Pulsatile Tinnitus Brief

Compiled April 1999
by Marsha A. Johnson, TRT Specialist, Audiologist, member of TRTA

It is strongly recommended that all individuals with pulsatile tinnitus locate an excellent physician with interest in the circulatory system and complete a thorough examination.

Based on my research this spring, which included reviewing 7 otolaryngology textbooks and over 250 research studies, the data appears to support the underlying cause for detecting a pulsatile tinnitus as physiologic in nature. That said, there are many, many cases of pulsatile tinnitus that defy diagnosis and identification of the causative agent.

Here are some general facts about this troubling condition:

Pulsatile tinnitus is most often classified as objective tinnitus, meaning that others may also hear the sound, using a stethoscope or other sophisticated equipment.

Dr. Abram Shulman, who directs the prestigious Martha Enteman Tinnitus Treatment Clinic in NYC, writes: "Objective tinnitus can be experienced by the examiner on auscultation of the auditory canal and/or of surrounding structures with use of an auscultation tube or stethoscope. The find on auscultation of a carotid bruit (noise) or a vascular bruit overlying the orbit and/or cranium may be a reflection of an arteriovenous (AV) malformation or fistula."(quote from Essentials of Otolaryngology, Third Edition).

Pulsatile tinnitus can also be related to the following conditions:

From Otolaryngology Head and Neck Surgery, Eighth Edition, the chapter written by Dr. Alexander J. Schleuning II (who practices at OHSU in Portland, Oregon). The notes in parentheses are my explanatory comments.

Pulsatile tinnitus can be heard as several characteristic sounds including a lower pitched thumping or booming, as well as a rougher blowing sound which is coincidental with respiration, or as a clicking, higher pitched rhythmic sensation. Finally there may be single, rhythmic beats, or multiple biphasic beats (like the clip-clop of the horse), or a swishing, swooshing sound.

A rapid clicking sensation may be due to the contractions of the middle ear and palatal muscles. Low humming tinnitus that is inaudible to the examiner may be due to venous blood flow or associated with Meniere’s disease when accompanied by vertigo and fluctuating hearing loss.

Objective tinnitus that is strongly associated with the timing of the heart beat is most likely the product of a blood vessel malformation of the arteries and veins of the head or neck area. These blood vessels are located adjacent to the ear on the surface of the head or just inside the head. These cases require special imaging techniques and often require surgery to resolve.

It is my sincere hope that everyone who experiences pulsating tinnitus will pursue a thorough medical evaluation to locate the cause, if possible. The research is full of reports about methods for repairing the problems that create this disturbing symptom. At the same time, there are many cases of pulsatile tinnitus, which are not pinpointed, and these tend to fall into the idiopathic category (meaning unknown causes). Individuals who find that the initial imaging results do not reveal abnormalities should insist on further examination and investigation. It is apparently possible to misread or miss these trouble spots that may be tangled in other structures or hidden by bone or other tissue. Newer techniques have been employed that help determine the site of lesion in the majority of cases.

Based on the numerous studies, some listed below, and others, which revealed similar or identical data, the cure rates for PT are quite high, once the problem area has been identified.

These are arranged by year of the study. Authors are cited, as are important findings. Studies were included based on the amount of information, introduction of new techniques or diagnosis, or the number of patients included in the study. Authors’ names and year of publication are included, and the original studies may be located by finding access to MEDLINE database (use your Internet search engines to locate an access point). Abstracts of most studies are located on Medline, for the entire article you will need to order through a internet document provider, go to your nearest medical school library, or access a medical library via internet such as LonesomeDoc service offered by OHSU here in Portland, Oregon.

1996 to1999

Pulsatile Tinnitus and Angioplasty and Stenting of the Petrous Carotid Artery--tinnitus that results from blood flow turbulence was corrected using angioplasty (using a tiny balloon to press open a partially closed blood vessel)---------- and stenting (inserting a new artificial blood vessel wall).

