Toward a Diagnostic Imaging Algorithm for Undifferentiated Pulsatile Tinnitus

• Published in: Otology & neurotology
• Main Authors: Cavarocchi, Caitlin, Wong, Kevin, Cao, Austin C, Hwa, Tiffany P, Quimby, Alexandra E, Eliades, Steven J, Ruckenstein, Michael J, Bigelow, Douglas C, Choudhri, Omar A, Brant, Jason A
• Format: Journal Article
• Language: English
• Published: United States 01.09.2024
• ISSN: 1537-4505
• DOI: 10.1097/MAO.0000000000004254

Decisions around the diagnostic evaluation for pulsatile tinnitus (PT) remain challenging. We describe the usage patterns and diagnostic accuracy of imaging modalities and propose an evidence-based diagnostic approach for undifferentiated PT. Retrospective. Single otology/neurotology clinic. Patients with PT presenting between 2009 and 2020. Sensitivity, specificity, diagnostic yield, and diagnostic accuracy. A total of 315 subjects met inclusion criteria (74% female, mean ± SD age = 52 ± 17 years). Subjects were divided into four cohorts based on exam findings: normal (n = 229), venous cohort (n = 34), arterial cohort (n = 16), and outer/middle ear pathology cohort (n = 40). In total, 53% of patients received a nonidiopathic diagnosis for PT. The most common identifiable cause was sigmoid sinus dehiscence (78%) in the venous cohort, carotid stenosis (36%) in the arterial cohort, and glomus tumor (56%) in the outer/middle ear pathology cohort. There was a higher diagnostic rate among patients with positive exam findings compared to those with unrevealing exams (p = 0.04). Imaging studies with the highest diagnostic yield were computed tomography (CT) venography (44%), formal angiography (42%), and magnetic resonance venography (40%); studies with the highest specificity were formal angiography (0.82), CT angiography (0.67), and CT venography (0.67). A diagnostic algorithm is proposed. Reaching a diagnosis in patients with PT requires a systematic approach, taking into account both clinical and radiographic information. Physical examination is a key first step for differentiating patients into venous, arterial, and other cohorts to narrow down the likely pathology and determine which radiographic studies have the highest yield and accuracy.