Clinical utility of imaging for pulsatile tinnitus

Pulsatile tinnitus affects millions of patients annually, yet the prevalence of time-sensitive imaging findings remains unclear. There is limited consensus regarding initial imaging workup between radiological and otological guidelines; diagnostic algorithms have been proposed but are based on strict patient criteria. We aimed to elucidate the prevalence of time-sensitive imaging findings in the workup of pulsatile tinnitus and assess imaging associations with outcomes.

This retrospective study included a cohort of 100 randomly sampled patients from academic medical centers, community hospitals, and outpatient clinics in a single healthcare system with an ICD-10 code for pulsatile tinnitus in the electronic health record from 1/1/2014-12/31/2023.

93% (93/100) of sampled patients had tinnitus that was pulsatile, the remaining were incorrectly coded. 77% (72/93) were female. The median age was 61 (IQR: 43-66). 81% (75/93) had imaging performed. 6.5% (6/93, 95% CI: 1.5%-11.4%) had a time-sensitive imaging finding: pseudoaneurysm, arteriovenous fistula, clival mass, severe carotid stenosis, fibromuscular dysplasia, and loss of right cavernous internal carotid artery flow. 23% (21/93) had documented symptom resolution, 44% (41/93) were documented as unresolved, and 33% (31/93) had no documented resolution status. There was a significant association between patients with at least one imaging finding and receiving treatment (p < 0.01) yet there was no association between having an imaging finding and resolution of symptoms (p = 0.74).

A small number of patients with pulsatile tinnitus appear to benefit from imaging to identify time-sensitive findings, otherwise imaging does not appear to have an important impact on guiding treatment toward symptom resolution.