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Pulsatile tinnitus due to lateral sinus
stenoses
Pathophysiology, diagnosis and
treatment
Pr Emmanuel Houdart
Service de Neuroradiologie
Hôpital Lariboisière, Paris
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Disclosures
• None
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Main messages
• 1- Pulsatile tinnitus (PT) are totally different
than continuous tinnitus and consequently,
one must recognize the pulsatility during
consultation by imitation of the sound
• 2- Stenosis of the lateral sinus is the first
cause of PT in young woman
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Tinnitus : simple auditory perception
without external sound
• Either that there is no sound to hear :
continuous tinnitus : disorder of the inner ear
(95 %)
• Or that the sound is « intimate » : pulsation
close to the inner ear : pulsatile tinnitus (5%)
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A pulsatile tinnitus is the normal perception
of an abnormal flow : the sensory organ is not
involved
• Disease is located in
first approximation in
the lateral sinus
• Clinical and
radiological
investigations must be
vascular
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How do we examine a pulsatile tinnitus ?
• Auscultation of the skull : negative in venous pulsatile
• Compression of cervical
vessels : in venous pulsatile
tinnitus, sound is
interrupted by the
compression of the
ipsilateral internal jugular
vein
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Venous pulsatile tinnitus
• Compressing the internal
jugular vein stop the
drainage into the ispilateral
sinus and therefore stops
the flow in the vessel
where the sound originates
• Stenosis of the lateral
sinus is the first cause of
venous pulsatile tinnitus
AP gauche
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Stenosis of the lateral sinus is a disease
that has been recognized in the late 90
• It is a true disease that affects the wall of the
sinus and it should be called « primitive sinus
stenosis » (different than stenosis after
recanalization of a sinus thrombosis)
• Its frequency has increased during the two last
decades, in parallel with the increase of
obesity
• It can lead to different symptoms including
pulsatile tinnitus or intracranial hypertension
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How to recognize those stenosis ?
Angio MR or Angio CT
Normal Stenosis
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Granulation or « intrinsic stenosis »
• Endoluminal defect following the CSF signal (hyposignal T1)
• On the transverse sinus
• Without mass effect on the parenchyma
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Extrinsic stenosis
• No endoluminal
defect
• Long stenosis
• Better seen in
coronal views
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Normal Extrinsic
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Pathophysiology of PT : acceleration of the
flow in front of the stenosis (up to 10 times)
creates turbulences downstream by inner ear
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20 cm/s to 170 cm/s
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This cause is now treatable by
stenting of the stenosis
• 28 yo woman with left
venous pulsatile tinnitus
• Endovascular Doppler
found acceleration of the
flow up to 8 times in
front of the stenosis
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Intial Post
• On / Off effect on the tinnitus
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IIH : idiopathic intracranial
hypertension is the second
manifestation of those stenosis
• Headaches, visual troubles
(visual eclipse, diplopia)
• CSF : pressure > 20 cm
H2O
• Papilledema i.e objective
sign to confirm the cure of
the disease
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It appeared in late 90 that IIH was
constantly associated to sinus
stenosis
• And with an elevation of the pressure above the stenosis i.e into the superior sagittal sinus (SSS)
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And, we know that SSS participates to
the CSF drainage
• Therefore, an elevated
SSS pressure can lead
to reduce CSF drainage
and finally elevation of
the intracranial
pressure
• Supports the treatment
by stenting
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Stenting solves the IIH (with
disappearance of papilledema)
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Indirect sign of the lateral sinus stenosis
: empty sella and dilation of the sheath
of the cranial nerves (third nerves here)
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Normal Empty sella
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Hyperpressure into SSS leads
CSF to drain into accessories
spaces• In case of elevated
venous pressure in
SSS those
accessories ways
are over used
explaining the
visibility of the CSF
around cranial
nerves
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And sometimes, this leads to
spontaneous CSF leakage, last
presentation of lateral sinus stenosis
• Due to sponatenous
dura-mater perforation
• Seen by ENT
• Rhinorrhea, otorrhea,
meningitis
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Epidemiology of spontaneous
CSF leaks
• Nelson et al. The rising incidence of
spontaneous CSF leaks in the US and the
association with obesity. Otol Neurotol
2015; 36(3): 476-80
• Their frequency increased these last 20
years in parallel with obesity
• 3 % of all leaks before 2000 to about 20 %
nowadays
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Spontaneous left otorrhea
• That was surgically
fixed
• Our ENT surgeons,
now, look at lateral
sinus stenosis facing
such patient
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Stenosis and empty sella
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Stenting of the lateral sinus is
performed to prevent against recurrent
CSF leakage
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To conclude
• Pulsatile tinnitus must be recognized
because most of them are curable
• There are many causes of pulsatile tinnitus,
however, venous stenosis is the leading
cause in young women and is treatable
• Primitive lateral stenosis is a new
pathologic entity whose frequency increases
with overweight