Surg Radiol Anat
DOI 10.1007/s00276-016-1629-6
ORIGINAL ARTICLE
The relationship between tinnitus and vascular anomalies
on temporal bone CT scan: a retrospective case control study
Betul Kizildag1 • Nagihan Bilal1 • Nursel Yurttutan1 • Mehmet Akif Sarica1
Gulay Gungor1 • Murat Baykara1
Received: 2 July 2015 / Accepted: 18 January 2016
Ó Springer-Verlag France 2016
Abstract
Introduction Tinnitus is a common symptom in which
etiology is unclear in a group of patients. Some of anatomic
or vascular variations diagnosed on temporal bone com-
puted tomography (CT) has been known to cause tinnitus
particulary pulsatile form. Therefore significance of these
anatomic variations has not been validated in patients with
nonpulsatile tinnitus. The aim of this study is to ascertain
several anatomic variations previously attributed to pul-
satile tinnitus in nonpulsatile tinnitus patients. And sec-
ondly to assess the relationship between the amount of
sigmoid sinus bulging and mastoid emissary vein (MEV),
enlargement of those was not evaluated before in tinnitus
patients.
Methods Retrospectively, temporal bone CT scans of 70
patients with an existing complaint of tinnitus with unex-
plained etiology were enrolled. As a control group, 70
patients were selected from paranasal sinus CT scans
without any otological or clinical findings.
Results The type of tinnitus was subjective and nonpul-
satile in the overall group. The diameters of enlarged MEV
on the left side were significantly higher in the tinnitus
group. Carotid canal dehiscence and high riding jugular
bulb were significantly higher in the tinnitus patients.
Petrous bone pneumatization was significantly lower in the
tinnitus patients than in the control group.
Conclusions In patients who complained of subjective
nonpulsatile tinnitus with unknown etiology, some tem-
poral bone vascular variations, including high riding
& Betul Kizildag
dr.betulkizildag@hotmail.com
1
School of Medicine, Sutcuimam University,
Kahramanmaras, Turkey
•
jugular bulb, dehiscent carotid canal, left-sided MEV
enlargement, and petrous bone pneumatization, seemed to
have an association with tinnitus. Further studies compar-
ing all these entities between pulsatile and nonpulsatile
groups and healthy controls should be undertaken.
Keywords Bulging sigmoid sinus
Mastoid emissary
vein
Temporal bone computed tomography
Tinnitus
Introduction
The definition of tinnitus is the perception of various
spontaneous sounds generated inside the head, including
hissing, ringing or sizzling. It is not a rare symptom; it
affects approximately 10 % of the adult population in
England, interfering with the normal quality of life in
0.5 % [1]. Although it is an auditory sensation, it can be
associated with various components, especially otological
diseases, some psychiatric disorders (e.g., anxiety,
depression), drugs (analgesics, antibiotics, antineoplastics),
or addictions (cigarettes, alcohol) [2, 3]. Tinnitus patients
are usually referred to the Ear, Nose and Throat (ENT)
Department [4].
The sensation of tinnitus is experienced heteroge-
neously. Therefore, further discrimination of tinnitus as
pulsatile (synchronous with the heart beat) or nonpulsatile;
subjective or objective; unilateral or bilateral should be
helpful for further investigation or for the management of
patients. For example, an unilateral nonpulsatile tinnitus
complaint should be explored for retrocochlear lesion.
Besides this, pulsatile tinnitus suggests vascular anomaly
or variant commonly identified by imaging techniques [4,
5]. Understanding the mechanisms of tinnitus still remains
a dilemma both in scientific and clinical areas. As a
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hypothesis, maybe some anatomical variations change or
reinforce the increasing tendency of tinnitus or the per-
ception of tinnitus.
Imaging aims to find out a potentially treatable etiology
in tinnitus patients. In pulsatile tinnitus patients, which
constitute 1 % of all tinnitus group, some vascular or
anatomic variations also have been detected in temporal
bone computed tomography (CT), including jugular bulb
anomalies (jugular vein asymmetry, a high jugular bulb, a
dehiscent jugular bulb [1], an aberrant internal carotid
artery (ICA), dehiscent carotid canal [1], sigmoid sinus
(SS) dehiscence/diverticulum [5–7] or petrous bone
pneumatization (PBP) [8].
