Is it truly in sync with the heartbeat? Does it increase in frequency with exercise? Can they count the number of beats per minute? Is it the same as the pulse frequency? Can they stop the sound by neck compression ( venous sinus stenosis)? Is there neck pain ( dissection?). So, what is the approach? Ask to describe the sound. However, a large minority are not and need a prompt workup. How do we approach pulsatile tinnitus? First, it is key to validate the patient’s likely already formed conclusion - that their sound is different from a constant pitch. Whether objective or subjective, pulsatile tinnitus is significant and warrants a thorough evaluation Could still be a dural fistula, venous stenosis, etc. Lack of objective pulsatile tinnitus - subjective pulsatile tinnitus - does not mean anything. Finally, it is entirely possible that your own hearing is not what it used to be… So, when “objective” pulsatile tinnitus is present, that is helpful. Most importantly, just because the sound is not heard does not mean it is not real or significant. “Objective” means that someone other than the patient can hear the sound. However, it is important not to put to much emphasis on “objective” pulsatile tinnitus. Hearing the sound is a near certainty that a cause will be found. It is important to listen with a stethoscope over the ear and mastoid eminence to see if the sound can be heard. Venous sinus stenois is by far the most common, and also most under-recognized, cause of pulsatile tinnitus in general and venous pulsatile tinnitus in particular. If the sound stops, it is almost certainly due to venous sinus stenosis or another venous sinus cause, such as dehiscent jugular plate or diverticulum. The last maneuver of gentle neck pressure, which occludes the ipsilateral jugular vein, is particularly important. Many patients report being able to change the volume or pitch of sound by various maneuvers such as neck repositioning, Valsalva maneuver (holding breath and bearing down), or by gentle pressure on the side of the neck. Bilateral sounds can also have vascular etiology, but it is rare. This is simply because vascular abnormalities which cause PT are usually lateralized. Courtesy of The majority of sounds are unilateral. Here are a few other sample sounds of Pulsatile Tinnitus, recorded by actual patients. Same idea - relative silence corresponds to times of jugular compression Here is the sound on the “bad” side in the same patient. When compression is released, the sound comes back. Periods of relative silence correspond to times when the jugular vein is compressed. This is how loud venous stenosis can get. The sound is so loud on the right that it drowns out this sound on the left. Here is a real-life quite severe PT auscultated with a stethoscope on the OTHER side of the sound (sound on right, stethoscope on left mastoid bone). Of course, most cases of PT have nothing to do with cardiac pathology. The most common is a “whoosh” - it is a low frequency sound which is similar to a “baby sonogram.” Some patients are able to record their sound by placing a sensitive microphone into the ear or onto areas of the head, or find a similar sounding recording among the different sounds of cardiac murmurs (like aortic regurgitation). Various descriptions of the sound are given and in some cases recorded. The challenge is to figure out what is the source of sound. With pulsatile tinnitus, the sound comes from the inside. There is usually nothing wrong with the ear, which is simply doing its job of hearing sounds. It is a sound usually caused by some kind of abnormal, turbulent blood flow near the ear. It is completely different from nonpulsatile tinnitus. What is pulsatile tinnitus? It is a pulse-syncronous sound, more often than not unilateral. Once pulsatile tinnitus is gone, hearing is magically back to baseline. Many who are told they have hearing loss simply cannot hear well because the sound interferes with the hearing test. In contrast, pulsatile tinnitus patients usually have normal hearing. It is completely different from nonpulsatile, constant tinnitus which is usually a high-pitched sound and is often associated with hearing loss. As usual, patients are right - it is almost always a blood flow problem. They believe that some kind of abnormal blood flow has begun and are afraid that something may burst inside. Most patients correctly interpret it as a vascular issue rather than an ear problem. The constant, pulse-synchronous sound can be both alarming and profoundly disturbing. Pulsatile Tinnitus is one of the least understood and most frequently underdiagnosed vascular symptoms. This section is dedicated to the ancient and hallowed institution of Trial by Jury - and the Jury Duty service which yielded time to finally put this together
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