Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus

Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus Meghan P. Jairam , Simon Kidanemariam , Aleena Malik , C. Eduardo Corrales , Chong Hyun Suh , View ORCID Profile Jeffrey P Guenette doi: https://doi.org/10.1101/2025.02.25.25322858 Meghan P. Jairam 1 Division of Neuroradiology, Brigham and Women’s Hospital , Boston, MA, USA MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Simon Kidanemariam 1 Division of Neuroradiology, Brigham and Women’s Hospital , Boston, MA, USA 2 The Warren Alpert Medical School of Brown University , Providence, RI, USA BS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Aleena Malik 3 University of Toronto , Toronto, ON, Canada BSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site C. Eduardo Corrales 4 Division of Otolaryngology-Head and Neck Surgery, Brigham and Women’s Hospital , Boston, MA, USA MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Chong Hyun Suh 5 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine , Seoul, Korea MD PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jeffrey P Guenette 1 Division of Neuroradiology, Brigham and Women’s Hospital , Boston, MA, USA MD MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jeffrey P Guenette For correspondence: jpguenette{at}bwh.harvard.edu Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Objective Aggregate published data on the imaging of pulsatile tinnitus as a step toward building a framework for an evidence-based approach to diagnostic imaging for this symptom. Materials & Methods A systematic review was performed. PUBMED and EMBASE were searched on December 1, 2021 for English-language articles on diagnostic imaging of pulsatile tinnitus. Articles that involved non-standard imaging techniques and those that focused on management of pulsatile tinnitus were excluded. Extracted data included: number of males and females; signs, symptoms, and physical examination findings with associated patient counts; imaging findings; count of patients with imaging-identified cause of pulsatile tinnitus; reported associated interventions and outcomes. Results 41 articles were included with a total of 2,633 reported patients. 10 studies were prospective. MRA appears to be capable of identifying many of the same pathologies traditionally diagnosed with DSA. Few head-to-head comparisons were performed. In head-to-head comparisons of MRI and MRA, MRA was often able to identify more pathology. There was no clear relationship identified between specific symptoms and the imaging modality chosen, indicating that the imaging evaluation of pulsatile tinnitus is likely sensitive to the preferences of the evaluating provider. Conclusion There is limited evidence to inform best practices for the initial imaging evaluation of pulsatile tinnitus and preference-sensitive provider decisions will continue to guide the pulsatile tinnitus workup. We encourage prospective studies with multimodality imaging comparisons to build evidence that would support the development of more effective, efficient, and equitable protocols and pathways for the imaging evaluation of pulsatile tinnitus. Clinical Relevance Statement Evidence is not available in support of any single optimal imaging evaluation of pulsatile tinnitus, but prudent imaging will include evaluation for life-threatening causes such as dural arteriovenous fistula and arteriovenous malformation. Key Points - Many imaging findings associated with pulsatile tinnitus may not be causal. - Current evidence is insufficient to indicate the optimal imaging evaluation. - Local preference-based imaging algorithms are reasonable in the absence of new high-level evidence. Introduction Pulsatile tinnitus is a rhythmic sound, often described by patients as whooshing or thumping, that is heard in either one or both ears.[ 1 ] Pulsatile tinnitus can be categorized as objective when the examining physician can hear the rhythmic sound or subjective when the sound is only discernable to the patient.[ 2 ] To some patients, the constant rhythmic sound can be extremely debilitating and can lead to anxiety, depression, and a lower quality of life.