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Congenital cranial dysinnervation disorders involve abberant connections between cranial nerves, often resulting in synkinetic activation of target muscles. Marcus-Gunn jaw winking ptosis and Duane retraction syndrome are some of the more well-known examples of this phenomenon. We present serial video of a child with congenital trigemino-abducens synkinesis, a lesser known congenital cranial dysinnervation disorder, to demonstrate the characteristics of this likely under-diagnosed presentation., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To compare the effects of Kabat rehabilitation and Mime therapy on facial disability and synkinesis in patients with Bell's palsy., Methods: The single-blind, randomised clinical trial was conducted at the Physiotherapy Department of the University of Lahore Teaching Hospital, Lahore, Pakistan, from May to October 2023, and comprised adults of either gender aged 25-50 years having sub-acute or chronic unilateral Bell's palsy of non-congenital origin. The patients were randomised into Kabat rehabilitation group A and mime therapy group B. Conventional physical therapy was given to both groups additionally. Facial disability was assessed using the Facial Disability Index scale, and synkinesis was observed using the House-Brackmann Facial Nerve Grading Scale. Data was analysed using SPSS 25., Results: Of the 72 patients, 41(56.9%) were females and 31(43.1%) were males. The overall mean age was 37.77±6.98 years, mean body mass index was 25.71±5.71kg/m2 and 41(56.9%) patients had left-sided palsy. Facial disability and synkinesis were significantly different in both groups post-intervention (p<0.001), while intergroup differences were significant in the 3rd and 6th weeks (p<0.001)., Conclusions: Kabat rehabilitation led to more significant improvements in synkinesis and facial disability compared to mime therapy., Clinical Trial Number: Clinical trials.gov registration id: NCT06029855.

Background:  Muscles affected by postparetic synkinesis have imbalanced tonicity that limit perioral mimetic movement and inhibit the ability to smile. The depressor anguli oris (DAO) muscle has been a common myectomy target for the treatment of perioral synkinesis. While addition of buccinator myectomies to DAO myectomies has risen, no studies have analyzed the effects of buccinator myectomies. The goal of this study was to evaluate and compare the effects of a DAO myectomy with and without concomitant buccinator myectomy through objective facial metrics and subjective patient-reported outcomes., Methods:  This study is a retrospective review of patients with postparetic synkinesis who underwent DAO myectomy (DAO myectomy group) or DAO myectomy with buccinator myectomy (DAO + Buccinator myectomies group). Outcomes included postoperative differences in objective smile measures (smile angle, excursion, and dental show) using validated software and patient-reported outcomes using the Facial Disability Index (FDI) questionnaire and a myectomy-specific questionnaire., Results:  After chart review, 18 patients were included in the DAO myectomy group and 19 in the DAO + Buccinator myectomies group. There were no significant postoperative differences between the groups in (1) smile excursion, angle, or dental show at resting, closed smile, or open smile ( p  > 0.05), (2) FDI physical and social scores, p  = 0.198 and 0.932, respectively, or (3) myectomy-specific questionnaire responses ( p  > 0.05)., Conclusion:  The addition of a buccinator myectomy to a DAO myectomy does not provide significant clinical benefit when compared with an isolated DAO myectomy, based on objective measures and subjective patient-reported outcomes., Competing Interests: None declared., (Thieme. All rights reserved.)

Oculomotor synkinesis is an unusual phenomenon that encompasses various presentations with few associations reported in the literature. It can occur with or without a previous setting of oculomotor nerve injury. The authors present the first reported case of bilateral congenital trochlear-oculomotor synkinesis in a 5-month-old infant. [ J Pediatr Ophthalmol Strabismus . 2024;61(5):e50-e53.] .

Background: Little is known about how depression and appearance anxiety affect patient reporting of synkinesis severity. Learning/Study Objective: Measure prevalence of depression and appearance anxiety in facial synkinesis and correlations between subjective and surgeon-graded synkinesis severity. Design Type: Prospective cohort. Methods: Patients with synkinesis volunteered and completed: Synkinesis Assessment Questionnaire (SAQ), facial clinimetric evaluation (FaCE) scale, Center for Epidemiological Studies Depression Scale (CES-D), and Fear of Negative Appearance Evaluation Scale (FNAES). Standardized videos were scored by facial plastic surgeons using Sunnybrook Scale and eFaCE. Multivariate linear regression was used to compare patient- and surgeon-graded metrics. Results: One hundred patients participated, 91 were female. Mean age was 56.4 (12.3). Eight percent identified as Black and 87% White. The most common nerve injury etiology was idiopathic (47%). Mean synkinesis duration was 7.6 years (6.2). Twenty percent and 15% reported history of an anxiety or depressive disorder, respectively. Patient (SAQ, FaCE) and clinician (Sunnybrook, eFaCE) scores were correlated (Pearson's r 0.223-0.294, p  < 0.05). Upon adjusting for CES-D/FNAES, correlations between most patient and clinician metrics became stronger. As CES-D and FNAES worsened, patient-clinician correlations weakened. Conclusions: Depression and appearance anxiety may affect patient reporting of synkinesis severity. Worse mental health scores may decorrelate patient and clinician synkinesis assessments.

Competing Interests: The author reports no conflicts of interest.

