If you hear a rhythmic whooshing or thumping sound in your ear that matches your heartbeat, you are likely dealing with pulsatile tinnitus. This is not the same as regular tinnitus — that constant ringing or buzzing millions of people experience. Pulsatile tinnitus causes are different because they almost always point to a real, physical source. Blood flowing near or through structures in your ear creates an actual sound your brain picks up. About 3 to 5 percent of all tinnitus cases are pulsatile, according to research published in the Journal of Vascular and Interventional Neurology. That might sound small, but it translates to millions of Americans, many of them over 60.
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The distinction matters. Regular tinnitus is usually caused by hearing nerve damage. Pulsatile tinnitus is caused by changes in blood flow. That means doctors can often find the source. And in many cases, they can treat it.
What Is the Most Common Cause of Pulsatile Tinnitus
So what is the most common cause of pulsatile tinnitus? In most patients over 60, it comes down to atherosclerosis — the buildup of fatty deposits inside artery walls. When plaque narrows arteries near the ear, blood has to push through a tighter space. That creates turbulent flow. Turbulent flow makes noise. Your ear picks it up.
The carotid artery runs right alongside the middle ear structures. Even a modest amount of plaque in the carotid can produce a sound loud enough to hear, especially at night when everything else is quiet.
A 2019 study in Otology & Neurotology found that among patients over 55 presenting with pulsatile tinnitus, atherosclerotic changes in the carotid or vertebral arteries were identified in roughly 40 percent of cases. That makes it the single most frequent identifiable cause in older adults.
High Blood Pressure
Hypertension is the second most common contributor. When blood pressure is elevated, blood moves through vessels with more force. More force means more turbulence. More turbulence means more audible blood flow. About 65 percent of Americans aged 60 and older have hypertension, per CDC data. Many of them don’t know their blood pressure is poorly controlled because they feel fine otherwise — until they start hearing that rhythmic pulse in one or both ears.
Margaret, a 68-year-old retired teacher in Ohio, told her ENT she’d been hearing a “whoosh-whoosh” sound for three months. Her blood pressure in the office measured 168/94. After adjusting her medication, the sound reduced by about 80 percent within six weeks. No procedure needed.
Anemia and Blood Viscosity Changes
When your blood is thinner than normal — which happens with iron-deficiency anemia — it flows faster and more turbulently. Anemia is surprisingly common in adults over 60. The World Health Organization estimates it affects about 24 percent of older adults globally. In someone with anemia, the heart pumps harder to compensate for reduced oxygen-carrying capacity. That extra cardiac output pushes blood through ear-adjacent vessels with enough force to generate an audible pulse.
A simple complete blood count (CBC) can identify this. If iron levels are low, supplementation or dietary changes often resolve the pulsatile tinnitus within weeks.
Vascular Causes of Pulsatile Tinnitus
Beyond atherosclerosis, several specific vascular abnormalities cause pulsatile tinnitus. These are less common individually but important to rule out because some require intervention.
Dural Arteriovenous Fistula
A dural arteriovenous fistula (DAVF) is an abnormal connection between an artery and a vein in the covering of the brain. Blood bypasses the capillary bed entirely and flows directly from high-pressure artery into low-pressure vein. That creates a loud, pulsatile sound.
DAVFs account for roughly 2 to 3 percent of all pulsatile tinnitus cases. They are more common after age 50 and slightly more common in women. The concern here is that some DAVFs can cause neurological problems or even hemorrhage if left untreated. Treatment typically involves endovascular embolization — a catheter-based procedure performed by interventional neuroradiologists.
Sigmoid Sinus Abnormalities
The sigmoid sinus is a large venous channel that drains blood from the brain. It runs directly behind the ear. In some people, the bony wall separating the sigmoid sinus from the middle ear is thin or has a gap (dehiscence). When that happens, you hear blood flowing through the sinus with every heartbeat.
CT imaging of the temporal bone can identify sigmoid sinus dehiscence or diverticulum. A diverticulum is a small outpouching of the sinus wall. Both conditions are well-documented pulsatile tinnitus causes in the medical literature. Surgical repair is an option when symptoms significantly affect quality of life.
Carotid Artery Stenosis
Narrowing of the carotid artery by 50 percent or more can produce an audible bruit — a turbulent sound that travels to the ear. This is closely related to atherosclerosis but represents a more advanced stage. Carotid stenosis is concerning beyond the tinnitus itself because it raises stroke risk. An ultrasound of the carotid arteries (carotid duplex) is a simple, non-invasive test that can measure the degree of narrowing.
About 5 to 10 percent of adults over 65 have significant carotid stenosis according to population studies. Not all of them will have pulsatile tinnitus, but when the narrowing is near the ear, the sound can be prominent.
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Pulsatile Tinnitus in One Ear Only
When someone experiences pulsatile tinnitus in one ear only, it usually means the problem is localized to one side of the head. This is actually helpful diagnostically because it narrows down where doctors need to look.
