What causes pulsatile tinnitus (hearing one's heartbeat through the ears)?

What Causes You to Hear Your Heart Beating Through Your Ears

Hearing your heartbeat in your ears—called pulsatile tinnitus—is caused by turbulent blood flow in vessels near your ear that becomes audible to your auditory system, and this symptom requires urgent imaging evaluation because over 70% of cases have an identifiable structural or vascular cause, including life-threatening conditions like arterial dissection or dural arteriovenous fistulas that can lead to stroke if missed. 1, 2

Primary Mechanisms Creating the Sound

The sound you hear occurs when abnormal blood flow patterns in nearby vessels create vibrations that transmit to your inner ear structures:

• Atherosclerotic carotid artery disease is the single most common cause (17.5% of cases), where cholesterol buildup creates turbulent flow that generates audible pulsations synchronized with your heartbeat 1, 3
• Idiopathic intracranial hypertension (pseudotumor cerebri) is the second most common cause, particularly in young overweight women, where elevated brain pressure causes sigmoid sinus wall abnormalities that create venous turbulence 1
• Highly vascularized skull base tumors (paragangliomas, glomus tumors) account for 16% of cases and create pulsatile sounds through their abnormal blood vessel networks 1, 4

Life-Threatening Causes That Cannot Be Missed

Several dangerous conditions present initially with only pulsatile tinnitus before catastrophic complications:

• Dural arteriovenous fistulas (8% of cases) create abnormal connections between arteries and veins that can cause hemorrhagic or ischemic stroke if untreated—this is the most critical diagnosis to exclude 1
• Arterial dissection represents a tear in the carotid or vertebral artery wall requiring urgent anticoagulation to prevent stroke 1
• Arteriovenous malformations are high-flow vascular lesions with 2-3% annual hemorrhage risk and 10-30% mortality from first hemorrhage 1

Structural and Venous Causes

Anatomic abnormalities that allow normal blood flow to become audible:

• Jugular bulb abnormalities (high-riding jugular bulb or dehiscence of the sigmoid plate) allow venous turbulence to transmit directly to the middle ear 1
• Sigmoid sinus diverticulum or dehiscence commonly associates with intracranial hypertension and creates venous flow sounds 1
• Superior semicircular canal dehiscence is a bony defect in the inner ear that allows transmission of vascular sounds that would normally be inaudible 1

Critical Diagnostic Distinctions

Understanding these features determines urgency and imaging strategy:

• Objective pulsatile tinnitus (examiner can hear it with stethoscope) is rare but strongly indicates vascular pathology requiring immediate workup, while subjective pulsatile tinnitus (only you hear it) 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
• Tinnitus relieved by pressing on your neck (carotid or jugular compression) suggests venous etiology like sigmoid sinus abnormalities or potentially arterial dissection 1, 5

Immediate Evaluation Required

You need urgent imaging because dismissing pulsatile tinnitus as benign is a dangerous pitfall—identifiable causes exist in over 70% of cases, and missing conditions like dural arteriovenous fistula can result in catastrophic hemorrhage before other symptoms develop. 1, 2

First-Line Imaging Strategy

The American College of Radiology provides clear guidance on initial studies:

• High-resolution CT temporal bone (non-contrast) is first-line when paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy are suspected based on examination 1
• CT angiography (CTA) of head and neck with contrast is first-line when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations 1
• MRI with contrast and MR angiography is reserved for cerebellopontine angle lesions, vascular malformations not identified on CT/CTA, or when initial imaging is negative but clinical suspicion remains high 1

Key Clinical Examination Findings

Specific examination findings guide imaging selection:

• Otoscopic examination may reveal vascular retrotympanic masses (paragangliomas appearing as reddish pulsatile masses behind the eardrum)—missing this leads to delayed diagnosis and inappropriate imaging 1
• Auscultation over the ear, mastoid, orbit, and neck may detect objective bruits in arteriovenous fistulas or high-flow vascular lesions 6, 7
• Vision changes or papilledema in young overweight women with headaches suggests intracranial hypertension, which can cause permanent vision loss if missed 1

Common Pitfalls to Avoid

• Missing dural arteriovenous fistula is life-threatening because it can present with isolated pulsatile tinnitus before catastrophic hemorrhage—maintain high index of suspicion and order appropriate vascular imaging 1
• Inadequate otoscopic examination leads to delayed diagnosis of paragangliomas and inappropriate imaging selection 1
• Overlooking intracranial hypertension in the classic demographic (young, overweight women with headaches) can result in irreversible vision loss 1
• Assuming bilateral pulsatile tinnitus is benign—unlike bilateral non-pulsatile tinnitus, bilateral pulsatile tinnitus still requires imaging evaluation 5