A Warning on Venous Ligation for Pulsatile Tinnitus

Augmented or turbulent flow within the transverse-sigmoid-jugular venous system is one of the more common causes of pulsatile tinnitus. Characteristically, the pulsation can be temporarily muted or even abolished by relatively gentle compression of the ipsilateral neck. As patients may be quite disturbed by this symptom, clinicians understandably are tempted to bring relief through ligation of the jugular vein in the neck and/or compression of the sigmoid sinus and jugular bulb within the temporal bone. The purpose of this communication is to warn surgeons against undertaking this measure because it risks serious neurologic injury. As a group, we have encountered series of patients in whom venous ligation has triggered florid pseudotumor cerebri accompanied by severe headaches, progressive visual loss, and other disturbing neurologic symptoms. Noisy flow originating from the jugulo-sigmoid system venous system usually indicates either stenosis with downstream turbulence or augmented flow through a dominant system. The latter may occur due to stenosis or atresia of the contralateral system. The flow through the noisy side can be essential to maintaining physiological intracranial hemodynamics. Ill-advised interruption can trigger serious intracranial venous hypertension. Closure at the sigmoid sinus level or jugular bulb is especially perilous because it eliminates the alternative pathway via the petrosal sinuses. While we would have preferred to present a formal case series, these patients were not under our direct care but rather came to our attention through the medical–legal process. In our opinion, there is rarely, if ever, an indication for interruption of a major venous pathway solely for the purpose of alleviating pulsatile tinnitus. Robert K. Jackler, M.D. Derald E. Brackmann, M.D. Aristides Sismanis, M.D.