubling pulsatile tinnitus is most often not due to ear disease but rather the ear picking up uncommonly noisy blood flow in adjacent vascular structures. The most common cause is turbulent flow in the sigmoid sinus. This may be due to irregularities in the vessel’s wall caused by arachnoid granulations, mural thrombus, or diverticulum. Pulsatile tinnitus typically emanates from the dominant sigmoid sinus, most commonly on the right side. While the characteristic of the pulsation simulates the pitch of arterial flow, it is due to the high pressures in the brain’s primary venous outflow conduit. Characteristically compression of the jugular vein in the neck either transiently muffles or eliminates the pulsation that, in turn, is augmented when the compression is released. On examination, pulsatile tinnitus may be subjective (only heard by the patient) or objective (audible to the examiner via a stethoscope). Audible pulsatile tinnitus is most often due to arteriovenous fistula.
Imaging such as CT or MR angiography is important to evaluate for dural arteriovenous fistula which is usually treated endovascularly. In evaluation of pulsatile tinnitus, the author prefers a combination of CT temporal bone (to identify sinus wall dehiscence, high jugular bulb, anomalous carotid artery, superior semicircular canal dehiscence, or glomus tumor) combined with CT angiography imaging both arterial (AV fistula) and venous (intraluminal sigmoid irregularities) anatomies. Ophthalmological examination for papilledema and visual field defect is often indicated to evaluate for pseudotumor cerebri. Treatment of troublesome pulsatile tinnitus of venous origin involves creation of a sound baffle in the mastoid and/or hypotympanum. Ligation of the jugular vein in the neck or packing of the jugular bulb is contraindicated due to the risk of triggering intracranial venous insufficiency. Endovascular procedures, including stenting, are alternative options especially for the obliteration of arteriovenous fistulae.
Further Reading
Ahsan SF, Seidman M, Yaremchuk K. What is the best imaging modality in evaluating patients with unilateral pulsatile tinnitus? Laryngoscope 2015;125(2):284–285 PubMed
DeHart AN, Shaia WT, Coelho DH. Hydroxyapatite cement resurfacing the dehiscent jugular bulb: novel treatment for pulsatile tinnitus. Laryngoscope 2018;128(5):1186–1190 PubMed
Lansley JA, Tucker W, Eriksen MR, Riordan-Eva P, Connor SEJ. Sigmoid sinus diverticulum, dehiscence, and venous sinus stenosis: potential causes of pulsatile tinnitus in patients with idiopathic intracranial hypertension? AJNR Am J Neuroradiol 2017;38(9):1783–1788 PubMed
Pegge SAH, Steens SCA, Kunst HPM, Meijer FJA. Pulsatile tinnitus: differential diagnosis and radiological work-up. Curr Radiol Rep 2017;5(1):5 PubMed
Reardon MA, Raghavan P. Venous abnormalities leading to tinnitus: imaging evaluation. Neuroimaging Clin N Am 2016;26(2):237–245 PubMed
Serulle Y, Miller TR, Gandhi D. Dural arteriovenous fistulae: imaging and management. Neuroimaging Clin N Am 2016;26(2):247–258 PubMed
Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg 2011;19(5):348–357 PubMed
Song JJ, Kim YJ, Kim SY, et al. Sinus wall resurfacing for patients with temporal bone venous sinus diverticulum and ipsilateral pulsatile tinnitus. Neurosurgery 2015;77(5):709–717, discussion 717 PubMed
Trivelato FP, Araújo JF, Dos Santos Silva R, Rezende MT, Ulhôa AC, Castro GD. Endovascular treatment of pulsatile tinnitus associated with transverse sigmoid sinus aneurysms and jugular bulb anomalies. Interv Neuroradiol 2015;21(4):548–551 PubMed
Wang AC, Nelson AN, Pino C, Svider PF, Hong RS, Chan E. Management of sigmoid sinus associated pulsatile tinnitus: a systematic review of the literature. Otol Neurotol 2017;38(10):1390–1396 PubMed
Yeo WX, Xu SH, Tan TY, Low YM, Yuen HW. Surgical management of pulsatile tinnitus secondary to jugular bulb or sigmoid sinus diverticulum with review of literature. Am J Otolaryngol 2018;39(2):247–252 PubMed
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