What could be causing my dry scratchy deep pain in the upper neck muscles, slight tinnitus (ringing in the ears) when turning my neck, and persistent off-balance feeling while standing, despite having full range of motion (ROM) in my neck and symptoms subsiding when laying down?

Clinical Assessment: Cervicogenic Somatic Tinnitus with Orthostatic Component

Your symptoms strongly suggest cervicogenic somatic tinnitus (CST) combined with orthostatic intolerance, and you should undergo targeted cervical spine evaluation with manual rotation testing and trigger point examination, followed by audiometric assessment if cervical findings are positive. 1

Primary Diagnostic Consideration

Your constellation of symptoms—deep upper neck muscle pain, tinnitus with neck turning, positional relief when lying down, and balance disturbance while standing—points to a cervical spine origin rather than a primary otologic or vascular problem. 1

Key Clinical Features Supporting Cervicogenic Tinnitus:

• Temporal relationship: The tinnitus occurs specifically with neck movement (turning), which is pathognomonic for CST 1
• Mechanical pattern: Symptoms resolve when lying down, indicating a postural/mechanical component 1
• Preserved range of motion: Full cervical ROM with pain suggests muscular dysfunction rather than structural pathology 1, 2
• Neck muscle involvement: "Dry scratchy deep pain" in upper neck muscles is consistent with cervical proprioceptive impairment 2

Orthostatic Intolerance Component

Your off-balance feeling while standing that resolves when lying down, combined with "heavy eyes," represents orthostatic intolerance symptoms. 3

Specific Features to Note:

• Visual disturbances (heavy eyes) are a recognized symptom of orthostatic intolerance 3
• Tinnitus itself is listed as a hearing disturbance associated with orthostatic syndromes 3
• Neck pain (occipital/paracervical region) is specifically mentioned as part of orthostatic intolerance presentation 3
• The symptom pattern (worse standing, better lying) suggests either initial orthostatic hypotension or delayed progressive orthostatic hypotension 3

Recommended Clinical Evaluation

Immediate Physical Examination Tests:

1. Manual rotation test: Passive cervical rotation to assess for reproduction of tinnitus (positive test has 90% specificity for CST) 1
2. Trigger point examination: Palpation of upper cervical muscles—absence of trigger points makes CST less likely (LR 0.3) 1
3. Adapted Spurling test: Cervical compression with rotation (positive test increases probability of CST to 78%) 1
4. Neck Bournemouth Questionnaire: Score <14 points makes CST unlikely (sensitivity 80%) 1

Orthostatic Vital Signs:

• Measure blood pressure and heart rate lying down, then at 1 minute and 3 minutes after standing 3
• Look for systolic BP drop ≥20 mmHg or diastolic drop ≥10 mmHg (defines classical orthostatic hypotension) 3
• Assess for symptoms occurring within 0-30 seconds (initial OH) versus 3-30 minutes (delayed progressive OH) 3

Imaging Considerations

You do NOT need imaging at this time. 3

The American Academy of Otolaryngology-Head and Neck Surgery and American College of Radiology both recommend against imaging for tinnitus that is:

• Nonpulsatile 3
• Not associated with focal neurological abnormalities 3
• Not associated with asymmetric hearing loss 3
• Not localizing to one ear exclusively 3

Your tinnitus occurs only with neck movement (mechanical trigger), making structural imaging unnecessary unless cervical spine-specific red flags emerge. 3

Audiometric Testing Decision

Obtain a comprehensive audiologic examination because your tinnitus is unilateral (occurs with turning, suggesting lateralization) and you should rule out asymmetric hearing loss. 3

The American Academy of Otolaryngology recommends prompt audiologic examination for:

• Unilateral tinnitus 3
• Persistent tinnitus ≥6 months 3
• Tinnitus associated with hearing difficulties 3

Management Algorithm

If Cervical Tests Are Positive (CST Confirmed):

1. Cervical proprioceptive retraining exercises: Target sensorimotor control and muscle coordination 2
2. Physical therapy: Focus on deep neck flexor strengthening and endurance 1, 2
3. Trigger point treatment: If trigger points identified 1
4. Postural correction: Address any contributing ergonomic factors 2

If Orthostatic Hypotension Confirmed:

1. Review medications: Any vasoactive drugs or diuretics can cause or worsen orthostatic symptoms 3
2. Increase fluid and salt intake: First-line conservative management 3
3. Compression stockings: For venous pooling 3
4. Gradual position changes: Avoid rapid standing 3

Critical Pitfalls to Avoid

• Do not dismiss this as benign positional vertigo: The symptom pattern doesn't fit vestibular pathology—you have balance issues without true vertigo, and symptoms are posture-dependent 3
• Do not pursue vascular imaging: Your tinnitus is NOT pulsatile (not synchronous with heartbeat), making vascular causes extremely unlikely 3, 4
• Do not assume anxiety/depression: While these can contribute to tinnitus perception, your clear mechanical triggers and orthostatic pattern indicate a structural/physiologic cause 1, 2
• Do not ignore medication history: If you're taking alpha-blockers, antihypertensives, or diuretics, these commonly cause orthostatic symptoms 3

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if you develop:

• Focal neurological deficits (weakness, numbness, coordination problems) 3
• Severe headache or vision changes (could indicate intracranial hypertension) 3
• True pulsatile tinnitus (rhythmic with heartbeat) 3, 4
• Asymmetric hearing loss 3
• Fever or constitutional symptoms (infection/inflammation) 3