[ 3 ] Furthermore, pulsatile tinnitus can be the sign of a serious underlying condition, such as arteriovenous fistula,[ 4 ] which can have a mortality rate as high as 20% when left untreated.[ 5 ] Almost half of pulsatile tinnitus cases ultimately have a treatable cause.[ 6 , 7 ] Patients presenting with pulsatile tinnitus-like symptoms typically undergo a physical examination and diagnostic imaging workup. In approximately 70% of cases, imaging alone can help identify underlying etiologies.[ 8 ] However, arterial, venous, neoplastic, middle and inner ear, and neurological causes of pulsatile tinnitus are best identified on specific types of imaging examinations (e.g. temporal bone CT versus MRA) and may not be identifiable on others. With multiple potential imaging examinations to choose from and multiple published diagnostic algorithms, selecting the proper imaging examination can be challenging.[ 8 – 11 ] There is not currently aggregated data on the relative utility of the various possible imaging examinations, allowing for substantial preference-sensitive variation in examination ordering patterns based on individual provider’s familiarity and anecdotal experience with pulsatile tinnitus. The goal of this systematic review is to aggregate published data on the imaging of pulsatile tinnitus as a step toward building a comprehensive framework for an evidence-based approach to diagnostic imaging for this symptom. We include presenting symptoms, physical examination findings, imaging modality chosen based on symptoms, and the full range of associated diagnostic findings for each published study of each imaging examination type. Methods This systematic review of published literature did not require IRB approval and was reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.[ 12 , 13 ] Given the expectation of minimal evidence for analysis, a review protocol was not prepared or registered. PUBMED and EMBASE were searched from database inception to December 1, 2021 inclusively for English-language articles. The search term used was ("pulsatile tinnitus") AND ((computed tomography) OR (CT) OR (CT angiography) OR (CTA) OR (magnetic resonance) OR (MRI) OR (MR angiography) OR (MRA) OR (ultrasound) OR (sonograph*) OR (angiography)). For Level 1 phase of screening, 2 reviewers (MPJ, RC) independently screened all articles by their title and abstract and excluded articles that did not report on signs/symptoms suspicious of pulsatile tinnitus prior to imaging work-up. Articles detailing the evaluation or imaging of non-pulsatile tinnitus were excluded. Additionally, case reports, case series with fewer than three patients, review articles, letters, comments, notes, and editorials were excluded. In the event of conflict, discussion between the reviewers was led to consensus or, if needed, a third reviewer (JPG) was involved to resolve the conflict. The remaining studies underwent Level 2 screening where full texts were assessed to determine eligibility by two independent reviewers (MPJ, SK). In the event of conflict, discussion between the reviewers was led to consensus or, if needed, a third reviewer (JPG) was involved to resolve the conflict. Specifically, those articles with the following imaging modalities were included: Head CT, Temporal Bone CT, Head/Neck CTA, Brain MRI, Temporal Bone MRI (also called Internal Auditory Canal MRI), Head/Neck MRA/MRV, Ultrasound (US), digital subtraction angiography (DSA), all with standard techniques. At this stage, articles that involved non-standard imaging techniques and those that focused on management of pulsatile tinnitus, as opposed to the initial work-up, were excluded. The remaining eligible studies underwent a final round of data extraction and synthesis for inclusion in this systematic review. Extracted data included: number of males and females; signs, symptoms, and physical examination findings with associated patient counts; imaging findings; count of patients with imaging-identified cause of pulsatile tinnitus; reported associated interventions and outcomes. Bias was assessed by one author (JPG) using the Revised Risk of Bias Assessment Tool for Nonrandomized Studies of Interventions (RoBANS 2).