Atypical Presentation of Focal Dystonia in Female Bassoonist: A Case Study

Background: Focal dystonia is a disorder characterized by sustained or intermittent muscle contractions causing abnormal or repetitive movements. Musicians dystonia is focal task-specific dystonia (FTSD) elicited in professional musicians during instrumental playing. Approximately 1% of all professional musicians develop musician's dystonia. Demographically, male musicians tend to be affected more than women, with a male: female ratio of 4:1. Embouchure dystonia falls under the category of FTSD that affects the jaw or tongue in musicians that play woodwind instruments such as oboe, clarinet, bassoon, and flute. The purpose of this case study is to highlight an unusual presentation of focal dystonia. Case Information: We present this case of a 74-year-old female bassoonist with a clinical presentation of jaw weakness and tremor. The patient reported that the symptoms only occurred when she played her instrument. The patient's past medical history includes TMJ and rheumatoid arthritis. Physical exam findings revealed a contraction of the muscles of facial expression accompanied by small tremor-like movements of the chin when playing the bassoon. EMG/NCS studies were ordered along with MRI, which incidentally showed vestibular schwannoma. Although unrelated to the patient's symptoms, a referral was made to otolaryngology. With normal EMG results, a trial of propranolol was initiated with a concern of possible essential tremor, but patient failed to respond to the medicine. Due to the task-specific nature of the patient's symptoms, occurring only when she plays, we initiated a multidisciplinary treatment plan for focal dystonia. The patient was referred to a speech-language pathologist, and we started several home exercises to help with the movement disorder. In addition, the patient was suggested to start movement-based therapies such as the Alexander technique, yoga, and Feldenkrais. The patient was also offered counseling to help her process this serious diagnosis that can dramatically affect a musician's career. The patient also had significant joint and myofascial pain which was treated with osteopathic manipulative treatment and trigger point injections. Conclusions: This case presents an embouchure dystonia that is atypical. Our patient did not fit the typical clinical picture of young, male musician complaining of unwanted movements. While task specific, her movements mimicked essential tremor at times, not to mention other rheumatologic and musculoskeletal conditions such as degenerative joint disease and myofascial pain that contributed to the chief complaint. With the incidental findings of vestibular schwannoma, her diagnostic process was complicated as well. This case highlights the importance of including FTSD on the differential for any musician that presents to the clinic with a complaint of unwanted movements, weakness or tremor regardless of past medical history, age, and gender. Although unclear at initial presentation, with careful history, physical examination, and appropriate diagnostic tests, our team was able to arrive at the correct diagnosis and initiate appropriate treatment.