Melanie Cole, MS (HOST): Welcome to UAB MedCast. I'm Melanie Cole and we have a panel for you today to discuss pulsatile tinnitus, diagnostic approach, and treatment strategies. Joining me is Dr. Erica McCarty Walsh. She's a Neurotologist and an Assistant Professor at UAB Medicine and Dr. Jesse Jones. He's an Interventional Neuroradiologist and an Assistant Professor at UAB Medicine.

Doctors, thank you so much for joining us today. And Dr. Walsh, I'd like you to start by speaking about pulsatile tinnitus and how it's different than what we've typically thought about. And can the patient, when they're describing it to you, can they describe this in detail? Speak about it a little bit.

Erika McCarty Walsh, MD, PhD: Absolutely. Thanks so much for having me. So when we think about tinnitus, most often we think of the garden variety of what we consider non-pulsatile tinnitus. So that's the experience of having a ringing, buzzing or a chirping in the ear that's more of a constant tone when present. About 40 million Americans have that in the U.S. So that's very common. Much less common is pulsatile tinnitus. So, that's hearing a noise in the ear that matches a patient's heartbeat. Some patients describe it as a thumping, but many describe it as a whooshing or a low pitched sound. The way a patient can confirm whether or not the sound they're experiencing is pulsatile is by gently touching the side of their neck to feel for their carotid pulse, or gently feeling their wrist to feel for the radial pulse.

The thump that they feel with their fingers should match the noise that they hear. Other important details that we get for patients, or other associated symptoms, including what we call autophony, hearing their voice echo, any hearing loss, any pain or drainage from the ear, and whether any positioning changes their experience. So some patients will say, if they turn their head a certain way, lay down, or perform other maneuvers, their tinnitus gets worse or better.

Host: So interesting and so many people suffer with this. Dr. Walsh, sticking with you for a second, what in the patient's medical history or pre-existing conditions might contribute to this? Are there associated symptoms or comorbid conditions that might be present such as vertigo, benign positional vertigo, headaches, visual disturbances? Do we know what all goes together to cause this or contribute to it?

Erika McCarty Walsh, MD, PhD: One challenging thing with pulsatile tinnitus is there actually are a wide variety of causes, and I'm sure we'll talk more about that a little bit later. As a Neurotologist, I'm often interested in primary otologic or ear related complaints. So I ask patients questions about hearing loss, prior ear surgery, dizziness is definitely a question. I'm often very interested in vertigo or the sensation of motion. Discharge or drainage from the ear. Those are questions that can point me towards otologic causes of pulsatile tinnitus.

Host: And Dr. Jones, why don't you jump in here? How is this diagnosed and worked up? Speak about imaging studies or what should be considered to evaluate any kind of abnormalities.

Jesse Jones, MD: Well, like Dr. Walsh mentioned, tinnitus has a broad range of causes and so it's really important when the patient experiences tinnitus to go and see an expert otologist like Dr. Walsh who can work them up and really kind of drill down through a history and a physical to narrow down what that could be. When patients see me they typically have gone through a process like that already and there's a high suspicion they have a vascular cause of their pulsatile tinnitus.

Host: Why don't you expand on that then, Dr. Jones? What's the next step?

Jesse Jones, MD: So, pulsatile tinnitus or PT, when it does indeed have a vascular cause, where there's a high suspicion that it does, even within the vascular causes, there's many of them, and so what my job is to dig a little deeper and try to sort out of all the possible things from a vascular perspective that may be causing the PT, which of those is it, or none. Typically that's done through a procedure called an angiogram, which is a minimally invasive procedure to take a look at the blood vessels in much more detail.

Erika McCarty Walsh, MD, PhD: So before a patient undergoes a formal angiogram, they usually start out with me, and so, I have a few tasks when I see a new patient with pulsatile tinnitus. One is I really want to confirm that they are having pulsatile tinnitus and sometimes patients haven't really been able to observe their symptoms more carefully and so we have a discussion and some education around that.

