Middle Ear Myoclonus: A Treatable Cause of Objective Tinnitus

Middle Ear Myoclonus: A Treatable Cause of Objective Tinnitus

1. Caroline M. Kolb, (presenter)
2. Denby Fukuda
3. David Y. Healy, MD

Abstract
Objective: 1) Describe the presentation of an underdiagnosed cause of objective tinnitus. 2) Review the current literature and present an algorithm on diagnosis and management of middle ear myoclonus. 3) Use video to demonstrate surgical ablation of the stapedial and tensor tympani tendons to alleviate middle ear myoclonus.

Method: This retrospective study analyzes the presentation and management of 6 patients diagnosed with middle ear myoclonus from 2009 to 2011. A review of the literature revealed 15 additional cases of middle ear myoclonus. An algorithm for the diagnosis and management of these patients is presented.

Results: We report on the diagnostic findings of 6 patients identified at a tertiary care military medical center with middle ear myoclonus. Four of the 6 patients had a significant history of loud, explosive noise exposure during military deployments. Patients were diagnosed based on history, examination findings, and standard audiometry testing using a nonstimulated, spontaneous acoustic reflex decay tracing. Fifteen additional reported cases of either stapedial or tensor tympani myoclonus were identified in the English language literature. Observation, medications, botulinum toxin, and surgical sectioning of the stapedius and/or tensor tympani are recognized treatments of this disorder.

Conclusion: Middle ear myoclonus is an underdiagnosed cause of objective tinnitus likely due to lack of familiarity with diagnostic findings. For symptomatic myoclonus, middle ear exploration with transection of the stapedius tendon, tensor tympani tendon, or both demonstrated the best outcomes, with 100% of patients achieving complete relief of tinnitus.

 

The "tinnitus" they are describing is the sound of the fluttering though, not normal T. I have T and this thing.

Is cutting the muscle what they suggest? I've read that that rarely helps

edit: oh they're talking about having this all the time? damn.

i only get one spasm as response to my own voice in silent enviroment

 

You took our hope away! I've been having bad noise, so I'm desperate. Where's the knife?
Yeah, If it was common you would think they would be doing tons of them.

 

i could be wrong

 

It does sound like fluttering that can be heard externally is the most common symptom, but I wonder why some people have
hissing like Tim said he did on another forum. And he said he was to multiple ENT's. I will try to contact Tim somehow if possible. I think I'm chasing my tail again.

 

A interesting post I found today about the spasm of the stapedius muscle:

