Pulsatile Tinnitus has Many Causes

In headache disorders, pulsatile tinnitus can help diagnosis. If present with a new onset severe headache or persistent severe headache, it may indicate idiopathic intracranial hypertension (IIH) - 50% of people with IIH will report this when asked.

Tinnitus is a buzzing, ringing or whistling noise in the ear. It can be objective - that is can be heard by others. It can be subjective - that is only heard by the patient.

In headache disorders, pulsatile tinnitus is worth enquiring about. However, subjective non-pulsatile tinnitus is not a helpful symptom in the assessment of severe headache disorders.

1. Dural Arterio-venous Fistula
These can develop after trauma or venous thrombosis, and new onset may suggest one of these - approximate incidence is one per 500,000 per year. It is probably the commonest cause of new onset pulsatile noises with normal ear examination. These fistula can be attached to any of the venous sinuses - transverse, saggital, sigmoid or cavernous. A fistula is an abnormal connection between an artery and a vein which bypasses the capillary bed.
2. Glomus Tumours, also called paraganglioma or chemodectoma
They can arise from perineural tissue of the ear drum (tympanic membrane - glomus tympanicum), jugular vein (glomus jugulare) or from both structures (glomus tympanicojugulare). An MRI scan will usually detect these lesions, although sometimes high resolution CT scanning will detect them. Requires specialist surgery to treat.
3. Intracerebral Arteriovenous Malformation (an "AVM")
4. Cavernous Angioma of middle ear
5. Abberant Carotid Artery
Sometimes the carotid artery does not develop in the normal place. Instead, blood flows through the middle ear through a huge inferior tympanic artery - this a congenital problem - one you are borm with. In some cases the carotid artery seems to erode through the bone into the middle ear as you get older - so called dehiscent carotid artery. Specialist assessment is required. The major error would be to try and biopsy them which could result in serious haemorrhage - a fatal outcome is possible if you start to bleed internally from a carotid artery.
6. Persistent Stapedial Artery
Another congenital artery which persists. Usually in these cases the middle meningeal artery is absent.
7. Jugular Bulb Dehiscence
The jugular vein can erode into the temporal bone and due to proximity to the middle ear cause pulsatile tinnitus.
8. Carotid Artery Atheroma / atherosclerosis
9. Carotid Dissection
10. Fibromuscular Dysplasia of carotid artery
11. Vascular Loop Compression of vestibulocochlear nerve at root entry zone
This is controversial, but some authros have reported successful treatment following microvascular decompression. I'm sceptical on this one!
12. Venous Hum - hyperdynamic circulation
13. Otosclerosis, (hyperaemia of adjacent structures)
14. Idiopathic Intracranial Hypertension
It is now thought that the pulsatile tinnitus is due to turbulant venous circulation, where high pressure probably causes partial compression of venous channels in the brain leading to turbulence, which causes the pulsatile noise.
15. Palatal myoclonus
I've included this. Although not strictly pulsatile - that is in time with your pulse, it can cause repeated clicks in the ear, which can be heard by bed-partners at night - even while you sleep.