Objective: To describe a case of tremor of the lips and perioral muscles in a flutist only when forming her embouchure or playing flute.

Background: Task or position specific tremors may affect orolingual structures and have been described in musicians. There has been some controversy regarding classification of task-specific tremors as a form of task-specific dystonia, or as a separate entity.1

Methods: A 63-year old female professional flutist was evaluated for several years of difficulty with flute playing. She first noticed trouble controlling vibrato followed by development of unwanted rhythmic oscillations of her lips and mouth only when she would form her embouchure or play her flute. The movements would not occur with any other activity such as eating, drinking, speaking, singing, or whistling. She did not detect sustained pulling of any part of her face or mouth, though felt a slight tightness in her throat when playing. She experienced no tremor or dystonic posturing elsewhere on her body. Approximately 20 years prior to the onset of her current symptoms she had intermittent tremor in the jaw and mouth occurring only during high-stress performances or auditions and significantly improved with as-needed propranolol.

Results: Exam showed regular, rhythmic (6-7Hz) shaking of the lips and perioral muscles only when forming the shape of her embouchure or playing flute. Movements primarily involved zygomaticus, orbicularis oris, and mentalis muscles. No tremor was observed with other oral movements or in other body regions. There was no clear dystonic posturing of facial or perioral muscles; however, there was possibly very subtle dystonic pulling of left more than right fingers. There were subtle mirror movements of contralateral fingers when she was given a sequential tapping task with either hand. Interestingly, she was found to have some reduction in tremor when playing flute with a tongue depressor clenched between her right-side molars. Brain MRI was unremarkable. Her presentation was felt most consistent with a task-specific embouchure tremor, but with features suggestive of dystonia as well, including possible sensory trick, subtle posturing in the fingers, and mirror movements in the hands. There was no significant improvement in tremor with levodopa trial or propranolol, but she reported modest improvement with mirtazapine.

Conclusions: This case illustrates the potential for overlapping features in task-specific tremor and dystonia.

References: 1. Silverdale MA, Schneider SA, Bhatia KP, Lang AE. The spectrum of orolingual tremor–a proposed classification system. Mov Disord 2008;23:159-167.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/task-specific-embouchure-dystonia-in-a-flutist/