I. Etiology
Facial muscle spasm is a paroxysmal involuntary twitching of the hemifacial muscles, usually limited to one side of the face, and therefore also called hemifacial spasm, occasionally seen in both sides. It starts from the orbicularis oculi muscle, and gradually develops to the cheek and even the whole half of the face, and the reverse development is less common. It can be aggravated by fatigue and tension, especially when speaking and smiling, and can become spastic in severe cases. It mostly starts in middle age, with the youngest age reported to be two years old. In recent years, statistics have shown that the onset of HSF is not related to gender, and in a few cases, mild facial paralysis may occur.
Vascular factors
In 1875, Schulitze et al. reported a case of HFS in which a “cherry” sized basilar artery aneurysm was found in the facial nerve during autopsy. It is now known that approximately 80% to 90% of HFS is due to vascular compression of the facial nerve exiting the brainstem region. Clinical data suggest that the anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) are the predominant vascular factors causing HFS, while the superior cerebellar artery (SCA) is the second.
It is known that the SCA originates from the junction of the basilar artery and the posterior cerebral artery and has the most constant course, whereas the PICA and AICA are relatively more variable and therefore prone to form vascular loops or ectopic compression of the facial nerve; in addition, the superior vagus artery and other large variant arteries such as the vertebral artery and the basilar artery may also cause compression of the facial nerve, resulting in HFS. Recent studies have shown that a single venous vessel can also cause HFS when it compresses the facial nerve, and the above-mentioned vessels can form a combined compression of the facial nerve by both or more of them, which affects the prognosis of HFS surgery to some extent.
Non-vascular factors
Non-vascular occupying lesions in the pontocerebellar angle (CPA), such as granulomas, tumors and cysts, can also produce HFS, which may be caused by
Singh et al. reported a case of a CPA epidermoid cyst that displaced the AICA and compressed the facial nerve, resulting in HFS;
2. direct compression of the facial nerve by the occupancy;
3, the influence of the abnormal blood vessels of the occupancy itself such as arteriovenous malformation, meningioma, aneurysm, etc.
In young patients, localized arachnoid thickening may be one of the main causes of HFS, while some congenital disorders such as Arnold-Chiari malformation and congenital arachnoid cyst may cause HFS. In young patients, localized arachnoid thickening may be one of the main causes of HFS, while some congenital disorders such as Arnold-Chiari malformation and congenital arachnoid cyst may occasionally cause HFS.
IV. Other factors
The presence of compression factors in the exocortical region of the facial nerve is the main cause of HFS, and most authors have observed during pontocerebellar horn surgery that the presence of vascular compression in areas other than the exocortical region of the facial nerve does not produce HFS, whereas Kuroki et al. observed in an animal model that demyelinating lesions of the facial nerve in areas other than the exocortical region of the facial nerve can show electromyographic changes similar to HFS. Further investigation is needed to determine whether the presence of compression factors in areas other than the brainstem region of the facial nerve leads to HFS.
In addition, HFS can also be seen in some systemic diseases such as multiple sclerosis. Only a few cases of familial HFS have been reported so far, and the mechanism is still unknown, but it is presumed to be genetically related.
V. Clinical manifestations
Some patients with primary facial myasthenia gravis mostly develop it after middle age, more often in women. In the early stage of the disease, it is mostly paroxysmal involuntary twitching of the orbicularis oculi muscle on one side, which gradually and slowly expands to other facial muscles on one side of the face, and the twitching of the corners of the mouth muscle is most easily noticed. The degree of twitching varies, and it is paroxysmal, rapid and irregular twitching.
The initial twitch is light and lasts for only a few seconds, and then it gradually grows for several minutes or longer, while the interval is gradually shortened and the twitch gradually increases in frequency. In severe cases, it is tonic, causing the ipsilateral eye to be unable to open, the corner of the mouth to be skewed to the ipsilateral side and unable to speak, often aggravated by fatigue, mental tension and voluntary movement, but it cannot imitate or control its seizure by itself. A convulsion can last from a few seconds to more than 10 minutes, with intervals of variable length. The patient feels distracted and unable to work or study, which seriously affects the patient’s physical and mental health.
