Evaluation and treatment of pulsatile tinnitus associated with sigmoid sinus wall anomalies

Flow Analysis of Central Venous Outflow Tract: A New Approach to Understanding Pulse-Synchronous Tinnitus

OBJECTIVE

Pulse-synchronous tinnitus (PST) has been linked to multiple anatomical variants of the central venous outflow tract (CVOT) including sigmoid sinus (SS) dehiscence and diverticulum. This study investigates flow turbulence, pressure, and wall shear stress along the CVOT and proposes a mechanism that results in SS dehiscence and PST.

STUDY DESIGN

Case series.

SETTING

Tertiary Academic Center.

METHODS

Venous models were reconstructed from computed tomography scans of 3 patients with unilateral PST. Two models for each patient are obtained: a symptomatic and contralateral asymptomatic side. A turbulent model-enabled commercial flow solver was used to simulate the pulsatile blood flow over the cardiac cycle through the models. Fluid flow through the transverse and SS junction was analyzed to observe the velocity, pressure, turbulent kinetic energy (TKE), and shear stress over a simulated cardiac cycle.

RESULTS

Fluid flow on the symptomatic side showed increased vorticity in the presence of an SS diverticulum. Higher TKE with periodicity following the cardiac cycle was observed on the symptomatic side, and a sharp increase was observed if SS diverticulum was present. Shear stress was highest near the narrowest segments of the vessel. Pressure was observed to be lower on the symptomatic side at the transverse-SS junction for all 3 patients.

CONCLUSION

Computational fluid dynamics modeling of blood flow through the CVOT in PST suggests that low pressure may be the cause of dehiscence, and tinnitus may result from periodic increases in TKE.

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.

Temporal bone remodeling is an indicator of transverse sinus stenosis on computed tomography

PURPOSE

The purpose of this study was to identify potential association between transverse sinus stenosis (TSS) and temporal bone thinning downstream of TSS on computed tomography (CT).

MATERIALS AND METHODS

Clinical and radiological data of patients with venous pulsatile tinnitus due to TSS (TSS group) and treated with stenting from 2019 to 2022 were retrospectively collected. An age-matched control group of patients with venous or neutral pulsatile tinnitus (control group) was built. CT measurements of temporal bone thickness were performed at the level of transverse-sigmoid sinus junction (E1) and the occipitomastoid suture (E2). E1; E2 and E1/E2 ratios obtained in TSS and control groups were compared.

RESULTS

A total of 122 patients with venous pulsatile tinnitus were included. There were 56 patients with TSS (TSS group; 56 women; mean age, 35.5 ± 11.3 [standard deviation] years) and 66 patients without TSS (control group; 54 women; mean age, 37.7 ± 10.5 [standard deviation] years). E1 measurements and E1/E2 ratios on the symptomatic and dominant sides were significantly lower in the TSS group by comparison with the contralateral side of the same group (P < 0.05) and the ipsilateral side of the control group (P < 0.05). There were no differences in median E2 values between the TSS group (6.8 mm; range: 3.5-10.8 mm) and the control group (7.1 mm; range: 2.9-11.2 mm) (P = 0.098). E1 = 0 mm was found only in the TSS group. At receiver operating characteristic (ROC) analysis, an E1/E2 ratio threshold of 0.562 maximized the ability to predict presence of TSS. An E1/E2 ratio < 0.562 was predictive of symptomatic TSS with an accuracy of 74% (95% confidence interval: 65-82%). The AUC for the diagnosis of TSS was 0.807 (95% CI: 0.729-0.885).

CONCLUSION

Temporal bone thickness is significantly reduced downstream of the stenosis on the pulsatile tinnitus side and may be a good indicator of symptomatic TSS.

Endovascular stenting using a sagittal sinus approach for sigmoid sinus wall dehiscence related to intractable pulsatile tinnitus: a case series

BACKGROUND

Sigmoid sinus wall dehiscence can lead to pulsatile tinnitus with a significant decrease in quality of life, occasionally leading to psychiatric disorders. Several surgical and endovascular procedures have been described for resolving dehiscence. Within endovascular procedures, the sagittal sinus approach could be a technical alternative for tracking and accurate stent positioning within the sigmoid sinus when the jugular bulb anatomy is unfavorable.

CASE PRESENTATION

A retrospective case series of three patients with pulsatile tinnitus due to sigmoid sinus wall dehiscence without intracranial hypertension was reviewed from January 2018 to January 2022. From the participants enrolled, the median age was 50.3 years (range 43-63), with 67% self-identifying as female and 33% as male. They self-identified as Hispanic. Sigmoid sinus dehiscence was diagnosed using angiotomography, and contralateral transverse sinus stenosis was observed in all patients. Patients underwent surgery via a navigated endovascular sagittal sinus approach for sigmoid sinus stenting. No neurological complications were associated with the procedure. Pulsatile tinnitus improved after the procedure in all patients.

CONCLUSIONS

Superior sagittal sinus resection for sigmoid sinus wall stenting is a safe and effective technique. Pulsatile tinnitus due to sigmoid sinus wall dehiscence could be treated using the endovascular resurfacing stenting technique. However, further research is needed to evaluate the potential benefit of contralateral stenting for removing sinus dehiscence when venous stenosis is detected. However, resurfacing sigmoid sinus wall dehiscence results in symptomatic improvement.

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.

Cerebral Venous Thrombosis and Persistent Pulsatile Tinnitus After Sigmoid Sinus Resurfacing Surgery

We report a case with rare complication of cerebral venous thrombosis, as well as an incomplete response, after sigmoid sinus resurfacing surgery for pulsatile tinnitus (PT). A 24-year-old female patient with PT originating from the sigmoid sinus underwent sigmoid sinus resurfacing surgery. The tinnitus was immediately resolved, but it recurred with headache 5 days after surgery. A cerebral venous thrombosis was identified and treated, but PT persisted, although its frequency and loudness decreased. Sigmoid sinus resurfacing surgery is a safe and effective method to treat PT, but in some patients, it can cause serious complications and/or persistent tinnitus. In our patient, factors such as changes in blood viscosity due to warfarin intake or increased blood flow due to weight loss may have influenced the persistence of the tinnitus. It is important to identify the various associated factors and the weight of each of these factors to provide more tailored treatment of PT for individual patients in the future and to reduce complications and increase the effectiveness of sigmoid sinus resurfacing surgery.

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.

Dynamics of cerebrospinal fluid pressure alterations and bilateral transverse-sigmoid sinus morphologies in Asian patients with venous pulsatile tinnitus

OBJECTIVE

This study was performed to investigate the dynamics of intracranial pressure (ICP) alterations and bilateral transverse-sigmoid sinus morphologies in patients with venous pulsatile tinnitus (PT).

METHODS

This retrospective study involved 27 patients with venous PT associated with sigmoid sinus wall anomalies. ICP and ICP metrics were measured by cerebrospinal fluid manometry and internal jugular vein compression tests. Correlation analysis was performed to determine the statistical correlation between ICP and the morphological metrics.

RESULTS

The mean ICP was 212.5 ± 47.3 mmH2O. The median Δ ICP total was 130 (range, 55-150) mmH2O. The Δ ICP total was linearly correlated with the open lumbar pressure, and a significant difference was found between patients with normal and elevated cerebrospinal fluid pressure. The Δ ICP difference was linearly correlated with the Len difference and Vol difference . Δ ICP was linearly correlated with Len difference .

CONCLUSIONS

Complete obstruction of flow patency should be avoided in patients with low ICP and large volumetric/patency differences in the bilateral transverse-sigmoid sinus systems.

Causes and outcomes of revision surgery in subjects with pulsatile tinnitus

INTRODUCTION

Once the underlying pathology has been identified, pulsatile tinnitus (PT) can be treated successfully with surgical or interventional management. However, some patients experience residual or recurrent symptoms following initially successful surgical treatment, and require revision surgery or additional procedures. Here, we report a case series of patients who had undergone revision surgery or interventional treatment, and suggest possible ways of minimizing the need for revision.

