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MANAGEMENT of POST-FACIAL PARALYSIS SYNKINESIS
MANAGEMENT of POST-FACIAL PARALYSIS SYNKINESIS
Edited by
BABAK AZIZZADEH MD, FACS
Associate Clinical Professor, David Geffen School of Medicine at UCLA
Diplomat, American Board of Facial Plastic & Reconstructive Surgery
Fellow, American Academy of Facial Plastic & Reconstructive Surgery
Fellow, American College of Surgeons
CHARLES NDUKA MB BS, MA(OXON), MD, FRCS, FRCS(PLAS)
Consultant Plastic Surgeon, Facial Palsy Unit
Department of Plastic & Reconstructive Surgery
Queen Victoria Hospital
East Grinstead, UK
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Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Control Number: 2021939103
ISBN 978-0-323-67331-0
e_ISBN 978-0-323-75510-8
Content Strategist: Jessica McCool/Belinda Kuhn
Content Development Specialist: Trinity Hutton/Veronika Watkins
Project Manager: Julie Taylor
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Printed in the United States
Video Table of Contents, vi
Preface, vii
Acknowledgements, viii Dedication, ix Contributors, x
1 Facial Nerve and Muscle Anatomy, 1 G. Nina Lu, Patrick J. Byrne
2 Etiology, Epidemiology, and Pathophysiology of Post-Facial Paralysis Synkinesis, 13 Kofi D.O. Boahene
3 Psychosocial Impact of Facial Palsy, 19
Ietske J. Siemann, Carien H.G. Beurskens
4 Facial Nerve Consultation, 25
Stephanie Warrington, Sara MacDowell, Laura Hetzler
5 Smile Analysis for Facial Nerve Disorders, 33 Scott R. Chaiet
6 The Role of Botulinum Toxin in Facial Palsy Management, 39
Ruben Yap Kannan, Charles Nduka
7 Assessment and Grading of Synkinesis and Facial Palsy, 51
Helen Hartley, Wendy Blumenow, Rebecca Williams, Adel Fattah
8 Objective Measurement of Outcomes in Facial Palsy, 59
Gerd Fabian Volk, Jovanna Thielker, Oliver Mothes, Orlando Guntinas-Lichius
9 Facial Neuromuscular Retraining for Synkinesis, 75 H. Jacqueline Diels
10 Eyelid Rehabilitation in Post-Facial Paralysis With Synkinesis, 91
Amy Patel Jain, Yao Wang, Julia Kerolus, Babak Azizzadeh, Guy Massry
11 Surgical Management of Post-Facial Paralysis Synkinesis, 101 Mike Zein, Babak Azizzadeh
Appendix: Instructions for Sonography of the Mimic Musculature, 109 Index, 135
Video Table of Contents
CHAPTER 1
Video 1.1 Levator labii superioris vector of pull
CHAPTER 3
Video 3.1 Alternatives for facial expressions
CHAPTER 4
Video 4.1 Flaccid paralysis
Video 4.2 Synkinesis
CHAPTER 7
Video 7.1 Example of iatrogenic synkinesis
Video 7.2 Post-operative rehabilitation therapy for gracilis patients
Video 7.3 Additional assessments for bilateral facial palsy patients
CHAPTER 8
Video 8.1 Example of a standard photo session
Video 8.2 Example of pathologic spontaneous activity recorded by a needle-electromyography of the musculus orbicularis oris
Video 8.3 Montage of video and electromyography from a patient with synkinesis. Two needle-EMGelectrodes are inserted in two different muscles: channel 1 shows M. orbicularis oris; channel 2 shows M. zygomaticus. Sound comes from channel 1
Video 8.4 Montage of video and electromyography from a patient with synkinesis. Two needle-EMGelectrodes are inserted in two different muscles:
channel 1 shows M. orbicularis oris; channel 2 shows M. zygomaticus. Sound comes from channel 2
Video 8.5 Montage of video and electromyography from a participant without synkinesis. Two needleEMG - electrodes are inserted in two different muscles: channel 1 shows M. orbicularis oris; channel 2 shows M. zygomaticus. Sound comes from channel 1
Video 8.6 Montage of video and electromyography from a participant without synkinesis. Two needle-EMG - electrodes are inserted in two different muscles: channel 1 shows M. orbicularis oris; channel 2 shows M. zygomaticus. Sound comes from channel 1
Video 8.7 Sonography of the corner of the mouth while patient with synkinesis is performing eye blinks
CHAPTER 9
Video 9.1 Inhibition of oculi synkinesis during fNMR
Video 9.2 Inhibition of synkinesis using sEMG feedback
Video 9.3 Movement acquisition during fNMR using proprioception
Video 9.4 Dynamic demonstration of synkinetic inhibition during evaluation
Video 9.5 Identifying botulinum toxin injection site(s) for buccinator
CHAPTER 10
