When you hear a rhythmic thumping, whooshing, or pounding sound inside your ear that seems to follow the beat of your heart, you are experiencing pulsatile tinnitus. This symptom is different from the more common forms of tinnitus, which typically present as a constant ringing, buzzing, or hissing noise that does not have a discernible rhythm. The rhythmic nature of pulsatile tinnitus is its defining characteristic, making it feel like a live soundtrack of your body’s circulation.
The experience can be unsettling because the noise is often perceived as loud and persistent, especially in quiet environments. Unlike non-pulsatile tinnitus, this rhythmic form frequently has a specific, identifiable physical cause. The presence of a pulse-synchronous sound points directly toward a mechanical or vascular origin near the ear. Because a physical cause is often found, a thorough medical evaluation is important to identify the source and determine the appropriate management plan.
Understanding Pulsatile Tinnitus
The perception of a thumping sound results from an internal sound being generated near the middle and inner ear and amplified to a detectable level. This sound is closely tied to the body’s vascular structures, specifically major arteries and veins. The resulting noise is rhythmic because it originates from the flow of blood, which naturally pulses with each heart contraction.
Pulsatile tinnitus is categorized into two types: subjective and objective. Subjective means only the patient can hear the sound. Objective pulsatile tinnitus is rarer, occurring when a medical professional can also hear the sound, usually by placing a stethoscope over the patient’s neck or near the ear.
The most common mechanical source is turbulent blood flow in vessels near the ear. When blood flow is disrupted, it creates a noisy, rushing sound, similar to water moving through a constricted pipe. This turbulence can be caused by a narrowing in a vessel, an increase in the volume or velocity of blood flow, or a structural anomaly that places a vessel closer to the hearing mechanism.
A separate, non-vascular mechanism can also cause a rhythmic or rapid thumping, though it is not always pulse-synchronous. This involves middle ear muscle spasms, known as myoclonus, affecting small muscles like the tensor tympani or stapedius. These involuntary contractions produce a rapid, clicking or thumping sound.
Primary Conditions Causing the Thumping
The underlying causes of pulsatile tinnitus are grouped based on whether they involve the vascular system, structural anatomy, or muscular function. Vascular issues are the most frequent cause, involving changes in the speed, volume, or smoothness of blood flow through the vessels of the head and neck.
Vascular Issues
Conditions causing turbulent blood flow are often located in the carotid artery or the large venous sinuses within the skull. Atherosclerosis, the narrowing of arteries due to plaque buildup, can disrupt smooth blood flow, leading to an audible whooshing sound synchronized with the pulse. High blood pressure (hypertension) also increases the force and velocity of blood flow, making circulation sounds more noticeable.
Certain conditions affect the large veins that drain blood from the brain. Transverse or sigmoid sinus stenosis, a narrowing of these venous channels, creates localized turbulence and pressure changes transmitted as a pulsing noise. Another cause is arteriovenous malformations (AVMs), abnormal tangles of arteries and veins that cause high-pressure blood flow, generating significant turbulence.
Structural/Anatomical Issues
Some cases result from anatomical variations or defects that remove the protective barrier between the vascular and auditory systems. Sigmoid sinus wall dehiscence involves a thinning in the bone separating the sigmoid sinus (a large vein) from the middle ear. This bony gap allows the sound of blood flow to be more easily conducted to the hearing apparatus.
A related structural variation is a high jugular bulb, where the top portion of the jugular vein sits abnormally high near the middle ear. Superior semicircular canal dehiscence (SSCD) is a defect in the bone overlying one of the inner ear canals. This defect makes the inner ear more sensitive to internal sounds, including the pulse, pressure changes, and loud external noises.
Muscular Issues
A different category of non-vascular causes involves the involuntary movements of muscles within or near the ear. Middle ear myoclonus is characterized by rapid, repetitive spasms of the tensor tympani or stapedius muscles. These spasms create a rapid, non-pulse-synchronous clicking or thumping sound. Another related condition is palatal myoclonus, where muscles in the roof of the mouth spasm, and the clicking sound travels up the Eustachian tube into the ear.
Medical Evaluation and Treatment Approaches
A medical evaluation begins with a detailed history to confirm the sound is synchronous with the patient’s pulse. The physical examination includes auscultation, where a doctor uses a stethoscope over the ear, neck, and mastoid bone to check for an objective sound, called a bruit. Simple maneuvers, such as gently pressing on the jugular vein, can provide clues, as a temporary reduction in sound may suggest a venous cause.
Imaging is a necessary step to pinpoint the source of the thumping. Computed tomography (CT) scans visualize the bony anatomy of the temporal bone to detect structural issues like dehiscence or an abnormally positioned jugular bulb. Magnetic resonance imaging (MRI) is often combined with magnetic resonance angiography (MRA) or venography (MRV) to visualize blood vessels and soft tissues, helping identify tumors, aneurysms, or flow abnormalities.
Treatment depends entirely on the underlying cause identified during the evaluation. For vascular causes like high blood pressure or atherosclerosis, management involves medication to control hypertension and reduce cardiovascular risk factors. For venous issues, such as severe venous sinus stenosis, a minimally invasive procedure like venous stenting may be used to widen the vessel and restore smooth blood flow.
If the thumping is caused by a structural defect, such as a dehiscence, surgical repair may be an option to patch the bony defect. In cases of middle ear myoclonus, certain medications may be prescribed to reduce the muscle spasms. Consulting with a specialist like an otolaryngologist or a neuro-otologist is important for finding a definitive diagnosis and appropriate treatment.