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Table of Contents    
LETTER TO EDITOR
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1708-1709

A Case of Palatal Myoclonus


Department of Neurology, LifeCare Medical Centre, Coimbatore, Tamil Nadu, India

Date of Submission25-Feb-2020
Date of Decision11-Jul-2020
Date of Acceptance11-Jul-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Pranesh M Bheemarao
Emeritus Professor of Neurology (PSG IMSR, Coimbatore), Ananda Nilaya, 11, 5th Street, Tatabad, Coimbatore - 641 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355183

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How to cite this article:
Bheemarao PM, Mohan VR, Siby E. A Case of Palatal Myoclonus. Neurol India 2022;70:1708-9

How to cite this URL:
Bheemarao PM, Mohan VR, Siby E. A Case of Palatal Myoclonus. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1708-9. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1708/355183




Sir,

Palatal myoclonus or also known as palatal tremors is an uncommon condition. It is a segmental myoclonus characterised by involuntary rhythmic jerky movements of the soft palate and palatal musculature.[1] It may produce clicking sound in the ear and thus some patients report to the ENT specialist initially.

We report of a male patient aged 66 years who had a CVA, Right hemiparesis and dysphasia three years ago. Has HT for 6 years but no DM. Has come for persisting slurring of speech. No dysphagia for solids or liquids.

On examination, he was well nourished, with a BMI of 23.4 kg/sq.m right hander, BP 140/80 supine, and 140/70 on standing, pulse 62/mt, regular, occasional ectopics. Had mild slurring of spoken speech, could read and write well. All cranial nerves were normal except for Palatal Myoclonus [Video 1]. There was no myoclonus of face, eyes, tongue or jaw. Gag and pharyngeal reflexes were normal. No limb weakness. Tendon jerks were brisker on the right side as compared to left side. Plantar reflex was extensor on right side, flexor on left side, walks well. Sensory systems were normal. Other systems were normal.



MRI of brain showed extensive small focal haemorrhages in the base of the brain, that is, thalami, basal ganglia, brainstem, cerebellar hemispheres, and old extensive lacunar infarcts [Figure 1]. Intracranial MRA and carotid & vertebral artery Doppler were normal except for mild atherosclerosis, Hb 14.5g, TC 8200, N70, L30, platelets 3,20,000, and ESR 20 in 1 h. Fasting blood sugar 100 mg/dL and 2 h PP 140 mg/dL. Blood urea 32 mg, creatinie 1.0, urine no albumin, or deposits. Blood HIV negative, blood VDRL negative, CRP 1 mg/L, thyroid function test normal, ANA negative, pANCA and cANCA negative, fasting B12-350, fasting lipid profile normal, PT, INR, and aPTT were normal; serum proteins with electrophoresis were normal and HbS-Ag was negative.
Figure 1: MRA of brain: (a–c) GRE images and (d) T2

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  Discussion Top


Palatal myoclonus was due to extensive small vessel disease producing both small haemorrhages, and lacunar infarctions in large areas of the brain especially base of brain, brainstem and cerebellar hemispheres. The patient had no relevant symptoms due to the Palatal Myoclonus such as clicking sound (tinnitus). He also had no bulbar symptoms such as nasal regurgitation of food or dysphagia. The patient had no symptoms due to the palatal myolonus.

Palatal myoclonus or tremors can be up to 150 times a minute, it persists in sleep also. The tremors is due to the rhythmic contraction of tensor veli palatini muscle. The lesion is in the Mollaret's Triangle.[2] There have been reports of hypertrophic degeneration of the inferior olivary nucleus involving the Triangle – i.e., Dentate nucleus, Red nucleus, inferior Olivary Nucleus and central tegmental tracts.[2]

Of 278 patients of palatal myoclonus, published by Deuschl et al., 210 were symptomatic.[3] The most common causes are stroke, trauma, tumour, demyelinating disease. Palatal myoclonus can also occur due to unknown cause. Opiods perhaps seem to improve the Palatal Myoclonus. From an extensive study of Movement Disorders after Stroke by Hardley et al.,[4] Palatal Myoclonus has been described in Pontine or Bulbar strokes. A similar study has been made by Bansil et al.[5] A report on a postinfectious patient with Palatal Myoclonus and opsoclonus has been reported from PGI, Chandigarh by Shrivastava and Tussu,[6] this was a 58-year-old male presenting with acute onset opsoclonus, myoclonus, cerebellar ataxia and palatal myoclonus. As the patient had fever for 5 days with diarrhoea, he was suspected to have a Viral infection. Mayer et al.[7] report on palatal myoclonus due to vertebral artery compressing the Inferior Olive. The patient improved after surgical decompression, 25 months later there has been a recurrence.

A discussion on the Nosology of Essential palatal myoclonus has been made by C. Zodikoff et al.[8] They discuss the possible causes of the condition.

As regards treatment sumatriptan, oxitriptan, carbamazepine, clonazepam, and botulinum toxin have been tried and the results are not fully satisfactory. Our patient has received clonazepam but the palatal myoclonus persists.

In conclusion, a patient with asymptomatic palatal myoclonus following CVD is reported. The patient had extensive small bleeds and old lacunes in the base of the brain, brainstem and cerebellum. The etiology was probably extensive small vessel disease due to long-standing hypertension.

Declaration of patient consent

Taken as per specifications.

Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Arora V, Smith M. Palatal myoclonus: A long follow-up experience. Indian J Otol 2015;21:294.  Back to cited text no. 1
  [Full text]  
2.
Goyal M, Versnick E, Tuite P, Cyr JS, Kucharczyk W, Montanera W, et al. Hypertrophic olivary degeneration: Metaanalysis of the temporal evolution of MR findings. AJNR Am J Neuroradiol 2000;21:1073-7.  Back to cited text no. 2
    
3.
Deuschl G, Mischke G, Schenck E, Schulte-Mönting J, Lücking CH. Symptomatic and essential rhythmic palatal myoclonus. Brain 1990;113:1645-72.  Back to cited text no. 3
    
4.
Handley A, Medcalf P, Hellier K, Dutta D. Movement disorders after stroke. Age Ageing 2009;38:260-6.  Back to cited text no. 4
    
5.
Bansil S, Prakash N, Kaye J, Wrigley S, Manata C, Stevens-Haas C, et al. Movement disorders after stroke in adults: A review. Tremor Other Hyperkinet Mov (N Y) 2012;2:1-7.  Back to cited text no. 5
    
6.
Srivastava T, Thussu A. Palatal myoclonus in post infectious opsoclonus myoclonus syndrome: A case report. Neurol India 1999;47:133-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Mayer MA, David CE, Chahin NS. Palatal myoclonus secondary to vertebral arrtery compression of the inferior olive. J Neuroimaging 2000;10:221-3.  Back to cited text no. 7
    
8.
Zadikoff C, Lang AE, Klein C. The 'essentials' of essential Palatal Tremor: A reappraisal of the nosology. Brain 2006;129:832-40.  Back to cited text no. 8
    


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