Bothered by a whooshing, humming, buzzing or ‘heartbeat’ in your ears?

When Dr. Kevin Shah’s patients wake up from surgery, it’s not unusual for them to start crying.

But he doesn’t take it personally: They’re tears of joy.

As an endovascular neurosurgeon at Novant Health Brain & Spine Surgery - Kimel Park, in Winston-Salem, Shah spends hours in complex surgeries fixing brain bleeds, aneurysms and tumors — but one of the most rewarding procedures he performs is a minimally invasive outpatient surgery.

Patients who undergo it have dealt with a relentless, and sometimes crippling, background noise called pulsatile tinnitus, an especially debilitating form of tinnitus. They’ve struggled to sleep, work and listen to loved ones. Some confide in Shah that they’ve considered ending their life because of the noise.

After surgery with Shah, they hear — silence.

What is pulsatile tinnitus?

You’ve probably heard of tinnitus: When a person hears ringing or buzzing in one or both ears. The noise is “in their head;” no one else can hear it, and there isn’t a clear cause “on the outside” for the noise. Estimates are that 10% to 25% of adults have it at some point in time.

Pulsatile tinnitus is a less common type of tinnitus.

Patients with pulsatile tinnitus hear a sound created by the arteries and veins next to the inner ear. They describe it as a whooshing, buzzing, or humming that sounds like it’s coming from the back of their head, often synced with their pulse. Some tell Shah, “I can hear my heartbeat.”

Why do they hear this sound?

Their veins or arteries are narrowed, enlarged, or flowing differently than they should, so blood pulses faster than normal through the veins and arteries. This is called “turbulent blood flow.”

Shah explains it to patients like this: When you turn on a hose, there’s a gentle flowing sound. But if you put your thumb on the end of the water hose, blocking or changing the water flow, the hose sounds different: sputtering, hissing, gurgling.

Normally, blood flows through our arteries and veins like water through a hose. But in pulsatile tinnitus, Shah said, “It’s like the thumb is going on and off the hose all day and all night and every waking moment of your life.” Right next to your ear.

How does pulsatile tinnitus affect patients?

For most people, pulsatile tinnitus is a fleeting sensation that happens so irregularly that they can ignore it. You may have experienced it briefly after an intense workout, or when lying down.

But for some patients, the noise is “constant, almost relentless, and it can be exhausting mentally,” Shah said. “They can have difficulty having a normal conversation with someone because the noise is so loud and so overbearing.” The noise is amplified in quiet settings, so the patient never experiences silence. Many can struggle with fatigue, depression and anxiety.

What causes pulsatile tinnitus?

Pulsatile tinnitus isn’t a disease in itself; it’s a symptom of one of the following:

• A narrowed, enlarged, or abnormal artery or vein next to the inner ear: This is the most common cause.
• Something more serious: In approximately 5% of patients, pulsatile tinnitus is a symptom of a more serious problem, like a vascular malformation, arteriovenous fistula or aneurysm.
• Pregnancy: Pulsatile tinnitus isn’t medically concerning during pregnancy; it’s usually temporary and stops when the baby is born.
• High blood pressure (hypertension): Some people with hypertension will hear “whooshing” when their blood pressure spikes.
• Obesity: Pulsatile tinnitus is also linked to obesity.

How is pulsatile tinnitus diagnosed?

Typically, a patient tells their primary care doctor or an ear-nose-throat (ENT) doctor about the noise. If their doctor suspects that it might be pulsatile tinnitus, they send the patient to a neuroendovascular specialist like Shah. The specialist will do a physical exam and order specialized MRI imaging to determine the cause and a treatment.

What are the nonsurgical treatment options?

Treatment is tailored for the patient depending on what they can tolerate, what they want, what their particular problem is, and what their goals are in the next three months, three years and 30 years, Shah said. Here are the options he discusses with patients:

• Lifestyle treatments: If the patient’s pulsatile tinnitus is caused by high blood pressure or obesity, lowering blood pressure through exercising, eating a low-sodium diet, medication, and losing weight can reduce or stop the symptoms. For some, this can be tricky: “When you tell them, ‘You have to lose 30 pounds for this sound to go away,’ some people have a hard time doing that,” Shah said. “And some people lose 30 pounds and gain it right back.” Injectable GLP-1 medications can help some lose weight and maintain weight loss.
• Cognitive-behavioral therapy: For some patients, it isn’t medically necessary to treat their pulsatile tinnitus. They can ignore it or learn new ways to cope through cognitive-behavioral therapy.
• Sound therapy: Some ENT doctors are testing an audiological treatment that cancels out the sound a patient hears by playing a different sound in their ear — sort of like how noise-canceling headphones work. This treatment is not widely available yet.

What are the surgical options for pulsatile tinnitus?

If the nonsurgical options have been tried or surgical is deemed to be the best move:

• Same-day surgery: Surgery aims to remove the turbulent blood flow from around the inner ear. For patients who have a narrowed or enlarged vein or artery next to their inner ear, a surgeon can “unkink the hose” (change the flow of blood), then put a stent inside to “keep the hose from kinking again.” This is a minimally invasive surgery called “venous sinus stenting.” It is performed as a same-day procedure, meaning that the patient comes in the morning, gets the procedure done, and goes home later that day.
• More intense surgery: There are surgical options for patients whose symptoms are due to a vascular malformation, arteriovenous fistulas or aneurysm, too — but it's no longer a one-day surgery and has a different risk profile. Still, the surgery itself is quick and patients are usually discharged the next day, Shah said, adding, “I understand the trepidation. But I consider this almost like a minor procedure, and the impact is so big.” Recommended surgery may be called “embolization,” “surgical occlusion,” or “stereotactic radiosurgery.”

Whether they needed same-day surgery or a slightly more-intense surgery, patients share one thing in common: Their emotional response.

“The treatment is usually immediate — so when they wake up from anesthesia, they don't hear a sound,” Shah said. “They start crying, because it's been years since they have ever heard silence.”

Being able to quiet the unwanted noise and help patients better hear the sounds they want to hear “makes my work very meaningful,” Shah said. “I may not fully know what they’ve experienced for so many years, but it’s gratifying to see them get relief.”