Aberrant Facial Nerve Regeneration Research Articles

Combining early lower eyelid surgery with neuromuscular retraining for synkinesis prevention after facial palsy: the role of the eye in aberrant facial nerve regeneration.

Facial synkinesis (FS) is a distressing sequela of facial palsy (FP) characterized by involuntary, simultaneous movements of facial muscles occurring during voluntary facial expressions. Treatment of synkinesis is challenging, and preventive methods are needed. This study evaluated the efficacy of physical facial nerve rehabilitation (PFNR) therapy alone vs. PNFR with eyelid surgery to correct lagophthalmos and prevent the onset of synkinesis. Twenty five outpatients were randomized to receive either PFNR alone (neuromuscular retraining and Kabat proprioceptive neuromuscular facilitation) or PNFR and early (90 days after FP onset) eyelid surgery (involving a conservative oculoplastic correction for lagophthalmos with epiphora or ectropion). Comprehensive otolaryngological assessments and Magnetic Resonance Imaging (MRI) were conducted. Synkinesis progression was measured using Another Disease Scale (ADS) at baseline, 3-, 6-, 12-, and 24-months post-treatment. The data were analyzed with ANOVA, τ-test, Chi-Square analyses. Patients undergoing eyelid surgery with PFNR showed faster (p < 0.001) and better recovery of facial movements (p < 0.05) than patients receiving PFNR alone comparing T0 and T12 (p < 0.0001). No synkinesis were observed in the PFNR plus surgery group while 37% of patients in PFNR alone had synkinesis (p = 0.03). At 24 months, none of the patients in the surgery group presented synkinesis. Combining early surgical treatment of paralytic lagophthalmos or epiphora with PFNR accelerated functional recovery and reduced synkinesis in patients with FP compared to facial rehabilitation alone. Further investigations in larger populations with long-term follow-up are needed. https://clinicaltrials.gov/study/NCT06538103, NCT06538103.

Switchover study of onabotulinumtoxinA to incobotulinumtoxinA for facial dystonia.

When making a cost-saving it is important to ensure there is no loss of efficacy. Clinical effectiveness and efficiency of incobotulinumtoxinA compared to onabotulinumtoxinA in facial dystonia is unclear. Our aim is to evaluate switching from onabotulinumtoxinA to incobotulinumtoxinA in the treatment of essential blepharospasm (EB), hemifacial spasm (HFS) and aberrant facial nerve regeneration (AFR). A retrospective study of a prospective, single-masked switchover audit from onabotulinumtoxinA to incobotulinumtoxinA. Twenty essential EB, 12 HFS and six AFR patients. A switchover from stable onabotulinumtoxinA to incobotulinumtoxinA using a 1:1 unit ratio and contemporaneous efficacy measures. Two nurse injectors performed the injections over a period of 6 years. Each masked patient received three onabotulinumtoxinA and three incobotulinumtoxinA over a minimum of 2 years. At each visit, a blepharospasm disability score (BDS), Jankovic score (JS), subjective improvement (SI), duration of maximum effect (DME) and complications were recorded. A cost comparison per unit dose was made. Twenty EB, 12 HFS and six AFR received 114 onabotulinumtoxinA and 114 incobotulinumtoxinA treatments. Both brands had similar efficacy, but SI (P < .01) and DME (P < .05) were higher in the HFS group with incobotulinumtoxinA. Complications included bruising (two onabotulinumtoxinA, one incobotulinumtoxinA) and ptosis (three onabotulinumtoxinA, zero incobotulinumtoxinA). OnabotulinumtoxinA was 33% pricier. Switching from onabotulinumtoxinA to incobotulinumtoxinA did not result in an inferior outcome for the treatment of facial dystonia and led to a cost-saving for the department.

Re: "Paradoxical Prominence of Nasolabial Fold as a Sign of Aberrant Facial Nerve Regeneration: .

The authors have no financial or conflicts of interest to disclose. Correspondence: Michael K. Yoon, M.D., 243 Charles Street, Boston, MA 02114 ([email protected])

Reply Re: "Paradoxical Prominence of Nasolabial Fold as a Sign of Aberrant Facial Nerve Regeneration: .

Reply Re: "Paradoxical Prominence of Nasolabial Fold as a Sign of Aberrant Facial Nerve Regeneration: .

