Pulsatile tinnitus is the perception of a rhythmic sound in the ear that precisely matches one’s heartbeat. This throbbing, whooshing, or humming noise often leads to immediate concern about its cause. While the symptom can be a harmless, temporary occurrence, it may also signal a condition requiring prompt medical evaluation. Determining when this internal pulsing is benign and when it signals a serious underlying health issue is important for appropriate care.
Understanding Pulsatile Tinnitus
Pulsatile tinnitus is characterized by its synchronization with the cardiac cycle, meaning the sound rises and falls exactly with the pulse. The sensation is often described as a steady whoosh, throb, or pump, differentiating it from the continuous ringing or buzzing of non-pulsatile tinnitus. This rhythmicity points toward a vascular or circulatory origin for the sound.
The sound involves the movement of blood through arteries and veins located near the auditory structures of the inner and middle ear. Normally, blood flow is smooth and quiet (laminar flow). If the flow rate increases significantly or if a blood vessel becomes narrowed or irregular, the flow becomes turbulent, creating audible vibrations. Because these sounds originate from a physical source, pulsatile tinnitus is often classified as “objective,” meaning a physician can sometimes hear the sound using a stethoscope placed near the ear or neck.
Temporary and Benign Causes
Many instances of pulsatile tinnitus are linked to temporary changes in the body’s circulatory system that do not represent a lasting health threat. These benign causes typically involve a generalized increase in blood flow, making the normal sounds of circulation louder. Strenuous exercise, high levels of stress, or a sudden spike in blood pressure can temporarily increase the speed and force of blood movement, making the whooshing audible.
Certain systemic health conditions can also create a hyperdynamic circulatory state, resulting in a similar temporary pulsing sound. Anemia, particularly iron-deficiency anemia, causes the heart to work harder to compensate for reduced oxygen capacity, increasing blood flow perceived near the ear. Similarly, hyperthyroidism accelerates the body’s metabolism and heart rate, leading to a faster, noisier flow of blood. These systemic issues are treatable, and the tinnitus typically resolves once the underlying condition is managed.
Another category of temporary causes involves the amplification of normal body sounds due to conductive hearing loss. Conditions like ear wax buildup, fluid accumulation in the middle ear (otitis media), or a perforated eardrum block external environmental sounds. This acoustic dampening removes the masking effect of outside noise, allowing the individual to perceive the quiet sounds of their own internal circulation. Furthermore, some medications, notably high-dose NSAIDs and aspirin, can be ototoxic, causing temporary inner ear disturbances that resolve upon discontinuing the drug.
Indicators of a Serious Underlying Issue
While many causes are benign, pulsatile tinnitus can signal a serious condition, especially when persistent or accompanied by other neurological symptoms. Serious causes involve structural or functional issues within the vascular system near the head and neck. Atherosclerosis, the hardening and narrowing of arteries due to plaque buildup, can cause turbulent blood flow in the carotid artery, generating a loud, rhythmic sound that requires urgent evaluation.
Other serious vascular abnormalities include arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs), which are abnormal connections between arteries and veins. These direct shunts bypass the normal capillary network, causing high-pressure blood to rush into low-pressure veins, creating an intense, turbulent sound. Vascular tumors, such as glomus tumors, are also a concern because these highly vascular growths can press on or grow within the middle ear and nearby blood vessels, leading to an amplified, pulsating noise.
Pulsatile tinnitus can also signal elevated pressure within the skull, a condition known as Idiopathic Intracranial Hypertension (IIH). In IIH, excess cerebrospinal fluid (CSF) or impaired CSF drainage causes pressure to build up around the brain and its venous sinuses, frequently leading to pulsatile tinnitus. The presence of accompanying red-flag symptoms increases the need for immediate medical attention. These symptoms include:
- Severe or worsening headaches.
- Changes in vision, such as temporary loss of sight or double vision.
- Dizziness.
- Any newly developed hearing loss.
Medical Evaluation and Treatment Options
A medical evaluation begins with a detailed history and a physical examination, including an otoscopic check and auscultation. During auscultation, the physician uses a stethoscope to listen over the ear, neck, and skull for the objective sound, or “bruit,” to pinpoint the sound’s location. A simple jugular vein compression test, where symptoms temporarily resolve when light pressure is applied to the jugular vein, often indicates a venous cause, such as those related to IIH.
Imaging Modalities
Imaging studies are often the next step to visualize the complex vascular and bony structures of the head. Different modalities are used depending on the suspected cause:
- High-Resolution Computed Tomography (HRCT) of the temporal bone identifies issues with bony structures, such as a high-riding jugular bulb, sigmoid sinus diverticula, or glomus tumors.
- Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) screen for vascular malformations, aneurysms, and venous sinus stenosis, often associated with IIH.
- For complex vascular cases, Digital Subtraction Angiography (DSA) is the gold standard, providing a dynamic, high-resolution view of blood flow.
Treatment is entirely dependent on the underlying diagnosis. For benign causes like anemia or hypertension, managing the systemic condition with medication or lifestyle adjustments, such as weight loss for IIH, often resolves the pulsing sound. For structural causes, endovascular procedures are a common, minimally invasive option. These procedures involve placing a stent to widen a narrowed vein or artery (e.g., in venous sinus or carotid stenosis) or performing embolization to block the abnormal blood supply to AVMs or glomus tumors using injected coils or glue.