Pulsatile tinnitus associated with dehiscent internal carotid artery: An irremediable condition?

Otic Capsule Dehiscences Simulating Other Inner Ear Diseases: Characterization, Clinical Profile, and Follow-Up-Is Ménière's Disease the Sole Cause of Vertigo and Fluctuating Hearing Loss?

INTRODUCTION

We present a series of six cases whose clinical presentations exhibited audiovestibular manifestations of a third mobile window mechanism, bearing a reasonable resemblance to Ménière's disease and otosclerosis. The occurrence of these cases in such a short period has prompted a review of the underlying causes of its development. Understanding the pathophysiology of third mobile window syndrome and considering these entities in the differential diagnosis of conditions presenting with vertigo and hearing loss with slight air-bone gaps is essential for comprehending this group of pathologies.

MATERIALS AND METHODS

A descriptive retrospective cohort study of six cases diagnosed at a tertiary center. All of them went through auditive and vestibular examinations before and after a therapeutic strategy was performed.

RESULTS

Out of 84 cases of dehiscences described in our center during the period from 2014 to 2024, 78 belonged to superior semicircular canal dehiscence, while 6 were other otic capsule dehiscences. Among these six patients with a mean age of 47.17 years (range: 18-73), all had some form of otic capsule dehiscence with auditory and/or vestibular repercussions, measured through hearing and vestibular tests, with abnormalities in the results in five out of six patients. Two of them were diagnosed with Ménière's disease (MD). Another two had cochleo-vestibular hydrops without meeting the diagnostic criteria for MD. In two cases, the otic capsule dehiscence diagnosis resulted from an intraoperative complication due to a gusher phenomenon, while in one case, it was an accidental radiological finding. All responded well to the proposed treatment, whether medical or surgical, if needed.

CONCLUSIONS

Otic capsule dehiscences are relatively new and unfamiliar entities that should be considered when faced with cases clinically suggestive of Ménière's disease, with discrepancies in complementary tests or a poor response to treatment. While high-sensitivity and specificity audiovestibular tests exist, completing the study with imaging, especially petrous bone CT scans, is necessary to locate and characterize the otic capsule defect responsible for the clinical presentation.

Outcomes in Managing Vascular Tinnitus: Institutional Experience and Review of 6-Year Literature

To evaluate the outcomes in patients of vascular tinnitus managed at our institute. The clinical data of all patients diagnosed with pulsatile tinnitus from January 2014 to April 2022 and managed at AIIMS, Bhubaneswar, was retrospectively reviewed. The diagnosis, treatment and outcomes were analyzed. A 6-year literature review was performed from March 2015 to April 2021. Our series discusses managing eleven cases of vascular tinnitus with varied aetiology and their outcomes. Out of the eleven cases, eight patients underwent surgical or radiological intervention, and seven had complete resolution of symptoms. Of the eleven patients, three had partial resolution. The 6-year literature review revealed sigmoid and transverse sinus as the most common causative anatomical sites for pulsatile tinnitus. Amongst those who received an intervention, 83.56% of the patients had complete resolution of symptoms. Vascular tinnitus can be cured if the exact vessel causing it is localized. Clinical suspicion is based on the character of tinnitus and patient history. A careful evaluation of the head and neck sites for any vascular anomaly that can cause pulsatile tinnitus must be done. Radiology demonstrates treatable causes of it. It delineates the aberrant anatomical variations that can lead to this disturbing aetiology. Treatable causes are best addressed, and pathology should be taken care of. A multidisciplinary team comprising ENT surgeons, audiologists and interventional radiologists must identify and treat the pathology.

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.

