Diagnostic Approach to Pulsatile Tinnitus: A Narrative Review

Pulsatile Tinnitus: Differential Diagnosis and Approach to Management

PURPOSE OF REVIEW

The purpose of this review is to provide an updated approach to the evaluation and management of pulsatile tinnitus (PT), an uncommon but often treatable subtype of tinnitus.

RECENT FINDINGS

Secondary PT can be due to either vascular or non-vascular etiologies, including, but not limited to: neoplasm, arteriovenous malformation or fistula, idiopathic intracranial hypertension, dural venous sinus stenosis, otoacoustic etiologies (e.g., otosclerosis, patulous eustachian tube) and bony defects (e.g., superior semicircular canal dehiscence). Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies. If initial vascular imaging is negative and a vascular etiology is strongly suspected, digital subtraction angiography (DSA) may further aid in the diagnosis. Many vascular etiologies of PT can be managed endovascularly, often leading to PT improvement or resolution. Notably, venous sinus stenting is an emerging therapy for PT secondary to idiopathic intracranial hypertension with venous sinus stenosis. Careful history and physical exam can help establish the differential diagnosis for PT and guide subsequent evaluation and management. Additional studies on the efficacy and long-term outcome of venous sinus stenting for venous stenosis are warranted.

Back to Bernoulli: a simple formula for trans-stenotic pressure gradients and retrospective estimation of flow rates in cerebral venous disease

BACKGROUND

Venous sinus stenosis can be associated with cerebrovascular disorders. Understanding the role of blood flow disturbances in these disorders is often hampered by the lack of patient-specific flow rates. Our goal was to demonstrate the impact of this by predicting individual flow rates retrospectively from routine manometry and angiography.

METHODS

Ten cases, spanning a range of stenosis severities and pressure gradients, were selected from a cohort of patients who had undergone venous stenting for pulsatile tinnitus. Lumen geometries were digitally segmented from CT venograms. A simplified Bernoulli formula was derived to estimate individual cycle-average flow rates from clinical pressure gradients and minimum lumen cross-section areas. High-fidelity pulsatile computational fluid dynamics (CFD) simulations were performed to compare predictions of flow disturbances using generic versus individual flow rates, and to validate the Bernoulli formula.

RESULTS

Individual flow rates derived from the Bernoulli formula deviated by up to 47% from the assumed generic flow rate, resulting in substantial differences in CFD predictions of post-stenotic flow instabilities. Pressure gradients estimated by the simplified Bernoulli formula were, however, highly predictive of pressure gradients from the full CFD simulations (R2=0.95; slope=0.98, 95% CI 0.88 to 1.09).

CONCLUSIONS

A simple Bernoulli formula can predict CFD-estimated trans-stenotic pressure gradients in realistic venous geometries. As demonstrated here, this may be used to recover individual flow rates from routine-but-invasive clinical measurements; however, it also suggests a simpler path towards non-invasive estimation of trans-stenotic pressure gradients that may avoid some of the challenges associated with 4D flow MRI approaches.

Noninvasive Treatment of Venous Pulsatile Tinnitus with an Internal Jugular Vein Compression Collar

OBJECTIVE

The study was conducted to evaluate the safety and efficacy of mild internal jugular (IJV) compression via an FDA approved compression collar for symptomatic treatment of venous pulsatile tinnitus.

METHODS

This is a prospective study that recruited 20 adult patients with venous pulsatile tinnitus. Participants completed the Tinnitus Handicap Inventory (THI), were fitted with the collar, and rated symptom intensity on a 10-point tinnitus intensity scale before and during collar use. Once weekly for 4 weeks, they answered a survey quantifying days used, average tinnitus intensity before and after wearing the collar each day of use, and any safety concerns. Lastly, they completed an exit interview. The primary outcome was symptomatic relief, with secondary outcomes of safety, effect of treatment setting, effect of time, and quality of life assessed via nonparametric testing.

RESULTS

18 participants completed the study, and 276 paired daily before use/during use intensity scores were submitted. The median symptom intensity without the collar was 6 (IQR 4, 7), whereas with the collar it was 3 (IQR 2, 5), for a median symptomatic relief of 50%. The collar had a significant effect in reducing symptom intensity (p < 0.0001) and burden of illness via the THI (p < 0.0001). There was no effect of setting, frequency, or time on symptomatic relief with the collar. There were no adverse safety events reported aside from minor discomfort upon initial application.

CONCLUSIONS

Venous compression collars offer acute symptom relief for patients with venous pulsatile tinnitus. Further study is needed to assess safety and efficacy of longitudinal use.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3342-3348, 2024.

