From the Guidelines
Pulsatile tinnitus requires immediate medical attention to identify and address the underlying vascular cause, which may involve imaging studies like CT angiography, MRI/MRA, or ultrasound, as recommended by the most recent guidelines 1. Pulsatile tinnitus is a rhythmic sound in the ears that typically synchronizes with your heartbeat, often indicating a vascular abnormality such as arteriovenous malformations, carotid artery stenosis, or venous abnormalities. The diagnosis of pulsatile tinnitus should start with a targeted history and physical examination to identify conditions that may relieve tinnitus, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines 1. Some key points to consider in the diagnosis and management of pulsatile tinnitus include:
- The importance of prompt medical evaluation to identify the underlying cause, which may involve imaging studies like CT angiography, MRI/MRA, or ultrasound 1.
- The potential benefits of cognitive-behavioral therapy (CBT) in managing persistent, bothersome tinnitus, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines 1.
- The distinction between pulsatile and nonpulsatile tinnitus, with pulsatile tinnitus often representing actual sound created by turbulent blood flow near the ear structures, rather than the perception of sound without an external source. While awaiting diagnosis, sound therapy or white noise machines may provide temporary symptom relief. It is essential to note that the treatment of pulsatile tinnitus targets the underlying cause, and there is no standard medication regimen for pulsatile tinnitus itself. For example, if it's caused by high blood pressure, antihypertensive medications may help; if due to a vascular tumor, surgical intervention might be necessary. The most recent guidelines from the American College of Radiology 1 provide the best approach to diagnosing and managing pulsatile tinnitus, emphasizing the importance of imaging studies in evaluating for a middle ear mass or vascular etiology.
From the Research
Definition and Prevalence of Pulsatile Tinnitus
- Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke 2, 3.
- It is estimated that an underlying cause of pulsatile tinnitus can be identified in more than 70% of patients with a thorough evaluation 2.
Causes of Pulsatile Tinnitus
- The causes of pulsatile tinnitus can be categorized into structural, metabolic, and vascular groups 2.
- Structural causes include neoplasms and temporal bone pathologic abnormalities 2.
- Metabolic causes include ototoxic medications and systemic causes of high cardiac output 2.
- Vascular causes include idiopathic intracranial hypertension and dural arteriovenous fistulas 2, 3.
Diagnostic Evaluation of Pulsatile Tinnitus
- A thorough diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy 2, 3.
- Non-invasive imaging modalities such as CT, ultrasound, and MRI can be used to identify underlying causes while minimizing risks of invasive diagnostic angiography 4, 5.
- MRI is increasingly preferred as the first-line screening test for its diagnostic efficacy and safety 4.
- Specific MRI sequences such as time-of-flight magnetic resonance angiography, arterial spin labeling, and diffusion-weighted imaging can be used to highlight different elements of cerebrovascular anatomy and physiology 6.
Management of Pulsatile Tinnitus
- When a vascular cause of pulsatile tinnitus has been established, attention must be focused on the patient's risk of hemorrhagic stroke, ischemic stroke, or blindness, as well as the risks of the available treatment options 3.
- A comprehensive and targeted radiographic imaging protocol can help guide the management of pulsatile tinnitus 6.