A 33 year old male presented acutely with headaches, dysarthria and increasing drowsiness in the context of previous ventriculoperitoneal (VP) shunting. The background was significant for medulloblastoma diagnosed at age 8 years, treated with surgical resection and adjuvant chemoradiotherapy. Other medical issues included hypopituitarism, radiation retinopathy and osteoporosis. A review 12 months prior had noted nocturnal stridor and palatal myoclonus which was presumed to be secondary to radiotherapy changes within the posterior fossa. Initial imaging demonstrated hydrocephalus with a calcified and obstructed intra-abdominal portion of the VP shunt. A shunt revision was performed with radiological resolution of hydrocephalus. Days after the shunt revision, the patient developed hiccups and stridor progressing to respiratory failure requiring intubation then tracheostomy formation. Flexible nasendoscopy (FNE) demonstrated bilateral adducted midline vocal folds with no change in positioning in response to inspiration, expiration or vocalisation suggestive of dystonia. FNE also observed 3 Hz coarse supraglottic, pharyngeal and palatal rhythmic myoclonus (Videos and ). The patient later developed ocular pendular nystagmus and rhythmic facial muscle twitching consistent with the syndrome of oculopalatal tremor (OPT). Repeat electroencephalograms (EEGs) did not demonstrate epileptiform activity, nor a cortical electrical correlate for the OPT. There was no response in the OPT or tonic positioning of the vocal folds to trials of benzodiazepines, sodium valproate, levetiracetam or pulse steroids. MRI imaging demonstrated T2 hyperintensity within the bilateral inferior olivary nuclei consistent with progressed HOD. It also showed known cerebellar atrophy and gliosis secondary to previous surgery and radiotherapy, and bilateral calcified subdural haematomas complicating long-term VP shunting. There were no abnormalities identified in the basal ganglia. Previous MRI imaging after the completion of childhood medulloblastoma treatment did not show any evidence of developing HOD. FNE was repeated at 6 weeks with unchanged dystonic midline positioning of the vocal folds. In discussion with the patient and family, the tracheostomy was decannulated after a period of 10 weeks and the patient was palliated. Laryngeal EMG was not performed as it would not change the palliative management.