Pulsatile Tinnitus Evaluation and Management

Immediate Clinical Assessment and Imaging

The American College of Radiology recommends performing a focused evaluation, including otoscopic examination, to guide imaging selection and identify red flags, in patients presenting with pulsatile tinnitus 1, 2
A comprehensive audiologic examination, including pure tone audiometry, speech audiometry, and acoustic reflex testing, should be performed within 4 weeks to document asymmetric hearing loss indicating retrocochlear pathology 1, 2
The first-line imaging study for patients with pulsatile tinnitus is CT angiography (CTA) of the head and neck with contrast using a mixed arterial-venous phase, which can identify dural arteriovenous fistulas, arterial dissection, and atherosclerotic carotid artery disease 1, 2

The Journal of the American College of Radiology suggests that high-resolution CT temporal bone should be ordered if otoscopy reveals a vascular retrotympanic mass, to identify paragangliomas, glomus tumors, and other abnormalities 3, 1, 2
Atherosclerotic carotid artery disease is the most common cause of pulsatile tinnitus, occurring in 17.5% of cases, and is particularly relevant in patients with hypertension, hyperlipidemia, or diabetes 1
Dural arteriovenous fistulas are a life-threatening cause of pulsatile tinnitus, occurring in 8% of cases, and require urgent identification and treatment 1

The American College of Cardiology recommends medical management, including antiplatelet therapy, statin, and blood pressure control, for patients with atherosclerotic carotid stenosis, and carotid endarterectomy or stenting for hemodynamically significant stenosis 1
Immediate anticoagulation or antiplatelet therapy is recommended for patients with arterial dissection 1, 2
Endovascular embolization or surgical treatment is recommended for patients with dural arteriovenous fistulas 1, 2