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Hsieh YL, Gao X, Chen X, Wang S, Wang W. Resurfacing Dehiscence(s) Without Reducing Diverticulum Effectively Silences Pulsatile Tinnitus: Novel Surgical Techniques for Diverticulum and Intraoperative Microphone Monitoring. Otol Neurotol 2024; 45:154-162. [PMID: 38152047 DOI: 10.1097/mao.0000000000004075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To emphasize the surgical importance of addressing dehiscence over diverticulum in resolving pulsatile tinnitus (PT) in patients with sigmoid sinus wall anomalies (SSWAs) and investigate anatomical differences. STUDY DESIGN Retrospective data analysis. SETTING Multi-institutional tertiary university medical centers. PATIENTS Fifty participants (dehiscence/diverticulum, 29:21 cases) with SSWA-associated PT were included in the study. All 21 diverticulum participants underwent surgical intervention. INTERVENTIONS 1) Surgical intervention with novel techniques monitored by intraoperative microphone. 2) Radiologic and ophthalmologic imaging methods. MAIN OUTCOME MEASURES Quantitative and qualitative preoperative and postoperative alterations of PT and anatomical differences between dehiscence and diverticulum. RESULTS Addressing dehiscence overlying diverticulum and sigmoid sinus wall dehiscences significantly reduced visual analog score and Tinnitus Handicap Inventory ( p < 0.01). Sinus wall reconstruction led to substantial PT sound intensity reduction in the frequency range of 20 to 1000 Hz and 20 to 500 Hz (paired-sample t test, p < 0.01). Diploic vein analysis showed a significant positive correlation in 85.7% of the diverticulum cohort compared with the dehiscence cohort ( p < 0.01). Eight percent of the participants exhibited papilledema, which was limited to the dehiscence cohort. CONCLUSION 1) Effective reduction of PT can be achieved by addressing all dehiscences, including those overlying the diverticulum, without the need to exclude the diverticulum. 2) Diploic vein may involve in the formation of diverticulum, and loss of dura mater and vascular wall thickness are observed at the SSWA locations.
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Affiliation(s)
- Yue-Lin Hsieh
- ENT Institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University
| | - Xiuli Gao
- Department of Radiology, Eye & ENT Hospital, Fudan University
| | - Xi Chen
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shenjiang Wang
- Department of Radiology, Eye & ENT Hospital, Fudan University
| | - Wuqing Wang
- ENT Institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University
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Hsieh YL, Zuo B, Shi Y, Wang S, Wang W. Dynamics of cerebrospinal fluid pressure alterations and bilateral transverse-sigmoid sinus morphologies in Asian patients with venous pulsatile tinnitus. J Int Med Res 2023; 51:3000605231187949. [PMID: 37548322 PMCID: PMC10408352 DOI: 10.1177/03000605231187949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/21/2023] [Indexed: 08/08/2023] Open
Abstract
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.
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Affiliation(s)
- Yue-Lin Hsieh
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, China
| | - Bo Zuo
- Department of Neurology, Shanghai Xuhui District Central Hospital, Fudan University, Shanghai, 200031, China
| | - Yanhui Shi
- Department of Neurology, Shanghai Xuhui District Central Hospital, Fudan University, Shanghai, 200031, China
| | - Shenjiang Wang
- Department of Radiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, China
| | - Wuqing Wang
- ENT institute and Department of Otorhinolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, China
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Hsieh YL, Wang S, Wang W. Case Report: Venous pulsatile tinnitus induced by enlarged oblique occipital sinus and resultant diverticulum/dehiscence of the sigmoid-jugular wall. Front Surg 2023; 9:1014649. [PMID: 36684374 PMCID: PMC9852330 DOI: 10.3389/fsurg.2022.1014649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 01/09/2023] Open
Abstract
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 (Vmn) and flow volume (FVOL) 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.