Most of the convulsions stop after sleep. Bilateral lateral muscle spasms are rarely seen. If there is, it is often started on both sides successively, and most of the convulsions stop on one side, then the other side has another attack, and the convulsions are light on one side and light on the other side, and the simultaneous onset and convulsions on both sides have not been reported. A few patients have mild facial pain during convulsions, and individual cases may be accompanied by ipsilateral headache and tinnitus.
The intensity of spasms is graded according to Cohen et al.
Grade 0: no spasms;
Grade 1: Increased transients or mild facial muscle tremors caused by external stimuli;
Grade 2: spontaneous mild tremors of eyelids and facial muscles without functional impairment;
Grade 3: pronounced spasticity and mild dysfunction;
Grade 4: severe spasm and dysfunction, e.g., the patient is unable to read and has difficulty walking alone because he cannot keep his eyes open. Neurological examination is not positive except for paroxysmal twitching of facial muscles. A small number of patients may have mild paralysis of the affected facial muscles in the late stage of the disease.
VI. Treatment
The cause of facial muscle spasm is generally due to excessive fatigue, tension, dry fire, internal heat, and external wind and cold.
Western medicine says: blood vessels compressing the facial nerve later cause adhesions, facial nerve ischemia and hypoxia caused by facial nerve spasm. Most of them are paroxysmal involuntary twitching of the hemifacial muscles, usually confined to one side of the face, thus also called hemifacial spasm, occasionally seen in both. It starts from the orbicularis oculi muscle and gradually progresses to the cheeks and even the whole face, and the reverse development is less common. It can be exacerbated by fatigue and tension, especially when speaking and smiling, and can become spastic in severe cases. It mostly starts in middle age, and the youngest age is reported to be two years old. Previously, it was thought to be more prevalent in females.
In recent years, statistics have shown that the onset of the disease is independent of gender. In a few cases, mild facial paralysis may develop.
If your friend is diagnosed with facial spasm, it is best not to have acupuncture, because the disease itself is afraid of stimulation, sometimes acupuncture will aggravate the disease, and some people see the effect at the time, but later relapses will be powerful. In addition to taking carbamazepine or phenytoin sodium these anti-sedative anti-epileptic drugs only control, and long-term taking side effects are also very big, dependence is also relatively strong. You can take some B1B12 but it has little effect.
Botulinum toxin type A is also only controlled, generally playing a shot can control the longest one year, or six months to three months, long time injection will produce resistance, and because the botulinum toxin type A only paralyzes the nerves of the face caused by artificial facial paralysis, so at the time after playing facial muscle spasm will be controlled. However, patients who have been injected for a long time will have more or less facial paralysis. Surgical treatment of this disease is relatively more ideal than the two methods mentioned above, and more patients will adopt it. However, the recurrence rate is also very high. The most one patient has had four surgeries in clinical contact.
At present, Western medicine treatment is no more than the above-mentioned methods. There are also many Chinese medicine treatments in China, most of which are mainly based on oral Chinese medicine, but most of the traditional oral medicine is simply to open the meridians, dispel the wind and transform them, only to see the effect, but it is difficult to solve the problem at the root.
The use of bee therapy has certain efficacy, but the treatment process is longer, persistently, can be expected to cure.
1.Medication
In addition to phenytoin sodium or carbamazepine and other drugs may be effective for some light patients, general central sedatives, inhibitors and hormones are not significantly effective. In the past, procaine, anhydrous alcohol or 5% phenol glycerin were commonly used for injection at the stem mammary foramen to cause temporary necrotic degeneration of nerve fibers and reduce abnormal excitation conduction, with a single injection of 0.3-0.5 ml to reach the level of mild facial paralysis. Too large a dose will produce permanent facial paralysis, and too small a dose will still cause a relapse after 3 to 5 months. It is rarely used now.
