Association Between Tinnitus and Cervical Radiculopathy
Yes, there is a recognized association between tinnitus and cervical spine disorders, including cervical radiculopathy, termed "cervicogenic somatic tinnitus" (CST). This subtype of tinnitus arises from cervical spine dysfunctions and is characterized by the temporal coincidence of neck pain and tinnitus appearing or worsening together 1, 2.
Clinical Evidence for the Association
The connection between cervical pathology and tinnitus is supported by multiple lines of evidence:
Cervicogenic somatic tinnitus occurs in approximately 43% of patients with chronic tinnitus who also have neck complaints 2. The diagnosis is established when tinnitus and neck pain appear or increase simultaneously 2.
Cervical nerve involvement can directly cause tinnitus, as demonstrated by cases where treatment of the C3 and C4 cervical nerves resulted in tinnitus reduction in 19% of patients 3. The presence of anterior spurs at C3 combined with hearing loss at 2 kHz predicted the best response to cervical nerve therapy 3.
Mechanical compression of nerve roots by vascular structures in the cervical spine can manifest as both radiculopathy and pulsatile tinnitus, as documented in cases of vertebral arteriovenous fistulas at the C1 level 4.
Diagnostic Criteria and Clinical Presentation
To establish CST as distinct from other tinnitus etiologies, specific clinical features must be present:
Neck Bournemouth Questionnaire (NBQ) scores >14 points indicate significant neck complaints that support the diagnosis of CST 1, 2. Conversely, NBQ scores <14 points make CST less likely (sensitivity 80%, likelihood ratio 0.3, posttest probability 19%) 2.
Positive manual rotation test and adapted Spurling test strongly support CST diagnosis (likelihood ratio 5, specificity 90%, posttest probability 78%) 2.
Presence of cervical trigger points has 82% sensitivity for CST, while their absence reduces the probability to 22% 2.
Co-variation of tinnitus and neck complaints (both increasing or decreasing simultaneously) is a key diagnostic feature and prognostic indicator 5.
Important Clinical Distinctions
The AAO-HNS guidelines provide critical context for when cervical pathology should be considered:
Imaging is NOT recommended for tinnitus that is bilateral, nonpulsatile, and without focal neurological abnormalities or asymmetric hearing loss 6. This represents the majority of tinnitus cases and should not prompt cervical spine evaluation.
Unilateral persistent tinnitus warrants comprehensive audiological examination first 6, not immediate cervical spine imaging.
Pulsatile tinnitus requires different diagnostic considerations focused on vascular pathology rather than cervical radiculopathy 6.
Treatment Implications
When CST is appropriately diagnosed, cervical-directed therapy can be effective:
Multimodal cervical physical therapy (manual mobilizations and exercises) for 6 weeks demonstrated positive effects on tinnitus severity in patients with CST 1, 5.
Patients with co-varying tinnitus and neck complaints had significantly lower tinnitus severity scores after treatment (p=0.001) and at 6-week follow-up (p=0.03) 5.
Low-pitched tinnitus that increases with inadequate cervical postures, combined with co-varying neck complaints, predicts better response to cervical physical therapy (adjusted R²=0.357) 5.
Critical Pitfalls to Avoid
Do not pursue cervical spine imaging or treatment for typical bilateral nonpulsatile tinnitus without neck complaints, as this violates AAO-HNS strong recommendations against imaging in such cases 6.
Do not diagnose CST without documented temporal relationship between neck pain and tinnitus onset or exacerbation 2.
Do not overlook otological causes—comprehensive audiological examination remains essential before attributing tinnitus to cervical pathology 6.
Recognize that cervical radiculopathy typically presents with upper limb pain and sensorimotor deficits 6, not isolated tinnitus. When both conditions coexist, ensure each is independently justified rather than assuming causation.
Algorithmic Approach
Step 1: Determine tinnitus characteristics—unilateral vs bilateral, pulsatile vs nonpulsatile, associated hearing loss 6.
Step 2: If bilateral, nonpulsatile, without focal neurological findings or asymmetric hearing loss—stop cervical evaluation per AAO-HNS guidelines 6.
Step 3: If unilateral or with neck complaints, assess NBQ score and temporal relationship between tinnitus and neck pain 2.
Step 4: If NBQ >14 and co-varying symptoms present, perform manual rotation test, adapted Spurling test, and trigger point examination 2.
Step 5: If clinical tests positive and CST diagnosis established, initiate 6-week multimodal cervical physical therapy before considering imaging 1, 5.
Step 6: Reserve MRI cervical spine for cases with true radiculopathy symptoms (upper limb pain, motor/sensory deficits) that meet standard imaging criteria 6, not for isolated tinnitus.