The five muscles of the soft palate include the tensor veli palatini, levator veli palatini, musculus uvulae, palatoglossus, and palatopharyngeus [
3]. Importantly, regarding our case, the tensor veli palatini tightens the anterior soft palate, flattens the arch, and opens the Eustachian tube. If it is affected unilaterally, it will deviate the soft palate laterally, and overactivity explains the audible click noted by the patient and heard on examination. The levator veli palatini tightens the posterior soft palate and raises the soft palate.
Palatal myoclonus generally entails a visible elevation of the palate, its five muscles, and uvula and may include myoclonus of other oropharyngeal muscles. It is crucial to rule out any structural lesions (e.g., inferior olivary hypertrophy) before diagnosing essential palatal myoclonus. This is a rare case of a patient with focal, unilateral palatal myoclonus without uvula elevation, and focal contraction only visualized on close inspection with concurrent auscultation. The cause of tinnitus in this disorder is not well understood, but one theory is that abnormal muscle contractions can induce pressure changes in the Eustachian tube, leading to disequilibrium between the atmospheric pressure and the middle ear pressure, which produces oscillations in the tympanic membrane causing tinnitus [
4,
5]. Focal palatal myoclonus has rarely been reported [
2]. The differential diagnosis for clicking tinnitus includes focal middle ear myoclonus due to tensor tympani or stapedius contraction with increasing tension. This cannot be visualized on oral examination but rather by examination of the tympanic membrane on otoscopic examination and confirmed by tympanometry [
6]. Unfortunately, we were unable to perform tympanometry or electromyography on our patient, as he did not return for follow-up in our clinic. Treatments such as anticonvulsants, anxiolytics, and surgical interventions are largely unsuccessful. Botulinum toxin can be injected into the levator veli palatini and/or the tensor veli palatini muscles and has been reported to provide symptomatic relief [
7]. This patient elected to see an otolaryngologist for injections and reported mild improvement in the clicking and tinnitus. The side effects of this treatment include dysphagia, hypernasality, or nasopharyngeal regurgitation [
8,
9]. This case illustrates that practitioners should perform careful oral examinations with auscultation to detect focal myoclonic contractions in a patient with ear clicking without obvious palatal or uvula elevation.