FLEX January 2024

Clinical Review & Education Review

Diagnostic Approach to Pulsatile Tinnitus

Endovascular treatment of the arterial causes of PT usually results in resolution of symptoms. Often, indications for treat ment of the arterial causes of PT include not only the disabling symptom itself, but prevention of ischemic or hemorrhagic stroke, which form a stronger evidence basis. Conclusions Pulsatile tinnitus can be a maddening symptom with debilitating psychiatric effects, and has myriad causes, some of which pose significant risk to neurologic, ocular, or otologic health. Organizing PT’s causes into structural, metabolic, and vas cular groups facilitates appropriate testing, referral, and treat ment. Nuanced medical history, physical examination, and imaging evaluation, as presented herein, can often lead to a reasonable diagnosis. A complete clinical evaluation of PT should include a detailed history, assessment of psychiatric effects, provocative maneuvers during physical examination, and MRI to assess for dangerous structural or vascular causes.

headaches, along with a relatively low complication and failure rate. 25,26 Arteriovenous fistulas are abnormal connections between arter ies and veins. Dural arteriovenous fistulas (dAVFs) are typically between dural arteries and a venous sinus, most commonly at the transverse sigmoid sinus, marginal sinus and/or condylar veins, cavernous sinus, or vertebral venous plexus. 27-30 Dural arteriovenous fistulas are some times associated with venous sinus thrombosis, which may occur fol lowing an infection, trauma, or surgery. A dAVF with cortical vein reflux carries a high-risk of intracranial hemorrhage, with high potential for death or permanent disability if untreated. Therefore, high-risk dAVF is the most dangerous possible underlying cause of PT and cannot be missed during the diagnostic evaluation. Spontaneous resolution of PT with development of a headache is an ominous clinical sign that may sig nify disease progression to venous sinus occlusion and cortical vein re flux. Endovascular treatment is first-line therapy for AVFs, as determined by cervicocerebral angiography. Arteriovenous malformations (AVMs) can rarely cause PT as well. Imaging evaluation of PT must include MRI with ASL and MRA sequences to evaluate for these dangerous causes ofPT.

ARTICLE INFORMATION Accepted for Publication: December 23, 2021. Published Online: February 24, 2022. doi:10.1001/jamaoto.2021.4470 Author Affiliations: Department of Radiology & Biomedical Imaging, University of California, San Francisco (Narsinh, Saloner, Rauschecker, Safoora, Shah, Amans); Department of Radiology & Radiological Science, Johns Hopkins University, Baltimore, Maryland (Hui); Department of Neurology, University of California, San Francisco (Tu-Chan, Meisel); Department of Otolaryngology, University of California, San Francisco (Sharon). Author Contributions: Drs Narsinh and Amans had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Narsinh, Hui, Saloner, Rauschecker, Safoora, Shah, Meisel, Amans. Acquisition, analysis, or interpretation of data: Narsinh, Saloner, Tu-Chan, Sharon, Rauschecker, Amans. Drafting of the manuscript: Narsinh, Safoora. Critical revision of the manuscript for important intellectual content: Narsinh, Hui, Saloner, Tu-Chan, Sharon, Rauschecker, Shah, Meisel, Amans. Obtained funding: Amans. Administrative, technical, or material support: Hui, Saloner, Rauschecker, Meisel. Supervision: Narsinh, Sharon, Rauschecker, Shah, Amans. Conflict of Interest Disclosures: DrSharon reported grants from Eli Lilly & Co, grants from Advanced Bionics, and consulting fees from Spiral Therapeutics outside the submitted work. Dr Rauschecker reported grants from RSNA outside the submitted work. Dr Amans reported grants from National Institutes of Health and grants from the Department of Defense during the conduct of the study; personal fees from Stryker Neurovascular; consultant fees, personal fees from Medtronic; consultant fees, personal fees from Microvention; consultant fees, personal fees from Mind Frame; stock options outside the submitted

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work; in addition, Dr Amans had a patent for System for Diagnosis of Pulsatile Tinnitus pending, a patent for Cerebral Blood Flow Reorganization pending, and a patent for Cerebral Venous Sinus Stent pending. No other disclosures were reported. Funding/Support: Dr Narsinh received funding support from NIH NIBIB 5R01EB012031. Dr Amans received funding support from NIH NHLBI R56HL149124 and DoD CDMRP W81XWH-21-1-0753. Role of the Funder/Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. REFERENCES 1 . Heller AJ. Classification and epidemiology of tinnitus. Otolaryngol Clin North Am . 2003;36(2): 239-248. doi:10.1016/S0030-6665(02)00160-3 2 . Bhatt JM, Lin HW, Bhattacharyya N. Prevalence, severity, exposures, and treatment patterns of tinnitus in the United States. JAMA Otolaryngol Head Neck Surg . 2016;142(10):959-965. doi:10. 1001/jamaoto.2016.1700 3 . Nondahl DM, Cruickshanks KJ, Wiley TL, Klein R, Klein BEK, Tweed TS. Prevalence and 5-year incidence of tinnitus among older adults: the epidemiology of hearing loss study. J Am Acad Audiol . 2002;13(6):323-331. doi:10.1055/s-0040-1715975 4 . Adams PF, Hendershot GE, Marano MA; Centers for Disease Control and Prevention/National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10 . 1999;(200):1-203. 5 . Salazar JW, Meisel K, Smith ER, Quiggle A, McCoy DB, Amans MR. Depression in patients with tinnitus: a systematic review. Otolaryngol Head NeckSurg . 2019;161(1):28-35. doi:10.1177/ 0194599819835178 6 . Valluru K, Parkhill J, Gautam A, et al. Sound measurement in patient-specific 3D printed bench

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