In a patient with polycythemia vera presenting with unilateral tinnitus, can cervical radiculopathy be the underlying cause?

Cervical Radiculopathy Does Not Cause Unilateral Tinnitus

Cervical radiculopathy cannot explain unilateral tinnitus in your patient with polycythemia vera, as nerve root compression produces dermatomal arm pain and paresthesias—not auditory symptoms. 1, 2 The tinnitus requires urgent vascular and structural imaging because polycythemia vera creates a prothrombotic state that significantly increases risk for life-threatening causes of unilateral tinnitus.

Why Cervical Radiculopathy Is Not the Cause

Cervical radiculopathy results from compression and inflammation of cervical nerve roots in the neural foramen, most commonly from disc herniation or facet joint spondylosis. 1, 2 The clinical syndrome consists of:

• Arm pain in a dermatomal distribution of the affected nerve root 1, 2
• Paresthesias following dermatomal patterns in the upper extremity 1
• Motor weakness in muscles innervated by the compressed root 1
• Neck pain that may or may not accompany the radicular symptoms 1

Tinnitus is not a recognized manifestation of cervical radiculopathy in any of the clinical literature defining this syndrome. 1, 2, 3, 4 The cervical nerve roots (C5-T1) innervate upper extremity structures, not auditory pathways.

The Real Concern: Polycythemia Vera and Thrombotic Risk

Your patient's polycythemia vera creates a critical context that demands immediate attention to the tinnitus:

• Polycythemia vera causes a baseline prothrombotic state through multiple mechanisms including elevated hematocrit increasing blood viscosity, qualitative platelet defects with increased thromboxane A2 production, and activation of coagulation proteins. 5
• Thrombosis risk is substantially elevated even with phlebotomy, as factors beyond hematocrit (platelets, leukocytes, endothelial dysfunction) contribute to clot formation. 5
• Arterial thrombosis can occur in atypical sites in polycythemia vera patients, including cerebrovascular territories. 5

Urgent Diagnostic Approach for Unilateral Tinnitus

Order CT angiography (CTA) of the head and neck with contrast immediately as the first-line study, because unilateral tinnitus has an identifiable structural or vascular cause in over 70% of cases, and missing life-threatening entities like arterial dissection or dural arteriovenous fistula can result in catastrophic hemorrhage or stroke. 6

Critical Vascular Causes to Rule Out

The following conditions are potentially life-threatening and must be excluded urgently:

• Arterial dissection requires immediate identification and anticoagulation or antiplatelet therapy 6, 7
• Dural arteriovenous fistula accounts for 8% of pulsatile tinnitus cases and can lead to hemorrhagic or ischemic stroke if untreated 6
• Atherosclerotic carotid artery disease is the most frequent cause of pulsatile tinnitus (17.5% of cases) and results from turbulent flow 6

Determine Tinnitus Character

Before imaging, clarify whether the tinnitus is:

• Pulsatile (synchronous with heartbeat): strongly suggests vascular pathology requiring immediate workup 6, 8
• Non-pulsatile: still requires imaging when unilateral, as unilateral presentation has higher likelihood of identifiable structural cause 6, 8

Complete the Initial Workup

• Perform comprehensive otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions), cerumen impaction, or middle ear effusion 6, 7
• Order comprehensive audiologic examination within 4 weeks including pure tone audiometry, speech audiometry, and acoustic reflex testing to document any asymmetric hearing loss 6, 8

Imaging Algorithm

First-line: CTA head and neck with mixed arterial-venous phase (20-25 seconds post-contrast) captures both arterial and venous pathology in a single acquisition, evaluating for:

• Arterial dissection 6, 7
• Dural arteriovenous fistulas 6, 7
• Atherosclerotic carotid disease 6
• Sigmoid sinus diverticulum or dehiscence 6, 7
• Arteriovenous malformations 6

Alternative first-line: High-resolution CT temporal bone (non-contrast) if otoscopy reveals a retrotympanic mass, to evaluate for:

• Paragangliomas or glomus tumors (16% of pulsatile tinnitus cases) 6, 7
• Jugular bulb abnormalities 6
• Superior semicircular canal dehiscence 6, 8

Second-line: MRI brain with contrast plus MR angiography/venography if CTA is negative but clinical suspicion remains high, to assess for:

• Cerebellopontine angle lesions (vestibular schwannoma) 6, 7
• Subtle vascular malformations 6
• Intracranial hypertension 6

Common Pitfalls to Avoid

• Do not dismiss unilateral tinnitus as benign without imaging, as treatable and life-threatening causes are common, especially in a prothrombotic patient with polycythemia vera 6
• Do not attribute tinnitus to cervical spine pathology without evidence of auditory pathway involvement—cervical radiculopathy produces upper extremity symptoms, not cranial nerve dysfunction 1, 2
• Do not delay imaging while pursuing conservative neck treatments, as this risks missing time-sensitive vascular emergencies like arterial dissection 6
• Do not order MRI as the initial study when vascular causes are suspected—CTA provides superior evaluation of arterial and venous pathology with faster acquisition 6