What causes pulsatile tinnitus and how is it treated?

Pulsatile Tinnitus: Causes and Treatment

If you hear your pulse in your ear (pulsatile tinnitus), you need imaging studies to identify potentially treatable and sometimes life-threatening vascular abnormalities, structural lesions, or intracranial hypertension that are present in over 70% of cases. 1, 2

What Causes Pulsatile Tinnitus

Pulsatile tinnitus occurs when you perceive rhythmic sound synchronized with your heartbeat, and unlike common non-pulsatile tinnitus, it almost always has an identifiable underlying cause that requires investigation. 1

Primary Vascular Causes

• Arterial abnormalities: Atherosclerotic carotid artery disease with turbulent flow, carotid artery stenosis, arterial dissection, and dural arteriovenous fistulas 1, 3
• Venous abnormalities: Jugular bulb abnormalities (high jugular bulb or dehiscence), sigmoid sinus diverticulum or dehiscence, abnormal condylar and mastoid emissary veins 1, 4
• Vascular malformations: Arteriovenous malformations and fistulas 1

Structural Causes

• Vascular masses: Paragangliomas (glomus tumors) and adenomatous middle ear tumors that appear as retrotympanic masses 1, 4
• Temporal bone pathology: Superior semicircular canal dehiscence 1, 4

Metabolic/Systemic Causes

• Intracranial hypertension: Idiopathic intracranial hypertension (pseudotumor cerebri) 1, 2
• High cardiac output states: Anemia (including pernicious anemia), hyperthyroidism, and other conditions causing hyperdynamic circulation 2, 5

Diagnostic Evaluation

Initial Clinical Assessment

Perform otoscopy first to identify vascular retrotympanic masses, which are visible on examination and immediately narrow the differential diagnosis to paragangliomas or adenomatous tumors. 1, 4

Obtain comprehensive audiologic examination for all patients with unilateral or persistent pulsatile tinnitus (≥6 months duration). 1, 4

Check for objective tinnitus by auscultating over the ear, mastoid, neck, and periorbital regions—if you can hear the sound, this confirms objective tinnitus and strongly suggests vascular pathology. 1

First-Line Imaging

Order CT temporal bone and/or CT angiography (CTA) of head and neck with contrast as your initial imaging study. 1, 4

• CT temporal bone identifies paragangliomas, middle ear tumors, superior semicircular canal dehiscence, and aberrant vascular anatomy 1, 4
• CTA detects arteriovenous fistulas, arterial dissection, carotid stenosis, and sigmoid sinus abnormalities 1, 4
• Temporal bone reconstructions can be created from CTA source images without additional radiation 1

Second-Line Imaging

Use MRI/MRA with contrast when CT/CTA is non-diagnostic or to better characterize lesions, particularly for cerebellopontine angle masses, intracranial vascular malformations, and soft tissue characterization. 1, 4

Additional Studies When Indicated

• Carotid duplex ultrasound: For suspected extracranial carotid stenosis 1
• Catheter angiography: Reserved for objective pulsatile tinnitus with inconclusive noninvasive imaging, or for treatment planning of identified vascular lesions 1
• Fundoscopic examination: Essential to exclude papilledema from intracranial hypertension 6

Treatment Approaches

Treatment must target the specific underlying cause rather than just managing symptoms. 4, 7

Vascular Lesions

• Arterial dissection: Anticoagulation or antiplatelet therapy 4
• Sigmoid sinus diverticulum/dehiscence: Surgical repair or endovascular embolization 4
• Dural arteriovenous fistulas: Endovascular embolization or surgical intervention 1
• Carotid stenosis: Carotid endarterectomy or stenting when hemodynamically significant 3

Structural Lesions

• Paragangliomas: Surgical resection, radiation therapy, or observation depending on size and symptoms 1
• Superior semicircular canal dehiscence: Surgical repair for severe symptomatic cases 4

Metabolic Causes

• Intracranial hypertension: Weight loss, acetazolamide, or CSF diversion procedures 1
• Anemia: Treat underlying cause (e.g., vitamin B12 replacement for pernicious anemia) to correct hyperdynamic circulation 5

Critical Pitfalls to Avoid

Never dismiss pulsatile tinnitus as benign primary tinnitus—it requires imaging evaluation because life-threatening conditions like arteriovenous fistulas can present with this symptom and may lead to hemorrhagic or ischemic stroke if missed. 2, 8, 6

Do not order imaging for bilateral, non-pulsatile tinnitus without focal neurologic deficits or asymmetric hearing loss, as this represents a completely different entity (primary tinnitus) that does not benefit from imaging. 1

Avoid using antidepressants, anticonvulsants, or anxiolytics as primary treatment for pulsatile tinnitus without first identifying and addressing the underlying structural or vascular cause. 1, 4, 7

Do not recommend dietary supplements (Ginkgo biloba, melatonin, zinc) as these have no role in treating pulsatile tinnitus. 4, 7

Recognize that unilateral pulsatile tinnitus has higher risk of serious pathology than bilateral symptoms and mandates more aggressive investigation. 4, 7