What could be causing pulsations in my ears and how can I get treated for it, considering I may have a history of cardiovascular disease, hypertension, ear problems, or anxiety?

Pulsatile Tinnitus: Evaluation and Management

Immediate Clinical Assessment

You need urgent imaging evaluation 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, 2

The first critical distinction is determining whether your tinnitus is truly pulsatile (synchronous with your heartbeat) versus other rhythmic sounds, as this fundamentally changes the diagnostic approach and urgency. 3, 1

Key Clinical Features to Assess

• Objective versus subjective tinnitus: If the sound is audible to an examiner (objective), this strongly suggests vascular pathology requiring immediate workup. 3, 1 However, even subjective pulsatile tinnitus (heard only by you) warrants comprehensive imaging in nearly all cases. 1

• Unilateral versus bilateral: Unilateral pulsatile tinnitus has a higher likelihood of identifiable structural or vascular cause. 1

• Compression test: If your pulsatile tinnitus is relieved by pressing on your neck (carotid or jugular compression), this suggests venous etiology like sigmoid sinus abnormalities or jugular bulb variants, or potentially arterial dissection. 1

• Associated symptoms: Vision changes, headaches, or neurologic deficits require different imaging protocols and increase urgency. 1

Most Common Causes

The differential diagnosis includes life-threatening conditions that must not be missed:

Arterial Causes

• Atherosclerotic carotid artery disease is the most frequent cause, accounting for 17.5% of cases, resulting from turbulent blood flow. 1
• Arterial dissection is potentially life-threatening and requires urgent identification. 1

Arteriovenous Causes

• Dural arteriovenous fistulas account for 8% of cases and can lead to hemorrhagic or ischemic stroke if untreated—this is a critical diagnosis that cannot be missed. 1, 2
• Arteriovenous malformations are high-flow vascular lesions that can cause pulsatile tinnitus. 1

Venous Causes

• Idiopathic intracranial hypertension (pseudotumor cerebri) is the second most common cause, particularly in young, overweight women with headaches, and can cause vision loss if missed. 1
• Jugular bulb abnormalities including high-riding jugular bulb or dehiscence of the sigmoid plate. 1
• Sigmoid sinus diverticulum or dehiscence commonly associated with intracranial hypertension. 1

Structural Causes

• Paragangliomas (glomus tympanicum/jugulare) and other highly vascularized skull base tumors account for 16% of cases and appear as vascular retrotympanic masses on otoscopy. 1, 4
• Superior semicircular canal dehiscence is a bony defect that allows transmission of vascular sounds. 1

First-Line Imaging Strategy

Order high-resolution CT temporal bone (non-contrast) OR CT angiography (CTA) of head and neck with contrast as your first-line study, depending on suspected cause. 1

When to Order CT Temporal Bone (Non-Contrast)

Use this as first-line when suspecting: 1

• Paragangliomas or glomus tumors
• Adenomatous middle ear tumors
• Jugular bulb abnormalities
• Superior semicircular canal dehiscence
• Aberrant vascular anatomy

When to Order CTA Head and Neck (With Contrast)

Use this as first-line when suspecting: 1

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

A practical approach: CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure, making CTA a reasonable first choice when the etiology is unclear. 1

When to Order MRI/MRA

Reserve MRI with contrast and MR angiography for: 1

• Suspected cerebellopontine angle lesions (vestibular schwannoma)
• Vascular malformations not identified on CT/CTA
• Contraindications to iodinated contrast
• When CT/CTA are negative but clinical suspicion remains high

Special Considerations Based on Your History

If You Have Cardiovascular Disease or Hypertension

• Atherosclerotic carotid artery disease becomes more likely as the cause. 1
• Start with CTA head and neck to evaluate arterial pathology. 1

If You Have Ear Problems

• Otoscopic examination is essential before imaging to identify vascular retrotympanic masses (paragangliomas), which can be diagnosed on physical exam alone. 1
• Start with CT temporal bone if a middle ear mass or structural abnormality is suspected. 1

If You Have Anxiety

• While anxiety can contribute to non-pulsatile tinnitus, pulsatile tinnitus still requires imaging evaluation regardless of psychiatric history. 3, 1
• Patients with tinnitus and severe anxiety or depression require prompt identification and intervention due to increased suicide risk. 3, 5

If You Are a Young, Overweight Woman with Headaches

• You are at high risk for idiopathic intracranial hypertension, which can cause permanent vision loss if untreated. 1
• Urgent ophthalmologic evaluation for papilledema is essential. 1
• CTA head and neck is the preferred first-line study to evaluate venous sinus anatomy. 1

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging—identifiable causes exist in >70% of cases. 1, 2
• Missing dural arteriovenous fistula is life-threatening—it can present with isolated pulsatile tinnitus before catastrophic hemorrhage. 1
• Inadequate otoscopic examination can lead to delayed diagnosis of paragangliomas. 1
• Overlooking intracranial hypertension in young, overweight women with headaches can lead to permanent vision loss. 1

Treatment Approach

Treatment depends entirely on the underlying cause identified on imaging: 1

• Paragangliomas/glomus tumors: Surgical resection, radiation therapy, or observation depending on size and symptoms
• Superior semicircular canal dehiscence: Surgical repair if symptoms are debilitating
• Sigmoid sinus diverticulum: Surgical repair or stenting in severe cases
• Idiopathic intracranial hypertension: Weight loss, acetazolamide, or surgical intervention (venous sinus stenting, optic nerve sheath fenestration)
• Dural arteriovenous fistulas: Endovascular embolization or surgical disconnection
• Arterial dissection: Anticoagulation or antiplatelet therapy, endovascular intervention in select cases