What is Pulsatile Tinnitus?
Tinnitus is a condition where you hear a sound in your ears even when there is no actual external sound. It’s a common issue that ear doctors deal with regularly. Tinnitus can be short-term or long-term, depending on the root cause. In fact, up to 75% of adults have experienced either short-term or long-term tinnitus at least once.
Correctly diagnosing tinnitus relies on an in-depth review of your health history and a physical checkup. When considering tinnitus, one thing that doctors look for is whether the sound has a regular rhythm (pulsatile) or not (non-pulsatile). The majority of people with tinnitus experience the non-pulsatile type, usually due to age-related hearing loss, also known as presbycusis.
Since non-pulsatile tinnitus is more common, diagnosing and treating pulsatile tinnitus can be a bit challenging for doctors. Once it’s confirmed that the tinnitus is pulsatile, the causes are further studied to understand if they are blood flow-related (vascular) or not (non-vascular). Vascular causes can be classified further into whether they are due to arteries or veins. Often, doctors can make this distinction based on your health history and a physical exam, but sometimes they may also need to use imaging technology like x-rays or scans.
We’ll be discussing the wide range of causes for pulsatile tinnitus and some ways to systematically approach the diagnosis of this complicated symptom. Even though tinnitus is relatively rare, it’s important for early detection and treatment to ensure the best possible outcome.
What Causes Pulsatile Tinnitus?
The causes of pulsatile tinnitus – a condition where you hear a rhythmic pulsing, often in time with your heartbeat – can be broadly divided into two categories: blood-vessel related (vascular) and not related to blood vessels (non-vascular).
Among the blood-vessel-related causes, the ones related to arteries are more common. Things that can cause this include uncontrolled high blood pressure, which needs to be managed properly before further treatments can be considered. Another common cause is turbulent flow in the arteries, where the smooth, ripple-free flow of blood gets disrupted, causing turbulence. It’s this turbulent flow that the patient can hear, leading to pulsatile tinnitus.
The most common cause of pulsatile tinnitus is a disease where the arteries in the neck (carotid arteries) get narrow because of hardening and narrowing of the arteries (atherosclerosis). This narrowing can cause a turbulent blood flow, leading to pulsatile tinnitus. A natural variation in the position of the artery at the base of the brain can also cause pulsatile tinnitus, even in patients with normal blood pressure levels who don’t have atherosclerosis. Another cause could be diseases like fibromuscular dysplasia or Takayasu disease, which are quite rare.
Sometimes, tumors (also known as paragangliomas or glomus tumors) in the area of the jugular opening and middle ear, or in the body of the carotid artery can lead to pulsatile tinnitus. This condition can be seen during an ear examination, and patients usually report pulsatile tinnitus in one ear that can also be heard by the healthcare provider when they listen to the patient’s neck or ear.
The most common cause when it comes to conditions related to veins, is a condition called idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri. This condition is most frequently seen in young, overweight women who may also experience changes in their vision and headaches. It’s believed that these patients experience rhythmic changes in pressure of the fluid around the brain and spinal cord.
Causes of pulsatile tinnitus that are not related to blood vessels are less common, but include conditions that increase the heart’s output such as pregnancy, anemia, and overactive thyroid, and muscle spasms in the palate and middle ear.
Understanding the possible causes can help healthcare providers to better identify and manage the cause of a patient’s pulsatile tinnitus.
Risk Factors and Frequency for Pulsatile Tinnitus
The number of people who experience tinnitus (a ringing or buzzing in the ears) is not well-defined due to the lack of a standard way to identify it. As many as 75% of adults have experienced tinnitus at least once. Persistent tinnitus, which lasts for a longer time, is estimated to affect between 5.1% and 42.7% of people, with more cases in males and older people. The wide range in the estimates is largely due to the varying standards of different studies. It is also more common in older individuals as it can be caused by age-related hearing loss. Of all the tinnitus cases, less than 10% experience pulsatile tinnitus, a form of tinnitus where the noise is rhythmic and often in tune with the heartbeat.