Injection method: The patient lies on his side, disinfect the affected side of the subauricular mastoid with alcohol and iodine, at the junction of the cartilage at the base of the external auditory canal and the anterior margin of the mastoid, use a 20-21 gauge needle, connect a 2ml syringe, point the tip of the needle to the upper front, at an angle of 30 degrees with the horizontal line of the skull base, pierce 3cm into a depression, inject 1ml of 1% procaine first, do not pluck the needle, observe whether facial paralysis occurs for 1 to 2 minutes, if If facial paralysis occurs, it means that the nerve stem is hit, and then the empty needle with water and alcohol is attached and 0.3~0.5ml of alcohol or phenol glycerin is injected, and obvious facial paralysis will occur and the spasm will disappear. After half a year, facial paralysis can be gradually recovered, about 2/3 of the patients will also have a recurrence of spasm.
2.Radiofrequency temperature-controlled thermal coagulation therapy
The radiofrequency cannula needle is stabbed into the stem mammary foramen in accordance with the above method, and using the principle of electric coupling, heat is generated between nerve fibers by radiofrequency, and the temperature is 65～70℃. Under the supervision of the facial nerve function monitor, the temperature is controlled to make the nerve thermal coagulation denaturation to reduce the nerve fibers that conduct abnormal impulses. The same facial palsy should occur after surgery, and the old disease will recur during the gradual recovery of facial palsy in 1 to 2 years, otherwise the electric heat is excessive, and although the spasm can be long-term without seizure, it will be replaced by permanent facial palsy.
3.Surgical treatment
(1) Facial nerve stem crush and branch severance
Under local anesthesia, an incision is made under the stem mammary foramen, the nerve trunk is identified, and the nerve trunk is pressed with vascular forceps. If the distal branches are identified, the nerve branch responsible for the main spasm is identified under electrical stimulation and selectively cut, the effect is better than compression, but mild facial palsy still has to occur after the operation, and there is also recurrence after 1 to 2 years.
(2) Facial nerve decompression surgery
The decompression of the facial nerve by grinding the bony canal of the facial nerve out of the skull was first adopted by Proud in 1953. In 1972, Pulec thought that the scope of decompression in the mastoid process alone was too small, and the top of the internal auditory canal and the vagus segment should be decompressed at the same time.
In 1965, Cawthorne reported 13 cases in which no abnormalities were found. Decompression is complex, and especially total segmental decompression is not only difficult but also dangerous. It is also debatable whether the so-called efficacy is due to the trauma to the facial nerve during surgery, not the effect of decompression.
(3) Combing of the vertical segment of the facial nerve
Scoville (1965) ground the vertical segment of the facial nerve canal in accordance with the above method, and then dissected the vertical segment longitudinally by 1 cm with a fibrous knife and spaced it with silicone film.
(4) Facial nerve wire ligature
Designed for the authors, the facial nerve trunk is strangled with a 1 mm diameter wire to do permanent compression, and the degree of strangulation can be adjusted at will. The method is simple and reliable, and is suitable for those who are old and frail and not suitable for open exploration, and more suitable for general primary care units.
Under local anesthesia, an arc-shaped incision is made under the earlobe, along the angle of the mandible, the posterior edge of the parotid gland is separated, the main trunk of the facial nerve is found, a stainless steel wire is taken to run through the bone coat in front of the mastoid process, twisted and fixed as a fulcrum, and then the nerve trunk is strangled around the nerve, and the facial muscle activity is observed on one side of the strangulation until the spasm stops and the facial paralysis is mild. Generally, it is appropriate to close the eye fissure without reaching 1~2mm. The wire is left outside the incision and is not cut for the time being. Once the spasm is observed to have recurrence the next morning, the last pressure adjustment is made and the excess wire is cut and buried under the skin. If there is any recurrence after the operation, the incision can be opened and the tail section of the wire can be found to be strangled now. If long-term facial paralysis does not recover, wire release can also be performed. The disadvantage of this method is that there must be facial paralysis for 3-6 months after surgery, and the recurrence rate is high, reaching 30%.
(5) Intracranial manifest microvascular decompression
Jannetta advocated it in 1966, and it is now a common method in international neurosurgery.
