FLEX January 2024

Clinical Review & Education

JAMA Otolaryngology–Head & Neck Surgery | Review

Diagnostic Approach to Pulsatile Tinnitus A Narrative Review

Kazim H. Narsinh, MD; Ferdinand Hui, MD; David Saloner, PhD; Adelyn Tu-Chan, MD; Jeffrey Sharon, MD; Andreas M. Rauschecker, MD, PhD; Fatima Safoora, MBBS; Vinil Shah, MD; Karl Meisel, MD; Matthew R. Amans, MD

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IMPORTANCE Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke. Careful diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy. OBSERVATIONS An underlying cause of pulsatile tinnitus can be identified in more than 70% of patients with a thorough evaluation. We advocate categorizing the myriad causes of pulsatile tinnitus into structural, metabolic, and vascular groups. Structural causes of pulsatile tinnitus include neoplasms and temporal bone pathologic abnormalities. Metabolic causes of pulsatile tinnitus include ototoxic medications and systemic causes of high cardiac output. Vascular causes of pulsatile tinnitus include idiopathic intracranial hypertension and dural arteriovenous fistulas. This categorization facilitates a practical evaluation, referral, and treatment pattern. CONCLUSIONS AND RELEVANCE Categorizing the underlying cause of pulsatile tinnitus ensures that dangerous causes of pulsatile tinnitus are not missed, and that patients receive the appropriate care from the proper specialist when needed.

Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: KazimH. Narsinh, MD (kazim.narsinh@ucsf. edu), and Matthew R. Amans, MD (matthew.amans@ucsf.edu), Department of Radiology & Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, L-349, San Francisco, CA94143.

P ulsatile tinnitus (PT) is a symptom referring to an abnormal perception of rhythmic sound without an extracorporeal source, affecting between 3 and 5 million Americans. 1-4 Pul satile tinnitus can have a negative effect on patients’ psychological and physical health, leading to insomnia, anxiety, depression, and poor concentration. 5 Seeking an underlying cause of PT is essential because many of them pose a significant risk of stroke, blindness, or deafness. Hence, some of the causes of PT warrant treatment to mitigate risk to cerebrovascular, otologic, or ophthalmologic health, whereas other causes may be treated to address the symptom it self and its psychiatric comorbidities. This review describes our di agnostic approach to PT. Rather than providing a detailed list of pos sible diagnoses, our goal is to provide an approach for physicians to evaluate patients with PT. Observations Our diagnostic approach categorizes causes of PT into structural, metabolic, and vascular groups ( Table ). This categorization facili tates appropriate and practical diagnostic evaluation, referral, and treatment in a patient-centric fashion rather than focusing on ana tomic compartments alone. Pathophysiology Pulsatile tinnitus often originates from vascular structures in the head or neck in proximity to the cochlea. 6 Alternatively, normal JAMA Otolaryngol Head Neck Surg . 2022;148(5):476-483. doi:10.1001/jamaoto.2021.4470 Published online February 24, 2022.

sounds within the body can be perceived more intensely because of inner ear alterations to sound conduction, or loss of masking ability. Clinical Presentation Unlike nonpulsatile tinnitus, an underlying cause of PT can be identified in more than 70% of patients with a thorough evaluation. 7 Careful attention to a patient’s medical history and examination can often lead to a correct diagnosis. The initial clini cal counter should record the PT’s onset, progression, severity, and exacerbating or mitigating positions, movements, or other factors. The history should also include any associated symptoms, particularly hearing loss, headache (also including any positional component), vision changes, vertigo, anxiety, or depression, and, crucially, assess the effect on the patient’s life. For example, in patients with a history of recent neck manipulation, arterial dis section should be suspected and one should have a low threshold to initiate low-dose aspirin for stroke prevention, even if the diag nosis is not yet confirmed. The PT itself should be further charac terized by synchronicity with the patient’s heartbeat and pitch. Pulse-synchronous PT is often related to abnormal vascular flow in structures near the cochlea. 6 Specifically, abnormal blood flow in the transverse sinus, sigmoid sinus, internal jugular vein, or condylar veins can stimulate the inner hair cells of the cochlea and result in PT. However, pulse-asynchronous PT (without concomi tant atrial fibrillation) is usually associated with a mechanical rather than a vascular cause. Specifically, normal sounds within

476 JAMA Otolaryngology–Head & Neck Surgery May 2022 Volume 148, Number 5 (Reprinted)

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