Pulsatile tinnitus: A harbinger of a greater ill?

Background. Pulsatile tinnitus is an uncommon otologic symptom, which may be the presenting complaint of a potentially devastating pathology. Understanding this manifestation as a possible symptom of a significant vascular abnormality is crucial to guide management and treatment. Methods and Results. We describe a 38‐year‐old woman with sudden‐onset right‐sided pulsatile tinnitus. A right extracranial internal carotid artery (ICA) dissection was diagnosed with MRI/magnetic resonance angiography (MRA) and treated with anticoagulation. Follow‐up MRI/MRA demonstrated complete resolution. Two months later, left‐sided pulsatile tinnitus evolved. An MRI/MRA of the neck demonstrated left‐sided extracranial ICA dissection. She was treated in a similar fashion and a repeat MRI/MRA demonstrated its resolution. Conclusion. Spontaneous extracranial ICA dissection may present with pulsatile tinnitus as the only symptom in 4% to 50% of patients. Subsequent evolution of a contralateral dissection is even more uncommon. Generally, treatment of this phenomenon is conservative utilizing anticoagulation or aspirin; however, surgical intervention may be necessary. © 2008 Wiley Periodicals, Inc. Head Neck 2009