What is pulsatile tinnitus?
Tinnitus is the perception of a sound that has no external source. Most people with tinnitus hear a buzzing, hissing or ringing.
Less commonly, the sound has a rhythm to it: a whooshing, thumping, throbbing or pulsing that keeps time with your heartbeat. This is called pulsatile tinnitus, and it is thought to affect fewer than 10% of people with tinnitus. Unlike ordinary tinnitus, which only the person can hear (subjective tinnitus), pulsatile tinnitus can sometimes be heard by a clinician during an examination (objective tinnitus) because it usually comes from real sound: blood moving near the ear.
- Pulsatile tinnitus is a rhythmic sound that keeps time with your heartbeat, usually caused by changes in blood flow near the ear.
- It is uncommon, affecting fewer than 1 in 10 people with tinnitus.
- Most causes are harmless, but it should be checked by a doctor because it can occasionally signal a blood-vessel problem.
- Seek prompt medical advice if it is sudden, in one ear only, or comes with hearing loss, dizziness, severe headache or vision changes.
- Treatment depends on the cause; where none is found, CBT and sound therapy can reduce how intrusive the sound feels.
What does pulsatile tinnitus sound like?
People describe it in different ways, including:
- a heartbeat or pulse in the ear
- a whooshing or "wind" sound
- a thumping, thudding or throbbing
- a swishing or rushing noise, often more noticeable at night or in a quiet room
The key feature is that the sound is rhythmic and usually matches your pulse.
How to check if you have pulsatile tinnitus
A simple check is to feel the pulse in your wrist while you listen to the sound in your ear, and see whether the two are in time with each other. If the sound speeds up when your heart rate rises (for example after exercise) and beats in time with your pulse, it is likely to be pulsatile tinnitus.
Is pulsatile tinnitus dangerous? When to see a doctor
In most people, pulsatile tinnitus is caused by harmless changes in blood flow and is not dangerous. However, because it can occasionally be a sign of an underlying condition affecting the blood vessels, it is sensible to have it checked by a doctor rather than ignoring it.
You should see a doctor if your pulsatile tinnitus is persistent, and seek prompt medical advice if it is accompanied by any of the following:
- sudden or rapidly worsening symptoms
- a sound in only one ear
- hearing loss, dizziness or balance problems
- a severe or persistent headache, or changes to your vision
- weakness, numbness, or difficulty speaking
These do not mean something serious is definitely wrong, but they are reasons to be seen sooner rather than later so that any treatable cause can be identified. Pulsatile tinnitus is one of the situations in tinnitus where getting professional help matters, because while many causes are benign, some can be treated and a few should not be left undiagnosed.
What causes pulsatile tinnitus?
Like other causes of tinnitus, the underlying reason is often hard to pin down. Pulsatile tinnitus is usually related to one of three things: more blood flowing near the ear, more turbulent (and therefore noisier) blood flow, or the ear simply becoming better at picking up sounds that are normally there. The causes below range from very common to rare.
Systemic causes (changes across the whole body)
Several common conditions increase blood flow or make the heart pump more forcefully, which can produce pulsatile tinnitus. These include:
- pregnancy
- high blood pressure (hypertension)
- vigorous physical exercise
- anaemia (too little haemoglobin to carry oxygen, so the heart works harder)
- an overactive thyroid gland (hyperthyroidism)
The thyroid and pulsatile tinnitus
The thyroid is worth singling out because it is a common question. An overactive thyroid raises the heart rate and the force of each heartbeat, which can make blood flow near the ear more noticeable and produce a pulsing sound. Less often, an underactive thyroid (hypothyroidism) is also reported alongside tinnitus. In both cases, the tinnitus is a knock-on effect of the thyroid problem rather than an ear condition in its own right, and it often settles once the thyroid is treated. If you have pulsatile tinnitus together with symptoms such as unexplained weight change, palpitations, feeling unusually hot or cold, or fatigue, it is worth asking your doctor about a thyroid blood test.
Changes in blood flow close to the ear
We all have blood flowing through vessels in the head and neck, but we are not usually aware of it. If the thin sheets of bone separating those vessels from the ear become thinner, the sound can transmit more easily and be picked up by the ear. This can happen in a condition called idiopathic (or benign) intracranial hypertension, where higher pressure of the fluid around the brain presses on this bone. This condition most often affects younger and middle-aged women, although it can occur at any age. A similar effect can occur when blood moving through the sigmoid sinus (a large vein that runs close to the ear) becomes turbulent, for example because of a small out-pouching (diverticulum) or a thin or roughened vein wall [3].