In daily head and neck radiology practice, we come
across varying grades of bulging of the SS. Laterally swing
of SS has a closer contact with posterior mastoid cells
while medial swing of SS leads proximity to the semicir-
cular canal and endolymphatic sac [9].
The skull of the posterior fossa hosts many valveless
veins passing through calvarial apertures for the drainage
of the posterior fossa sinuses. Mastoid emissary vein
(MEV) is one of them, which connects SS to the posterior
auricular or occipital vein via the mastoid foramen. The
diameter and number of MEV vary from patient to patient
[10]. MEV enlargement was presented as a cause of pul-
satile tinnitus in two distinct cases in the literature [11–13].
As far as we know, the occurrence and significance of
MEV and the bulging SS through the posterior mastoid
have not been detected.
The main goal of this study was to reveal any associa-
tion between the grade of SS bulging and MEV enlarge-
ment in patients with tinnitus. The secondary goal was to
ascertain the incidence and significance of vascular
abnormalities in these patients.
We retrospectively analyzed the temporal bone CT of
patients presenting with tinnitus to determine the grade of
the bulging SS into the posterior mastoid by measuring the
diameter of the SS curve. We also compared the diameter
of MEV between patients with or without tinnitus. We also
detected CT findings on temporal bone of those whowere
previously associated with tinnitus, such as the asymmetric
jugular vein, SS dehiscence/diverticulum, the high jugular
bulb, the dehiscent jugular bulb, the aberrant ICA, carotid
canal dehiscence and PBP. We then compared the inci-
dence of all these entities with a control group.
Materials and methods
Patient population
In this study, we retrospectively browsed medical reports
of patients who were referred to the Radiology Department
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Surg Radiol Anat
from the ENT Department, in a secondary care unit, for
temporal bone CT between September 2014 and May 2015.
Among them, patients with a tinnitus complaint were
extracted for further analysis of their CT scans by three
experienced radiologists (BK, NY, GG). Patients with prior
ear surgery, acoustic schwannoma, meningioma, a history
of or findings of otitis media, hearing loss, and other pos-
sible causes of tinnitus (otosclerosis, hypertension, diabetes
mellitus, anxiety, depression, ototoxic medications, etc.)
were excluded. A total of 70 patients met the inclusion
criteria and the type and localization of tinnitus were noted
for each. As a control group, an additional 70 patients were
selected from consecutive paranasal sinus CT scans cov-
ering the temporal bone without any otological, clinical, or
radiological findings. Ethical approval of the study was
obtained from the ethics committee of our institution.
CT examination protocol
Temporal bone CT studies without a contrast agent were
obtained using a 64 detector-row scanner (LightSpeed
VCT, GE Medical Systems, Milwaukee, WI, USA) with a
standard temporal bone CT protocol, a setting tube voltage
of 130 kVp, a tube current of 100–350 mA, a slice thick-
ness 0.625 mm, a reconstruction increment 1 mm, a scan
field of view (FOV) of 25 cm and a matrix of 512 9 512
with high-resolution bone algorithm. Coronal reformatted
images were created from isometric axial volume data.
Paranasal sinus CT studies were obtained from the same
scanner without a contrast agent.
Image evaluation and analysis
Images were retrospectively evaluated by a consensus of
three experienced professionals. Images were reviewed for
finding those where tinnitus was previously attributed: SS
dehiscence/diverticulum, high jugular bulb, dehiscent
jugular bulb, aberrant ICA, carotid canal dehiscence, and
PBP.
A high riding jugular bulb was defined as the position of
the upper jugular vein (jugular bulb) being higher than the
floor of the internal acoustic canal level [9]. A dehiscent
jugular bulb was defined as the absence of dense bony
septa between the tympanic cavity and the jugular bulb [9].
ICA dehiscence was defined as a lack of cortical cov-
ering of the internal carotid artery in the horizontal portion
of the petrous carotid canal segment near to the petrous
bone [14]. The asymmetric jugular vein and transverse
sinus were defined as being a unilaterally larger internal
jugular vein in continuity with a transverse sinus [15]. PBP
was determined as the air density within the anterior part of
the petrous bone accepting the anterior wall of the ICA as
an imaginary oblique border line [8]. SS dehiscence was
Surg Radiol Anat
defined as the absence of bone surrounding the SS [16]. SS
diverticulum was defined as being an asymmetric protru-
sion within the wall [16]. The aberrant SS was defined as
the course of the SS being more anterior or lateral than
normal [9]. In this study, this is quantified by drawing the
outer margin of the SS in temporal bone at the level of the
cochlea, which creates a C-shaped arc.