May 16, 2012

To: Stapedial Myoclonus

The Stapedius Muscle is spasming. I have had hissing and ringing
since undergoing shoulder surgery. The noise was dibilitating, I
could do nothing, relationship was tested with my best friend and
fiancee, work suffered. I could not go into a noisy enviroment and
had to seclude myself in the confines of my house and listen to
nothing but silence. I have spent thousands of dollars trying to
find out what has happened to me--I would wake up in the middle of
the night with the grinding sound of iron rubbing together, I would
get an un-nerving hissing noise after I drove my car vehicle any
distance, had to drive at night and take Ambien to get to sleep.
Drinking alcohol STOPPED the problem temporarily--the next day I paid
a price as it came back twice as bad.
I went to 3 audiologists, they all said I had high frequency hearing
loss but my hearing in voice level was fine. No other hearing
problems with exception that my left ear heard things much louder. I
started wearing an ear plug after two months...I was able to control
the problem if I stayed away from noise but came back as soon as I
took the plugs out. I was on Xanex, that made it worse. Ambien put
me to sleep and I could not wait to go to bed at night--I dreaded
walking up. I could no longer take naps during the day, for two
months I never took a nap. 2 ENTs and my primary doctor were at a
loss. I had a diagnosis of a sinus infection, which I did in fact
have but after 7 weeks of taking antibiotics, an MRI and 3 CT scans
yield nothing other than my infection cleared up but no change in the
"tinnitus" hissing and ringing, and tones.
I noticed after I took a shower the problem would go away only to
come back starting with a very small fluttering noise, but after 20
minutes or so it was so annoying and distressing that after 2 months
I was having to live with this problem possibly for the rest of my
life.
Guess what--the second ENT said to me, "there is not much I can do
for you" but he said he did have case like this once before and said
I could try the medication--he said he gave Valium in the 90s to a
patient who was really stressed out over pretty much the same symtoms
(symptoms)--he gave him the Valium to help him relax when he got
stressed out--the patient called him up and said the problem went
away!!! During the treatment he noticed that when the fluttering
started that if he took a valium, the problem subsided.
Diagnosis, very rare inner ear myoclonus. This may not be so rare
because there are alot of people told there is nothing more we can
do. Lots of people living with it. There is the smallest muscle in
the body called the Stapedius muscle, when that muscle goes into
spasm from stress or whatever, it will cause the tones, hissing,
fluttering, etc. I was given Cychlobenzedrine. $11 for 60 tablets
generic. I think it is called Flexeril as the trade name. 3 hours
after I left the ENT office, I was symptom free. It came back later
but I took another pill and it went away. There is a treatment for
chronic Stapedius problems--the muscle needs to be cut. All the
cases where this treatment as been performed were instant
successes--no side affects. However, I have had the medication now
for 10 days and I am able to control the problem and it really
appears to be going away. The spasms are stopping. Sound creates
the spasm as well as stress. Sound it stress, mental anquish is
stress..Cychlobenzedrine relaxes muscles...just leg chronic leg
cramps in footballs and basketball players, this muscle can
continuously go into spasm for months, only subsiding after long
sleep and naps, which I had neither of--the problem exasperated--now
it is on the mend. Ear Plugs in the bad ear still but I take it out
more and more each day--So after $30,000 in medical tests and fading
hope, $5 worth of ear plugs and $11 worth of muscle relaxers did the
job!
I really hope that my story helps allot of people. This is a
bloodless afflictions, people begin to think you are making it all
up, look at you like you are some big baby. No blood, no scars,
because we all know how to behave properly we don't walk into the
doctor screaming--we compose ourselves and behave as we are expected
to. If I walked into my house with a finger cut off screaming,
everyone would be helping--if I started vomiting profusely, I would
get care that I needed.
When you have probably the worse affliction of all, screaming noise
in your head that only you can here. You have a big problem
convincing anyone what is really happening. I literally was
contemplating something bad, I knew I could not live a descent life
with this sort of problem going on--all the people around me would be
affected by this problem if it went on indefinitly. Would I have
hurt myself, probably not--the thought was there as a way out.
When I went to my first ENT and told him what this pill did for me,
he instantly said, "I never thought of that" it makes sense. I like
the guy, he was always real honest with me--once you get past the ear
drum they can't see what is going on very easily.
Don't use the word tinnitus---use "ear fluttering out of control
creating a havoc within my head", that is what I said to the second
ENT. That got me results.. The ENTs have a preconceived definition
of tinnitus--that is it is an annoying sound, live with it. Be more
specific and keep up the fight, find someone who will listen to you.
Let me know if this helps anyone out there.
Sincerely,
Tim

 

Thanks Tim wherever you are!!

I had some fluttering sound this morning in my right ear followed by light hissing. I think muscle relaxers are worth a try. The stapedius muscle could be in a light spasm. That is the path I am on currently, although always subject to change. I am more confident on this causing tinnitus than anything to date.

 

Hi, I have this flutering also hyperacusis.

In a few days I will write my clinical presentation. Two questions:

Middle Ear Myoclonus is the same of TTTS (tonic tensor tympani syndrome) ?

Someone can explain more about "There is a treatment for chronic Stapedius problems--the muscle needs to be cut."

Thanks

 

I really don't know if Middle Ear Myoclonus is the same of TTTS (tonic tensor tympani syndrome) ? The only thing I know is I have a very loud disturbing hissing sound primarily in my left ear with possible " crossover noise" to my right ear.

