Associate Professor of Neurology Cairo University CairoNeuro Botulinum toxin in hemifacial spasm A real Face Off 2 Agenda Hemifacial spasm 3 Anatomy of facial muscles Definition ID: 505273
Download Presentation The PPT/PDF document "Amr Hasan, M.D." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Amr Hasan, M.D.
Associate Professor of
Neurology
Cairo University
CairoNeuro
Botulinum toxin in hemifacial spasm: A real
“Face Off”Slide2
2Slide3
Agenda
Hemifacial spasm
3
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide4
Agenda
Hemifacial spasm
4
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide5
Anatomy of facial
muscles5Slide6
Anatomy of facial
muscles6Slide7
Anatomy of facial
muscles7Slide8
Anatomy of facial
muscles8Slide9
Anatomy of facial
muscles9Slide10
Anatomy of facial
muscles
10Slide11
11
Anatomy of facial
musclesSlide12
Anatomy of facial
muscles
12Slide13
Anatomy of facial
muscles13Slide14
Anatomy of facial
muscles (circumorbital and
palpebral muscles)
14Slide15
Anatomy of facial
muscles (circumorbital and
palpebral muscles)
15Slide16
16
Anatomy of facial muscles
(
circumorbital
and
palpebral muscles)Slide17
17
Anatomy of facial muscles
(Nasal Muscles)Slide18
18
Anatomy of facial muscles
(Nasal Muscles)Slide19
19
Anatomy of facial muscles
(Nasal Muscles)Slide20
20
1
Elevator,retractor
and
evertors
of upper lip
ZM,ZM,LLS,LAO,LLSAN,risorius
2
Depressor,retractor
and
evertors
of lower lip
DLI,DAO,Mentalis
3
Compound sphincter
OO
Anatomy of facial muscles
(
Buccolabial
muscles)Slide21
21
Anatomy of facial muscles
(
Buccolabial
muscles)Slide22
22
Anatomy of facial muscles
(
Buccolabial
muscles)Slide23
23
Anatomy of facial muscles
(
Buccolabial
muscles)Slide24
24
Anatomy of facial muscles
(
Buccolabial
muscles)Slide25
25
Anatomy of facial muscles
(
Buccolabial
muscles)Slide26
26
Anatomy of facial musclesSlide27
QUIZ
27
14
15Slide28
Agenda
Hemifacial spasm
28
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide29
Agenda
Hemifacial spasm
29
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide30
Hemifacial
SpasmCharacterized by:
30
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.Slide31
Agenda
Hemifacial spasm
31
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide32
Agenda
Hemifacial spasm
32
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide33
Hemifacial
SpasmCauses:
33
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
.Slide34
Hemifacial
SpasmCauses:
34
Secondary
causes such as trauma or
Bell palsy.Familial
Idiopathic Slide35
35
Hemifacial
Spasm
Causes:Slide36
Agenda
Hemifacial spasm
36
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide37
Agenda
Hemifacial spasm
37
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide38
Hemifacial
spasm
38
1
The first theory:
E
phaptic
transmission, which is electrical activity crossing from one demyelinated neuron to another resulting in a false
synapse.
2
The second theory:
I
nvolves abnormal activity of
axons
at the
facial nerve
root end zone secondary to compressive damage/
demyelination.
3
The
third theory
:
or "Kindling theory" involves increased excitability of the
facial nerve
nucleus due to feedback from a damaged facial nerve.Slide39
Agenda
Hemifacial spasm
39
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide40
Agenda
Hemifacial spasm
40
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide41
Hemifacial
spasm
41
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.Slide42
Hemifacial
spasm
42
Painless
, no
sensory loss.
Involves entire side of face.
HS most often begins insidiously in the orbicularis oculi muscle.Slide43
Hemifacial
spasm
43
Contractions gradually spread to other muscles of the face including the
platysmaSlide44
Hemifacial
spasm
44
Hemifacial
Spasm
Typical
Atypical
Lower Eyelid
Lip/Cheekbone Area
Lip/Cheekbone
Area
Lower EyelidSlide45
Hemifacial
spasmDifferential
Dx:
45
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
Slide46
Hemifacial
spasm
Blepharospasm:46
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).Slide47
Hemifacial
spasm
Blepharospasm:47
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 strokeSlide48
Agenda
Hemifacial spasm
48
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide49
Agenda
Hemifacial spasm
49
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide50
Hemifacial
spasm
50
Work Up
MRI of
cerebellopontine angle to R/O tumorSlide51
51Slide52
Agenda
Hemifacial spasm
52
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide53
Agenda
Hemifacial spasm
53
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide54
Hemifacial
spasmTreatment
54
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).Slide55
Sites of injection
55Slide56
Sites of injection
56Slide57
57
Sites of injection Slide58
Sites of injection
58Slide59
Sites of injection
59Slide60
Sites of injection
60Slide61
Sites of
injection for BEB
61Slide62
Sites of
injection
62Slide63
Ptosis (7-11%)
Lagophthalmos (5-12%)
Symptomatic dry eyes
Diplopia (<1%)
Ecchymosis
Lower facial weakness
Potential adverse effect
63
Facial assymetry.Slide64
Agenda
Hemifacial spasm
64
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide65
Agenda
Hemifacial spasm
65
Anatomy of facial muscles
Definition
Aetiology
Pathophysiology .
Investigations
Clinical features and differential diagnosis.
Botulium
toxin
in
hemifacial
spasm
Video
presenationsSlide66
66
VIDEO PRESENTATIONSSlide67
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 dayMRI Brain : Normal
67Slide68
68
Case 1Slide69
69
Case 1Slide70
Case 2
16 ys old girl.Student 4 years ago, she had Bell’s palsyAfterwhich, she started to develop
Rt HFSEmbarrasing and disfiguring
70Slide71
71
Case 2Slide72
72
Case 2Slide73
Case 3
42 ys old Yemenese man.Employee 2 years ago, he started to develop bilateral facial
dyskinsia (ocular, facial, orobuccal) Khat
73Slide74
74
Case 3Slide75
75
Case 3Slide76
Pearls
76
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 Slide77
77Slide78
78