Management of Synkinesis

 

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ABSTRACT

Facial synkinesis is one of the most distressing consequences of facial paralysis. Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group. The pathophysiologic basis of facial synkinesis is likely multifactorial although the predominant mechanism appears to be aberrant regeneration of facial nerve fibers to the facial muscle groups after facial nerve injury. Patients experience hypertonic contractures and synkinetic movements such as eye closure with volitional movement of the mouth or midfacial movement during volitional or reflexive eye closure. Synkinesis can cause functional limitation with activities such as eating, drinking, smiling, and may even lead to social isolation. Evaluation of synkinesis is primarily subjective with facial grading scales such as the Sunnybrook scale. Objective measures of synkinesis using computerized video analysis show promise although no objective techniques are currently widely used. The most common therapeutic modalities for the treatment of facial synkinesis include (1) botulinum toxin type A (BTX-A) injections for selective chemodenervation of affected muscle groups and (2) facial neuromuscular retraining. Biofeedback using mirrors or electromyography has been used both for the treatment and prevention of facial synkinesis. Other treatment options include surgical therapies, such as selective neurolysis or myectomy, although these have been rendered nearly obsolete with the advent of BTX-A.

REFERENCES

• 1 Coulson S E, O'dwyer N J, Adams R D, Croxson G R. Expression of emotion and quality of life after facial nerve paralysis.  Otol Neurotol. 2004;  25 1014-1019
  CrossrefPubMedGoogle Scholar
• 2 Neely J G, Neufeld P S. Defining functional limitation, disability, and societal limitations in patients with facial paresis: initial pilot questionnaire.  Am J Otol. 1996;  17 340-342
  CrossrefPubMedGoogle Scholar
• 3 Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies.  Acta Otolaryngol Suppl. 2002;  (549) 4-30
  PubMedGoogle Scholar
• 4 Crumley R L. Mechanisms of synkinesis.  Laryngoscope. 1979;  89 1847-1854
  PubMedGoogle Scholar
• 5 Yamamoto E, Nishimura H, Hirono Y. Occurrence of sequelae in Bell's palsy.  Acta Otolaryngol Suppl. 1988;  446 93-96
  PubMedGoogle Scholar
• 6 Langworth E P, Taverner D. The prognosis in facial palsy.  Brain. 1963;  86 465-480
  CrossrefPubMedGoogle Scholar
• 7 Celik M, Forta H, Vural C. The development of synkinesis after facial nerve paralysis.  Eur Neurol. 2000;  43 147-151
  CrossrefPubMedGoogle Scholar
• 8 Guerrissi J O. Selective myectomy for postparetic facial synkinesis.  Plast Reconstr Surg. 1991;  87 459-466
  PubMedGoogle Scholar
• 9 Moran C J, Neely J G. Patterns of facial nerve synkinesis.  Laryngoscope. 1996;  106(12 Pt 1) 1491-1496
  CrossrefPubMedGoogle Scholar
• 10 Marin Amat M. Sur le syndrome ou phenomen de Marcus Gunn. Annales d'oculistique (Paris). 1919 156: 513-528
  Google Scholar
• 11 Sunderland S. Nerve and Nerve Injuries. 2nd ed. London, UK; Churchill Livingstone 1978: 88-97
  Google Scholar
• 12 Montserrat L, Benito M. Facial synkinesis and aberrant regeneration of facial nerve. In: Jankovic J, Tolos E Advances in Neurology. New York, NY; Raven Press 1988: 211-224
  Google Scholar
• 13 Choi D, Raisman G. Somatotopic organization of the facial nucleus is disrupted after lesioning and regeneration of the facial nerve: the histological representation of synkinesis.  Neurosurgery. 2002;  50 355-362 discussion 362-363
  PubMedGoogle Scholar
