CLINICAL AND RESEARCH REPORTS
Alive With the Sound of Music: A Case Series on
Patients Presenting With Musical Hallucinations in
a General Hospital
Rochelle Melina Kinson, M.B. B.Ch. B.A.O., M.Med., Wen Phei Lim, M.B.B.S., M.Med.,
Habeebul Rahman, M.Med., M.R.C.Psych.
Musical hallucinations are a rare phenomenon that renders appropriate identification and treatment a challenge. This case
series describes three women who presented with hearing complex, familiar melodies in the absence of external stimuli on
a background of hearing impairment.
J Neuropsychiatry Clin Neurosci 2015; 27:e51–e53; doi: 10.1176/appi.neuropsych.13110327
Auditory hallucinations primarily of musical content [i.e., musical
hallucinations (MH)] in the absence of other psychiatric
symptoms are uncommon and lie at the interface between
otology, neurology, and psychiatry. Despite its presence in the
scientific literature for more than 150 years, very little sys-
tematic evidence is available.
Our article highlights three cases of hearing-impaired
female patients who presented to the psychiatric service
complaining of hearing familiar complex melodies in the
absence of an external stimulus. Presentation of these cases
was approved by the National Healthcare Group Domain
Specific Review Board.
CASE DESCRIPTIONS
Case 1
“Ms. X” is an 81-year-old widowed Chinese woman. She was
treated with radiotherapy for nasopharyngeal carcinoma
two decades ago and was in remission. Ms. X developed
a depressive episode 2 years ago and has been maintained on
venlafaxine 75 mg/day with complete remission. She com-
plained of hearing music for 2 months, which was louder over
the left ear on a background of gradually progressive bilateral
hearing loss for several years. The music comprised tunes and
lyrics of familiar songs from the 1980s, usually louder in noisy
environments, and she was not able to control it. The symp-
toms did not affect her functioning; she retained full insight
and remained euthymic throughout her follow-up.
On mental state examination, Ms. X was a well-groomed,
elderly Chinese woman who remained engaged throughout the
assessment. She was euthymic and had no other perceptual
J Neuropsychiatry Clin Neurosci 27:1, Winter 2015
abnormalities or delusional beliefs. She scored 29/30 on the
Mini Mental State Examination. Basic blood investigations
and MRI scans of the internal auditory meatus were unremark-
able. Endoscopic examination demonstrated postradiotherapy
changes. An MRI scan of the brain showed age-related micro-
vascular ischemic changes. Audiometry revealed bilateral sym-
metrical moderate-severe sensorineural hearing loss (hearing
threshold at the 40- to 50-dB range, no air-bone gap).
Hearing aids did not reduce the intensity of the music.
Venlafaxine was gradually tapered off with no recurrence in
mood symptoms or changes in MH. Ms. X did not wish to
take additional psychotropics.
Case 2
“Ms. Y” is an 80-year-old widowed Chinese woman with no
formal education. She complained of progressive bilateral
hearing loss for the last 10 years and was diagnosed with age-
related hearing loss.
She complained of hearing music for the last 5 years
(approximately 5 years after the onset of hearing impair-
ment) in the absence of an external stimulus. She described
it as tunes and lyrics of Cantonese opera music, which she
was familiar with in her childhood. It was repetitive and
occurred in external space throughout the day “as if coming
from a radio,” with no aggravating or relieving factors. Al-
though she enjoyed the music on most days, Ms. Y described
occasional frustration with her inability to control it. She
retained full insight into the nature of her symptoms, and it
did not affect her functioning. Although there were in-
frequent lapses in short-term memory, no other aspects of
cognition were affected.
neuro.psychiatryonline.org e51
MUSICAL HALLUCINATIONS IN A GENERAL HOSPITAL SETTING
On mental state examination, Ms. Y was a neat, elderly
Chinese woman who was euthymic and displayed an ap-
propriate affect. She had auditory hallucinations of musical
content and no other perceptual abnormalities. Ms. Y de-
clined a cognitive assessment.
Audiometry revealed moderate-severe sensorineural hear-
ing loss with an auditory threshold of 55 dB in both ears (done
after the onset of hearing loss but before the onset of MH).
Repeat audiometry on two other occasions almost 6 years apart
showed a stable pattern of hearing loss. Ms. Y declined further
investigations and psychotropics. On follow-up, there were no
changes in the symptoms, and she continued to decline a hear-
ing aid, citing discomfort.
Case 3
“Ms. Z” is a 53-year-old Chinese woman who presented with
left-sided hearing loss for 1 week, which was preceded by
a fever. She complained of hearing familiar tunes in her left
ear since the onset of hearing loss. The tunes were familiar to
her (e.g., the national anthem, Christmas carols, and pop
songs). She would hear them for variable durations; on oc-
casion throughout the day. She retained full insight into the
nature of her symptoms.
