Overview

Pulsatile tinnitus is a specific type of tinnitus where you hear a rhythmic sound in your ears or head. This sound often feels like a thumping, whooshing, or throbbing, and it usually keeps time with your own heartbeat. It's like being aware of your pulse inside your ear.

Unlike other forms of tinnitus, which might be a constant ringing or hissing, pulsatile tinnitus is often linked to issues with blood circulation. This means that sometimes, a specific cause can be found and treated, which can lead to the sound improving or even disappearing. While it can be a worrying symptom, it's important to know that medical professionals can sometimes hear this sound too, using a stethoscope, which is why it's sometimes called "objective" tinnitus.

The sounds can be very noticeable, especially when your surroundings are quiet, such as at night. This can make it difficult to concentrate, relax, or get a good night's sleep. If you suddenly develop pulsatile tinnitus, it's always a good idea to seek medical advice promptly.

Symptoms and Causes

Understanding why pulsatile tinnitus happens and how it feels can help you and your doctor work together to find the best way forward.

Symptoms

The main symptom of pulsatile tinnitus is hearing a rhythmic sound that matches your heartbeat. This sound can be described in various ways:

• Thumping: A strong, regular beat.
• Whooshing: A soft, rushing sound, like wind or water.
• Throbbing: A pulsating sensation or sound.

You might notice these sounds in one ear (unilateral) or both ears (bilateral). Sometimes, people describe a more unusual "machine gun-like" noise, which can be caused by tiny muscle spasms in the middle ear or the Eustachian tube (the small tube connecting your middle ear to the back of your nose).

These sounds tend to become much more noticeable when your environment is quiet, making them particularly bothersome at night when you're trying to sleep. This can significantly affect your ability to concentrate during the day and can disrupt your sleep patterns. Stress or being in very loud environments can sometimes make the perception of the tinnitus even stronger.

Occasionally, the sound might not be in time with your heartbeat; this is called non-synchronous pulsatile tinnitus. It might feel more like a physical sensation and can be caused by muscle spasms in the palate (the roof of your mouth) or the middle ear.

Causes

Pulsatile tinnitus often has a specific underlying reason, which is why it's so important to investigate. The causes generally fall into a few categories:

• Changes in Blood Flow:
• • Increased Blood Flow (Hyperdynamic Circulation): When blood flows more quickly or strongly through your body, you might become more aware of it. This can happen during strenuous exercise, pregnancy, if you have severe anaemia (low red blood cell count), or an overactive thyroid gland (hyperthyroidism). Sometimes, it's simply a heightened awareness of your normal blood flow within your head.
  • Turbulent Blood Flow: If blood vessels near your ear are narrowed or have an irregular shape, blood can flow through them less smoothly, creating a turbulent sound. Conditions like atherosclerosis (hardening and narrowing of the arteries) or idiopathic intracranial hypertension (increased pressure around the brain) can cause this.
  • Blood Vessel Disorders: Problems with the blood vessels themselves, such as carotid stenosis (narrowing of the main artery in your neck), aneurysms (bulges in blood vessel walls), or arteriovenous malformations (abnormal connections between arteries and veins), can lead to pulsatile tinnitus. Rarely, a persistent open foetal stapedial artery (a blood vessel that usually closes before birth) can cause a localised increase in blood flow.
• Conductive Hearing Loss: If you have hearing loss that affects how sound travels through your outer or middle ear (conductive hearing loss), external sounds are muffled. This can make you more aware of internal body sounds, including your pulse, because there's less background noise to mask it. Conditions like middle ear infections with fluid (otitis media with effusion) can cause this.
• Muscle Spasms: As mentioned, tiny, involuntary spasms of muscles in your middle ear or around the Eustachian tube can create clicking or "machine gun-like" sounds that are not always in time with your heartbeat. This is known as myoclonus.
• Benign Growths or Tumours: Very occasionally, benign (non-cancerous) growths or tumours in the head or neck area, such as a glomus tumour (a rare, slow-growing tumour often found near the ear), can have their own blood supply, leading to increased or turbulent blood flow that you hear.

Diagnosis and Investigations

When you experience pulsatile tinnitus, your doctor will take a careful approach to understand the cause. The process usually involves a detailed discussion about your symptoms and a thorough physical examination, followed by specific tests.