Video 10.1 Eyelid and periorbital reconstructive surgery
Preface
This book grew from the seed of an idea planted in 2017 at the 13th International Facial Nerve Symposium, organized and hosted by Babak Azizzadeh and colleagues. It gathered over 500 professionals from over 40 countries in Los Angeles to share knowledge and research about facial paralysis. There was an excellent panel session on synkinesis with contributions from Jackie
Diels, Daniel Labbé, Mark Lucarelli, Guy Massry, Bill Slattery, and Matt White. It was clear that there is immense knowledge about the management of synkinesis in the heads of the international faculty that needed to be captured in one place. The result is this book, which has drawn upon leading experts from across the world to distill their knowledge within these pages.
Acknowledgements
Acknowledgements from Charles Nduka
I would like to thank the thousands of patients affected by synkinesis who have allowed me to be part of their care team. They have provided me with important insights and inspiration. I am especially grateful to the Facial Palsy UK community of patients, their families, and supporters who have taught me so much about the impact that facial paralysis has on their lives.
I am grateful to my multidisciplinary colleagues at the Queen Victoria Hospital in East Grinstead, including facial therapists Trina Neville, Tamsin Gwynn, and Karen Young, psychological therapist Beth Jordan, and my plastic surgery colleague Ruben Kannan. I am also grateful for the ongoing support of the oculoplastic team led by Raman Malhotra and André Litwin, and the facial nerve team at Guy’s Hospital in London. Without the encouragement, patience, and support of Veronika Watkins, Jessica McCool, and the Elsevier team, this book would not have been possible.
Acknowledgements from Babak Azizzadeh
My personal journey as a physician has been so rewarding, with my family, patients, mentors, and colleagues having an integral role in my passion for treating patients with facial nerve disorders. During the very early part of my residency training, one of my wife’s closest friends developed facial paralysis due to a benign brain tumor and that started my deep curiosity into this most challenging of all medical and surgical disorders. During my early days as a resident in Head & Neck Surgery at UCLA, Drs. Rinaldo Canalis, Tom Calcatterra, Keith Blackwell, and Gerald Berke were integral in my training in microsurgery, in-depth
understanding of the facial nerve anatomy, and the complexity of treating cranial nerve disorders. I was privileged to train in facial plastic and reconstructive surgery at the Massachusetts Eye & Ear Infirmary which completely changed the trajectory of my career. During my fellowship at Harvard Medical School, I was fortunate enough to be trained by Dr. Mack Cheney who had himself dedicated his life to microsurgery, facial plastic surgery, and facial paralysis and, along with Drs. Mark Varvares and Daniel Deschler, gave me the necessary medical and surgical tools to further develop my skills. After returning to Los Angeles, I was privileged to be surrounded by a passionate team of subspecialists who share the same desire, allowing us to look at facial nerve disorders from a multidisciplinary approach. Drs. Babak Larian, Guy Massry, Bill Slattery, Randy Sherman, Greg Lekovic, and Jackie Diels have been inspirational and I have learned so much from each of them almost every single day. I have also been fortunate to have met so many pioneers of the field such as Dr. Douglas Harrison who have mentored and inspired me. I also want to thank my contemporaries Drs. Tessa Hadlock and Patrick Byrne who continue to push the envelope in this emerging field of study. I would be remiss not to share how lucky I have been to have Dr. Babak Larian as the most compassionate and talented partner who has been with me every step of the way for over two decades. He and I have operated together, dreamed together, devised new approaches, and managed the most challenging medical and surgical cases. Finally, this book would not have become reality without Jessica McCool, Veronika Watkins, and the rest of the Elsevier team. They have been the ultimate professionals in their own field.
