What to do for transient pulsating tinnitus?

Management of Transient Pulsatile Tinnitus

Transient pulsatile tinnitus requires thorough evaluation including imaging studies to rule out potentially serious underlying vascular causes, even when symptoms are intermittent. 1

Initial Assessment

• Determine if the tinnitus is truly pulsatile (synchronous with heartbeat) and unilateral, which requires more urgent evaluation than bilateral non-pulsatile tinnitus 1
• Complete otologic examination to identify any visible vascular retrotympanic mass 1
• Comprehensive audiologic examination is essential, especially for unilateral or persistent (≥6 months) tinnitus 1, 2
• Auscultation of the ears, neck, and head to detect objective tinnitus (audible to examiner) 1, 3

Diagnostic Imaging

• First-line imaging: CT of temporal bone and/or CT angiography (CTA) of head and neck with contrast 1, 2

  • Temporal bone CT is particularly useful for identifying paragangliomas, middle ear tumors, or vascular anatomic variants 1, 2
  • CTA can detect arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 1, 2

• Second-line imaging: MRI and MR angiography (MRA) with contrast 1, 2

  • Especially valuable for evaluating cerebellopontine angle lesions and vascular malformations 1, 2
  • Better for soft tissue evaluation than CT 1

Common Causes and Management

• Vascular abnormalities (most common cause of pulsatile tinnitus) 4, 5

  • Arterial causes: atherosclerosis, dissection, fibromuscular dysplasia 6
  • Arteriovenous causes: dural arteriovenous fistulas, vascular tumors 5, 6
  • Venous causes: intracranial hypertension, venous sinus anomalies 2, 6

• Treatment approaches:

  • Arterial dissection: anticoagulation or antiplatelet therapy 2
  • Sigmoid sinus diverticulum/dehiscence: surgical repair or endovascular embolization 2
  • Superior semicircular canal dehiscence: surgical repair for severe symptomatic cases 2
  • Vascular tumors (e.g., glomus tumors): surgical removal or radiation therapy 3, 4

Important Considerations

• Even transient pulsatile tinnitus warrants imaging evaluation, as it may indicate an underlying vascular abnormality that could lead to stroke or hemorrhage 5, 6
• Pulsatile tinnitus can be identified in more than 70% of cases with appropriate evaluation 5
• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics without addressing the underlying cause 1, 2
• Dietary supplements like Ginkgo biloba, melatonin, or zinc are not recommended as primary treatment 1, 2

Referral Guidelines

• Refer to otolaryngology for initial evaluation and management 3, 4
• Consider neurology or neurosurgery consultation for suspected intracranial causes 5, 6
• Interventional radiology consultation for potential endovascular treatment options 2, 6

Follow-up

• If no cause is identified after thorough evaluation, consider periodic reassessment, especially if symptoms persist or worsen 7, 4
• Patient reassurance and education about the condition are important components of management 1, 7