CT evaluation of unilateral pulsatile tinnitus with jugular bulb wall dehiscence

Improving Diagnostic Yield in Patients with Pulsatile Tinnitus: A Ten-Year Analysis

OBJECTIVES

To determine the yield of a comprehensive diagnostic algorithm for patients with pulsatile tinnitus (PT) and to review the common etiologies and present clinical pears for their diagnosis.

METHODS

Retrospective chart review of patients with PT from 2013 to 2023. Charts were reviewed for demographic data (age, sex, BMI), side of PT (or bilateral), specialty clinic of initial evaluation, coexistent symptoms in addition to PT, and final diagnosis (or non-diagnosis). Clinical, audiometric, laboratory, and radiographic data were collected. Putative chart diagnoses were reviewed by the authors and deemed likely or unlikely to be the source of the patient's PT. Those with "unlikely" were grouped in the "idiopathic" cohort. The diagnostic algorithm is presented in detail.

RESULTS

Two hundred and 90 patients were included for analysis. The overall diagnostic yield was 90.7% for all patients and 95.6% for those patients who completed the recommended workup - a substantial improvement over published rates. Twenty-nine etiologies were identified with the most common etiology was idiopathic intracranial hypertension (IIH). Twenty-one diagnoses comprised no more than 5% of patients. Seventy-three patients (25.2%) had more than one pathology as a potential source for their PT.

CONCLUSIONS

PT can present a diagnostic challenge to the clinician. The findings of this study, however, reveal that proper evaluation based on obtaining a thorough history, performing a physical examination, coupled with properly directed imaging studies and blood testing can accomplish a high diagnostic yield of at least one potential etiology.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:1148-1154, 2025.

Evaluation and analysis of the transmission route of sigmoid sinus tinnitus by HRCT of the temporal bone: A retrospective analysis

OBJECTIVE

This study aims to analyze anatomical parameters of the transmission route of sigmoid sinus tinnitus (SST) to explore its mechanism and speculate on possible responsible anatomical abnormalities.

METHODS

Clinical data were retrospectively collected from SST and sigmoid sinus wall dehiscence (SSWD) patients suggested by temporal bone high resolution computed tomography (HRCT), with and without tinnitus, at the First Affiliated Hospital of Chongqing Medical University from January 2015 to August 2022. Patients were divided into SSWD tinnitus (n = 61), and non-tinnitus (n = 60) groups based on HRCT features. Mimics Medical 22.0 and 3-matic Medical 13.0 software measured curvature of the sigmoid sinus bone wall, defect distribution, related parameters, distance to the tympanic sinus and cochlear window, degree of mastoid pneumatization, temporal bone air chamber surface area, volume, and S/V value. Mechanisms were analyzed by comparing clinical data and imaging anatomical parameters between groups.

RESULTS

The tinnitus group was significantly younger and had more severe low-frequency hearing loss (P = 0.002). The degree of mastoid pneumatization was significantly lower in the tinnitus group (P = 0.032). The volume of the temporal bone air chamber was smaller (P = 0.020), and the S/V value was higher in the tinnitus group (P = 0.001). Bone wall defects in the lower curvature were protective against tinnitus (P = 0.007, OR = 0.071). Larger maximum transverse diameter of the defect increased tinnitus risk (P = 0.030, OR = 1.875). Higher S/V value was also a significant risk factor (P = 0.009, OR = 24.210).

CONCLUSIONS

SST patients exhibit significant female and right-sided predominance, with low-frequency hearing loss. Defects in the superior curvature and descending part of the sigmoid groove are more likely to cause tinnitus. Larger transverse diameters and higher S/V values are independent risk factors for tinnitus. Over-pneumatized temporal bones do not facilitate transmission of sigmoid sinus blood flow murmur, highlighting the importance of specific anatomical features in SST development.

Cerebral Sinus Hemodynamics in Adults Revealed by 4D Flow MRI

BACKGROUND

The hemodynamics of the cerebral sinuses play a vital role in understanding blood flow-related diseases, yet the hemodynamics of the cerebral sinuses in normal adults remains an unresolved issue.

PURPOSE

To evaluate hemodynamics in the cerebral sinus of adults using 4-dimensional flow MRI (4D Flow MRI).

STUDY TYPE

Cross-sectional.

POPULATION

Ninety-nine healthy volunteers (mean age, 42.88 ± 13.16 years old; females/males, 55/44).

FIELD STRENGTH/SEQUENCE

3 T/4D Flow MRI.

ASSESSMENT

The blood flow velocity, average blood flow rate (Q), and vortexes at the superior sagittal sinus (SSS), straight sinus (STS), transverse sinus, sigmoid sinus, and jugular bulb of each volunteer were evaluated by two independent neuroradiologists. The relationship between the total cerebral Q and sex and age was also assessed. Twelve volunteers underwent two scans within a month.

STATISTICAL TESTS

The intraclass correlation coefficient (ICC) evaluated the inter-observer agreement. Blood flow parameters among volunteers were compared by the independent-sample t-test or Mann-Whitney U test. The multiple linear regression equation was used to evaluate the relationship between total cerebral Q and age and sex. P < 0.05 indicated statistical significance.

RESULTS

The test-retest and interobserver reliability of average velocity and Q were moderate to high (ICC: 0.54-0.99). Cerebral sinus velocity varied by segment and cardiac cycle. The SSS's velocity and Q increased downstream and Q near torcular herophili was 3.5 times that through the STS. The total cerebral Q decreased by 0.06 mL/s per year (β = -0.06 ± 0.013) and was sex-independent within the group. Vortexes were found in 12.12%, 8.9%, and 59.8% of torcular herophili, transverse-sigmoid junction, and jugular bulb, respectively, and were related to higher upstream flow.

DATA CONCLUSION

Cerebral sinuses could be measured visually and quantitatively in vivo by 4D Flow MRI, providing a basis for future research on pulsating tinnitus, multiple sclerosis, and other related diseases.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Cerebral venous sinus stenting and jugular bulb embolization for pulsatile tinnitus: A case report

Background

Pulsatile tinnitus (PT) is a rare form of tinnitus that aligns with the heartbeat. It is typically brought on by lesions with significant vascularity, which produce aberrant sound conduction and increase the risk of mental health issues and hearing loss. Venous PT is more prevalent than arterial PT. Open procedures or interventional procedures can be used to treat PT. We present here a case of PT caused by venous luminal stenosis combined with jugular bulb (JB) malformation, which was improved by stenting and JB embolization.

Case presentation

A 59-year-old woman presented with long-term tinnitus consistent with heart rhythm and hearing loss, accompanied by anxiety, insomnia, and depression. The results of brain MRV, CT, and DSA showed stenosis of the right sigmoid sinus and high jugular bulb (JB) with dehiscence of the JB wall. The patient saw a significant improvement in PT symptoms following sigmoid sinus stenting and spring coil embolization of the high JB, following the diagnosis of PT. The patient had no PT recurrence for the course of the 31-month follow-up period.

Conclusion

In the present PT case, there was a simultaneous onset of the right sigmoid sinus stenosis and the high JB with the JB wall abnormalities. Sigmoid sinus stenting and spring coil embolization of high JB may be a treatment for the PT, but the prevention of post-stenting complications is still an issue that requires great attention and needs further study.