Arch Otorhinolaryngol. A systematic review of postparetic synkinesis treatment. Furthermore, the first small series of studies are published using this approach post-hoc, i.e., when synkinesis has developed and if patients show severe eye closure during smiling. (2021) 147:46774. The method can also be used to demonstrate to the patients the effect of a proposed myotomy. doi: 10.1016/j.anl.2013.01.001, 12. Physical therapy for bell's palsy (Idiopathic Facial Paralysis). Our center offers options for improving facial paralysis from all causes and duration. doi: 10.1093/ptj/76.12.1288, 35. Make an Appointment (650) 736-3223 What is Synkinesis? (2004) 18:458. In synkinesis, the muscles of the face contract unintentionally. Stability of benefits of mime therapy in sequelae of facial nerve paresis during a 1-year period. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. Pico, picos and spider: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. Volk GF, Roediger B, Geiler K, Kuttenreich AM, Klingner CM, Dobel C, et al. Patterns of cortical reorganization in facial synkinesis: a task functional magnetic resonance imaging study, Decreased Distance between Representation Sites of Distinct Facial Movements in Facial Synkinesis-A Task fMRI Study, Frequency and location of synkineses in patients with peripheral facial nerve paresis. doi: 10.1136/bmj.n71, 7. These unintentional movements are caused by an undifferentiated regeneration of the facial nerve that occurs after being compressed or partially damaged. Synkinesis is the medical term for abnormal or unwanted movement of the face. Dr. Azizzadeh explains the cost of surgery, Botox, or neuromuscular retraining before treatment is performed. Our center has advanced the technique of transplanting the gracilis muscle as a single vector muscle flap to restore facial symmetry or a multiple vector muscle flap to produce a better smile with teeth display. Effectiveness comparisons of antiviral treatments for bell palsy: a systematic review and network meta-analysis. Otolaryngol Head Neck Surg. Typical injection sites are displayed on the right hemiface. Furthermore, this systematic review showed that long-term data on treatment outcomes and data on the long-term quality of life of these patients are missing. Then, a multi-step process is used to help a patient retrain the muscles at the neurological (brain) level. These patients typically have a high and continuous high motivation for rehabilitation. Dr. Azizzadeh performs a synkinesis treatment only if he believes it can help a patient safely and effectively achieve his or her desired results. Disclaimer. Facial synkinesis refers to inappropriate and unintended muscle movements in the face with certain voluntary facial expressions. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. About 30-40% of patients with acute facial palsy do not recover completely and develop synkinesis ( 2 ). Furthermore, disturbing synkinesis of the right depressor anguli oris of the platysma can be observed. doi: 10.1007/s00405-021-06895-2, 45. doi: 10.4103/1673-5374.313055, 28. doi: 10.1002/lio2.95, 47. doi: 10.1089/fpsam.2020.0604, 46. Spatial patterns of intrinsic brain activity and functional connectivity in facial synkinesis patients. revealed 502 studies with large overlap to the retrieval of Lapidus et al. The use of PROMs such as the FaCE, FDI, and SAQ will show the clinician that many patients with facial synkinesis also feel a severe reduction in quality of life (4345). J Plast Reconstr Aesth Surg. (310) 657-2203 Facial Paralysis Synkinesis: Understanding Symptoms, Diagnosis and Treatment Facial paralysis synkinesis refers to the "simultaneous movement" that occurs after Bell's palsy or instances where the facial nerve has been cut and sewn back together. Comparatively, patients who ignore these exercises may struggle to overcome their synkinesis symptoms. Example of typical signs of synkinesis at rest and during movements. Continual rehabilitation motivation of patients with postparalytic facial nerve syndrome. Table 1 summarizes the pathomechanisms of facial synkinesis. In the first phase, a systematic literature search on the topic in PubMed and ScienceDirect starting in 2008 resulted in 132 articles. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Considering the low level of evidence and outcome, selection should be done with caution. Synkinesis = "syn" meaning "together" and "kinesis" meaning "movement". doi: 10.1016/S0194-59989670206-1, 30. Plast Reconstruct Surg. Facial Nerve Center - Johns Hopkins Medicine Patients who do not fully recover from Bells palsy are likely to develop synkinesis. Whether the selection of the brand has an effect on treatment intervals and dosage over time is not entirely clear (76). Our research from 2018 to May 2022 retrieved another 208 records. Releasing the smile: depressor anguli oris excision in the context of managing nonflaccid facial palsy. Timing and selection of diagnostic and therapeutic interventions in facial palsy are critical. Frequently Asked Questions About Facial Nerve Disorders Synkinesis Advice - Facial Palsy UK The most common visible manifestations of synkinesis at rest are: The effects of synkinesis are frequently more apparent on facial movements, and as a general rule more extreme/large ranges of movement cause greater asymmetry. (D) The same can be seen when the patient is pursing the lips. Lead Editors - Wendy Walker, Jess Bell, Kim Jackson, Tarina van der Stockt, Rishika Babburu, Sheik Abdul Khadir and WikiSysop. 