Journal of Neurology

, Volume 245, Issue 3, pp 137–142 | Cite as

Pulsatile tinnitus —a review of 84 patients

  • Daniel Waldvogel
  • Heinrich P. MattleEmail author
  • Matthias Sturzenegger
  • Gerhard Schroth
Original Communications


Pulsatile tinnitus can be annoying for a patient and can also be the only clue to a potentially devastating and life-threatening disease. In order to understand its clinical spectrum and management better we analysed the files of 84 patients seen at our institution over a 10-year period. Noninvasive techniques (ultrasound, computed tomography, magnetic resonance imaging) and angiography were employed as investigations tailored to the individual patient. A vascular disorder [i.e. arteriovenous fistula, dissection of the internal carotid artery (ICA), fibromuscular dysplasia, aneurysm of the ICA and sinus thrombosis] was found in 36 patients (42%), most commonly a durai arteriovenous fistula or a carotid-cavernous sinus fistula. In 26 patients with a vascular abnormality, pulsatile tinnitus was the presenting symptom. In 12 patients (14%), nonvascular disorders such as glomus tumour or intracranial hypertension with a variety of causes explained the tinnitus. We conclude that patients with pulsatile tinnitus should be investigated with noninvasive techniques. If these are negative or to clarify abnormal findings of noninvasive techniques selective angiography is needed for diagnosis and to guide treatment