[ 14 ] Results A total of 670 articles were identified from database search. Level 1 screening was performed on 605 articles after duplicates were removed, resulting in 77 articles for Level 2 full-text review. The Level 2 screening yielded 41 articles for inclusion.[ 6 , 8 , 15 – 53 ] A PRISMA flow diagram is provided as Figure 1 . Supplementary Tables 1 through 7 list the extracted details from the included articles. Download figure Open in new tab Figure 1: PRISMA Flow Diagram The 44 studies included a total of 2,633 patients. In many studies, the number of patients who had imaging with a specific imaging modality was not specified. Of the studies in which numbers were specified, 401 underwent Head CT, an unspecified total number underwent Temporal Bone CT and MRA, 143 Head/Neck CTA/CTV, 346 Brain MRI, zero Temporal Bone MRI, 120 Head/Neck MRA, 369 Ultrasound (US), 290 digital subtraction angiography (DSA), and 149 catheter angiography not specified as DSA. High risk of bias was present in most studies, particularly with regard to comparability of the target group (no comparison group in most studies), blinding of assessors, and selective outcome report (Supplemental Table 8). Ten studies were prospective studies.[ 20 , 27 , 30 , 38 , 43 , 44 , 46 , 47 , 50 , 51 ] Varied imaging modalities were used to evaluate pulsatile tinnitus in these prospective studies, including DSA, CTA/CTV, CT, MRA, MRI, and carotid doppler ultrasound. In addition to pulsatile tinnitus, 83 patients also presented with dizziness, 255 patients with headache, and 41 patients with hearing loss, however there is likely bias based on the assessing provider speciality. Rarely, studied patients presented with hypertension, head trauma, dysphasia, aphasia, papilledema, amaurosis fugax, hemiparesis, or Horner’s syndrome in addition to pulsatile tinnitus. Physical examination findings and type of imaging A variety of imaging modalities were used to workup the disappearance of pulsatile tinnitus upon compression of the ipsilateral jugular vein. For example, in those patients with the disappearance of pulsatile tinnitus upon compression of the ipsilateral vein, temporal bone CT [ 18 , 19 ] was used to diagnose high jugular bulb. CT was used to diagnose sigmoid sinus diverticulum, jugular bulb diverticulum, dehiscent jugular bulb, large emissary vein, sinus thrombosis, and petrosquamosal sinus.[ 25 ] CTA was used to diagnose dominant venous systems, transverse sinus diverticulum/stenosis, high riding jugular bulb without bone dehiscence, IJV stenosis, intra mastoid venous channel, external carotid artery stenosis and other arterial and venous causes, in addition to focal defects of the mastoid shelf. [ 8 , 34 , 53 , 54 ] In other patients with disappearance of pulsatile tinnitus upon ipsilateral compression of the vein, MRA/V was used to diagnose transverse sigmoid sinus stenosis[ 55 ] as well as jugular bulb diverticulum, large condylar vein, prominent emissary vein, venous sinus aneurysm, venous sinus stenosis, dural arteriovenous fistula, and arteriovenous malformation.[ 49 ] Digital subtraction was used to diagnose dural arteriovenous fistula, fibromuscular dysplasia, sigmoid sinus diverticulum, venous outflow obstruction, and mastoid emissary vein.[ 31 , 33 ] In patients with an ipsilateral carotid bruit and no otoscopy findings, carotid ultrasonography was ordered.[ 22 ] In this study, among patients who underwent carotid ultrasonography, only 4/34 patients obtained an imaging diagnosis and were found to have atherosclerosis. In those patients with conductive and sensorineural hearing loss, some providers obtained a temporal bone CT, and those patients were found to have a jugular bulb diverticulum and vestibular aqueduct dehiscence.[ 56 ] Other providers obtained a CTA/V and those patients were found to have extracranial tortuosities of the ICA.[ 5 ] Some patients were found to have a bruit and/or observed tumor with an occasional red hemotympanum on physical examination. In these patients, catheter angiography was used to identify jugular glomus, AV malformation, external carotid artery stenosis, vertebrojugular fistula, glomus tympanicum, acoustic neuroma.