• 14 Choi D, Raisman G. Disorganization of the facial nucleus after nerve lesioning and regeneration in the rat: effects of transplanting candidate reparative cells to the site of injury.  Neurosurgery. 2005;  56 1093-1100 discussion 1093-1100
  PubMedGoogle Scholar
• 15 Baker R S, Stava M W, Nelson K R, May P J, Huffman M D, Porter J D. Aberrant reinnervation of facial musculature in a subhuman primate: a correlative analysis of eyelid kinematics, muscle synkinesis, and motoneuron localization.  Neurology. 1994;  44 2165-2173
  PubMedGoogle Scholar
• 16 Oge A E, Yayla V, Demir G A, Eraksoy M. Excitability of facial nucleus and related brain-stem reflexes in hemifacial spasm, post-facial palsy synkinesis and facial myokymia.  Clin Neurophysiol. 2005;  116 1542-1554
  CrossrefPubMedGoogle Scholar
• 17 Rijntjes M, Tegenthoff M, Liepert J et al.. Cortical reorganization in patients with facial palsy.  Ann Neurol. 1997;  41 621-630
  CrossrefPubMedGoogle Scholar
• 18 House J W, Brackmann D E. Facial nerve grading system.  Otolaryngol Head Neck Surg. 1985;  93 146-147
  Google Scholar
• 19 May M. Facial paralysis, peripheral type: a proposed method of reporting. (Emphasis on diagnosis and prognosis, as well as electrical and chorda tympani nerve testing).  Laryngoscope. 1970;  80 331-390
  PubMedGoogle Scholar
• 20 Fisch U. Surgery for Bell's palsy.  Arch Otolaryngol. 1981;  107 1-11
  Google Scholar
• 21 House J W. Facial nerve grading systems.  Laryngoscope. 1983;  93 1056-1069
  PubMedGoogle Scholar
• 22 Kang T S, Vrabec J T, Giddings N, Terris D J. Facial nerve grading systems (1985-2002): beyond the House-Brackmann scale.  Otol Neurotol. 2002;  23 767-771
  PubMedGoogle Scholar
• 23 Linstrom C J. Objective facial motion analysis in patients with facial nerve dysfunction.  Laryngoscope. 2002;  112(7 Pt 1) 1129-1147
  CrossrefPubMedGoogle Scholar
• 24 Coulson S E, Croxon G R. Assessing physiotherapy rehabilitation outcomes following facial nerve paralysis.  Aust J Otolaryngol. 1994;  2 20-24
  PubMedGoogle Scholar
• 25 Ross B G, Fradet G, Nedzelski J M. Development of a sensitive clinical facial grading system.  Otolaryngol Head Neck Surg. 1996;  114 380-386
  CrossrefPubMedGoogle Scholar
• 26 Coulson S E, Croxson G R, Adams R D, O'Dwyer N J. Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis.  Otolaryngol Head Neck Surg. 2005;  132 543-549
  CrossrefPubMedGoogle Scholar
• 27 Mehta R P, Wernick-Robinson M, Hadlock T A. Validation of the Synkinesis Assessment Questionnaire.  Laryngoscope. 2007;  117 923-926
  CrossrefPubMedGoogle Scholar
• 28 On A Y, Yaltirik H P, Kirazli Y. Agreement between clinical and electromyographic assessments during the course of peripheric facial paralysis.  Clin Rehabil. 2007;  21 344-350
  CrossrefPubMedGoogle Scholar
• 29 Burres S A. Facial biomechanics: the standards of normal.  Laryngoscope. 1985;  95 708-714
  PubMedGoogle Scholar
• 30 Neely J G, Jekel J F, Cheung J Y. Variations in maximum amplitude of facial expressions between and within normal subjects.  Otolaryngol Head Neck Surg. 1994;  110 60-63
  PubMedGoogle Scholar
• 31 Helling T D, Neely J G. Validation of objective measures for facial paralysis.  Laryngoscope. 1997;  107 1345-1349
  PubMedGoogle Scholar
• 32 Meier-Gallati V, Scriba H, Fisch U. Objective scaling of facial nerve function based on area analysis (OSCAR).  Otolaryngol Head Neck Surg. 1998;  118 545-550
  PubMedGoogle Scholar
• 33 Rogers C R, Schmidt K L, VanSwearingen J M et al.. Automated facial image analysis: detecting improvement in abnormal facial movement after treatment with botulinum toxin A.  Ann Plast Surg. 2007;  58 39-47
