Sigmoid Sinus Diverticulum: A New Surgical Approach to the Correction of Pulsatile Tinnitus

[Molan]

A special thanks to fish for finding this on another forum but I thought I would post the study incase some people missed out on reading about it.

It seems that surgery was shown to give immediate and lasting relief to patients with Pulsatile Tinnitus.


Sigmoid Sinus Diverticulum: A New Surgical Approach to the Correction of Pulsatile Tinnitus

Otto, Kristen J.*; Hudgins, Patricia A.†; Abdelkafy, Wael*‡; Mattox, Douglas E.*

Abstract


Objective: Tinnitus represents a bothersome symptom not infrequently encountered in an otology practice. Tinnitus can be the harbinger of identifiable middle or inner ear abnormality; but more frequently, tinnitus stands alone as a subjective symptom with no easy treatment. When a patient complains of tinnitus that is pulsatile in nature, a thorough workup is indicated to rule out vascular abnormality. We report of a new diagnostic finding and method of surgical correction for select patients with pulsatile tinnitus.


Study Design: Retrospective case series.


Setting: Tertiary care, academic referral center.


Patients: Among patients seen for complaints of unilateral or bilateral pulsatile tinnitus, five were identified with diverticula of the sigmoid sinus. All patients had normal in-office otoscopic, tympanometric, and audiometric evaluations. Patients with paragangliomas or benign intracranial hypertension were excluded. Auscultation of the pinna or mastoid revealed an audible bruit in most patients. All patients underwent computed tomographic angiography of the temporal bone. In all cases, this finding was on the side coincident with the tinnitus.


Intervention: Three of five patients underwent transmastoid reconstruction of the sigmoid sinus.


Main Outcome Measure: Patients were evaluated clinically for presence or absence of pulsatile tinnitus after reconstructive surgery.


Results: All patients electing surgical reconstruction had immediate and lasting resolution of the tinnitus.


Conclusion: Surgical reconstruction can provide lasting symptom relief for patients with pulsatile tinnitus and computed tomographic evidence of a sigmoid sinus diverticulum.


http://journals.lww.com/otology-neu...=2007&issue=01000&article=00009&type=abstract

 

[Karen]

Thank you for this information, Molan! I'm hoping this will help others with this condition. As for me, I have already had a CT scan of the temporal bone, and it did not show any evidence of a sigmoid sinus problem. It is worthwhile for anyone with pulsatile tinnitus to get tested for conditions such as this.

 

[Molan]

Hey Karen! Fish is the one who deserves the credit as he mentioned this in a post a while ago that he had seen it on another forum.

I'm sorry this information dosen't help you personally but who knows they might find something else in the future that helps Pulsatile Tinnitus in cases like yours.

 

[Karen]

Thanks to Fish for mentioning this possible cure! I do hope it helps someone out there.
I'm still hopeful that there will be some sort of breakthrough in the next few years that will help us all.

In the meantime, I'm not giving up, and have been trying natural supplements, homeopathic remedy, chiropractic, etc. to get through each day. I'll certainly let everyone know if I stumble across anything that works!

 

[Molan]

Yay Karen! That's the spirit!

There is more and more things coming out that have been said to help with this condition. If we keep learning and experimenting we are bound to eventually come across something!

 

[Aisling]

Hi I am new to these forums but how would you know if your tinnitus is pulsatile? My left ear has a hum but I notice if I do anything energetic it gets louder you know when my heart beat increases. Would this suggest its pulsatile. This is my most annoying part of my tinnitus-the hum. But I also have a hiss type sound in both ears when I lie down.

 

[Karen]

Hi, Aisling, and welcome! I can only speak from my own experience, but I have a soft booming sound that is in tune with my heartbeat, plus a steady hissing sound. The booming sound is my pulsatile tinnitus, the other is "regular" tinnitus.

Try checking the sound after exercise, and see if it is in alignment with your pulse. If not, you probably have regular tinnitus. It is not uncommon to have more than one tinnitus tone, and most people notice their tinnitus most when they lie down at night.

Do you only have it in your left ear, or in both ears?

Maybe other people can answer your question, as to whether or not they notice their tinnitus more after anything strenuous, such as exercise. Anyone want to respond?

 

[Roger Cloutier]

I can relate to what you said about your hissing or whooshing sound when you lay down. It also occurs for me when I sit down as well. It's been a 50/50 proposition at bed time, should I lay on my left or my right ? Lately the right seems to be better. One thing about my tinnitus, is that it always changes. My whooshing sound replaced a smaller tinnitus sound/a humming or low roaring, about 3 months into my getting tinnitus.
I feel a little neurotic saying this, but I believe that their is a relationship to getting the whooshing/pulsatile sound and listening to a sound therapy program from Australia, called Sound Therapy International/Rafaele Joudry. I listened to specially designed tapes for hours a day as specified in the manual, and 3 months into the program I started getting the whooshing sound. I also relate trying out a hearing aid for about 1 - 2 weeks with giving me tinnitus in the first place. Seems strange, but the experience must of affected my psyche in a profoundly negative way, have you heard about the ''fight or flee'' mechanism ?

