middle ear myoclonus

1. Middle Ear Myoclonus Cured by Selective Tenotomy
of the Tensor Tympani: Strategies for Targeted
Intervention for Middle Ear Muscles
*†Hiroshi Hidaka, *†Youhei Honkura, †Jun Ota, †Shigeki Gorai,
*Tetsuaki Kawase, and *Toshimitsu Kobayashi
*Department of OtolaryngologyYHead and Neck Surgery, Tohoku University Graduate School of
Medicine, Sendai, Miyagi; and ÞDepartment of Otolaryngology, Iwaki Kyoritsu General Hospital,
Iwaki, Fukushima, Japan
Objective: To describe a case of middle ear myoclonus that was
successfully cured by selective transection of the tensor tympani
(TT) without sectioning the stapedius tendon (ST) and to review
previously reported cases, elucidating precipitating factors for
interventions targeting middle ear muscles.
Data Sources: One case we encountered and a recent systematic
review published in 2012.
Study Selections: In addition to our case, 23 cases identified by
the previous systematic review regarding middle ear myoclonus
in which surgical interventions were conducted.
Data Synthesis: Outcomes for selective tenotomy of TT or ST
were analyzed focusing on the following 6 preoperative factors: 1)
history of facial palsy, 2) provoking factors for tinnitus, 3) aus-
cultation of the ear, 4) movement of the ear drum, 5) complication
with palatal myoclonus, and 6) confirmation of myoclonus during
surgery. Among these, the first 2 factors represented signifi-
cant factors for selective tenotomy of ST ( p G 0.05 and p G 0.01,
respectively). Furthermore, no auscultation of the ear was sig-
nificant for selective tenotomy ( p G 0.01), specifically for ST.
Confirmation of muscle contraction during surgery contributed
significantly ( p G 0.01) to targeted intervention, but selective
tenotomy of TT was successfully performed in 3 cases without
such confirmation by confirming variations in compliance with
tympanometry
Conclusion: Assessment of the history of facial palsy, provoking
factor of tinnitus, auscultation of the ear, and confirmation of
myoclonus during surgery appear helpful in predicting which
middle ear muscle is undergoing myoclonus. Furthermore, long-
timeYbased tympanometry offers objective information for plan-
ning targeted intervention for middle ear muscles and clarifying
clinical outcomes. Key Words: Middle ear myoclonusV
TinnitusVTenotomyVTensor tympaniVTympanic membrane
complianceVStapedius tendon.
Otol Neurotol 34:1552Y1558, 2013.
Myoclonus is a sudden, involuntary jerking of a muscle
or group of muscles. Middle ear myoclonus is a rare
disorder produced by repetitive contractions of the middle
ear muscles. Bhiamrco et al. (1) recently conducted a
systematic review of management strategies for middle
ear myoclonus and stated that differentiating between the
diagnoses of stapedial myoclonus and tensor tympani
(TT) myoclonus has not been described in detail in the
literature, and definitive, objective methods of separating
one from the other are currently lacking. Other than
the present lack of consensus regarding treatment, no
previous studies showed objective changes in outcome
by assessing responses to intervention before and after
treatment.
We report herein a case of middle ear myoclonus
that was successfully cured by selective transection of the
TT without sectioning the stapedius tendon (ST). Clinical
outcomes were clearly indicated by both endoscopic oto-
logic findings and impedance audiometry. To elucidate
factors contributing to selective tenotomy of middle ear
muscles for middle ear myoclonus, a meta-analysis was
also conducted for our case and 23 surgically treated cases
included in the previous systematic review. Specifically, we
focused on the following 6 factors: 1) past history of facial
palsy, 2) provoking factors for tinnitus, 3) auscultation
of the ear, 4) movement of the ear drum, 5) complication
Address correspondence and reprint requests to Hiroshi Hidaka, M.D.,
Ph.D., Department of OtolaryngologyYHead and Neck Surgery, Tohoku
University Graduate School of Medicine, 1-1 Seiryomachi, Aoba-ku,
Sendai 980-8575, Japan; E-mail: ZAY00015@nifty.com
The authors disclose no conflicts of interest.
