What imaging studies are recommended for patients presenting with tinnitus?

Imaging Recommendations for Tinnitus

Imaging studies should not be obtained for patients with tinnitus unless they have one or more of the following: tinnitus that localizes to one ear, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss. 1

Initial Assessment Before Considering Imaging

• A comprehensive otologic examination and audiometric evaluation should be performed before any imaging is considered 1, 2
• Audiologic examination is recommended for all patients with unilateral, persistent (≥6 months), or hearing difficulty-associated tinnitus 1, 2
• Tinnitus should be classified as either pulsatile or non-pulsatile, as this determines the imaging approach 1, 2

Imaging Recommendations Based on Tinnitus Type

For Pulsatile Tinnitus:

• First-line imaging options:

  • Dedicated temporal bone CT for suspected vascular retrotympanic mass or subjective pulsatile tinnitus 1
  • CT angiography (CTA) of head and neck with contrast to identify vascular abnormalities 1, 3

• Second-line imaging options:

  • MRI and MR angiography (MRA) with contrast, especially useful for evaluating cerebellopontine angle lesions and vascular malformations 1
  • Time-resolved gadolinium-enhanced MRA for suspected dural arteriovenous fistulas 1

For Non-pulsatile Tinnitus:

• Imaging is indicated only if:

  • Tinnitus is unilateral 1, 4
  • Associated with asymmetric hearing loss 1
  • Associated with focal neurological abnormalities 1

• Recommended imaging for indicated non-pulsatile tinnitus:

  • MRI is the study of choice to exclude vestibular schwannoma or other cerebellopontine angle neoplasms 5
  • Internal auditory canal (IAC) protocol MRI with thin-section, heavily T2-weighted sequences 1

Important Considerations

• Routine neuroimaging for bilateral, non-pulsatile tinnitus without other symptoms has low yield and should be avoided 1, 4
• For CTA, a mixed arterial and venous phase through the head and neck can be performed to allow evaluation of both arterial and venous pathology in a single examination 1
• Temporal bone CT reconstructions can be created from high-resolution CTA source images without additional radiation exposure 1
• The American Academy of Otolaryngology-Head and Neck Surgery has made a strong recommendation against imaging studies for tinnitus that is bilateral, non-pulsatile, and not associated with focal neurologic abnormalities or asymmetric hearing loss 1

Clinical Pitfalls to Avoid

• Ordering unnecessary imaging for non-pulsatile bilateral tinnitus without other symptoms, which increases costs and radiation exposure with minimal benefit 1, 4
• Failing to distinguish between pulsatile and non-pulsatile tinnitus before selecting imaging studies 1, 5
• Overlooking the need for comprehensive audiologic evaluation before imaging 1, 2
• Missing potentially dangerous causes such as vascular tumors and vestibular schwannoma by not ordering appropriate imaging when indicated 4, 5