How to diagnose and manage pulsatile tinnitus?

Assessment and Management of Pulsatile Tinnitus

Pulsatile tinnitus requires comprehensive imaging evaluation to identify underlying vascular abnormalities, as it is frequently associated with treatable conditions that can significantly impact morbidity and mortality if left undiagnosed. 1, 2

Initial Classification and Evaluation

• Distinguish between subjective tinnitus (heard only by the patient) and objective tinnitus (audible to the examiner), with objective tinnitus strongly suggesting an underlying vascular abnormality 1
• Perform a targeted otologic examination to identify potential vascular retrotympanic masses and assess for focal neurological abnormalities 1
• Complete a comprehensive audiologic examination for patients with unilateral, persistent (≥6 months), or hearing loss-associated tinnitus 1
• Determine if tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as pulsatile tinnitus almost always requires imaging evaluation 2, 3

Imaging Recommendations

• Dedicated temporal bone CT should be used as a first-line study for pulsatile tinnitus or when a vascular cause is suspected 1, 2
• CT angiography (CTA) of the head and neck with contrast should be considered to evaluate for vascular abnormalities such as arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 1, 2
• MRI and MR angiography with contrast may be used as second-line imaging, particularly for evaluating cerebellopontine angle lesions and vascular malformations 2
• Imaging should not be performed for bilateral, non-pulsatile tinnitus without other concerning features 1

Common Causes of Pulsatile Tinnitus

• Vascular abnormalities: arteriovenous fistulas, arteriovenous malformations, carotid stenosis, vascular tumors (paragangliomas/glomus tumors) 1, 2, 4
• Venous causes: idiopathic intracranial hypertension, venous sinus stenosis, high jugular bulb, sigmoid sinus diverticulum 2, 5, 4
• Arterial causes: arteriosclerosis, arterial dissection, fibromuscular dysplasia 5, 4
• Bony abnormalities: superior semicircular canal dehiscence, sigmoid sinus wall dehiscence 2, 3
• Neoplasms: highly vascularized skull base tumors 4

Management Approach

• For identified vascular causes, targeted treatment of the underlying condition is recommended 2
• Specific treatments include:
  • Arterial dissection: anticoagulation or antiplatelet therapy 2
  • Sigmoid sinus diverticulum or dehiscence: surgical repair or endovascular embolization 2
  • Jugular bulb abnormalities: surgical intervention in symptomatic cases 2
  • Venous sinus stenosis: venous sinus stenting is an emerging therapy 6
• For persistent, bothersome tinnitus without identifiable or treatable cause:
  • Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life 2
  • Hearing aid evaluation for patients with associated hearing loss 1
  • Sound therapy may be recommended 1

Important Considerations and Pitfalls

• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 1, 2
• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics for treatment without addressing the underlying cause 1, 2
• Dietary supplements like Ginkgo biloba, melatonin, or zinc are not recommended as primary treatment 1, 2
• In approximately 70% of patients with pulsatile tinnitus, an underlying cause can be identified with thorough evaluation 7
• The most common causes in clinical practice include highly vascularized tumors of the temporal bone (16%), venous normal variants and anomalies (14%), and vascular stenoses (9%) 4

Diagnostic Algorithm for Pulsatile Tinnitus

1. Determine if tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile 1, 8
2. For pulsatile tinnitus, perform otoscopic examination to identify potential retrotympanic mass 1
3. Conduct audiologic assessment to identify associated hearing loss 1
4. Proceed with first-line imaging: temporal bone CT and/or CTA with contrast 1, 2
5. If initial imaging is negative but vascular etiology is strongly suspected, consider MRI/MRA or digital subtraction angiography 2, 6
6. Once diagnosis is established, implement targeted treatment for the specific underlying cause 2