The next step is I want to look for non-vascular causes of pulsatile tinnitus. And what that's most commonly going to be is different forms of middle ear disease or inner ear disease. So patients who have a middle ear effusion or fluid behind the eardrum, a conductive hearing loss, they on their own can experience pulsatile tinnitus.

There are some more unusual conditions like superior semicircular canal dehiscence that can lead to pulsatile tinnitus. So my first workup after a physical exam and history is a CT of the temporal bone. It allows me to see the middle ear mechanism and the inner ear really clearly. It also lets me make some judgments about the vessels that are associated with the ear.

So I always say to patients, it's kind of amazing that we don't all hear our pulse in our ear because the carotid artery system and the jugular system both run right through the temporal bone. And so you can have abnormalities of the carotid where it crosses the temporal bone or of the sigmoid sinus or transverse sinus that I can often see some abnormalities of on the CT .

I also oftentimes get a CT angiogram of the head and neck. That lets me look at the carotid system carefully and look for any major evidence of carotid artery disease or other abnormalities or stenosis that would help guide treatment.

Host: Dr. Walsh, why don't you speak about some of the treatments. Start with any non-pharmacologic interventions, whether it's lifestyle changes or any kind of retraining therapy that may alleviate some of the symptoms and then we'll get into medicational and possibly interventional.

Erika McCarty Walsh, MD, PhD: Yeah, that's a great question. So, pulsatile tinnitus is a little bit different than our garden variety non-pulsatile tinnitus in terms of the range of options available. And I think our understanding of pulsatile tinnitus continues to expand. So we have better tech now, we have better imaging, we have better understanding of the vascular dynamics of the central nervous system. And there are things that we think contribute to pulsatile tinnitus now that we didn't understand before, but if they have a primary otologic cause of pulsatile tinnitus, then we can address that. So if they have a conductive hearing loss, I can perform surgery to correct that. If they have superior semicircular canal dehiscence, I can do surgery to correct that.

But sometimes, in conjunction with the patient, we ultimately decide that their symptoms don't warrant an invasive therapy. So, understanding the cause for some patients is adequate. They want to make sure that they don't have a life threatening vascular lesion or something similar. There's not great evidence for medication for the pulsatile tinnitus alone.

The caveat to that would be in patients who we suspect have elevated intracranial pressure or idiopathic intracranial hypertension. And I oftentimes ask my neuro ophthalmology colleagues to evaluate these patients for papilledema to look for that. In which case initiating medication that lower intracranial pressure may be effective for decreasing pulsatile tinnitus.

Host: Dr. Jones, why don't you jump in here for patients with objective pulsatile tinnitus? Is there a need for a surgical intervention such as arterial embolization or vascular surgery? Is that something that's very common?

Jesse Jones, MD: It can be part of the workup. And there are certain situations where there may be a concern, like Dr. Walsh is saying, where there's not otologic cause of the PT, but certainly a patient has a very good history for PT and there are certain diseases out there that we want to exclude, like a dural fistula, for instance, that would be one of the potentially life threatening vascular causes of PT that we want to know about.

And dural fistulas are very difficult to diagnose without a dynamic study like an angiogram. And so that's oftentimes what we're asked to do is to exclude a dural fistula. That being said, dural fistula, even though it's a well known cause of PT, is also a very rare cause, and so for every angiogram we do, I would say, maybe 10 percent actually have a dural fistula, but there are many other causes vascular wise that we can pick up on an angiogram, and so if I don't find a dural fistula, I continue to look on for other causes.

Those things could be, like Dr. Walsh mentioned, if they have idiopathic intracranial hypertension, or IIH; oftentimes their veins will be slightly compressed, and when the vein is compressed, it's almost like if you were to whistle through like a pipe, and if you put some narrowing in it, it'll make a sound, and so that sound is actually heard by the patient through their ear, and that whistling sound in the vein, we can actually diagnose through the angiogram and do some kind of provocative maneuvers like, increasing the flow or decreasing the flow in the vein and asking the patient at that time, do you hear any difference?

And that really helps us kind of narrow down to what the cause of the tinnitus is.

