Ear clicks in palatal tremor caused by activity of the levator veli palatini

Botulinum Toxin Therapy for Oromandibular Dystonia and Other Movement Disorders in the Stomatognathic System

Various movement disorders, such as oromandibular dystonia, oral dyskinesia, bruxism, functional (psychogenic) movement disorder, and tremors, exist in the stomatognathic system. Most patients experiencing involuntary movements due to these disorders visit dentists or oral surgeons, who may be the first healthcare providers. However, differential diagnoses require neurological and dental knowledge. This study aimed to review scientific advances in botulinum toxin therapy for these conditions. The results indicated that botulinum toxin injection is effective and safe, with few side effects in most cases when properly administered by an experienced clinician. The diagnosis and treatment of movement disorders in the stomatognathic system require both neurological and dental or oral surgical knowledge and skills, and well-designed multicenter trials with a multidisciplinary team approach must be necessary to ensure accurate diagnosis and proper treatment.

Focal Unilateral Palatal Myoclonus Causing Objective Clicking Tinnitus without Uvula Elevation Diagnosed by Concurrent Auscultation

Palatal myoclonus generally entails a visible elevation of the palate and uvula and may be accompanied by myoclonus of other oropharyngeal muscles. A 55-year-old man presented with left ear clicking and hyperacusis. Examination showed arrhythmic left lateral soft palate contraction in the tensor veli palatini region without elevation of the uvula, which correlated with an audible click by auscultation with a stethoscope over the left ear. This is a rare case of focal, unilateral palatal myoclonus without visual uvula elevation with concurrent auscultation, demonstrating the importance of careful examination to detect focal myoclonic contractions.

Botulinum Toxin Treatment of Objective Tinnitus Because of Essential Palatal Tremor: A Systematic Review

INTRODUCTION

In contrast to subjective tinnitus, objective tinnitus can be heard by the examiner as well as by the patient. It can be triggered by, among many other etiologies, idiopathic muscular tremor in the soft palate, the essential palatal tremor (EPT). Many treatment modalities have been investigated, of which only Botulinum toxin (BT) injections have shown promising results.

GOAL

The aim of this study was to evaluate the effect of BT treatment on objective tinnitus due to EPT by a systematic review of the literature.

METHODS

In accordance with PRISMA guideline a systematic literature search in three databases was performed.

RESULTS

Twenty-two studies fulfilled the inclusion criteria, mainly case reports and case series. A total of 51 BT treated patients diagnosed with EPT were identified in the literature. The studies were evaluated with focus on diagnostics, injection technique and BT dose, follow-up, effect on objective tinnitus, complications, and adverse effects.

CONCLUSIONS

The included studies suffer from an extremely low evidence level with several sources of bias. When optimally injected, BT seems to be an effective treatment of objective tinnitus due to EPT, with few adverse effects and complications. We suggest BT injections as first choice in case of EPT and present a guideline regarding diagnostics, treatment, and follow-up.

Essential palatal tremor treated with botulinum toxin

Palatal tremor is a rare movement disorder characterized by rhythmic movement of the soft palate. There are two subtypes: essential and symptomatic palatal tremor. Essential palatal tremor is characterized by tinnitus and an absence of other neurological deficits. Different treatment options have been used to treat palatal tremor, with varying success rates. Here we describe a patient with essential palatal tremor and who was treated with botulinum toxin injections.

Middle ear myoclonus: two informative cases and a systematic discussion of myogenic tinnitus

Background

The term middle ear myoclonus (MEM) has been invoked to explain symptoms of tinnitus presumably caused by the dysfunctional movement of either of the two muscles that insert in the middle ear: tensor tympani and stapedius. MEM has been characterized through heterogeneous case reports in the otolaryngology literature, where clinical presentation is variable, phenomenology is scarcely described, the pathogenic muscle is usually not specified, natural history is unknown, and the presumptive definitive treatment, tensor tympani or stapedius tendon lysis, is inconsistently effective. It is not surprising that no unique acoustogenic mechanism or pathophysiologic process has been identified to explain MEM, one of several descriptive diagnoses associated with the complicated disorders of myogenic tinnitus.

Methods

Here, we explore MEM from the neurologist’s perspective. Following the detailed descriptions of two informative cases from our clinic, we systematically evaluate the different mechanisms and movement disorder phenomena that could lead to a diagnosis of MEM.

Results

From a functional neuroanatomic perspective, we explain how tensor tympani MEM is best explained as a form of peritubal myogenic tinnitus, similar to the related disorder of essential palatal tremor. From a pathogenic perspective, we discuss how MEM symptomatology may reflect different mechanical and neurologic processes. We emphasize the diagnostic imperative to recognize when myogenic tinnitus is consistent with a psychogenic origin.

Discussion

Both individual patient care and further elucidation of MEM will rely on more detailed clinical characterization as well as multidisciplinary input from neurology, otolaryngology, and dentistry.

