What are the initial diagnostic tests for a 66-year-old male with left-sided head and neck pain?

Diagnostic Tests for Left-Sided Head and Neck Pain in a 66-Year-Old Male

For a 66-year-old male with left-sided head and neck pain, the initial diagnostic approach should include a thorough history and physical examination to identify red flags that would warrant immediate investigation, with imaging reserved for cases with suspicious findings. 1

Initial Assessment

History Taking - Red Flags to Identify

• Age >40 years (patient is 66) - increases suspicion for head and neck squamous cell carcinoma 2
• Duration of symptoms (≥2 weeks is concerning for malignancy) 2
• Associated symptoms that increase suspicion for malignancy:
  • Hoarseness, otalgia, hearing loss 2
  • Dysphagia or odynophagia 2
  • Weight loss 2
  • Hemoptysis or blood in saliva 2
• Risk factors for malignancy:
  • Tobacco and alcohol use 2
  • Prior head and neck cancer history 2
  • Immunocompromised status 2
• Vascular symptoms:
  • Sudden onset of severe headache (worst headache of life) 3
  • Throbbing pain over carotid bifurcation (suggests carotidynia) 4

Physical Examination

• Palpation of neck for masses:
  • Assess mobility, texture (firm texture is concerning), size (>1.5 cm is suspicious) 2
  • Tenderness (nontender masses are more concerning for malignancy) 2
• Complete head and neck examination:
  • Oral cavity and oropharynx inspection for ulcerations or masses 2
  • Tonsil symmetry assessment 2
  • Skin examination of face, neck, and scalp for lesions 2
• Neurological examination to assess for focal deficits 1, 3

Diagnostic Testing Algorithm

Step 1: If No Red Flags Present

• No imaging is recommended initially 1
• Consider conservative management with follow-up in 2-4 weeks if symptoms persist 1

Step 2: If Red Flags Present, Order Appropriate Imaging

• For suspected malignancy (based on history and physical exam findings):

  • Contrast-enhanced CT or MRI of neck 2
  • Ultrasound can be used for initial evaluation of neck masses 5

• For suspected vascular etiology (sudden onset, worst headache):

  • CT angiography (CTA) or MR angiography (MRA) of the neck 2

• For suspected cervicogenic headache:

  • Plain radiographs of cervical spine as first-line imaging 2, 5
  • MRI without contrast if neurological symptoms develop 5

Step 3: Additional Testing Based on Initial Findings

• If neck mass is identified and malignancy is suspected:
  • Fine needle aspiration (FNA) biopsy 2
• If temporal arteritis is suspected (in elderly patients with unilateral head pain):
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 6
  • Consider temporal artery biopsy if laboratory markers are elevated 6

Common Pitfalls to Avoid

• Ordering unnecessary imaging in the absence of red flags, as this rarely changes management in acute, uncomplicated neck pain 1
• Overlooking the possibility of referred pain from cervical spine to head (cervicogenic headache) 7
• Failing to recognize that neck pain is commonly associated with primary headache disorders such as migraine and tension-type headache 7
• Dismissing the possibility of serious vascular conditions like carotid dissection or temporal arteritis in elderly patients 6

Important Considerations

• The American College of Radiology notes that degenerative changes in the cervical spine are common in asymptomatic individuals over 50 years of age and correlate poorly with symptoms 5
• MRI has a high rate of abnormal findings in asymptomatic individuals and should be reserved for cases with focal neurologic symptoms or pain refractory to conventional treatment 1
• Bony prominences of cervical vertebrae can be mistaken for masses on physical examination 5