Prognostic value of electroneurography using the midline method for predicting the development of synkinesis after peripheral facial palsy.

OBJECTIVE: The prognostic value of electroneurography (ENoG) for predicting the incidence of synkinesis is reportedly about 40 % using the formal standard method (ENoG-SM). However, the prognostic value of ENoG using the newly developed midline method (ENoG-MM) has not been determined. The aim of this study was to demonstrate the optimal prognostic value and advantages of ENoG-MM for predicting the incidence of synkinesis. METHODS: Participants were 573 patients treated for peripheral facial palsy including Bell's palsy or Ramsay Hunt syndrome. We investigated the clinical presence of any oral-ocular or ocular-oral synkinesis from the medical records. ENoG-MM and ENoG-SM were performed 10-14 days after symptom onset. In ENoG-MM, compound muscle action potentials were recorded by placing the anode on the mental protuberance and the cathode on the philtrum. In ENoG-SM, electrodes were placed on the nasolabial fold. Synkinesis was clinically assessed at the end of follow-up or at >1 year after onset. The sensitivity and specificity of ENoG values for predicting the incidence of synkinesis were compared between ENoG-MM and ENoG-SM at every 5 % around 40 % (range, 30-50 %). RESULTS: At every 5 % of ENoG values around 40 %, ENoG-MM provided higher sensitivity and lower specificity for predicting the incidence of synkinesis compared with ENoG-SM. In particular, when the cut-off value was set at 45 %, sensitivity was 100 % and 95.3 % with ENoG-MM and ENoG-SM, respectively. CONCLUSION: In peripheral facial palsy, ENoG-MM offered higher sensitivity than ENoG-SM for predicting synkinesis. ENoG-MM is useful for screening patients at risk of developing synkinesis. In clinical practice, an ENoG-MM cut-off value of 45 % must be the optimal prognostic value because of the 100 % sensitivity.

Ocular-oral synkinesis caused by partial injury of the zygomatic and buccal branches of the facial nerve after mid-face trauma.

BACKGROUND: Facial nerve paralysis induced by acute traumatic facial nerve injuries limited to the zygomatic and buccal branches shows unique complications, such as strong co-contractions of the lower facial muscles around the lips during voluntary blinking (ocular-oral synkinesis). We investigated the characteristics of facial complications after facial nerve injury in the mid-face area and reported the treatment results. METHODS: A total of 21 patients with facial nerve injuries to the zygomatic and/or buccal branches were evaluated for the degree of facial synkinesis and mouth asymmetry. Patients with mild-to-moderate symptoms were treated using physical rehabilitation therapy combined with botulinum toxin (Botox) injection, and patients with severe or uncontrolled symptoms were treated using surgical therapy. RESULTS: Initial/final mean synkinesis scores and mouth asymmetry degrees were 2.17/1.75 and 0.85/0.66 in the physical therapy group and 3.11/0.78 and 2.41/-0.31 in the surgery group, respectively. Physical therapy with Botox injection alone did not show significant improvements in synkinetic symptoms of the patients with mild-to-moderate synkinesis (p > 0.05), whereas surgical therapy resulted in significant improvements in synkinesis and mouth asymmetry (p < 0.05). CONCLUSIONS: Surgical treatment is an effective adjustment procedure for the management of facial complications in patients with severe or uncontrolled synkinesis after facial nerve injury to the mid-face area.

Different Cortical Activation of Facial Synkinesis Patients with Different Course of Disease: A Task fMRI Study.

