If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Objectives. Pulsatile tinnitus is a rare and often disabling condition. Pulsatile tinnitus sometimes occurs in patients with severe atherosclerotic carotid stenosis. It is uncertain whether carotid endarterectomy (CEA) relieves pulsatile tinnitus in patients with severe carotid stenosis.
Design, Materials and Methods. This is a retrospective study of 14 patients with pulsatile tinnitus who underwent CEA. Demographic and clinical features and pre-operative duplex results were recorded. Operative results in this group were assessed.
Results. CEA relieved symptoms of pulsatile tinnitus in 10 out of 14 cases (70%). Of 10 patients that had lateralisable tinnitus and ipsilateral surgery, 9 (90%) reported symptomatic improvement.
Conclusions. CEA is effective in improving pulsatile tinnitus in patients with unilateral symptoms and severe ipsilateral carotid stenosis.
Pulsatile tinnitus is usually related to A-V malformations, arterio-venous fistulae, either congenital or post-traumatic in origin, or benign intra-cranial hypertension. Carotid atherosclerotic disease less commonly causes pulsatile tinnitus, accounting for 8–16% of cases.
The aim of this study is to see whether CEA relieves pulsatile tinnitus in patients with significant carotid artery disease, and to document the clinical circumstances of the presentation of pulsatile tinnitus due to carotid stenosis.
2. Materials and Methods
A list of all 658 patients that had undergone CEA at the Princess Alexandra Hospital, Brisbane, Australia, between 1993 and 2000, was obtained from the operating theatre database. The charts of these patients were examined for documentation of the symptom pulsatile tinnitus to identify the study cohort. Demographic data, symptomatology details and duplex ultrasound scan results of this cohort were recorded. Patients with pre-operative pulsatile tinnitus were contacted to determine the effect of surgery on that symptom if that was not recorded in the hospital chart. Confounding factors, such as thyroid disease and other causes of hyperdynamic circulation were sought in the patient's chart. A history of hypertension was noted. All CEA operations were performed by one of six consultant vascular surgeons.
Of 658 patients that underwent CEA, 17 (2.6%) had pulsatile tinnitus. Three patients were lost to follow-up. The remaining 14 formed the study cohort. The results of the study group demographics and presenting symptoms are shown in Table 1, Table 2. Details of the clinical findings, duplex ultrasound scans and treatment outcomes are in Table 3. In no cases were hyperthyroidism or other causes of a hyperdynamic circulation present.
In 12 cases tinnitus was unilateral and in two bilateral or generalised. Ten cases gained symptom relief (71%) following CEA. Eight reported complete resolution and two significant improvements in pulsatile tinnitus symptoms. Nine of the 10 patients that had improvement post-operatively, underwent CEA for a severe stenosis ipsilateral to the side of pulsatile tinnitus. One patient with improvement underwent CEA of a severe stenosis contralateral to the side of pulsatile symptoms. Of the four patients with no improvement of tinnitus following CEA: two had bilateral tinnitus pre-operatively, one underwent partial resection of a tortuous internal carotid artery (ICA) and ICA reconstruction in addition to CEA and one had bilateral severe stenosis with bilateral endarterectomy.
In nine patients the endarterectomy wound was closed primarily. Four had ‘Braun’ patch angioplasty and one an internal carotid artery reconstruction. There were no transient ischaemic attacks, strokes or deaths in the 30-day post-operative period.
Thirteen (93%) had audible bruits pre-operatively. All four patients that did not gain relief of tinnitus had unilateral carotid bruits on the same side as their surgery. The bruits were absent post-operatively in all the unsuccessfully treated patients. Of the 10 patients that did benefit in terms of relief of tinnitus: nine had a pre-operative bruit with three of these being bilateral and two had bruits post-operatively (Table 3).
CEA is performed to reduce the risk of stroke in symptomatic patients with a stenosis greater than 50% and in patients with a severe asymptomatic stenosis in whom life expectancy is good.
Pulsatile tinnitus is a disabling symptom that occurred infrequently in our series being present in only 2.6% of patients undergoing CEA. Whilst pulsatile tinnitus was present in all study cases, it was of such severity that it was the presenting symptom that lead to investigations that ultimately lead to CEA in 9 (64%) of these cases.
The demographic and clinical findings of our cohort with pulsatile tinnitus were similar to other patients undergoing CEA. Other authors have reported that pulsatile tinnitus predominantly affects the 20–40 years age group and is rare in those over 65 years old.
However, their samples included aetiologies other than carotid atheromatous disease, such as A-V malformations, which occur in younger patients.
This study of 14 cases shows that CEA relieved pulsatile tinnitus in nine out of ten patients (90%) with the following criteria:
Lateralisation of symptoms.
CEA ipsilateral to side of pulsatile tinnitus.
One patient had lateralisable symptoms but underwent a contralateral endarterectomy with symptom improvement. Patients with bilateral tinnitus did not have symptom relief following CEA, although there were only two such cases. CEA is usually performed on the basis of carotid duplex ultrasound scanning without angiography at our institution, so we do not have information about the presence of intracranial stenotic disease in these patients.
To conclude that pulsatile tinnitus is due to turbulent blood flow through the internal carotid artery would pre-suppose that a pre-operative carotid bruit would disappear post-operatively. Our series confirms that there does not appear to be any connection between a bruit and pulsatile tinnitus,
with resolution of the bruit in all cases with persistent tinnitus and with residual bruits in two cases with symptom resolution.
The primary aim of CEA remains stroke prevention. The results of this study may assist vascular surgeons advising patients undergoing CEA about the likelihood of the additional benefit of resolution of pulsatile tinnitus if present.
This is the largest series to look at the effect of CEA on pulsatile tinnitus. CEA improved pulsatile tinnitus in 10 of the 14 cases (70%). This proportion was increased to 90% in patients with unilateral symptoms and ipsilateral disease with ipsilateral CEA. Patients with pulsatile tinnitus should be properly assessed to look for causes other than carotid atheroma before advising on prognosis or considering any possible treatments. CEA is effective in improving pulsatile tinnitus in patients with severe carotid stenosis.
To submit a comment for a journal article, please use the space above and note the following:
We will review submitted comments as soon as possible, striving for within two business days.
This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
We require that commenters identify themselves with names and affiliations.