Have you ever heard a soft or loud noise in your ear, like a whooshing, that matches your heartbeat? That is known as pulsatile tinnitus, and it’s considered a rare form of tinnitus. It’s not a condition, but a symptom of an underlying cardiovascular condition.¹ 

Pulsatile tinnitus is complex to diagnose. Healthcare providers will look at your heartbeat and hearing, and they may also perform additional tests to rule out other issues. Once diagnosed, your treatment will target the underlying condition causing your tinnitus.

This article aims to help you understand what pulsatile tinnitus is, its diagnosis and its treatment. Keep reading for more information!

Understanding pulsatile tinnitus

Tinnitus is an auditory perception that you experience internally, meaning only you can hear it. That noise can vary from person to person, so you might hear it as a ringing, whistling or buzzing sound, which can either be non-pulsatile (the common one) or pulsatile. Less than 10% of patients with tinnitus are diagnosed with the pulsatile version.^1,2

Pulsatile tinnitus is a rare form of tinnitus with a complex diagnosis. This form of tinnitus consists of you hearing a whooshing sound in your ear that is synchronised with your heartbeat. This occurrence is a symptom of underlying cardiovascular issues. Furthermore, pulsatile tinnitus can be categorised into vascular and nonvascular causes.¹ 

Vascular causes

Vascular causes can be further broken down into arterial or venous problems, with arterial ones being more common.^1,2 These conditions include:

• Dural arteriovenous fistula (dAVF) 
• Arteriovenous malformation (AVM)
• Aneurysm
• Internal carotid artery stenosis  
• Transverse sinus stenosis (abnormal narrowing of transverse sinuses-veins at the back of your head that drain blood from the brain and cranium)
• Elevated cardiac output
• Idiopathic intracranial hypertension (IIH) (this is the most common venous cause)
• Paragangliomas
• Fibromuscular dysplasia (FMD)
• Takayasu disease

Nonvascular causes

Nonvascular causes that can lead to pulsatile tinnitus are:

• Osseous pathologies (bone impairments or diseases) like Paget Disease, Otosclerosis or bone tumours
• Metabolic diseases that increase cardiac output like anaemia and thyrotoxicosis
• Pregnancy
• Middle ear myoclonus ^1,2

Diagnosis of pulsatile tinnitus

As previously mentioned, pulsatile tinnitus is a symptom of an underlying condition. Your general practitioner (GP) will need to determine your type of tinnitus (pulsatile or not), and whether it's unilateral (on one side) or bilateral (on both sides). Once it’s established you have the pulsatile kind, your GP is going to categorise it into either vascular or non-vascular. If it’s a vascular issue, they will ascertain if it affects the arteries or veins^1,2 This process will help you get the most optimal treatment. Here is how a medical professional might obtain your diagnosis:

Patient history and symptoms assessment

Your GP will ask you to describe your symptoms, and they will also inquire about other concurrent complaints like vertigo, hearing loss, ear pain, ear discharge, noise exposure, possible neurological defects, as well as head and neck surgeries.^1,2 This will help them make a differential diagnosis.

In addition, your healthcare provider can look at your past medical history to check whether you suffer from any of the previously mentioned disorders that could cause pulsatile tinnitus. Moreover, they can also go through your list of medications, as some medicines like antibiotics and chemotherapy agents can cause inner ear damage, and others like nonsteroidal anti-inflammatory medications, aspirin, and herbal supplements can make tinnitus worse.¹

Physical examination

A physical exam will give your GP more information about your tinnitus. For instance, your physician will perform an auscultation with a stethoscope, to listen to your neck and skull and see if they can hear a sound that’s in time with your pulse. This is caused by turbulent blood flow, and if your GP can hear it, then it’s considered an objective pulsatile tinnitus, whilst if they can’t, it’s a subjective pulsatile tinnitus.^1,3 