Financial Disclosures: None.
Supplemental digital content is available in the text.
Otology & Neurotology
34:1552Y1558 Ó 2013, Otology & Neurotology, Inc.
1552
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

2. with palatal myoclonus, and 6) confirmation of myoclonus
during surgery.
CASE REPORT
A 39-year-old woman presented with a 1-month history
of pulsatile tinnitus in the left ear. No history of previous ear
surgery or local trauma was elicited.
Endoscopic examination and recording revealed move-
ments of the left tympanic membrane (see Video, Supple-
mentary Digital Content, http://links.lww.com/MAO/A172)
that coincided with tinnitus. No palatal spasm was noted
under nasopharyngeal endoscopy. Pure-tone audiometry
showed a normal auditory threshold of 8 dBHL (averages
of 500, 1,000, and 2,000 Hz) on both sides.
Auscultation of the ear did not reveal objective tinnitus.
Stapedial reflex measured by a commercial impedance
audiometer (RS-22; RION, Kokubunji, Japan) was
clearly present on the contralateral side (Fig. 1A) but was
difficult to recognize on the left because of marked
fluctuations in baseline impedance (Fig. 1B). Using the
same equipment in the absence of an auditory stimulus,
recording of long-timeYbased tympanic membrane com-
pliance for 20-second epochs without sound stimulation
revealed perturbations with a cycle of 1 to 2 times per
second in the trace, which were synchronized with audi-
ble clicking. No patulous Eustachian tube was identified
using tubo-tympano-aerodynamography (2) on either
side (data not shown).
Neurologic evaluation including brain magnetic reso-
nance imaging (MRI) revealed no evidence of intracere-
bral or other systematic lesions such as palatal myoclonus
or systematic myoclonic syndrome, vascular cause or
multiple sclerosis.
Based on all these findings, a diagnosis of middle ear
myoclonus was established. Therapeutic options includ-
ing surgery and other treatment modalities such as phar-
macological treatment, relaxation therapy, and tinnitus
masking were proposed, and the patient chose to undergo
surgery.
Exploratory tympanotomy was performed via an en-
daural approach under local anesthesia. Elevation of a
tympano-meatal flap resulted in relief from tinnitus, and
FIG. 1. A and B, Preoperative auto-mode stapedial reflex measured by impedance audiometry on the sides contralateral (A) and ipsilateral
(B) to tinnitus. C and D, The same auto-mode stapedial reflex measured postoperatively. Note disappearance of perturbations on the ip-
silateral side, revealing clear stapedial reflexes on the left.
1553SELECTIVE TENOTOMY FOR MIDDLE EAR MYOCLONUS
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

3. muscle contractions failed to be observed in either the
stapedial muscle or TT. However, the patient felt the
same sound as tinnitus when the TT was touched. We
thus transected the TT, resulting in resolution of tinnitus.
In terms of ST, touching the muscle produced a sensation
that was different from the perceived tinnitus. Further-
more, preoperative compliance measurement implied
that the myoclonus would be attributable to the TT.
Based on these findings, we preserved the ST.
As of 1.5 years postoperatively, the patient has not
experienced any recurrence of tinnitus, and her hearing
remained normal with an averaged threshold of 10 dBHL.
Stapedial reflex conducted 2 months after surgery showed
preservation of reflex (Fig. 1D), and recording of long-
timeYbased tympanic membrane compliance without sound
stimulation revealed resolution of the fluctuations (Fig. 2C).
The review board of Tohoku University Hospital ap-
proved publication of this case reports.
MATERIALS AND METHODS
A recent systematic review (1) of middle ear myoclonus pub-
lished in 2012 yielded a total of 21 articles that were examined for
the analysis. Among these, 23 cases from 10 articles were treated
using surgery (3Y13). After including the present case, we de-
veloped their analysis by critically reviewing these 24 cases and
conducting a meta-analysis of precipitating factors for selective
tenotomy of TT or ST.
