BACKGROUND: Pulsatile tinnitus (PT) is a debilitating condition with substantial morbidity related to quality of life. Cerebral venous sinus stenosis has recently emerged as a non-infrequent cause of PT, either in the setting of concurrent idiopathic intracranial hypertension (IIH) or due to primary venous stenosis. Venous sinus stenting (VSS) is an endovascular technique that can be used to treat venous stenosis. However, it is unclear if outcomes are different between patients with primary venogenic PT and IIH associated PT.
METHODS: A systematic literature review and pooled analysis was completed to evaluate the clinical outcomes of PT in patients undergoing cerebral VSS. Outcome measures included: Improved PT, complete resolution of PT, PT recurrence at follow up. Subgroup analysis between patients with IIH and primary PT was completed.
RESULTS: In total, 28 studies were identified with 616 patients. The proportion of improved PT symptoms after VSS had an overall pooled rate of 91.7% (CI:88.1%-95.2%; I2=65%) and no difference between subgroups (P=0.12). Complete resolution after VSS had an overall pooled rate of 88.6% (CI:84.0%-93.3%; I2=68%) and no significant difference between subgroups (P=0.35). Recurrent PT after stenting occurred in 6.5% of cases (CI:1.7%-11.3%; I2=62%). Furthermore, subgroup analysis demonstrated that IIH patients had a significantly higher recurrence rate (10.6%; CI:5.2%-16.1%; I2=26%) compared to patients treated with venous stenting for PT as the primary indication (2.0%; CI:0.8%-4.7%; I2=0%) (P<0.0001).
CONCLUSIONS: Venous stenting in patients with pulsatile tinnitus results in a substantial decrease and often complete resolution of symptoms. PT is more likely to recur in patients with IIH-associated PT.

Objective:To explore the effect of surgical treatment of the pulsatile tinnitus associated with sigmoid sinus on the dominant side of reflux. Methods:The clinical data of 43 patients with reflux dominant side pulsating tinnitus admitted by the same doctor from 2017 to 2023 were retrospectively studied to observe the curative effect of surgical treatment. Operation method: The sound insulation barrier was established by repair technique of bone wall defect of sigmoid sinus with \"capping method\", without changing the blood flow and blood vessel wall of sigmoid sinus. Results:No surgical complications occurred in all patients. During the follow-up period of 3 months to 6.9 years, 14 patients（32.6%） were cured, 18 patients（41.9%） were significantly effective, 4 patients（9.3%） were effective, and 7 patients（16.3%） were ineffective. The difference of tinnitus grade before and after surgery was statistically significant. Conclusion:In this group of cases, the sound insulation barrier was established by \"capping method\" technique of repairing bone wall defect of sigmoid sinus, which effectively avoided the disturbance of hemorheology status and vascular wall, thus avoiding the risk of venous wall stenosis and thrombosis on the dominant reflux side. The surgical method was easy to master, and the curative effect was significant, which was worthy of clinical promotion.
目的：探讨回流优势侧乙状窦相关性搏动性耳鸣的临床外科技术及疗效。 方法：回顾性研究2017年1月-2023年11月由同一位医生收治的43例回流优势侧搏动性耳鸣患者的临床资料，观察手术治疗的疗效。术式：应用“盖帽法”乙状窦骨壁缺损修复技术建立隔声屏障，不改变乙状窦血管壁和血流流变状态。 结果：所有患者均未出现手术并发症。随访3个月～6.9年，43例患者痊愈14例（32.6%），显效18例（41.9%），有效4例（9.3%），无效7例（16.3%），手术前后耳鸣分级的差异有统计学意义（P<0.05）。 结论：应用“盖帽法”乙状窦骨壁缺损修复技术建立隔声屏障，有效地规避了对血液流变学状态及血管壁的干扰，从而避免了优势回流侧静脉管壁狭窄及血栓形成的风险，手术方法容易掌握，疗效显著，值得临床推广。.

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.

