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Synchronous pulsatile tinnitus — MSRA MCQ

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ModerateMRISynchronous pulsatile tinnitusMSRA

A 52-year-old woman reports a 6-month history of a constant right-sided low-pitched noise that occurs in time with her heartbeat. It is not altered by jaw movement. She has no hearing loss, vertigo, otalgia, headache, visual symptoms, focal neurological symptoms or recent head injury. Otoscopy, cranial nerve examination and fundoscopy are normal. Audiological assessment is normal. There is no clinical suspicion of a middle-ear mass or temporal-bone abnormality, and she can undergo MRI. Which is the most appropriate next imaging investigation?

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Correct answer: D — Arrange magnetic resonance angiography or MRI of the head, neck, temporal bones and internal auditory meati

This is synchronous pulsatile tinnitus because the perceived sound is time-locked to the heartbeat. NICE recommends imaging for pulsatile tinnitus. In synchronous pulsatile tinnitus with normal clinical examination and audiological assessment, the recommended investigation is magnetic resonance angiography (MRA) or MRI of the head, neck, temporal bone and internal auditory meati (IAM). The normal otoscopy and absence of features suggesting a middle-ear or osseous lesion are important discriminators. Contrast-enhanced CT of the temporal bone is the preferred initial investigation when an osseous or middle-ear abnormality is suspected, for example a glomus tumour. In this case, MRI/MRA is suitable and provides the appropriate wider assessment for vascular and soft-tissue causes. MRI of the IAM alone is used in selected non-pulsatile unilateral tinnitus presentations or suspected retrocochlear disease, but is too limited here. MRI of the brain alone does not assess the full recommended anatomical territory. Non-contrast temporal-bone CT is not the NICE pathway for synchronous pulsatile tinnitus with normal examination and audiology. Contrast-enhanced CT of the head, neck, temporal bones and IAM is an appropriate alternative if MRI/MRA cannot be performed, rather than the first choice in this patient.

Reference: NICE NG155: Tinnitus: assessment and management — Recommendations, section 1.4.9 (11 March 2020) — https://www.nice.org.uk/guidance/ng155/chapter/Recommendations NICE NG155: Tinnitus: assessment and management — Rationale and impact, imaging to investigate pulsatile tinnitus (11 March 2020) — https://www.nice.org.uk/guidance/ng155/chapter/Rationale-and-impact