Palatal myoclonus associated with orofacial buccal dystonia

Palatal myoclonus is a rare condition in which there are rhythmic jerky movements of the soft palate and sometimes of the other muscles innervated by the brainstem A particularly annoying symptom is a rhythmic clicking sound in the ear due to the opening and closing of the Eustachian tube. Orofacial buccal dystonia is a focal dystonia with sustained spasms of the masticatory, facial or lingual muscles. The frequent symptoms of this disease have mainly been reported to be involuntary and possibly painful jaw opening, closing, deflecting and retruding, or a combination of the above. However, the subtle and unnoticeable involuntary movement of multiple facial muscles, which might be an infrequent symptom of orofacial buccal dystonia, makes this disease hard to diagnose. Understanding the functional orofacial anatomy that is responsible for the clinical signs and symptoms is necessary for making a proper diagnosis. Here we report on a rare case of palatal myoclonus that was associated with orofacial buccal dystonia, and such a case has not been previously reported. We describe the diagnostic approach and excellent treatment results after Botulinum toxin A (Dysport) injection and proper counseling.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement

Evidence is emerging for the use of botulinum neurotoxin type-A (BoNT-A) for niche indications including pain independent of spasticity. Pain indications such as chronic nociceptive back pain, piriformis syndrome, chronic myofascial pain, pelvic pain, complex regional pain syndrome, facial pain and neuropathic pain are outlined in this paper. Of these, class I evidence is available for the treatment of chronic nociceptive low back pain, piriformis syndrome, myofascial pain, facial pain, neuropathic pain and plantar fasciitis. Peri-operative use of BoNT-A is emerging, with indications including planning for surgery and facilitating surgery, as well as healing and improving analgesia post-operatively. Evidence is limited, although there are some reports that clinicians are successfully using BoNT-A peri-operatively. There is class I evidence showing pre-operative use of BoNT-A has a beneficial effect on outcomes following adductor-release surgery. The use of BoNT for treatment of tremor, other than neck tremor in the setting of cervical dystonia, including evidence for upper limb tremor, cranial tremor and non-dystonic neck tremor is reviewed. The evidence is variable at this stage, and further study is required to develop definitive recommendations for the clinical utility of BoNT-A for these indications.

Therapeutic uses of botulinum toxin: from facial palsy to autonomic disorders

BACKGROUND

The therapeutic uses of botulinum toxin have been expanding due to deeper knowledge of its molecular behaviour and different mechanisms of action.

OBJECTIVE

To present suggested doses of Botox and Dysport for controlling the muscle hyperkinetic activity in facial palsy in the perioral area and to review other uses.

METHODS

An extensive updated literature review on the success and limits of the botulinum neurotoxin (BoNT) therapeutic treatments.

RESULTS/CONCLUSION

BoNT can be considered to be the preferred single method for many disorders; it has substituted for some conventional surgical methods and it can be associated with other therapies to increase overall treatment performance. Depending on the disorder, the lack of permanent effect causes no major inconvenience.

Efficacy and complication of botulinum toxin injection in palatal myoclonus: Experience from a patient

We report the outcome of botulinum toxin injection for essential palatal myoclonus, given on two occasions over a period of one year, in an eight-year-old boy, the youngest patient treated with botulinum toxin to date. Though there was significant relief of ear clicks each time after the injection, he developed severe palatal palsy following the second injection, which persisted for a month. We suggest that appropriate caution needs to be exercised when repeating botulinum toxin injections for palatal myoclonus in children.

Botulinum toxin: Clinical use

Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.

Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature

Palatal tremor (formerly palatal myoclonus) is an extremely rare, but potentially treatable cause, of objective tinnitus. The tinnitus is thought to be secondary to rhythmic involuntary movements of the soft palate. Its aetiology is variable and it remains difficult to treat. Many different medical and surgical remedies have been tried but none have demonstrated reproducible success. Botulinum toxin has been used in sporadic cases and seems to produce good results. Ten patients with palatal tremor have presented to this department over the last three years. After discussion with the patients with regard to the management of this condition and possible complications, five opted for botulinum toxin therapy and five declined further intervention. Clinical diagnosis was made on the confirmation of soft palate movements synchronous with an audible clicking noise. Five patients underwent botulinum toxin injection into the insertion of the levator and tensor veli palatini muscles. Of the five that were treated with toxin, four showed complete resolution of symptoms after a course of treatment. Only one patient reported transient side effects. This would suggest that botulinum toxin is a safe and effective first line treatment for palatal tremor.

Endonasal approach of salpingopharyngeus muscle for the treatment of ear click related to palatal tremor

Palatal tremor (PT) is a rare disease associated with rhythmic movements of the soft palate. It can be separated into two distinct clinical entities: symptomatic and essential. Most patients with essential PT complain of the rhythmic ear clicks and in some cases tinnitus, but usually have an uneventful medical history. Symptomatic PT patients are often unaware of the palatal movements and have symptoms and signs of brainstem or cerebellar dysfunction. We describe the case of a 25-year-old patient who developed severe essential PT, with very distressing bilateral objective tinnitus, constantly perceived as ear clicks. Several oral medications were prescribed with poor results. No significant improvement was obtained with repetitive injections of botulinum toxin type A (BTX A) distributed in soft palate muscles. Because of the continuous tinnitus and its impact on the patient's quality of life, chemical denervation of the salpingopharyngeus muscles, which is involved in the production of tinnitus, with BTX A was performed endonasally under endoscopic guidance. The result was very satisfactory. Tinnitus due to essential PT may be satisfactorily treated by endonasal injection of BTX into the salpingopharyngeus and palatopharyngeus muscles.