Background: Homolateral Imitative Synkinesis (HIS) is a rare form of associative movement between the ipsilateral upper and lower limbs. The incidence of HIS or its correlation with various movements remains uninvestigated. This study expounds on the characteristics of HIS, the frequency at which it occurs, and its relationship with movement, particularly walking., Methods: This study included 1328 patients with acute stroke admitted to our healthcare facility between October 2019 and February 2022. We evaluated the severity of motor paralysis and sensory impairment in instances where HIS manifested, and assessed the relationship between HIS, basic activities, and gait., Results: HIS was observed in 13/1328 patients. Motor paralysis was mild in all the cases. Each patient displayed a degree of sensory impairment, albeit of varying severity. HIS did not manifest during basic activities but was evident during walking movements in five instances. These patients displayed involuntary repetitive lifting of their upper limbs during the swing phase of their gait. Some individuals expressed discontent with involuntary upper-limb movements, citing them as contributors to a suboptimal gait., Conclusions: This study identified HIS as a rare syndrome, manifesting at a rate of 0.9%. Focus was more common in patients with damage to the thalamus and parietal lobe. No manifestations of the HIS occurred during basic activities, suggesting a weak correlation between the HIS and such activities. Certain patients exhibit HIS during gait, report suboptimal gait, and have an increased risk of falls, potentially influencing their gait proficiency., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Although patients with facial palsy often complain of disturbed eye blinking which may lead to visual impairment, a blinking analysis is not part of routine grading of facial palsy. Twenty minutes of spontaneous eye blinking at rest of 30 patients with facial palsy (6 with acute palsy; 24 patients with facial synkinesis; median age: 58 years, 67% female), and 30 matched healthy probands (median age: 57 years; 67% female) was smart phone video recorded. A custom computer program automatically extracted eye measures and determined the eye closure rate (eye aspect ratio [EAR]), blink frequency, and blink duration. Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI) were assessed as patient-reported outcome measures. The minimal EAR, i.e., minimal visible eye surface during blinking, was significantly higher on the paretic side in patients with acute facial palsy than in patients with synkinesis or in healthy controls. The blinking frequency on the affected side was significantly lower in both patient groups compared to healthy controls. Vice versa, blink duration was longer in both patient groups. There was no clear correlation between the blinking values and FaCE and FDI. Blinking parameters are easy to estimate automatically and add a functionally important parameter to facial grading., (© 2024. The Author(s).)

Les syncinésies représentent une séquelle invalidante de la paralysie faciale, qui aggrave l'asymétrie des visages, et diminue la qualité de vie des patients. Leur physiopathologie est partiellement connue, mais ne permet pas d'expliquer l'ensemble des syncinésies. Nous rapportons une revue de littérature de l'état de l'art des connaissances sur la physiopathologie des syncinésies, ainsi que sur leur prise en charge. Il est admis que le mécanisme physiopathologique des syncinésies est mixte. Les phénomènes de plasticité cérébrale, repousse nerveuse aberrante, hyperexcitabilité du noyau de nerf facial et transmission nerveuse éphaptique ont été observés. Nous proposons une nouvelle hypothèse physiopathologique : les syncinésies pourraient être la conséquence du démasquage de circuits latents, existants chez le sujet sain. Nous évoquons trois potentiels circuits latents : les contractions synergiques physiologiques, le recrutement d'unités motrices adjacentes, et la réactivation de circuits latents à distance, de compensation de fonction. Les options de traitement sont multiples, dominées par la chémodénervation dont l'efficacité est indéniable. La rééducation a également prouvé son efficacité, notamment avec les techniques de feedback. Enfin, la chirurgie vient en aide à ces options. Cependant, les indications des différents traitements restent à codifier. La validation de notre hypothèse physiopathologique permettrait une meilleure compréhension et un meilleur dépistage des syncinésies, afin de pouvoir proposer une prise en charge plus adaptée. 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. We report a literature review of the state of the art concerning the knowledge on synkinesis physiopathology, as well as their management. 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. 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. [ABSTRACT FROM AUTHOR]

Introduction: Synkinesis refers to abnormal involuntary facial movements that accompany volitional facial movements. Despite a 55% incidence of synkinesis reported in patients with enduring facial paralysis, there is still a lack of complete understanding of this debilitating condition, leading to functional limitations and decreased quality of life. 1 This article reviews the diagnostic assessment, etiology, pathophysiology, rehabilitation, and nonsurgical and surgical treatments for facial synkinesis., Methods: A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "facial," "synkinesis," "palsy," and various combinations of the terms., Results: The resultant inability to control the full extent of one's facial movements has functional and psychosocial consequences and may result in social withdrawal with a significant decrease in quality of life. An understanding of facial mimetic musculature is imperative in guiding appropriate intervention. While chemodenervation with botulinum toxin and neurorehabilitation have continued to be the primary treatment strategy for facial synkinesis, novel techniques such as selective myectomy, selective neurolysis, free-functioning muscle transfer, and nerve grafting techniques are becoming increasingly utilized in treatment regimens. Facial rehabilitation, including neuromuscular retraining, soft tissue massage, and relaxation therapy in addition to chemodenervation with botulinum toxin, remains the cornerstone of treatment. In cases of severe, intractable synkinesis and non-flaccid facial paralysis, surgical interventions, including selective neurectomy, selective myectomy, nerve grafting, or free muscle transfer, may play a more significant role in alleviating symptoms., Discussion: A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes. Ultimately, therapy should be tailored to the severity and pattern of synkinesis, and each patient approached on a case-by-case basis. A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The prognostic value of electroneurography (ENoG) for predicting the incidence of synkinesis is reportedly about 40 % using the formal standard method (ENoG-SM). However, the prognostic value of ENoG using the newly developed midline method (ENoG-MM) has not been determined. The aim of this study was to demonstrate the optimal prognostic value and advantages of ENoG-MM for predicting the incidence of synkinesis., Methods: Participants were 573 patients treated for peripheral facial palsy including Bell's palsy or Ramsay Hunt syndrome. We investigated the clinical presence of any oral-ocular or ocular-oral synkinesis from the medical records. ENoG-MM and ENoG-SM were performed 10-14 days after symptom onset. In ENoG-MM, compound muscle action potentials were recorded by placing the anode on the mental protuberance and the cathode on the philtrum. In ENoG-SM, electrodes were placed on the nasolabial fold. Synkinesis was clinically assessed at the end of follow-up or at >1 year after onset. The sensitivity and specificity of ENoG values for predicting the incidence of synkinesis were compared between ENoG-MM and ENoG-SM at every 5 % around 40 % (range, 30-50 %)., Results: At every 5 % of ENoG values around 40 %, ENoG-MM provided higher sensitivity and lower specificity for predicting the incidence of synkinesis compared with ENoG-SM. In particular, when the cut-off value was set at 45 %, sensitivity was 100 % and 95.3 % with ENoG-MM and ENoG-SM, respectively., Conclusion: In peripheral facial palsy, ENoG-MM offered higher sensitivity than ENoG-SM for predicting synkinesis. ENoG-MM is useful for screening patients at risk of developing synkinesis. In clinical practice, an ENoG-MM cut-off value of 45 % must be the optimal prognostic value because of the 100 % sensitivity., Competing Interests: Disclosure of interest The authors declare no conflicts of interest in association with the present study., (Copyright © 2024. Published by Elsevier B.V.)