Facial synkinesis is a disease characterized by unintentional activation of facial muscles, which causes that the patients cannot control their facial expressions independently. Previous studies have shown that its pathogenesis is related to the reorganization of cerebral cortex, but it remains unclear what brain changes the patients have at different stage of the disease. For this study, we recruited 30 patients with facial synkinesis and 19 healthy control subjects from Shanghai Huashan Hospital. All participants completed bilateral blinking and grinning tasks while functional magnetic resonance imaging (fMRI) data was collected. We measured the brain activation strength of each task and observed the activation similarity of the ipsilateral tasks. Then we explored the correlation between activation pattern and clinical scale. Results showed different activation pattern along the courses of disease for blinking and grinning task, which may be due to the inconsistent process of cortical reorganization. The late stage group activated more in blinking task, but the least in grinning tasks, especially on the affected side (p<0.001 at voxel level, p<0.05 at cluster level, FWE corrected). Compared with healthy controls, the activation of patients between tasks on the affected side is more similar(p<0.05). There was a negative correlation in right postcentral gyrus between activation similarity and scale scores (symmetry of voluntary movement scores: R = -0.469, p = 0.009). This could be attributed to the rearrangement of the nervous system following facial nerve injury, leading to incorrect connections between nerves and muscles. Our study may be helpful for understanding mechanism of facial synkinesis and provide basis for the stage-dependent diagnosis and treatment.

Minimization of facial synkinesis.

PURPOSE OF REVIEW: To summarize the treatment options available for the management of postparalytic facial synkinesis which include facial rehabilitation, chemodenervation, and a spectrum of surgical interventions. RECENT FINDINGS: Facial rehabilitation and botulinum toxin chemodenervation represent the foundation of facial synkinesis management, with specific treatment paradigms directed by individual patient needs. Evolving surgical approaches range from isolated selective myectomies or neurectomies to combination approaches which may incorporate various types of nerve transfer with gracilis free muscle transplantation. SUMMARY: Postparalytic facial synkinesis bears significant patient morbidity due to aesthetic and functional implications. Management strategies must balance patient goals with treatment risks and typically progress stepwise from the least to most invasive interventions. Emerging techniques reveal a convergence in approaches to facial reanimation and synkinesis mitigation.

Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis.

Management of post-facial paralysis synkinesis has evolved for the past decade with diversification of neuromuscular retraining, chemodenervation, and advanced surgical reanimation techniques. Chemodenervation with botulinum toxin-A is a commonly used treatment modality for synkinesis patients. Treatment has shifted from solely weakening the unaffected contralateral facial musculature for rote symmetry to selective reduction of undesired or overactive synkinetic muscles, allowing for a more organized motion of the recovered musculature. Facial neuromuscular retraining should be considered a crucial component of treating patients with synkinesis along with soft tissue mobilization, but specifics of these are beyond the scope of this article. Our goal was to create a descriptive platform for our method of chemodenervation treatment in the evolving field of post-facial paralysis synkinesis. A multi-institutional and multidisciplinary comparison of techniques was performed with photograph and video creation, review, and discussion over an electronic platform with all authors. Anatomic specifics of each region of the face and individual muscles were considered. A muscle by muscle algorithm for synkinesis therapy was created to include chemodenervation with botulinum toxin that should be considered for patients suffering from post-facial paralysis synkinesis.

Commentary on: "Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis," by Hetzler et al.

In this commentary, we discuss Hetzler et al.'s article, "Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis." The authors do an excellent job of presenting a guide for practitioners to use when initiating chemodenervation treatment for patients with nonflaccid facial paralysis. Standardization of outcome assessment tools and rigorous data collection will further refine treatment algorithms.

Neuromuscular retraining therapy combined with preceding botulinum toxin A injection for chronic facial paralysis.

BACKGROUND: Neuromuscular retraining therapy (NMRT) is the central treatment for synkinesis. The efficacy of botulinum toxin type A (BTX-A) may be enhanced with the addition of physical therapy. OBJECTIVES: To investigate the effects of NMRT combined with preceding BTX-A injection (NMRT-B) on facial synkinesis and asymmetry in chronic facial paralysis. MATERIALS AND METHODS: We recruited 99 patients with unilateral facial paralysis and no recovery for > 6 months who underwent NMRT-B for > 1 year. The patients were scheduled to receive NMRT after 1-2 weeks of BTX-A injection. We used a computer-based numerical scoring system to evaluate the facial functions. Primary, secondary, and final facial movement scores were evaluated before and after 1 year of treatment. RESULTS: Patients with chronic facial paralysis who underwent NMRT-B exhibited improved facial movement after 1 year of treatment. NMRT-B provided satisfactory control of synkinesis and improved the primary movements. The mean primary and final facial movement scores were significantly increased after treatment, while the mean secondary facial movement scores were significantly decreased. CONCLUSIONS AND SIGNIFICANCE: NMRT-B improved the final facial movement in patients with chronic facial paralysis and synkinesis, regardless of the degrees of facial synkinesis and asymmetry before treatment.

