Most tinnitus is bilateral, symmetric and accompanies age- or noise-related hearing loss, and it does not need imaging. The features that change that are unilateral tinnitus, asymmetric sensorineural hearing loss on audiometry, pulsatile tinnitus, and focal neurological signs. Unilateral tinnitus with asymmetric hearing loss raises the question of a vestibular schwannoma, for which MRI of the internal auditory meatus is the standard investigation. Pulsatile tinnitus points towards vascular causes and needs a different work-up, often starting with otoscopy and vascular imaging. An audiogram before imaging is what separates the patients who need a scan from those who do not.
- Arrange an audiogram for every patient with persistent tinnitus.
- Refer for MRI of the internal auditory meatus when tinnitus is unilateral with asymmetric hearing loss.
- Investigate pulsatile tinnitus separately for vascular causes.
- Do not image bilateral, symmetric tinnitus without other concerning features.
Why it matters
Targeted imaging finds the rare serious cause without scanning the many who do not need it.
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