Abstract

Background: Pulsatile tinnitus presents as a unique variation of tinnitus in which a conscious perception of the heartbeat is localized to the ears in either unilateral or bilateral fashion. The sensation is typically caused by an increase in turbulent blood flow in the affected ear, in most cases, due to a structural abnormality of the venous sinuses – the most common of which being stenosis. Herein, we discuss the etiology of pulsatile tinnitus followed by indications for treatment of various pathologies which have been successfully treated with venous sinus stenting and have led to resolution of auditory symptoms.

Methods: The authors queried PubMed database using combinations of the keywords “venous sinus stenting,” “endovascular treatment,” and “pulsatile tinnitus” to identify relevant studies published in English after 2001 and before December 1, 2020 and verified selected.

Results: Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting.

Conclusion: The success of venous sinus stenting is clinically relevant as an effective treatment option for patients suffering from pulsatile tinnitus. Future applications and studies are needed and are currently being developed to further demonstrate the effectiveness of stents in the treatment of pulsatile tinnitus.

Keywords: Angioplasty, Neuro-otology, Pulsatile tinnitus, Venous sinus stenosis, Venous sinus stenting

INTRODUCTION

Tinnitus, often described as “ringing in the ears,” is the persistent, unwanted perception of sound, usually in the absence of a genuine physical source. There are two general subtypes of tinnitus: pulsatile and nonpulsatile. In nonpulsatile tinnitus, the sound is caused by a hearing malfunction. However, in pulsatile tinnitus, hearing is intact and the tinnitus is usually due to perception of turbulent, accelerated, or normal blood or cerebrospinal fluid (CSF) flow within vessels proximal to ear.[ 27 , 50 ] Diagnosis of pulsatile tinnitus includes examination of comprehensive clinical data as well as magnetic resonance imaging (MRI) and even digital subtractive angiography (DSA) in some patients.[ 4 , 22 ] Current treatments include lifestyle modifications and medications aimed at the reduction of high blood pressure which may be an underlying cause in some patients.[ 22 , 27 ]

Venous stenting procedures have been established as an effective in patients with pulsatile tinnitus resulting from vascular abnormalities.[ 4 , 6 , 50 ] However, in the remaining cases of pulsatile tinnitus of nonvascular origin, resulting from abnormal flow of CSF, stenting of venous sinuses is emerging as an effective treatment.[ 9 , 32 , 50 ] In a prospective cohort study, most patients experienced complete or near complete resolution of their symptoms after stenting of the lateral venous sinus demonstrating the safety and efficacy of this technique.[ 38 ] In this review, we will provide a contemporary and comprehensive assessment of venous sinus stenting as a treatment of pulsatile tinnitus stemming from various etiologies and provide necessary information for patient selection and approach in treatment.

PATIENT SELECTION

Symptoms

Patients with intractable pulsatile tinnitus present with an array of symptoms, the most common of which being a conscious perception of the heartbeat within the ears of the affected individual (typically unilateral, but in rare cases can present bilaterally).[ 6 ] Patients tend to describe pulsatile tinnitus as a “whooshing” sensation in the affected ear, due to an increase in turbulent blood flow.[ 5 ] The loudness of the tinnitus is found to be reduced by head rotation or ipsilateral neck compression; however, this relief is temporary in duration.[ 5 ] Decibel range for loudness in cases of pulsatile tinnitus can extend from 30 to 85 dB and frequencies between 125 and 1000 Hz.[ 5 ] As a result, patients tend to report decreases in sleep duration, as well as decreased quality of life, with severe cases also presenting with concomitant depression.[ 25 ]

