What could be causing a 6-month history of tinnitus (ringing in the ears) in the left ear and a metallic taste, which started after a muscle tear in the left arm during a workout with heavy weights in an adult who regularly engages in physical activity?

Evaluation of Unilateral Tinnitus and Metallic Taste Following Upper Extremity Muscle Injury

This presentation requires urgent imaging evaluation with CT angiography of the head and neck, as the temporal relationship between heavy weightlifting and symptom onset raises concern for arterial dissection—a life-threatening vascular cause of pulsatile tinnitus that can present with unilateral tinnitus and requires immediate identification. 1, 2

Critical Diagnostic Considerations

Primary Concern: Vascular Etiology

The temporal association between heavy weightlifting (Valsalva maneuver during straining) and sudden onset of unilateral tinnitus is a red flag for arterial dissection. 2

• Arterial dissection is a potentially life-threatening condition that can occur with sudden neck movements, straining, or trauma during weightlifting 2
• The American College of Radiology identifies arterial dissection as requiring urgent identification in patients with pulsatile tinnitus 2
• Tinnitus relieved by carotid or jugular compression suggests venous etiology or arterial dissection 2

Secondary Consideration: Somatosensory Tinnitus

The muscle tear in the left arm during heavy lifting may have been accompanied by cervical spine strain or temporomandibular dysfunction, which can cause somatosensory tinnitus. 3, 4

• Myofascial trigger points in head, neck, and shoulder girdle muscles strongly correlate with tinnitus (p<0.001), with 56% of patients able to modulate their tinnitus through digital compression of these points 4
• Tinnitus of myofascial origin can be diminished or completely abolished with appropriate treatment including trigger point deactivation and specific exercises 3
• Physical symptoms are frequently present in tinnitus patients, with 69% reporting neck pain and 44% reporting bruxism 5

Metallic Taste Significance

The copper/metallic taste is an unusual associated symptom that may suggest:

• Neurological involvement (cranial nerve dysfunction) 1
• Medication effect if any supplements or medications were started around the injury
• Blood in the oral cavity from temporomandibular joint dysfunction or bruxism 5

Immediate Diagnostic Workup

First-Line Imaging

Order CT angiography (CTA) of the head and neck with contrast immediately to evaluate for:

• Arterial dissection (carotid or vertebral) 2
• Dural arteriovenous fistulas (8% of pulsatile tinnitus cases, can lead to hemorrhagic or ischemic stroke) 2
• Atherosclerotic carotid artery disease (17.5% of pulsatile tinnitus cases) 2
• Arteriovenous malformations 2

The American College of Radiology recommends CTA as first-line when suspecting these vascular causes. 2

Essential Clinical Assessment

Before or concurrent with imaging, perform:

1. Detailed tinnitus characterization: 1, 2

   • Is it pulsatile (synchronous with heartbeat) or non-pulsatile?
   • Can the patient modulate it with jaw movements, neck movements, or muscle compression? 4, 5
   • Does carotid or jugular compression relieve symptoms? 2

2. Neurological examination: 2

   • Focal neurological deficits (cranial nerve abnormalities, motor/sensory deficits)
   • Visual changes or papilledema (suggests intracranial hypertension) 2

3. Otoscopic examination: 2

   • Vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind tympanic membrane) 2

4. Cervical spine and temporomandibular assessment: 3, 4

   • Palpate for myofascial trigger points in masseter, temporalis, sternocleidomastoid, and trapezius muscles 4
   • Assess for temporomandibular joint tenderness or clicking 5
   • Evaluate cervical range of motion and tenderness 3

5. Comprehensive audiologic examination within 4 weeks: 1, 2

   • Pure tone audiometry
   • Speech audiometry
   • Acoustic reflex testing
   • Assess for asymmetric hearing loss (would require MRI internal auditory canals with contrast) 2

Algorithmic Management Based on Findings

If CTA Reveals Arterial Dissection

• Immediate neurology/neurosurgery consultation 2
• Anticoagulation or antiplatelet therapy per vascular neurology protocols
• Serial imaging to monitor for progression or pseudoaneurysm formation

If CTA Reveals Dural AVF or AVM

• Urgent neurosurgery/interventional neuroradiology referral 2
• Dural AVF carries risk of hemorrhagic or ischemic stroke if untreated 2
• Catheter angiography for definitive characterization and treatment planning 2

If CTA is Negative but Symptoms Persist

• Proceed to MRI brain with contrast and MR angiography/venography to evaluate for: 2
  • Cerebellopontine angle lesions
  • Subtle vascular malformations not visible on CTA
  • Venous sinus abnormalities

If All Vascular Imaging is Negative

Focus on somatosensory tinnitus evaluation and treatment: 3, 4

1. Physical therapy referral for:

   • Myofascial trigger point deactivation 3
   • Cervical spine mobilization and strengthening exercises 3
   • Temporomandibular joint exercises if indicated 5

2. Audiological rehabilitation if hearing loss is present: 1, 6

   • Hearing aids (even for mild or unilateral hearing loss) 6
   • Sound therapy for symptomatic relief 6

3. Cognitive behavioral therapy (strongest evidence for improving quality of life in persistent, bothersome tinnitus) 1, 6

4. Education and counseling about tinnitus mechanisms, natural history, and management strategies 1, 6

Critical Pitfalls to Avoid

• Never dismiss unilateral tinnitus as benign without imaging, as identifiable causes exist in >70% of pulsatile tinnitus cases 1, 2
• Do not delay imaging in the setting of temporal relationship to physical trauma/strain, as arterial dissection can progress to stroke 2
• Avoid ordering MRI as first-line study when vascular causes are suspected—CTA is superior for arterial pathology 2
• Do not overlook myofascial dysfunction as a treatable cause if vascular workup is negative 3, 4
• Screen for anxiety and depression, as patients with tinnitus and severe psychiatric comorbidities have increased suicide risk and require prompt intervention 1, 6

Treatments NOT Recommended

The American Academy of Otolaryngology-Head and Neck Surgery recommends against the following for primary tinnitus treatment: 6

• Antidepressants, anticonvulsants, or anxiolytics (insufficient evidence, potential side effects)
• Intratympanic medications
• Dietary supplements (Ginkgo biloba, melatonin, zinc)