[ 28 , 57 ] In other patients (some of which had a red mass on physical examination), digital subtraction angiography was used to identify a vascular mass, frontal lobe arteriovenous malformation, jugular vein thrombosis, or large jugular bulb.[ 58 ] In Sila,[ 42 ] several patients had audible bruits and digital subtraction angiography was used to identify arteriovenous malformations, ICA occlusion/stenosis, carotid dissections, and arterial ectasia. Sources of pulsatile tinnitus and type of imaging All 7 studies using ultrasound evaluated for and showed atherosclerosis but did not show any other causes of pulsatile tinnitus. Although catheter angiography is considered one of the gold standards, MRA/MRV was used to identify the same pathologies. Direct comparison of types of imaging When comparing imaging modalities to one another for the identification of specific causes of pulsatile tinnitus, carotid, doppler and cranial sonography appear adequate at evaluating specifically for atherosclerosis as a cause of pulsatile tinnitus. In head-to-head comparisons of MRI and MRA, MRA was often able to identify more pathology. For example, in Dietz et al. 1994, when compared with MRI, MRA better identified dural arteriorvenous fistula, high jugular bulb, and jugular bulb diverticulum.[ 24 ] In Tsai et al. 2016, out of 28 patients with suspicion for dural arteriovenous fistula based on initial imaging with carotid duplex sonography, 25 underwent additional imaging with either MRI/MRA or CT/CTA, suggesting that if the suspicion for a dural arteriovenous fistula is high enough, an MRI/MRA or CT/CTA should be obtained.[ 59 ] Specifically, the MRI/MRA features of dural arteriovenous fistula included cerebral sinus opacification, enlargement or clustering of arterial external carotid artery branches, and abnormal vasculature around the brain surface. CT/CTA revealed vessels close to or inside skull bones. The authors report that if all the patients in this study (n = 155) initially underwent MRI and MRA, the total cost would have been $154,070. Because the patients were initially screened with carotid duplex sonography, the costs were significantly lower. Discussion In this systematic review, we aggregated all published research data on the diagnostic imaging of pulsatile tinnitus. We outlined all reported presenting symptoms, physical examination findings, imaging modality chosen based on symptoms, and the full range of associated diagnostic findings for each published study of each imaging examination type. There was no clear relationship identified between specific symptoms and the imaging modality chosen, indicating that the imaging evaluation of pulsatile tinnitus is largely sensitive to the preferences of the evaluating provider. The most common finding on physical examination was the disappearance of pulsatile tinnitus upon compression of the ipsilateral jugular vein. For this physical examination finding, a variety of imaging modalities were used in diagnosis. To evaluate specifically for atherosclerosis as a cause of pulsatile tinnitus, carotid, doppler and cranial sonography were determined to be equally useful. In the published English-language literature reviewed, very few head-to-head comparisons were performed, except for head-to-head comparisons of MRI and MRA, in which MRA was often able to identify more pathology.[ 24 ] MRA appears to be capable of identifying many of the same pathologies traditionally diagnosed with DSA. There are several limitations of this study. First, the literature included in this review consisted mostly of retrospective studies with high risk of bias. Some potential causes of pulsatile tinnitus, such as superior semicircular canal dehiscence, are known but there were no diagnostic imaging studies on the topic that were identified in our screening process.