question on pulsating tinnitus

[sakura]

I am wondering what the work up for pulsating tinnitus is? Is MRI with contrast of the head preferred or carotid US? Has anyone seen this diagnosed? Is this something that one should be concerned about? What is the most common cause? Thanks for responding.

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[forbin]

Major possibilities on the differential are arterial stenosis (carotid or intracranial vessel), pseudotumor cerebri (obese, young-middle aged women), glomus tumor, myoclonus of palate/tensor tympani (usually rapid pulsatile tinnitus).

Your history and exam should lead you to one of these as the most likely. It's important to listen for bruits- my chairman likes to take the pts into the audiology testing booth to listen. Need good cranial nerve exam and look at ears under the microscope to eval for glomus tumors. Any tinnitus pt should get an audiogram as well.

If you suspect arterial stenosis, should get dopplers + CTA (or MRA in pts with kidney issues), refer to vascular surgeon if positive imaging. Pseudotumor pts, should get MRA/MRV of brain and refer to neurology. Glomus tumors can be treated surgically or with XRT depending on size and location. For tensor tympani myoclonus, you can divide the muscle surgically. Palatal myoclonus is a little more tricky- many medications have been tried which usually don't work well. Can also try botox or surgical section of tensor veli palatini and levator palatini muscles.

 

[sakura]

I was with an attending when we saw the patient with the above symptoms/conditions. The patient mentioned that the pulsating is like a swishing booming sound. Although rare, it would wake him from sleeping. The pulsations would only be at night, occurring sitting up or lying down. Worse lying down. The pulsations would occur unilaterally. He mentioned that it would last for a month and then resolve for a week, then return. Most recently, the pulsations were gone for about 5 months and then returned. This is when he decided to see the doctor. Total, he has had the pulsations for about 1&1/2 years, coming and going. He denied having headaches, amnesia or hypertension. There was no carotid bruits. The guy seemed to be in good health and about 40 years old. My attending sent him for an MRI with contrast, but I read where a carotid doppler would be useful. It was an interesting case. I have not seen this before and don't know what the appropriate first steps are.

 

[resxn]

Forbin has a good DDx, would add to that venous hum which is very common and also aneurysm.

Just dx'd a guy 3 days ago with 3mm AICA aneurysm whose presenting complaint was pulsatile tinnitus.

My w/u is H&P first. If negative, carotid duplex. If negative MRA/MRV. If negative, try valium or botox on palate. If negative, otologist punt.

 

[drivesmecraazee]

Forbin has a good DDx, would add to that venous hum which is very common and also aneurysm.

Just dx'd a guy 3 days ago with 3mm AICA aneurysm whose presenting complaint was pulsatile tinnitus.

My w/u is H&P first. If negative, carotid duplex. If negative MRA/MRV. If negative, try valium or botox on palate. If negative, otologist punt.

An otologist is an ENT, right? A regular ENT can't handle this?
Seems like an interesting case.

 

[Reck]

here there is some further information. If it doesn't contain any answer I would contact directly the guy D. De Ridder. (his e-mail is on the page)

http://www.oorsuizen.be/index_EN.htm

 

[Pir8DeacDoc]

An otologist is an ENT, right? A regular ENT can't handle this?
Seems like an interesting case.

He's saying he's exhausted his options as a general ENT and at that point the patient would be better suited to see an otologist.

 

[resxn]

It's not that the general ENT can't handle it (although that is sometimes the case, at least for me) but rather I don't want to handle it.

Yes, I'm saying that it's nice to be the specialist, but sometimes with unhappy or undiagnosed patients, it's nice not to be the last word, especially when there isn't much that can be done about something. In my world that's good for difficult to diagnose or treat: dizziness, tinnitus, TMJ, headache syndromes, and cough which all come to mind fairly quickly.

 

[Neuropathia]

Wasn't there another diagnostic means: some special form of tympanometrie? In case of a pulsation there's a change in the middle ear pressure taht can be recorded. Since I can remember only one case that we had I'm not all that sure.

 

[resxn]

Wasn't there another diagnostic means: some special form of tympanometrie? In case of a pulsation there's a change in the middle ear pressure taht can be recorded. Since I can remember only one case that we had I'm not all that sure.

If the pulsatile tinnitus is from a patulous eustachian tube (unusual cause of pulsatile tinnitus) then tympanometry can record the changing pressures. However, sometimes you can even observe the TM shifting position with respirations.

I suppose it may be able to as well with a glomus which is putting intermittent pressure on the TM, but I can't think of really many other situations where tympanometry would show this. Also, even if it did it's not diagnostic and wouldn't preclude further work-up.