Surgical treatment of pulsatile tinnitus arising from sigmoid sinus wall anomalies

Pulsatile tinnitus (PT) caused by sigmoid sinus (SS) wall anomalies, most commonly diverticulum and dehiscence, represents a prevalent and potentially reversible venous etiology. This narrative review summarizes contemporary concepts in diagnosis and treatment and proposes a practical framework for clinical decision-making. The characteristic features of venous-type PT are first outlined, with emphasis on strict clinicoradiologic correlation using high-resolution temporal bone computed tomography and magnetic resonance venography to distinguish SS wall abnormalities from other vascular causes, such as dural arteriovenous fistulas (AVFs), high-riding jugular bulbs, and idiopathic intracranial hypertension. Patient selection, contraindications, and clinical "red flags" are then discussed, with particular attention to scenarios in which transmastoid surgery may be ineffective or pose substantial risk and in which systemic therapy or venous sinus stenting should be prioritized. The main transmastoid strategies include sinus wall resurfacing, tailored re-roofing with autologous bone, and diverticulectomy with multilayer reconstruction. These strategies are compared with endovascular approaches in terms of their technical principles, indications, and reported outcomes. Particular attention is given to reconstructive materials, such as polymethylmethacrylate cement, hydroxyapatite, and bone grafts, with consideration of their short- to midterm performance and the current limitations of evidence regarding long-term durability. Integrating these considerations, a stepwise algorithm is proposed to guide the selection of conservative, surgical, or endovascular treatment based on symptom profiles and imaging findings. In carefully selected patients, these strategies can achieve high rates of PT improvement and meaningful gains in quality of life, while highlighting the need for prospective outcome studies with long-term follow-up.