Pulsatile Tinnitus Due to a Large Mastoid Emissary Vein: Successfully Managed with Percutaneous Embolization in a Novel Approach.

Tinnitus refers to the perception of sound without any external stimuli which can be pulsatile or non-pulsatile. Dilated mastoid emissary vein (MEV) can cause pulsatile tinnitus. Herein, we report a case of persistent pulsatile tinnitus with dilated MEV managed successfully with percutaneous coiling of MEV in a 36 years male.

Persistent Stapedial Artery in Adhesive Otitis Media: A Case Report.

A persistent stapedial artery (PSA) is a rare embryologic remnant that typically involutes at week 10 of embryogenesis. However, if it is persistent, it may lead to conductive hearing loss and pulsatile tinnitus. It is of utmost importance to identify such an anomaly, as it leads to serious complications intraoperatively if overlooked. Proper clinical and radiological assessment helps an otologist recognize the PSA. We describe the case of a 24-year-old female presenting with a chronically discharging ear in addition to pulsatile tinnitus and conductive hearing loss with an incidental finding of a PSA upon otoscopy.

Interactive effect of hemodynamics in transverse sigmoid sinus and bone morphology on venous pulsatile tinnitus: a four-dimensional (4D) flow magnetic resonance imaging (MRI) study.

Background: The hemodynamic pathogenesis of venous pulsatile tinnitus (VPT) is still unclear. This study aimed to explore the mechanism of bone morphology and hemodynamic changes in transverse sigmoid sinus (TSS) on VPT patients. Methods: 49 patients with unilateral VPT, 26 patients with subjective tinnitus and 36 healthy controls were included in this retrospective clinical trial. Four-dimensional (4D) flow magnetic resonance imaging (MRI) was used to evaluate the hemodynamics of the TSS. High-resolution computed tomography was used to assess the perivenous bone structures. All images were independently assessed for each participant by two trained neuroradiologists. Kolmogorov-Smirnov test was used to determine the normal distribution of the data. Chi-square test and nonparametric test were used to compare classified or continuous variables. Stepwise linear regression and mediation effect analysis was used to explore the relationship between bone dehiscence (BD), hemodynamic factors and VPT symptoms. Results: Peak velocity (P=0.001) and maximum energy loss (P=0.041) in VPT group were risk factors for the severity of tinnitus. Energy loss [indirect effect =0.692, P<0.005, 95% confidence interval (CI): 0.201-1.377] and peak velocity (indirect effect =0.899, P<0.005, 95% CI: 0.406-1.582) demonstrated the complete mediation effect between the BD and VPT. BD showed a complete mediation effect between the wall shear stress (WSS) and VPT (indirect effect =15.181, P<0.005, 95% CI: 3.448-35.493). Conclusions: Cross-talk between the hemodynamic changes of TSS and BD can regulate the VPT symptoms. This type of analysis might be helpful in establishing the possible occurrence and development mechanism of the hemodynamics and bone morphology of the VPT.

Novel technique utilizing polymethylmethacrylate cement for the treatment of pulsatile tinnitus caused by different sigmoid sinus pathologies.

PURPOSE: Sigmoid sinus anomalies such as dehiscence or diverticula may present with pulsatile tinnitus (PT) and low-frequency hearing loss. Occasionally, these symptoms are severe, necessitating resurfacing of the affected area to restore a normal-appearing sinus wall. This study describes three cases wherein we managed PT attributed to sigmoid sinus anomalies using polymethylmethacrylate (PMMA) bone cement, a novel material. METHODS: Three patients with PT without any history of illnesses initially underwent cortical mastoidectomy to expose the affected area and resurface the sinus wall. Subsequently, PMMA bone cement was used to reconstruct any bony defects causing PT symptoms. Viscosity of the bone cement was altered based on specific characteristics and causes of the affected area. Additionally, we performed the water occlusion test (WOT), audiological assessment, the Tinnitus Handicap Inventory score (THI), and temporal computed tomography, both pre- and postoperatively, to assess the extent of PT. RESULTS: Preoperatively, all three patients had tinnitus that dissipated with pressure on the neck and the water occlusion test (WOT), with no reported vertigo, trauma, or ear infections. Moreover, all three cases had a severe handicap according to the THI. In contrast, all cases had reduced PT and a significantly decreased THI score postoperatively, as well as no recurrence or complications and no instances of increased intracranial hypertension at the 12-month follow-up. CONCLUSION: All cases showed promising results, emphasizing the sustained benefits of this novel intervention for the management of PT.

[Surgical technique and effect of the pulsatile tinnitus associated with sigmoid sinus on the dominant side of reflux].

