What is the management and treatment of pulsatile tinnitus?

Management and Treatment of Pulsatile Tinnitus

The management of pulsatile tinnitus requires imaging evaluation to identify underlying vascular abnormalities, followed by targeted treatment of the specific cause identified. 1, 2

Diagnostic Evaluation

• Comprehensive otologic examination is essential to determine if a vascular retrotympanic mass is present before proceeding with imaging 1
• Audiometric examination should be performed to identify any associated hearing loss 1
• Pulsatile tinnitus (both subjective and objective) requires imaging to identify potentially treatable underlying causes 1, 2

First-line Imaging

• Dedicated temporal bone CT is recommended as a first-line study for pulsatile tinnitus to identify paragangliomas, adenomatous middle ear tumors, or variant vascular anatomy 1
• CT angiography (CTA) of head and neck with contrast is also supported as a first-line imaging modality to evaluate vascular abnormalities 1, 2
• Temporal bone CT reconstructions can be created from high-resolution CTA images without additional radiation exposure 1

Second-line Imaging

• MRI and MR angiography (MRA) with contrast are recommended as second-line imaging options 1, 3
• MRI is particularly useful for evaluating cerebellopontine angle lesions and vascular malformations 3

Treatment Based on Underlying Cause

Vascular Causes

• Arterial dissection should be treated with anticoagulation or antiplatelet therapy 2, 4
• Sigmoid sinus diverticulum or dehiscence requires surgical repair or endovascular embolization 2, 5
• Dural arteriovenous fistulas can be managed endovascularly, often leading to improvement or resolution of pulsatile tinnitus 5, 4
• Venous sinus stenting is an emerging therapy for pulsatile tinnitus secondary to idiopathic intracranial hypertension with venous sinus stenosis 5
• Jugular bulb abnormalities may require surgical intervention in symptomatic cases 3, 6

Structural Causes

• Paragangliomas or glomus tumors require surgical removal or radiation therapy 7, 6
• Superior semicircular canal dehiscence should be surgically repaired in severe symptomatic cases 1, 2
• Otosclerosis may be treated with stapedectomy if causing significant symptoms 5

Non-specific Management

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent tinnitus when specific treatments are not available or effective 3, 8
• Hearing aids are recommended for patients with associated hearing loss, even if mild 8

Important Considerations

• Pulsatile tinnitus almost always requires imaging evaluation, unlike bilateral non-pulsatile tinnitus 1, 2
• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 1, 8
• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics for treatment without addressing the underlying cause 2, 8
• Dietary supplements like Ginkgo biloba, melatonin, or zinc are not recommended as primary treatment 2, 8
• Failure to establish correct diagnosis may have serious consequences, as potentially life-threatening disorders may be present 9

Treatment Algorithm

1. Determine if tinnitus is pulsatile or non-pulsatile 1, 6
2. For pulsatile tinnitus, perform comprehensive otologic and audiometric examination 1
3. Proceed with first-line imaging: temporal bone CT and/or CTA with contrast 1, 2
4. If first-line imaging is inconclusive but vascular etiology is strongly suspected, proceed with MRI/MRA 3, 5
5. Once specific cause is identified, implement targeted treatment (surgical, endovascular, or medical) 2, 4
6. For persistent symptoms despite treatment, consider CBT and sound therapy 8