Emery, Ferguson, Williams, 1998

 

Two pts. were found to have primary paragangliomas of the facial nerve canals. Both pts. had facial paresis or pulsatile tinnitus.

Petrus, Lo, 1996

 

Two pts. with Arnold-Chiari malformation (a blood vessel malformation) and one pt. with a congenital stenosis (narrowing) of the sylvian aqueduct had pulsatile tinnitus. Intercranial hypertension was a primary complaint in all 3 cases. Decompression surgery in one pt. relieved the symptom. This study documents cases of congenital central nervous system defects which can cause PT.

Wiggs, Sismanis, Laine, 1996

 

A dural (sac around the brain) malformation resulted in PT and was located using computed tomography/angiography imaging.

Koenigsberg 1996

 

PT presented in a pt. as a symptom of pseudotumour cerebri (intracranial hypertension syndrome)

Petrus, Lo 1996

 

Three cases of dural AV fistula with PT reported treated successfully by embolization surgery. Angiography of the carotid and vertebral arteries should be performed to judge source of blood flow and drainage.

Morales, Rama, Diez, Quintana, de Saro 1996

 

Magnetic resonance angiograph and venography of tumors and vascular compression lesions recommended for diagnosis of PT.

Van Hemert, 1997

 

AV fistulas including transverse and sigmoid sinuses in 30 patients who underwent panangiography. Bruit (blood vessel noise), PT and headache were the most common symptoms. Embolization was performed in all cases except one where baloon occlusion of the transverse sinus was attempted. 18 pts. were cured, 11 were improved and 1 was unchanged. Complications from the surgeries included transient stroke (1), transient facial paralysis, and a slight skin infection.

Olteanu-Nerbe, Uhl, Steiger, Yousry, Reulen 1997

 

An dural AV fistula in the left transverse sigmoid sinus with PT was reported in 1 case. MRI showed a mass and embolization was completed. PT disappeared.

Matsugama, Noguchi, Kakizaki, Kashihara 1997

 

PT in a female for 14 years was found to have jugular megabulb of the right side, discovered during exploratory surgery.

Abilleira, Rmoero-Vidal, Alvarez-Sabin, Ibarra, Molina, Codina, 1997

 

Neuro vascular decompression of the VIII cranial nerve in 10 pts. with facial spasms and one-sided tinnitus. Tinnitus was markedly improved in 8 pts. and both PT and continous tinnitus improved. Pts. did experience hearing loss.

Ryu, Yamamoto, Sugiyama, Uemura, Nozue 1998

 

One pt. with PT and hypertriglyceridemia whose imaging tests revealed a high position enlarged jugular bulb with slowed blood flow.

Lopez-Escamez, Gamero, Castillo, Amador 1997

 

Intracranial hypertension can cause audible PT.

Biousse, Newman, Lessell, 1998

 

PT of a one-sided nature was found in a person with dopamine-secreting glomus jugular tumor. Other side effects included palpitations and depression.

Troughton, Fry, Allison, Nicholls, 1998

 

Eighty four pts. with PT over a 10 year period received non invasive imaging examinations. Thirty six were found to have a vascular disorder (42%), most commonly a dural AV fistula or a carotid-cavernous sinus fistula. In 12 pts. (14%) there were nonvascular disorders such as glomus tumors or intracranial hypertension. PT pts. should receive non invasive techniques first, then followed by angiography as need.

Waldvogel, Mattle, Sturzenegger, Schroth, 1998

 

One case of a malformed carotid artery which was eroding the bony capsule of the inner ear is cited as an unusual case of PT.

Yao, Benjamin, Korzec 1998

 

Thirteen pts. with AV fistulas of the external carotid artery were treated with endovascular emobolization. Most frequent symptom was PT, followed by bruit, visual problems, headache, and a pulsatile mass in the neck. Trauma caused the fistula in 10 of the pts. and occured spontaneously in the other 3 pts. All the pts. were cured following the surgery and there were no signficant complications.

