What is the recommended evaluation and management for a patient with tinnitus (ringing in the ears) in the left ear for one year and headaches on the left side?

Evaluation and Management of Unilateral Tinnitus with Ipsilateral Headaches

This patient requires comprehensive audiologic testing and MRI with contrast to rule out vestibular schwannoma or other retrocochlear pathology, given the unilateral presentation lasting one year. 1, 2

Immediate Diagnostic Workup

History and Physical Examination

Obtain specific details about the tinnitus characteristics:

• Determine if the tinnitus is pulsatile or non-pulsatile, as pulsatile tinnitus suggests vascular etiology requiring different imaging 2
• Assess whether the tinnitus changes with jaw movements or yawning, which suggests temporomandibular joint dysfunction or vascular abnormalities 2
• Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 3
• Complete cranial nerve examination, especially focusing on CN VIII and other focal neurological deficits 3
• Examine the temporomandibular joint given the ipsilateral headaches, as TMJ dysfunction can cause both symptoms 1, 2
• Auscultate the neck, periauricular region, and temporal area for bruits if any pulsatile component exists 3

Mandatory Audiologic Testing

Obtain comprehensive audiologic examination immediately, including:

• Pure tone audiometry 1, 3
• Speech audiometry 1, 3
• Acoustic reflex testing 1, 3

This testing is non-negotiable for unilateral tinnitus, even if the patient does not perceive hearing loss, as subclinical hearing loss may be revealed through audiometry 1

Imaging Studies

MRI with contrast is indicated for unilateral tinnitus to evaluate for vestibular schwannoma or other retrocochlear pathology 1, 2, 3. The American College of Radiology guidelines specify that imaging should be obtained when there is unilateral or asymmetric tinnitus 4, 1.

Consider CT temporal bone if:

• Suspected bony abnormalities 2
• Middle ear pathology is suspected 2
• Pulsatile component suggests vascular abnormalities like sigmoid sinus dehiscence or jugular bulb abnormalities 2

Management Algorithm Based on Findings

If Imaging and Audiometry Are Normal

Cognitive behavioral therapy is the first-line treatment for persistent, bothersome tinnitus, as it is the only treatment proven to improve quality of life 1, 5

Additional management options:

• Sound therapy may be offered as second-line for auditory masking, though evidence is less robust 1
• Education and counseling are mandatory for all patients, including discussion of natural history and realistic expectations 1
• Avoid routine pharmacologic interventions without documented hearing loss 1

If Hearing Loss Is Documented

Recommend hearing aid evaluation if audiometry reveals hearing loss, as amplification may improve both hearing and tinnitus 3

If TMJ Dysfunction Is Identified

Address TMJ dysfunction through dental/jaw therapies, as this may relieve both the tinnitus and ipsilateral headaches 2

If Vascular Abnormality Is Found

Surgical repair or embolization may be indicated in severe cases of vascular-related tinnitus 2

Critical Red Flags

This patient's presentation warrants urgent evaluation because:

• Unilateral tinnitus carries higher risk of underlying pathology compared to bilateral tinnitus 1, 2
• Duration of one year qualifies as persistent tinnitus requiring comprehensive workup 3
• Ipsilateral headaches may indicate intracranial pathology requiring neuroimaging 1

Common Pitfalls to Avoid

• Do not skip imaging for unilateral tinnitus, even without apparent hearing loss, as this is a red flag requiring investigation 1, 2
• Do not prescribe antidepressants or anxiolytics without addressing the underlying cause first 2
• Do not recommend dietary supplements like Ginkgo biloba, melatonin, or zinc as primary treatment 2
• Do not overlook mild hearing loss that may benefit from amplification 3