What is the diagnosis and treatment approach for pulsatile tinnitus?

Diagnosis and Treatment Approach for Pulsatile Tinnitus

Pulsatile tinnitus requires imaging evaluation to identify underlying vascular abnormalities, which are present in more than 70% of cases and often treatable through medical, endovascular, or surgical interventions. 1, 2

Diagnostic Classification

• Pulsatile tinnitus is classified as objective (audible to the examiner) or subjective (perceived only by the patient), with both types warranting thorough evaluation for vascular causes 1
• Comprehensive otologic examination is essential to identify potential vascular retrotympanic masses before proceeding with imaging 1, 3
• Audiometric examination should be performed for all patients with unilateral or persistent tinnitus (≥6 months) 3

Diagnostic Imaging Algorithm

First-Line Imaging

• Dedicated temporal bone CT is recommended as first-line imaging for vascular retrotympanic mass or subjective pulsatile tinnitus to identify:

  • Paragangliomas or adenomatous middle ear tumors 1
  • Variant vascular anatomy 1
  • Semicircular canal dehiscence 1

• CT angiography (CTA) of head and neck with contrast is equally recommended as first-line imaging to detect:

  • Dural arteriovenous fistulas 1
  • Arterial dissection 1
  • Sigmoid sinus wall diverticulum or anomalies 1
  • Aberrant arterial or venous anatomy 1

Second-Line Imaging

• MRI and MR angiography (MRA) with contrast are valuable for evaluating:

  • Cerebellopontine angle lesions 1
  • Vascular malformations 1, 3
  • Idiopathic intracranial hypertension 1, 4

• Digital subtraction angiography (DSA) may be necessary when initial vascular imaging is negative but vascular etiology is strongly suspected 4

Common Causes and Specific Treatments

Vascular Causes

• Arterial dissection: Treat with anticoagulation or antiplatelet therapy 3
• Sigmoid sinus diverticulum or dehiscence: Surgical repair or endovascular embolization 3, 5
• Dural arteriovenous fistulas: Endovascular treatment often leads to improvement or resolution 4, 5
• Idiopathic intracranial hypertension with venous sinus stenosis: Consider venous sinus stenting 4
• Atherosclerotic carotid artery disease: Most common etiology (17.5% of cases) 6

Structural Causes

• Superior semicircular canal dehiscence: Surgical repair for severe symptomatic cases 3
• Temporal bone pathologies: Treatment depends on specific pathology 2
• Glomus tumors (paragangliomas): Surgical resection or radiation therapy 1

Metabolic Causes

• High cardiac output states (hyperthyroidism, anemia): Treat underlying condition 2, 6
• Medication-induced: Consider medication review and possible adjustments 2

Important Considerations and Pitfalls

• Pulsatile tinnitus differs significantly from non-pulsatile tinnitus in evaluation approach and treatment options 1, 7
• Prompt identification and intervention are critical for patients with severe anxiety or depression due to increased suicide risk 1
• Unlike bilateral non-pulsatile tinnitus, pulsatile tinnitus almost always requires imaging evaluation 3, 7
• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics without addressing the underlying cause 3
• Dietary supplements (Ginkgo biloba, melatonin, zinc) are not recommended as primary treatment 3
• Cognitive behavioral therapy may be beneficial for managing the psychological impact of persistent tinnitus when structural causes have been addressed 7