<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p>
<div id="_idContainer000">
<p class="ltrs-br-ltr-br-title"><span class="bold"><a id="_idTextAnchor000"></a>Auditory Hallucinations or Tinnitus? A Case of Framing Effects and a High Jugular Bulb</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> Framing effects have an influence on medical decision-making; these effects stem from heuristics that physicians commonly use to diagnose patients.<span class="htm-cite"><a href="#ref1">1</a></span> The framing itself may be created by the patient’s past medical history, family history, or specific associated symptom as examples. However, the bias created by framing can also lead to missed diagnoses.<span class="htm-cite"><a href="#ref2">2</a>,<a href="#ref3">3</a></span> For example, tinnitus can occur in patients with a high jugular bulb,<span class="htm-cite"><a href="#ref4">4</a>,<a href="#ref5">5</a></span> but if the clinical picture is framed with a history of psychosis, there is potential for bias toward labeling the subjective auditory symptom as a hallucination. The following case emphasizes this specific bias.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Mr A, a 56-year-old Hispanic, undomiciled, unemployed man, presented to the emergency department for chest pain and what seemed to be atypical tinnitus in his right ear. His past medical history included hypoacusia in the left ear due to meningitis during childhood, as well as hepatitis C, hypertension, depression, schizoaffective disorder, and polysubstance abuse. He had been attempting detoxification for both opiate and alcohol abuse, although these attempts were never successful as he claimed to have used both substances shortly before presenting to the hospital. He came to the emergency department complaining of chest tightness that was occurring for 1 week. However, he simultaneously complained of a very loud “ringing, beeping, and whistling” noise in his right ear. This noise was associated with headaches and agitation. He complained at the time of feeling depressed and having suicidal ideation, with the noise playing a significant role in his mood.</p>
<p class="ltrs-br-ltr-br-body-text">He was admitted to the medical floor initially to rule out an acute coronary syndrome. No laboratory abnormalities were noted at admission. After his chest pain was determined to be etiologically musculoskeletal, the psychiatry department was consulted for his depressive symptoms, and the otolaryngology (ENT) department was consulted for his auditory symptoms. The patient was eventually transferred to the psychiatry department because of his suicidal ideations. His diagnosis was noted to be schizophrenia (<span class="italic">DSM-5</span> criteria) due to his constricted affect, poor insight and judgment, and poor reliability and impulse control and potentially due to his previous diagnoses and his auditory symptoms. His medications were reconciled, and he was started again on quetiapine, trazodone, lipitor, amlodipine, and aspirin.</p>
<div id="figure" class="right"> <a href="#" onclick="createFigure('f1'); return false;"><img src="17l02108F1.jpg" alt="Figure 1" id="f1" border="0" /></a>
<p class="click-to-enlarge">Click figure to enlarge</p>
</div>
<p class="ltrs-br-ltr-br-body-text">The ENT consult discovered no significant clinical findings; the patient also disclosed no associated symptoms besides headache, agitation, and depression. A computed tomography (CT) angiogram was done to further investigate potential etiologies. The imaging showed a high right jugular bulb (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span>). Thus, there may have indeed been turbulent blood flow preceding a stenotic portion of his right internal jugular vein. This radiologic finding offered a potential alternative explanation for his auditory complaints besides the designation of auditory hallucinations.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">The presence of a high jugular bulb, which can erode into the inner ear, was noted in 8.5% of temporal bone CT scans and 8.2% of temporal bone specimens.<span class="htm-cite"><a href="#ref6">6</a></span> High jugular bulbs have been known to potentially cause a pulsatile tinnitus<span class="htm-cite"><a href="#ref7">7</a></span> and a subjectively nonpulsatile tinnitus.<span class="htm-cite"><a href="#ref4">4</a></span> They can also cause a variety of other inner ear disturbances, resulting in symptoms such as hearing loss, vertigo, and imbalance.<span class="htm-cite"><a href="#ref5">5</a></span> Jugular vein ligation has been shown to successfully treat tinnitus, although the symptom has spontaneously regressed in some individuals.<span class="htm-cite"><a href="#ref8">8</a></span> Nevertheless, surgical management is generally the most definitive treatment for this abnormality.<span class="htm-cite"><a href="#ref9">9</a></span></p>
<p class="ltrs-br-ltr-br-body-text">Although this patient was a poor historian and provided a very nonspecific temporal account of his tinnitus, the presence of his jugular abnormality cannot be ignored as an etiology for his symptoms. Framing effects were certainly witnessed in the management of this patient with regard to his past psychiatric history of schizoaffective disorder and his current suicidal ideations. These effects allowed for a delay in referral to treat his tinnitus and potentially reduce his psychosocial comorbidities.</p>
<p class="ltrs-br-ltr-br-body-text">Framing effects have a significant influence on medical decision-making.<span class="htm-cite"><a href="#ref1">1–3</a></span> It has also been suggested that framing effects are generally underappreciated and understudied in common medical practice.<span class="htm-cite"><a href="#ref10">10</a></span> Diagnostic checklists, including an effective cognitive approach, may reduce the risk of failed heuristics.<span class="htm-cite"><a href="#ref11">11</a></span> Nevertheless, framing effects and other medical decision-making biases should be further empirically studied so that patients may receive the best possible treatment.</p>