Differences in frequencies of various factors between groups
were statistically examined using Fisher’s exact test with
Statview version 5 software (SAS, Cary, NC, USA).
RESULTS
Sex, Age, and Etiologies
Summarized data from the 24 cases (3Y13) are indicated
in Table 1. Mean age at the time of surgery was 29.9 T
10.5 years, with a male-to-female ratio of 13:11. In terms
of affected side, no clear predilections were evident (left,
10; right, 7; bilateral, 7). All of the cases presented with
tinnitus. Most commonly, a clicking or buzzing quality is
described, but this varies widely between patients, as de-
scribed previously (1).
Precipitating Factors for Selective Tenotomy
of ST or TT
Among the 24 cases, 13 cases underwent selective
tenotomy of ST, and 4 cases underwent selective tenotomy
of TT. The remaining 7 cases underwent tenotomy of
FIG. 2. A, Preoperative long-timeYbased tympanic membrane compliance for 20 seconds without sound stimulation, revealing sharp
perturbations (left). B, Preoperative long-timeYbased tympanic membrane with sound stimulus (1 kHz, 100 dBSPL), showing stapedial
reflex. Note the sharp perturbations were discontinuous with the reflex. C, Postoperative long-timeYbased tympanic membrane compliance
for 20 seconds without sound stimulation, showing disappearance of perturbations.
1554 H. HIDAKA ET AL.
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

4. both tendons. Table 2 examined whether selective teno-
tomy of middle ear muscles was influenced by various
precipitating factors.
Regarding a past history of facial palsy, all 10 cases
with a positive history underwent selective ST tenotomy.
Conversely, only 7 (50%) of the 14 cases with no history
of facial palsy underwent selective tenotomy. Specifi-
cally, 4 cases received TT tenotomy, and 3 cases received
ST tenotomy. Frequencies of selective tenotomy between
these 2 groups were significantly different (Fisher’s exact
test, p = 0.019).
Focusing on factors that induce tinnitus, 13 (93%) of
14 cases showing a provoking factor for tinnitus received
selective tenotomy of ST. Conversely, only 4 of 10 cases
without such a factor received selective tenotomy (TT,
n = 3; ST, n = 1). Frequencies differed significantly be-
tween these groups (Fisher’s exact test, p = 0.009).
Among all 24 cases, information about the objectivity of
tinnitus (perceivable by an external listener) was available
in 20 cases. These 20 patients were categorized according
to objectivity, and 43% (3/7) of cases with objective tinnitus
underwent selective tenotomy (ST, n = 1; TT, n = 2).
Conversely, all 13 cases without objective tinnitus received
selective tenotomy (ST, n = 12; TT, n = 1). Frequency also
differed significantly between these 2 groups (Fisher’s
exact test, p = 0.007).
In terms of eardrum movement, information was avail-
able in 22 cases. Categorizing these patients according to
whether examinations showed movement of the eardrum,
57% (4/7) of cases in which movement of the ear drum was
seen underwent selective tenotomy (ST, n = 1; TT, n = 3).
On the other hand, 87% (13/15) of cases without eardrum
movement received selective tenotomy (ST, n = 12; TT,
n = 1). No significant differences were identified between
groups (Fisher’s exact test, p = 0.27).
Among all 24 cases, only 2 cases reported by Oliveria et al.
(10) showed both palatal and TT myoclonus. These 2 cases
both underwent selective tenotomy of TT. Conversely,
59% (13/22) of cases without palatal myoclonus received
ST tenotomy. Frequency did not differ significantly be-
tween these 2 groups (Fisher’s exact test, p 9 0.999).
