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Essential palatal myoclonus following dental surgery: A case report

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Various presentations of essential palatal myoclonus, a condition characterized by clicking noises and palatal muscle spasm, have been reported in the literature. We are reporting the first case of essential palatal myoclonus following dental treatment. A 31-year-old Caucasian man presented to our Ear, Nose and Throat department complaining of objective clicking tinnitus occurring immediately after he had undergone root canal treatment on his right lower third molar 3 months ago. Magnetic resonance imaging of his head revealed no abnormalities in the cerebrum, cerebellum or brainstem making the diagnosis essential palatal myoclonus. He returned a week later, and 20 units of botulinum toxin A (Allergan) were injected into his left tensor veli palatine muscle. He reported an immediate improvement; however, symptoms recurred 6 months later. Dental treatment can be a trigger of essential palatal myoclonus. Botulinum toxin injections are an effective treatment for short-term relief of symptoms.
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CA S E R E P O R T Open Access
Essential palatal myoclonus following dental
surgery: a case report
Jeff H Lam
1*
, Mairi E Fullarton
1
and Alex MD Bennett
2
Abstract
Introduction: Various presentations of essential palatal myoclonus, a condition characterized by clicking noises and
palatal muscle spasm, have been reported in the literature. We are reporting the first case of essential palatal
myoclonus following dental treatment.
Case presentation: A 31-year-old Caucasian man presented to our Ear, Nose and Throat department complaining
of objective clicking tinnitus occurring immediately after he had undergone root canal treatment on his right lower
third molar 3 months ago. Magnetic resonance imaging of his head revealed no abnormalities in the cerebrum,
cerebellum or brainstem making the diagnosis essential palatal myoclonus. He returned a week later, and 20 units
of botulinum toxin A (Allergan) were injected into his left tensor veli palatine muscle. He reported an immediate
improvement; however, symptoms recurred 6 months later.
Conclusions: Dental treatment can be a trigger of essential palatal myoclonus. Botul inum toxin injections are an
effective treatment for short-term relief of symptoms.
Keywords: Botulinum injection, Dental surgery, Essential palatal myoclonus, Muscle spasm, Soft palate, Tinnitus
Introduction
Palatal myoclonus (PM; or palatal tremor) is a rare con-
dition affecting the muscles of the soft palate. It typically
presents with clicking noises and muscle spasms felt at
the back of the throat. PM is divided into two subtypes:
essential (EPM) and symp tomatic (SPM). EPM describes
an objective clicking secondary to rhythmic movements
of the tensor veli palatini ( TVP), occurring intermittently
throughout the day but not during sleep [1]. Previous li-
terature demonstrates that EPM typically presents in late
childhood [2,3], and occurs in the absence of any cerebel-
lar or brainstem lesion.
SPM involves the levator veli palatini muscles (Figure 1),
and is usually caused by a lesion in the GuillainMollaret
triangle, which comprises the dentate, red and inferior
olivary nuclei [4]. In contrast to EPM, SPM does cause
symptoms during sleep.
We report the first case of EPM following dental
treatment.
Case presentation
A 31-year-old Caucasian man presented to our Ear, Nose
and Throat department complaining of bilateral objec-
tive clicking tinnitus occurring immediately after he had
undergone root canal treatment on his right lower third
molar 3 months ago. The dental surgery was uneventful
but the patient felt his mouth was over-extended during
the procedure. The tinnitus was constant and he could
not exert any control over his symptoms. He reported
his symptoms were bilateral but alternating in severity
between the right and left sides. As the patient lived
alone, it was not known whether his symptoms occurred
during sleep. He denied any symptoms of the pharynx,
larynx or esophagus or any other auditory symptoms. He
appeared anxious but there was no significant past me-
dical history. He was not taking any regular medications.
Examination of the patient revealed objective clicking
predominantly on the right side. On inspection of his
oral cavity, muscle spasms of his soft palate were ob-
served. He was subsequently sent for magnetic resonance
imaging of his head, which revealed no abnormalities in
the cerebrum, cerebellum or brainstem making the diag-
nosis EPM. He returned a week later, and 20 units of
botulinum toxin A (Allergan) were injected into his left
* Correspondence: H.P.J.Lam@sms.ed.ac.uk
1
College of Medicine, University of Edinburgh, 47 Little France Crescent,
Edinburgh EH16 4TJ, UK
Full list of author information is available at the end of the article
JOURNAL OF MEDICAL
CASE REPORTS
© 2013 Lam et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Lam et al. Journal of Medical Case Reports 2013, 7:241
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tensor veli palatine muscle. He reported an immediate im-
provement with no side effects; however, symptoms had
recurred at follow-up 6 months later. He was subsequently
referred for consideration of radio-frequency ablation with
the aim of achieving long-term symptom relief.
Discussion
As previously mentioned, the primary muscle affected in
EPM is the TVP. The left and right TVP share a com-
mon aponeurosis which extends between the pterygoid
hamuli. This anatomical connection provides an expla-
nation for the typically bilateral symptoms of EPM [5].
Psychogenic PM is a subtype of EPM which has a
similar presentation. Physical triggers for the condition
such as endoscopy have been reported in this condition
[6]. However, the primary factor in distinguishing psy-
chogenic PM is the ability of the patient to exert vo-
luntary control over his or her symptoms [7] and our
patient was unable to demonstrate this, making a psy-
chogenic cause for his symptoms unlikely.
The exact precipitant of PM in this case is unclear.
