Introduction
Brainstem lesions in the triangle of Guillain and Mollaret interrupt dentato-rubro-olivary pathway. Interruption of this circuit results in a characteristic, though rare, movement disorder called palatal tremor that presents with recurring rhythmic contractions of the soft palate and sometimes synchronous twitching of the lower facial muscles, pharynx, larynx, trunk, and extremities. We reported cases of dysphasia patients with palatal tremor.
Case 1) A 61-year old man presented with hoarseness, dysarthria and dysphasia. Physical examination revealed palatal tremor. Palatal tremor could be visualized during VFSS, with inadequate bolus formation, nasal regurgitation, delayed swallowing reflex, reduced laryngeal elevation and aspiration at thickened fluids. Brain MRI demonstrated focal infarction at left cerebellum and left pons and hemorrhagic transformation at left posterior midbrain involving superior cerebellar peduncle. (Fig 1.) Case 2) A 63-year old man presented with hoarseness, dysarthria and dysphasia. Physical examination revealed palatal tremor with synchronous twitching of lower facial muscles, pharynx and larynx. Palatal tremor could be visualized during VFSS, with inadequate bolus formation, delayed swallowing reflex and aspiration at thickened fluids. Brain MRI demonstrated focal infarction at left cerebellum, left pons and both midbrain involving superior cerebellar peduncle. (Fig 2.) Case 3) A 40-year old woman presented with dysphasia, hoarseness and dysarthria. Physical examination revealed palatal tremor. Palatal tremor could be visualized during VFSS with pre-mature bolus loss, delayed swallowing reflex and aspiration at thickened fluids. Brain MRI demonstrated ICH at right posterior midbrain involving superior cerebellar peduncle. (Fig 3.)
Conclusion
We reported three rare cases of dysphasia patients with palatal tremor with lesion in the triangle of Guillain and Mollaret, especially superior cerebellar peduncle without involvement of the medulla. The review of these rare cases confirmed through both physical assessment and MRI may help understand and learn about dysphasia patients with palatal tremor as a result of lesion in the triangle of Guillain and Mollaret. |
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