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Arq Neuropsiquiatr 2011;69(2-B):395-400

Musical hallucination associated

with hearing loss
Tanit Ganz Sanchez1, Savya Cybelle Milhomem Rocha2,
Keila Alessandra Baraldi Knobel3, Mrcia Akemi Kii4,
Rosa Maria Rodrigues dos Santos5, Cristiana Borges Pereira6
ABSTRACT
In spite of the fact that musical hallucination have a significant impact on patients
lives, they have received very little attention of experts. Some researchers agree on
a combination of peripheral and central dysfunctions as the mechanism that causes
hallucination. The most accepted physiopathology of musical hallucination associated
to hearing loss (caused by cochlear lesion, cochlear nerve lesion or by interruption
of mesencephalon or pontine auditory information) is the disinhibition of auditory
memory circuits due to sensory deprivation. Concerning the cortical area involved in
musical hallucination, there is evidence that the excitatory mechanism of the superior
temporal gyrus, as in epilepsies, is responsible for musical hallucination. In musical
release hallucination there is also activation of the auditory association cortex. Finally,
considering the laterality, functional studies with musical perception and imagery in normal
individuals showed that songs with words cause bilateral temporal activation and melodies
activate only the right lobe. The effect of hearing aids on the improvement of musical
hallucination as a result of the hearing loss improvement is well documented. It happens
because auditory hallucination may be influenced by the external acoustical environment.
Neuroleptics, antidepressants and anticonvulsants have been used in the treatment of
musical hallucination. Cases of improvement with the administration of carbamazepine,
meclobemide and donepezil were reported, but the results obtained were not consistent.
Key words: musical hallucination, auditory hallucination, hearning loss, deafness.
Alucinaes musicais associadas a perda auditiva

Correspondence
Tanit Ganz Sanchez
Av. Padre Pereira de Andrade 353
05469-000 So Paulo SP - Brasil
E-mail: tanitsanchez@gmail.com
Support
Study perfomed as a collaboration
between the Tinnitus Research
Group of Otolaryngology Discipline
and the Neurology Discipline of So
Paulo University Medical School
Received 1 July 2010
Received in final form 29 November 2010
Accepted 6 December 2010

RESUMO
Apesar das alucinaes musicais causarem grandes repercusses na vida dos pacientes,
sempre foram pouco valorizadas e estudadas pelos profissionais. Alguns investigadores
sugerem uma combinao de disfunes perifricas e centrais como o mecanismo
causador das alucinaes. A fisiopatologia mais aceita entre os pesquisadores de
alucinao musical associada hipoacusia ou anacusia (causada por leso coclear, de
nervo coclear ou interrupo de informao na ponte ou mesencfalo) a desibinio de
circuitos de memria auditiva devido deprivao sensorial. Em relao s reas corticais
envolvidas na alucinao musical, h evidncia de que um mecanismo excitatrio no
crtex temporal superior, como nas epilepsias, seja responsvel pela alucinao musical.
Finalmente, considerando a lateralidade, estudos funcionais de percepo e imagtica
em indivduos normais mostraram que canes com letras levam a ativao temporal
bilateral e melodias ativam apenas o lobo temporal direito. bem documentado o efeito
de aparelhos auditivos na alucinao musical atravs de uma melhora da perda auditiva.
1

MD, PhD, Associate Professor and Head of Tinnitus Research Group of Otolaryngology Discipline of So Paulo University
Medical School, So Paulo SP, Brazil; 2Post graduation student of Otolaryngology Discipline of So Paulo University Medical
School, So Paulo SP, Brazil; 3Audiologist, PhD, post-Doctoral Fellow at Faculdade de Cincias Mdicas da Universidade de
Campinas, Campinas SP, Brazil; 4MD, PhD, Member of Tinnitus Research Group of Otolaryngology Discipline of So Paulo
University Medical School, So Paulo SP, Brazil; 5Psychologist, Post-Graduated by the Otolaryngology Discipline of So Paulo
University Medical School, So Paulo SP, Brazil; 6MD, PhD, Neurology Discipline of So Paulo University Medical School,
So Paulo SP, Brazil.
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Arq Neuropsiquiatr 2011;69(2-B)

Neurolpticos, antidepressivos e anticonvulsivantes tm sido usados no tratamento de

alucinao musical na experincia clnica, mas no h eficcia comprovada na maioria dos
casos. H casos descritos na literatura com melhora das alucinaes musicais com uso
de carbamazepina, meclobemide e donepezil, entretanto sem resultados consistentes.
Palavras-chave: alucinaes musicais, alucinaes auditivas, perda auditiva, surdez.

