What is the best course of action for a patient with no significant past medical history presenting with constant tinnitus, intermittent pain, and new focal deficits?

Urgent Imaging Required for Tinnitus with Focal Neurological Deficits

A patient with constant tinnitus, intermittent pain, and new focal neurological deficits requires immediate CT angiography (CTA) of the head and neck with contrast as the first-line imaging study, as focal deficits combined with tinnitus mandate urgent evaluation for life-threatening vascular causes including arterial dissection, dural arteriovenous fistula, or stroke. 1, 2

Why Focal Deficits Change Everything

The presence of focal neurological deficits fundamentally transforms this from a routine tinnitus evaluation into a neurological emergency requiring immediate vascular imaging. 1, 2

• The American Academy of Otolaryngology explicitly recommends imaging for tinnitus associated with focal neurological abnormalities, making this an absolute indication regardless of whether the tinnitus is pulsatile or non-pulsatile. 1, 3
• Focal deficits suggest intracranial pathology that could represent arterial dissection (life-threatening), dural arteriovenous fistula (8% of pulsatile tinnitus cases, can cause hemorrhagic or ischemic stroke), or acute stroke. 2, 3
• Missing arterial dissection or dural AVF can result in catastrophic hemorrhage or stroke, making timely diagnosis essential even when tinnitus is the primary complaint. 2

First-Line Imaging Strategy

Order CT angiography (CTA) of head and neck with contrast using a mixed arterial-venous phase (20-25 seconds post-contrast injection) to capture both arterial and venous pathology in a single acquisition. 1, 2

Why CTA First:

• CTA evaluates for arterial dissection, dural arteriovenous fistulas, atherosclerotic carotid disease, arteriovenous malformations, and sigmoid sinus abnormalities—all potentially life-threatening causes. 1, 2
• The mixed phase protocol allows assessment of both arterial and venous anatomy without additional radiation exposure compared to separate arterial and venous studies. 1, 2
• CTA source images can be reconstructed to create dedicated temporal bone CT images in bone window settings, providing comprehensive evaluation without additional scanning. 1

If CTA is Negative but Clinical Suspicion Remains High:

• Proceed to MRI brain with contrast and MR angiography (MRA) to evaluate for cerebellopontine angle lesions, subtle vascular malformations, or other intracranial pathology not visible on CTA. 1, 2
• MRI with specialized internal auditory canal protocols includes thin-section heavily T2-weighted sequences to evaluate for vascular loops and small vestibular schwannomas. 1

Concurrent Essential Workup

While arranging urgent imaging, complete these evaluations immediately:

• Comprehensive audiologic examination within 4 weeks (pure tone audiometry, speech audiometry, acoustic reflex testing) to document any asymmetric hearing loss, which would further support retrocochlear or vascular pathology. 3, 4
• Detailed neurologic examination to characterize the focal deficits and assess for additional cranial nerve involvement or signs of increased intracranial pressure. 3, 4
• Otoscopic examination to identify any vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind the tympanic membrane). 1, 2

Critical Diagnostic Considerations

Determine if Tinnitus is Pulsatile:

• If pulsatile (synchronous with heartbeat), this dramatically increases the likelihood of identifiable vascular pathology—over 70% of pulsatile tinnitus cases have an identifiable structural or vascular cause. 2, 3
• Pulsatile tinnitus combined with focal deficits raises immediate concern for dural AVF, arterial dissection, or AVM. 2
• If non-pulsatile, the focal deficits still mandate imaging, but the differential shifts toward stroke, mass lesion, or demyelinating disease rather than primary vascular tinnitus causes. 1, 3

Assess Pain Characteristics:

• Intermittent pain could represent vascular headache from arterial dissection, increased intracranial pressure, or referred pain from temporomandibular joint dysfunction. 5
• Sudden severe headache ("thunderclap") would suggest subarachnoid hemorrhage or arterial dissection requiring immediate emergency department evaluation. 1

Life-Threatening Causes Not to Miss

Arterial Dissection:

• Potentially life-threatening condition requiring urgent identification and anticoagulation consideration. 2
• Can present with tinnitus, focal deficits, and neck/head pain. 2
• CTA is the diagnostic test of choice. 2

Dural Arteriovenous Fistula:

• Accounts for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated. 2, 3
• Can present with isolated pulsatile tinnitus before catastrophic hemorrhage. 2
• Requires high index of suspicion and appropriate vascular imaging (CTA or catheter angiography for definitive diagnosis). 2

Arteriovenous Malformation:

• AVMs carry a 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage. 2
• Most commonly present with hemorrhage (>50%), seizures (20-25%), or headaches (15%), but can present with pulsatile tinnitus. 2
• CTA is first-line imaging, with catheter angiography reserved for definitive characterization. 2

Common Pitfalls to Avoid

• Do not dismiss this as benign tinnitus requiring only audiometry—focal neurological deficits are an absolute indication for urgent vascular imaging. 1, 2
• Do not order MRI brain without MRA—if choosing MRI, always include vascular imaging (MRA) given the concern for vascular pathology. 1, 2
• Do not order high-resolution CT temporal bone alone—while useful for structural causes of tinnitus (paragangliomas, superior semicircular canal dehiscence), it does not evaluate vascular pathology adequately. 1, 2
• Do not delay imaging for audiometry—while audiometry is important, vascular imaging takes priority when focal deficits are present. 1, 3

What NOT to Do

The American Academy of Otolaryngology specifically recommends against imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features—but this patient has focal neurological deficits, which completely changes the recommendation. 1, 3, 4