Pulsatile Tinnitus with High-Riding Jugular Bulb

Understanding the Diagnosis

The American College of Radiology suggests that a high-riding jugular bulb can cause pulsatile tinnitus and vestibular symptoms due to turbulent venous flow and potential compression of adjacent vestibular structures 1, 2
The combination of pulsatile tinnitus with vestibular symptoms in the setting of a high-riding jugular bulb suggests possible turbulent venous flow creating audible pulsations 4
A high-riding jugular bulb is a well-recognized anatomical variant that can cause pulsatile tinnitus and vestibular symptoms, with a strong suggestion that it is the primary culprit when seen on CT angiography as the only abnormality 2, 3

The American College of Radiology recommends high-resolution CT temporal bone without contrast as the next critical step to fully characterize the jugular bulb anatomy and identify associated abnormalities 1, 2, 3
The temporal bone CT should evaluate for jugular bulb dehiscence, whether the bony wall separating the jugular bulb from the middle ear or inner ear is intact 1, 2
The temporal bone CT should also evaluate for sigmoid sinus wall abnormalities, which are commonly associated with venous pulsatile tinnitus 1, 5
The American College of Radiology suggests that CT angiography alone is insufficient for evaluating high-riding jugular bulb, as it lacks the high-resolution bone algorithm and small field-of-view needed to assess temporal bone microanatomy 1, 2

If the high-resolution temporal bone CT is unrevealing, the American College of Radiology recommends considering CTA head and neck with IV contrast to evaluate for dural arteriovenous fistula, arteriovenous malformations, and sigmoid sinus stenosis or transverse sinus abnormalities 1, 5
The ACR Appropriateness Criteria recommend CTA head and neck as first-line imaging for pulsatile tinnitus when vascular pathology is suspected, as it can detect both arterial and venous etiologies while providing bone detail from thin-section reconstructions 1, 5

The American College of Radiology advises against performing otoscopic examination looking for a retrotympanic mass, as inadvertent biopsy of vascular variants can cause devastating complications 2, 3
The American College of Radiology recommends not dismissing the vestibular symptoms, as they may suggest possible compression of the vestibular aqueduct or increased venous pressure effects 4
The American College of Radiology suggests not ordering MRI/MRA as first-line imaging, as it cannot adequately assess the temporal bone microanatomy needed to characterize high-riding jugular bulb and associated dehiscences 1, 2