Pulsatile tinnitus (PT) is a common symptom originating from turbulent blood flow within blood vessels (veins and arteries). It is often described as a swooshing, whooshing, thumbing, or fetal monitor sound, which happens in time with the heartbeat. Most often the origin of these sounds are within the head, though can occasionally come from the neck or chest. An accurate diagnosis of the underlying cause of this symptom is essential to effective treatment.
PT should not be confused with other audible rhythmic sounds that are not in time with the heartbeat. These conditions are rare and most often are secondary to spontaneous contractions of the middle ear or throat muscles, similar to leg cramps. These sounds are often described as clicking, popping, crackling, flag flapping, rumbling, drum bell, and buzzing. Stimuli such as external sounds, as well as burping, talking, and touching the skin around the ear or head may trigger these rhythmic sounds.
Patients with PT should be initially evaluated by an Otolaryngologist (Ear, Nose, and Throat) specialist with expertise in this symptom. A thorough history must be taken focusing on timing, onset, severity, arrgravating/alleviating conditions, etc. The physical is a comprehensive head and neck exam, and should always include listening to the skull, neck, and chest with a stethoscope. In addition, an audiogram (hearing test) should be obtained in all patients. Depending upon the findings of the examination and the hearing test, imaging consistint of either a CT, MRI, or ultrasound may be ordered. In very rare instances an angiogram is required. On occasion further diagnostic testing is required and referral to a neurologist, or an interventional radiologist may be necessary to arrive at a diagnosis. Blood tests such as red blood count (hemoglobin), cholesterol level, and thyroid tests are obtained when anemia, hyperthyroidism, or atherosclerosis are suspected.
In our experience, the most common causes of etiologies of PT are stated below.
1. Idiopathic intracranial hypertension syndrome. (Historically known as “benign intracranial hypertension” or “pseudotumor cerebri”). This is a condition characterized by build-up of pressure inside the skull/brain and mostly affects obese females of childbearing age. In addition to PT, headaches and blurred vision are other associated symptoms.
2. Sigmoid sinus and jugular bulb abnormalities. This is when the shape of major veins inside the head results in turbulunce of blood flow. This condition does not have the risk of a stroke
3. Glomus tumors of the middle ear and the undersurface of the skull. These are benign slow growing tumors, but if left untreated can substantially impact quality of life.
4. Atherosclerosis of the arteries of the neck (carotid arteries). This is a hardening of the arteries secondary to deposits of cholesterol and other fats in the walls of the arteries that cause turbulence.
5. Migraine. Up to 2% of individuals with migraine have PT, which usually occurs in both ears and tends to be high frequency (pitch).
6. Arterio-venous fistula/malformations. This condition usually results in extremely loud pulsations. This has the risk of a potential stroke but is fortunately relatively rare.
7. Superior Semicircular Canal Dehiscence Syndrome: This is an absence of bone over the balance canals. Although frequently associated with imbalance/dizziness, one of the most common symptoms is PT.
8. Sensorineural (nerve type) of hearing loss. Usually affects older individuals (hearing loss of aging). PT is usually ocurs in both ears and unlike most PT, is high-pitched.
9. Low blood count of various etiologies (Anemia)
10. Fibromuscular dysplasia. This disease mainly involves the arteries of the neck and kidneys. It is mainly seen in women between 20 and 60 years of age and PT can be the only symptom. High blood pressure and headache are other potential manifestations
11. Pregnancy. PT may develop rarely during the third trimester of pregnancy and is likely due to a normal increase in blood volume. This condition usually subsides soon after delivery.
Treatment of Pulsatile Tinnitus
Successful treatment of PT is entirely dependent on an accurate diagnosis. As most causes are benign and not life-threatening, observation (no intervention) is reasonable for many patients. However, for those with more serious conditions causing PT or for those who PT is extremely bothersome, there are many possible treatments.
Conditions that can be treated medically are idiopathic intracranial hypertension, anemia, and migraines. The other conditions can be treated with either surgery or interventional radiology procedures. For those conditions that are related to obesity, weight-reduction surgery can be very successful.
Caution: Some patients and even surgeons may be tempted to “tie off” the large veins in the neck, especially if compression of these veins in the clinic results in a decrease/elimination of the PT. This proceddure should never be performed as it is not only ineffective in the long-term, it is associated with sigificant, often life-threatening risks.
Fortunately, recent advancements in the understanding of the various causes of PT have led to relatively simple and minimal risk interventions. VCU has been known as a world center for the study and treatment of PT and its’ treatment for over 40 years.