Can pulsatile tinnitus occur after cervical trauma?

Pulsatile Tinnitus After Neck Injury: Evidence-Based Evaluation

Yes, pulsatile tinnitus can absolutely occur after cervical trauma, and this presentation demands urgent imaging evaluation because neck injuries can cause life-threatening vascular complications—particularly arterial dissection—that present with pulsatile tinnitus as the sole initial symptom. 1, 2

Critical Vascular Injuries That Cause Post-Traumatic Pulsatile Tinnitus

Life-Threatening Arterial Causes

• Carotid or vertebral artery dissection is a potentially catastrophic complication of neck trauma that can present with isolated pulsatile tinnitus before progressing to stroke, and requires immediate identification and treatment with anticoagulation or antiplatelet therapy. 3, 1, 2
• A documented case report describes a 38-year-old man who developed left-sided pulsatile tinnitus as the only symptom after stumbling, which was subsequently diagnosed as internal carotid artery dissection on MRA; the stenosis and tinnitus resolved spontaneously after 2 months of antihypertensive therapy. 2
• Arteriovenous malformations and fistulas can develop or become symptomatic after trauma, accounting for 8% of pulsatile tinnitus cases overall, and carry risk of hemorrhagic or ischemic stroke if untreated. 3, 1

Venous and Structural Causes

• Traumatic venous sinus thrombosis or stenosis can produce turbulent flow patterns that manifest as pulsatile tinnitus. 3
• Jugular bulb abnormalities or sigmoid sinus dehiscence may be traumatically induced or unmasked by neck injury. 3
• Up to 53% of individuals with traumatic brain injuries develop tinnitus (though not all pulsatile), emphasizing the high incidence of auditory sequelae after head and neck trauma. 1

Immediate Diagnostic Algorithm

First-Line Imaging Selection

Order CT angiography (CTA) of the head and neck with contrast using a mixed arterial-venous phase (20-25 seconds post-contrast) as the initial study. This single acquisition captures both arterial dissection and venous abnormalities without additional radiation exposure, and is the American College of Radiology's recommended first-line test for suspected vascular causes of pulsatile tinnitus. 3

When to Escalate to Second-Line Imaging

• If CTA is negative but clinical suspicion remains high (particularly with history of trauma), proceed to MRI brain with gadolinium-enhanced MRA/MRV to detect subtle vascular malformations, arterial dissection not visible on CTA, or cerebellopontine angle lesions. 3
• MRA specifically identified the luminal stenosis with pseudolumen in the case report of post-traumatic carotid dissection presenting as isolated pulsatile tinnitus. 2

Alternative First-Line Approach

• If otoscopic examination reveals a vascular retrotympanic mass (suggesting traumatic vascular injury to middle ear structures), order high-resolution non-contrast CT temporal bone instead of CTA. 3, 4

Clinical Examination Priorities

Essential Physical Findings to Document

• Perform thorough otoscopic examination to identify vascular retrotympanic masses, hemotympanum, or tympanic membrane perforation that would alter imaging selection. 3, 4
• Test jugular/carotid compression: relief of pulsatile tinnitus with gentle compression suggests venous etiology (sigmoid sinus abnormalities) or, paradoxically, arterial dissection. 3, 5
• Assess for objective versus subjective tinnitus: place stethoscope over neck vessels and temporal region—objective tinnitus (audible to examiner) strongly suggests vascular pathology and may warrant proceeding directly to catheter angiography. 3
• Document any focal neurological deficits, as these shift evaluation away from tinnitus protocols toward acute stroke/hemorrhage imaging. 3

Audiologic Testing

• Order comprehensive audiologic examination (pure-tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks to identify asymmetric hearing loss that may indicate additional traumatic injury to cochlear structures. 3

Critical Pitfalls to Avoid

Never Dismiss Post-Traumatic Pulsatile Tinnitus

• The literature documents an "evident mismatch between the high incidence of trauma-associated tinnitus and scarce literature on the topic," meaning this presentation is underrecognized and undertreated. 1
• Identifiable structural or vascular causes exist in >70% of all pulsatile tinnitus cases, and missing arterial dissection or dural arteriovenous fistula can result in catastrophic hemorrhage or stroke. 3

Do Not Delay Imaging

• Pulsatile tinnitus after neck trauma is NOT an indication for conservative "wait and see" management—it requires urgent vascular imaging regardless of whether other symptoms are present. 3, 1, 2
• The case report of isolated post-traumatic pulsatile tinnitus from carotid dissection demonstrates that this symptom can be the only warning sign before potential stroke. 2

Recognize Treatable Surgical Causes

• Ossicular chain disruption, traumatic eardrum perforation, or perilymphatic fistula can all cause pulsatile or non-pulsatile tinnitus after neck/head trauma and are surgically correctable. 1
• High-resolution temporal bone CT will identify these middle ear injuries if present. 3

Additional Trauma-Specific Considerations

• Consider post-traumatic stress disorder (PTSD) as a contributing factor to tinnitus severity and distress, particularly in patients with severe anxiety or depression, who require prompt psychiatric evaluation due to increased suicide risk. 3, 1
• Mechanical, pressure-related, noise-related head trauma, and emotional trauma can all cause tinnitus through different mechanisms, requiring individualized diagnostic approaches. 1
• Consistent and standardized assessment of tinnitus and hearing-related sequelae after trauma is recommended for both clinical care improvement and understanding of pathophysiological mechanisms. 1