Wisdom tooth surgery is occasionally complicated by
damage to the branches of the mandibular nerve, most
commonly the inferior alveolar and lingual nerves, but
not the medial pterygoid nerve which supplies the T VP.
However, this case raises the possibility of medial ptery-
goid nerve damage followin g dental surgery as a cause
of EPM.
Botulinum toxin is the only pharmacological therapy
which has consistently been proven to be effective in the
treatment of PM [8]. Up to 30 units are injected unila-
terally into the soft palate at the site of insertion of
the TVP and levator [9]. Side effects of treatment are
usually brief and include voice change and nasopharyngeal
regurgitation [10]. More severe side effects are rare and
include Eustachian tube dysfunction and velopharyngeal
inadequacy [8].
Systemic treatments that have been evaluated in the
management of PM include phenytoin, barbiturates,
benzodiazepines, carbamazepine, sodium valproate and
anticholinergics, however, many of these drugs are asso-
ciated with troublesome sedative and metabolic side
effects [11]. A previous case report has shown that radio-
frequency ablation may be effective in abolishing abnor-
mal movements of the soft palate [12].
Conclusions
Dental treatment can be a trigger of EPM. Botulinum
toxin injection is an effective treatment for short-term
relief of symptoms.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for re-
view by the Editor-in-Chief of this journal.
Abbreviations
EPM: Essential palatal myoclonus; PM: Palatal myoclonus; SPM: Symptomatic
palatal myoclonus; TVP: Tensor veli palatini.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
AB was the consultant responsible for diagnosing and treating the patient in
this case report. AB provided the information to JL and MF, who wrote the
paper under ABs supervision. All authors have read and approved the final
version of this manuscript.
Figure 1 Anatomy of the soft palate.
Lam et al. Journal of Medical Case Reports 2013, 7:241 Page 2 of 3
http://www.jmedicalcasereports.com/content/7/1/241
Author details
1
College of Medicine, University of Edinburgh, 47 Little France Crescent,
Edinburgh EH16 4TJ, UK.
2
Department of Otolaryngology, Lauriston Building,
Lauriston Place, Edinburgh EH3 9HA, UK.
Received: 18 March 2013 Accepted: 11 September 2013
Published: 14 October 2013
References
1. Pearce JM: Palatal Myoclonus (syn. Palatal Tremor). Eur Neurol 2008,
60(6):312315.
2. Camistol-Plana J, Majumdar A, Fernández-Alvarez E: Palatal tremor in
childhood: clinical and therapeutic considerations. Dev Med Child Neural
2006, 48:982984.
3. Schwartz RH, Bahadori RS, Myseros JS: Loud clicking sounds associated
with rapid soft palate muscle contractions. Pediatr Emer Care 2012,
28:158159.
4. Guillain G, Mollaret P, Bertrand I: Sur la lesion responsible du syndrome
myoclonique du tronc cerebral. Rev Neurol (Paris) 1993, 3:666674.
5. Deuschl G, Toro C, Hallett M: Symptomatic and essential palatal tremor. 2.
Differences of palatal movements. Mov Disord 1994, 9(6):676678.
6. Stamelou M, Saifee TA, Edwards MJ, Bhatia KP: Psychogenic palatal
tremor may be underrecognized: reappraisal of a large series of cases.
Mov Disord 2012, 27(9):11641168.
7. Ross S, Jankovic J: Palatal myoclonus: an unusual presentation. Mov Disord
2005, 20(9):12001203.
8. Bryce GE, Morrison MD: Botulinum toxin treatment of essential palatal
myoclonus tinnitus. J Otolaryngol 1998, 27(4):213216.
9. Karuse E, Heinen F, Gurkov R: Difference in outcome of botulinum toxin
treatment of essential palatal tremor in children and adults. Am J
Otolaryngol 2010, 31(2):9195.
10. Penney SE, Bruce IA, Saeed SR: Botulinum toxin is effective and safe for
palatal tremor: a report of five cases and a review of the literature.
J Neurol 2006, 253(7):857860.
11. Chitkara A, Cultrara A, Blitzer A: Palatal myoclonus: treatment with
botulinum toxin. Operative Tech in Otolaryngol Head Neck Surg 2004,
15(2):114117.
12. Aydin O, Iseri M, Ozturk M: Radiofrequency ablation in the treatment of
idiopathic bilateral palatal myoclonus: a new indication. Ann Otol Rhinol
Laryngol 2006, 115(11):824826.
doi:10.1186/1752-1947-7-241
Cite this article as: Lam et al.: Essential palatal myoclonus following
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Palatal myoclonus is a rare neurological disorder, which manifests as involuntary palatal contractions. It may be related to an underlying neurological abnormality or it may be of unknown etiology. The most common symptom is objective clicking tinnitus. Systemic treatment is largely unsuccessful. The use of botulinum toxin type A has been effective in treating the symptom with limited adverse effects.
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The purpose of this study was to review the use of botulinum toxin in the treatment of essential palatal myoclonus tinnitus. Two case series. Four to 10 units of botulium toxin are injected into the tensor veli palatini muscle. The dose and interval between doses is titrated according to patient symptoms. With bilateral symptoms, injection is alternated between sides at sequential visits. Relief of tinnitus with cessation of palatal contractions. Both patients had relief of tinnitus. One patient required ventilation tube placement to relieve aural fullness. Tensor veli palatini botulinium toxin injection is an effective treatment for essential palatal myoclonus tinnitus.
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