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Definitions

• Dystonia is sustained, involuntary or repetitive muscle contractions causing abnormal posturing or twisting of a body part
  • A dystonia may be focal and task specific muscle contraction abnormality - such as musicians' hand dystonia 
  • "Musician's dystonia" refers to task-specific dystonia while playing musical instrument
• Embouchure (from French 'bouche' = mouth) refers to the positioning of perioral and facial muscles including tongue and teeth to play a wind instrument
  • Definition proposed by Woldendorp et al (2016): 'the process needed to adjust the amount, pressure, and direction of the air flow ... as it travels fhrough the mouth... between the lips by the position and/or movments of the tonuge, teeth, jaws, cheeks, and lipe to produce a tone in a wind instrument"
  • As per Termsarasab and Frucht (2016): "The embouchure refers to the complex pattern of muscles of the face, jaw, tongue, and pharynx used to control the force and amplitude of airflow into the mouthpiece of a brass or woodwind instrument"
  • Storms et al (2016) quote Philip Farkas (1962) defining embouchure: "the mouth, lip, chin, and cheek muscles, tensed and shaped in a precise and cooperative manner, and then blown through for the purpose of setting the air-column into vibration when these lips are placed upon the mouthpiece of a brass instrument."
• ​Embouchure dysfunction: aka emboucure problems or embouchure disorder are issues related to the embouchure. As per Storms (2016) "embouchure dysfunction often preceds the development of embouchure dystonia" (also Steinmetz 2014) 
• Embouchure dystonia (ED) is specific to the perioral and facial muscles affecting musicians of wind instruments (Ray and Pal 2022
  • As per Frucht (2016): a 'focal task-specific dystonia affecting the muscles that control the flow of air into the mouthpiece of a brass or woodwind instrument"
  • "Losing one's chops" (Mitchell 2020)
  • As per Termsarab and Frucht (2016): "Because ED is an uncommon disorder and there are no formal diagnostic criteria or goldstandard method for the diagnosis"
  • "Losing the lip" (Storms 2016)

Background

Musicians, due to their highly trained movements, may be susceptible to occupational dystonias -  including those triggered by repetitive motor activity -associated with a specific task. (Aránguiz 2011)

Embrochure dystonia

Presentation

Typical presentation: painless deterioration in task-specific embouchure positioning with features such as "tremor; lip pulling; lip-lock" (Frucht 2016); jaw and tongue abnormalities with progression over months that may affect brass (trumpet, French horn, trombone, tuba) and woodwind players (piccol, flute, oboe, clarinet, saxophone, and bassoon). 

Diagnosis "challenging even for experienced neruologists" (Frucht 2016) 

Discussion has found some support for the onset of ED (Tubiana, 2003; Schmidt et al 2013) to be associated with the following of a traumatic experience or a 'trigering incident that elevates stress levels' before first symptoms as reported by Détári and Egermann (2022). Détári and Egermann report that their 'exploratory study shows that psychologtical and psychosocial factors might play a role in the developemt of MFD" (Musicians' Focal Dystonia)

Epidemiology

Studies of musicians affected by embouchure include

• Steinmetz et al (2014) - through self-administered questionnaire regarding emboucure problems in professional brass players; questionnaire sent to 127 professional orchestras in Germany (May to June 2007) with 32.2% response rate (154 trumpet/218 horn/175 trombone/ and 36 tuba players)
  • 30% reported embouchure fatigue: "tiredness of the musculoskeletal structures involved in producing the embouchure,as known to all wind players"
  • 59% reported with 'other' embouchure disorders 
    • 9.7% (9.1% of male and 15% of female participants) reported sick leave due to embouchure disorders as some stage; of those 9.7% reporting sick leave, 67..3% reported recovery from embouchure crisis in the past with average length of crisis = 41.3 months
    • 26% of brass players reported 'cramping, a potential symptom of focal dystonia" 
    • Management included changing embouchure technique and breathing technique
  • Musicians with embouchure disorders with higher prevalence of:
    1. Being older
    2. Started to play their instrument later in life
    3. Having had longer cumulative practice time
    4. Having higher workloads
    5. Having "perfection traits"and anxiety
• Baur et al (2011) - focal task specific tremor overrepresented in bowed string players  'because of the repetitive nature of similar movements in this group". Focal task specific tremor (FT) was higher in bowed string players (9.9%) compared to 'others' (2.0%) among 591 patients recruited from the Hanorvber Institute of Music Physiology and Musicians' Medicine - with 'others' including keyboard, woodwind, brass and percussion.   
• Chesky et al (2002) as recorded by Steinmetz et Al (2014) - reporting on handicap related to embouchure in brass players identified
  • 17% loss of lip control
  • 18% mouth lesions
  • 13% TMJ syndrome
  • 11% acquired dental malocclusion
• Termsarasab and Frucht (2016) through review of 139 patients with embouchure dysfunction identified 30 with non-dystonic embouchure problems (NED) and compared them with 109 with embouchure dystonia (ED) identifying the workup to include focused history and physical exam and that most "do not require further investigations, except fo the possiblity of a lip ultrasound"
  • NED (non-dystonic) in 30 patients: infraorbital neuropathy in 10 (33%); overuse syndrome (13.3%); orbicularis oris tear - termed 'Satchmo syndrome' (13.3%) and 'assorted diagnosis - including Parkinson's disease or Essential Tremor (10%)
    • Discomfort common (60%)
    • Pain in 14 patients (14.7%) - half of whom were diagnosed with infraorbital neuropathy 
  • ED (embouchure dystonia) - classified among the 109 in their series according to 6 clinical phenotypes (3.7% unspecified)
    • Embouchure Tremor (35.8%)
    • Lip-pulling (20.2%)
    • Jaw Dystonia (19.3%)
    • Lip-locking (13.8%)
    • Tongue dystonia (3.7%)
    • Meige syndrome (3.7%)  see also: Meige's Syndrome

