Injections

in the wrist can cause hand weakness, and dysphagia, hoarseness, and breathiness

can occur with injections into the neck or vocal cords. The use of botulinum toxin

injections in the United States is also limited by cost. Treatment should occur with

the lowest dose, and the interval should be as long as possible between injections.

DBS of the ventral intermediate nucleus of the thalamus or unilateral thalamotomy is

possibly efficacious in reducing ET.

170 Greater improvement in self-reported

measures of function and fewer adverse events make DBS the preferred surgical

option of the two.

170

Because K.H. is otherwise healthy, she is a good candidate for propranolol

therapy. Propranolol can be initiated as needed or on a scheduled basis depending on

the degree of impairment and desire of the patient. If the decision is made with K.H.

to use propranolol on an as-needed basis, she should begin with one-half of a 20-mg

tablet administered 30 minutes to 1 hour before the desired effect. The dose can be

increased from one-half to two tablets. An example of a situation in which this may

occur is whether she wants to avoid embarrassment with attending a social activity

or before certain tasks requiring manual dexterity at work. Given the degree of her

impairment, she is probably a better candidate for chronic suppressive therapy with

propranolol. In this situation, she can be prescribed 10 mg twice daily, because it can

be safely and easily up-titrated every few days to a minimally effective dose,

generally not more than 120 to 360 mg/day in divided doses.

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