  CrossrefPubMedGoogle Scholar
• 34 Mehta R P, Zhang S, Hadlock T A. Novel 3D video for quantification of facial movement.  Otolaryngol Head Neck Surg. 2008;  138 468-472
  CrossrefPubMedGoogle Scholar
• 35 Wu Z B, Silverman C A, Linstrom C J, Tessema B, Cosetti M K. Objective computerized versus subjective analysis of facial synkinesis.  Laryngoscope. 2005;  115 2118-2122
  CrossrefPubMedGoogle Scholar
• 36 Coulson S E, Croxson G R, Gilleard W L. Three-dimensional quantification of the symmetry of normal facial movement.  Otol Neurotol. 2002;  23 999-1002
  CrossrefPubMedGoogle Scholar
• 37 Trotman C A, Gross M M, Moffatt K. Reliability of a three-dimensional method for measuring facial animation: a case report.  Angle Orthod. 1996;  66 195-198
  PubMedGoogle Scholar
• 38 Frey M, Giovanoli P, Gerber H, Slameczka M, Stüssi E. Three-dimensional video analysis of facial movements: a new method to assess the quantity and quality of the smile.  Plast Reconstr Surg. 1999;  104 2032-2039
  PubMedGoogle Scholar
• 39 Beurskens C H, Heymans P G. Physiotherapy in patients with facial nerve paresis: description of outcomes.  Am J Otolaryngol. 2004;  25 394-400
  CrossrefPubMedGoogle Scholar
• 40 Mosforth J, Taverner D. Physiotherapy for Bell's palsy.  BMJ. 1958;  2 675-677
  CrossrefPubMedGoogle Scholar
• 41 Ross B, Nedzelski J M, McLean J A. Efficacy of feedback training in long-standing facial nerve paresis.  Laryngoscope. 1991;  101(7 Pt 1) 744-750
  PubMedGoogle Scholar
• 42 Segal B, Hunter T, Danys I, Freedman C, Black M. Minimizing synkinesis during rehabilitation of the paralyzed face: preliminary assessment of a new small-movement therapy.  J Otolaryngol. 1995;  24 149-153
  PubMedGoogle Scholar
• 43 Ohye R G, Altenberger E A. Bell's palsy.  Am Fam Physician. 1989;  40 159-166
  PubMedGoogle Scholar
• 44 Bateman D E. Facial palsy.  Br J Hosp Med. 1992;  47 430-431
  PubMedGoogle Scholar
• 45 Balliet R, Shinn J B, Bach-y-Rita P. Facial paralysis rehabilitation: retraining selective muscle control.  Int Rehabil Med. 1982;  4 67-74
  PubMedGoogle Scholar
• 46 Segal B, Zompa I, Danys I et al.. Symmetry and synkinesis during rehabilitation of unilateral facial paralysis.  J Otolaryngol. 1995;  24 143-148
  PubMedGoogle Scholar
• 47 Brach J S, VanSwearingen J M, Lenert J, Johnson P C. Facial neuromuscular retraining for oral synkinesis.  Plast Reconstr Surg. 1997;  99 1922-1931 discussion 1932-1933
  PubMedGoogle Scholar
• 48 Devriese P P, Bronk J. Non-surgical rehabilitation of facial expression. In: Fisch U Facial Nerve Surgery. Kugler Medical 1977: 290-294
  Google Scholar
• 49 Beurskens C H, Heymans P G. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial.  Aust J Physiother. 2006;  52 177-183
  CrossrefPubMedGoogle Scholar
• 50 Beurskens C H, Heymans P G. Physiotherapy in patients with facial nerve paresis: description of outcomes.  Am J Otolaryngol. 2004;  25(6) 394-400
  CrossrefPubMedGoogle Scholar
• 51 Brudny J J. Biofeedback in facial paralysis: electromyographic rehabilitation. In: L. Rubin The Paralyzed Face. St. Louis, MO; Mosby-Yearbook 1991
  Google Scholar
• 52 Baumel J J. Trigeminal-facial nerve communications. Their function in facial muscle innervation and reinnervation.  Arch Otolaryngol. 1974;  99 34-44
  CrossrefPubMedGoogle Scholar
• 53 Burgess P R, Wei J Y, Clark F J, Simon J. Signaling of kinesthetic information by peripheral sensory receptors.  Annu Rev Neurosci. 1982;  5 171-187
  CrossrefPubMedGoogle Scholar