Key words

Tinnitus, pulsatile Differential diagnosis Vascular diseases Glomus tumour Angiography 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Adler JR, Ropper AH (1986) Self-audible venous bruits and high jugular bulb. Arch Neurol 43:257–259PubMedGoogle Scholar
  2. 2.
    Arenberg I, McCreary H (1972) Objective tinnitus aurium and durai arteriovenous malformations of the posterior fossa. Ann Otol Rhinol Laryngol 80:111–120Google Scholar
  3. 3.
    Austin JR, Maceri DR (1993) Anterior communicating artery aneurysm presenting as pulsatile tinnitus. ORL J Othorhinolaryngol Relat Spec 55:54–57Google Scholar
  4. 4.
    Bjork H (1954) Objective tinnitus due to clonus of the soft palate. Acta Otolaryngol (Stockh) [Suppl] 116:39–45CrossRefGoogle Scholar
  5. 5.
    Bonafé A, Joomye H, Jaeger P, Fraysse B, Manelfe C (1993) Histiocytosis X of the petrous bone in the adult: MRI. Neuroradiology 36:330–333CrossRefGoogle Scholar
  6. 6.
    Buckwalter J, Sasaki C, Virapongse C, Kier E, Bauman N (1983) Pulsatile tinnitus arising from jugular megabulb deformity: a treatment rationale. Laryngoscope 93:1534–1539PubMedCrossRefGoogle Scholar
  7. 7.
    Cambell J, Simons R (1987) Brachiocephalic artery stenosis presenting with objective tinnitus. J Laryngol Otol 101:718–720Google Scholar
  8. 8.
    Campbell G, Renner G, Estrem SA (1992) Bilateral aberrant internal carotid arteries. Otolaryngol Head Neck Surg 107:124–128PubMedGoogle Scholar
  9. 9.
    Cary F (1961) Symptomatic venous hum. N Engl J Med 264:869–870PubMedGoogle Scholar
  10. 10.
    Chaloupka JC, Kibble MB, Hoffman JC (1992) Ascending pharyngeal artery-internal jugular vein fistula complicating radical neck dissection. Neuroradiology 34:524–525PubMedCrossRefGoogle Scholar
  11. 11.
    Cochran J, Kosmicki P (1979) Tinnitus as a presenting symptom of pernicious anemia. Otol Rhinol Laryngol 88:297Google Scholar
  12. 12.
    Conley J, Hillard V (1969) Aneurysma of the internal carotid artery presenting in the middle ear. Arch Otolaryngol 90:39–43Google Scholar
  13. 13.
    Courteney-Harris RG, Ford GR, Innes AJ, Colin JF (1990) Pulsatile tinnitus: three cases of arteriovenous fistula treated by ligation of the occipital artery. J Laryngol Otol 104:421–422PubMedGoogle Scholar
  14. 14.
    Davies DG (1968) Paget’s disease of the temporal bone. Acta Otolaryngol (Stockh) [Suppl] 65:1–47Google Scholar
  15. 15.
    Dietz RR, Davis WL, Harnsberger HR, Jacobs JM, Blatter DD (1994) MR imaging and MR angiography in the evaluation of pulsatile tinnitus. AJNR Am J Neuroradiol 15:879–889PubMedGoogle Scholar
  16. 16.
    Donald JJ, Raphael MJ (1991) Pulsatile tinnitus relieved by angioplasty. Clin Radiol 43:132–134PubMedCrossRefGoogle Scholar
  17. 17.
    Dufour JJ, Lavigne F, Plante R, Caouette H (1985) Pulsatile tinnitus and fibromuscular dysplasia of the internal carotid artery. J Otolaryngol 14:293–295PubMedGoogle Scholar
  18. 18.
    Fernandez A (1983) Objective tinnitus: a case report. Am J Laryngol 4:312–314Google Scholar
  19. 19.
    Forte V, Turner A, Liu P (1989) Objective tinnitus associated with abnormal emissary veins. Otolaryngology 18:232–235Google Scholar
  20. 20.
    Glasscock M, Dickins J, Jackson C, Wiet R (1980) Vascular anomalies of the middle ear. Laryngoscope 90:77–88PubMedCrossRefGoogle Scholar
  21. 21.
    Hasso AN (1994) Imaging of pulsatile tinnitus: basic examination versus comprehensive examination package. AJNR Am J Neuroradiol 15:879–889Google Scholar
  22. 22.
    Herrmann C, Crandall P, Fang H (1957) Palatal myoclonus: a new approach to the understanding of its production. Neurology 7:37–51PubMedGoogle Scholar
  23. 23.
    Houser O, Campbell R, Sundt T (1979) Arteriovenous malformation affecting the transverse durai venous sinus —an aquired lesion. Mayo Clin Proc 54:651–661PubMedGoogle Scholar
  24. 24.
    Jungreis CA (1991) Pulsatile tinnitus from a durai arteriovenous fistula. Ann Otol Rhinol Laryngol 100:951–953PubMedGoogle Scholar
  25. 25.
    Lamberg P, Cantrell R (1986) Objective tinnitus in association with abnormal posterior condylar emissary vein. Am J Otolaryngol 7:204–207Google Scholar
  26. 26.
    Lenarz T, Plinkert PK (1992) Glomus tumors of the temporal bone: staging, surgical approach and results. Laryngorhinootologie 71:149–157PubMedCrossRefGoogle Scholar
  27. 27.
    Lesinski S, Chambers A, Komray R, Reiser M, Khodadad G (1979) Why not the eighth nerve? Neurovascular compression —probable cause for pulsatile tinnitus. Otolarnygol Head Neck Surg 87:89–94Google Scholar
  28. 28.
    Leveque H, Bialostozky F, Blanchard C, Suter C (1979) Tympanometry in the evaluation of vascular lesions of the middle ear and tinnitus of vascular origin. Laryngoscope 89:1197–1218PubMedCrossRefGoogle Scholar
  29. 29.
    Lewis J, Stephens D, Huws D (1992) Suicide in tinnitus sufferers. J Audiol Med 1:30–37Google Scholar
  30. 30.
    Louwrens HD, Botha J, Van-der-Merwe DM (1989) Subjective pulsatile tinnitus cured by carotid endarterectomy. A case report. S Afr Med J 75:496–497Google Scholar
  31. 31.