METHODS

Between January 2014 and March 2023, a total of seven subjects underwent revision surgery or interventional treatment for persistent or recurrent PT after initial surgical treatment. Demographic data, reasons for revision, and changes in symptoms before and after revision were analyzed retrospectively. Temporal bone computed tomographic angiography images were reviewed to identify the causes and reasons for revision.

RESULTS

Of the seven subjects, six underwent sigmoid sinus (SS) resurfacing/reshaping due to ipsilateral diverticulum (Div) or dehiscence (Deh), and one underwent jugular bulb (JB) resurfacing due to a high-riding JB with bony Deh. Of the five subjects who underwent revision SS surgery due to recurrent SS-Div or SS-Deh, three showed marked resolution of PT, while the other two showed partial improvement of the symptoms. One subject who underwent revision JB resurfacing, and another who underwent additional transarterial embolization for a concurrent ipsilateral dural arteriovenous fistula, reported marked improvement of PT.

DISCUSSION

The possibility of recurrence should be taken into account when performing surgical intervention in patients with PT. The likelihood of recurrence can be minimized through a comprehensive evaluation to identify possible multiple etiologies, and through the use of durable materials and appropriate surgical methods.

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.

Anxiety, Depression, and Symptom Severity in Patients with Pulsatile and Non-Pulsatile Tinnitus

OBJECTIVE(S)

To compare the rates of anxiety and depression between patients with pulsatile (PT) and non-pulsatile tinnitus (NPT), and their correlation with tinnitus severity.

METHODS

A prospective cross-sectional study of consecutive patients presenting either to the otolaryngology clinic for pulsatile (PT) and NPT or to a tertiary care tinnitus habituation program (THP) were administered the tinnitus handicap inventory (THI), 7-item general anxiety disorder scale (GAD-7), and 9-item patient health questionnaire (PHQ-9). Median scores between groups and correlation of scores within groups were calculated and compared.

RESULTS

Median THI scores were significantly higher for THP and PT patients as compared with unselected NPT patients (58 and 44 vs. 20, p ≤ 0.001). Median GAD-7 (10 vs. 2.5 and 2, p ≤ 0.001) and PHQ-9 (7 vs. 4 and 4, p = 0.04) scores were highest in THP patients compared with PT and NPT. The strongest correlation between tinnitus handicap and psychiatric measures was seen in THP patients.

CONCLUSION

THP patients report higher levels of anxiety and depression compared with PT and other NPT patients. Tinnitus severity correlates more strongly with GAD-7 and PHQ-9 scores in THP patients compared with other patient groups. PT patients have a greater self-perceived tinnitus handicap than the general cohort of NPT patients, statistically comparable to THP patients. Despite this, anxiety and depression are not more severe in patients with PT as they are in THP patients.

LEVEL OF EVIDENCE

2B Laryngoscope, 133:683-688, 2023.

Focal meato-mastoid fistula closure using bony sigmoid sinus plate

OBJECTIVE

This study aimed to analyse the effectiveness of using the bony sigmoid sinus plate for repair of meato-mastoid fistulae.

METHOD

A retrospective study of all cases between January 2013 and December 2019 at our secondary-tertiary centre was conducted. Inclusion criteria for study were: (1) cases with focal meato-mastoid fistulae and (2) focal meato-mastoid fistulae that were repaired by using bony sigmoid sinus plate using the bony sigmoid sinus plate technique. There were 13 cases that fulfilled these criteria.

RESULTS

The outcome of the repair of meato-mastoid fistulae with bony sigmoid sinus plate was very encouraging. All 13 cases did well. Two patients had delayed epithelialisation at 9 and 12 months after surgery.

CONCLUSION

The technique of repairing meato-mastoid fistulae by using bony sigmoid sinus plate is simple, repeatable and provides effective physiological reconstruction of the posterior canal wall. Bony sigmoid sinus plate is easily and locally available in all cases undergoing cortical mastoidectomy. This plate of bone has a curvature, consistency and structure that match well with that of the posterior or superior canal wall. In addition, this technique is cost-effective with good patient compliance.

CT evaluation of unilateral pulsatile tinnitus with jugular bulb wall dehiscence

OBJECTIVES

To investigate the imaging features of unilateral pulsatile tinnitus (PT) with jugular bulb wall dehiscence (JBWD).

METHODS

Computerized tomography angiography images of unilateral PT patients were reviewed between 2019 and 2021. Thirty-one symptomatic JBWD patients without sigmoid sinus wall dehiscence (SSWD) were included. Thirty-eight patients with SSWD were used as the control group. The prevalence of JBWD was calculated. The area and height of the jugular bulb, the extent of dehiscence, the presence of jugular bulb diverticulum, posterior condylar emissary vein (PCEV), oblique occipital sinus (OOS), venous outflow laterality (VOL), the degree of transverse sinus stenosis (TSS), and the pituitary height to sella turcica ratio were compared between the two groups.

RESULTS

The prevalence of JBWD was 12.1%, and JBWD was established as a causative diagnosis in 5.0% of unilateral PT patients. There were no statistical differences in the gender, symptomatic side, or VOL between the two groups. The area of the jugular bulb was larger and the height was higher (p_area < 0.001, p_height = 0.005). The prevalence of jugular bulb diverticulum was higher in the JBWD group (p = 0.002). The degree of symptomatic TSS was less severe (p < 0.001), and the prevalence of bilateral TSS was lower in the JBWD group (p < 0.001). The pituitary height to sella turcica ratio was greater (p = 0.004), the prevalence of PCEV (p = 0.014) was lower, and OOS (p = 0.015) was greater in the JBWD group.

CONCLUSIONS

The correlating factors of PT with JBWD and PT with SSWD are significantly different. These findings can further facilitate early and efficient PT treatment.

KEY POINTS

• The incidence of jugular bulb dehiscence (JBWD) accounted for approximately 12.1% in pulsatile tinnitus (PT) patients, and JBWD was established as a causative diagnosis in 5.0% of PT patients. • PT required large blood flows and abnormal flow patterns, whether in JBWD or sigmoid sinus wall dehiscence groups. • JBWD causing PT has some unique characteristic findings on CT.

Case Report: Venous pulsatile tinnitus induced by enlarged oblique occipital sinus and resultant diverticulum/dehiscence of the sigmoid-jugular wall

Pulsatile tinnitus (PT) caused by enlarged oblique occipital sinus (OOS) and resultant diverticulum/dehiscence of the sigmoid-jugular wall has not been described in previous literature. This study recruits one case of PT induced by ipsilateral enlarged OOS and sigmoid-jugular wall diverticulum (case 1) alongside one case of PT induced by ipsilateral enlarged OOS and sigmoid-jugular wall dehiscence (case 2). Various radiologic and computational techniques including computed tomography (CT), magnetic resonance (MR) imaging, Doppler ultrasound, and computational fluid dynamics (CFD) simulation were implemented. Transmastoid sinus wall reconstruction was performed on case 1 with a large sigmoid-jugular diverticulum potentially traumatizing the facial nerve canal. Contrast-enhanced CT or MR venogram images coupling with three-dimensional reconstructed are advantageous in revealing the covert route of OOS that runs under the cerebellum and drains directly into jugular bulb (JB) region. PT in case 1 was successfully eliminated after transmastoid sinus wall reconstruction surgery. Tinnitus handicap inventory score in case 1 reduced from 70 to 0. The ipsilateral jugular outflow mean velocity (V_mn) and flow volume (F_VOL) were 42.5 cm/s and 25.9 g/s (case 1 prior to surgery) and 56.6 cm/s and 41.2 g/s (case 2), respectively. Based on CFD simulation, the peak flow velocity in OOS was 1.85 m/s and 2.1 m/s, the wall pressure of the diverticular dome and dehiscence area of the SS-JB wall was 1724.7 Pa and 369.8 Pa in case 1 and 2, respectively. Enlarged OOS caries greater flow kinetic energy that possibly induces sigmoid-jugular wall diverticulum/dehiscence; transmastoid surgical method is safe and therapeutically effective against PT induced by enlarged OOS.