Dedication from Charles Nduka
To my wife Jules for her continued understanding and patience.
Dedication from Babak Azizzadeh
I dedicate this book to all my patients who have entrusted me to help them in their own journeys.
Contributors
Babak Azizzadeh MD
Associate Clinical Professor, David Geffen School of Medicine at UCLA
Diplomat, American Board of Facial Plastic & Reconstructive Surgery
Fellow, American Academy of Facial Plastic & Reconstructive Surgery Fellow, American College of Surgeons
Carien Beurskens PhD Doctor Physiotherapy
Radboud University Medical Center Nijmegen, Netherlands
Wendy Blumenow Bsc (Hons), RCSLT, HCPC
Principal Speech & Language Therapist
Alder Hey Children’s NHS Foundation Trust Liverpool, UK
Kofi Boahene MD Professor Department of Otolaryngology, Head and Neck Surgery
Johns Hopkins University School of Medicine Baltimore MD, USA
Patrick Byrne MD Chairman
The Cleveland Clinic Head and Neck Institute Cleveland OH, USA
Scott Chaiet MD, MBA Assistant Professor
Division of Otolaryngology, Department of Surgery University of Wisconsin School of Medicine & Public Health Madison WI, USA
H. Jacqueline Diels OT
Facial Retraining Specialist
Rehabilitation
Facial Retraining LLC Madison WI, USA
Adel Fattah PhD, FRCS(Plast)
Consultant Plastic Surgeon
Regional Paediatric Burns and Plastic Surgery Service
Alder Hey Children’s NHS Foundation Trust Liverpool, UK
Orlando Guntinas-Lichius MD Professor and Chairman
ENT Department
Jena University Hospital
Jena, Germany;
Facial Nerve Center
Jena University Hospital
Jena, Germany;
Medical Faculty, Friedrich-Schiller-University
Jena, Germany
Helen Hartley MSc, BSc
Highly Specialist Paediatric Physiotherapist
Physiotherapy Department
Alder Hey Children’s NHS Foundation Trust Liverpool, UK
Laura Hetzler MD, FACS
Associate Professor and Program Director
Department of Otolaryngology – Head and Neck Surgery
Queen Victoria Hospital East Grinstead West Sussex, UK
Julia Kerolus MD
Assistant Professor
Otolaryngology – Head and Neck Surgery
University of Illinois at Chicago Chicago IL, USA
G. Nina Lu MD
Assistant Professor
Otolaryngology
University of Washington
Seattle WA, USA
Sara MacDowell PT, DPT
Doctor of Physical Therapy
Our Lady of the Lake Hearing and Balance Center Baton Rouge LA, USA
Guy Massry MD
Ophthalmic Plastic & Reconstructive Surgery Beverly Hills, California, CA, USA; Clinical Professor of Ophthalmology University of Southern California, Keck School of Medicine, CA, USA; Diplomat, American Board of Ophthalmology; Fellow, American Society of Ophthalmic Plastic and Reconstructive Surgery
Oliver Mothes MSc Computer Vision Group Friedrich Schiller University Jena Thuringia, Germany
Charles Nduka MB BS, MA(OXON), MD, FRCS, FRCS(Plas)
Consultant Plastic Surgeon, Facial Palsy Unit Department of Plastic & Reconstructive Surgery Queen Victoria Hospital East Grinstead, UK
Amy Patel Jain MD Oculoplastics
Cedars-Sinai Los Angeles CA, USA
Ietske Siemann MSc Medical Psychology Radboud University Medical Center Nijmegen, Netherlands
Jovanna Thielker MD ENT Department
Jena University Hospital Jena, Germany; Facial Nerve Center
Jena University Hospital Jena, Germany; Medical Faculty, Friedrich-Schiller-University Jena, Germany
Gerd Fabian Volk Priv. Doz. Dr. med. habil.
