palatal tremor ( pt ) is a rare disorder presenting as unilateral or bilateral rhythmic involuntary movements of the soft palate . this condition is also called  palatal myoclonus  or  palatal nystagmus  . the movement though rhythmic like tremor , consists of repetitive rather than oscillatory movements of agonist muscles only , thus having some similarity with myoclonus . essential palatal tremor ( ept ) and  symptomatic palatal tremor ( spt ) . the tremors in ept produce audible click due to the contraction of the tensor valipalatini muscle which disappear during sleep . spt does not produce audible click and the tremors continues to be present during sleep . simultaneous tremors of other regional structures with cranial nerve innervation may be present in spt causing pendular oscillopsia , laryngeal involvement interrupting speech and rhythmic limb tremors . the ept has similar prevalence rates in males and females unlike spt which is more common in males . essential tremors ( et ) in general are marked by a bimodal age distribution , peaking in the second and sixth decades . prevalence estimates for essential tremor of any anatomical site range from 0.4% to 5.6% of the population older than 40 years of age . familial clustering of et ranges from 17% to 100% , with autosomal dominance being the suspected mode of inheritance . the different lesions which interrupt the dentato - rubral - olivary pathway which is called the guillain - mollaret triangle have been implicated in spt . the exact site of pathology in ept is unclear thus indicating the two are different disease processes . the drugs used are sodium valproate , flunarizine and local infiltration of botulinum toxin but these reports have not been replicated . there is mention of the utility of benzodiazepines in ept in the literature but no reports are available for the same . clonazepam has been thought to be useful in the treatment of palatal tremors probably because of its gamma amino butyric acid ( gaba ) agonistic property . a 30-year old married female patient from a semi - urban area presented with the complaints of pain in the lower part of face , behind the ears , back side of neck which was more on the left side . initially the illness was progressive in nature for a year and then reached plateau phase . she reported clicking sound in her ears which was even audible to people at one meter distance when she opened her mouth . the clicking sound was louder when she opened her mouth and was not under her control . she also complained of poor concentration and mild impairment in work because of pain symptoms . she did not report of pervasive depressive or anxiety symptoms but she was worried about the illness . the presence of co - morbid psychiatric disorders was ruled out using mini scale ( mini international neuropsychiatric interview , english version 6.0.0 ) . general physical examination ( gpe ) revealed symmetrical rhythmic flapping movements of the soft palate and the uvula . she did not have associated regional tremors . a detailed central nervous system ( cns ) magnetic resonance imaging ( mri ) of the brain was normal and did not reveal any signal changes in olivary nucleus . she was started on clonazepam 0.75 mg /day and gradually increased to 3 mg / day over the next two months . the improvement in her symptoms started within one week and by her third visit at the end of three months , she reported an improvement of 80% in her pain symptoms and the clicking sound . video of the palatal tremor was taken to compare the improvement before and after administration of the medication to assess improvement . ept is a heterogeneous condition which currently has no demonstrable cause and no accompanying physical or radiological signs . neurophysiological studies suggest the involvement of a central oscillator within the olivo - cerebello - thalamo - cortical circuit . this over activity may be due to impaired central inhibition and converging evidence points toward a potential role of gaba dysfunction in tremor generation . the inferior olivary nucleus receives a gaba - ergic input from the dentate nucleus , red nucleus and basal ganglia . the gabaergic system inhibits electronic coupling of inferior olivary neurons , and when this pathway is disrupted may result in hyper synchronous firing of these polysynaptic neurons . the neurons of the olive are extensively coupled by gap junctions , which may relate to their capacity to oscillate when there is loss of normal gaba - ergic inhibition . one hypothesis is that tremors may arise from an imbalance between basal ganglia and cerebellar outputs . according to this theory , damaged cerebellar outflow in et may produce an imbalance that is normalized by eliminating the surviving ( tremor - generating ) output from the basal ganglia . it is also possible that the involvement of putamen is more common in patients of ept than it is believed to be . clonazepam thus may act on the gabanergic neurons of dentate nucleus , red nucleus and basal ganglia and increase the inhibition on the olivary nucleus and may lead to reduction in palatal tremors . the pharmacological treatment for pt includes a variety of agents such as anticonvulsants like benzodiazepines , anticholinergic agents , calcium channel blockers , 5-hydroxytryptamine ( 5ht ) and 5ht agonists ( sumatriptan ) , nootropics ( piracetam ) , placebos and botulinum toxin . relaxation techniques , voluntary mechanisms such as the valsalva maneuver and dental devices have also been attempted . however , it is also not clear whether the same set of medications can be used in ept and spt which are thought to be of different etiologies . in a study by mahasuar et al . , on possible drug induced palatal tremors , clonazepam was used in the dose of 0.5 mg / day . however the withdrawal of offending drug ( lithium ) and the introduction of clonazepam occurred simultaneously and thus it can not be assumed that the reduction in symptoms was solely due to clonazepam . drug therapy in ept as in any essential tremors does not cure , prevent or slow the rate of disease progression and is considered symptomatic treatment . treatment is not required if the patient does not have significant functional or psychosocial disability . patients should be informed that although significant benefit may be derived , complete tremor eradication is not a realistic expectation . however as this report is on only one patient , replication of the study result is required .
essential palatal tremor ( ept ) is a rare disorder presenting as unilateral or bilateral rhythmic involuntary movements of the soft palate . 
 there is mention of the utility of benzodiazepines like clonazepam probably because of their gamma amino butyric acid ( gaba ) agonistic property . but no reports are available for the same . here 
 we report a 30-year old married female patient who presented with the complaints of pain in the lower part of face , behind the ears , back side of neck and clicking sound in her . 
 general physical examination ( gpe ) revealed symmetrical rhythmic flapping movements of the soft palate and the uvula . 
 central nervous system ( cns ) examination did not reveal any focal deficits and magnetic resonance imaging ( mri ) of the brain was normal . 
 she was diagnosed as having ept and treated successfully with clonazepam .