Turbulent blood flow and vascular causes
As we get older, fatty deposits (atheroma) can build up inside blood vessels. As blood is forced through these narrowed sections it becomes turbulent, a bit like water rushing over rapids, and this turbulence can be heard. Turbulence in the carotid artery in the neck is one example. Narrowing of the veins that drain the brain (venous sinus stenosis) can do the same.
Less commonly, pulsatile tinnitus is linked to blood-vessel conditions such as arteriovenous malformations or dural arteriovenous fistulas (abnormal connections between arteries and veins), or to a narrowing of the internal jugular vein. Rare causes include a persistent stapedial artery (a vessel that normally disappears before birth) or a paraganglioma or glomus tumour, which are usually benign growths with a rich blood supply near the ear. These causes are uncommon, but they are part of the reason doctors take pulsatile tinnitus seriously: in one review of 84 patients with pulsatile tinnitus, a vascular cause was identified in around 42% and a non-vascular cause such as a glomus tumour or raised intracranial pressure in a further 14% [4]. In a large study of people with fibromuscular dysplasia, a type of arterial disease, about 37% reported pulsatile tinnitus [2].
Becoming more aware of normal blood flow
Sometimes the blood flow itself is normal, but you become more aware of it. This can happen when less outside sound reaches the ear, for example with some types of hearing loss such as glue ear, or because the hearing pathways have become more sensitive, as happens in ordinary tinnitus. Stress and anxiety can heighten this awareness too, which is why the sound often feels louder when you are tired, worried or lying awake at night.
At a glance, the causes range from very common to rare:
| How common | Examples | What is happening |
|---|---|---|
| Common | High blood pressure, pregnancy, vigorous exercise, anaemia, overactive thyroid | More blood flow, or a harder-pumping heart, makes normal blood flow near the ear audible |
| Less common | Idiopathic intracranial hypertension, sigmoid sinus problems, atherosclerosis or carotid turbulence, venous sinus stenosis | Turbulent flow, or thinned bone near the ear, lets the sound reach the ear more easily |
| Rare | Arteriovenous malformation, dural arteriovenous fistula, glomus tumour or paraganglioma, persistent stapedial artery | Abnormal vessels or growths near the ear; these usually need a scan to identify |
Pulsatile tinnitus in one ear, in both ears, or that comes and goes
Pulsatile tinnitus can be felt in one ear or in both. A sound in only one ear is worth mentioning to your doctor, as it is more likely to point to a local cause near that ear that is worth investigating. Many people notice the sound comes and goes, or is louder when lying down, at night, or in a quiet room, simply because there is less background noise to mask it. It can also be more noticeable at times when blood flow is higher, such as during exercise, pregnancy, or around your period. A sound that comes and goes is not in itself a sign that something is seriously wrong, but a persistent or one-sided sound should still be assessed.
How is pulsatile tinnitus diagnosed?
Diagnosis starts with a conversation and an examination. Your doctor will ask what the sound is like, whether it is in one or both ears, what makes it better or worse, and about any other symptoms. They will usually examine your ears and listen over the neck and around the ear to check whether the blood flow sounds turbulent or can be heard in an unusual place.
Depending on what they find, further tests may be arranged. Blood tests can check for anaemia or an overactive thyroid. Imaging is used to look at the blood vessels and structures around the ear, and may include MRI, CT or ultrasound of the neck vessels. Sometimes specialised scans of the blood vessels, known as MR or CT angiography, are used [1]. The exact combination of tests varies between healthcare providers and depends on the suspected cause.
How is pulsatile tinnitus treated, and how can you stop the pulsing?
There is no single treatment for pulsatile tinnitus, because the right approach depends on the cause. The most effective way to reduce or stop the pulsing sound is to identify and treat any underlying condition, which is why getting it assessed matters.
For example, if high blood pressure or an overactive thyroid is found, treating that condition can ease the tinnitus. If anaemia is the cause, the reason for it is looked into and corrected. Where the sound comes from a specific structural problem in a blood vessel, treatment may involve a procedure or surgery, though this is less common and is something a specialist would discuss in detail. Many people, once they understand the cause and have been reassured that it is not dangerous, find that they no longer feel the need for further treatment.
Managing the sound and the distress it causes
While you are being assessed, or if no treatable cause is found, the focus shifts to reducing how intrusive and distressing the sound feels. Approaches that are widely used for tinnitus more generally include cognitive behavioural therapy (CBT) and sound therapy. CBT does not remove the sound; it helps you respond to it differently so that it fades into the background and bothers you less. Research has reported that CBT can improve quality of life and reduce the impact of tinnitus. Simple steps such as managing stress, sleeping well and using background sound in quiet rooms can also help make the sound less noticeable. It is worth remembering that there is rarely a quick fix, but there are several ways to manage tinnitus over time.
