Pulsatile tinnitus arising from jugular megabulb deformity: a treatment rationale

Pulsatile tinnitus is a rare presenting symptom in patients with enlarged jugular bulbs. We will describe three young women presenting with right pulsatile tinnitus associated with a megabulb deformity of the temporal bone. After extensive radiologic and audiologic evaluation, no vascular or bony abnormalities could be identified. All three patients demonstrated pulsatile bruits over the right temple. Pulsatile tinnitus disappeared with ipsilateral jugular compression suggesting flow rather than pressure to be responsible for abnormal auditory symptoms. This observation formed the basis of our treatment recommendations. Because of progressively debilitating pulsatile tinnitus, two patients elected right internal jugular vein ligations under local anesthesia. Both patients were relieved of tinnitus. We conclude that jugular vein ligation can be a safe and effective surgical treatment for pulsatile tinnitus resulting from a jugular megabulb deformity, provided two criteria are met: 1. The presence of an expanding tumor is ruled out. 2. The presence of contralateral venous drainage is established by angiography or brain scan. Anatomic and functional hemodynamic considerations of brain circulation will be emphasized in the discussion of our treatment rationale.