FLEX January 2024

10976817, 2019, 5, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599818823205 by National Institutes Of Health, Wiley Online Library on [12/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Liu et al

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Figure 4. PRISMA flowchart of article search in PubMed, Embase, and Cochrane Database and study selection. PT, pulsatile tinnitus.

surgery. 8,26,27 In 1 case, the PT associated with ICA dehis cence may have gradually started returning since postopera tive day 10. 8 Resurfacing outcomes were also stratified by the source and density of the resurfacing materials used ( Table 2 ). Regarding material source, 83 resurfacing cases used autolo gous materials only; 9 used artificial materials only; and 48 used a combination. Two studies reported resurfacing cases with artificial (bone cement) and autologous (temporalis fascia) material. 4,25 Three studies reported mixed resurfa cing cases with artificial materials in some cases and autolo gous materials in others. 7,8,26 These 3 studies were analyzed by individual case data to assess outcomes by the source of material used. Regarding material density, 132 (94%) resur facing cases used hard materials, and 8 (6%) used soft materials. Because different vascular sources (eg, ICA, jugular bulb, and sigmoid sinus) may cause PT by different patho physiologic mechanisms, we describe resurfacing outcomes for each vascular source separately. Arterial Wall Anomalies or Aberrancy Five included studies reported a total of 5 resurfacing cases and 1 conceptually similar case involving pushing an

the tympanic membrane, which prompted investigation of a dehiscent high-riding jugular bulb without preoperative ima ging ( Table 1 ). In assessing risk of bias, 7 studies were assessed as low risk 5,8,14,24-27 and 13 as high risk 4,6,7,9,10,22,28-34 for selec tive outcome reporting. For incomplete outcome data, 8 studies were assessed as low risk 6-8,14,24-26,33 and 4 as high risk, 4,5,27,30 and 8 studies could not be assessed because they reported only 1 case 9,10,22,28,29,31,32,34 (Supplemental Table S1, available in the online version of the article). A total of 141 resurfacing cases involving 138 patients were included. Among cases performed, 39 were on the left ear and 75 on the right ear, and 27 were not specified by 1 study. 24 For patient sex, 21 were male and 117 were female. Among the patients undergoing resurfacing procedures, there was a significant association of right-sidedness (66%, P \ .001) and female sex (85%, P \ .001) with PT. Patient age ranged from 8 to 86 years; the mean was 44.8 years. Mean follow-up was 18.5 months ( Table 1 ). Resurfacing outcomes for the 141 cases included 106 (75%) with complete resolution, 15 (11%) with partial reso lution, 19 (13%) with no resolution, and 1 (1%) with wor sened PT. Among cases with partial resolution, recurrent PT was noted in 4 cases between 3 months and 4.5 years after