Surgical treatment of pulsatile tinnitus related to the sigmoid sinus

Objective

Tinnitus-a common clinical symptom-can be categorized into pulsatile tinnitus (PT) and non-PT. Among these, PT is usually associated with sigmoid sinus symptoms, such as sigmoid sinus wall defect or diverticulum, for which various surgical treatments are available. We have discussed the clinical efficacy of surgery for sigmoid sinus-associated PT via the transmastoid approach in this study.

Methods

We conducted a retrospective review of 4 patients who underwent surgery for sigmoid sinus-associated PT via the transmastoid approach at Nanjing Drum Tower Hospital from January to December 2020. Of these, 2 patients had sigmoid sinus wall defect and 2 had sigmoid sinus diverticulum. Post-operative tinnitus grading and surgical efficacy were determined.

Results

After surgery, PT dissolved in 3 patients, while tinnitus significantly decreased in 1 patient. During the follow-up period of 12-18 months, none of the 4 patients showed complications related to increased intracranial pressure or venous sinus thrombosis, and tinnitus symptoms disappeared in 3 patients without recurrence, although 1 patient occasionally developed tinnitus. Postoperative thin-slice CTA of the temporal bone indicated that the sigmoid sinus bone wall defect or diverticulum was completely repaired with a thick soft tissue coverage.

Conclusion

Surgical repair of sigmoid sinus-associated PT via the transmastoid approach deserves clinical promotion as it exhibited better efficiency while being relatively less invasive.

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.

Study on the correlation between hemodynamic status of the transverse sinus-sigmoid sinus and the clinical efficacy of sigmoid sinus wall reconstruction

BACKGROUND AND PURPOSE

For patients with pulsatile tinnitus who have both transverse sinus stenosis and sigmoid sinus wall anomalies, sigmoid sinus wall reconstruction surgery is the first-choice treatment when the trans-stenotic pressure gradient less than 10 mmHg. However, not all patients are cured by surgery. We hypothesized the abnormal hemodynamics caused by transverse sinus stenosis is associated with the clinical efficacy of surgery.

METHODS

Eight pulsatile tinnitus patients treated with surgery were retrospectively reviewed (4 rehabilitated, 4 nonrehabilitated). All patients had radiologically diagnosed transverse sinus stenosis and sigmoid sinus wall anomalies. A numerical simulation of the hemodynamics of the transverse sinus-sigmoid sinus was performed using computational fluid dynamics technology. Changes in the blood flow patterns before and after surgery were observed. The blood flow velocity at the stenosis, vorticity of blood flow in the sigmoid sinus and wall pressure distribution in the sigmoid sinus wall anomalies area were compared.

RESULTS

The blood flow velocity in the stenosis (preoperative P = 0.04, postoperative P = 0.004) and vorticity in the sigmoid sinus (preoperative P = 0.02, postoperative P = 0.007) pre- and post-surgery were significantly higher in the non-rehabilitation group than in the rehabilitation group. No significant difference was found in the wall pressure distribution in the sigmoid sinus wall anomalies area (preoperative P = 0.12, postoperative P = 0.24).

CONCLUSIONS

There is a clear correlation between the abnormal hemodynamic status caused by transverse sinus stenosis and the clinical efficacy of surgery. The blood flow velocity at the stenosis and vorticity of blood flow in the sigmoid sinus are factors influencing the clinical efficacy of surgery.

Influence of sigmoid plate and dura mater on vascular wall displacement, vibroacoustic/hydroacoustic sources characteristics, and frequency-loudness assessments of venous pulsatile tinnitus: A coupled-computational fluid dynamics study combining transcanal recording investigation

Investigations of pulsatile tinnitus (PT) caused by sigmoid sinus wall anomalies (SSWAs) using computational fluid dynamics (CFD) have recently increased in prevalence. However, accurate modeling of anatomical structures regarding sigmoid plate dehiscence and acoustic sources of PT remains lacking. This study incorporates coupled CFD techniques, micro-computed tomography, and scanning electron microscope to reveal the vibroacoustic and hydroacoustic sources and displacement characteristics of the transverse-sigmoid sinus system. Furthermore, the in vivo transcanal-recording technique combined with ipsilateral internal jugular vein compression was implemented to cross-reference the captured acoustic profile of PT with the calculated results. In this study, the transient state coupled CFD technique was used to calculate the vibroacoustic and hydroacoustic sources. The dehiscent sigmoid plate and periosteal dura mater were then reconstructed. The displacement characteristics and acoustic results were analyzed. The displacement of the vascular wall underneath the dehiscent area was 9.6 times larger than that of the sigmoid plate and 3,617 times smaller than that of the vascular wall without the overlying osseous structures. The peak amplitude of flow-induced vibroacoustic noise was 119.3 dB at 20.2 Hz measured at the transverse sinus. Within the observed 20–1,000 Hz frequency range, the largest peak amplitude of hydroacoustic noise was 80.0 dB at 20.2 Hz located at the jugular bulb region. The simulated results conformed with the in vivo acoustic profile which the major frequency of PT falls within 1,000 Hz. In conclusion, 1) the sigmoid plate and dura mater greatly impact vascular wall displacement, which should not be overlooked in CFD simulations. 2) By incorporating the transcanal recording technique with IJV compression test, the primary frequency of PT was found fluctuating below 1,000 Hz, which matches the frequency component simulated by the current CFD technique; amplitude-wise, however, the peak amplitude of in vivo pulse-synchronous somatosound measures approximately 10 dB, which is comparatively lesser than the CFD results and the subjectively perceived loudness of PT. Thus, the transmission pathway, intramastoid acoustic impedance/amplification effect, and the perceptive threshold of PT require further investigations to minimize the incidence of surgical failure.

Intracranial pressure, lateral sinus patency, and jugular ultrasound hemodynamics in patients with venous pulsatile tinnitus

The clinical and hemodynamic characteristics of venous pulsatile tinnitus (PT) patients with normal or elevated cerebrospinal fluid pressure (CSFP) have not been clearly differentiated. This study aimed to explore CSFP among patients with PT as the solitary symptom, as well as quantitatively and qualitatively assess the role of the degree of transverse sinus (TS) stenosis and jugular hemodynamics in venous PT patients. A total of 50 subjects with venous PT with or without sigmoid sinus wall anomalies (SSWAs) were enrolled in this study. In addition to radiologic assessments for TS stenosis and invagination of arachnoid granulation (AG) in TS, CSFP and jugular hemodynamics were measured via cerebrospinal fluid (CSF) manometry and Doppler ultrasound. Apart from group comparisons and correlation analyses, multivariate linear regression, and receiver operating characteristic (ROC) models were used to identify the sensitivity and specificity of the index of transverse sinus stenosis (ITSS) and hemodynamic variables with inferential significance. The mean CSFP of all cases was 199.5 ± 52.7 mmH2O, with no statistical difference in CSFP between the diverticulum and dehiscence groups. Multivariate linear regression analysis demonstrated that CSFP was linearly correlated with ITSS and pulsatility index (PI). ROC analysis showed that the area under the ROC curve of PI was 0.693 at 200 mmH2O threshold, and the best PI cut-off value was 0.467, with a sensitivity of 65.7% and specificity of 81.8%. For 250 mmH2O threshold, the area under the ROC curve of PI was 0.718, and the best PI cut-off value was 0.467 with a sensitivity of 68.4% and specificity of 75.0%. Additionally, the area under the ROC curve of ITSS was 0.757, and the best ITSS cutoff value was 8.5 (p = 0.002, 95% CI = 0.616–0.898) with a sensitivity of 72.4% and specificity of 75.0% at 200 mmH2O threshold. In conclusion, patients with venous PT as the only presenting symptom should be suspected of having borderline or increased CSFP when they present with high ITSS, BMI and low PI. Further, AG in TS without encephalocele and empty sellae are not limiting findings for differentiating the level of CSFP in patients with venous PT.