How Oto can help
Pulsatile tinnitus is usually a sign of something happening with blood flow, so the first step is always to see a doctor so any treatable cause can be found or ruled out. Oto does not diagnose or treat the underlying cause.
What the Oto app is designed to help with is the distress and intrusiveness that tinnitus of any kind can bring. Once serious causes have been excluded by a clinician, Oto offers evidence-based CBT techniques and tools to help you cope with the sound and notice it less, including:
- CBT-based techniques for tinnitus-related distress
- sound enrichment and audio landscapes
- mindfulness and relaxation activities
- exercises for physical wellbeing, including shoulder, neck and jaw stretches
You can also join Oto's Tinnitus Support Group, a community for people with tinnitus and related conditions.
Frequently asked questions
What is pulsatile tinnitus?
Pulsatile tinnitus is a type of tinnitus where you hear a rhythmic sound, such as a whooshing, thumping or pulsing, that usually keeps time with your heartbeat. It is most often caused by changes in blood flow near the ear.
Is pulsatile tinnitus dangerous?
In most people pulsatile tinnitus is caused by harmless changes in blood flow and is not dangerous. Because it can occasionally point to an underlying blood-vessel condition, it should be checked by a doctor, and you should seek prompt advice if it is sudden, in one ear only, or comes with hearing loss, dizziness, severe headache or vision changes.
What is the most common cause of pulsatile tinnitus?
It is usually related to changes in blood flow near the ear. Common contributors include high blood pressure, an overactive thyroid, anaemia and pregnancy, while less common causes involve turbulence or narrowing in the blood vessels of the head and neck.
Why can I hear my heartbeat in my ear?
Hearing your heartbeat in your ear is the main feature of pulsatile tinnitus. It usually happens because blood flow near the ear has increased or become more turbulent, or because the ear has become more sensitive to sounds that are normally there. It is often more noticeable at night or in a quiet room.
Can thyroid problems cause pulsatile tinnitus?
Yes. An overactive thyroid raises the heart rate and the force of each heartbeat, which can make blood flow near the ear more noticeable and produce a pulsing sound. The tinnitus often settles once the thyroid problem is treated.
Why is the pulsing only in one ear?
Pulsatile tinnitus in one ear is more likely to point to a local cause near that ear, such as turbulence in a nearby blood vessel. It is worth mentioning a one-sided sound to your doctor so it can be assessed.
How can I stop the pulsing sound in my ear?
The most reliable way to reduce the sound is to identify and treat any underlying cause, so the first step is to see a doctor. Where no treatable cause is found, approaches such as CBT, sound therapy, stress management and using background sound can make the sound less intrusive over time.
Can pulsatile tinnitus go away on its own?
It can. When pulsatile tinnitus is linked to a temporary or treatable cause, such as pregnancy, anaemia or an overactive thyroid, it often eases once that cause is resolved. If no specific cause is found the sound may persist, but it can usually be made far less intrusive over time with approaches such as CBT and sound therapy.
Can stress or anxiety cause pulsatile tinnitus?
Stress and anxiety do not directly cause pulsatile tinnitus, but they can make you more aware of the sound and more distressed by it, so it can feel louder and more constant. Managing stress, and techniques such as CBT, can reduce how intrusive it feels even when the underlying sound has not changed.
What tests are used for pulsatile tinnitus?
Assessment usually starts with an examination and listening over the ear and neck. Depending on the findings, blood tests and imaging such as MRI, CT, ultrasound or angiography may be used to look at the blood vessels and structures around the ear.
References
1. Hofmann, E., Behr, R., Neumann-Haefelin, T., & Schwager, K. (2013). Pulsatile tinnitus: imaging and differential diagnosis. Deutsches Arzteblatt International. https://pubmed.ncbi.nlm.nih.gov/23885280/
2. Dicks, A. B., Gornik, H. L., Gu, X., Bacharach, M., & Mahlay, N. F. (2021). Association of fibromuscular dysplasia and pulsatile tinnitus. Journal of the American Heart Association. https://www.ahajournals.org/doi/pdf/10.1161/JAHA.121.021962
3. Lansley, J. A., Tucker, W., Eriksen, M. R., & Riordan-Eva, P. (2017). Sigmoid sinus diverticulum, dehiscence, and venous sinus stenosis. American Journal of Neuroradiology. https://www.ajnr.org/content/ajnr/38/9/1783.full.pdf
4. Waldvogel, D., Mattle, H. P., Sturzenegger, M., & Schroth, G. (1998). Pulsatile tinnitus: a review of 84 patients. Journal of Neurology. https://boris.unibe.ch/117566/1/415_2009_Article_82450137415.pdf