Signs and Symptoms of Pulsatile Tinnitus
If a patient comes in reporting tinnitus, which is a ringing or noise in the ears, understanding their medical history is really important. The doctor needs to determine if the tinnitus is rhythmic or steady, and if it affects one or both ears. This will help guide how the doctor treats the patient. Tinnitus can be either rhythmic or steady and can affect either one ear or both. Additional key points of information include when the symptoms started, what makes it better or worse, how long it lasts, and if the quality or severity of the noise changes. Sometimes, patients will describe the tinnitus as being extremely loud and unbearable, which could indicate a critical condition known as an arteriovenous malformation.
It’s also important for the doctor to understand if the patient has experienced any hearing loss, dizziness, ear discharge, ear pain, exposure to loud noises, or nerve damage. A history of ear infections and surgeries in the head or neck can also provide valuable information. The patient’s medication list is important to check as well, because some medications can damage the ear and make tinnitus worse.
- Rhythmic or steady tinnitus
- Affects one or both ears
- Start of symptoms
- What makes it better or worse
- How long it lasts
- Change in noise
- Hearing loss
- Dizziness
- Ear discharge
- Ear pain
- Loud noise exposure
- Nerve damage
- History of ear infections
- History of head or neck surgeries
A physical exam can provide further insights into the cause of tinnitus. Special attention should be given to the ears, nerves in the head and neck, and the heart. Checking the patient’s heartbeat can also be useful for identifying the cause.
The physical exam may also include checking key areas like the joint connecting your jaw to your skull. Some conditions may cause a pulsing mass or unusual movement of the eardrum, or even issues with balance. It’s also really important to check the patient’s blood pressure and how their heart sounds, as these can affect their tinnitus. For example, abnormal blood flow may cause the tinnitus to match the beat of the heart.
By feeling for any abnormal blood vessels or heartbeats, the doctor can gain insights into whether the tinnitus is related to heart or blood vessel issues. Checking if tinnitus changes when moving or pressing on certain areas of the head and neck can also give clues about whether it’s being caused by blood vessel or heart issues.
Testing for Pulsatile Tinnitus
People who are experiencing tinnitus, a condition that causes a constant ringing, buzzing, or pulsating sound, might need to undergo several tests to find out what’s causing it. One of the first tests your doctor might suggest is an audiologic evaluation. This can include a pure tone test, where you listen to different pitches and sound levels, and a speech audiometry test, that measures how well you can hear speech. The test can also include tympanograms, a test that measures the pressure and movement of your eardrum.
If the test shows that you have lost at least 20 decibels of hearing, especially in low frequencies, the audiogram could be repeated with light pressure applied to the large vein on the side of your neck where you hear the tinnitus. If your hearing improves, it might indicate a condition called Idiopathic Intracranial Hypertension (IIH).
Even though the results from standard lab tests might come back normal, they can still help rule out certain medical conditions that might cause your heart to pump more blood than usual, leading to the tinnitus.
Depending on the results of the audiogram and basic lab tests, the doctor might also recommend a Doppler ultrasound. This test measures the flow of blood through your carotid artery and can identify blockages or narrowing that can cause tinnitus.
More advanced imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) can also be used to find issues with blood vessels that might be causing the tinnitus. For issues related to arteries not clearly identified by Doppler ultrasound, the doctor might recommend CT angiography (CTA). CTA is also used to identify aneurysms, swollen blood vessels that can cause tinnitus. MRI Venography (MRV) is particularly useful for examining issues related to veins.
If your doctor suspects issues with your temporal bones (the bones around your ear), a CT scan of these bones might be recommended. If you have neurological symptoms, brain imaging with CT or MRI might be ordered to look for serious causes of tinnitus.
Some conditions, such as Idiopathic Intracranial Hypertension (IIH), may require further testing. The condition can be diagnosed if the CT or MRI of your brain looks normal, but a spinal tap, a procedure that measures the pressure of fluid surrounding your brain and spinal cord, reveals increased pressure. An eye exam can also reveal swelling of the optic nerve, a condition known as papilledema, which can indicate IIH.