Short- and Long-term Central Action of Botulinum Neurotoxin Treatment in Laryngeal Dystonia

BACKGROUND AND OBJECTIVES

Laryngeal dystonia (LD) is isolated task-specific focal dystonia selectively impairing speech production. The first choice of LD treatment is botulinum neurotoxin (BoNT) injections into the affected laryngeal muscles. However, whether BoNT has a lasting therapeutic effect on disorder pathophysiology is unknown. We investigated short-term and long-term effects of BoNT treatment on brain function in patients with LD.

METHODS

A total of 161 participants were included in the functional MRI study. Statistical analyses examined central BoNT effects in patients with LD who were stratified based on the effectiveness and duration of treatment.

RESULTS

Patients with LD who were treated and benefited from BoNT injections had reduced activity in the left precuneus compared with BoNT-naive and treatment nonbenefiting patients. In addition, BoNT-treated patients with adductor LD had decreased activity in the right thalamus, whereas BoNT-treated abductor patients with LD had reduced activity in the left inferior frontal cortex. No statistically significant differences in brain activity were found between patients with shorter (1-5 years) and longer (13-28 years) treatment durations. However, patients with intermediate treatment duration of 6-12 years showed reduced activity in the right cerebellum compared with patients with both shorter and longer treatment durations and reduced activity in the right prefrontal cortex compared with patients with shorter treatment duration.

DISCUSSION

Our findings suggest that the left precuneus is the site of short-term BoNT central action in patients with LD, whereas the prefrontal-cerebellar axis is engaged in the BoNT response in patients with intermediate treatment duration of 6-12 years. Involvement of these structures points to indirect action of BoNT treatment on the dystonic sensorimotor network through modulation of motor sequence planning and coordination.

Retroauricular/Transcranial Color-Coded Doppler Ultrasound Approach in Junction With Ipsilateral Neck Compression on Real-Time Hydroacoustic Variation of Venous Pulsatile Tinnitus

Alterations in dural venous sinus hemodynamics have recently been suggested as the major contributing factors in venous pulsatile tinnitus (PT). Nevertheless, little is known about the association between real-time alterations in hemodynamics and the subjective perception of venous PT. This study aimed to investigate the hydroacoustic correlations among diverticular vortices, mainstream sinus flow, and PT using various Doppler ultrasound techniques. Nineteen venous PT patients with protrusive diverticulum were recruited. The mainstream sinus and diverticular hemodynamics before and after ipsilateral internal jugular vein (IJV) compression were investigated using an innovative retroauricular color-coded Doppler (RCCD) method to examine the correlation between the disappearance of PT and hemodynamic alterations. To reveal the hydroacoustic characteristics of disparate segments of venous return, a computational fluid dynamics (CFD) technique combined with the transcranial color-coded Doppler method was performed. When the ipsilateral IJV was compressed, PT disappeared, as the mean velocity of mainstream sinus flow and diverticular vortex decreased by 51.2 and 50.6%, respectively. The vortex inside the diverticulum persisted in 18 of 19 subjects. The CFD simulation showed that the flow amplitude generated inside the transverse–sigmoid sinus was segmental, and the largest flow amplitude difference was 20.5 dB. The difference in flow amplitude between the mainstream sinus flow and the diverticular flow was less than 1 dB. In conclusion, the sensation of PT is closely associated with the flow of kinetic energy rather than the formation of a vortex, whereby the amplitude of PT is correlated to the magnitude of the flow velocity and pressure gradient. Additionally, the range of velocity reduction revealed by the RCCD method may serve as a presurgical individual baseline curative marker that may potentially optimize the surgical outcomes.

Preoperative Significance of Ipsilateral Manual Neck Compression in Patients With Pulsatile Tinnitus Secondary to Sigmoid Sinus Dehiscences and Diverticula

Venous pulsatile tinnitus (PT) is characterized by an auditory perception of pulse-synchronous sound, suppressed by compression of the ipsilateral internal jugular vein. We sought to determine the preoperative prognostic significance of the effect of ipsilateral neck manual compression on the PT loudness and audiometric changes in patients with sigmoid sinus dehiscences (SS-Deh) and diverticula (SS-Div) by comparing postoperative improvements in ipsilateral low-frequency hearing loss (LFHL) in pure-tone audiogram (PTA) and PT symptoms. Twenty-two subjects with PT originating from SS-Deh/Div were recruited. Air-conduction hearing thresholds were measured using PTA at three time points: twice preoperatively (with neutral neck position and with ipsilateral manual compression of internal jugular vein) and once at 3-months postoperatively with neutral neck position. We defined a positive neck compression effect as a threshold improvement of ≥ 10 dB HL at 250 or 500 Hz after manual neck compression. All but two subjects presented with ipsilateral LFHL in the neutral position. The average hearing threshold in the neutral position markedly improved after manual neck compression, indicating that LFHL originated from the masking effect of venous PT. All subjects had subjective improvements in PT and LFHL after sigmoid sinus surgeries, confirming that LFHL resulted from the masking effect of PT. Additionally, improvement of LFHL after neck compression could be regarded as a positive prognostic indicator after surgery. Collectively, elimination of PT loudness and improvement of LFHL with manual compression over the ipsilateral neck may suggest the venous origin of the PT and predict a favorable outcome following repair of SS-Deh/SS-Div.

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.

Management of vascular causes of pulsatile tinnitus

Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke. Careful diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy. When a vascular cause of pulsatile tinnitus has been established, attention must be focused on the patient's risk of hemorrhagic stroke, ischemic stroke, or blindness, as well as the risks of the available treatment options, in order to guide decision-making. Herein we review our approach to management of the vascular causes of pulsatile tinnitus and provide a literature review while highlighting gaps in our current knowledge and evidence basis.

Altered Neurovascular Coupling in Unilateral Pulsatile Tinnitus

Objective

Altered cerebral blood flow (CBF) and regional homogeneity (ReHo) have been reported in pulsatile tinnitus (PT) patients. We aimed to explore regional neurovascular coupling changes in PT patients.

Materials and Methods

Twenty-four right PT patients and 25 sex- and age-matched normal controls were included in this study. All subjects received arterial spin labeling imaging to measure CBF and functional MRI to compute ReHo. CBF/ReHo ratio was used to assess regional neurovascular coupling between the two groups. We also analyzed the correlation between CBF/ReHo ratio and clinical data from the PT patients.

Results

PT patients exhibited increased CBF/ReHo ratio in left middle temporal gyrus and right angular gyrus than normal controls, and no decreased CBF/ReHo ratio was found. CBF/ReHo ratio in the left middle temporal gyrus of PT patients was positively correlated with Tinnitus Handicap Inventory score (r = 0.433, p = 0.035).

Conclusion

These findings indicated that patients with PT exhibit abnormal neurovascular coupling, which provides new information for understanding the neuropathological mechanisms underlying PT.

