What should be done for an elderly male with severe posterior neck pain and recent onset of tinnitus?

Urgent Imaging Required for Suspected Cervicogenic Tinnitus with Vascular Risk

This elderly male with severe posterior neck pain (8/10 burning) and new-onset tinnitus requires immediate CT angiography (CTA) of the head and neck to rule out life-threatening arterial dissection, followed by targeted cervical spine evaluation if vascular pathology is excluded. 1

Immediate Diagnostic Priority: Rule Out Vascular Emergency

The combination of severe neck pain with acute tinnitus onset in an elderly patient is a red flag for arterial dissection, which can present with isolated pulsatile tinnitus before catastrophic stroke. 1

• Order CTA head and neck with contrast as the first-line study because arterial dissection is a potentially life-threatening condition requiring urgent identification, and missing this diagnosis can result in stroke. 1
• The American College of Radiology specifically recommends CTA when suspecting arterial dissection, atherosclerotic carotid disease, or dural arteriovenous fistulas—all of which can present with neck pain and tinnitus. 1
• Dural arteriovenous fistulas account for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated. 1

Critical Clinical Assessment While Awaiting Imaging

Determine whether the tinnitus is pulsatile (synchronous with heartbeat) versus constant, as this fundamentally changes the differential diagnosis. 1

• If tinnitus is pulsatile: This strongly suggests vascular pathology (arterial dissection, atherosclerotic disease, dural AVF) and mandates urgent CTA. 1
• If tinnitus is non-pulsatile but unilateral: This still requires imaging per American Academy of Otolaryngology guidelines, though cervicogenic causes become more likely. 2
• Assess for neurological deficits, asymmetric hearing loss, or visual changes—any of these require immediate evaluation using respective protocols rather than standard tinnitus workup. 1

If Vascular Imaging is Negative: Cervicogenic Tinnitus Evaluation

Once life-threatening vascular causes are excluded, the severe posterior neck pain with burning sensation strongly suggests cervicogenic somatic tinnitus (CST). 3, 4

Diagnostic Criteria for Cervicogenic Somatic Tinnitus

• Temporal coincidence of neck pain and tinnitus appearance is the predominant diagnostic feature of CST. 4
• Complete a Neck Bournemouth Questionnaire (NBQ)—scores ≥14 points support CST diagnosis (sensitivity 80%, likelihood ratio 0.3 if <14). 4
• Perform manual rotation test and adapted Spurling test—positive results indicate 78% posttest probability of CST (specificity 90%, LR 5). 4
• Assess for cervical trigger points—presence supports CST diagnosis (sensitivity 82%, LR 0.3 if absent). 4

Imaging for Cervical Spine Pathology

• Order high-resolution CT temporal bone (non-contrast) or cervical spine imaging if vascular studies are negative and clinical examination supports cervicogenic origin. 1
• Cervical spine x-rays may show degenerative changes with facet hypertrophy, particularly at C2-C3 levels, which have documented association with tinnitus. 3

Treatment Algorithm After Diagnosis

If Cervicogenic Somatic Tinnitus is Confirmed:

• Consider diagnostic C2-C3 medial branch block if facet arthropathy is identified on imaging—complete resolution of tinnitus for >6 hours predicts success with radiofrequency ablation. 3
• Radiofrequency ablation of C2-C3 medial branches has demonstrated complete symptom resolution at one-year follow-up in documented cases. 3
• Trigger point deactivation, specific exercises, and treatment of underlying muscle dysfunction can diminish or abolish tinnitus of myofascial origin. 5

Concurrent Audiologic Evaluation:

• Obtain comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing, as recommended by the American Academy of Otolaryngology for unilateral or persistent tinnitus. 2
• This is mandatory even if the patient denies hearing difficulties, because unilateral tinnitus requires audiologic assessment. 2

Symptomatic Management:

• Provide education and counseling about tinnitus management strategies for all patients with persistent, bothersome tinnitus. 2
• Recommend cognitive behavioral therapy (CBT) as the strongest evidence-based treatment for improving quality of life in tinnitus patients. 6, 2
• Recommend hearing aids if audiologic examination reveals any hearing loss, even if mild or unilateral. 6, 2
• Do NOT prescribe antidepressants, anticonvulsants, anxiolytics, or dietary supplements (Ginkgo biloba, melatonin, zinc) as these lack evidence for tinnitus treatment. 6, 2

Common Pitfalls to Avoid

• Missing arterial dissection by attributing symptoms to benign cervical spine disease without vascular imaging—this is the most critical error in this presentation. 1
• Dismissing pulsatile tinnitus as benign—pulsatile tinnitus requires imaging in nearly all cases due to identifiable causes in >70% of cases. 1
• Inadequate otoscopic examination can miss vascular retrotympanic masses (paragangliomas) that require different management. 1
• Overlooking the temporal relationship between neck pain onset and tinnitus onset, which is the key diagnostic feature of cervicogenic somatic tinnitus. 4