MEV was defined as the calvarial venous structure
running from the SS to the posterior auricular or occipital
vein via the mastoid foramen [17]. The largest diameter of
MEV was measured. Dimensions larger than 1.5 mm were
recorded as a sign of enlargement. On each image, mea-
surements from MEV and SS curve on temporal bone were
achieved. The measurements of the curve of the SS bulging
is shown in Fig. 1 and the MEV is shown in Fig. 2.
Statistical analysis
We performed all statistical analyses using SPSS statistics
22 (IBM, Armonk/NY, USA). In our cohort, the Mann–
Whitney U test and Pearson correlation analysis were
performed. p values below 0.05 were considered
significant.
Results
This study consisted of 70 tinnitus and 70 control
patients—a total of 140 patients overall. The age distri-
bution of all the patients ranged from 10 to 73 years with a
Fig. 1 Displaying measurement of sigmoid sinus bulging; dashed
line indicates borders of the curve on the bone. Thick yellow line is
depth of curve on mastoid bone (color figure online)
Fig. 2 Mastoid emissary vein enlargement on right side in a 40-year-
old male with left sided tinnitus
mean age of 42.1. Gender distribution in the tinnitus group
was 36 (51.4 %) male and 34 (48.6 %) female; in control
group the distribution was 45 (64.3 %) male and 25
(35.7 %) female. The ‘‘side’’ of tinnitus was left in 40 %,
right in 32.9 %, and bilateral in 27.1 % of patients. The
type of tinnitus was subjective and nonpulsatile overall.
The frequencies of the appearance of the asymmetric
jugular vein, the high riding jugular bulb, jugular vein
dehiscence, PBP, MEV enlargement are demonstrated in
Table 1.
The mean MEV widths in the whole group were
2.32 ± 0.79 mm on the right side and 2.23 ± 0.76 mm on
the left; in the control group 2.28 ± 0.76 mm on the right
side and 1.96 ± 0.58 mm on the left; in the tinnitus group
2.34 ± 0.82 mm on the right side and 2.36 ± 0.81 mm on
the left. MEV diameters and SS curve mean diameters are
shown in Table 2. In both the tinnitus patient group and the
control group, there was no evidence of SS
dehiscence/diverticulum.
The gender balance was the same in each group;
however, the average age in the control group was
younger than that of the tinnitus group. No significant
difference was noted between the two groups in terms of
jugular vein asymmetry, the diameters of SS curve on
each side, and the diameters of MEV on the right side
(Table 2). The diameters of MEV on the left side were
significantly higher in the tinnitus patient group than in
the control group.
Carotid canal dehiscence was significantly higher in the
tinnitus group (p = 0.043). High riding jugular bulbs were
detected more frequently in patient group (p = 0.005).
PBP was not significantly strong, but it was lower in the
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Table 1 The frequencies of the

No. of patient % No. of control %
appearance of the asymmetric
jugular vein, the high riding CT 70 100 70 100
jugular bulb, jugular vein and
carotid canal dehiscence, Asymmetric jugular vein 44 62.85 46 65.71
petrous bone pneumatization High jugular bulb 14 20 3 4.3
and MEV enlargement is seen Dehiscent jugular bulb 1 1.4 – –
Dehiscent ICA channel 4 5.7 – –
Petrous bone pneumatization 10 14.3 20 28.6
MEV enlargement 54 77.14 25 35.7
MEV mastoid emissary vein

Table 2 Mean MEV and SS

Tinnitus Control
curve diameters are being
shown Right Left Right Left

MEV (mm) 2.36 ± 0.82 2.34 ± 0.81 2.28 ± 0.76 1.96 ± 0.58
SS curve (mm) 6.32 5.02 5.88 4.99
MEV mastoid emissary vein, SS sigmoid sinus

tinnitus patient group than in the control group
(p = 0.049).
Tinnitus was present on the left side more frequently in
older patients according to the correlation analyses
[rho(r) 0.299; p = 0.012]. There were four female tinnitus
patients with carotid canal dehiscence; two were on the left
side and two were bilateral. The left asymmetric jugular
vein was correlated with left-sided tinnitus (r 0.254;
p = 0.034). The side of tinnitus and the asymmetric
jugular vein were correlated (r 0.254; p = 0.034).
