Endovascular Treatment of Pulsatile Tinnitus by Sigmoid Sinus Aneurysm: Technical Note and Review of the Literature

Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Silencing Pulsatile Tinnitus: A Novel Technique of Periosteal Flap Obliteration for Sigmoid Sinus Diverticulum Variants

OBJECTIVE

Review of a sigmoid sinus diverticuli (SSDi) variants surgically managed with a novel technique using an inferior periosteal flap.

STUDY DESIGN

Case series.

SETTING

Tertiary referral center.

PATIENTS

Patients presenting with pulsatile tinnitus to a tertiary referral center between January 1, 2015, and June 31, 2021, who were diagnosed with SSDi variants on CT temporal bone and who received surgical management for these SSDi variants.

INTERVENTIONS

Obliteration of SSDi variants using a novel technique with an inferiorly based periosteal flap.

MAIN OUTCOME MEASURES

Pure-tone audiometry, Tinnitus Handicap Inventory score, and visual analogue scale score for tinnitus severity (loudness, awareness, annoyance, and effect on life).

RESULTS

Include statistical measures as appropriate.

CONCLUSIONS

We would like to propose the use of an inferiorly based periosteal flap as an option for obliteration and concomitant hemostasis of more sizeable or complex (e.g., bifid) SSDi. Further study of this technique with a long-term follow-up will be needed to evaluate its long-term safety and efficacy.

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.

The Relationships Among Transverse Sinus Stenosis Measured by CT Venography, Venous Trans-stenotic Pressure Gradient and Intracranial Pressure in Patients With Unilateral Venous Pulsatile Tinnitus

Objectives

To assess a non-invasive means of predicting a venous trans-stenotic pressure gradient (TPG) and intracranial pressure (ICP) as opposed to invasive examinations in unilateral venous pulsatile tinnitus (PT) patients.

Methods

Thirty patients with unilateral venous PT who presented symptomatic-sided transverse sinus stenosis (TSS) on computed tomography venography (CTV), ipsilateral TPG measured by digital subtraction angiography (DSA) and cerebrospinal fluid (CSF) pressure measured by lumbar puncture were included. The ratio of TSS was calculated by dividing the cross-sectional areas of the maximal stenosed transverse sinus by that of the adjacent normal transverse sinus on CTV. The correlations among and predictive values of TSS, TPG, and ICP were analyzed.

Results

In patients with unilateral venous PT, the symptomatic-sided and average bilateral TSS values were 78 ± 11 and 77 ± 9%; ICP, 230.50 ± 55.75 mmH₂O; and the TPG, 9.51 ± 5.76 mmHg. The symptomatic-sided TSS was linearly and positively correlated with TPG (R² = 0.400), and the symptomatic-sided and bilateral average TSS both showed weak correlations with ICP (R² = 0.288, R′² = 0.156). When the degree of TSS increased by 10%, the TPG and ICP increased by approximately 3.3 mmHg and 25.8 mmH₂O, respectively. The receiver operating characteristic curve showed the optimal threshold of ipsilateral TSS for a positive TPG was 0.75, while TSS had no significant predictive value for ICP (p > 0.05). TPG and ICP also exhibited a linear positive correlation (R² = 0.552). When ICP increased by 10 mmH₂O, the TPG increased by approximately 0.77 mmHg, and the optimal threshold of ICP for a positive TPG was 227.5.

Conclusion

TSS, TPG, and ICP are interrelated. TSS measured by CTV can predict TPG in patients with unilateral venous PT.

Venous Causes of Pulsatile Tinnitus: Clinical Presentation, Clinical and Radiographic Evaluation, Pathogenesis, and Endovascular Treatments: A Literature Review

Tinnitus is an abnormal perception of a sound without external stimulation. Venous pulsatile tinnitus (VPT) is a specific form of tinnitus characterized by an objective and often subjective bruit that occurs as a result of localized venous abnormalities. Clinical evaluation relies on sound quality, duration, and precipitating factors. Idiopathic intracranial hypertension (IIH) and transverse sinus stenosis (TSS) are among the most common causes of VPT. Other causes include sigmoid sinus wall abnormalities (SSWAs), jugular vein anomalies (JVAs), and emissary veins anomalies. These anomalies can be detected on magnetic resonance imaging, magnetic resonance angiography/magnetic resonance venography, and high-resolution temporal bone computed tomography. The pathogenesis behind the VPT includes turbulent blood flow as a result of luminal stenosis or abnormal dilation, amplification of internal sound due to temporal bone defects, and abnormal position of the venous sinus system structures adjacent to the bony structures of the auditive apparatus. Based on these theories, different interventional treatment modalities can be applied to treat the underlying causes. Endovascular treatments have shown high efficacy and safety among those treatments which include stenting of the lateral sinus stenosis in IIH and TSS, coiling of the SSWA and JVA, and embolization of emissary veins anomalies. Further studies are needed to understand the natural history of these anomalies and the efficacy of treatments of VPT, which-unlike other types of tinnitus-can be cured with proper treatment.

