What is the recommended diagnostic work‑up and initial management for a healthy 28‑year‑old woman with new‑onset pulsatile tinnitus over the past few months?

Pulsatile Tinnitus in a 28-Year-Old Woman: Diagnostic Work-Up and Management

Order CT angiography (CTA) of the head and neck with contrast as your first-line imaging study, using a mixed arterial-venous phase acquisition to capture both arterial and venous pathology in a single scan. This young woman requires urgent imaging because pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases, and missing life-threatening etiologies like dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke 1, 2, 3.

Immediate Clinical Assessment

Before ordering imaging, perform these specific evaluations:

• Otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile masses behind the tympanic membrane), cerumen impaction, or middle ear effusion 1, 2, 3
• Auscultation over the neck, periauricular area, and mastoid to detect objective tinnitus—if you can hear the sound, this strongly suggests vascular pathology requiring immediate work-up 2
• Jugular/carotid compression test: Have the patient compress the ipsilateral jugular vein or carotid artery; relief of tinnitus suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 2
• Neurologic examination to identify focal deficits that would shift the evaluation toward stroke or mass lesion protocols 2
• Blood pressure measurement and assessment for signs of intracranial hypertension (papilledema on fundoscopy, headache, vision changes)—particularly important in this demographic 2, 3

Audiologic Testing

Order comprehensive audiologic examination within 4 weeks, including pure-tone audiometry, speech audiometry, and acoustic reflex testing 2, 3. Do not postpone this testing. Asymmetric hearing loss changes the imaging algorithm and raises concern for retrocochlear pathology like vestibular schwannoma, which would require MRI of the internal auditory canals with contrast instead of CTA 2.

First-Line Imaging Strategy

The imaging choice depends on otoscopic findings:

If Otoscopy Shows a Vascular Retrotympanic Mass:

Order high-resolution CT temporal bone (non-contrast) to evaluate for paragangliomas (glomus tympanicum/jugulare), adenomatous middle ear tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy 1, 2, 3.

If Otoscopy is Normal (Most Common Scenario):

Order CT angiography of head and neck with contrast using a mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in a single acquisition 2, 3. This protocol evaluates for:

Arterial causes:

• Atherosclerotic carotid artery disease (most common cause at 17.5% of cases) 2, 3
• Arterial dissection (life-threatening, requires urgent identification) 2, 3
• Fibromuscular dysplasia 1

Arteriovenous causes:

• Dural arteriovenous fistulas (8% of cases, can cause hemorrhagic or ischemic stroke if untreated) 2, 3
• Arteriovenous malformations 1, 2

Venous causes (particularly relevant in young women):

• Idiopathic intracranial hypertension with transverse sinus stenosis (second most common cause overall) 2, 3
• Sigmoid sinus diverticulum or dehiscence 1, 2, 3
• High-riding jugular bulb 1, 2
• Prominent mastoid or condylar emissary veins 1, 2

Key technical point: CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure, providing both vascular and bony detail 2.

Second-Line Imaging (If CTA is Negative)

If CTA is negative but clinical suspicion remains high, proceed to MRI brain with contrast and MR angiography/venography 1, 2, 3. This is particularly useful for:

• Cerebellopontine angle lesions (vestibular schwannoma)
• Subtle vascular malformations not visible on CTA
• Detailed assessment of transverse and sigmoid sinuses
• Evaluation for intracranial hypertension

Time-resolved gadolinium-enhanced MRA with arterial spin-labeling technique has high sensitivity and specificity for dural arteriovenous fistulas 1.

Critical Diagnostic Considerations for This Patient

This 28-year-old woman fits the highest-risk demographic for idiopathic intracranial hypertension (IIH), which is the second most common cause of pulsatile tinnitus 2, 3. Young, overweight women with headaches and pulsatile tinnitus represent a high-risk group 2. IIH causes pulsatile tinnitus through transverse sinus stenosis and sigmoid sinus wall abnormalities, and responds dramatically to treatment in nearly 100% of cases when truly pulsatile 2.

Ask specifically about:

• Headaches (present in most IIH cases)
• Vision changes, transient visual obscurations, or diplopia (can lead to permanent vision loss if missed) 2
• Recent weight gain 2
• Positional variation of tinnitus (worse when lying down suggests venous etiology)

Common Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are common, with identifiable pathology in 70-91% of cases 1, 2, 4
• Do not miss dural arteriovenous fistula—this can present with isolated pulsatile tinnitus before catastrophic hemorrhage; it requires high index of suspicion and appropriate vascular imaging 2, 5
• Do not perform inadequate otoscopic examination—missing a vascular retrotympanic mass leads to inappropriate imaging selection and delayed diagnosis 2
• Do not overlook intracranial hypertension in young overweight women—this can cause permanent vision loss if papilledema progresses untreated 2
• Do not order MRI/MRA alone as first-line imaging—CTA is superior for most vascular causes and provides excellent temporal bone detail from source images 2, 3

When to Proceed to Catheter Angiography

Reserve digital subtraction angiography for 6, 5:

• Objective pulsatile tinnitus (audible to examiner)
• Inconclusive noninvasive imaging with high clinical suspicion
• Definitive characterization of suspected dural arteriovenous fistula or arteriovenous malformation identified on CTA/MRA
• Treatment planning for confirmed vascular lesions

Management Considerations

Treatment depends entirely on the underlying cause identified on imaging 3, 7, 6:

• Atherosclerotic carotid stenosis: Medical management (antiplatelet therapy, statin, blood pressure control); carotid endarterectomy or stenting for hemodynamically significant stenosis 3
• Arterial dissection: Immediate anticoagulation or antiplatelet therapy 3
• Dural arteriovenous fistula: Endovascular embolization or surgical treatment 3, 7
• Idiopathic intracranial hypertension: Weight loss, acetazolamide, venous sinus stenting in selected cases 7, 6
• Sigmoid sinus diverticulum/dehiscence: Surgical repair or stenting in severe cases 2, 7
• Paragangliomas: Surgical resection, radiation therapy, or observation depending on size and symptoms 2

The key message: Pulsatile tinnitus is vascular until proven otherwise, and this patient requires imaging evaluation regardless of how "benign" the presentation appears. 2, 4