Objective:To explore the effect of surgical treatment of the pulsatile tinnitus associated with sigmoid sinus on the dominant side of reflux. Methods:The clinical data of 43 patients with reflux dominant side pulsating tinnitus admitted by the same doctor from 2017 to 2023 were retrospectively studied to observe the curative effect of surgical treatment. Operation method: The sound insulation barrier was established by repair technique of bone wall defect of sigmoid sinus with "capping method", without changing the blood flow and blood vessel wall of sigmoid sinus. Results:No surgical complications occurred in all patients. During the follow-up period of 3 months to 6.9 years, 14 patients（32.6%） were cured, 18 patients（41.9%） were significantly effective, 4 patients（9.3%） were effective, and 7 patients（16.3%） were ineffective. The difference of tinnitus grade before and after surgery was statistically significant. Conclusion:In this group of cases, the sound insulation barrier was established by "capping method" technique of repairing bone wall defect of sigmoid sinus, which effectively avoided the disturbance of hemorheology status and vascular wall, thus avoiding the risk of venous wall stenosis and thrombosis on the dominant reflux side. The surgical method was easy to master, and the curative effect was significant, which was worthy of clinical promotion.

What should otolaryngologists know about dural venous sinus stenting?

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.

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.

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.

Pulsatile Tinnitus: Differential Diagnosis and Approach to Management.

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

Foundations of the Diagnosis and Management of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus.

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.

Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus.

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.

Future Directions and Innovations in Venous Sinus Stenting.

This review explores the future role of venous sinus stenting (VSS) in the management of idiopathic intracranial hypertension and pulsatile tinnitus. Despite its favorable safety profile and clinical outcomes compared with traditional treatments, VSS is not yet the standard of care for these conditions, lacking high-level evidence data and guidelines for patient selection and indications. Current and recently completed clinical trials are expected to provide data to support the adoption of VSS as a primary treatment option. Additionally, VSS shows potential in treating other conditions, such as dural arteriovenous fistula and cerebral venous sinus thrombosis, and it is likely that the procedure will continue to see an expansion of its approved indications. The current lack of dedicated venous stenting technology is being addressed with promising advancements, which may improve procedural ease and patient outcomes. VSS also offers potential for expansion into modulation of brain electrophysiology via endovascular routes, offering exciting possibilities for neurodiagnostics and treatment of neurodegenerative disorders.

Surgical Management of Pulsatile Tinnitus due to Sigmoid Sinus Diverticulum and Dehiscence - A Technical Note.

Pulsatile tinnitus (PT) is the perception of an auditory sensation without an external source and in synchrony with the heartbeat. One of the most common cases of PT is bony anomalies of the sigmoid sinus, including dehiscence or diverticula. This case report describes a 26-year-old female patient who presented with pulsatile tinnitus caused by sigmoid sinus diverticula and dehiscence, which was successfully treated with cortical mastoidectomy with diverticula closure using pedicled temporalis fascia and resurfacing of the dehiscence with autogenous bone pate along with bone cement. We recommend thorough clinical and radiological workup to rule out other possible causes of PT before surgical intervention. In addition, we would like to highlight the surgical technique using pedicled temporalis fascia that we have used in our patient, which is easily reproducible and offers successful outcomes.

Hemodynamic assessments of unilateral pulsatile tinnitus with jugular bulb wall dehiscence using 4D flow magnetic resonance imaging.

Background: Pulsatile tinnitus (PT) is a type of tinnitus characterized by a rhythmic sound that is synchronous with the heartbeat. One of the possible causes of PT is the jugular bulb wall dehiscence (JBWD). However, the hemodynamics of this condition are not well understood. To elucidate this issue, the present study aimed to compare the blood flow of PT patients with JBWD, PT patients with sigmoid sinus wall dehiscence (SSWD), and volunteers. Methods: A retrospective case-control study was conducted, which enrolled patients with unilateral PT who had undergone both computed tomography angiography (CTA) and four-dimensional (4D) flow magnetic resonance imaging (MRI) examinations at the Department of Otolaryngology-Head and Neck Surgery of Beijing Friendship Hospital affiliated to Capital Medical University between January 2019 and July 2023. After excluding the possible causes of PT, the patients were divided into the JBWD group and SSWD group according to the presence or absence of JBWD and/or SSWD. Finally, 11 female unilateral PT patients with JBWD (JBWD group, 11sides), 22 age- and side-matched female patients with SSWD (SSWD group, 22 sides), and 22 age-matched female volunteers (volunteer group, 36 sides) were enrolled. The area, maximum voxel velocity (Vv-max), maximum velocity (Vmax), average velocity (Vavg), and average blood flow rate (Q) were measured in the transverse sinuses (TSs), sigmoid sinuses (SSs), and jugular bulb (JB). The vortex flow pattern was also assessed. Fisher's exact test and Bonferroni correction were used for count data, with P<0.017 was considered statistically significant. Shapiro-Wilk test, one-way analysis of variance (ANOVA), Kruskal-Wallis H test, paired-samples t-test, and Wilcoxon matched-pairs signed-rank test were used for continuous variables depending on the distribution and variance of the data. The P<0.05 and corrected P<0.05 was considered statistically significant. Results: The area and Q of TSs and JB on the symptomatic side were higher than those on the contralateral side in the JBWD group (TSs: Parea=0.004, Pflow=0.002; JB: Parea=0.034, Pflow=0.018). The area was larger and velocities were lower in the JBWD group at the TSs than the SSWD group (Parea=0.004, PVv-max=0.009, PVmax=0.021, PVavg=0.026), and velocities were higher at the distal TSs and SSs than the volunteer group (TSs: PVv-max=0.042, PVmax=0.046, PVavg=0.040; SSs: PVv-max=0.007, PVmax=0.001, PVavg=0.001). At the JB, the JBWD group also had higher Vv-max than the volunteer group (P=0.012). The occurrence rate of vortex at JB in the JBWD group was higher than both the JBWD and the volunteer groups (P=0.002<0.017 and P=0.009<0.017, respectively). Conclusions: The blood flow of the intracranial venous sinus was different between the JBWD group and the SSWD group. The indicators that can differentiate include Vv-max, Vmax, Vavg, vortex, and TSs cross-sectional area.

