Tinnitus after hemodialysis catheter placement

A 39-year-old male with end-stage renal disease secondary to IgA nephropathy and coincident chronic hepatitis B infection with liver cirrhosis had been maintained on peritoneal dialysis. An episode of peritonitis necessitated a conversion to hemodialysis via a temporary hemodialysis catheter. However, several attempts to access the right internal jugular vein were unsuccessful, eventually requiring temporary catheterization of the right femoral vein. The patient felt a 'buzzing' noise in his right ear almost immediately after the attempt. Duplex ultrasound examination revealed no evidence of an arteriovenous fistula or any other vascular defect. He was subsequently commenced on maintenance hemodialysis and discharged. After 2 months of hemodialysis, he eventually complained of loud continuous tinnitus in his right ear ever since the attempted internal jugular vein insertion. Examination revealed a loud 'machinery' bruit over the right side of the neck and right chest wall. Magnetic resonance angiography of his neck confirmed the existence of an arteriovenous fistula. Anatomically this involved the root of the right vertebral artery and vertebral venous plexus (Figure 1, indicated by arrow). The patient underwent combined liver and kidney transplantations, and subsequent endoluminal balloon occlusion of the fistula. He is now symptom-free, with excellent graft function. Patients may not report important, although trivial-seeming, symptoms for some time, especially after a negative test result, and more diligent enquiry is often needed in these cases.