Neuroradiologist Reveals Truth About Pulsatile Tinnitus Treatment

Ben Thompson, AuD.

Have you ever had questions about pulsatile tinnitus? Certain sounds in the ears that may synchronize with the heartbeat or the vascular system? Today, I’m happy to share a podcast session with Dr. Athos Patsaildes, who’s a medical doctor in the state of New York. Dr. Patsalides is an internationally renowned interventional neuroradiologist and serves as the director of neuro-interventional surgery at North Shore University Hospital. He is a specialist in conditions related to neurology, surgery, and radiology, and he treats vascular conditions of the brain and the spine, including brain aneurysms, and other kinds of conditions related to the veins and the arteries. And Dr. Patsalides is here today to talk about a topic that is somewhat confusing for the medical profession, as well as for patients who are trying to navigate it, pulsatile tinnitus, Dr. Patsalides welcome, and please share us your knowledge of this condition.

Athos Patsalides, M.D.

Hello and I’m happy to have this conversation with you. I’m very passionate about patient education and I think this is a great forum for that. So the first question I think is spot on you know, what is pulsatile tinnitus? And there’s a confusion in the medical community and the patients about the difference between tinnitus or tinnitus, and some people say, and pulsatile tinnitus, and the, I think the hallmark or the major distinction is that the pulsatile tinnitus is essentially a rhythmic sound in your ear, it could be one or both ears and is synchronized with the heart rate.

And sometimes it’s difficult to know for sure if it’s synchronized with the heart rate, I ask patients to try and find the pulse in the neck or in the wrist and try to see if that works. For the most part, people understand that, the rhythm of the sound is synchronized with the heart rate, it gets worse or faster when they exert themselves and gets slower when they are like more relaxed. But again, pulsatile tinnitus, synchronized sound with the heart rate.

Ben Thompson, AuD.

And what is the difference between typical tinnitus related to hearing loss or stress-induced tinnitus or other medical conditions? What’s the difference between that and pulsatile tinnitus? Can we have both at the same time? And is a little pulsatile tinnitus okay? This is something that confuses audiologists like me, my patient reported some pulsatile tinnitus, is it enough for it to be investigated, or is a little bit of pulsatile tinnitus okay?

Athos Patsalides, M.D.

That’s an excellent question. I will start by saying that some patients can have both. The major distinction is that the majority of pulsatile tinnitus is related to a change in blood flow, close to the ear. So the ear is working fine, and it’s picking up a noise that shouldn’t be there, to begin with, versus the non-pulsatile tinnitus or the ringing tinnitus is more likely than not a problem inherent to the ear apparatus to the sound system. So, that is kind of the major distinction and there can be some overlap as you alluded to, the priority when you see a patient with pulsatile tinnitus is to exclude life-threatening problems related to blood flow prominence in the head and neck area, and that doesn’t necessarily correlate with the intensity of the pulsatile tinnitus, you can have a life-threatening problem with minimal intensity of pulsatile tinnitus, or you may have what I call a benign problem with very high intensity of pulsatile tinnitus. So the intensity does not necessarily mean that this is worrisome or not, I think every patient with pulsatile tinnitus deserves work up to at least exclude life-threatening or concerning changes in blood flow in the division of the head and neck.

Ben Thompson, AuD.

And how would you recommend to give advice to that person who’s listening? Who says, “Dr. Patsalides, that’s me, I want to come see you. Well, I might not be able to come to New York. Who should I see and what kind of questions or tests should I advocate for?”

Athos Patsalides, M.D.

There is no a 100% consensus on what test should be done first, but my personal experience, my personal preference of all these years, is to order a set of MRI scans. I think getting an MRI scan is for as part easy, safe, and accessible to, you know almost everybody these days, and it does not involve a procedure, does not involve an invasive procedure to understand if there is at least a life threatening problem. So my first thought on this, is order a test called a MRA, MRA is a type of MRI scan that looks at the arteries, hence the name MR angiogram. That will exclude most of the ominous or life-threatening problems related to the pulsatile tinnitus.

Ben Thompson, AuD.

Mm, thank you for that, and now let’s give a big perspective, today we’re going to talk about, as we have so far, diagnosing it correctly, and certain tests, objective tests can help you, the medical doctor, accurately diagnose that. Now, I want to hear some stories about how that has changed people’s lives and some of the most common diagnoses that are treatable, and then later we can talk about the different treatment options. As we know, tinnitus is a tricky medical conditions. Sometimes there is no hard and fast, quick, cure treatment, however, there are ways to manage it. So I want to hear a bit about how you approach treatment and management based on the different diagnosis. But if you can, I know that in this field, as medical professionals, one of the gifts, is to be able to work with people who come in thinking, “Hey, other people have told me there’s nothing they can do.” And then after some time, being able to change the tinnitus and change their life. So, what are your thoughts on those experiences? What kind of help do people get? What are the common diagnoses that you’re finding and you’re helping?