2226 Nelson Highway Approximately 10 percent of Bells palsy patients experience synkinesis, and 5 percent suffer complete facial paralysis. As a result, synkinesis between the various motor supply areas is impossible. Halani SH, Sanchez CV, Hembd AS, Mohanty AJ, Reisch J, Rozen SM. In order to simulate the effect of myectomy, the target muscles can be blocked with local anesthesia. Degree of self-reported facial impairment correlates with social impairment in individuals with facial paralysis and synkinesis. With facial neuromuscular retraining, a synkinesis patient can limit abnormal movement patterns that otherwise would result in auto-paralysis of different facial muscle groups. doi: 10.1097/PRS.0000000000007572, 32. There are a few pioneering publications performing facial nerve reconstruction combined with selective neurectomy (a technique originally applied after the occurrence of facial synkinesis, refer below). doi: 10.1016/S0004-9514(06)70026-5, 67. Facial Nerve Disorders | Vanderbilt Health Nashville, TN 9401 Wilshire Blvd #650 Synkinesis can occur anytime that the facial nerve is injured but still intact, or anytime the facial nerve has been repaired. For example, people coping with stress and anxiety may be prone to involuntary facial twitching and grimacing. (2020) 61:34753. (2020) 22:3629. Recommendation: Surgery in form of selective myectomy or neurectomy is a third-line treatment option and the decision should be individualized and done with caution, after discussing possible complications and limited success rate. Even a transoral injection into the buccinator muscle can be helpful in patients with cheek biting, difficulty eating, and speech abnormalities (70, 71). Since the first comprehensive review by Crumley in 1979, our current knowledge of the background, especially on the role of cortical control in facial synkinesis, has increased (3). No use, distribution or reproduction is permitted which does not comply with these terms. Osthues M, Kuttenreich AM, Volk GF, Dobel C, Strauss B, Altmann U, et al. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Azizzadeh B, Nduka C. Management of Post-Facial Paralysis Synkinesis. Schedulean appointment today. Krane NA, Genther D, Weierich K, Hanseler H, Liu SW, Mowery A, et al. Treatments offered at our center include the following: Treatments offered at our center include the following: Synkinesis is one of the undesired results of facial nerve injury and recovery. Dr. Azizzadeh pioneered the selective neurolysis procedure for his patients who could not generate a proper smile due to their synkinesis and partial facial paralysis. Specific clinical grading systems of facial synkinesis, sophisticated electrophysiological testing, and patient self-reported outcome measures allow for a precise definition of the patient's individual physical and psychosocial burden. doi: 10.1002/lary.27739, 29. (2018) 20:196201. Bylund N, Jensson D, Enghag S, Berg T, Marsk E, Hultcrantz M, et al. Facial synkinesis (post-paralytic facial synkinesis; post-paralytic facial nerve syndrome with synkinesis) is a symptom in which a voluntary facial muscle movement causes the simultaneous involuntary contraction of other facial muscles, which can occur in all facial muscles . Laryngoscope. (1979) 89:184754. doi: 10.1080/02688697.2020.1773396, 23. However, the additional effect to improve smiling is not convincing (88). Wu JJ, Lu YC, Zheng MX, Hua XY, Shan CL, Ding W, et al. The procedure can also be combined with myotomy of the platysma. An official website of the United States government. doi: 10.1097/PRS.0b013e318230e758, 91. Facial neuromuscular retraining for oral synkinesis. When the person is not moving their face, synkinesis may still be visible[3]. Outcomes of buccinator treatment with botulinum toxin in facial synkinesis. In the acute stage, physiotherapy uses passive techniques to reduce facial muscle tension and sensory stimulation to promote the reactivated motor skills. Stress and anxiety wont cause synkinesis, but they can cause involuntary facial muscle movements. Other signs of facial synkinesis include: This often results in abnormal facial muscle patterns that can range in severity. Drawing by Sonja Burger. . Patel PN, Owen SR, Norton CP, Emerson BT, Bronaugh AB, Ries WR, et al. Synkinesis (AKA aberrant regeneration) occurs after injury to the facial nerve and it is a common sequelae of facial palsy. Our physicians collaboratively work with other departments within Johns Hopkins Medicine to develop a care plan best for you. A therapist will teach a patient how to perform these exercises properly and ensure that he or she fully understands the ins and outs of each exercise. EMG electrodes are placed on the muscle whose control ought to be improved (for instance, zygomatic muscle) and on the muscle which should not be moved synkinetically (for instance, orbicularis oculi muscle). In addition, neuromuscular retraining focuses on muscle re-coordination rather than stimulation, and patients should not