As an otherwise healthy adult, I hear my own heartbeat in one or both ears (pulsatile tinnitus); what are the possible causes and what work‑up and management should be undertaken?

Pulsatile Tinnitus: Diagnostic Workup and Management

As an otherwise healthy adult with pulsatile tinnitus, you require 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

Immediate Clinical Assessment

Your physician should perform the following focused evaluation:

• Otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as red pulsating masses behind the eardrum), cerumen impaction, or middle ear abnormalities 1, 2
• Auscultation over your neck, periauricular area (around the ear), and mastoid bone to detect objective tinnitus (a bruit or whooshing sound the examiner can hear) 1
• Jugular/carotid compression test: gentle compression of the jugular vein or carotid artery while you report whether the pulsatile sound changes—relief with compression suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 1
• Neurologic examination to identify any focal deficits that would suggest intracranial pathology 1
• Comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks to document any asymmetric hearing loss, which would raise concern for retrocochlear pathology like vestibular schwannoma 1, 2

First-Line Imaging Strategy

The American College of Radiology provides clear guidance on initial imaging selection based on suspected cause 1:

Option 1: CT Angiography (CTA) Head and Neck with Contrast

Order this first if suspecting:

• Dural arteriovenous fistulas (8% of cases—life-threatening, can cause hemorrhagic or ischemic stroke) 1, 2
• Arterial dissection (potentially life-threatening, requires urgent identification) 1
• Atherosclerotic carotid artery disease (most common cause at 17.5% of cases) 1, 2, 3
• Sigmoid sinus diverticulum or dehiscence 1
• Arteriovenous malformations 1

Technical detail: Use a mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in a single acquisition, reducing radiation while maximizing diagnostic yield 1, 2

Option 2: High-Resolution CT Temporal Bone (Non-Contrast)

Order this first if otoscopy reveals a vascular retrotympanic mass or if suspecting:

• Paragangliomas or glomus tumors (16% of cases—appear as vascular masses on otoscopy) 1, 2
• Jugular bulb abnormalities (high-riding jugular bulb or dehiscence of the sigmoid plate) 1
• Superior semicircular canal dehiscence (bony defect allowing transmission of vascular sounds) 1
• Aberrant venous anatomy 1

Key advantage: CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure 1

Most Common Causes to Consider

The differential diagnosis is extensive, but these are the most frequent:

1. Atherosclerotic carotid artery disease (17.5%)—turbulent flow from stenosis 1, 3
2. Idiopathic intracranial hypertension (second most common)—particularly in young, overweight women with headaches; can cause vision loss if missed 1
3. Paragangliomas/glomus tumors (16%)—highly vascularized skull base tumors 1
4. Dural arteriovenous fistulas (8%)—life-threatening, can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1

When to Proceed to Advanced Imaging

If initial CT/CTA is negative but clinical suspicion remains high, the American College of Radiology recommends 1, 2:

• MRI brain with contrast and MR angiography/venography (MRA/MRV) to evaluate for:

  • Cerebellopontine angle lesions (vestibular schwannoma)
  • Vascular malformations not identified on CT/CTA
  • Subtle venous sinus abnormalities
  • Intracranial hypertension findings

• Catheter angiography should be reserved for cases with objective pulsatile tinnitus (examiner can hear it), inconclusive noninvasive imaging, or definitive characterization of suspected dural AVF or AVM 1

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are common, with identifiable causes in >70% of cases 1
• Do not miss dural arteriovenous fistula—this life-threatening cause requires high index of suspicion and appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
• Do not perform inadequate otoscopic examination—this can lead to delayed diagnosis of vascular retrotympanic masses (paragangliomas) and inappropriate imaging selection 1
• Do not overlook intracranial hypertension—particularly in young, overweight women with headaches, as this can lead to permanent vision loss 1

Management Based on Identified Cause

Once imaging identifies the cause, treatment varies:

• Atherosclerotic carotid stenosis: Medical management (antiplatelet therapy, statin, blood pressure control); carotid endarterectomy or stenting for hemodynamically significant stenosis 2
• Arterial dissection: Immediate anticoagulation or antiplatelet therapy 2
• Dural arteriovenous fistulas: Endovascular embolization or surgical treatment 2
• Paragangliomas/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
• Idiopathic intracranial hypertension: Treatment (weight loss, acetazolamide, lumbar puncture) results in dramatic resolution of pulsatile tinnitus in nearly 100% of cases 1

Important Clinical Distinctions

• Unilateral pulsatile tinnitus has a higher likelihood of identifiable structural or vascular cause compared to bilateral 1
• Objective pulsatile tinnitus (audible to examiner) is rare and strongly suggests vascular pathology requiring immediate workup 1
• Bilateral pulsatile tinnitus should prompt evaluation for systemic conditions causing increased cardiac output (anemia, hyperthyroidism, pregnancy) before extensive imaging 4