FLEX January 2024

Clinical Review & Education Review

Diagnostic Approach to Pulsatile Tinnitus

Figure 2. Intracochlear Schwannoma

Figure 3. Fibromuscular Dysplasia

Axial view of left cochlea A

Time-resolved MRA of carotid arteries A

Anteriogram of left carotid artery B

Coronal view of left cochlea B

Anteriogram of right carotid artery

Anteriogram of the right kidney artery D

C

Axial view of left cochlear mass C

Behavioral treatments including cognitive behavior therapy and tinnitus retraining therapy are effective treatments for tinni tus not resolved or adequately treated by pharmacologic, inter ventional, or surgical methods. 16 Transcranial magnetic stimula tion may have a role in tinnitus suppression, but additional trials are needed to demonstrate long-term reproducible efficacy. 17,18 Vascular Causes of PT Arterial causes of PT have characteristic features in the history, physi cal examination, and imaging approach outlined above. Arterial causes of PT include carotid artery stenosis, dissection, fibromuscular dyspla sia, aneurysm, aberrant internal carotid artery, and arteriovenous fis tula (AVF). The presence of a carotid bruit on neck auscultation typically A middle-aged woman with right-sided pulsatile tinnitus without exacerbating or mitigating factors and history of hypertension. A, Coronal time-resolved contrast-enhanced (TRICKS) head and neck magnetic resonance imaging (MRI) demonstrates a “beaded” appearance (arrowheads) of the cervical segments of both internal carotid arteries. B, Left internal carotid arteriogram in frontal projection demonstrates beaded appearance (arrowhead) of the upper cervical segment of the left internal carotid artery. C, Right common carotid arteriogram demonstrates beaded appearance (arrowhead) of the cervical segment of the right internal carotid artery. D, Right kidney arteriogram demonstrates beaded appearance (arrowhead) of the mid and distal segments of the renal artery. Renal artery angioplasty can mitigate pulsatile tinnitus by decreasing the pulse pressure.

Audiometry results D

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Left-sided pulse synchronous pulsatile tinnitus without exacerbating or mitigating factors, as well as left-sided hearing loss. A, Axial T1-weighted enhanced spin-echo (CUBE) magnetic resonance imaging (MRI) with fat saturation demonstrates punctate focus of enhancement (arrowhead) in the left cochlea. B, Coronal T1-weighted enhanced 3D fast spin-echo (CUBE) MRI with fat saturation demonstrates punctate focus of enhancement (arrowhead) in the left cochlea. C, Axial balanced steady state free precession (bSSFP; FIESTA) MRI demonstrates left cochlear mass (arrowhead). D, Audiometry results demonstrate high-frequency sensorineural hearing loss on the left (arrowhead).

480 JAMA Otolaryngology–Head & Neck Surgery May 2022 Volume 148, Number 5 (Reprinted)

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