Discussion
This study has demonstrated that in the nonpulsatile tin-
nitus patient group with unexplained etiology, some vas-
cular variations of the temporal bone, previously
mentioned as causes of pulsatile tinnitus, had a higher
incidence than in the control group. In addition, MEV
enlargement, which has been previously associated with
pulsatile tinnitus in the literature [10–13] was compared to
the control group in our study. Left-sided MEV enlarge-
ment was significantly higher in the tinnitus patient group
(p = 0.029). We also evaluated PBP, which has been
suggested previously as an underlying cause of pulsatile
tinnitus. Our results demonstrated a significant lower fre-
quency of PBP, which is contrary to previous results [8].
The quantification of SS bulging into the mastoid bone by
measuring the SS curve (Fig. 1) revealed an insignificant
change between the groups in the current study.
Tinnitus is a very complex symptom and has a hetero-
geneous etiology. Pathophysiological mechanisms of
tinnitus compromise some neural theories, including
spontaneous firing of neurons due to temporal synchrony
[2]. Different types of tinnitus may be explained by dif-
ferent mechanisms in the ear or the brain [2]. We have the
hypothesis that in some tinnitus patients, blood flow within
the vessels around the temporal bone, including mastoid or
temporal parts, may increase the perception of tinnitus
even in nonpulsatile forms. In this study, we evaluated
tinnitus patients to assess if there was any association with
vascular abnormalities of the temporal bone in CT, which
have been mentioned before as a cause of pulsatile tinnitus.
To the best of our knowledge, any study was held inter-
esting in all these vascular abnormalities previously related
pulsatile tinnitus, including asymmetric jugular vein, high
riding jugular bulbus, dehiscent jugular bulbus, aberrant
ICA, carotid canal dehiscence, SS diverticulum/
dehiscence.
An asymmetric jugular vein is a vascular variation,
which commonly exists on the right side, apart from
pathologic conditions such as dural arteriovenous fistulas
and is accepted as being asymptomatic [1]. In our study,
although the frequency of dilation of the asymmetric
jugular vein did not differ between the tinnitus patient
group (right side 26.4 %) and the control group (right side
23.6 %), the existence of left asymmetric jugular vein
dilatation was well correlated in patients with left-sided
tinnitus (p \ 0.05). In older patients, asymmetric jugular
vein dilation was seen more frequently on the left side.
Jugular bulb anomalies have been stated among the causes
of pulsatile tinnitus [1]. The incidence of a high riding
jugular bulb in the normal population was reported as
6–28 % and the incidence of a dehiscent jugular bulb

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Fig. 3 High riding jugular bulb (arrow) is visible at mid portion level
of internal acoustic canal in a 44-year-old men with right sided
tinnitus
(Fig. 3) was reported as 4–5 % in literature [18–20]. In our
study, high jugular bulbus frequency was 4.3 % in the
control group and 20 % in the tinnitus group in which a
significant difference occurred (p \ 0.05). In the current
study, the dehiscent jugular bulb was present in 1.4 % of
tinnitus patients without significant difference among
patients and controls.
Aberrant ICA, another well-known cause of pulsatile
tinnitus displaying agenesis of unilateral ICA, did not exist
in our cohorts. But four of our patients had a normal course
of ICA with a dehiscent canal [14] in which two were
bilateral and two were located on the left side (Fig. 4). In
literature, the rate of dehiscent carotid canal was 1 % [21].
In our study, carotid canal dehiscence was found to be
significantly higher in the tinnitus patient group (5.8 %)
than in the control group (0 %) (p \ 0.05). Carotid canal
dehiscence was found more frequently in female and older
patients according to our study. None of the dehiscent
carotid canal patients had a positive Doppler ultrasound,
otological examination findings or pulsatile tinnitus.
