What could be causing my pulsatile tinnitus, constant pressure in my head and face, and balance issues?

Evaluation of Pulsatile Tinnitus with Facial Pressure and Balance Issues

You need urgent imaging evaluation with CT angiography (CTA) of the head and neck because your combination of pulsatile tinnitus, constant head/face pressure, and persistent balance problems for two years strongly suggests an underlying vascular or structural abnormality that could be life-threatening if missed, such as dural arteriovenous fistula, arterial dissection, or idiopathic intracranial hypertension. 1

Why This Requires Immediate Action

Your symptom constellation is concerning for several reasons:

• Pulsatile tinnitus has an identifiable cause in over 70% of cases, and many of these causes are treatable or potentially life-threatening if left undiagnosed 1, 2, 3
• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus cases and can lead to catastrophic hemorrhagic or ischemic stroke if untreated 1
• Arterial dissection is a potentially life-threatening condition requiring urgent identification 1
• The combination of pulsatile tinnitus with balance issues and facial pressure suggests either a vascular abnormality affecting the posterior circulation or increased intracranial pressure 4, 1

Most Likely Diagnostic Categories

Based on your specific symptoms, the differential diagnosis includes:

Venous Causes (Most Common with Your Symptom Pattern)

• Idiopathic intracranial hypertension (IIH) is the second most common cause of pulsatile tinnitus and classically presents with headache, facial pressure, and can cause balance disturbances 1
• Sigmoid sinus diverticulum or dehiscence is commonly associated with intracranial hypertension and can cause pulsatile tinnitus 1
• Transverse sinus stenosis can cause venous pulsatile tinnitus and is often associated with IIH 5

Arterial Causes (Life-Threatening)

• Atherosclerotic carotid artery disease accounts for 17.5% of pulsatile tinnitus cases due to turbulent flow 1
• Arterial dissection must be ruled out urgently 1

Arteriovenous Causes (Life-Threatening)

• Dural arteriovenous fistulas can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
• Arteriovenous malformations are high-flow vascular lesions that carry a 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage 1

Structural Causes

• Highly vascularized skull base tumors (paragangliomas, glomus tumors) account for 16% of pulsatile tinnitus cases 1, 6
• Superior semicircular canal dehiscence is a bony defect that allows transmission of vascular sounds and can cause balance disturbances 1

Recommended Imaging Strategy

First-line imaging: Order CT angiography (CTA) of the head and neck with contrast 1

This study is preferred because:

• CTA evaluates for life-threatening vascular causes including dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, and arteriovenous malformations 1
• A mixed arterial-venous phase (20-25 seconds post-contrast) CTA captures both arterial and venous pathology in a single acquisition 1
• CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure 1

If CTA is negative but clinical suspicion remains high:

• Proceed to MRI brain with contrast and MR venography (MRV) to evaluate for venous sinus abnormalities, cerebellopontine angle lesions, or subtle vascular malformations 1
• MRI with MRA is reserved for cerebellopontine angle lesions (vestibular schwannoma) or when CT/CTA are negative 1

If noninvasive imaging is inconclusive:

• Catheter angiography should be considered for definitive characterization of suspected dural AVF or AVM 1

Critical Clinical Distinctions

• Determine if your tinnitus is truly synchronous with your heartbeat (pulsatile) versus other rhythmic sounds, as this fundamentally changes the diagnostic approach 1
• Assess whether the tinnitus is unilateral or bilateral - unilateral pulsatile tinnitus has a higher likelihood of identifiable structural or vascular cause 1
• Try gentle compression of your carotid or jugular vein - if this relieves the tinnitus, it suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1

Additional Evaluation Needed

• Comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing is recommended for persistent tinnitus 1
• Thorough otoscopic examination to identify vascular retrotympanic masses (paragangliomas) or other middle ear pathology 4, 1
• Assessment for neurologic deficits - any focal neurologic findings should be evaluated using ACR criteria for cerebrovascular disease rather than tinnitus protocols 4, 1

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign is dangerous - pulsatile tinnitus almost always requires imaging evaluation due to identifiable causes in >70% of cases 1
• Missing dural AVF is life-threatening - it requires high index of suspicion and appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
• Inadequate otoscopic examination can lead to delayed diagnosis, particularly in cases of vascular retrotympanic masses 1
• Overlooking intracranial hypertension in patients with headaches and facial pressure can lead to vision loss if missed 1

What to Expect Next

After imaging is completed, treatment depends on the underlying cause:

• Paragangliomas or glomus tumors can be treated with surgical resection, radiation therapy, or observation depending on size and symptoms 1
• Sigmoid sinus diverticulum can be treated with surgical repair or stenting in severe cases 1
• Venous sinus stenosis may be treated with endovascular stenting, which is an emerging therapy showing promising results 7, 5
• Superior semicircular canal dehiscence can be treated with surgical repair if symptoms are debilitating 1

The key message: Do not delay imaging evaluation. Your symptoms have persisted for two years, and the longer a treatable or dangerous cause goes undiagnosed, the higher the risk of permanent complications or catastrophic events. 1, 2, 3