Juvenile Nasopharyngeal Angiofibroma in Adolescent Female with Subsequent ICA Canal Dehiscence: An Unknown Entity

Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign vascular tumour typically occurring in adolescent males. Presentation beyond this age group and in female is rare. Classically it was surgically removed by various external approaches. Present gold standard of therapy is endoscopic excision. This is less morbid, avoids external scar and allows complete tumour removal under magnified view. Dehiscent internal carotid artery (ICA) canal is a rare condition which presents mostly as a pulsatile tinnitus or otalgia. Accidental injury to the exposed vessel during ear surgery may cause devastating consequences. Present case is a lady who was operated for left NPA 10 years back when she was 11 years age. Presently she presented with left ear pain which was diagnosed to be due to dehiscent ICA canal. We present a comprehensive review of world literature on the incidence of nasopharyngeal and extra-nasopharyngeal angiofibroma in women in the region of nose and para-nasal sinuses. There has been only 3 cases of NPA in adolescent females documented till date. This is the first documented case of NPA in adolescent female with subsequent ICA dehiscence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-03008-7.

Anatomical Variations of the Jugular Foramen Region in Patients with Pulsatile Tinnitus

Objective  Structural anomalies of the jugular foramen (JF) and adjacent structures may contribute to development of pulsatile tinnitus (PT). The goal of this study was to assess anatomical variants in the ipsilateral JF region in patients with PT and to explore possible predisposing factors for PT. Methods  One hundred ninety-five patients with PT who underwent CT angiography and venography of the temporal bone were retrospectively analyzed. Anatomic variants including dominance of the ipsilateral JF, bony deficiency of the sigmoid sinus and internal carotid artery canal, high riding or dehiscent jugular bulb, dehiscence of the superior semicircular canal, tumors in the JF region, or cerebellopontine angle were assessed. Results  Of 195 patients with PT, the prevalence of a dominant JF on the ipsilateral side of patients with PT was 67.2%. Furthermore, the dominant JF demonstrated a significant correlation with the presence of ipsilateral PT ( p  < 0.001). No anatomical variants were present in 22 patients (11.3%), whereas in patients with structural variants, bony deficiency of the sigmoid sinus was most common (65.6%), followed by high riding (54.9%) or dehiscent jugular bulb (14.4%). Dehiscent internal carotid artery canal (3.1%) and superior semicircular canal (4.1%) were occasionally identified, while arteriovenous fistula, arterial aneurysm and tumors arising from the JF region or cerebellopontine angle were rarely encountered. Conclusion  Structural abnormalities of the JF and adjacent structures may predispose to the development of PT. Knowledge of these anatomical variants in the JF region may help establish a clinical strategy for addressing PT.

[Aberrant internal carotid artery: a rare cause of cough: about a clinical case]

Aberrant course of the internal carotid artery is a rare congenital malformation. Aberrant course of cervical internal carotid artery accounts for 5% of cases. Several cases of fatal hemorrhage due to an injury to the aberrant internal carotid artery have been observed in patients undergoing pharyngeal surgery procedures. This was associated with a lack of detection during surgery. Ear nose and throat (ENT) practitioner need to know it. We here report a case of aberrant internal carotid manifesting as chronic cough due to the contact of the epiglottis with the pharyngeal mass caused by the aberrant artery. The patient was treated for chronic lung disease without success. This particular anatomical condition should be suspected in patients with pharyngeal mass before any invasive procedure.

Endoscopic Intervention of Aberrant Carotid Artery in the Middle Ear

OBJECTIVE

To describe surgical management for transcanal endoscopic ear surgery (TEES) in two patients with aberrant internal carotid artery (ICA) in the middle ear.

PATIENTS

A young girl who complained of pulsatile tinnitus and an elderly man who presented with ear bleeding. Otoendoscopy examination revealed a pulsatile reddish mass protruding through the tympanic membrane in both patients.

INTERVENTIONS

A combination of clinical assessments and imaging supported the diagnosis of aberrant ICA in the middle ear. Transcanal endoscopic reinforcement of the artery was performed; tragal cartilage was used as a shield to strengthen the carotid canal defect.

