What does it mean if I can hear my heartbeat through my eardrum?

Hearing Your Heartbeat Through Your Eardrum: What It Means

If you can hear your heartbeat through your eardrum, you have pulsatile tinnitus—a symptom that requires medical evaluation because an identifiable and often treatable underlying cause is found in over 70% of cases, and some causes can be life-threatening if missed. 1, 2

What This Symptom Indicates

Pulsatile tinnitus is the perception of a rhythmic sound synchronized with your heartbeat, distinct from the more common continuous ringing or buzzing of non-pulsatile tinnitus. 1 This symptom warrants thorough evaluation because it can signal:

• Vascular abnormalities including arterial dissection, dural arteriovenous fistulas (8% of cases), or arteriovenous malformations—all potentially life-threatening conditions 3, 2
• Atherosclerotic carotid artery disease (the most common cause at 17.5% of cases), where turbulent blood flow creates audible pulsations 3
• Idiopathic intracranial hypertension (the second most common cause), particularly in young, overweight women with headaches, which can lead to permanent vision loss if untreated 3
• Vascular tumors such as paragangliomas or glomus tumors (16% of cases) 3
• Venous abnormalities including jugular bulb variants, sigmoid sinus diverticulum, or dehiscence 3
• High cardiac output states from anemia, hyperthyroidism, or other metabolic conditions 2, 4

Critical Distinctions That Guide Your Evaluation

Objective versus subjective: If someone else (like a doctor with a stethoscope) can hear your pulsatile tinnitus, this strongly suggests vascular pathology requiring immediate workup. 3 However, even subjective pulsatile tinnitus (only you can hear it) warrants comprehensive imaging in nearly all cases. 3

Unilateral versus bilateral: One-sided pulsatile tinnitus has higher likelihood of an identifiable structural or vascular cause. 3

Compression test: If your pulsatile tinnitus stops when you press on your neck (carotid or jugular compression), this suggests either venous etiology like sigmoid sinus abnormalities or arterial dissection. 3

What You Should Do Next

Immediate evaluation is required because missing dangerous causes like dural arteriovenous fistulas can result in catastrophic hemorrhage or stroke. 3, 2, 5

Step 1: Clinical Assessment

You need a thorough otoscopic examination (looking in your ear with a special light) because certain findings guide the entire imaging strategy. 1, 3 Specifically, your doctor should look for:

• Vascular retrotympanic masses (reddish pulsating mass behind the eardrum suggesting paraganglioma) 1, 3
• Signs of middle ear pathology 1
• Asymmetric hearing on examination 1, 6

Your doctor should also assess for:

• Neurological deficits (weakness, numbness, vision changes) 1, 3
• Headaches, especially in young overweight women (suggesting intracranial hypertension) 3
• Recent trauma 1

Step 2: Audiometric Testing

A comprehensive audiologic examination is essential for any unilateral or persistent tinnitus to document asymmetric hearing loss. 3, 6

Step 3: Imaging Strategy

The American College of Radiology provides clear first-line imaging recommendations: 1, 3

Option A: High-resolution CT temporal bone (non-contrast) is preferred when suspecting:

• Paragangliomas or glomus tumors 1, 3
• Jugular bulb abnormalities 1, 3
• Superior semicircular canal dehiscence 1, 3
• Aberrant vascular anatomy 1, 3

Option B: CT angiography (CTA) of head and neck with contrast is preferred when suspecting:

• Dural arteriovenous fistulas 1, 3
• Arterial dissection 1, 3
• Atherosclerotic carotid artery disease 1, 3
• Sigmoid sinus diverticulum or dehiscence 1, 3
• Arteriovenous malformations 1, 3

A mixed arterial-venous phase CTA (obtained 20-25 seconds after contrast injection) can capture both arterial and venous pathology in a single study, reducing radiation exposure. 1, 3

MRI with contrast and MR angiography should be reserved for:

• Suspected cerebellopontine angle lesions (acoustic neuroma) 1, 3
• When CT/CTA are negative but clinical suspicion remains high 1, 3
• Patients with contraindications to iodinated contrast 3

Common Pitfalls to Avoid

Do not dismiss pulsatile tinnitus as benign. Unlike non-pulsatile, bilateral tinnitus (which rarely requires imaging), pulsatile tinnitus almost always requires imaging evaluation. 1, 3

Do not miss dural arteriovenous fistulas. These life-threatening lesions can present with isolated pulsatile tinnitus before catastrophic hemorrhage and require high index of suspicion with appropriate vascular imaging. 3, 2

Do not skip the otoscopic examination. Inadequate examination can lead to delayed diagnosis and inappropriate imaging selection, particularly for vascular retrotympanic masses like paragangliomas. 1, 3

Do not overlook intracranial hypertension, especially in young, overweight women with headaches, as this can cause permanent vision loss if missed. 3

When to Seek Urgent Care

Seek immediate evaluation if you have pulsatile tinnitus with:

• Vision changes or headaches 3
• Sudden onset with hearing loss 6
• Focal neurological symptoms (weakness, numbness, speech difficulty) 1, 3
• Severe anxiety or depression (increased suicide risk) 7, 6