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Toward a Diagnostic Imaging Algorithm for Undifferentiated Pulsatile Tinnitus
Caitlin Cavarocchi1, Kevin Wong1, Austin C Cao1
1Department of Otorhinolaryngology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Objective:
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.
Study Design:
Retrospective.
Setting:
Single otology/neurotology clinic.
Subjects:
Patients with PT presenting between 2009 and 2020.
Main Outcome Measures:
Sensitivity, specificity, diagnostic yield, and diagnostic accuracy.
Results:
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.
Conclusions:
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.