• 54 Dalla Toffola E, Bossi D, Buonocore M, Montomoli C, Petrucci L, Alfonsi E. Usefulness of BFB/EMG in facial palsy rehabilitation.  Disabil Rehabil. 2005;  27 809-815
  CrossrefPubMedGoogle Scholar
• 55 Ross B, Nedzelski J M, McLean J A. Efficacy of feedback training in long-standing facial nerve paresis.  Laryngoscope. 1991;  101(7 Pt 1) 744-750
  PubMedGoogle Scholar
• 56 Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N. Biofeedback rehabilitation for prevention of synkinesis after facial palsy.  Otolaryngol Head Neck Surg. 2003;  128 539-543
  CrossrefPubMedGoogle Scholar
• 57 VanSwearingen J M, Brach J S. Changes in facial movement and synkinesis with facial neuromuscular reeducation.  Plast Reconstr Surg. 2003;  111 2370-2375
  PubMedGoogle Scholar
• 58 Cronin G W, Steenerson R L. The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation.  Otolaryngol Head Neck Surg. 2003;  128 534-538
  CrossrefPubMedGoogle Scholar
• 59 Brach J S, VanSwearingen J M. Physical therapy for facial paralysis: a tailored treatment approach.  Phys Ther. 1999;  79 397-404
  PubMedGoogle Scholar
• 60 Clark R P, Berris C E. Botulinum toxin: a treatment for facial asymmetry caused by facial nerve paralysis.  Plast Reconstr Surg. 1989;  84 353-355
  CrossrefPubMedGoogle Scholar
• 61 Roggenkämper P, Laskawi R, Damenz W, Schröder M, Nüssgens Z. Botulinum toxin treatment of synkinesia following facial paralysis.  HNO. 1990;  38 295-297
  PubMedGoogle Scholar
• 62 Chong P N, Ong B, Chan R. Botulinum toxin in the treatment of facial dyskinesias.  Ann Acad Med Singapore. 1991;  20 223-227
  PubMedGoogle Scholar
• 63 Comella J X, Molgo J, Faille L. Sprouting of mammalian motor nerve terminals induced by in vivo injection of botulinum type-D toxin and the functional recovery of paralysed neuromuscular junctions.  Neurosci Lett. 1993;  153 61-64
  CrossrefPubMedGoogle Scholar
• 64 Armstrong M W, Mountain R E, Murray J A. Treatment of facial synkinesis and facial asymmetry with botulinum toxin type A following facial nerve palsy.  Clin Otolaryngol Allied Sci. 1996;  21 15-20
  CrossrefPubMedGoogle Scholar
• 65 Smet-Dieleman H, Van de Heyning P H, Tassignon M J. Botulinum A toxin injection in patients with facial nerve palsy.  Acta Otorhinolaryngol Belg. 1993;  47 359-363
  PubMedGoogle Scholar
• 66 Mountain R E, Murray J A, Quaba A. Management of facial synkinesis with Clostridium botulinum toxin injection.  Clin Otolaryngol Allied Sci.. 1992;  17 223-224
  PubMedGoogle Scholar
• 67 Roggenkämper P, Laskawi R, Damenz W, Schröder M, Nüssgens Z. Involuntary lid closure caused by defective healing of facial paralysis and its treatment with botulinum toxin.  Klin Monatsbl Augenheilkd. 1991;  198 268-270
  Article in Thieme ConnectPubMedGoogle Scholar
• 68 Chua A CN, Quhill F, Jones E, Voon L W, Ahad M, Rowson N. Treatment of aberrant facial nerve regeneration with botulinum toxin.  Orbit. 2004;  23 213-218
  CrossrefPubMedGoogle Scholar
• 69 Ito H, Ito H, Nakano S, Kusaka H. Low-dose subcutaneous injection of botulinum toxin type A for facial synkinesis and hyperlacrimation.  Acta Neurol Scand. 2007;  115 271-274
  CrossrefPubMedGoogle Scholar
• 70 Borodic G, Bartley M, Slattery W et al.. Botulinum toxin for aberrant facial nerve regeneration: double-blind, placebo-controlled trial using subjective endpoints.  Plast Reconstr Surg. 2005;  116 36-43
  PubMedGoogle Scholar
• 71 Guerrissi J O. Selective myectomy for postparetic facial synkinesis.  Plast Reconstr Surg. 1991;  87 459-466
  PubMedGoogle Scholar

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