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Home , Audiology, Eardrum, Ear canal, Eustachian tube, Middle ear, Stapedius muscle

FEATURE

Middle muscle disorders: presentation, diagnosis and management

BY MANOHAR BANCE

Patients often report symptoms relating to disorders of the muscles. Prof Bance gives us an overview of the and function, as well as guides our diagnosis and management.

he middle ear muscles (MEMs) are a noise rhythm with their finger while taking muscles regrowing to the stapedius, causing mystery, both in their physiological the patient’s pulse. Other rarer causes of stapedial contractions either heard as clicks function in man, and particularly noises in the ear are foreign bodies, such as or as distortion with blinking or Tin their pathophysiological hair on the , or even insects moving facial movements [4]. This can also occur contributions to symptoms when they in the , assessed by otoscopy. with hemifacial spasm. In addition, forced malfunction. While the stapedius contracts Crackles/noises/clicks can arise from eye closure can cause TT contraction and in response to sound (e.g. audiometric many areas of the body. One area is the sounds in the ear [5]. Many subjects can also stapedial reflexes), it responds rather slowly , and it is not uncommon voluntarily contract their middle muscles, for impulse noise, and has been also shown for patients to have crackling with particularly the TT by pharyngeal muscle to respond to vocalisation [1].The stapedius . This may be normal, or arise contractions, although they may not realise muscle is supplied by the facial . because of enlarged abutting the this is what they are doing [3]. The tensor tympani (TT) is supplied by the nasopharyngeal opening and hitting the ET More commonly, people have idiopathic Vth nerve, as part of a system which also cushions, or from the mucous membranes/ contractions of the middle ear muscles. innervates the tensor veli palatini (TVP) and mucous film of the ET coming apart and These can be of several types, but the palatal muscles that open the eustachian back together during the swallowing- most common is a paroxysmal ‘fluttering’ tube. Indeed, the TT is physically connected induced opening of the ET. These kinds of sound in the ear, like a butterfly flapping to the TVP muscle, and it can be difficult sounds can be very bothersome to some its wings. There is no concrete evidence to separate if the originating pathology is patients, and may respond to grommets, for this, but this is often thought to be in the TVP or the TT. The TT does not seem which can be tested with a . At from the . Other types to respond to sound in man, but has been other times, there may be rhythmic clicking are more irregular clicks and sounds. reported to respond to face stroking, puffs sounds arising from the contractions of If fiberoptic nasopharyngoscopy is of air against the eyes, electrical stimulation the palatine muscles that open and close performed simultaneously, there is often of the and swallowing (reviewed by the ET, from pathologies such as palatal co-contraction of the pharyngeal muscles Bance et al [2]), it can also be voluntarily myclonus or tremor. This is associated with and, if seen, is more likely to indicate TT contracted by some people [3]. semi-rhythmic movements from the palate, contraction. It is not uncommon though for There are two types of symptom and should be investigated with brain both MEM to co-contract, the author has complexes that can arise from middle ear MRI as some are caused by lesions in the seen this with endoscopy, even though they muscle dysfunction; those from dynamic dento-rubro-olivary tract, although most are supplied by different . middle ear dysfunction (i.e. repeated are idiopathic. These can be sometimes In all these types of clicks and crackles, contractions, resulting in clicks or other helped with botox injections. Other causes stethoscope tubing should be placed in the sounds) and tonic contraction, resulting in of clicking are from the TMJ joint, with ear canal, and the sounds listened for, while fixed change in the length of the muscle opening and closing of the mouth, arising the patient taps out the sound they hear to and a sustained pull on the structures it from degeneration of the articular disc, or see if they are synchronous to the objective attaches to. arthritis of the joint. sounds. The patient’s palate can be also be Of true contractions of the MEMs, some Dynamic contractions presenting palpated, while the sounds are tapped out, are caused by synkinetic contractions of to see if there is co-contraction. Attempts as clicks, crackles or noises in the the stapedius muscle following a facial to elicit MEM contractions can be made ear nerve paralysis. In this syndrome, partial by stroking the face, forced eye closure, or These have to be differentiated from degeneration of the results in blowing on closed . pulsatile , which is relatively easily aberrant regrowth of nerve fibres, with some done by asking the patient to beat out the fibres that would have gone to the facial Audiometric diagnosis The main tools are auscultation and long- time base , i.e. measuring the acoustic immittance for many seconds, “Of true contractions of the MEMs, some are caused by often using the reflex decay settings in synkinetic contractions of the stapedius muscle following tympanometers with the sound set to contralateral and very low levels, and the a ” contralateral insert phone not placed.

ent and audiology news | MARCH/APRIL 2019 | VOL 28 NO 1 | www.entandaudiologynews.com AUDIOLOGY FEATURE

