What causes a pulsating sound in my ears?

Causes of Pulsating Sound in Ears

Pulsatile tinnitus is most commonly caused by vascular abnormalities including arteriovenous fistulas, vascular masses, aberrant arterial or venous anatomy, and intracranial hypertension, which require appropriate imaging for diagnosis and management. 1

Understanding Pulsatile Tinnitus

Pulsatile tinnitus is characterized by a rhythmic sound that synchronizes with your heartbeat. Unlike regular tinnitus, which presents as a continuous ringing or buzzing, pulsatile tinnitus has a distinct pulsing quality that corresponds to your pulse.

Key Characteristics:

• Rhythmic sound that matches your heartbeat
• Can be subjective (heard only by the patient) or objective (can be heard by an examiner)
• May be unilateral (one ear) or bilateral (both ears)

Common Causes of Pulsatile Tinnitus

1. Vascular Abnormalities (Most Common)

• Arteriovenous malformations/fistulas - abnormal connections between arteries and veins 1
• Vascular masses - such as paragangliomas (glomus tumors) 1, 2
• Aberrant arterial or venous anatomy - including persistent petrosquamosal sinus 1
• Jugular bulb abnormalities - high-riding or dehiscent jugular bulb 1
• Sigmoid sinus wall abnormalities - including diverticulum 1

2. Vascular Disease

• Atherosclerotic carotid artery disease - causing turbulent blood flow 1, 2
• Arterial dissection - tears in arterial walls 1

3. Intracranial Pressure Abnormalities

• Intracranial hypertension (pseudotumor cerebri syndrome) 1, 2

4. Other Causes

• Palatal or middle ear myoclonus - muscle contractions causing clicking sounds 1
• Eustachian tube dysfunction - can cause clicking or popping sounds 1
• Venous hum - sounds generated within the venous system of the brain 3

Diagnostic Approach

When pulsatile tinnitus is present, imaging is strongly recommended to identify potentially treatable underlying causes:

First-Line Imaging Options:

1. Dedicated temporal bone CT - excellent for identifying:

   • Middle ear masses
   • Vascular anomalies
   • Semicircular canal dehiscence 1

2. CT angiography (CTA) of head and neck - best for:

   • Arterial and venous abnormalities
   • Dural arteriovenous fistulas
   • Vascular malformations 1

Alternative or Additional Imaging:

• MRI and MR angiography - comparable accuracy to catheter angiography for many vascular abnormalities 1
• Carotid ultrasound - helpful for suspected carotid stenosis 1
• Catheter angiography - reserved for objective pulsatile tinnitus with inconclusive noninvasive imaging 1

Important Clinical Considerations

Warning Signs Requiring Urgent Evaluation:

• Objective tinnitus (audible to examiner)
• Pulsatile tinnitus with focal neurological deficits
• Visible retrotympanic mass on examination

Pitfalls to Avoid:

1. Misdiagnosis as non-pulsatile tinnitus - careful questioning about the sound quality is essential
2. Overlooking potentially serious causes - arteriovenous shunts or carotid stenosis can be life-threatening 2
3. Failure to distinguish between pulse-synchronous and pulse-asynchronous sounds - the latter may indicate myoclonus rather than vascular causes 1

Quality of Life Impact:

Pulsatile tinnitus can significantly impact quality of life, causing anxiety, depression, and sleep disturbances. Patients with severe psychological distress require prompt identification and intervention, as suicide has been reported in patients with tinnitus who have coexisting psychiatric illness 1.

Management Approach

Management depends on identifying and treating the underlying cause:

• Vascular abnormalities may require endovascular, surgical, or radiation therapy 1
• Intracranial hypertension typically requires medical management
• Symptomatic treatment may be needed while investigating the cause

Remember that pulsatile tinnitus often represents an underlying medical condition that may be treatable, making proper diagnosis crucial for optimal outcomes.