What is the initial approach for a patient presenting with unilateral tinnitus for 2 days and a normal tympanic membrane?

Initial Management of Unilateral Tinnitus for 2 Days

For a patient with unilateral tinnitus of 2 days duration and a normal tympanic membrane, you should obtain a comprehensive audiologic examination promptly and perform a targeted history and physical examination to identify potentially serious underlying causes, particularly focusing on whether the tinnitus is pulsatile or non-pulsatile. 1, 2

Immediate Clinical Assessment

Critical History Elements

• Determine if the tinnitus is pulsatile or non-pulsatile, as this fundamentally changes your differential diagnosis—pulsatile tinnitus suggests vascular etiologies while non-pulsatile suggests otologic or neurologic causes 2, 3
• Assess for red flag symptoms including focal neurological deficits, asymmetric hearing loss, recent trauma, history of malignancy, or severe anxiety/depression 4
• Characterize the tinnitus: laterality (already established as unilateral), quality (ringing, buzzing, clicking, pulsing), pitch, loudness, and any modifying factors such as changes with jaw movement or position 2, 4
• Screen for TMJ dysfunction by asking if the tinnitus worsens with yawning or jaw movements, as this is a common treatable cause of unilateral tinnitus 2, 4

Targeted Physical Examination

• Complete otologic examination to confirm the normal tympanic membrane finding and check specifically for retrotympanic masses or vascular abnormalities 2
• Neurological examination focusing on cranial nerves, particularly CN VIII function, to identify focal deficits that would mandate urgent imaging 1, 4
• TMJ assessment including palpation and range of motion testing, given the close anatomical relationship between TMJ and ear structures 2

Audiologic Testing

Obtain a comprehensive audiologic examination promptly (ideally within 4 weeks) rather than waiting for symptoms to persist 6 months, as unilateral tinnitus is a specific indication for immediate testing regardless of duration 1, 5. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends prompt audiologic examination for unilateral tinnitus to prioritize evaluation, identify unsuspected hearing loss, and initiate workup for serious diseases 1, 5.

The audiologic battery should include:

• Pure tone audiometry to measure hearing thresholds across frequencies 5
• Speech audiometry for functional hearing assessment 5
• Tympanometry/immittance testing to evaluate middle ear function and rule out conductive pathology 5
• Acoustic reflex testing as part of the comprehensive evaluation 5

Imaging Decisions

Do not routinely order imaging at this initial presentation unless specific red flags are present 1, 4. However, given that this is unilateral tinnitus, imaging becomes indicated if audiometry reveals:

• Asymmetric or unilateral hearing loss → MRI with contrast to exclude vestibular schwannoma or other retrocochlear pathology 2, 5
• Pulsatile quality → CT temporal bone for bony abnormalities or MRI/MRA for vascular causes 1, 2
• Any focal neurological abnormalities on examination 1, 4

The 2023 ACR Appropriateness Criteria emphasize that imaging decisions should be guided by the clinical presentation and otoscopic findings, with different imaging modalities appropriate for different suspected etiologies 1.

Common Pitfalls to Avoid

• Do not delay audiologic testing waiting for the 6-month "persistent" threshold—unilateral tinnitus warrants prompt evaluation regardless of duration 1, 5
• Do not assume normal hearing based on patient report alone, as hearing loss may be unsuspected or mild 5
• Do not order imaging reflexively without first completing the history, examination, and audiometry, as most cases will not require imaging 1, 6
• Do not overlook TMJ dysfunction as a treatable cause, especially if symptoms worsen with jaw movements 2, 4

Initial Counseling

Even at this early presentation, provide education about tinnitus to reduce anxiety and set appropriate expectations 1, 6. Explain that:

• Most tinnitus is benign and associated with hearing changes 3, 7
• The evaluation will systematically rule out serious causes 7, 6
• Many patients experience spontaneous improvement, particularly with recent-onset tinnitus 6
• Effective management strategies exist if symptoms persist 1, 8

Follow-Up Plan

After completing audiometry and based on those results, you will determine whether imaging is needed and whether referral to otolaryngology is appropriate 1, 7. Unilateral tinnitus requires more thorough investigation than bilateral tinnitus due to higher risk of underlying pathology 2, making this systematic approach essential for patient safety.