What is the appropriate diagnosis and treatment for a patient presenting with pulsing tinnitus, potentially associated with underlying vascular or cardiovascular issues, such as hypertension or anemia?

Pulsatile Tinnitus: Diagnosis and Management

Immediate Clinical Assessment

Pulsatile tinnitus requires urgent imaging evaluation because this symptom 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

Critical Initial Distinctions

• Determine if the tinnitus is truly pulsatile (synchronous with heartbeat) versus other rhythmic sounds, as this fundamentally changes diagnostic urgency and approach 1
• Assess for objective versus subjective tinnitus: Objective pulsatile tinnitus (audible to examiner) is rare and strongly suggests vascular pathology requiring immediate workup, while subjective pulsatile tinnitus (patient only) still warrants comprehensive imaging in nearly all cases 3, 1
• Perform thorough otoscopic examination to identify vascular retrotympanic masses (paragangliomas), as this finding directly guides imaging selection and can prevent delayed diagnosis 3, 1
• Test jugular/carotid compression: Relief of pulsatile tinnitus upon compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1
• Document any asymmetric hearing loss or focal neurologic deficits, as these require different imaging protocols per ACR criteria 1

Life-Threatening Causes That Cannot Be Missed

• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated—this requires high index of suspicion as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 4
• Arterial dissection is a potentially life-threatening condition requiring urgent identification 1, 5
• Arteriovenous malformations carry a 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage, making timely diagnosis essential even when presenting symptom is only tinnitus 1

First-Line Imaging Strategy

When to Order CT Temporal Bone (Non-Contrast, High-Resolution)

Order high-resolution CT temporal bone as the first-line study when suspecting: 3, 1

• Paragangliomas or glomus tumors (appear as vascular retrotympanic masses on otoscopy—most common structural cause at 16% of cases) 1, 4
• Jugular bulb abnormalities (high-riding jugular bulb or dehiscence of sigmoid plate) 3, 1
• Superior semicircular canal dehiscence (bony defect allowing transmission of vascular sounds) 3, 1
• Aberrant venous anatomy (persistent petrosquamosal sinus, abnormal condylar/mastoid emissary veins) 3, 1
• Sigmoid sinus diverticulum or dehiscence (commonly associated with intracranial hypertension) 1

When to Order CT Angiography (CTA) Head and Neck with Contrast

Order CTA head and neck with contrast as the first-line study when suspecting: 3, 1

• Atherosclerotic carotid artery disease (most frequent cause at 17.5% of cases, resulting from turbulent flow) 1, 6
• Dural arteriovenous fistulas (8% of cases—life-threatening if missed) 1, 4
• Arterial dissection 1, 5
• Arteriovenous malformations 1
• Use mixed arterial-venous phase (20-25 seconds post-contrast) to capture 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

Second-Line Imaging When Initial Studies Are Negative

Reserve MRI with contrast and MR angiography (MRA) for: 3, 1

• Cerebellopontine angle lesions or acoustic neuroma 1
• Vascular malformations not identified on CT/CTA 3, 1
• Patients with contraindications to iodinated contrast 1
• When CT/CTA are negative but clinical suspicion remains high 3, 1

Note: MRV alone is insufficient for evaluating pulsatile tinnitus—CT temporal bone or CTA head and neck should be performed as the initial study 1

High-Risk Clinical Scenarios Requiring Immediate Action

Young Overweight Women with Headaches and Vision Changes

• This demographic represents high risk for idiopathic intracranial hypertension (IIH), the second most common cause of pulsatile tinnitus, associated with sigmoid sinus wall abnormalities 1
• Vision loss can occur if IIH is missed, making urgent evaluation critical 1
• IIH-related pulsatile tinnitus responds dramatically to treatment in nearly 100% of cases when truly pulsatile 1
• Order CTA head and neck with contrast as first-line study to evaluate for venous sinus abnormalities and life-threatening vascular causes 1

Patients with Severe Anxiety or Depression

• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention because suicide is reported in tinnitus patients with co-existing psychiatric illness 3, 7

Common Diagnostic Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign without imaging is a critical error, as treatable and life-threatening causes are identifiable in >70% of cases 1, 2
• Inadequate otoscopic examination can lead to delayed diagnosis and inappropriate imaging selection, particularly missing paragangliomas 1
• Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features represents inappropriate resource utilization—ACR recommends against this 3, 1
• Missing dural AVF by not maintaining high index of suspicion and ordering appropriate vascular imaging 1
• Overlooking intracranial hypertension in young, overweight women with headaches 1

Treatment Considerations Based on Etiology

• Paragangliomas or glomus tumors: Surgical resection, radiation therapy, or observation depending on size and symptoms 1
• Superior semicircular canal dehiscence: Surgical repair if symptoms are debilitating 1
• Sigmoid sinus diverticulum: Surgical repair or stenting in severe cases 1
• Dural AVF or AVM: Catheter angiography for definitive characterization, followed by endovascular treatment, surgical resection, or radiation therapy 1

Audiologic Evaluation

• Obtain comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) for any unilateral or persistent tinnitus to document asymmetric hearing loss 1
• Hearing aid evaluation is recommended for patients with hearing loss, even mild or unilateral, as hearing aids provide significant relief 1