What causes a heartbeat sound in my ear?

Hearing a Heartbeat Sound in Your Ear (Pulsatile Tinnitus)

You are experiencing pulsatile tinnitus—a rhythmic sound synchronized with your heartbeat—which requires medical evaluation to identify potentially treatable vascular or structural causes that could affect your long-term health. 1

What This Symptom Means

Pulsatile tinnitus is a repetitive sound that coincides with your heartbeat, distinct from the more common continuous ringing or buzzing in the ears. 1 This is not a benign variant of typical tinnitus and warrants investigation because it can signal underlying vascular abnormalities, structural problems, or increased intracranial pressure. 1

Why This Requires Evaluation

The primary purpose of evaluating pulsatile tinnitus is to determine if an underlying condition can be addressed with medical, endovascular, surgical, or radiation therapy. 1 Key concerning causes include:

• Vascular masses (glomus tumors, paragangliomas) 1
• Aberrant arterial or venous anatomy (aberrant carotid artery, high-riding jugular bulb) 1
• Vascular malformations (arteriovenous malformations, dural arteriovenous fistulas) 1
• Intracranial hypertension (idiopathic intracranial hypertension/pseudotumor cerebri) 1
• Atherosclerotic carotid artery disease causing turbulent flow 1
• Abnormal emissary veins 1

Initial Clinical Assessment You Need

Before any imaging, you must undergo a comprehensive otologic examination to check for a vascular retrotympanic mass visible behind your eardrum, plus audiometric testing and medication review. 1 This initial evaluation determines whether the tinnitus is:

• Objective (audible to the examiner with a stethoscope)—strongly suggests vascular abnormality 1
• Subjective (only you can hear it)—still requires workup for vascular causes 1

The examiner should specifically listen over your neck, skull, and periauricular area for bruits that would indicate vascular pathology. 1

Imaging That Should Be Performed

For pulsatile tinnitus, imaging is indicated to identify treatable causes. 1 The American College of Radiology guidelines recommend imaging for both subjective and objective pulsatile tinnitus (excluding cases clearly due to myoclonus or Eustachian tube dysfunction). 1

The imaging workup typically includes temporal bone imaging and vascular imaging to evaluate both the ear structures and blood vessels. 1

Critical Distinction from Other Conditions

This is not the same as:

• Nonpulsatile tinnitus (continuous ringing/buzzing), which is usually benign and related to hearing loss 1
• Cardiac arrhythmias causing palpitations, which you would feel throughout your body 2
• Simple awareness of your heartbeat during anxiety or exercise 3

Important Caveats

Do not delay evaluation if you also experience:

• Sudden hearing loss in one ear 1
• Neurological symptoms (vision changes, headaches, weakness) 1
• The sound is only in one ear 1

The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends against imaging for nonpulsatile tinnitus that doesn't localize to one ear and lacks neurological symptoms, but pulsatile tinnitus falls into a different category requiring investigation. 1

Quality of Life Considerations

While investigating the cause, be aware that tinnitus can significantly impact quality of life and is associated with anxiety and depression. 1 If you experience severe anxiety or depression alongside this symptom, prompt mental health evaluation is warranted, as suicide has been reported in tinnitus patients with co-existing psychiatric illness. 1

Next Steps

Schedule an appointment with an otolaryngologist (ENT specialist) or your primary care physician who can perform the initial otologic examination and coordinate appropriate imaging studies. 1 Do not accept reassurance without proper evaluation, as pulsatile tinnitus has identifiable and potentially treatable causes in many cases. 1