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Diagnostic Approach to Pulsatile TinnitusA Narrative Review

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME

Importance  Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke. Careful diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy.

Observations  An underlying cause of pulsatile tinnitus can be identified in more than 70% of patients with a thorough evaluation. We advocate categorizing the myriad causes of pulsatile tinnitus into structural, metabolic, and vascular groups. Structural causes of pulsatile tinnitus include neoplasms and temporal bone pathologic abnormalities. Metabolic causes of pulsatile tinnitus include ototoxic medications and systemic causes of high cardiac output. Vascular causes of pulsatile tinnitus include idiopathic intracranial hypertension and dural arteriovenous fistulas. This categorization facilitates a practical evaluation, referral, and treatment pattern.

Conclusions and Relevance  Categorizing the underlying cause of pulsatile tinnitus ensures that dangerous causes of pulsatile tinnitus are not missed, and that patients receive the appropriate care from the proper specialist when needed.

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Article Information

Accepted for Publication: December 23, 2021.

Published Online: February 24, 2022. doi:10.1001/jamaoto.2021.4470

Corresponding Author: Kazim H. Narsinh, MD (kazim.narsinh@ucsf.edu), and Matthew R. Amans, MD (matthew.amans@ucsf.edu), Department of Radiology & Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, L-349, San Francisco, CA 94143.

Author Contributions: Drs Narsinh and Amans had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Narsinh, Hui, Saloner, Rauschecker, Safoora, Shah, Meisel, Amans.

Acquisition, analysis, or interpretation of data: Narsinh, Saloner, Tu-Chan, Sharon, Rauschecker, Amans.

Drafting of the manuscript: Narsinh, Safoora.

Critical revision of the manuscript for important intellectual content: Narsinh, Hui, Saloner, Tu-Chan, Sharon, Rauschecker, Shah, Meisel, Amans.

Obtained funding: Amans.

Administrative, technical, or material support: Hui, Saloner, Rauschecker, Meisel.

Supervision: Narsinh, Sharon, Rauschecker, Shah, Amans.

Conflict of Interest Disclosures: Dr Sharon reported grants from Eli Lilly & Co, grants from Advanced Bionics, and consulting fees from Spiral Therapeutics outside the submitted work. Dr Rauschecker reported grants from RSNA outside the submitted work. Dr Amans reported grants from National Institutes of Health and grants from the Department of Defense during the conduct of the study; personal fees from Stryker Neurovascular; consultant fees, personal fees from Medtronic; consultant fees, personal fees from Microvention; consultant fees, personal fees from Mind Frame; stock options outside the submitted work; in addition, Dr Amans had a patent for System for Diagnosis of Pulsatile Tinnitus pending, a patent for Cerebral Blood Flow Reorganization pending, and a patent for Cerebral Venous Sinus Stent pending. No other disclosures were reported.

Funding/Support: Dr Narsinh received funding support from NIH NIBIB 5R01EB012031. Dr Amans received funding support from NIH NHLBI R56HL149124 and DoD CDMRP W81XWH-21-1-0753.

Role of the Funder/Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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