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Imaging Findings Associated
with Pulsatile Tinnitus
DANIEL THOMAS GINAT MD, MS
UNIVERSITY OF CHICAGO MEDICAL CENTER
GUL MOONIS MD
COLUMBIA UNIVERSITY MEDICAL CENTER
eEdE-162
Disclosures
None
Please email Daniel Ginat at [email protected] with questions or comments.
Introduction
• Tinnitus is a sound in the ear, such as buzzing, ringing, or
whistling, occurring without external stimulus.
• Tinnitus may be subjective or both subjective and
objective.
• The evaluation of a patient with tinnitus requires a
detailed history, neurootologic physical examination with
otoscopy, a comprehensive audiologic evaluation with
hearing thresholds, and imaging studies.
Subjective Tinnitus
• Most common type of tinnitus.
• Only heard by the patient.
• Associated symptoms depend on cause:
• Vertigo – superior semicircular canal dehiscence & Meniere’s
disease
• Conductive hearing loss – otosclerosis & superior semicircular
canal dehiscence
• Sensorineural hearing loss – vestibular schwannoma,
presbyacusis, & noise induced hearing loss
Objective Tinnitus
An actual sound made by the human body.
Physical explanation for perceived noise.
Often due to a vascular process.
Can be due to other physiologic sounds:
• Muscular contractions (palatal myoclonus – clicking)
• Respiration (patulous Eustachian tube)
• Venous hum (flow murmurs)
• Frequently can be perceived by an observer.
•
•
•
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Pulsatile Tinnitus
• Can be altered with compression of arterial or
venous structures.
• Can be perceived by the examiner if stethoscope
placed in the right location.
• Can be venous or arterial.
• Tends to produce whooshing sound.
• Cardiac rhythm synchronous.
Pulsatile Tinnitus Causes
•
•
Congenital vascular malformations
•
Aberrant carotid, persistent stapedial artery, aneurysms
•
High-riding jugular bulb, venous diverticula, dehiscences
Vascular tumors
•
Paragangliomas: glomus tympanicum or glomus jugulare, metastasis
•
Arteriovenous malformations and fistulas
•
Narrowing of the transverse sinus
•
•
•
Pseudotumor cerebri
•
Transverse sinus thrombosis
Arterial stenosis
•
Carotid artery dissection
•
Carotid atherosclerosis
•
Fibromuscular dysplasia
•
Microvascular compression
Miscellaneous
•
Superior semicircular canal dehiscence, otospongiosis, Paget’s disease, inflammatory hyperemia
Imaging Options
•
Overall, radiologic imaging is effective in detecting causes
of pulsatile tinnitus in approximately 70% of cases in
conjunction with clinical evaluation.
•
High-resolution contrast-enhanced CT or MRI are reasonable
options and are regarded as the imaging modalities of
choice.
•
In the absence of objective pulsatile tinnitus, CTA or MRA are
appropriate initial exams.
•
If there is suspicion for arteriovenous fistulas, angiography
should be performed.
Aberrant Carotid Artery &
Persistent Stapedial Artery
Coronal CT image shows the
left internal carotid artery within
the hypotympanum (arrow).
Axial CT image shows the
stapedial artery passing through
the obturator foramen (arrow).
Aberrant Carotid Artery &
Persistent Stapedial Artery
•
Enters middle ear through enlarged inferior tympanic
canaliculus and then travels through middle ear to enter
horizontal portion of carotid canal through dehiscence in
carotid plate.
•
May also cause conductive hearing loss due to mass effect
on the ossicles.
•
May be associated with persistent stapedial artery, which
can also contribute to pulsatile tinnitus.
Petrous Carotid Aneurysm
Coronal CT image shows an
expansile lesion of the right
petrous carotid canal (arrow).
Catheter angiogram reveals an
aneurysm of the horizontal
petrous carotid artery (arrow).
Petrous Carotid Aneurysm
•
Most petrous aneurysms are large and fusiform and believed
to be congenital in origin.
•
Other etiologies for petrous aneurysms are radiation injury,
trauma, and infection.
