HSC Section 8_April 2017

G. Madani, S.E.J. Connor

Reported incidence of structural abnormalities in patients investigated for all causes of pulsatile tinnitus

Table 1

Waldvogel 4

Sonmez 5

Remley 6

Krishnan 7

Dietz 8

Sismanis 9

Author

Total no. of patients (Percentage with objective tinnitus)

84 (42%)

74 (15%)

100 (25%)

16 (6%)

49 (33%)

145 (8%)

Investigations a Ultrasound

68 26 33

12 72

Not stated

Computed tomography

69 24

10 49 49 17

Magnetic resonance imaging Magnetic resonance angiography

7 7 5

7

Selective angiography

46

68

CTA/V

16

Cause found

57 (68%)

50 (68%)

80 (80%)

7 (44%)

28 (57%)

132 (91%)

Vascular anomaly

Aberrant ICA

1 (1%) 3 (4%)

8 (8%) 5 (5%) 7 (7%) 1 (1%) 1 (1%)

Dehiscent jugular bulb High-riding jugular bulb

1 (2%)

21 (28%)

1 (6%) 1 (6%)

JB/transverse sinus diverticulum Enlarged cortical draining vein

1 (1%)

2 (4%) 1 (2%)

Vascular loop

1 (1%)

1 (1%) 6 (4%)

Vascular tortuosity

Dominant venous system b

6 (38%)

Acquired vasculopathy Dural AVF

17 (20%)

2 (3%)

15 (15%)

3(%)

Pial AVF

9 (18%) 1 (2%)

Carotico-cavernous fistula Atheromatous ICA disease Fibromuscular dysplasia

6 (7%) 7 (8%) 5 (6%) 1 (1%)

16 (22%)

5 (5%) 4 (4%) 2 (2%) 1 (1%)

2 (4%)

ICA aneurysm ICA dissection

3 (4%)

2 (1%)

Extracranial AVF/M

1 (2%) 1 (2%)

1 (1%)

Venous sinus thrombosis

1 (1%)

Tumour Paraganglioma

5 (6%) 1 (1%) 1 (1%)

2 (3%)

25(25% 2 (2%) 2 (2%)

17 (12%)

Meningioma

5 (10%)

Other

1 (1%)

1 (1%)

56 c (39%)

Idiopathic intracranial hypertension

4 (5%)

2 (4%)

Venous sinus stenosis

1 (1%)

1 (6%)

Other Otospongiosis

4 (3%) 1 (1%) 10 (8%)

Myoclonus

Systemic causes

1 (1%)

No aetiology found in patients with objective tinnitus (%)

7 (8%)

0

0

Not stated 0

Not stated

CTA/V, computed tomography angiography/venography; ICA, internal carotid artery; AVF, arteriovenous fistulae. a Some patients underwent multiple investigations. b Association with the venous sinus dominance is speculative. c Four other patients had radiographic features of idiopathic intracranial hypertension but declined lumbar puncture.

Various imaging strategies have been proposed for the investigation of PT in the otoscopically normal patient and they continue to evolve. MRI (with gadolinium), MR angiography (MRA), MR venogra- phy (MRV), carotid ultrasound, CT with and without contrast medium, and conventional angiography have all been used rather inconsistently in

previous patient series. Combined CT angiography and venography (CTA/V) may be performed with 100 ml contrast medium injected at 3 e 4 ml/s and a fixed delay of 25 s using contemporary multisec- tion CT. This approach shows considerable promise and has the advantage of demonstrating arterial, venous, skull-base, and middle-ear disease entities

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