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central nervous system abnormalities (mainly focal seizures and ventricular dilatation), referable to the homolateral hemisphere, are conjoined (Hosten) The signi cance of these associations is unclear Wilson and Hoxie have pointed out the frequent coexistence of facial asymmetry in adults with congenital or early-onset superior oblique palsy and compensatory head tilt or torticollis If the peripheral facial paralysis has existed for some time and return of motor function has begun but is incomplete, a kind of contracture (in reality a continuous diffuse myokymic contraction) may appear The palpebral ssure becomes narrowed, and the nasolabial fold deepens Attempts to move one group of facial muscles result in contraction of all of them (associated movements, or synkinesis) Spasms of facial muscles may develop and persist inde nitely, being initiated by every facial movement With the passage of time, the corner of the mouth and even the tip of the nose may become pulled to the affected side This is a special acquired form of hemifacial spasm, the more common variety of which is described below Anomalous regeneration of the seventh nerve bers, following Bell s palsy or other injury, may result in other curious disorders that represent limited types of synkineses The most common is the jaw-winking phenomenon (also called Wartenberg s or inverse Marcus-Gunn sign), in which jaw movements, especially lateral movements (engaging the pterygoid muscle), cause an involuntary closure of the eyelid ipsilateral to the movement If regenerating bers originally connected with the orbicularis oculi become connected with the orbicularis oris, closure of the lids may cause a retraction of the corner of the mouth; or if visceromotor bers originally innervating the salivary glands later come to innervate the lacrimal gland, anomalous tearing (crocodile tears) occurs whenever the patient salivates A similar mechanism explains gustatory sweating of the cheek and upper lip Hemifacial Spasm The facial muscles on one side may be involved in painless irregular clonic contractions of varying degree (hemifacial spasm) This condition develops in the fth and sixth decades, affects women more than men, and it usually proves to be due to a compressive lesion of the facial nerve, most often by a tortuous branch of the basilar artery that lies on the ventral surface of the pons and forms a loop under the proximal nerve Less often the cause of compression is a basilar artery aneurysm, or an acoustic nerve tumor or meningioma The spasm usually begins in the orbicularis oculi muscle and gradually spreads to other muscles on that side of the face, including the platysma The paroxysm may be induced or aggravated by voluntary and re exive movements of the face There was for a time controversy concerning the pathogenesis of hemifacial spasm Jannetta attributed all cases to a compression of the root of the facial nerve by an aberrant looped blood vessel Microsurgical decompression of the root with the interposition of a pledget between the vessel and the root has relieved the facial spasm in most of his cases These results have been corroborated by Barker and associates in a series of 705 patients followed postoperatively for an average period of 8 years; 84 percent achieved an excellent result An even higher rate of bene t was obtained in a prospective series by Illingworth and colleagues (cure of 81 of 83 patients) The pathophysiology of the spasm is believed to be focal demyelination nerve root compression The demyelinated axon is theorized to activating adjacent nerve bers by ephaptic transmission ( arti cial synapse of Granit et al) Another possible source of the.

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Inserting a Single Barcode into Microsoft Excel . Switch to the Add-Ins tab. Open the TBarCode Panel . Position the mouse cursor in a cell. Select the barcode type (e.g. Code 128). Enter the barcode data or use the default data for the selected barcode . Adjust the size of the barcode (width, height, module width etc).

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spasm is spontaneous ectopic excitation arising in injured bers Nielsen and Jannetta have shown that ephaptic transmission disappears after the nerve is decompressed Treatment Surgical decompression of a vascular loop, which involves exploration of the posterior fossa, carries some small risk The facial muscles may be weakened, sometimes permanently Another complication has been deafness due to injury of the adjacent eighth nerve Also, there is a modest risk of recurrence of the spasms, usually within 2 years of the operation (Piatt and Wilkins) Operative success depends on tight dural closure to prevent CSF leakage from the posterior fossa The authors suggest that patients with idiopathic hemifacial spasm should rst be treated medically Alexander and Moses noted that carbamazepine (Tegretol) in a dosage of 600 to 1200 mg/day controlled the spasm in two thirds of the patients Baclofen or gabapentin can be tried if carbamazepine fails Some patients cannot tolerate these drugs, have only brief remissions, or fail to respond; they may be treated with botulinum toxin injected into the orbicularis oculi and other facial muscles The hemifacial spasms are relieved for 4 to 5 months and injections can be repeated without danger Some patients have been injected repeatedly for more than 5 years without apparent adverse effects Failing these conservative measures, surgery is quite appropriate Other Disorders of the Facial Nerve Facial myokymia is a ne rippling activity of all the muscles of one side of the face mentioned above It develops most often in the course of multiple sclerosis or a brainstem glioma It has also occurred after other diseases of the facial nerve, eg, in GBS, in which case it is usually bilateral We have seen it more often in the recovery stage than in the early phase of GBS The brillary nature of the involuntary movements and their arrhythmicity tend to distinguish them from the coarser intermittent facial spasms and contracture, tics, tardive dyskinesia, and clonus The EMG pattern is one of spontaneous asynchronous discharge of adjacent motor units, appearing singly or in doublets or triplets at a rate varying from 30 to 70 cycles per second Demyelination of the intrapontine part of the facial nerve and possibly supranuclear disinhibition of the facial nucleus have been the postulated mechanisms But the observation of facial myokymia in GBS informs us that the abnormal movement may have its origin in a lesion at any point along the nerve (see pages 1194 and 1278 for further discussion of myokymia) A clonic or tonic contraction of one side of the face may be the sole manifestation of a cerebral cortical seizure Involuntary recurrent spasm of both eyelids (blepharospasm) may occur with almost any form of dystonia but is most frequent in elderly persons as an isolated phenomenon, and there may be varying degrees of spasm of the other facial muscles (see page 93) Relaxant and tranquilizing drugs are of little help in this disorder, but injections of botulinum toxin into the orbicularis oculi muscles give temporary or lasting relief A few of our patients have been helped (paradoxically) by L-dopa; baclofen, clonazepam, and tetrabenazine in increasing doses may be helpful In the past, failing these measures, the periorbital muscles were destroyed by injections of doxorubicin or surgical myectomy (Hallett and Daroff) With the advent of botulinum treatment, there is no longer a need to resort to these extreme measures In some cases, blepharospasm subsides spontaneously Rhythmic unilateral myoclonia, akin to palatal myoclonus, may be restricted to facial, lingual, or laryngeal muscles Hypersensitivity of the facial nerve occurs in hypocalcemic.

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Raised, erythematic, symptomatic, con ned to original region of injury Histologically, collagen bundles are atter than normal skin and set in wavy pattern Express myo broblasts, increased mast cells2,4 Generally resolve over time Good treatment response

c(k) =

tetany; spasm of the facial muscles is elicited by tapping in front of the ear (Chvostek sign)

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