Selective neurectomy for nonflaccid facial palsy.

PURPOSE OF REVIEW: To review the evolving role of selective neurectomy in the management of patients with synkinesis including the history of selective neurectomy, operative techniques, and clinical outcomes. RECENT FINDINGS: Modified selective neurectomy alone or in conjunction with other procedures achieves more durable outcomes based on objective measures such as time to recurrence of symptoms and units of botulinum toxin required postoperatively. This is also reflected on patient reported quality of life outcome measures. Regarding operative technique, lower rates of oral incompetence are reported with division of an average of 6.7 nerve branches as opposed to more branches. SUMMARY: Chemodenervation has long been the mainstay of treatment in facial synkinesis, but in recent years, the paradigm has begun to shift in favor of incorporating interventions with more durable outcomes such as modified selective neurectomy. Modified selective neurectomy is often performed with other simultaneous surgeries such as nerve transfer, rhytidectomy, lid surgery and static facial reanimation primarily to address periocular synkinesis and synkinetic smile. The outcomes have been favorable with improvement in quality-of-life measures and a decrease in botulinum toxin requirements.

Neuromuscular retraining therapy for early stage severe Bell's palsy patients minimizes facial synkinesis.

OBJECTIVE: To explore whether early physical interventions, including neuromuscular retraining therapy, can minimize excessive movement or any unwanted co-contraction after a severe Bell's palsy. DATA SOURCES: From March 2021 to August 2022, the therapist treated Bell's palsy patients for the acute (<3 months, Group A), subacute (3-6 months, Group B) and chronic (> 6 months, Group C) stages of the condition. METHODS: We explored whether early physical interventions, including neuromuscular retraining therapy, can minimize facial synkinesis after a severe episode of Bell's palsy. Each patient was informed about the potential for synkinesis and the therapist explained that the main purpose of neuromuscular retraining therapy is to learn new patterns to minimize synkinesis. The facial function of Group A was compared to that of Groups B and C using the 'Synkinesis' scale of the Sunnybrook Facial Grading System. RESULTS: The final facial function score after neuromuscular retraining therapy was significantly associated with both the initial electroneuronographic degeneration rate and initial facial function. Early therapy did not prevent synkinetic movement in 84.7% of the patients. But, there was a significant difference between patients who started early neuromuscular retraining therapy and other groups in final facial function. CONCLUSION: Synkinesis in Bell's palsy patients can be minimized if physiotherapy commences before synkinesis develops; appropriate neuromuscular retraining therapy timing is essential. A patient with sudden severe Bell's palsy should receive oral steroids as soon as possible, along with physical therapy (including neuromuscular retraining therapy) within 3 months, to minimize synkinesis just before synkinesis onset.

Modified Selective Neurectomy for Post Facial Paralysis Synkinesis Smile Dysfunction.

Following incomplete facial nerve injury, patients may develop aberrant facial nerve reinnervation, which can result in facial synkinesis. The treatment goals for patients with postfacial paralysis synkinesis are to improve resting oral commissure position, oral competence, facial and cervical tightness, and smile symmetry and spontaneity. Modified selective neurectomy of the facial nerve as described by Azizzadeh and colleagues is a targeted surgical method that allows the surgeon to eliminate the antagonist movements of the face and allow the favorable movements of the face to predominate, resulting in a more natural smile.

Ocular-Oral Synkinesis Without Facial Palsy After Trauma: A Case Report.

Ocular-oral synkinesis refers to the unintended contraction of the perioral muscles during voluntary eye closure. This phenomenon can either be congenital or occasionally develop during recovery from facial palsy. In this study, we report a case of ocular-oral synkinesis without facial palsy after trauma.

