The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Platysma Synkinesis in Facial Palsy and Botulinum Toxin Type A Anna Dall’Angelo, MD; Silvia Mandrini, MD; Vittorio Sala, MD; Chiara Pavese, MD; Ettore Carlisi, MD; Mario Comelli, MS; Elena D. Toffola, MD Objectives/Hypothesis: Facial synkinesis is a well-known disabling occurrence following severe facial palsy. Platysma muscle, innervated by the facial nerve, can be involved in synkinesis as well, but thus far has been little investigated. The aim of our study is to evaluate the presence of platysma synkinesis and its clinical evolution after onabotulinumtoxinA (BoNT-A) (BotoxV; Allergan Pharmaceuticals, Irvine, CA) injections. Study Design: Retrospective study. Methods: Sixty-nine patients were treated for synkinesis following facial palsy. Of those, 45 were affected by platysma synkinesis and thus were injected in the platysma muscle. The total number of sessions was 124. The Sunnybrook Facial Grading System (SFGS) and a specific platysmal evaluation for the presence and severity of synkinesis and local symptoms were performed before and after BoNT-A treatments. Results: Platysma synkinesis was present in 65.2% of the sample and was associated with subjective complaints in 85.5% of the cases. The facial expressions more related to platysma synkinesis were snarl, followed by open-mouth smile and lip pucker. After each BoNT-A treatment, there was an improvement in facial symmetry at rest and during voluntary movements, a global reduction of synkinesis, and a specific reduction of synkinesis and symptoms related to the platysma. No adverse reaction to BoNT-A occurred. Conclusion: Platysma involvement represents a recurring and symptomatic problem in patients affected by synkinetic recovery following facial palsy. After BoNT-A injections, there is a reduction in platysma synkinesis and related symptoms. Key Words: Facial palsy, platysma, synkinesis, onabotulinumtoxinA, BotoxV. Level of Evidence: 4. Laryngoscope, 124:2513–2517, 2014 R
R
INTRODUCTION Severe facial palsy with muscle denervation can lead to incomplete recovery with impairment in facial expressivity and functionality.1–3 Regeneration processes of facial nerve fibers can lead to aberrant nervous branches sprouting; this flawed reinnervation causes static and dynamic asymmetry of the face and synkinesis, that is, synchronous and involuntary movements during voluntary facial movements.4–8 Common facial synkinesis involves mouth movements and is triggered by blinking or eye narrowing while smiling or lip puckering.1,9,10 Many authors have investigated asymmetry and synkinesis following facial palsy, along with their possible solutions.1,8,11–14 Currently, treatment with botulinum toxin type A (BoNT-A) (BotoxV; Allergan Pharmaceuticals, Irvine, CA) is the gold standard.15–18 Although platysma muscle, innervated by the facial nerve, also is involved in facial palsy, it has been little
considered—even by the most widely used grading systems for the evaluation of facial palsy.19 Platysma synkinesis in facial palsy is reported in some articles without specific quantitative assessments.12,13,20–22 There are several studies in the literature about the esthetical use of BoNT-A platysma injections23–28; however, it seems that only one study considered the effect of botulinum toxin treatment on platysma synkinesis.12 Henstrom reported platysmectomy as an effective approach in treating neck synkinesis associated with chronic hypertonic activity of the platysma muscle.13 The aim of our study is to evaluate the presence of platysma synkinesis following facial palsy and to evaluate its clinical evolution after treatment with BoNT-A.
R
From the Physical Medicine and Rehabilitation (A.D’A., S.M., V.S., the Department of Brain and Behaviour Science (M.C.), University of Pavia; and the Rehabilitation Unit, Fondazione IRCCS Policlinico San Matteo (E.C., E.D.T.), Pavia, Italy. Editor’s Note: This Manuscript was accepted for publication April 21, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Professor Elena Dalla Toffola, Rehabilitation Unit, Fondazione IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100 Pavia, Italy. E-mail: [email protected] C.P., E.D.T.);
DOI: 10.1002/lary.24732
Laryngoscope 124: November 2014
MATERIALS AND METHODS Patients Enrollment Between January 2009 and March 2013, 69 patients with synkinesis following facial palsy were treated with BoNT-A in the outpatient clinic of the Physical Medicine and Rehabilitation Unit, San Matteo Care and Research Institute, Pavia, Italy. For this study, we considered all consecutive patients treated with BoNT-A injections for platysma synkinesis (45 patients, 35 females; 124 sessions).
Clinical Evaluation Clinical-functional evaluation was performed both before the treatment (on the same day) and after a median of 18 days (interquartile ranges [IQR] 14–23).
Dall’Angelo et al.: Platysma Synkinesis and Botulinum Toxin
2513
TABLE I. Number of Patients, Injection Sites, and BoNT-A (BotoxV) International Units per Session. R
Session Number
Number of Patients Per Session
Median (IQR) Number of Sites
Mean 6 SD BoNT-A Dose (IU)
All procedures complied with the standards established by the Declaration of Helsinki, and all patients signed an informed consent form stipulated according to the prescriptions of the Institutional Review Board of the San Matteo Care and Research Institute, Pavia, Italy.
1
45
2 (2–3)
6.8 6 3.6
Statistics
2
28
3 (2–3.5)
7.8 6 3.5
3 4
20 14
3 (2–4) 4 (2–5)
8.2 6 3.1 9.9 6 4.8
Each infiltration session was considered as a single case. Categorical variables are expressed by numbers and percentages, whereas quantitative variables are represented by means and standard deviations or medians and IQR, as appropriate. The comparison between preinfiltration and postinfiltration treatment was performed with the McNemar test for dichotomous variables and the Wilcoxon test for nonparametric paired samples. Two-sided P values < 0.05 were considered as statistically significant. MedCalc 11.2.1 for Windows (MedCalc Software bvba, Ostend, Belgium) was used for statistical analysis.
