Palatal Tremor

April 10, 2024

The roof of the oral cavity is called the palate. It is the concave structure in the upper jaw that separates the oral and the nasal cavities. It plays an important role in speech and is also an area through which many important blood vessels and nerves pass through.

The palate can be divided into two types: the hard palate and the soft palate. The hard palate is named so as there is an underlying bone present. It forms the front portion of the palate. The soft palate on the other hand does not have an underlying bone. It lies posteriorly or towards the back.

The soft palate closes the nasal pathway during swallowing and it also helps in producing certain consonants during speech. There are five important muscles attached to the soft palate. The actions of these muscles are controlled by the vagus and trigeminal nerve.

A tremor is by definition an involuntary, rhythmic, oscillatory and fixed movement of one or more body parts. The tremors occur at a certain frequency which is usually constant. When such a tremor occurs in the soft palate, it is called a palatal tremor or palatal myoclonus.

There are different types of palatal tremors, each of which has its own etiology, signs, symptoms and treatment options. There are three types of palatal tremors and we shall be reviewing each one briefly.

Essential palatal tremor

Essential palatal tremor occurs without any underlying abnormally or pathology. Apart from palatal tremors, the patient may have loud ear-clicking. The main muscle involved in the tensor veli palatini. Multiple nerves contribute to the causation of these tremors. In almost half of the cases, the tremors disappear when the patient is asleep. Administration of anesthesia in that muscle stops the tremors. An MRI of the brain reveals a normal neural network.

Symptomatic palatal tremor

Symptomatic Palatal Tremor can occur due to multiple reasons. Concerning the blood vessels, there can be an internal blockage or rupture of one of the blood vessels in the brain. The patient may already be suffering from a degenerative inflammatory condition like sarcoidosis, multiple sclerosis, etc. Spinocerebellar Ataxia is a genetic condition that may contribute to palatal tremors. Tic-borne infectious diseases, presence of tumors, traumatic injury to the brain, epilepsy, drug overdose, etc. are the other possible reasons that can cause palatal tremors.

The patient can present with tremors in the lower jaw as well, blurry vision, weakness in muscles, generalized uncoordinated body movements, difficulty in speech and throat clicking. The involved muscle is the levator veli palatini. The tremors occur due to dysfunction in one or more than one nerves. The palatal tremors may persist even after the patient is asleep. Even an anesthesia may not be sufficient to suppress the symptomatic palatal tremor. A MRI scan can reveal degeneration or hypertrophy (abnormal proliferation) of the region of the brain called the medulla.

Progressive Ataxia with Palatal tremors

This type of palatal tremor is often seen as a subtype of symptomatic palatal tremor. It is accompanied with multiple problems associated with vision. The patient may have an illusionary unstable vision and may not be able to have a single center in his or her field of vision. The patient can have partial paralysis of some of the body parts which can hinder their ability to maintain a body balance. Signs of Parkinsonism and neuropathy are not uncommon.

The muscle involved in this type of palatal tremor is levator veli palatini. Tremors persist even after the patient falls asleep. Tinnitus or ringing of the ear is a commonly associated symptom.

Treatment for palatal tremor

Essential Palatal Tremor has a better prognosis than the other types of tremors. Drugs like clonazepam, carbamazepine, phenytoin, valproate, gabapentin, flunarizine, lamotrigine, trihexyphenidyl, sumatriptan and botulinum toxin have shown some promising results. However, none of these drugs are definitive treatment options for palatal tremors. This is because once the patient stops consuming those drugs, many cases have reported the recurrence of the palatal tremors.

Removal of underlying lesion through surgery does not guarantee the resolution of the tremors. Gluten-free diet has also been advocated for progressive ataxia palatal tremors. There is no definitive treatment to halt progressive ataxia.

Palatal tremors should never be ignored by the patient. Some patients may also have a voluntary control on their palatal muscles which can sometimes trigger the tremors. In each case whatsoever, the patient must undergo a MRI scan to understand the presence and extent of the pathology. 

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