From the Guidelines
Pulsatile tinnitus requires prompt medical evaluation to identify its underlying cause, which may indicate vascular abnormalities such as arteriovenous malformations, carotid artery stenosis, or elevated intracranial pressure, and diagnosis typically involves a thorough physical examination and imaging studies such as CT angiography, MRI/MRA, or ultrasound, as recommended by the most recent study 1.
Key Considerations
- Pulsatile tinnitus is a rhythmic sound in the ears that synchronizes with the heartbeat, differing from regular tinnitus which is often a constant ringing or buzzing.
- The condition may signal serious underlying vascular causes, making immediate medical evaluation crucial, especially if the tinnitus is unilateral, as noted in 1.
- A thorough physical examination, including otoscopy and listening over the neck, skull, and around the ears with a stethoscope, is essential for guiding the diagnostic approach, as emphasized in 1.
- Imaging studies such as CT angiography, MRI/MRA, or ultrasound are critical for identifying the underlying cause, with the choice of imaging modality depending on the clinical evaluation and history, as discussed in 1 and supported by 2 and 3.
Diagnostic Approach
- The diagnostic algorithm should progress from less invasive to more invasive imaging studies based on a detailed history and clinical evaluation, as recommended in 1.
- For patients with pulsatile tinnitus and no retrotympanic lesion on otoscopy, a diagnostic approach considering vascular etiologies such as carotid atherosclerosis, dissection, or intracranial causes like arteriovenous malformation is necessary, as outlined in 1.
- Venous causes, including transverse sinus stenosis or sigmoid sinus diverticulum, and bony abnormalities like superior semicircular canal dehiscence, should also be considered, as mentioned in 1.
Management
- Treatment of pulsatile tinnitus depends entirely on the underlying cause, with some cases requiring surgical intervention for vascular abnormalities and others managed with medication for conditions related to hypertension or intracranial pressure, as implied by the need for accurate diagnosis in 1.
- While awaiting medical evaluation, avoiding caffeine, alcohol, and loud noises can help mitigate exacerbating symptoms, as suggested by general principles of managing tinnitus.
Evidence Basis
- The most recent and highest quality study 1 provides the basis for these recommendations, emphasizing the importance of a thorough clinical evaluation and appropriate imaging studies for diagnosing and managing pulsatile tinnitus.
- Previous studies 2, 3 support the use of imaging modalities like CT angiography and MRI/MRA in the diagnostic workup, but 1 offers the most current and comprehensive guidance.
From the Research
Definition and Causes of Pulsatile Tinnitus
- Pulsatile tinnitus is a debilitating symptom that can be a harbinger of hemorrhagic or ischemic stroke 4, 5.
- It is a sound from within the body, mostly of vascular origin, that stimulates the patient's hearing in the same way as an external sound does, generally at the same pace as the pulse 6.
- The causes of pulsatile tinnitus can be categorized into structural, metabolic, and vascular groups 4.
- Structural causes include neoplasms and temporal bone pathologic abnormalities 4.
- Metabolic causes include ototoxic medications and systemic causes of high cardiac output 4.
- Vascular causes include idiopathic intracranial hypertension and dural arteriovenous fistulas 4, 5.
Diagnosis and Evaluation of Pulsatile Tinnitus
- A thorough evaluation can identify an underlying cause of pulsatile tinnitus in more than 70% of patients 4.
- A standard workup begins with a targeted history and physical examination to identify treatable causes and associated symptoms that may improve with treatment 7.
- A comprehensive audiologic evaluation should be performed for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems 7.
- Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 7.
- MRI and MR angiography can be used to evaluate pulsatile tinnitus, with a focused, physiology-based protocol 8.
Management and Treatment of Pulsatile Tinnitus
- When a vascular cause of pulsatile tinnitus has been established, attention must be focused on the patient's risk of hemorrhagic stroke, ischemic stroke, or blindness, as well as the risks of the available treatment options 5.
- Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus 7.
- Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive 7.
- Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments, respectively 7.
- Avoidance of noise exposure may help prevent the development or progression of tinnitus 7.