Middle Ear Myoclonus Cured by Selective Tenotomy of the Tensor Tympani: Strategies for Targeted Intervention for Middle Ear Muscles

Computed tomography Scan Size Analysis of stapedius and tensor tympani muscles in middle ear myoclonic tinnitus

Objectives

To analyze the sizes of the stapedius and tensor tympani (TT) muscles using a temporal bone CT (TBCT) scan in patients with middle ear myoclonic tinnitus (MEMT) and investigate their value for the diagnosis of this rare cause of tinnitus.

Methods

Medical records and TBCT of patients with MEMT or vascular tinnitus (VT) at Seoul St. Mary's Hospital from January 2012 to December 2022 were reviewed. The stapedius and TT muscles were analyzed.

Results

Thirty-eight patients with unilateral MEMT and 39 patients with VT were included. More males were in the MEMT group compared to the VT group (MEMT: n = 24, VT: n = 8, p = .001). The mean age of the MEMT group was younger compared to the VT group (MEMT: 35 ± 12 years, VT: 44 ± 14.3 years, p = .005). The mean BMI for the MEMT group was less than the VT group (MEMT: 22.3 ± 2.5, VT: 24.8 ± 4.36, p = .010). The mean length and width of the stapedius in the MEMT group were larger than those of the VT group (Length MEMT: 1.47 ± 0.60 mm, VT: 0.98 ± 0.24 mm, p = .001; Width MEMT: 0.89 ± 0.32 mm, VT: 0.72 ± 0.19 mm, p = .009). The mean length and width of the TT in the MEMT group were larger than that of the VT group (Length MEMT: 3.10 ± 0.50 mm, VT: 2.27 ± 0.42, p = .001; Width MEMT: 2.02 ± 0.36, VT: 1.75 ± 0.26 p = .001).

Conclusion

The mean length and width of the stapedius and TT muscles measured in the MEMT group were longer and wider than the VT group. This suggests the use TBCT scan as a diagnostic tool for MEMT. Further studies with a larger study group to validate the results of this study are recommended.Level of Evidence: 4.

Exploring the middle ear function in patients with a cluster of symptoms including tinnitus, hyperacusis, ear fullness and/or pain

Middle ear muscle (MEM) abnormalities have been proposed to be involved in the development of ear-related symptoms such as tinnitus, hyperacusis, ear fullness, dizziness and/or otalgia. This cluster of symptoms have been called the Tonic Tensor Tympani Syndrome (TTTS) because of the supposed involvement of the tensor tympani muscle (TTM). However, the putative link between MEM dysfunction and the symptoms has not been proven yet and the detailed mechanisms (the causal chain) of TTTS are still elusive. It has been speculated that sudden loud sound (acoustic shock) may impair the functioning of the MEM, specifically the TTM, after an excessive contraction. This would result in inflammatory processes, activation of the trigeminal nerve and a change of the MEMs state into a hypersensitive one, that may be associated to the cluster of symptoms listed above. The goal of this study is to provide further insights into the mechanisms of TTTS. The middle ear function of 11 patients who reported TTTS symptoms has been investigated using either admittancemetry and/or measurement of air pressure in the sealed external auditory canal. While the former method measured the middle ear stiffness the latter provides an estimate of the tympanic membrane displacement. Most patients displayed results consistent with phasic contractions of the TTM (n = 9) and/or Eustachian Tube (ET) dysfunction (n = 6). The MEM contraction or ET dysfunction could be evoked by acoustic stimulation (n = 3), somatic maneuvers (n = 3), or pressure changes in the ear canal (n = 3). Spontaneous TTM contraction (n = 1) or ET opening (n = 1) could also be observed. Finally, voluntary contraction of MEM was also reported (n = 5). On the other hand, tonic contraction of the TTM could not be observed in any patient. The implications of these results for the mechanisms of TTTS are discussed.

Middle ear myoclonus: Systematic review of results and complications for various treatment approaches

OBJECTIVE

To perform a systematic review of the diagnosis and treatment of patients with pulsatile tinnitus secondary to middle ear myoclonus.