Senior Consultant
ENT Department
Jena University Hospital Jena, Germany; Head Facial Nerve Center
Jena University Hospital Jena, Germany; Medical Faculty, Friedrich-Schiller-University Jena, Germany
Yao Wang MD Fellow Physician
Ophthalmology and Surgery
Cedars-Sinai Medical Center Los Angeles CA, USA
Stephanie Warrington MD
Department of Otolaryngology – Head Neck Surgery
LSU Health Sciences Center New Orleans LA, USA
Rebecca Williams BSc (Hons)
Specialist Paediatric Physiotherapist
Alder Hey Children’s NHS Foundation Trust Liverpool, UK
Mike Zein MB, MSc
Bascom Palmer Eye Institute University of Miami Miami FL, USA
Facial Nerve and Muscle Anatomy
INTRODUCTION
The facial nerve, also known as the seventh cranial nerve, combines motor, general sensory, special sensory, and autonomic (visceral) components. The intricate course of the facial nerve as it runs intracranially, intratemporally, and extratemporally is essential for any surgeon operating in the head and neck to understand. The facial nerve innervates the muscles derived from the second branchial arch and carries sensory and parasympathetic fibers of the nervus intermedius. The facial muscles, also known as mimetic muscles, function to protect the eye, maintain the nasal airway, provide oral continence, and articulate speech. Equally as important, these mimetic muscles provide humans the means for emotional expression and interpersonal communication. This chapter details an anatomic description of the facial nerve and musculature with a focus on anatomy and physiology as they relate to facial nerve disorder and treatment.
FACIAL NERVE
The facial nerve provides a diverse range of functions via efferent and afferent innervation to structures of the second branchial arch. The most well-associated function of the facial nerve is its innervation of striated muscles of facial expression. These functions will be the focus of this chapter. However, additional efferent motor fibers provide innervation to the stapedius muscle, the stylohyoid muscle, and the posterior belly of the digastric. Collectively, these motor fibers represent the special visceral efferents comprising the majority of the facial nerve fibers. The remaining efferent fibers of the facial nerve are general efferent fibers and form autonomic contributions. These autonomic nerves travel via the greater superficial petrosal nerve (GSPN) to the lacrimal gland and seromucinous glands of the nasal cavity and via the chorda tympani to the submandibular and sublingual glands. Traveling with this autonomic system, visceral afferent fibers supply visceral sensation to the mucosa of the nose, pharynx, and palate. Additional afferent inputs include special sensory fibers and somatic sensory fibers. Special sensory fibers for taste to the anterior two-thirds of the tongue, tonsillar fossa, and palate originate from the geniculate
ganglion cell bodies and travel within the chorda tympani and GSPN. Somatic sensory fibers provide touch sensation to the external auditory canal and conchal skin of the auricle as well as proprioceptive information from the facial muscles (Fig. 1.1).
