Ear, Nose and Throat (ENT)
Synkinesis is the abnormal movement of one part of the face with intentional movement of another part of the face. For example, when attempting to smile, the eye may close or when attempting to close the eyes, the neck may tighten. Synkinesis may present after any type of facial paralysis and usually starts after three to six months, but may develop up to two to three years after the paralysis. It may lead to eye problems, difficulty eating and speaking, social isolation and facial pain.
Medical treatment is typically undertaken only after at least a three month trial of facial therapy to improve the synkinesis. The treatment is with botulinum myomodulator (Botox, Dysport or Xeomin) with targeted treatment to the affected facial musculature. This treatment, when combined with physical therapy, leads to improvement in the symptoms of most patients with this disorder. The procedure is almost always covered by insurance plans, including Medicare.
Facial physical therapy is probably the single most important aspect of the treatment of facial synkinesis. Through this treatment, patients are able to retrain the brain to help decrease the effects of synkinesis. In addition, techniques are taught to help decrease the asymmetry, facial deformity and facial pain that may be present.
Surgery is reserved for those patients who have tired of receiving botulinum myomodulator therapy and have been determined to benefit from resection of the offending muscle or nerve branch. Procedures that are specifically targeted at treating synkinesis include the following listed below:
- Platysmectomy: The platysma is a large flat muscle in the neck that extends towards the lower portion of the jaw. This muscle is controlled by the facial nerve and is a frequent site of synkinesis. Synkinesis of this muscle may lead to decreased ability to lift up the corner of the mouth when attempting to smile, because the platysma pulls down on the corner of the mouth opposing the action of the smile muscles. It may also be associated with a prominent band in the neck and neck pain from chronic contraction of the muscle. The procedure involves resection of a portion of the muscle through one of the deeper neck creases in the neck. The procedure is typically performed in the clinic under local anesthesia.
- Resection of the lower lip depressors: There are several muscles that cause the lower lip to depress. These muscles may be responsible for asymmetry when smiling or speaking. In most cases of facial paralysis where lower lip asymmetry is a concern, the lip depressor muscles no longer pull down the corner of the lip, whereas the non-paralyzed side continues to pull down as it did before the paralysis. This leads to lower lip asymmetry. The treatment is to resect the still active depressor muscle on the opposite side to lead to a more symmetric lower lip. This procedure is typically performed under local anesthesia in the clinic.
- Resection of the nerves that lead to overactive eye closure: Eye closure resulting from synkinesis is usually treated with botulinum myomodulator; however, if a patient tires of this treatment, the nerve that controls eye closure can be resected leading to improvement in eye opening.