Clonazepam for palatal myoclonus

Difference in outcome of botulinum toxin treatment of essential palatal tremor in children and adults

PURPOSE

The objective of this clinical study was to investigate the history and clinical findings in 10 patients having an essential palatal tremor. Furthermore, a botulinum toxin A (BTA) therapy in 5 cases was carried out, and the outcome was analyzed.

MATERIALS AND METHODS

Seven adult and 3 pediatric patients with essential palatal tremor were examined at presentation, before and after start of treatment, and every 3 months or when symptoms recurred. Findings were documented by endoscopic video recordings, electromyography, tympanometry, and ear canal microphone recording. The BTA injections were performed in local or general anesthesia, under elecromyographic guidance.

RESULTS

The BTA therapy in all 5 patients was successful. Surprisingly, 2 of these patients, aged 10 and 6 years, remained in remission for several years after a single successful injection.

CONCLUSION

Botulinum toxin therapy is a safe and effective treatment of essential palatal tremor and seems to be especially useful in pediatric patients. The long lasting effect in children hints toward a pathophysiologic difference between pediatric and adult essential palatal tremor.

Treatment for severe palatoclonus by occlusion of the eustachian tube

PURPOSE

Surgical blocking of the eustachian tube is presented as an ultimate treatment option in a 11-year-old suicidal boy with a therapy-resistant, persistent clicking tinnitus caused by myoclonus of the levator veli palatini.

PATIENT

An 11-year-old boy decompensated psychologically as a result of loud and objective tinnitus. The tinnitus could be heard easily by an examiner by bringing his own ear at a distance of approximately 20 to 30 cm to the left ear of the patient. No neurologic etiology for the tinnitus could be traced. Pediatric psychiatric evaluation resulted in a recommendation to perform, as a last resort, an experimental surgical option like blockage of the eustachian tube.

INTERVENTION

Treatment with Tegretol (Novartis, The Netherlands) had no effect. Treatment with Dysport (Ipsen) botulin toxin with 30 to 60 U was temporarily effective. Finally, 60 U were not effective anymore. As last refugium, a surgical blockage of the eustachian tube has been performed, first with bone cement and later by a more conventional surgical blockage of that bony tube.

OUTCOME

After surgical blockage of the bony part of the eustachian tube, the objective tinnitus disappeared. Blockage of the protympanum by bone cement resulted in only 1 year of successful blocking. After recurrence of the tinnitus combined with aeration of the middle ear, a second surgical transcanal approach was successful in blocking the eustachian tube. With a grommet, the hearing level remained within 10 dB for 0.5 to 8.0 kHz.