DATABASES REVIEWED

PubMed, EMBASE, and Scopus.

METHODS

A systematic review was performed using standardized methodology. Computerized and manual searches were performed to identify studies of all ages (patients) who had middle ear myoclonus (intervention). All study designs were assessed. Extracted data included demographics, clinical features, duration of followup as well as the diagnosis and reversibility of symptoms with medical or surgical intervention. Studies were included if they included subjects with middle ear myoclonus. Exclusion criteria included letters/commentaries and reviews.

RESULTS

Twenty articles representing 115 subjects with middle ear myoclonus were included. The mean age was 29.7 (range 6-67). The follow-up period ranged from 5 weeks to 36 months. Primary treatment consists of medical therapy utilising anxiolytics, antiepileptics, botulinum toxin and surgical treatment involving division of middle ear muscular tendon(s). In total, 60 patients underwent middle ear muscular tenotomies, with division of both stapedius and tensor tympani tendons being the most prevalent (88%). Limitations in the data arose from study design, related comorbidities such as palatal myoclonus, and concomitant drug administration. No study provided any objective criteria to diagnose this condition or evaluate post-treatment outcome.

CONCLUSION

Middle ear myoclonus is an entity that is poorly assessed in the literature. There is a lack of consensus regarding the criteria and strategies for both diagnosing and treating this condition. Although level of evidence of current studies remains modest, it is felt that a stepwise approach is deemed best, with therapeutic decisions being made on an individual basis, evaluating each patient's specific circumstances and priorities.

Isolated Ear Clicks with Partial Voluntary Control

Background: Ear click is a rare type of objective tinnitus, classically described with associated palatal tremor/myoclonus (PT). Case report: A 15-year-old boy reported a constant bilateral ear clicking for 4 years, that could be stopped at will for a few seconds. Clinically, the ear clicks were audible without visible eardrum or palatal movement, and could be entrained by the examiner. Brain MRI was normal. Discussion: We propose to classify this as isolated ear clicks with partial voluntary control, putting it into context with other subcategories of “essential” or “isolated” PT.

Pulsatile tinnitus caused by pneumocephalus after Janneta surgery

Pulsatile tinnitus of nonvascular origin is rare. We herein present a case of pulsatile tinnitus complicated with Jannetta surgery due to a communication created between the drilled mastoid cells and epidural space. She was successfully cured by otological surgery where the mastoid tip was packed with bone cement. A 68-year-old woman was referred to the previous hospital with complaints of right autophony, aural fullness, hyperacusis to her footsteps, and pulsatile tinnitus for the past three years. She had received Jannetta surgery for right hemifacial spasm seven years before. The computed tomography (CT) of the right temporal bone showed bony dehiscence between the mastoid cells and posterior cranial fossa. She underwent otological surgery to obliterate the tip of the mastoid cavity with artificial bone cement (BIOPEX^Ⓡ) under general anesthesia. Her annoying aural symptoms were immediately abolished and she has been free from symptoms at ten months after surgery. It is critical to ensure the closure of any communication created between the middle ear and epidural space during surgeries in order to prevent the occurrence of pulsatile tinnitus.

Diagnosis of Stapedial Myoclonus Using Endoscopic Visualization

BACKGROUND

Stapedial myoclonus is an uncommon condition involving the rhythmic contraction of the stapedial tendon that may result in a host of symptoms, including tinnitus . There is a dearth of robust diagnostic modalities to diagnose stapedial myoclonus, and most patients are treated without definitive diagnosis. Herein, we hypothesize that stapedial myoclonus can be readily diagnosed by awake otoendoscopy (see Video, Supplemental Digital Content 1, http://links.lww.com/MAO/A997).

