Unilateral neck pain and headache, vocal hoarseness, swallowing difficulty, and fainting attacks: a case report of idiopathic carotidynia with unusual clinical manifestations

Neck pain is a common complaint, but when it’s paired with hoarseness, trouble swallowing, or sudden fainting, it may signal a rare condition called idiopathic carotidynia. A 2019 case study from neurologists at Anhui Medical University in China highlights how this inflammation of the carotid artery sheath can present with unexpected symptoms—and how quickly targeted treatment can relieve them.

The study was led by Xian-Wen Chen, Juan Li, Cui-Ping Ren, and Yue Jiao from the Department of Neurology at The First Affiliated Hospital of Anhui Medical University in Hefei, China. Their report details a 71-year-old woman whose symptoms went beyond typical neck pain to include nerve-related issues and fainting—offering new insights into how carotidynia can manifest.

The Patient’s Journey

The woman sought care after 10 days of worsening pain: what started as a mild, dull headache evolved into sharp pain in her left temple and upper neck. She also developed a hoarse voice and noticed that swallowing food triggered intense pain, choking, and coughing. In the two days before admission, she fainted twice: each episode lasted 2–3 minutes, with paleness and sweating but no seizure-like movements (e.g., limb jerks).

On exam, doctors found tenderness when pressing the left side of her neck (over the carotid artery) and a hoarse voice. Touching the left laryngeal wall (part of the throat) caused pain, though her gag reflex remained intact. Crucially, palpating the carotid bulb (where the artery splits into two branches) did not trigger another fainting spell—ruling out immediate mechanical causes for her syncope.

Imaging and Tests Point to Inflammation

Magnetic resonance imaging (MRI) revealed a key clue: bright “high T2-weighted signals” around the left carotid artery and internal jugular vein. These signals indicate inflammation in the carotid sheath—the fibrous tissue that wraps around the carotid artery, jugular vein, and nearby nerves (including the vagus and glossopharyngeal nerves). Unlike most cases of carotidynia (which typically affect only the artery’s “bifurcation,” where it splits), this inflammation extended from the top to the bottom of the common carotid artery.

A computed tomography angiogram (CTA) ruled out life-threatening issues like carotid dissection (a tear in the artery wall), aneurysm (a bulge), or severe stenosis (narrowing). Only a small, harmless calcium deposit (plaque) was found in the initial segment of the internal carotid artery.

Blood tests and additional imaging ruled out other conditions:

Vasculitis: No signs of inflammation in large arteries (e.g., Takayasu arteritis, giant-cell arteritis).
Infections: Negative results for syphilis, Lyme disease, hepatitis B/C, and tuberculosis.
Autoimmune/rheumatoid diseases: Normal inflammatory markers (C-reactive protein, erythrocyte sedimentation rate) and negative tests for anti-nuclear antibodies (ANAs) and anti-neutrophil cytoplasm antibodies (ANCAs).

Steroids Relieve Symptoms in Days

The team diagnosed idiopathic carotidynia—inflammation of the carotid sheath with no clear cause—based on:

Unilateral neck pain radiating to the temple and throat.
Tenderness over the carotid artery.
Inflammatory signals on MRI.
No structural abnormalities (e.g., dissection, aneurysm).
A rapid response to steroid treatment.

The patient received intravenous dexamethasone (10 mg daily). Within 3 days, her neck and head pain resolved. Over 11 days, her hoarseness, swallowing trouble, and fainting risk improved completely. A follow-up MRI one month later showed the inflammatory signals had partly faded—and she remained symptom-free.

What Makes This Case Unique?

Most reported cases of idiopathic carotidynia feature only neck pain radiating to the head or throat. This patient’s symptoms were more complex, offering two key insights:

Nerve involvement: Hoarseness and swallowing difficulty likely stemmed from inflammation affecting the vagus nerve (which controls voice and swallowing) and glossopharyngeal nerve (which manages throat sensation)—both located in the carotid sheath.
Extensive inflammation: The MRI showed inflammation along the entire length of the carotid sheath, not just the bifurcation. This suggests carotidynia can affect more of the artery than previously thought.
Fainting spells: The syncope may have been caused by overstimulation of the carotid sinus—a pressure sensor in the artery that regulates blood pressure. Inflammation could have made the sinus overly sensitive, triggering sudden drops in heart rate and blood pressure.

While a 2010 case report (Sato et al.) described carotidynia with fainting, this is one of the first to link the condition to both vagus nerve symptoms (hoarseness) and glossopharyngeal nerve issues (swallowing trouble).

Why This Matters for Patients and Doctors

Idiopathic carotidynia is often misdiagnosed because its symptoms overlap with more common issues (e.g., muscle strain, migraine). This case highlights three critical takeaways:

Unusual symptoms should trigger further testing: If neck pain is paired with hoarseness, swallowing difficulty, or fainting, doctors should check the carotid sheath for inflammation via MRI.
Steroids are highly effective: Even severe symptoms can resolve quickly with anti-inflammatory treatment.
Imaging is non-negotiable: MRI and CTA are essential to rule out life-threatening conditions (e.g., dissection) and confirm carotidynia.

The case meets the diagnostic criteria for idiopathic carotidynia set by the International Headache Society (1988) and recent guidelines from Tardy et al. (2007), which redefine the condition as “idiopathic carotiditis” (inflammation without a known cause).

Final Thoughts

This case expands our understanding of idiopathic carotidynia by showing it can cause nerve-related symptoms and extensive inflammation. For patients, it offers hope: even confusing, distressing symptoms can be treated effectively. For doctors, it underscores the importance of considering rare conditions when common explanations don’t fit.

The patient provided written consent for her clinical information and images to be published. The study was funded by the Science Foundation of Anhui Province, China (No. 1608085MH170).

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