Sandwich technique for sigmoid sinus wall reconstruction for treatment of pulsatile tinnitus caused by sigmoid sinus diverticulum/dehiscence

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.

Dynamic Volume Computed Tomography for Characterizing Pulsatile Tinnitus Caused by Sigmoid Sinus Diverticulum with Bone Defects: Clinical Implications

OBJECTIVE

The objective of this study is to investigate the diagnosis of dynamic volume computed tomography (CT) for pulsatile tinnitus caused by sigmoid sinus diverticulum (SSD) and bone defects.

METHODS

Data obtained by dynamic volume CT from 35 patients with SSD were retrospectively collected. Then the ear morphological parameters, including bone defect, transverse sinus stenosis, position of the jugular bulb, jugular bulb diverticulum, defect of the jugular bulb wall, gross venous sinus thrombosis and SSD, and blood perfusion parameters, including cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT), were evaluated and compared between the tinnitus side and the asymptomatic side of the ear.

RESULTS

The maximum diameters of the bone defects on the tinnitus side were greater than those on the asymptomatic side (Horizontal 6.36±2.35mm vs. 1.12±0.78mm; Longitudinal 4.87±1.25 vs. 0.88±0.06mm). Dynamic volume CT visually displayed the SSD herniated into the adjacent mastoid via the bone defect. Transverse sinus stenosis, high position of the jugular bulb, jugular bulb diverticulum, defect of the jugular bulb wall, and gross venous sinus thrombosis were present more frequently on the tinnitus side than on the asymptomatic side (P < 0.05). Moreover, CBF, CBV, and MTT were significantly greater on the tinnitus side than on the asymptomatic side (P < 0.05).

CONCLUSION

Dynamic volume CT examination is an effective method for the diagnosis of pulsatile tinnitus caused by SSD with bone defects.

Hemodynamic mechanism of pulsatile tinnitus caused by venous diverticulum treated with coil embolization

BACKGROUND AND OBJECTIVE

Coil embolization has become a new treatment method for pulsatile tinnitus (PT) caused by sigmoid sinus diverticulum (SSD). Although this therapy has achieved good results in clinical reports, the hemodynamic mechanism of coils in the treatment of PT in SSD remained unclear.

METHODS

Finite element method (FEM) and computational fluid dynamics (CFD) were combined to explore the hemodynamic mechanism of coil embolization in SSD treatment. Three personalized geometric models of sigmoid sinus were established according to the CTA data of patients. Coil model were established by FEM, and the hemodynamic differences of SSD before and after coiling were compared by transient CFD method.

RESULTS

Velocity streamlines disappeared in the SSD after coiling. At the peak time (t1 = 0.22 s), the SSD-average velocity decreased in every patient. The average value of the decreased in three patients was 0.154 ± 0.028 m/s (mean ± SD). Wall average pressure (P_avg) also showed a decline in every patient. Average of decrements of three patients was 17.69 ± 4.91 Pa (mean ± SD). Average WSS (WSS_avg) was also reduced in every patient. The average value of WSS drop was 9.74 ± 3.02 Pa (mean ± SD). After coiling, the proportion of low-velocity region in the sigmoid sinus cortical plate dehiscence (SSCPD) area increased. Average of increments was 22.1 ± 5.36% (mean ± SD).

CONCLUSIONS

A reduction in SSD-average velocity, wall pressure, and WSS were the short-term hemodynamic mechanism of coil embolization for PT. Coil embolization increased the proportion of low-velocity region in the SSCPD area, thereby creating a hemodynamic environment that easily produced thrombus and protects blood vessels from the impact of blood flow. This phenomenon was the long-term effect of coil embolization.

Transtemporal Sigmoid Sinus Decompression: A Novel Surgical Procedure for the Treatment of Idiopathic Pulsatile Tinnitus

OBJECTIVE

Idiopathic pulsatile tinnitus (IPT) is associated with high patient morbidity although treatment methods remain unsatisfactory. In the present study, the transtemporal sigmoid sinus decompression is used in the treatment of idiopathic pulsatile tinnitus.

STUDY DESIGN

Retrospective case study.

SETTING

Tertiary referral center.

PATIENTS

From 2005 to 2020, 287 patients presented with a complaint of pulsatile tinnitus. After exclusion criteria, 25 patients were diagnosed with IPT. Those patients underwent treatment and were included in a retrospective study.

INTERVENTIONS

Following failed conservative therapies, the primary author performed a transtemporal sigmoid sinus decompression surgery on the patients under general anesthesia.

MAIN OUTCOME MEASURES

Long-term resolution of IPT was measured using the Tinnitus Handicap Inventory (THI). Outcome measurements were taken preoperatively, immediately postoperatively, three months postoperatively, and the status of all 25 patients is known at the time of this study.

