Observation of a reversible, medication-induced change in pitch perception

A case of auditory disturbance caused by lacosamide

We report a case of auditory disturbance in an adult female that developed after starting lacosamide treatment for epilepsy. While carbamazepine is known to change auditory pitch perception in some patients, that has not been previously reported as a side effect of lacosamide administration. In our description of pitch perception deficit associated with lacosamide, we outline features seen in our patient and compare our findings with those of previous reports describing carbamazepine-associated auditory disturbance.

Vestibular Function in Adults With Epilepsy of Unknown Etiology

OBJECTIVE

This study aimed to evaluate vestibular function in adults with chronic epilepsy of unknown etiology in the inter-ictal period.

BACKGROUND

Epilepsy is a chronic medical disorder. Life-long therapy may be required in one-third of patients. Epilepsy is associated with comorbid somatic conditions which impairs patients' quality of life.

METHODS

This cross-sectional study included 28 with generalized tonic clonic (GTC) convulsions and 14 and 3 with temporal (TLE) and frontal lobe (FLE) epilepsies with secondary generalization (all were on regular carbamazepine therapy) and 40 healthy control subjects. The patients' mean age was 34.97 ± 7.35 years and the duration of illness was 18.75 ± 7.99 years. All underwent videonystagmography (VNG).

RESULTS

Compared with controls, patients had frequent vestibular symptoms including dizziness (62.22%) (p = 0.0001) and sense of imbalance (44.44%) (p = 0.0001). Eleven patients (24.44%) had central vestibular dysfunction (p = 0.0001); 9 (20%) had mixed vestibular dysfunction and one (2.22%) had peripheral vestibular dysfunction (p = 0.0001). Abnormalities were observed in saccadic (44.4%) and pursuit (42.2%) eye movements, optokinetic nystagmus (42.2%) and positioning/positional (11.11%) and caloric (13.33%) testing. TLE and FLE were associated with more VNG abnormalities than GTC. No significant differences were observed in the demographic and clinical characteristics between patients with and without VNG abnormalities.

CONCLUSION

Vestibular manifestations are frequent in patients with epilepsy. This may be a result of the permanent damaging effect of chronic epilepsy on the vestibular cortical areas and/or a toxic effect from prolonged carbamazepine therapy on the peripheral and central vestibular systems.

Absolute pitch may not be so absolute

Most people cannot name the musical note that corresponds to a particular pitch without being provided a reference note, but those people with absolute pitch (AP) can do this accurately. Early experience during a developmental period is often thought to convey identity and stability of the note categories in people with AP, but the plasticity of these categories has not been investigated. Here we provide the first evidence that the note categories of adults with AP can change with listening experience. Participants with AP showed shifts in perception in direct accord with prior exposure to music detuned by a fraction of a semitone. This suggests that the apparent stability of AP categories is conferred not by early experience but rather by the cultural norms adopted for tuning music.

Music and epilepsy: a critical review

The effect of music on patients with epileptic seizures is complex and at present poorly understood. Clinical studies suggest that the processing of music within the human brain involves numerous cortical areas, extending beyond Heschl's gyrus and working within connected networks. These networks could be recruited during a seizure manifesting as musical phenomena. Similarly, if certain areas within the network are hyperexcitable, then there is a potential that particular sounds or certain music could act as epileptogenic triggers. This occurs in the case of musicogenic epilepsy, whereby seizures are triggered by music. Although it appears that this condition is rare, the exact prevalence is unknown, as often patients do not implicate music as an epileptogenic trigger and routine electroencephalography does not use sound in seizure provocation. Music therapy for refractory epilepsy remains controversial, and further research is needed to explore the potential anticonvulsant role of music. Dopaminergic system modulation and the ambivalent action of cognitive and sensory input in ictogenesis may provide possible theories for the dichotomous proconvulsant and anticonvulsant role of music in epilepsy. The effect of antiepileptic drugs and surgery on musicality should not be underestimated. Altered pitch perception in relation to carbamazepine is rare, but health care professionals should discuss this risk or consider alternative medication particularly if the patient is a professional musician or native-born Japanese. Studies observing the effect of epilepsy surgery on musicality suggest a risk with right temporal lobectomy, although the extent of this risk and correlation to size and area of resection need further delineation. This potential risk may bring into question whether tests on musical perception and memory should form part of the preoperative neuropsychological workup for patients embarking on surgery, particularly that of the right temporal lobe.