Under general anesthesia, the suboccipital or posterior sigmoid sinus pathway is used to resect the occipital bone to make a 3×4 cm bone window, cut open the meninges, enter the pontocerebellar horn, find out the VII and VIII cranial nerves, if any occupying lesions or arachnoid adhesions are found, they can be resected and decomposed, if there are compressive vessels, microscopic instruments can be used to separate them, if they cannot be separated, Silicone or Teflon sheets can be used to spacer them, or muscle sheets can be used to fill in the blood vessels and the blood vessels. Muscle sheets can also be used to fill in between the vessels and the nerves.
These vessels are mostly tripped by the anterior inferior cerebellar artery, which is the main blood supplier to the brainstem. Any injury or bleeding or induced vasospasm or thrombosis during surgery will cause ischemic edema in the brainstem, resulting in serious adverse consequences. Even spasm or thrombosis of the internal auditory artery can cause total deafness.
Clinically, it has been observed that in 1/3 of the patients with arteries crossing between the VII and VIII nerves or with branches of the internal auditory artery entering the internal auditory tract at the top of the trip, vascular decompression operations are difficult or impossible to separate and pad, and in many other patients no compressible vessels can be identified, so vascular decompression cannot be applied. For this reason, the authors devised a new surgical method called intracranial segmental facial nerve trunk commissurotomy and achieved satisfactory results.
(6) Intracranial facial nerve trunk commissurotomy (longitudinal nerve splitting)
Operate according to vascular decompression, enter the pontocerebellar angle, find VII and VIII cranial nerves, free the facial nerve trunk, and perform multi-level splitting with a fibrous knife along its long axis between the root of the brainstem and the mouth of the internal auditory canal, determining the level of splitting according to the degree of spasm, generally splitting 10 to 20 times, and in many cases, splitting dozens of times, combing the originally compressed vessels and restoring them to their original position.
After 2-5 years of follow-up, the efficiency of the operation can be increased to more than 98%, and the recurrence rate is reduced to 6%. The main advantage of this method is that it has wider indications than vascular decompression, less recurrence rate and higher cure rate, especially the reduction of deafness complications, which has replaced vascular decompression. The reason for its effectiveness may be that the nerve fiber combing destroys the abnormal potential accumulation in the nerve root area and prevents the potential release of abnormal impulses.
In summary, there are many surgical methods for the treatment of facial spasm, each with its own advantages and disadvantages, which should be used flexibly in clinical practice according to the patient’s condition and medical conditions. Idiopathic facial myospasm is mostly seen in adults over 40 years of age and may be associated with arteriosclerosis and hypertensive lesions. If the patient is a young person under 30 years of age, it often suggests the presence of neurostimulating lesions in the cerebellar cerebellar horn, internal auditory canal, geniculate ganglion, middle ear mastoid, or parotid gland, such as congenital cholesteatoma, hemangioma, auditory neuroma, and arachnoid cyst. Spasticity is a red flag for the disease. In such cases, a comprehensive neurological examination and, if necessary, a cranial CT or MRI should be performed promptly, but it is better to wait under observation to avoid delaying treatment.
(7) Chinese medicine treatment
The modern treatment of facial spasm with acupuncture was reported no later than the mid-1960s. In 1965, some people tried the intradermal acupuncture method, and in the 1970s, further exploration was made, such as the use of deep acupuncture and long stay acupuncture method, the mu-acupuncture method that only needles the healthy side but not the affected side, etc. We use acupuncture point injection in the most obvious place of twitching, also has some effect. However, in general, the practice is still relatively small, and most of the articles are reported internally.
Since the 1980s, the treatment of facial muscle spasm has received more attention from the acupuncture community, not only because of the large increase in the number of cases observed, but also because of the exploration of various aspects of the acupuncture method, which has led to the emergence of some unique acupuncture methods, such as the cluster acupuncture method, the method of stimulating the facial nerve trunk, the method of superficial acupuncture of the skin and the method of Xingqi, etc. When it is difficult to apply the traditional acupuncture method to the facial nerve trunk, the acupuncture method has become more effective. When the traditional acupuncture method is difficult to achieve results, the use of the above-mentioned acupuncture method is often effective.