RESULTS

Transtemporal sigmoid sinus decompression was performed on 25 patients (mean age: 51.7 years, 80.0% female). Out of the 25 patients, 23 (92.0%) patients experienced complete resolution of their IPT. Statistically significant differences based on preoperative THI (mean THI: 4.19) were evident immediately after surgery (mean THI: 1.31; p < 0.001), at 3 months postoperatively (mean THI: 1.19; p < 0.001), and over a mean follow-up time of 68.7 months (range, 3-168 months) (mean THI: 1.38; p < 0.001). Out of the two patients considered unsuccessful, Case 21 experienced a partial resolution. No major postoperative complications occurred.

CONCLUSIONS

Transtemporal sigmoid sinus decompression is a safe and effective surgical procedure demonstrated to give near total resolution in properly selected patients and provides long-term relief for patients with IPT.

Hemodynamic study of the therapeutic effects of the different degrees of sigmoid sinus diverticulum reconstruction on patients

Sigmoid sinus diverticulum (SSD) is a common pathophysiology of pulsatile tinnitus (PT) and mainly treated by SSD reconstruction surgery. The degree of reconstruction is an important indicator of SSD reconstruction surgery, but its impact on the effect of SSD reconstruction is unclear. This study aimed to clarify the effect of the degree of SSD reconstruction on diverticulum reconstruction surgical treatment. One patient-specific case (control subject) was reconstructed based on the computed tomography angiography (CTA) images of patients with PT. The SSD reconstruction degree was used as a new index in this study. And the case of 30% (case 1), 60% (case 2), and 100% (case 3) of the diverticulum reconstruction degree of control subject were constructed. Transient-state computational fluid dynamics was performed. Wall pressure distribution, wall average pressure (P_avg) of SSD, flow pattern (velocity streamlines and velocity vector), wall shear stress (WSS) and averaged WSS (WSS_avg) were calculated and used in evaluating the hemodynamic differences among the DRD cases. Results demonstrated that change in SSD pressure was not linear with increase in DRD. The DRD that reached 60% of the original diverticulum was effective. At the peak point of the inlet boundary condition (T1 = 0.22s), the P_avg of SSD had a nonlinear change (control subject, 126.967 Pa vs. case 1, 126.274 Pa vs. case 2, 106.897 Pa vs. case 3, 94.116 Pa). Flow vorticity decreased gradually, and the smoothness of the streamlines increased with DRD. WSS_avg slightly changed with increasing DRD. The high-speed flow blood hit the diverticulum entrance and then swirled to hit the area of the sigmoid sinus wall abnormal. It was concluded that flow patterns related to PT differ with DRD. In diverticulum reconstruction surgery, there is a threshold value, and only when the DRD exceeds this value (60% or 70% or 80%), it will have a noticeable effect. In this study, DRD should at least reach 60% of the original diverticulum. When DRD is insufficient, hemodynamic change in the diverticulum is small, and the PT may have remained. SSD may be caused by high-speed blood flow.

Treatment of pulsatile tinnitus caused by anomalies of the sigmoid sinus wall via combined internal and external sigmoid sinus wall reconstruction with 3D temporal bone CT guidance

PURPOSE

The present analysis aims to describe a surgical approach wherein pulsatile tinnitus (PT) arising due to sigmoid sinus wall anomalies (SSWA) can be treated via combination internal and external sigmoid sinus wall reconstruction. We further evaluated the utility of temporal bone 3D-CT imaging during both the pre- and post-operative assessments of all treated patients.

METHODS

Data pertaining to 11 patients that had undergone sigmoid sinus wall reconstruction were retrospectively analyzed. All of these patients underwent preoperative 3D-CT imaging assessment. These patients were additionally subjected to sigmoid sinus wall reconstruction via a combined internal and external layer approach. Postoperatively, all patients underwent a radiological assessment of auricular cartilage and autologous bone powered displacement. Patients were additionally asked about any subjective changes in PT or associated symptoms at follow-up time points.

RESULTS

SSWA in the 3D-CT imaging from these patients were all distinct. In 10/11 patients, PT fully resolved following reconstruction of the sinus wall. The remaining patients exhibited significant improvements in symptoms postoperatively, with PT fully resolving within a 1-month follow-up period. No patients suffered any major complications.

CONCLUSIONS

Temporal bone 3D-CT imaging allow for effective visualization of SSWA, enabling effective pre- and post-operative assessments of treated patients. A combined internal and external layer approach to sigmoid sinus wall reconstruction can be implemented safely and effectively, yielding high rates of satisfactory outcomes and achieving rigid reconstruction of this surface. As such, there is clear value in the consideration of this approach when treating individuals suffering from PT as a result of SSWA.