Clinical presentation and imaging findings in patients with pulsatile tinnitus and sigmoid sinus diverticulum/dehiscence.

OBJECTIVE: Sigmoid sinus diverticulum/dehiscence (SSDD) is an increasingly recognized venous cause for pulsatile tinnitus (PT). SSDD is amenable to surgical/endovascular intervention. We aim to understand the clinical and imaging features of patients with PT due to SSDD. STUDY DESIGN: Retrospective CT study and chart review. SETTING: Tertiary-care, academic center. PATIENTS: Cohort 1: 200 consecutive unique temporal bone CT were blindly reviewed for anatomic findings associated with PT. Cohort 2: 61 patients with PT were evaluated for otologic manifestations. INTERVENTION(S): All patients underwent a temporal bone CT for evaluation of PT. Clinical information was gathered using electronic medical records. MAIN OUTCOME MEASURE(S): Otologic symptoms and physical findings (including body mass index (BMI), mastoid/neck bruits) were analyzed. Temporal bone CT scans were evaluated for the presence of SSDD and other possible causes of PT. RESULTS: Cohort 1: 35 cases of SSDD were identified (18%); 10 (29%) true diverticula; and 25 (71%) dehiscence. Sixty-six percent were right sided. Twelve patients had PT (34%). Patients with SSDD are more likely to have PT (p = 0.003). A significant association between right SSDD and PT was found (p = 0.001). Cohort 2: 15 out of 61 patients had PT and CT-confirmed SSDD. All were female subjects; average age was 45 years (26-73 yr). Radiologic evaluation revealed 10 SSDD cases on the right (66.7%), 2 on the left (13.3%%), and 3 bilateral (20%). Sensorineural hearing loss was seen in 8 (53%), aural fullness in 12 (80%). Average BMI was 32.2 (21.0-59.82), and 4 (26%) had audible mastoid bruits. CONCLUSION: SSDD may be the most common identifiable cause for PT from venous origin and is potentially treatable. Temporal bone CT scans should be included in a complete evaluation of PT.

saline-infused sonohysterography: tips for achieving greater success.

Saline-infused sonohysterography (SIS) may help improve visualization of the endometrium and endometrial cavity and assess tubal patency. Although most SIS procedures are straightforward, a variety of pitfalls may lead to an unsuccessful procedure or incomplete evaluation. SIS should be scheduled between days 4 and 10 of the patient's menstrual cycle, when the endometrium is at its thinnest, and physiologic changes during the secretory phase are not present. Performing preprocedure imaging serves many purposes, such as depicting hydrosalpinx, causes of uterine and adnexal tenderness, and pelvic inflammatory disease, as well as assessing the size and position of the uterus and the orientation of the cervix. It is important not to presume that fibroids are the cause of bleeding when the endometrium is obscured at preprocedure imaging. Obstacles to a successful procedure include issues related to patient anxiety and discomfort, which may be prevented or minimized at almost every step of the procedure. Inability to obtain access to the cervix is the most common cause of unsuccessful SIS; proper patient positioning in a semi-upright lithotomy position is important. Injection of air during any US-guided procedure may lead to shadowing that obscures the region of interest. Adequate distention of the endometrial cavity is crucial for successful SIS, and optimal positioning of the distended balloon may improve the degree of distention. However, poor distention may be indicative of an underlying pathologic condition. Knowledge of these pitfalls and the strategies to overcome them may prevent premature or unnecessary termination of an otherwise successful study.