With regard to confirmation of myoclonus during
surgery, all 14 cases in which myoclonus of the middle
ear was confirmed during surgery received selective
tenotomy (ST, n = 13; TT, n = 1). Conversely, only 30%
(3/10) of patients without such confirmation during sur-
gery underwent selective tenotomy. Frequency of con-
firmation differed significantly between groups (Fisher’s
exact test, p = 0.0003).
In terms of clinical outcomes after surgery, information
was not available for the second case by Oliveria et al.
(10). Among the remaining 23 cases, 21 (91%) showed
TABLE 1 Summary of 23 previously reported cases and our case of middle ear myoclonus for which surgery was performed
Study Year Age (yr) Sex Affected side Appearance of tinnitus Facial palsy
Provoking
factor of
tinnitus
Watanabe et al. (3) 1974
Case 1 19 F L Cracking + Closure of eyelids
Case 2 32 M R Low-tone + Movement of angle of the mouth
Case 3 28 M L Cracking + Closure of eyelids
Case 4 26 M R Low-tone + Movement of angle of the mouth
Case 5 24 F L Cracking + Movement of angle of the mouth
Case 6 17 F L Low-tone + Closure of eyelids, movement of angle of the mouth
Case 7 32 F R Flapping low-tone + Closure of eyelids, movement of angle of the mouth
Case 8 37 M R Cracking + Closure of eyelids, movement of angle of the mouth
Williams (4) 1980 34 M L NA + Concurrent with eye blinks
Marchiando et al. (5) 1983
Case 1 22 M Bil Clicking j Triggered by conversation, loud noise
Case 2 37 M R Static j Triggered by conversation, loud noise
Badia et al. (6) 1994
Case 1 31 F R Clicking j None
Case 2 30 M L Bubbling j Low-frequency sounds
Case 3 56 M L Grasshopper-like noise j None
Bento et al. (7) 1998 21 F L High-frequency sound j None
Zipfel et al. (8) 2000 44 F Bil Rhythmic ’rushing wind’ j None
Cohen and Perez (9) 2003 32 F Bil Twitches of irregular order j None
Oliveira et al. (10) 2003
Case 1 40 F Bil Click j None
Case 2 11 M L Click j Talking, swallowing, moving neck
Golz et al. (11,12) 2003
Case 1 14 M Bil Click j None
Case 2 20 M Bil Low-pitched buzzing noise j None
Case 3 45 F Bil Click j None
Van der Gaag (13) 2004 27 M L Fluctuating + Voluntary contraction of mimetic muscles
Present case 39 F R Pulsatile j None
Bil indicates bilaterally affected; TT, tensor tympani; L, left side; NA, not applicable; R, right side; ST, stapedius tendon.
1555SELECTIVE TENOTOMY FOR MIDDLE EAR MYOCLONUS
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

5. full resolution of tinnitus. The remaining 2 cases showed
partial resolution after selective tenotomy. Specifically,
the second case reported by Marchiando et al. (5) showed
90% improvement at 1 year after selective tenotomy of
ST. The other case was the first case reported by Oliveria
et al. (10), in which symptoms became tolerable, and
the patient declined further medication. Categorizing the
23 cases according to the outcome of full resolution,
management using selective tenotomy was not revealed
as a significant factor (Fisher’s exact test, p 9 0.999).
DISCUSSION
Tinnitus due to middle ear myoclonus is quite uncom-
mon, and relatively few studies have showed objective
changes in outcome by assessing response to intervention
before and after treatment (3,4,10). We present a unique
case that was successfully managed by sectioning the TT
while preserving the ST, with the clinical outcomes ob-
jectively confirmed by long-timeYbased tympanometry.
Differential diagnoses for middle ear myoclonus include
intermittent palatal myoclonus and patulous Eustachian
tube. The former, which is ruled out by oral and/or
nasoendoscopic examination, is usually bilateral, and the
sound is related to the action of the Eusthachian tube or
peritubal muscles (6,14). The latter, which is ruled out by
tubo-tympano-aerodynamography, may give rise to a crack-
ing sensation in the ear, although the most frequent symp-
tom is autophony (15,16).
