It is pretty common in some people to listen to your heartbeat or a pulse in your ear when lying down in bed. It is medically known as pulsatile tinnitus. Sometimes it is in one ear or sometimes in both. Although it is not something very serious about your health, it can be aggravated if your blood pressure is high. If your blood pressure is normal, it is not a cause of concern. Still, it may be intensified by any increased “catecholamine” release (for example, adrenaline) in situations such as caffeine consumption, anxiety, fear, etc.

What it Feels Like With Pulsatile Tinnitus or Hearing Heartbeat in the Ear?

Tinnitus is the sensation of ringing, whistling, or rushing sound in your ear in the absence of an external source. If you have regular a thumping or whooshing sound in one or both ears, which follow a steady beat, you may have this rare form of tinnitus. The sound may be a, or it may be more complex like machinery or the twittering of birds. By contrast, pulsatile tinnitus is a rhythmical sound that usually has the same rate as the heartbeat. This is checked by feeling the pulse while listening to the heartbeat in the ear. 

The noise comes from inside your body. In pulsatile tinnitus, the chances to find a specific cause are more than in the non-pulsatile form, but it is still challenging to identify a cause. The doctor may be able to hear it, too, if they listen with a stethoscope. It’s also called rhythmic, vascular, or pulse-synchronous tinnitus.

What Are the Symptoms of Pulsatile Tinnitus?

It regularly hears a pulse in your ear, a sound with a steady beat that sync with your pulse. It may be only one ear. The sound can often be loud, distracting, or sometimes even unbearable and cause difficulty in sleeping.

If a person has high pressure in the fluid around the brain, a condition called idiopathic intracranial hypertension, few other symptoms that may develop are

•  Headaches
•  Dizziness
•  Vision problems
•  Hearing loss

If you have idiopathic intracranial hypertension, it is advisable to lose weight, take medication, or have surgery.

What Causes Pulsatile Tinnitus?

Pulsatile tinnitus is caused primarily by a change in blood flow in the vessels adjacent to the ear. The ear vessels have large arteries and veins in the neck and base of the skull, while smaller ones are in the ear. Various factors can alter the blood flow:

Generalised Increased Blood Flow

Blood that flows quickly makes more noise than blood that is flowing slowly. There can be an increase in blood flow throughout the body in strenuous exercise or pregnancy. It can also occur in severe anaemia,  hyperthyroidism ( increased production of thyroid hormone by the thyroid gland)or thyrotoxicosis.

Localised Increased Flow

Sometimes blood flow increases in a single blood vessel or group of blood vessels rather than a generalised increase. For example, during foetal development, an artery in our middle ear called the stapedial artery is present, which closes before birth. t can occasionally persist, causing blood flow adjacent to middle ear structures leading to pulsatile tinnitus. 

High Blood Pressure

When the blood pressure rises, blood strikes an increased force against the inner walls of the arteries. More forceful blood flow in arteries in or around the ears is more effortless for your ears to detect.

Atherosclerosis

Blockage in the arteries caused by a buildup of cholesterol, fats, and waste materials can cause a turbulent blood flow. If this is the cause, a person may hear a rhythmic noise in one of the ears.

Turbulent Blood Flow

Atherosclerosis causes The blood flow to become turbulent rather than smooth inside a blood vessel due to the hardening of the arteries. Narrowed neck arteries (carotid arteries) or veins (jugular vein) can cause a change in blood flow to and from the head. The ears may become sensitised to this turbulent or irregular circulation, causing pulsatile tinnitus.

Head or Beck Tumours

A tumour pressing against a vein can also cause pulsatile tinnitus. The majority of tumours associated with pulsatile tinnitus are benign but not malignant. 

Abnormal Capillaries

Sometimes a problem with the tiny blood vessels which connect your arteries to your veins, or capillaries, can cause pulsatile tinnitus. This condition is called arteriovenous malformation, which generally affects only one ear.

Altered Awareness

Another reason is altered awareness and can be increased by several factors:

• Conductive hearing loss such as a perforated eardrum tends to make people more aware of sounds inside their bodies because they no longer have the masking effect of external sounds.
• The heightened sensitivity in the auditory pathways can alert the brain to normalise the noise in blood vessels in a similar way that the awareness of non-pulsatile tinnitus is generated.