                      

Management

Behavioral Management

• Rehabilitation focussed on healthy technique with concurrent attention to psychological and psychosocial factors (Détári and Egermann (2022).
• "Preventions strategies" Through a survey done through the Air Force Survey Office comparing the lower incidence of embrouchure problems in musicians in the 'Air National Guard' (16% with problems) compared to 'Active Duty' musicians (49% with problems) Storms et al (2016) suggested the more demanding schedule of active duty musicians could contribute and identified potential benefit from an 'irregular practice scheule with the addition of practice-free days as a method to avoid the development of embouchure dysfunction"
• Addressing orofacial muscle tension (Iltis 2016)
• "Retraining"  (Horisawa 2018)

Oral/Dental Splints

• Mitchell et al (2020) identified that a 70 year old physician developed an isolated tremor occuring with use of trumpet mouthpiece that disappeared completely with placing a coin between his teeth while playing - then substituting it with a rubber spacer to diminish risk of injuring his teeth. Similar improvement in oromandibular dystonia has been identified with patients using 'sensory tricks' (Gonzalez-Alegre 2014) including a tongue blade secured between their teeth with creation of prostheses to then created with similar effect that in one case report was ireported with only short-lived benefit (Schneider 2011)

Oral Medication

• Treatment with oral medications has had limited benefit in the management of embouchure dystonia.  Review of the literature has demonstrated attempts with the usage of benzodiazepines, anticholinergics, and baclofen.  However, none of these agents have provided any significant improvement in dystonia symptoms.
• Per Termsarasab and Frucht (2016): Treatment of tremor variant of ED "may benefit partially from treatment with propranolol"
• Anticholinergics and baclofen (Horisawa 2018)

Botulinum Toxin

• Treatment with botulinum toxin has had limited benefit in the management of embouchure dystonia.  Review of the literature has demonstrated multiple attempts at injection of the lips or perioral muscles.  However, no reports exist within the literature of significant improvement with any particular target or standardized approach for embouchure dystonia
• Per Termsarasab and Frucht (2016): Treatment of ED by senior author- "injected botulinum toxin in several patients, with disappointing results and frequent side effects of excess weakness"

Surgery via Pallidotomy

• Harisawa et al (2018) reported long term improvement in managmeent of task specific ED in a single patient following bilateral pallidotomy following 'little effect' of anticholinergics, sensory tricks, and bolutinum toxin injections for 'task-specific ED' in a professional brass and woodwind instrument player with discomfort playing the saxophone at age 43 progressing to pulling laterallly and upward movement of upper lip resulting in air leakage - unable to play professionally - leaving his job. Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) was offered but defered due to patient aversion to implantation of mechanical device in body. Due to predominant left sided symptoms - a right-sided pallidotomy was done with monopolar radiofrequency probe - 'permanent lesions were created using thermocoagulation at 70°C for 40 s.'  Improvement was noted for 2 weeks followed by onset of lateral pulling of the right lip - leading to left sided pallidotomy 6 months later (same manner as first) - with symptoms significantly improved permitting him to continue to play brass instruments professionally at the time of followup one year later.  These investigators conclude that if available conservative treatments have failed "stereotactic pallidotomy can be considered the last resort for treating refractory ED"

 

 

References

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