Many years later and more experienced with tinnitus patients, I have consistently heard a similar complaint from patients and colleagues. The auditory perception of hearing music or singing is reported in the literature and called musical tinnitus, auditory imagery, musical ear syndrome or auditory hallucinations. Many of these cases go unreported because patients are afraid that family, friends and professionals will think they have mental illness. In fact, most patients have that underlying fear themselves, a fear that may unnecessarily exacerbate their condition.

Although the definition for tinnitus and auditory hallucinations are the same-phantom sensory phenomena in the absence of real external sensory stimuli-using the term "hallucination" can be detrimental because it elicits such negative emotions and reactions. Most patients instinctively know that what they are experiencing, whatever it is called, is "weird," and they worry that they are "losing their mind." We can help them understand that there is a difference between psychiatric auditory hallucinations that generally occur with mental illness and non-psychiatric auditory hallucinations that generally occur with hearing loss. People who experience psychiatric auditory hallucinations generally hear voices which speak clearly and directly to them. People who experience non-psychiatric auditory hallucinations mostly hear music, singing or unclear babbling.

Sometimes the condition is exacerbated by a professional who is not knowledgeable about the condition or the neurophysiology of tinnitus. Consider the woman who reported she heard a tenor singing. It began while she was in the hospital. She thought she was hearing Muzak but, when she went home, she could still hear the singing at night. Although the music was soft and pleasant and actually helped her sleep, she became very concerned when her physician suggested that she see a psychiatrist. Following counseling from an experienced tinnitus specialist, she was relieved and is doing fine.

Some patients report having non-bothersome typical tinnitus, and then suddenly they experience a musical component that is alarming and can be debilitating. This was the case with an elderly man who experienced profound hearing loss in one ear, moderate loss in the other ear and mild, non-bothersome tinnitus. Suddenly, following a medication change, he noticed a very loud unending sequence of six distinct songs. He became extremely distressed and contacted his audiologist who referred him to a tinnitus specialist.

It is not clear what causes the more complex auditory perception to occur, but lack of auditory stimuli due to damaged hair cells is usually considered the main culprit. Stressful events, anxiety or medications may be contributors. Generally, the condition is more common in elderly hard-of-hearing patients. Therefore, consider including music in your description of tinnitus (i.e., ringing, hissing, crickets, music, etc.) in your initial evaluation of hearing loss. Often, the patient will feel "safe" about reporting the symptom if you initiate the topic.

Let the patient know that this symptom has been reported by others and they are not alone. Reassure them that it is not an indicator of mental illness and encourage a rich auditory environment. If the patient is bothered by the symptom, consider referring to an audiologist that specializes in tinnitus treatment. Most patients are successfully treated with a combination of counseling and sound therapy.

Merideth Eldridge, MA, is a tinnitus consultant at Eldridge Consulting, LLC, and a member of the Tinnitus Practitioners Association Board of Directors. For more information or to find an audiologist in your area that specializes in tinnitus treatment: www.tinnituspractitioners.com.