Unilateral pulsatile tinnitus — meaning just one ear — is more likely to have an identifiable structural cause compared to bilateral cases. A 2020 retrospective review in the American Journal of Neuroradiology found that patients with pulsatile tinnitus in one ear only had a treatable cause identified on imaging in approximately 57 percent of cases.
Common causes of one-sided pulsatile tinnitus include:
Sigmoid sinus diverticulum or dehiscence on that side. Carotid artery stenosis on the affected side. A glomus tumor (paraganglioma) in the middle ear. Dural arteriovenous fistula draining on one side. Aberrant internal carotid artery.
Glomus Tumors
Glomus tumors — also called paragangliomas — are slow-growing vascular tumors that arise in the middle ear or jugular bulb area. They are benign in the vast majority of cases (less than 5 percent are malignant). But they are highly vascular, meaning blood flows through them abundantly. That blood flow creates a pulsatile sound.
A glomus tympanicum sits right in the middle ear. On examination, a doctor may see a reddish mass behind the eardrum. These tumors are more common in women and typically present between ages 50 and 70. Treatment options include surgical removal, radiation therapy, or observation depending on size and patient factors.
Robert, a 72-year-old man in Texas, noticed a pounding sound in his left ear that had been gradually increasing over a year. His primary care physician looked in his ear and saw a reddish discoloration behind the eardrum. CT and MRI confirmed a glomus jugulare tumor. After radiation therapy, the pulsing sound decreased substantially over the following months.
Less Common Pulsatile Tinnitus Causes
Idiopathic Intracranial Hypertension
Idiopathic intracranial hypertension (IIH) means elevated pressure of the cerebrospinal fluid around the brain without a tumor or other obvious cause. It used to be called pseudotumor cerebri. IIH is more common in younger overweight women, but it does occur in older adults as well.
The elevated pressure compresses venous sinuses, creating turbulent flow that the ear picks up. Pulsatile tinnitus is one of the most common symptoms of IIH — reported by about 52 to 65 percent of patients with the condition according to published case series. Other symptoms include headaches that worsen when lying down, vision changes, and neck stiffness.
Diagnosis involves measuring opening pressure during a lumbar puncture. Treatment includes weight loss, the medication acetazolamide (which reduces fluid production), and in some cases, a shunt procedure.
Thyroid Disease
Hyperthyroidism — an overactive thyroid — increases cardiac output and heart rate. More blood flowing faster through the same vessels means more opportunity for turbulence and audible flow. Thyroid disease is diagnosed with a simple blood test (TSH, free T4). Treatment with medication, radioactive iodine, or surgery typically resolves the associated pulsatile tinnitus.
Abnormal Jugular Bulb
The jugular bulb is the beginning of the internal jugular vein, located just below the middle ear. In some people, the jugular bulb sits higher than normal (high-riding jugular bulb) or protrudes into the middle ear space. When this happens, turbulent venous blood flow becomes audible. High-resolution CT of the temporal bone can identify this variant. It is found incidentally in about 3 to 6 percent of temporal bone CT scans.
How Doctors Diagnose Pulsatile Tinnitus Causes
The diagnostic workup for pulsatile tinnitus is more involved than for regular tinnitus. Because the causes are structural and vascular, imaging is usually necessary.
Physical Examination
The first step is a thorough ear examination. A doctor may be able to hear the pulsatile sound using a stethoscope placed near the ear or on the neck. If the doctor can hear it, that confirms it is objective pulsatile tinnitus — meaning the sound is real and measurable, not just perceived by the patient.
The doctor will also check blood pressure, listen to the carotid arteries for bruits, examine the eardrum for masses or vascular anomalies, and test hearing.
Imaging Studies
CT angiography (CTA) and MR angiography (MRA) are the primary imaging tools. CTA provides excellent detail of bone and vessels. MRA avoids radiation and is better for soft tissue and venous structures. Many specialists order both.
High-resolution CT of the temporal bone is particularly useful for identifying sigmoid sinus abnormalities, jugular bulb variants, and glomus tumors. Digital subtraction angiography (DSA) — a catheter-based test — remains the gold standard for diagnosing dural arteriovenous fistulas, though it is invasive and typically reserved for cases where non-invasive imaging is inconclusive.
A 2021 study in Radiology found that when a comprehensive imaging protocol was used (including both CTA and MRI/MRA), a definitive cause of pulsatile tinnitus was identified in 70 percent of patients. Without complete imaging, many causes go undetected.
Blood Work
Basic labs should include a complete blood count to check for anemia, thyroid function tests, and a metabolic panel. These are inexpensive, widely available tests that can identify easily treatable causes.
When Pulsatile Tinnitus Is an Emergency
Most pulsatile tinnitus is not an emergency. But certain scenarios require urgent evaluation.
