Intended for healthcare professionals

Endgames Case Review

A case of pulsatile tinnitus

BMJ 2017; 356 doi: (Published 05 January 2017) Cite this as: BMJ 2017;356:i6402
  1. Karan Jolly, core surgical trainee 2, ear, nose, and throat surgery1,
  2. Pawanjit Hare, foundation year doctor2,
  3. Richard Irving, ear, nose, and throat consultant1,
  4. Peter Monksfield, ear, nose, and throat consultant1
  1. 1Queen Elizabeth Hospital Birmingham, Birmingham, UK
  2. 2Good Hope Hospital, Birmingham, UK
  1. Correspondence to K Jolly kjolly{at}

A 32 year old man presented to his primary care doctor with an eight month history of hearing loss and a pulsatile noise that sounded like a heartbeat in his left ear. In the previous four months he had experienced otalgia in the left ear and headaches. On examination, the doctor noticed a mass behind the left tympanic membrane, with pulsation of the membrane. Tuning fork tests identified a conductive hearing loss in the left ear. Other than headaches, there were no red flag symptoms such as weight loss, fever, or other signs of raised intracranial pressure. The patient was referred to an ear, nose, and throat specialist, who noted that the left tympanic membrane was intact and facial nerve function on both sides was normal. There was an obvious pulsating mass behind the left tympanic membrane (fig 1). Endoscopic examination of the larynx showed normal vocal cord movement, but there was evidence of a hypoglossal palsy on the left side, with unilateral tongue wasting. The patient had some difficulty articulating speech but reported no dysphagia. Audiometry confirmed a conductive hearing loss in the left ear. Contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI) (fig 2) of the base of the patient’s skull showed an enhanced jugular fossa mass on the left side.

Fig 1 Left tympanic membrane

Fig 2 T2 weighted magnetic resonance image of the head


  • 1. What are the differential diagnoses for pulsatile tinnitus?

  • 2. What is the most likely diagnosis?

  • 3. What are the management options?


1. What are the differential diagnoses for pulsatile tinnitus?

Short answer

Differential diagnoses include vascular stenosis due to atherosclerotic plaques; arteriovenous fistula; vascular tumours (including paragangliomas), and intracranial hypertension. Alternatively, the tinnitus can result from increased sensitivity to normal bodily noises such as blood flow. This can be due to conductive hearing loss caused by wax obstruction …

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