[ 60 , 61 ] Second, there were very few prospective and head-to-head comparison studies. There was no suitable quantitative data to perform a meta-analysis. In conclusion, there is limited evidence to inform best practices for the initial imaging evaluation of pulsatile tinnitus and preference-sensitive provider decisions will continue to guide the pulsatile tinnitus workup. We encourage prospective studies with multimodality imaging comparisons to build evidence that would support the development of more effective, efficient, and equitable protocols and pathways for the imaging evaluation of pulsatile tinnitus. Data Availability All data produced in the present work are contained in the manuscript View this table: View inline View popup Download powerpoint Supplemental Table 1 Carotid, doppler, and cranial ultrasonography View this table: View inline View popup Supplemental Table 2 Temporal bone CT and CT View this table: View inline View popup Download powerpoint Supplemental Table 3 Catheter angiography View this table: View inline View popup Download powerpoint Supplemental Table 4 CTA/V View this table: View inline View popup Supplemental Table 5 MRA/V View this table: View inline View popup Supplemental Table 6 MRI View this table: View inline View popup Supplemental Table 7 DSA (including IVDSA) View this table: View inline View popup Supplemental Table 8 RoBANS 2 Scoring Footnotes Jeffrey P. Guenette is the recipient of research funding from the National Institute of Biomedical Imaging and Bioengineering (K08 EB034299) and the Agency for Healthcare Research and Quality (AHRQ R18 HS029348). C. Eduardo Corrales M.D. is an employee and shareholder of Regeneron Pharmaceuticals, Inc. Abbreviations CT X-Ray Computed Tomography CTA X-Ray Computed Tomography Angiography MRI Magnetic Resonance Imaging MRA Magnetic Resonance Angiography MRV Magnetic Resonance Venography US Ultrasound DSA Digital Subtraction Angiography References 1. ↵ Risey J , Amedee G ( 1998 ) Pulsatile tinnitus . Tinnitus Today 9 : 11 OpenUrl 2. ↵ Remley KB , Coit WE , Harnsberger HR , et al. ( 1990 ) Pulsatile tinnitus and the vascular tympanic membrane: CT, MR, and angiographic findings . Radiology 174 : 383 – 389 . doi: 10.1148/radiology.174.2.2296650 OpenUrl CrossRef PubMed Web of Science 3. ↵ Williams AP , Gourishetti SC , Flaherty MA , Eisenman DJ ( 2023 ) Anxiety, Depression, and Symptom Severity in Patients with Pulsatile and Non-Pulsatile Tinnitus . The Laryngoscope 133 : 683 – 688 . doi: 10.1002/lary.30238 OpenUrl CrossRef PubMed 4. ↵ Sismanis A ( 2011 ) Pulsatile tinnitus: contemporary assessment and management . Current opinion in otolaryngology & head and neck surgery 19 : 348 – 357 OpenUrl 5. ↵ Sismanis A ( 2003 ) Pulsatile tinnitus . Otolaryngologic Clinics of North America 36 : 389 – 402 OpenUrl CrossRef PubMed Web of Science 6. ↵ Lynch P , Mitton T , Killeen DE , et al. ( 2022 ) Diagnosing Pulsatile Tinnitus: A Review of 251 Patients . Otology & Neurotology 43 : 128 – 136 . doi: 10.1097/MAO.0000000000003370 OpenUrl CrossRef PubMed 7. ↵ Liyanage S , Singh A , Savundra P , Kalan A ( 2006 ) Pulsatile tinnitus . The Journal of Laryngology & Otology 120 : 93 – 97 OpenUrl PubMed 8. ↵ Mattox DE , Hudgins P ( 2008 ) Algorithm for evaluation of pulsatile tinnitus . Acta Oto-Laryngologica 128 : 427 – 431 . doi: 10.1080/00016480701840106 OpenUrl CrossRef PubMed 9. Schleuning II AJ ( 1991 ) Management of the Patient with Tinnitus . Medical Clinics of North America 75 : 1225 – 1237 . doi: 10.1016/S0025-7125(16)30383-2 OpenUrl CrossRef PubMed 10. Goroll AH , Mulley AG ( 2012 ) Primary Care Medicine: Office Evaluation and Management of the Adult Patient . Lippincott Williams & Wilkins 11. ↵ Henry JA , Zaugg TL , Myers PJ , et al. ( 2010 ) A triage guide for tinnitus . Journal of Family Practice 59 : 389 OpenUrl PubMed 12. ↵ Page MJ , McKenzie JE , Bossuyt PM , et al. ( 2021 ) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ n 71 . doi: 10.1136/bmj.n71 OpenUrl FREE Full Text 13. ↵ Park HY , Suh CH , Woo S , et al. ( 2022 ) Quality Reporting of Systematic Review and Meta-Analysis According to PRISMA 2020 Guidelines: Results from Recently Published Papers in the Korean Journal of Radiology . Korean J Radiol 23 : 355 . doi: 10.3348/kjr.2021.0808 OpenUrl CrossRef PubMed 14. ↵ Seo H-J , Kim SY , Lee YJ , Park J-E ( 2023 ) RoBANS 2: A Revised Risk of Bias Assessment Tool for Nonrandomized Studies of Interventions . Korean J Fam Med 44 : 249 – 260 . doi: 10.4082/kjfm.23.0034 OpenUrl CrossRef