Pulsatile tinnitus

Last revised by Derek Smith on 19 Oct 2023

Pulsatile tinnitus is a specific type of tinnitus and refers to the perception of rhythmic noise, usually in time with the patient's heartbeat, in the absence of an external source, which is most commonly, but not exclusively, due to underlying vascular pathology.

Patients describe a pulsing noise that sounds like rushing, flowing, or humming. Some recognize synchronization with their pulse and an increase in the sensation with physical activity or in a recumbent position 10.

Tinnitus, including pulsatile tinnitus, is subcategorized as subjective or objective 10:

  • subjective tinnitus: heard only by the patient

  • objective tinnitus: heard by the clinician on auscultation (neck or mastoid region)

Non-pulsatile tinnitus is almost always subjective, but some cases of pulsatile tinnitus are objective 11.

Additional findings on the clinical history and physical examination can narrow the differential diagnosis 11:

Numerous causes of pulsatile tinnitus are recognized 4,7-11:

CT, MRI, ultrasound, and digital subtraction angiography (DSA) provide complementary information in the evaluation of pulsatile tinnitus given the diversity of causes. In patients with pulsatile tinnitus without myoclonus or Eustachian tube dysfunction, the American College of Radiology in 2017 rated the following imaging exams as "usually appropriate" 14:

  • CTA of the head with contrast

  • CTA of the head and neck with contrast

  • CT venography of the head with contrast

  • CT of the temporal bone without contrast

  • MRI of the head and internal auditory canal without and with contrast

  • MRA of the head without and with contrast

The following imaging exams were rated as "may be appropriate" 14:

  • MRI of the head and internal auditory canal without contrast

  • MRA of the head without contrast

  • MR venography of the head without and with contrast

  • MR venography of the head without contrast

  • arteriography of the cervicocerebral vessels

  • ultrasound duplex Doppler of the carotid arteries

Given the wide range of entities that may present with pulsatile tinnitus, it is beyond the scope of this article to discuss each in turn. Rather, please refer to the articles for the specific entities above for individual imaging findings.

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Cases and figures

  • Case 1: sigmoid sinus diverticulum
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  • Case 2: aberrant right internal carotid artery
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  • Case 3: dural arteriovenous fistula
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