Pulsatile Tinnitus, Dizziness, and Venous Outflow Physiology: A Retrospective Cohort with Nested Vestibular Phenotyping and a Proposed Otology-Led Diagnostic Pathway

Background/Objectives: Pulsatile tinnitus (PT), headache, dizziness, and venous or pressure-associated imaging findings often coexist, but their relationships are incompletely defined, and otolaryngologists lack a practical evaluation pathway. We aimed to (1) characterize the clinical, imaging, and hemodynamic phenotype of adults evaluated for PT; (2) describe vestibular findings in a nested subgroup; and (3) propose an otology-led diagnostic pathway. Methods: Retrospective cohort of 29 adults with physician-documented PT (June 2024–May 2026), reported according to STROBE. A nested subgroup of five patients with interpretable video-oculography (VOG) underwent detailed vestibular review. Results: Migraine was documented in 20/29 (69.0%) and motion sensitivity in 9/29 (31.0%). Of 16 patients with magnetic resonance imaging/venography, 8 had an empty or partially empty sella and 6 had transverse-sinus narrowing, hypoplasia, or occlusion. Papilledema was absent in all 6 patients with documented ophthalmologic evaluation. Seven underwent catheter-based venous evaluation; one with transverse–sigmoid gradients of approximately 23 and 24 mmHg had PT resolution after stenting. In the nested subgroup, two patients had caloric abnormalities and three had position-sensitive mixed-vector ocular drift. Conclusions: Sound, vestibular symptoms, visual risk, and venous hemodynamics overlapped without a single causal pathway. We propose a stepwise, imaging-first pathway that evaluates these domains separately and a testable hypothesis for the vestibular findings.