Pseudoptosis after Aberrant facial nerve regeneration (AFR): an under-recognized entity

Pseudoptosis after Aberrant facial nerve regeneration (AFR): an under-recognized entity

Treatment of Pseudoptosis Secondary to Aberrant Regeneration of the Facial Nerve With Botulinum Toxin Type A

To report on low-dose minimal injection treatment using botulinum toxin A for pseudoptosis secondary to aberrant facial nerve regeneration. A retrospective chart review was carried out on 16 consecutive patients with pseudoptosis secondary to aberrant facial nerve regeneration who received botulinum toxin A injections. Study patients include 6 men and 10 women with median age of 65 years (range 34-78). Etiology of facial nerve palsy included Bell palsy (11), surgical injury (2), trauma (2), and Ramsay-Hunt syndrome (1). Mean duration of facial nerve palsy was 8.5 years (1.1-30). Mean duration of pseudoptosis was 6.8 years (0.5-29). Botulinum toxin A (Botox; Allergan) injections were given in the medial and lateral pretarsal upper eyelid orbicularis oculi with some patients also receiving a central and/or additional lateral injection. Mean number of injections was 2.6 (2-4). Mean total dose was 10.3 units (5-20). Subjective improvement of symptoms at follow up was noted in all cases. Margin reflex distance in all patients showed statistically significant (p < 0.001) mean improvement of 1.6 mm (0.5-2.5) during orbicularis oris contracture. No side effects were reported, and all patients desired repeat injections. Repeat injection was performed at 3- to 6-month intervals, with most patients (12) returning every 3 months. Mean follow up was 12.2 months (3-61). Using low doses of carefully injected botulinum toxin A into the upper eyelid can provide safe and successful treatment of pseudoptosis due to aberrant facial nerve regeneration.

A Comparison of Facial Muscle Squeezing versus Non-facial Muscle Squeezing on the Efficacy of BotulinumToxin-A Injections for the Treatment of Facial Dystonia

Background:This study was performed to address whether voluntary muscle squeezing post botulinum toxin-A treatment with increased neuronal activity translates into noticeable patient benefit in practice.Methods: This was a prospective, consecutive, double crossover interventional study. Participants were receiving regular (3 monthly) botulinum toxin-A treatment for aberrant facial nerve regeneration (AFNR), benign essential blepharospasm (BEB) or hemifacial spasm (HFS). Twenty-six participants were recruited and these were randomised into two groups (A and B). Group A performed a program of intensive facial exercises for 5 minutes after their first and third treatment whereas after their second treatment, they were asked to rest in a seated position for 5 minutes, and instructed not to talk or perform any voluntary movements of their face. Conversely group B were only asked to perform squeezing exercises after their second treatment. Outcomes were evaluated objectively using video-recordings and subjectively by questionnaire and telephone interview of participants.Results: Video-recording data was complete for 21 participants. There was a mean 40% reduction in the frequency of facial muscle spasms and a 33% lower severity score (video-recordings graded by 1 masked investigator) where intensive facial exercises were performed post-treatment. These findings did not reach statistical significance (Mann- Whitney two-tailed test; p = 0.367).Conclusion: Although statistical significance was not achievable, this study suggested a possible trend towards an increased efficacy of botulinum toxin-A, with facial muscle squeezing post BTX treatment. Future studies with a larger number and a better defined subset of subjects may lead to statistical significance.

Síndrome de Marin-Amat y Marcus-Gunn invertido. Presentación de 2 casos de sincinesia facial

Marin-Amat's syndrome is a rare associated movement, wherein contraction of orbicularis oculi is brought about by opening of the jaw in association with aberrant regeneration of facial nerve. This is the opposite of the Marcus-Gunn phenomenon; hence it has also been called Inverted Marcus-Gunn Phenomenon. Moreover in this case the opened the mouth or moved the jaw, the eye would close. This phenomenon is congenital and the closure of the eye is due to inhibition of the levator palpebrae superioris. We present two cases, one acquired after the surgery of tuberculosus cervical adenitis and other congenital with reference to the presentation, course and treatment. This entity is rare in children, with few reported cases, although probably will be found more frequently if looked for carefully. The diagnosis is clinical and does not require additional tests, although EMG may be useful to demonstrate the synkinesis.

Evaluation and treatment of synkinesis with botulinum toxin following facial nerve palsy

Purpose. To assess the effect and efficacy of botulinum toxin type A (BTX-A) in reducing synkinesis in aberrant facial nerve regeneration (following facial paralysis).Method. A total of 55 sessions of BTX-A (Botox®) infiltration were performed on 30 patients (23 female) with synkinesis after facial palsy. Each subject was injected with 2.5 units of BTX-A in each injection site (the sites were chosen on a case-by-case basis). The synkinetic muscles targeted include: orbicularis oculi, zygomaticus major, depressor labii inferioris, platysma, healthy frontalis and healthy corrugator supercilii. The patients were examined using the Sunnybrook Facial Grading System, both before the BTX-A treatment and after an average of 35 days.Results. All 30 patients experienced improvement to the synkinesis after treatment. Total scores: median pre-BTX-A: 40; post 53 p = 0.004. Resting symmetry scores: mean pre-BTX-A −7.1; post: −3.5; median pre −5 [interquartile range (IQR) −10 to −5]; post: −5 (IQR −5 to 0); p = 0.0001. Symmetry of voluntary movement median pre-BTX-A: 56 post 60 p = 0.10. Synkinesis scores: median pre-BTX-A: −9 post −3 p < 0.0001. Mean duration of improvement was 4 months.Conclusions. BTX-A injection treatment was effective in reducing facial synkinesis, thus improving facial expression symmetry both at rest and in voluntary movements.

