# Tinnitus > Tinnitus for FMGE ENT: pulsatile versus subjective, glomus tumour, palatal myoclonus, salicylate ototoxicity, schwannoma red flags and retraining therapy. - Canonical URL: https://prepelephant.com/topics/fmge/ent/tinnitus-fmge - Exam / course: FMGE · Subject: ENT - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Tinnitus", PrepElephant, https://prepelephant.com/topics/fmge/ent/tinnitus-fmge ## Direct answer Pulsatile tinnitus is never to be dismissed: it means a real, usually vascular sound — a glomus tympanicum tumour, an arteriovenous fistula, a high jugular bulb or carotid stenosis — and it warrants imaging. Ordinary subjective tinnitus, the perception of sound without an external source, accompanies cochlear disease of every kind, most often presbycusis, noise injury and Meniere disease. Management rests on explanation, sound enrichment and cognitive behavioural therapy or tinnitus retraining, with hearing aids when loss exists; the crucial triage rule is that unilateral tinnitus or tinnitus with asymmetric hearing loss needs MRI to exclude vestibular schwannoma. ## What you must remember - Subjective tinnitus (only the patient hears it) is the common sort; objective tinnitus (audible to the examiner too) is vascular or muscular and always has an anatomical cause. - Pulsatile, synchronous with the pulse: think glomus tympanicum or jugulare (paraganglioma — a red mass behind the drum, "rising sun" appearance, blanches on pressure with pneumatic speculum), carotid artery stenosis or dissection, dural arteriovenous fistula, anaemia or thyrotoxicosis, and a dehiscent high jugular bulb. - Rhythmic clicking, non-pulsatile: palatal myoclonus (tensor veli palatini) or middle-ear myoclonus (tensor tympani, stapedius) — audible to the examiner as clicking with palatal twitching. - Unilateral tinnitus, asymmetric hearing loss or tinnitus with poor speech discrimination mandates gadolinium MRI of the internal auditory meatus — vestibular schwannoma until excluded. - Drug causes to list: high-dose salicylates and other NSAIDs (usually reversible on withdrawal), quinine, aminoglycosides, loop diuretics and cisplatin. - Meniere tinnitus is typically low-pitched and roaring, fluctuating with attacks; presbycusic and noise-related tinnitus is high-pitched hissing — the pitch pairs with the disease. - Management ladder: explanation and education, avoiding silence with sound enrichment (maskers, ambient noise), hearing aids for underlying loss, cognitive behavioural therapy and tinnitus retraining therapy (TRT); no drug has strong evidence for chronic tinnitus. ## Working through unilateral tinnitus Reason through the clinic pathway. A 55-year-old man reports six months of a high-pitched hiss in the left ear, now with mild hearing difficulty on the telephone. Step one: characterise the sound — is it pulsatile? He says no, it is constant. Step two: examine — otoscopy for a red mass behind the drum (glomus), a normal drum both sides here; check the neck for bruits, and auscultate the ear and neck, listening for objective sound. Step three: audiometry. Suppose it shows an asymmetric left high-frequency loss, 15 dB worse than the right. That asymmetry, not the tinnitus pitch, decides the next step: MRI of the internal auditory meatus with gadolinium, because a small vestibular schwannoma produces exactly this picture — progressive unilateral tinnitus with high-frequency loss and reduced discrimination. If imaging is clear, management shifts to reassurance, sound enrichment and a hearing aid if the loss warrants it, plus protection from further noise. Contrast the other patients in the same session. A young woman with anaemia from menorrhagia hears her heartbeat in both ears — anaemic flow murmur; treat the anaemia, and the sound fades. A middle-aged woman hears clicking at night, and you can see her soft palate twitch — palatal myoclonus; the workup includes neurological review, and management options range from reassurance to botulinum injection. An elderly woman with a red pulsatile mass behind her intact drum and pulsatile tinnitus that fades when the speculum pressure rises has a glomus tympanicum: CT temporal bone and CT angiography stage it, and excision or radiosurgery follows. Each pattern is self-announcing once the two questions — pulsatile or not, one ear or two — are asked, which is why those two questions head every tinnitus clinic sheet. ## How the exam frames it The recurring one-liners are: pulsatile tinnitus with a red mass behind the eardrum answers glomus tympanicum; clicking tinnitus with visible palatal movement answers palatal myoclonus; tinnitus after high-dose aspirin answers salicylate (reversible); unilateral tinnitus with asymmetric hearing loss answers MRI for vestibular schwannoma; and the therapy question — no drug is first-line for chronic tinnitus; counselling with sound therapy, CBT and TRT are the evidence-based answers. The trap option is prescribing betahistine or a vasodilator for isolated chronic tinnitus and calling it done; stems penalise exactly that reflex. ## Frequently asked questions ### Which causes underlie pulsatile tinnitus? Glomus tumours, carotid stenosis or dissection, dural arteriovenous fistulae, high or dehiscent jugular bulb, and hyperdynamic states such as anaemia and thyrotoxicosis. ### What is the significance of unilateral tinnitus? Combined with asymmetric hearing loss or reduced speech discrimination, it raises suspicion of vestibular schwannoma and requires gadolinium-enhanced MRI of the internal auditory meatus. ### Which drugs commonly cause tinnitus? High-dose salicylates and NSAIDs, quinine, aminoglycoside antibiotics, loop diuretics and cisplatin — salicylate tinnitus usually reverses on withdrawal. ### What is tinnitus retraining therapy? A structured programme of directive counselling plus low-level broadband sound from noise generators, aiming to habituate the brain to the tinnitus rather than mask it completely. ### How does a glomus tumour present at the ear? Pulsatile tinnitus with hearing loss and a red, pulsatile mass behind an intact tympanic membrane ("rising sun"), blanching on positive pneumatic pressure.