Treatment of Pulsatile Tinnitus Associated with Multiple Factors

413 Numerous factors may lead to pulsatile tinnitus (PT), including atherosclerosis, benign intracranial hypertension, glomus tympanicum tumor, dural arteriovenous fistulas (dAVFs), abnormalities of the sigmoid sinus (dehiscence and diverticulum), and jugular bulb anomalies (glomus jugular tumor, diverticulum, high‑riding or dehiscent jugular bulb). However, exact causes often cannot be found in many patients even after a detailed physical examination and extensive auxiliary examinations. [1] Moreover, no effective treatment is available for these patients. Patients with PT associated with multiple factors are seldom reported, and the condition is essentially intractable. Here, we reported three cases with PT involving multiple factors. A 38‑year‑old woman presented with a chief complaint of PT on her right side for 7 years. The results of pure tone audiometry and acoustic immittance were normal. Her PT could be alleviated after compressing the ipsilateral jugular vein. Digital subtraction angiography (DSA) and computed tomography angiography (CTA) revealed a small diverticulum on the right‑side of her sigmoid sinus, and a vascular malformation was found in the right frontal‑parietal lobe. With a strong desire to relieve the PT and her consent, the patient was hospitalized to remove the diverticulum by surgery at the Department of Otolaryngology, Beijing Tongren Hospital, in April 2012. The diverticulum was skeletonized and reduced with extraluminal placement of the temporalis fascia and autologous bone pate. The patient experienced no change in the PT after this surgery, although the diverticulum was eliminated completely as shown in the postoperative CTA. Then, the CTA findings before and after the surgery were studied again. Extensive bone defects (dehiscence) were found in the right‑side sigmoid sinus wall. She also had a high‑riding and dehiscent jugular bulb, a possible underlying factor for PT. With the patient's consent, a second surgery was performed under local anesthesia for reconstruction of the dehiscent wall of the sigmoid sinus and jugular bulb in December 2012. The patient experienced immediate resolution of the PT when the partial sigmoid sinus dehiscent wall was reconstructed with autologous bone pate. However, she was so nervous and anxious under local anesthesia that the surgery was discontinued. She had milder PT, approximately 30% of the loudness of the preoperative PT, immediately after the surgery. The patient's mild PT persisted stably at 15 months after the second surgery, when the last follow‑up occurred. A postoperative CTA after the secondary surgery demonstrated that the dehiscent sigmoid sinus wall had been reconstructed partially, and the high‑riding and …