Any type of auditory perception in the absence of a

corresponding external acoustic stimulus can be called
an auditory hallucination1-3. Although the same definition applies to tinnitus4, the two symptoms have different causes and contents and should therefore be distinguished from one another even if they occur in the
same patient3, Since 65 to 80% of the patients suffering
from tinnitus report alteration in the intensity or frequency during contraction of head and neck muscles5,6,
this somatic stimulation can be useful in establishing the
distinction between both symptoms3. Moreover, silence
seems to affect tinnitus and auditory hallucination in patients with both symptoms who had undergone complete otological and psychiatric investigations. Whereas
those patients were more aware of tinnitus in quiet environments, auditory hallucination remained the same1.
A dimensional classification model suggests the existence of a continuum between mental disorders and
normal personality, where disorders are the complete opposite of normality1. Thus, some hallucinations might
occur in the normal population, as shown in several
studies1,7-11.
Auditory hallucination has already been described
in various emotional and organic disorders, including
psichiatric disorders12, degenerative neurological diseases, depression13, stroke14, hearing loss, temporal epilepsy15, drug16 or radiotherapy17 side effects and in healthy
individuals during hypnosis18.
Auditory hallucination has recently attracted the attention of experts that treat patients with tinnitus, since
musical hallucination has been reported in old patients
with hearing loss. These patients hear musical tones
and melodies in the absence of the corresponding external acoustic stimulus 13. Although these symptoms
may significantly impair the quality of life for sufferers,
few studies have been conducted on the subject and few
health professionals are prepared to treat such cases19.
Bibliographic review of musical hallucinosis in non-psychiatric patients has mostly identified case reports and
few articles based on significant cases. Berrios et al. have
studied 46 cases, associated or not to auditory loss20 and
although their research should not be regarded with absolute certainty, it must be stressed that this is probably
the largest survey sample used in the assessment of musical hallucinosis ever reported.
The aims of the present article are: [1] To review the
396

current science literature concerning auditory hallucinosis, with emphasis on musical hallucinosis; [2] To
connect this symptom to the presence of tinnitus and
hearing loss; [3] To discuss the current treatment options.
Literature review
Definition and nomenclature There is some concern about the most appropriate nomenclature for each
hallucinatory experience. Hallucination and hallucinosis
are the terms most frequently used, but they may have
different meanings. The nomenclature and definition according to DSM-IV are as follow21:
a) Hallucination is a distortion of sensory perception
with the same qualities of a real perception, but without
external stimulation of a sensory organ. It can be visual,
auditory, olfactory, gustative or tactile.
b) Hallucinosis refers to the perception by the patient
of the hallucination as a pathological event.
Although most of the patients with musical hallucination are aware of the pahtological aspect of what they
hear, most papers use the term hallucination, instead of
hallucinosis. A recent review suggests that the term hallucinosis may be used only when auditory hallucinations
are attributable to lesions within the pedunculus cerebri
(and/ or midbrain, pons, or diencephalon), which should
be referred as brainstem auditory hallucinosis22.
Musical hallucination is a specific type of complex
auditory hallucination where the patient hears continuous or intermittent musical tones and melodies in
the absence of corresponding external acoustic stimulus. When associated to hearing loss, it usually consists of melodies learned by the patient in a period when
his/her hearing was normal (ex.: religious chants, childrens songs, etc)13. Most of the times the patient is totally aware of this phenomenon, and he/she is able to
recognize this experience as something strange and uncommon. In eldery, musical hallucination may evolve
into voice hallucination19. In some cases, patients hear
both, melodies and voices11,23,24.
Prevalence Musical hallucination is a very heterogeneous and may be a rare phenomenon in general hospital setting16, but not so uncommon in psychiatric practice2,25. Its prevalence was 0.16% among 3,678 psychiatric
patients of two general hospitals16. However, among 190
psychiatric outpatients this prevalence increased up to
20%, probably due to the occurrence of obsessive-com-