I am seeing a ENT D.O. this Friday and will update after my appt. with him. I really cannot stand to live with my current noise!! I was seemingly normal one day after a cervical & head manipulation by a family practice D.O.-- but it did not happen right away. I also took a muscle relaxer later so maybe both things helped to quiet my headnoise.

I am sure you would have to meet certain criteria before they would even consider cutting your Stapedius muscle.

Please do update on your clinical presentation. Thanks

 

Erlend you should be all over this!

 

What? All over what?

Btw I've noticed that massaging my ears with the palms of my hands almost eliminates my T for several minutes. Maybe my T is to some degree caused by muscle tension? is that even possible?

 

WTH are you talking about @ResonanceCEO? Did you find the Holy Grail? Being all the tinnitus treatments are in trials and who knows when anything will be available to the public, is it unreasonable to look at some somatic causes of tinnitus?

 

Thanks Just1. Yes, I need some criteria before consider cutting stapedius muscle, is only information. I wish you a good recuperation with your doctor this friday. I understand what you mean. Euncourage!

 

The muscle is there to dampen internal vibrations and aid the stapes from moving around too much. I've read cutting it can cause hyperactive for some because the intensity of vibrations from the drum is unimpeded.

I think it's a crap shoot.

 

Who is Tim? Is dead?...

More information about this study.. but someone have complet study?
http://oto.sagepub.com/content/145/2_suppl/P98.1.full.pdf+html

Thanks

 

What you are describing could also be your tensor tympani muscle. Like the stapedius it's there to dampen internal vibrations. I have the misfortune of being one the people who can manual tense their tensor tympani muscle on demand. Sometimes I'll unconsciously tensing the muscle and wake up to a rumbling sound in my ears. It's rare by annoying.

 

Just did some quick research, and can say definitely that MEM and Tensor Tympani Syndrome are different conditions. MEM involves the stapedius muscle, while TTS involves, unsurprisingly, the tensor tympani. These are two different muscles with different connections in the middle ear and different nerves of innervation (V and VII, respectively). However, the treatment is basically the same, either botox or cutting the muscle.

It's considered mostly a mechanism underlying objective tinnitus, mainly "typewriter" tinnitus, though some patients have subjective.

 

I think the symptoms of TTS and stapedium myocloni are differents.
Stapedium myocloni: you feel a smoth trapped not in TTS

 

Hi everyone, I need some help. My boyfriend has Middle Ear Myoclonus and was wondering what he could take to help with the symptoms. If you have some suggestions of which medication he should take and at what dosage worked for you, that would be extremely helpful. Thanks.

 

Hi All, I think I have this problem. I believe in my case this is for TMJ problems, but i will go to a dentist to be sure. Anyway, besides spams and fullness I feel pain in the ear, specially with loud noises. I know that everyone would tell me that this is hyperacusis but the weird thing is that if I press me ear for a couple of seconds, then the same loud noise doesn't heart me, at least for a while. It is very strange. It seems that theres something related to a muscle in the ear but don't know what.
I have an appointment with an ENT the next days but I don't think he will know about this.

 

@Greengirl45 Hi Greengirl45 - I just made this account to respond to this post. I followed the thread about your boyfriend, and my symptoms are the exact same. Clicking noise in right ear randomly came on three months ago. Responds to my voice, other voices, running water, keyboard typing. I all of a sudden can't go to loud places now without the clicking.

I do not have any tinnitus or hyperacusis, and have had zero problems with my ears prior to this. I just randomly woke up with it one morning.

I am curious if your boyfriend found a resolution to the problem? Any info you can share would be appreciated.

 

TTTS is supposedly more likely to produce objective tinnitus due to the size and attachment of the muscle involved. Stapedial myoclonus is less likely to produce an objective tinnitus, because it is much smaller and has a different attachment. Both muscles are found in the middle ear.

 

Can this Stapedius Muscle spasming cause 24/7 hissing, or it is just on temporary base when muscle is under the spasm?

 

Hi.

