Can pulsating tinnitus be related to underlying vascular abnormalities?

Pulsating Tinnitus and Vascular Abnormalities

Pulsating tinnitus is strongly associated with underlying vascular abnormalities and requires appropriate imaging for diagnosis and management. 1 This symptom warrants thorough investigation as it may indicate potentially serious vascular conditions that could affect morbidity and mortality.

Understanding Pulsatile Tinnitus

Pulsatile tinnitus is characterized by a repetitive sound that coincides with your heartbeat, distinguishing it from the more common nonpulsatile (continuous) tinnitus. It can be classified as:

• Objective pulsatile tinnitus: Audible to both the patient and examining healthcare provider, strongly suggesting an underlying vascular abnormality 1
• Subjective pulsatile tinnitus: Heard only by the patient but still often associated with vascular causes

Common Vascular Causes of Pulsatile Tinnitus

Pulsatile tinnitus can originate from various vascular abnormalities:

• Arterial causes:

  • Atherosclerotic carotid artery disease 1, 2
  • Arterial dissection 1, 2
  • Arterial anatomic variants at the skull base 2
  • Intracranial aneurysms (rare but serious) 3

• Venous causes:

  • Jugular bulb abnormalities 1
  • Sigmoid sinus wall anomalies 1
  • Venous cerebral thrombosis 4
  • Intracranial hypertension 1, 5

• Arteriovenous causes:

  • Dural arteriovenous fistulas 1, 5
  • Vascular skull base tumors (paragangliomas) 1, 5
  • Arteriovenous malformations 5

Diagnostic Approach

The American College of Radiology and American Academy of Otolaryngology-Head and Neck Surgery recommend the following imaging approach for pulsatile tinnitus:

1. First-line imaging:

   • CT angiography (CTA) of head and neck - Provides excellent visualization of vascular structures and can identify arterial abnormalities, venous anomalies, and vascular masses 1, 6
   • Dedicated temporal bone CT - Especially useful when a vascular retrotympanic mass is suspected 1

2. Alternative or additional imaging:

   • MRI with MR angiography (MRA) - Particularly valuable for evaluating intracranial structures and vascular malformations 1, 6
   • Catheter angiography - Reserved for cases with objective pulsatile tinnitus with inconclusive noninvasive imaging or for further characterization of dural AVFs 1
   • Carotid duplex ultrasound - Helpful to evaluate extracranial carotid stenosis when suspected as the cause 1

Management Considerations

Management depends on the underlying cause:

• Vascular abnormalities: May require endovascular, surgical, or radiation therapy 1
• Intracranial hypertension: Medical management to reduce pressure 1, 5
• Venous thrombosis: Anticoagulation therapy (can lead to full recovery in most cases) 4
• Symptomatic relief: Sound therapy options and cognitive behavioral therapy may help manage symptoms while addressing underlying causes 6

Important Cautions

• Do not miss serious vascular causes: Some vascular abnormalities like aneurysms presenting as pulsatile tinnitus are rare but potentially life-threatening 3
• Avoid unnecessary interventions: Thorough evaluation is essential before any intervention, as some vascular variants may represent compensatory mechanisms rather than pathology 7
• Consider multiple imaging modalities: No single imaging technique can identify all potential causes 1, 5
• Don't overlook non-vascular causes: While vascular causes are common, other conditions like intracranial hypertension can present similarly 1, 6

If you're experiencing pulsatile tinnitus, prompt evaluation by a healthcare provider is essential to identify potentially serious underlying conditions and guide appropriate management.