Case study
Objective Tinnitus from Palatal Myoclonus. Use of Botulinum Toxin: A Case Report
Mioclonía palatal como causa de acúfeno objetivo. Uso de toxina botulínica: a propósito de un caso
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Use of Botulinum Toxin: A Case Report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "392" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Noemi Conill Tobías, Carlos de Paula Vernetta, Francisco Javier García Callejo, Jaime Marco Algarra" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Noemi" "apellidos" => "Conill Tobías" "email" => array:1 [ 0 => "noeconill@hotmail.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carlos" "apellidos" => "de Paula Vernetta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "García Callejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Jaime" "apellidos" => "Marco Algarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio Otorrinolaringología, Hospital Clínico Universitario, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mioclonía palatal como causa de acúfeno objetivo. Uso de toxina botulínica: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 870 "Ancho" => 938 "Tamanyo" => 106520 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Points of injection at the levator (front) and tensor (back) veli palatini muscles. Endoscopic view of the right nasal fossa.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 78-year-old female patient with a history of arterial hypertension and depressive symptoms, in the context of chronic objective tinnitus.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We performed oropharyngeal inspection, otoscopy, nasofibroscopy, liminal tone audiometry, tinnitometry, tympanometry and distortion-product otoacoustic emissions (DPOAE), leading to the diagnosis of palatal myoclonus. The patient had previously been examined by computed tomography (CT) and magnetic resonance imaging (MRI) tests at the Neurology Service, and both assessments were within normal limits.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was intervened under local anaesthesia and direct vision with a 0° rigid endoscope. We injected 10<span class="elsevierStyleHsp" style=""></span>units (U) of botulinum toxin, subtype A (5U in the tensor of the soft palate [tensor veli palatini] and 5<span class="elsevierStyleHsp" style=""></span>U in the elevator of the soft palate [levator veli palatini], bilaterally) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). We performed weekly controls during the first month and then after 3 and 6 months. Tinnitus disappeared after 7 days. On the 15th day we observed bilateral paralysis of the tensor and levator veli palatini muscles, noting only a slight contraction of the left soft palate, without associated symptoms. As a side effect, we observed open rhinolalia during the first week of treatment, which generated nasal fluid reflux on 2 occasions. There was no evidence of otalgia or increase of hearing loss (bilateral, moderate, and mixed hearing loss). Neither did we observe episodes of dysphagia or aspiration. Correct laryngeal function after injection was also observed during follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tinnitus reappeared after 5 months, although its intensity was less than the initial, so we decided to administer a second dose of type-A botulinum toxin (30<span class="elsevierStyleHsp" style=""></span>U).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Objective tinnitus can present various aetiologies, with palatal myoclonus being one of the most unusual. This rare pathology<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> is generated by a rhythmic, involuntary contraction of the soft palate.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Botulinum toxin subtype A is indicated in all those pathologies resulting from muscular hyperfunction and autonomic dysfunction. It binds to cholinergic nerve endings, resulting in flaccid muscular paralysis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its peak effect occurs within 7–14 days, and muscular function is re-established within 3–6 months. Its repeated use does not result in muscle atrophy or permanent degeneration.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the present case, the patient suffered objective tinnitus which had intensified to the point of significantly affecting her daily activities. In the diagnosis, we highlighted the repeated presence of a notch in the impedance curve which corresponded to the tinnitus observed in the patient. Oropharyngeal examination and nasofibroscopy were also consistent with the diagnosis. In order to calculate the dose, we began by using the lowest effective dose published in the literature,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–9</span></a> noting minimal side effects. We subsequently decided to increase the dose (30<span class="elsevierStyleHsp" style=""></span>U), without observing a significant increase in its duration of effect.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The use of botulinum toxin for the treatment of palatal myoclonus in our case obtained optimal results with minimal side effects. The only inconvenient was the temporary effect of the toxin, which required repeated injections every 5–6 months.