skip to main content

Pulse-synchronous pulsatile tinnitus — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardMRIPulse-synchronous pulsatile tinnitusMSRA

A 61-year-old man presents with 4 months of right-sided pulse-synchronous tinnitus. It is continuous, matches his radial pulse and is more noticeable at night. He has no headache, visual disturbance, focal neurological symptoms, vertigo or hearing loss. Otoscopy is normal, with no retrotympanic mass. Pure-tone audiometry is normal and symmetrical. He has a dual-chamber pacemaker with an abandoned lead; the regional MRI safety team confirms that MRI cannot be undertaken. What is the most appropriate imaging investigation?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Arrange contrast-enhanced CT of the head, neck, temporal bones and internal auditory meati

Explanation lettering: D = shown as A · C = shown as B · B = shown as C · E = shown as D · A = shown as E

This is pulse-synchronous pulsatile tinnitus, for which imaging is indicated even when otoscopy, audiometry and neurological examination are normal. In a person with normal clinical examination and audiological assessment, NICE recommends MRI/magnetic resonance angiography of the head, neck, temporal bone and internal auditory meati as the preferred investigation. However, MRI has been confirmed as contraindicated in this patient because of his pacing system and abandoned lead. The appropriate alternative is therefore contrast-enhanced CT covering the head, neck, temporal bones and internal auditory meati. A is incorrect because the absence of focal signs does not remove the indication to investigate synchronous pulsatile tinnitus. B and E are inappropriate because MRI-based imaging cannot be performed. C is initially attractive because temporal-bone CT is appropriate when an osseous or middle-ear lesion, such as a glomus tumour, is suspected. Here, normal otoscopy, absence of a retrotympanic mass and normal symmetrical hearing make that limited protocol insufficient. The broader contrast-enhanced CT protocol is needed when MRI-based vascular and soft-tissue imaging is unavailable.

Reference: NICE NG155: Tinnitus: assessment and management — Imaging: pulsatile tinnitus (2020) — https://www.nice.org.uk/guidance/ng155/chapter/Recommendations NICE NG155: Tinnitus: assessment and management — Imaging: pulsatile tinnitus (2020) — https://www.nice.org.uk/guidance/ng155/chapter/Recommendations