Facial palsy can result in a serious complication known as facial synkinesis, causing both physical and psychological harm to the patients. There is growing evidence that patients with facial synkinesis have brain abnormalities, but the brain mechanisms and underlying imaging biomarkers remain unclear. Here, we employed functional magnetic resonance imaging (fMRI) to investigate brain function in 31 unilateral post facial palsy synkinesis patients and 25 healthy controls during different facial expression movements and at rest. Combining surface-based mass-univariate analysis and multivariate pattern analysis, we identified diffused activation and intrinsic connection patterns in the primary motor cortex and the somatosensory cortex on the patient's affected side. Further, we classified post facial palsy synkinesis patients from healthy subjects with favorable accuracy using the support vector machine based on both task-related and resting-state functional magnetic resonance imaging data. Together, these findings indicate the potential of the identified functional reorganizations to serve as neuroimaging biomarkers for facial synkinesis diagnosis., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The widely used botox type A (BTX-A) is effective against synkinesis in facial palsy sequelae. Repeated injections are necessary and permanent improvements have been reported. We objectively evaluated the changes in synkinesis at >6 months after BTX-A injection, including changes over time with the number of administrations., Methods: In 48 patients who received multiple BTX-A injections, evaluation by the Sunnybrook Facial Grading System (FGS) and integrated electromyography (iEMG) was performed before treatment and at least 6 months after the first, second, and third BTX-A injection. The iEMG ratio on the affected and healthy sides was calculated for each mimetic muscle and mimic motion., Results: There was no significant difference in the FGS synkinesis score before treatment and after the third injection, although an improvement was observed. The iEMG ratio was significantly improved in the orbicularis oculi with open-mouth smile and lip pucker after the third dose compared to before treatment. The orbicularis oris showed a significant improvement when the eyelids were closed, while the platysma showed a significant improvement when the eyelids were closed and when the lip was pursed. Multiple regression analysis revealed that the orbicularis oculi and platysma had a greater effect on the iEMG ratio for the number of treatments than other factors., Conclusions: Repeated BTX-A injections showed improvements in synkinesis for the orbicularis oculi, orbicularis oris, and platysma, even after >6 months, compared to before treatment., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Objectives/hypothesis: Laryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom-/disease-related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum., Study Design: Open, prospective study, gender-match and age balanced by decade., Methods: Forty-six healthy participants (age 20-78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI-10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid-lateral cricoarytenoid muscle complex (TA-LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second., Results: Of participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age., Conclusion: Abnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s., Level of Evidence: 3 Laryngoscope, 131:2065-2069, 2021., (© 2021 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: To assess botulinum toxin treatment for buccinator muscle synkinesis including: how often the synkinesis was troublesome; who benefitted and how from the treatment; and what were the adverse effects, ideal dosage, and injection site., Subjects and Methods: Facial palsy (FP) patients and patients with hemifacial spasms who were attending for multiple site botulinum-toxin treatment for facial sequelae were assessed for buccinator synkinesis. The study group comprises those experiencing buccinator synkinesis with associated bothering symptoms who were willing to try injection also to the buccinator muscle., Results: During 9/2017-12/2019, 126 different patients with facial sequelae were treated with multiple-site botulin-toxin injections by the author. Of them, 83 (66%) received injection also for buccinator synkinesis and 66/82 (80%) wanted to continue with the buccinator injections. The most remarkable results were seen with FP patients biting the mucus membrane of their cheek: usually the biting ceased totally. Patients with powerful hemifacial cheek spasms also experienced cessation of the spasms, contrasting any previous treatments. Adverse effects were mostly mild: slight weakness of the corner of the mouth or additional leakage of saliva or liquids. Only a few patients experienced more pronounced adverse effects. The most posterior contracting part of the buccinator muscle proved to be the best site for the injection., Conclusions: Buccinator synkinesis was very common and its treatment gave many patients additional relief from facial sequelae symptoms. Professionals treating patients with synkinesis and hemifacial spasms should add well-tolerated buccinator injections to their repertoire of injection sites., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: Treatment with botulinum toxin A (BoNT) is the therapy of choice for many patients with facial synkinesis. Repeated injections relieve hypertonicity and hyperkinesis of reinnervated mimic muscles. Aim of the study was to prove if the injection regime and dosage of BoNT change during long-time therapy., Design: Retrospective analysis of patients´ data, who were treated for synkinesis with BoNT from 1998 to 2018., Setting: Tertiary referral facial nerve centre., Participants: Injection pattern of BoNT was based on clinical symptoms, observations of the specialist and on previous treatment pattern. Onabotulinumtoxin (OnaBoNT), Incobotulinumtoxin (IncoBoNT) and Abobotulinumtoxin (AboBoNT) were available for treatment. Patients consulted our department for following treatment as soon as the symptoms re-occurred., Main Outcome Measures: Change in dosage and injection pattern, the time intervals between treatments over the entire therapy period., Results: Seventy-three patients were repeatedly injected. The median number of treatments was 18, the median treatment interval was 3.0 months. During the initial treatment, orbicularis oculi and the mentalis muscles were the most frequently injected muscles (94%). During repeated treatment, the number of injected muscles increased significantly (P < .0001), whereas the dose per muscle remained stable. The initial dose was 24 U (95%-CI 22-27 U) for OnaBoNT and IncoBoNT; 69 U for AboBoNT(95%-CI 44-94 U). We observed a significant increase in dosage for OnaBoNT and IncoBoNT (P < .0001) during the long-term therapy. The time intervals between treatments were stable for all three BoNT preparations (P > .05)., Conclusions: We observed significant change in treatment dose and injection pattern of BoNT in patients with facial synkinesis. These results provide an orientation in dose finding and injection regimen of BoNT in the long-term course of therapy., (© 2021 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd.)

