What could cause right‑ear chirping tinnitus accompanied by vertigo, and what urgent evaluation and treatment are recommended?

Right Ear Chirping Tinnitus with Vertigo: Urgent Evaluation and Management

You must urgently obtain imaging—either high-resolution CT temporal bone or CT angiography of the head and neck—because unilateral tinnitus with vertigo has an identifiable structural or vascular cause in over 70% of cases, and missing life-threatening conditions like dural arteriovenous fistula, arterial dissection, or vestibular schwannoma can result in catastrophic hemorrhage, stroke, or permanent hearing loss. 1, 2

Immediate Clinical Assessment

Before ordering imaging, perform these specific evaluations to guide your imaging selection:

• Otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind the tympanic membrane), cerumen impaction, or middle ear effusion 1, 2
• Characterize the tinnitus precisely: Is it truly pulsatile (synchronous with heartbeat) or non-pulsatile chirping? Pulsatile tinnitus strongly suggests vascular pathology requiring immediate workup 3, 1
• Characterize the vertigo duration and triggers: Seconds suggests BPPV, minutes to hours suggests Menière's disease or vestibular migraine, prolonged (>24 hours) suggests labyrinthitis or vestibular neuritis 3
• Neurologic examination for focal deficits (dysphonia, dysphagia, visual changes, limb weakness) suggesting stroke or posterior fossa mass 3, 1
• Jugular/carotid compression test: Gentle compression that relieves tinnitus suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection 1, 2

First-Line Imaging Strategy

Your imaging choice depends on otoscopy findings and tinnitus character:

• If vascular retrotympanic mass present on otoscopy: Order high-resolution CT temporal bone (non-contrast) to identify paragangliomas (16% of pulsatile tinnitus cases), glomus tumors, or adenomatous middle ear tumors 1, 2

• If otoscopy normal and tinnitus is pulsatile or chirping: Order CT angiography (CTA) head and neck with contrast using mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in a single acquisition 1, 2

  • This identifies dural arteriovenous fistulas (8% of cases, life-threatening), arterial dissection (requires immediate anticoagulation), atherosclerotic carotid disease (17.5% of cases), sigmoid sinus diverticulum/dehiscence, and arteriovenous malformations 1, 2

• Comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks to document asymmetric hearing loss indicating retrocochlear pathology like vestibular schwannoma 1, 2, 4

Critical Differential Diagnosis by Clinical Pattern

The combination of unilateral tinnitus and vertigo narrows your differential significantly:

Most Likely Diagnoses (Require Urgent Imaging):

• Vestibular schwannoma: Chronic imbalance more likely than episodic vertigo, asymmetric hearing loss and tinnitus that doesn't fluctuate, requires MRI internal auditory canals with contrast 3

• Menière's disease: Episodic vertigo lasting 20 minutes to 12 hours, fluctuating hearing loss, aural fullness, and tinnitus in the affected ear—but vertigo attacks are spontaneous, not positional 3

• Labyrinthitis: Sudden severe vertigo with profound hearing loss lasting >24 hours, not episodic or fluctuating 3

• Dural arteriovenous fistula: Pulsatile tinnitus, can present with isolated symptoms before catastrophic hemorrhage, accounts for 8% of pulsatile tinnitus 1, 2

• Arterial dissection: Life-threatening, requires immediate anticoagulation/antiplatelet therapy, may present with pulsatile tinnitus and vertigo 1, 2

Less Likely (But Important to Exclude):

• BPPV: Positional vertigo lasting seconds (not minutes/hours), not associated with hearing loss or tinnitus, short duration of vertigo spells 3

  • The presence of tinnitus makes BPPV unlikely, though 19.3% of BPPV patients report concurrent tinnitus that is typically slight and intermittent 5

• Vestibular migraine: Attacks lasting hours (can be minutes or >24 hours), hearing loss less likely, patients often have migraine history with photophobia 3

• Stroke/ischemia: Vertigo with nausea, vomiting, severe imbalance, visual blurring, drop attacks—insults are permanent and don't fluctuate, usually no associated hearing loss or tinnitus, may have dysphagia or dysphonia 3

Second-Line Imaging (If Initial Studies Negative)

• MRI brain with contrast and MR angiography (MRA) when CT/CTA are negative but clinical suspicion remains high, to evaluate for cerebellopontine angle lesions, subtle vascular malformations, or vestibular schwannoma 1, 2
• Use specialized internal auditory canal protocols with thin-section heavily T2-weighted sequences for small vestibular schwannomas 1

Common Pitfalls to Avoid

• Dismissing unilateral tinnitus with vertigo as benign BPPV without imaging: BPPV is not associated with tinnitus in its classic presentation; the presence of tinnitus demands imaging to exclude serious pathology 3

• Missing dural AVF: This life-threatening cause requires high index of suspicion and appropriate vascular imaging (CTA), as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 2

• Inadequate otoscopic examination: Missing a vascular retrotympanic mass (paraganglioma) leads to inappropriate imaging selection and delayed diagnosis 1, 2

• Ordering MRI when CT is more appropriate: For suspected paragangliomas, sigmoid sinus abnormalities, or superior semicircular canal dehiscence, high-resolution CT temporal bone is the preferred initial study 1, 2

• Waiting to image: Unilateral tinnitus with vertigo requires urgent imaging regardless of symptom duration, as treatable and life-threatening causes are common 1, 2