Chapter 13: Treatment of Pulsatile Tinnitus

Pulsatile tinnitus (PT) is defined as the self-perception of one’s blood flow, accounting for about 4% of all patients with a chief complaint of tinnitus. PT etiologies can be classified into different categories, including abnormal sound production such as sigmoid sinus wall and transverse sinus anomalies, abnormal sound perception like third mobile window syndromes and Eustachian tube dysfunction, a combination of both, or causes of unknown mechanisms such as migraine and Meniere’s disease. It is crucial to explain to patients that PT is a symptom of an underlying disease. Based on the findings of a comprehensive review of the patient’s medical history, focusing on PT and its associated otologic and non-otologic symptoms, physical examination, and hearing evaluation, appropriate imaging can be ordered to aid in the diagnosis. Parasympathetic paragangliomas, specifically jugulotympanic paraganglia, are associated with PT due to their location within the middle ear and/or jugular foramen. In addition, PT is one of the most common presenting symptoms in patients with idiopathic intracranial hypertension (IIH). Furthermore, sigmoid sinus wall abnormalities and transverse sinus stenosis, frequently associated with IIH, can also cause PT. Dural vascular lesions, specifically type I lesions of the transverse sigmoid sinus, are an important cause of arterial PT. A dehiscence in the superior semicircular canal is another cause of PT by increasing inner ear compliance and sensitivity to bone-conducted sounds as well as potentially having the third window transmitting dural pulsations to the cochlea. Finally, in patients with a normal imaging workup and normal neuroophthalmologic exam, otologic migraine should be considered as a potential etiology for PT. For each of these conditions, several treatment options are available. However, when a specific cause cannot be found, non-specific treatments, such as tinnitus habituation therapies, masking, and cognitive therapies, like cognitive behavioral therapy, can be employed.