•
Otologic manifestations include conductive and sensorineural
hearing loss and tinnitus, with rupture seen in 25% as initial
presentation.
•
Endovascular treatment is the mainstay of treatment.
Venous Sinus Dehiscences &
Diverticula
Axial and coronal CT images show right sigmoid sinus
diverticulum and dehiscences involving the mastoid air cells
and mastoid cortex (arrows).
Venous Sinus Dehiscences &
Diverticula
•
Sigmoid sinus diverticulum and dehiscence is
perhaps the most common identifiable cause for
pulsatile tinnitus of venous origin, with a
prevalence of 23% in symptomatic patients.
•
Dehiscence of the sigmoid sinus can involve erode
into the mastoid air cells or the mastoid cortex, or
both.
Glomus Tympanicum
Axial CT images shows a soft tissue opacity in the middle ear, along the cochlear
promontory (arr0w). The coronal post-contrast T1-weighted MRI shows avid
enhancement in the lesion (arrow). Catheter digital subtraction angiography shows
marked hypervascularity in the lesion (arrow).
Glomus Tympanicum
•
•
•
•
Often apparent on otoscopic examination as a pulsating
reddish mass, the role of imaging is to differentiate these
from glomus jugulotympanicum.
Most glomus tympanicum tumors arise on the cochlear
promontory.
CT without contrast is adequate for delineating the extent
of the tumor.
Avid enhancement and a “salt and pepper” appearance
can be observed on MRI.
Temporal Bone Metastases
Initial presentation of prostate cancer as pulsatile tinnitus due to a
metastasis. The CT, CTA, and post-contrast T1-weighted MRI show a
lytic, enhancing mass (arrows) in the left temporal bone with
associated compression of the left jugular bulb (oval).
Temporal Bone Metastases
•
Rare cause of pulsatile tinnitus due to vascular
impingement or tumor hyperemia.
•
The presence of accompanying new cranial
nerve deficits should raise the suspicion for a
malignancy.
•
Serial scanning in patients at high risk of metastatic
disease may be warranted.
Dural Arteriovenous Fistula
The patient presented with a retroauricular bruit and had a remote
history of temporal bone trauma. The 3D hybrid CTA image shows a
prominent occipital artery (arrow) that drains into the junction of the left
transverse sinus with the sigmoid sinus.
Dural Arteriovenous Fistula
• Related to trauma, prior craniotomy, or dural sinus
thrombosis.
• Classified according to direction of flow and presence or
absence of cortical venous drainage
• Most common locations: cavernous, transverse, & sigmoid
sinuses.
• Findings may be subtle on cross sectional imaging and
requires high index of suspicion.
Pseudotumor Cerebri
Sagittal T1-weighted MRI shows an enlarged partially empty sella in a
young obese female. The MRA MIP shows constriction of the bilateral
transverse sinuses (arrows). The axial T2-weighted MRI shows mild bulging
of the bilateral optic nerve discs (arrows).
Pseudotumor Cerebri
•
Venous pulsatile tinnitus can result from conditions
associated increased intracranial pressure.
•
Characteristic neuroimaging findings for pseudotumor
cerebri (Idiopathic intracranial hypertension) include a
partially empty sella, constriction of the transverse
sinuses, and optic nerve disc and optic nerve sheath
cerebrospinal fluid prominence.
Atherosclerotic Disease
New pulsatile tinnitus due to new basilar artery steno-occlusive disease (arrow).
Initial MRI MIP
MRI MIP 8 years later
Atherosclerotic Disease
•
Pulsatile tinnitus can be the first manifestation
atherosclerotic disease.
•
Most commonly associated with significant
stenosis of the internal carotid arteries.
•
Both the head and neck vasculature should be
covered on imaging.
Fibromuscular Dysplasia
Coronal MRA MIP image shows a beaded appearance of the right
internal carotid artery (arrow).
Axial MRA MRIP images shows narrowing of the right petrous internal
carotid artery (arrow), due to dissection.