Miscellaneous

Some causes of pulsatile tinnitus do not fall into these categories. One such condition is called benign or idiopathic intracranial hypertension, characterised by headaches and visual disturbance and pulsatile tinnitus. It occurs most frequently in overweight young or middle-aged women; however, it can occur at any age and in both genders. Anaemia or an overactive thyroid gland can also be a cause. It is essential to state that although these are common causes of pulsatile tinnitus and that anyone with this symptom should advise by an appropriate health practitioner.

How is Pulsatile Tinnitus Diagnosed?

The examination by a doctor includes a review of the symptoms and medical history of the patient. The doctor uses a stethoscope to listen to the chest, neck, and skull. Suppose the doctor can also hear a pulsatile noise, its objective pulsatile tinnitus. If not, it’s called subjective pulsatile tinnitus. There are a few hearing tests to determine whether there has been any hearing loss in one or both ears. The doctor may order some imaging tests as well. These include:

Ultrasound

Modern ultrasound scanning uses a Doppler technique to show the blood flow within the blood vessels in the neck.

Magnetic Resonance Imaging (MRI)

It produces pictures of the head and inner ears using magnetic fields rather than X-rays. 

Magnetic Resonance Angiography (MRA)

MRA can produce images of the inside of arteries or veins, showing up irregularities or narrowing the vessel.

Computerised tomographic angiography (CTA)

It is done by injecting a substance that shows up on X-rays and then performing a CT scan to obtain images of the inside of blood vessels.

Computerised Tomography (CT)

This technique uses computer-controlled X-rays to generate detailed images of the body.

Angiography

Angiography is looking at the inside of vessels by injecting a contrast medium into the ear vessel under investigation and taking a conventional X-ray, which produces more explicit and more detailed pictures.

Other Investigations

Blood tests may be needed to investigate pulsatile tinnitus. The patient may also be tested for high blood pressure and given a blood test to check for thyroid disease or anaemia. If benign intracranial hypertension is suspected, the doctor may ask for a different opinion from other specialised doctors such as ophthalmologists or neurologists, who may request their technical investigations.

How is Pulsatile Tinnitus Treated?

Pulsatile tinnitus treatment involves addressing the underlying cause. High blood pressure and blood vessels conditions can usually be treated with a combination of medications and lifestyle changes, including:

• a low-sodium diet
• Exercise
• no smoking
• stress reduction

If the disease relates to a specific problem in an artery or vein, surgery or a catheter procedure can be an option to treat the condition using a stent-a flexible mesh tube placed in a blocked artery to open it and improve blood flow. 

Can Pulsatile Tinnitus Cause Complications?

Pulsatile tinnitus can cause problems such as interference in sleep. Poor sleep can lead to:

• difficulty to concentration
• low energy
• cardiovascular problems
• weight gain and other metabolism issues

What Can be Done About Pulsatile Tinnitus?

If a specific cause is diagnosed, this may point to a particular solution. For example, anaemia requires treatment with medication or blood transfusion, and glue ear can be treated with grommets. Similarly, perforations can be closed with grafts, and narrowed segments of an artery can be repaired.

There are various methods to manage tinnitus that people find helpful for people with pulsatile tinnitus who have no demonstrable abnormality. These include sound therapy, relaxation therapy, cognitive behaviour therapy (CBT), counselling, mindfulness meditation, or Tinnitus Retraining Therapy (TRT).

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Sources:

• Daneshi, A., Hadizadeh, H., Mahmoudian, S., Sahebjam, S., & Jalesi, A. (2004). Pulsatile tinnitus and carotid artery atherosclerosis. International Tinnitus Journal, 10(2), 161-164
  tinnitusjournal.com/articles/pulsatile-tinnitus-and-carotid-artery-atherosclerosis.pdf
• Hain, T. C. (n.d.). Tinnitus
  american-hearing.org/disorders/tinnitus/
• Hofmann, E., Behr, R., Neumann-Haefelin, T., & Schwager, K. (2013, June). Pulsatile tinnitus: Imaging and differential diagnosis. Deutsches Ärzteblatt International, 110(26), 451-458
  ncbi.nlm.nih.gov/pmc/articles/PMC3719451/
• Mayo Clinic Staff. (2016, February 1). Tinnitus: Symptoms and causes
  mayoclinic.org/diseases-conditions/tinnitus/symptoms-causes/dxc-20180362
• Pulsatile tinnitus. (n.d.)
  tinnitus.org.uk/pulsatile-tinnitus