|Year : 2011 | Volume
| Issue : 3 | Page : 123-126
Dilated petrosquamosal sinus, mastoid emissary vein, and external jugular vein: A rare cause of pulsatile tinnitus, vertigo, and sensorineural hearing loss
H Alsherhri1, B Alqahtani2, M Alqahtani3
1 Prince Salman Hospital, Riyadh, Saudi Arabia
2 King Saud Medical City, Riyadh, Saudi Arabia
3 Riyadh Military Hospital, Riyadh, Saudi Arabia
|Date of Web Publication||26-Dec-2011|
King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
We describe the clinical and radiological finding in a 57-year-old male with dilated petrosquamosal sinus, mastoid emissary vein, and external jugular vein on the right side; presented with pulsatile tinntus for three years and associated with vertigo and mild hearing loss in the right ear with normal clinical examination. Audiological assessment revealed mild sensorineural hearing loss in the right ear and normal tympanogram. Computed tomography scan with contrast show dilated petrosquamosal sinus, mastoid emissary vein, and external jugular vein on the right side showing the relationship between this abnormality and pulsatile tinntus, vertigo, and sensorineural hearing loss as one of differentials and its surgical importance in ear surgery as the first case to be reported with this combination of anomalies.
Keywords: External jugular vein, Mastoid emissary vein, Petrosquamosal sinus, Pulsatile tinntus, Sensorineural hearing loss
|How to cite this article:|
Alsherhri H, Alqahtani B, Alqahtani M. Dilated petrosquamosal sinus, mastoid emissary vein, and external jugular vein: A rare cause of pulsatile tinnitus, vertigo, and sensorineural hearing loss. Indian J Otol 2011;17:123-6
|How to cite this URL:|
Alsherhri H, Alqahtani B, Alqahtani M. Dilated petrosquamosal sinus, mastoid emissary vein, and external jugular vein: A rare cause of pulsatile tinnitus, vertigo, and sensorineural hearing loss. Indian J Otol [serial online] 2011 [cited 2019 Apr 23];17:123-6. Available from: http://www.indianjotol.org/text.asp?2011/17/3/123/91196
| Introduction|| |
Tinntus is one of the annoying symptoms which may vary from negligible to severe that may lead to depression or suicide. Around 10% of population in the USA has tinnitus and 60% of them have no diagnosis, despite extensive workup done for them. 
Tinnitus is of two types: subjective and objective; in subjective, noise is only heard by the patient and it can be on one side or on both the sides with the association of other symptoms like sensorineural hearing loss or vertigo. It can be associated with conditions like drug, allergy, or systemic illness, while objective one can be heard by both patients, and examina, which most of the time is related to a vascular cause. 
Complete history and examinations including ear examination, auscultations, other neurological symptoms and signs like cranial nerves involvement, hearing loss, vertigo, or if related to previous trauma or ear surgery can give clues to differentiate between types of tinnitus, usually vascular cause suggested if tinnitus is pulse synchronous. 
Imaging studies are helpful in this condition, especially if tinnitus is permanent or associated with change in other tests like auditory brainstem response or hearing loss in pure tone audiometery. ,
| Case Report|| |
A 57-year-old male with controlled diabetes mellitus and mild hypertension, presented with tinnitus for three years (continuous, pulsatile, high pitch, synchronous with heart beating). It gets relieved occasionally after he play sports and take shower and then starts again after few hours.
Vertiginous attacks for two years (lasting for 20-60 minutes), true vertigo, it was related to head movement when he turned his head to either sides, but more toward the right side, and associated with nausea, vomiting, sweating and imbalance, no change of tinnitus, no aural fullness or hearing loss during the attacks, no cardiac or neurological symptoms, no headache. Three attacks of vertigo during the first year and five attacks during the last year have been observed. The last one is the most severe one lasting for seven hours, which was two months ago and has been admitted in the hospital and was associated with hearing loss in the right ear. He claimed that his hearing loss improved after iv cephazoline. No family history of similar complaints or migraine. He mentioned that he can predict that he will have vertigo. Now, since the last vertiginous attack two months ago, no more attacks of vertigo have been observed, but still continues to have tinnitus and mild hearing loss, occasional imbalance mainly on the right side. He avoids looking quickly to right or left, instead he moves the head slowly to each side because when he turns the head quickly, he experiences vertigo. He was diagnosed of Mιniθre's disease and was started on betahistine dihydrochloride, but has shown no improvement.
Physical examinations were unremarkable including auscultation of the post auricular area and pressure on internal jugular vein does not change the tinnitus, but after Computed tomography (CT) finding, re-evaluation of the patient has shown that the noise has decreased when applying pressure over area of right external jugular vein with low pitched sound over that area and pre-auricular area as well going with tinnitus. Normal balance tests and no nystagmus has been observed. PTA mild SNHL mainly in middle and higher frequency
Tympanogram was normal. ENG was not done. Routine blood works were normal.
