14Red Flags on Examination

FThe job of red-flag thinking

Idiopathic, bilateral, symmetrical tinnitus accompanying age- or noise-related hearing loss is overwhelmingly the common picture, and it does not need imaging. The purpose of a red-flag framework is the opposite of reassurance-seeking: it exists to catch the small minority in whom tinnitus is the presenting clue to a vestibular schwannoma, a vascular lesion, raised intracranial pressure or a structural ear problem.

National guidance frames the examination explicitly around this triage: the examiner is looking for the features that distinguish benign tinnitus from the cases that warrant audiometry, imaging or specialist referral [2014]. A red flag is therefore not a diagnosis — it is a trigger that changes the next step.

TAsymmetry: the unilateral red flag

Tinnitus that is strictly unilateral, or accompanied by asymmetric sensorineural hearing loss, is the classic warning for retrocochlear pathology. The lesion most feared is vestibular schwannoma, and the supporting bedside signs are speech discrimination that is disproportionately poor for the pure-tone thresholds, and on tuning forks a Weber that lateralises to the better ear with a positive Rinne on the affected side — the sensorineural pattern.

Because the consequence of missing one is significant, unilateral tinnitus with asymmetric SNHL is a standard indication for gadolinium-enhanced MRI of the internal auditory canals. Guidance is careful here: imaging should be targeted, not reflexive, but genuine asymmetry is one of the situations where it is clearly justified [2014] [2019].

CPulsatile tinnitus: listen, then look

Pulsatile tinnitus — a sound synchronous with the heartbeat — is a distinct red flag because it points to a vascular source that may be objective and may be treatable. The bedside response is twofold. First, auscultate: place the bell over the mastoid, the periauricular region, the neck and the orbit in a quiet room, asking the patient to hold their breath; a bruit synchronous with the tinnitus strongly suggests a dural arteriovenous fistula, carotid pathology, an aberrant carotid or a venous-sinus anomaly. Second, look: a red or bluish retrotympanic mass on otoscopy may be a glomus tumour, a high-riding jugular bulb or a dehiscent carotid — lesions that must never be probed or biopsied.

In a young, often overweight woman, pulsatile tinnitus with headache, transient visual obscurations or papilloedema raises idiopathic intracranial hypertension, which demands fundoscopy and dedicated venous imaging. Any of these findings moves the patient to vascular or cross-sectional imaging (CT/MR angiography or venography) rather than routine follow-up [2013].

CFocal neurology, otoscopic masses and sudden loss

Three further categories complete the matrix. Focal neurological signs — facial weakness or numbness, an absent corneal reflex, diplopia, ataxia, or other cranial-nerve deficits alongside tinnitus — suggest mass effect in the cerebellopontine angle or brainstem and warrant urgent neuroimaging and neurology involvement. An otoscopic mass or structural abnormality (retrotympanic vascular mass, but also cholesteatoma or a suspicious lesion) is a red flag in its own right.

Finally, sudden sensorineural hearing loss accompanied by tinnitus is a true otological emergency: it is time-critical because early treatment improves the chance of recovery, so it should be escalated the same day rather than worked up at leisure. Bringing these together — unilateral/asymmetric, pulsatile/vascular, neurological, otoscopic-structural and sudden-loss — gives a five-domain red-flag matrix that maps each finding onto a defined action [2014].