I have aural fullness and tinnitus; what is the appropriate initial evaluation and management?

Aural Fullness and Tinnitus: Initial Evaluation and Management

You need to determine immediately whether your tinnitus is pulsatile (synchronous with your heartbeat) or non-pulsatile, because pulsatile tinnitus requires urgent imaging to rule out life-threatening vascular causes, whereas non-pulsatile tinnitus typically does not. 1

Critical First Step: Characterize the Tinnitus

• Pulsatile tinnitus (rhythmic, beating with your pulse) has an identifiable structural or vascular cause in over 70% of cases, including potentially life-threatening conditions like arterial dissection, dural arteriovenous fistulas, or carotid stenosis that can lead to stroke if missed. 1, 2

• Non-pulsatile tinnitus (ringing, buzzing, hissing) is most commonly associated with sensorineural hearing loss and rarely requires imaging unless it is unilateral or accompanied by asymmetric hearing loss. 3, 4

If Your Tinnitus is Pulsatile: Urgent Workup Required

Immediate Clinical Assessment

• Obtain a comprehensive audiologic examination within 4 weeks, including pure-tone audiometry, speech audiometry, and acoustic reflex testing, to identify asymmetric hearing loss that may indicate retrocochlear pathology like vestibular schwannoma. 1, 2

• Undergo otoscopic examination to detect vascular retrotympanic masses (which appear as red pulsatile lesions behind the eardrum and suggest paragangliomas or glomus tumors). 1, 2

First-Line Imaging

• Get CT angiography (CTA) of the head and neck with contrast using a mixed arterial-venous phase as your first imaging study, because this single scan identifies the most common and dangerous causes: atherosclerotic carotid disease (17.5% of cases), dural arteriovenous fistulas (8% of cases, can cause stroke), arterial dissection, sigmoid sinus abnormalities, and arteriovenous malformations. 1, 2

• Alternative: Get high-resolution CT of the temporal bone (non-contrast) only if your otoscopic exam shows a vascular mass behind the eardrum, as this better evaluates paragangliomas, jugular bulb abnormalities, and superior semicircular canal dehiscence. 1, 2

Second-Line Imaging if CTA is Negative

• Proceed to MRI brain with contrast plus MR angiography/venography if CTA is negative but suspicion remains high, to evaluate for cerebellopontine angle lesions, subtle vascular malformations, intracranial hypertension (especially if you are a young overweight woman with headaches), or sigmoid sinus wall abnormalities. 1, 2

Common Pitfall to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging, because treatable and life-threatening causes are present in the majority of cases, and missing a dural arteriovenous fistula can result in catastrophic hemorrhage. 1, 2

If Your Tinnitus is Non-Pulsatile: Standard Workup

When Imaging IS Required

• Get MRI of the internal auditory canals with contrast if your tinnitus is unilateral or you have asymmetric hearing loss, because this raises concern for vestibular schwannoma (acoustic neuroma), which almost always causes unilateral tinnitus with hearing loss. 1, 3, 4

• Get imaging urgently if you have focal neurologic deficits (weakness, numbness, vision changes, coordination problems), as this shifts the evaluation away from tinnitus protocols toward stroke or mass lesion workup. 1

When Imaging is NOT Required

• Do not get imaging if your tinnitus is bilateral, symmetric, and non-pulsatile without localizing features, because the diagnostic yield is extremely low and represents inappropriate resource utilization. 1, 4

Essential Audiologic Testing

• Obtain comprehensive audiologic examination within 4 weeks for any persistent tinnitus (lasting 6 months or longer) or unilateral tinnitus, because sensorineural hearing loss is the most common underlying cause and hearing aids provide significant relief with strong supporting evidence. 1, 3, 4

Otoscopic Examination

• Have your ear canals examined to identify simple reversible causes like cerumen impaction or middle ear effusion, which can cause both tinnitus and aural fullness. 3, 5

Additional Evaluation for Aural Fullness

• Consider Menière's disease if you have episodic vertigo, fluctuating hearing loss, and aural fullness in addition to tinnitus, as this is a classic triad requiring specific management. 3, 5

• Screen for anxiety and depression using validated instruments, because these conditions frequently coexist with bothersome tinnitus, influence management decisions, and patients with severe psychiatric symptoms require prompt intervention due to suicide risk. 1, 3

Initial Management While Awaiting Workup

• Avoid further noise exposure to prevent progression of tinnitus and hearing loss. 4

• Receive education and counseling about tinnitus mechanisms, natural history, and management strategies at your initial visit, as this empowers you and sets realistic expectations. 1, 4

• Consider cognitive behavioral therapy if your tinnitus is bothersome, as this is the only treatment proven to improve quality of life in tinnitus patients. 4

• Pursue hearing aid evaluation if audiometry documents hearing loss, because hearing aids are first-line therapy with strong evidence for tinnitus symptom improvement. 1, 4

Red Flags Requiring Urgent Evaluation

• Pulsatile quality (synchronous with heartbeat) 1, 2
• Unilateral presentation 1, 4
• Focal neurologic deficits (weakness, vision changes, coordination problems) 1
• Asymmetric hearing loss 1, 4
• Severe anxiety or depression (suicide risk) 1, 3
• Tinnitus that wakes you from sleep (suggests objective tinnitus with vascular or neuromuscular cause) 3