What are the likely causes of ear fullness with tinnitus and the recommended initial management?

Ear Fullness with Tinnitus: Likely Causes and Initial Management

The combination of ear fullness and tinnitus most commonly indicates sensorineural hearing loss, but you must urgently rule out Ménière's disease, sudden sensorineural hearing loss, and—if the tinnitus is pulsatile—life-threatening vascular pathology. 1

Immediate Clinical Assessment

Determine whether the tinnitus is pulsatile (synchronous with heartbeat) or non-pulsatile, as this fundamentally changes your diagnostic approach and urgency. 1, 2

Critical Red Flags Requiring Urgent Imaging

• Pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases, including dural arteriovenous fistula and arterial dissection that can cause catastrophic hemorrhage or stroke if missed. 2
• Unilateral presentation raises suspicion for vestibular schwannoma or other retrocochlear pathology. 1
• Focal neurological deficits shift the evaluation away from tinnitus protocols toward stroke or mass lesion workup. 2
• Asymmetric hearing loss mandates MRI of internal auditory canals with contrast to exclude vestibular schwannoma. 2

Essential History Elements

• Duration and pattern of symptoms: Episodic versus constant, fluctuating versus progressive. 3
• Associated vertigo episodes: Two or more episodes lasting 20 minutes to 24 hours suggest Ménière's disease. 3
• Hearing fluctuation: Abrupt changes alternating between worsening and improving indicate early Ménière's disease. 3
• Character of tinnitus: Ringing, buzzing, clicking, or pulsations—with pulsatile quality demanding vascular evaluation. 1
• Positional variation: Relief with jugular or carotid compression suggests venous etiology or arterial dissection. 2
• Noise exposure history: Occupational or recreational exposure is a major risk factor for sensorineural hearing loss and tinnitus. 1
• Ototoxic medication use: Platinum-based chemotherapy, aminoglycosides, loop diuretics, and high-dose aspirin. 1, 4

Physical Examination Priorities

• Otoscopic examination to identify cerumen impaction, middle ear effusion, or vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions behind the tympanic membrane). 1, 2
• Auscultation over the neck, periauricular area, and mastoid to detect objective tinnitus from vascular abnormalities. 1
• Neurologic examination to identify focal deficits suggesting intracranial pathology. 2
• Jugular/carotid compression test: Symptom relief suggests venous source (sigmoid sinus abnormality, jugular bulb variant) or arterial dissection. 2

Diagnostic Testing Algorithm

First-Line: Comprehensive Audiologic Examination

Order audiometry within 4 weeks for any persistent (≥6 months), unilateral, or bothersome tinnitus with ear fullness. 4, 5

• Pure-tone audiometry measures hearing levels across frequencies and identifies sensorineural versus conductive loss. 3
• Speech audiometry assesses word recognition and functional hearing. 3
• Acoustic reflex testing helps localize lesions and identify retrocochlear pathology. 3

Imaging Decision Tree

DO NOT Image If:

• Bilateral, symmetric, non-pulsatile tinnitus without localizing features—this represents low-value care with no benefit. 4, 2

DO Image If Any of the Following:

For Pulsatile Tinnitus:

• First-line: CT angiography (CTA) of 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. 2
• Alternative first-line: High-resolution CT temporal bone (non-contrast) if otoscopy reveals a vascular retrotympanic mass suggesting paraganglioma. 2
• Second-line: MRI brain with contrast plus MR angiography/venography if CTA is negative but clinical suspicion remains high. 2

For Non-Pulsatile Unilateral Tinnitus with Asymmetric Hearing Loss:

• MRI of internal auditory canals with contrast to exclude vestibular schwannoma. 2

Most Likely Diagnoses by Clinical Pattern

Non-Pulsatile Tinnitus with Ear Fullness

Sensorineural hearing loss is the single most common underlying cause, particularly in bothersome tinnitus without obvious ear pathology. 1

Ménière's disease presents with the classic tetrad: episodic vertigo (20 minutes to 24 hours), fluctuating hearing loss, tinnitus, and ear fullness/pressure. 3

Sudden sensorineural hearing loss is a medical emergency requiring urgent evaluation and treatment with high-dose oral corticosteroids within 2 weeks of onset. 1, 6

Otosclerosis causes conductive hearing loss with tinnitus and requires identification as a treatable secondary cause. 1

Cerumen impaction is a simple, reversible cause identifiable on otoscopic examination. 1

Pulsatile Tinnitus with Ear Fullness

Atherosclerotic carotid artery disease accounts for 17.5% of pulsatile tinnitus cases due to turbulent flow. 2

Idiopathic intracranial hypertension is the second most common cause, particularly in young overweight women with headaches; untreated cases risk permanent vision loss. 2

Dural arteriovenous fistulas account for 8% of cases and can lead to hemorrhagic or ischemic stroke if untreated. 2

Paragangliomas (glomus tumors) account for 16% of cases and appear as vascular retrotympanic masses on otoscopy. 2

Sigmoid sinus diverticulum or dehiscence is commonly associated with intracranial hypertension. 2

Evidence-Based Management

For Confirmed Sensorineural Hearing Loss

Recommend hearing aid evaluation even for mild or unilateral hearing loss, as hearing aids provide significant tinnitus relief with strong supporting evidence. 4

For Persistent, Bothersome Tinnitus

Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus. 4

Provide education and counseling about tinnitus mechanisms, natural history, and management strategies at the initial visit. 4

Sound therapy may be offered as a management option for symptomatic relief, though evidence is less robust than for CBT. 4

Treatments to AVOID

Do NOT recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent tinnitus due to insufficient evidence and potential side effects. 4

Do NOT recommend dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit. 4

Critical Psychiatric Screening

Screen all patients with bothersome tinnitus for severe anxiety or depression using validated instruments, as these conditions carry documented increased suicide risk and require prompt psychiatric intervention. 1, 4

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign without imaging—treatable and life-threatening vascular causes are common. 2
• Ordering imaging for bilateral, symmetric, non-pulsatile tinnitus—this represents inappropriate resource utilization with no benefit. 4, 2
• Missing mild hearing loss—obtain audiometry even when patients don't report hearing difficulties, as amplification can provide significant relief. 4
• Delaying audiometry—testing should be obtained within 4 weeks for persistent or unilateral tinnitus. 4
• Overlooking Ménière's disease—the combination of ear fullness, tinnitus, and fluctuating hearing loss (even without prominent vertigo) warrants consideration of this diagnosis. 3
• Inadequate otoscopic examination—failure to identify vascular retrotympanic masses leads to delayed diagnosis and inappropriate imaging selection. 2

Follow-Up Strategy

Reassess patients whose symptoms do not improve to exclude alternative diagnoses such as Ménière's disease, otosclerosis, or delayed acoustic neuroma. 4

Long-term follow-up is necessary because underlying causes are identified in 10-15% of bilateral tinnitus cases only after extended observation. 4