Outcome measures of brainwave entrainment using delta wave stimulation in individuals with tinnitus having normal hearing sensitivity

OBJECTIVE

The current study aimed to evaluate the efficacy of delta frequency binaural beats stimulation in treatment of individuals with tinnitus having normal hearing sensitivity.

METHOD

Twenty-four individuals who reported bothersome tinnitus in the presence of clinically normal hearing were grouped into two (I and II). The group was provided with delta frequency binaural beats and II was provided with white noise stimulation (both of 20 min duration) for 30 days. Post 30 days, the re-assessment of tinnitus handicap, depression, anxiety, and quality of life parameters were performed and compared with that of pre-treatment scores.

RESULTS

A considerable reduction of tinnitus handicap scores, depression and anxiety levels were observed for both the groups, except for the quality-of-life parameters. However, few of the participants showed limited or negligible improvement post-treatment. On comparison of reduction of scores observed across the groups, there was a higher reduction of scores observed for group I when compared to group II.

CONCLUSION

The current study was an initial attempt to study the efficacy of binaural beats in treatment of individuals with tinnitus having normal hearing. Apart from a few individuals, the delta wave stimulation acted as a helpful tool in improving tinnitus borne distress symptoms in such patients with normal hearing. The results of the present study put forward the scope of adapting binaural beats stimulation for the treatment of individuals presenting with tinnitus having normal hearing sensitivity. This technique could be adopted into clinical practice after extensive research involving an extended treatment duration on a larger population.

Causes of Pulsatile Tinnitus and Treatment Options

Pulsatile tinnitus (PT) requires detailed workup to evaluate for an underlying structural cause. With advances in neuroimaging, structural venous abnormalities that can cause PT have becoming increasingly recognized. A number of anomalies, including dural arteriovenous fistulas, idiopathic intracranial hypertension, transverse sinus stenosis, sigmoid sinus wall abnormalities, jugular venous anomalies, and hypertrophied emissary veins, have been implicated in flow disruption and turbulence in the vicinity of auditory structures, resulting in PT. Endovascular treatment options, including stenting, coiling, and embolization with liquid agents, have demonstrated high efficacy and safety. These treatments can lead to symptomatic relief in carefully selected cases.

The Effect of Physical Therapy on Somatosensory Tinnitus

Objective: The objective of this work was to assess the effect of physical therapy in patients with somatosensory tinnitus (ST) and explore the influence of physical therapy on clinical variables obtained before treatment. Methods: A total of 43 patients with ST were randomized to the immediate-start group (n = 20) and delayed-start group (n = 23). All patients received physical therapy for 1 week (seven sessions). Each session lasted 60 min. The Visual Analogue Scale (VAS), Tinnitus Handicap Inventory (THI), and numerical pain rating scale (NPRS) scores were documented at baseline and after treatment (week 1) for all patients. For subjects in the immediate-start group, the THI, VAS, and NPRS scores were measured after therapy (weeks 6, 9, and 12, respectively). Medical history characteristic functional activity scale (HCFA) scores were measured at baseline to assess the association between somatic symptoms and tinnitus. Results: At week 1, VAS, THI, and NPRS scores of patients in the immediate-start group were improved by 1.25 ± 1.59, 11.10 ± 15.10, and 0.95 ± 1.54 points, respectively, and were significantly higher than those in the delayed-start group (p < 0.05). The change in VAS, THI, and NPRS scores in the treatment group was significantly positively correlated with the scores of the HCFA before treatment (r = 0.786, p < 0.001; r = 0.680, p = 0.001; r = 0.796, p < 0.001). There was no significant difference in THI, VAS, and NPRS scores among patients in the immediate-start group between weeks 1, 6, 9, and 12 after treatment (p > 0.05). Conclusions: Although more participants were necessary in the further study, the study implies that physical therapy can reduce physical pain, improve tinnitus symptoms, and quality of life in ST patients without hearing loss, and the short-term curative effect is stable, especially for tinnitus patients with clear somatic symptoms.

Sigmoid Sinus Wall Anomalies Can Progress and May Not Be Congenital

OBJECTIVE

Sigmoid sinus wall anomalies (SSWA) are closely linked to venous pulsatile tinnitus (PT). This study aims to demonstrate that SSWA develops progressively rather than being congenital.

METHODS

We retrospectively analyzed 42 PT patients with SSWA who had at least two non-operative CT scans at our clinic. CT images were longitudinally assessed to track SSWA progression, while MRI and Doppler ultrasound evaluated transverse sinus stenosis and venous hemodynamics. Changes in PT perception were tracked using the tinnitus handicap inventory (THI) questionnaire.

