Palatal Tremor in a 16-Year-Old Female

A 16-year-old female presented with movements of the soft palate and audible, distressing ear clicks that have been present for 2 years. Examination revealed rhythmic movements of the distal palate unaffected by distraction and entrainment but can be controlled upon request ([Video 1]). Physical examination and magnetic resonance imaging (MRI) were otherwise normal. She was started on clonazepam 1 mg daily for a month, but due to lack of response, the dose was increased to 1-mg bid.[1] Two months after initiating the treatment, the intensity of ear clicks decreased, and the patient reported less distress but no full resolution.

Concurrent ear clicking with the distal soft palate's movements is characteristic of essential palatal tremor (EPT). The patient can, fully or partially, induce or inhibit the movement as requested.[2] Secondary palatal tremor (SPT), caused by lesions in the dentatoolivary tract, is usually associated with dysarthria, ataxia, and nystagmus, rather than ear clicks. The MRI will show lesions in Guillain–Mollaret triangle mostly due to stroke, demyelination, trauma, or encephalitis.[3] [4] In psychogenic palatal tremor, distraction and entertainability affect the tremor, without voluntary control.[3]

EPT results from repetitive contractions of tensor veli palatini due to unknown causes.[2] [3] Clonazepam, valproate, and levetiracetam are first-line options. The doses depend on patient's response.[1] [5]

Video 1 Rhythmic movements of the distal soft palate are noticed. However, these movements cease when the patient is asked to control it. Volitional control with normal neurological examination and imaging indicates essential palatal tremor.

Publication History

Received: 28 July 2020

Accepted: 13 September 2020

Article published online:
20 January 2021

• References

• 1 Saeed RR, Mohammed ZA. Essential rhythmic palatal myoclonus in a 51-year-old man. Oxf Med Case Rep 2016; 2016 (08) omw056
• 2 Samuel M, Kleiner-Fisman G, Lang AE. Voluntary control and a wider clinical spectrum of essential palatal tremor. Mov Disord 2004; 19 (06) 717-719
• 3 Zadikoff C, Lang AE, Klein C. The ‘essentials’ of essential palatal tremor: a reappraisal of the nosology. Brain 2006; 129 (Pt 4): 832-840
• 4 Deuschl G, Toro C, Valls-Solé J, Zeffiro T, Zee DS, Hallett M. Symptomatic and essential palatal tremor. 1. Clinical, physiological and MRI analysis. Brain 1994; 117 (Pt 4): 775-788
• 5 Kojovic M, Cordivari C, Bhatia K. Myoclonic disorders: a practical approach for diagnosis and treatment. Ther Adv Neurol Disorder 2011; 4 (01) 47-62