Differential Diagnosis for Pulsatile Tinnitus in a 57-Year-Old Female

Single Most Likely Diagnosis

• Benign Intracranial Hypertension (BIH): Also known as idiopathic intracranial hypertension, this condition is characterized by increased intracranial pressure without a detectable cause. It often presents with pulsatile tinnitus, and while it can be associated with headaches, their absence does not rule out the diagnosis. The condition is more common in women, especially those who are overweight.

Other Likely Diagnoses

• Vascular Malformations or Abnormalities: Conditions such as arteriovenous malformations (AVMs), carotid artery stenosis, or fibromuscular dysplasia can cause pulsatile tinnitus due to abnormal blood flow. These conditions might not always present with other symptoms like neurological deficits or headaches.
• Middle Ear Problems: Middle ear effusion, otosclerosis, or a patulous Eustachian tube can cause pulsatile tinnitus. These conditions might be more noticeable on one side, depending on the underlying cause.
• Anemia or Thyroid Disorders: Both anemia and thyroid disorders (especially hyperthyroidism) can lead to pulsatile tinnitus. These conditions can cause changes in blood flow or metabolism that might result in tinnitus.

Do Not Miss Diagnoses

• Giant Cell Arteritis: Although less common, giant cell arteritis is a condition that can lead to serious complications, including blindness, if not promptly treated. It typically presents with headaches, jaw claudication, and visual disturbances, but tinnitus can be an associated symptom.
• Acoustic Neuroma: A benign tumor on the nerve connecting the inner ear to the brain, which can cause tinnitus, hearing loss, and balance problems. Early detection is crucial for effective management.
• Carotid Artery Dissection: A tear in the carotid artery wall can lead to stroke or other severe complications. While it often presents with pain or neurological deficits, it's essential to consider in the differential due to its potential severity.

Rare Diagnoses

• Glomus Tumors: Rare, benign tumors of the middle ear or jugular bulb that can cause pulsatile tinnitus due to their vascular nature.
• Paget's Disease: A condition of bone that can affect the skull and lead to various symptoms, including tinnitus, due to its impact on the auditory system.
• Superior Semicircular Canal Dehiscence: A rare condition where there is an abnormal opening in the bone overlying the superior semicircular canal of the inner ear, which can cause a variety of auditory and vestibular symptoms, including pulsatile tinnitus.

Workup

The workup for pulsatile tinnitus should be tailored to the suspected underlying cause based on the patient's history and physical examination. Initial steps may include:

• Audiogram: To assess hearing and identify any hearing loss.
• Tympanometry and Acoustic Reflex Testing: To evaluate middle ear function.
• Complete Blood Count (CBC): To check for anemia.
• Thyroid Function Tests: To evaluate for thyroid disorders.
• Imaging Studies: Such as MRI or CT angiography of the head and neck to evaluate for vascular abnormalities, tumors, or other structural issues.
• Referral to an Otolaryngologist or Neurologist: For further evaluation and management, especially if a specific condition is suspected or if the diagnosis remains unclear after initial assessment.