Fluid-structure interaction study on the causes of mending material damage after sigmoid sinus wall reconstruction.

BACKGROUND AND OBJECTIVE: Sigmoid Sinus (SS) Wall Reconstruction (SSWR) is the mainstream treatment for pulsatile tinnitus (PT), but it has a high risk of recurrence. The damage of mending material is the key cause of recurrence, and its hemodynamic mechanism is still unclear. The purpose of this study was to investigate the hemodynamic causes of mending material breakage. METHODS: In this study, six patient-specific geometric models were reconstructed based on the data of the computed tomography angiography (CTA). The transient fluid-structure coupling method was performed to clarify the hemodynamic state of sigmoid sinus and the biomechanical state of the mending material. The distribution of stress and displacement and the flow pattern were calculated to evaluate the hemodynamic and biomechanics difference at the mending material area. RESULTS: The area of blood flow impact in some patients (2/6) was consistent with the damaged location of the mending material. The average stress (6/6) and average displacement (6/6) of damaged mending material were higher than those of complete mending material. All (6/6) patients showed that the high-stress and high-displacement proportion of the DMM region was higher than that of the CMM region. Moreover, the average stress fluctuation (6/6) and average displacement (6/6) fluctuation degree of damaged mending material is larger than that of complete mending material. CONCLUSIONS: The impact of blood and the uneven stress and displacement fluctuation of the mending material may be the causes of mending material damage. High stress and high displacement might be the key causes of the mending material damage.

Glomus tympanicum removal using transcanal endoscopic assisted surgery: An experience with six cases.

Objective: To evaluate an endoscopic approach in the management of glomus tumor, and also to investigate and evaluate its appropriateness and feasibility. Methods: Glomus tumors, also known as paragangliomas, are benign primary tumors of the middle ear. The advent of endoscopic ear surgery has provided new dimensions to the management of this highly vascular tumor. Retrospective analysis of six patients of glomus tympanicum, operated between July 2014 and June 2019, with modified Fisch classification Type A and B1, who were managed by a retroauricular transcanal endoscopic approach. Preoperative and postoperative analysis was done for these patients. Results: The chief complaint was pulsatile tinnitus, which disappeared in five cases and reduced in severity in one of them. Hearing was improved with reduction in air-bone gap in all the cases. No major complications or recurrence were observed in any of the patients after 12 months of follow-up. Conclusion: This endoscopic approach serves as a safe and reliable technique for tumor removal. It thus provides postoperative comfort for most of the patients.

ACR Appropriateness Criteria® Tinnitus: 2023 Update.

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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

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

Case report: Novel transtemporal transverse sinus decompression surgery to alleviate transverse sinus stenosis in a pulsatile tinnitus patient with restricted bilateral venous outflow.

Transverse sinus (TS) stenosis is common in individuals with venous pulsatile tinnitus (PT). While PT can be addressed by endoluminal or extraluminal methods, the former has shown promise in alleviating symptoms associated with increased intracranial pressure. This study explores the potential of extraluminal methods to alleviate TS stenosis and eliminate PT caused by sigmoid sinus diverticulum. A 31-year-old male patient presenting with left-sided PT, attributed to a large, pedunculated sigmoid sinus diverticulum along with severe ipsilateral TS stenosis and contralateral TS hypoplasia, underwent ipsilateral extraluminal TS decompression surgery following sigmoid sinus wall reconstruction under local anesthesia. Postoperative CT and MR angiography revealed a significant increase in the TS lumen from 0.269 to 0.42 cm2 (56.02%) 2 years after surgery. Cervical Doppler ultrasound demonstrated a 36.07% increase in ipsilateral outflow volume to 16.6 g/s and a 77.63% increase in contralateral outflow volume to 1.35 g/s. In conclusion, this pioneering study showcases the potential of transtemporal TS decompression surgery in creating space for adaptive expansion of the TS lumen. However, the procedure should be reserved for individuals with severely compromised venous return.

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.