From the Guidelines
Pulsatile tinnitus requires immediate medical attention as it may indicate an underlying vascular condition, and a thorough diagnostic workup including imaging studies like CT angiography or MRI is essential to identify and treat the cause. Pulsatile tinnitus is a rhythmic sound in the ears that typically synchronizes with your heartbeat, and it often has identifiable causes such as abnormal blood vessels near the ear, increased intracranial pressure, carotid artery disease, or high blood pressure 1. The diagnostic approach should be based on a detailed history and clinical evaluation, progressing from less invasive to more invasive imaging studies, with an otoscopic examination being extremely useful to guide optimal imaging evaluation 1.
Causes of Pulsatile Tinnitus
- Arterial lesions in the neck like carotid atherosclerosis, dissection, fibromuscular dysplasia of the carotids
- Intracranial etiologies such as arteriovenous malformation (AVM), dAVF, and vascular tumors like glomus jugulare
- Venous causes like transverse sinus stenosis, sigmoid sinus diverticulum, persistent petrosquamosal sinus, and prominent mastoid or condylar emissary veins
- Bony abnormalities such as superior semicircular canal dehiscence (SSCD), sigmoid sinus wall dehiscence, high jugular bulb, and Paget disease
Diagnostic Approach
- Thorough physical examination
- Hearing tests
- Imaging studies like CT angiography or MRI to visualize blood vessels
- Diagnostic algorithm based on a detailed history and clinical evaluation, progressing from less invasive to more invasive imaging studies 1
Treatment
- Focuses on addressing the underlying cause rather than the symptom itself
- If high blood pressure is the cause, blood pressure medications may be prescribed
- If a vascular abnormality is identified, surgical intervention might be necessary
- While waiting for medical evaluation, some find relief by elevating their head during sleep or avoiding caffeine and alcohol which can increase blood flow 1
From the Research
Definition and Diagnosis of Pulsatile Tinnitus
- Pulsatile tinnitus is a debilitating symptom that can be a harbinger of hemorrhagic or ischemic stroke, affecting millions of Americans 2.
- A thorough evaluation can identify an underlying cause of pulsatile tinnitus in more than 70% of patients 2.
- The causes of pulsatile tinnitus can be categorized into structural, metabolic, and vascular groups, facilitating a practical evaluation, referral, and treatment pattern 2.
Causes of Pulsatile Tinnitus
- Structural causes include neoplasms and temporal bone pathologic abnormalities 2.
- Metabolic causes include ototoxic medications and systemic causes of high cardiac output 2.
- Vascular causes include idiopathic intracranial hypertension and dural arteriovenous fistulas 2.
- Other potential causes of tinnitus include vascular tumors, vestibular schwannoma, and sensorineural hearing loss 3.
Diagnostic Evaluation and Imaging
- A standard workup for tinnitus begins with a targeted history and physical examination to identify treatable causes and associated symptoms 3.
- Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss 3.
- MR imaging provides a safe and effective means to evaluate pulsatile tinnitus, with specific sequences used to highlight different elements of cerebrovascular anatomy and physiology 4.
- CT and MRI can be useful in the diagnostic work-up of pulsatile tinnitus, providing complementary diagnostic information 5.
Treatment and Management
- Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus 3.
- Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive 3.
- Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments, respectively 3.
- Avoidance of noise exposure may help prevent the development or progression of tinnitus 3.