PubMed 15. ↵ Amans MR , Haraldsson H , Kao E , et al. ( 2018 ) MR Venous Flow in Sigmoid Sinus Diverticulum . AJNR Am J Neuroradiol 39 : 2108 – 2113 . doi: 10.3174/ajnr.A5833 OpenUrl Abstract / FREE Full Text 16. Bae SC , Kim DK , Yeo SW , et al. ( 2015 ) Single-center 10-year experience in treating patients with vascular tinnitus: diagnostic approaches and treatment outcomes . Clin Exp Otorhinolaryngol 8 : 7 – 12 . doi: 10.3342/ceo.2015.8.1.7 OpenUrl CrossRef PubMed 17. Baomin L , Yongbing S , Xiangyu C ( 2014 ) Angioplasty and stenting for intractable pulsatile tinnitus caused by dural venous sinus stenosis: a case series report . Otol Neurotol 35 : 366 – 70 . doi: 10.1097/MAO.0b013e3182990d52 OpenUrl CrossRef PubMed 18. ↵ Berguer R , Nowak P ( 2015 ) Treatment of venous pulsatile tinnitus in younger women . Ann Vasc Surg 29 : 650 – 3 . doi: 10.1016/j.avsg.2014.12.039 OpenUrl CrossRef PubMed 19. ↵ Buckwalter JA , Sasaki CT , Virapongse C , et al. ( 1983 ) Pulsatile tinnitus arising from jugular megabulb deformity: a treatment rationale . Laryngoscope 93 : 1534 – 9 . doi: 10.1288/00005537-198312000-00002 OpenUrl CrossRef PubMed Web of Science 20. ↵ Carmody RF , Seeger JF , Smith JR , et al. ( 1984 ) Digital subtraction angiography in head and neck radiology . Neuroradiology 26 : 261 – 6 . doi: 10.1007/bf00339768 OpenUrl CrossRef PubMed 21. Cortese J , Eliezer M , Guédon A , Houdart E ( 2021 ) Pulsatile Tinnitus Due to Stenosis of the Marginal Sinus: Diagnosis and Endovascular Treatment . AJNR Am J Neuroradiol . doi: 10.3174/ajnr.A7325 OpenUrl Abstract / FREE Full Text 22. ↵ Daneshi A , Hadizadeh H , Mahmoudian S , et al. ( 2004 ) Pulsatile tinnitus and carotid artery atherosclerosis . Int Tinnitus J 10 : 161 – 4 OpenUrl PubMed 23. Deuschl C , Göricke S , Gramsch C , et al. ( 2015 ) Value of DSA in the diagnostic workup of pulsatile tinnitus . PLoS ONE 10 :. doi: 10.1371/journal.pone.0117814 OpenUrl CrossRef 24. ↵ Dietz RR , Davis WL , Harnsberger HR , et al. ( 1994 ) MR imaging and MR angiography in the evaluation of pulsatile tinnitus . AJNR Am J Neuroradiol 15 : 879 – 89 OpenUrl Abstract / FREE Full Text 25. ↵ Dong C , Zhao PF , Yang JG , et al. ( 2015 ) Incidence of vascular anomalies and variants associated with unilateral venous pulsatile tinnitus in 242 patients based on dual-phase contrast-enhanced computed tomography . Chin Med J (Engl ) 128 : 581 – 5 . doi: 10.4103/0366-6999.151648 OpenUrl CrossRef PubMed 26. 26. Friedmann DR, Le BT, Pramanik BK, Lalwani AK ( 2010 ) Clinical spectrum of patients with erosion of the inner ear by jugular bulb abnormalities . Laryngoscope 120 : 365 – 72 . doi: 10.1002/lary.20699 OpenUrl CrossRef PubMed Web of Science 27. ↵ Harris S , Brismar J , Cronqvist S ( 1979 ) Pulsatile tinnitus and therapeutic embolization . Acta Otolaryngol 88 : 220 – 6 . doi: 10.3109/00016487909137163 OpenUrl CrossRef PubMed 28. ↵ Holgate RC , Wortzman G , Noyek AM , et al. ( 1977 ) Pulsatile tinnitus: the role of angiography . J Otolaryngol Suppl 3 : 49 – 62 OpenUrl PubMed 29. Kline NL , Angster K , Archer E , et al. ( 2020 ) Association of pulse synchronous tinnitus and sigmoid sinus wall abnormalities in patients with idiopathic intracranial hypertension . Am J Otolaryngol 41 : 102675 . doi: 10.1016/j.amjoto.2020.102675 OpenUrl CrossRef PubMed 30. ↵ Krishnan A , Mattox DE , Fountain AJ , Hudgins PA ( 2006 ) CT arteriography and venography in pulsatile tinnitus: preliminary results . AJNR Am J Neuroradiol 27 : 1635 – 8 OpenUrl PubMed Web of Science 31. ↵ Lekovic GP , Barnard ZR , Master A , et al. ( 2021 ) Role of cerebral digital subtraction angiography in the evaluation of pulse synchronous tinnitus . J Otol 16 : 225 – 230 . doi: 10.1016/j.joto.2021.03.002 OpenUrl CrossRef PubMed 32. Lyu AR , Park SJ , Kim D , et al. ( 2018 ) Radiologic features of vascular pulsatile tinnitus - suggestion of optimal diagnostic image workup modalities . Acta Otolaryngol 138 : 128 – 134 . doi: 10.1080/00016489.2017.1385847 OpenUrl CrossRef PubMed 33. ↵ Ma X-B , Wang G-P , Zeng R , Gong S-S ( 2015 ) Treatment of pulsatile tinnitus associated with multiple factors . Chinese Medical Journal 128 : 413 – 414 . doi: 