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Affiliation(s)
- Yue-Lin Hsieh
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China,Key Laboratory of Hearing Science, Ministry of Health, Shanghai, China
| | - Shenjiang Wang
- Department of Radiology, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
| | - Wuqing Wang
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China,Key Laboratory of Hearing Science, Ministry of Health, Shanghai, China,Correspondence: Wuqing Wang
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Hong Z, Liu X, Ding H, Zhao P, Gong S, Wang Z, Ghista D, Fan J. Flow patterns in the venous sinus of pulsatile tinnitus patients with transverse sinus stenosis and underlying vortical flow as a causative factor. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 227:107203. [PMID: 36370596 DOI: 10.1016/j.cmpb.2022.107203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Transverse sinus stenosis (TSS) is commonly found in Pulsatile Tinnitus (PT) patients. Vortex flow is prominent in venous sinus with stenosis, and so it is important to determine the distribution and strength of the vortical flow to understand its influence on the occurrence of PT. METHODS In this study, by using computational fluid dynamics for hemodynamic analysis in patient-specific geometries based on Magnetic Resonance Imaging (MRI), we have investigated the blood flow within the venous sinus of 16 subjects with PT. We have employed both laminar and turbulent flow models for simulations, to obtain (i) streamlines of velocity distribution in the venous sinus, and (ii) pressure distributions of flow patterns in the venous sinus. Then, hemodynamic analysis in the venous sinus recirculation zone was carried out, to determine the flow patterns at the junction of transverse sinuses and sigmoid sinuses. Finally, we have proposed a new model for turbulence evaluation based on the regression analysis of anatomic and hemodynamics parameters. RESULTS Correlation analysis between the anatomical parameters and the hemodynamic parameters has shown that stenosis at the transverse sinus was the main factor in the local hemodynamics variation in the venous sinus of patients; in this context, it is shown that vorticity can be used as a prime indicator of the severity of the stenosis function. Our results have shown a significant correlation between the vorticity and the stenotic maximum velocity (SMV) (r = 0.282, p = 0.004). Then, a parameterized prediction model is proposed to determine the vorticity in terms of flow and anatomic variables, termed as the turbulence eddy prediction model (TEP model). Our result have shown that the TEP model is sensitive to the dominant flow distribution, with a high correlation to the flow-based vorticity (r = 0.809, p = 0.009). CONCLUSIONS The quantification of the vorticity (as both vorticity and MVV) in the downstream of TSS could be a marker for indication of turbulent energy at the transverse-sigmoid sinus, which could potentially serve as a hemodynamic marker for the functional assessment of the PT-related TSS.
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Affiliation(s)
- Zhenxin Hong
- Foshan University, #18 Jiangwan 1st Road Foshan, Guangdong 528000, China
| | - Xin Liu
- Foshan University, #18 Jiangwan 1st Road Foshan, Guangdong 528000, China; Guangdong Academy Research on VR Industry, Foshan University, #18 Jiangwan 1st Road Foshan, Guangdong 528000, China
| | - Heyu Ding
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yongan Road, Xicheng District, Beijing 100050, China
| | - Pengfei Zhao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yongan Road, Xicheng District, Beijing 100050, China
| | - Shusheng Gong
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, No. 95, Yongan Road, Xicheng District, Beijing 100050, China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yongan Road, Xicheng District, Beijing 100050, China.
| | | | - Jinsong Fan
- Foshan University, #18 Jiangwan 1st Road Foshan, Guangdong 528000, China.
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Wang X, Hsieh YL, Xu X, Wang W. 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. Front Bioeng Biotechnol 2022; 10:948230. [PMID: 36420442 PMCID: PMC9676680 DOI: 10.3389/fbioe.2022.948230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Xing Wang
- School of Mechanical and Automotive Engineering, Xiamen University of Technology, Xiamen, China
| | - Yue-Lin Hsieh
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Shanghai, China
| | - Xiaobing Xu
- Department of Radiology, Eye and ENT Hospital, Fudan University, China
| | - Wuqing Wang
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Shanghai, China
- *Correspondence: Wuqing Wang,
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Gao X, Hsieh YL, Wang S, Shi S, Wang W. Intracranial pressure, lateral sinus patency, and jugular ultrasound hemodynamics in patients with venous pulsatile tinnitus. Front Neurol 2022; 13:992416. [PMID: 36188386 PMCID: PMC9523694 DOI: 10.3389/fneur.2022.992416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Xiuli Gao
- Department of Radiology, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
| | - Yue-Lin Hsieh
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Shanghai, China
| | - Shenjiang Wang
- Department of Radiology, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
| | - Suming Shi
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Shanghai, China
| | - Wuqing Wang
- Department of Otology and Skull Base Surgery, Eye Ear Nose & Throat Hospital, Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Shanghai, China
- *Correspondence: Wuqing Wang
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