In response to Palatal myoclonus: Algorithm for management with botulinum toxin based on clinical disease characteristics

We thank Dr. Ozdogan and colleagues for their comments regarding our article on the management of palatal myoclonus with botulinum toxin. As we state in the article, weakening of the palatal musculature to treat the symptoms of a clicking tinnitus, awareness of palatal movements with or without rhinolalia, or both can potentially lead to velopharyngeal incompetence, rhinophonia, dysphagia, and symptomatic Eustachian tube obstruction, with subsequent poor middle ear ventilation requiring tympanostomy tube placement. This is the reason to start with low doses and add toxin as necessary to minimize the risk of these side effects; however, patients should be counseled concerning the possibility of these adverse events before agreeing to the treatment. It should be noted that, in some cases, placement of ventilation tubes alone or stenting of the Eustachean tube can reduce the symptoms. In our case series of six patients, no patient had otitis media with effusion on clinical examination postinjection and no patient complained of aural fullness. Thus, impedance examinations were not conducted; our indication to perform such tests would have been based on the presence of symptoms or objective clinical examination findings.