Abstract: Botulinum toxin A is considered an effective treatment for involuntary facial movements. We examined whether treatment efficacy maintained or changed over time with two products, Botox and Dysport, in patients with hemifacial spasm, facial synkinesis and benign essential blepharospasm.We retrospectively investigated 87 consecutive patients (51 women, 36 men) who had undergone treatment for ≥6 years. Long-term effects, as well as side effects of Botox or Dysport local injections were evaluated. The first three treatments were considered the titration period and not taken into account when testing for dose changes.Mean treatment duration was 10 years (range 6-11, SD 1.0), 2441 treatments were administered, 1162 with Botox and 1279 with Dysport, the two brands were interchanged as needed. Good to full improvement was seen in 90% of patients both with both brands. Injection doses and treatment responses were consistent during the study with both drugs. No major side effects were reported, and relatively few minor adverse events were reported, with clear reduction from the titration period (6.1%), to the remainder of the study (3.9%).Botulinum toxin (BTX-A) is a satisfactory long-term treatment without need for dose increase over. Both Botox and Dysport were effective when used interchangeably., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives/hypothesis: Applying the principles of misdirected nerve regeneration to the larynx, Roger Crumley in 1989 coined the term laryngeal synkinesis (LS) which he later (2000) classified into 4 types (type I - good voice, type II - involuntary twitches and poor voice, type III - adduction during inspiration, type IV - abduction during phonation). Neurophysiological data were not available for all LS patients at that time. The current study was undertaken to utilize and test the Crumley classification for a clinical interrater comparison and, secondly, compare predicted with actual laryngeal electromyography (LEMG) results., Study Design: Descriptive study., Methods: Laryngoscopic and LEMG data of patients with unilateral vocal fold paralysis (VFP) of 6 months duration or longer were combined for retrospective evaluation. Forty-five data sets were available for laryngoscopic classification by two local laryngologists and by Roger Crumley. Twenty-three data sets with complete thyroarytenoid (TA) and posterior cricoarytenoid (PCA) - EMG data were used to compare predicted with actual LEMG results., Results: Local laryngologists were able to classify 24 of 45, Crumley 30 of 45 cases into one of the 4 synkinesis types. There was substantial agreement between examiners (Cohens Kappa 0.66 [P < .001]). Comparison of predicted and actual LEMG data showed only moderate agreement. EMG sykinesis rates were lower in TA than in PCA and highest in Crumley type I cases., Conclusion: The Crumley classification is helpful in describing and understanding synkinesis. It does not always correlate predictably with actual LEMG data. A complete LEMG mapping of all intrinsic muscles may improve understanding of chronic VFP., Level of Evidence: 4. Laryngoscope, 131:E1605-E1610, 2021., (© 2020 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background: Posttraumatic facial paralysis is a disabling condition. Current surgical management by faciofacial nerve suture provides limited recovery. To improve the outcome, the authors evaluated an add-on strategy based on a syngeneic transplantation of nasal olfactory stem cells in a rat model of facial nerve injury. The main readouts of the study were the recording of whisking function and buccal synkinesis., Methods: Sixty rats were allocated to three groups. Animals with a 2-mm facial nerve loss were repaired with a femoral vein, filled or not with olfactory stem cells. These two groups were compared to similarly injured rats but with a faciofacial nerve suture. Olfactory stem cells were purified from rat olfactory mucosa. Three months after surgery, facial motor performance was evaluated using video-based motion analysis and electromyography. Synkinesis was assessed by electromyography, using measure of buccal involuntary movements during blink reflex, and double retrograde labeling of regenerating motoneurons., Results: The authors' study reveals that olfactory stem cell transplantation induces functional recovery in comparison to nontransplanted and faciofacial nerve suture groups. They significantly increase (1) maximal amplitude of vibrissae protraction and retraction cycles and (2) angular velocity during protraction of vibrissae. They also reduce buccal synkinesis, according to the two techniques used. However, olfactory stem cell transplantation did not improve axonal regrowth of the facial nerve, 3 months after surgery., Conclusions: The authors show here that the adjuvant strategy of syngeneic transplantation of olfactory stem cells improves functional recovery. These promising results open the way for a phase I clinical trial based on the autologous engraftment of olfactory stem cells in patients with a facial nerve paralysis.

Purpose: This study aims to quantitatively compare the Jankovic assessment (JA) with electromyography (EMG)-based measures for assessing changes in facial movements in patients with facial dystonia., Materials and Methods: Thirteen patients (five males and eight females) affected with different forms of facial dystonia (hemifacial spasm and synkinesis) participated in this study. All patients were treated with Botulinum Toxin (BTX) and evaluated with the JA scale and EMG-based measures, including motor unit potentials (MUP) latency and presence of polyphasic potentials before and after BTX injection. Correlation between the JA scores and the EMG-based measures was calculated. Statistical analysis was performed with the Pearson test., Results: Correlation between the JA scores and the EMG-based measures was found to be statistically significant, both before and after treatment with BTX., Conclusion and Relevance: JA scores significantly correlated with more objective EMG-based measures, suggesting that the JA scale can be used to assess facial movement changes, for example elicited by a treatment such as BTX injection. Thus, in facial dystonia patients, the JA scale may be used for evaluating treatment outcomes as a valid and low-cost alternative to EMG., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Importance: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life., Objective: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes., Design, Setting, and Participants: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center., Intervention: Onabotulinum toxin A treatment of facial synkinesis., Main Outcomes and Measures: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment., Results: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis., Conclusion and Relevance: Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis., Level of Evidence: 3.