perform muscle-strengthening exercises as part of this treatment. Furthermore, there are no international standard protocols for facial training. Tolerability of facial electrostimulation in healthy adults and patients with facial synkinesis. All authors approved the final version. doi: 10.1089/fpsam.2020.0082, PubMed Abstract | CrossRef Full Text | Google Scholar, 3. Before he performs a synkinesis procedure, he establishes a plan that offers insights into all aspects of treatment. Otolaryngology Head & Neck Surgery - Stanford Medicine Crumley RL. Dr. Azizzadeh strives to help patients recover from synkinesis procedures as quickly as possible. The synkinesis is a result of misguided nerve regeneration following axonal damage. Surgery is reserved for individual cases with unsatisfactory first-line treatment. Too much or too little? Optimal therapy leads to symptom-free periods of at least 6 months. Front Rehabilit Sci. Figure 5. Only those patients with Bell's palsy and axonal damage can develop facial synkinesis. (2019) 397:127. Too much or too little? Austral J Physiother. Proprioceptive and joint receptors are absent in the face. Am J Otolaryngol. Dr. Azizzadeh then crafts a custom treatment plan to help a patient permanently address his or her facial paralysis. In: Guntinas-Lichius O, Schaitkin B, eds Facial Nerve Disorders and Diseases: Diagnosis and Management. J Neurol. Many patients ask us to explain the difference between facial paralysis vs. facial synkinesis. These patterns include: Synkinesis is caused by trauma to the facial nerve. The aim of this systematic review is to establish the base for a possible guideline, which would serve relevant providers (i.e., otorhinolaryngologists - head and neck surgeons and other medical specialists, therapeutic professionals, and the affected patients), as well as to provide practical recommendations for diagnostics and a graduated therapy of facial synkinesis. In a small randomized trial on unselected cases with mild-to-severe Bell's palsy, the synkinesis rate after prednisolone and/or acyclovir plus electrical stimulation was lower (4%) than after drug treatment only (12%) (53). Effect of 3 commercially available botulinum toxin neuromodulators on facial synkinesis: a randomized clinical trial. The cause of the injury may be Bell's Palsy, Ramsay Hunt Syndrome (less common), surgical damage (eg. These patients typically have a high and continuous high motivation for rehabilitation. Some patients with long-term facial paralysis and synkinesis may be candidates for a cross facial nerve graft and gracilis muscle transplant.These cutting-edge surgical procedures, combined with physical therapy, can help restore dynamic facial animation, such as the ability to smile, in facial paralysis patients. Federal government websites often end in .gov or .mil. Recommendation: Facial synkinesis is the result of a complex pathological regeneration with changes in the brainstem nucleus and the higher cortex. doi: 10.1055/s-0041-1732350, 89. However, each patient is different, and each treatment is tailored to a patient. are in effect starting April 24. Beurskens CH, Heymans PG. 2021 Nov 26:1455613211054627. doi: 10.1177/01455613211054627. Synkinesis cannot be prevented, however, there are certain things that patients can do to minimize its effect after Bells palsy. Whereas the duration of the botulinum toxin effect seems to be stable over years, the number of injected muscles and the overall dosage needed seems to increase over time (72). Derakhshan A, Miller MQ, Malka R, Gadkaree SK, Hadlock TA. The cause of the injury may be Bell's Palsy, Ramsay Hunt Syndrome (less common), surgical damage (eg. Facial Plast Surg Aesthet Med. (2010) 90:3917. A single-cohort comparison in postparetic facial synkinesis. Synkinetic brow function with brow depression is the result of co-contraction of the frontalis muscle with the corrugator, procerus, and superior portion of the orbicularis oculi muscles (86). doi: 10.1038/sj.eye.6700230, 39. Causes include: Ramsey Hunt syndrome: This complication of shingles (a painful rash due to reactivation of the virus that causes chickenpox) results in facial nerve weakness. (2009) 140:44550. Methods: One hundred three patients with postparalytic facial synkinesis were investigated (1985 to 2020). A relevant part of the available literature regards exclusively the sequelae of patients with idiopathic facial palsy (Bell's palsy). The patient is sitting in the front (right side). In either technique, the tension on the repurposed muscle and the site of attachment on the lip is carefully determined by muscle stimulation during the surgery to achieve the best result. The Synkinesis Assessment Questionnaire consists of nine questions and has been shown to be both valid and reliable as a dedicated measurement of synkinesis. Note restricted smile, involuntary right eye narrowing with smile, chin dimpling with eye closure, right cheek tightness with eye closure, and right neck bands with eye closure. For example, if botulinum toxin injected into the platysma muscle (neck muscle) improves smile and facial symmetry, then the nerve branch and muscle of the platysma canbe cut during a facelift-type surgery inorder to offer more permanent improvement. People who continuously experience involuntary facial muscle movements should pursue a medical diagnosis and treatment. Table 7. Facial muscles have a limited ability to provide feedback. