What could be causing an electric pulse sensation in my left neck?

Electric Pulse Sensation in Left Neck

This symptom most likely represents pulsatile tinnitus from a vascular or structural cause, and you need urgent imaging evaluation because over 70% of cases have an identifiable—and sometimes life-threatening—underlying pathology. 1

Immediate Clinical Assessment

Determine if this is truly pulsatile (synchronized with your heartbeat) versus other sensations, as this fundamentally changes the diagnostic approach and urgency. 1 The "electric pulse" description strongly suggests pulsatile tinnitus, which requires systematic vascular evaluation. 1

Critical Red Flags to Assess Now

• Perform otoscopic examination immediately to look for a reddish, pulsatile vascular mass behind the eardrum, which would indicate paraganglioma (glomus tumor) and change your imaging selection. 2, 3
• Check for any neurological deficits (weakness, numbness, vision changes, speech problems), as these shift the evaluation toward stroke, hemorrhage, or mass lesions requiring emergency imaging. 1
• Ask about vision changes or headaches, especially if you are a young overweight woman, as idiopathic intracranial hypertension is the second most common cause of pulsatile tinnitus and can cause permanent vision loss if missed. 1
• Test if the sensation changes with neck compression (gently press on the left side of your neck)—relief with compression suggests venous causes like sigmoid sinus abnormalities or arterial dissection. 1

Most Likely Diagnoses (in Order of Frequency)

Atherosclerotic Carotid Artery Disease (17.5% of cases)

• Turbulent blood flow through narrowed arteries creates the pulsing sensation. 1
• More common if you have cardiovascular risk factors (smoking, diabetes, hypertension, age >50). 1

Paragangliomas/Glomus Tumors (16% of cases)

• Highly vascularized tumors that appear as reddish, pulsatile masses on ear examination. 2, 3
• These are inherently pulsatile because their rich arterial blood supply creates rhythmic pulsations synchronized with your heartbeat. 3
• Visible on otoscopy as a vascular retrotympanic mass behind the eardrum. 3

Idiopathic Intracranial Hypertension (Second Most Common)

• Associated with sigmoid sinus wall abnormalities. 1
• Classic presentation: young overweight women with headaches and pulsatile tinnitus. 1

Dural Arteriovenous Fistula (8% of cases)

• This is life-threatening and can cause catastrophic hemorrhage or stroke if missed. 2, 1
• Requires high suspicion even with isolated pulsatile symptoms. 2

Other Vascular Causes

• Arterial dissection (potentially life-threatening). 1
• Jugular bulb abnormalities (high-riding jugular bulb or dehiscence). 1
• Sigmoid sinus diverticulum or dehiscence. 1
• Arteriovenous malformations. 1

Required Diagnostic Workup

First-Line Imaging (Choose Based on Clinical Findings)

If otoscopy shows a vascular retrotympanic mass:

• Order high-resolution CT temporal bone (non-contrast) as first-line study. 2, 3
• This identifies paragangliomas, glomus tumors, jugular bulb abnormalities, and superior semicircular canal dehiscence. 2

If no vascular mass on otoscopy OR if you have vision changes/neurological symptoms:

• Order CT angiography (CTA) of head and neck with contrast as first-line study. 2, 1
• Use mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in a single acquisition. 1
• This evaluates for dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, and sigmoid sinus abnormalities. 2

Additional Testing Required

• Comprehensive audiologic examination within 4 weeks (pure tone audiometry, speech audiometry, acoustic reflex testing) for any unilateral pulsatile sensation. 1

Second-Line Imaging (If Initial Studies Negative)

• MRI brain with contrast and MR angiography (MRA) if CT/CTA are negative but clinical suspicion remains high. 1
• This evaluates for cerebellopontine angle lesions, subtle vascular malformations, or venous sinus abnormalities not seen on CT. 1

Critical Pitfalls to Avoid

• Never dismiss this as benign without imaging—identifiable causes exist in over 70% of cases, and missing dural arteriovenous fistula can result in catastrophic hemorrhage. 2, 1
• Never biopsy a suspected vascular mass without imaging confirmation—inadvertent biopsy of an aberrant internal carotid artery or dehiscent jugular bulb can cause catastrophic hemorrhage. 3
• Do not skip otoscopic examination—this leads to delayed diagnosis of vascular retrotympanic masses (paragangliomas) and inappropriate imaging selection. 2
• Do not overlook intracranial hypertension, particularly in young overweight women with headaches, as this can lead to vision loss if missed. 1

What This Is NOT

This is not the neck pulsations seen with certain arrhythmias like atrioventricular nodal reentry tachycardia, which presents as visible bilateral neck pulsations during episodes of rapid heart rate (140-250 bpm) with palpitations and dizziness. 4, 5 Your unilateral, continuous "electric pulse" sensation requires vascular imaging evaluation. 1