Case study
A 29-year male with multiple sclerosis was booked into an emergency outpatient slot for a relapse assessment to have steroids. A week before, he woke with a ringing sound in his left ear (we refer to this symptom as tinnitus*). Over the next 5-10 minutes, he lost hearing in the left ear and developed severe vertigo and projectile vomiting. The vertigo was so severe he was unable to walk. He contacted his GP, who asked him to contact the neurology team at our hospital. The neurology trainee who spoke to him over the phone diagnosed an MS relapse, recommended anti-emetics (prochlorperazine), and contacted the MS clinical nurse specialist to arrange a relapse assessment visit.
He was diagnosed with MS three years ago after presenting with optic neuritis and a prior history of Bell’s palsy. He was started on dimethyl fumarate and had done well with NEIDA (no evident inflammatory disease activity).
* Tinnitus is a ringing or buzzing in the ear or ears unrelated to outside noise.
Prof G’s assessment
When I saw this patient in my clinic several days after the acute crisis, his symptoms had improved. He still had a severe ringing sound in his ear and moderate deafness in that ear. His vertigo was much better and only precipitated by head movement. He was unsteady on his feet, i.e. he had ataxia. When I examined his eye movements, he had torsional nystagmus with the slow phase to the left, indicating left inner ear problems. On direct questioning, he recalled a sensation of fullness in his left ear when his symptoms started.
Don’t always blame multiple sclerosis
It was clear that this patient did not have a brainstem MS relapse but had likely developed a new disease. I diagnosed him with probable Ménière's disease and referred him to the ENT (ear, nose, and throat) clinic for further work-up and treatment.
As expected, the MRI our trainee had booked showed no new brainstem lesion, which strongly supports my clinical judgement that this was not an MS relapse. Please note you do need to have a new lesion on MRI to have a relapse. The resolution of an MRI scan is not sensitive enough to detect MS lesions smaller than 3-4mm in size; hence, a small lesion in a critical site could cause an MS relapse and not be seen on MRI. In my experience, about a quarter of clinical relapses are not associated with lesions in the pathway to which you have localised the relapse. For more information on this topic, please read ‘Case study: am I having a relapse?’ (5-Jan-2022).
I now have three patients who have both MS and Ménière's disease. So yes, people with MS do get other diseases with neurological symptoms, and it is therefore important for HCPs (Healthcare professionals) not to assume that because someone has MS that any new neurological symptom or problem is due to their MS.
What is Ménière's disease?
Ménière's disease is an ear condition that can cause sudden attacks of vertigo, loss of balance, nausea ad vomiting, hearing loss and tinnitus. In the acute phase, patients often feel fullness in that ear. Ménière's disease is caused by increased fluid pressure in the inner ear. If the membrane holding this fluid ruptures and the two fluids in the inner ear mix, it stimulates the hair cells in the inner ear, which brings on the symptoms. Meniere’s is associated with recurrent attacks, which can cause the inner ear to lose function over time. Like MS relapse, the diagnosis of Meniere’s disease is clinical.
The treatment of Ménière’s is symptomatic to reduce and control symptoms. In general, non-surgical measures are sufficient to control the symptoms of Ménière’s. However, if vertigo remains a problem, surgical procedures can help and recently, the injection of long-acting steroids into the inner ear has been shown to reduce attacks.
Can multiple sclerosis cause tinnitus?
Yes, MS is a cause of tinnitus, but it is not discussed very often. The case above is one of a cluster of patients I have seen in the last 12 months with MS and tinnitus, which led me to look into the MS literature. I first went to the MS Bible, i.e. McAlpine’s Multiple Sclerosis (4th Edition), and there is no mention of tinnitus in the index. I then did an online search and found a small number of papers documenting that tinnitus does occur in pwMS, but I could not find out how common it is in pwMS and the clinical context it occurs in. Does tinnitus occur as part of an MS relapse, in progressive disease, as a complication of medications or due to another disease, such as Ménière’s?
This is why I am calling on you to help one of our MS Fellows complete a clinical audit on MS and tinnitus. We want to ascertain how common tinnitus is in people with MS, its clinical context, when it occurs, how severe it is and whether it is diagnosed and treated. I suspect that being a hidden symptom is often missed in routine clinical practice. We will use the results of this survey to assess the unmet need for treatment of tinnitus in pwMS and whether or not we need to do something to diagnose and treat tinnitus in our clinic. If you are willing to help, we would appreciate it if you could complete the following anonymous online survey, which will take about 5 minutes.
Click here to complete the survey, or paste the following link into your browser https://forms.gle/vu2TPf3Ud6xLf9sr7.
Please feel free to ask questions on this case study, and if you have tinnitus, let us know how it was treated and if it worked.
Thank you.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
Tinnitus: don't always blame MS