A case of severe pulsatile tinnitus cured with surgery

Tinnitus is an extraordinary disease in some ways. It affects 1/5 Americans (that’s 60+ million people) yet it is poorly understood and still, for the most part, untreatable. I cannot think of any other affliction that is at the same time so pervasive, yet so poorly managed. The most common form of tinnitus is non-pulsatile tinnitus, which is often described as a constant buzzing or ringing tone. This type of tinnitus is most often related to high frequency hearing loss, which can be diagnosed with a formal hearing test. Aside from recommending hear aids and white-noise, there is little else that’s been proven to work. It’s a frustrating diagnosis for both me and the patient.

So when a patient came to me complaining of several months of “roaring” tinnitus from his right ear, I was gearing myself up for the same disappointing conversation. But as I listened to this patient describe his tinnitus, several key points were elucidated that caught my attention: 1) his tinnitus was pulsatile, meaning it sounded like a heartbeat rather than a constant hum 2) certain positions seemed to make the noise better or worse 3) the patient felt that his hearing was more or less intact. The noise was so severe that the patient has only been able to sleep 3-4 hours a night. When the noise first started, he spent several hours searching his house for the source of the sound because he couldn’t believe it was coming from inside his own head.

On my physical exam, I was able to match the patient’s tinnitus to hear heartbeat, indicating this was most likely caused by a vascular anomaly. Furthermore, when I compressed his neck on the right side, his tinnitus magically disappeared. I counseled the patient that in situations like this, there is about a 10% chance we may find a specific abnormality on a CT scan. Furthermore, only a fraction of these abnormalities would actually be treatable, and would usually involve a moderately complex surgery. Most patients at this point would resign to just living with their tinnitus, but understandably, this young man was so affected by his tinnitus that he wanted to pursue every option available.

With expectation tempered, we obtained several scans designed to look for vascular anomalies near his ear. And there it was – an abnormal sigmoid sinus, which is a large vein that runs behind the ear. Turbulent flow caused by a defect in the bony covering of this vein was causing blood to become turbulent as it passed behind the ear. Long story short, the patient underwent surgery and has been tinnitus free for a month. It’s a small win in a long and frustrating battle against tinnitus and it gives me hope that future medical advances will one day allow me to better help every patient that comes into my office with all forms of tinnitus.