10.4103/0366-6999.150121 OpenUrl CrossRef PubMed 34. ↵ Mundada P , Singh A , Lingam RK ( 2015 ) CT arteriography and venography in the evaluation of Pulsatile tinnitus with normal otoscopic examination . Laryngoscope 125 : 979 – 84 . doi: 10.1002/lary.25010 OpenUrl CrossRef PubMed 35. Otto KJ , Hudgins PA , Abdelkafy W , Mattox DE ( 2007 ) Sigmoid sinus diverticulum: a new surgical approach to the correction of pulsatile tinnitus . Otol Neurotol 28 : 48 – 53 . doi: 10.1097/01.mao.0000247814.85829.f6 OpenUrl CrossRef PubMed Web of Science 36. Pelkonen O , Tikkakoski T , Luotonen J , Sotaniemi K ( 2004 ) Pulsatile tinnitus as a symptom of cervicocephalic arterial dissection . J Laryngol Otol 118 : 193 – 8 . doi: 10.1258/002221504322927955 OpenUrl CrossRef PubMed 37. Russell EJ , De Michaelis BJ , Wiet R , Meyer J ( 1995 ) Objective Pulse-Synchronous “Essential” Tinnitus due to Narrowing of the Transverse Dural Venous Sinus . Int Tinnitus J 1 : 127 – 137 OpenUrl PubMed 38. ↵ Sanchez TG , Santoro PP , Torres De Medeiros Í R , et al. ( 1998 ) Magnetic Resonance Angiography in Pulsatile Tinnitus: The Role of Anatomical Variations . Int Tinnitus J 4 : 122 – 126 OpenUrl PubMed 39. Shin EJ , Lalwani AK , Dowd CF ( 2000 ) Role of angiography in the evaluation of patients with pulsatile tinnitus . Laryngoscope 110 : 1916 – 20 . doi: 10.1097/00005537-200011000-00028 OpenUrl CrossRef PubMed Web of Science 40. Shownkeen H , Yoo K , Leonetti J , Origitano TC ( 2001 ) Endovascular treatment of transverse-sigmoid sinus dural arteriovenous malformations presenting as pulsatile tinnitus . Skull Base 11 : 13 – 23 . doi: 10.1055/s-2001-12782 OpenUrl CrossRef PubMed Web of Science 41. Shweel M , Hamdy B ( 2013 ) Diagnostic utility of magnetic resonance imaging and magnetic resonance angiography in the radiological evaluation of pulsatile tinnitus . American Journal of Otolaryngology - Head and Neck Medicine and Surgery 34 : 710 – 717 . doi: 10.1016/j.amjoto.2013.08.001 OpenUrl CrossRef 42. ↵ Sila CA , Furlan AJ , Little JR ( 1987 ) Pulsatile tinnitus . Stroke 18 : 252 – 6 . doi: 10.1161/01.str.18.1.252 OpenUrl Abstract / FREE Full Text 43. ↵ Sismanis A ( 1998 ) Pulsatile tinnitus . A 15 -year experience. Am J Otol 19:472–7 44. ↵ Sismanis A , Butts FM , Hughes GB ( 1990 ) Objective tinnitus in benign intracranial hypertension: an update . Laryngoscope 100 : 33 – 6 . doi: 10.1288/00005537-199001000-00008 OpenUrl CrossRef PubMed 45. Sismanis A , Girevendoulis A ( 2008 ) Pulsatile tinnitus associated with internal carotid artery morphologic abnormalities . Otol Neurotol 29 : 1032 – 6 . doi: 10.1097/MAO.0b013e3181865913 OpenUrl CrossRef PubMed 46. ↵ Sismanis A , Smoker WR ( 1994 ) Pulsatile tinnitus: recent advances in diagnosis . Laryngoscope 104 : 681 – 8 . doi: 10.1288/00005537-199406000-00007 OpenUrl CrossRef PubMed Web of Science 47. ↵ Sismanis A , Stamm MA , Sobel M ( 1994 ) Objective tinnitus in patients with atherosclerotic carotid artery disease . Am J Otol 15 : 404 – 7 OpenUrl PubMed Web of Science 48. Sonmez G , Basekim CC , Ozturk E , et al. ( 2007 ) Imaging of pulsatile tinnitus: a review of 74 patients . Clin Imaging 31 : 102 – 8 . doi: 10.1016/j.clinimag.2006.12.024 OpenUrl CrossRef PubMed Web of Science 49. ↵ Tao AJ , Parikh NS , Patsalides A ( 2021 ) The role of noninvasive imaging in the diagnostic workup for pulsatile tinnitus . Neuroradiol J 19714009211036696 . doi: 10.1177/19714009211036696 OpenUrl CrossRef 50. ↵ Terzi S , Arslanoğlu S , Demiray U , et al. ( 2015 ) Carotid Doppler ultrasound evaluation in patients with pulsatile tinnitus . Indian J Otolaryngol Head Neck Surg 67 : 43 – 7 . doi: 10.1007/s12070-014-0756-9 OpenUrl CrossRef PubMed 51. ↵ Tsai L-K , Yeh S-J , Tang S-C , et al. ( 2016 ) Validity of Carotid Duplex Sonography in Screening for Intracranial Dural Arteriovenous Fistula among Patients with Pulsatile Tinnitus . Ultrasound in Medicine and Biology 42 : 407 – 412 . doi: 10.1016/j.ultrasmedbio.2015.10.013 OpenUrl CrossRef PubMed 52. Waldvogel D , Mattle HP , Sturzenegger M , Schroth G ( 1998 ) Pulsatile tinnitus--a review of 84 patients . J Neurol 245 : 137 – 42 . doi: 10.1007/s004150050193 OpenUrl CrossRef PubMed Web of Science 