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pulsive disorders, since 30% of obsessive-compulsive patients have musical hallucinosis26. In elderly people with
hearing impairment, Cole et al. reported a prevalence
of 2.5%27.
Fischer et al. reported that hearing loss, brain disease, advanced age, and social isolation seem to play a
major role in the etiology of musical hallucination although the importance of each factor remains unclear19.
Women may also be more affected by musical hallucination19. However, before such consensus was reached,
this was considered to be a sample bias due to the fact
that women are more likely than men to seek medical
assistance, have a greater life expectancy. Besides, there
is no evidence that epilepsy, deafness, tinnitus or brain
tumor, which are all associated to musical hallucination,
are more common in women20.
Pathophysiology Despite the fact that musical hallucination is more common in older patients, there are
reports of this condition in young patients12,28, which can
lead us to assume that musical hallucination may not
be related to age, but to sensory deprivation. Some researchers suggest a combination of peripheral and central dysfunctions as a possible mechanism that causes
hallucination29.
Johns et al. reported a greater occurrence of musical
hallucination in patients with tinnitus than in schizophrenic patients, who usually have voice hallucinations1. On the other hand, cases of auditory hallucination
without hearing impairment show that otological alterations are not a necessary condition. Evers and Ellger
analysed pathological mechanisms, clinical and demographic characteristics of 132 cases of musical hallucination published in the literature between 1990 and 2003.
They classified the cases into five groups: hypoacusia,
psychiatric disorder, focal brain lesion, epilepsy and intoxication2.
In epileptic subjects the mechanism of musical hallucination caused by excitation is suggested. Penfield and
Jasper reported a case of a 16 year-old girl with headache
and epilepsy who reported listening to music during surgery with local anesthesia, when stimulated in the posterior region of the right superior temporal cortex30.
Recently, Kasai et al. described a woman with normal
audiometry and normal braim magnetic resonance imaging that suddenly had musical hallucination in the
form of familiar melodies. Records of magnetoencephalography and SPECT in the presence and absence of musical hallucination in this woman showed functional alterations compatible with excitation of specific areas of
the right auditory association cortex, as well as increase
of blood flow in the right superior temporal gyrus and
right inferior frontal gyrus during musical hallucination.
They concluded that the activation of these cortical areas

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Sanchez et al.

were the cause and the effect of musical hallucination

and that the right auditory association cortex was a possible origin of such hallucinations31.
Considering hearing loss (caused by cochlear lesion,
cochlear nerve lesion or by interruption of mesencephalon or pontine auditory information), the most accepted
physiopathology of musical hallucinosis is the disinhibition of auditory memory circuits due to sensory deprivation. Hearing loss seems to be an important factor
that predisposes to musical hallucination32, once this
condition occurs after several years of hypoacusis or anacusis33,34. Sensory deprivation seems to be the most consistent finding associated to unilateral auditory hallucination, which is usually ipsilateral to the otological lesion35
and suggests that in theses cases the etiology is organic36.
In patients with hypoacusia and musical hallucination, the sensory deprivation is responsible for the occurrence of hallucination, similar to visual hallucinations
that occur with visual deprivation37. In agreement to this
Cogans theory37, Hammeke et al.34 described the cases
of two patients who were affected by musical hallucination (childhood songs) after several years of progressive
deafness. They assumed that sensory deprivation was the
same primary neurophysiological mechanism for musical hallucination.
Other authors29,38 affirmed that the intensity of musical hallucination is higher when environmental noise
is softened. It also corroborates the hypothesis that the
mechanism of hallucination could be related to the reduction of auditory input. According to them, traces of
auditory memory could be released and reach consciousness in silent environments.
Considering the possible physiopathological role of
brainstem lesions on auditory hallucination, Cascino
and Adams reported on two patients with pontine tegmentum hemorrhage and another one with tumor of
mesencephalon. The three patients also had hypoacusia,
alteration in speech discrimination and hallucinations
related to piano, bell and machine sounds a few days
after the acute stage39. They suggested that hearing impairment resulted from lesions of the pontine auditory
system and mesencephalon, and that hallucinations
might have been caused by sensory deprivation. It was
assumed that the olivary-cochlear tract to the ciliated
cells has an inhibitory action and that probably some of
the descending pahtways from the cortex to the medial
geniculate body and futher to the inferior collicular have
also an inhibitory action. According to the authors, these
cases indicated that pure pontine lesions could change
the central auditory system and cause hallucinations in
patients who have an intact cochlea and auditory nerves.
In agreement with this theory, Murata et al. reported a
case of a patient suffering from long-term hearing loss
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in the left ear caused by a sequela of otitis media and a