(Left) Figure 1. Patterns expected during long time base tympanometry during dynamic contraction of the MEM (after Aron et al [3]). (Above) Figure 2. Expected tympanometric findings with TT contraction. With this setting, changes in the real- such as Meniere’s disease, myofascial possible that some disorders, such as acute time immittance can be seen. It must be TMJ syndromes, and migraine associated attacks of Meniere’s disease, are caused by emphasised that vocalisation can easily . Since then, the TT has been blamed intermittent short-lived contractions of the contaminate these findings, and the for everything from pressure in the ear, TT, but that these are not usually recorded audiologists must ask the patient to quietly tinnitus, distorted sound, and the acute as findings are normal between attacks. raise a finger when the sound is heard, attacks of Meniere ’s disease [2]. We have References and look for simultaneous changes in the also shown that voluntary TT contraction 1. Rainsbury JW, Aron M, Floyd D, Bance M. Vocalization- tracings. In the fluttering type of , can cause a small low frequency conductive induced stapedius contraction. Otol Neurotol sadly the act of putting an in often , with a small drop in the 2015;36(2):382-5. abolishes it (in fact this can be used as a conduction curve as well, probably from 2. Bance M, Makki FM, Garland P, et al. Effects of contraction on the middle ear therapy). the tinnitus heard during contraction and markers of a contracted muscle. Laryngoscope We have shown a method of [7]. Without any objective means of 2013;123(4):1021-7. distinguishing TT from stapedial muscle determining TT tonic contraction, this 3. Aron M, Floyd D, Bance M. Voluntary eardrum movement: a marker for tensor tympani contraction? [3]. Briefly, the immittance change is larger becomes somewhat of a ‘faith-based’ Otol Neurotol 2015;36(2):373-81. for a TT contraction than a stapedial one diagnosis, although it is possible that one 4. Donne AJ, Homer JJ, Woodhead CJ. Oculostapedial and, if repeated with positive pressure in ear might show signs of hypercontraction synkinesis following Bell’s palsy. J Laryngol Otol 2000;114(2):135-6. the ear canal, both responses get smaller when compared to the other side, if the 5. Lee GH, Bae SC, Jin SG, et al. Middle ear myoclonus but stay the same deflection direction tympanic membrane is absolutely without associated with forced closure in children: (i.e. both show a decrease in acoustic any dimeric segments or tympanosclerotic diagnosis and treatment outcome. Laryngoscope 2012;122(9):2071-5. admittance), but if the ear canal pressure is or other segments to explain this. There are 6. Klockhoff I. Impedance fluctuation and a ‘‘tensor made negative, then stapedial contraction no syndromes ascribed to tonic contraction tympani syndrome.’’ In: Proceedings of the 4th still shows a decrease in admittance, but of the stapedius muscle and, in fact, the International Symposium on Acoustic Impedance now TT contraction shows an increase in stapedius does not stay contracted for very Measurements; Lisbon Universidad Nova de Lisboa Ed Penha and Pizarro; September 25-28, 1979:69-76. admittance, as the tympanic membrane long, even in response to intense sounds. 7. Wickens B, Floyd D, Bance M. Audiometric findings with is stretched laterally by the negative ear voluntary tensor tympani contraction. J Otolaryngol canal pressure and TT contraction brings it Audiometric diagnosis Head Neck Surg 2017;46(1):2. back to its more natural resting position [3]. From studies and studies Figure 1 shows this pattern. in humans who can voluntarily contract their TT, we have found that TT contraction Tonic contractions of the MEM would result in a markedly lowered static Whether these tonic contractions exist compliance, and a slight shifting of the AUTHOR at all is controversial. Whereas dynamic tympanotric curve towards a negative contractions can be measured as change pressure peak [2] (see Figure 2). If symptoms from baseline, tonic contractions have are unilateral, and the ear in question has to be inferred, as there is no change to these findings, it might be reasonable to measure. The range of middle ear measured suspect tonic TT contraction in this ear. tympanometric compliances in normal subjects is large, and is dominated by the Conclusion tympanic membrane rather than the middle MEM disorders can be very difficult to ear muscles. Hence it is difficult to say if diagnose. Symptoms overlap with a myriad Professor Manohar Bance, MBChB MSc compliances seen in any one person are due of other causes of similar symptoms. Even FRCS FRCSC ABOto, to hypercontracted MEMs or just part of the when it is clear a MEM disorder is present, normal range. ‘Tensor Tympani Syndrome’ it can be very difficult to ascribe symptoms Professor of and Base Surgery, University of Cambridge; Honorary Consultant, was coined in the 1970s by Klockhoff [6], to one or other of the muscles, and they can Cambridge University Hospitals Trust, UK. to describe fluctuations in middle ear also co-contract. We describe audiometric impedance, associated with aural fullness, and clinical findings based on the author’s dysacusis, tinnitus, headaches and vertigo. experience and research in this area, but Declaration of Competing Interests: None declared. These are non-specific symptoms, and particularly in the case of tonic contractions may be associated with many conditions, of the TT, this remains a mystery. It is also

ent and audiology news | MARCH/APRIL 2019 | VOL 28 NO 1 | www.entandaudiologynews.com