From relief to aggravation: The intriguing tinnitus-opioid withdrawal paradox

Introduction:Opioids have been documented to induce tinnitus. However, tinnitus exacerbation with opioid withdrawal and relief upon re-administration of opioids has not been described. Methods:Case report:A 37-year-old male presented with a persistent ringing sensation in his ears for three years after cessation of chronic heroin abuse. The constant static tinnitus was accompanied by high and low-pitched sounds. Heroin one gram IV or morphine 125 mg IV temporarily alleviated the tinnitus for 6-8 hours, necessitating recurrent injections. Buprenorphine 8 mg, thrice a day, significantly reduced the intensity of tinnitus. The patient experienced auditory hallucinations independent of tinnitus. Results:Neurological examination: Cranial nerve VIII: Calibrated. Finger Rub Auditory Screening Test: standard. Weber and Rinne's tests: Negative. Decreased tinnitus intensity from 9/10 to 5/10 with mouth wide open. Psychiatric evaluation: Orientation: X 3. Suicidal thoughts with sad and congruent affect. Intact attention. Hypo-verbal speech. Slow thought process. Poor judgment and limited insight. Discussion:Tinnitus linked to heroin withdrawal and its relief with heroin or opioids implies a temporal relationship. The reduction in tinnitus with the mouth wide open would be consistent with the sound not being derived from the auditory apparatus but rather as a variant of central psychosis auditory hallucinations ascribed to micro-laryngeal movements. Cortically mediated opening of mouth widely inhibits micro-laryngeal movements and thus auditory hallucinations. Opioids may inhibit tinnitus through their cortical effects rather than otological effects. Investigation for tinnitus in those with opioid dependence may reveal a subgroup of patients who may benefit from tinnitus-alleviating medications, thus reducing the risk of relapse.