The etiology of middle ear myoclonus remains unclear,
but both loud noise and anxiety have been suggested
as possible causes (5Y8). Regarding treatment, several
options have been reported, including the use of muscle
relaxants, sedatives and anticonvulsants, and Botulinum
toxin (1,17). However, their effectiveness has been am-
biguous, and surgical sectioning of the middle ear muscles
via tympanotomy has been reported as a straightforward
and effective procedure (1,6,7,11,12).
Most reports addressing the effectiveness of surgical
intervention of the middle ear muscles comprised section-
ing both the ST and TT. Several reports have indicated
these procedures have no adverse effects, but myotenotomy
of the stapedius muscle would invariably lead to hyper-
acusis, or even phonophobia, which can have a devastating
effect on a patient’s life (17).
One of the themes for future research is the need for
reliable indications regarding which middle ear muscle is
experiencing myoclonus, to allow targeted interventions
(1). A recent systematic review of management strategies
for middle ear myoclonus concluded that differentiating the
Heard
objectively
Ear drum
movement
Complicated
with palatal
myoclonus
Acoustic
impedance
Intraoperative
confirmation
of muscle
contraction Tenotomy Outcomes
Acoustic
impedance
after operation
j j j NA + ST Full resolution NA
j j j Response during contraction
of mimetic muscles provoking tinnitus
+ ST Full resolution Abnormal response
disappeared.
j j j Response during contraction
of mimetic muscles provoking tinnitus
+ ST Full resolution Abnormal response
disappeared.
j j j Response during contraction of mimetic
muscles provoking tinnitus
+ ST Full resolution Abnormal response
disappeared.
j j j NA + ST Full resolution NA
j j j NA + ST Full resolution NA
j j j NA + ST Full resolution NA
j j j NA + ST Full resolution NA
j j j Dramatic change with eye blink + ST Full resolution Abnormal response
disappeared.
j j j Prolonged, continued increased
impedance during and after sound stimulus
+ ST Full resolution NA
j j j Prolonged increased impedance after
sound stimulus
+ ST Partial resolution (90%) NA
+ – j Normal reflex with normal decay j ST + TT Full resolution NA
NA NA j NA j ST + TT Full resolution NA
NA NA j NA j ST + TT Full resolution NA
+ j j Normal appearance j ST + TT Full resolution NA
NA + j Spontaneous rhythmic change rather
than expected acoustic reflex decay
j ST + TT Full resolution NA
NA + j Fluctuated j TT Full resolution NA
+ + + Variation synchronous with tinnitus + TT Partial resolution Variation remained,
presumably due to
palatal myoclonus
+ j + Variation synchronous with tinnitus j TT NA NA
+ + j Small cogwheel effect j ST + TT Full resolution NA
+ + j Fine cogwheel effect + ST Full resolution NA
+ + j Cogwheel effect j ST + TT Full resolution NA
j j j NA + ST Full resolution NA
j + j Fluctuated j TT Full resolution Abnormal response
disappeared.
1556 H. HIDAKA ET AL.
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

6. diagnosis of stapedial myoclonus from that of tensor tym-
pani myoclonus has not been well described in the litera-
ture, and at present, there are no definitive or objective
methods of separating one from the other (1). However,
they did not conduct a meta-analysis. This meta-analysis
of 23 previously reported cases that underwent surgery
together with the present case represents progress, inves-
tigating precipitating features to allow selective interven-
tion for middle ear myoclonus.
First, a past history of facial palsy is a significant factor
for selective intervention, specifically for ST tenotomy.
These results are consistent with remarks in previous re-
ports that most patients who received ST tenotomy
showed synkinesis of the facial muscles secondary to
facial nerve injury/palsy (1,3,4,13).
Second, provoking factors related to tinnitus were also
revealed as a significant factor for selective tenotomy.