Athos Patsalides, M.D.

I will start by the last part of your question, and I would say that, a lot of patients, and I think this has to do with lack of good education in the medical community, also, they don’t get the workup they deserve. They are told, “Oh, everybody has tinnitus, don’t worry about it.” And again, pulsatile tinnitus and non-pulsatile or regular tinnitus are different problems. So, I think, yes, there are many patients that are for years not properly assessed, or they don’t, are not recommended to have the proper workup. I think this is changing slowly because, mostly because of patient education, I think patients now insist on getting certain tests prescribed, as opposed to a few years ago, in terms of what, you know, how you approach this problem, I’ll say what I say to my patients in the office, there’s basically three big categories of problems that can cause pulsatile tinnitus. The first is like the serious, potentially life threatening problems that essentially involve abnormal blood flow in the area of the ear or in the area of the skull, that can affect the brain eventually, if left untreated, these are thankfully infrequent, but they are the first things that need to be ruled out there’s something called dural fistula something called AVM, Arteriovenous malformation, these are the main ones that we’re concerned about. Then is the second category, what I call benign problems of pulsatile tinnitus, and these are changes in blood flow that can result in pulsatile tinnitus, but they are not life threatening problems. They’re not going to cause a stroke, they’re not going to cause a brain bleed, and the decision to treat these depends on the impairment and quality of life. If somebody has a benign problem that cause pulsatile tinnitus, but the pulsatile tinnitus is not that debilitating, then we can just observe this problem and treat if things worse in the future. And these are problems typically from veins, something called venous stenosis, something called venous aneurysm, these, or both may often coexist, and this is something I treat a lot and I maybe will discuss a little bit later more about this. But again, this is the second category benign problems that are treatable if the pulsatile tinnitus is stability. And then the third category, is the category that nobody likes is the, are the vague causes of pulsatile tinnitus. There is no obvious vascular problem, and then this can be the pulsatile tinnitus could be related to neuromuscular problems, inflammation in the area of the ear, problems of hearing nerves, problems of the ear system, problems of the temporal bone that encases the ear. So these are like nonvascular problems, sometimes difficult to identify and difficult to treat, and with these problems, there is some overlap with the regular tinnitus, as well as the somatosensory tinnitus. So, the third category is the least gratifying for a vascular or cerebrovascular doctor like me, but obviously some patients belong to that category.

Ben Thompson, AuD.

And in your ideal medical system when the patient gets the right test, the doctor has the right training, and can help the patient to the best of their abilities, what is the success rate of helping or reducing pulsatile tinnitus from your experience?

Athos Patsalides, M.D.

I think that depends on two things. First, it depends on the diagnosis, and understanding the diagnosis correctly. And secondly, it depends on the experience of the surgeon or the physician, obviously. I would say that in, at least in my experience, a patient with a condition called dural arteriovenous fistula, that’s part of the first category of problems, I think the success rate is 100%. If you identify the problem and you know how to treat it, treatment is endovascular, meaning minimally invasive, then this access rate is essentially 100%. You eliminate the problem that causes the pulsatile tinnitus. Another common problem, probably the most common in my practice, and now that we realize this is the most common cause of pulsatile tinnitus in young women, it’s the venous problems, the venous stenosis and the venous aneurysm, and this is what I realized like five, six years ago, that is more prevalent than anybody ever thought, I started seeing this patients, and I realized that there is a need for understanding this problem and treating it effectively. But actually I never expected that it’s so prevalent. It is much more common than we ever thought. This problem is treatable, this is in the second category in the benign category of problems. And again, it’s young women, 20, 30, 40 years olds that seek help because the sun is so debilitating that affects, you know, the quality of daily life, the social life, professional life. Treatment is also done with a minimal invasive procedure, calls Venous Stenting that I developed for this group of patients, again five years ago, and the success rate, based on a clinical trial that I conducted, and also based on my experience since, it’s in the order of 98%. So, the success rates are very high, and when I say success, I mean resolution or near complete resolution of the pulsatile tinnitus, but again, this depend on making, you know, the accurate diagnosis, understanding the problem and training it very safely. Again, this is quality of life problem sometimes we have to be very, very safe ’cause, you know, you cannot substitute a quality of life problem, with a disability caused by treatment. So, patients have to be very careful with this.

Ben Thompson, AuD.

Yeah, thank you for that. So you’ve laid out some of the information here with how to diagnose with certain tests, what are the most common diagnoses in your experience, and what’s the effectiveness of different treatments. So this video, this podcast can serve as a guide as an introduction to someone who may be hearing the sound change with their heart rate, and wondering, “Hmm, what can I do?” I’m sure you have spent many, many hours counseling patients, working people through the process, as I know, as an audiologist, Dr. Ben Thompson here with Treble Health, is that, I help patients who have the primary or the more common type of tinnitus, which may be related to the ears or the stress induced systems, or other somatic types of causes. Now, what I know is tinnitus is very much a psycho emotional process, and it’s something that often takes a lot of time to figure out, hopefully with the help of a professional like us, what are some other common patterns, conversations, counseling that you have with your patients who come to see you in the clinic?

