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Asymmetric sensorineural hearing loss with unilateral non-pulsatile tinnitus — MSRA MCQ

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HardMRIAsymmetric sensorineural hearing loss with unilateral non-pulsatile tinnitusMSRA

A 48-year-old woman is reviewed in GP after audiology assessment for 8 months of persistent left-sided, non-pulsatile tinnitus and gradually progressive difficulty hearing speech in background noise. She has no vertigo, facial numbness or weakness, headache, otalgia, otorrhoea, or neurological symptoms. Otoscopy is normal and there is no middle-ear effusion. Pure-tone audiometry confirms left-sided sensorineural hearing loss, with a 15 dB asymmetry compared with the right ear at both 1 kHz and 2 kHz. She can undergo MRI. What is the most appropriate next imaging investigation?

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Correct answer: A — MRI of the internal auditory meati

MRI of the internal auditory meati (IAM) is the best next investigation. She has unilateral non-pulsatile tinnitus and asymmetric sensorineural hearing loss. Crucially, the asymmetry is 15 dB at 2 adjacent tested frequencies (1 and 2 kHz), which meets the NICE criterion for considering MRI IAM in people without localising signs. Dedicated IAM imaging is intended to assess for vestibular schwannoma or other cerebellopontine-angle pathology. Contrast-enhanced CT IAM is an alternative when MRI cannot be performed, not when MRI is suitable. A non-dedicated brain MRI may miss the optimal focused assessment of the IAM and cerebellopontine angle. CT temporal bones is more useful where bony temporal-bone or middle-ear pathology is suspected; this patient has normal otoscopy and sensorineural, rather than conductive, hearing loss. No imaging would be inappropriate because both the tinnitus laterality and the audiometric asymmetry support investigation. Facial weakness or another localising neurological sign would strengthen the indication further, but is not required here.

Reference: NICE NG98: Hearing loss in adults: assessment and management — Investigation using MRI (2018) — https://www.nice.org.uk/guidance/ng98/chapter/recommendations NICE NG155: Tinnitus: assessment and management — Imaging (2020) — https://www.nice.org.uk/guidance/ng155/chapter/Recommendations