What are the treatment options for pulsatile tinnitus?

Treatment Options for Pulsatile Tinnitus

For pulsatile tinnitus, treatment must target the underlying cause through appropriate diagnostic imaging followed by specific interventions including endovascular procedures, surgery, or sound therapy depending on the identified etiology. 1

Diagnostic Approach Before Treatment

The treatment of pulsatile tinnitus requires proper diagnosis through:

1. Imaging studies - Critical for identifying treatable causes:

   • First-line imaging options:
     • Dedicated temporal bone CT for suspected vascular retrotympanic mass 1
     • CT angiography (CTA) of head and neck for suspected vascular abnormalities 1
     • MRI/MRA for suspected intracranial vascular malformations 1

2. Key clinical distinction: Objective pulsatile tinnitus (audible to examiner) vs. subjective pulsatile tinnitus 1

Treatment Algorithm Based on Underlying Cause

1. Vascular Abnormalities

• Dural arteriovenous fistulas (AVFs):

  • Endovascular embolization
  • Surgical resection when embolization is not feasible 1

• Jugular bulb abnormalities:

  • Jugular vein ligation for megabulb deformities (when contralateral venous drainage is confirmed) 2
  • Endovascular stenting for sigmoid sinus diverticulum

• Atherosclerotic carotid disease:

  • Carotid endarterectomy or stenting when significant stenosis is present 1

2. Vascular Tumors

• Paragangliomas (glomus tumors):

  • Surgical resection
  • Radiation therapy for inoperable cases 1

• Middle ear adenomatous tumors:

  • Surgical excision 1

3. Intracranial Hypertension

• Medical management:
  • Weight loss
  • Acetazolamide or other diuretics
  • CSF shunting procedures in refractory cases 1

4. Non-Vascular Causes

• Superior semicircular canal dehiscence:

  • Surgical repair of the dehiscence 1

• Palatal or tympanic myoclonus:

  • Botulinum toxin injections
  • Muscle relaxants 1

Management of Persistent Bothersome Tinnitus

When specific causes are treated but tinnitus persists or when no treatable cause is found:

1. Sound therapy - May be recommended for persistent, bothersome tinnitus 1

   • External noise generators
   • Hearing aids when hearing loss is present 1

2. Cognitive behavioral therapy (CBT) - Strongly recommended for persistent bothersome tinnitus 1

   • Helps patients develop coping strategies
   • Reduces tinnitus-related distress

3. Education and counseling - Essential component of management 1

   • Information about the condition
   • Strategies to manage symptoms

Important Caveats and Pitfalls

• Avoid unnecessary medical therapy: Antidepressants, anticonvulsants, and anxiolytics should not be routinely prescribed specifically for tinnitus 1

• Avoid unproven supplements: Ginkgo biloba, melatonin, zinc, and other dietary supplements are not recommended 1

• Transcranial magnetic stimulation (TMS) is not recommended for routine treatment 1

• Beware of misdiagnosis: Normal vascular loops contacting the eighth cranial nerve are common incidental findings and should not be considered the cause of tinnitus without ruling out other etiologies 1

• Mental health monitoring: Patients with tinnitus and severe anxiety or depression require prompt identification and intervention due to increased suicide risk 1

The treatment approach must be guided by accurate diagnosis through appropriate imaging, followed by targeted interventions for the specific underlying cause, with supportive therapies for symptom management when needed.