Indications

In the event of pulsatile tinnitus, patients will typically present with some form of cerebrovascular disease to warrant treatment through venous sinus stenting. This commonly includes idiopathic intracranial hypertension, of which pulsatile tinnitus tends to present secondarily to primary reports of headaches, papilledema, and visual disturbances.[ 6 , 40 , 54 ] Updated Dandy criteria for diagnosis of idiopathic intracranial hypertension include the aforementioned signs of increased intracranial pressure (ICP) along with no other localizing neurologic signs (barring unilateral or bilateral VI nerve paresis), increased pressure in the CSF without any cytologic or chemical abnormalities, and normal to small ventricles as demonstrated by CT.[ 18 ] Studies have shown upward of 90% of patients with idiopathic intracranial hypertension also present with venous sinus stenosis (VSS), hence, the indication for stenting.[ 6 ]

Although there is no current standard for stenting in VSS as a result of idiopathic intracranial hypertension, prior studies describe cases of significant intracranial hypertension (with a pressure gradient >10 mmHg across the area of stenosis and VSS >50%) as key indications for stenting following failed conservative treatment.[ 7 , 13 , 16 , 49 ]

VSS can also cause pulsatile tinnitus without a noticeable increase in ICP, which also poses one of the controversies of stenting as to whether or not the surgical intervention is warranted.[ 43 , 54 ] Routine CT or MRI rarely shows an abnormality due to difficulty localizing stenosis which can be hidden at the transverse-sigmoid junction, but can be confirmed with DSA.[ 5 , 54 ] Further, it has been determined that hemodynamic shifts – particularly, vortex formation in the distal expansion of the transverse sinus – are found to produce the tinnitus without any additional symptoms.[ 43 ] In a study by Russell et al., clinical presentations of tinnitus without increased ICP were discussed but no treatment was implemented.[ 43 ] However, a study by Baomin et al. found that 43 out of 46 patients enrolled displayed signs of PT without an increase in ICP, and subsequent venous stenting was found to eliminate pulsatile tinnitus in all 46 patients with no recurrence noted, indicating a high degree of efficacy in cases of VSS whether or not ICP is present.[ 5 ]

Pulsatile tinnitus can also be caused by a sigmoid sinus diverticulum or dehiscence (SSDD) or venous sinus aneurysm when the lesion occurs proximal to mastoid air cells.[ 45 ] Schoeff et al. determined a 23% prevalence of pulsatile tinnitus in SSDD patients with MRI as the diagnostic modality of choice in these cases.[ 45 ] Another study by Grewal et al. determined a 34% prevalence of pulsatile tinnitus using CT as the diagnostic criteria in cases of SSDD, true diverticula, or dehiscence.[ 21 ] In these cases, temporal bone CT was specifically recommended for evaluation of patients with pulsatile tinnitus.[ 21 ] In addition, in cases of venous sinus aneurysm, stenting followed by coil embolization was found to eliminate pulsatile tinnitus symptoms, though larger studies are warranted to support these findings.[ 33 , 44 ]

First-line intervention for venous sinus thrombosis involves anti-coagulation therapy. However, in cases where patients are unresponsive to treatment or symptoms worsen over time, surgical intervention through stenting may be warranted, especially if pulsatile tinnitus is also present.[ 23 , 52 ]

Indications for stenting typically occur as a result of thrombus reformation following thrombectomy and unsuccessful balloon venoplasty (wherein a patient still exhibits stenosis) [ Figure 1 ].[ 39 , 42 ] Venous stenting may present as an effective treatment in the management and restoration of venous circulation following thrombosis, which may ultimately correct the PT symptoms as well.[ 17 ] However, there is currently a void in the literature examining the resolution of PT following treatment of venous sinus thrombosis.

Figure 1:

Indications for venous sinus stenting in cases of pulsatile tinnitus.

Pulsatile tinnitus is also found in cases of dural arteriovenous fistulas (AVF) or arteriovenous malformations (AVM), where stenting may present as an effective therapy, where concomitant VSS has manifested.[ 28 , 46 ] In the case of VSS with AVF, if first-line treatment through transvenous or transarterial embolization cannot be performed, stenting can be utilized to decrease pressure in the draining veins, reduce bleeding, and ultimately prolong the course of management so that future treatment can potentially be performed.[ 26 , 31 ] Cases of AVM have shown to be more difficult in management, as a case study by Tsumoto et al. found that sigmoid sinus stenting was followed by restenosis, rupture, and bleeding indicating the importance of consistent follow-up in patients with AVM, especially in cases of restenosis.[ 51 ] The biggest issue, however, is that there are few studies explicitly describing changes in PT following stenting in cases of AVF or AVM.

