What is the appropriate diagnosis and treatment for a patient with pulsatile tinnitus, potentially related to underlying vascular disease or other structural abnormalities?

Pulsatile Tinnitus: Diagnosis and Management

Immediate Clinical Action

Any patient presenting with pulsatile tinnitus requires urgent vascular imaging because this symptom indicates an underlying structural or vascular 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 Assessment

Distinguish Objective vs. Subjective Tinnitus

• Objective pulsatile tinnitus (audible to examiner with stethoscope) is rare but strongly indicates vascular pathology requiring immediate workup 1, 2
• Subjective pulsatile tinnitus (patient only) still warrants comprehensive imaging in nearly all cases 1, 2

Key Physical Examination Maneuvers

• Perform jugular/carotid compression test: Relief of tinnitus with compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1
• Complete otoscopic examination: Look for vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind tympanic membrane) 1, 2
• Assess for laterality: Unilateral pulsatile tinnitus has higher likelihood of identifiable structural or vascular cause compared to bilateral 1, 2

Essential Audiologic Testing

• Order comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks for any unilateral or persistent pulsatile tinnitus 1
• Asymmetric hearing loss changes the imaging algorithm and raises concern for retrocochlear pathology 1

---

First-Line Imaging Strategy

Choose Between Two Primary Imaging Modalities Based on Clinical Suspicion

Option 1: High-Resolution CT Temporal Bone (Non-Contrast) Order this first when suspecting: 1, 2

• Paragangliomas or glomus tumors (most common at 16% of cases)
• Jugular bulb abnormalities (high-riding jugular bulb accounts for 47.4% in some series) 3
• Superior semicircular canal dehiscence
• Sigmoid sinus diverticulum or dehiscence
• Aberrant venous anatomy

Option 2: CT Angiography (CTA) Head and Neck with Contrast Order this first when suspecting: 1, 2

• Dural arteriovenous fistulas (8% of cases, life-threatening)
• Arterial dissection (potentially fatal)
• Atherosclerotic carotid artery disease (most frequent cause at 17.5% of cases) 1, 4
• Arteriovenous malformations
• Use mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in single acquisition 1

When to Use MRI/MRA

Reserve MRI with contrast and MR angiography for: 1, 2

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

---

Life-Threatening Causes That Cannot Be Missed

Dural Arteriovenous Fistula (8% of cases)

• Can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 2
• Leads to hemorrhagic or ischemic stroke if untreated 1, 2
• Requires high index of suspicion and catheter angiography for definitive diagnosis 1
• Treatment: Endovascular embolization or surgical resection 2

Arterial Dissection

• Potentially life-threatening condition requiring urgent identification 1, 2
• May be relieved by carotid compression 1
• Treatment: Urgent anticoagulation or endovascular intervention depending on severity 2

Idiopathic Intracranial Hypertension (Second Most Common Cause)

• Particularly suspect in young, overweight women with headaches and pulsatile tinnitus 1
• Can lead to permanent vision loss if missed 1, 2
• Associated with sigmoid sinus wall abnormalities 1
• Pulsatile tinnitus from IIH responds dramatically to treatment in nearly 100% of cases 1

---

Common Treatable Causes and Their Management

Atherosclerotic Carotid Artery Disease (17.5% of cases)

• Results from turbulent flow 1, 4
• Carotid duplex or Doppler ultrasound helpful to delineate extracranial carotid stenosis 2
• Treatment: Medical management of atherosclerosis, consider carotid endarterectomy or stenting for severe stenosis

Paragangliomas/Glomus Tumors (16% of cases)

• Appear as vascular retrotympanic masses on otoscopy 1
• Best visualized on high-resolution CT temporal bone 1
• Treatment: Surgical resection, radiation therapy, or observation depending on size and symptoms 1, 2

Jugular Bulb Abnormalities (47.4% in some series)

• High-riding jugular bulb or dehiscence of sigmoid plate 1, 3
• Treatment: Usually observation; surgical intervention only if severely symptomatic

Superior Semicircular Canal Dehiscence

• Bony defect allows transmission of vascular sounds 1
• Treatment: Surgical repair if symptoms are debilitating 1, 2

Sigmoid Sinus Diverticulum or Dehiscence

• Commonly associated with intracranial hypertension 1
• Treatment: Surgical repair or stenting in severe cases 1, 2

---

Critical Pitfalls to Avoid

Never Dismiss Pulsatile Tinnitus as Benign Without Imaging

• Identifiable causes exist in >70% of cases 1, 2
• Treatable and life-threatening etiologies are common 2, 3

Do Not Perform Inadequate Otoscopic Examination

• Missing vascular retrotympanic masses (paragangliomas) leads to delayed diagnosis and inappropriate imaging selection 1, 2

Do Not Overlook Intracranial Hypertension in High-Risk Demographics

• Young, overweight women with headaches and pulsatile tinnitus require specific evaluation for IIH 1
• Vision loss is preventable with timely diagnosis 1, 2

Do Not Order MRV Alone

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

---

When Imaging is NOT Indicated

Do not order imaging for: 1

• Bilateral, symmetric, non-pulsatile tinnitus without localizing features
• This represents inappropriate resource utilization with no benefit