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Pulsatile Tinnitus With Imaging

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 40s presented with right pulsatile tinnitus. She reported constant pulsatile tinnitus with a whooshing quality for 4 years. Factors exacerbating her symptoms included holding her breath and turning her head to the left. She reported that compression of her right neck and turning her head to the right decreased the loudness of the tinnitus. She had not experienced hypertension, vertigo, sleep apnea, hyperthyroidism, hearing loss, head trauma, history of ear infections, otorrhea, rhinorrhea, ear surgery, or family history of ear problems. The external auditory canals were clear bilaterally. Tympanic membranes were intact and mobile bilaterally. There was no evidence of any vascular masses in the middle ear space. Results from testing with tuning forks were normal. Toynbee stethoscope revealed a bruit in the right ear that could be stopped with gentle compression of the right side of the neck. An audiogram showed hearing within normal limits with slight air-bone gaps present at 250, 1000, and 3000 Hz on the right and within normal limits on the left. Speech reception threshold on the right was 10 dB with a word recognition score of 100% bilaterally. The tympanogram result revealed type A bilaterally, and acoustic reflexes were all present. A computed tomographic (CT) temporal bone scan was completed (Figure 1).

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C. Sigmoid sinus diverticulum

Sigmoid sinus diverticulum (SSD) was demonstrated on imaging and was the cause of the patient’s pulsatile tinnitus. Two distinctive diverticula were demonstrated on high-resolution CT temporal bone scan: anterior (Figure 1, A) and superior (Figure 1, B). The other diagnoses listed in the quiz are not correct because gentle neck pressure would not resolve the tinnitus in these conditions. These other diagnoses were also ruled out given the lack CT imaging evidence and classic clinical signs and symptoms expressed by the patient.

Sigmoid sinus diverticulum was first reported as a cause of pulsatile tinnitus and successfully treated with endovascular coiling in 2000 by Houdart et al.1 Tinnitus is the perception of sound or noise without external source. It can be divided into 2 categories: pulsatile and nonpulsatile. Pulsatile tinnitus has a distinct differential diagnosis, which includes the following: persistent stapedial artery, aberrant internal carotid artery, carotid cochlear dehiscence, intracranial and/or dural arteriovenous fistula, intracranial vascular stenosis, idiopathic intracranial hypertension, jugular diverticulum, and superior semicircular canal dehisence.24

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Article Information

Corresponding Author: Carl M. Truesdale, MD, Department of Otolaryngology–Head and Neck Surgery, University of Michigan, 1500 E Medical Center Dr, 1903 Taubman Center-SPC 5312, Ann Arbor, MI 48109 (ctruesda@med.umich.edu).

Published Online: March 29, 2018. doi:10.1001/jamaoto.2018.0014

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

References
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2.
Koesling  S, Kunkel  P, Schul  T.  Vascular anomalies, sutures and small canals of the temporal bone on axial CT.  Eur J Radiol. 2005;54(3):335-343.PubMedGoogle ScholarCrossref
3.
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El Refaie  A, Davis  A, Kayan  A, Baskill  J, Lovell  E, Owen  V.  A questionnaire study of the quality of life and quality of family life of individuals complaining of tinnitus pre- and post-attendance at a tinnitus clinic.  Int J Audiol. 2004;43(7):410-416.PubMedGoogle ScholarCrossref
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Schoeff  S, Nicholas  B, Mukherjee  S, Kesser  BW.  Imaging prevalence of sigmoid sinus dehiscence among patients with and without pulsatile tinnitus.  Otolaryngol Head Neck Surg. 2014;150(5):841-846.PubMedGoogle ScholarCrossref
8.
Otto  KJ, Hudgins  PA, Abdelkafy  W, Mattox  DE.  Sigmoid sinus diverticulum.  Otol Neurotol. 2007;28(1):48-53.PubMedGoogle ScholarCrossref
9.
Eisenman  DJ.  Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence.  Otol Neurotol. 2011;32(7):1116-1119.PubMedGoogle ScholarCrossref
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Wang  AC, Nelson  AN, Pino  C, Svider  PF, Hong  RS, Chan  E.  Management of sigmoid sinus associated pulsatile tinnitus.  Otol Neurotol. 2017;38(10):1390-1396.PubMedGoogle ScholarCrossref
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