Long-term stability of spontaneous otoacoustic emissions

Spontaneous otoacoustic emissions (SOAEs) were measured longitudinally for durations up to 19.5 years. Initial ages of the subjects ranged from 6 to 41 years. The most compelling finding was a decrease in frequency of all emissions in all subjects, which was approximately linear in %/year and averaged 0.25%/year. SOAE levels also tended to decrease with age, a trend that was significant, but not consistent across emissions, either within or across subjects. Levels of individual SOAEs might decrease, increase, or remain relatively constant with age. Several types of frequency/level instabilities were noted in which some SOAEs within an ear interacted such that their levels were negatively correlated. These instabilities often persisted for many years. SOAEs were also measured in two females over the course of their pregnancies. No changes in SOAE levels or frequencies were seen, that were larger than have been reported in females over a menstrual cycle, suggesting that levels of female gonadal hormones do not have a significant direct effect on SOAE frequencies or levels.

Pitch perception abnormality as a side effect of carbamazepine

Carbamazepine (CBZ) is frequently used to treat patients with epilepsy, neuralgia, psychiatric diseases, etc. We prescribe it with care due to its side effects, mainly such as dizziness, sleepiness and cerebellar symptoms. But pitch perception abnormality is an uncommon side effect. We describe the case of a 12-year-old girl who exhibited half tone lowered pitch perception abnormality caused by CBZ. As CBZ acts as a central nervous system (CNS) inhibitor, we speculate that CBZ inhibits CNS and patients misperceive notes. We must prescribe CBZ with care to prevent pitch perception abnormalities.

Carbamazepine-induced transient auditory pitch-perception deficit

This report presents six cases of transient auditory disturbance caused by carbamazepine, with a particular focus on pitch-perception deficit. Basic disorders in the six cases included epilepsy (cryptogenic localization-related epilepsy and benign childhood epilepsy) and glossopharyngeal neuralgia. Since 1993, in which we reported the first description of transient pitch-perception deficit associated with carbamazepine, a further 26 cases have been reported. However, this carbamazepine-induced transient pitch-perception deficit may be more frequent than previously suspected. Moreover, because auditory disturbance occurs at therapeutic serum levels of carbamazepine, patient awareness of reversible hearing impairment on initiating carbamazepine therapy is important.

Carbamazepine induced pitch shift and octave space representation

Octave-circular pitch perception, the repetition of pitch scale qualities when surpassing the octave interval, has been observed in behavioral data from humans and monkeys, but the underlying anatomy and physiology is still unknown. Here we analyze octave circularity in a concert pianist with absolute pitch, both under medication with the neurotropic drug carbamazepine (CBZ) and without medication. Analysis of 4619 responses in a pitch identification task revealed an internal tone-scale representation, based on the norm-tone scale re A4=440 Hz, with an octave-circular pattern of strongly and weakly represented tones. CBZ caused a global down-shift of pitch (ca. 1 semitone at 500 Hz), but no down-shift of the octave-circular pattern of tone characteristics. This pattern was similar in the six tested octave ranges (32.7-2093 Hz), both under the control and the CBZ condition. Pattern repetition always occurred at octave intervals and did not reflect the stretched octaves of piano tuning. The results indicate that CBZ influences pitch detection peripheral of an octave-circular pitch representation. Thus they support previous evidence for pitch detection in the auditory midbrain and for octave-circular pitch mapping in the auditory thalamus.