If pulsatile tinnitus starts suddenly along with severe headache, weakness on one side of the body, vision loss, or difficulty speaking — that could indicate a stroke or vascular dissection. Call 911 immediately.
If pulsatile tinnitus is accompanied by progressive hearing loss, facial weakness, or neurological symptoms, same-week evaluation is warranted. A dural arteriovenous fistula with cortical venous drainage carries a hemorrhage risk of 8 to 10 percent per year according to published natural history studies. That’s high enough to justify urgent workup and treatment.
Treatment Options for Pulsatile Tinnitus
Treatment depends entirely on the cause. This is not a condition where one approach fits everyone.
Medical Management
If high blood pressure is the culprit, optimizing antihypertensive medications often resolves symptoms. If anemia is driving it, iron supplementation works. If hyperthyroidism is the cause, treating the thyroid normalizes blood flow.
For idiopathic intracranial hypertension, acetazolamide reduces cerebrospinal fluid production and lowers intracranial pressure. Weight loss of even 5 to 10 percent of body weight has been shown to significantly improve IIH symptoms.
Endovascular Procedures
For dural arteriovenous fistulas, endovascular embolization — threading a catheter through the femoral artery up to the brain and blocking the abnormal connection — has a success rate of 70 to 90 percent depending on the type and location of the fistula.
For sigmoid sinus diverticulum, endovascular coiling or stenting can reduce or eliminate the pulsatile sound. These procedures are performed by interventional neuroradiologists at specialized centers.
Surgical Options
Sigmoid sinus wall reconstruction involves placing bone wax, fascia, or bone graft over the dehiscent area to block sound transmission. Published case series report symptom resolution in 80 to 95 percent of patients.
Glomus tumor removal is a surgical procedure performed by neurotologists. For small tumors confined to the middle ear, outcomes are excellent with low complication rates.
Observation
Not every case needs intervention. If the cause is a benign anatomical variant (like a slightly high-riding jugular bulb) and the sound is mild, some patients choose to live with it. Sound masking devices and cognitive behavioral therapy can help manage the perception of the sound when treatment is not indicated or desired.
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Common Mistakes People Make With Pulsatile Tinnitus
The biggest mistake: assuming pulsatile tinnitus is the same as regular tinnitus and doing nothing about it. Regular tinnitus rarely has a dangerous underlying cause. Pulsatile tinnitus sometimes does. Ignoring it can mean missing treatable conditions like carotid stenosis (stroke risk) or dural fistulas (hemorrhage risk).
Second mistake: seeing only an audiologist. Audiologists are essential for regular tinnitus management, but pulsatile tinnitus often requires vascular imaging and specialist evaluation by an ENT, neurotologist, or interventional neuroradiologist. An audiogram alone will not identify the cause.
Third mistake: incomplete imaging. A standard brain MRI without angiography sequences will miss most vascular causes. Patients need to advocate for CT angiography or MR angiography specifically focused on the temporal bone and head/neck vasculature.
Fourth mistake: not mentioning that the sound is rhythmic or matches the heartbeat. Some patients just say “ringing in my ear” and get treated for regular tinnitus. The pulsatile quality is the key detail that should change the entire diagnostic approach.
Living With Pulsatile Tinnitus After 60
For those who have been thoroughly evaluated and either have a benign cause or have completed treatment, managing residual symptoms is important for quality of life.
White noise machines at night can mask the sound enough to allow sleep. Pillow speakers that play gentle ambient sound work well for many people. Regular cardiovascular exercise — approved by your doctor — helps maintain healthy blood flow patterns and can reduce the perception of the sound.
Stress and caffeine don’t cause pulsatile tinnitus, but they can make it louder temporarily by increasing heart rate and blood pressure. Reducing both may help with symptom intensity even if they don’t address the root cause.
Support groups exist, both online and in-person. The condition can feel isolating because it is invisible to others. Connecting with people who understand the experience helps psychologically. The Pulsatile Tinnitus Foundation and Whooshers.com are resources specifically for this community.
What to Tell Your Doctor
When you go in for an appointment about pulsatile tinnitus, be specific. Tell them the sound pulses with your heartbeat. Tell them which ear it’s in. Tell them if it changes when you press on your neck, turn your head, or lie down. All of these details help narrow the cause.
If your doctor dismisses the concern or prescribes hearing aids without imaging, consider getting a second opinion from a neurotologist — an ENT subspecialist trained specifically in ear-related neurological conditions. Pulsatile tinnitus causes are identifiable in the majority of cases when proper imaging is performed. You deserve that workup.
Understanding the causes of pulsatile tinnitus gives you the ability to have informed conversations with your medical team. Whether the source turns out to be high blood pressure, a vascular anomaly, or something else entirely, identifying pulsatile tinnitus causes early leads to better outcomes. If you found this article helpful, share it with someone who might be experiencing the same symptoms. And if you’re a Bing user, bookmark this page so you can return to it as you navigate your diagnostic journey.