OBJECTIVE: Pulse-synchronous tinnitus (PST) has been linked to multiple anatomical variants of the central venous outflow tract (CVOT) including sigmoid sinus (SS) dehiscence and diverticulum. This study investigates flow turbulence, pressure, and wall shear stress along the CVOT and proposes a mechanism that results in SS dehiscence and PST.
METHODS: Case series.
METHODS: Tertiary Academic Center.
METHODS: Venous models were reconstructed from computed tomography scans of 3 patients with unilateral PST. Two models for each patient are obtained: a symptomatic and contralateral asymptomatic side. A turbulent model-enabled commercial flow solver was used to simulate the pulsatile blood flow over the cardiac cycle through the models. Fluid flow through the transverse and SS junction was analyzed to observe the velocity, pressure, turbulent kinetic energy (TKE), and shear stress over a simulated cardiac cycle.
RESULTS: Fluid flow on the symptomatic side showed increased vorticity in the presence of an SS diverticulum. Higher TKE with periodicity following the cardiac cycle was observed on the symptomatic side, and a sharp increase was observed if SS diverticulum was present. Shear stress was highest near the narrowest segments of the vessel. Pressure was observed to be lower on the symptomatic side at the transverse-SS junction for all 3 patients.
CONCLUSIONS: Computational fluid dynamics modeling of blood flow through the CVOT in PST suggests that low pressure may be the cause of dehiscence, and tinnitus may result from periodic increases in TKE.

This study aimed to investigate the effect of the transverse sinus (TS) stenosis (TSS) position caused by arachnoid granulation on patients with venous pulsatile tinnitus (VPT) and to further identify the types of TSS that are of therapeutic significance for patients. Multiphysics interaction models of six patients with moderate TSS caused by arachnoid granulation and virtual stent placement in TSS were reconstructed, including three patients with TSS located in the middle segment of the TS (group 1) and three patients with TTS in the middle and proximal involvement segment of the TS (group 2). The transient multiphysics interaction simulation method was applied to elucidate the differences in biomechanical and acoustic parameters between the two groups. The results revealed that the blood flow pattern at the TS and sigmoid sinus junction was significantly changed depending on the stenosis position. Preoperative patients had increased blood flow in the TSS region and TSS downstream where the blood flow impacted the vessel wall. In group 1, the postoperative blood flow pattern, average wall pressure, vessel wall vibration, and sound pressure level of the three patients were comparable to the preoperative state. However, the postoperative blood flow velocity decreased in group 2. The postoperative average wall pressure, vessel wall vibration, and sound pressure level of the three patients were significantly improved compared with the preoperative state. Intravascular intervention therapy should be considered for patients with moderate TSS caused by arachnoid granulations in the middle and proximal involvement segment of the TS. TSS might not be considered the cause of VPT symptoms in patients with moderate TSS caused by arachnoid granulation in the middle segment of the TS.

OBJECTIVE: The purpose of this review is to provide an updated approach to the evaluation and management of pulsatile tinnitus (PT), an uncommon but often treatable subtype of tinnitus.
RESULTS: Secondary PT can be due to either vascular or non-vascular etiologies, including, but not limited to: neoplasm, arteriovenous malformation or fistula, idiopathic intracranial hypertension, dural venous sinus stenosis, otoacoustic etiologies (e.g., otosclerosis, patulous eustachian tube) and bony defects (e.g., superior semicircular canal dehiscence). Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies. If initial vascular imaging is negative and a vascular etiology is strongly suspected, digital subtraction angiography (DSA) may further aid in the diagnosis. Many vascular etiologies of PT can be managed endovascularly, often leading to PT improvement or resolution. Notably, venous sinus stenting is an emerging therapy for PT secondary to idiopathic intracranial hypertension with venous sinus stenosis. Careful history and physical exam can help establish the differential diagnosis for PT and guide subsequent evaluation and management. Additional studies on the efficacy and long-term outcome of venous sinus stenting for venous stenosis are warranted.

