Diagnostic Imaging Pathways - Tinnitus
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with tinnitus.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Acoustic Neuroma Image 1a and 1b (Magnetic Resonance Imaging): Pre- and post-contrast images demonstrating an enhancing lesion within the right cerebello-pontine angle and internal auditory canal (arrows). Appearances are typical of an acoustic neuroma. The lesion measures up to 17mm. Its medial aspect almost contacts the pons. A small vessel in interposed between the mass and the pons. The inferior aspect of the lesion approaches the fundus of the right internal auditory canal. |
| 1b |  |
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Teaching Points
Teaching Points
- Tinnitus, a buzzing or ringing in the ear, may be pulsatile or continuous (non-pulsatile)
- The distinction determines the most appropriate imaging study
- Gadolinium enhanced MRI is the study of choice for evaluation of non-pulsatile tinnitus
- Contrast enhanced CT (+/- CTA) is the initial imaging modality of choice for the investigation of pulsatile tinnitus
ct
Computed Tomography (CT)
- Contrast-enhanced CT scan of the temporal bones and brain is the imaging modality of choice for investigation of pulsatile tinnitus 1,2,3,4
- Allows delineation of the bony abnormalities that are associated with some of the vascular diseases 4
- Useful in delineation of the location and size of the jugular bulb and the course of the carotid artery in order to exclude an aberrant carotid artery or a vascular mass of the middle ear 3
- CT angiography of the head and neck may be required to exclude a vascular cause of pulsatile tinnitus
- Advantages: relatively inexpensive and widely available
- Limitations: ionising radiation and use of contrast agent
mra
Magnetic Resonance Imaging (MRI) in the Evaluation of Non-pulsatile Tinnitus
- Gadolinium enhanced MRI (with thin transverse and coronal T1- and T2- weighted images through the temporal bones, and transverse images through the entire brain) is the study of choice for evaluation of non-pulsatile tinnitus 1,2
- Helps exclude a vestibular schwannoma or other neoplasm of the cerebellopontine angle cistern in patients with non-pulsatile tinnitus. Brainstem pathology such as stroke or multiple sclerosis is also a consideration, and will be adequately imaged with MRI 1,2
- Limitations - limited availability and high expense
mri
Magnetic Resonance Imaging (MRI / MRA / MRV) in the Evaluation of Pulsatile Tinnitus
- Indications
- To evaluate patients with objective tinnitus or severe subjective tinnitus with or without otoscopic abnormality and normal CT scan findings 5
- To delineate an abnormality detected on CT
- To detect rare causes of pulsatile tinnitus such as multiple sclerosis and a Chiari I malformation not seen on CT 1
- Addition of MRA and MRV to conventional MRI greatly enhances the ability to show vascular lesions 5
- Superior to CT for enhancement of vascular tumours, typically paragangliomas 6, 7
- Limitations
tinnitus
Tinnitus
- Tinnitus, a buzzing or ringing in the ear, may be pulsatile or continuous (non-pulsatile) 1
- Pulsatile tinnitus (a discrete, repetitive sound that accompanies the patients pulse) suggests the presence of vascular abnormality (a tumour, a congenital anomaly, a malformation, or an acquired vasculopathy) 1
- Patients with non-pulsatile tinnitus (constant, unremitting noise) may require exclusion of cerebellopontine angle tumour, most often a vestibular schwannoma 1
- The distinction, with a detailed clinical evaluation, determines the most appropriate imaging study 1,2,3
- In vast majority, no pathology is identified 1,2,3
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology. 2000;216:342-9. (Review article)
- Marsot-Dupuch K. Pulsatile and nonpulsatile tinnitus: a systemic approach. Semin Ultrasound CT MR. 2001;22(3):250-70. (Review article)
- Sismanis A. Pulsatile tinnitus: a 15-year experience. Am J Otol. 1998;19:472-7. (Level II/III evidence)
- Remley KB, Coit WE, Harnsberger HR, et al. Pulsatile tinnitus and the vascular tympanic membrane: CT, MR and angiographic findings. Radiology. 1990;174:383-9. (Level III evidence)
- Dietz RR, Davis WL, Harnsberger HR, et al. MR imaging and MR angiography in the evaluation of pulsatile tinnitus. AJNR Am J Neuroradiol. 1994;15:879-89. (Level III evidence). View the reference
- Olsen WL, Dillon WP, Kelly WM, et al. MR imaging of paragangliomas. AJNR Am J Neuroradiol. 1986;7:1039-42. (Level IV evidence)
- Vogl T, Bruning R, Schedel H, et al. Paragangliomas of the jugular bulb and carotid body: MR imaging with short sequences and Gd-DTPA enhancement. AJNR Am J Neuroradiol. 1989;10:823-7. (Level III evidence)
- DeMarco JK, Dillon WP, Halbach VV, et al. Dural arteriovenous fistulas: evaluation with MR imaging. Radiology. 1990;175:193-9. (Level IV evidence)
- Shin EJ, Lalwani AK, Dowd CF. Role of angiography in the evaluation of patients with pulsatile tinnitus. Laryngoscope. 2000;110:1916-20. (Level III evidence)
Further Reading
- Lockwood AH, Salvi RJ, Burkard RF. Current concepts: tinnitus. N Engl J Med. 2002;347(12):904-10. (Review article)
- Willinsky RA. Tinnitus: imaging algorithms. Can Assoc Radiol J. 1992;43:93-9. (Review article)
- Branstetter B, Weissman J. The radiological evaluation of tinnitus. Eur Radiol. 2006;16(12):2792-802. (Review article)
Information for Consumers
Information for Consumers
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Information from the Royal Australian and New Zealand College of Radiologists’ website |
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans Magnetic Resonance Angiography (MRA) Magnetic Resonance Imaging (MRI) |
Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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