Aberrant Sylvian Vein Diverticulum and Tegmen Dehiscence-Induced Venous Pulsatile Tinnitus Phenotype Can Be Treated Via Transtemporal Surgery: A Case Report with 4D-Flow Magnetic Resonance Imaging.

Objective: To report the first successful surgical treatment of a rare subtype of venous pulsatile tinnitus (PT) caused by aberrant sylvian vein and tegmen dehiscence (SVTD) with a diverticulum and soft tissue enclosing the middle ear ossicles.

Patients: A 35-year-old female participant presented with more than 10-year left-side PT due to SVTD diverticulum.

Interventions: The participant underwent transtemporal surgery with a lateral minimally invasive approach to the epitympanum and aditus ad antrum after finding SVTD and diverticulum.

Main Outcome Measures: Contrast-enhanced CT, various magnetic resonance (MR) techniques, including the 4D-flow MR method, and transcanal recording examinations were utilized. The Tinnitus Handicap Inventory (THI) was employed to quantify the surgical efficacy in treating PT.

Results: PT was successfully resolved following resurfacing of the diverticulum located on the medial wall of the epitympanic space, with the patient achieving a THI score of 0. The 4D-flow MR indicated that the mean and largest velocities at the dehiscence area were 20.8 cm/s and 54.9 cm/s, respectively. The main frequency of PT fluctuated below 750 hz.

Conclusion: SVTD diverticulum-induced venous PT can be successfully treated via the transtemporal pathway. Additionally, this finding underscores the importance to carefully examine tegmen dehiscence and the exposed vasculature when managing venous PT.