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres95049" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82201" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95048" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82200" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of Interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82201" "palabras" => array:3 [ 0 => "Objective tinnitus" 1 => "Palatal myoclonus" 2 => "Botulinum toxin" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82200" "palabras" => array:3 [ 0 => "Acúfeno objetivo" 1 => "Mioclonía palatal" 2 => "Toxina botulínica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Objective tinnitus can have many different etiologies, palatal myoclonus being one of the less frequent. This type of tinnitus is generated by involuntary rhythmic contraction of the soft palate, which generates an audible click for the patient and for the explorer.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Botulinum toxin achieves temporary muscle paralysis through presynaptic inhibition of the acetylcholine level at the neuromuscular union.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We present a patient with long-term objective tinnitus, along with this patient's response to botulinum toxin injection.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El acúfeno objetivo o somatoacúfeno puede presentar múltiples etiologías, siendo una de las más infrecuentes la mioclonía palatal generada por la contracción rítmica e involuntaria del paladar blando que genera un click audible por el enfermo y el explorador.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La toxina botulínica genera una parálisis temporal a nivel muscular mediante la inhibición presináptica de la acetilcolina a nivel de la unión neuromuscular.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente con un acúfeno objetivo de larga evolución y su respuesta a la inyección con toxina botulínica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Conill Tobías N, et al. Mioclonía palatal como causa de acúfeno objetivo. Uso de toxina botulínica: a propósito de un caso. Acta Otorrinolaringol Esp. 2012;63:391–2.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 870 "Ancho" => 938 "Tamanyo" => 106520 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Points of injection at the levator (front) and tensor (back) veli palatini muscles. Endoscopic view of the right nasal fossa.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 707 "Ancho" => 942 "Tamanyo" => 118897 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Material for injection of botulinum toxin.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of clostridium botulinum toxin in palatal myoclonus. A preliminary report. A preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.R. Saaed" 1 => "G.B. Brokes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Laryngol Otol" "fecha" => "1993" "volumen" => "107" "paginaInicial" => "208" "paginaFinal" => "210" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8509697" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endonasal approach of salpingo pharyngeus muscle for the treatment of ear click related to palatal tremor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.F. Chien" 1 => "T.G. Sanchez" 2 => "L.U. Sennes" 3 => "E.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 4 | 0 | 4 |
| 2021 August | 1 | 2 | 3 |
| 2021 May | 1 | 2 | 3 |
| 2021 March | 0 | 24 | 24 |
| 2021 February | 0 | 22 | 22 |
| 2021 January | 0 | 35 | 35 |
| 2020 December | 0 | 15 | 15 |
| 2020 November | 0 | 24 | 24 |
| 2020 October | 0 | 11 | 11 |
| 2020 September | 0 | 4 | 4 |
| 2020 August | 0 | 1 | 1 |
| 2020 June | 0 | 4 | 4 |
| 2020 May | 0 | 6 | 6 |
| 2020 April | 0 | 2 | 2 |
| 2020 March | 25 | 5 | 30 |
| 2020 February | 34 | 14 | 48 |
| 2020 January | 33 | 11 | 44 |
| 2019 December | 43 | 13 | 56 |
| 2019 November | 22 | 18 | 40 |
| 2019 October | 32 | 12 | 44 |
| 2019 September | 27 | 13 | 40 |
| 2019 August | 16 | 13 | 29 |
| 2019 July | 27 | 21 | 48 |
| 2019 June | 42 | 31 | 73 |
| 2019 May | 96 | 53 | 149 |
| 2019 April | 64 | 24 | 88 |
| 2019 March | 23 | 9 | 32 |
| 2019 February | 18 | 8 | 26 |
| 2019 January | 15 | 10 | 25 |
| 2018 December | 19 | 10 | 29 |
| 2018 November | 16 | 11 | 27 |
| 2018 October | 13 | 10 | 23 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 31 | 3 | 34 |
| 2018 March | 1 | 4 | 5 |
| 2018 February | 8 | 6 | 14 |
| 2018 January | 2 | 6 | 8 |
| 2017 December | 4 | 12 | 16 |
| 2017 November | 11 | 7 | 18 |
| 2017 October | 12 | 13 | 25 |
| 2017 September | 10 | 9 | 19 |
| 2017 August | 18 | 15 | 33 |
| 2017 July | 24 | 5 | 29 |
| 2017 June | 17 | 21 | 38 |
| 2017 May | 23 | 13 | 36 |
| 2017 April | 17 | 7 | 24 |
| 2017 March | 11 | 13 | 24 |
| 2017 February | 9 | 9 | 18 |
| 2017 January | 3 | 2 | 5 |
| 2016 December | 15 | 14 | 29 |
| 2016 November | 22 | 5 | 27 |
| 2016 October | 30 | 10 | 40 |
| 2016 September | 27 | 14 | 41 |
| 2016 August | 19 | 5 | 24 |
| 2016 July | 16 | 8 | 24 |
| 2016 June | 19 | 11 | 30 |
| 2016 May | 24 | 20 | 44 |
| 2016 April | 21 | 16 | 37 |
| 2016 March | 25 | 18 | 43 |
| 2016 February | 27 | 20 | 47 |
| 2016 January | 27 | 21 | 48 |
| 2015 December | 24 | 15 | 39 |
| 2015 November | 19 | 7 | 26 |
| 2015 October | 19 | 9 | 28 |
| 2015 September | 20 | 9 | 29 |
| 2015 August | 42 | 6 | 48 |
| 2015 July | 20 | 5 | 25 |
| 2015 June | 6 | 2 | 8 |
| 2015 May | 18 | 1 | 19 |
| 2015 April | 18 | 8 | 26 |
| 2015 March | 31 | 10 | 41 |
| 2015 February | 24 | 4 | 28 |
| 2015 January | 26 | 5 | 31 |
| 2014 December | 35 | 10 | 45 |
| 2014 November | 32 | 4 | 36 |
| 2014 October | 42 | 10 | 52 |
| 2014 September | 40 | 7 | 47 |
| 2014 August | 17 | 3 | 20 |
| 2014 July | 22 | 6 | 28 |
| 2014 June | 18 | 1 | 19 |
| 2014 May | 12 | 3 | 15 |
| 2014 April | 14 | 4 | 18 |
| 2014 March | 11 | 5 | 16 |
| 2014 February | 9 | 4 | 13 |
| 2014 January | 9 | 6 | 15 |
| 2013 December | 15 | 6 | 21 |
| 2013 November | 8 | 7 | 15 |
| 2013 October | 16 | 11 | 27 |
| 2013 September | 12 | 4 | 16 |
| 2013 August | 15 | 2 | 17 |
| 2013 July | 1 | 0 | 1 |
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