Following trauma to her right frontal region, a 68-year-old woman suffered bilateral, benign, paroxysmal, positional vertigo and a left-sided, longitudinal petrosal bone fracture, with secondary facial palsy and ossicular luxation. From the onset, the patient complained of pulsatile, left-sided tinnitus. After eight weeks, she developed left-sided ocular symptoms, progressing from conjunctival hyperaemia and orbital oedema to an abducens nerve palsy, and ultimately to heart failure.

The case and the final diagnosis of carotico-cavernous fistula are discussed. Guidelines are proposed for a diagnostic approach to pulsatile tinnitus and for the optimal management of patients presenting with pulsatile tinnitus associated with ocular symptoms.

Pulsatile tinnitus is an uncommon otological symptom. Objective pulsatile tinnitus has numerous causes, including benign intracranial hypertension, glomus tumours and atherosclerotic carotid artery disease. History and physical examination can give important information as to the underlying diagnosis. Radiographic evaluation is essential in all patients with pulsatile tinnitus. Many patients have a treatable underlying aetiology. Early diagnosis and appropriate intervention may save patients from unnecessary morbidity.