A 65-year-old female presented to our clinic with a 2-year history of worsening bilateral pulsatile tinnitus. She described "humming" in both ears, in time with her heartbeat, which had become very difficult to ignore, to the point of being debilitating. She had no history of hearing loss. She denied autophony, hearing her eyeballs move, dizziness on straining, or any other symptoms pointing to a diagnosis of SSCD syndrome. Her past medical history was significant for hypothyroidism, overactive bladder, hypertension, chronic back pain, and a remote history of thrombocytopenia. She also reported being diagnosed with multiple vascular lesions in the head and neck, and some of these had been surgically removed during childhood, including one superficial and posterior to the right ear. Her medications included levothyroxine, gabapentin, hydromorphone, oxybutynin, and omeprazole. A complete blood cell count was ordered, showing no anemia or thrombocytopenia. Audiometry showed no hearing loss.
Neurological and head-and-neck examination were normal. Her tympanic membranes appeared normal bilaterally. Pressurization of the neck bilaterally did not alleviate the intensity of the tinnitus. Her symptoms were ameliorated with rotation of the neck to the left. No murmurs or bruits were heard on auscultation.
The patient underwent contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) scans (Figure 1) as part of the workup for her symptoms. The CT scan showed multiple, bilateral, enlarged, venous malformations in the neck and posterior to the ears (Figures 1(a) and 1(c)). The T2-weighted MRI (Figures 1(b) and 1(d)) scan showed similar findings. Notably, some of these dilated venous channels contained phleboliths, often seen in low-flow venous malformations. No intracranial or auricular malformations were seen. Magnetic resonance angiography (MRA) was also performed (not shown), revealing 2 small (<5 mm) incidental aneurysms in the paraophthalmic internal carotid artery, which were thought to not be causing any symptoms.