Lately, I found that anything that reduced my anxiety benefited me, but in a little while, I noticed that doing strenuous physical exercise, especially jogging, increased the whooshing sound. I also noticed that diet was important. I visited a homeopath when I first got tinnitus, and I followed a strict regime. I was also clinically depressed, so much so that along with the diet, I lost 35 lbs. in 1 month. I completely stopped eating most things I deemed unhealthy, especially sugar.
I read somewhere on this site how all patients who have a whooshings sound also have had cardio-vascular problems. Ditto, that's me, I had angioplasty about 13 years ago. There is also a diabetes/low blood sugar connection as well. Suffice to say that there is a ''vascular'' component to pulsatile tinnitus.

I recall hearing my first low tinnitus sound right around that same time, when I also started taking heart medications. I thought someone was playing their music too loud in the lower suite, and the bass frequencies were disturbing me as I tried to sleep. It didn't last, I had about 4 or 5 episodes like this.
Like most ''whooshers'' I noticed how positioning my head and body at times, affected the tinnitus. I noticed how pressing on certain parts of my head, be it the temples or the back of my head quieted the symptoms.
In finishing, it's nice to know that perhaps, surgery can intervene or even be a cure for pulsatile tinnitus.

Roger

 

[Karen]

Roger --- Somewhere (I think it was on Whooshers.com) I read that sudden weight loss could be a possible trigger for pulsatile tinnitus. It's possible that since you lost weight so quickly, that could have triggered the tinnitus to begin.

When you said "heart medicine" that struck a chord with me. My pulsating started shortly after I got myself off an ace inhibitor drug. Then, I was on and off blood pressure drugs for several months back in 2010. I finally got myself off a beta blocker in October 2010, which was kind of rough. My blood pressure went up and down for many months afterward, and has finally settled down. I've had pulsating tinnitus ever since then; I had hoped it would go away after I got off the drugs, but that did not happen.

I think you're right about the vascular component in pulsatile tinnitus. I wish my tests had been able to find something specific that could be fixed, but it didn't happen for me.

It's interesting that you say your pulsating/whooshing may have begun after listening to sound therapy for several hours per day. I've wondered about that, too. I've tried a couple of sound therapy programs, but they didn't help my pulsating. In fact, when I tried a tinnitus-masking hearing aid, it seemed to make the pulsating even worse. Very strange!

 

[Ellen Lee]

Hi, Aisling, and welcome! I can only speak from my own experience, but I have a soft booming sound that is in tune with my heartbeat, plus a steady hissing sound. The booming sound is my pulsatile tinnitus, the other is "regular" tinnitus.

Try checking the sound after exercise, and see if it is in alignment with your pulse. If not, you probably have regular tinnitus. It is not uncommon to have more than one tinnitus tone, and most people notice their tinnitus most when they lie down at night.

Do you only have it in your left ear, or in both ears?

Maybe other people can answer your question, as to whether or not they notice their tinnitus more after anything strenuous, such as exercise. Anyone want to respond?

Pulsatile tinnitus.
In ear, I hear a thumping sound in tune with my heartbeat.
Can be stopped by hand pressure.
And whoosh sounds when turning head or bending.
Is it necessary to find out if it is objective or subjective?
Was told PT rarely resolves on its own. Is this true?
Was told Tinnitus Retraining Therapy doesn't work for PT too. Anyone experience success?

Regular tinnitus.
High pitch sound in head.
Constant.
Anyone with similar experience?

 

[Karen]

Ellen -
My symptoms are very similar to yours, except that I cannot stop my thumping sound with hand pressure. It isn't necessary to find out if it is subjective or objective, but it would help to have a doctor check you out, just to be sure there are no other problems or complications.

I have both pulsating (in time with heartbeat) and ringing (high-pitched, constant sound).

I've had this for close to 3 years now, and it hasn't resolved on its own. However, it has gotten a little bit softer over time; or, maybe I've gotten used to it. I've had the standard tests, and they were unable to find anything.

How long have you had the pulsatile tinnitus? Have you been to a doctor, and/or had any tests?

 

[Ellen]

Karen, I've had PT for 6 weeks now. Endless round of ENT doctors adds to the stress, as they simply advocate waiting it out, saying scans in the majority do not find anything.

It took quite a bit of detective work to finally locate a T specialist doctor who has handled hundreds of tinnitus cases in detail. Hope he doesn't simply spend 5-10 minites on each case like the others do.