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. He requests photographs and other patient information before the meeting and encourages his patients to ask questions during the session. You can make an appointment at one of our convenient locations. Whereas some facial reanimation surgeries require two to three years before a patient achieves the final results, initial treatment results may become visible within one day of surgery. 2023 Apr;39(2):190-200. doi: 10.1055/a-1950-4483. Comprehensive facial rehabilitation improves function in people with facial paralysis: a 5-year experience at the massachusetts eye and ear infirmary. Facial palsy Facial reanimation Facial nerve Synkinesis KEY POINTS Facial palsy is a devastating condition encompassing a spectrum of movement disordersthat range from flaccid paralysis to postparalytic facial hyperactivity. Unauthorized use of these marks is strictly prohibited. An EMG guidance of the injections is not routinely performed but might be helpful if the initial treatment did not result in the desired effect. Latest advances in the management of facial synkinesis. (1993) 86:17981. In patients who previously dealt with Bells palsy, the facial nerve fibers may be implanted into different muscles and can inadvertently cause unwanted and involuntary movement of the facial muscles. Importance: Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. The temporalis tendon transfer procedure is often performed as an outpatient procedure and is followed by facial retraining therapy under the guidance of facial physical therapists. Guntinas-Lichius O, Genther DJ, Byrne PJ. Mehta RP, WernickRobinson M, Hadlock TA. Only a few popular grading systems allow for a classification of the degree of synkinesis. Selective neurectomy is reserved for patients who do not respond to rehabilitation therapy and who have a favorable response to botulinum toxin in the muscles around the lower lip and neck. The most common injection areas for Botox are: Botulinum Toxin injections can also be used to improve facial symmetry by reducing the activity of certain muscles on the normal side of the face, such as: Dr. Azizzadeh carefully evaluates a synkinesis patients jaw muscles and other facial features to determine if Botox can be safely performed. Facial Plast Surg Aesthet Med. It is believed to be due to an aberrant regeneration of axon during recovery or hyperexcitability of facial nucleus. When intra-temporal or a more proximal lesion occurs, stapedial synkinesis can occur, leading to changes in the hearing threshold (37). The first-line treatment is facial training, followed by botulinum toxin. Validation of the Synkinesis Assessment Questionnaire. 1173185, Mechanism of Injury / Pathological Process, Appearance of Synkinesis when the face is at rest, Appearance of Synkinesis when the face is moving. One part of the face may begin to move abnormally with the intentional movement of another part of the face - for example, the eyelids may involuntarily close when a person is attempting to smile. (2005) 21:391402. Neuromuscular retraining is a valuable part of rehabilitation for facial paralysis, which can help to restore function and control inappropriate facial movements (synkinesis). Facial re-education also involves wearing sunglasses to prevent squinting and massaging the intraoral buccal area. Your individualized treatment plan may involve one or more of these procedures: When the facial nerve is injured, the facial muscles responsible for facial expression begin to slowly atrophy and eventually become irreversibly scarred. Diagnostics should include a standardized assessment of the degree of synkinesis using validated clinician-graded instruments and synkinesis-specific patient-reported outcome measures. Understanding Bells Palsy: Causes, Symptoms, and Treatment Options, Acoustic Neuroma: Symptoms, Treatment, and Recovery, Facial Paralysis Synkinesis: Understanding Symptoms, Diagnosis and Treatment, Congenital Facial Paralysis: Causes, Symptoms, and Treatment, Hemifacial Microsomia: Causes, Symptoms, and Treatment, Hemifacial Spasm Treatment Options: BOTOX and Surgery, Ramsay Hunt Syndrome: Symptoms, Complications, and Treatment, Congenital Unilateral Lower Lip Paralysis (CULLP) Symptoms, Diagnosis, and Treatment, Selective Neurolysis For Facial Paralysis and Synkinesis, GRACILIS FREE FLAP GRACILIS MUSCLE TRANSPLANT |, Surgery for Synkinesis & Partial Facial Paralysis, 2017 International Facial Nerve Symposium, The eyes narrow when an individual smiles, The cheek lifts when a person closes his or her eyes, The neck muscle tightens when a person tries to whistle, Facial muscles become tight, leading to facial pain and headaches, A deeper cheek crease forms on the affected side of the face, causing the cheek to appear bulky, Static suspension of the corners of the mouth, Lower lip depressors (depressor anguli oris). Synkinesis begins 3-4 months after regeneration of FNP and continues for up to 2 years ( 8 - 10 ). Plus, Dr. Azizzadeh offers detailed instructions to help a patient prepare for his or her synkinesis treatment.