Specifically, all except 1 case received selective tenotomy
of ST, and symptoms were triggered by facial movements
(eyelid and/or mouth), conversation, or loud noise. These
provoking factors are presumably associated with the VII
cranial nerve. The only exceptional case underwent selec-
tive tonotomy of TT as the second case reported by Oliveira
et al. (10), with the complication of palatal myclonus.
Tinnitus in that case was mainly provoked by talking
and swallowing, implying a relationship with the palatinti
muscles supplied by the Vth cranial nerve, whose branches
also innervate the TT. Although no previous reports have
addressed these provoking factors as a reliable indication
of which middle ear muscle is undergoing myoclonus, the
present results offer insight into selective intervention for
middle ear myoclonus.
Third, the present meta-analysis revealed novel findings
that patients without objective tinnitus showed a signifi-
cantly higher prevalence of undergoing selective tenotomy.
Interestingly, all of these cases other than the present case
received selective tenotomy of ST. No background mech-
anisms have been conformed to explain why ST-related
myoclonus is difficult to be objectively heard as com-
pared with TT-related myoclonus. One hypothesis is
that the TT has insertions into the cartilaginous portion of
the Eustachian tube, and spontaneous TT contractions will
thus cause an increase in pressure (1), producing objective
sounds.
Fourth, eardrum movement was not identified as a sig-
nificant factor for selective tenotomy. However, 80%
(12/15) of cases in which visual movement of the tym-
panic membrane was not observed underwent selective
tenotomy of ST. These results are consistent with the ar-
gument that myoclonus of ST would not cause visible
movement of the tympanic membrane because of the way
the incudostapedial joint articulates (1,18).
Fifth, complication with palatal myoclonus also failed
to be identified as a significant factor. This might be at-
tributable to the small number of cases (2 cases) showing
complications of palatal myoclonus, but both cases re-
ceived tenotomy of TT. These results are plausible be-
cause both the tensor veli palatine muscle and TT are
supplied by the trigeminal nerve (1).
Sixth, confirmation of muscle contraction during surgery
represented a significant factor for selective tenotomy. Only
30% (3/10) of cases without such confirmation received
selective tenotomy. Interestingly, all 3 cases underwent
selective tenotomy of TT and were preoperatively sub-
jected to impedancinometry demonstrating fluctuations
(9,10), including the present case. A previous report
mentioned impedance audiometry as the only means by
which clinicians should evaluate patients with potential
stapedial muscle abnormalities, by demonstrating sustained
middle-ear muscle contractions synchronous with patient
complaint of tinnitus (5). In their cases, acoustic reflex
testing demonstrated sustained inappropriately prolonged
response after the cessation of sound presentation and
concurrent with the complaint of tinnitus. This may repre-
sent a kind of facial tic, that is, an uncontrolled, repetitive
contraction of specific facial nerve motor units. Conversely,
our case showed fluctuations of compliance presumably
discontinuous with stapedial reflex (Fig. 2), implying TT-
related myoclonus and thus supporting the potential use-
fulness of long-timeYbased acoustic reflex testing.
Because selective tenotomy itself does not seem to con-
tribute to clinical outcomes for full resolution of tinnitus,
TABLE 2 Outcome of selective tenotomy of the stapedius tendon or tensor tympani according to meta-analysis
Selective tenotomy of ST or TT
Yes% No% p
(A) History of facial palsy Yes 10 (0) 0 (100) 0.019
No 7 (50) 7 (50)
(B) Provoking factors of tinnitus Yes 13 (93) 1 (7) 0.009
No 4 (40) 6 (60)
(C) Heard objectively Yes 3 (43) 4 (57) 0.007
No 13 (100) 0 (0)
(D) Ear drum movement Yes 4 (57) 3 (43) 0.274
No 13 (87) 2 (13)
(E) Complication of palatal myoclonus Yes 2 (100) 0 (0) 90.9999
No 15 (68) 7 (32)
(F) Conformation of muscle contraction during surgery Yes 14 (100) 0 (0) 0.0003
No 3 (30) 7 (70)
Outcome after operation (full resolution) Yes 14 (88) 7 (100) 90.9999
No 2 (12) 0 (0)
1557SELECTIVE TENOTOMY FOR MIDDLE EAR MYOCLONUS
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

7. the present meta-analysis supports the need for development
of strategies for targeted tenotomy. As with the previous
systematic review (1), the evidence presented in the present
meta-analysis was through retrospective observation of
cases series and reports. Multi-institutional prospective
research assessing each precipitating preoperative factor,
recording long-timeYbased tympanometry both preopera-
tively and postoperatively, and sharing clinical outcomes
would be helpful to overcome these limitations.
