Workup and Differential Diagnosis of Pulsatile Tinnitus

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of pulsatile tinnitus. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate between arterial and venous causes of pulsatile tinnitus.

Summary

Pulsatile tinnitus: also known as pulse synchronous tinnitus; corresponds with each heartbeat; speaker evaluates the patient by palpating the radial pulse while the patient taps their leg when they hear the sound; ≈60% of patients have anxiety and depression

Differential diagnosis: causes of rhythmic, but not pulse synchronous, tinnitus include palatal myoclonus, foreign body in the ear, and patulous eustachian tubes

Assessment: check vital signs; patients with hypertension can have a sensation of pulsatile tinnitus that may be louder on one side because the sigmoid sinuses are asymmetric (it is louder on the side with the larger sigmoid sinus); audiography should be obtained to evaluate for conductive hearing loss

Examination: findings are normal in many patients; speaker uses computed tomography (CT) of the temporal bones to isolate the lesion

Differentiation between arterial vs venous causes: for venous issues, having patient gently press on the neck over the sternocleidomastoid muscle occludes the internal jugular vein; the pulsatile tinnitus may stop on the ipsilateral side or get louder on the contralateral side; venous issues are usually less concerning than arterial issues; stethoscope may be used to listen to the patient’s neck, and carotid bruits or sounds over the mastoids warrant imaging

Imaging: a review in 2017 showed that CT angiography is comprehensive and provides good detail of temporal bone, skull base, and vascular pathology, but lacks the ability to identify idiopathic intracranial hypertension or pseudotumor cerebri; magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) show pseudotumor cerebri but lack the ability to identify temporal bone pathologies; therefore, magnetic resonance imaging (MRI) is inadequate for detecting abnormalities in the middle ear cavity or skull base, patients presenting with early-onset conductive hearing loss (eg, otosclerosis), and dehiscence in the bone around the sigmoid or carotid

Venous causes of pulsatile tinnitus: pseudotumor cerebri is the most common venous cause of pulsatile tinnitus; stereotypical demographic is a young, morbidly obese woman; patients usually present with other symptoms, eg, headaches, blurred vision, dizziness; consider referral to a neurologist; acetazolamide (Diamox) 250 mg twice per day may help decrease intracranial pressure; sigmoid sinus diverticulum is another venous cause, but often no outpouching of the sigmoid sinus is present; typically presents with no bony covering; patients report a “whooshing” sound in the right ear that is relieved with compression of the lateral neck

Arterial causes: atherosclerotic carotid artery disease is the most common arterial cause and is typically seen in patients age ≥50 yr with risk factors for atherosclerosis; imaging is warranted; carotid artery dehiscence can occur when there is no bone overlying the petrous carotid artery; other causes include aberrant carotid arteries that course through the middle ear, dural arteriovenous fistulas (typically in fifth or sixth decade of life), and arteriovenous malformations (which requires referral to a neurointerventionalist)

Readings

Narsinh KH, Hui F, Saloner D, et al. Diagnostic Approach to Pulsatile Tinnitus: A Narrative Review. JAMA Otolaryngol Head Neck Surg. 2022;148(5):476-483. DOI: 10.1001/jamaoto.2021.4470. View Article; Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(5):348-357. DOI: 10.1097/MOO.0b013e3283493fd8. View Article; Valluru K, Parkhill J, Gautam A, et al. Sound Measurement in Patient-Specific 3D Printed Bench Models of Venous Pulsatile Tinnitus. Otol Neurotol. 2020;41(1):e7-e14. DOI: 10.1097/MAO.0000000000002452. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Chen was recorded at the Pacific Rim Otolaryngology–Head and Neck Surgery Update, held February 19-22, 2022, in Honolulu, HI, and presented by the University of California, San Francisco School of Medicine. For information about upcoming CME activities from this presenter, please visit meded.ucsf.edu/continuing-education. Audio Digest thanks the speakers and the University of California, San Francisco School of Medicine, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

FP704402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.