Diagnosis

Your journey to diagnosis will begin with a detailed conversation with your doctor. They will ask you about:

• Your Symptoms: When did the pulsatile tinnitus start? Is it in one ear or both? What does the sound feel like (thumping, whooshing, throbbing)? Is it constant or does it come and go? Does it match your heartbeat?
• Your Medical History: Any other health conditions you have, medications you take, and your general lifestyle.

Following this discussion, your doctor will perform a physical examination, which is crucial for identifying potential causes:

• Ear Examination: They will look closely into your ears to check your eardrums (tympanic membranes) for any signs of conductive hearing loss (problems with sound travelling through the ear) or any visible vascular lesions (abnormal blood vessels).
• Neck Examination: Your doctor will feel and listen to your neck for any signs of vascular tumours (growths related to blood vessels) or malformations. They might use a stethoscope to listen for any objective sounds (bruits) in your neck or over your skull, which can sometimes be heard by the clinician.
• Cardiovascular Examination: A thorough check of your heart and blood circulation will be performed, as bilateral (both-sided) pulsatile tinnitus is often linked to cardiovascular health.

If your doctor finds any abnormalities during this examination, or if your symptoms are persistent and concerning, they will consider further investigations.

Investigations

Because pulsatile tinnitus can be a sign of an underlying condition, imaging tests are often recommended to look for serious causes. The type of imaging will depend on your specific symptoms and what your doctor suspects:

• Magnetic Resonance Angiogram (MRA) or MRI Scan:
• • If your pulsatile tinnitus is synchronous (in time with your heartbeat) and your initial clinical and hearing assessments are normal, your doctor might suggest an MRA or MRI scan. These scans provide detailed images of your head, neck, temporal bone (the bone around your ear), and the internal auditory meatus (IAM – the canal that carries nerves from your inner ear to your brain). An MRA specifically looks at blood vessels.
• Contrast-Enhanced CT Scan:
• • If you cannot have an MRI (for example, if you have certain metal implants), a contrast-enhanced CT scan of the same areas (head, neck, temporal bone, and IAM) can be used as an alternative. Contrast dye helps highlight blood vessels and other structures.
  • If your doctor suspects a problem with the bone or middle ear, such as a glomus tumour, a contrast-enhanced CT scan of the temporal bone is often the first choice. This might be followed by an MRI to get more detail about the soft tissues.
• For Non-Synchronous Pulsatile Tinnitus:
• • If your pulsatile tinnitus is not in time with your heartbeat (e.g., due to muscle spasms like palatal myoclonus), an MRI of the head or a contrast-enhanced CT scan might be suggested to investigate the cause.
• Hearing Tests: While general hearing tests may not directly change the treatment for pulsatile tinnitus, they can identify any co-existing hearing loss. Addressing hearing loss, for example with hearing aids, can sometimes help manage the tinnitus by amplifying external sounds and making the internal sounds less noticeable.
• Blood Tests: These are less commonly used but might be considered if your doctor suspects a hyperdynamic cause, such as anaemia or an overactive thyroid.
• Ultrasound Scans: Sometimes, ultrasound scans are used to examine blood vessels in the neck.

In some urgent situations, such as sudden hearing loss (within 30 days), new neurological symptoms, severe uncontrolled dizziness, or if a stroke is suspected, you would be referred for immediate assessment (within 24 hours). If you are experiencing significant distress or rapidly worsening hearing loss, a referral within two weeks might be advised.

Management and Treatment

The most effective way to manage pulsatile tinnitus is often to treat the underlying cause, if one can be identified. Your treatment plan will be tailored to your specific diagnosis.

