Definition: It is the name given to the involuntary, involuntary, spontaneous contractions of the muscles on one side of the eye and face. Facial twitches typically begin around the eye, then spread to the muscles around the mouth on the same side, and sometimes to the muscles of the neck region. The twitches are initially in the form of attacks of 1 minute or less. While the initial attacks of these twitches are very rare, they become more frequent throughout the day as the disease becomes chronic. While watching increases during fatigue, stress, anxiety, excitement, it decreases during rest and sleep.
History; Facial twitching was described for the first time in 1888, and in 1940s, it was defined that there were arterial pressures on the facial nerves in cadaver studies. In 1945, facial twitches were reported in patients with cerebellum tumors. In 1947, arterial pressure was first described in patients with facial twitching. Today, neuroimaging techniques show that many patients with facial twitches have arterial pressure on the facial nerve.
General features; It is reported that it is seen in 14-15 people per 100 000 women, 7-8 people among 100 000 men. This rate is less than in patients with trigeminal neuralgia (TN), and 1 facial twitching is observed in 5 TN patients. Although they are most commonly seen at the age of 40-60 years, it has been known to occur in about 40 per 100 000 people at the age of 70. Women are affected twice as often as men. It has been reported that it is more common in people of Asian origin, due to the narrower volume of the cerebellum of those living in this region. Although genetic transmission has been reported, these forms are not common. Familial transmission has been reported in 1-2% of all facial twitches.
Clinical complaints and findings; Facial twitches are a chronic disease, and patients talk about painless, repetitive, and temporary twitches in the muscles around the face and mouth. There are intermittent irregular contractions in the muscles on one side of the face, and these contractions begin in the muscles around the eyes on one side, and then they are seen in the muscles around the mouth and sometimes even in the neck muscles. These involuntary movements cannot be stopped by the patient, they increase especially during excitement, anxiety, speaking, chewing and effort, and can be observed in 80% of cases during sleep. Although these rhythmic involuntary contractions are very rare at first, they come in very frequent seizures throughout the day over the years.
Types of facial twitches:
1: Primary facial twitches
The general features of this group of facial twitches are that there is no facial nerve palsy on the same side, no other lesion other than arterial pressure, and that it has a chronic course. In this group of patients, it causes twitching by preventing the conduction in the nerve by creating pressure on the facial nerve from the arteries (AICA, PICA). According to Gardner in 1968, it is the theory of transmission block and defined as a temporary flow arrest in the nerve.
2: Secondary facial twitching is usually caused by other underlying diseases;
Head trauma
Brain tumors (corner tumors, Paget’s disease)
Cerebrovascular diseases (aneurysm, AVM)
Multiple sclerosis
Diagnosis:
1: A good anamnesis and neurological examination: The presence of facial muscle movements in facial twitches is sufficient for the diagnosis of this disease. It is important to get the patient to talk to reveal the twitches. The patient’s speech or excitement makes the twitches, which are the image of this disease, visible. Neurological examination is usually normal in primary facial twitches. On the other hand, in sochondrial twitches, it may cause neurological complaints and findings related to the compression of the cerebellum or other adjacent brain stem nerves.
2: Brain Magnetic Resonance (MR) technique, one of the imaging methods, shows the causes of both primary and secondary facial twitches. When using this test technique, it is important to research and examine the facial nerve in particular. Since the causes of this disease are often not revealed in the normal brain MRI examination technique, special MRI of the facial nerve should be performed.
3: EMG (electromyelography) technique, which is one of the physiological conduction studies of the facial nerve, is important for differential diagnosis.
Differential diagnosis:
1: Facial tic. Similar involuntary movements in other muscles of the body other than the facial muscles. The difference from facial tic hemifacial spasm is partial suppression of tic movements.
2: Blepharospasm. It is bilateral. It is distinguished from hemifacial spasm by the involvement of symmetrical and synchronous eye muscles.
3: Oromandibular dystonia. There are repetitive and continuous contractions in the lower face, jaw, tongue, throat and mouth muscles, and the eye muscles are not involved.
4: Facial myokymia. It is continuous in the facial muscles. They are involuntary contractions similar to waves.
5: Tardive dysnesia. are stereotypical movements of the face, neck and arms. Rotation and facial wrinkling movements are typical.
6: Focal epileptic seizures. Focal epilepsy affecting one half of the face is mixed with facial twitches. EEG is important.
7: Psychogenic. The most important feature is that they are not seen at night while sleeping.
Treatment:
1: Medical treatment
2: Surgical treatment
Medical treatment. drugs used here; The purpose of carbomezapine, anticholinergics, baclofen, haloperidol, gabapentin, and other drugs is sedation. Perhaps these drugs can only be considered in mild cases and in patients who cannot be treated with surgical techniques. Apart from this, it should not be considered as a treatment option for facial twitches. The effect of this treatment is limited. Botulinium toxin injection: It causes loss of neuronal activity in the target organ by inhibiting the acetylcholine synapse. It was used for the first time in 1985 in facial twitches, the success rate reaches 75-90% according to different reports, the duration of action is limited to a few months, and it must be repeated. It has side effects such as dry eyes, paralysis of the eyelids and facial muscles, double vision, excessive tear secretion. The most common side effect is drooping of the eyelid at a rate of 20%, and the most important disadvantages of this treatment are its high cost and the need for repeated injections.
Surgical treatment: This treatment option is the gold standard method in this disease, microvascular decompression (MVD). Two criteria are important for applying this treatment option.
1. When repeated botox injections fail
2.MVD should not be administered as the first treatment option.
First of all, the correct analysis of the diagnosis of facial twitches and other diseases in the differential diagnosis is very important for the success of the treatment. Thin-section cerebellum MRI examination of the facial nerve is very important in its diagnosis. If there is a primary type (arterial compression) facial twitching, surgical success is over 70-90% if the MVD surgical technique is performed in experienced hands and in centers. In cases of failure, first of all, it is the cases that do not correctly define the cause of facial twitching. While the surgical mortality is 0% in experienced hands in MVD surgeries, side effects such as permanent or temporary facial paralysis are seen at a rate of 6-7%. This ratio is closely related to the imperial experience.