Objective: Facial synkinesis is a severe sequelae of facial nerve malfunction. Once the synkinesis is established, it is extremely difficult for patients to recover. Given that the restoration of motor or sensory function after peripheral nerve injury was closely related with cortical plasticity, we investigated cortical plasticity in facial synkinesis patients by the frequency-specific data which remains largely uncharacterized., Materials and Methods: Resting-state fMRI was conducted in 20 facial synkinesis patients and 19 healthy controls, and the amplitude of low-frequency fluctuation (ALFF) in five different frequency bands (slow-6: 0-0.01 Hz; slow-5: 0.01-0.027 Hz; slow-4: 0.027-0.073 Hz; slow-3: 0.073-0.167 Hz; and slow-2: 0.167-0.25 Hz) was calculated, respectively. And the relationship between ALFF and clinical outcomes was also analyzed., Results: Comparing with the healthy controls, facial synkinesis patients showed significantly different ALFF values, mainly in the sensorimotor areas. Furthermore, increased ALFF of the ipsilateral insula in the slow-6 band was significantly related with better facial nerve function., Conclusion: Increased ALFF values in the ipsilateral insula might reflect an abnormal state of hypercompensation in motor control of facial synkinesis patients. It provided valuable spatial information about the functionally aberrant regions, which implied the possible involvement of motor control system in facial synkinesis.

A 4-year-old girl with maxillary hypoplasia, intermittent exotropia, and high myopia displayed congenital oculonasal synkinesis. We examine the implications for pathogenesis of these disparate craniofacial findings.

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 .

This study aimed to investigate the cortical functional alterations in patients with unilateral facial synkinesis using the task-designed functional magnetic resonance imaging. Fourteen unilateral synkinesis followed by peripheral facial nerve palsy patients and eighteen healthy adults were recruited in this study. Four facial motor tasks, i.e. left/right blinking and left/right smiling, were performed by each subject during the scans. Based on the activation maps, the spatial distance between the representation sites in the contralateral pre-/post-central gyrus of left or right blinking and smiling tasks (i.e. left/right B-S-distance) were calculated. Patients with unilateral facial synkinesis showed decreased B-S-distances during blinking and smiling tasks on the affected half face (9.68 ± 3.92 mm) compared to both average distances in healthy controls (14.95 ± 5.55 mm; p = 0.002) and unaffected half face tasks in patients (16.19 ± 7.87 mm; p = 0.011). These findings demonstrated cortical reorganization in facial synkinesis and suggested a conceivable mechanism corresponding to the simultaneous facial movement. This potentially provides a new modulation target for preventive, therapeutic and rehabilitative maneuver of this disease., (Copyright © 2018 IBRO. Published by Elsevier Ltd. All rights reserved.)

We describe a patient with pseudoradial nerve palsy caused by acute ischaemic stroke ('cortical hand') to emphasise how preserved synkinetic wrist extension following fist closure can distinguish this from peripheral causes of wrist drop., Competing Interests: Competing interests: FB has received speakers' honoraria from Eisai and PeerVoice, payment for consultancy from Eisai, and travel support from Eisai, ITALFARMACO and UCB Pharma., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: Proper control of eye movements is critical to vision, but relatively little is known about the molecular mechanisms that regulate development and axon guidance in the ocular motor system or cause the abnormal innervation patterns (oculomotor synkinesis) seen in developmental disorders and after oculomotor nerve palsy. We developed an ex vivo slice assay that allows for live imaging and molecular manipulation of the growing oculomotor nerve, which we used to identify axon guidance cues that affect the oculomotor nerve., Methods: Ex vivo slices were generated from E10.5 IslMN-GFP embryos and grown for 24 to 72 hours. To assess for CXCR4 function, the specific inhibitor AMD3100 was added to the culture media. Cxcr4cko/cko:Isl-Cre:ISLMN-GFP and Cxcl12KO/KO:ISLMN-GFP embryos were cleared and imaged on a confocal microscope., Results: When AMD3100 was added to the slice cultures, oculomotor axons grew dorsally (away from the eye) rather than ventrally (toward the eye). Axons that had already exited the midbrain continued toward the eye. Loss of Cxcr4 or Cxcl12 in vivo caused misrouting of the oculomotor nerve dorsally and motor axons from the trigeminal motor nerve, which normally innervate the muscles of mastication, aberrantly innervated extraocular muscles in the orbit. This represents the first mouse model of trigeminal-oculomotor synkinesis., Conclusions: CXCR4/CXCL12 signaling is critical for the initial pathfinding decisions of oculomotor axons and their proper exit from the midbrain. Failure of the oculomotor nerve to innervate its extraocular muscle targets leads to aberrant innervation by other motor neurons, indicating that muscles lacking innervation may secrete cues that attract motor axons.

