What is the likely diagnosis and recommended evaluation for a patient presenting with unilateral tinnitus and ear fullness, right‑sided headache, intermittent flushing/tingling, generalized pruritus, and Raynaud’s phenomenon (fingers turning white in cold)?

Unilateral Tinnitus with Raynaud's Phenomenon and Systemic Symptoms: Diagnostic Approach

Order urgent CT angiography (CTA) of the head and neck with contrast using a mixed arterial-venous phase (20–25 seconds post-contrast) to evaluate for life-threatening vascular causes, particularly arterial dissection, dural arteriovenous fistula, and other vascular malformations that can present with unilateral tinnitus and systemic vasospastic symptoms. 1, 2, 3

Critical Clinical Context

Your constellation of symptoms—unilateral tinnitus with ear fullness, right-sided headache, Raynaud's phenomenon, and systemic flushing/tingling—raises immediate concern for an underlying vascular disorder that requires urgent evaluation. 1, 2, 3

• Unilateral tinnitus has an identifiable structural or vascular cause in over 70% of cases, making imaging essential rather than optional. 1, 2, 4
• The combination of Raynaud's phenomenon (episodic digital vasospasm) with unilateral auditory symptoms suggests a systemic vascular process that may involve both peripheral and cerebrovascular circulation. 5, 6
• Arterial dissection is a life-threatening emergency that can present with unilateral tinnitus, headache, and systemic vasospastic symptoms; missing this diagnosis can result in catastrophic stroke. 2, 3, 4

Immediate Diagnostic Workup

First-Line Imaging

CT angiography (CTA) of head and neck with contrast is your first-line study because: 1, 2, 3

• It simultaneously evaluates arterial causes (dissection, atherosclerotic disease, fibromuscular dysplasia) and venous causes (sigmoid sinus abnormalities, jugular bulb variants, dural arteriovenous fistulas) in a single acquisition. 2, 3, 4
• A mixed arterial-venous phase (20–25 seconds post-contrast) captures both arterial and venous pathology without additional radiation exposure. 3, 4
• It identifies dural arteriovenous fistulas, which account for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated. 2, 3, 4

Critical Vascular Pathologies to Exclude

Condition	Clinical Significance	Imaging Findings
Arterial dissection	Life-threatening; requires immediate anticoagulation or antiplatelet therapy	Intimal flap, double lumen, or vessel narrowing on CTA [2,3]
Dural arteriovenous fistula	8% of pulsatile tinnitus; risk of hemorrhagic stroke	Abnormal arteriovenous shunting on CTA [2,3,4]
Fibromuscular dysplasia	Systemic vasculopathy affecting multiple vascular beds	"String of beads" appearance in carotid arteries [4]
Sigmoid sinus diverticulum/dehiscence	Common with intracranial hypertension	Bony defect or outpouching on temporal bone CT [2,4]

Complementary Evaluation

Otoscopic Examination

Perform a comprehensive otoscopic examination before imaging to: 1, 2, 4

• Detect vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions behind the tympanic membrane), which would redirect you to high-resolution temporal bone CT instead of CTA. 1, 4
• Identify cerumen impaction or middle ear effusion as simple, reversible causes of ear fullness and tinnitus. 2

Audiologic Testing

Schedule a comprehensive audiologic examination (pure-tone audiometry, speech audiometry, acoustic reflex testing) within 4 weeks to: 1, 2

• Document any asymmetric hearing loss, which raises concern for retrocochlear pathology (vestibular schwannoma) and would require MRI of internal auditory canals with contrast. 1, 2, 7
• Establish baseline hearing status for ongoing management. 1, 2

Characterize the Tinnitus

Determine whether your tinnitus is: 1, 2, 4

• Pulsatile (synchronous with heartbeat) versus non-pulsatile (continuous buzzing/ringing)—pulsatile tinnitus strongly suggests vascular pathology and mandates immediate imaging. 1, 2, 4
• Positional (changes with head position)—suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection. 4

Secondary Imaging if CTA is Negative

If CTA is negative but clinical suspicion remains high, proceed to: 1, 2, 4

• MRI of the brain with gadolinium contrast plus MR angiography/venography (MRA/MRV) to evaluate for:
  • Cerebellopontine angle lesions (vestibular schwannoma, acoustic neuroma) 1, 2
  • Subtle vascular malformations not identified on CTA 1, 4
  • Intracranial hypertension (particularly in young overweight women with headaches) 4
  • Superior semicircular canal dehiscence (bony defect transmitting vascular sounds) 2, 4

Raynaud's Phenomenon Considerations

Your Raynaud's phenomenon (fingers turning white in cold) warrants separate evaluation: 5, 6

• Primary Raynaud's disease is idiopathic and benign, occurring without underlying systemic disease. 5, 6

• Secondary Raynaud's phenomenon is associated with:

  • Connective tissue diseases (systemic sclerosis, lupus, rheumatoid arthritis) 5, 8
  • Medications causing vasoconstriction (beta-blockers, ergotamine, sympathomimetics) 8
  • Vascular disorders (atherosclerosis, arterial dissection, fibromuscular dysplasia) 5, 6

• The combination of Raynaud's with unilateral tinnitus and headache raises concern for a systemic vascular disorder affecting multiple vascular beds, making urgent vascular imaging even more critical. 5, 6

Systemic Symptoms Interpretation

Your generalized pruritus, flushing, and tingling are non-specific but may suggest: 2

• Anxiety or depression (common comorbidities with tinnitus that require screening and treatment) 2, 7
• Medication side effects (if you are taking sympathomimetics, beta-blockers, or other vasoactive drugs) 8
• Systemic inflammatory or autoimmune process (if Raynaud's is secondary to connective tissue disease) 5

These symptoms do not change the urgent need for vascular imaging of your unilateral tinnitus and headache. 1, 2

Critical Pitfalls to Avoid

• Do not dismiss unilateral tinnitus as benign without imaging, especially with concurrent headache and systemic vasospastic symptoms—treatable and life-threatening vascular causes are common. 1, 2, 3
• Do not delay vascular imaging while pursuing conservative therapies or attributing symptoms to cervical spine pathology, as this may miss time-sensitive emergencies like arterial dissection. 3
• Do not use MRI as the initial study when vascular etiologies are suspected; CTA offers faster acquisition and superior arterial/venous assessment. 3, 4
• Do not overlook the psychological impact of sudden unilateral hearing loss or tinnitus—patients with severe anxiety or depression require prompt identification and intervention due to increased suicide risk. 1, 2

Summary of Immediate Actions

1. Order CTA head/neck with contrast (mixed arterial-venous phase) urgently. 1, 2, 3
2. Perform otoscopic examination to detect vascular retrotympanic masses or cerumen impaction. 1, 2, 4
3. Schedule comprehensive audiometry within 4 weeks to document asymmetric hearing loss. 1, 2
4. Characterize tinnitus quality (pulsatile vs. non-pulsatile, positional variation). 1, 2, 4
5. Evaluate Raynaud's phenomenon for secondary causes (connective tissue disease, medications, vascular disorders). 5, 8, 6
6. Screen for anxiety and depression given the psychological burden of tinnitus. 2, 7