Luo, Lirng, Tneg, Chen, Guo, Chang, 1998

 

One pt. with injury reported a PT and swelling in the area in front of the ear. An AV fistula was identified and surgery resulted in improvement.

Khabouri, 1997

 

Intercranial hypertension identified with headache and PT in 25 obese pts.

Wang, Silberstein, Patterson, Young 1998

 

PT in a man with head injury and headache reported. Behavioral interventions were used to modify his distress along with lifestyle changes, and the value of polygraphic assessment for evaluating treatment outcomes is stressed.

Hegel, Martin 1998

 

PT over 15 years in 145 pts. was studied. Evaluations were individualized and included radiologic testing, ultrasound, and spinal taps. Benign intracranial hypertension syndrome was the most common diagnosis (56 pts.). Carotid artery disease was next (24 pts.) and glomus tumors third most common (17 pts.). In 13 pts. a diagnosis could not be reached. Conclusion is that the majority of pts. with PT have a treatable underlying etiology.

Sismanis, 1998

 

Nine pts. were found using MRA to have excessive carotid artery, vertebral artery, and vertebrobasilar artery twistings. The pts. complained of migraine, PT or carotidynia.

Pelaez, Levine, Hafeez, Dulli, 1998

 

Transverse/signoid sinus dural AV fistulas are difficult to diagnose or locate using current technology. PT is the main symptom. Forty one pts. were evaluated and classified into 4 grades depending on their situations. Treatments included compression therapy, embolization, surgery. PT was the chief complaint in 90% of these cases. Angiography was the best tool for evaluation and MRI is much better to CT when scanning for fistulas. 82% of the pts. achieved resolution of the PT, and half ended up with obliteration of the fistula via surgery.

Shag, Lalwani, Dowd, 1999

 

A 29 year old woman with PT and poor hearing revealed a mass in the middle ear which proved to produce PT. This proved tobe an aberrant internal carotid artery coursing through the middle ear space.

Koizuka, Hattori, Tsutsumi, Sakuma, Katsumi, Kikuchi, Kato 1998

 

1991-1995

Jugular bulb was found to divert into the middle ear space or towards the petrous pyramid close to the inner ear in 4 cases: PT was a major symptom.

Presutti, Laudadio, 1991

 

Ten obese pts. with idiopathic intracranial hypertension including symptoms of daily headaches and PT were followed through various treatment therapies.

Marcelis, Silberstein, 1991

 

37 million Americans suffer from tinnitus associated with high fq. sensori neural loss, which may lead Mds to overlook serious underlying conditions associated with one-sided tinnitus, PT, fluctuating tinnitus or tinnitus associated with vertigo.

Marion, Cevette, 1991

 

PT in a patient revealed mass in the tympanic space, surgery revealed a large artery situated on the bony promontory in the middle ear which proved to be the internal carotid artery.

Fukuda, Penido, Munhoz, Mota, deOliveira 1991

 

Traumatic AV communications review which can cause swelling of the face with PT as a main symptom. Management is suggested as complete excision and ligation of the arterial feeding vessels. One case is reported.

Lbeau, Reychler 1991

 

A 57 year old male with PT and one sided hearing loss with one sided facial palsy had a mass in the right ear on the middle fossa near the geniculate ganglion. t was an tumor fed by the meningeal artery, and was removed with success.

Senke, Sasaki, Ohta, Sinohara, Takeda, Matsui, Ueda, Furuga, Murakami 1991

 

73 cases of glomus tumors were studied over 30 years, PT was the primary symptom in 1/2 of the pts. with hearing loss in 1/3 of the pts. These cases required diagnostic evaluation using high resolution CT as the number one choice. Surgical approach was used with few complications. Recurrence rate was less than 5%.

O’Leary, Shelton, Giddings, Kwartler, Brackman 1991

 

PT as a rare sign: characterized by rhythmic sound synchronous with heart beat., underlying causes vary widely, some may be life threatening. Major causes cited are cardiac or vascular malformations, metabolic disorders, hyperdynamic circulatory states, elevated intracranial pressure and tumors. Pts. need phsycial examination, audiologic assessment, CT scans for images. 1 case hx reported.

