Evidence of air‐conduction transmission pathway and strategized transtemporal operative techniques for venous pulsatile tinnitus: Combining water occlusion test and operative sensing applications

OBJECTIVES: (1) To establish evidence of the transmission pathway of venous pulsatile tinnitus (PT) associated with sigmoid sinus wall anomalies (SSWAs) and (2) quantify the efficacy of transtemporal surgery. METHODS: This retrospective study included 33 surgical cases of PT associated with SSWAs and 15 controls with venous PT without SSWAs. Quantitative water occlusion test (q‐WOT) and imaging data were acquired for preoperative evaluation prior to strategized transtemporal osteovascular reconstruction surgery. A condenser microphone and hydrophone were intraoperatively deployed to assess and monitor in vivo amplitude variations of the PT in eight participants. RESULTS: A total of 23 (69.6%) participants with SSWA responded to the q‐WOT with a median solution volume of 1.3 (1.1/1.6), which significantly differed from that observed in controls (p < 0.01). The change in the operative peak amplitude of the acoustic data was statistically significant (p < 0.01), from a median of 57.6 (55.5/57.9) dB SPL to 34.3 (33.4/38.8) dB SPL. CONCLUSION: Intraoperative application of acoustic sensors revealed that PT associated with SSWAs is predominantly transmitted via the air‐conduction pathway. If objective findings such as q‐WOT and sensing applications suggest that the transmission of venous PT is involved in middle ear air conduction, the reconstruction technique should be prioritized; if less involvement of middle ear air‐conduction is indicated, addressing flow pathologies may be imperative for resolving venous PT. LEVEL OF EVIDENCE: 4