By Marcello Cherchi, MD PhD
For patients
Pulsatile tinnitus consists of a rhythmic sound in one or both ears that is synchronous with the heartbeat. In some cases pulsatile tinnitus is due to an anomaly of a blood vessel, which may be identifiable on special vascular imaging studies. A patient with pulsatile tinnitus in whom a vascular cause is suspected often consults with a vascular neurosurgeon in order to determine the appropriate imaging study and whether intervention is appropriate.
For practitioners
Overview
A diagnosis of pulsatile tinnitus is suspected when the examiner palpates a patient’s pulse, has the patient “sound out” the pulsatile tinnitus that they are perceiving, and finds that the two patterns are synchronous. Pulsatile tinnitus sometimes appears to be associated with vascular abnormalities, though one must keep in mind that some vascular findings on imaging studies may be incidental rather than causal. When vascular phenomena are causal, venous causes are more common than arterial or arteriovenous ones. Some venous cases of pulsatile tinnitus are also associated with increased intracranial pressure.
Venous sources of pulsatile tinnitus include:
- Jugular bulb wall dehiscence
- Transverse sinus stenosis
- Sigmoid sinus diverticulum
- Sigmoid sinus wall dehiscence
- Enlarged oblique occipital sinus
- Stenoses of various dural venous sinuses from arachnoid granulations
- Superficial middle cerebral vein
- Dilated mastoid emissary vein
Arterial sources of pulsatile tinnitus include:
- Carotid artery stenosis
- Fibromuscular dysplasia
Arteriovenous sources include:
- Arteriovenous fistula
Practically, in a patient whose physical examination suggests pulsatile tinnitus of a vascular cause, referral to vascular neurosurgery is reasonable, as surgeons may have different recommendations for confirmatory imaging, and different recommendations for intervention (if appropriate).
Introduction
Vascularly-mediated pulsatile tinnitus is thought to be a hydroacoustic phenomenon that occurs because turbulent blood flow through a vessel produces sufficient vibrations to stimulate the cochlea. The pathway by which the kinetic energy from these vibrations reaches the cochlea is often uncertain (Wang, Hsieh et al. 2022). In particular, whether the kinetic energy from the turbulence is transmitted to the cochlea solely via bone conduction, or partly through air conduction via the middle ear space (Hsieh, Xu et al. 2021), is unclear.
Etiologies
The specific abnormal fluid dynamics required to provoke pulsatile tinnitus have not yet been well characterized.
A study using a novel Doppler technique reported that, “the sensation of PT [pulsatile tinnitus] is closely associated with the flow of kinetic energy rather than the formation of a vortex, whereby the amplitude of PT is correlated to the magnitude of the flow velocity and pressure gradient” (Gao, Hsieh et al. 2022).
In contrast, another study instead concluded that “vorticity” (production of vortices) is the fluid dynamic mechanism that generates tinnitus (Hong, Liu et al. 2022).
One study reported that unilateral pulsatile tinnitus is usually due to venous etiologies, less commonly to arterial etiologies or arteriovenous shunts (Cummins, Caton et al. 2022).
Associated mood disorders
Mood disorders are often comorbid with tinnitus in general, and this pattern holds specifically for pulsatile tinnitus as well.
One study of 157 pulsatile tinnitus patients noted mood disorders were common comorbidities, with depression in 25.5% and anxiety in 26.1% of patients (Formeister, Xiao et al. 2022).
One study reported that patients with pulsatile tinnitus exhibit a higher rate of anxiety and depression than patients with non-pulsatile tinnitus (Williams, Gourishetti et al. 2022).
Diagnostic physical examination
Typically a diagnosis of pulsatile tinnitus is suspected when the examiner palpates a patient’s pulse, has the patient “sound out” the pulsatile tinnitus that they are perceiving, and finds that the two patterns are synchronous.
In patients whose pulsatile tinnitus is due to sigmoid sinus dehiscence or diverticulum (see below), compression of the ipsilateral internal jugular vein may suppress the tinnitus (Lee, Lee et al. 2022).