Objective: To investigate factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy., Methods: A total of 37 patients with peripheral facial nerve palsy in Teine-Keijinkai Hospital were enrolled in this study. All patients showed synkinesis at 6 months after the onset of facial nerve palsy and were instructed in physical rehabilitation by expert staff from their first visit. The degree of synkinesis was evaluated at 6, 9 and 12 months after the onset of facial nerve palsy based on Sunnybrook facial grading system score and asymmetry in eye opening width. The patients were divided into two groups by age, gender, cause of palsy, electroneurography (ENoG) value, onset of synkinesis, initial treatment and timing of the start of physical rehabilitation., Results: Female patients and younger patients did not show any deterioration in synkinesis. Patients in the lower ENoG group and the later onset of synkinesis group showed significant deterioration in synkinesis after the 6th month from onset of facial palsy., Conclusion: Physical rehabilitation was shown to prevent significant deterioration in synkinesis in female and younger patients with facial nerve palsy. Careful follow-up with regard to synkinesis is required in cases in which the facial nerve damage is thought to be severe., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: We investigated whether the value of ENoG is a predictive factor for the development of facial synkinesis in patients with facial palsy., Methods: The degree of oral-ocular synkinesis was evaluated quantitatively by an asymmetry of the interpalpebral space width during the mouth movement (% eye opening). Twenty healthy volunteers without a history of facial palsy (12 men and 8 women; 25-65 years old; mean age: 42.3±9.7years) were included in the study to examine the normal range of % eye opening. Fifty-one patients with facial palsy including 38 with Bell palsy and 15 with herpes zoster oticus (28 men and 25 women; 11-86 years old; mean age: 54±19years) were enrolled to examine the relationship between the ENoG value 10-14days after the onset of facial palsy, and the % eye opening 12 months later. Receiver operating characteristic (ROC) curve for the ENoG value was then used to decide the optimum cut-off value as a predictor of the development of oral-ocular synkinesis., Results: We defined a % eye opening inferior to 85% as an index of the development of oral-ocular synkinesis. There was a significant correlation between the values of ENoG 10-14days after the onset of facial palsy and those of % eye opening 12 months later (ρ=0.81, p<0.001). The area under the ROC curve for the ENoG value was the predictor for the development of oral-ocular synkinesis at 0.913 (95%CI: 0.831-0.996, p<0.001). The optimum cut-off value of ENoG 10-14days after the onset of facial palsy was 46.5% to predict the development of oral-ocular synkinesis 12 months after the onset of facial palsy (sensitivity 97.1% and specificity 77.5%)., Conclusion: The value of ENoG 10-14days after the onset of facial palsy is a predictive factor for the development of facial synkinesis 12 months later. Since facial palsy patients with a ENoG value inferior to 46.5% have a high risk of developing synkinesis, they should receive the facial biofeedback rehabilitation with a mirror as a preventive therapy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Importance: The buccinator, despite being a prominent midface muscle, has been previously overlooked as a target in the treatment of facial synkinesis with botulinum toxin., Objective: To evaluate outcomes of patients treated with botulinum toxin to the buccinator muscle in the setting of facial synkinesis., Design, Setting, and Participants: Prospective cohort study of patients who underwent treatment for facial synkinesis with botulinum toxin over multiple treatment cycles during a 1-year period was carried out in a tertiary referral center., Interventions: Botulinum toxin treatment of facial musculature, including treatment cycles with and without buccinator injections., Main Outcomes and Measures: Subjective outcomes were evaluated using the Synkinesis Assessment Questionnaire (SAQ) prior to injection of botulinum toxin and 2 weeks after treatment. Outcomes of SAQ preinjection and postinjection scores were compared in patients who had at least 1 treatment cycle with and without buccinator injections. Subanalysis was performed on SAQ questions specific to buccinator function (facial tightness and lip movement)., Results: Of 84 patients who received botulinum toxin injections for facial synkinesis, 33 received injections into the buccinator muscle. Of the 33, 23 met inclusion criteria (19 [82.6%] women; mean [SD] age, 46 [10] years). These patients presented for 82 treatment visits, of which 44 (53.6%) involved buccinator injections and 38 (46.4%) were without buccinator injections. The most common etiology of facial paralysis included vestibular schwannoma (10 [43.5%] participants) and Bell Palsy (9 [39.1%] participants). All patients had improved posttreatment SAQ scores compared with prebotulinum scores regardless of buccinator treatment. Compared with treatment cycles in which the buccinator was not addressed, buccinator injections resulted in lower total postinjection SAQ scores (45.9; 95% CI, 38.8-46.8; vs 42.8; 95% CI, 41.3-50.4; P = .43) and greater differences in prebotox and postbotox injection outcomes (18; 95% CI, 16.2-21.8; vs 19; 95% CI, 14.2-21.8; P = .73). Subanalysis of buccinator-specific scores revealed significantly improved postbotox injection scores with the addition of buccinator injections (5.7; 95% CI, 5.0-6.4; vs 4.1; 95% CI, 3.7-4.6; P = .004) and this corresponded to greater differences between prebotulinum and postbotulinum injection scores (3.3; 95% CI, 2.7-3.9; vs 2.0; 95% CI, 1.4-2.6; P = .02). The duration of botulinum toxin effect was similar both with and without buccinator treatment (66.8; 95% CI, 61.7-69.6; vs 65.7; 95% CI, 62.5-71.1; P = .72)., Conclusions and Relevance: The buccinator is a symptomatic muscle in the facial synkinesis population. Treatment with botulinum toxin is safe, effective and significantly improves patient symptoms., Level of Evidence: 3.

Background: Aberrant reinnervation and synkinesis are common and debilitating after facial palsy. Paradoxical frontalis activation can antagonize eye closure and increase the risk of corneal damage. If recognized, judicious botulinum toxin injection to the affected side may reduce this risk., Methods: One hundred consecutive patients with synkinesis were identified from a prospective database. Routine facial view photographs were converted to a standardized scale using iris diameter. The vertical distance from the midpoint of the midcanthal line to the inferior border of the eyebrow was measured bilaterally. A value of p < 0.05 was considered significant., Results: Eighty-two patients were included, with a median age of 44 years (interquartile range, 33 to 59 years); 59 of the patients were women. The commonest cause was idiopathic (n = 55). The median time since onset of palsy was 13 months (interquartile range, 6.5 to 27 months). There was less midpoint of the midcanthal line to the inferior border of the eyebrow excursion on the synkinetic side of the face (p < 0.001). Twenty-two patients (27 percent) displayed paradoxical frontalis movement on the affected side of their face, with increased midpoint of the midcanthal line to the inferior border of the eyebrow distance (eyebrow raise) when attempting eye closure compared with eyebrow raise (n = 19), and tight eye closure compared with gentle eye closure (n = 3)., Conclusions: This study highlights the phenomenon of paradoxical frontalis activation during eye closure. This is often underrecognized and may contribute to lagophthalmos. The authors found it to be present in 27 percent of patients with moderate or severe synkinesis. Further dynamic studies are required to understand the relationship among frontalis activity, eye closure, and the effects of its inhibition.

