What is the likely diagnosis for neck and jaw tightness with dysphagia, pulsatile jaw and ear pain, headache, and hand paresthesia, and what is the appropriate urgent management?

Urgent Evaluation for Giant Cell Arteritis (Temporal Arteritis) Required

This constellation of symptoms—neck and jaw tightness with pulsatile jaw pain, dysphagia, headache, and hand paresthesias—raises immediate concern for giant cell arteritis (GCA), which requires urgent evaluation and treatment within 24-48 hours to prevent irreversible vision loss. 1

Critical Red Flags Present

Your symptom pattern includes multiple features that distinguish GCA from benign temporomandibular disorders:

• Pulsatile jaw pain with chewing (jaw claudication) is highly specific for GCA and represents ischemia of the masseter muscles from external carotid artery involvement 1, 2
• Temporal region involvement with headache is the classic presentation 1
• Difficulty swallowing can occur with GCA due to pharyngeal muscle ischemia 1
• Hand paresthesias may represent peripheral neuropathy or vascular compromise, both associated with systemic vasculitis 1

Immediate Diagnostic Steps

Obtain these tests urgently (within 24 hours):

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)—both are typically markedly elevated in GCA (ESR often >50 mm/hr) 1
• Complete blood count—may show anemia and thrombocytosis 1
• Physical examination focusing on:
  • Temporal artery palpation for tenderness, prominence, or absent pulse 1
  • Scalp tenderness over the temporal region 1
  • Visual acuity and fundoscopic examination 1

Why This Cannot Wait

• Vision loss occurs in 15-20% of untreated GCA patients and is typically irreversible once it develops 1
• Jaw claudication is present in 30-50% of GCA cases and is one of the most specific symptoms 2
• Treatment must begin within 2 weeks of symptom onset to prevent complications, ideally within 24-48 hours of diagnosis 1

Urgent Treatment Protocol

If GCA is suspected based on clinical presentation:

• Start high-dose corticosteroids immediately (prednisone 40-60 mg daily or equivalent) even before temporal artery biopsy, as treatment should not be delayed for diagnostic confirmation 1
• Arrange temporal artery biopsy within 1-2 weeks of starting steroids (biopsy remains diagnostic for up to 2 weeks after steroid initiation) 1
• Ophthalmology consultation if any visual symptoms are present 1

Alternative Diagnoses to Consider (But Less Likely)

While GCA is the most urgent concern, other conditions in the differential include:

• Carotidynia: Presents with neck pain over carotid bifurcation, may radiate to jaw and ear, but typically lacks systemic symptoms and has normal inflammatory markers 3
• Temporomandibular joint (TMJ) syndrome: Causes jaw pain with chewing but is typically bilateral, lacks pulsatile quality, and has normal ESR/CRP 1
• Cervicogenic dysphagia: Cervical spine disorders can cause swallowing difficulties, but would not explain pulsatile pain or systemic symptoms 4, 5
• Glossopharyngeal neuralgia: Causes sharp, shooting pain in throat/ear triggered by swallowing, but pain is paroxysmal (seconds to minutes), not continuous 1

Critical Pitfall to Avoid

Do not dismiss this as TMJ syndrome simply because jaw pain is present. The key distinguishing features are:

• TMJ pain worsens with jaw movement and is tender over the joint itself 1
• GCA jaw claudication is specifically triggered by prolonged chewing (like eating a meal) and improves with rest, mimicking muscle ischemia 1, 2
• GCA patients are typically over 50 years old with constitutional symptoms (fatigue, weight loss, fever) 1

Imaging Considerations

Imaging is NOT the first priority—clinical diagnosis and laboratory confirmation guide immediate treatment 1. However:

• MRI of the head/neck may be appropriate if neurologic symptoms progress or if cervical vascular dissection is suspected 1
• Temporal artery ultrasound can show characteristic "halo sign" in experienced hands but should not delay treatment 1
• Cervical spine imaging is not indicated unless mechanical neck pathology is strongly suspected after GCA is excluded 1

Proceed directly to emergency department or urgent rheumatology/internal medicine evaluation today for ESR/CRP testing and clinical assessment. The combination of jaw claudication, headache, and dysphagia in the appropriate age group mandates immediate evaluation for GCA to prevent permanent vision loss. 1