Pulsatile and nonpulsatile tinnitus: a systemic approach.

Tinnitus is an annoying symptom that affects approximately 10% of the population. Unfortunately, in more than 60% of patients, even an extensive workup may not lead to diagnosis, partly because of the diverse causes of the symptom. The imaging protocol study should therefore be adapted to the history of the patient, and each imaging study should underline which etiologies it may exclude. Imaging studies should only be performed after a careful clinical examination and otoscopy. Some characteristic clinical findings are suggestive of such etiologies as pulsed synchronous tinnitus or positional tinnitus, varying with the venous pressure. History of associated neurological deficits, nerve palsies, trauma, ischemic attacks, and visual disturbance (in overweight women) may modify the imaging protocol. Study of the brain and the cervical vessels should always be included to rule out a benign intracranial hypertension. Path and size of the internal carotid artery should be systematically described with regard to the size of the jugular vein and presence of emissary veins. Objective pulsatile tinnitus and tinnitus in children always need a careful imaging study.