Clicking in the ear for all to hear – approaching a diagnostic challenge.

Objective tinnitus is defined as a condition, in which both patient and examiner can hear the emitted sound. A well-known cause is muscle contraction of the musculus levator or tensor veli palatini, also referred to as palatal myoclonus. Since these are extremely rare phenomena, there are few case reports in the international literature. We present a case series of three patients aged 9 to 25, who presented with arrhythmic clicking ear noises and a resulting high level of emotional distress. Based on the performed diagnostics (physical examination, direct endoscopy, audiometry) as well as the analysis of the emitted noises, we describe the challenges in diagnostic and therapy of myoclonus-induced objective tinnitus. Click emissions recorded with an electret microphone in the external ear canal showed peak values ​​of 38-77dBSPL with a duration of 2-800ms. The objective and subjective audiological diagnosis was unremarkable in all three cases, an additional MRI of the brain showed no pathology. In none of the cases did ear microscopy show movements of the tympanic membrane as an indication of middle ear myoclonus. A locally circumscribed palatal myoclonus could be confirmed visually in one and by direct palpation in another case. Therapeutically, the local palatal application of botulinum toxin lead to improvement or resolution of the symptoms. Objective tinnitus as a result of PM is a very rare disease with relevant psychological strain for those affected. A careful intraoral examination should also include palpation. The local application of botulinum toxin should be considered as an effective therapy option.

Publication History

Article published online:
27 June 2023