Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 4 Issue: 5

Self-Decapitation Attempt Attributed to Tinnitus and Oral Corticosteroids

Katelin Sisler MD1*, Annika Meyer MD1, Sean Miller MD2 and Jastin Antisdel MD, FACS2
1Saint Louis University School of Medicine, Saint Louis, MO, USA
2Department of Otolaryngology – Head & Neck Surgery, Saint Louis University,Saint Louis, MO, USA
Corresponding author : Katelin E Sisler, MD
1402 S. Grand Blvd, St. Louis, MO, 63104, USA
Tel: 808-781-8461; Fax: 314-977-8088
E-mail: [email protected]
Received: March 16, 2015 Accepted: July 02, 2015 Published: July 06, 2015
Citation: Sisler K, Meyer A, Miller S, Antisdel JMD (2015) Self-Decapitation Attempt attributed to Tinnitus and Oral Corticosteroids. J Otol Rhinol 4:4. doi:10.4172/2324-8785.1000236

Abstract

Objectives: 1. Review the relationship between severe tinnitus and suicidal ideation; including documented cases in the literature. 2. Discuss the increased risk of suicidal ideation and attempts in patients with a history of psychiatric illness who receives high dose corticosteroid treatment.

Methods: Case report describing a patient with multiple psychiatric comorbidities who received high-dose corticosteroids to treat tinnitus with subsequent suicide attempt.

Results: 49 year-old male with a history of anxiety, depression, and schizoaffective disorder was suffering from severe, bilateral tinnitus. After completing a high dose steroid treatment for tinnitus given by another clinician, he attempted to commit suicide by acetaminophen ingestion and self-decapitation with a hand saw. Subsequent treatment included emergent neck exploration, tracheostomy, resuspension of his vocal cords/Broyle’s ligament, and closure of a laryngotracheal defect with an omohyoid myofascial flap. Patient recovered with good voice quality and no significant sequelae. Psychiatry further managed his mood disorders.

Conclusion: Tinnitus is a very common and often easily dismissed diagnosis that is considered a nuisance by most who suffer from symptoms. In certain populations, the morbidity of tinnitus is severe, particularly those with coincident psychiatric illness. Clinicians must be cognizant of the impact that tinnitus can have on their patient’s life, and must select corticosteroid treatment appropriately, especially for those with a history of mood disorders.

Keywords: Self-Decapitation; Tinnitus; Oral Corticosteroids

Keywords

Self-Decapitation; Tinnitus; Oral Corticosteroids

Introduction

Tinnitus is the perception of sound without an external source [1]. It is a common phenomenon with the incidence increasing with age and being found more often in males. Severe tinnitus occurs in 3 to 5% of affected patients and it can greatly affect quality of life [1]. Complications of tinnitus include hearing loss, hyperacusis, insomnia, anxiety, and depression [2]. Suicide attempt is a much rarer complication; however, in the past 10 years there have been a few reported cases that implicate tinnitus as the cause of suicide [2].

Case Report

A 49 year old male with a complex psychiatric history of attention deficit hyperactivity disorder (ADHD), anxiety, depression, and schizoaffective disorder was transferred from an outside hospital already intubated. In a suicide attempt the previous night, the patient took 10 capsules of acetaminophen and lacerated his throat with a handsaw. He lost consciousness and was found approximately 12 hours later by his wife, who called an ambulance. Physical exam on arrival to our tertiary hospital was notable for a gaping transverse wound of the anterior neck, with exposure of the crico-thyroid junction and the endotracheal tube (ETT) was visible within the sawed-open trachea (Figure 1). He was taken to the OR for an emergent neck exploration, tracheostomy, closure of the laryngotracheal defect with an omohyoid myofascial flap, and wound closure of his neck (Figure 2). The surgery and postoperative course were uncomplicated. He was successfully decannulated and subsequently able to phonate effectively. He also passed a swallow study before hospital discharge.
Figure 1: Image of Anterior Neck Preoperatively. Highlighted regions represent the under surface of the true cords prior to suspension along the superior aspect of the laryngeal cartilage.
Figure 2: Intra-operative Advancement Flap Repair. Arrow demonstrates the reflected muscle belly of the omohyoid in place over the anterior tracheal wall defect.
Further history revealed that the patients’ psychiatrist had transitioned his antipsychotic medications within the past 6 months. He was tolerating that adjustment well, but began to experience severe tinnitus over the three weeks preceding his suicide attempt. He was prescribed a Medrol dose pack followed by a high-dose prednisone taper under the direction of an outside otolaryngologist. Medical records detailing the rationale for this treatment course were unavailable. He attempted to commit suicide shortly thereafter, citing tinnitus and abdominal pain as contributory factors.
Postoperatively the patient continued to complain of bilateral tinnitus, which then lessened to tinnitus in the left ear after one week. He also received psychiatric care during his hospital stay, and was placed back on a previously tolerated medication regimen. He denied any further thoughts of suicide and was discharged home on postoperative day 14.

Discussion

Tinnitus causes substantial medical and quality of life impairment for millions. Up to 25% of patients with chronic tinnitus consider it to be a significant problem [3]. For our patient, without knowing the exact cause of his tinnitus and why he was prescribed corticosteroids initially, it is difficult to evaluate if that was a proper treatment choice. There are many otologic conditions that cause tinnitus in which corticosteroids are used as part of standard treatment, such as Meniere’s disease. However, there are other contributing factors with this patient that must be taken into account, including his history of psychiatric illness. This outcome could have simply been the natural course of his ailments, but it is important to note the potential side effects of corticosteroid use. People treated with glucocorticoids have nearly a sevenfold higher risk of committing or attempting suicide compared with people unexposed to glucocorticoids [4].
Furthermore, the incidence is even higher in patients with a prior history of psychiatric illness [4]. This relationship between cortisol and mood disorders still remains uncertain [5]. Elevated levels of cortisol have been seen in a subset of patients with depression, and may have a direct impact on the severity of its symptoms [5]. But, it is also possible that cortisol levels increase due to the stress associated with being in a depressed state [5].

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