INTRACRANIAL
Facial muscle movement starts with a conscious or unconscious impulse in the motor cortex of the precentral gyrus of the cerebral hemispheres. The majority of cerebral fibers then project to the contralateral facial motor nucleus via the corticobulbar tract through the thalamus along the posterior limb of the internal capsule. However, a subset of cerebral fibers controlling movement of the frontalis and upper orbicularis oculi project to both the ipsilateral and contralateral facial motor nuclei. A central lesion will thus cause frontalis-sparing facial paralysis due to the bilateral contributions to the upper face. The precentral gyrus fibers synapse in the facial motor nucleus, residing in the pontine tegmentum. Postsynaptic fibers then travel dorsally within the brainstem, loop around the floor of the fourth ventricle at the facial colliculus, and exit the ventrolateral aspect of the brainstem at the caudal border of the pons in the cerebellopontine angle (Fig. 1.2).
Collectively known as the nervus intermedius, preganglionic fibers of the superior salivatory nucleus and sensory fibers from the nucleus of tractus solitarius exit the brainstem directly lateral to the facial nerve motor root. Together, the facial nerve motor root and nervus intermedius enter the internal auditory canal (IAC) at the porus acusticus. For the purposes of this chapter, the facial motor root and nervus intermedius will be collectively referred to as the facial nerve.
INTRATEMPORAL
Meatal
The facial nerve travels through the temporal bone via a bony channel, the fallopian canal. The first segment of the fallopian canal is the meatal segment or IAC. The facial nerve travels in the superior anterior aspect of the IAC. The transverse (falciform) crest separates the facial nerve from the cochlear nerve inferiorly and Bill’s bar, a lateral ridge of bone, and separates the facial nerve from the superior vestibular nerve posteriorly. Within the IAC, the nerve lacks a fibrous sheath
G. Nina Lu, Patrick J. Byrne
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Lowell, P., 174
Luck, rays of, 190
Lumber (in world building), 235, 243
Macroscopic survey, 154, 227, 299, 304
Man, 169, 178
Man-years, 180
Mars, 172
Mass, increase with velocity, 39, 50, 59
Mathematician, 161, 209, 337, 347
Matrix, 208
Matter, 1, 31, 156, 203, 248, 262
Maxwell, J. C., 8, 60, 156, 237
Measures of structure, 234, 268
Mechanical models, 209
Mechanics and Geometry, 137
Mendelian theory, 250
Mental state, 279
Metric, 142, 153
Metrical and non-metrical properties, 275
Michelson-Morley experiment, 5, 11
Microscopic analysis, reaction from, 103
Milky Way, 163
Miller, D. C., 5
Mind and matter, 259, 268, 278; selection by mind, 239, 243, 264
Mind-stuff, 276
Minkowski, H., 34, 53
Mirror, distortion by moving, 11
Models, 198, 209, 344
Molecular bombardment, 113, 131
Momentum, 153, 208, 223, 239, 262
Monomarks, 231
Moon, origin of, 171
Morley, E. W., 5
Motion, law of, 123
Multiplicationist, 86
Multiplicity of space and time frames, 20, 35, 61
Myself, 42, 53
Mysticism, defence of, 323; religious, 338
Nautical Almanac, 150
Nebulae, 165
Nebular observers, 9, 12
Neptune, 49
Neutral stuff, 280
Neutral wedge, 48
New quantum theory, 206
Newton, 111, 122, 201; quotation from, 111
Newtonian scheme, 4, 18, 125
Non-empty space, 127, 153, 238
Non-Euclidean geometry, 157
Nonsense, problem of, 344
Now-lines, 42, 47, 49, 184
Nucleus of atom, 3
Objectivity of “becoming”, 94; of a picture, 107
Observer, attributes of, 15, 337
Odds, 301, 303
