What is the recommended next step for a 12-week pregnant adult presenting with 3 weeks of right pulsatile tinnitus and a normal hearing test?

Management of Pulsatile Tinnitus in Pregnancy

Imaging with MR angiography is strongly recommended for a pregnant patient with pulsatile tinnitus, even with normal hearing, as pulsatile tinnitus often indicates an underlying vascular abnormality that may be serious or life-threatening. 1

Rationale for Imaging in Pulsatile Tinnitus

Pulsatile tinnitus requires different management than non-pulsatile tinnitus because:

• It frequently indicates an underlying vascular pathology that may require intervention 1, 2
• Potential causes include arteriovenous malformations/fistulas, vascular tumors, venous sinus stenosis, and carotid artery abnormalities 2, 3
• The American College of Radiology specifically recommends imaging for pulsatile tinnitus, as it often represents a treatable condition 4, 1

Imaging Recommendations for Pregnant Patients

For a 12-week pregnant patient with pulsatile tinnitus:

1. First-line imaging: Non-contrast MR angiography (MRA)

   • Avoids radiation exposure and gadolinium contrast agents
   • Can effectively evaluate vascular anomalies, malformations, and dissections 4
   • Provides visualization of the relationship between nerves and blood vessels

2. Alternative if MRA is contraindicated:

   • Consider delaying imaging until after pregnancy if symptoms are mild and non-progressive
   • Carotid duplex/Doppler ultrasound can help evaluate extracranial carotid stenosis if that's suspected 4

Clinical Considerations

• The normal hearing test does not rule out significant pathology in pulsatile tinnitus 1, 5
• Unilateral (right-sided) presentation increases concern for a focal lesion 1
• Recent onset (3 weeks) warrants prompt evaluation rather than watchful waiting 2

Important Caveats

• Pregnancy-specific considerations:

  • Non-contrast MRI is preferred to avoid gadolinium exposure to the fetus
  • CT angiography, while excellent for vascular evaluation, involves radiation exposure and should be avoided during pregnancy if possible 3

• Common pitfalls to avoid:

  • Dismissing pulsatile tinnitus as benign without imaging evaluation
  • Failing to distinguish between pulsatile and non-pulsatile tinnitus (which have different management pathways)
  • Assuming normal hearing excludes serious pathology 1

Follow-up Recommendations

• Schedule follow-up within 4-6 weeks to assess symptom progression 1
• If imaging reveals a vascular abnormality, referral to appropriate specialists (neurosurgery, interventional neuroradiology, or vascular surgery) may be necessary 1, 2
• Consider otolaryngology consultation for comprehensive evaluation of the ear and temporal bone 6

Pulsatile tinnitus represents a distinct clinical entity from non-pulsatile tinnitus and requires imaging evaluation even with normal hearing, as it can be the presenting symptom of potentially serious vascular pathology.