What are the recommended next steps for a patient with unilateral tinnitus (ringing in one ear) in the right ear and a history of treated neck pain, who has undergone physical therapy (PT) for neck pain?

Unilateral Right-Sided Tinnitus Management

For a patient with unilateral right ear tinnitus and a history of treated neck pain, you must obtain comprehensive audiologic testing immediately and strongly consider imaging with MRI of the internal auditory canals with contrast to rule out vestibular schwannoma and other retrocochlear pathology. 1

Why Unilateral Tinnitus Demands Aggressive Workup

Unilateral tinnitus carries a significantly higher risk of underlying pathology compared to bilateral tinnitus, even when the patient does not perceive hearing loss. 1 The differential diagnosis includes:

• Vestibular schwannoma (acoustic neuroma) - the most critical diagnosis to exclude 1, 2
• Temporomandibular joint dysfunction - particularly relevant given your neck pain history 1, 3
• Eustachian tube dysfunction 1
• Superior semicircular canal dehiscence 1
• Vascular abnormalities 1

The history of neck pain, even if previously treated, raises the possibility of TMJ dysfunction or cervical radiculopathy contributing to the tinnitus through somatosensory-auditory interactions. 3, 4

Required Diagnostic Workup

Step 1: Comprehensive Audiologic Testing (Within 4 Weeks)

You need pure tone audiometry, speech audiometry, and acoustic reflex testing promptly. 1, 5 This is non-negotiable for unilateral tinnitus because:

• Subclinical hearing loss may be present even without perceived hearing difficulties 1
• Asymmetric hearing loss would mandate MRI imaging 1, 2
• The audiogram guides all subsequent management decisions 5

Step 2: Targeted Physical Examination

Perform a focused exam looking for:

• Otoscopic examination - to identify middle ear pathology or vascular masses 1, 3
• TMJ assessment - palpate for tenderness, assess jaw movements, listen for clicking (especially relevant with neck pain history) 1, 3
• Neurologic examination - to identify any focal deficits that would indicate urgent pathology 1, 3
• Cervical spine palpation - assess for trigger points and whether neck manipulation modulates the tinnitus 3, 4

Step 3: Imaging Decision

If audiometry shows asymmetric or unilateral hearing loss: Order MRI of internal auditory canals with contrast immediately to evaluate for vestibular schwannoma. 1, 2

If audiometry is symmetric and normal: Imaging is still strongly recommended for unilateral tinnitus, though the urgency is lower. 1, 5 The American Academy of Otolaryngology guidelines specifically identify unilateral tinnitus as a red flag warranting imaging consideration. 1

Do NOT order imaging if: The tinnitus were bilateral, symmetric, non-pulsatile, and without localizing features - but this is not your case. 1, 5

Critical Questions to Clarify

Before proceeding, determine:

1. Is the tinnitus pulsatile (synchronous with heartbeat)? If yes, this completely changes the workup to focus on vascular causes and requires CT angiography or high-resolution CT temporal bone. 6, 7

2. Can you modulate the tinnitus with jaw movements or neck positioning? If yes, this strongly suggests TMJ dysfunction or cervical somatosensory contribution. 3, 4

3. Any associated symptoms? Vertigo, hearing loss, aural fullness, headaches, or vision changes would alter the diagnostic pathway. 3

Management After Diagnosis

Once serious pathology is excluded:

• Education and counseling about tinnitus mechanisms and natural history for all patients 1, 5
• Cognitive behavioral therapy is the only treatment proven to improve quality of life and should be offered as first-line therapy 1, 5
• Sound therapy may be offered as second-line for auditory masking 1, 5
• Hearing aids if any hearing loss is documented, even if mild 1, 5

Common Pitfalls to Avoid

• Do not dismiss unilateral tinnitus as benign without proper workup - missing a vestibular schwannoma can have serious consequences 1, 2
• Do not wait arbitrarily before obtaining audiometry - testing should occur within 4 weeks for unilateral presentation 1, 5
• Do not assume the neck pain is unrelated - TMJ dysfunction and cervical issues can directly cause or modulate tinnitus 3, 4
• Do not order pharmacologic treatments routinely - antidepressants, anticonvulsants, supplements (Ginkgo biloba, zinc, melatonin) are not recommended for routine tinnitus management 5