Local anaesthetic surgical treatment of severe objective pulsatile tinnitus: a useful technique

Abstract

Objective pulsatile tinnitus is a rare condition with an often dramatic presentation. We present the case of a 70-year-old woman who presented with over two years’ history of unilateral distressing objective pulsatile tinnitus. Carotid arteriography revealed a highly tortuous internal carotid artery. Computed tomography of the ipsilateral temporal bones showed a large jugular bulb. Internal jugular vein ligation under local anaesthetic yielded immediate resolution of her symptoms.

Tinnitus (also called tinnitus aurium) is derived from the Latin word tinnire, meaning to ring. It refers to the perception of sound in the absence of any corresponding external sound. Pulsatile tinnitus (PT) is often caused by a change in blood flow in or around the ear or a change in the awareness of that blood flow.

Case History

We report the case of a 70-year-old woman who was referred to the vascular outpatient clinic with over two years’ history of distressing left objective PT. The patient had a tinnitus handicap score of 86 (always heard, disturbed sleep patterns, interferes with daily activities). She noticed that the tinnitus resolved when she pressed against the upper part of the left neck.

An examination confirmed objective/audible tinnitus. The patient had a normal otoscopic examination. An audiogram showed a bilateral mild high frequency sensorineural hearing loss consistent with presbycusis. Carotid duplex ultrasonography revealed an extremely tortuous left internal carotid with mild atherosclerotic disease in the carotid bulb. Duplex compression of the left jugular vein ablated the tinnitus. Magnetic resonance angiography revealed a dominant left sigmoid sinus and internal jugular vein (IJV) with no significant carotid stenosis. Turbulence from carotid tortuosity amplified by the IJV was deemed a possible diagnosis.

The patient underwent left carotid exploration under local anaesthetic. She was found to have a huge IJV, clamping of which resulted in complete obliteration of the tinnitus (Fig 1). The IJV was therefore ligated and divided (Fig 2). The carotid tortuosity was not treated.

Figure 1.

Clamped internal jugular vein (IJV)

Figure 2.

Large internal jugular vein (IJV) divided

Postoperatively, the patient had resolution of her symptoms. At two months’ follow up she remained free of symptoms and was discharged from further follow up.

Discussion

The incidence of tinnitus has been estimated as 7–32%.¹ Sometimes referred to as vascular tinnitus, PT represents 3% of all tinnitus. The mean age at presentation reported in the literature is 52.8 years with a slight female preponderance.² Reported causes of PT are represented in Table 1.

Table 1.

Causes of pulsatile tinnitus

Arterial lesions	Dural arteriovenous fistulas Atherosclerosis Internal carotid artery dissection
Venous lesions	Jugular bulb anomalies3 Benign intracranial hypertension
Others	High cardiac output states

Evaluation of patients with PT begins with a detailed history. PT can occur in isolation but may also be associated with hearing loss, headaches, visual blurring, hypertension and coronary artery disease. History may also reveal anaemia or hyperthyroidism. Examination involves otoscopy auscultation for objective bruit, and a complete physical and detailed neurological examination. Investigations will depend on the clinical presentation but include a full blood count and thyroid function tests.

Radiology is an important adjunct to diagnosis in patients with PT. Modalities include duplex ultrasonography, echocardiography, magnetic resonance imaging/angiography, angiography and computed tomography. Vascular lesions are the most frequent radiologically demonstrable cause of PT.⁴

Treatment of PT depends on the specific cause identified. Conservative treatment is adopted for idiopathic PT. Ligation of the IJV in selected patients can cure tinnitus and reverse hearing loss.⁵

Conclusions

Objective PT represents a small but very important subset of tinnitus. Careful evaluation and investigation of patients provide a diagnosis in the majority of cases. As shown by this case, neck exploration under local anaesthetic is a useful technique in the diagnosis and treatment of objective PT.