Objective Tinnitus: Causes, Diagnosis & Treatment of Audible Ear Noises

Objective Tinnitus: When the Examiner Can Hear It Too

Objective tinnitus (somatosound) is rare (<1% of tinnitus) and generated by a physical sound source within or near the ear that can be detected by an examiner.

Classification by Source

Category	Specific Causes	Sound Character
Vascular (pulsatile)	Dural AV fistula, carotid stenosis/dissection, high jugular bulb, glomus tumor, AVM, venous hum, hypertension, anemia, thyrotoxicosis	Rhythmic, heartbeat-synchronous (whoosh, thump)
Muscular (myoclonus)	Middle ear: tensor tympani, stapedius myoclonus; Palatal myoclonus (levator veli palatini)	Clicking, buzzing, fluttering; may be rhythmic or irregular
Eustachian tube	Patulous ET (autophony), ETD with respiration-synchronous sounds	Breath-synchronous roaring, clicking
TMJ / Structural	TMJ click/pop, crepitus; dental implants contacting bone	Mechanical clicks with jaw movement
Foreign body / Cerumen	Hair on TM, insect, wax against TM	Rustling, scratching with movement

Diagnostic Approach

Examiner auscultation: Stethoscope over mastoid, neck, periauricular; patient's ear canal with probe microphone
Provocative maneuvers: Valsalva, head turning, jaw movement, breath-holding, compression of ipsilateral jugular vein
Audiometry + tympanometry: Rule out conductive component
Imaging (guided by sound type):

Pulsatile: CTA neck/head, MRV, catheter angiography (gold standard for fistula)
Muscular: MRI brain (brainstem), high-res CT temporal bone
Patulous ET: Nasal endoscopy, tubomanometry

Treatment by Etiology

Vascular: Endovascular embolization (fistula, AVM), stenting (stenosis), surgery (glomus), medical (HTN, anemia, thyroid)
Muscular: Botulinum toxin to tensor tympani/stapedius (transcanal or endoscopic); palatal myoclonus → Botox to levator veli palatini, anticonvulsants
Patulous ET: Saline drops, weight gain, tympanostomy tube, cautery, filler injection
TMJ: Splint, physical therapy, botox, arthrocentesis
Foreign body: Removal

Key Distinction

Objective tinnitus has a physical generator → potentially curable by treating source
Subjective tinnitus is neural perception → management focuses on habituation
Many patients have both components

If your tinnitus might be audible to others, request an examiner auscultation—it changes the diagnostic and therapeutic pathway entirely.