What is the diagnosis and treatment for a patient with a 2-year history of pulsatile tinnitus, balance problems, and pressure in the face and head, who has not responded to Augmentin (amoxicillin/clavulanate) and steroid tapers, and has undergone clear MRI, CT, and CTV scans?

Diagnosis: Likely Idiopathic Intracranial Hypertension (IIH)

Your constellation of bilateral pulsatile tinnitus, facial/head pressure, balance problems, visible pulse in peripheral vision, and ear pressure requiring constant popping—despite clear MRI, CTV, and sinus imaging—strongly suggests idiopathic intracranial hypertension (IIH, also called pseudotumor cerebri), which is the second most common cause of pulsatile tinnitus and can present without the classic findings of headache or papilledema. 1

Why This Diagnosis Fits Your Presentation

• IIH accounts for the second highest proportion of pulsatile tinnitus cases and is specifically associated with sigmoid sinus wall abnormalities that cause the pressure sensations and balance problems you describe. 1

• The bilateral nature of your pulsatile tinnitus, combined with persistent pressure symptoms and balance disturbance, points toward a venous/pressure etiology rather than arterial or structural causes. 1

• Your visible pulse in peripheral vision in bright rooms is a pathognomonic sign of elevated intracranial pressure—this represents transmitted pulsations through the optic nerve sheath. 1

• The constant ear pressure requiring popping and the sensation of "a brick in your head" causing unsteadiness are classic manifestations of elevated intracranial pressure affecting the vestibular system and creating pressure gradients across the middle ear. 1, 2

Critical Diagnostic Gap in Your Workup

Your imaging was incomplete for diagnosing IIH—you need specific evaluation for venous sinus abnormalities and elevated opening pressure on lumbar puncture, which were not assessed by standard MRI, CTV, or sinus CT. 1

Required Next Steps:

• Obtain CT angiography (CTA) of head and neck with mixed arterial-venous phase (20-25 seconds post-contrast) to evaluate for sigmoid sinus diverticulum, transverse sinus stenosis, and other venous abnormalities associated with IIH. 1, 2

• Schedule lumbar puncture with opening pressure measurement—this is the definitive diagnostic test for IIH, with opening pressure >25 cm H2O confirming the diagnosis. 1

• Obtain formal ophthalmologic examination with fundoscopy to assess for papilledema, though its absence does not exclude IIH (you can have IIH without papilledema, especially early in the disease course). 1

Why Your Previous Imaging Missed This

• Standard MRI and CTV protocols are not optimized to detect the subtle venous sinus abnormalities (sigmoid sinus wall irregularities, diverticula, or stenosis) that cause IIH-related pulsatile tinnitus. 1, 2

• The American College of Radiology specifically recommends CTA with venous phase imaging for suspected venous causes of pulsatile tinnitus, which differs from standard stroke protocols. 1

Treatment Options Once Diagnosed

Medical Management (First-Line):

• Acetazolamide (carbonic anhydrase inhibitor) is the primary medical treatment for IIH, reducing CSF production and lowering intracranial pressure—typical starting dose 500-1000 mg daily, titrated up to 2000-4000 mg daily as needed. 1

• Weight loss of 5-10% body weight significantly improves IIH symptoms and can lead to complete resolution in many patients. 1

• Serial lumbar punctures for CSF drainage can provide temporary relief while medical therapy takes effect. 1

Interventional/Surgical Options (If Medical Management Fails):

• Venous sinus stenting is highly effective for IIH with documented transverse/sigmoid sinus stenosis, with studies showing 80-90% symptom resolution and excellent safety profile. 1, 2

• Sigmoid sinus wall reconstruction or resurfacing for sigmoid sinus diverticulum or dehiscence can eliminate pulsatile tinnitus in carefully selected cases. 1, 2

• Optic nerve sheath fenestration or ventriculoperitoneal shunt placement are reserved for cases with progressive vision loss or refractory symptoms despite maximal medical therapy. 1

Life-Threatening Causes to Definitively Rule Out

Before settling on IIH diagnosis, you must exclude these dangerous etiologies that can present similarly:

• Dural arteriovenous fistula (AVF) accounts for 8% of pulsatile tinnitus cases and can cause catastrophic hemorrhagic or ischemic stroke if missed—requires CTA with arterial phase to exclude. 1, 3

• Arterial dissection is potentially life-threatening and requires urgent identification—CTA will evaluate for this. 1

• Arteriovenous malformations carry 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage—must be excluded with vascular imaging. 1

Common Pitfalls in Your Case

• Dismissing pulsatile tinnitus as benign or sinus-related is a dangerous error—pulsatile tinnitus has identifiable causes in >70% of cases and almost always requires imaging evaluation. 1, 4

• Treating with antibiotics and steroids for presumed sinus infection when imaging shows no sinus disease wastes time and delays correct diagnosis—your clear sinus CT should have immediately redirected the workup toward vascular/pressure etiologies. 5

• Missing IIH in patients without classic papilledema or severe headache is common—you can have isolated pulsatile tinnitus as the presenting symptom of IIH, especially early in the disease. 1, 6

• Overlooking medication-induced intracranial hypertension—review if you've taken tetracyclines (doxycycline, minocycline), vitamin A derivatives, or other medications associated with elevated intracranial pressure. 6

Immediate Action Plan

1. Contact neurology or neuro-ophthalmology for urgent evaluation—do not wait months for appointments given your 2-year symptom duration and risk of vision loss from untreated IIH. 1

2. Request CTA head/neck with venous phase imaging specifically to evaluate for venous sinus abnormalities and exclude arterial causes. 1

3. Schedule lumbar puncture with opening pressure measurement—this provides both diagnostic information and therapeutic relief if pressure is elevated. 1

4. Obtain formal ophthalmologic examination with dilated fundoscopy and visual field testing to assess for papilledema and document baseline visual function. 1

5. If you are overweight, begin weight loss efforts immediately as this can significantly improve symptoms even before other treatments take effect. 1

Why Balance Problems and Pressure Correlate

Elevated intracranial pressure directly affects the vestibular system through increased pressure transmission to the inner ear structures, causing the balance disturbance and constant sensation of pressure that worsens with position changes or Valsalva maneuvers. 1, 2 The "brick in your head" sensation causing wobbliness is the physical manifestation of elevated CSF pressure compressing brain structures and disrupting normal vestibular function. 1