Palatal myoclonus: an unusual presentation

We describe a 16-year-old woman with an unusual clinical presentation of palatal myoclonus after a severe upper respiratory infection. Besides the postinfectious onset, this case is unique in that the rhythmical contractions of her oropharynx, larynx, and esophagus occur in couplets rather than single contractions of typical essential palatal myoclonus. Additionally, these contractions are present only during the inspiratory phase of respiration. Imaging and other diagnostic studies show no evidence of cerebellar or brainstem pathology. This case broadens the phenomenology of palatal myoclonus and illustrates the occasional overlap in clinical features between essential and symptomatic palatal myoclonus.

Palatal tremor suppressed by mouth opening: clinical and neurophysiological correlations in two patients

We report clinical and neurophysiological findings in two patients with palatal tremor (PT). In both patients a prompt and persistent suppression of palatal movements and clicking sounds is caused by slight passive or active mouth opening. One patient has a typical essential palatal tremor (EPT) according to current classification criteria. The other one has a PT characterized by involuntary activation of levator veli palatini and genioglossus muscles. Objective clicking sounds were observed late during the course of the disease. A symptomatic aetiology was excluded, suggesting a diagnosis of atypical EPT. Our observations further confirm that unusual features of some cases may not fit current PT classification criteria. These two cases have several features that distinguish them from voluntary PT and from psychogenic PT. We emphasize that clear cut modulating phenomena may be relevant features in both typical and atypical involuntary EPT. We finally focus on the significance of jaw posture in determining PT suppression in our patients.

New therapeutic indications for botulinum toxins

The efficacy of botulinum toxin (BTX) without systemic effects has led to the rapid development of applications in neuromuscular disorders, hyperactivity of sudomotor cholinergic-mediated glandular function, and pain syndromes. The successful use of BTX in conditions with muscle overactivity, such as dystonia and spasticity, has been established and new areas in the field of movement disorders such as tics, tremor, myoclonic jerks, and stuttering has been explored with satisfactory results. Strategies to temporarily inactivate muscle function after orthopaedic or neurosurgery have also been developed. BTX treatment of hyperhidrosis was followed by its application in other hypersecretory conditions (hyperlacrimation and nasal hypersecretion) and in excessive drooling. Studies are in progress, aimed at optimising the technique and protocol of administration. Other applications for BTX have been proposed in gastroenterological and urogenital practice; it appears to be effective in replacing standard surgical procedures. Trials of BTX in painful conditions are ongoing mainly on refractory tension headache, migraine, and backache as well as dystonia-complex regional pain syndrome and myofascial pain with promising results. Recently, the fastest growing use for BTX toxin has been in the cosmetic applications. Clearly, the indications for the use of BTX are expanding, but further clinical trials will be needed in many different areas.

Objective tinnitus associated with essential laryngeal myoclonus: report of two cases

We report on two patients with an objective tinnitus. In the first one, the objective tinnitus was unique as it was due to bilateral rhythmic contractions of the vocal cords. In the second, the objective tinnitus arose from Eustachian tube contractions and was associated with up and down movements of the larynx. In both patients, the abnormal laryngeal movement shared most of the characteristics of palatal or palatolaryngeal myoclonus and was thought to be laryngeal myoclonus. Its origin remained essential as all the investigations were negative.

Case of essential palatal tremor: atypical features and remarkable benefit from botulinum toxin injection

We describe a 21-year-old man with essential palatal tremor. The patient had rhythmic contractions not only of tensor veli palatini but also of facial, lingual, temporalis, pharyngeal, and neck muscles. He had some voluntary control of palatal tremor and ear clicks. He was treated with 5 units of botulinum toxin-A (BOTOX) injected into each tensor veli palatini, and had complete resolution of all the symptoms.

A re-evaluation of the mechanism of action of botulinum toxin on facial movement disorders in man

Despite a lot of research aimed at clarifying the mechanism of action of botulinum toxin, mostly at supraspinal levels, a complete understanding of it is still elusive. However, recent investigations, including our own, allow us to suggest that, in facial muscles, the effects of botulinum toxin are not only in the neuromuscular junctions affecting the acetylcholine release but also modify the sensory inflow with subsequent changes on the muscle spindle-gammamotoneuron system.

Voluntary palatal tremor in two siblings

We report two siblings with palatal tremor (PT) and ear clicks who can voluntarily elicit or suppress both PT and ear clicks by just "thinking" about starting or stopping the sounds. The patients were also able to voluntarily modulate the frequency of their ear clicks and PT. They did not have any signs of cerebellar, brain stem, or other neurologic disease. These familial palatal movements may represent a variant of palatal tremor but can not satisfactorily be classified as either symptomatic or essential PT.