BACKGROUND: Sigmoid sinus wall dehiscence can lead to pulsatile tinnitus with a significant decrease in quality of life, occasionally leading to psychiatric disorders. Several surgical and endovascular procedures have been described for resolving dehiscence. Within endovascular procedures, the sagittal sinus approach could be a technical alternative for tracking and accurate stent positioning within the sigmoid sinus when the jugular bulb anatomy is unfavorable.
METHODS: A retrospective case series of three patients with pulsatile tinnitus due to sigmoid sinus wall dehiscence without intracranial hypertension was reviewed from January 2018 to January 2022. From the participants enrolled, the median age was 50.3 years (range 43-63), with 67% self-identifying as female and 33% as male. They self-identified as Hispanic. Sigmoid sinus dehiscence was diagnosed using angiotomography, and contralateral transverse sinus stenosis was observed in all patients. Patients underwent surgery via a navigated endovascular sagittal sinus approach for sigmoid sinus stenting. No neurological complications were associated with the procedure. Pulsatile tinnitus improved after the procedure in all patients.
CONCLUSIONS: Superior sagittal sinus resection for sigmoid sinus wall stenting is a safe and effective technique. Pulsatile tinnitus due to sigmoid sinus wall dehiscence could be treated using the endovascular resurfacing stenting technique. However, further research is needed to evaluate the potential benefit of contralateral stenting for removing sinus dehiscence when venous stenosis is detected. However, resurfacing sigmoid sinus wall dehiscence results in symptomatic improvement.

OBJECTIVE: Sigmoid sinus wall anomalies (SSWA) are closely linked to venous pulsatile tinnitus (PT). This study aims to demonstrate that SSWA develops progressively rather than being congenital.
METHODS: We retrospectively analyzed 42 PT patients with SSWA who had at least two non-operative CT scans at our clinic. CT images were longitudinally assessed to track SSWA progression, while MRI and Doppler ultrasound evaluated transverse sinus stenosis and venous hemodynamics. Changes in PT perception were tracked using the tinnitus handicap inventory (THI) questionnaire.
RESULTS: Among the 42 SSWA patients, 12 (28.6%) exhibited progression. Anastomosis between diploic vein and diverticulum was significantly higher compared to the dehiscence cohort (p < 0.01). Within the diverticulum group, seven individuals (30.4%) experienced enlargement, with a mean diverticular wall expansion of 5.9% ± 11.4%. Progressive erosion was observed in two cases (12.5%) in the dehiscence cohort, with a mean sigmoid plate erosion of 3.8% ± 10.1%. In cases progressing from dehiscence to diverticulum, three subjects transitioned, with a mean sigmoid sinus wall length expansion of 43.8% ± 31.9%. SSWA progression showed a significant negative correlation with QBILATERAL (r = -0.857, p = 0.014), and there was a significant difference between initial and revisit THI scores (p < 0.01).
CONCLUSIONS: SSWA can undergo morphological progression, indicating it is a progressive clinical condition rather than congenital.
METHODS: 4 Laryngoscope, 2024.

Pulsatile tinnitus (PT) requires detailed workup to evaluate for an underlying structural cause. With advances in neuroimaging, structural venous abnormalities that can cause PT have becoming increasingly recognized. A number of anomalies, including dural arteriovenous fistulas, idiopathic intracranial hypertension, transverse sinus stenosis, sigmoid sinus wall abnormalities, jugular venous anomalies, and hypertrophied emissary veins, have been implicated in flow disruption and turbulence in the vicinity of auditory structures, resulting in PT. Endovascular treatment options, including stenting, coiling, and embolization with liquid agents, have demonstrated high efficacy and safety. These treatments can lead to symptomatic relief in carefully selected cases.

Venous sinus stenting for dural venous sinus outflow obstruction due to an intrinsic filling obstruction or extrinsic stenosis is an increasingly popular treatment strategy for idiopathic intracranial hypertension (IIH) and isolated pulsatile tinnitus (PT). The most common site of stenosis is the lateral venous sinus at the transverse-sigmoid junction. Approximately 10% of the population has a persistent occipital venous sinus (OVS), a variant that may be the dominant venous drainage pathway in the setting of a hypoplastic or aplastic transverse sinus. OVS stenosis has been rarely associated with IIH and isolated PT with only a handful published cases. We herein report a retrospective series of OVS stenting in five patients, four of whom presented with non-IIH PT and one with IIH.