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Subjective pulsatile tinnitus cured bycarotid endarterectomyA case report

H. D. LOUWRENS, J. BOTHA, D. M. VAN DER MERWE

A 70-year-old woman with unilateral pulsatile tinnitus wasrelieved of the complaint after carotid endarterectomy. Internalcarotid artery stenosis presenting with pulsatile tinnitus israre. Endarterectomy can relieve symptoms if the correctdiagnosis is made.

S AIr Med J 1989; 75: 496-497.

Case report

An otherwise healthy 70-year-old woman with unilateral tinni­tus was referred to Tygerberg Hospital by her general practi­tioner. The tinnitus, confined to the left ear, was accentuatedby bending forward and by reclining at night. In the absenceof environmental noise, the 'bicycle pumping' in the left earwas more troublesome. The patient volunteered that the noisewas synchronous with her heartbeat.

On examination a loud systolic murmur, localised to the leftcarotid bifurcation, was detectable. Duplex Doppler examina­tion confirmed the presence of a type D2 stenosis of the left

Departments of Surgery and Otorhinolaryngology, Uni­versity of Stelienbosch and Tygerberg Hospital, Parow­valiei, CPH. D. LOUWRENS, M.B. CH.B., M.MED. (CHIR.), F.CS. (S.A.)

J. BOTHA, M.B. CH.B.

Panorama Medical Centre, Rothschild Boulevard, Parow,CPD. M. VAN DER MERWE, M.B. CH. B., M.MED. (CHIR.), F.CS. (S.A.),

F.R.C.S.

Accepted 6 July 1988.

internal carotid artery (80 - 99%) and a D 1 stenosis of the rightinternal carotid artery (50 - 79%). However, no murmur wasdetectable over the right carotid bifurcation. The ultrasono­graphic fmdings on the Doppler scan were confIrmed bycarotid angiography (Fig. 1).

The diagnosis of pulsatile tinnitus was one of exclusion ofother causes made by the Department of Otorhinolaryngology.

Endarterectomy of the left internal carotid artery completelyrelieved the patient's symptoms, which have not recurred.

Discussion

Pulsatile tinnitus, a rare symptom of carotid artery stenosis, isthe perception of sounds synchronous with the heartbeat.Accurate diagnosis of pulsatile tinnitus is important since it isusually amenable to therapy and progression of the underlyingdisease can be detrimental to health. l Except for intraluminalarterial irregularities, other arterial causes of tinnitus includearteriovenous shunts and arterio-arterial shunts of varioussorts. Non-arterial causes are: cervical venous hum; elevatedcardiac output; heart murmurs; abnormalities of the jugularbulb; elevated intracranial pressure; vascular neoplasms of theinternal ear; and primary intratemporal bone meningiomas.

Careful assessment of the patient is mandatory before carotidendarterectomy can be considered. 0ne approach l to a defInitediagnosis by way of exclusion of other possible causes mightconsist of otoscopic examination and audiological assessmentfollowed by computed tomography of the head. Should thesetests prove negative and papilloedema is present, a lumbarpuncture should be performed carefully to exclude raisedintracranial pressure. Finally, an arteriogram will confirm the

Fig. 1. Riglit carotid system.

presumed diagnosis and exclude other arterial and non-arterialcauses.

The acrual reduction in surface diameter necessary to producea bruit varies greatly and depends on the character of theplaque, which in turn -determines the amount of turbulentflow present. In our patient significant stenoses were presentin both internal carotid arteries but there was bruit andtinnitus only on the left.

The probable mechanism which caused pulsatile tinnitus inthis patient was the conduction of sound energy by the skulJ.2Since the source of energy generation was in close proximityto the skull, the physiological mechanisms responsible for theattenuation of normal body sounds were inadequate to copewith this abnormal body sound. Consequently, the murmurwas perceived as pulsatile tinnitus especially in the absence ofambient noise.

After endarterectomy, both bruit and symptoms disappearedsimultaneously.

SAMT VOL 75 20 MEI 1989 497

Fig. 2. Left carotid system.

We thank Professor D. F. du Toit for critical review of themanuscript.

REFERENCES

l. Levine SB. Puls.tile tinnitus. Laryngoscope 1987; 97: 401-406.2. B.l1anryne J, Groves J. Diseases of rhe Ear, Nose and Throat. 4th ed.

London: Bunerworths, 1979: 96-98.