Official scientific attitude, 286, 334
Operator, 208
Orbit jumps of electron, 191, 196, 205, 215, 300, 312
Organisation, 68, 70, 104
Ought, 345
Oxygen and vegetation, 174
’s and ’s, 208, 223, 327
Pacific Ocean, 171
Particle, 202, 211, 218
Past, relative and absolute, 48
Pedantry, 340, 342
Permanence, 241
Personal aspect of spiritual world, 337
Phoenix complex, 85
Photoelectric effect, 187
Photon, 190
Physical time, 40
Picture and paint, 106
Picture of gravitation, 115, 138, 157
Plan, Nature’s, 27
Planck, M., 185
Plurality of worlds, 169
Pointer readings, 251
Ponderomotive force, 237
Porosity of matter, 1
Potential (gravitational), 261
Potential energy, 213
Potential gradient, 96
Pound sterling, relativity of, 26
Predestination, 293, 303
Predictability of events, 147, 228, 300, 307
Primary law, 66, 75, 98; insufficiency of, 107
Primary scheme of physics, 76, 129, 295
Principal curvature, 120, 139
Principia, 4
Principle of Correspondence, 196
Principle of detailed balancing, 80
Principle of indeterminacy, 220, 306
Probability, 216, 315
Proof and plausibility, 337
Proper-distance, 25
Proper-time, 37
Proportion, sense of, 341
Proton, 3
Psi ( ), 216, 305
Pure mathematician, 161, 337, 347
Purpose, 105
-numbers, 208, 270
Quantum, 184; size of, 200
Quantum laws, 193
Quantum numbers, 191, 205
Quest of the absolute, 26, 122; of science, 110, 287; of reality, 328
Quotations from Boswell, 326
Brooke, Rupert, 317
Clifford, W. K., 278
Dickens, 32
Einstein, A., 294
Hegel, 147
Huxley, T. H., 173
Kronecker, L., 246
Lamb, H., 316
Lewis Carroll, 28, 291, 344
Milton, 167
Newton, 111
Nursery Rhymes, 64, 70, 262
Omar Khayyam, 64, 293
O’Shaughnessy, A., 325
Russell, Bertrand, 160, 278
Quotations from (cont.)
Shakespeare, 21, 39, 83, 292, 330
Swift, 341
Whitehead, A. N., 145
Radiation pressure, 58
Random element, 64; measurement of, 74
Reality, meaning of, 282, 326
Really true, 34
Rectification of curves, 125
Rejuvenescence, theories of, 85, 169
Relata and relations, 230
Relativity of velocity, 10, 54, 59, 61; of space-frames, 21; of magnetic field, 22; of distance, 25; of pound sterling, 26; of Now (simultaneity), 46, 61; of acceleration, 129; of standard of length, 143
Time in physics, 36; time lived (proper-time), 40; dual recognition of, 51, 100; time’s arrow, 69; infinity of, 83; summary of conclusions, 101; time-triangles, 133; reality of, 275
Time-scale in astronomy, 167
Touch, sense of, 273
Track, longest, 125, 135, 148
Trade Union of matter, 126
Transcendental laws, 245
Traveller, time lived by, 39, 126, 135
Triangles in space and time, 133
Tug of gravitation, 115, 122
Undoing, 65
Unhappening, 94, 108
Uniformity, basis of, 145
Unknowable entities, 221, 308
Utopia, 265
Values, 243, 330
Vegetation on Mars, 173
Velocity, relativity of, 10; upper limit to, 56
Velocity through aether, 30, 32
Velocity of light, 46, 54
Venus, 170
Victorian physicist, ideals of, 209, 259
View-point, 92, 283
Void, 13, 137
Volition, 310
Watertight compartments, 194
Wave-group, 213, 217, 225
Wave-length, measurement of, 24
Wave-mechanics, 211
Wave-theory of matter, 202
Wavicle, 201
Wells, H. G., 67
White dwarfs, 203
Whitehead, A. N., 145, 249
Whittaker, E. T., 181
Winding up of universe, 83
World building, 230
World-lines, 253
Worm, four-dimensional, 42, 87, 92
Wright, W. H., 172
Wrong frames of reference, 116
X (Mr.), 262, 268
TRANSCRIBER’S NOTES
On page 32, the reference to Einstein has been replaced by Dickens as shown in the Index. This quote appears in “Martin Chuzzlewit” published in 1843.
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