This document discusses pulsatile tinnitus, which is a type of tinnitus perceived as a pulsating, clicking, or fluttering sound that is either synchronous or non-synchronous with the heartbeat. Synchronous pulsatile tinnitus may be caused by abnormal vascular anatomy near the ear or idiopathic intracranial hypertension. Non-synchronous pulsatile tinnitus is often related to muscle contractions in the middle ear, palate, or neck that create sounds or vibrations. Investigations include imaging tests and physical exams, while treatments range from supportive therapies to surgery depending on the underlying cause.

1. Tinnitus

2. Pulsatile tinnitus
• Perception of sound is not that of a continuous form
• The perceived sound  form of a pulsation, clicking or fluttering
• Specific subtype of tinnitus management different
• Classified
↓
synchronous
 non-synchronous

3. Pathological causes of pulsatile tinnitus

4. Synchronous pulsatile tinnitus
• Synchronous pulsatile tinnitus may result of abnormal
vascular anatomy in the vicinity of the peripheral auditory
system.
• Systemic aberrations ofthe circulation hyperdynamic
circulation role in development
• Idiopathic intracranial hypertension or pseudotumor cerebri
gaining attention as the cause of synchronous pulsatile
tinnitus
• Superior semicircular canal dehiscence syndrome beginning
to gain attention as the cause

5. Investigation
• Simple bood test  to exclude anaemia and thyrotoxicosis.
• Contrast-enhanced computed tomography of temporal bone,
scalp, brain If otoscopy reveals a retrotympanic mass
• duplex carotid ultrasonography atherosclerotic carotid artery
disease
• Angiographic imaging often reserved for severe recalcitrant
cases
• Ophthalmological assessment,lumbar puncture If idiopathic
intracranial hypertension is suspected

6. Treatment
Supportive
• When no obvious cause is identified, providing reassurance
These patients  CBT or TRT
• Sound therapies subjective idiopathic tinnitus

7. Surgerical management of pulsatile tinnitus
• Depending on the causative pathology treatments may
include decompressive and destructive procedures
• Microvascular decompression of vascular loops vascular
loops -close proximity to the cochlear nerves of patients with
tinnitus

8. Non-synchronous pulsatile tinnitus
• Tinnitus may manifest itself as a train of rhythmical clicks or a
buzzing or fluttering noise or sensation that is not synchronous
with the pulse.
• Sounds often related to myoclonic activity middle ear muscle
• Other muscles within the head and neck region like palatal
muscle
• Contraction tensor tympani and/or stapedius muscle -
>clicking or buzzing noise
• Tinnitus muscle contraction noise,vibration of the tympanic
membrane or movement of the ossicular chain

9. INVESTIGATION
• Tympanometry middle ear myoclonus
• MRI recommended to exclude a pathology with the triangle of
Guillain–Mollaret palatal myoclonus
↓
palatal myoclonus

10. TREATMENT
Pharmological
• use of benzodiazepines,orphenadrine,
carbamazepine,piracetamand botulinum toxin
Supportive treatment
• Relaxation therapy,psychotherapy,tinnitus maskingand
biofeedback
Surgical
• surgical division of the middle ear tendons(both tensor tympani
and stapedius)