A nonmusical paradigm for identifying absolute pitch possessors

The ability to identify and reproduce sounds of specific frequencies is remarkable and uncommon. The etiology and defining characteristics of this skill, absolute pitch (AP), have been very controversial. One theory suggests that AP requires a specific type of early musical training and that the ability to encode and remember tones depends on these learned musical associations. An alternate theory argues that AP may be strongly dependent on hereditary factors and relatively independent of musical experience. To date, it has been difficult to test these hypotheses because all previous paradigms for identifying AP have required subjects to employ knowledge of musical nomenclature. As such, these tests are insensitive to the possibility of discovering AP in either nonmusicians or musicians of non-Western training. Based on previous literature in pitch memory, a paradigm is presented that is intended to distinguish between AP possessors and nonpossessors independent of the subjects' musical experience. The efficacy of this method is then tested with 20 classically defined AP possessors and 22 nonpossessors. Data from these groups strongly support the validity of the paradigm. The use of a nonmusical paradigm to identify AP may facilitate research into many aspects of this phenomenon.

Elevated pitch perception owing to carbamazepine-activating effect on the peripheral auditory system: auditory brainstem response study

Auditory disturbance is an uncommon side effect of carbamazepine, the pathophysiologic mechanism of which has not been clearly elucidated. We performed an auditory brainstem response study in a 9-year-old boy with epilepsy who had suffered from falsely higher pitch perception immediately after the start of carbamazepine treatment. The auditory brainstem response results showed that both the peak latency of wave V and the interpeak latencies of waves I to V were significantly prolonged with 85 dB HL click stimulation and that the peak amplitudes of the waves were noticeably elevated, particularly with lower click stimulation intensity. Although it has been shown that carbamazepine has a suppressive effect on the central nervous system, these auditory brainstem response findings might constitute evidence of a carbamazepine-activating effect on the peripheral auditory system, which probably increased the sensitivity to low-pitched sounds, causing the development of falsely higher pitch perception in our patient.

Carbamazepine-induced abnormal pitch perception

A 7-year-old boy began to complain that his pitch perception was decreased just after oral medication with carbamazepine was initiated for the treatment of epilepsy. When he played the piano, he felt as if he had played a musical note of almost a half pitch lower than he had. His pitch perception recovered soon after the cessation of carbamazepine. A 14-year-old girl noted a lowered pitch of music sounds while she played the piano just after the administration of carbamazepine for the treatment of epilepsy. Carbamazepine was withdrawn and the auditory symptoms disappeared. Both patients were musically trained. Reversible pitch perception abnormalities are a rare adverse effect of carbamazepine, however, the clinical features of the reported cases were similar; they were musically trained, young, female and Japanese. Although the mechanism remains unclear, we have to pay attention to this subtle adverse effect when we treat epileptic patients with carbamazepine.

Pitch perception shift: a rare side-effect of carbamazepine

Carbamazepine-induced pitch perception shifts have rarely been described. Two cases of shifted pitch perception developing during medication with carbamazepine are described. Case 1 possessed absolute pitch. Her pitch perception shift disappeared with the discontinuance of carbamazepine. Case 2 did not have absolute pitch. Even though he experienced a pitch perception shift, he developed a tolerance to the shift. We concluded that carbamazepine was the cause of the pitch perception shift in the first case, while the second case probably became attuned to the change in pitch perception because he did not possess absolute pitch.

Reversible pitch perception deficit caused by carbamazepine

Carbamazepine (CBZ) is an antiepileptic drug frequently used to treat a variety of neurologic diseases or symptoms. In addition, the drug is used as a mood stabilizer in patients with affective or schizophrenic disorders. Among its adverse effects, auditory disturbance is described rarely. In this report, we describe a 25-year-old woman who noted falsely higher pitch perception after starting CBZ treatment for schizoaffective disorder. We also review the literature reporting CBZ-associated abnormal pitch perception.