This article reviews the most common neurosurgical causes of pulse synchronous tinnitus. Traditionally, tinnitus has been characterised as subjective vs. objective, or vascular vs. nonvascular. The authors observe that, in some cases, pulsatile tinnitus (PT) is not heard by examiners while many nonvascular sources cause pulse synchronous tinnitus. Therefore, they suggest classifying PT as arterial vs. venous and then further classifying their causes as vascular vs. nonvascular. For example, arterial (systolic) vascular causes include carotid stenosis, fibromuscular dysplasia (FMD), and arteriovenous malformations while arterial nonvascular causes include glomus tumours and superior canal dehiscence syndrome. Similarly, venous (diastolic) vascular causes include dural venous sinus thrombosis and jugular bulb abnormalities etc, and venous nonvascular causes include intracranial hypertension and Chiari malformation. The authors conclude that though PT falls within the purview of the otolaryngologist, it can be the first and only presenting symptom of several conditions which require neurosurgical management. The article presents an interesting argument for revisiting the classification for PT.