CASE REPORT

A 21-year-old healthy male professional singer presented with a rhythmic "thumping sound" heard in both ears for 5 years. Symptoms were triggered by singing and were worse on the right side. Work-up, including otologic exam, audiologic testing, and high resolution imaging, was unrevealing. Given symptomatology, stapedial tendon myoclonus was suspected.While awake in the operating room, an inferior myringotomy was made, and both 1.9 mm 0 and 30 degree 3-CCD Hopkins rod endoscopes were used to visualize the middle ear space using a transcanal approach. There was robust movement of the tendon with patient vocalization that corresponded precisely with the timing of tinnitus. The patient subsequently underwent transection of the right stapedial tendon under general anesthesia using otoendoscopic visualization. The pyramidal eminence was also removed to avoid future regeneration. The patient underwent an identical procedure on the contralateral ear 3 months later with complete resolution of symptoms bilaterally.

CONCLUSION

Stapedial myoclonus was diagnosed by transtympanic otoendoscopy in an awake patient. This approach may be readily applied in awake patients suspected of having stapedial myoclonus. Transection of the stapedial tendon in these patients resolves tinnitus.

A Novel Technique for the Diagnosis and Management of Middle Ear Myoclonus

A novel technique for the diagnosis and management of middle ear myoclonus is described. A patient with middle ear myoclonus underwent a trans-canal microscopic middle ear exploration with injection of botulinum toxin into the stapedius and tensor tympani muscles. Postoperatively, the patient noted complete resolution of symptoms. This is the first report of the use of botulinum toxin directly applied to the middle ear musculature via a trans-canal approach for the management of middle ear myoclonus. This approach is both a useful diagnostic and therapeutic tool that allows for temporary muscle paralysis prior to offering definitive surgical management. Laryngoscope, 131:E248-E249, 2021.

Treatment of objective tinnitus with transpalatal Botox® injection in a pediatric patient with middle ear myoclonus: A case report

We describe a case of bilateral middle ear myoclonus (MEM) that was treated with trans-palatal Botox^® injection after failing surgery to section the tensor tympani and stapedial tendons. MEM is a rare disorder resulting from rhythmic contraction of middle ear muscles. An 8-year old girl presented with audible clicking tinnitus, and resultant inability to focus in school. Her parents declined medical therapy, and she underwent surgeries for tendon lysis, with only temporary relief. She had successful response to trans-palatal Botox^® injection to the tensor veli palatini aponeurosis. Trans-palatal Botox^® injection is a safe and reasonable alternative for treatment of MEM.

[Myoclonus of the middle ear]

The objective of the present study was to overview the foreign literature concerning middle ear myoclonus (MEM) known to be the most common cause of the manifestations of objective tinnitus. The authors reports two typical clinical cases of myoclonus of the middle ear. The present article is aimed at the enhancement of the awareness of the otorhinolaryngologists, audiologists, and neurologists of the condition of interest as a way to promote the further progress in its treatment.

Long-Term Effects of Middle Ear Tendon Resection on Middle Ear Myoclonic Tinnitus, Hearing, and Hyperacusis

Objective: To evaluate the therapeutic effects of middle ear tendon resection (METR) on middle ear myoclonic tinnitus (MEMT) and to investigate its long-term effects on hearing and hyperacusis. Materials and Methods: Thirty-seven patients with MEMT with a mean age of 33.2 ± 11.8 years were included in this study. METR was performed on all 37 MEMT patients (41 ears) between November 2004 and August 2016. The mean follow-up period was 16.1 months. We examined changes in tinnitus and accompanying stress and depression in patients after surgery, and examined the hearing changes and the occurrence of complications including hyperacusis. Results: After surgery, 34 (91.9%) patients exhibited complete resolution of MEMT during their follow-up period, and 3 patients showed a partial response. The mean Visual Analog Scale (VAS) scores for tinnitus severity, the Tinnitus Handicap Inventory (THI), and stress index decreased significantly after surgery (p < 0.05, paired t test). No patient developed hearing loss or hyperacusis following surgery. Preexisting hyperacusis even improved in most of the patients with intractable MEMT after surgery. Recurrence of the symptom occurred in only 1 patient, who underwent revision surgery with improvement. We observed 1 case of postoperative delayed facial palsy with complete recovery in 2 weeks. Conclusions: METR seems to be an effective and safe treatment option for intractable MEMT, considering its high control rate of tinnitus and no long-term harmful effects on hearing and hyperacusis.

