Objective tinnitus is when the sound can be heard by someone other than the person who is suffering from tinnitus. This sound is generally a pulsatile or whooshing tinnitus. The large blood vessels that carry the blood to and from the brain (the internal carotid artery and the jugular vein) both travel within millimeters of the inner ear or the space behind the ear drum. In addition, other large blood vessels (termed venous sinuses) travel around the ear. Any change in the flow of blood in these vessels, any abnormal blood vessel, or a tumor that has lots of blood vessels in it around the ear can cause the sensation of a pulsatile tinnitus. The patients will generally complain of a pulsing in the ear or the sensation of hearing one’s synchronous heart beat in their ear.

 

The possible causes of pulsatile (whooshing) tinnitus include,

 

You should be asked about signs of high pressure in your head including headaches, double vision, or change in vision due to high pressure in the brain. Finally, the doctor should ask you about pregnancy, or any new life stressors.

 

Your doctor should examine your ears (best done with a microscope) to look for a tumor behind your ear drum, they should listen over your neck and behind your ear on the mastoids. They should also gently press your jugular vein to see if the symptoms improve.  Finally, your doctor should examine the back of your eye for signs of pressure. This is best done by a neuro-ophthalmologist.

 

An MRI and MRA of the brain and internal auditory canals (ears) with gadolinium (contrast) will help to rule out a majority of the abnormalities listed above. In addition, a blood test for thyroid and blood (hemoglobin) test will rule out low thyroid hormone levels or low blood levels.  A pregnancy test may be obtained. If a high brain pressure (benign intracranial hypertension) is suspected, a neuro-ophthalmology consultation and possible lumbar puncture (spinal tap) may be performed after imaging of the brain to rule out a mass. A CT scan of the temporal bones to rule out a tumor of the ear (glomus tympanicum), sigmoid sinus diverticulum, and superior canal dehiscence. A hearing test needs to be obtained to make sure no conductive hearing loss (e.g., fluid behind the ear drum, otosclerosis) is present.

 

The treatment of pulsatile tinnitus depends on what the cause of the whooshing tinnitus is. Generally, this is done best by an ear nose and throat (ideally an ear subspecialist (otologist/neuro-otologist)).  

 

Someone suspected of benign intracranial hypertension should be referred to a neuro-ophthalmologist. Dural AV fistulas should be referred to neurointerventional radiology specialists for interventional treatment.

 

Superior canal dehiscence and sigmoid sinus diverticulum can be treated with surgery.

 

 

 

 

 

 

 

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