Workup for Tinnitus and Phantosmia in a 40-Year-Old Female
The appropriate workup for a 40-year-old female with tinnitus and phantosmia (smell of smoke) should begin with a comprehensive audiologic evaluation and should not include imaging unless specific red flags are present. 1
Initial Evaluation
Audiologic Assessment
- Complete audiologic evaluation including:
- Pure tone audiometry
- Speech audiometry
- Tympanometry
- Acoustic reflex testing
- Otoacoustic emissions (when indicated) 1
Tinnitus Classification
- Determine if tinnitus is:
Phantosmia Evaluation
- Detailed history of the phantosmia:
- Onset (sudden vs. gradual)
- Duration and frequency
- Specific characteristics (only smoke smell or other odors)
- Associated symptoms (headache, seizures, etc.)
Imaging Decision Algorithm
Imaging should NOT be routinely ordered for tinnitus unless one or more of the following are present:
- Unilateral tinnitus
- Pulsatile tinnitus
- Focal neurological abnormalities
- Asymmetric hearing loss 1
If imaging is indicated based on the above criteria, select the appropriate study:
| Clinical Presentation | Recommended Imaging |
|---|---|
| Pulsatile tinnitus | CT angiography or MR angiography |
| Unilateral tinnitus with asymmetric hearing loss | MRI with contrast of internal auditory canals |
| Focal neurological findings | MRI brain with contrast |
Additional Considerations
Screening for Associated Conditions
- Assess for anxiety and depression, which commonly coexist with tinnitus 1
- Screen for suicide risk in patients with severe psychological distress 1
- Evaluate for conditions that may cause phantosmia, including:
- Neurological disorders
- Sinonasal disease
- Medication side effects
Common Pitfalls to Avoid
- Ordering unnecessary imaging for bilateral, non-pulsatile tinnitus without asymmetric hearing loss or focal neurological findings 1
- Delaying audiologic evaluation in patients with unilateral tinnitus 1
- Failing to recognize that phantosmia (like idiopathic phantosmia) often improves or resolves over time (>50% of cases improve or disappear after 5 years) 3
- Missing the connection between tinnitus and potential hearing loss, which is a common association 4, 5
Follow-up Recommendations
- Schedule follow-up within 4-6 weeks to assess response to initial management
- If symptoms persist or worsen, consider referral to specialized care:
- Otolaryngology
- Neurology (especially for persistent phantosmia)
- Specialized tinnitus/hyperacusis clinic 1
Remember that while tinnitus is often associated with hearing loss, phantosmia requires separate evaluation as it may have different underlying causes, though idiopathic phantosmia is common and often benign 3.