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.

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.

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.

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.

[Buccinator muscle: A new target for botulinum toxin injections in the treatment of facial paralysis sequelae]. / Le muscle buccinateur : une nouvelle cible pour les injections de toxine botulique dans le traitement des séquelles de paralysie faciale.

AIM OF THE STUDY: Facial paralysis can cause aesthetic and functional sequelae such as spasms and synkinesis. Botulinum toxin injection is one of the key treatments for these sequelae. Its use is widely reported in the literature for many muscles of the face but little for the buccinator muscle. However, its hyperactivity can be disabling, generating chewing and smile disorders in particular. The aim of this prospective study is to report the effects of botulinum toxin using a questionnaire specifically for the buccinator muscle. PATIENTS AND METHODS: The study was conducted on 13 patients. The facial paralysis was of various origins. The questionnaire consisted of 10 questions each assessing a facial mimic involving the buccinator muscle. The rating scale ranged from -10 (major deterioration) to 10 (major improvement) for each question. The evaluation was done at 1 and 4 months after the injection. We found an improvement for all the mimics and gestures evaluated (0 to 7.38 at 1 month and 0.15 to 6.62 at 4 months). This improvement was greater at 1 month than at 4 months. Few side effects were reported. CONCLUSION: Botulinum toxin injections are an effective, safe therapeutic solution for the treatment of the facial paralysis sequelae of the buccinator muscle through a new specific questionnaire. Subsequently, it would be interesting to carry out an evaluation on a larger population and to compare it with other recognized scores in facial paralysis.

Decreased ACKR3 (CXCR7) function causes oculomotor synkinesis in mice and humans.

Oculomotor synkinesis is the involuntary movement of the eyes or eyelids with a voluntary attempt at a different movement. The chemokine receptor CXCR4 and its ligand CXCL12 regulate oculomotor nerve development; mice with loss of either molecule have oculomotor synkinesis. In a consanguineous family with congenital ptosis and elevation of the ptotic eyelid with ipsilateral abduction, we identified a co-segregating homozygous missense variant (c.772G>A) in ACKR3, which encodes an atypical chemokine receptor that binds CXCL12 and functions as a scavenger receptor, regulating levels of CXCL12 available for CXCR4 signaling. The mutant protein (p.V258M) is expressed and traffics to the cell surface but has a lower binding affinity for CXCL12. Mice with loss of Ackr3 have variable phenotypes that include misrouting of the oculomotor and abducens nerves. All embryos show oculomotor nerve misrouting, ranging from complete misprojection in the midbrain, to aberrant peripheral branching, to a thin nerve, which aberrantly innervates the lateral rectus (as seen in Duane syndrome). The abducens nerve phenotype ranges from complete absence, to aberrant projections within the orbit, to a normal trajectory. Loss of ACKR3 in the midbrain leads to downregulation of CXCR4 protein, consistent with reports that excess CXCL12 causes ligand-induced degradation of CXCR4. Correspondingly, excess CXCL12 applied to ex vivo oculomotor slices causes axon misrouting, similar to inhibition of CXCR4. Thus, ACKR3, through its regulation of CXCL12 levels, is an important regulator of axon guidance in the oculomotor system; complete loss causes oculomotor synkinesis in mice, while reduced function causes oculomotor synkinesis in humans.

French Translation and Validation of the Synkinesis Assessment Questionnaire.

Synkinesis is a distressing sequela of peripheral facial palsy (PFP). This study aimed to translate and validate the Synkinesis Assessment Questionnaire (SAQ), a reliable patient-reported outcome evaluation tool for synkinesis, in French. The SAQ was translated following a standard forward-backward translation procedure. After a cognitive debriefing with 10 PFP patients, the SAQ-F was assessed amongst 50 patients for internal consistency, known-group validity, construct validity, criterion validity, and test-retest reliability. Results demonstrated that the SAQ-F was valid, reliable, and had a unidimensional structure. The SAQ-F should be accompanied by clinician-based scales, to provide valuable additional information on the severity of synkinesis.

Diagnostic limitation of laryngostroboscopy in comparison to laryngeal electromyography in synkinesis in unilateral vocal fold paralysis.