53. ↵ Xue J , Li T , Sun X , Liu Y ( 2012 ) Focal defect of mastoid bone shell in the region of the transverse-sigmoid junction: A new cause of pulsatile tinnitus . Journal of Laryngology and Otology 126 : 409 – 413 . doi: 10.1017/S0022215111003458 OpenUrl CrossRef PubMed 54. ↵ Krishnan A , Mattox DE , Fountain AJ , Hudgins PA ( 2006 ) CT arteriography and venography in pulsatile tinnitus: preliminary results . AJNR Am J Neuroradiol 27 : 1635 – 8 OpenUrl PubMed Web of Science 55. ↵ Baomin L , Yongbing S , Xiangyu C ( 2014 ) Angioplasty and stenting for intractable pulsatile tinnitus caused by dural venous sinus stenosis: a case series report . Otol Neurotol 35 : 366 – 70 . doi: 10.1097/MAO.0b013e3182990d52 OpenUrl CrossRef PubMed 56. ↵ Friedmann DR , Le BT , Pramanik BK , Lalwani AK ( 2010 ) Clinical spectrum of patients with erosion of the inner ear by jugular bulb abnormalities . Laryngoscope 120 : 365 – 72 . doi: 10.1002/lary.20699 OpenUrl CrossRef PubMed Web of Science 57. ↵ Harris S , Brismar J , Cronqvist S ( 1979 ) Pulsatile tinnitus and therapeutic embolization . Acta Otolaryngol 88 : 220 – 6 . doi: 10.3109/00016487909137163 OpenUrl CrossRef PubMed 58. ↵ Carmody RF , Seeger JF , Smith JR , et al. ( 1984 ) Digital subtraction angiography in head and neck radiology . Neuroradiology 26 : 261 – 6 . doi: 10.1007/bf00339768 OpenUrl CrossRef PubMed 59. ↵ Tsai L-K , Yeh S-J , Tang S-C , et al. ( 2016 ) Validity of Carotid Duplex Sonography in Screening for Intracranial Dural Arteriovenous Fistula among Patients with Pulsatile Tinnitus . Ultrasound in Medicine and Biology 42 : 407 – 412 . doi: 10.1016/j.ultrasmedbio.2015.10.013 OpenUrl CrossRef PubMed 60. ↵ Aw GE , Parker GD , Halmagyi GM , Saxby AJ ( 2021 ) Pulsatile Tinnitus in Superior Semicircular Canal Dehiscence Cured by Endovascular Coil Occlusion of the Superior Petrosal Sinus . Otology & Neurotology 42 : e629 – e630 . doi: 10.1097/MAO.0000000000003012 OpenUrl CrossRef PubMed 61. ↵ Liu Z , Bi W , Li J , et al. ( 2015 ) Superior semicircular canal dehiscence in relation to the superior petrosal sinus: a potential cause of pulsatile tinnitus . Clinical Radiology 70 : 943 – 947 . doi: 10.1016/j.crad.2015.04.017 OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted February 25, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus Meghan P. Jairam , Simon Kidanemariam , Aleena Malik , C. Eduardo Corrales , Chong Hyun Suh , Jeffrey P Guenette medRxiv 2025.02.25.25322858; doi: https://doi.org/10.1101/2025.02.25.25322858 Share This Article: Copy Citation Tools Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus Meghan P. Jairam , Simon Kidanemariam , Aleena Malik , C. Eduardo Corrales , Chong Hyun Suh , Jeffrey P Guenette medRxiv 2025.02.25.25322858; doi: https://doi.org/10.1101/2025.02.25.25322858 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Otolaryngology Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (299) Cardiovascular Medicine (4422) Dentistry and Oral Medicine (443) Dermatology (382) Emergency Medicine (607) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1507) Epidemiology (15219) Forensic Medicine (30) Gastroenterology (1123) Genetic and Genomic Medicine (6584) Geriatric Medicine (667) Health Economics (997) Health Informatics (4524) Health Policy (1367) Health Systems and Quality Improvement (1611) Hematology (540) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15909) Intensive Care and Critical Care Medicine (1103) Medical Education (622) Medical Ethics (145) Nephrology (667) Neurology (6586) Nursing (345) Nutrition (998) Obstetrics and Gynecology (1143) Occupational and Environmental Health (956) Oncology (3331) Ophthalmology (970) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (663) Pediatrics (1690) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5437) Public and Global Health (9218) Radiology and Imaging (2194) Rehabilitation Medicine and Physical Therapy (1369) Respiratory Medicine (1195) Rheumatology (593) Sexual and Reproductive Health (709) Sports Medicine (529) Surgery (709) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9ff736af9bd00db4',t:'MTc3OTQwNDU5Nw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();