What is the treatment for pulsatile tinnitus?

Treatment for Pulsatile Tinnitus

For pulsatile tinnitus, diagnostic imaging is essential to identify and treat the underlying vascular abnormality, with CT angiography or dedicated temporal bone CT recommended as first-line imaging studies. 1

Initial Evaluation

Pulsatile tinnitus requires a thorough evaluation to identify potentially serious underlying causes:

• Key characteristics to assess:

  • Unilateral vs bilateral symptoms
  • Pulse-synchronous nature (matching heartbeat)
  • Objective (audible to examiner) vs subjective tinnitus
  • Associated symptoms (hearing loss, neurological deficits)

• Physical examination focus:

  • Otoscopic examination for retrotympanic mass
  • Auscultation of head/neck for bruits
  • Assessment of cranial nerves
  • Blood pressure measurement

Diagnostic Approach

The main purpose of imaging is to identify underlying vascular abnormalities that can be treated with medical, endovascular, surgical, or radiation therapy 1:

First-line Imaging:

• Dedicated temporal bone CT - Recommended for:

  • Vascular retrotympanic mass
  • Subjective pulsatile tinnitus
  • Detecting paragangliomas, middle ear tumors, or variant vascular anatomy 1

• CT Angiography (CTA) of head and neck - Equally appropriate first-line study to evaluate:

  • Arterial and venous anatomy
  • Vascular variants
  • Dural arteriovenous fistulas
  • Arterial dissection
  • Sigmoid sinus wall abnormalities 1

Second-line or Supplementary Imaging:

• MRI and MR Angiography - Comparable accuracy to catheter angiography in some cases 1
• Digital Subtraction Angiography (DSA) - For cases with high suspicion of vascular etiology but negative initial imaging 2

Common Causes and Treatments

Pulsatile tinnitus may result from:

1. Vascular abnormalities:

   • Arteriovenous malformations or fistulas
   • Carotid artery stenosis
   • Jugular bulb abnormalities
   • Persistent petrosquamosal sinus
   • Vascular tumors (paragangliomas)

2. Non-vascular causes:

   • Idiopathic intracranial hypertension
   • Superior semicircular canal dehiscence
   • Otosclerosis
   • Patulous eustachian tube

Treatment Approaches

Treatment is directed at the underlying cause:

• Vascular abnormalities:

  • Endovascular procedures (embolization, stenting)
  • Surgical intervention
  • Radiation therapy for certain tumors

• Idiopathic intracranial hypertension:

  • Weight loss
  • Acetazolamide
  • Venous sinus stenting in cases with venous stenosis 2

• Otologic causes:

  • Surgical correction for superior canal dehiscence
  • Stapedectomy for otosclerosis

Important Considerations

• Pulsatile tinnitus requires imaging even when otoscopic examination is normal 1
• Unlike non-pulsatile tinnitus, pulsatile tinnitus often has an identifiable and potentially treatable cause 3
• Failure to diagnose the underlying cause may have serious consequences if a life-threatening disorder is present 4
• The majority of patients with pulsatile tinnitus have a treatable condition 4

Remember that pulsatile tinnitus differs significantly from non-pulsatile tinnitus in evaluation and management approach. While non-pulsatile tinnitus often requires symptom management (hearing aids, sound therapy, cognitive behavioral therapy), pulsatile tinnitus typically requires identification and treatment of the underlying vascular or structural abnormality.