What is the initial workup for a patient presenting with tinnitus and hearing loss?

Initial Workup for Tinnitus and Hearing Loss

All patients presenting with tinnitus and hearing loss require a comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing, with imaging reserved only for specific red flag features. 1

Step 1: Obtain Targeted History

Collect detailed tinnitus characteristics to identify treatable underlying conditions and determine imaging necessity:

• Onset, duration, and laterality – Unilateral tinnitus has higher likelihood of structural pathology requiring imaging 1, 2
• Quality and pattern – Distinguish pulsatile (synchronous with heartbeat) from non-pulsatile tinnitus, as pulsatile tinnitus indicates vascular or structural abnormality in >70% of cases and requires urgent imaging evaluation 3
• Associated symptoms – Screen for vertigo, otalgia, otorrhea, neurological symptoms, headaches, and vision changes 1, 2
• Hearing loss characteristics – Document whether hearing loss is unilateral/asymmetric or bilateral, as asymmetric hearing loss mandates imaging 1, 3
• Temporal pattern – Differentiate recent onset from persistent tinnitus (≥6 months duration) to guide management intensity 1

Step 2: Perform Focused Physical Examination

• Otoscopic examination – Identify cerumen impaction, tympanic membrane abnormalities, middle ear pathology, or vascular retrotympanic masses suggestive of paragangliomas 1, 3
• Cranial nerve examination – Focus on CN VIII to evaluate hearing status and identify focal neurological deficits 1
• Auscultation – Listen over neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 1
• Carotid/jugular compression maneuver – If tinnitus is relieved by compression, this suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 3

Step 3: Order Comprehensive Audiologic Examination

This is mandatory for all patients with tinnitus and hearing loss, regardless of laterality or duration: 1

• Pure tone audiometry – Documents hearing thresholds and identifies asymmetric hearing loss 1, 4
• Speech audiometry – Assesses speech recognition ability 1
• Acoustic reflex testing – Evaluates middle ear and auditory pathway function 1
• Loudness discomfort levels – Measure at audiometric frequencies if hyperacusis (sound tolerance problems) is present 1

Step 4: Determine Imaging Necessity

Imaging should NOT be obtained unless one or more of the following red flags are present: 1, 3

Absolute Indications for Imaging:

• Pulsatile tinnitus – Requires CT angiography (CTA) of head and neck with contrast as first-line study to evaluate for dural arteriovenous fistulas (life-threatening, 8% of cases), arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations 3
• Unilateral or asymmetric hearing loss – Requires imaging to exclude vestibular schwannoma or other cerebellopontine angle lesions 1, 3
• Focal neurological abnormalities – Mandates immediate imaging 1, 2

Additional High-Risk Features Requiring Imaging:

• Objective tinnitus (audible to examiner) – Strongly suggests vascular pathology requiring immediate workup 3
• History of malignancy, recent trauma, or prior neck surgery 2
• Vision changes – Particularly in young overweight women with headaches, suggests idiopathic intracranial hypertension (second most common cause of pulsatile tinnitus) 3

Imaging Selection Algorithm:

• First-line for pulsatile tinnitus: CT angiography (CTA) of head and neck with contrast 3
• First-line for suspected middle ear pathology: High-resolution CT temporal bone (non-contrast) for paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 3
• Second-line if CTA/CT negative but suspicion remains: MRI with contrast and MR angiography (MRA) 3
• Avoid imaging for: Non-pulsatile, bilateral tinnitus without neurological symptoms or asymmetric hearing loss 1, 3

Step 5: Classify Tinnitus Severity and Duration

• Distinguish bothersome from non-bothersome tinnitus – Determines management intensity and need for therapeutic interventions 1
• Differentiate recent onset (<6 months) from persistent (≥6 months) – Persistent, bothersome tinnitus requires more aggressive management strategies 1

Critical Pitfalls to Avoid

• Missing dural arteriovenous fistula – Can present with isolated pulsatile tinnitus before catastrophic hemorrhage; requires high index of suspicion 3
• Dismissing pulsatile tinnitus as benign – Almost always requires imaging due to identifiable causes in >70% of cases 3
• Inadequate otoscopic examination – Can miss vascular retrotympanic masses (paragangliomas) leading to delayed diagnosis 3
• Overlooking intracranial hypertension – Particularly in young overweight women with headaches and vision changes; can lead to permanent vision loss if missed 3
• Ordering unnecessary imaging – Avoid imaging for bilateral, non-pulsatile tinnitus without localizing features 1, 3