<p class="references_references-heading"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1.	</span>Gong J, Zhang Y, Yang Z, et al. The framing effect in medical decision-making: a review of the literature. <span class="italic">Psychol Health Med</span>. 2013;18(6):645–653. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=23387993&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1080/13548506.2013.766352"><span class="pubmed-crossref">doi:10.1080/13548506.2013.766352</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2.	</span>Vickrey BG, Samuels MA, Ropper AH. How neurologists think: a cognitive psychology perspective on missed diagnoses. <span class="italic">Ann Neurol</span>. 2010;67(4):425–433. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=20437577&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1002/ana.21907"><span class="pubmed-crossref">doi:10.1002/ana.21907</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3.	</span>Leo RJ, DuBois RL. A case of olfactory groove meningioma misdiagnosed as schizophrenia. <span class="italic">J Clin Psychiatry</span>. 2016;77(1):67–68. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=26845263&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.4088/JCP.15cr09829"><span class="pubmed-crossref">doi:10.4088/JCP.15cr09829</span></a></p>
<p class="references-references-text-1-9"><a name="ref4"></a><span class="htm-ref"> 4.	</span>Bektas D, Caylan R. Non-pulsatile subjective tinnitus without hearing loss may be caused by undetectable sounds originating from venous system of the brain. <span class="italic">Med Hypotheses</span>. 2008;71(2):245–248. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=18472353&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1016/j.mehy.2008.03.024"><span class="pubmed-crossref">doi:10.1016/j.mehy.2008.03.024</span></a></p>
<p class="references-references-text-1-9"><a name="ref5"></a><span class="htm-ref"> 5.	</span>Friedmann DR, Eubig J, Winata LS, et al. A clinical and histopathologic study of jugular bulb abnormalities. <span class="italic">Arch Otolaryngol Head Neck Surg</span>. 2012;138(1):66–71. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=22249632&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1001/archoto.2011.231"><span class="pubmed-crossref">doi:10.1001/archoto.2011.231</span></a></p>
<p class="references-references-text-1-9"><a name="ref6"></a><span class="htm-ref"> 6.	</span>Friedmann DR, Eubig J, Winata LS, et al. Prevalence of jugular bulb abnormalities and resultant inner ear dehiscence: a histopathologic and radiologic study. <span class="italic">Otolaryngol Head Neck Surg</span>. 2012;147(4):750–756. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=22619257&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1177/0194599812448615"><span class="pubmed-crossref">doi:10.1177/0194599812448615</span></a></p>
<p class="references-references-text-1-9"><a name="ref7"></a><span class="htm-ref"> 7.	</span>Reardon MA, Raghavan P. Venous abnormalities leading to tinnitus: Imaging evaluation. <span class="italic">Neuroimaging Clin N Am</span>. 2016;26(2):237–245. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=27154606&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1016/j.nic.2015.12.006"><span class="pubmed-crossref">doi:10.1016/j.nic.2015.12.006</span></a></p>
<p class="references-references-text-1-9"><a name="ref8"></a><span class="htm-ref"> 8.	</span>Golueke PJ, Panetta T, Sclafani S, et al. Tinnitus originating from an abnormal jugular bulb: treatment by jugular vein ligation. <span class="italic">J Vasc Surg</span>. 1987;6(3):248–251. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3625880&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1016/0741-5214(87)90036-X"><span class="pubmed-crossref">doi:10.1016/0741-5214(87)90036-X</span></a></p>
<p class="references-references-text-1-9"><a name="ref9"></a><span class="htm-ref"> 9.	</span>Roberts DS, Chen B, Slattery W. Surgical management of a high jugular bulb. <span class="italic">Ear Nose Throat J</span>. 2016;95(8):306–309. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=27551837&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a></p>
<p class="references-references-text-10-99"><a name="ref10"></a>10.	Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. <span class="italic">Med Decis Making</span>. 2015;35(4):539–557. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=25145577&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1177/0272989X14547740"><span class="pubmed-crossref">doi:10.1177/0272989X14547740</span></a></p>
<p class="references-references-text-10-99"><a name="ref11"></a>11.	Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. <span class="italic">Acad Med</span>. 2011;86(3):307–313. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21248608&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1097/ACM.0b013e31820824cd"><span class="pubmed-crossref">doi:10.1097/ACM.0b013e31820824cd</span></a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Evan Hy Einstein, BA</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:evan_einstein@nymc.edu">
evan_einstein@nymc.edu</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Mauricio González-Arias, MD</span><span class="superscript">b</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Akshatha Sunil Kamath, MD</span><span class="superscript">b</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Lindsey Channen, BS</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Taimur Mirza, MD</span><span class="superscript">b</span></p>
<p class="end-matter"><span class="superscript">a</span>New York Medical College, Valhalla, New York</p>
<p class="end-matter"><span class="superscript">b</span>Metropolitan Hospital Center, New York, New York</p>
<p class="end-matter"><span class="bold-italic">Conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Patient consent:</span> Verbal permission was received from the patient to publish this case, and the information was de-identified to protect anonymity.</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> August 31, 2017.</p>
<p class="end-matter"><span class="italic">Prim Care Companion CNS Disord 2017;19(4):17l02108</span></p>
<p class="doi-line"><span class="italic">
https://doi.org/</span><span class="doi">10.4088/PCC.17l02108</span></p>
<p class="end-matter"><span class="italic">© Copyright 2017 Physicians Postgraduate Press, Inc.</span></p>
</div>