From the Guidelines
If you experience pulsatile tinnitus, you should seek medical evaluation as it can sometimes indicate underlying vascular conditions that may be life-threatening or significantly impact your quality of life. Pulsatile tinnitus is a rhythmic sound in the ears that typically synchronizes with your heartbeat, and it often has identifiable causes that may be treatable 1. Common causes include high blood pressure, vascular abnormalities like arteriovenous malformations, carotid artery stenosis, venous sinus stenosis, or tumors like paragangliomas.
Some key points to consider in the evaluation of pulsatile tinnitus include:
- A thorough physical examination, including listening over the neck, skull, and around the ears with a stethoscope, to identify any abnormal sounds or masses
- Imaging studies such as CT angiography, MRI/MRA, or ultrasound to visualize blood vessels and identify any vascular abnormalities 1
- A detailed history to identify any potential underlying causes, such as high blood pressure, anemia, or thyroid disorders
- Examination for retrotympanic lesions on otoscopy, which can help guide the choice of imaging modality 1
Treatment should focus on addressing the underlying cause rather than the symptom itself, and may involve medications, surgical intervention, or endovascular procedures 1. For example, if high blood pressure is the cause, blood pressure medications may help, while vascular abnormalities might require surgical intervention or endovascular procedures. While waiting for medical evaluation, you might find temporary relief by elevating your head while sleeping or avoiding stimulants like caffeine that can increase blood pressure and heart rate. Pulsatile tinnitus differs from regular tinnitus because it represents actual blood flow sounds being transmitted to your ear rather than a phantom sound perception.
It's essential to note that pulsatile tinnitus can be a symptom of a serious underlying condition, and prompt medical evaluation is necessary to determine the cause and appropriate treatment. The American College of Radiology recommends a targeted history and clinical examination as the initial evaluation, followed by imaging studies as needed 1. By prioritizing the evaluation and treatment of pulsatile tinnitus, clinicians can improve patient outcomes and reduce the risk of morbidity and mortality associated with underlying vascular conditions.
From the Research
Definition and Prevalence of Pulsatile Tinnitus
- Pulsatile tinnitus is a debilitating symptom that affects millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke 2.
- It is an uncommon but often treatable subtype of tinnitus 3.
- Pulsatile tinnitus can severely impact quality of life and may indicate a life-threatening process 4.
Causes of Pulsatile Tinnitus
- The causes of pulsatile tinnitus can be categorized into structural, metabolic, and vascular groups 2.
- 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, 3.
- Other causes include arteriovenous malformation or fistula, dural venous sinus stenosis, otoacoustic etiologies, and bony defects 3.
Diagnosis and Evaluation of Pulsatile Tinnitus
- A thorough evaluation can identify an underlying cause of pulsatile tinnitus in more than 70% of patients 2.
- Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies 3.
- Digital subtraction angiography (DSA) may further aid in the diagnosis if initial vascular imaging is negative and a vascular etiology is strongly suspected 3.
- A comprehensive and targeted radiographic imaging protocol, including MR sequences, can be used to evaluate pulsatile tinnitus 4.
- A careful history and physical exam can help establish the differential diagnosis for pulsatile tinnitus and guide subsequent evaluation and management 3, 5, 6.
Treatment and Management of Pulsatile Tinnitus
- Many vascular etiologies of pulsatile tinnitus can be managed endovascularly, often leading to improvement or resolution of symptoms 3.
- Venous sinus stenting is an emerging therapy for pulsatile tinnitus secondary to idiopathic intracranial hypertension with venous sinus stenosis 3.
- Treatment of pulsatile tinnitus depends on the underlying cause, and a timely and accurate diagnosis can often lead to effective treatment 4, 5.