RESULTS

Assisted by fine endoscopic instruments, the protruding arteries were separated without damage to the surrounding structures and reinforced using tragal cartilage. Both patients' symptoms improved postoperatively; they reported tinnitus relief and hearing improvement.

CONCLUSION

To prevent catastrophic events, diagnosis of aberrant ICA is important before any surgical intervention. With appropriate management, surgical intervention using transcanal endoscopic ear surgery offers a clear view of the surgical field and is an excellent choice for management of aberrant ICA.

Hypotympanic Sound Baffle for Amelioration of Pulsatile Tinnitus due to Carotid and Jugular Bulb Dehiscence

OBJECTIVE

To share our experience with treating pulsatile tinnitus by insulating a dehiscent carotid artery with a hypotympanic sound baffle, and compare outcomes with a similar resurfacing approach for jugular bulb wall anomalies.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary academic medical center.

PATIENTS

Adult patients with troublesome pulsatile tinnitus with radiologic evidence of carotid artery dehiscence or jugular bulb wall anomaly within the temporal bone.

INTERVENTION

Hypotympanic exposure of vessel followed by resurfacing using hydroxyapatite cement (carotid dehiscence) or autologous tissue (jugular bulb wall anomalies).

MAIN OUTCOMES MEASURES

Alleviation or reduction of pulsatile tinnitus.

RESULTS

Two patients presented with unilateral, debilitating pulsatile tinnitus and history and imaging consistent with carotid dehiscence and underwent hypotympanic resurfacing with hydroxyapatite cement. Both had considerable initial improvement of tinnitus, and 40% resolution of tinnitus with improved quality of life at an average follow-up of 13.5 months. Two patients with jugular bulb dehiscence/diverticulum treated by resurfacing had complete elimination of symptoms at an average follow up of 17.3 months. There were no major adverse outcomes (permanent hearing loss, vascular injury, or intracranial hypertension).

CONCLUSION

Creation of a hypotympanic sound baffle offers promise as a means of reducing pulsatile tinnitus emanating from a dehiscent carotid artery transmitted to the tympanum, with substantial improvement in reported functional ability. Treatment of venous etiologies of pulsatile tinnitus with similar techniques demonstrates higher success rates, which may be attributable to incomplete resurfacing of carotid artery dehiscence along its extent towards the petrous apex due to safety concerns.

Systematic Review of Temporal Bone-Resurfacing Techniques for Pulsatile Tinnitus Associated with Vascular Wall Anomalies

OBJECTIVE

To systematically review literature evidence on temporal bone-resurfacing techniques for pulsatile tinnitus (PT) associated with vascular wall anomalies.

DATA SOURCES

We searched PubMed, Embase, and the Cochrane Database. The period covered was from 1962 to 2018.

REVIEW METHODS

We included studies in all languages that reported resurfacing outcomes for patients with PT and radiographic evidence or direct visualization of sigmoid sinus wall anomaly, jugular bulb wall anomaly, or dehiscent or aberrant internal carotid artery.

RESULTS

Of 954 citations retrieved in database searches and 5 citations retrieved from reference lists, 20 studies with a total of 141 resurfacing cases involving 138 patients were included. Resurfacing outcomes for arterial sources of PT showed 3 of 5 cases (60%) with complete resolution and 2 (40%) with partial resolution. Jugular bulb sources of PT showed 11 of 14 cases (79%) with complete resolution and 1 (7%) with partial resolution. Sigmoid sinus sources of PT showed 91 of 121 cases (75%) with complete resolution and 12 (10%) with partial resolution. Symptoms occurred more in females and on the right side. Most cases (94%) used hard-density materials for resurfacing. Material density did not appear to be associated with resurfacing outcomes. Use of autologous materials was associated with improved outcomes for arterial sources resurfacing. Major complications involving sigmoid sinus thrombosis or compression were reported in 4% of cases without long-term morbidity or mortality.

CONCLUSIONS

Resurfacing surgery is likely effective and well tolerated for select patients with PT associated with various vascular wall anomalies.