Sigmoid sinus diverticulum (SSD) has been increasingly reported as a cause of pulsatile tinnitus (PT). While both endovascular and surgical treatments have been used, there is a lack of consensus on the treatment modality to treat SSD. We conducted a systematic review of the available literature to compare the clinical outcomes and safety of endovascular versus surgical approaches for treating SSD.
Methods
A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify studies encompassing the management of SSD. Studies reporting the clinical outcomes and safety of endovascular or surgical treatments for SSD between January 2000 and January 2023 were included. Results were characterized using descriptive statistics.
Results
Endovascular treatment (EVT) was reported by 17 articles, yielding 26 patients with 27 diverticula. Surgical treatment was reported by 20 articles, yielding 105 patients with 107 diverticula. EVT led to complete or near-complete resolution in all patients with SSD and PT. Complications occurred in 3.7% (1/27) with a return to baseline after 2 months. There were no permanent complications from EVT. Surgical treatment resulted in complete resolution in 77.6% (83/107) of cases, incomplete resolution in 11.2% (12/107), and no resolution in 11.2% (12/107). Significant complications occurred in 9.3% (10/107) of the surgical-treated patients.
Conclusion
EVT in patients with PT and venous diverticulum appears more effective and safer than surgical treatment, but large studies are lacking. Studies directly comparing endovascular and surgical treatment are needed.
NarsinhKHHuiFSalonerD, et al.Diagnostic approach to pulsatile tinnitus: a narrative review. JAMA Otolaryngol– Head Neck Surg2022; 148: 476–483.
2.
ErlandssonSIHallbergLR. Prediction of quality of life in patients with tinnitus. Br J Audiol2000; 34: 11–20.
3.
AmansMMattayRHillsNK, et al.More than just noise: Association of pulsatile tinnitus with anxiety, depression, and reduction of quality of life. Interv Neuroradiol. Published online April 17, 2023:159101992311687. doi:https://doi.org/10.1177/15910199231168751
4.
NarsinhKHHuiFDuvvuriM, et al.Management of vascular causes of pulsatile tinnitus. J Neurointerventional Surg2022; 14: 1151–1157.
5.
CapirossiCLaisoACapassoF, et al.Pulsatile tinnitus due to stenosis of the supraclinoid segment of the internal carotid artery: Management with a low-profile self-expanding stent. Interv Neuroradiol. Published online June 3, 2022:159101992211060. doi:https://doi.org/10.1177/15910199221106036
6.
CumminsDDCatonMTHemphillK, et al.Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation. J NeuroInterventional Surg. Published online September 8, 2022:neurintsurg-2022-019259. doi:https://doi.org/10.1136/jnis-2022-019259
7.
AbdalkaderMNguyenTNNorbashAM, et al.State of the art: venous causes of pulsatile tinnitus and diagnostic considerations guiding endovascular therapy. Radiology2021; 300: 2–16.
8.
RazENossekEJethanamestD, et al.Emergence of venous stenosis as the dominant cause of pulsatile tinnitus. Stroke Vasc Interv Neurol2022; 2: e000154.
9.
AbdalkaderMHuiFAmansMR, et al.Cerebral venous disorders: Diagnosis and endovascular management. J Neuroradiol. Published online 2023. doi:https://doi.org/10.1016/j.neurad.2023.06.002
10.
AbdalkaderMMaACohenM, et al.Endovascular coiling of large mastoid emissary vein causing pulsatile tinnitus. Interv Neuroradiol2020; 26: 821–825.
11.
MattoxDEHudginsP. Algorithm for evaluation of pulsatile tinnitus. Acta Otolaryngol (Stockh)2008; 128: 427–431.
12.
DongCZhaoPFYangJG, et al.Incidence of vascular anomalies and variants associated with unilateral venous pulsatile tinnitus in 242 patients based on dual-phase contrast-enhanced computed tomography. Chin Med J (Engl)2015; 128: 581–585.
13.
ParkYHKwonHJ. Awake embolization of sigmoid sinus diverticulum causing pulsatile tinnitus: simultaneous confirmative diagnosis and treatment. Interv Neuroradiol2011; 17: 376–379. www.centauro.it
CuellarHMaitiTPatraDP, et al.Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of the literature. World Neurosurg2018; 113: 238–243.