PURPOSE: In clinical practice, laryngo(strobo)scopy (LS) is still mainly used for diagnostics and management of unilateral vocal fold paralysis (UFVP), although only laryngeal electromyography (LEMG) can provide information on causes of vocal fold immobility, especially on possible synkinetic reinnervation after recurrent laryngeal nerve (RLN) injury. The goal of this retrospective study was the evaluation whether signs of synkinetic reinnervation in LS can be objectified in comparison to LEMG data. METHODS: Between 1/2015 and 2/2018, 50 patients with laryngostroboscopically suspected UVFP received routine LEMG examination. The LEMG findings were retrospectively compared with LS findings. The LEMG data analysis focused on the diagnosis of synkinetic reinnervation of the TA/LCA and/or PCA. The digital LS recordings were retrospectively re-evaluated by phoniatricians considering 22 selected laryngostroboscopic parameters. RESULTS: LEMG revealed synkinesis in 23 (46%) and absence of synkinesis in 27 (54%) patients. None of the 22 parameters showed significant association between patients with synkinetic reinnervation and LS findings. The only laryngostroboscopic parameter that was significantly associated with a silent LEMG signal compared to single fiber activity in LEMG was a length difference on the side of the UVFP (p-value 0.0001; OR 14.5 (95% CI 3.047-66.81; Sensitivity 0.5; Specificity 0.9355). CONCLUSION: Our findings show that synkinesis cannot be diagnosed using only LS. This study underlines the importance of LEMG in clinical routine for detection of laryngeal synkinesis in patients with UVFP before any further therapeutic steps are initiated to avoid later therapy failure.

Oral-Ocular Synkinesis in a 21-Year Old Female Head Trauma Patient Following Facial Nerve Decompression Surgery.

ABSTRACT: Facial synkinesis can happen as a negative event following the recovery of facial nerve paralysis. In this case report, five months after right facial nerve decompression surgery following right sided head trauma, a 21-year-old female patient developed oral-ocular synkinesis. During her attempt to voluntarily smile, she experienced uncontrolled winking of her right eye. Exercise therapy was used as a treatment modality which largely improved her facial nerve function and decreased her synkinesis. As a treatment modality, exercise therapy was used which saw a great improvement in both her facial nerve function and decreased her synkinesis.

Epineurectomy of Facial Nerve Trunk for Refractory Oral-Ocular and Oculo-Oral Synkinesis Following Bell Palsy.

BACKGROUND: Synkinesis is a common sequelae after incomplete recovery from Bell palsy. Current first-line treatments include botulinum toxin injection and physical therapy. However, patients unresponsive to these treatments may require further surgery. Various surgical treatments have been reported, but no consensus has been reached for the optimal surgery. In a guinea pig model of synkinesis, the facial nerve trunk (FNT) was observed using a scanning electron microscope. Based on the results of scanning electron microscope and clinical ultrasonography, the authors chose FNT as the therapeutic target. METHODS: The authors performed epineurectomy of FNT for 11 patients with refractory oral-ocular and oculo-oral synkinesis under abnormal muscle response and facial electromyography monitoring. The postoperative assessments at 1 year were conducted using Sunnybrook Facial Grading System and Facial Disability Index scale. Furthermore, the epineurium excised during the operation was collected as the specimen and submitted for histopathological examination; the cadaveric FNT served as the control group. RESULTS: The follow-up results showed significant relief from synkinesis (4.91 ±â€Š0.37 versus 10.18 ±â€Š0.64, P < 0.01), improvement of physical (84.55 ±â€Š1.96 versus 73.18 ±â€Š3.65, P < 0.01) and social functions (77.09 ±â€Š3.24 versus 61.82 ±â€Š6.28, P < 0.01), with no worsening of facial paralysis in the patients. The histopathological examination revealed many nerve fibers in the epineurium, suggesting that FNT was the area of aberrant axon regeneration. CONCLUSIONS: Epineurectomy of FNT is a safe and effective surgical remedy. It can be considered as a surgical option for patients with refractory oral-ocular and oculo-oral synkinesis following Bell palsy.

Ptosis With Aberrant Facial Nerve Regeneration Following Bell Palsy.

