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Amr Hasan, M.D. Lecturer of Neurology - Cairo University
CairoNeuro 2014
Botulinum toxin in hemifacial
spasm: A real “Face Off”
2
Agenda
Hemifacial spasm
3
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
4
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Anatomy of facial muscles
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Anatomy of facial muscles
6
Anatomy of facial muscles
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Anatomy of facial muscles
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Anatomy of facial muscles
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Anatomy of facial muscles
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Anatomy of facial muscles
Anatomy of facial muscles
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Anatomy of facial muscles
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Anatomy of facial muscles (circumorbital and palpebral muscles)
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Anatomy of facial muscles (circumorbital and palpebral muscles)
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Anatomy of facial muscles (circumorbital and palpebral muscles)
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Anatomy of facial muscles (Nasal Muscles)
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Anatomy of facial muscles (Nasal Muscles)
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Anatomy of facial muscles (Nasal Muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles (Buccolabial muscles)
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Anatomy of facial muscles
QUIZ
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Agenda
Hemifacial spasm
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• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
29
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial Spasm
Characterized by:
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• Paroxysmal, involuntary
clonic and tonic
synchronous contraction
of the muscles
innervated by the facial
nerve on one side.
• The spasms are due to
brief burst of normal
motor units firing at high
frequency.
Agenda
Hemifacial spasm
31
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
32
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial Spasm
Causes:
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• Vascular compression of the
facial nerve by a dolichoectatic
(a distorted, dilated, and
elongated) vertebral artery or
tortuous AICA.
• Facial nerve compression by a
mass, brainstem lesions such as
stroke or multiple sclerosis
plaques.
Hemifacial Spasm
Causes:
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• Secondary causes
such as trauma or Bell
palsy.
• Familial
• Idiopathic
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Hemifacial Spasm
Causes:
Agenda
Hemifacial spasm
36
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
37
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial spasm
38
transmission, which is electrical activity crossing from one phapticEsynapse.demyelinated neuron to another resulting in a false
root end zone facial nerve at the axonsnvolves abnormal activity of Idemyelination.secondary to compressive damage/
facial nerve or "Kindling theory" involves increased excitability of the nucleus due to feedback from a damaged facial nerve.
Agenda
Hemifacial spasm
39
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
40
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial spasm
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• Unilateral (rarely bilateral) spasm involving half of the facial
muscles, typically lasting several minutes at a time.
• Affects women more than men.
• Onset fifth and sixth decade.
• Persists during sleep.
Hemifacial spasm
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• Painless, no sensory loss.
• Involves entire side of face.
• HS most often begins insidiously in the orbicularis oculi
muscle.
Hemifacial spasm
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• Contractions gradually spread to
other muscles of the face
including the platysma
Hemifacial spasm
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Hemifacial spasm
Differential Dx:
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• Blepharospasm
• Meige’s syndrome (not to be confused with Meigs' syndrome,the triad of ascites,pleural effusion and benign ovarian tumor)
• Tourette’s syndrome (multiple compulsive muscle spasms associated with
utterances of bizarre sounds or vile words).
• Trigeminal Neuralgia (acute episodes of pain in the distribution of the V CN)
• Eyelid Myokymia (eyelid twitches; caffeine & stress)
• Tardive Dyskinesia (Orofacial dyskinesia, associated with dystonic
movements of the trunk and limbs, from long-term antipsychotic drug use)
• Eyelid apraxia
Hemifacial spasm
Blepharospasm:
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• Onset: usually in adult life (sixth & seventh decade)
• 3:1 female predominance
• Always Bilateral, episodic, involuntary contractions of the orbicularis
oculi (therefore, may not involve other facial muscles).
• Disappears during sleep.
• Possible association with involuntary spasm of the lower facial
musculature (orofacial dyskinesia or Meige’s Syndrome).
Hemifacial spasm
Blepharospasm:
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• Etiology:
• Adults: usually idiopathic (“essential blepharospasm”) related to
dysfunction of the basal ganglia and limbic system.
• May occur in patients with:
Parkinson’s disease
Progressive supranuclear palsy
Huntington’s disease
Multiple Sclerosis
Brainstem stroke
Agenda
Hemifacial spasm
48
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
49
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial spasm
50
• Work Up – MRI of cerebellopontine angle to R/O tumor
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Agenda
Hemifacial spasm
52
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
53
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Hemifacial spasm
Treatment
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• Pharmachologic: Carbomazepine, Baclofen, Clonazepam,
Neurontin
• Botulinum toxin
• Surgery: Janetta procedure=posterior fossa craniotomy with
insertion of inert material b/w vascular loop and VII nerve (to
decrompress the nerve).
Sites of injection
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Sites of injection
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Sites of injection
Sites of injection
58
Sites of injection
59
Sites of injection
60
Sites of injection for BEB
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Sites of injection
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• Ptosis (7-11%)
• Lagophthalmos (5-12%)
• Symptomatic dry eyes
• Diplopia (<1%)
• Ecchymosis
• Lower facial weakness
Potential adverse effect
63
• Facial assymetry.
Agenda
Hemifacial spasm
64
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
Agenda
Hemifacial spasm
65
• Anatomy of facial muscles
• Definition
• Aetiology
• Pathophysiology .
• Investigations
• Clinical features and differential diagnosis.
• Botulium toxin in hemifacial spasm
• Video presenations
66
Case 1
• 32 ys old male.
• Unremarkable medical history.
• 3 years ago started to develop Rt HFS
• Increasing in frequency up to being continous
all over the day
• MRI Brain : Normal
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Case 1
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Case 1
Case 2
• 16 ys old girl.
• Student
• 4 years ago, she had Bell’s palsy
• Afterwhich, she started to develop Rt HFS
• Embarrasing and disfiguring
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71
Case 2
72
Case 2
Case 3
• 42 ys old Yemenese man.
• Employee
• 2 years ago, he started to develop bilateral
facial dyskinsia (ocular, facial, orobuccal)
• Khat
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Case 3
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Case 3
Pearls
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• Up to 50 units at one treatment.
• Injection should not be made inferior to the nasolabial fold! Injections here
cause lip droop that in turns leads to very annoying lip biting by the patient.
• Avoid injecting the mid portion of the upper lid so as to avoid paralyzing the
levator palpebri and causing ptosis.
• Avoid orbicularis oris
• Smaller dose for zygomaticus major
• Lower dose if secondary to facial palsy
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