Surgical management of pulsatile tinnitus secondary to jugular bulb or sigmoid sinus diverticulum with review of literature

INTRODUCTION

Jugular bulb and sigmoid sinus anomalies are well-known causes of vascular pulsatile tinnitus. Common anomalies reported in the literature include high-riding and/or dehiscent jugular bulb, and sigmoid sinus dehiscence. However, cases of pulsatile tinnitus due to diverticulosis of the jugular bulb or sigmoid sinus are less commonly encountered, with the best management option yet to be established. In particular, reports on surgical management of pulsatile tinnitus caused by jugular bulb diverticulum have been lacking in the literature.

OBJECTIVES

To report two cases of pulsatile tinnitus with jugular bulb and/or sigmoid sinus diverticulum, and their management strategies and outcomes. In this series, we describe the first reported successful case of pulsatile tinnitus due to jugular bulb diverticulum that was surgically-treated.

SUBJECTS AND METHODS

Two patients diagnosed with either jugular bulb and/or sigmoid sinus diverticulum, who had presented to the Otolaryngology clinic with pulsatile tinnitus between 2016 and 2017, were studied. Demographic and clinical data were obtained, including their management details and clinical outcomes.

RESULTS

Two cases (one with jugular bulb diverticulum and one with both sigmoid sinus and jugular bulb diverticula) underwent surgical intervention, and both had immediate resolution of pulsatile tinnitus post-operatively. This was sustained at subsequent follow-up visits at the outpatient clinic, and there were no major complications encountered for both cases intra- and post-operatively.

CONCLUSION

Transmastoid reconstruction/resurfacing of jugular bulb and sigmoid sinus diverticulum with/without obliteration of the diverticulum is a safe and effective approach in the management of bothersome pulsatile tinnitus arising from these causes.

Idiopathic oculostapedial synkinesis without history of facial nerve palsy

OBJECTIVE

To report a case of idiopathic oculostapedial synkinesis without facial nerve disorder.

PATIENT

A 30-year-old woman with tinnitus synchronous with eye closure is presented. The patient had no history of facial nerve disorder.

RESULT

An impedance audiometer, in the absence of an auditory stimulus, was used to record tympanic membrane compliance without sound stimulation, revealing decreased compliance in the concomitant with eye blinking. Her symptoms disappeared spontaneously, so no intervention was undertaken.

CONCLUSION

Although oculostapedial synkinesis is often observed as one of the sequelae of facial nerve palsy, idiopathic oculostapedial synkinesis is very rare. The use of an impedance audiometer in the absence of an auditory stimulus is very useful for demonstrating objective changes in the compliance of the tympanic membrane. It is assumed that the cause of the synkinesis in our case was abnormal transmission of signals for orbicularis oculi muscle to the stapedial and orbicularis oris muscles rather than misdirected regenerating fibers. Resection of the stapedial muscle tendon should be considered if her symptoms recur.

Feasibility of endoscopic treatment of middle ear myoclonus: a cadaveric study

Stapedius and tensor tympani tenotomy is a relatively simple surgical procedure commonly performed to control pulsatile tinnitus due to middle ear myoclonus and for several other indications. We designed a cadaveric study to assess the feasibility of an entirely endoscopic approach to stapedius and tensor tympani tenotomy. We performed this endoscopic ear surgery in 10 cadaveric temporal bones and summarized our experience. Endoscopic stapedius and tensor tympani section is a new, minimally invasive treatment option for middle ear myoclonus that should be considered as the first line surgical approach in patients who fail medical therapy. The use of an endoscopic approach allows for easier access and vastly superior visualization of the relevant anatomy, which in turn allows the surgeon to minimize tissue dissection. The entire operation, including raising the tympanomeatal flap and tendon section, can be safely completed under visualization with a rigid endoscope.