What is the workup and treatment for a patient presenting with tinnitus and ear fullness?

Workup for Tinnitus and Ear Fullness

A comprehensive audiologic examination should be performed for all patients presenting with tinnitus and ear fullness, regardless of laterality, duration, or perceived hearing status, to identify underlying causes and guide appropriate treatment. 1, 2

Initial Assessment

History

• Obtain detailed tinnitus characteristics including onset, duration, laterality, quality, pitch, loudness, and pattern 2
• Assess for associated symptoms such as hearing loss, vertigo, otalgia, otorrhea, or neurological symptoms 2
• Document fluctuations in symptoms, which may suggest Ménière's disease 1, 3
• Keeping a symptom journal can help with accurate diagnosis 1

Physical Examination

• Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 2
• Conduct cranial nerve examination, especially focusing on hearing (CN VIII) 2
• Auscultate the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 2, 4

Diagnostic Testing

Audiologic Evaluation

• Audiogram (hearing test) should be performed promptly, preferably within 4 weeks of assessment 1, 2
  • Measures hearing levels from low to high frequency
  • Can detect hearing loss that may be unsuspected
  • Helps characterize the nature of hearing loss (conductive, sensorineural, or mixed; unilateral or bilateral) 1

Additional Testing Based on Clinical Findings

• Video- or electronystagmogram if vertigo is present 1

  • Evaluates vestibular function of the ear and coordination with brain
  • May cause temporary vertigo, nausea, and discomfort during testing 1

• Electrocochleography may be considered 1

  • Measures electrical responses of the cochlea and auditory nerve
  • May cause discomfort in the ear 1

• Sound tolerance testing if hyperacusis is present 2, 5

  • Measures loudness discomfort levels at audiometric frequencies 5

Imaging Studies

• Do not obtain imaging studies unless one or more of the following are present 1, 2:

  • Tinnitus that localizes to one ear
  • Pulsatile tinnitus
  • Focal neurological abnormalities
  • Asymmetric hearing loss

• MRI of the brain when indicated 1

  • Uses magnetic energy to view brain and nerve anatomy
  • Intravenous contrast often required
  • Contraindicated in patients with certain implants
  • May cause discomfort in patients with claustrophobia 1

Special Considerations

Ménière's Disease Evaluation

• Consider Ménière's disease when tinnitus is accompanied by:

  • Episodes of vertigo lasting 20 minutes to 24 hours
  • Fluctuating hearing loss
  • Ear fullness 1, 3

• Endolymphatic hydrops (excess fluid in inner ear) is frequently present in patients with fluctuating tinnitus and ear fullness, even when vertigo is not reported 3

Pulsatile Tinnitus

• Requires more urgent evaluation than non-pulsatile tinnitus 4
• Almost always requires imaging evaluation 6
• May indicate underlying vascular abnormality 6

Treatment Approaches

First-Line Treatments

• Education and counseling about tinnitus management strategies 2, 6
• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life 6, 7
• Hearing aids for patients with hearing loss and tinnitus, even if hearing loss is mild or unilateral 6
• Sound therapy may provide symptomatic relief 6

Treatments Not Recommended

• Antidepressants, anticonvulsants, or anxiolytics for primary treatment of persistent tinnitus 6
• Dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 6

Common Pitfalls to Avoid

• Overlooking mild hearing loss that could benefit from hearing aid intervention 6
• Obtaining unnecessary imaging studies for non-pulsatile, bilateral tinnitus without neurological symptoms 2, 6
• Prescribing medications without clear evidence of benefit 6
• Recommending unproven treatments such as dietary supplements 2, 6