Unilateral Pulsatile Tinnitus: Initial Management

Immediate Clinical Assessment

The American College of Radiology recommends performing an otoscopic examination to identify vascular retrotympanic masses, as this finding fundamentally changes the imaging selection 2, 1
A neurologic examination should be performed to detect focal deficits suggesting intracranial pathology, particularly signs of increased intracranial pressure or stroke 1
The American College of Radiology suggests performing a jugular/carotid compression test during auscultation to relieve pulsatile tinnitus with gentle compression, suggesting a venous etiology or arterial dissection 1
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 3, 1

High-resolution CT temporal bone (non-contrast) should be ordered as the first-line study if a vascular retrotympanic mass is present on otoscopy, to identify paragangliomas, adenomatous middle ear tumors, and other structural causes 1
The American College of Radiology recommends ordering CTA head and neck with contrast using a mixed arterial-venous phase if otoscopy is normal, to capture both arterial and venous pathology 3, 1
CTA identifies dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus diverticulum/dehiscence, and arteriovenous malformations 1

Atherosclerotic carotid artery disease is a common cause of unilateral pulsatile tinnitus, accounting for 17.5% of cases, and is due to turbulent flow 1
Idiopathic intracranial hypertension is the second most common cause, especially in young overweight women with headaches, and can cause vision loss if missed 1
Paragangliomas and glomus tumors account for 16% of cases and can be identified on high-resolution CT temporal bone (non-contrast) 1
Dural arteriovenous fistulas are a life-threatening cause, accounting for 8% of cases, and can lead to hemorrhagic or ischemic stroke 1
Arterial dissection requires immediate anticoagulation/antiplatelet therapy and can be identified on CTA head and neck with contrast 1, 4

MRI brain with contrast and MR angiography (MRA) should be ordered when CT/CTA are negative but clinical suspicion remains high, to evaluate for cerebellopontine angle lesions and subtle vascular malformations 1
Specialized internal auditory canal protocols with thin-section heavily T2-weighted sequences can evaluate for vascular loops and small vestibular schwannomas 3

Arterial dissection should be treated with anticoagulation or antiplatelet therapy 4
Sigmoid sinus diverticulum/dehiscence should be treated with surgical repair or endovascular embolization 4
Superior semicircular canal dehiscence should be treated with surgical repair if symptoms are debilitating 1, 4
Paragangliomas/glomus tumors should be treated with surgical resection, radiation therapy, or observation depending on size and symptoms 1
Dural AVF should be treated with endovascular embolization or surgical treatment 1