Contribution of the Synkinesis Assessment Questionnaire and the Sunnybrook Facial Grading System to the evaluation of synkinesis after peripheral facial palsy: A STROBE observational study.

OBJECTIVES: The main aim of the study was to determine whether the perception of synkinesis by patients with peripheral facial palsy (PFP) matched their clinician's severity assessment. Secondary objectives comprised: (1) to determine whether objective measurement of synkinesis matched the patient's perception; and (2) is to identify factors influencing patients' perceptions. METHODS: This retrospective study took place from January to May 2020. Forty patients (8 per PFP grade, I-V/VI; 20 women, 20 men) filled out the Synkinesis Assessment Questionnaire (SAQ) and were assessed on the Sunnybrook Facial Grading System (SFGS). Photographs were analyzed on MEEI-Facegram software. RESULTS: Perceived synkinesis (total SAQ) matched objective grades (SFGS) (Z=2.89; P=0.004), especially for smiling (Z=3.84; P<0.001) and lip protrusion (Z=3.79; P<0.001). Synkinesis on lip protrusion was a more sensitive indicator of perceived synkinesis than synkinesis on smiling (Z=2.96; P=0.003). Duration (ρ=0.5137; P<0.001) and grade of PFP (Chi2=13.82; P=0.008) heightened the perception of synkinesis. CONCLUSION: Patient-reported outcome measures (PROMs) such as the SAQ are relevant for clinical evaluation.

Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis.

BACKGROUND: Synkinesis is defined as involuntary movements accompanying by voluntary movements and can occur during the aftermath of peripheral facial palsy, causing functional, aesthetic and psychological problems in the patient. Botulinum toxin A (BTX-A) is frequently used as a safe and effective treatment; however, there is no standardized guideline for the use of BTX-A in synkinesis. The purpose of this article is to review and summarize studies about the BTX-A treatment of synkinesis in patients with a history of peripheral facial palsy; including given dosages, injection sites and time intervals between injections. MATERIALS AND METHODS: A multi-database systematic literature search was performed in October 2020 using the following databases: Pubmed, Embase, Medline, and The Cochrane Library. Two authors rated the methodological quality of the included studies independently using the 'Newcastle-Ottawa Quality Assessment Scale' for non-randomised studies' (NOS). RESULTS: Four-thousand-five-hundred-and-nineteen articles were found of which 34 studies met the inclusion criteria, in total comprising 1314 patients. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author FJ and AS) was 0.78. Thirty-one studies investigated the reported dosage injected, 17 studies reported injection location and 17 studies investigated time intervals. A meta-analysis was performed for three studies comprising 106 patients, on the effects of BTX-A treatment on the Synkinesis Assessment Questionnaire (SAQ) scores. The mean difference was 11.599 (range 9.422-13.766), p < 0.01. However, due to inconsistent reporting of data of the included studies, no relationship with the dosage and location could be assessed. CONCLUSIONS: Many treatment strategies for synkinesis exist, consisting of varying BTX-A brands, dosages, time intervals and different injection locations. Moreover, the individual complaints are very specific, which complicates creating a standardized chemodenervation treatment protocol. The BTX-A treatment of long-term synkinesis is very individual and further studies should focus on a patient-tailored treatment instead of trying to standardize treatment.

Synkinesis and Communicative Participation.

Background: Facial palsy (FP) impacts verbal and nonverbal communication, but the effect of synkinesis on communicative ability is unknown. Objective: Among patients with nonflaccid FP, or synkinesis, is there a correlation between disease-specific quality-of-life and communicative ability or dysfunction? Methods: Retrospective study of a series of adult patients with unilateral synkinesis. Subjects were evaluated using the Communicative Participation Item Bank (CPIB) Short Form, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Associations between these scales were evaluated by computing Pearson correlation coefficients. Results: A total of 69 confirmed synkinesis patients were included. Synkinesis patient mean (standard deviation) CPIB score was 20.68 (±8.27; range of scale 0-30), indicative of communication restriction. A strong correlation was observed between total CPIB and FaCE scores (r = 0.66), indicating patients with synkinesis who reported better facial function also reported greater communicative ability. There was a weak correlation between CPIB and SAQ scores (r = -0.27). Conclusion: Synkinesis is associated with significant deficits in communicative ability. Communication restrictions track strongly with the FaCE scale.

