Phantom Concerts: Decoding Musical Ear Syndrome in Older Adults

A 93-year-old woman presented at Cleveland Clinic with acute auditory hallucinations. She reported hearing dogs howling and a men’s choir singing in a cathedral, but no neurological symptoms were found. Her medical history included hearing loss, paroxysmal atrial fibrillation, hypothyroidism, depression and stroke.

A workup revealed a urinary tract infection (UTI); other lab tests, EEG, brain MRI and neurological examinations were unremarkable. Although her hallucinations improved in the weeks following treatment of her UTI, they persisted episodically and seemed to worsen when the patient wasn’t wearing her hearing aids.

Given the benign neurological findings; symptoms linked to the absence of hearing aids; and absence of prior hallucinations, cognitive and neuropsychiatric disorders, a diagnosis of exclusion for musical ear syndrome (MES) was made.

Signs and symptoms

MES is a rare and perplexing nonpsychiatric phenomenon in which patients perceive auditory hallucinations (typically musical in nature) without external stimuli. The disorder has been compared to Charles Bonnet syndrome, which can cause visual hallucinations in those who are visually impaired.

In many cases, the cause of MES is never found, but the condition is most common in patients with hearing impairment; other risk factors include advanced age, brain lesions, atrophy and neuropsychiatric disorders.

“Unfortunately, MES is frequently mistaken for dementia in older adults, but it’s important to differentiate the disorder from those that impair cognitive functioning and lead to psychosis,” explains Cleveland Clinic geriatrician Ronan Factora, MD. “Although auditory hallucinations may spark delusional beliefs, patients with MES will maintain some degree of insight about their symptoms.”

Mechanism of action

MES is believed to result from hypersensitivity in the auditory cortex associated with sensory deprivation, Dr. Factora says. Damage to cilia in the cochlea/inner ear can reduce input, causing the brain to generate phantom sounds to fill the void with previous auditory memories.

Previous case studies involving fMRI have shown evidence of hyperactivity in the auditory, memory and emotion-processing regions of the brain in patients with MES. Cortical thinning in the left medial orbito-frontal cortex and right temporal gyrus indicates neural reorganization in response to cortical reduction. Increased activation in the brain’s emotional regions may indicate distress linked to the symptoms of MES.

Managing the disorder

Although the syndrome is not life-threatening, persistent hallucinations may be disturbing and can substantially affect patients’ quality of life. Because the symptoms can last for minutes, hours or even longer, MES can be an intrusive, distressing experience that warrants clinical sensitivity, Dr. Factora says.

“Patients and their caregivers should be educated about the diagnosis and reassured that the symptoms are not a sign of mental illness,” he explains. “Fearing judgment, patients are often reluctant to discuss their hallucinations, which can delay treatment and lead to feelings of isolation.”

Dr. Factora urges clinicians to consider MES in older patients presenting with complex auditory hallucinations without evidence of cognitive or neuropsychiatric impairment.

While no curative treatment for the disorder exists, addressing underlying hearing loss can help alleviate symptoms, Dr. Factora notes. In addition, cognitive behavioral therapy can help patients accept the hallucinations, build coping strategies and avoid potential lifestyle triggers like stress and poor sleep.