Treatment Options for Pulsatile Tinnitus
In around 70% of patients with pulsating tinnitus (a condition where you hear a rhythmic noise, often in time with your heartbeat, in your ears), doctors can find a specific cause. Identifying this cause helps guide how the patient is cared for and treated. Depending on the cause of the tinnitus, care could involve a variety of health professionals working together and treatments may vary from simply monitoring the condition to prescribing medications or even performing surgery.
There are some treatments for tinnitus that may also be suggested. For example, reducing intake of substances like caffeine, participating in cognitive behavioral therapy (a type of talk therapy that helps people manage problems by changing the way they think and behave), undergoing tinnitus retraining therapy (a treatment that retrains the brain to reduce awareness and annoyance of tinnitus), or using sound therapy (a therapeutic method that uses sound to improve physical and mental health). However, it is important to note that there isn’t specific research available on how effective these methods are on treating pulsating tinnitus.
What else can Pulsatile Tinnitus be?
Identifying the cause of a throbbing ear noise, or pulsatile tinnitus, can be daunting because so many different conditions can cause it. The first step in finding the cause is to figure out if the tinnitus is related to blood vessels (vascular) or not (non-vascular). From there, it’s necessary to differentiate between conditions that involve arteries versus those that involve veins.
A diagram might be useful in visually organizing these conditions. Following this guideline can help healthcare professionals provide the right treatment for most patients with pulsatile tinnitus.
Here are some common conditions that may cause pulsatile tinnitus:
- Arteriovenous fistula (abnormal connection between an artery and a vein)
- Atherosclerotic vascular stenosis (artery narrowing due to the buildup of fats, cholesterol, and other substances)
- Idiopathic intracranial hypertension (increase in pressure around the brain without a known cause)
- Anomalous basilar artery (rare variation in a major brain blood vessel)
- Paraganglioma (rare tumor of certain nerve cells)
- Tensor tympani myoclonus (involuntary muscle spasms in the middle ear)
- Paget’s Disease (chronic bone disorder)
- Otosclerosis (abnormal bone growth in the ear)
What to expect with Pulsatile Tinnitus
The outlook for a condition known as pulsatile tinnitus – a type of ringing in the ears that is rhythmical and often in time with your heartbeat – relies greatly on what’s causing it.
If pulsatile tinnitus is due to complex heart diseases, it can worsen patient’s health and possibly increase the risk of death. On the other hand, there are other causes with no severe long-term effects. Patients might even experience relief from their symptoms once the root cause is treated.
Identifying and treating the problem promptly is the best way to improve the patient’s health.
Possible Complications When Diagnosed with Pulsatile Tinnitus
The side effects of pulsatile tinnitus, a condition characterized by whooshing or thumping sounds in the ears, can differ depending on its cause. While sometimes the underlying cause can be harmless, the tinnitus could also indicate a more severe illness. There’s also a risk of further health issues, both from the condition itself and from invasive treatments like surgery or radiation therapy.
Possible Side Effects of Pulsatile Tinnitus:
- Harmless underlying causes
- Potential indication of a more serious illness
- Health issues from the condition itself
- Complications from invasive treatments like surgery or radiation
Preventing Pulsatile Tinnitus
It’s important for patients to be actively involved in their own treatment plan. This can be achieved by keeping them informed about their condition. Pulsatile tinnitus, a condition where a person hears a rhythmic pulsing sound, often in sync with their heartbeat, can have many causes. The patients need to thoroughly understand their specific condition. For instance, for those with carotid bruits, which are abnormal sounds heard when the doctor listens to the carotid artery in the neck, they should be taught ways to improve their heart health. They should also be informed about the importance of regular check-ups with their primary care doctor.
For patients with idiopathic pulsatile tinnitus, where the cause of the condition is unknown, it’s important to reassure them that there’s no significant identifiable harmful condition causing their symptoms. Some patients may even find that their symptoms are more bearable once they know that they don’t have a serious underlying condition.
