Pulsatile Tinnitus: Causes of Hearing Your Heartbeat in Your Ear

For most people who experience tinnitus, the sound is an elusive ringing, buzzing, or hissing that only they can hear. But for a smaller subset of the population, the sound is different. It is a rhythmic whooshing, thumping, or throbbing that is perfectly in sync with their own heartbeat. This condition, known as pulsatile tinnitus, is not just a nuisance; it is often a symptom of an underlying medical condition that requires a thorough medical evaluation. Unlike traditional, or “subjective,” tinnitus, pulsatile tinnitus is often an objective sound. This means the sound is an actual physical sound generated by blood flow, which in some cases can be heard by a doctor using a stethoscope. The presence of this rhythmic sound is a critical signal from your body that should not be ignored. This guide will explain the physiological basis of pulsatile tinnitus, detail its common and rare causes, and outline why a medical evaluation is so crucial.

Pulsatile tinnitus is a rare form of tinnitus where the sound has a discernible rhythm that matches the person’s heart rate. The sound is often described as a throbbing, whooshing, or pulsating sensation. It is typically heard in one ear, but can sometimes be heard in both. The sound is often more prominent when a person is lying down, especially in a quiet room at night, because the sound of external noise is absent.

The key distinction between pulsatile tinnitus and traditional tinnitus lies in its cause and its nature. Traditional tinnitus is often a neurological phenomenon, caused by damage to the auditory nerve or other parts of the hearing system, and the sound is only perceived by the individual. In contrast, pulsatile tinnitus is almost always a sign that there is an audible sound of blood flow near the ear that is being transmitted to the cochlea ^[1].

The ear is located near a complex network of major blood vessels. The carotid arteries and jugular veins, which are the main vessels that supply and drain the head and neck, run very close to the middle and inner ear. Normally, blood flow through these vessels is silent. However, anything that creates turbulent or altered blood flow can generate a sound that is picked up by the delicate structures of the inner ear.

This turbulent flow can be caused by three main factors:

1. Increased Blood Flow: An increased volume or speed of blood moving through a vessel.
2. Narrowing of a Vessel: A constriction in a blood vessel that forces blood through a smaller opening, increasing its velocity and creating a sound.
3. Abnormal Connection: A direct, abnormal connection between a high-pressure artery and a low-pressure vein ^[2].

The cause of pulsatile tinnitus is usually a treatable medical condition. A doctor’s primary goal is to find the source of the sound, which can range from a minor issue to a serious vascular or neurological problem.

• Atherosclerosis: A buildup of plaque in the arteries (atherosclerosis) can cause them to narrow. This narrowing, particularly in the carotid arteries of the neck, can create a turbulent blood flow that generates a whooshing sound, which can be transmitted to the ear ^[3].
• Venous Hum: This is a very common and usually benign cause. A “venous hum” is the sound of normal blood flow in the large jugular veins of the neck. This sound can become more prominent when blood flow is increased, such as during exercise, or when the person is lying down, as the blood flow to the head increases. It’s often louder in children and can be eliminated by pressing gently on the neck, which is a key diagnostic clue for a physician ^[4].
• Arteriovenous Malformations (AVMs) and Fistulas: These are rare but more serious causes. An AVM is a congenital condition—a tangle of abnormal arteries and veins—and a fistula is an abnormal, direct connection between an artery and a vein. Both can cause a high-pressure, turbulent flow of blood that is often the source of pulsatile tinnitus ^[5].
• Dissections: A dissection is a tear in the inner lining of a blood vessel. This can cause blood to flow between the layers, creating a flap that causes turbulent flow and can be a source of pulsatile tinnitus. This is a medical emergency and often presents with head or neck pain ^[6].

• Increased Intracranial Pressure (IIH): Idiopathic Intracranial Hypertension (IIH) is a condition where the pressure of the cerebrospinal fluid around the brain is too high. This can put pressure on the veins that drain the brain (e.g., the transverse sinus), causing a restricted flow and a pulsing sound. This is often accompanied by headaches and visual changes ^[7].
• Glomus Tumors: These are rare, benign tumors that can grow in the middle ear or near the jugular bulb. They are rich in blood vessels and can be a source of a pulsating sound ^[8].
• High Blood Pressure: Elevated blood pressure can increase the force and speed of blood flow, making the sound of the heartbeat more audible to the sensitive structures of the inner ear.
• Anemia: Severe anemia can cause the heart to pump more forcefully to compensate for a lack of oxygen-carrying red blood cells, which can make the sound of blood flow more prominent and audible.

If you are experiencing pulsatile tinnitus, it is crucial to consult a doctor. Do not assume it is harmless or that it will go away on its own. The first and most important step is to get an accurate diagnosis.

• Consult a Specialist: Your primary care physician will likely refer you to an otolaryngologist (ENT doctor) or a neurologist.
• Diagnostic Workup: Your doctor will likely order a number of tests to pinpoint the cause:
  • Physical Exam: Your doctor will use a stethoscope to listen to your neck, head, and around your ear to see if they can hear the pulsating sound (confirming it is objective).
  • Imaging Studies: This is the key to diagnosis. A doctor will likely order an MRA (Magnetic Resonance Angiography) or a CTA (CT Angiography) to visualize the arteries and veins in the head and neck and look for any abnormalities ^[9].
  • Blood Tests: To check for conditions like anemia or thyroid issues.