Disclosures: Cheng-Chuan Chiang, DO: No financial relationships or conflicts of interest

Case Diagnosis: Palato-Pharyngo-Laryngeal Myoclonus

Case Description: An 81-year-old male with a history of recurrent left cerebellopontine meningioma presented with altered mental status, found to have left middle cranial fossa mass with vasogenic edema of the temporal lobe. He was treated with dexamethasone and left craniotomy tumor resection. Modified barium swallow study (MBSS) during inpatient rehabilitation demonstrated palato-pharyngo-laryngeal myoclonus with decompensated oropharyngeal swallow and aspiration to all liquid consistencies; he was started on pureed solids and IV fluids for hydration. After two weeks of speech therapy, repeat MBSS continued to demonstrate aspiration of all liquid consistencies; thus, alternative means of enteral nutrition were recommended.

Setting: Acute Comprehensive Inpatient Rehabilitation HospitalAssessment/

Results: Brain MRI revealed abnormalities of cranial nerves IX and X with hypertrophic right inferior olive in the GMT likely due to chronic post-surgical changes of the left dentate nucleus. Conservative treatment included valproic acid and targeted speech therapy for lingual resistive exercises, chin tuck against resistance, and expiratory muscle strength training.

Discussion: There are about 200 cases reporting a strong association between palatal myoclonus and dysphagia involving muscles of the velum, pharynx, and layrnx. It is often related to disrupted connections of the dentato-rubro-olivary pathway in the Guillain-Mollaret triangle (GMT). In our case, we suspect that the meningioma and surgical resection may have disrupted this pathway. Currently, there is no standard of care, but literature indicates potential efficacy with valproic acid, gabapentin, memantine, botox, and or speech therapy.

Conclusion: In the field of physiatry, dysphagia is a common impairment in neurorehabilitation patients. This case depicts the importance of evaluating for palatal myoclonus as part of the dysphagia assessment. Along with identifying abnormalities in the GMT area, MRI can assist with early detection and prospective medical interventions. Further case-control studies would be indicated to study the prognosis of patients with early palatal myoclonus diagnosis receiving appropriate treatments.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/palato-pharyngo-laryngeal-myoclonus-as-a-rare-cause-of-dysphagia-a-case-report/