Hemifacial Spasm

The patient is a 72 year old man with myopia, childhood exotropia, progressive age related ptosis and right hemifacial spasm. Hemifacial spasm (HS) most often begins insidiously in the orbicularis oculi muscle in the early stages, as in this man. He presented with a 2 year history of involuntary twitching of the right upper eyelid, which he described as "a quiver". The twitching slowly progressed to involve the ipsilateral facial muscles. On some occasions the twitching was almost continuous and he sat watching television with his hand over his right eye. His hemifacial spasms were aggravated by emotional stress and fatigue and precipitated by active movement of any facial muscle. Just asking him to show his teeth provoked right sided facial spasm. Past History: Negative for trauma, a previous lower motor neuron facial palsy (Bell's Palsy), impaired sensation of the face and face pain. He had no history of deafness or tinnitus. Investigations: Electromyography: Electromyographic study confirmed that the HS was due to brief bursts of normal motor units firing at high frequency. (HS is not a focal dystonia). Brain MRI is required in these cases to rule out: 1.A basilar artery aneurysm 2.An acoustic nerve tumor 3.Posterior fossa meningioma 4.Pontine glioma Brain MRI with contrast showed: A small enchancing vessel crossing the root entry zone of the right 7th and 8th cranial nerve. No corresponding vessel was noted on the controlateral side. Diagnosis: Neurovascular compression syndrome of the facial nerve root Microsurgical decompression: Microsurgical decompression of the facial nerve root was recommended but, not unexpectedly, the patient declined because of the risks of a posterior craniotomy. Botulinum toxin therapy: He was referred to the Movement Disorder Clinic for treatment with Botulinum toxin (BT). BT injections successfully suppressed the HS in this patient and he continued receiving this treatment on a routine basis over many months. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/95