Mahlo, Kellermann, 1991

 

Review of tinnitus, subjective and objective, and techniques for evaluating condition are discussed based on different pathologies: retrotympanic masses, retrocochlear lesions, cochlear abnormalities, infection, cholesteatoma, acquired vascular abnormaility (accidents), and more.

Willinsky 1992

 

36 pts. with glomus tumors of the temporal bone were operated on: PT, hearing loss, and paresis of the lower cranial nerves were present most often. High resolution CT scanning was used. Results showed a need for earlier diagnosis.

Lenarz, Plinkert, 1992

 

A 57 year old male sufferent from PT and vertigo attacks with right sided facial spasm. Treatment had been completed for attacks of Meniere’s syndrome which was not effective. A CT scan and vertebral angiography revealed an enlarge vertebral artery and compression of the VII and VIII cranial nerve was suspected. Decompression surgery was perform and the PT, dizziness, and spasm disappeared.

Ohashi, Yasumura, Nakagawa, Misukoshi, Kuze 1992

 

Aberrant internal cortid arteries in middle ears can manifect vertigo, tinnitus, or hearing loss. Red or blue mass seen behind the eardrum is one clinical finding: PT may be present. View can be obscured by ear infection, etc. and required radiological studies prior to surgical intervention.

Campbell, Renner, Estrem 1992

 

AV of the ascending pharyngeal and internal jugular vein is rare but may present with PT.

Chaloupka, Kibble, Hoffman 1992

 

Objective tinnitus can be caused by a vascular abnormality of the cervical region, skull base, or intracranium. Flow can be perceived as PT. Aberrant carotid artery, high riding jugular bulb, or a glomus tumor can produce PT. Other causes of PT include: arteriovenous malformations, atherosclerotic vascular disease, intracranial tumor with elevated cerebrospinal fluid pressure. Aneurysm presenting with PT is extremely rare: only 8 have been identified to date in the medical reports.

Austin, Maceri, 1993

 

A jugular glomus tumor arises from the glomus bodies located in the adventitia of the dome of the jugular bulb. Resembles a carotid body tumor closely. A 41 year old women with PT and uncontrollable high blood pressure is reported. Following surgery and removal, blood pressure normalized.

Maasen, Lenarz, Ruck, Bien, Overkamp, Kaiserling, 1993

 

Cysts in the petrous bones associated with PT and palsy were studied.

Jaeger, Bonafe, Fraysse, Manelfe, 1993

 

Vascular malformation responsible for PT in 2 cases with dural AV malformation and high riding jugular bulb. Techniques for diagnosis are reported.

Stenglein, Cidlinsky 1993

 

PT in an unusual case of iatrogenic AV malformation following a myringoplasty and following surgery. Evaluation and diagnosis of PT underlying conditions is stressed, especially angiography in addition to evamin, otoscopy, audiology, and CT scans.

Agrawal, Flood, Bradley 1993

 

Embolization of a dural AV fistula which presented with atypical facial pain and rightsided PT for 10 years. This same defect was present in other family members, and surgry resolved the compression of the trigeminal nerve and resolved the PT.

Ott, Bien, Krasznai 1993

 

PT and AV fistula reported in France. Vascular radiography revealed the defect. Another case of AV in the occipito-sinus area with PT is discussed.

Machini, Kennel, Hermann, Piller, Hemar, Conraux 1993

 

Study reports cases of vascular anomalies include intra and extra cranial AV malformations and glomus jugulare tumors as being main causes of PT. Benign cranial hypertension is also identified as a cause. PT may also present as a humming resulting from venous flow with a one sided effect. Ligation (tying off) of the internal jugular vein appears to be a successful treatment.