16.
HoudartEChapotRMerlandJJ. Aneurysm of a dural sigmoid sinus: a novel vascular cause of pulsatile tinnitus. Ann Neurol2000; 48: 669–671.
17.
Ganz SanchezTMuraoMHaloI, et al.A new therapeutic procedure for treatment of objective venous pulsatile tinnitus. Int Tinnitus J2002; 8: 54–57.
18.
ZentenoMMurillo-BonillaLMartínezS, et al.Endovascular treatment of a transverse-sigmoid Sinus aneurysm presenting as pulsatile tinnitus case report mal-formation; DS = digital subtraction; GDC = Guglielmi detachable coil; IJV = internal jugular vein; TSS = transverse-sigmoid Sinus. J Neurosurg2004; 100: 120–122.
19.
GardAPKlopperHBThorellWE. Successful endovascular treatment of pulsatile tinnitus caused by a sigmoid sinus aneurysm: a case report and review of the literature. Interv Neuroradiol2009; 15: 425–428.
20.
MehannaRShaltoniHMorsiH,et al.Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus A case report and review of literature. Interv Neuroradiol2010; 16: 451–454. www.centauro.it
21.
Santos-FrancoJALeeANava-SalgadoG, et al.Hybrid carotid stent for the management of a venous aneurysm of the sigmoid sinus treated by sole stenting. Vasc Endovascular Surg2012; 46: 342–346.
22.
LenckSMosimannPJLabeyrieMA,et al.Pulsatile tinnitus caused by an aneurysm of the transverse-sigmoid sinus: a new case report and review of literature. J Neuroradiol2012; 39: 276–279.
23.
AmansM. Resolution of pulsatile tinnitus after coil embolization of sigmoid sinus diverticulum. Austin J Cerebrovasc Dis2014; 1.
24.
LiBLvXWuZ, et al.Stent-assisted coil embolization of a transverse-sigmoid sinus diverticulum presenting with pulsatile tinnitus. Turk Neurosurg2016; 26: 632–634.
25.
ShastriRKChaudharyNPandeyAS, et al.Venous diverticula causing pulsatile tinnitus treated with coil embolization and stent placement with resolution of symptoms. Report of Two Cases and Review of the Literature. Otol Neurotol2017; 38: e302–e307.
26.
HanYYangQYangZ, et al.Computational fluid dynamics simulation of hemodynamic alterations in sigmoid Sinus diverticulum and ipsilateral upstream Sinus stenosis after stent implantation in patients with pulsatile tinnitus. World Neurosurg2017; 106: 308–314.
27.
QiuXYZhaoPFDingHY, et al.Bone remodeling in sigmoid sinus diverticulum after stenting for transverse sinus stenosis in pulsatile tinnitus: a case report. World J Clin Cases2021; 9: 2320–2325.
28.
FaridMAlawamryAZaitounMMA, et al.Relentless pulsatile tinnitus secondary to dural sinovenous stenosis: is endovascular sinus stenting the answer?Clin Radiol2021; 76: 526–531.
29.
KesharySREverettTAlvaradoAM,et al.Stent-assisted coiling of dural sinus diverticula: a case series. J Neurointerventional Surg2022; 14: 920–924.
30.
OttoKJHudginsA‡waelA,et al.Sigmoid Sinus Diverticulum: A New Surgical Approach to the Correction of Pulsatile Tinnitus.
31.
GologorskyYMeyerSAPostAF, et al.Novel surgical treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus: technical case report. Neurosurgery2009; 64: 393–394.
32.
EisenmanDJ. Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings. Otol Neurotol2011; 32: 1116–1119.
SongJJKimYJKimSY, et al.Sinus wall resurfacing for patients with temporal bone venous sinus diverticulum and ipsilateral pulsatile tinnitus. Neurosurgery2015; 77: 709–717.
35.
WangGPZengRMaXB, et al.Surgical treatment of pulsatile tinnitus caused by the sigmoid sinus diverticulum: a preliminary study. Medicine2015; 94: e882.
36.
GuoPWangWQ. Degree of sigmoid sinus compression and the symptom relief using magnetic resonance angiography in venous pulsating tinnitus. Clin Exp Otorhinolaryngol2015; 8: 111–116.
