In a patient with unilateral whooshing sound behind the ear, which physical examination findings should be assessed to determine the source and what cardiac signs should be evaluated for possible cardiac involvement?

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Last updated: October 23, 2026 • View editorial policy

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Physical Examination for Unilateral Whooshing Behind the Ear

For a patient with unilateral whooshing behind the ear, perform otoscopy first to look for a vascular retrotympanic lesion (pulsating red mass behind the tympanic membrane), then auscultate over the periauricular area, mastoid, neck, and orbit for bruits, and assess for cardiac murmurs and signs of high cardiac output states. 1

Essential Physical Examination Components

1. Otoscopic Examination (Critical First Step)

This is the most important examination because it fundamentally changes your diagnostic algorithm 1:

  • Look for vascular retrotympanic lesions: A pulsating reddish/bluish mass visible behind the tympanic membrane suggests:

    • Glomus tympanicum or jugulotympanicum
    • Aberrant internal carotid artery
    • Dehiscent jugular bulb
    • Persistent stapedial artery

  • Note: If you see a vascular retrotympanic lesion, do not biopsy - inadvertent biopsy can cause devastating hemorrhagic complications 1

  • Also check for non-vascular causes: cerumen impaction, chronic otitis media, tympanic membrane perforation, cholesteatoma 1

2. Auscultation for Objective Tinnitus

The whooshing sound suggests pulsatile tinnitus (PT), which can be objective in some cases 1:

  • Periauricular region: Place stethoscope over and behind the affected ear
  • Mastoid area: Listen directly over the mastoid process
  • Neck: Auscultate carotid arteries bilaterally for bruits (suggests carotid stenosis/atherosclerosis)
  • Orbit/temporal region: Listen for orbital bruits (suggests dural arteriovenous fistula)
  • Timing: Determine if any bruit is pulse-synchronous

3. Cardiac Assessment for Cardiac Involvement

Signs of high cardiac output states (can cause bilateral or unilateral PT) 2:

  • Cardiac auscultation:

    • Listen for flow murmurs (systolic ejection murmurs from hyperdynamic states)
    • Assess for valvular abnormalities (particularly aortic stenosis or regurgitation)
    • Check for tachycardia

  • Signs of anemia: Pallor, tachycardia, flow murmurs

  • Signs of hyperthyroidism: Tachycardia, tremor, thyroid enlargement, warm moist skin

  • Signs of pregnancy: If applicable

  • Blood pressure: Hypertension can contribute to PT

4. Neurological Examination

Check for focal neurological deficits that would mandate imaging 3:

  • Cranial nerve examination (particularly CN VII, VIII)
  • Cerebellar signs
  • Motor/sensory deficits
  • Papilledema (suggests idiopathic intracranial hypertension, which causes PT)

5. Hearing Assessment

  • Weber and Rinne tests: Asymmetric hearing loss requires prompt comprehensive audiologic examination 3
  • Unilateral or asymmetric findings increase likelihood of underlying pathology

Clinical Decision Algorithm

If otoscopy shows vascular retrotympanic lesion → High-resolution CT temporal bone without contrast is the initial imaging of choice 1

If otoscopy is normal but PT is present → Consider:

  • CT angiography/venography (mixed arterial-venous phase) for vascular causes
  • MRI/MRA for dural arteriovenous fistula
  • Carotid duplex ultrasound if neck bruit present 1

If cardiac signs present → Address systemic high-output state (anemia, hyperthyroidism) as this may resolve the PT 2

If focal neurological signs or asymmetric hearing loss → Imaging is mandatory 3

Common Pitfalls

  • Don't skip otoscopy: This single examination determines your entire diagnostic pathway 1
  • Don't assume it's benign: Unilateral PT has higher likelihood of underlying vascular pathology than bilateral PT 2
  • Don't order imaging indiscriminately: If PT is bilateral, no focal neurological signs, and no asymmetric hearing loss, imaging may not be indicated initially - address systemic causes first 3
  • Don't biopsy retrotympanic masses without imaging: Vascular variants can cause catastrophic bleeding 1

The key is that otoscopy findings drive everything else - a vascular retrotympanic lesion requires CT temporal bone, while normal otoscopy with PT requires vascular imaging (CTA/CTV or MRA/MRV) 1.

References

1
Guideline

acr appropriateness criteria® tinnitus: 2023 update.

Journal of the American College of Radiology, 2023

3
Guideline

clinical practice guideline: tinnitus executive summary.

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2014

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.