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Carotidynia
Introduction
Carotidynia, also known as Fay syndrome or transient perivascular inflammation of the carotid artery (TIPIC) syndrome, is a very rare disorder presenting with unilateral neck and facial pain. Carotidynia is classified as an idiopathic neck pain syndrome and is associated with point tenderness over the bifurcation of the carotid artery. The pain may radiate to the ear or forehead. Symptoms are made worse by head movements, chewing, yawning, coughing, or swallowing. Increased pulsations are noted in the associated carotid artery. Carotidynia is most commonly unilateral; however, bilateral cases have been reported.[1][2]
Patients report self-limited episodes of neck pain, with each episode lasting approximately 7 to 14 days. Most patients experience a relapse of episodes every 1 to 6 months.[3] Diagnosis is primarily clinical, based on patient history and physical examination, with imaging such as neck ultrasound used to rule out other causes. While neurological deficits are generally absent, some cases have reported neurological events. Carotidynia is often confused with more serious conditions like carotid artery dissection or neoplasms, contributing to patient anxiety.
Treatment is usually supportive, involving rest, NSAIDs, and reassurance. In persistent cases, corticosteroids may be prescribed, while other medications, such as calcium channel blockers or selective serotonin reuptake inhibitors, have been explored. The condition typically resolves spontaneously, with follow-up imaging showing regression of vascular inflammation.
Etiology
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Etiology
The exact etiology of carotidynia remains unknown, with various infectious, autoimmune, inflammatory, and traumatic etiologies having been proposed.[4] In 1927, Fay described carotidynia as "an atypical radiating pain in the neck with tenderness over carotid bifurcation," with Roseman defining carotidynia as a distinct syndrome with cardinal signs of tenderness over the carotid artery and ipsilateral neck pain.[5] In 1988, the International Headache Society (IHS) classified carotidynia as a headache if associated with any of the following features:
- Pain, swelling, or increased pulsation on applying pressure to the carotid artery
- Exclusion of structural causes of carotid pain
- Neuralgia of head and neck with spontaneous resolution in <14 days
- Pain on either side of the neck with possible radiation to the head [6]
However, in 1994, Hill and Hastings asserted that carotidynia is a "painful symptom rather than a disease" associated with migraine, viral pharyngitis, or lumenal carotid disease in the majority of cases.[7] In the same year, Biousse and Bousser argued that carotidynia should be considered a "nonvalidated entity" as none of the diagnostic criteria proposed by the IHS in 1988 is consistently found in the reported cases of carotidynia.[8] Furthermore, Lecler, in 2017, argued based on scientific evidence that "thickened wall and infiltration of the perivascular fat involving the carotid bifurcation TIPIC syndrome" should be included in the new International Classification of Headache Disorders (ICHD). Interestingly, based on current research evidence, Lecler argued that TIPIC syndrome should be used instead of carotidynia.[9]
Although previously classified as a migraine variant, carotidynia was finally removed from the classification of headaches by the IHS in 2004 after much controversy. Carotidynia is now generally accepted as a component of a distinct vague neck pain syndrome, not a migraine variant. Modern imaging techniques have revealed inflammation of the vascular adventitia in many cases, resulting in the adoption of the term TIPIC syndrome.