Athos Patsalides, M.D.

So I would say that the, just to lay it out there for the people who watch this podcast to be clear on this, is that the workup requires, in my practice at least, is that test called MRA to look at the arteries, and the test called MRV, which is an MRI to look at the veins, and assess them by an ENT or audiologist. I think an audiogram is very important because you want to make sure that the hearing is intact or almost intact when you’re evaluating a patient with pulsatile tinnitus. So, these three tests are, I ask for every patient. Now, in terms of what are the direct signs or what is the patient experience when they try to figure out what they have? I think it’s important to understand or try to understand if they have pulsatile versus the regular tinnitus. They can try a few different things. One is it to feel their pulse and see if that sound matches with, the rate of their pulse, matches the rate of the rhythm of the sounds that they hear. Sometimes patients with venous problems, if they press on their neck with gently on the side of the pulsatile tinnitus, it may resolve or almost resolve, this happens because by pressing on the jugular vein in the neck, you change the blood flow in the vein that is causing the pulsatile tinnitus. So that’s a very telling sign of having pulsatile tinnitus from a venous cause, and again, another issue is the changes of the intensity and the rate of pulsatile tinnitus with exertion versus relaxation, ’cause as the blood pressure and the heart rate change, when somebody exerts themselves, then the opposite can happen when they relax and the pulsatile tinnitus rhythm goes along those changes. I think what I learned over years from patients is that, sometimes you have to insist on getting the workup you deserve. And it’s true that not everybody can come to New York, or travel out of States, even though the, you know, with Telehealth, a lot of these options are much easier today, but I think patients should insist even with their primary doctors that we need to get tested for certain things, you know, the pulsatile tinnitus is not okay to have, at least further things need to be, certain things need to be ruled out, and some of these things are very important to be ruled out for the overall health of the patient. So, I think this is my message is, you know, continue asking for the proper workup. And I think there is improvement in the last few years but again, mostly because of patient education, and the patient support groups, but there’s a lot more to be done. But at the end of the day, every patient pulsatile tinnitus needs a minimum workup, MRA, MRV, audiogram.

Ben Thompson, AuD.

Thank you for that, thank you so much. And one thing that I have come across helping patients with tinnitus in different places, sometimes they live in a rural community, and what I have found is a helpful tool is to recommend to have a full workup of your pulsatile tinnitus contact the largest university medical center within your area and ask them, “Do you have services for pulsatile tinnitus?” I found that that’s successful of seeking the a city, seeking an urban medical center, oftentimes there’s a concentration of qualified doctors there, would you agree with that?

Athos Patsalides, M.D.

Well, I think at the very minimum they should be able to get good quality imaging and good quality workup. I think that very few doctors specialize in pulsatile tinnitus seriously, meaning understanding the nuances of the real problems, when to treat, when to observe, you know, the ramifications of treatment, not every patient with a vascular change who has pulsatile tinnitus need surgery minimal invasive or not. This is a decision that depends on, you know, the risk of having that condition that causes pulsatile tinnitus as well as the potential risk of treatment, and the expertise of the surgeon and as you alluded earlier, there are a lot of patients that will don’t need to necessarily need surgery, they need reassurance, I think that’s key, reassure a patient that, “Yes you hear your heart within your ear, but there is no condition that is life threatening or that is ominous for you.” So that’s, I think that goes a long way. And then, there’s other other means like sound masking, psychological support, there is sometimes the hearing aids help, or even, you know there are patients that I’ve seen that benefited from physical therapy for neck or vestibular physical therapy. So, it doesn’t mean that patients necessarily are going to end up having surgery, I would probably say the majority of patients do not need surgery and they need other other treatments, but yes, at least at the very least, they should have proper workup and I think in a urban setting, or in a big university setting, hospital setting, that should be done, and then, then it’s also easy for them to get second opinions, reach specialists even if they’re far.

Ben Thompson, AuD.

Thank you, Dr. Patsalides, and my final question is, what about pulsatile tinnitus, related to eustachian tube dysfunction, does eustachian tube problems between the back of the nose and the throat and the behind the ear, does that ever lead to pulsatile tinnitus but it’s not a dangerous type?

Athos Patsalides, M.D.

I think there are ENT problems that lead to pulsatile tinnitus, that are not necessarily easy to understand, or easy to pinpoint to, and I think eustachian tube is one. Like TMJ is another, but is really not easy to understand why a joint problem will result in pulsatile tinnitus. I think both of these problems, the eustachian tube and and TMJ, yes, are not dangerous problems to have. I think they result in pulsatile tinnitus because they may increase sensitivity to certain frequencies that, you know, result in overhearing like normal blood flow, perhaps. But yes, it’s possible and it’s not a dangerous problem.