Brief episodes of pulsatile tinnitus are common, as people become aware of hearing their pulse in their ear – most just need simple reassurance. Awareness can be increased by conductive hearing loss (e.g. perforated ear drum, glue ear) as the masking effects of external sounds are lost. Awareness is also increased by heightened sensitivity to the normal noise of intracerebral blood flow (just as can happen in non-pulsatile tinnitus). People commonly hear their own pulse after exercise.True, persistent pulsatile tinnitus is rare. It is considered subjective or objective, the latter being heard by the clinician too, usually in time to the heartbeat.
The causes are:
- HYPERDYNAMIC CIRCULATION:
- Anaemia
- Thyrotoxicosis
- Pregnancy
- Exercise
- LOCAL BRUITS (causing objective tinnitus – detected on examination of the neck or base of skull):
- Localised increased blood flow – local tumours (most are benign); non-closure of foetal stapedial artery
- Local turbulent blood flow – atherosclerosis
- Idiopathic intracranial hypertension
- NON-SYNCHRONOUS PULSATILE TINNITUS (ie not in time to the heart beat) can be caused by palatal or middle ear myoclonus. Direct questioning often reveals this to be a physical sensation rather than just a noise. These patients should be referred for ENT review on a routine basis providing there are no other concerning features.
Who to refer:
- Those with persistent pulsatile tinnitus, noting that it often settles. If there are no red flags, it is reasonable to exclude other causes first (see above) and wait to see if the tinnitus settles, before deciding if referral is indicated. The Lothian ENT specialist view is that if this is not associated with any other ENT or neurological red flags it is reasonable to wait six weeks before referral. This is because pulsatile tinnitus will often disappear once any acute infective or inflammatory conditions have resolved.
- Those with non-synchronous pulsatile tinnitus for which there is no obvious explanation.
Please assess and document the following in referral – this will guide preliminary investigations prior to patient being seen:
- Tinnitus type – tonal / pulsatile, unilateral / bilateral
- Other ear symptoms – pain, discharge, vertigo, hearing loss, previous ear surgery
- Otoscopy findings, free field speech testing, tuning fork tests (if hearing loss)
- Auscultation of neck + around ear.
Who not to refer:
- Those with short-lived episodes and no objective confirmation of bruits
- Those with a hyperdynamic cause (see above)
- Those with an obvious cause, and no red flags e.g. those with new onset otitis media with effusion
- Those with a carotid bruit and TIA symptoms should follow the neurology TIA pathway – please see here
- If the tinnitus intrusive and disturbing to the patient, please refer to Audiology for help with tinnitus management.
How to refer:
- Via SCI Gateway to ENT – Ear at Lauriston or St John’s, Livingston.
- For those with no red flags, who need help managing their tinnitus, please refer via SCI Gateway to Audiology at Lauriston or St John’s.
The British Tinnitus Association has useful leaflets on pulsatile tinnitus: Download.ashx (tinnitus.org.uk)
