Pulsatile Tinnitus

Tinnitus (a sound you can hear in the absence of an external sound) can be described as ringing, buzzing, chirping, roaring, pulsating, beating etc. Tinnitus that pulsates in time with your heartbeat is termed pulse-synchronous tinnitus.

The differentials for a pulsating noise in your ear(s) include:

Any conductive hearing loss, such as otosclerosis: This occurs because the conductive hearing loss cuts out ambient noise, permitting you to hear body-generated sounds better

Superior Canal Dehiscence Syndrome (SCDS): This is a disorder in which the bone between the apex of the superior semicircular canal (part of your balance system) and the middle cranial fossa (in which the middle part of your brain lies) is absent. This leads to some unusual symptoms such as loud sounds/coughing/sneezing triggering vertigo (dizziness), or the ability to hear your heartbeat/eyes move.

Glomus tumours/middle ear adenomas: These are benign but vascular tumours in the middle ear

Idiopathic Intracranial Hypertension: this high pressure of the fluids around the brain typically presents in overweight females with headaches and reduced vision

Vascular causes/abnormal blood vessels: artery-->venous fistula/Jugular bulb/sigmoid/carotid stenosis, dehiscence, diverticulum, aneurysm. The character of the tinnitus changes with neck rotation/compression of the Internal Juglar Vein, and a bruit/murmur of turbulent blood flow can sometimes be heard with a stethoscope when listening to the head/neck region

Skull base tumours

Referred heart sounds: the sound from a heart murmur (for example due to turbulent blood flow through a heart valve) can sometimes be transmitted up the blood vessels of the neck and heard as a pulsating sound

Systemic/high cardiac output: Hyperthyroidism, anaemia, pregnancy etc

If you are suffering from pulsatile tinnitus your ENT doctor will ask you questions to narrow down the likely causes, examine your ears, head and neck, listen to your head, neck and heart with a stethoscope, and arrange a hearing test. Further investigation may be required such as a CT, MRI, angiogram, echocardiogram or VEMPs (if available) to elucidate the cause. Treatment options will depend on the investigation findings, and how disabling your symptoms are. Onward referral to a Neurologist, Cardiologist, vascular or skull base surgeon may be required.

Clicking tinnitus can be due to:

Palatal myoclonus: spasms of the muscles of the soft palate. This is sometimes visible through the mouth or on a prolonged tympanogram. It responds to muscle relaxants or Botox injections (of the soft palate). An MRI of the brain should be requested to rule out MS.

Stapedial or tensor tympani muscle spasm: within the middle ear there are tiny muscles that contract in response to excessively loud sounds to tense the ear drum, we presume to protect our hearing. Occasionally these muscles can spasm giving a clicking or crackling noise. The diagnosis can be made by witnessing the ear drum move under a microscope in a typical fashion, and a prolonged tympanogram. It usually settles with caffeine reduction and  muscle relaxants, but surgical division of the muscles can (rarely) be performed if required.

Patulous Eustachian Tube: This is an abnormally wide opening of the Eustachian tube (the tube that connects the back of the nose to the middle ear). It usually occurs following weight loss but is associated with Rheumatoid Arthritis/Raynaud’s. An echo noise can be heard, worse with breathing in and out through the nose, and improved when lying flat/hanging your head below your body. The ear drum can be seen to move with forced nasal respiration on the affected side under a microscope. Prolonged tympanometry and a nasendoscopy to witness the movement at the back of the nose may aid the diagnosis. Treatment involves stopping nasal decongestants, increasing fluid input during exercise and Ipratropium nasal sprays. Potassium Iodide drops (taken in squash) can help too. The Eustachian tube can be surgically plumped up through the nose, or blocked from the middle ear above. A grommet (a hollow plastic tube that sits in the ear drum) helps with the fulness sensation, but is not useful for the extra sounds people with this condition hear. An ENT doctor will also be able to advise on the best management for a Patulous Eustachian Tube associated with an atelectatic/thinned ear drum – this may require concomitant ear surgery.

It is also normal to hear your ear drum pop/click whenever you yawn or swallow as you open/close your Eustachian tube.