CT scan with contrast for head and neck was done and it has shown the following:
- Right prominent petro-squamosalsinus
- Dilated right mastoid emissary vein
- Dilated right external jugular vein
- Widen right post-glenoid foramen
- No inner ear anomaly
- No neck mass, no compression over right external jugular vein or thoracic inlet.
| Discussion|| |
Tinnitus has many classifications; one of them is subjective, where the noise is heard by the patient only; and the other is objective tinnitus, where the noise can be heard by both, the patient and the examina. There are many causes for subjective tinnitus like labrynthitis, otits media, ototoxicity, and otosclerosis. 
Objective tinnitus, like in our patient, can be further divided into pulsatile and non-pulsatile; and pulsatile objective tinnitus can be due to intracranial or extracranial origin. In around 70% of the patients with this type of tinnitus, the diagnosis will be achieved by imaging studies and treatment plan can be started accordingly. 
In our patient, the imaging study used was CT scan with intravenous contrast and it was enough to reach the diagnosis and to see other associated anomalies that may share to cause the blood flow turbulent, and hence tinnitus was from venous origin. There are many different causes of objective pulsatile tinnitus due to venous origin like high jugular bulb or enlarged jugular foramen, which can be defined as dilated when the difference between vascular portion of jugular foramen diameter is more than two cm,  but in our patient, the difference was less than two cm; so we can rule out the jugular foramen cause.
In general, emissary veins connect the internal and external venous network of the skull. Sometimes, turbulents of blood flow can cause noise (tinnitus) which may be decreased by applying pressure to area of responsible vein. Mastoid emissary vein connect suboccipital venous plexus to sigmoid sinus through mastoid foramen.  Its diameter normally varies from 0.8 mm to 4.5 mm, if it is less than 0.8 mm, we will consider it as rumentery and if it is more than 4.5 mm, it will be considered as dilated. ,,, Right mastoid emissary vein diameter in our patient was about 10 mm, so we consider it as a dilated vein [Figure 1], which is the most common emissary vein that can cause objective venous plusatile tinnitus, but due to its place, applying pressure to its area was difficult to decide if we completely stopped that vein flow and then tinnitus or not.
Other causes like condyler emissary vein and rarely transverse sinus stenosis.  All the previous structures were normal in our patient.
Other abnormal finding in our patient was dilated petro-squamosalsinus in right side and its diameter varies from 4.4 mm to 6.8 mm [Figure 2]. Petro-squamosalsinus was first described by Knott in 1881 and was named a Knott sinus. , It is presented in fetal life and developed from pro-otic group of veins, connecting deep temporal vein to transverse sinus. It is running in the angle between petrous and squamous part of temporal bone. 
The communication between deep temporal and transverse sinus through post glenoid foramen that hosting postglenoid fetal vein. ,,, Its diameter was 5 mm [Figure 3]. Then, continuation of temporal vein to external jugular vein which was also dilated in this patient with no abberant distal obstruction, the diameter of external jugular vein was 11.7 mm [Figure 4]. This explains the reason when applying pressure over the area of deep temporal vein or external jugular vein causes decrease in tinnitus pitch by 50% according to the patient and does not disappear completely due to the presence of mastoid emissary vein dilatation. Petro-squamosalsinus was described before CT scan based on temporal bone disecssions, , but now-a-days, CT scan give us an excellent tool to help in the diagnosis of vascular anomaly in temporal bone which is much easier and faster with detailed description of the structure. We use CT scan with contrast to help in diagnosis of this case and 3D reconstructive method was very helpful to see courses of these abnormal veins and position of gleniod foramen [Figure 4].
|Figure 4: 3D reconstructive CT showing different venous abnormality in right side|
Click here to view
Petro-squamosalsinus was reported in patients with different clinical presentation like sensorineural hearing loss, conductive hearing loss, vertigo, and founded in a patient with CHARGE association. 
Both petro-squamosalsinus and dilated mastoid emissary veins were reported in two patients; one with conductive hearing loss and the other with sensorineural hearing loss.  But in this case, the patient has sensorineural hearing loss, tinnitus, and vertigo which made Mιniθre's disease as one of the strong defferntial. We can't explain the presence of vertigo in this patient although it was reported before, but tinnitus presentation is first time to be reported in association with petro-squamosalsinus. The combination of presence of petro-squamosalsinus, dilated mastoid vein, dilated external jugular vein, tinnitus, vertigo, and sensorineural hearing loss is first described in our patient which was not described before in the literature.
In general, presence of any vascular anomaly in the temporal bone raise the hazard of surgical procedure in such patients as severe bleeding. ,
Our management was reassurance of the patient, explaining the nature of his problem, neglecting tinnitus and there is no serious disease like malignant tumor. Also, we asked him to avoid turning his head quickly to any side in order to minimize the attacks of vertigo. With the follow-up of every six months, the patient has informed us that he has been following our instructions well and that he is felling much better now with only one mild attack of vertigo over the last six months, and tinnitus is still there, but it is not annoying him anymore.
| Summary|| |
Tinnitus and vertigo are annoying symptoms which need a lot of work-up to reach the proper diagnosis. Patients with petro-squamosalsinus (PSS), dilated mastoid emissay vein, and external jugular vein may be presented with vertigo, tinnitus, and hearing loss. CT scan is a very helpful tool to diagnose those patients with excellent result by reassurance when the patient has idea about his/her disease. This combination of anomalies is first time to be described in the literature.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]