What is the next step for a patient with one-week pulsatile tinnitus?

Next Step for One-Week Pulsatile Tinnitus

Order urgent imaging with either high-resolution CT temporal bone (non-contrast) or CT angiography (CTA) of head and neck with contrast, as pulsatile tinnitus 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 Required

Before ordering imaging, perform these specific evaluations:

• Determine if the tinnitus is objective (audible to examiner) versus subjective (patient only) - objective pulsatile tinnitus is rare and strongly suggests vascular pathology requiring immediate workup 1
• Perform otoscopic examination to identify vascular retrotympanic masses such as paragangliomas, which appear as red pulsatile masses behind the tympanic membrane 1
• Test carotid and jugular compression - relief with compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1, 2
• Assess for unilateral versus bilateral presentation - unilateral pulsatile tinnitus has higher likelihood of identifiable structural or vascular cause 1
• Check for neurologic deficits or asymmetric hearing loss - these require different imaging protocols 1

First-Line Imaging Selection

The choice between two imaging modalities depends on clinical suspicion:

Order CT Temporal Bone (Non-Contrast, High-Resolution) if suspecting:

• Paragangliomas or glomus tumors (account for 16% of cases) 1
• Jugular bulb abnormalities (high-riding jugular bulb or sigmoid plate dehiscence) 1
• Superior semicircular canal dehiscence 1
• Aberrant vascular anatomy 1
• Adenomatous middle ear tumors 1

Order CTA Head and Neck with Contrast if suspecting:

• Dural arteriovenous fistulas (8% of cases, life-threatening - can cause hemorrhagic or ischemic stroke) 1
• Arterial dissection (life-threatening, requires urgent identification) 1
• Atherosclerotic carotid artery disease (most common cause at 17.5% of cases) 1, 3
• Sigmoid sinus diverticulum or dehiscence 1
• Arteriovenous malformations 1

Practical approach: CTA with mixed arterial-venous phase (20-25 seconds post-contrast) captures both arterial and venous pathology in a single acquisition and can be reconstructed to create temporal bone images without additional radiation exposure. 1

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign - it almost always requires imaging evaluation due to identifiable causes in >70% of cases, unlike bilateral non-pulsatile tinnitus which typically does not require imaging 1, 4
• Missing dural AVF is life-threatening - this requires high index of suspicion as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
• Inadequate otoscopic examination leads to delayed diagnosis - particularly for vascular retrotympanic masses like paragangliomas that are visible on examination 1
• Overlooking intracranial hypertension - the second most common cause of pulsatile tinnitus, particularly in young overweight women with headaches, can lead to vision loss if missed 1

If Initial Imaging is Negative

• Proceed to MRI with contrast and MR angiography (MRA) when CT/CTA are negative but clinical suspicion remains high 1
• MRI/MRA is particularly useful for cerebellopontine angle lesions, vascular malformations not identified on CT/CTA, or patients with contraindications to iodinated contrast 1

Audiometric Testing

• Order comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing for any unilateral or persistent tinnitus 1
• Ipsilateral low-frequency hearing loss may indicate significant vascular pathology close to the cochlea and can serve as an objective marker 5

Timeline Consideration

While the American Academy of Otolaryngology defines "persistent" tinnitus as lasting 6 months or more 1, pulsatile tinnitus at one week already warrants urgent imaging because the symptom itself—regardless of duration—indicates potential vascular or structural pathology that can be life-threatening 1, 4.