①Facial muscle spasm
The efficiency of various acupuncture methods in treating this disease is generally around 80%. Some people have compared the acupuncture method with general acupuncture method or other Chinese and Western medicine therapies, and found that regardless of the recent and long-term efficacy, the method of acupuncture is superior [2]. Of course, it should be noted that facial spasm is a stubborn and recurring disease, which requires patient treatment, and the practitioner should switch to another acupoint stimulation method in time when one method is not effective.
②Nerve Stem Stimulation Method
acupuncture points
Main acupuncture point: A-Ye point.
Supporting points: Hegu, orbicularis oculi spasm plus Yuzhang and Sibai, facial muscle spasm plus Yingxiang and Chengjiao.
Location of the A-Yi point: the midpoint of the line connecting the anterior earlobe notch and the root of the earlobe on the affected side, or 5 mm below the anterior edge of the mastoid tip. Underneath it is the nearest point of the facial nerve junction, about 0.5 cm after the posterior edge of the mandibular branch.
Treatment
Only the main point and the Hegu point are taken at each time, and the remaining points are chosen according to the symptoms. After sterilization and local anesthesia with 2% procaine at the A-Ye point, two 28-gauge 2.5-4 cm long milli-needles (1-1.5 inches) are used to pierce the A-Ye point and the Hegu point, respectively. The A-Ye point requires the facial nerve stem to be pierced. When the prick is hit, the patient has a strong electrical sensation or deep ear pain, and the operator has a breech feeling in his hand. At this point, the A-Ye point and the Hegu point are connected to the electroacupuncture instrument, and the current should not be too high at the beginning, and the frequency is not limited to the regular twitching of the index and thumb.
When the use of lifting and inserting techniques or electroacupuncture stimulation so that facial nerve damage, the expression muscle can appear relaxed (facial paralysis). The rest of the matching points should make the needle under the soreness or numbness inductance. Each needle 20-30 minutes, every 5-7 days needling 1 time. Generally needles 2 to 3 times. If the superficial blood vessels are damaged, swelling may occur after the needle, which will subside in a few days. If complications such as vertigo and vomiting occur after the needle, rest for 1 to 2 hours will recover.
Efficacy evaluation
Efficacy criteria: apparent effect: mild weakness of the affected lateral muscles and cessation of convulsions; ineffective: slight improvement or no change in the number or degree of convulsions.
A total of 110 cases were treated, 107 cases (97.3%) were effective, 3 cases (2.7%) were ineffective, and the total effective rate was 97.3%. By follow-up, it was found that the average effective time was about 10 months, with the longest being up to 28 months [4-6].
(③) Acupoint implantation
acupuncture point taken
Main acupuncture point: A-Ye acupuncture point
Location of the A-Yi point: it is the point of the plate machine for facial muscle spasm.
Treatment
First, disinfect the affected face routinely, then gently tap the face with a skin needle, from top to bottom, from left to right, repeatedly and carefully. After 3 days, remove the buried needles and use the previous method to find the A-Yi point and then bury the needles again. 5 times is a course of treatment, with an interval of 7 days.
Evaluation of efficacy
According to similar criteria, 45 cases were treated, 35 cases were controlled, 5 cases were effective, 3 cases were effective, and 2 cases were ineffective. The total effective rate was 95.6%.
④Plexus acupuncture method
Acupuncture points
Main acupuncture point: A-yi point.
Supporting points: Sibai, Yuzhang, Zanzhu, Yingxiang, and Chee Che.
Location of the A-Yi point: the starting point of facial spasm.
Treatment
The main point must be taken each time, using the series of stabbing method. The method is to take 15-30 No. 30-32 milli needles (0.5-1.5 inch long). The shallow stabbing into the ayurvedic point, taking intensive rows of needles, or scattered stabs (which are spaced 0.5 to 1 cm wide), should cause the skin at the tip of the needle to protrude, forming a small mound, and leaving the needle body suspended without falling. The matching acupuncture points are then taken near the facial muscle spasm 2 to 3 points, which should also be shallowly pricked. Retained needles 20-30 minutes, once a day, 10 times for a course of treatment. This method of acupuncture, the patient has a slight pain, some patients have a slight feeling of heat at the acupuncture site, or skin congestion and redness, are normal.