    Marcelis J, Silberstein SD (1991) Idiopathic intracranial hypertension without papilledema. Arch Neurol 48:392–399PubMedGoogle Scholar
  32. 32.
    Meador K, Swift T (1984) Tinnitus from intracranial hypertension. Neurology 34:1258–1261PubMedGoogle Scholar
  33. 33.
    Mokri B, Sundt TJ, Houser O, Piepgras D (1986) Spontaneous dissection of the cervical internal carotid artery. Ann Neurol 19:126–138PubMedCrossRefGoogle Scholar
  34. 34.
    Morrison G (1989) Pulsatile tinnitus and durai arteriovenous malformation. J Laryngol Otol 103:1073–1075PubMedGoogle Scholar
  35. 35.
    Nishikawa M, Handa H, Hirai O, Munaka M, Watanabe S, Yamakawa H, Kinoshita Y (1989) Intolerable pulsesynchronous tinnitus caused by occlusion of the contralateral common carotid artery. A successful treatment by aortocarotid bypass surgery. Acta Neurochir (Wien) 101:1–2CrossRefGoogle Scholar
  36. 36.
    O’Leary MJ, Shelton C, Giddings NA, Kwartler J, Brackmann DE (1991) Glomus tympanicum tumors: a clinical perspective. Laryngoscope 101:1038–1043PubMedGoogle Scholar
  37. 37.
    Ohashi N, Yasumura S, Nakagawa H, Mizukoshi K, Kuze S (1992) Vascular cross-compression of the VIIth and VIIIth cranial nerves. J Laryngol Otol 106:436–439PubMedCrossRefGoogle Scholar
  38. 38.
    Ott D, Bien S, Krasznai L (1993) Embolization of a tentorial durai arterio-venous fistula presenting as atypical trigeminal neuralgia. Headache 33:503–508PubMedCrossRefGoogle Scholar
  39. 39.
    Presutti L, Laudadio P (1991) Jugular bulb diverticula. ORL J Othorhinolaryngol Relat Spec 53:57–60Google Scholar
  40. 40.
    Pulec J (1967) Abnormally patent eustachian tubes: treatment with injection of polytetrafluoroethylene (Teflon) paste. Laryngoscope 77:1543–1554PubMedCrossRefGoogle Scholar
  41. 41.
    Remley KB, Coit WE, Harnsberger HR, Smoker WRK, Jacobs JM, McIff EB (1990) Pulsatile tinnitus and the vascular tympanic membrane: CT, MR, and angiographic findings. Radiology 174:383–389PubMedGoogle Scholar
  42. 42.
    Russell E, Huckman M, Rosenberg M (1983) Sudden onset of headache, proptosis and roaring tinnitus in a hypertensive 60 year old woman. JAMA 249:3223–3224PubMedCrossRefGoogle Scholar
  43. 43.
    Sila CA, Furlan AJ, Little JR (1987) Pulsatile tinnitus. Stroke 18:252–256PubMedGoogle Scholar
  44. 44.
    Sismanis A, Smoker WRK (1994) Pulsatile tinnitus: recent advances in diagnosis. Laryngoscope 104:681–688PubMedGoogle Scholar
  45. 45.
    Sismanis A, Hughes G, Abedi E, et al (1985) Otologic symptoms and findings of the pseudotumor cerebri syndrome: a preliminary report. Otolaryngol Head Neck Surg 93:398–402PubMedGoogle Scholar
  46. 46.
    Sismanis A, Butts FM, Hughes GB (1990) Objective tinnitus in benign intracranial hypertension: an update. Laryngoscope 100:33–36PubMedGoogle Scholar
  47. 47.
    Sismanis A, Callari RH, Slomka WS, Butts FM (1990) Auditory-evoked responses in benign intracranial hypertension syndrome. Laryngoscope 100:1152–1155PubMedGoogle Scholar
  48. 48.
    Spector G, Ciralsky R, Ogura J (1975) Glomus tumors in the head and neck. III. Analysis of clinical manifestations. Ann Otol Rhinol Larnygnol 84:72–79Google Scholar
  49. 49.
    Steffen TN (1968) Vascular anomalies of the middle ear. Laryngoscope 78:171–197PubMedCrossRefGoogle Scholar
  50. 50.
    Sturzenegger M (1995) Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol 242:231–238PubMedCrossRefGoogle Scholar
  51. 51.
    Taber J (1965) Cavernous hemangioma of the middle ear and mastoid. Laryngoscope 75:673–677Google Scholar
  52. 52.
    Thie A, Spitzer K, Lachenmayer L, Kunze K, et al (1988) Prolonged vasospasm in migraine detected by noninvasive transcranial Doppler ultrasound. Headache 28:183–186PubMedCrossRefGoogle Scholar
  53. 53.
    Thie A, Goossens-Merkt H, Freitag J, Spitzer K, Zeumer H, Kunze K (1993) Pulsatile tinnitus: clinical and angiological evaluation. Cerebrovasc Dis 3:160–167CrossRefGoogle Scholar
  54. 54.
    Vogel J, Juergens M, Balzer J, Mack M, Bergman C, Grevers G, Lissner J, Felix R (1994) Glomus tumors of the skull base: combined use of MR angiography and spin-echo imaging. Radiology 192:103–110Google Scholar
  55. 55.
    Ward P, Babin R, Calcaterra T, Konrad H (1975) Operative treatment of surgical lesions with objective tinnitus. Ann Otol Rhinol Laryngol 84:473–482PubMedGoogle Scholar
  56. 56.
    Wells R, Smith R (1982) Fibromuscular dysplasia of the internal carotid artery: a long follow-up. Neurosurgery 10:39–43PubMedCrossRefGoogle Scholar
  57. 57.
    Willinsky RA (1992) Tinnitus: imaging algorithms. J Can Assoc Radiol 43:93–99Google Scholar
  58. 58.
    Yardley M, Knight L (1992) Extra cranial arteriovenous malformations presenting as pulsatile tinnitus. Br J Clin Pract 46:71–72PubMedGoogle Scholar

Copyright information

© Springer-Verlag 1998

Authors and Affiliations

  • Daniel Waldvogel
    • 1
  • Heinrich P. Mattle
    • 1
    Email author
  • Matthias Sturzenegger
    • 1
  • Gerhard Schroth
    • 2
  1. 1.Department of NeurologyInselspitalBernSwitzerland
  2. 2.Department of NeuroradiologyUniversity of Bern, InselspitalBernSwitzerland

Personalised recommendations