PBP was evaluated as a cause of pulsatile tinnitus by
Sözen et al. suggesting that pneumatization around ICA
within petrous bone acts as an amplifier of sound from
blood flow [8]. The incidence of PBP in the normal pop-
ulation ranges from 21 to 35 % in various studies [8, 22,
23]. The incidence of PBP in our control group was similar
to that shown in previous studies [8, 22, 23]. In contrast to
the study by Sözen et al. [8], we found lower PBP fre-
quency values in the tinnitus patient group (14.3 %)
compared to the control group (22.6 %) (p \ 0.05). From
this result we think that air cells surrounding the petrous
Fig. 4 Carotid canal dehiscence (arrow) is seen on horizontal
segment of internal carotid artery on petrous bone in a 39-year-old
women with right sided complain. Otoscopic examination of her was
normal
carotid channel may act as a barrier for conducting vibra-
tions of blood flow from the ICA to the perilymph and the
endolymph. More studies should be held regarding the
association between PBP and tinnitus.
The aberrant SS presents a more lateral course of vein
into mastoid air cells, or anteriorly into inner air structures
due to close contact with the posterior semicircular channel
and the endolymphatic sac [9]. In this study, we quantified
the aberrant course of SS by drawing an outer margin of SS
in the temporal bone, at the level of the cochlea, which
creates a C-shaped arch; then we measured the depth of this
arch as shown in Fig. 2. We did this in order to standardize
the measurements, which did not differ between the tin-
nitus patient group and the control group. Further studies
comparing pulsatile and nonpulsatile tinnitus with controls
should be planned using the method of quantification by
measuring the depth of SS arch in the temporal bone.
SS dehiscence/diverticulum was shown to exist in 20 %
of pulsatile tinnitus patients in which surgical or inter-
ventional procedures could be an alternative in the man-
agement of their condition [16, 24, 25]. Our study group
did not consist of any SS dehiscence/diverticulum and
there were no pulsatile tinnitus patients in our study.
The enlargement of MEV as a cause of tinnitus was
attributed to pulsatile tinnitus in a few previous case reports
[11, 12]. The vicinity of MEV posteriorly to the mastoid air
cells suggest that this will lead to tinnitus in these patients.
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MEV has a bidirectional flow, displaying the compensatory
role between intracranial and extracranial vasculature. As
far as we know, the relationship between tinnitus and MEV
has not been studied except for case reports [5, 11–13]. In
the current study, for the first time, we compared the
incidence of MEV enlargement between a nonpulsatile
tinnitus group and a control group. In the literature,
diameters of MEVs range from 1.1 to 5.6 mm (with a
median of 3.5 mm) and 60 % of patients had MEV smaller
than 2 mm [11, 12]. In this study, we accepted MEV larger
than 1.5 mm as enlargement. Accordingly, left MEV
enlargement was correlated with age and was mostly seen
in older patients (r = -2.90; p \ 0.05). Right MEV
enlargement was common in patients with jugular vein
asymmetry on the left, thus explaining the compensation of
contralateral dural sinus drainage by MEV. On the left
side, MEV enlargement was significantly higher in the
tinnitus patient group compared with the control group
(p = 0.029).
There are some limitations in our study. First, our study
population was not composed of pulsatile tinnitus patients
probably due to lower number of patients in study group
extracted from secondary care unite. Pulsatile tinnitus
patients are known to be the patient group who reveal bony
variations including SS dehiscence or/diverticulum some
of which can be reconstructed surgically. In a recent study
by Zhao et al. they found out that some anatomic changes
including dominant venous flow, high jugular bulbus,
transverse sinus stenosis and intracranial hypertension were
more frequent in pulsatile tinnitus side, and suggested that
they should participate the perception of pulsatile tinnitus
[5]. They compared pulsatile tinnitus patients with healthy
controls in their study [5]. Large series are needed to
compare both pulsatile and nonpulsatile tinnitus with
healthy controls. Second, this is a retrospective study;
medical records were obtained from the hospital informa-
tion system. Third, the control group was not age matched.
Fourth, the control group was selected from patients who
had paranasal sinus CT performed, which acted as an
internal bias during interpretation of images.
Conclusion
According to the results of the current study, patients com-
plained of subjective nonpulsatile tinnitus with unknown
etiology, some temporal bone vascular variations, including
a high riding jugular bulb, dehiscent carotid canal, left-sided
MEV enlargement and PBP as a nonvascular variation,
seemed to have an association with tinnitus. Further studies
comparing all of these entities between pulsatile and non-
pulsatile groups and healthy controls are needed.
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Surg Radiol Anat
Acknowledgments The article is not supported by any
organizations.
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