TIPIC or Fay syndrome is not classified as vasculitis because carotidynia involves only the vascular adventitia, whereas true vasculitis involves inflammation of all vessel wall layers.[10] Moreover, vasculitis typically affects vessels throughout the body (often vessels of a similar size throughout the body). In contrast, carotidynia only involves the carotid artery, and the remainder of the body vessels are unaffected.[2][11] Catotidynia, as a syndrome, can be associated with other forms of extracranial vascular headaches.[12] In rare cases, carotidynia can be associated with nasopharyngeal carcinoma, anti-cancer chemotherapy, and high-altitude travel.[4][13][14]
Epidemiology
Carotidynia is rare, and the exact prevalence is unknown. The most commonly cited study reported a prevalence of 2.8% in patients presenting with acute neck pain.[3] The median age of presentation in some case series has been reported to be in the fourth and fifth decade with a 1.5 to 1 female-to-male ratio.[3] Similarly, in another study with 100 patients by Lovshin et al, the occurrence of carotidynia was more common in women than in men, with a ratio of 4:1.[12]
Pathophysiology
Carotidynia presents as a distinct inflammation of the vascular and perivascular tissues, most commonly at the level of the carotid bifurcation, leading to the thickening of the vessel wall without significant luminal narrowing.[15] Since the diameter of the lumen is preserved, the cardiovascular hemodynamics of the carotid artery is not disturbed. Case reports of carotidynia in the setting of vascular disease and lumenal narrowing have been reported, though whether these all would meet modern diagnostic criteria for TIPIC is unclear.[16] Furthermore, the presence of an intact carotid artery lumen with normal blood flow and amorphous enhanced surrounding soft tissues are typical radiological features that further support TIPIC syndrome as a distinct inflammatory response.[17]
Histopathology
The vessel wall may show low-grade chronic active inflammation and mild fibrosis in patients with carotidynia on histological examination.[18] The proliferation of small blood vessels and prominent endothelial cells embedded in a fibromyxoid stroma are noted.[18] Other cell types include predominant lymphocytes, fibroblasts, mast cells, and a few polymorphonuclear leukocytes.[19]
On gross examination during carotid endarterectomies, carotidynia appears as a fibrinous grey exudate.[18] This finding is distinct from the carotid artery atherosclerotic plaque due to its prevalence in a younger age group and outward thickening of the vessel wall compared to the thickening of the intima in an atherosclerotic plaque. Furthermore, carotidynia lacks calcification, and the clinical course of this lesion is short (about 14 days) compared to the chronic nature of atherosclerotic plaque.[20]
History and Physical
Carotidynia is primarily diagnosed clinically, made with a thorough history and a physical examination. Patients with carotidynia frequently report a clinical history that includes self-resolving episodes of unilateral or bilateral pain in the neck, which may radiate to the head, and tenderness over the carotid bulb. Signs of active infection, eg, chills, cervical lymphadenopathy, erythema, and ear or throat pain, are absent.[19] Some patients develop the disorder after an upper respiratory tract infection, indicating that perhaps an immune reaction may have occurred.[21]
Physical examination should include a thorough review of the ear, nose, and throat and evaluation for lymphadenopathy in the head and neck. A thorough neck examination is critical, including thyroid for thyroid tenderness and other neck masses or lymphadenopathy. Physical examination typically reveals a point tenderness in the lateral neck over the carotid bifurcation. Palpation of the carotid artery can worsen the pain, leading the pain to radiate to the ipsilateral ear. A systolic carotid bruit might be appreciated in some cases.[19]
Although most of the literature reports a normal neurological examination, a case series reported neurological events in 8 out of 47 patients recruited in the study.[19][3] Therefore, the possibility of neurological implications of this entity cannot be entirely excluded. Furthermore, many patients report anxiety, which might be attributed to a delay in the definitive diagnosis, and a fear of more serious diagnoses like carotid artery dissection and neoplasms of the head and neck.[7][19][22]
Evaluation
Laboratory Studies
Carotidynia has conventionally been a diagnosis of exclusion. Therefore, results of laboratory studies, including complete blood count (CBC), thyroid function tests, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), are normal.
Other potential tests to evaluate a patient for carotidynia include serum amyloid A and soluble intracellular adhesion molecule-1 (ICAM-1) levels, but their routine use is not recommended due to insufficient evidence of their diagnostic or prognostic utility.[19] An equally important part of the diagnostic workup is aimed at excluding differential diagnoses. A raised neutrophil count on CBC points towards possible infection, eg, sialadenitis, lymphadenitis, or peritonsillar abscess, as a cause of the neck pain.[19] Significantly elevated ESR and CRP levels may warrant a temporal artery biopsy to evaluate for giant cell temporal arteritis. An abnormal TSH can indicate thyroiditis.
