Fig. 1

Algorithm for evaluation of ED depicts the thought process behind evaluating patients with ED in the office. The figure proceeds from left to right. Once the diagnosis of ED is suspected (and non-dystonic disorders such as overuse syndrome, inferior orbital neuropathy, embouchure tears and lip trauma are excluded), the first priority is to determine the primary phenotype. Of the six phenotypes, jaw and tongue involvement are noteworthy for their risk of spread of dystonia to speaking and eating (red text). Next, range and technique specificity, coincident writer’s cramp, and the presence of sensory tricks should be ascertained. Finally, if dystonia has spread to speech or eating, or if the jaw or tongue phenotype is present, patients should be counseled to stop playing