What workup is indicated for a patient with a 3‑month history of persistent tinnitus and intermittent presyncope?

Workup for 3-Month History of Tinnitus and Intermittent Lightheadedness

This patient requires comprehensive audiologic examination within 4 weeks and targeted imaging based on tinnitus characteristics, with urgent evaluation if the tinnitus is pulsatile or the lightheadedness represents true presyncope. 1, 2

Immediate Clinical Characterization Required

Tinnitus Quality Assessment

• Determine if the tinnitus is pulsatile (synchronous with heartbeat) versus non-pulsatile, as this fundamentally changes the diagnostic urgency and imaging strategy—pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases and can indicate life-threatening conditions like dural arteriovenous fistula or arterial dissection. 2
• Assess laterality (unilateral vs bilateral), as unilateral tinnitus has higher likelihood of identifiable structural pathology and mandates imaging. 2
• Document whether the tinnitus is bothersome versus non-bothersome, as this determines treatment intensity and need for intervention beyond diagnostic workup. 1

Lightheadedness Characterization

• Distinguish true presyncope (near-fainting) from vertigo (spinning sensation) versus non-specific dizziness, as presyncope with pulsatile tinnitus raises concern for vascular pathology including arterial dissection or high-flow vascular malformations. 2
• Assess for focal neurological deficits, as any neurologic abnormalities shift the evaluation away from tinnitus-specific protocols toward urgent stroke/mass lesion workup. 2

Mandatory First-Line Testing

Audiologic Evaluation

• Order comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing within 4 weeks for any persistent tinnitus (≥3 months qualifies as persistent per the 6-month threshold guideline). 1, 2
• This testing documents baseline hearing status, identifies asymmetric hearing loss (which requires different imaging protocol), and guides hearing aid evaluation if sensorineural hearing loss is present. 1, 2

Physical Examination Essentials

• Perform thorough otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile masses behind tympanic membrane), cerumen impaction, or middle ear effusion. 2
• Conduct jugular/carotid compression test if tinnitus is pulsatile—relief with compression suggests venous etiology (sigmoid sinus abnormalities) or arterial dissection. 2
• Complete neurologic examination focusing on cranial nerves, cerebellar function, and gait to identify focal deficits. 2
• Auscultate around the ear and neck for objective tinnitus (audible bruits), which strongly suggests vascular pathology requiring immediate workup. 2, 3

Imaging Decision Algorithm

IF Tinnitus is Pulsatile:

• Order CT angiography (CTA) of head and neck with contrast as first-line study using mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial causes (dural AVF, arterial dissection, atherosclerotic carotid disease) and venous causes (sigmoid sinus diverticulum, jugular bulb abnormalities) in single acquisition. 2
• Alternative: Order high-resolution CT temporal bone (non-contrast) if clinical suspicion points toward paragangliomas, glomus tumors, superior semicircular canal dehiscence, or jugular bulb abnormalities based on otoscopic findings. 2
• If initial imaging negative but clinical suspicion remains high, proceed to MRI brain with contrast and MR angiography/venography to evaluate for subtle vascular malformations or cerebellopontine angle lesions. 2

IF Tinnitus is Non-Pulsatile AND Unilateral:

• Order MRI of internal auditory canals with contrast to evaluate for vestibular schwannoma (acoustic neuroma), especially if accompanied by asymmetric hearing loss. 2, 4

IF Tinnitus is Non-Pulsatile AND Bilateral/Symmetric:

• Do NOT order imaging—this represents inappropriate resource utilization with no benefit, as bilateral symmetric non-pulsatile tinnitus without localizing features has extremely low yield for structural pathology. 1, 2

Red Flags Requiring Urgent Imaging Regardless of Tinnitus Type

• Any focal neurological deficits (order CTA head/neck emergently). 2
• Asymmetric or unilateral hearing loss (changes imaging protocol to MRI IAC with contrast). 2
• Objective tinnitus audible to examiner (strongly suggests vascular pathology). 2
• Associated vision changes (raises concern for idiopathic intracranial hypertension, second most common cause of pulsatile tinnitus). 2

Additional Workup Based on Clinical Context

If Lightheadedness Suggests Cardiovascular Etiology

• Consider basic metabolic panel, CBC, and orthostatic vital signs to evaluate for anemia, electrolyte abnormalities, or orthostatic hypotension. 5
• Assess cardiovascular risk factors including dyslipidemia and atherosclerosis, as these are significantly associated with tinnitus and hearing loss. 5

If Bothersome Tinnitus Identified

• Screen for anxiety and depression using validated instruments, as these are both cause and consequence of tinnitus and require prompt identification for appropriate referral. 1, 6
• Provide education and counseling about tinnitus mechanisms, natural history, and management strategies at initial visit. 1

Treatment Considerations Based on Findings

If Hearing Loss Documented on Audiometry

• Recommend hearing aid evaluation even for mild or unilateral hearing loss, as hearing aids have strong evidence for tinnitus relief and represent first-line audiologic intervention. 1, 6

If Persistent Bothersome Tinnitus Without Remediable Cause

• Refer for Cognitive Behavioral Therapy (CBT), which has the strongest evidence for improving quality of life in tinnitus patients. 6, 4
• Consider sound therapy as adjunctive management option for symptomatic relief. 6

Critical Pitfalls to Avoid

• Do not dismiss pulsatile tinnitus as benign without imaging—treatable and life-threatening causes (dural AVF, arterial dissection) are common and can lead to catastrophic hemorrhage or stroke if missed. 2
• Do not delay audiometry waiting for arbitrary time periods—obtain testing within 4 weeks for any persistent or unilateral tinnitus. 2
• Do not order imaging for bilateral symmetric non-pulsatile tinnitus—this represents low-yield expensive testing with potential harms. 1, 2
• Do not miss inadequate otoscopic examination—vascular retrotympanic masses (paragangliomas) can be identified on physical exam and change imaging selection. 2
• Do not overlook intracranial hypertension in young overweight women with headaches and pulsatile tinnitus, as this can cause vision loss if untreated. 2