What Is Pulsatile Tinnitus?
Tinnitus is the perception of sound when no corresponding external sound is present. It may be described as ringing, buzzing, whistling, humming, clicking or hissing. Tinnitus is a symptom rather than a disease, and its sound, pitch, loudness and frequency can vary considerably between individuals.
Pulsatile tinnitus is a rhythmic sound that often follows the same beat as your pulse or heartbeat. People may describe it as throbbing, whooshing, beating or rushing in one or both ears. Unlike the more common forms of tinnitus, pulsatile tinnitus may be related to blood flow, blood vessels or another physical sound generated within the body.
Because pulsatile tinnitus can sometimes have an identifiable and treatable medical cause, new or persistent symptoms should be assessed by a doctor. An audiologist can also evaluate your hearing and help identify whether an ear or hearing condition may be contributing.
Seek urgent medical attention if pulsatile tinnitus begins suddenly, follows a head injury, or occurs with sudden hearing loss, severe dizziness, facial weakness, vision changes, difficulty speaking, weakness or other neurological symptoms.
What Causes Pulsatile Tinnitus?
Pulsatile tinnitus has a range of possible causes. In many cases, it is associated with a change in blood flow or an increased awareness of blood moving through vessels near the ear. Other cases may be related to conditions affecting the ear, hearing system, muscles, skull or surrounding structures.
The sound may result from blood moving more quickly than usual, turbulent blood flow, changes in the structure of a blood vessel, or a hearing condition that makes internal body sounds easier to notice. Sometimes no definite cause is found even after appropriate investigation.
Causes of Increased or Turbulent Blood Flow
Changes in blood flow may occur throughout the body or within blood vessels near the head and ears. Faster or less even blood flow may produce a sound that becomes audible to the person experiencing it.
Generalised increases in blood flow may occur during strenuous exercise or pregnancy. They may also be associated with anaemia, an overactive thyroid gland, fever or other conditions that affect circulation. High blood pressure may make pulsatile tinnitus more noticeable in some people, although it is not the only possible cause.
Localised changes may involve arteries, veins or smaller blood vessels near the ear, neck or base of the skull.
| Possible cause | Description |
|---|---|
| Atherosclerosis | A build-up of fatty deposits can narrow or stiffen an artery. This may create turbulent blood flow that can sometimes be heard as a pulsing sound. |
| Blood-vessel abnormalities | Narrowing, unusual positioning or structural changes in arteries or veins near the ear may alter blood flow and cause pulse-synchronous tinnitus. |
| Arteriovenous malformation or fistula | An abnormal connection between an artery and a vein can produce turbulent blood flow. These conditions require medical investigation and specialist management. |
| Benign vascular tumours | Certain uncommon growths in or near the middle ear contain many blood vessels and may cause pulsatile tinnitus. Not every tumour associated with tinnitus is vascular or benign, so imaging may be needed to establish the cause. |
| Head or neck injury | Trauma can occasionally affect blood vessels, the hearing system or surrounding structures. New pulsatile tinnitus following an injury requires prompt medical assessment. |
| Raised pressure around the brain | Conditions involving elevated intracranial pressure can cause pulsatile tinnitus and may also produce headaches or visual symptoms. |
Can Hearing Loss Make Blood Flow More Noticeable?
Conductive hearing loss can make internal body sounds more noticeable. Conductive hearing loss occurs when sound is prevented from travelling efficiently through the outer or middle ear.
Conditions such as impacted earwax, middle-ear fluid, an eardrum problem or changes in the middle-ear bones may reduce the external sounds that would normally mask sounds generated within the body. This can increase awareness of blood flow, breathing, chewing or other internal sounds.
Treating a reversible conductive hearing problem may reduce pulsatile tinnitus when that condition is responsible. However, hearing loss should not be assumed to be the cause until other medical possibilities have been considered.
How Is Pulsatile Tinnitus Assessed?
An assessment usually begins with a detailed medical history. Your doctor may ask when the sound started, whether it affects one or both ears, whether it matches your heartbeat, and whether you have hearing loss, dizziness, headaches, visual changes, cardiovascular conditions or a history of head and neck injury.
Your ears may be examined with an otoscope to check the ear canal and eardrum. Your doctor may also check your blood pressure and listen around the ear, neck, skull and chest with a stethoscope for a sound known as a bruit.
When a clinician can also detect the sound, it may be described as objective tinnitus. However, an inability to hear it through a stethoscope does not rule out a vascular or other physical cause. The distinction between objective and subjective tinnitus is therefore only one part of the assessment.