• Treating the Underlying Condition:
• • If your pulsatile tinnitus is caused by a blood vessel issue like carotid stenosis or an aneurysm, specific medical treatments or surgical procedures may be recommended to address these conditions.
  • For conditions like severe anaemia or an overactive thyroid, treating these medical issues will often lead to a significant improvement or resolution of the pulsatile tinnitus.
  • If conductive hearing loss is contributing to your symptoms, addressing this (e.g., treating a middle ear infection or using hearing aids) can help.
  • In rare cases where a benign tumour is the cause, specific drug treatments or surgical removal might be an option, which can sometimes offer a cure.
• Coping Strategies (When No Specific Cause is Found or for Symptom Relief):
  Even if a specific cause isn't found, or while you're awaiting treatment, there are many strategies to help you cope with the symptoms and reduce their impact on your daily life:
• • Sound Therapy: This involves using external sounds to distract your brain from the tinnitus. This could be background music, nature sounds, or specialised noise generators (which look a bit like hearing aids). For those with co-existing hearing loss, hearing aids can be very beneficial as they amplify ambient sounds, providing a distraction from the tinnitus.
  • Relaxation Techniques and Meditation: Tinnitus can often be made worse by stress. Learning relaxation exercises, deep breathing, and meditation can help reduce stress levels and make the tinnitus less intrusive.
  • Mindfulness: Mindfulness practices teach you to observe your thoughts and sensations, including tinnitus, without judgment. This can help reduce the emotional reaction to the sound.
  • Cognitive Behavioural Therapy (CBT): CBT is a type of talking therapy that helps you change how you think about and react to your tinnitus. It can be very effective in reducing the distress and anxiety associated with the condition.
  • Tinnitus Retraining Therapy (TRT): TRT combines sound therapy with counselling to help your brain learn to ignore the tinnitus sound, making it less noticeable over time.
  • Addressing Hearing Loss: If you have any degree of hearing loss alongside your pulsatile tinnitus, correcting this with hearing aids can often help mask the internal sounds and improve your overall hearing.

It's important to remember that while tinnitus can be frustrating, many people learn to manage it effectively, and for pulsatile tinnitus, finding and treating the cause often leads to significant improvement.

Prevention

Preventing pulsatile tinnitus often involves addressing the underlying health conditions that can cause it. While not all causes are preventable, there are steps you can take to reduce your risk or manage factors that might contribute to it:

• Maintain Cardiovascular Health: Many causes of pulsatile tinnitus are related to blood flow. Eating a balanced diet, exercising regularly, maintaining a healthy weight, and avoiding smoking can help prevent conditions like atherosclerosis (hardening of the arteries) and high blood pressure, which can affect blood vessel health.
• Manage Existing Health Conditions: If you have conditions like high blood pressure, high cholesterol, diabetes, anaemia, or thyroid disorders, working closely with your doctor to manage them effectively can reduce the risk of complications, including pulsatile tinnitus.
• Protect Your Hearing: While pulsatile tinnitus is distinct from general tinnitus, conductive hearing loss can make you more aware of internal body sounds. Protecting your ears from loud noise and seeking prompt treatment for ear infections can help maintain good ear health.
• Reduce Stress: Stress can often make the perception of tinnitus worse. Practising stress-reduction techniques like mindfulness, meditation, or regular exercise can help manage your overall well-being and potentially lessen the impact of tinnitus.
• Avoid Excessive Noise Exposure: Although pulsatile tinnitus is often internal, loud noise exposure can sometimes exacerbate the perception of any tinnitus. Protecting your ears in noisy environments is generally good practice.

By taking care of your general health and addressing any underlying medical conditions, you can help minimise your risk of developing pulsatile tinnitus or reduce its impact if it occurs.

Outlook / Prognosis

The outlook for pulsatile tinnitus is often quite positive, especially compared to other forms of tinnitus. This is because a specific underlying cause is more frequently identified, and treating that cause can often lead to a significant improvement or even a complete resolution of the symptoms.

For many people, particularly those with brief episodes or where the cause is related to temporary factors like exercise or pregnancy, the pulsatile tinnitus may resolve on its own or with simple reassurance. If your doctor finds no serious "red flags" during your initial assessment, a period of observation (around six weeks) is often reasonable, as symptoms can frequently settle down during this time.

If an underlying condition such as anaemia, an overactive thyroid, or a blood vessel issue is identified and successfully treated, you can expect the pulsatile tinnitus to lessen or disappear. In some cases, specific drug treatments or surgical interventions can offer a cure or significant improvement for a small group of patients.

However, if a specific cause cannot be found, or if the underlying condition cannot be fully cured, living with pulsatile tinnitus can still be challenging. It can be debilitating, affecting your ability to concentrate, relax, and get restful sleep. In these situations, the focus shifts to managing the symptoms effectively. With strategies like sound therapy, relaxation techniques, mindfulness, Cognitive Behavioural Therapy (CBT), and Tinnitus Retraining Therapy (TRT), many individuals learn to cope with the sound, reducing its impact on their quality of life. Over time, the brain often adapts, and the perception of the tinnitus may diminish, becoming less intrusive.

It's important to remember that while pulsatile tinnitus can be distressing, there are many avenues for investigation and support, and for a significant number of people, a positive outcome is achievable.