 

[Ellen]

Karen, do email me at temporary email - forumpage@gmail.com

Sharing some personal detailed notes with you as we have similar Ts.

 

[Karen]

Hi, Ellen,
I can start a personal conversation with you on Tinnitus Talk. I'll be sending you a personal message soon; you'll receive an E-mail, but don't respond to it. Instead, log onto Tinnitus Talk, and you'll have a message in your In Box.

 

[kenji]

i heard over and over surgery for tinnitus doesn't work

 

[Markku]

i heard over and over surgery for tinnitus doesn't work

Pulsatile tinnitus is a different beast. Sometimes the root cause can be surgically fixed and the PT stops.

 

[Karen]

That's right. Pulsatile tinnitus is often due to a vascular issue, which can be surgically repaired or corrected. Ringing tinnitus cannot be cured in that way; at least, not at this time.

 

[Frédéric]

Pattern and severity of transverse sinus stenosis in patients with pulsatile tinnitus associated with sigmoid sinus wall anomalies

Abstract
Objective
Describe the location and severity of transverse sinus stenosis (TSS) in a consecutive series of patients with intraoperatively confirmed sigmoid sinus wall abnormalities (SSWA).

Methods
A retrospective review of imaging studies from patients undergoing sinus wall reconstruction for pulsatile tinnitus associated with SSWA "was performed." Qualitative and quantitative analyses of the TSS, including the side, type, location, extent, and severity, were performed and compared with normal controls and historical controls with idiopathic intracranial hypertension (IIH).

Results
Twenty‐six of 36 subjects had adequate imaging data. The majority of subjects had some degree of bilateral TSS, and the majority of stenoses involved the distal transverse sinus. Subjects with diverticulum were significantly more likely than those with dehiscence to have ipsilateral distal TSS (16 of 16 vs. 4 of 10, P = 0.009). The mean minimum transverse sinus diameter, stenosis severity grade, and overall posterior venous sinus outflow were significantly worse in the subjects as compared to normal controls (P = 0.002), although not as severe as the comparable values in historical controls with IIH (P < 0.003).

Conclusion
Subjects with SSWA have a high incidence of TSS, with patterns differing between those with dehiscence and diverticulum. Severity of TSS and overall posterior fossa venous outflow are worse as compared to normal controls but not as severe as in subjects with IIH. These findings have implications for the pathophysiology and management of SSWA.

Source: https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.28168

 

[Frédéric]

https://chicagoear.com/blogpost/pul...d-by-sigmoid-sinus-dehiscence-or-diverticulum

 

[Teresa Carter]

Hi, Aisling, and welcome! I can only speak from my own experience, but I have a soft booming sound that is in tune with my heartbeat, plus a steady hissing sound. The booming sound is my pulsatile tinnitus, the other is "regular" tinnitus.

Try checking the sound after exercise, and see if it is in alignment with your pulse. If not, you probably have regular tinnitus. It is not uncommon to have more than one tinnitus tone, and most people notice their tinnitus most when they lie down at night.

Do you only have it in your left ear, or in both ears?

Maybe other people can answer your question, as to whether or not they notice their tinnitus more after anything strenuous, such as exercise. Anyone want to respond?

 

[Teresa Carter]

Hi everyone. Im new to this site. However, I have pulsation tinnitus and recently found out is is due to the vascular disorder SSD sigmoid sinus diverticulum. The sound increases with strenuous exercise and sometimes relieved by pressing the jugular in neck. I spoke with ENT and surgery is risky because it's basically creating a bulge or aneurysm at jugular bulb. My symptoms are so depressing, Im thinking of taking the risk. I can't sleep, work out, or have intense sex! I had a CT scan and it was almost missed by radiologist. A neurologist/ENT caught it and gave surgery as option or therapy to cope with symptoms as this is a vascular defect.

 

[tiniturtle]

Pulsatile tinnitus is a different beast. Sometimes the root cause can be surgically fixed and the PT stops.

Most cases can be cured by surgery, and there are varying causes. The ones that can't be cured or treated are in the minority.

Pulsatile tinnitus.
In ear, I hear a thumping sound in tune with my heartbeat.
Can be stopped by hand pressure.
And whoosh sounds when turning head or bending.
Is it necessary to find out if it is objective or subjective?
Was told PT rarely resolves on its own. Is this true?
Was told Tinnitus Retraining Therapy doesn't work for PT too. Anyone experience success?

Regular tinnitus.
High pitch sound in head.
Constant.
Anyone with similar experience?

This sounds like PT due to vascular causes. Tinnitus and Pulsatile Tinnitus are completely separate and not related. An ENT can't help you with this, you should consult a neuro interventional radiologist. Your PT can go away, but that isn't always a good thing, in my case, when mine did, it indicated a life threatening issue. Mine was cured with surgery.

