Intermittent Pulsatile Tinnitus: Diagnosis and Management
Direct Answer
An intermittent pulsating sound synchronous with your heartbeat requires urgent imaging evaluation with high-resolution CT temporal bone or CT angiography of the head and neck, as this symptom indicates an underlying vascular or structural abnormality in over 70% of cases, and missing life-threatening causes like dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke. 1
Immediate Clinical Assessment
Determine if the pulsatile tinnitus is objective (audible to examiner) or subjective (patient only):
- Objective pulsatile tinnitus is rare and strongly suggests vascular pathology requiring immediate workup 1
- Subjective pulsatile tinnitus still warrants comprehensive imaging in nearly all cases 1
- Unilateral pulsatile tinnitus has higher likelihood of identifiable structural or vascular cause compared to bilateral 1
Perform targeted otoscopic examination to identify vascular retrotympanic masses:
- Look for glomus tympanicum or glomus jugulare tumors appearing as reddish-blue masses behind the tympanic membrane 2, 1
- Missing these on otoscopy leads to delayed diagnosis and inappropriate imaging selection 1
Test for compression relief:
- Tinnitus relieved by carotid or jugular compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1
Most Likely Diagnoses (In Order of Frequency)
Atherosclerotic carotid artery disease (17.5% of cases):
- Results from turbulent flow in stenotic vessels 1, 3
- Can be identified on CT angiography or MR angiography 4
Idiopathic intracranial hypertension (10% of cases):
- Second most common cause, associated with sigmoid sinus wall abnormalities 1, 3
- Particularly suspect in young, overweight women with headaches 1
- Can lead to vision loss if missed 1
Paragangliomas/glomus tumors (16% of cases):
- Highly vascularized skull base tumors 1
- Visible on otoscopy as vascular retrotympanic masses 1
- Best seen on high-resolution CT temporal bone 2
Dural arteriovenous fistulas (8% of cases):
- This is the most critical diagnosis not to miss - can lead to hemorrhagic or ischemic stroke if untreated 1
- Often elusive on cross-sectional imaging; conventional angiography may be necessary 4
First-Line Imaging Strategy
Choose between two initial imaging approaches based on clinical suspicion:
Option 1: High-resolution CT temporal bone (non-contrast)
Order this first when suspecting: 2, 1
- Paragangliomas or glomus tumors
- Jugular bulb abnormalities (high-riding or dehiscent)
- Superior semicircular canal dehiscence
- Aberrant vascular anatomy
- Sigmoid sinus wall dehiscence
Option 2: CT angiography (CTA) of head and neck with contrast
Order this first when suspecting: 1, 5
- Dural arteriovenous fistulas
- Arterial dissection (potentially life-threatening)
- Atherosclerotic carotid artery disease
- Sigmoid sinus diverticulum or dehiscence
- Arteriovenous malformations
Important technical note: CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure 1
Second-Line Imaging (If Initial Studies Negative)
Reserve MRI with contrast and MR angiography for: 1
- Suspected cerebellopontine angle lesions or acoustic neuroma
- Vascular malformations not identified on CT/CTA
- Patients with contraindications to iodinated contrast
- When CT/CTA are negative but clinical suspicion remains high
Life-Threatening Causes That Cannot Be Missed
Dural arteriovenous fistula:
- Requires high index of suspicion 1
- Can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
- May require conventional angiography if not seen on CTA 4
Arterial dissection:
- Potentially life-threatening condition requiring urgent identification 1
- Best identified on CTA or MRA 4
Carotid artery stenosis:
- Must be ruled out due to stroke risk 6
Treatment Approaches Based on Etiology
Paragangliomas or glomus tumors:
- Surgical resection, radiation therapy, or observation depending on size and symptoms 1
Superior semicircular canal dehiscence:
- Surgical repair if symptoms are debilitating 1
Sigmoid sinus diverticulum:
- Surgical repair or stenting in severe cases 1
Venous sinus stenosis/intracranial hypertension:
- Venous stenting can provide relief in some patients, though its indiscriminate use is controversial 2
Critical Pitfalls to Avoid
Dismissing pulsatile tinnitus as benign:
- This is the most common error - pulsatile tinnitus almost always requires imaging evaluation due to identifiable causes in >70% of cases 1
Inadequate otoscopic examination:
- Can lead to delayed diagnosis of paragangliomas that are visible on direct examination 1
Missing dural AVF:
- Requires high index of suspicion as it can present before catastrophic hemorrhage 1
Overlooking intracranial hypertension in at-risk populations:
- Young, overweight women with headaches are at highest risk for vision loss 1