ABSTRACT: Bell palsy is the most common lesion affecting the facial nerve. Aberrant facial nerve regeneration following facial nerve palsy may cause facial nerve synkinesis and ptosis. The authors present a 65-year-old male who suffered from left peripheral facial nerve palsy in 2017. During the recovery period, he had moderate ptosis in primary gaze, and he also noted left upper eyelid closure when he tried to blow something or puff his cheeks. Neurologic examination was normal except for the synkinetic movements as described above. Surgery was planned with an attempt to resect a part of the orbicularis oculi muscle (OOM) to decrease the synkinetic eyelid closure. In addition, the levator muscle was advanced for treatment of the ptosis. Before surgery, an electromyography study by a neurologist showed normal activity of the OOM but failed to demonstrate the relationship between this muscle and other muscles due to technique failure. However, after surgery electromyography studies of the facial and orbicularis oris muscle suggested that cheek puffing produced contraction in the OOM. During follow-up time, the patient was satisfied with the surgical results. To the best of our knowledge, this is the first report to describe ptosis with aberrant facial synkinesis during cheek puffing was treated with surgery.

[Synkinesis in facial palsy: What do we know about the physiopathology?] / Syncinésies dans la paralysie faciale : que savons-nous de la physiopathologie ?

INTRODUCTION: Synkinesis is a disabling sequelae of facial palsy, which worsens facial asymmetry and diminishes the patients' quality of life. Their physiopathology is partially known, but cannot explain all the synkinesis. MATERIAL AND METHODS: We report a literature review of the state of the art concerning the knowledge on synkinesis physiopathology, as well as their management. RESULTS: It is accepted that the physiopathological mechanism of synkinesis is mixed. The phenomena of cerebral plasticity, aberrant nerve regrowth, hyperexcitability of the facial nerve nucleus and ephaptic nerve transmission, have been observed. We propose a new physiopathological hypothesis: synkinesis could be the consequence of latent circuits activation, preexisting in the healthy subject. We could propose three potential latent circuits: physiological synergistic contractions, adjacent motor units recruitment, and reactivation of remote latent circuits for function compensation. The treatment options are multiple, dominated by chemodenervation, whose effectiveness is undeniable. Rehabilitation has also proven its effectiveness, particularly with feedback techniques. Finally, surgery helps with these options. However, the indications of the different treatments remain to be codified. CONCLUSION: The validation of our physiopathological hypothesis would allow a better understanding and a better screening of synkinesis, in order to propose a more adapted treatment.

Tolerability of facial electrostimulation in healthy adults and patients with facial synkinesis.

PURPOSE: To evaluate optimal stimulation parameters with regard to discomfort and tolerability for transcutaneous electrostimulation of facial muscles in healthy participants and patients with postparetic facial synkinesis. METHODS: Two prospective studies were performed. First, single pulse monophasic stimulation with rectangular pulses was compared to triangular pulses in 48 healthy controls. Second, 30 healthy controls were compared to 30 patients with postparetic facial synkinesis with rectangular pulse form. Motor twitch threshold, tolerability threshold, and discomfort were assessed using a numeric rating scale at both thresholds. RESULTS: Discomfort at motor threshold was significantly lower for rectangular than for triangular pulses. Average motor and tolerability thresholds were higher for patients than for healthy participants. Discomfort at motor threshold was significantly lower for healthy controls compared to patients. Major side effects were not seen. CONCLUSIONS: Surface electrostimulation for selective functional and tolerable facial muscle contractions in patients with postparetic facial synkinesis is feasible.

Nerve Switch for Reducing Synkinesis After Gracilis Muscle Transfer Innervated Via the Masseter Nerve.

BACKGROUND: In surgical treatment for longstanding facial paralysis, muscle transplantation is considered a useful and important method. To obtain a spontaneous smile, the use of the facial nerve of the healthy side as a motor source is better, but use of the masseter nerve allows prompt reinnervation and powerful movement. However, in some patients in whom the masseter nerve is used, separating masticatory movement and commissure contraction is difficult. Solutions for such patients have not been determined. CASE HISTORY AND DISCUSSION: A 46-year-old female patient presented with longstanding complete facial paralysis after resection of a right acoustic neurinoma. As initial surgery, free gracilis transfer was performed on the cheek, but the patient experienced commissure movement during meals postsurgery. Secondary corrective surgery was performed to detach the motor nerve of the gracilis from the masseter nerve and suture it to the facial nerve of the healthy side via cross-face nerve graft. The symptom improved but partially recurred. Improvement in synkinetic movement can be obtained by performing cross-face nerve grafting and subsequent nerve switch.