REFERENCES
1. Bhimrao SK, Masterson L, Baguley D. Systematic review of man-
agement strategies for middle ear myoclonus. Otolaryngol Head Neck
Surg 2007;146:698Y706.
2. Kumazawa T, Honjo I, Honda K. Aerodynamic pattern of Eustachian
tube dysfunction. Arch Otorhinolaryngol 1977;215:317Y23.
3. Watanabe I, Kumagami H, Tsuda Y. Tinnitus due to abnormal
contraction of stapedial muscle: an abnormal phenomenon in the
course of facial nerve paralysis and its audiological significance.
ORL J Otorhinolaryngol Relat Spec 1974;36:217Y26.
4. Williams JD. Unusual but treatable cause of fluctuating tinnitus.
Ann Otol Rhinol Laryngol 1980;89:239Y40.
5. Marchiando A, Per-Lee JH, Jackson RT. Tinnitus due to idiopathic
stapedial muscle spasm. Ear Nose Throat J 1983;62:8Y13.
6. Badia L, Parikh A, Brookes GB. Management of middle ear my-
oclonus. J Laryngol Otol 1994;108:380Y2.
7. Bento RF, Sanchez TG, Miniti A, et al. Continuous, high-frequency
objective tinnitus caused by middle ear myoclonus. Ear Nose Throat
J 1998;77:814Y8.
8. Zipfel TE, Kaza SR, Greene JS. Middle-ear myoclonus. J Laryngol
Otol 2000;114:207Y209.
9. Cohen D, Perez R. Bilateral myoclonus of the tensor tympani: a case
report. Otolaryngol Head Neck Surg 2003;128:441.
10. Oliveria CA, Negreiros J, Cavalcante IC, et al. Palatal and middle ear
myoclonus: a cause for objective tinnitus. Int Tinnitus J 2003;9:37Y41.
11. Golz A, Fradis M, Netzer A, et al. Bilateral tinnitus due to middle-
ear myoclonus. Int Tinnitus J 2003;9:52Y5.
12. Golz A, Fradis M, Martzu D, et al. Stapedius muscle myoclonus.
Ann Otol Rhinol Laryngol 2003;112:522Y4.
13. Van der Gaag NA. Myoclonus of the stapedius muscle after a skull
base fracuture [in Dutch]. Ned Tijds Keel Neus Oorheelkunde 2004;
10:41Y3.
14. Pulec J, Simonton K. Palatal myoclonus: a report of two cases.
Laryngoscope 1961;71:668Y71.
15. O’connor AF. Autophony and the patulous Eustachian tube. Laryn-
goscope 1981;91:1427Y35.
16. Kobayashi T, Hasegawa J, Kikuchi T, et al. Masked patulous
Eustachian tube: an important diagnostic precaution before middle
ear surgery. Tohoku J Exp Med 2009;218:317Y24.
17. Liu HB, Fan JP, Lin SZ, et al. Botox transient treatment of tinnitus
due to stapedius myoclonus: case report. Clin Neurol Neurosurg
2011;113:57Y8.
18. Howsam GD, Sharma A, Lambden SP, et al. Bilateral objective
tinnitus secondary to congenital middle-ear myoclonus. J Laryngol
Otol 2005;119:489Y91.
1558 H. HIDAKA ET AL.
Otology & Neurotology, Vol. 34, No. 9, 2013
Copyright © 2013 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.