Relentless pulsatile tinnitus secondary to dural sinovenous stenosis: is endovascular sinus stenting the answer?

AIM

To assess the efficacy of endovascular venous sinus stenting (EVSS) in treating pulsatile tinnitus (PT) caused by dural venous sinus stenosis (DVSS), and to determine whether it is an adequate remedy in cases with concurrent venous anomalies.

MATERIALS AND METHODS

Seventeen patients (13 female and four male) with PT due to DVSS were treated using EVSS. The trans-stenotic pressure gradient (PG) was measured before and after stenting. The effect of stenting on the tinnitus was evaluated by questioning the patients at day 0, and at 3, 6, and 9 months after stenting.

RESULTS

Except for one patient who continued to complain of PT, all of the patients, including two with concomitant sinus diverticula, described complete resolution of the tinnitus immediately following stenting. The post-stenting PG was significantly lower than the pre-stenting PG (p<0.0001). No procedure related complications occurred and no recurrence was recorded during the follow-up period.

CONCLUSION

EVSS is a safe and successful treatment for PT due to DVSS even in cases with coexistent sinus diverticula.

Association Between Sigmoid Sinusoidal Tinnitus and Low-Frequency Sensorineural Hearing Loss: A Retrospective Study at a Single Center

BACKGROUND We aimed to explore the correlation between patients' sigmoid sinusoidal tinnitus (SST) and low-frequency sensorineural hearing loss (LFSHL) and illustrate the underlying mechanism. MATERIAL AND METHODS Seven healthy volunteers with normal hearing were subjected to 125-, 250-, and 500-Hz pure sound and different white noise-masking intensities. A retrospective analysis was made on the clinical data and postoperative follow-up data of 59 patients with SST in the First Affiliated Hospital of Chongqing Medical University. The patients' sex, age, chief complaints, affected site, concomitant symptoms, course of disease, pure-tone audiometry (PTA) results, tinnitus discomfort loudness scale results, imaging examination, and complications were collected. RESULTS The results of the simulation experiment showed that the threshold of each frequency segment was higher after noise masking than before masking; the intensity of noise masking was positively correlated with hearing loss, and the changes of the hearing threshold of the 3 frequencies before and after masking were statistically significant (P<0.05). Fifty-nine patients with SST were documented between January 2015 and January 2020. After the operation, their low-frequency hearing was recovered to normal; 11 cases had significantly alleviated tinnitus and 9 cases were cured. CONCLUSIONS SST often causes corresponding pseudo-low-frequency hearing loss due to the noise-masking effect. The center frequency of tinnitus appears not to be 250-Hz or 500-Hz octave frequency of PTA, barring the detection of the pseudo-hearing loss in the audiometry chart of most patients. Surgery positively affects patients with SST, and the pseudo-LFSHL can be completely recovered after the operation as a result of tinnitus elimination.

Cerebral Venous Stenting for Pulsatile Tinnitus After Unsuccessful Jugular Ligation: Case Report and Literature Review

Pulsatile tinnitus constitutes up to 10% of all tinnitus cases. Cerebral venous stenosis is a known etiology of pulsatile tinnitus. Treatment of pulsatile tinnitus secondary to venous stenosis with venous stenting has been reported in the literature but is not performed routinely. We would like to report a case of chronic pulsatile tinnitus treated with venous stent in a patient who previously underwent jugular vein ligation.

Endovascular treatment of debilitating tinnitus secondary to cerebral venous sinus abnormalities: a literature review and technical illustration

Background and objective

Pulsatile tinnitus (PT) can be debilitating and lead to significant morbidity. Cerebral venous sinus lesions, such as venous sinus stenosis, diverticula, and high-riding jugular bulb, are uncommon causes of PT, for which there is no standard treatment. Endovascular interventions have shown promising results for PT secondary to idiopathic intracranial hypertension, and may be a valid therapeutic option for isolated venous PT.

Methods

We conducted a systematic literature review on the outcome and safety of endovascular treatment for patients with isolated, debilitating venous PT. The venous lesion characteristics, endovascular techniques, complications, and clinical outcomes were assessed. In addition, an illustrative case of endovascular stenting for PT caused by venous sinus stenosis was included.

Results

A total of 41 patients (90.2% female) from 26 papers were included. The median age was 46 years (IQR 23; range 25–72 years). Focal venous sinus stenosis (20 patients) and sinus diverticula (14 patients) were the most common culprit lesions. Endovascular treatment included venous sinus stenting in 35 patients, 11 of whom had adjuvant coil embolization, and coil embolization alone in six patients. Complete resolution of the tinnitus was achieved in 95.1% of patients. There was one complication of cerebellar infarct, and no procedure-related mortality.

Conclusions

In patients with debilitating PT secondary to venous sinus lesions, endovascular treatment by stenting and/or coil embolization appears to be safe and effective. Prospective randomized studies with objective outcome assessments are needed to confirm the treatment benefits.