Pulsatile tinnitus

Pulsatile tinnitus is a sound in the ear that beats in time with your pulse. Unlike ordinary ringing tinnitus it usually has a physical cause in a blood vessel near the ear, and many of those causes can be treated.

What it is

You hear your own blood flow. That happens when flow near the ear becomes turbulent, when a vein is narrowed or when an artery connects directly to a vein. Causes I look for include narrowing of the venous sinuses with or without raised pressure inside the head, a dural arteriovenous fistula, abnormalities of the jugular vein or the bone around it and narrowing or dissection of the carotid artery. Anaemia, an overactive thyroid and high blood pressure can also produce it.

How it is found

I start with a careful history and examination, including gently pressing on the neck vein to see whether the noise changes. Imaging follows: MRI with venography and a fine-detail CT of the ear and neck vessels. When the pictures point to the veins, a catheter venogram with pressure measurements, done awake as a day case, confirms whether a narrowing is significant. When they point to a fistula, a catheter angiogram maps it.

How I treat it

Treatment is directed at the cause. Venous sinus narrowing with a pressure gradient responds to stenting. Fistulas are closed by embolisation. Bony defects over the sigmoid sinus and jugular bulb problems are treated with ENT colleagues. Arterial narrowing is managed medically or with a stent. Where no treatable cause is found, or where the risk of treatment is not justified, I say so, and I can point you to the sound therapy and support that help.

What to expect

Most of the investigation is outpatient. The treatments themselves are described on their own pages. I run a dedicated clinic for this problem because it is so often dismissed as untreatable.