Objectives In patients with unilateral vocal fold paralysis (UVFP), laryngeal electromyography (LEMG) occasionally observes synkinesis in laryngeal muscles, a condition that could impair vocal fold mobility and voice control. This study aims to evaluate the impact of synkinesis on UVFP patients. Study Design A retrospective case-control study. Setting Medical center. Subjects and Methods Patients with UVFP onset >6 months were recruited (N = 104). The outcome measurements included LEMG, quantitative LEMG analysis of thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex, glottal gap measured by videolaryngostroboscopy, voice-related quality of life, and voice acoustic analysis. Results According to the LEMG analysis, 8 patients (8%) had synkinesis, and 96 (92%) did not. In the synkinesis group, TA-LCA turn frequency in the lesioned side was comparable to that in the healthy side ( P = .52). Patients in the synkinesis group had higher TA-LCA turn frequency ( P = .001), higher probability of cricothyroid muscle dysfunction ( P = .04), and better voice-related quality of life ( P = .01) but objective voice outcomes comparable to those in the nonsynkinesis group. Conclusions Patients with synkinesis will have near-complete restoration in TA-LCA turn frequency but still experience voice impairment, a finding that is compatible with the mechanism of aberrant reinnervation. However, patients with synkinesis have better disease-related quality of life than do those without 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.

Background: This study evaluates the effect of incobotulinumtoxinA in the acute and chronic phases of facial nerve palsy after neurosurgical interventions., Methods: Patients received incobotulinumtoxinA injections (active treatment group) or standard rehabilitation treatment (control group). Functional efficacy was assessed using House-Brackmann, Yanagihara System and Sunnybrook Facial Grading scales, and Facial Disability Index self-assessment., Results: Significant improvements on all scales were seen after 1month of incobotulinumtoxinA treatment (active treatment group, р<0.05), but only after 3months of rehabilitation treatment (control group, р<0.05). At 1 and 2years post-surgery, the prevalence of synkinesis was significantly higher in patients in the control group compared with those receiving incobotulinumtoxinA treatment (р<0.05 and р<0.001, respectively)., Conclusions: IncobotulinumtoxinA treatment resulted in significant improvements in facial symmetry in patients with facial nerve injury following neurosurgical interventions. Treatment was effective for the correction of the compensatory hyperactivity of mimic muscles on the unaffected side that develops in the acute period of facial nerve palsy, and for the correction of synkinesis in the affected side that develops in the long-term period. Appropriate dosing and patient education to perform exercises to restore mimic muscle function should be considered in multimodal treatment., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: The researchers analyzed facial patterns in subjects with facial synkinesis after facial paralysis and evaluated the involved muscles to aid in the development of effective treatments for facial synkinesis., Methods: A total of 142 subjects were included in the study, the primary measure for synkinesis was determined by video analysis involving the strongest combination of two muscle groups that contributed to facial expression. The secondary measure of synkinesis was the analysis of its severity using the SB grading system, while observing the number of facial synkinetic movements., Results: The most common type of facial synkinesis was oral-ocular synkinesis (n = 137). Other synkinesis such as ocular-oral, ocular-nasal, ocular-chin, ocular-stapedial, chin-ocular and chin-oral synkinesis continued to coexist together with oral-ocular synkinesis. The results of BTX-A treatment are assessed based on the number of facial synkinetic movements observed and the evaluation of initial facial function., Conclusion: The effectiveness of botulinum toxin A (BTX-A) treatment should be considered on an individual basis, according to the initial state of facial function. A patient with mild facial synkinesis restricted to the oral-ocular area and with a high score on the Sunnybrook (SB) facial nerve grading system would be the best candidate for BTX-A treatment.

Importance: Aberrant depressor anguli oris (DAO) activity may arise after recovery from acute facial paralysis and restrict movement of the oral commissure., Objective: To quantify the degree to which DAO inhibition affects smile dynamics and perceived emotional state., Design, Setting, and Participants: In this prospective, pretest-posttest study performed at an academic tertiary referral hospital, patients with unilateral postparalysis facial palsy were studied from January 16 through April 30, 2016., Interventions: Local anesthetic injection into the ipsilateral DAO., Main Outcomes and Measures: Healthy- and paretic-side commissure displacements from the midline lower vermillion border referenced to the horizontal plane were calculated from random-ordered photographs of full-effort smile before and after injection, and random-ordered hemifacial photographs of the paretic side were assessed as expressing positive, negative, or indiscernible emotion., Results: Twenty patients were identified as having unilateral postparalysis facial palsy with marked synkinesis of the ipsilateral DAO. Patient mean age was 46 years (range, 24-67 years), with a male to female ratio of 1:3. Mean paretic-side commissure displacement increased from 27.45 mm at 21.65° above the horizontal plane to 29.35 mm at 23.58° after DAO weakening (mean difference, 1.90 mm; 95% CI, 1.26-2.54 mm; and 1.93°; 95% CI, 0.34°-3.51°; P < .001 and P = .20, respectively). Symmetry of excursion between sides improved by 2.00 mm (95% CI, 1.16-2.83 mm; P < .001) and 2.71° (95% CI, 1.38°-4.03°; P < .001). At baseline, observers assessed 7 of 20 paretic hemifaces (35%) as expressing positive emotion; this proportion increased to 13 of 20 (65%) after DAO weakening (P = .03)., Conclusions and Relevance: Ipsilateral DAO weakening results in significant improvements in smile dynamics and perceived expression of positive emotion on the paretic hemiface in postparalysis facial palsy. A trial of DAO weakening should be offered to patients with this disfiguring complication of Bell palsy and similar facial nerve insults., Level of Evidence: 3.