Further cardiac tests along with vitals, allow your GP to see if you suffer from hypertension, stenosis or any other cardiovascular problem, which could be the cause of your tinnitus. What’s more, your palpitations can aid your healthcare provider in differentiating between an arterial and a venous condition.¹

Additionally, cranial nerve exams, pneumatic otoscopy and the tuning fork examination are performed to look for infections, eardrum perforation and tumours in the middle ear.^1,3

Diagnostic tests

Your physician can request different types of tests to obtain a diagnosis, like:

• Audiological evaluation: with pure tone and speech audiometry with tympanograms, to find out what underlying disturbances you might have
• Doppler ultrasound: to see how your blood flows through your veins and arteries, and to determine if you suffer from carotid stenosis
• Computed tomography angiography (CTA): an X-ray scan to help identify aneurysms and other vascular problems, in the head and neck, that may cause tinnitus
• Magnetic resonance imaging (MRI): a scan which uses magnetic fields and radio waves to generate images from the inside of your ears and neck. Once again, this can give details about any vascular pathologies
• Magnetic resonance angiography (MRA): this type of scan, which works like an MRI, is designed to specifically look at blood vessels and detect issues they might have ^1,2           

Treatment options

Treatment will be guided by the underlying illness that is causing your pulsatile tinnitus. Therapeutic techniques can range from medications to surgical interventions that will target your condition, and this can reduce or make your internal noise. However, sometimes your diagnostic tests might rule out any possible underlying conditions, so in this case, your GP may suggest the following options to manage pulsatile tinnitus:

• Sound maskers: using sound generators can hide your pulsatile tinnitus and provide you with relief. Research has shown that white-noise generators can relieve your tinnitus and improve your sleep.³ You might prefer hearing soothing noises, nature-related sounds, music, or other types of noise
• Hearing aids: these devices can amplify and introduce ambience noise which can also alleviate your tinnitus
• Counselling and cognitive behavioural therapy (CBT): these options aim to teach you how to deal with and accept pulsatile tinnitus and the negative feelings it may produce you. They can also teach you relaxation techniques to help you feel less frustrated or stressed
• Melatonin: Research suggests that melatonin may improve tinnitus and sleep disturbances caused by it.⁴ However, this study did not have a placebo group, and overall, research is still limited, so further studies are needed
• Management options: your GP might suggest some lifestyle changes to relieve your symptoms and improve your quality of life. These management options could be improving your sleep, decreasing alcohol and caffeine consumption, reducing stress, and dietary changes that lower cholesterol.³    

Prognosis and follow-up

Pulsatile tinnitus prognosis will depend on the underlying condition that causes it. If you are getting treatment for health problems, this could go away. Additionally, it is better if you tackle it as early as possible for an optimal outcome. Moreover, following the previously mentioned treatment recommendation could help you habituate to it if necessary, and improve your quality of life.   

Summary

Pulsatile tinnitus, an inner auditory perception, is a rare form of tinnitus that happens as a consequence of an underlying condition that can be vascular or nonvascular. This form of tinnitus is a bit complex to diagnose, and your healthcare provider will need to look at your medical history, perform a physical exam, and order some specific tests to identify the disorder that’s causing the pulsatile tinnitus. There is no specific treatment for this, but rather therapeutic strategies target the underlying conditions, which may make the tinnitus go away. There are, however, some recommendations you could follow like therapy to learn to habituate to it, or noise generators to mask it. Dealing with it -or with the causing disease- in the early stages, will have an optimal outcome for your health and quality of life.

FAQs

Can I live a normal life with pulsatile tinnitus?

That depends on the underlying problem that is causing your tinnitus. If it’s left untreated, it may have extremely negative outcomes in your health. So you should seek medical help as soon as you may detect something is wrong.

Can I prevent pulsatile tinnitus?

You might not always be able to prevent underlying conditions that are causing your tinnitus. However, eating a healthy balanced diet, exercising frequently, dealing with stress and sleeping properly might reduce your risk of suffering from these illnesses.