pulsatile tinnitus

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Pulsatile tinnitus is a specific type of tinnitus and refers to the perception of rhythmic noise, usually in time with the patient's heartbeat, in the absence of an external source, which is most commonly but not exclusively due to underlying vascular pathology.

Clinical presentation

Patients describe pulsing noise that sounds like rushing, flowing, or humming. Some recognize synchronization with their pulse and an increase in the sensation with physical activity or in a recumbent position .

subjective pulsatile tinnatus: heard only by the patient
objective pulastile tinnatus: heard by clinician on auscultation (neck or mastoid region)

Pulsatile tinnitus of venous origin may be associated with a low-pitched hum on auscultation and suppression of symptoms with manual pressure on the ipsilateral internal jugular vein.

On otoscopy, neoplasms and vascular anomalies protruding into the middle ear cavity may be seen as a retrotympanic vascular mass.

Pathology

Numerous causes of pulsatile tinnitus are recognized, including:

Vascular

venous
- idiopathic intracranial hypertension (most common in this category) with or without transverse sinus stenosis
- variant/anomalous vessel within the temporal bone
  - sigmoid sinus diverticulum or laterally placed sigmoid sinus ,with or without sigmoid plate dehiscence (most common in this category)
  - jugular bulb diverticulum or high riding jugular bulb, with or without jugular plate dehiscence
  - abnormal mastoid emissary veins
arterial
- arterial stenosis (usually involving internal carotid artery)
  - atherosclerosis (most common in this category, especially in the elderly)
  - dissection
  - fibromuscular dysplasia
- variant/anomalous vessel within the temporal bone
  - aberrant internal carotid artery (most common in this category)
  - lateralized internal carotid artery
  - persistent stapedial artery
- aneurysm of the internal carotid artery, less commonly vertebral or anterior inferior cerebellar artery
arteriovenous transition
- dural arteriovenous fistula (most common in this category), including caroticocavernous fistula
- arteriovenous malformation

Hypervascular tumors

paraganglioma (most common in this category)
- glomus tympanicum paraganglioma
- glomus jugulotympanicum paraganglioma
hemangioma
meningioma
Langerhans cell histiocytosis
hypervascular metastasis

Non-vascular

palatal myoclonus involving the tensor veli palatini, levator veli palatini, salpingopharyngeus, and/or superior pharyngeal constrictor muscles (most common in this category)
middle ear myoclonus involving the stapedius or tensor tympani muscles

Radiographic features

CT, MRI and digital subtraction angiography (DSA) are all useful, depending on the underlying cause. They provide complementary information in the evaluation of pulsatile tinnitus.

Given the wide range of entities that may present with pulsatile tinnitus, it is beyond the scope of this article to discuss each in turn. Rather, please refer to the articles for the specific entities above for individual imaging findings.