ACR Appropriateness Criteria® Tinnitus: 2023 Update


Vikas Jain, MetroHealth Medical Center, Cleveland, Ohio. Electronic address:
Bruno Policeni, Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Amy F. Juliano, Panel Vice-Chair, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.
Oliver Adunka, The Ohio State University Wexner Medical Center, Columbus, Ohio; American Academy of Otolaryngology-Head and Neck Surgery.
Mohit Agarwal, Froedtert Memorial Lutheran Hospital Medical College of Wisconsin, Milwaukee, Wisconsin.
Prachi Dubey, Houston Methodist Hospital, Houston, Texas.
Elliott R. Friedman, Houston Methodist Hospital, Houston, Texas.
Maria K. Gule-Monroe, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Mari Hagiwara, New York University Langone Medical Center, New York, New York.
Christopher H. Hunt, Mayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging.
Bruce M. Lo, Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians.
Esther S. Oh, Johns Hopkins University School of Medicine, Baltimore, Maryland; American Geriatrics Society.
Tanya J. Rath, Mayo Clinic Arizona, Phoenix, Arizona.
J Kirk Roberts, Columbia University Medical Center, New York, New York; American Academy of Neurology.
David Schultz, Evansville Primary Care, Evansville, Indiana; American Academy of Family Physicians.
M Reza Taheri, George Washington University Hospital, Washington, District of Columbia.
David Zander, University of Colorado Denver, Denver, Colorado.
Judah Burns, Specialty Chair, Montefiore Medical Center, Bronx, New York.

Document Type

Journal Article

Publication Date



Journal of the American College of Radiology : JACR








AUC; Appropriateness Criteria; appropriate use criteria; dural arteriovenous fistula; dural sinus stenosis; glomus tumors; nonpulsatile tinnitus; pulsatile tinnitus; tinnitus


Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.