hearing loss in the right ear as a consequence of a pontine hemorrhage. After the stroke, the patient had musical hallucination, but it disappeared after recovery of
hearing in the right ear. The authors pointed out that the
hemorrhagic lesion had probably impaired the auditory
pathways in the coclear nucleus and cochlear nerve on
the right side. They suggested that the association of musical hallucination and deafness caused by brainstream
lesion may result from distortions in the normal processing of sensory information, thus causing abnormal
perceptions40.
Further, Schielke et al. described a patient with pontine dorsal lesion and hearing loss who had musical hallucination. The authors reviewed the literature data
about 10 patients withbrainstem lesion and musical hallucination and noticed that in most of these patients the
symptom had occurred 1 to 14 days later the onset of an
unilateral or bilateral sudden hearing loss. Except for one
patient, all the others had lesion of the lateral or paramedian portion of the pontine tegment, with possible impairment of the intermediate and dorsal acoustic stria,
the trapezoid body, the superior olivary nucleus and the
lateral lemniscus, and that a relationship between peripheral lesions and musical hallucination was unlikely
in such cases. They also inferred that a possible lesion in
the pontine reticular formation could reduce the inhibition to the thalamus and cortex and thus, pontine inhibitory pathways could be related to musical hallucination41.
Cortical lesions have also been described in patientes
with musical hallucination. Cerrato et al. described one
case of musical hallucination related to a lesion of temporal lobe in a 35-year-old professional musician who experienced a short episode (90 minutes) of musical hallucination. The patient had a moderate motor dysfunction
in his right hand, but did not have hearing loss, psychiatric diseases, nor used alcohol or drugs. Seven days later,
the patient had undergone complete investigation. The
computed tomography showed a small hyperattenuating
subcortical lesion in the left temporal lobe, the brain
magnetic resonance imaging showed a hemorrhagic lesion of the putamen and on the left external capsule, next
to the insula and to the acoustic radiation. Mildly abnormal slow activity in the temporal region, without epileptiform waves was found on electroencephalograms.
Cerebral angiography, audiometry and evoked auditory
potentials were normal. The lesions encountered were attributed to a cavernous angioma. The auditory hallucination was characterized by a symphonic melody very similar to the one the patient had been listening a few hours
before the occurrence of the symptom, which reinforces
the hypothesis that the neural circuits related to auditory memory are closely involved with the mechanisms
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that generate auditory hallucination14. The authors emphasize that the lesion that caused musical hallucination
in this case was on the left hemesphere. and speculated
that the musical training might have deviated the musical representation from the non-dominant hemisphere
to the dominant hemisphere. Usualy brain lesions such
as tumors, stroke or epileptic focus are usualy found in
the right or non-dominant brain hemisphere of individuals with musical hallucination. This may suggest a dissociation from schizophrenia, since auditory hallucination
in schizophrenic patients is related to left or dominant
hemisphere lesions20.
Other mechanisms were also reported. Wodarz et al.
described a patient with musical hallucination and calcifications of basal ganglions, who also suffered from hypoparathyroidism and metabolic alterations. The correction of these conditions coincided with the decrease of
the hallucinations42. Gordon and Gilbert argued that otological diseases facilitate the occurrence of musical hallucination induced by drugs43 and Gilbert described a
deaf patient with musical hallucination induced by pentoxifillin who managed to voluntarily modify the hallucination by concentrating on a favorite melody that was
not the one she has been listening44. Other authors also
described some patients who were able to replace the
ongoing musical hallucination with another melody by
means of concentration or subvocalization32-34. Ross et
al. suggested that the cause of the auditory hallucination
is not necessarily related to the auditory pathways33, and
this poit of view was shared by Miller and Crosby, that
described a case of a patient who could change the hallucination melody by means of visual stimuli (turning the
pages of a books)32.
Functional imaging in musical hallucination
A group of authors evaluated three patterns related to
musical perception and imagery: songs (with words),
melodies and timbre45-47. The authors noticed that both
processes of musical perception and imagery occurred
in similar cortical areas. Musical perception activated
the primary auditory cortex and the auditory association cortex, whereas musical imagery activated the auditory association cortex in the superior temporal gyrus
without activating the primary auditory cortex45. When
songs and timbre were evaluated there was bilateral temporal activation45,47, whereas in melody evaluation only
the right lobe was activated. The authors reported also
that the imagery of songs45 and melodies46, but not that
of timbre47, activated frontal lobes. These activation was
in both frontal lobes for songs45 and only in the right lobe
for melodies46. Comparable data were obtained from the
evaluation of verbal and musical auditory hallucination
and imagery, with activation of the secondary (but not
primary) auditory cortex48-52.