Botulinum Toxin for Aberrant Facial Nerve Regeneration: Double-Blind, Placebo-Controlled Trial Using Subjective Endpoints

Aberrant facial nerve regeneration syndrome is systematically studied by constructing a subjective questionnaire organized into pertinent domains (impairment of quality of life, social interactions, perception of self-appearance, visual function, and perception of problem severity) and by physical assessment of degree of involuntary palpebral fissure closure during routine facial movements using videotaping and a physicians' grading scale. The videotape measurements of corneal light reflex to upper lid margin distance and vertical palpebral distance were made during adynamic and active facial expression. Thirty-six patients were studied (six in an open-label pilot study design and 30 in a multicenter, double-blind, placebo-controlled trial). Botulinum toxin type A injections consistently suppressed the degree of involuntary eyelid movement associated with smiling, chewing, and puckering by each measurement and in both study designs. In all subjective morbidity domains, improvement was demonstrated in the double-blind study design (quality of life, p < 0.05; social interaction, p < 0.001; personal appearance, p < 0.001; peripheral visual impairment, p < 0.01; and perception of severity, p < 0.05). Correlation between degrees of physical impairment was significant but low comparing degree of subjective impairment to direct videotaped measurements. Correlation was more significant comparing subjective scores to the physicians' grading scale assessment of degree of physical impairment. Impairment in quality of life, social interactions, and self-assessment of appearance closely reflected the nature of the morbidity associated with palpebral fissure asymmetry associated with aberrant facial nerve regeneration. The physicians' grading scale best reflected subjective morbidity over direct videotaped measurements.

Aberrant facial nerve regeneration (AFR): an under-recognized cause of ptosis.

Aberrant facial nerve regeneration (AFR) following facial nerve palsy may give rise to ptosis because of increased orbicularis tone. We describe a series of patients presenting with ptosis where the underlying aetiology of AFR was often not recognized by the referring clinicians. Retrospective case review. A total of 15 cases with ptosis, secondary to AFR, were seen at the Royal Adelaide Hospital Oculoplastic Clinic between 2000 and 2002. Of these, 10 (67%) were referred by general ophthalmologists. Ptosis was the only reason for referral in 11 patients (73%) and features of AFR or a past history of facial nerve palsy were not mentioned in seven referrals (overall 46%). All patients reported a previous facial palsy. The palpebral aperture was reduced on the affected side with reduction in both upper and lower margin reflex distance (MRD) by a mean of 1.5+/-0.7 mm (P<0.001) and 1.0+/-0.3 mm (P<0.001), respectively. The orbicularis tone was increased and strength reduced on the affected side in all patients. However, none had lagophthalmos. Signs of AFR were demonstrated in all patients with either an increase in ptosis or eyelid closure on the affected side during cheek puffing. Patients with AFR following facial nerve palsy may present with ptosis without recognition of the underlying aetiology. Signs of AFR ptosis include a decreased palpebral aperture with a reduced upper and lower MRD. The diagnosis can be established with demonstration of an increase in ptosis during cheek puffing. Recognition of AFR is important in these cases owing to the implications for management and post-operative patient satisfaction.

Treatment of aberrant facial nerve regeneration with botulinum toxin A

purpose To assess the effect and efficacy of botulinum toxin type A (BTX-A) at reducing and maintaining eyelid synkinesia in aberrant facial nerve regeneration, while concurrently observing for the presence of side effects to differing treatment doses. methods A prospective interventional study of five patients with eyelid synkinesia resulting from aberrant regeneration of the facial nerve. Patients were treated with injections of either 120, 80 or 40 units of BTX-A (Dysport) into the orbicularis oculi. Objective and subjective reduction in synkinesia, maintenance of response and presence of side effects were recorded. results All five patients had improvement of the synkinesia with BTX-A treatment. Lower doses were found to be as effective as higher doses. Mean duration of abolished synkinesia was three months. Two patients developed a ptosis which resolved spontaneously. None of the patients treated with the lowest dose of 40 units developed a ptosis. conclusion Low-dose BTX-A has a lower incidence of ptosis and is effective in the treatment of aberrant facial nerve regeneration.

Botulinum A toxin for treatment of aberrant facial nerve regeneration.

Twelve patients with involuntary synkinetic eyelid closure were given 40 injections of botulinum A toxin. Temporary improvement in involuntary eyelid closure was observed in all 12 patients. Eleven of the 12 patients desired repeated injections. Dose requirements for this indication were compared with doses used in 697 injections in 112 patients with essential blepharospasm and Meige syndrome. Additionally, dose comparisons were made with 269 injections in 71 patients with hemifacial spasm. Dose requirements needed to treat aberrant regeneration of the facial nerve were substantially less than needed to treat blepharospasm and Meige syndrome. The dose requirement was similar to that in hemifacial spasm treatment. The reason for the differences probably relates to existing muscular denervation associated with hemifacial spasm and aberrant facial nerve regeneration.