Therapeutic Validation of Venous Pulsatile Tinnitus and Biomaterial Applications for Temporal Bone Reconstruction Surgery Using Multi-sensing Platforms and Coupled Computational Techniques

The application of grafts and biomaterials is a cardinal therapeutic procedure to resolve venous pulsatile tinnitus (PT) caused by temporal bone dehiscence during transtemporal reconstructive surgery. However, the transmission mechanism of venous PT remains unclear, and the sound absorption and insulation properties of different repair materials have not been specified. This study quantifies the vibroacoustic characteristics of PT, sources the major transmission pathway of PT, and verifies the therapeutic effect of different material applications using joint multi-sensing platforms and coupled computational fluid dynamics (CFD) techniques. The in vivo intraoperative acoustic and vibroacoustic characteristics of intrasinus blood flow motion and dehiscent sigmoid plate of a typical venous PT patient were investigated using acoustic and displacement sensors. The acoustical, morphological, and mechanical properties of the dehiscent sigmoid plate, grafts harvested from a cadaveric head, and other biomaterials were acquired using acoustical impedance tubes, micro-CT, scanning electron microscopy, and mercury porosimetry, as appropriate. To analyze the therapeutic effect of our previous reconstructive techniques, coupled CFD simulations were performed using the acquired mechanical properties of biomaterials and patient-specific radiologic data. The peak in vivo intraoperatively gauged, peak simulated vibroacoustic and peak simulated hydroacoustic amplitude of PT prior to sigmoid plate reconstruction were 64.0, 70.4, and 72.8 dB, respectively. After the solidified gelatin sponge–bone wax repair technique, the intraoperative gauged peak amplitude of PT was reduced from 64.0 to 47.3 dB. Among three different reconstructive techniques based on CFD results, the vibroacoustic and hydroacoustic sounds were reduced to 65.9 and 68.6 dB (temporalis–cartilage technique), 63.5 and 63.1 dB (solidified gelatin sponge technique), and 42.4 and 39.2 dB (solidified gelatin sponge–bone wax technique). In conclusion, the current novel biosensing applications and coupled CFD techniques indicate that the sensation of PT correlates with the motion and impact from venous flow, causing vibroacoustic and hydroacoustic sources that transmit via the air-conduction transmission pathway. The transtemporal reconstructive surgical efficacy depends on the established areal density of applied grafts and/or biomaterials, in which the total transmission loss of PT should surpass the amplitude of the measured loudness of PT.

Transverse Sinus Stenosis in Venous Pulsatile Tinnitus Patients May Lead to Brain Perfusion and White Matter Changes

Objective: Transverse sinus stenosis (TSS) is associated with various symptoms, but whether it can lead to pathological brain changes is unclear. This study aimed to investigate brain changes in venous pulsatile tinnitus (PT) patients with TSS.

Materials and Methods: In this study, fifty-five consecutive venous PT patients and fifty age- and gender-matched healthy controls (HCs) were investigated. In CT venography, the combined conduit score (CCS) was used to assess the degree of TSS in venous PT patients. Magnetic resonance venography was used to assess TSS in HCs. All the participants had undergone arterial spin labeling and structural MRI scans.

Results: Two patients without TSS and ten HCs with TSS were excluded. Fifty-three venous PT patients with TSS and 40 HCs without TSS were included in this study. All the patients had unilateral cases: 16 on the left and 37 on the right. Based on the CCS, the patients were divided into high-degree TSS (a score of 1–2) (n = 30) and low-degree TSS groups (a score of 3–4) (n = 23). In the whole brain and gray matter, the patients with high-degree TSS showed decreased cerebral blood flow (CBF) compared with patients with low-degree TSS as well as HCs (P < 0.05), and no significant difference in CBF was found in patients with low-degree TSS and HCs (P > 0.05). In white matter (WM) regions, the patients with high-degree TSS exhibited decreased CBF relative to the HCs (P < 0.05). The incidence of cloud-like WM hyperintensity was significantly higher in the above two patient groups than in the HC group (P < 0.05).

Conclusion: TSS in venous PT patients may lead to decreased CBF and cloud-like WM hyperintensity. These neuroimaging findings may provide new insights into pathological TSS in venous PT.

Effect of Emissary Vein on Hemodynamics of the Transverse- Sigmoid Sinus Junction

Objective: To investigate the effect of the blood flow direction and afflux location of emissary veins (EVs) on the hemodynamics of the transverse-sigmoid sinus (TS-SS) junction.

Methods: A patient-specific geometric model was constructed using computed tomography venography (CTV) and 4D flow MR data from a venous pulsatile tinnitus (PT) patient. New EV models were assembled with the afflux at the superior, middle and inferior portions of the SS from the original model, and inlet and outlet directions were applied. Computational fluid dynamics (CFD) simulation was performed to analyze the wall pressure and flow pattern of the TS-SS junction in each condition.

Results: Compared to the model without EVs, the wall pressure was greatly increased in models with inlet flow and greatly decreased in models with outlet flow. The more closely the EV approached the TS-SS, the larger the pressure in models with inlet flow, and the smaller the pressure in models with outlet flow. The flow streamline in the lateral part of the TS-SS junction was smooth in all models. The streamlines in the medial part were regular spirals in outlet models and chaotic in inlet models. The streamlines showed no obvious changes regardless of afflux location. The velocity at the TS-SS junction of inlet models were uniform, medium-low flow rate, while in control and outlet models were the lateral high flow rate and the central low flow rate.

Conclusion: The flow direction and afflux location of EVs affect the hemodynamics of the TS-SS junction, which may influence the severity of PT.

Evidence of air-conduction transmission pathway and strategized transtemporal operative techniques for venous pulsatile tinnitus: Combining water occlusion test and operative sensing applications

OBJECTIVES

(1) To establish evidence of the transmission pathway of venous pulsatile tinnitus (PT) associated with sigmoid sinus wall anomalies (SSWAs) and (2) quantify the efficacy of transtemporal surgery.

METHODS

This retrospective study included 33 surgical cases of PT associated with SSWAs and 15 controls with venous PT without SSWAs. Quantitative water occlusion test (q-WOT) and imaging data were acquired for preoperative evaluation prior to strategized transtemporal osteovascular reconstruction surgery. A condenser microphone and hydrophone were intraoperatively deployed to assess and monitor in vivo amplitude variations of the PT in eight participants.

RESULTS

A total of 23 (69.6%) participants with SSWA responded to the q-WOT with a median solution volume of 1.3 (1.1/1.6), which significantly differed from that observed in controls (p < 0.01). The change in the operative peak amplitude of the acoustic data was statistically significant (p < 0.01), from a median of 57.6 (55.5/57.9) dB SPL to 34.3 (33.4/38.8) dB SPL.

CONCLUSION

Intraoperative application of acoustic sensors revealed that PT associated with SSWAs is predominantly transmitted via the air-conduction pathway. If objective findings such as q-WOT and sensing applications suggest that the transmission of venous PT is involved in middle ear air conduction, the reconstruction technique should be prioritized; if less involvement of middle ear air-conduction is indicated, addressing flow pathologies may be imperative for resolving venous PT.

LEVEL OF EVIDENCE

4.

Pulsatile Tinnitus Due to Stenosis of the Marginal Sinus: Diagnosis and Endovascular Treatment

BACKGROUND AND PURPOSE

Venous pulsatile tinnitus is a disabling condition mainly caused by a stenosis of the lateral sinus. Here, we aimed to report a novel cause of venous pulsatile tinnitus, stenosis of the marginal sinus.

MATERIALS AND METHODS

We retrospectively analyzed patients with isolated venous pulsatile tinnitus for which the suspected cause was a stenosis of the marginal sinus, treated or not, between January 2017 and December 2020. Patient charts and imaging were systematically reviewed. All patients underwent noncontrast temporal bone CT and MR imaging.

RESULTS

Eight patients (7 women; median age, 36 years) were included. Six patients (75%) were overweight, and 1 patient had idiopathic intracranial hypertension. All patients presented with a typical venous pulsatile tinnitus. The stenosis of the marginal sinus was detected using oblique reconstructions on postcontrast 3D MR imaging. There was no other pathologic finding except ipsilateral stenosis of the lateral sinus in 3 patients. Four patients underwent endovascular therapy with placement of a stent in the marginal sinus, leading to complete resolution of the pulsatile tinnitus for all of them. No complication occurred. Of note, the symptoms of intracranial hypertension also regressed after stent placement in that patient.