I have this vibration in my stapedius muscle 24/7, followed by a lot of other noises. Is it due to the stapedius vibrating I have these other sounds you think?

I am getting an operation to cut this muscle soon, just waiting for a date. Is this recommended?

 

Keep us informed...Please.

 

Is it a fluttering? Are you sure it is the stapedius and not the tensor tympani? What do you mean by "followed by a lot of noises"?
A surgery is considered the last option from what I have read on here and on the H-network. Some people get better by but some get worse. So if I were you, I would try to look into it more to be more certain. @japongus knows quite a lot about it. Maybe you should ask him.

 

Has anyone actually had surgery to correct this?

 

Thanks to @lapidus for bringing this to my attention but for some reason it didn't show in the alert box.

Who told you this vibration was of the stapedius?

Who wants to operate on you?

I've read a lot about this but I am still clueless and I don't know which is right and wrong. There have been positive and negative reports about tenotomies for middle ear myoclonus. In the chat-hyperacusis forum, healthboards forum and myoclonus proboards forum, positive were lib and JoeM and vasilia among others that you find once you read the threads they were in. But there have been negative experiences, and on chat-hyperacusis there is Trashboat and Astrid which are very worrying. And then there are some other partial failures or partial successes which are poorly explained. Maybe we can all read all of their experiences and maybe with a communal effort we can find differences in their profiles that led to each of their successes and failures.

The academic literature is usually very positive but of very poor quality because we need more quality, we need fuller descriptions from successful and unsuccessful patients to try to determine what sounds and effects come from what parts of the middle and inner ear. There was a recent poster presentation however at Baylor College of Medicine

that talks about 2 successes and 4 failures, but it doesn't specify further what the hell it's talking about, whether this were just inconsequential failures, serious failures, partial failures or just incomplete successes. I tried to contact Zhenh Huang in her email address but she's no longer a student there, maybe you live close to Jeffrey Vrabec, who appears to be the teacher in that project, and he knows more about these profiles and can tell us something.

What I'm trying to find out now is if a stapedius can cause a high pitched tinnitus that can't be heard from the outside, and I'm lining up a bunch of questions to phone lib about to see what she knows. I visited Aristides Sismanis a few months ago and either he was evasive about what he knew or I wasn't in form when I visited and failed to insist and ask him the required questions about whether his diagnosis of possible myoclonus of me is based on a stab in the dark or well fundamented experience.

I've also been reading about tinnitus in stapedectomy in otosclerosis and over there doctors seem more confident that low rumbling could be ''due to impairment of the mechanics of the cochlea and that creating an opening in the Žfixed foot plate alleviates this situation'' or that it could be ''due to conductive deafness due to
normally sub-audible tympanic and peri-tympanic vascular and muscular noises that are unmasked by the conductive deŽficit''. So it would seem its neither the stapedius nor the central cortex that does it but half way between the two because it says ''
According to Causse stapes fiŽxation results in reduction of inner ear fluid vibration which is more
marked for low frequency sound than for high frequencies. This in turn means that fewer nerve
impulses reach the auditory cortex, particularly in those nerves concerned with low frequencies.
As a result of this the cortex stimulates the outer hairs via their afferent supply to a greater extent
than normal and this produces tinnitus.'' (
Effect of stapedectomy on subjective tinnitus
Marcin Szymanski and others 2003
And I'm also reading up on round window reinforcement where symptoms of ''myoclonus'' and ''hyperacusis'' seem to overlap and there's disagreement among neurotologists about the logic of the operation.

 

Also what is your myoclonus like, continuous or pulsating? is it more of a sound than a pulling feeling, or it more of a pull than a sound? is it a ring or is it a thump? Are you sensitive to many sounds to what kind of sounds?

the stapedius could be provoking the cochlea to create a rumbling I guess, but I'm just not sure what happens when its cut.

 

It is not the tensor tympany, I have taken many tests. Another test showed that is the stapedius vibrating. The other sounds I was talking about, is that the more the stapedius vibrates, the more other sounds I get. Dont know how to explain