Mental state examination revealed a middle-aged Chinese
woman who was well groomed, engaging, and euthymic.
Apart from musical hallucinations, there were no other psy-
chotic symptoms elicited. Initial examination revealed a right
middle ear clear effusion. Endoscopic examination of the
upper airway was normal. Audiometry showed bilateral mixed
hearing loss, which was worse in the left ear (auditory thresh-
old 50 dB in right ear and 70 dB in left ear) with an air-bone
gap of 20–30 dB in the right ear and 10–20 dB in the left ear.
She was given a course of oral prednisolone but continued
to experience progressive hearing loss over the subsequent
5 months. Repeat audiometry showed bilateral conductive hear-
ing loss, which was greater on the left. A CT scan of the middle
ear was normal.
A trial of clonazepam and a temporary bone-adjusted
hearing aid did not help with her symptoms.
DISCUSSION
Musical hallucinations on a background of hearing impair-
ment has been described infrequently in the literature,
largely comprising case reports and case series. Cole et al,1 in
a survey of 125 patients over the age of 65 with hearing
impairment, found that approximately 2.5% experienced
MH. More recently, Teunisse et al2 documented a preva-
lence of 3.6% with significant associations between female
sex and predominant left-sided hearing impairment. No as-
sociation between age and severity of hearing impairment
was found in this study. Interestingly, in Ms. X’s and Ms. Z’s
cases, MH occurred louder in the ear with greater hearing
impairment (both left sided).
Berrios et al3 examined 46 cases (80% women; mean age,
60 years) and found that two-thirds were hearing impaired
e52 neuro.psychiatryonline.org
and three-quarters had no psychiatric illness. A more recent
review of 132 cases of MH extracted from the literature after
19904 echoed these findings. They too found that, overall,
there was a preponderance of older women in their sample,
with those with central nervous system pathology being
significantly younger. Hearing loss played a large part in the
possible etiology, as 61% of the patients had a history of
hearing loss or deafness. Similarly, this was seen in the three
cases we report. Although generalizations should be made
with caution, it appears that female gender, older age, and
hearing impairment are possible associations, although the
extent of the individual associations in terms of etiology is as
yet unknown. In our case series, the auditory thresholds
varied from 45 to 70 dB. Auditory threshold and its associ-
ation with the development of MH has not been explored in
the literature to date and would be an interesting future
consideration.
Consistent with the reports in the current literature, all
three of these patients complained of hearing complex, or-
ganized, repetitive, nonthreatening, vivid, and familiar mu-
sic. Interestingly, the MH was familiar tunes to the three
women, although they did not attach any specific emotional
meaning to any of the songs or music they heard.
Several pathways have been proposed as mechanisms for
etiology. Because of the reported association between
hearing impairment and MH, it has been postulated that
the cochlea is the origin of pathology. Griffiths5 proposed
that hearing loss results in a reduction in afferent auditory
inputs. This then leads to a reduction in levels of inhibition
from higher centers and a consequent relative overactivity
in auditory association cortices. This, however, would
mean that most hearing-impaired individuals would ex-
perience MH and vice versa, which is not always the case,
suggesting that the interplay is more complex than what is
currently understood.
Assessments of these patients are varied, and the focus
would be determined by the specialty of the physician who is
conducting the assessment. MH may not always be distressing,
and most of those afflicted would retain insight. A thorough
assessment and reassurance that affected individuals are not
psychiatrically or medically unwell may be all that is needed
as in the cases we described.
Reports on successful treatment have been limited to case
reports over the years. Using a hearing aid has been shown to
treat MH.6 Antipsychotics,7,8 anticholinesterase inhibitors,9
anticonvulsants,10–13 and antidepressants in the presence of
a depressive disorder14 have shown benefits; however, there
is no general consensus on first-line options, dosage, and
duration of treatment.
In our case series, two of the three cases described above
did not benefit from hearing aids in terms of improvement of
MH. It is noteworthy that the presence of MH was not af-
fected by tailing off of venlafaxine for Ms. X, and Ms. Z did
not benefit from a trial of clonazepam. In all three cases, the
reassurance that there was no sinister physical or psychi-
atric illness was sufficient to improve distress.
J Neuropsychiatry Clin Neurosci 27:1, Winter 2015

CONCLUSIONS
This case series highlights several clinical features of interest
and the difficulties in management. Increased awareness and
future research is paramount.
AUTHOR AND ARTICLE INFORMATION
From the Dept. of Psychological Medicine, Tan Tock Seng Hospital,
Singapore.
Send correspondence to Rochelle Melina Kinson; e-mail: rochelle_kinson@
ttsh.com.sg
Received Nov. 1, 2013; revised Feb. 17, 2014; accepted Feb. 24, 2014.
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