What is the diagnosis and treatment approach for pulsatile tinnitus?

Pulsatile Tinnitus: Diagnosis and Treatment

Pulsatile tinnitus almost always requires imaging evaluation to identify underlying vascular or structural abnormalities, as more than 70% of cases have an identifiable—and often treatable—cause, including life-threatening conditions like arterial dissection and dural arteriovenous fistulas. 1, 2

Initial Clinical Evaluation

Critical History and Physical Examination Elements

• Perform otoscopy immediately to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile masses behind the tympanic membrane) 1, 3
• Test carotid and jugular compression during auscultation—relief with compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1, 4
• Auscultate the neck, periauricular region, and skull for objective bruits—if audible to examiner, this strongly suggests vascular pathology requiring immediate workup 1
• Document laterality—unilateral pulsatile tinnitus has higher likelihood of identifiable structural or vascular cause 1
• Obtain complete audiologic evaluation for all patients with unilateral or persistent tinnitus (≥6 months) 3

Red Flags Requiring Urgent Evaluation

• Young, overweight women with headaches—suspect idiopathic intracranial hypertension (second most common cause at 10% of cases), which can cause vision loss if missed 1, 5
• Any neurologic deficits or asymmetric hearing loss—follow respective ACR criteria for those conditions rather than tinnitus protocols 6
• Severe anxiety or depression—requires prompt intervention due to increased suicide risk 4

Imaging Algorithm

First-Line Imaging (Choose Based on Clinical Suspicion)

CT temporal bone (non-contrast, high-resolution) is the initial study of choice for: 6, 3

• Suspected paragangliomas or glomus tumors (16% of cases)
• Adenomatous middle ear tumors
• Jugular bulb abnormalities (high-riding bulb, sigmoid plate dehiscence)
• Superior semicircular canal dehiscence
• Aberrant vascular anatomy

CT angiography (CTA) of head and neck with contrast should be obtained when suspecting: 6, 3

• Dural arteriovenous fistulas (8% of cases—life-threatening if missed)
• Arterial dissection (potentially fatal)
• Atherosclerotic carotid disease (most common cause at 17.5% of cases)
• Sigmoid sinus diverticulum or dehiscence
• Arteriovenous malformations

Second-Line Imaging

MRI and MR angiography (MRA) with contrast are reserved for: 6, 3

• Cerebellopontine angle lesions
• Vascular malformations not identified on CT/CTA
• When CT/CTA are negative but clinical suspicion remains high

Digital subtraction angiography (DSA) is the gold standard when: 7

• Initial vascular imaging is negative but vascular etiology strongly suspected
• Dural arteriovenous fistula cannot be excluded by non-invasive imaging

Treatment by Specific Etiology

Arterial Causes

• Atherosclerotic carotid disease (17.5% of cases): Medical management of cardiovascular risk factors; consider carotid endarterectomy or stenting for severe stenosis 1, 5
• Arterial dissection: Anticoagulation or antiplatelet therapy urgently 3, 4
• Dural arteriovenous fistulas: Endovascular embolization or surgical disconnection—critical to prevent hemorrhagic or ischemic stroke 1, 8
• Arteriovenous malformations: Endovascular treatment, surgical resection, or radiosurgery depending on location and size 1

Venous Causes

• Idiopathic intracranial hypertension (10% of cases): Weight loss, acetazolamide, topiramate; venous sinus stenting is emerging therapy for associated venous stenosis 1, 7
• Sigmoid sinus diverticulum or dehiscence: Surgical repair or endovascular embolization 3, 4
• Jugular bulb abnormalities: Surgical intervention in symptomatic cases 4

Structural Causes

• Paragangliomas (glomus tympanicum/jugulare): Surgical resection, radiation therapy, or observation depending on size and symptoms 1
• Superior semicircular canal dehiscence: Surgical repair (middle fossa or transmastoid approach) for severe symptoms 3, 4

Non-Vascular Causes

• Somatic tinnitus (cervical nerve/muscle dysfunction): Physical therapy, postural adjustments, manual therapy 4
• Eustachian tube dysfunction: Specific exercises or interventions targeting the tube 4

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign—identifiable causes exist in >70% of cases, many requiring urgent treatment 1, 2
• Missing dural AVF is life-threatening—maintain high index of suspicion and obtain appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 8
• Inadequate otoscopy leads to delayed diagnosis—particularly for vascular retrotympanic masses that are visible on examination 1, 3
• Do NOT use antidepressants, anticonvulsants, or anxiolytics routinely without addressing the underlying vascular or structural cause 3, 4
• Do NOT recommend dietary supplements (Ginkgo biloba, melatonin, zinc) as primary treatment—no evidence supports their use 3, 4

When Imaging is NOT Indicated

Subjective, nonpulsatile, bilateral tinnitus without localizing features does not typically require imaging 6