From the Guidelines
Pulsatile tinnitus is a serious condition that requires immediate medical attention, as it may indicate underlying vascular issues, such as high blood pressure, atherosclerosis, tumors, or vascular malformations, and can significantly impact quality of life 1. The main symptoms of pulsatile tinnitus include hearing a whooshing, thumping, or pounding sound that synchronizes with your pulse, and can be accompanied by additional symptoms such as dizziness, hearing loss, headaches, and a feeling of fullness in the affected ear. Some key points to consider when evaluating pulsatile tinnitus include:
- The condition can be either subjective or objective, and can be pulse-synchronous or pulse-asynchronous 1
- Imaging studies, such as temporal bone CT and CTA, may be necessary to evaluate for a middle ear mass or vascular etiology, and MRI may be considered as a noninvasive alternative to screen for a suspected intracranial vascular malformation 1
- A targeted history and clinical examination are essential in determining the underlying cause of pulsatile tinnitus, and a prompt and comprehensive audiological examination may be necessary in patients with hearing problems or unilateral persistent tinnitus 1
- The American Academy of Otolaryngology and Head and Neck Surgery Foundation (AAO-HNS) guidelines recommend against imaging studies for patients with nonpulsatile tinnitus that does not localize to one ear and is not associated with focal neurological abnormalities or asymmetric hearing loss 1 It is crucial to seek medical attention promptly if you experience pulsatile tinnitus, especially if it's sudden or accompanied by other symptoms, to ensure proper diagnosis and treatment, and to prevent potential complications that can impact morbidity, mortality, and quality of life 1.
From the Research
Pulsatile Tinnitus Symptoms
Pulsatile tinnitus is a debilitating symptom that can be a harbinger of hemorrhagic or ischemic stroke 2. The symptoms of pulsatile tinnitus can vary, but it is often described as a pulse-synchronous sound.
Causes of Pulsatile Tinnitus
The causes of pulsatile tinnitus can be categorized into:
- Structural causes, such as neoplasms and temporal bone pathologic abnormalities 2
- Metabolic causes, such as ototoxic medications and systemic causes of high cardiac output 2
- Vascular causes, such as idiopathic intracranial hypertension and dural arteriovenous fistulas 2, 3 Some common causes of pulsatile tinnitus include:
- Arteriosclerosis, dissection, and fibromuscular dysplasia 3
- Arteriovenous fistulae and highly vascularized skull base tumors 3
- Intracranial hypertension and anomalies of the basal veins and sinuses 3
Diagnosis and Evaluation
A thorough diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy 2. The evaluation of pulsatile tinnitus should include:
- A comprehensive history and physical examination 4, 5
- Imaging studies, such as MRI, MR angiography, CT angiography, and CT without contrast 5, 6
- A focused, physiology-based protocol for MRI and MR angiography evaluation 5
Diagnostic Rate of Imaging Studies
The diagnostic rate of imaging studies for pulsatile tinnitus varies, with MRI with contrast and CT without contrast preferentially identifying patients with nonvascular etiologies, while MR angiography and CT angiography identifying patients with vascular etiologies 6. MR-based imaging is preferred for neoplasms, while CT-based imaging is preferred for semicircular canal dehiscence 6.