Therapy of Involuntary Movements of Soft Palatewith Objective Tinnitus by Means of Botulotoxin

Overview

S u m m a r y:
In classical textbooks on Otolaryngology, involuntary movements of soft palate aredescribed as myoclonus or myorrhythmia. Neurophysiologists describe the phenomenon as a softpalate tremor for the predominantly regular frequency. Two forms of the tremor are differentiated:essential and symptomatic. The cause of essential tremor remains unclear,whereas the symptomatictremor originates in disorders of the function of nucleus olivae and nucleus dentatus cerebelli. Nochanges of density were observed in MRI examination in the essential tremor, while hyperdensitywas noted in T-weighted images in ventral part of medulla oblongata, i.e. in the area of nucleusolivae. In the case of essential tremor, involuntary movements of soft palate were observed, basedespecially on contractions of m. tensor veli palatini, whereas involuntary contractions of m. levatorveli palatini occurred in the symptomatic tremor. It is particularly the essential tremor, which isaccompanied with objective tinnitus, originating during opening of the orifice of Eustachian tubein contractions of m. tensor veli palatini. Involuntary contractions of m. tensor veli palatini and theresulting objective tinnitus were repeatedly favorably influenced by administration of botulotoxininto m. tensor veli palatini.Essential tremor was observed in two patients. The frequency was irregular in both of them. Noneurological finding suggesting that the symptomatic tremor is based on an organic defect wasdetected in either of them. At the same time, one of the patients, a 41-year man was affected bycontractions of m. tensor veli palatini on both sides with extension of soft palate, being accompaniedby objective registration of clattered tinnitus. The other patient, a 51-year woman was affected bycontractions of m. tensor veli palatiniwith symmetrical elevation of soft palate. Botox, 10 units,wasadministered into soft palate muscles (into m. tensor veli palatini in the 41-year man and into m.levator veli palatini in the 51-year woman) on both sides. In the male patients, where the tremorwas induced by contractions of m. tensor veli palatini, there was a significant improvement oftinnitus, but it reappeared after 4 weeks. After 4 months of Botox, 7 units, was administered againinto both m. tensor veli palatini muscles with subsequent deterioration of tinnitus, which was notregistered by objective examination. Twitching occurred in m. sternocleidomastoideus as well asdyspnoa attacks, accompaniedwith marked changes in behavior and the patient was recommendedfor psychiatric therapy. In the 51-year woman, there was a diminution of tinnitus which finallyalmost dissappeared. After deterioration of the previously manifested complaints with locomotionof cervical spine and pains the contractions of soft palate and its elevation with objective registrationof clattering tinnitus reappear during movements of the head into outer position and back tothe middle position. Involuntary movements of soft palate at rest occur only exceptionally beingaccompanied by tinnitus of low intensity and not registered by objective examination.Etiological mechanism of the origin of involuntary movements of soft palate with objective tinnitusin the two patients proved to be completely different. It was apparently a manifestation of psychosomaticdisease in one of them, whereas in the other patient the motor involuntary stereotype wasapparently induced by reflex mechanism on the basis of disorders in cervical spine dynamics.Botulotoxin, by virtue of its effect, entered the motor involuntary stereotype induced by variousetiological mechanisms.

Key words:
myoclonus of soft palate, objective tinnitus, botulotoxin.