Most cases of PT can be cured with surgery. Instead of my typing my story out every time, please see these links, this will tell you everything you need to know:

https://www.tinnitustalk.com/thread...d-to-do-to-get-answers-and-a-diagnosis.36645/

http://neuroangio.org/diagnosis-and-treatment-of-pulsatile-tinnitus/

As far as these postings as "new" procedures, these aren't new. However, they are done more frequently now. I've had multiple dural arteriovenous fistula. My PT was solved by curing the fistula, however, I also had a stent placed in my transverse/sigmoid sinus. This was to keep the vein open and prevent it from collapsing, which happened on the left side of my head due to a delay in diagnosis (that's why the PT went away, the vein closed up). These stents are placed in cases like these, or in the case of Intracranial Hypertension.

With PT, what you are hearing is turbulent blood flow. It is not a phantom sound like with tinnitus.

This will probably be of value as well:

http://neuroangio.org/patient-information/patient-information-brain-dural-fistula/

This site was written by the doctors that treat me. They are exceptional.

 

[Frédéric]

Hemodynamic study on the different therapeutic effects of SSWD resurfacing surgery on patients with pulsatile tinnitus

Highlights

Sigmoid sinus wall anomalies (SSWA) are a common pathophysiology of pulsatile tinnitus (PT) and usually treated by sigmoid sinus wall dehiscence (SSWD) resurfacing surgery. However, symptoms of tinnitus remain unrelieved after surgery in some patients with PT, and even new tinnitus appears. The cause of the difference in therapeutic effects is unclear.

This manuscript investigated the clarify the hemodynamic factors affecting the therapeutic effects of SSWD resurfacing surgery. The present study is the first to investigate the effect of PT treatment from a hemodynamic perspective. The results demonstrated no significant difference in the preoperative and postoperative wall Pavg between rehabilitation and non-rehabilitation patients. However, a significant difference in the changes of wall Pavg pre- and postoperation was found, which mainly caused the different therapeutic effects. Previous studies suggested that the vortex may be one of the influencing factors on PT. The present study did not find any difference in the vorticity between postoperative rehabilitation and non-rehabilitation patients.


Abstract
Sigmoid sinus wall anomalies (SSWA) are a common pathophysiology of pulsatile tinnitus (PT) and usually treated by sigmoid sinus wall dehiscence (SSWD) resurfacing surgery. However, symptoms of tinnitus remain unrelieved after surgery in some patients with PT, and even new tinnitus appears. The cause of the difference in therapeutic effects is unclear. In this study, eight patient-specific SSWA geometric models were reconstructed on the basis of computed tomography angiography, including four cases of postoperative rehabilitation (group 1, 1–4 cases) and four cases of non-rehabilitation (group 2, 5–8 cases). Transient-state computational fluid dynamics (CFD) was performed to clarify the SS blood flow pattern and hemodynamic states. The wall pressure distribution on SSWA area, pressure difference, and flow pattern in SS were calculated to evaluate the hemodynamic changes of rehabilitation and non-rehabilitation patients before and after surgery. The difference of hemodynamics between these patients was statistically analyzed. The accuracy of CFD simulation was evaluated by cross validating the numerical and particle image velocimetry experimental results. Results showed that the SSWA area in patients with PT was loaded with high pressure. No difference was found in the hemodynamic characteristics between the two groups pre- and postoperation. When the average pressure (Pavg) and time-average Pavg (TAPavg) on the SSWA area were studied, the TAPavg difference pre- and postoperation between the two groups was found significant (p = 0.0021). The TAPavg difference had a negative change in postoperative rehabilitation patients (case 1, -44.49 Pa vs. case 2, -15.85 Pa vs. case 3, -25.88 Pa vs. case 4, -16.58 Pa). The postoperative TAPavg of non-rehabilitation patients was higher than the preoperative one (case 5, 24.70 Pa vs. case 6, 28.56 Pa vs. case 7, 5.81 Pa vs. case 8, 13.04 Pa). The velocity streamlines in the SS with rehabilitation became smoother and more regular than that without rehabilitation. By contrast, the velocity streamlines in SS without rehabilitation showed increased twisting and curling. No difference was found in time-average volume-averaged vorticity (TAVavgV) between the two groups. Therefore, the high pressure of the vessel wall on SSWA area was one of the causes of PT. The variation of SSWA wall pressure difference before and after PT was the cause of the difference in therapeutic effects after SSWD resurfacing surgery. In patients with SSWA, disordered blood flow in SS was another cause of PT. SSWD repair may relieve tinnitus to some extent, but blood flow disorders may still arise.

Source: https://www.sciencedirect.com/science/article/abs/pii/S0169260719322461