Reply-To: otohns@otohns.net From: "Erez Bendet, MD" To: Multiple recipients of list OTOHNS >What does the group do for workup of a patient with pulsatile tinnitus = with a normal physical exam, specifically with a normal tm without = reddish mass behind the drum? What about with a normal exam, but the = sound is stopped with pressure over the jugular? Listen for objective tinnitus (Toynbee stethoscope), listen for bruits over carotids, jugular, mastoid, eye, scalp. Listen for heart murmurs. See if head rotation may change the tinnitus (vertebral artery kinked?) Fundus, especially if obese (for BIH= benign intracranial hypertension). BP measurement. Hb (anemia), hyperT4, pregnancy - high output states Audio + tympanometry (ET dysfunction) Proceed to imaging according to severity of Sx and if consistent by the time patient has returned from tests, ophthalmology etc (not necessarily in that sequence): Doppler carotids/jugular/vertebrals for turbulent blood flow, tortuous jugular). Brain CT with contrast (BIH, vascular lesion, dominant lateral/sigmoid sinus )+ temporal bones/skull base HRCT (high/prominent/dehiscent jugular bulb, dehiscent carotid, eroded jugular foramen-glomus, MRI, MRA, MRA. Four-vessel and cerebral angio if index of suspicion for dural AVM is high of course also the venogram phase). Erez Bendet, MD Otolaryngology-HNS 2 Ben-Zvi Ave. Jaffa ISRAEL