RESULTS

Among the 42 SSWA patients, 12 (28.6%) exhibited progression. Anastomosis between diploic vein and diverticulum was significantly higher compared to the dehiscence cohort (p < 0.01). Within the diverticulum group, seven individuals (30.4%) experienced enlargement, with a mean diverticular wall expansion of 5.9% ± 11.4%. Progressive erosion was observed in two cases (12.5%) in the dehiscence cohort, with a mean sigmoid plate erosion of 3.8% ± 10.1%. In cases progressing from dehiscence to diverticulum, three subjects transitioned, with a mean sigmoid sinus wall length expansion of 43.8% ± 31.9%. SSWA progression showed a significant negative correlation with QBILATERAL (r = -0.857, p = 0.014), and there was a significant difference between initial and revisit THI scores (p < 0.01).

CONCLUSION

SSWA can undergo morphological progression, indicating it is a progressive clinical condition rather than congenital.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Novel, braided, self-expandable stent designed for the treatment of pulsatile tinnitus caused by intracranial venous stenosis: first-in-human experience and long-term outcomes

BACKGROUND

Pulsatile tinnitus (PT) can be a disabling clinical condition, which may be caused by a sigmoid/transverse sinus stenosis (STSS). Intracranial venous stenting with off-label carotid or peripheral venous stents has been used successfully to treat this condition. We present the results of a cohort of patients presenting with PT treated with a novel, dedicated, braided stent for the endovascular treatment of STSS.

METHODS

Twelve patients presenting with PT and associated STSS were treated at our institution (December 2022-June 2023). All clinical and procedural variables were prospectively collected. We used the Tinnitus Function Index (TFI) and the Tinnitus Handicap Inventory (THI) scores to assess the impact of PT on quality of life before and after the treatment (mean follow-up: 10.3 months).

RESULTS

Twelve women (mean age: 44±16.5 years) presenting with PT and STSS were treated. Mean pretreatment TFI/THI scores were 78.8/77. The BosStent was successfully deployed in all patients. We experienced no intraprocedural/postoperative complications. Intra-stent angioplasty was performed in three cases. All patients reported a complete resolution of PT symptoms within 1 month and remained stable and PT-free at the last follow-up (mean posttreatment TFI/THI score: 7.1/5, p<0001).

CONCLUSIONS

The BosStent was successfully used in a cohort of patients with PT without any intraprocedural complications. All the patients experienced a complete resolution of PT symptoms after 1 month, which was stable during the follow-up period. Further studies with larger populations will be necessary to investigate the safety and effectiveness of this novel stent for the treatment of PT with STSS.

Clinical evaluation of pulsatile tinnitus: history and physical examination techniques to predict vascular etiology

BACKGROUND

Pulsatile tinnitus (PT) may be due to a spectrum of cerebrovascular etiologies, ranging from benign venous turbulence to life threatening dural arteriovenous fistulas. A focused clinical history and physical examination provide clues to the ultimate diagnosis; however, the predictive accuracy of these features in determining PT etiology remains uncertain.

METHODS

Patients with clinical PT evaluation and DSA were included. The final etiology of PT after DSA was categorized as shunting, venous, arterial, or non-vascular. Clinical variables were compared between etiologies using multivariate logistic regression, and performance at predicting PT etiology was determined by area under the receiver operating curve (AUROC).

RESULTS

164 patients were included. On multivariate analysis, patient reported high pitch PT (relative risk (RR) 33.81; 95% CI 3.81 to 882.80) compared with exclusively low pitch PT and presence of a bruit on physical examination (9.95; 2.04 to 62.08; P=0.007) were associated with shunting PT. Hearing loss was associated with a lower risk of shunting PT (0.16; 0.03 to 0.79; P=0.029). Alleviation of PT with ipsilateral lateral neck pressure was associated with a higher risk of venous PT (5.24; 1.62 to 21.01; P=0.010). An AUROC of 0.882 was achieved for predicting the presence or absence of a shunt and 0.751 for venous PT.

CONCLUSION

In patients with PT, clinical history and physical examination can achieve high performance at detecting a shunting lesion. Potentially treatable venous etiologies may also be suggested by relief with neck compression.

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.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Cerebral venous disorders: Diagnosis and endovascular management

The role of the venous circulation in neurological diseases has been underestimated. In this review, we present an overview of the intracranial venous anatomy, venous disorders of the central nervous system, and options for endovascular management. We discuss the role the venous circulation plays in various neurological diseases including cerebrospinal fluid (CSF) disorders (intracranial hypertension and intracranial hypotension), arteriovenous diseases, and pulsatile tinnitus. We also shed light on emergent cerebral venous interventions including transvenous brain-computer interface implantation, transvenous treatment of communicating hydrocephalus, and the endovascular treatment of CSF-venous disorders.

Venous balloon test occlusion for pulsatile tinnitus assessment: A clinical feasibility study

BACKGROUND

Pulsatile tinnitus (PT) can have huge impact on the patients' quality of life and can be associated with curable vascular anomalies. In the present study, we aim firstly to describe our protocol for venous BTO and secondly to report possible predictors for a positive BTO test.

