Pulsatile Tinnitus Associated With Internal Carotid Artery Morphologic Abnormalities

Improving Diagnostic Yield in Patients with Pulsatile Tinnitus: A Ten-Year Analysis

OBJECTIVES

To determine the yield of a comprehensive diagnostic algorithm for patients with pulsatile tinnitus (PT) and to review the common etiologies and present clinical pears for their diagnosis.

METHODS

Retrospective chart review of patients with PT from 2013 to 2023. Charts were reviewed for demographic data (age, sex, BMI), side of PT (or bilateral), specialty clinic of initial evaluation, coexistent symptoms in addition to PT, and final diagnosis (or non-diagnosis). Clinical, audiometric, laboratory, and radiographic data were collected. Putative chart diagnoses were reviewed by the authors and deemed likely or unlikely to be the source of the patient's PT. Those with "unlikely" were grouped in the "idiopathic" cohort. The diagnostic algorithm is presented in detail.

RESULTS

Two hundred and 90 patients were included for analysis. The overall diagnostic yield was 90.7% for all patients and 95.6% for those patients who completed the recommended workup - a substantial improvement over published rates. Twenty-nine etiologies were identified with the most common etiology was idiopathic intracranial hypertension (IIH). Twenty-one diagnoses comprised no more than 5% of patients. Seventy-three patients (25.2%) had more than one pathology as a potential source for their PT.

CONCLUSIONS

PT can present a diagnostic challenge to the clinician. The findings of this study, however, reveal that proper evaluation based on obtaining a thorough history, performing a physical examination, coupled with properly directed imaging studies and blood testing can accomplish a high diagnostic yield of at least one potential etiology.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Simple Things Are Not Simple: Pulsatile Tinnitus due to Tortuous Occipital Artery

BACKGROUND

Pulsatile tinnitus is often a chronic and debilitating condition and normally has a vascular origin. We describe a case of pulsatile tinnitus due to an aberrant branch of the external carotid artery (ECA), which has not been reported previously.

METHOD

A 67-year-old female with chronic unilateral pulsatile tinnitus, which could be controlled completely with direct pressure on a small tortuous superficial branch behind her left ear. This was confirmed with doppler to be an unusually tortuous occipital branch of the ECA. Under local anesthesia, this vessel was identified with intraoperative doppler and ligated.

RESULT

Complete resolution of tinnitus immediately, with consistent results 3 months postoperatively.

CONCLUSIONS

Pulsatile tinnitus due to aberrances in the occipital ECA branch is rare, and in this case, was successfully treated with minor surgery.

Current Understanding of Dolichoarteriopathies of the Internal Carotid Artery: A Review

Dolichoarteriopathies of the internal carotid artery (DICAs) are not uncommon, and although several studies have investigated DICAs, several questions regarding the etiology and best management course for DICAs remain unanswered. It is also difficult to correlate the occurrence of DICAs with the onset of clinical symptoms. Therefore, we surveyed the literature in PubMed and performed a review of DICAs to offer a comprehensive picture of our understanding of DICAs. We found that DICAs can be classified into three types, specifically tortuous, coiling and kinking, and are not associated with atherosclerotic risk factors. Cerebral hemodynamic changes are mainly associated with the degree of bending of DICAs. DICAs can result in symptoms of the brain and eyes due to insufficient blood supply and can co-occur with a pulsatile cervical mass, a pharyngeal bulge and pulsation. The diagnostic tools for the assessment of DICAs include Doppler ultrasonography, computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), and although DSA remains the gold standard, Doppler ultrasonography is a convenient method that provides useful data for the morphological evaluation of DICAs. CTA and MRA are efficient methods for detecting the morphology of the cervical segment of DICAs. Some DICAs should be treated surgically based on certain indications, and several methods, including correcting the bending or shortening of DICAs, have been developed for the treatment of DICAs. The appropriate treatment of DICAs results in good outcomes and is associated with low morbidity and mortality rates. However, despite the success of surgical reconstruction, an appropriate therapeutic treatment remains a subject of numerous debates due to the lack of multicentric, randomized, prospective studies.

Aberrant extracranial internal carotid arteries: New insights, implications, and demand for a clinical grading system

BACKGROUND

Aberrant internal carotid arteries (ICAs) are not rare anatomic variations. The purpose of this study was for us to highlight their relevance and underline the need for a clinical grading system in addition to the currently used anatomic classification.

METHODS

This systematic quality assessment study over 7 years includes 125 adults with 231 aberrant ICAs. Digital imaging datasets were analyzed and ICAs classified according to the anatomic classification in tortuosity, kinking, and coiling. Risk potential for ICA injury was estimated from the vessel's relation to the pharynx and neck.

RESULTS

The analysis revealed a high frequency of medial and lateral ICA aberrations that seem surgically relevant, but the risk potential for injury was not reflected by the anatomic classification. Our previously proposed clinical grading system was reviewed and updated.

CONCLUSION

Aberrant ICAs are underestimated anatomic variations with high clinical impact for transoral and transcervical interventions. The introduced clinicoradiologic grading system could be of major benefit. © 2015 Wiley Periodicals, Inc. Head Neck 38: E687-E693, 2016.

Pulsatile tinnitus: contemporary assessment and management

PURPOSE OF REVIEW

Pulsatile tinnitus is an uncommon otologic symptom, which often presents a diagnostic and management dilemma to the otolaryngologist. The majority of patients with pulsatile tinnitus have a treatable cause. Failure to establish correct diagnosis may have disastrous consequences, because a potentially life-threatening, underlying disorder may be present. The purpose of this review is to familiarize the otolaryngologist with the most common causes, evaluation, and management of pulsatile tinnitus.

RECENT FINDINGS

The pathophysiology, classification, various causes, evaluation, and management of the most common causes of pulsatile tinnitus are presented in this review.

SUMMARY

Pulsatile tinnitus deserves a thorough evaluation and, in the majority of cases, there is a treatable underlying cause. The possibility of a life-threatening cause needs to be ruled out in every patient with pulsatile tinnitus. The otolaryngologist should be familiar with the evaluation and management of this symptom.

Pulsatile tinnitus arising from aberrant internal carotid artery at nasopharynx

Pulsatile tinnitus arising from an aberrant internal carotid artery at the level of the nasopharynx is rarely found. We present a case of a 74-year-old woman complaining of pulsatile tinnitus in the right ear. The tinnitus was not audible by auscultation. Endoscopic examination revealed pulsating swelling of the nasopharyngeal wall on the right side. Computed tomography angiography of the head and neck region showed medial and superficial transposition of the right internal carotid artery at the level of the nasopharynx. The artery was located right next to the orifice of the Eustachian tube and coursed along the distal portion of the tube. The patient's perception of tinnitus was improved after explaining the cause of the tinnitus and reassuring her about the-condition.