Differential Diagnosis

The patient's symptoms of experiencing a sensation of her pulse or heartbeat in her right ear, particularly when lying down, along with a feeling of fullness in the ear, can be approached by considering the following categories:

• Single Most Likely Diagnosis

  • Benign Paroxysmal Positional Vertigo (BPPV) or more likely, a variant of it, given the positional nature of the symptoms: Although BPPV typically presents with vertigo, the positional component and the sensation of fullness could align with this diagnosis, especially if the patient is experiencing subtle vertigo or imbalance not explicitly mentioned.
  • Alternatively, Idiopathic Pulsatile Tinnitus: Given the specific symptom of hearing her pulse in one ear, this could be a primary consideration, especially if the fullness is related to the sensation of the pulse.

• Other Likely Diagnoses

  • Middle Ear Effusion: The feeling of fullness in the ear could suggest fluid in the middle ear, which might cause a sensation of hearing one's pulse due to the fluid's effect on sound conduction.
  • Eustachian Tube Dysfunction: This condition can cause a feeling of fullness in the ear and could potentially lead to the sensation of hearing one's pulse, especially if there's altered pressure or fluid dynamics in the ear.
  • Pulsatile Tinnitus due to Vascular Causes: While less common, changes in blood flow or vascular abnormalities near the ear could cause pulsatile tinnitus, especially if the patient has started new medications that could affect blood flow or pressure.

• Do Not Miss Diagnoses

  • Glomus Jugulare Tumor or Other Vascular Tumors: Although rare, these tumors can cause pulsatile tinnitus due to their vascular nature and proximity to the ear. Missing this diagnosis could have significant implications.
  • Carotid Artery Stenosis or Atherosclerosis: Significant stenosis could potentially cause turbulent blood flow leading to pulsatile tinnitus. Given the potential for stroke, this is a critical diagnosis not to miss.
  • Temporal Bone Fracture or Other Trauma: Even though the patient denies recent trauma, it's essential to consider the possibility of an unrecognized or minor injury that could lead to the symptoms described.

• Rare Diagnoses

  • Superior Semicircular Canal Dehiscence: A rare condition where there's an abnormal opening in the bone overlying the superior semicircular canal, which can cause a variety of auditory and vestibular symptoms, including pulsatile tinnitus.
  • Patulous Eustachian Tube: A condition where the Eustachian tube remains open, leading to autophony (hearing one's internal sounds unusually loudly) and potentially pulsatile tinnitus.
  • Vascular Malformations or Fistulas: Abnormal connections between arteries and veins can cause pulsatile tinnitus due to the abnormal blood flow patterns.