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review.

BACKGROUND: Synkinesis is commonly encountered after flaccid facial paralysis and can have a detrimental impact on a patient's life. First-line treatment of synkinesis is chemodenervation with botulinum toxin (Botox) and neuromuscular retraining. Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and free gracilis muscle transfer. Data on surgical management of synkinesis using SN is limited. EVIDENCE REVIEW: PubMed, Embase, Cochrane CENTRAL, Cochrane Neuromuscular Register, Clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform were searched using a comprehensive keyword strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-only texts published in the past 20 years were included. Two independent investigators reviewed 906 abstracts and 7 studies met inclusion criteria. Demographics, etiology of paralysis, time to surgery, and primary outcomes studied were collected. FINDINGS: A total of 250 patients were included across 7 studies. In 6 out of 7 studies, Botox was used prior to surgical intervention. Two studies showed significant reduction in Botox dosage postoperatively, while one study showed no difference. Other primary outcomes included the House-Brackmann Score, palpebral fissure width, electronic clinician-graded facial function scale (eFACE) score, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Three studies showed significant improvement in the eFACE score, two studies showed significant improvement in the FaCE scale, while one study showed improvement in quality of life measured by the SAQ. CONCLUSION: SN can be considered as an adjunct to other management options including neuromuscular retraining, Botox, selective myectomy, and reanimation procedures. While there is great heterogeneity of study design in the studies included, many cohorts showed improvement in facial symmetry, facial function, and quality of life. There remains a great gap in knowledge in this subject matter and a need for large well-designed prospective studies comparing this technique to other management options.

Translation, cross-cultural adaptation, and validation of the Italian version of the Synkinesis Assessment Questionnaire in individuals with peripheral facial palsy.

BACKGROUND: After peripheral facial palsy, the onset of facial synkinesis results in aesthetic disfigurement and local muscle tension or pain, with possible deterioration of patient's well-being and social participation. The availability of valid instruments to evaluate patient-reported severity of facial synkinesis is important to capture the subjective perception of facial impairment. AIM: To generate and validate an Italian version of the Synkinesis Assessment Questionnaire, a patient-reported outcome measure to assess patient-perceived severity of facial synkinesis after peripheral facial palsy. DESIGN: Observational study. SETTING: Outpatient clinic of a Rehabilitation Unit. POPULATION: Seventy-five patients with peripheral facial palsy. METHODS: Through a process of translation and cross-cultural adaptation, we generated the Italian version of the questionnaire (SAQ-IT) and administered it twice to patients with peripheral facial palsy. We evaluated the clinical severity with the Sunnybrook Facial Grading System (SFGS) and the physical and social/well-being function with the two subscales of the Facial Disability Index (FDI-PHY and FDI-SWB, respectively). RESULTS: Cronbach's alpha was 0.87. Item-total correlations ranged from 0.30 to 0.70, while inter-item correlations ranged from 0.15 to 0.82, with an average value of 0.48. Test-retest reliability showed an Intraclass Correlation Coefficient of 0.946 (95% confidence interval: 0.916-0.966). The minimum detectable change (with a 95% confidence level, MDC95) was 13.14 points. The correlation between SAQ-IT and the SFGS synkinesis subscore was rho=0.74, while that with the SFGS composite score was rho=0.25, with the FDI-PHY rho=-0.11 and with the FDI-SWB rho=-0.13. CONCLUSIONS: Our study validates the SAQ-IT in Italian-speaking individuals with peripheral facial palsy, confirming its acceptable psychometric properties, and providing the MDC95. CLINICAL REHABILITATION IMPACT: The availability of a valid instrument for the evaluation of patient-perceived severity of facial synkinesis plays an important role in the definition of tailored rehabilitative interventions after peripheral facial palsy.