Fibromuscular Dysplasia
•
Fibromuscular Dysplasia is an arteriopathy that may lead to
stenosis, aneurysm, and dissection most common in young
females.
•
Pulsatile tinnitus is a presenting symptom in approximately onethird of patients and is associated with a pattern of multi-vessel
involvement, increased involvement of the cervical carotid
and/or vertebral arteries, and cervical artery dissection.
•
The characteristic finding is alternating stenoses and dilatations,
causing a string of beads appearance.
Vascular Loop Syndrome
Coronal FIESTA MRI show a vascular structure (arrow) impinging
upon the right cranial nerve 7 and 8 complex (arrowhead).
Vascular Loop Syndrome
•
Pulsatile tinnitus can be caused by arterial or venous vascular
loops and may be accompanied by vertigo.
•
Impingement upon the cranial nerve 7 and 8 complex in the
cerebellopontine angle cistern or internal auditory canal can
best be observed on FIESTA/CISS/DRIVE MRI sequences.
•
May be treated successfully by microvascular decompression.
Superior Semicircular Canal
Dehiscence
The patient presented with dizziness, pulsatile tinnitus, hyperacusis, otalgia,
and fullness in the right ear. Stenver and Pöschl CT images show deficiency
of bone along the apex of the right superior semicircular canal (arrows).
Superior Semicircular Canal
Dehiscence
•
Pulsatile tinnitus results from transmission of the normal
pulse-related pressure changes within the cranial cavity
to the inner ear.
•
Temporal bone CT is the modality of choice for
diagnosing superior semicircular canal dehiscence by the
lack of overlying bone, particularly via Stenver and Pöschl
views.
Otospongiosis
Axial CT images shows extensive demineralization of the otic capsule (arrows).
Otospongiosis
•
Otospongiosis contains arteriovenous microfistulas which
can lead to pulsatile tinnitus.
•
Demineralization in the region of the fissula ante fenestram
and/or otic capsule can be observed on CT.
•
The affected areas display enhancement due to the
vascular nature of otospongiosis.
Inflammatory and
Hypermetabolic Conditions
Otomastoiditis. The MRI shows
enhancement throughout the
right mastoid air cells and an
epidural abscess (arrow).
Paget disease. Sagittal CT image
show diffuse expansion of the skull
diplopic space and lucency of the
otic capsule (arrow).
Inflammatory and
Hypermetabolic Conditions
•
Infectious and inflammatory processes in and around the
temporal bone, including mastoiditis and Paget disease, can
lead to pulsatile tinnitus due to increased regional blood flow.
•
Otomastoiditis appears opacification on CT and associated
enhancement of the mucosa and sometimes the bone marrow
is apparent on MRI.
•
Paget disease has variable imaging manifestations depending
upon the stage of disease, but can appear as bone marrow
expansion and demineralization on CT during the active phase
with pulsatile tinnitus, cranial nerve deficits and Eustachian tube
dysfunction.
Selected References
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Sismanis A. Pulsatile tinnitus. Otolaryngol Clin North Am. 2003; 36: 389-402, viii.
Deuschl C, Göricke S, Gramsch C, Özkan N, Lehnerdt G, Kastrup O,
Ringelstein A, Wanke I, Forsting M, Schlamann M. Value of DSA in the
diagnostic workup of pulsatile tinnitus. PLoS One. 2015 Feb
17;10(2):e0117814.
Sonmez G, Basekim CC, Ozturk E, Gungor A, Kizilkaya E. Imaging of pulsatile
tinnitus: a review of 74 patients. Clin Imaging. 2007 Mar-Apr;31(2):102-8.
Juliano AF, Ginat DT, Moonis G. Imaging review of the temporal bone: part I.
Anatomy and inflammatory and neoplastic processes. Radiology. 2013
Oct;269(1):17-33
Juliano AF, Ginat DT, Moonis G. Imaging Review of the Temporal Bone: Part
II. Traumatic, Postoperative, and Noninflammatory Nonneoplastic
Conditions. Radiology. 2015 Sep;276(3):655-72.