Host: That's cool.

Erika McCarty Walsh, MD, PhD: Dr. Jones is absolutely correct. And, I think one of the challenging things about pulsatile tinnitus is there's a non-trivial cohort of patients in who we don't identify the cause. And so when I've evaluated a patient looking for otologic sources or the type of vascular sources I look for, and then send on to Dr. Jones and say, hey, do you think this person is appropriate for an angiogram? It's really shared decision making, so certainly if they have other worrisome neurologic signs, that's one thing; but there are times that we get an angiogram on a patient, and they've had a full extensive workup, and we don't find a clear cause, and so it's a balance, and it's part of a discussion with the patient. And I do try to, I keep a kind of an open investigative mind, but I also give the caveat that sometimes we don't get a clear answer for this.

Jesse Jones, MD: Dr. Walsh brings up a great point as well about how sometimes it's just a peace of mind. So if we can find a cause of a tinnitus that say is not a dangerous cause, but it's able to explained to the patient why they're feeling that or hearing that, that oftentimes can be enough for the patient, that peace of mind.

And so they may not need to go on to a potentially dangerous treatment if all they need to know is that the cause of their tinnitus is something that's actually not harmful. And so that's also an important part of our workup.

Host: And such an important part, and as you both said, shared decision making, and Dr. Walsh along those lines; in cases where a definitive cause cannot be identified, how does the patient get supported in coping with and managing their symptoms on a longterm basis? How do you monitor them and help them through this? How long does it usually go on?

Erika McCarty Walsh, MD, PhD: Yeah it's a great question. I have had patients over the years who have experienced spontaneous resolution. I've had patients who have kind of continued to have it on and off for their whole lives. And then if we truly, you know, a patient's had a thorough workup they've had an angiogram that is normal, and we have that reassuring piece of data; then we get into tinnitus management strategies. And I believe you alluded to this a little bit earlier. So things that we know that are helpful for tinnitus, of the pulsatile or non-pulsatile variety, are tools that we have to decrease how activating it is for the patient.

So for many patients, tinnitus is a cycle. So they have the noise. The noise is bothersome. It's distracting. That is stressful for the patient and then the noise becomes more apparent. So the tools that we have to help patients who have chronic tinnitus and whom we don't have a reversible cause, are things like cognitive behavioral therapy.

That's a type of supportive psychotherapy where you learn relaxation technique, what we call tinnitus masking. So that's running a white noise machine, a fan, music in the background to avoid that kind of contrast between the tinnitus and silence. And there are actually some apps available for that.

So, there are all sorts of free or inexpensive apps where patients can play around with different masking techniques to help with their tinnitus.

Host: Dr. Jones, last word to you. What would you like other providers to take away from this multidisciplinary collaborative episode about pulsatile tinnitus and really when it's important that they refer to the experts at UAB Medicine?

Jesse Jones, MD: Well, I think with patients in general, you know, pain is probably the number one thing that brings people in to see a doctor. Pulsitile Tinnitus, or PT, it's somewhat a pain in the sense that it's something the patient actually experiences and it triggers them to go seek medical attention. And I don't think someone with tinnitus should just be ignored and say, oh, that's a common thing and that's not a big deal.

It is indeed a concerning sign. And so I encourage physicians who see patients who are describing tinnitus or especially pulsitile tinnitus, to refer them to an otologist to get a more thorough workup because it could be a serious condition underlying that can be discovered through the techniques Dr. Walsh and I just described.

Host: Dr. Walsh, do you have any final thoughts you'd like to say?

Erika McCarty Walsh, MD, PhD: I agree wholeheartedly with Dr. Jones. Pulsatile tinnitus does without question, require evaluation. So, we have busy providers in multiple specialties who may be listening to this, but it is worth taking a pause if patients complain of head noise or tinnitus and saying do you feel it matches your heartbeat? Does it have a rhythmic quality? Probing that a little bit so that we can take a look and make sure that we're not missing something serious and important.

Host: Thank you both so much. for, such an informative episode and for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please always remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. Thanks so much for tuning in today.