Objectives/Hypothesis: To evaluate the relative efficacy of unilateral and bilateral injections of botulinum toxin injection (BOTOX) in the treatment of essential tremor of the voice (ETV). Study Design:Prospective open-label crossover study. Methods: Patients referred to the Neurolaryngology Clinic at Toronto General Hospital with a diagnosis of ETV were eligible for the study. Patients were sequentially assigned to receive BOTOX as either a bilateral 2.5-U or a unilateral 15-U electromyography-guided injection, followed by the alternative injection 16 to 18 weeks later. Acoustic, aerodynamic, and nasopharyngoscopic data were collected approximately 2, 6, 10, and 16 weeks after each injection. Patients were asked to provide a perceptual evaluation of BOTOX effects at the conclusion of the study. Results: Three of 10 patients demonstrated an objective reduction in tremor severity with bilateral injection, and 2 of 9 with unilateral injection. However, 8 of 10 patients wished to be re-injected at the conclusion of the study. A reduction in vocal effort appeared to be coincident with reduction in laryngeal airway resistance after BO-TOX injection. Conclusions: Using objective acoustic measures, only a small proportion of patients achieved benefit from BOTOX injection for ETV. However, a majority of patients in our study benefited from a subjective reduction in vocal effort that may have been attributable to reduced laryngeal airway resistance.

The clinical spectrum of intracranial hypotension can be broadened to include parkinsonism, cerebellar ataxia, and prominent bulbar dysfunction. As with more common manifestations of the disorder, these features may resolve after appropriate treatment.

Objectives: To review the clinical characteristics and associated features found in patients with psychogenic tremor. Methods: Ten-year retrospective review of charts of all patients and videotapes of fifty-one patients diagnosed by the senior author as having psychogenic tremor. Results: Seventy patients fulfilled the diagnostic criteria for clinically definite psychogenic tremors. Psychogenic tremors usually started abruptly (73%), often with the maximal disability at onset (46%), and then took static (46%) or fluctuating (17%) courses. Psychogenic tremors usually started in one limb and spread rapidly to a generalized or mixed distribution. Spontaneous resolution and recurrence, easy distractibility together with entrainment and response to suggestion were characteristic features. Presence of functional symptoms and signs and refractoriness to conventional antitremor drugs were common. Conclusions: Psychogenic tremor is generally not a diagnosis of exclusion. The presence of characteristic features on history and especially clinical examination can permit an accurate diagnosis and avoid unnecessary investigations. RESUME: Caracteristiques historiques et cliniques du tremblement psychogene: revue de 70 cas. Objectifs: Nous revoyons les caracteristiques cliniques et les manifestations associees observees chez les patients atteints de tremblement psychogene. Methodes: Nous avons proc6de a une revue retrospective des dossiers de tous les patients et aux enregistrements video de cinquante et un patients chez qui I'auteur senior a pose un diagnostic de temblement psychogene. Resultats: Les criteres diagnostiques cliniques du tremblement psychogene eteient presents chez soixante-dix patients. Le tremblement psychogene commencait habituellement abruptement (73%), donnant lieu sou vent k une invalidit6 maximale au dfibut (46%) avec une evolution stable (46%) ou fluctuante (17%). Les tremblements psychogenes commencaient habituellement dans un membre et se propageaient rapidement en une distribution g6n6ralis£e ou mixte. La resolution spontanee et la recidive, la distractibilitd ainsi que l'entrainement et la r6ponse & la suggestion dtaient des manifestations caracteristiques. La presence de symptomes et de signes fonctionnels et le fait que le tremblement soit refractaire aux medicaments antitremblement 6taient frequents. Conclusions: Le tremblement psychogene n'est g6neralement pas un diagnostic d'exclusion. La presence de manifestations caracteristiques a l'histoire et surtout a l'examen clinique peut permettre un diagnostic exact et eViter des investigations inutiles.

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