Evaluation of therapeutic effect
Similar to the aforementioned criteria evaluation, a total of 30 cases, control for 18 cases (60.0%), apparent effect 5 cases (16.7%), improved 7 cases (23.3%), the efficiency reached 100%. This method is simple and easy to implement, and adherence to treatment is the key to achieving efficacy [7].
⑤ Acupoint injection
Acupuncture points
Main acupoints: cataract, cheek car, sun, and dicang.
Supporting points: pupil s, zygomatic s, hegu, yanglingquan, and fengchi.
Treatment
Solution: mixed injection (sodium phenobarbital plus 1% procaine hydrochloride injection); 32 chromium phosphate salt (radioactive colloid).
Choose 1 or 2 main points and 1 or 2 matching points each time. Choose any one of the above medicinal solutions. For the first group of drugs, take 0.1 g of sodium phenobarbital injection plus 1 ml of 1% procaine hydrochloride and mix it for acupoint injection. Group 2 drug, using a scalp needle injection, the needle inserted into the acupuncture point, can be slowly lifted up and down, but not twisted, after the patient gets air, the drug solution will be slowly injected, each point injected 0.1 to 0.2 ml (containing about 10 to 20 microcurie) of sterile colloidal 32 chromium phosphate solution.
Group 1 solution daily or every other day, 10 times for a course of treatment; Group 2 solution once a week, two consecutive times for a course of treatment, after 15 days for another course of treatment.
Evaluation of therapeutic effect
A total of 134 cases were treated with the acupoint injection method, and evaluated by similar criteria as described previously, 26 cases (19.4%) were controlled, 64 cases (47.8%) were significantly effective, 41 cases (30.6%) were improved, and 3 cases (2.2%) were ineffective, with an overall effective rate of 97.8% [8, 9].
(6) Body acupuncture
Acupuncture points
Main acupoints: pinch Chengjiao through Chengjiao, Chengjiao through Di Cang, Di Cang through Yingxiang, Zygomatic s (or Sun) through Xiaoguan, and Sibai (or Zanzhu) through Miming.
Supporting points: wind-cold stagnation: hegu through laogong, taichong through yongquan; yin deficiency and yang hyperactivity: fuyao through tarsus yang and shengqu.
Treatment
Take all main points and add matching points according to the symptoms. The needle is twisted for 1 minute after entering the needle, and is retained for 1 to 2 hours, and the needle is performed once every 20 minutes; Shen Que is moxibutated with 3 to 5 strokes of salt. 5 times as a course of treatment, with an interval of 5 days.
Evaluation of therapeutic effect
A total of 68 cases were treated, and the results showed that 26 cases were cured, 25 cases were effective, 10 cases were effective, and 7 cases were ineffective, with an overall efficiency of 88.2%.
(7) Warm acupuncture with cupping
Acupuncture points
Main acupoints: Di Cang (or A-Yi point), Hou Xi, Si Bai.
Supporting points: Yingxiang, Renzhong, Chengjiao, and Chee Che.
Location of A-Yi point: the starting point of facial muscle twitching (mostly at the corner of the mouth or 2 cm away from the confluence of the upper and lower lips).
Treatment
Use a milli-needle to penetrate at an angle of 30 degrees from the main acupuncture point Dicang or AYi point to the Yingxiang point in the direction of the inner corner of the affected eye, 2.5-3.5 inches; penetrate Dicang to the cheek car for 2-3 inches; penetrate Renzhong from Dicang and Chengjue from Dicang. Houxi straight prick 1.5-2.5 inches, the lowest oblique prick through 3/4 of the palm part of the hand. Retain the needle for 1.5 to 2 hours and apply moxibustion with hygienic incense to the end of the needle.
Take a small glass fire pot (or bottle) with a caliber of 0.6 to 1 inch, make a dough with water and roll it into noodles and turn it at the mouth of the pot, then cast the fire method, cupping the fire pot on the four white points, and leave the pot for 20 to 30 minutes. Every other day, 10 times for a course of treatment.
Evaluation of treatment effect
A total of 572 cases were treated, 459 cases were cured, 73 cases were effective, 19 cases were effective, and 21 cases were ineffective, with a total effective rate of 96.3%.