I am experiencing pulsatile tinnitus (a rhythmic whooshing or thumping in my ears that matches my heartbeat); what are the possible causes and how should it be evaluated and treated?

Pulsatile Tinnitus: Urgent Evaluation Required

If you are hearing your heartbeat in your ears (pulsatile tinnitus), you need imaging evaluation urgently 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

Why This Matters

• Identifiable pathology is found in 70–91% of pulsatile tinnitus cases, making this fundamentally different from common non-pulsatile tinnitus where imaging is usually unnecessary. 1
• Life-threatening causes include: dural arteriovenous fistulas (8% of cases, can cause stroke), arterial dissection (requires urgent anticoagulation), and highly vascularized skull base tumors (16% of cases). 1, 2, 3
• The most common cause is atherosclerotic carotid artery disease (17.5% of cases), followed by idiopathic intracranial hypertension (10% of cases, can cause permanent vision loss if untreated). 1, 4

Immediate Clinical Assessment

Perform these specific evaluations before ordering imaging:

• Otoscopic examination to look for a red, pulsatile mass behind the eardrum (suggests paraganglioma/glomus tumor). 1, 2
• Determine laterality: unilateral pulsatile tinnitus has higher likelihood of identifiable structural cause than bilateral. 1
• Compression test: press gently on your neck vessels—if the sound stops with jugular or carotid compression, this suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection. 1
• Check for objective tinnitus: have a clinician listen over your neck, ear, and mastoid area with a stethoscope—if they can hear it too, this strongly suggests vascular pathology requiring immediate workup. 1

First-Line Imaging Strategy

The American College of Radiology provides clear guidance on which imaging to order first:

If otoscopy shows a vascular mass behind the eardrum:

• Order high-resolution CT temporal bone (non-contrast) to evaluate for paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence. 1, 2

If otoscopy is normal (most common scenario):

• Order CT angiography (CTA) 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 study. 1, 2
• This single study can identify: dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, arteriovenous malformations, and venous sinus stenosis. 1, 2
• CTA source images can be reconstructed to create temporal bone CT images without additional radiation, giving you both vascular and bony detail. 1

If CTA is negative but symptoms persist:

• Proceed to MRI brain with contrast plus MR angiography/venography to evaluate for subtle vascular malformations, cerebellopontine angle lesions, or intracranial hypertension. 1, 2

Additional Required Testing

• Comprehensive audiologic examination within 4 weeks (pure tone audiometry, speech audiometry, acoustic reflex testing) to document any asymmetric hearing loss that might indicate retrocochlear pathology like vestibular schwannoma. 1, 2

Specific Causes and Their Treatments

Atherosclerotic carotid disease (17.5% of cases):

• Treatment: Medical management with antiplatelet therapy, statin, and blood pressure control; carotid endarterectomy or stenting for hemodynamically significant stenosis. 2

Idiopathic intracranial hypertension (10% of cases):

• High-risk population: young, overweight women with headaches and vision changes. 1
• Treatment: Weight loss, acetazolamide, lumbar puncture; responds dramatically to treatment in nearly 100% of cases when truly pulsatile. 1
• Critical: Can cause permanent vision loss if missed. 1

Dural arteriovenous fistula (8% of cases):

• Treatment: Endovascular embolization or surgical treatment urgently. 2
• Why urgent: Can lead to hemorrhagic or ischemic stroke if untreated. 1

Arterial dissection:

• Treatment: Immediate anticoagulation or antiplatelet therapy. 2

Paragangliomas/glomus tumors (16% of cases):

• Treatment: Surgical resection, radiation therapy, or observation depending on size and symptoms. 1

Sigmoid sinus diverticulum or dehiscence:

• Treatment: Surgical repair or stenting in severe cases. 1

Superior semicircular canal dehiscence:

• Treatment: Surgical repair if symptoms are debilitating. 1

Critical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes are found in the majority of cases. 1
• Don't miss dural AVF—requires high index of suspicion and appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage. 1
• Don't perform inadequate otoscopic examination—missing a vascular retrotympanic mass leads to delayed diagnosis and inappropriate imaging selection. 1
• Don't overlook intracranial hypertension in young, overweight women with headaches—can cause permanent vision loss. 1
• Don't confuse this with common non-pulsatile tinnitus—bilateral, symmetric, non-pulsatile tinnitus does NOT require imaging, but pulsatile tinnitus almost always does. 1

When Imaging Is NOT Needed

The only scenario where imaging is not indicated: bilateral, symmetric, non-pulsatile tinnitus without localizing features, hearing loss, or neurologic deficits. 1 Your pulsatile tinnitus does not meet this low-risk criterion and requires imaging. 1