CONCLUSIONS

Marginal sinus stenosis is a novel cause of venous pulsatile tinnitus, which can be easily detected on MR imaging. Marginal sinus stent placement is safe and efficient. We hypothesized that the marginal sinus stenosis pathophysiology is similar to that of lateral sinus stenosis, which is a common and well-known cause of venous pulsatile tinnitus, explaining the similar clinical presentation and endovascular management.

Diploic vein as a newly treatable cause of pulsatile tinnitus: A case report

BACKGROUND

Pulsatile tinnitus (PT) is an annoying sound that can be eliminated with targeted treatment of the cause. However, the causes of PT have not been fully elucidated.

CASE SUMMARY

A 38-year-old woman with right-sided objective PT underwent preoperative computed tomography arteriography and venography (CTA/V). A 3.8 mm vine diploic vein (DV), which passed through the mastoid air cells posteriorly in a dehiscent canal and was continuous with the transverse-sigmoid sinus, was thought to be the causative finding. Four-dimensional flow magnetic resonance (4D flow MR) imaging showed that the blood in the DV flowed toward the transverse-sigmoid sinus. The closer the blood was to the transverse-sigmoid sinus, the higher the velocity. No vortex or turbulence was found in the DV or adjacent transverse sinus. The sound was eliminated immediately after ligation of the DV with no recurrence during a three-month follow-up. No flow signal of the DV was noted on postoperative 4D flow MR.

CONCLUSION

A DV may be a treatable cause of PT. CTA/V and 4D flow MR could be utilized to determine the morphological and hemodynamic characteristics of the DV.

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.

Associations among Audiometric, Doppler Hydroacoustic, and Subjective Outcomes of Venous Pulsatile Tinnitus

OBJECTIVE

Venous pulsatile tinnitus (PT) has received increasing attention recently. As analyses of psychophysical and neuropsychological dimensions of venous PT are lacking, this study aimed to quantitatively and qualitatively investigate the correlation among audiometric, hydroacoustic, and subjective outcomes in patients with PT.

METHODS

Fifty-five venous PT patients, with or without sigmoid sinus wall anomalies (SSWAs), were subdivided into SSWAs (n = 30) and non-SSWAs (n = 25) groups. Audiometric and hemodynamic evaluations were assessed. Questionnaires including the Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale (HADS), and Athens Insomnia Scale (AIS) were deployed to evaluate the psychological impacts of PT.

RESULTS

Among 55 subjects, PT frequency-related pure-tone audiometry (PTA) was significantly different between ipsilesional non-PT frequency-related PTA (p < 0.01), ipsilateral jugular vein compression PTA (p < 0.01), and contralesional ear PTA (p < 0.01). In contrast with the pulsatility index and flow velocity, bilateral EOET and flow volume were significantly different (p < 0.01). Of the 3 questionnaire types, there was a strong correlation between HADS anxiety and AIS scores (r = 0.658, p < 0.01). The duration of PT was not correlated with subjective outcomes, and there was no statistical significance found among audiometric, hemodynamic, and subjective outcomes between SSWAs and non-SSWAs groups.

CONCLUSIONS

(1) The duration of PT was irrelevant to the increase of PTA. (2) Venous PT is the perception of vascular flow sound, in which hydroacoustic characteristics can be highly independent. (3) Anxiety, depression, and sleep disorders commonly prevail among PT patients.

Imaging Characteristics of Sigmoid Sinus Wall Anomalies, Idiopathic Intracranial Hypertension, and Spontaneous CSF Leaks

OBJECTIVE

To assess the frequency of radiographic features of elevated intracranial pressure (ICP) in patients with sigmoid sinus wall anomalies (SSWA) and compare to those in idiopathic intracranial hypertension (IIH) and spontaneous CSF (sCSF) leaks.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

110 patients - 62 SSWAs, 19 IIH, 29 sCSF leaks.

MAIN OUTCOME MEASURES

Demographics, comorbidities and radiographic features by diagnosis.

RESULTS

Imaging findings indicative of elevated ICP were similar across all three groups, as were body mass index, hyperlipidemia and diabetes. On univariate analysis, sCSF leak patients were significantly older than SSWA (60 vs. 41 years, p < 0.001) and IIH (60 vs. 40 years, p < 0.001) patients. They had a greater prevalence of arachnoid granulations than SSWA (75.8% vs. 37.1%, p < 0.01) and tegmen dehiscence than both SSWA and IIH (93.1% vs. 75.8% vs. 57.8%, p = 0.01), though a lower prevalence of empty sella than SSWA (44.8% vs. 72.5%, p < 0.001). SSWAs were present in roughly 44.3% of IIH and sCSF leak patients, and IIH in roughly 15.8% of SSWA and sCSF leak patients. Age (OR = 1.1, p = 0.001), hypertension (OR = 8.3, p = 0.01) and empty sella (OR = 0.1, p = 0.01) were predictive of sCSF leaks compared to SSWAs on multivariate analysis.

CONCLUSIONS

Many radiographic and clinical features of elevated ICP are found at similar rates among patients with SSWA, IIH and sCSF leaks, suggesting a common underlying process. SSWAs seem to present earlier along this spectrum of phenotypes, while sCSF leaks present later. Differences in age, metabolic syndrome and ICP may influence a patient's clinical presentation.

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Laryngeal Dystonia: Multidisciplinary Update on Terminology, Pathophysiology, and Research Priorities

OBJECTIVE

To delineate research priorities for improving clinical management of laryngeal dystonia, the NIH convened a multidisciplinary panel of experts for a 1-day workshop to examine the current progress in understanding its etiopathophysiology and clinical care.

METHODS

The participants reviewed the current terminology of disorder and discussed advances in understanding its pathophysiology since a similar workshop was held in 2005. Clinical and research gaps were identified, and recommendations for future directions were delineated.

RESULTS

The panel unanimously agreed to adopt the term "laryngeal dystonia" instead of "spasmodic dysphonia" to reflect the current progress in characterizations of this disorder. Laryngeal dystonia was recognized as a multifactorial, phenotypically heterogeneous form of isolated dystonia. Its etiology remains unknown, whereas the pathophysiology likely involves large-scale functional and structural brain network disorganization. Current challenges include the lack of clinically validated diagnostic markers and outcome measures and the paucity of therapies that address the disorder pathophysiology.

CONCLUSION

Research priorities should be guided by challenges in clinical management of laryngeal dystonia. Identification of disorder-specific biomarkers would allow the development of novel diagnostic tools and unified measures of treatment outcome. Elucidation of the critical nodes within neural networks that cause or modulate symptoms would allow the development of targeted therapies that address the underlying pathophysiology. Given the rarity of laryngeal dystonia, future rapid research progress may be facilitated by multicenter, national and international collaborations.

Bone remodeling in sigmoid sinus diverticulum after stenting for transverse sinus stenosis in pulsatile tinnitus: A case report

BACKGROUND

Pulsatile tinnitus (PT) is a potentially disabling symptom that has received increasing attention. Multiple causes of PT have been confirmed by targeted treatment. However, dynamic changes of related structures in PT patients with multiple causes after stenting for ipsilateral transverse sinus stenosis (TSS) have not been previously reported. We report such a case and present postoperative computed tomography venography (CTV) follow-up findings to demonstrate the decreased sigmoid sinus diverticulum and bone remodeling.

CASE SUMMARY

A 45-year-old man suffered from left-sided PT for 15 years that was occasionally accompanied by headache and dizziness. Pre-operative CTV revealed left-sided sigmoid sinus wall anomalies (SSWAs), TSS, outflow dominance, large posterior condylar emissary vein, and an empty sella turcica. A cerebrospinal fluid pressure of 270 mmH₂O was further detected. The sound disappeared immediately after stenting for ipsilateral TSS, with no recurrence during 2 years of follow-up. After the procedure, the patient underwent four consecutive CTV examinations. The diverticulum decreased 6 mo after the procedure with new bone remodeling. The density of the remodeled bone was further increased 1 year later, and a hardened edge was formed 2 years later.

