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Carotid Endarterectomy Relieves Pulsatile Tinnitus Associated with Severe Ipsilateral Carotid Stenosis

      Abstract

      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.

      Keywords

      1. Introduction

      Pulsatile tinnitus is a rare and disabling condition that can significantly impair quality of life with an increased risk of suicide in severe cases.
      • Lewis J
      • Stephens D
      • Huws D
      Suicide in tinnitus sufferers.
      • Folmer R.L
      • Griest S.E
      • Meikle M.B
      • Martin W.H
      Tinnitus severity, loudness and depression.
      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.
      • Waldvogel D
      • Mattle H.P
      • Sturzenegger M
      • Schroth G
      Pulsatile tinnitus-a review of 84 patients.
      • Sismanis A
      Pulsatile tinnitus.
      A number of surgical procedures for pulsatile tinnitus have been described.
      • Waldvogel D
      • Mattle H.P
      • Sturzenegger M
      • Schroth G
      Pulsatile tinnitus-a review of 84 patients.
      In those cases relating to carotid artery disease only three case reports have been published: Two advocated ipsilateral carotid endarterectomy (CEA);
      • Carlin R.E
      • McGraw D.J
      • Anderson C.B
      Objective tinnitus resulting from internal carotid artery stenosis.
      • Louwrens H.D
      • Botha J
      • Van Der Merwe D.M
      Subjective pulsatile tinnitus cured by carotid endarterectomy.
      one highlighted the success of a contralateral endarterectomy.
      • Norman L.K.V
      • West P.D.B
      • Perry P.M
      Unilateral pulsatile tinnitus relieved by contralateral carotid endarterectomy.
      Ligation of the external carotid artery has been attempted in the past, particularly for tinnitus related to A-V malformations.
      • Waldvogel D
      • Mattle H.P
      • Sturzenegger M
      • Schroth G
      Pulsatile tinnitus-a review of 84 patients.
      Internal jugular vein ligation and surgical lowering of a high bulb
      • Couloigner V
      • Grayeli A.B
      • Bouccara D
      • Julien N
      • Sterkers O
      Surgical treatment of the high jugular bulb in patients with Meniere's disease and pulsatile tinnitus.
      have also been postulated in relation to pulsatile tinnitus that can be ablated by pressure over the internal jugular vein or altered head posture, a manoeuvre first described by Mann in 1906.
      • Waldvogel D
      • Mattle H.P
      • Sturzenegger M
      • Schroth G
      Pulsatile tinnitus-a review of 84 patients.
      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.

      3. Results

      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.
      Table 1Demographic features of the study group
      Median Age68.8yrs (53-80)
      Male10 (72%)
      Female4 (28%)
      Side of operation:
      There are 16 CEA's in the case group because two were bilateral.
      Right6 (37%)
      Left10 (63%)
      There are 16 CEA's in the case group because two were bilateral.
      Table 2Presenting symptoms
      Pulsatile Tinnitus9 (64%)
      TIA's2 (14%)
      CVA0
      Amaurosis Fugax0
      Asymptomatic3 (21%)
      Table 3Details of case group
      PatientAgeSide of TinnitusSide of OperationSymptom reliefSide of bruitPost-operative bruitsPre-operative DuplexPost-operative Duplex
      169LeftBilateralNoLeftNoLeft 80–99%, Right 80–99%Patent
      263LeftLeftYesLeftNoLeft 80–99%Patent
      365RightRightYesRightNoRight 80–99%Patent
      474RightRightYesBilateralNoRight 50–79%Patent
      567BilateralLeftNoLeftNoLeft 80–99%Patent
      678LeftLeftPartialNoNoLeft 80–99%Patent
      780LeftRightPartialBilateralLeftRight 50–79%Left 50–79%, Right patent
      871RightRightYesRightNoRight 80–99%Patent
      966BilateralLeftNoLeftNoLeft 80–99%Patent
      1053LeftBilateralYesBilateralBilateralLeft 80–99%, Right 50–79%Left 50–79%, Right 80–99%
      1163LeftLeftYesNoNoLeft 80–99%Patent
      1269LeftLeftNoLeftNoLeft 80–99%Patent
      1370LeftLeftYesLeftNoLeft 80–99%Patent
      1475RightLeftYesLeftNoLeft 50–79%patent
      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).

      4. Discussion

      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.
      The North American Symptomatic Carotid Endarterectomy Trial Collaborators
      Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis.
      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.
      • Waldvogel D
      • Mattle H.P
      • Sturzenegger M
      • Schroth G
      Pulsatile tinnitus-a review of 84 patients.
      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,
      • Davies K.N
      • Humphrey P.R
      Do carotid bruits predict disease of the internal carotid arteries?.
      • Murie J.A
      • Sheldon C.D
      • Quin R.O
      Carotid artery bruit: association with internal carotid stenosis and intraluminal turbulence.
      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.

      5. Conclusion

      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.

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