What is the management approach for patients with pulsatile tinnitus?

Management of Pulsatile Tinnitus

For patients with pulsatile tinnitus, a temporal bone CT scan or CT angiography (CTA) should be performed as first-line imaging to identify the underlying vascular cause, which is often treatable. 1, 2

Diagnostic Approach

Initial Evaluation

• Perform targeted history and physical examination to distinguish between:
  • Objective tinnitus (audible to examiner) - strongly suggests vascular abnormality 2
  • Subjective pulsatile tinnitus - still requires vascular evaluation 2
• Check for retrotympanic mass during otologic examination 2
• Perform jugular compression test - if tinnitus resolves with compression, suggests venous cause 3
• Assess for focal neurologic abnormalities or asymmetric hearing loss 1

Imaging Studies

1. First-line imaging options:

   • Temporal bone CT scan - excellent for detecting paragangliomas, adenomatous tumors, and vascular variants 2, 1
   • CT angiography (CTA) of head and neck - best for vascular causes 2, 1

2. Additional imaging when indicated:

   • MRI/MRA - complementary to CT for soft tissue evaluation 4
   • Digital subtraction angiography (DSA) - if initial vascular imaging is negative but vascular etiology still suspected 4

Differential Diagnosis by Category

Vascular Causes

• Arterial:

  • Arteriovenous malformations or fistulas
  • Carotid artery stenosis
  • Vascular loops in internal auditory canal
  • Aneurysms

• Venous:

  • Idiopathic intracranial hypertension with venous sinus stenosis
  • Jugular bulb abnormalities (high riding, dehiscent)
  • Aberrant venous anatomy

Structural Causes

• Paragangliomas (glomus tumors)
• Temporal bone abnormalities
• Superior semicircular canal dehiscence
• Otosclerosis

Metabolic/Systemic Causes

• High cardiac output states
• Medication-induced

Treatment Approach

1. Address underlying cause:

   • Vascular abnormalities:

     • Endovascular procedures for arteriovenous malformations/fistulas 4
     • Venous sinus stenting for idiopathic intracranial hypertension with venous stenosis 4
     • Jugular vein ligation for jugular megabulb (only if contralateral venous drainage is confirmed) 3

   • Neoplastic causes:

     • Surgical resection or radiation therapy for paragangliomas 2, 5

   • Structural abnormalities:

     • Surgical correction for superior semicircular canal dehiscence 2
     • Management of otosclerosis 6

2. When no treatable cause is found:

   • Sound therapy for symptomatic relief 1
   • Cognitive Behavioral Therapy (CBT) for managing associated distress 1

Important Clinical Considerations

• Pulsatile tinnitus can be identified in over 70% of cases with thorough evaluation 7
• Failure to diagnose may have serious consequences as some causes (e.g., vascular malformations) can lead to hemorrhagic or ischemic stroke 7, 5
• Red flags requiring immediate attention:
  • Sudden onset with hearing loss
  • Tinnitus after head trauma
  • Associated dizziness or balance problems
  • Worsening headache
  • Focal neurological deficits 1

Common Pitfalls to Avoid

• Misclassifying pulsatile tinnitus as non-pulsatile subjective tinnitus
• Failing to perform appropriate imaging studies
• Overlooking the possibility of a vascular cause
• Premature conclusion that tinnitus is idiopathic before complete evaluation
• Using treatments recommended for non-pulsatile tinnitus (supplements, medications) without addressing underlying cause 1