Imaging Studies
Additionally, to exclude other vascular and nonvascular causes of neck pain, diagnosis of carotidynia requires imaging studies. A neck ultrasound is recommended as the initial screening test; characteristic findings of carotidynia include hypoechoic thickening, mild luminal narrowing, and outward extension of the carotid wall in the region of tenderness.[23][24] Because the wall thickening is eccentric, the blood flow through the lumen of the carotid artery is not disturbed.[25] In contrast, concentric wall thickening, calcification, and plaque are findings indicative of carotid artery atherosclerosis.
Computed tomography (CT) scan, digital subtraction arteriography, positron emission tomography (PET) scans, and magnetic resonance imaging (MRI) are not recommended for routine evaluation, as these confer little additional benefit, expose the patient to potentially harmful radiation and intravenous contrast agents, and incur increased expense.[25] However, these investigations should be considered if the ultrasound is inconclusive or an alternate diagnosis is more likely.
Some authors argue that if the patient is younger than 40 or presents with neurological deficits (eg, Horner's syndrome) suggestive of carotid artery dissection, a multidetector CT angiography (MDCTA) may be the initial diagnostic modality of choice.[26] A normal MDCTA can rule out carotid artery dissection. An MRI may be justified in older patients with a clinical presentation consistent with giant cell arteritis, especially if the ESR or CRP are elevated. In such cases, high-resolution images of superficial cranial vessels (eg, the superficial temporal artery) should be obtained. A biopsy may be performed to confirm a giant-cell arteritis diagnosis.
In cases where a recent use of corticosteroids might have decreased the inflammation and obscured the radiologic features, an MRI may help reach a diagnosis.[27][28][29] Increased uptake or enhancement in T1-weighted images involving the distal common carotid artery (CCA) and carotid bulb enhanced with gadolinium is suggestive of carotidynia.[30]
Recently, PET scans have been utilized to evaluate patients with suspected carotidynia if the diagnosis remains elusive despite Doppler US, CT, and MRI of the neck. A PET scan demonstrates a focus of glucose hypermetabolism in the carotid bifurcation region in the absence of systemic vasculitis or pathologic changes in the carotid lumen. Although the finding of hypermetabolism of glucose is nonspecific, the absence of a neck mass (ruling out cervical neoplasia as a cause of neck pain), the self-limiting clinical course of each episode, and immediate response to steroid treatment provide sufficient evidence to diagnose carotidynia.[2][11]
A characteristic feature of carotidynia is the resolution of these imaging findings in follow-up studies. Continued regression of the hypoechoic lesion of the carotid wall is appreciated on serial ultrasounds over the next few days. Other studies confirm a decrease in the maximum standard uptake volume (SUV) of (18F)-fluorodeoxyglucose activity in the repeat PET/CT after 6 months.[2] Such radiologic observation led to the adoption of the term TIPIC syndrome.[20][31][32]
Treatment / Management
Since carotidynia is a self-limiting condition that spontaneously resolves within 7 to 14 days, the treatment is generally supportive. Initial treatment includes rest, reassurance, and nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.[24][25][27][33][34][30] If symptoms persist, a short course of corticosteroids is usually prescribed.[30][35] The use of calcium channel blockers, selective serotonin reuptake inhibitors (eg, fluoxetine), and benzodiazepines have also been reported.[36][19](B3)
In the past, antimigraine medications such as propranolol, tricyclic antidepressants, ergotamine, and methysergide were frequently used for the treatment of carotidynia.[37] However, this trend decreased once carotidynia was removed from the International Classification of Headache Disorders in 2004. In recent years, a recent case report described the efficacy of an antimigraine medication, almotriptan, in alleviating the symptoms of a patient diagnosed with carotidynia.[38] Furthermore, stress management can be helpful.[19](B3)
Differential Diagnosis
Among vascular disorders, the primary differential diagnoses of lateral neck pain are carotid dissection and giant cell arteritis.[39] Carotid artery dissection is usually associated with neurological deficits, and Horner's syndrome, comprising of ptosis, miosis, and anhidrosis, is present in about half the cases of carotid dissection.[40] Conversely, neurological findings are absent in the vast majority of cases of carotidynia. Other possible differential diagnoses in a patient presenting with unilateral neck pain include:
- Unilateral neck pain
- Infectious: Infections of the oropharynx, oral cavity, and glands (lymphadenitis, sialadenitis, peritonsillar abscess, and thyroiditis)
- Neurological: Migraine headache, trigeminal neuralgia
- Neoplastic: Head and neck neoplasms
- Musculoskeletal: Cervical spondylitis, temporomandibular joint syndrome, Eagle syndrome
- Isolated carotid artery pain
Pertinent Studies and Ongoing Trials
Owing to the rarity of carotidynia, no placebo-controlled trials have been arranged to compare the efficacy of various pharmacological interventions used for this condition.[19]
Prognosis
Each episode of carotidynia is self-limiting, typically lasting 7 to 14 days. The use of NSAIDs and corticosteroids can expedite the resolution of symptoms. However, patients frequently experience a relapse of episodes every 1 to 6 months.