Diagnostic testing
Some investigators have attempted more technological means of diagnosing pulsatile tinnitus. For example, one group simultaneously recorded (1) sound using a sensitive microphone in the ear, and (2) the cardiac pulse, and then developed an automated detection algorithm to identify synchrony between the two patterns (Ubbink, van Dijk et al. 2022).
Imaging studies
While it seems logical to seek vascular abnormalities in a patient with pulsatile tinnitus, one should keep in mind that some vascular findings on imaging may be incidental rather than actually responsible for the pulsatile tinnitus. This point is made firmly by Walthers and colleagues (Walters, Chung et al. 2022).
Broadly speaking venous sources of pulsatile tinnitus are more common than arterial ones. Some of the relevant anatomy is depicted in the figures below (Liu, Boursiquot et al. 2019).
Imaging studies: jugular bulb abnormalities
Investigators performed CT angiography (venography) on patients with unilateral pulsatile tinnitus and identified jugular bulb wall dehiscence (JBWD) in 12.1%, and believed the JBWD to be the cause of the tinnitus in 5.0% of cases (Dai, Zhao et al. 2023).
A case reported a terminal plate dehiscence of the jugular bulb as the source of pulsatile tinnitus (Guerra-Leal, Garcia-Gutierrez et al. 2022).
Investigators reported two cases of pulsatile tinnitus due to an “enlarged oblique occipital sinus” that, in one case was associated with a sigmoid-jugular wall diverticulum, and in another case was associated with a sigmoid-jugular wall dehiscence (Hsieh, Wang et al. 2022).
Imaging studies (venous): sigmoid sinus diverticulum
Some investigators favor specialized imaging protocols in patients with pulsatile tinnitus. For example, one group favored dynamic volume CT to detect “tinnitus caused by SSD [sigmoid sinus diverticulum] with bone defects” (Zhang, Mao et al. 2022).
Imaging studies (venous): venous stenosis
A CT venography study of patients with unilateral pulsatile tinnitus found that “the degree and length of ipsilesional transverse sinus stenosis (TSS) are positively correlated with transstenotic pressure gradient (TPG) in unilateral PT [pulsatile tinnitus] patients with SSWA” (sigmoid sinus wall anomalies) (Zhao, Ding et al. 2021).
A study of patients whose pulsatile tinnitus was due to transverse sinus stenosis noted that, “In white matter regions, the patients with high-degree TSS [transverse sinus stenosis] exhibited decreased CBF [cerebral blood flow]” relative to the healthy control subjects, and concluded that, “TSS in venous PT [pulsatile tinnitus] patients may lead to decreased CBF and cloud-like WM hyperintensity” (Li, Xu et al. 2021).
Imaging studies (venous): arachnoid granulations
One study reported a higher incidence of dural venous sinus arachnoid granulations in patients with pulsatile tinnitus than in those with non-pulsatile tinnitus (Bauschard, Reichl et al. 2022).
One study of four patients with unilateral pulsatile tinnitus who underwent MR and digital subtraction angiography reported that all patients had “moderate-to-severe stenoses from large arachnoid granulations within the implicated transverse sinus” (Gadot, Hoang et al. 2023).
One study of tinnitus patients found an association between the presence of “brain herniation into arachnoid granulations of the dural venous sinus” and the presence of idiopathic intracranial hypertension (Smith, Caton et al. 2022).
Imaging studies (venous): intracranial hypertension
Investigators compared CT angiography (venography) in one group of idiopathic intracranial hypertension (IIH) patients with unilateral pulsatile tinnitus (PT), and one group of IIH patients without pulsatile tinnitus. In comparison to IIH patients without PT, those IIH patients with PT had a higher proportion of venous outflow laterality and sigmoid sinus diverticula, and that the sigmoid sinus diverticula were always accompanied with sigmoid sinus wall dehiscence (Zhao, Jiang et al. 2021).
A study of patients with pulsatile tinnitus underwent cerebrospinal fluid manometry and Doppler ultrasound. The investigators concluded that in “Patients with venous PT [pulsatile tinnitus] as the only presenting symptom should be suspected of having increased CSFP [cerebrospinal fluid pressure] when they present with high ITSS [index of transverse sinus stenosis], BMI [body mass index] and low PI [pulsatility index]” (Gao, Hsieh et al. 2022).