CONCLUSION

PT associated with SSWAs, TSS, and idiopathic intracranial hypertension can be cured by stenting for TSS alone. And bone remodeling around SSWAs is a more significant finding.

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.

Altered cerebral blood flow in patients with unilateral venous pulsatile tinnitus: an arterial spin labeling study

Objectives:

Abnormal neuronal activity and functional connectivity have been reported in patients with venous pulsatile tinnitus (PT). As neuronal activity is closely coupled to regional brain perfusion, the purpose of this study was to investigate the cerebral blood flow (CBF) alterations in patients with unilateral venous PT using arterial spin labeling (ASL).

Methods:

This study included patients with right-sided PT between January 2018 and July 2019. A healthy control (HC) group matched 1:1 for gender and age was also recruited. All subjects underwent ASL scanning using 3.0T MRI. The correlation between altered CBF and Tinnitus Handicap Inventory (THI) score as well as PT duration was analyzed.

Results

Twenty-one patients with right-sided PT and 21 HCs were included. The mean PT duration of the patients was 35.9 ± 32.2 months, and the mean THI score was 64.1 ± 20.3. Compared with the HCs, the PT patients exhibited increased CBF in the left inferior parietal gyrus and decreased CBF in the bilateral lingual gyrus (family-wise error corrected, p < 0.05). The increased CBF in the left inferior parietal gyrus showed a positive correlation with the THI score in PT patients (r = 0.501, p = 0.021).

Conclusions

PT patients exhibit regional CBF alterations. The increased CBF in the left inferior parietal gyrus may reflect the severity of PT.

Advances in knowledge:

This study not only presents evidence for the potential neuropathology of PT from the perspective of CBF alterations but also offers a new method for investigating the neuropathological mechanism of PT.

Computational fluid dynamics study of the effect of transverse sinus stenosis on the blood flow pattern in the ipsilateral superior curve of the sigmoid sinus

OBJECTIVE

To investigate the effect of different types of transverse sinus stenosis on blood flow patterns in the ipsilateral superior curve of the sigmoid sinus.

METHODS

According to the morphology of transverse and sigmoid sinus sections in pulsatile tinnitus patients, ten idealized models with different degrees and positions of transverse sinus stenosis were constructed. Computational fluid dynamics simulations were performed to compare the hemodynamic characteristics among these models. Follow-up images of previous cases were included, which preliminarily confirmed the hypothesis that bone plate erosion of the sigmoid sinus sulcus is related to blood flow impingement.

RESULTS

Blood flow impingement on the superior curve of the sigmoid sinus wall intensified with increasing degree of stenosis and decreased with increasing distance between the stenosis and the sigmoid sinus. The impact zone was generally confined to the anterior and lateral walls of the superior curve of the sigmoid sinus. When the stenosis was located far from the middle of the transverse sinus, the blood flow impingement on the sigmoid sinus wall was very weak.

CONCLUSIONS

When stenosis is located far from the sigmoid sinus, the causes of tinnitus should be comprehensively considered instead of assuming that stenosis is the main cause. Bone plate erosion of the sigmoid sinus sulcus was promoted by blood flow impingement.

KEY POINTS

• Ten idealized models with different degrees and positions of stenosis were constructed. • The causes of pulsatile tinnitus should be comprehensively considered. • Sigmoid sinus plate dehiscence was promoted by blood flow impingement.

Effects of different morphologic abnormalities on hemodynamics in patients with venous pulsatile tinnitus: A four-dimensional flow magnetic resonance imaging study

The effects of morphologic abnormalities, including sigmoid sinus wall dehiscence (SSWD), transverse sinus stenosis (TSS), and sigmoid sinus diverticulum (SSD), on hemodynamics in venous pulsatile tinnitus (PT) patients have not been established. The aim of this study was to evaluate the effects of SSWD, TSS, and SSD on the hemodynamics of transverse‐sigmoid sinus in venous PT patients. This was a prospective study with 44 venous PT patients and 12 healthy controls. A 3 T/four‐dimensional (4D) flow magnetic resonance imaging with fast field echo was used. Computed tomography arteriography/venography was used to assess ipsilateral SSWD, TSS, and SSD. Maximum velocity (V_max), average velocity (V_avg), and average flow (Flow_avg) were measured. Blood flow patterns were independently assessed by three neuroradiologists. One‐way analysis of variance or Kruskal–Wallis test was also used. On the symptomatic side, all patients had SSWD, 33 patients had TSS, and 22 patients had SSD. Compared with healthy controls, patients with TSS, without TSS, with SSD, and without SSD all showed higher V_max (all p < 0.050), V_avg (all p < 0.050), and Flow_avg (all p < 0.050). Patients with TSS showed higher V_max (p < 0.050) and V_avg (p < 0.050) than those without TSS, and no significant difference in Flow_avg was found between the two groups (p = 0.408). No significant differences in V_max, V_avg, and Flow_avg were found between patients with and without SSD (all p = 1.000). Jet‐like flow in the stenosis and downstream of the stenosis was observed in all patients with TSS. Vortex in SSD was observed in 15 patients with SSD (68%). High blood velocity and flow may be characteristic markers of venous PT. SSWD may be a necessary condition for venous PT. TSS may further increase the blood velocity and form a jet‐like flow. SSD may be related to vortex formation but had no significant effect on blood velocity and flow.

Level of Evidence

2

Technical Efficacy Stage

3

Hydroacoustic analysis and extraluminal compression surgical insights of venous pulsatile tinnitus

OBJECTIVE

This study aimed to quantitatively and qualitatively evaluate the hydroacoustic changes from "presence" to "disappearance" of pulsatile tinnitus (PT) with the extraluminal compression surgical technique. The recent issues of concern pertaining to the hydroacoustic characteristics of sigmoid sinus wall anomalies and distal transverse sinus stenosis (dTSS) were discussed.

METHODS

This study was based on a retrospective case series. Seventy-seven patients with PT and transverse-sigmoid sinus enlargement with or without transverse-sigmoid sinus junction anomalies and transverse sinus stenosis (TSS) who had undergone extraluminal compression surgery under local anesthesia were included. Management of intractable intraoperative challenges and techniques for reversal extraluminal compression were introduced. Anatomical measurements, intraoperative color-coded Doppler ultrasonography, spectro-temporal analysis, and computational fluid dynamics were employed to analyze the hydroacoustic characteristics of PT.

RESULTS

The efficacy of the extraluminal compression technique was evident with the significant reduction in peak turbulent kinetic energy, vorticity, and mean pressure gradient at the transverse-sigmoid junction, resulting in over 20% reduction in PT amplitude. dTSS is a common finding in patients with PT exhibiting transverse-sigmoid sinus enlargement. Patients with dTSS presented with significant differences in hemodynamic characteristics as compared to those without. Linear regression analysis showed that the flow disturbance (turbulent kinetic energy and vorticity) was closely associated with the degree of dTSS, whereas the flow amplitude was not related to the degree or location of TSS. Low-pulsatory vortex flow at the transverse-sigmoid junction was visualized during an intraoperative color-coded Doppler examination, and the displayed low-frequency PT sound corresponded to the patients' subjective perception of PT.

CONCLUSION

(1) A reduction of over 20% of the flow-induced noise is the therapeutic goal of extraluminal compression technique. Since reductions in the magnitude of hemodynamic parameters, including turbulent kinetic energy, vorticity, and mean pressure gradient, render the flow-induced noise inaudible, besides sigmoid sinus wall anomalies, it is likely that PT develops from the aggregation of flow-based pathologies. (2) Although dTSS and diverticulum may greatly affect the hemodynamics at the transverse-sigmoid junction, in contrast to dehiscence, dTSS and diverticulum may not be the limiting factors for PT development.

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.

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial

OBJECTIVES

This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis.

METHODS

Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded.

RESULTS

A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events.

