The Laryngoscope Lippincott Williams & Wilkins, Inc. © 2006 The American Laryngological, Rhinological and Otological Society, Inc. Objective Pulsatile Tinnitus: A Video Clip Demonstration of the Condition Jayesh Doshi, MBChB(Hons), MRCS(Edin); Shahram Anari, MD, MRCS; Sean Carrie, FRCS(ORL) Pulsatile tinnitus is an uncommon condition. We describe a case of pulsatile tinnitus and visu- ally demonstrate a pulsating tympanic membrane caused by a postoperative cerebrospinal leak into the mastoid air cells following resection of a left temporal petrous meningioma. To our knowledge, this is the first case in the literature where an objective pulsatile tinnitus has been captured on video (see www.laryngoscope.com). Laryngoscope, 116:1926, 2006 CASE REPORT A 72-year-old woman underwent microvascular decompres- sion of her left trigeminal nerve by the neurosurgeons for trigem- inal neuralgia. The cause of her symptoms was found to be from a left petrous meningioma compressing the superior cerebellar artery onto the fifth cranial nerve. The meningioma was resected successfully however the operation was complicated by a small dural venous tear which was stopped with Surgicel (oxidized cellulose; Johnson & Johnson, New Brunswick, NJ). Postopera- tively she made an unremarkable recovery. Two months later she presented with a week’s history of decreased hearing and tinnitus in her left ear and she was referred for an otolaryngology assess- ment. Clinical examination with a non-pneumatic otoscope re- vealed fluid behind a pulsating left tympanic membrane; the pulsation was synchronous with her arterial pulse. The right ear was normal. Pure tone audiometry showed a left-sided conductive hearing loss down to 50 dB with an air-bone gap of 30 dB. A computed tomography (CT) scan revealed opacification of her left mastoid cells. A cerebrospinal fluid leak into the mastoid cells was suspected and she underwent exploration of the operation site by the neurosurgeons. This confirmed the presence of an extradural cerebrospinal fluid collection arising from an iatro- genic communication between the upper end of the craniotomy and the mastoid air cells. This defect was repaired with bio-glue. Postoperatively the pulsatile tinnitus had completely resolved and the follow-up at six months was unremarkable. DISCUSSION Pulsatile tinnitus is a rare condition. The causes of pulsatile tinnitus are commonly divided into vascular or nonvascular cases. Vascular causes include abnormalities of the jugular bulb and internal carotid artery. Nonvascular causes include intracranial hypertension, skull base menin- goceles and medication (enalapril, verapamil). 1 There are numerous cases in the medical literature describing vascular and non-vascular causes of pulsatile tinnitus. 2,3,4,5 One case report used a static picture to demonstrate a glomus tumor as a cause for pulsatile tinnitus. 6 Our case is unique as it includes a dynamic real time visual demonstration of the pulsating tympanic mem- brane through non-pneumatic otoscopy (see www.laryngo- scope.com). This pulsatile tinnitus was due to transmis- sion of the dural pulsation through the leaking cerebrospinal fluid into the mastoid air cells that could be consequently visualized in the left middle ear by the pul- sating tympanic membrane. This is a rare cause for pul- satile tinnitus but emphasizes the importance of accurate history taking, especially in relation to the chronology of events to identify any precipitating factors (e.g., the past surgical treatments). BIBLIOGRAPHY 1. Kale SU, Pfleiderer AG, Cradwick JC. Bilateral defects of the tegmen tympani associated with brain and dural prolapse in a patient with pulsatile tinnitus. J Laryngol Otol 2000; 114(11):861– 864. 2. Koizuka I, Hattori K, Tsutsumi K, et al. Objective tinnitus caused by an aberrant internal carotid artery. Auris Nasus Larynx 1998;25(3):323–7. 3. Vories A, Liening D. Spontaneous dissection of the internal carotid artery presenting with pulsatile tinnitus. Am J Otolaryngol 1998;19(3):213–5. 4. Yao W, Benjamin LC 3rd, Korzec K. Aberrant internal carotid artery causing erosion of the otic capsule: an unusual cause of pulsatile tinnitus. Otolaryngol Head Neck Surg 1998; 118(5):678 –9. 5. Biousse V, Newman NJ, Lessell S. Audible pulsatile tinnitus in idiopathic intracranial hypertension. Neurology 1998; 50(4):1185– 6. 6. Woo JK, van Hasselt CA. Pulsatile tinnitus illustrated. Oto- laryngol Head Neck Surg 1997;117(3 Pt 1):292. From the Department of Otolaryngology, Freeman Hospital, New- castle Upon Tyne, UK. Editor’s Note: This Manuscript was accepted for publication July 25, 2006. Send correspondence to Jayesh Doshi, Apartment 20 Adderstone Court, 17 Adderstone Crescent, Jesmond, Newcastle Upon Tyne NE2 2EA, United Kingdom. E-mail: jayeshdoshi@hotmail.com DOI: 10.1097/01.mlg.0000240968.55613.5d Laryngoscope 116: October 2006 Doshi et al.:Pulsatile Tinnitus Video 1926