I hear a pulsatile (whooshing) sound in my right ear only when I lie on my right side, with no hearing loss, pain, dizziness, or neurological symptoms and normal blood pressure; what is the likely cause and recommended management?

Positional Pulsatile Tinnitus: Likely Benign Vascular Phenomenon

Your positional pulsatile tinnitus that occurs only when lying on your right side, without any red flag symptoms, most likely represents benign venous compression or altered blood flow dynamics that does not require imaging or treatment, but you should still undergo a focused clinical evaluation to confirm the absence of concerning features. 1

Why This Is Likely Benign

Your presentation has several reassuring features that distinguish it from pathological causes:

• Strictly positional nature – The fact that your pulsatile tinnitus occurs only when lying on your right side strongly suggests mechanical compression of venous structures (jugular vein or sigmoid sinus) rather than a fixed vascular abnormality 1, 2

• Absence of red flags – You have no hearing loss, pain, dizziness, neurological symptoms, or abnormal blood pressure, which makes life-threatening causes like arterial dissection, dural arteriovenous fistula, or intracranial hypertension extremely unlikely 1, 3

• Unilateral but position-dependent – While unilateral pulsatile tinnitus typically warrants investigation, the strict positional trigger (only when lying on that side) suggests transient venous compression rather than structural pathology 1, 4

What You Need: Focused Clinical Evaluation

Despite the benign presentation, you should undergo a targeted assessment to rule out treatable causes:

• Otoscopic examination is mandatory to exclude vascular retrotympanic masses (paragangliomas/glomus tumors) that can appear as reddish pulsatile masses behind the eardrum 1, 3

• Jugular/carotid compression test during the pulsatile episode can help confirm venous etiology – if gentle compression of the jugular vein on your right neck relieves the sound, this strongly supports benign venous compression 1

• Blood pressure measurement in multiple positions (lying, sitting, standing) to exclude hypertension as a contributing factor 1

• Comprehensive audiologic examination (pure tone audiometry, speech audiometry) is recommended by the American Academy of Otolaryngology for any unilateral or persistent tinnitus to document baseline hearing and exclude asymmetric hearing loss 1

When Imaging Is NOT Needed

The American College of Radiology provides clear guidance that imaging is not indicated for your presentation because:

• Pulsatile tinnitus that is strictly positional and completely resolves when changing position suggests transient mechanical factors rather than fixed structural abnormalities 1

• The absence of hearing loss, neurological deficits, objective tinnitus (audible to examiner), or continuous pulsatile tinnitus makes serious vascular causes (dural AVF, arterial dissection, atherosclerotic disease) highly unlikely 1, 4

• Imaging would be appropriate if you had: continuous pulsatile tinnitus regardless of position, associated hearing loss, headaches, vision changes, or if the sound were audible to your physician on auscultation 1, 3

Common Pitfall to Avoid

Do not dismiss this without at least one clinical evaluation – While your presentation is reassuring, the American College of Radiology warns that pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases when properly investigated 1. A single focused examination can confirm the benign nature and provide reassurance, whereas ignoring it entirely could miss the rare case of early intracranial hypertension or venous sinus abnormality 1, 4

The Mechanism Behind Your Symptoms

When you lie on your right side, gravitational forces and direct compression can:

• Compress the right jugular vein against surrounding structures, creating turbulent venous flow that becomes audible 1, 2

• Alter the pressure dynamics in the sigmoid sinus (the large venous channel in your skull), making normal blood flow temporarily audible 1, 4

• Increase awareness of normal vascular sounds due to the ear being pressed against the pillow, which occludes external sounds and amplifies internal body sounds 2

What to Expect

• Most cases of purely positional pulsatile tinnitus without red flags require no treatment beyond reassurance after clinical evaluation 1, 2

• If the sound becomes bothersome, simple measures like using a softer pillow, elevating your head slightly, or sleeping on your left side typically provide relief 2

• If new symptoms develop (hearing loss, continuous pulsatile tinnitus, headaches, vision changes), you should return for re-evaluation and likely imaging 1, 3