What are the first through fifth most common causes of pulsatile tinnitus in a female individual with a likely higher body mass index (BMI)?

Most Common Causes of Pulsatile Tinnitus (Ranked 1-5)

In a female patient with likely higher BMI presenting with pulsatile tinnitus, the five most common causes in order are: (1) atherosclerotic carotid artery disease (17.5% of cases), (2) idiopathic intracranial hypertension (10-16% of cases, particularly common in young overweight women), (3) highly vascularized skull base tumors including paragangliomas and glomus tumors (16% of cases), (4) dural arteriovenous fistulas (8% of cases), and (5) venous anatomic variants and abnormalities including jugular bulb abnormalities and sigmoid sinus abnormalities (14% of cases). 1, 2

First Most Common Cause: Atherosclerotic Carotid Artery Disease

• Atherosclerotic carotid artery disease accounts for 17.5% of pulsatile tinnitus cases, making it the single most frequent identifiable cause. 1, 2
• The mechanism involves turbulent blood flow through stenotic or irregular arterial segments, which generates audible pulsations synchronized with the cardiac cycle. 1
• This diagnosis becomes more likely with advancing age, hypertension, hyperlipidemia, diabetes, and smoking history. 1

Second Most Common Cause: Idiopathic Intracranial Hypertension (IIH)

• Idiopathic intracranial hypertension is the second most common cause of pulsatile tinnitus overall, with prevalence ranging from 10% in some series to being strongly associated with sigmoid sinus wall abnormalities. 1, 2
• This diagnosis is particularly critical in your patient population: young, overweight women with higher BMI represent the highest-risk demographic for IIH. 1
• IIH-related pulsatile tinnitus is commonly associated with sigmoid sinus diverticulum or dehiscence, and missing this diagnosis can lead to permanent vision loss. 1
• The tinnitus in IIH is often relieved by carotid or jugular compression, suggesting venous etiology. 1

Third Most Common Cause: Highly Vascularized Skull Base Tumors

• Paragangliomas (glomus tympanicum/jugulare) and other highly vascularized temporal bone tumors account for 16% of pulsatile tinnitus cases. 1, 3
• These tumors appear as vascular retrotympanic masses on otoscopy, making inadequate otoscopic examination a critical pitfall that can delay diagnosis. 1
• Paragangliomas are benign but locally aggressive tumors that require specialized imaging (high-resolution CT temporal bone non-contrast) for diagnosis. 1

Fourth Most Common Cause: Dural Arteriovenous Fistulas

• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus cases but represent a life-threatening condition requiring urgent identification. 1, 3
• Missing this diagnosis is a critical pitfall, as dural AVF can lead to catastrophic hemorrhagic or ischemic stroke even when presenting with isolated pulsatile tinnitus. 1
• These require high index of suspicion and appropriate vascular imaging (CTA head and neck with contrast), as they may present before hemorrhage occurs. 1
• Catheter angiography is often needed for definitive diagnosis and treatment planning. 1

Fifth Most Common Cause: Venous Anatomic Variants and Abnormalities

• Venous causes collectively account for approximately 14% of cases and include jugular bulb abnormalities (high-riding jugular bulb or dehiscence of the sigmoid plate), sigmoid sinus diverticulum or dehiscence, and aberrant venous anatomy (persistent petrosquamosal sinus, abnormal condylar and mastoid emissary veins). 1, 3
• Sigmoid sinus abnormalities are commonly associated with intracranial hypertension, creating overlap with the second most common cause. 1
• Tinnitus from venous causes is typically relieved by carotid or jugular compression, providing a useful clinical clue. 1

Critical Clinical Context for Your Patient Population

• The combination of female sex and higher BMI dramatically increases the likelihood that idiopathic intracranial hypertension is the underlying cause, potentially making it the most likely diagnosis in this specific demographic rather than the second most common cause overall. 1
• If your patient also reports headaches or any visual symptoms, IIH becomes the leading diagnostic consideration and requires urgent ophthalmologic evaluation to prevent vision loss. 1
• Pulsatile tinnitus has an identifiable cause in over 70% of cases, making imaging evaluation mandatory rather than optional. 1, 4