This case report describes the successful treatment of a patient's severe tinnitus caused by stapedius myoclonus (involuntary muscle spasms) using local injections of botulinum toxin type A (Botox). The patient experienced relief from tinnitus within two days of receiving Botox placed near the stapedius muscle through a perforation in her eardrum. The tinnitus did not return for three months. When it recurred at four months, a second Botox treatment again provided rapid relief. The report concludes that local Botox injections may be an effective treatment for tinnitus caused by stapedius or other muscle spasms in the ear.

1. Clinical Neurology and Neurosurgery 113 (2011) 57–58
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Clinical Neurology and Neurosurgery
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Case report
Botox transient treatment of tinnitus due to stapedius myoclonus: Case report
Hai-Bin Liu, Jing-Ping Fan, Shun-Zhang Lin∗
, Shu-Wei Zhao∗
, Zheng Lin
Department of Otolaryngology-Head & Neck Surgery, ChangZheng Hospital, Second Military Medical University, Fengyang Road 415, Huangpu District, Shanghai, China
a r t i c l e i n f o
Article history:
Received 21 October 2009
Received in revised form 23 July 2010
Accepted 31 July 2010
Available online 25 August 2010
Keywords:
Botulinum toxin type A
Tinnitus
Stapedius myoclonus
a b s t r a c t
Object: To explore the feasibility of using botulinum toxin type A (BTXA) to treat tinnitus due to stapedius
myoclonus.
Method: A piece of gelfoam containing BTXA (25 U/ml) was placed, through a perforation in tympanic
membrane, into the middle ear cavity of a patient suffering from tinnitus due to stapedius myoclonus.
Results: The tinnitus disappeared on the second day after the BTXA treatment. The patient was free of
symptoms during a 3-month follow-up period. Tinnitus reappeared at 4 months, and disappeared after
second BTXA local treatment.
Conclusion: Local BTXA treatment may be considered as a treatment for tinnitus caused by stapedius
myoclonus.
Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved.
1. Introduction
Tinnitus is the perception of sound in the absence of correspond-
ing external stimulus. It can be caused by a wide variety of factors,
including infection, foreign objects, and a number of medications.
Tinnitus caused by stapedius myoclonus is rare, but could severely
limit the ability of the patients to conduct daily activities as simple
as eating, talking, and walking. We successfully treated a patient
with tinnitus caused by stapedius myoclonus with Botox.
2. Case report
A 42-year-old woman presented with severe low-pitched tinni-
tus in the left side for more than 1 year. Upon physical examination,
periodical spasm was noted on the left side of the face. Tympanic
membrane had a 3 mm × 3 mm perforation, but the tympanic cavity
was clear. Synchronous movement of the stapes with facial mus-
cle twitch was noted under endotoscopic examination. No palatal
spasm was noted under a nasopharyngeal endoscope. An audio-
gram revealed elevated threshold of 30 dB HL at 500–2000 Hz.
Acoustic reflex threshold was absent upon impedance examination.
Brain CT and MRI were unremarkable. A microvascular compres-
sion of the facial nerve is not notable. Multiple sclerosis was
excluded by clinical, laboratory and radiological examination.
Based on these findings, stapedius myoclonus was established
as the cause of tinnitus. The patient consented to treatment with
local BTXA, described below in detail.
∗ Corresponding authors. Tel.: +86 021 81885962; fax: +86 021 63520020.
E-mail addresses: linshunzhang@163.com (S.-Z. Lin), zhaoshw1@yahoo.com.cn
(S.-W. Zhao).
A piece of gelfoam (2 mm × 2 mm × 1 mm) soaked with BTXA
(25 U/ml, Lanzhou Institute of Biological Products; Lanzhou, China)
was placed through the perforation of tympanic membrane into
tympanic cavity, as close to the tendon of stapedius as possible.
Tinnitus disappeared on the second day after the treatment. The
monthly follow-up consisted of general ear exam, audiogram and
middle ear exam under an endotoscope. The patient was free from
tinnitus for 3 months. Tinnitus recurred at 4 months. The patient
received Botox treatment identical to the first treatment. Tinnitus
disappeared on the second day of the treatment.
3. Discussion
Myogenic tinnitus of stapedius muscle is commonly treated
with noise masking [1]. However, noise masking is inconvenient,
with uncertain efficacy [2]. Anticonvulsants are also commonly
used to treat this condition, with some success. However, these
medications need to be given on a daily basis. Also, anticon-
vulsants often have serious side effects. Lidocaine is effective in
controlling severe tinnitus [3,4], but must be given intravenously.
Lidocaine could suppress the central nervous system, and also
has significant action on the cardiovascular system (e.g. arrhyth-
mia, hypotension, and even cardiac arrest). Myotenotomy of the
stapedius muscle is effective, but invariably leads to hyperacu-
sis [5], even phonophobia which can have a devastating affect
on both his/her personal and professional life. Botulinum toxin A
blocks acetylcholine release at the neuromuscular junction, and
thus causes muscle paralysis [6]. Botox has been used widely in
cosmetic surgery [7]. Due to the presence of tympanic perforation
in this case, we decided to use local Botox to treat tinnitus caused
by stapedius myoclonus. The treatment was a complete success:
the patient was free from tinnitus from the second day after the
0303-8467/$ – see front matter. Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.clineuro.2010.07.022

2. 58 H.-B. Liu et al. / Clinical Neurology and Neurosurgery 113 (2011) 57–58
treatment until 4 months later. Repeated treatment at 4 months
obliterated tinnitus.
We speculate that local Botox treatment can be used to man-
age tinnitus caused by myoclonus of other muscles, such as tensor
tympani muscles. In this particular case, the perforation of the tym-
panic membrane allowed for direct application of Botox to the site
of myoclonus. Delivering Botox to the site of action represents a
challenge in patients with intact tympanic membrane, but could
be achieved with microinjection.
Conflict of interest
None.
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