A patient is described with a right-sided tortuous siphon-like extracranial internal carotid artery leading to highly distressing ipsilateral heart beat synchronous pulsatile tinnitus, scoring 9/10 measuring loudness. Dilating the balloon during the occlusion test in or distal to the siphon-like anomaly reduces the arterial pulsations. Subsequently, surgery is performed using Teflon as an external construct to straighten the siphon-like anomaly. Postoperatively, the pulsations improve to 5/10 in a standing position and disappear during a reclined position. By adding a hearing aid, the pulsations are almost completely gone during a standing position (1/10) and remain absent in a reclined position. 1. Introduction Tinnitus is a common symptom affecting 10%–15% of the population [1]. The most common form of tinnitus is nonpulsatile tinnitus, which is most often related to hearing loss, and therefore has been considered as an auditory phantom percept, analogous to phantom pain [2]. Pulsatile tinnitus is not as common as nonpulsatile tinnitus. It is most commonly seen in the presence of abnormal extracranial or intracranial blood vessels or intracranial hypertension, and it is not related to an abnormally functioning auditory system. Pulsatile tinnitus can be subdivided into arterial heart beat synchronous or venous “hum-like” pulsatile tinnitus [3]. It can sometimes be heard by the clinician, in which case it is called objective tinnitus. The perceived pulsations are most likely transmitted via the cerebrospinal fluid to the cochlea [4], a mechanism similar to what has been proposed as an explanation for bone conduction [5–7]. Since heart beat synchronous tinnitus is predominantly vascular in origin, almost all causes of pulsatile tinnitus, except benign intracranial hypertension [8–10], can be diagnosed by different forms of angiography, such as classical intra-arterial or intravenous angiography, CT angiography, or more frequently magnetic resonance angiography. A common cause of arterial pulsatile tinnitus is carotid stenosis [8–10], often linked to atherosclerotic disease [11, 12], but a stenotic subclavian [13] or external carotid artery [14] or reversal of blood flow in an aberrant occipital artery can also cause pulsatile tinnitus [15]. Basically, any disease that changes the flow pattern into a turbulent flow can cause pulsatile tinnitus. Fibromuscular dysplasia is such an example [16, 17] as is a turbulent flow generated by looping of the AICA in the internal acoustic canal [4, 18]. Arterial heart beat synchronous pulsatile tinnitus associated with
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