Management of Neck Pain with Tinnitus and Paresthesias in a Young Adult
This patient requires reassurance and conservative management with close monitoring, but should undergo comprehensive audiologic examination within 4 weeks to exclude sudden sensorineural hearing loss, which can present subtly with transient symptoms and carries risk of permanent hearing loss if missed. 1, 2
Immediate Clinical Assessment
Key distinguishing features to clarify:
Determine if tinnitus is truly pulsatile (synchronous with heartbeat) versus non-pulsatile, as this fundamentally changes diagnostic urgency—pulsatile tinnitus has identifiable vascular or structural causes in over 70% of cases and may indicate life-threatening pathology like dural arteriovenous fistula or arterial dissection. 3
Assess laterality carefully: The patient reports "intermittent ear ringing"—if this is unilateral or asymmetric, imaging becomes necessary even without other red flags. 2 Bilateral, symmetric, non-pulsatile tinnitus without focal deficits does not require imaging. 3, 2
Evaluate the tingling with head movement: This suggests possible cervical radiculopathy or nerve root irritation, though the normal exam makes significant pathology less likely. 4 The combination of neck pain and paresthesias with specific head positioning warrants consideration of mechanical cervical spine pathology. 5, 6
Red Flags Assessment (Critical to Exclude)
The ACR Appropriateness Criteria identifies specific "red flags" that mandate imaging in cervical pain: 4
- Increased risk for fracture (not present—no trauma)
- Malignancy or constitutional symptoms like fever/weight loss (not reported)
- Infection risk factors (immunosuppression, IV drug use—not present)
- Vascular etiology suspected (no objective findings)
- Spinal cord injury or myelopathy signs (normal exam)
- Coagulopathy (not mentioned)
This patient has NO red flags for urgent imaging of the cervical spine. 4
Audiologic Evaluation (Priority Action)
Order comprehensive audiologic examination within 4 weeks, including pure tone audiometry, speech audiometry, and acoustic reflex testing. 1, 2 This is critical because:
- Sudden sensorineural hearing loss (SSNHL) can present with transient hearing loss and tinnitus as primary symptoms, even when hearing loss is not obvious to the patient. 1
- The primary presenting symptom is often "full or blocked ear" sensation rather than obvious deafness, leading to delayed diagnosis. 1
- SSNHL affects 5-20 per 100,000 people, with 32-65% recovering spontaneously if identified and treated within 2 weeks with corticosteroids. 1
- Missing this diagnosis has catastrophic consequences for hearing recovery and quality of life. 1
Imaging Decision Algorithm
Do NOT order imaging at this time based on the following guideline-based criteria: 4, 3, 2
For cervical spine: The ACR Appropriateness Criteria states that acute neck pain (<6 weeks) without radiculopathy, trauma, or red flags does NOT warrant initial imaging. 4 Most acute neck pain resolves with conservative management. 5
For tinnitus: The American Academy of Otolaryngology makes a strong recommendation AGAINST imaging for tinnitus that is bilateral, non-pulsatile, and not associated with focal neurologic abnormalities or asymmetric hearing loss. 2 The American College of Radiology concurs that imaging represents inappropriate resource utilization in this scenario. 3
Imaging WOULD be indicated if: 3, 2
- Tinnitus is confirmed to be pulsatile
- Tinnitus is unilateral or asymmetric
- Audiometry reveals asymmetric hearing loss
- Focal neurologic deficits develop
- Symptoms persist beyond 6 weeks despite conservative management 4
Conservative Management Plan
- Continue current effective strategy (Tiger Balm and massage)
- Consider adding structured exercise therapy, which has the strongest evidence for benefit in neck pain 5
- If muscle spasm is prominent, short-term muscle relaxants may be considered 5
- Most acute neck pain resolves within weeks, though 50% may have some residual symptoms at 1 year 5
Tinnitus management: 2
- Provide education about tinnitus mechanisms, natural history, and the fact that most patients adapt over time 2
- Reassure that intermittent, self-limited symptoms are common and typically benign when not associated with other red flags 2
- Approximately 10-15% of adults experience tinnitus, but only 20% require clinical intervention 7, 2
Follow-Up Strategy
Schedule follow-up in 4-6 weeks to: 4, 2
- Review audiometry results
- Reassess symptom progression or resolution
- Re-examine for any new neurologic findings
- Determine if symptoms have become persistent (≥6 months), which would change management approach 2
Instruct patient to return immediately if: 3, 1
- Tinnitus becomes constant or clearly pulsatile
- Hearing loss becomes noticeable or persistent
- New focal neurologic symptoms develop
- Severe headaches or vision changes occur
- Symptoms worsen significantly despite conservative measures
Common Pitfalls to Avoid
Do not dismiss transient hearing loss as insignificant—this may represent early SSNHL, which requires prompt corticosteroid therapy within 2 weeks for optimal outcomes. 1 The window for effective treatment is narrow.
Do not order MRI or CT imaging for bilateral, symmetric, non-pulsatile tinnitus—this represents inappropriate resource utilization with no demonstrated benefit and potential harms from unnecessary testing. 3, 2
Do not assume cervical spine pathology explains the ear symptoms—while referred otalgia from cervical spine arthritis can occur (particularly from C1-2 facet joints), this is uncommon in a 24-year-old without significant cervical pathology on exam. 4, 8 The more likely connection is that both are benign, self-limited conditions occurring coincidentally.
Do not overlook psychological comorbidity—patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk. 3, 7, 2 Screen for mood disorders if symptoms become bothersome or persistent.