Imaging studies (venous): rarer etiologies
One case report described pulsatile tinnitus from a superficial middle cerebral vein via a tympanic cavity dehiscence (Sing, Lim et al. 2022).
A dilated mastoid emissary vein has been reported as a cause of pulsatile tinnitus (Yang, Zhang et al. 2022).
Imaging studies (arterial): carotid artery stenosis
A case of a patient with unilateral pulsatile tinnitus attributed to a stenotic internal carotid artery reported that the tinnitus resolved after carotid artery stenting (Bains, Early et al. 2022).
A case of a patient with supraclinoid stenosis of the internal carotid artery ipsilateral to unilateral pulsatile tinnitus experienced resolution of the tinnitus after stenting of the stenosis (Capirossi, Laiso et al. 2022).
Imaging studies (arterial): fibromuscular dysplasia
One study described a patient suffering from medically refractory pulsatile tinnitus who was found to have fibromuscular dysplasia. Placement of a Casper stent in the carotid artery eliminated the tinnitus (Vanzin, Martio et al. 2021).
Imaging studies: multiple etiologies
General discussions of venous pulsatile tinnitus usually cover a differential diagnosis that includes, “sigmoid sinus wall anomalies, transverse and sigmoid sinus stenosis, jugular bulb anomalies, and prominent posterior fossa emissary veins” (Reardon and Raghavan 2016).
A case series of 157 patients with pulsatile tinnitus who underwent CT angiography and venography reported transverse venous sinus stenosis in 59% (bilateral in 39% and unilateral in 20%), osseous etiologies in 10% (superior canal dehiscence or thinning), sigmoid sinus dehiscence in 1 patient, and dural arteriovenous fistula in 2% (Formeister, Xiao et al. 2022).
Another study concluded that pulsatile tinnitus due to dural arteriovenous fistula is “not rare” (Li, Xu et al. 2022).
Treatment
Depending on a patient’s particular circumstances, the radiographic findings, and the level of confidence that a specific vascular anomaly is the source of pulsatile tinnitus, a vascular neurosurgeon may consider intervention.
Treatment: venous
One set of investigators reported that, “Two cases (one with jugular bulb diverticulum and one with both sigmoid sinus and jugular bulb diverticula) underwent surgical intervention, and both had immediate resolution of pulsatile tinnitus post-operatively” (Yeo, Xu et al. 2018).
A review concluded that venous sinus stenting is effective in treatment of pulsatile tinnitus arising from venous sinus stenosis (Fiani, Kondilis et al. 2021).
Treatment of pulsatile tinnitus due to sigmoid sinus diverticulum has also been performed with coil embolization (Liu, Mu et al. 2022).
One group reported pulsatile tinnitus in a patient found on CT angiography to have a sigmoid sinus diverticulum. This was surgically decompressed and “recontounred” (Spangler, McElveen et al. 2022).
One group treated idiopathic pulsatile tinnitus (i.e., without any apparent vascular anomalies) with transtemporal sigmoid sinus decompression, with favorable results (Slater, Duhon et al. 2022).
In cases where dehiscence (such as venous jugular bulb dehiscence) is believed to be the source of pulsatile tinnitus, there is debate regarding the type of material that should be employed in the surgical repair (Hsieh, Gao et al. 2021).
Surgical reconstruction of the sigmoid sinus wall in patients with sigmoid sinus wall dehiscence or sigmoid sinus diverticulum is not always successful in abolishing the pulsatile tinnitus (Li, Wang et al. 2022).
Treatment: arterial
A case of a patient with unilateral pulsatile tinnitus attributed to a stenotic internal carotid artery reported that the tinnitus resolved after carotid artery stenting (Bains, Early et al. 2022).
A case of a patient with supraclinoid stenosis of the internal carotid artery ipsilateral to unilateral pulsatile tinnitus experienced resolution of the tinnitus after stenting of the stenosis (Capirossi, Laiso et al. 2022).
One study described a patient suffering from medically refractory pulsatile tinnitus who was found to have fibromuscular dyslpasia. Placement of a Casper stent in the carotid artery eliminated the tinnitus (Vanzin, Martio et al. 2021).
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