Medical Imaging for Pulsatile Tinnitus
Medical imaging is commonly considered for persistent pulsatile tinnitus because it can help identify or rule out blood-vessel abnormalities, tumours and other structural causes. The appropriate test depends on your symptoms, examination findings and the suspected source of the sound.
Testing may include magnetic resonance imaging (MRI), magnetic resonance angiography or venography, computed tomography (CT), CT angiography, ultrasound or catheter angiography. Not every person requires every test, and a doctor or specialist will determine the most suitable investigation.
Hearing Tests for Pulsatile Tinnitus
A hearing assessment can identify whether hearing loss, a middle-ear condition or another audiological factor is present. Testing commonly includes pure-tone audiometry and tympanometry.
During pure-tone audiometry, sounds of different pitches and loudness levels are presented through headphones or earphones. You respond whenever you hear a sound, allowing the audiologist to identify the softest sounds you can detect across a range of frequencies.
Tympanometry measures how the eardrum and middle ear respond to changes in air pressure. A small probe is placed at the entrance of the ear canal, and the results can help identify middle-ear fluid, pressure problems, eardrum abnormalities or other causes of conductive hearing loss.
A hearing assessment is an important part of the investigation, but it does not replace medical evaluation when pulsatile tinnitus may have a vascular or neurological cause.
How Is Pulsatile Tinnitus Treated?
Treatment depends on the underlying cause. When a specific medical or hearing condition is identified, treating that condition may reduce or resolve the pulsatile sound. Results vary, and improvement cannot be guaranteed in every case.
Possible treatment pathways may include:
- Anaemia or thyroid disease: Treatment may involve medicines, supplements or other medical care directed by a doctor.
- High blood pressure or cardiovascular disease: Management may include prescribed medication, monitoring and clinically appropriate lifestyle changes.
- Earwax or middle-ear conditions: Treatment may include professional earwax removal, medication, monitoring, grommets or another procedure, depending on the diagnosis.
- Conductive hearing loss: Management may involve medical treatment, surgery or hearing aids, depending on the cause and whether it can be corrected.
- Blood-vessel abnormalities: Some conditions may require monitoring, medication, an endovascular procedure or surgery under the care of an appropriate specialist.
- Raised intracranial pressure: Treatment focuses on reducing the pressure and managing its underlying cause under medical supervision.
Managing Pulsatile Tinnitus When No Cause Is Found
Sometimes investigations do not identify a treatable physical cause. In these cases, management may focus on reducing how noticeable or distressing the sound is and addressing its effects on sleep, concentration and emotional wellbeing.
- Education and reassurance: Understanding the condition and the results of your investigations may reduce uncertainty and anxiety.
- Sound enrichment: Gentle background sound, a fan, quiet music or a sound generator may reduce the contrast between the pulsing sound and a quiet environment.
- Cognitive behavioural therapy: CBT can help reduce tinnitus-related distress and improve coping, even when the sound itself remains present.
- Counselling: Individualised support can help address anxiety, frustration, sleep disruption and the effect of tinnitus on daily life.
- Relaxation and mindfulness strategies: These approaches may help manage stress and reduce the attention given to tinnitus.
- Hearing aids: When hearing loss is also present, appropriately fitted hearing aids may improve access to external sounds and make tinnitus less prominent for some people.
- Tinnitus-focused rehabilitation: Some clinicians offer structured programmes that combine education, counselling and sound-based strategies.
Some people gradually habituate to tinnitus, meaning the brain begins to treat the sound as unimportant and it becomes less intrusive. Habituation can take time and does not mean that medical assessment should be skipped.
When Should You Seek Help?
Arrange an appointment with your doctor if you experience pulsatile tinnitus, especially when it is new, persistent, affects only one ear or is becoming more noticeable. Your doctor can determine whether medical imaging or specialist referral is appropriate.
Seek urgent medical care when pulsatile tinnitus:
- starts suddenly;
- appears after a head or neck injury;
- occurs with sudden or rapidly worsening hearing loss;
- occurs with severe dizziness, balance problems or fainting;
- is accompanied by severe headache or visual changes; or
- occurs with facial weakness, difficulty speaking, weakness, numbness or another neurological symptom.
An audiologist can assess your hearing and middle-ear function, while your doctor or an ear, nose and throat specialist can investigate possible medical and vascular causes. Coordinated assessment is often the most appropriate approach for pulsatile tinnitus.