37.
RaghavanPSerulleYGandhiD, et al.Postoperative imaging findings following sigmoid sinus wall reconstruction for pulse synchronous tinnitus. Am J Neuroradiol2016; 37: 136–142.
38.
SzczesnyCKumarRMuzzafarJ, et al.Sigmoid sinus diverticulum with perisinus pneumatization causing pulsatile tinnitus: a rare entity. J Hear Sci2017; 7: 47–52.
39.
YeoWXXuSHTanTY, et al.Surgical management of pulsatile tinnitus secondary to jugular bulb or sigmoid sinus diverticulum with review of literature. Am J Otolaryngol - Head Neck Med Surg2018; 39: 247–252.
40.
HassanniaFCarrSDBusatoGM,et al.Clipping of sigmoid sinus diverticulum: how i do it. J Laryngol Otol2018; 132: 837–839.
41.
AhamedHPhilipAIrodiA, et al.Sigmoid sinus diverticulum and dehiscence: diagnosis and management. Indian J Otol2019; 25: 84.
42.
LeeSYKimMKBaeYJ, et al.Longitudinal analysis of surgical outcome in subjects with pulsatile tinnitus originating from the sigmoid sinus. Sci Rep2020; 10. doi:https://doi.org/10.1038/s41598-020-75348-3
43.
NewberryIHighlandJDeTorresA,et al.Transmastoid hydroxyapatite resurfacing for sigmoid sinus wall anomalies causing pulsatile tinnitus. Ann Otol Rhinol Laryngol2021; 130: 885–891.
44.
AgilinkoJDreverSKWai LowWK, et al.Acellular dermis (SureDerm®) use for managing pulsatile tinnitus: a long-term follow-up of a novel surgical technique. GMS Interdiscip Plast Reconstr Surg DGPW2021; 10: Doc06.
45.
LiDWangGZengR, et al.Analysis of revision surgery following surgical reconstruction of the sigmoid Sinus wall in patients with pulsatile tinnitus. J Int Adv Otol2022; 18: 358–364.
46.
SpanglerDJMcElveenJTMcLearPW. Sigmoid sinus diverticulum—A unique case of pulsatile tinnitus. Ear Nose Throat J. Published online 2022. doi:https://doi.org/10.1177/01455613221097197
47.
XingYGaoSZhouY, et al.Surgical treatment of pulsatile tinnitus related to the sigmoid sinus. J Otol2023; 18: 21–25.
48.
ChuaCAHanJSKimY, et al.Silencing pulsatile tinnitus: a novel technique of periosteal flap obliteration for sigmoid Sinus diverticulum variants. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol2023; 44: 246–251.
49.
ZhangCLiQLiS. Physical and psychological outcomes of simple sigmoid sinus bony wall repair for pulsatile tinnitus due to sigmoid sinus wall anomalies. Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol - Head Neck Surg2019; 276: 1327–1334.
50.
TownsendRKJostAAmansMR, et al.Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations. J NeuroInterventional Surg2022; 14. neurintsurg-2021-017361. doi:https://doi.org/10.1136/neurintsurg-2021-017361
51.
LiuLMuZKangY, et al.Hemodynamic mechanism of pulsatile tinnitus caused by venous diverticulum treated with coil embolization. Comput Methods Programs Biomed2022: 215. doi:https://doi.org/10.1016/j.cmpb.2022.106617
52.
AmansMRHaraldssonHKaoE, et al.MR Venous flow in sigmoid Sinus diverticulum. AJNR Am J Neuroradiol2018; 39: 2108–2113.
53.
ZengRWangGPLiuZH, et al.Sigmoid sinus wall reconstruction for pulsatile tinnitus caused by sigmoid sinus wall dehiscence: A single-center experience. PLoS ONE2016; 11. doi:https://doi.org/10.1371/journal.pone.0164728
54.
CharbonnierGCancelliereNMRusticiA, et al.Venous balloon test occlusion for pulsatile tinnitus assessment: a clinical feasibility study. Interv Neuroradiol. Published online May 25, 2023: 159101992311781. doi:https://doi.org/10.1177/15910199231178160