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Nevertheless, hallucination differ from imagery, since

this one is intentionally generated by the individual,
whereas the hallucination is usually not under the patient control and may result from a failure in metacognitive abilities involved in the distinction between external
and internal sources of information53.
Griffiths proposed a model to explain musical
hallucination in six subjects with acquired bilateral
neurosensory auditory loss without signs of psychosis
or epilepsy11. The model suggested three hierarchically
organized modules of temporal patterns perception:
the first would be responsible for the perception of
isolated sounds; the second one for the perception and
imagery of the temporal pattern formed by combined
sounds, and the third one for the codification, recognition and memory. According to this model, deaf patients loose acoustic afference for the first module, with
consequent reduction of afference for the second
module. This would provoke spontaneous activity in the
second module of perception and imagery with consequent increase of activity in the third module of recognition and memory. The model also suggests reciprocal
interaction of the module of recognition and memory
with the module of perception and imagery, which would
increase in case of deafness. Imaging examinations did
not show activation of the primary auditory cortex, but
showed activation of the superior temporal gyrus11. These
findings corroborate the proposed model, because the
areas activated during the worsening of musical hallucination correspond to the areas activated during musical imagery in subjects who do not suffer from auditory hallucination.
In conclusion, concerning the cortical area involved
in musical hallucinosis, there is evidence that the excitatory mechanism of the superior temporal gyrus, as in
epilepsies, is responsible for musical hallucinosis. From
a functional point of view, this region is also activated
in musical perception and imagery, as shown in PET
studies. In musical release hallucinosis there is also activation of the auditory association cortex. Finally, considering the laterality, functional studies with musical perception and imagery in normal individuals showed that
songs with words cause bilateral temporal activation and
melodies activate only the right lobe.
Treatment
Some authors point out that the hearing aid can improve or even eliminate musical hallucination32-34. This
improvement happens because auditory hallucination
may be influenced by the external acoustical environment. In other words, the symptom is usually worse in
quiet moments and better in the presence of environmental sounds.

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Sanchez et al.

Hammeke et al. report the use of anticonvulsant, antipsychotic and vitamin supplements in patients with
musical hallucination, but all these options showed low
efficacy34. On the other hand, Tanriverdi et al. described
a patient with depression associated to musical hallucination who significantly improved with the use of meclobemide and recommended the use of antidepressants
in association with low doses of anticholinergics for this
patient subgroup12.
Gertz et al.54 and Terao and Tani55 described elderly
patients with hearing loss who benefited from the use of
carbamazepine and had reduction or elimination of musical hallucination.
Ukai et al. reported a case of patient with musical
hallucination that had improvement of musical hallucination with the administration of donepezil56. This drug
is usually prescribed to patients suffering from CharlesBonnet syndrome. As an anticholinesterasic, donepezil
acts in cholinergic neurons which, in turn, may show
age-related dysfunctions. Since the medication may improve musical hallucination, the authors suggested that
age-related dysfunction of cholinergic neurons may be
related to the released phenomenon.
Recently, Garca-Toro et al. reported clinical benefit
of transcranial magnetic stimulation (rTMS) for patients
with auditory hallucinations and tinnitus57 and Cosentino et al. reported one case of post-traumatic complex
auditory hallucination treated with rTMS58.
Conclusion
In spite of the fact that musical hallucinosis have a
significant impact on patients lives, they have received
very little attention of experts. Thus, it is important to
perform otological evaluation of these patients, besides
the neurological and psychiatric assessments.
The Tinnitus Research Group of the Otolaryngology
Discipline of the So Paulo University Meedical School
has recently identified some non-psychiatric patients
with auditory hallucination, mostly musical hallucination. The prevalence of this auditory hallucinosis among
otological patients has probably been underestimated.
We noticed that many patients were resistent in reporting their symptoms, probably because this symptom
is culturally associated to mental diseases,. Moreover,
otorhinolaryngologists do not usually ask their patients
with hypoacusia about auditory hallucinations.
Some studies reported the possibility of improvement
or even elimination of this auditory hallucination with
the reversion of the hearing loss or with the administration of medication. Thus, we consider that otorhinolaryngologists should play a more decisive role in the investigation and management of these patients, usually with
a well integrated interdisciplinary team.
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1.
2.
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13.

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28.

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