![]() These effects allowed for a delay in referral to treat his tinnitus and potentially reduce his psychosocial comorbidities.įraming effects have a significant influence on medical decision-making. ![]() 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. 9Īlthough 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. 8 Nevertheless, surgical management is generally the most definitive treatment for this abnormality. 5 Jugular vein ligation has been shown to successfully treat tinnitus, although the symptom has spontaneously regressed in some individuals. 4 They can also cause a variety of other inner ear disturbances, resulting in symptoms such as hearing loss, vertigo, and imbalance. 6 High jugular bulbs have been known to potentially cause a pulsatile tinnitus 7 and a subjectively nonpulsatile tinnitus. 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. This radiologic finding offered a potential alternative explanation for his auditory complaints besides the designation of auditory hallucinations. Thus, there may have indeed been turbulent blood flow preceding a stenotic portion of his right internal jugular vein. ![]() The imaging showed a high right jugular bulb ( Figure 1). A computed tomography (CT) angiogram was done to further investigate potential etiologies. The ENT consult discovered no significant clinical findings the patient also disclosed no associated symptoms besides headache, agitation, and depression. He complained at the time of feeling depressed and having suicidal ideation, with the noise playing a significant role in his mood. This noise was associated with headaches and agitation. However, he simultaneously complained of a very loud "ringing, beeping, and whistling" noise in his right ear. He came to the emergency department complaining of chest tightness that was occurring for 1 week. 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. 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. 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. The following case emphasizes this specific bias.Ĭase report. 2, 3 For example, tinnitus can occur in patients with a high jugular bulb, 4, 5 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. However, the bias created by framing can also lead to missed diagnoses. 1 The framing itself may be created by the patient’s past medical history, family history, or specific associated symptom as examples. To the Editor: Framing effects have an influence on medical decision-making these effects stem from heuristics that physicians commonly use to diagnose patients. Auditory Hallucinations or Tinnitus? A Case of Framing Effects and a High Jugular Bulb
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