From the Guidelines
The management of patients with pulsatile tinnitus begins with a thorough diagnostic evaluation to identify the underlying cause, as this symptom often indicates a vascular abnormality. Initial assessment should include a comprehensive history, physical examination, and appropriate imaging studies such as CT angiography, MRI with MR angiography, or catheter angiography depending on clinical suspicion 1. The diagnostic algorithm should progress from less invasive to more invasive imaging studies, guided by the history and clinical evaluation. Treatment is directed at the underlying etiology rather than symptom suppression. For vascular causes like arteriovenous malformations or dural arteriovenous fistulas, endovascular embolization or surgical intervention may be necessary. Venous causes such as sigmoid sinus diverticulum might require venous stenting or surgical repair. If the cause is atherosclerotic disease, management of cardiovascular risk factors with statins, antihypertensives, and lifestyle modifications is appropriate. For intracranial hypertension, acetazolamide or topiramate may be prescribed, along with weight loss counseling and possibly CSF diversion procedures in severe cases 1. Patients with anemia-induced pulsatile tinnitus require iron supplementation or blood transfusions based on hemoglobin levels. Throughout management, patient education about the condition and reassurance are essential, particularly when the underlying cause is benign. Regular follow-up is important to monitor treatment efficacy and disease progression.
Some key considerations in the management of pulsatile tinnitus include:
- Identifying the underlying cause through a comprehensive diagnostic evaluation
- Directing treatment at the underlying etiology rather than symptom suppression
- Using imaging studies such as CT angiography, MRI with MR angiography, or catheter angiography to guide treatment
- Managing cardiovascular risk factors for atherosclerotic disease
- Prescribing acetazolamide or topiramate for intracranial hypertension
- Providing patient education and reassurance throughout management
It is essential to note that the management of pulsatile tinnitus should be individualized based on the underlying cause and the patient's specific needs. A thorough diagnostic evaluation and a multidisciplinary approach to treatment are crucial in achieving optimal outcomes 1.
From the Research
Management Approach for Pulsatile Tinnitus
The management approach for patients with pulsatile tinnitus involves a thorough diagnostic evaluation to identify the underlying cause, which can be categorized into structural, metabolic, and vascular groups 2.
- Diagnostic Evaluation: A comprehensive diagnostic evaluation is crucial in providing optimal care and guiding the appropriate treatment strategy 2, 3. This evaluation may include computed-tomographic angiography (CTA) studies, computed tomography (CT) scanning, magnetic resonance imaging (MRI), and CT arteriography-venography (CT A-V) of the head and neck 4, 3.
- Categorization of Causes: Categorizing the causes of pulsatile tinnitus into structural, metabolic, and vascular groups facilitates a practical evaluation, referral, and treatment pattern 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, dural arteriovenous fistulas, and arteriovenous malformations (AVMs) of the head and neck 2, 5.
- Treatment Strategy: 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, in order to guide decision-making 5.
- Importance of Early Diagnosis: Early diagnosis and treatment of pulsatile tinnitus are crucial, as failure to establish a correct diagnosis may have disastrous consequences, including potentially life-threatening underlying disorders 6.