Synkinesis Between Orbicularis Oculi and Procerus Muscles: Video Presentation of an Unusual Type of Aberrant Innervation after Cosmetic Rhinoplasty.

BACKGROUND: Synkinesis is a recognized complication following peripheral facial nerve paralysis. Different types of synkinesis have been described, with oral-ocular and ocular-oral synkinesis being the most common. Ocular-nasal synkinesis has been reported in two patients following cosmetic rhinoplasty. However, synkinesis between the orbicularis oculi and procerus muscles has not been reported by now. METHODS: This is an interventional case report. RESULTS: Two women, aged 42 and 37 years, presented with unilateral contraction of the medial eyebrow muscles (procerus) with spontaneous or voluntary blinking, 4 and 5 months after cosmetic rhinoplasty, respectively. Both were successfully treated with injection of botulinum toxin A. CONCLUSIONS: Surgical trauma is inevitable during every procedure, including rhinoplasty, and may damage the fine structures including branches of the facial nerve innervating the muscles. Gentle tissue handling may minimize iatrogenic injury to the fine motor branches of the facial nerve and prevent subsequent aberrant innervation and synkinesis. Botulinum toxin A injection can effectively, yet temporarily, resolve the unintentional contractions and provide significant patient comfort. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Recovery of facial expressions using functional electrical stimulation after full-face transplantation.

BACKGROUND: We assessed the recovery of 2 face transplantation patients with measures of complexity during neuromuscular rehabilitation. Cognitive rehabilitation methods and functional electrical stimulation were used to improve facial emotional expressions of full-face transplantation patients for 5 months. Rehabilitation and analyses were conducted at approximately 3 years after full facial transplantation in the patient group. We report complexity analysis of surface electromyography signals of these two patients in comparison to the results of 10 healthy individuals. METHODS: Facial surface electromyography data were collected during 6 basic emotional expressions and 4 primary facial movements from 2 full-face transplantation patients and 10 healthy individuals to determine a strategy of functional electrical stimulation and understand the mechanisms of rehabilitation. A new personalized rehabilitation technique was developed using the wavelet packet method. Rehabilitation sessions were applied twice a month for 5 months. Subsequently, motor and functional progress was assessed by comparing the fuzzy entropy of surface electromyography data against the results obtained from patients before rehabilitation and the mean results obtained from 10 healthy subjects. RESULTS: At the end of personalized rehabilitation, the patient group showed improvements in their facial symmetry and their ability to perform basic facial expressions and primary facial movements. Similarity in the pattern of fuzzy entropy for facial expressions between the patient group and healthy individuals increased. Synkinesis was detected during primary facial movements in the patient group, and one patient showed synkinesis during the happiness expression. Synkinesis in the lower face region of one of the patients was eliminated for the lid tightening movement. CONCLUSIONS: The recovery of emotional expressions after personalized rehabilitation was satisfactory to the patients. The assessment with complexity analysis of sEMG data can be used for developing new neurorehabilitation techniques and detecting synkinesis after full-face transplantation.

Objective assessment of the reliability of the House-Brackmann and Fisch grading of synkinesis.

The objective of this paper is to assess synkinesis associated with post paretic voluntary facial movements using the objective OSCAR method and to investigate the correlation between synkinesis and paresis to compare the objective results with the subjective scaling systems of Fisch and House-Brackmann. The development of an objective assessment of synkinesis with the OSCAR method is focused on the clinically most relevant eye-mouth and forehead-mouth synkinetic movements. Thirteen patients with unilateral facial paralysis and synkinesis of the University Hospital Zurich were examined. Two types of clinically relevant facial synkinesis were found: a maximal synkinesis and a relative synkinesis. Neither Synkinesis-Index correlates well with the underlying degree of global facial palsy. The relative Synkinesis-Index (rSI) correlates well with the subjective evaluation of synkinesis according to the Fisch Grading, but shows a poor correlation with the traditional House-Brackmann grading. Therefore a single scaling index combining the degree of facial nerve palsy and synkinesis is inappropriate and we propose the use of two independent scaling systems for the evaluation of facial palsy: one for the voluntary facial movements, the other for the involuntary synkinetic movements. The adequate evaluation of the post paretic face should include the results of both scaling systems.