Nehru, al-Khaboori, Kishore 1993

 

Review of a high jugular bulb is not uncommon in the temporal bone, five cases are discussed and 52 cases reviewed. Most often the condition occurs on the right side with PT and may be present with an abnormal bone formation, aberrant sinusjugular system or decreased pneumatization (air pressure) of the mastoid bone. Most people with this condition, however, do not experience PT. High resolution computerized tomograph scan is the most convenient tool for imaging. Exploratory tympanomotomy is not recommended and jugular vein ligation has been reported with good results. Regular long term follow up for pts. without symptoms is recommended.

Lin Hsu Lin 1993

 

Discusses arterial dissection with bleeding into the vessel walls: associated with crevical trauma or underlying vascular disease. The internal carotid artery is most comon side and can occur in young or middleaged adults, most common symptoms are head or neck pain, PT, palsy, headache, and possibly stroke. Angiography is used to determine the defect, and there is a risk of cerebral complications can result. MRI is non invasive and ultrasound is developing which are increasingly used.

Mas 1993

 

Aberrant internal carotid artery is a young woman with PT and hearing loss is diagnosed using a CT scan and angiography. A large persistent stapedial artery was present with stapes bone fixation of unknown cause. Stapedectomy was performed and PT resolved.

Pirodda, Sorrenti, Marliani, Cappello 1994

 

PT can present problems: 100 pts. with PT are reviewed and the use of magnetic resonance angiography discussed. With MRI, PT diagnosis has been advanced considerably. Cerebral angiography is presently indicated in only a few cases. Cited as major causes are intracranial hypertension, glomus tumors, carotid atherosclerosis.

Sismanis, Smoker 1994

 

Imaging techniques for PT examination are discussed in detail.

Hasso 1994

 

The use of MR imaging and MR angiography for PT diagnosis is discussed and 49 cases are cited. 28 pts. showed vascular lesions or paraganglioma, with the majority seen best with MRA. Lesions included dural AV defects (9), extracranial AV defects (3), paragangliomas (5), jugular bulb variations (3), aberrant internal carotid arteries (1), internal carotid artery stenosis (narrowing) (1), tortuous (twisting) internal carotid artery (1), carotid artery dissection (separation) (1), transverse sinus stenosis (2) and and AV malformation (2). MRA with spin-echo imaging, markedly enhances the ability of MR to diagnosis PT.

Dietz, Davis, Harnsberger, Jacobs, Blatter 1994

 

54 pts. were followed after angiography to find intracranial hemorrhage and AV fistulae. Risk of hemorrhage for brain damage with dural AV condition was 1.6% during almost 7 years (the length of the follow-up period). Potential predictors of brain damage included lesions of the petrosal sinus and straight sinus. PT improved in more than half of the pts. and resolved in 75% following surgery during the period of the study. Pts. without sinus or venous outflow blockage discovered during the initial imaging were more likely to improve or remain stable that pts. with an occlusion.

Brown, Wieberg, Nichols, 1994

 

Objective tinnitus usually has a vascular origin, but dural (brain casing) AV fistulas are rare--here is a case of an AV meningeal fistula of the lateral sinus with PT. This condition is discussed along with diagnosis and treatment strategies.

Morais, Sancho, Garcia-Porrero, Bachiller, Alonso-Vielba, Miyar 1994

 

High Resolution Computed Tomography is needed for pts. with temporal bone disease---8 cases discussed and clinical conditions included PT, hearing loss, etc. etc.

Tan, Lim, Boey 1994

 

Audiologic findings in glomus tumors is discussed: hearing loss, PT, retrotympanic mass.

Baguley, Irving, Hardy, Harada, Moffat 1994

 

Discussed which techniques should be used in magnetic resonance imaging for diagnosing PT.

Brunberg 1995

 

12 cases of atherosclerotic artery disease and PT were reported with stenosis (narrowing) of the vessel in all cases. This should be highly suspected in pts. with PT older than 50 years and have associated cardio vascular risk factors. PT can be the first manifestation of the disease. Ultrasound studies of the carotid arteries can confirm the diagnosis and a vascular surgeon should be consulted.

Sismanis, Stamm, Sobel 1994