Complications
Although carotidynia is classically described as a self-limiting condition lasting about 7 to 14 days, recent studies have shown an association with carotid artery thrombosis and neurological events.[44] Due to the elusive nature of this entity, patients might be subjected to unnecessary invasive and noninvasive investigations and, therefore, be exposed to the significant radiation of CT scans and strong magnetic fields of MRI.[45]
Clinicians trying to differentiate carotidynia from giant cell temporal arteritis may perform a temporal artery biopsy. Consequently, patients may experience possible biopsy-related complications. Patients might also report anxiety at prolonged, expensive testing and lack of a definitive diagnosis. Therefore, clinicians are encouraged to accept carotidynia as a clinical entity so that patients can avoid the hazards of unnecessary testing.[46]
Deterrence and Patient Education
Carotidynia is associated with anxiety in many patients. Patients should be reassured about the relatively benign nature of this condition, as compared to carotid artery dissection, giant cell temporal arteritis, and neck neoplasms. However, they should also be counseled that relapse of symptoms is not an uncommon occurrence, with the majority of patients experiencing a repeat episode within 1 to 6 months. Additionally, patients should be reassessed clinically and advised on the potential for reoccurrence of carotidynia, which is also usually benign.[19]
Pearls and Other Issues
Carotidynia, or TIPIC syndrome, though rare, is underdiagnosed, and the cause for such pain remains hypothetical. Many reasons related to the autoimmune process, reaction to a drug, or an unknown inflammatory process are considered potential causes. Carotidynia typically presents with unilateral facial and neck pain. NSAIDs or aspirin are preferred medications, which may lead to symptom resolution within 2 weeks.[47]
Enhancing Healthcare Team Outcomes
Effective management of carotidynia requires an interprofessional team approach to ensure accurate diagnosis, appropriate treatment, and optimal patient outcomes. Physicians and advanced practitioners play a crucial role in early recognition by performing thorough history-taking and physical examinations to differentiate carotidynia from more serious conditions such as carotid artery dissection or neoplasms. Nurses contribute by assessing patient symptoms, providing education on symptom management, and addressing patient concerns to alleviate anxiety. Pharmacists support the team by ensuring appropriate medication selection, particularly when NSAIDs or corticosteroids are prescribed, and monitoring for potential drug interactions or contraindications.
Interprofessional communication and care coordination are essential to streamline patient-centered care and enhance safety. Collaboration between specialists, including radiologists and neurologists, helps confirm diagnoses while minimizing unnecessary imaging or invasive procedures. Healthcare professionals must engage in shared decision-making, educating patients about the benign and self-limiting nature of carotidynia while providing reassurance. An international registry under development will facilitate future study, emphasizing the importance of continued education and research. By fostering teamwork and enhancing diagnostic strategies, healthcare teams can improve patient outcomes, reduce unnecessary interventions, and optimize the overall quality of care for individuals with carotidynia.
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