METHODS

All consecutive PT patients undergoing BTO for the purpose of determining eligibility for venous neuro-intervention were included. We recommend BTO for patients when there is uncertainty in the association of the venous pathology identified on non-invasive cross-sectional imaging (CTV or MRV) and the patient's symptoms.

RESULTS

Between May 2016 and October 2022, we recorded 29 venous balloon test occlusions fulfilling our inclusions criteria. Over the 29 procedures scheduled, 8 finally did not lead to a successful balloon test occlusion. The main reason was that the patient did not hear the PT on the day the angiogram was performed. Two patients could not have the BTO due to difficulties in venous navigation. After BTO, only four patients of our cohort were scheduled for an endovascular treatment.

CONCLUSION

We describe a technique and present a single cohort of venous BTO in severe PT patients with unclear anatomical cause. This angiographic test was useful to exclude patients from endovascular surgery and discuss the most probable cause of the PT. Complexity of vascular PT should support a patient-based approach when discussing interventional treatment.

Global research hot spot and trends in tinnitus treatment between 2000 and 2021: A bibliometric and visualized study

Background

In the 21^st century, the prevalence of tinnitus is increasing, impacting approximately one in five people. It is a very complicated condition that significantly affects quality of life. Despite the availability of hundreds of tinnitus treatment options, none are very successful. In light of this, there has been a steady increase in studies on tinnitus treatments in the recent past. To comprehend them better, this study used bibliometric approaches to analyze and summarize 21^st century scientific research accomplishments in tinnitus treatment.

Methods

The Web of Science Core Collection (WoSCC) was searched for papers that had been published and related to the treatment of tinnitus. VOSviewer, CiteSpace, R, and Tableau software programs were used to conduct bibliometric studies. To evaluate and visualize the results.

Results

2,933 publications on tinnitus treatment were found in 74 countries. Between 2000 and 2021, publications increased steadily. Otolaryngology-Head & Neck Surgery had the highest impact factor, whereas Otology & Neurotology had the most magazines and the highest h, g, and m index. Langguth B was the most prolific author in terms of productivity during the past 21 years. Numerous eminent authors and organizations from multiple nations collaborated. With 626 papers, the United States of America (USA) contributed the most to this field, making them the leading contributor. Neuroplasticity, sound therapy, and cognitive behavioral therapy (CBT) have attracted the attention of researchers, leading to the development of innovative diagnostic and treatment strategies for tinnitus.

Conclusion

This bibliometric study provides a comprehensive analysis of worldwide publications, cooperation, and research hotspots in tinnitus therapy, revealing the present status of research on this issue and guiding tinnitus treatment research in the coming years.

Combined Arterial and Venous Phase Computed Tomographic Imaging of the Skull Base in Pulsatile Tinnitus

OBJECTIVE

To describe the demographic, clinical, and radiologic findings in a consecutive series of patients presenting with a chief complaint of pulsatile tinnitus (PT).

STUDY DESIGN

Retrospective review of 157 patients undergoing a combined arterial/venous phase computed tomographic (CT) imaging study.

SETTING

Tertiary referral center.

PATIENTS

Adult patients referred to neurotology faculty for evaluation of PT between 2016 and 2020.

INTERVENTIONS

Triple phase high-resolution arteriography/venography/temporal bone CT.

MAIN OUTCOME MEASURES

Prevalence of osseous, venous, and/or arterial pathology, clinicodemographic characteristics.

RESULTS

One hundred fifty-seven adults (mean age, 52 years; 79.6% female) were evaluated. A history of migraine headaches was common (19.7%). The average body mass index was 30.0 (standard deviation, 6.8), and 17.2% of subjects had a diagnosis of obstructive sleep apnea. Idiopathic intracranial hypertension was diagnosed by elevated opening pressure on lumbar puncture in 13.4%. Comorbid depression and anxiety were common (25.5% and 26.1%, respectively). Overall, abnormalities were found in 79.0% of scans, with bilateral transverse sinus stenosis (TSS) seen in 38.9% and unilateral TSS found in 20.4%. Fifteen subjects (9.6%) had evidence of osseous etiologies, including superior canal dehiscence or thinning in 8.9% and sigmoid sinus dehiscence in one subject. There were 3 dural arteriovenous fistulae identified. Unilateral PT was ipsilateral to the side of TSS in 84.4% of subjects with unilateral TSS.

CONCLUSION

In a large consecutive series of patients with PT referred for CT venography/arteriography, transverse sinus stenosis was the most common finding at 59%. Venous etiologies for PT should be suspected when patients are referred to neurotologists for evaluation.