Another known source of intractable pulsatile tinnitus is arterial supply aneurysms or atherosclerosis. Regarding aneurysms, the aneurysm can be intracranial or extracranial internal carotid artery, but most typically in the petrous portion of the internal carotid artery. Sound is transmitted to the inner ear creating the tinnitus sensation. Direct treatment with endovascular coiling or surgical clipping is the treatment of choice for resolution of symptoms.

Contraindications

Contraindications for the treatment of pulsatile tinnitus itself vary, however, in the case of venous sinus stenting; contraindications are more related to surgical intervention or the diagnostic modality rather than the specific procedure. Hypoplasia of the contralateral sigmoid sinus or small petrous hemangiomas has been reported by Couloigner et al. as a contraindication to surgical intervention due to risk of increased ICP following intervention.[ 10 ] From the diagnostic perspective, contraindications are present for patients allergic to contrast material in contrast-enhanced CT, in which case MRI becomes the preferred imaging modality to diagnose pulsatile tinnitus.[ 53 ]

TECHNIQUE

Before venous sinus stenting, patients are premedicated with antiplatelet therapy such as aspirin and clopidogrel, and the stenotic area is localized in the dural venous sinus using magnetic resonance venography. Stenosis may be unilateral or bilateral with involvement of the dominant lateral sinus or both lateral sinuses, respectively.[ 6 ] To confirm stenosis presence and severity, a microcatheter is inserted through the common femoral vein into the dural venous sinus with patients under local anesthesia. Venous manometry is used to measure the pressure at different areas, such as the transverse sinus, sigmoid sinus, superior sagittal sinus, and jugular bulb.[ 6 ] A pressure gradient of 6–8 mmHg is generally used to assess candidacy for stenting.[ 15 ] Under general anesthesia, a guidance catheter is directed into the venous sinus, and a dilation balloon is used to enlarge the area of stenosis. A self-expanding stent is inserted through the catheter and positioned across the stenotic region. Venography and manometry are repeated to measure pressure and assess venous drainage after stenting. Patients are observed for any signs of hemorrhage, hematoma, or compression before being discharged and instructed to continue taking aspirin and clopidogrel for 3–6 months followed by aspirin monotherapy. [ 5 , 8 , 16 ]

OUTCOMES

It has been hypothesized in patients with pulsatile tinnitus with idiopathic intracranial hypertension and sinus stenosis, venous sinus stenting across the stenosis can alter venous flow dynamics and minimize turbulence to resolve pulsatile tinnitus.[ 6 ] Thus, improvement or complete resolution of tinnitus is the desired outcome of venous sinus stenting for these patients.

To identify studies reporting outcomes from venous sinus stenting in patients with intractable pulsatile tinnitus, the authors queried PubMed using combinations of the keywords: venous sinus stenting, endovascular treatment, and pulsatile tinnitus to identify relevant studies published in English after 2001 and before December 1, 2021. The authors verified selected publications by conducting a supplemental reverse bibliography search from previously published case reports, systematic reviews, and/or meta-analyses. Sixteen observational studies were identified and are listed in Table 1 showing a resolution range from 53% to 100%.[ 20 , 48 , 3 , 14 , 19 , 37 , 29 ]

Table 1:

Studies evaluating pulsatile tinnitus following venous sinus stenting.

Across studies, investigators assessed postoperative clinical outcomes by evaluating for persistence or resolution of pulsatile tinnitus in the immediate postoperative period or at the patient’s first postoperative clinic visit. Among included studies, follow-up time ranged from 3 months to 3 years. Following venous sinus stenting, pulsatile tinnitus resolved in 94% of all cases included in [ Table 1 ] (range, 53–100%).

