To describe a variant of Tullio’s phenomenon, a sound-induced spontaneous cerebrospinal fluid (CSF) leak.

Tullio’s phenomenon is traditionally described as vertigo or nystagmus induced in response to an auditory stimulus. Here we present a patient that developed a sound-induced spontaneous CSF leak.

Our patient is a 58-year-old right-handed female with history of relapsing remitting multiple sclerosis. While attending a concert from a symphony orchestra she had a very unusual experience. She described sitting right next to a very large speaker, at the time of a crescendo in the musical piece, she developed instantaneously, the worst headache of her life. She was taken to the emergency room and subsequently admitted initially to rule out a subarachnoid hemorrhage. Her neurological examination showed no papillitis in her fundus examination, there was no nuchal rigidity, nor focal muscular weakness. Moreover, a full workup including CT of the head, lumbar puncture, and a formal angiogram failed to reveal a subarachnoid hemorrhage.  However, during this admission, we were able to elicit a history of improved pain laying down and exacerbating pain upon sitting or standing. This led to our suspicion of a possible CSF leak. To our delight, blood patch was applied empirically and the pain and syndrome aborted instantaneously.  

We hypothesized that the transmission of sound via the external ear to the ossicular chain, to the oval window at the stapes foot plate, and then to the cochlear aqueduct, and vis a vis into the CSF, created a pressure wave that may have been considerable enough to have effectuated an actual tear, likely a Tarlov sleeve, causing thus a CSF leak.