Background: Only few studies have considered the effects of the combined treatment with onabotulinumtoxinA (BoNT-A) injections and biofeedback (BFB) rehabilitation in the recovery of postparetic facial synkinesis (PPFS)., Aim: To explore the presence of a persistent improvement in facial function out of the pharmacological effect of BoNT-A in subjects with established PPFS, after repeated sessions of BoNT-A injections combined with an educational facial training program using mirror biofeedback (BFB) exercises. Secondary objective was to investigate the trend of the presumed persistent improvement., Study Design: Case-series study., Setting: Outpatient Clinic of Physical Medicine and Rehabilitation Unit., Population: Twenty-seven patients (22 females; mean age 45±16 years) affected by an established peripheral facial palsy, treated with a minimum of three BoNT-A injections in association with mirror BFB rehabilitation. The interval between consecutive BoNT-A injections was at least five months., Methods: At baseline and before every BoNT-A injection+mirror BFB session (when the effect of the previous BoNT-A injection had vanished), patients were assessed with the Italian version of Sunnybrook Facial Grading System (SB). The statistical analysis considered SB composite and partial scores before each treatment session compared to the baseline scores., Results: A significant improvement of the SB composite and partial scores was observed until the fourth session. Considering the "Symmetry of Voluntary Movement" partial score, the main improvement was observed in the muscles of the lower part of the face., Conclusions: In a chronic stage of postparetic facial synkinesis, patients may benefit from a combined therapy with repeated BoNT-A injections and an educational facial training program with mirror BFB exercises, gaining an improvement of the facial function up to the fourth session. This improvement reflects the acquired ability to use facial muscle correctly. It doesn't involve the injected muscles but those trained with mirror biofeedback exercises and it persists also when BoNT-A action has vanished., Clinical Rehabilitation Impact: The combined therapy with repeated BoNT-A injections and an educational facial training program using mirror BFB exercises may be useful in the motor recovery of the muscles of the lower part of the face not injected but trained.

A 39-year-old woman was admitted to hospital because of a sensory hemisyndrome caused by a contrast-enhancing demyelinating lesion of the cervical cord. MRI, CSF examination and subsequent clinical and neuroradiological follow-up led to the diagnosis of multiple sclerosis. The patient had noticed an involuntary contraction of a small muscle fascicle on the right side of the chin for a year. Electromyographic and video recordings confirmed the synkinesis between the orbicularis oculi and lower facial muscles, a finding distinct from the myokymic discharges reported in multiple sclerosis and more similar to the synkinesis associated with hemifacial spasm., (© The Author(s), 2015.)

Facial nucleus motoneurons innervating the facial expressive muscles are involved in a wide range of motor activities, however, the types of movement related neurons and their electrophysiological transformation after peripheral facial nerve injury haven't been revealed. This study was designed to elucidate the types of facial nucleus motoneurons and their alterations of discharge parameters following peripheral facial nerve injury in vivo. Here we set up a rat model by implanting electrode arrays into the brainstem and recorded the electrophysiological signals of facial nucleus neurons in the intact rats for 5 days, then transected the trunk of facial nerve (TF), and continued the record for 4 weeks. At the 4th week post-surgery, the morphological changes of TFs were analyzed. In this paper, we described two types of putative facial nucleus motoneurons based on their electrophysiological properties and their firing frequency adaptation. Type I motoneurons (n=57.6%) were characterized by a sustained spike adaptation, Type II motoneurons (n=26.2%) were identified by a phasic fast spike firing. Facial palsy and synkinesia, caused by neurotmesis of TF, were accompanied by firing rates reduction and firing pattern alteration of motoneurons. Our findings suggest the presence of two types of facial nucleus motorneurons, and their response patterns after neurotmesis support the notion that the discharge pattern of motorneurons may play an important role in the facial nerve function., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation (FaCE) Scale Instrument outcomes when treating hemifacial spasm (HFS) with onabotulinumtoxinA., Methods: An Institutional Review Board-approved retrospective review of records of 66 HFS patients treated with onabotulinumtoxinA. SFGS and FaCE surveys were completed prior to onabotulinumtoxinA therapy and at 1 month follow up. Surveys were analyzed for differences using paired Student t tests, with statistical significance set at p < 0.05. Correlations were determined using Spearman correlation (rs), with coefficients of ≥0.40 or ≤-0.40 considered significant., Results: There were 22 complete data sets. SFGS composite score improved from mean, 56.9 (SD, 12.3) to 63.6 (SD, 12.3), p < 0.01. SFGS subdomain synkinesis score significantly improved (p < 0.01). The FaCE scale subdomain oral function significantly worsened (p = 0.05). The Δ pre-/post-SFGS composite score did not correlate with the Δ pre-/post-FaCE composite score (rs = 0.24). There was a significant positive correlation between SFGS composite score and FaCE social function score (rs = 0.462, p = 0.03) and between SFGS voluntary movement score and FaCE social function score (rs = 0.477, p = 0.03). Subgroup analysis of single FaCE questions demonstrated no statistical change in subjective dry eye (p = 0.30)., Conclusions: There was an improvement in social functioning in treated HFS patients, which positively correlated with improvement in overall objective voluntary facial movement. There was no statistical difference in subjective dry eye symptoms. The overall SFGS composite score improved following treatment of HFS with botulinum toxin. This information can be used when counseling expected outcomes in HFS patients treated with onabotulinumtoxinA.