In a recent prospective study by Boddy et al., immediate and complete resolution of pulsatile tinnitus following venous sinus stenting in patients with idiopathic intracranial hypertension and distal transverse sinus stenosis was reported. This study was the only to use the tinnitus handicap inventory (THI), a common patient-reported outcome measure used in clinical trials to assess tinnitus.[ 24 , 34 , 35 ] The authors categorized tinnitus severity based on THI at prestent, 0 days, and 1, 3, 6, 12, 18, and 24-month follow-up. Notably, subjects reported resolution of tinnitus on the same day of the procedure (day-0).[ 6 ] There was significant improvement of THI with a mean change THI of 2.7 (95% CI: 2.3–3.1 THI, P < 0.001).[ 6 ]

Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting [summarized in Table 2 ]. Puffer et al. noted that pulsatile tinnitus resolved in 38 of 41 patients (93%) after stent placement. A systematic review by Starke et al. reported that resolution of tinnitus at a mean clinical follow-up of 22 months was achieved in 52 of 56 patients, or 92.9% (95% CI 88.7–97.1%).[ 47 ] In a recent meta-analysis by Nicholson et al., overall improvement in pulsatile tinnitus was seen in 134 of 154 patients, or 90.3% (95% CI 83.8–96.70%), but significant study heterogeneity was reported.[ 36 ]

Table 2:

Clinical outcomes reported by systematic reviews and meta-analyses.

Minor complications were uncommon, but those reported include transient focal headache, femoral pseudoaneurysm, and self-limited retroperitoneal hemorrhage.[ 11 , 12 , 16 , 30 ] Similarly, further operative management was rarely indicated. Fields et al. and Radvany et al. similarly reported a combined total of three cases which required further management with VP shunt.[ 16 , 41 ] Ahmed et al. reported that re-stenting was necessary in 6/52 (12%) of cases where 5/6 patients required additional stent placement and the remaining patient required 4 sequential stents.[ 2 ]

Although there is no randomized data supporting venous sinus stenting for treatment of pulsatile tinnitus at present, a prospective and randomized trial is ongoing at the Weill Medical College of Cornell University (NCT02734576).

CONCLUSION

Venous sinus stenting presents as an effective treatment option for patients suffering from pulsatile tinnitus and a concomitant cerebrovascular disease. As solo therapy, venous stenting has successfully reduced, if not outright eliminated pulsatile tinnitus in cases of IIH following conservative treatment failure, VSS where pulsatile tinnitus is present without additional symptoms and venous sinus thrombosis in cases where anticoagulant treatment is unsuccessful in reducing pulsatile tinnitus. Further, in combination therapy with coil embolization, venous stenting was shown to effectively reduce pulsatile tinnitus in patients presenting with venous sinus aneurysm. In cases of inoperable AVM or AVM with poor drainage or if failed embolization in AVF, stenting presents as a potential option to reduce severity of the physiologic issue at hand as well as the pulsatile tinnitus itself.

Although the data regarding resolution of pulsatile tinnitus through stenting is incredibly promising, there are limitations in the interpretation of said data due to smaller study cohorts. This is particularly true in studies describing AVM which are typically single case studies presenting with various complications making it difficult to ascertain the effectiveness of stenting when a patient is high-risk for rupture and restenosis. Although the Dandy criteria are currently utilized for diagnosis of IIH, criteria for determining whether venous stenting is warranted are not entirely clear and a consensus on such criteria has yet to be established. Additional studies are also needed to determine long-term resolution of pulsatile tinnitus in patients with venous sinus thrombosis as the current literature available did not present with sufficient data specifically investigating the connection between stenting in venous sinus thrombosis and pulsatile tinnitus severity (and ultimately resolution). The current data available describe venous sinus stenting as an effective tool for treatment of pulsatile tinnitus from a variety of etiologies, either as first-line therapy or as an adjunct. As such, further studies are indicated to assess the effectiveness in larger cohorts of patients of which pulsatile tinnitus presents as a chief complaint.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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