CONCLUSION

Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

Association of pulse synchronous tinnitus and sigmoid sinus wall abnormalities in patients with idiopathic intracranial hypertension

PURPOSE

Pulse synchronous tinnitus (PT) is common in patients with idiopathic intracranial hypertension (IIH) and in those with sigmoid sinus wall abnormalities (SSWAs). Although patients with SSWAs and IIH share many clinical features, the incidence of SSWAs in patients with IIH and its relationship to PT in this cohort is less well established. The purpose of this study is to assess the incidence of SSWAs in patients with IIH and PT, and to determine if there is an association between SSWAs and PT in this population.

MATERIALS AND METHODS

Prospective computed tomography (CT) study of adults with IIH. Subjective PT was correlated with presence or absence of SSWAs on CT.

RESULTS

22 subjects were enrolled and 14 subsequently underwent CT. The incidence of SSWAs was significantly higher in subjects with PT than without (70% vs. 0%, p = 0.02). Mean age, BMI and opening pressures did not differ between those with and without SSWAs or PT.

CONCLUSIONS

There is a high incidence of SSWAs in subjects with IIH and PT. These findings support an association between SSWAs and PT, and implicate SSWAs as a possible cause of, or contributing factor to, PT in patients with IIH. Patients with IIH and PT that does not resolve with reducing intracranial pressure should undergo diagnostic CT and consider treatment of a SSWA if present.

Patterns of audiometric threshold shifts from pulsatile tinnitus due to sigmoid sinus wall anomalies

PURPOSE

To determine the severity and nature of audiometric threshold shifts for patients with pulsatile tinnitus (PT) due to sigmoid sinus wall anomalies (SSWA).

MATERIALS AND METHODS

38 patients with SSWAs and available pre-operative audiograms were examined. Low- and high-frequency pure tone averages (LF-PTA, HF-PTA) were calculated. Audiometric data were compared between affected and unaffected ears, with the interaural difference (affected-unaffected PTA) representing the change in hearing due to PT. Additionally, post-operative change was examined in 14 patients with available data.

RESULTS

The average pre-operative air conduction (AC) LF-PTA was 17.04 dB on the affected side and 11.38 dB on the unaffected side (p < 0.001). The mean AC HF-PTA was significantly higher on the affected side as well (16.45 dB vs. 14.08 dB, p = 0.008). All shifts were sensorineural, with no significant air-bone gaps, and most subjects still had low-frequency thresholds in the normal range. Though the post-op change was not significant due to attrition, 5/14 patients (35.7%) had complete resolution of their pre-op interaural difference. A similar number developed a HF-PTA post-op threshold elevation in the surgical ear.

CONCLUSIONS

PT due to SSWAs causes a mean 6 dB low-frequency bone-conduction threshold elevation, and smaller high-frequency threshold shifts, due to masking. Patients with larger threshold shifts should have other potential causes of hearing loss explored.

LEVEL OF EVIDENCE

Level IV.

CT venography correlate of transverse sinus stenosis and venous transstenotic pressure gradient in unilateral pulsatile tinnitus patients with sigmoid sinus wall anomalies

Objectives

To investigate the correlation between transverse sinus stenosis (TSS) and transstenotic pressure gradient (TPG) in unilateral pulsatile tinnitus (PT) patients with sigmoid sinus wall anomalies (SSWA).

Methods

Fifty-seven patients with unilateral venous PT were retrospectively included. All of them underwent CT venography and catheter manometry, accompanied with SSWA. The degree, length, shape (intrinsic/extrinsic/dysplasia), location (proximal/middle/distal, referring to the relative position of TSS and the Labbé vein junction) of TSS, the types of SSWA (dehiscence/diverticulum), and the degree of transverse sinus outflow laterality were assessed, and the correlations with ipsilesional TPG were analyzed.

Results

The mean value of ipsilesional TPG was 7.61 ± 0.52 mmHg. The degree and length of ipsilesional TSS were positively correlated with TPG (p < 0.001, p’ < 0.001), respectively. TPG was significantly larger in patients with contralateral transverse sinus dysplasia than those without (p = 0.023) and significantly smaller in patients with ipsilesional sigmoid sinus diverticulum than those with isolated dehiscence (p = 0.001). No statistical difference in TPG was shown between ipsilesional TSSs of different shapes or locations (p > 0.05). No correlation was noted between the degree of ipsilesional transverse sinus outflow laterality and TPG (p = 0.051). Stepwise linear regression indicated that the degree (β = 9.207, 95% CI = 3.558–14.856), length (β = 0.122, 95% CI = 0.025–0.220) of ipsilesional TSS, and contralateral transverse sinus dysplasia (β = 1.875, 95% CI = 0.220–3.530) were significantly correlated with TPG (R² = 0.471).

Conclusions

The degree, length of ipsilesional TSS, and contralateral transverse sinus dysplasia may be used to predict TPG in unilateral PT patients with SSWA.

Key Points

• CT venography may act as a screening tool to help low-probability unilateral pulsatile tinnitus (PT) patients with sigmoid sinus wall anomalies (SSWA) avoid invasive catheter manometry.

• The degree and length of ipsilesional transverse sinus stenosis (TSS) are positively correlated with transtenotic pressure gradient (TPG) in unilateral PT patients with SSWA.

• Ipsilesional TPG is larger in unilateral PT patients with contralateral transverse sinus dysplasia than those without and is smaller in unilateral PT patients with sigmoid sinus diverticulum than those with isolated dehiscence.

Longitudinal analysis of surgical outcome in subjects with pulsatile tinnitus originating from the sigmoid sinus

A dominant sigmoid sinus with either diverticulum or dehiscence (SS-Div/SS-Deh) is a common cause of pulsatile tinnitus (PT). For PT originating from SS-Div/SS-Deh, an etiology-specific and secure reconstruction using firm materials is vital for optimal outcomes. As a follow-up to our previous reports on transmastoid SS resurfacing or reshaping for SS-Div/SS-Deh, this study aimed to evaluate the long-term results of transmastoid resurfacing/reshaping. We retrospectively reviewed 20 PT patients who were diagnosed with SS-Div/SS-Deh, underwent transmastoid resurfacing/reshaping, and were followed up for more than 1 year postoperatively. For PT, immediate and long-term changes (> 1 year) in loudness and annoyance were analyzed using the visual analog scale (VAS). Additionally, pre and postoperative objective measurements of PT using transcanal sound recording and spectro-temporal analysis (TSR-STA), imaging results, and audiological findings were comprehensively analyzed. Significant improvements in PT were sustained or enhanced for > 1 year (median follow-up period: 37 months, range: 12–54 months). On TSR-STA, both peak and root mean square amplitudes decreased after surgery. Also, the average pure-tone threshold at 250 Hz improved after surgery. Thus, our long-term follow-up data confirmed that the surgical management of PT originating from SS-Div/SS-Deh is successful with regard to both objective and subjective measures.

DYT-TUBB4A (DYT4 Dystonia): New Clinical and Genetic Observations

OBJECTIVE

To report 4 novel TUBB4A mutations leading to laryngeal and cervical dystonia with frequent generalization.

METHODS

We screened 4 families including a total of 11 definitely affected members with a clinical picture resembling the original description.

RESULTS

Four novel variants in the TUBB4A gene have been identified: D295N, R46M, Q424H, and R121W. In silico modeling showed that all variants have characteristics similar to R2G. The variants segregate with the disease in 3 of the families with evidence of incomplete penetrance in 2 of them. All 4 variants would be classified as likely pathogenic. The clinical picture particularly included laryngeal dystonia (often the site of onset), associated with cervical and upper limb dystonia and frequent generalization. Laryngeal dystonia was extremely prevalent (>90%) both in the original cases and in this case series. The hobby horse gait was evident in only 1 patient in this case series.

CONCLUSIONS

Our interpretation is that laryngeal involvement is a hallmark feature of DYT-TUBB4A. Nevertheless, TUBB4A mutations remain an exceedingly rare cause of laryngeal or other isolated dystonia.