A 19-year-old heavy metal singer with a history of congenital micrognathia, posttraumatic stress disorder, and anxiety developed isolated movements of the soft palate after lower mandible corrective surgery (osteotomy and genioplasty). He endorsed ear clicks and control over the movements. On examination, there were rhythmic movements of the distal soft palate, characteristic of essential palatal tremor (EPT). However, their change in frequency and amplitude on command (video on the Neurology® Web site at www.neurology.org) indicated volitional control. Unlike psychogenic EPT, whereby variability and entrainability must be present1 and endorsed as involuntary (“a-volitional”), patients with volitional EPT admit to full control and no disability (figure). They have also been categorized as the “voluntary/special skill” EPT variant.2 No neurologic investigations are warranted in patients with volitional EPT.
“Essential” palatal tremor (EPT) can be distinguished from the slow tremor (myorhythmia) of secondary palatal tremor (SPT) by the lack of associated neurologic deficits. EPT, in turn, can be segregated into 3 overlapping clinical variants, as inspired by the nosography proposed by Zadikoff, Lang, and Klein2: psychogenic EPT, where a variable and suppressible tremor occurs against the will (“anti-voluntary”); secondary EPT, partially volitional and temporarily suppressible (“un-voluntary”); and volitional EPT, where there is complete control and no disability (patient reported here).
Footnotes
Supplemental data at www.neurology.org
Author contributions: Jose Biller: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, acquisition of data, study supervision. Alberto J. Espay: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and gave final approval, study supervision.
Study funding: No targeted funding reported.
Disclosure: J. Biller reports no disclosures. A. Espay is supported by the K23 career development award (NIMH, 1K23MH092735); has received grant support from CleveMed/Great Lakes Neurotechnologies, Davis Phinney Foundation, and Michael J Fox Foundation; has received personal compensation as a consultant/scientific advisory board member for Solvay (now Abbvie), Chelsea Therapeutics, TEVA, Impax, Merz, Solstice Neurosciences, Eli Lilly, and USWorldMeds; and has received honoraria from Novartis, UCB, TEVA, the American Academy of Neurology, and the Movement Disorders Society. He serves as Associate Editor of Movement Disorders and Frontiers in Movement Disorders and on the editorial board of The European Neurological Journal. Go to Neurology.org for full disclosures.
- © 2013 American Academy of Neurology
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