What could be causing my daily pressure and balance issues, accompanied by pulsatile tinnitus, despite a normal Magnetic Resonance Venography (MRV) scan and no sinus diagnosis, and how should I manage these symptoms?

Evaluation and Management of Chronic Pressure, Balance Issues, and Pulsatile Tinnitus

You need urgent imaging with CT angiography (CTA) of the head and neck with contrast as your first-line study, because 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

Why Your Symptoms Require Immediate Workup

Your combination of constant pressure, balance problems lasting two years, and pulsatile tinnitus does not fit benign paroxysmal positional vertigo (BPPV), which causes brief episodes (seconds to minutes) triggered by specific head movements—not continuous all-day symptoms. 2 BPPV does not cause constant severe dizziness that is unaffected by position or movement, and it does not cause pulsatile tinnitus. 2

The pulsatile tinnitus component is the critical red flag here. Even though your MRV was normal, this does not exclude the majority of causes:

• Atherosclerotic carotid artery disease (most common cause at 17.5% of cases) creates turbulent flow that standard MRV may not adequately assess 1
• Idiopathic intracranial hypertension (second most common cause) can present with normal MRV but requires dedicated venous phase imaging to identify sigmoid sinus wall abnormalities 1
• Dural arteriovenous fistulas (8% of cases) are life-threatening and can lead to hemorrhagic or ischemic stroke if untreated, yet may be missed on standard MRV 1
• Sigmoid sinus diverticulum or dehiscence commonly associates with intracranial hypertension and requires high-resolution temporal bone imaging 1

Your Specific Diagnostic Pathway

First-Line Imaging: CTA Head and Neck with Contrast

The American College of Radiology recommends CTA as first-line when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations. 1 A mixed arterial-venous phase (20-25 seconds post-contrast) captures both arterial and venous pathology in a single acquisition. 1

Critical advantage: CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure, allowing simultaneous evaluation of bony abnormalities like superior semicircular canal dehiscence or jugular bulb variants. 1

If CTA is Negative

The American College of Radiology recommends proceeding to MRI brain with contrast and MR angiography (MRA) to evaluate for:

• Cerebellopontine angle lesions 1
• Subtle vascular malformations not visible on CTA 1
• Venous sinus abnormalities requiring dedicated venous imaging 1

Essential Clinical Maneuvers During Evaluation

Perform carotid and jugular compression testing: If your tinnitus temporarily disappears with compression, this strongly suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection. 1 This simple bedside test dramatically narrows the differential diagnosis.

Why Your Normal MRV Doesn't Exclude Serious Pathology

Standard MRV protocols often miss:

• Sigmoid sinus wall dehiscence or diverticulum requires dedicated high-resolution temporal bone CT, not MRV 1, 3
• Dural arteriovenous fistulas are notoriously elusive on cross-sectional imaging and may require catheter angiography for definitive diagnosis 4, 5
• Venous sinus stenosis associated with intracranial hypertension needs specific venous phase timing that standard MRV may not capture 1
• Dilated mastoid emissary veins can cause bilateral pulsatile tinnitus but require dedicated venous imaging to identify 6

Critical Pitfalls to Avoid

Do not dismiss this as benign without comprehensive vascular imaging. Pulsatile tinnitus almost always requires imaging evaluation due to identifiable causes in >70% of cases. 1 The American College of Radiology explicitly warns that dismissing pulsatile tinnitus without appropriate imaging is a dangerous error. 1

Missing dural AVF is life-threatening: This condition can present with isolated pulsatile tinnitus before catastrophic hemorrhage, and requires high index of suspicion with appropriate vascular imaging. 1 In one case series, dural AVF accounted for 8% of pulsatile tinnitus cases. 4

Inadequate otoscopic examination delays diagnosis: Vascular retrotympanic masses (paragangliomas) account for 16% of pulsatile tinnitus cases and can be identified on direct visualization, avoiding unnecessary imaging delays. 1, 4

Special Consideration: Intracranial Hypertension

Your demographic matters here. If you are a young, overweight woman with headaches, you represent a high-risk demographic for idiopathic intracranial hypertension (IIH), the second most common cause of pulsatile tinnitus. 1 IIH can cause vision loss if missed, making ophthalmologic evaluation with fundoscopy essential. 7

Additional Diagnostic Testing Required

Beyond imaging, you need:

• Comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing to document any asymmetric hearing loss 1
• Fundoscopic examination to exclude papilledema from increased intracranial pressure 7
• Detailed otoscopic examination to identify vascular retrotympanic masses 1, 3

Bottom Line on Management

Your two-year history of constant pressure and balance issues with pulsatile tinnitus represents either:

1. An undiagnosed vascular abnormality requiring specific imaging protocols you haven't yet received
2. Idiopathic intracranial hypertension with venous sinus abnormalities not captured on standard MRV
3. A concurrent vestibular or CNS disorder that persistent positional vertigo symptoms may indicate 2

The next step is CTA head and neck with contrast, not observation or symptomatic management. 1 If this is negative, proceed to MRI/MRA with dedicated venous imaging. 1 The goal is identifying treatable causes before complications occur, particularly given the life-threatening potential of missed dural AVF or arterial dissection. 1, 4