From the Guidelines
Pulsatile tinnitus requires immediate medical attention to rule out serious underlying vascular conditions, and a thorough diagnostic workup, including a detailed history, physical examination, and imaging studies, is essential to identify its cause. The diagnosis of pulsatile tinnitus typically involves a step-by-step approach, starting with a thorough physical examination, including otoscopy and listening over the neck, skull, and ears with a stethoscope, as highlighted in the 2023 update of the ACR Appropriateness Criteria for tinnitus 1.
Key Considerations
- A detailed history and clinical evaluation are crucial in guiding the choice of imaging modality, as pulsatile tinnitus can result from various vascular etiologies, including arterial lesions in the neck, intracranial etiologies, and venous causes such as transverse sinus stenosis or sigmoid sinus diverticulum 1.
- Imaging studies such as CT angiography, MRI/MRA, or ultrasound may be necessary to evaluate for a middle ear mass or vascular etiology, with the choice of imaging modality depending on the clinical assessment and history 1.
- Treatment of pulsatile tinnitus depends entirely on the underlying cause, which can range from managing high blood pressure with antihypertensive medications to surgical intervention for vascular abnormalities.
Diagnostic Approach
- The history and physical examination may suggest pulsatile tinnitus due to systemic causes such as pregnancy-related hemodynamic changes, anemia, thyrotoxicosis, or mechanical causes like palatal or tympanic myoclonus, Eustachian tube contractions, or temporomandibular joint problems 1.
- Structural and anatomic causes of pulsatile tinnitus can be found in up to 44% to 91% of patients, emphasizing the importance of a thorough diagnostic workup to identify potentially treatable causes 1.
Management
- Prompt medical evaluation is crucial for pulsatile tinnitus, as it can indicate serious underlying conditions that require timely intervention. While waiting for medical evaluation, tracking when symptoms worsen can provide valuable diagnostic information for the healthcare provider.
From the Research
Definition and Diagnosis of Pulsatile Tinnitus
- Pulsatile tinnitus is a debilitating symptom that can be a harbinger of hemorrhagic or ischemic stroke 2, 3.
- A thorough evaluation can identify an underlying cause of pulsatile tinnitus in more than 70% of patients 2.
- The causes of pulsatile tinnitus can be categorized into structural, metabolic, and vascular groups 2.
Categorization of Pulsatile Tinnitus Causes
- Structural causes include neoplasms and temporal bone pathologic abnormalities 2.
- Metabolic causes include ototoxic medications and systemic causes of high cardiac output 2.
- Vascular causes include idiopathic intracranial hypertension and dural arteriovenous fistulas 2, 4.
Diagnostic Evaluation
- Clinical assessment with a history and physical examination can suggest a diagnosis, but is rarely definitive 5.
- Radiographic imaging protocols, such as MRI and MR angiography, can provide a comprehensive evaluation of pulsatile tinnitus 5, 6.
- CT arteriography-venography (CT A-V) can identify various causes of pulsatile tinnitus, including vascular and non-vascular causes 6.
Treatment of Pulsatile Tinnitus
- Endovascular treatments, such as stenting and coiling, have shown high efficacy and safety in treating venous causes of pulsatile tinnitus 4.
- Proper treatment can cure pulsatile tinnitus, unlike other types of tinnitus 4.
- A structured reporting template can ensure that all potential causes of pulsatile tinnitus are considered on a CT A-V study 6.