Symptom: Pulsatile Tinnitus : The Hearing Journal – LWW Journals
A 65-year-old man presented with a history of left-sided pulsatile tinnitus that had been going on since 2019. He reported having had a head trauma a few months before the onset of his symptom. He said that the sound is suppressed by pressing gently over the left carotid and mastoid area, with no other modifying or related symptoms. The patient denies hearing loss, otalgia, otorrhea, vertigo, or facial nerve symptoms, but he has aural pressure on the left side. He has no history …….
A 65-year-old man presented with a history of left-sided pulsatile tinnitus that had been going on since 2019. He reported having had a head trauma a few months before the onset of his symptom. He said that the sound is suppressed by pressing gently over the left carotid and mastoid area, with no other modifying or related symptoms. The patient denies hearing loss, otalgia, otorrhea, vertigo, or facial nerve symptoms, but he has aural pressure on the left side. He has no history of severe infection or intracranial surgery. His microscopic ear exam and head and neck examination were normal. A very faint bruit could be heard with the bell of the stethoscope over the left mastoid.
Axial (horizontal) source images of the MRA showing arterial flow (white line and dots denoted by arrow) in the sigmoid sinus on the patient’s left (right side of image). Audiology, tinnitus hearing loss.
Figure 2:
Coronal (parallel to the face) T1 post-contrast MRI showing arterial flow voids (black spot, white arrow) in the left sigmoid sinus. Audiology, tinnitus hearing loss.
Figure 3:
Axial (horizontal) T1 post-contrast MRI demonstrating the distinct flow void (dark area) in the left sigmoid sinus (white arrow) in the left sigmoid sinus. Audiology, tinnitus hearing loss.
Figure 4:
Axial (horizontal) TOF MRA demonstrating arterial flow (dashed white arrow) around or inside the left sigmoid sinus. Audiology, tinnitus hearing loss.
Figure 5:
A. Lateral view angiography of the left external carotid demonstrating feeding arteries arising from the right middle meningeal, posterior auricular, and occipital arteries. B. Lateral view angiography of the left external carotid during arterial and venous phase showing blood and small arterioles inside sigmoid sinus. Audiology, tinnitus hearing loss.
Table 1:
Classification of Intracranial DAVF Borden Classification.
Table 2:
Classification of Intracranial DAVF Cognard Classification.
DIAGNOSIS: DURAL ARTERIOVENOUS FISTULA
Patients with objective tinnitus constitute less than 1% of the patients presenting with tinnitus. This somatosound is usually generated by turbulent blood flow through dilated or stenotic vessels. 1 The differential diagnosis of pulsatile tinnitus is long; it includes vascular etiologies—such as arteriovenous malformation (AVM), dural arteriovenous fistula (DAVF), and internal carotid artery stenosis—and non-vascular causes such as tumors of the temporal bone, idiopathic intracranial hypertension, and migraine. 2 A workup must be done to recognize uncommon but potentially life-threatening causes.
The examination of a pulsatile tinnitus includes microscopic ear examination and auscultation of the neck and over the area of the mastoid with the bell portion of the stethoscope. We generally place our other hand on the opposite temporal area to press the head into …….
Source: https://journals.lww.com/thehearingjournal/Fulltext/2022/05000/Symptom__Pulsatile_Tinnitus.9.aspx
