A 63-year-old male patient presents with the above findings (see video). He reports that the spasms are present even during sleep. If his symptoms are due to vascular compression of the facial nerve, where along the course of the nerve, does this compression most commonly occur?
Oculoplastics
Periocular Malpositions and Involutional Changes
No
U
A
The patient’s symptoms are most likely due to hemifacial spasms. This is most commonly caused by vascular compression of the facial (seventh) nerve at its root exit zone at the level of the brainstem. Therefore, hemifcial spasms warrant MRI/MRA imaging of the facial nerve.
Review of Facial Dystonias:
Benign Essential Blepharospasms(BEB):
Usually Bilateral since the etiology is thought to be central. Therefore, they disappear during sleep.
No workup is required because they are considered – as the name suggests - "benign."
Treatment: botulinum toxin, subtotal myectomy of the orbicularis. Of note, some patients present with inability or difficulty opening their eyelids, aka apraxia of eyelid opening. This is due to the fact that the eyelid retractors (i.e, levator) cannot overcome the constant contracting of the eyelid protractor (i.e., orbicularis).
Patients with BEB, who additionally have apraxia of eyelid opening, benefit from ptosis repair (often with a frontalis sling) in addition to weakening the orbicularis muscle (either surgically or with neurotoxins).
Meige Syndrome is a disorder characterized by blepharospasm with lower facial involvement. Treatment: botulinum toxin.
Hemifacial spasms
As the name suggests, they involve half the face (i.e., unilateral). Therefore, the pathology must be unilateral and in fact, is due to vascular compression of the facial nerve at the brainstem, which warrants imaging (MRI/MRA) along the course of the facial nerve.
Since the compression is present whether a patient is awake or asleep, hemifacial spasms do not disappear during sleep. Rarely, hemifacial spasms are due to a cerebellopontine angle tumor (e.g., pontine glioma). Treatment: botulinum toxin or surgical decompression of the facial nerve.
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