Silencing middle ear myoclonus (Part one)

Written by: Professor Manohar Bance
Published: | Updated: 26/10/2021
Edited by: Karolyn Judge

The inner-ear noises that people with middle ear myoclonus (MEM) experience can be so severe that they’re unable to sleep. Learning to live with the symptoms may not be practical for those with such debilitating effects, so what can be done to solve the problem?


In the first part of a double series of articles, one of the UK’s leading otologists, Professor Manohar Bance, provides a comprehensive answer to this question. He discusses the ins and outs of middle ear myoclonus in expert detail.


In part two, you can find out more about diagnosis, treatment and management of middle ear myoclonus.


Lady with calm expression having an ear exam


What is middle ear myoclonus?

MEM is the involuntary contraction of the muscles in the middle ear, specifically the tensor tympani, and the stapedius muscles. It is not really clear what these muscles do normally. The stapedius contracts in response to loud sound, and possibly might be useful to protect the inner ear from noise, but it is controversial how effective this is.


The tensor tympani doesn’t contract in response to noise, normally, and it is unclear what, if any, role it has in humans. It might be left over from different use in other species, but has evolved, like the appendix, to have little role in humans. 



What are the signs of middle ear myoclonus? 

Signs can be crackling, clicking or thumping noises in the ear, as well as fluttering in the ear. These may be severe enough to prevent sleep, and are often triggered by sound, and sometimes by scratching of the face. The thumps are usually irregular, and not in time with the heartbeat. The fluttering might be more associated with the stapedius muscle, and can often be felt as much as heard.



Is it a symptom associated with other conditions?  

It has to be distinguished from other conditions such as palatal myoclonus or typewriter tinnitus, as well as eustachian tube disorders.


Palatal myoclonus is a neurological condition that can cause a clicking sound in the ears, and is often present all the time, instead of coming and going. It is caused by the muscles in the palate (soft part at the back of the throat when you open your mouth) contracting rhythmically, which opens and closes the eustachian tube. This is what is heard. It is not helped by cutting the tensor tympani tendon, but is treated with Botox© injections into the palate.


The eustachian tube connects the back of the nose to the middle ear, and usually only opens when you swallow, to let air into the middle ear. The muscles that open the eustachian tube (the tensor veli palatini) is connected to the tensor tympani muscle in the middle ear, and they are both innervated by the trigeminal nerve, so it is quite possible that sometimes there may be contractions of both the palate muscles and the tensor tympani at the same time. In these cases, it can be unclear if cutting the tensor tympani will get rid of clicking sounds in the ear.


Typewriter tinnitus is thought to arise from the hearing nerve, and sounds like someone typing on an old-fashioned typewriter. Again, it is not helped by cutting the tensor tympani.


Other kinds of middle-ear muscle problems can be forced eye closure induced, when someone closes their eyes tightly, they may hear a click. This is likely from middle ear muscles.


Some people also think there may be a condition called ‘Tensor Tympani Syndrome’, in which the tensor tympani muscle is clenched all the time. Symptoms such as buzzing noises, pressure in the ear and muffling of sound have all be ascribed to this. It is very difficult to prove, as we can measure and hear contractions of the middle ear muscles when it is contracting and relaxing, but if a muscle is continuously contracted, there is nothing to hear or measure. 



References to Professor Bance’s work here:

1: Wickens B, Floyd D, Bance M. Audiometric findings with voluntary tensor tympani contraction. J Otolaryngol Head Neck Surg. 2017 Jan 5;46(1):2. doi: 10.1186/s40463-016-0182-y. PMID: 28057076; PMCID: PMC5217611.

2: Aron M, Floyd D, Bance M. Voluntary eardrum movement: a marker for tensor tympani contraction? Otol Neurotol. 2015 Feb;36(2):373-81. doi: 10.1097/MAO.0000000000000382. PMID: 24751734.

3: Bance M, Makki FM, Garland P, Alian WA, van Wijhe RG, Savage J. Effects of tensor tympani muscle contraction on the middle ear and markers of a contracted muscle. Laryngoscope. 2013 Apr;123(4):1021-7. doi: 10.1002/lary.23711. Epub 2012 Nov 20. PMID: 23169583. –++



Finding life with middle ear myoclonus difficult? Visit Professor Bance’s Top Doctors profile, at your convenience, to arrange an appointment with this leading specialist. 

By Professor Manohar Bance
Otolaryngology / ENT

Professor Manohar Bance is one of the UK’s leading otologists. Practising in Cambridge at Spire Cambridge Lea Hospital, he has been a subspecialist in diseases and surgery of the ear for 23 years, during which time he has performed thousands of major ear surgeries.
Professor Bance’s practice covers the management of all diseases of the ear including otosclerosischronic ear diseaseeardrum perforationgenetic hearing losscholesteatomatumours of the middle and inner ear. He also treats vertigo caused by a number of different diseases of the ear, such as Meniere´s disease, vestibular migraine and BPPV.
Professor Bance also specialises in Eustachian tube disorders such as balloon dilatation of the Eustachian tube, and patulous Eustachian tube. He has run a Eustachian tube disorders clinic for 12 years. Professor Bance is an expert in the selection and the fitting of cochlear implants, and collaborates closely with engineers to produce the next generation of machine-neural interfaces.
Professor Bance originally qualified from the University of Manchester before pursuing training in Canada. His residency was at the University of Toronto, and he practised as a consultant there for six years. He also received his MSc in Neurophysiology from the University of Toronto.  He then moved on to Dalhousie University, where he became Professor and Head of the Division of Otolaryngology-Head and Neck Surgery at Dalhousie University in Canada, and Director of the EAR Lab.
After a 21-year career at Dalhousie, Professor Bance moved back to the UK where he became the inaugural Professor of Otology and Skull Base Surgery at the University of Cambridge and was Fellowship trained in Otology and Neurotology. He has over 220 peer reviewed publications and 9 book chapters as well as being a co-editor of two books. Much of Professor Bance´s research has been on middle ear surgery, as well as how to optimize hearing results. His current research is on the optimization of cochlear implant and middle ear implant hearing results.  
Professor Bance is a board member of the Politzer Society, a member of the American Otology Society, the American Neurotology Society, the Triological Society and the Collegium Otorhinolaryngologica Amicitiae Sacrum. He is also president of the RSM Otology section and chair of the British Cochlear Group. Professor Bance is also a council member of the British Society of Otology and is Academic lead in Otology and Neurotology at Cambridge University Hospitals Trust. He has been invited to speak at hundreds of meetings worldwide.

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