5
8
3.5 (3–4.3)
9.9 6 3.3
6 7
5 3
4 (3–4) 4 (3.5–5.5)
10.7 6 1.2 12 6 4.4
8
1
4
10 R V
BoNT-A 5 botulinum toxin type A (Botox ; Allergan Pharmaceuticals, Irvine, CA); IQR 5 interquartile range; IU 5 international units; SD 5 standard deviation.
At each assessment, a global facial function evaluation was performed with the Italian version of the Sunnybrook Facial Grading System (SFGS).29 The scale is comprised of three specific sections with partial scores (resting symmetry: from 220 to 0; symmetry of voluntary movement: 20 to 100; synkinesis associated with five specified voluntary movements: 215 to 0) and a composite score ranging from 0 (5 complete palsy) to 100 (5 normal facial function).29,30 The SFGS encompasses the functions of the facial muscles involved in five standard expressions: forehead wrinkle (frontalis), gentle eye closure (orbicularis oculi), open-mouth smile (zygomaticus/risorius), snarl (levator labii superioris alaeque nasi), and lip pucker (orbicularis oris superior/orbicularis oris inferior). Furthermore, we carried out a specific evaluation structured as follows: Symmetry at rest: The presence or absence of asymmetric platysmal “bands” or “cords” was reported; Platysma synkinesis during voluntary movement: Platysma synkinesis was reported and scored according to the degree of involuntary muscle contraction (0 5 none; 1 5 slight; 2 5 obvious but not disfiguring; 3 5 disfiguring synkinesis) associated with the five standard expressions of the SFGS (forehead wrinkle; gentle eye closure; snarl; open-mouth smile; lip pucker). Whenever a patient presented more than one synkinesis, we considered the most serious one; Subjective evaluation: No complaint, aesthetic loss, cramps/ muscle tightness, pain, or combined complaints were reported.
Procedure We administered BoNT-A, 100 international units (IU) diluted in 4 mL of 0.9% saline. Injections were administered subcutaneously in platysmal bands with a 25-gauge, 16-mm needle. We started the treatment with an initial dose of BoNT-A of approximately 2.5 IU per injection site, which is similar to the dose used in other studies.12,15 In the following sessions, we gradually adjusted the BoNT-A dose and the number of injection sites according to the resulting therapeutic response. Exclusion criteria were ongoing anticoagulant therapy, pregnancy, breast-feeding, active infection in the area to be treated, neuromuscular junction disorders, or known hypersensitivity to any BoNT-A constituent. The occurrence of side effects was also investigated at follow-up evaluations.
Laryngoscope 124: November 2014
2514
RESULTS Population Forty-five patients (mean age 44 6 15 years; 35 females) were treated for facial and platysma synkinesis for a total of 124 sessions. Of these, 28 patients underwent more than one BoNT-A treatment (mean number of sessions per person 5 2, 8; range 1–8). The number of sessions per patient depended on when each patient began the BoNT-A treatment; those who previously underwent the first infiltration were more likely to participate in a greater number of sessions. Moreover, the frequency of treatments was related to the personal needs and determinations of the single patients. Reinjection only took place after the effect of the previous session had already vanished. The population data is as follows: The aetiology of palsy was Bell’s palsy in 18 patients (40%), Ramsay-Hunt in 7 (15.6%), post-neuroma surgery in 14 (31.1%), post-meningioma surgery in 2 (4.4%), posttraumatic in 4 (8.9%). None of the patients underwent dynamic facial nerve reanimation; Palsy affected the right side of the face of 25 patients (55.6%); The median time lapse between the facial palsy onset and the first infiltration with BoNT-A was 18 months (IQR 13.4–29.3); At each session, the median total dose of BoNT-A was 17.7 IU (7.5–33.5); the median number of platysmal sites was three sites (2–7); and the median platysmal BoNT-A dose was 8.2 IU (5–17). In Table I, for each infiltration session we report the number of patients, the median number and IQR of injection sites, and the average number and standard deviation of BoNT-A IU injected; The median time of BoNT-A action, reported by patients, was 4 months (IQR 3–4).
No adverse effects were reported during the follow-up assessments, except for transient bruising in three patients.
Clinical Evaluation Sunnybrook Facial Grading System. After BoNT-A treatment, all patients presented an improvement of SFGS composite score, with an amelioration of the symmetry at rest and during voluntary movement and a reduction of synkinesis, as shown in Table II. Dall’Angelo et al.: Platysma Synkinesis and Botulinum Toxin
TABLE II. Sunnybrook Facial Grading System Scores Before and After BoNT-A (BotoxV) Treatment. R
Symmetry Of Voluntary Movement
Resting Symmetry
Median IQR P
Before
After
25
25
Before
210 to 0 25 to 0
Rhinological and Otological Society, Inc.
Platysma Synkinesis in Facial Palsy and Botulinum Toxin Type A Anna Dall’Angelo, MD; Silvia Mandrini, MD; Vittorio Sala, MD; Chiara Pavese, MD; Ettore Carlisi, MD; Mario Comelli, MS; Elena D. Toffola, MD Objectives/Hypothesis: Facial synkinesis is a well-known disabling occurrence following severe facial palsy. Platysma muscle, innervated by the facial nerve, can be involved in synkinesis as well, but thus far has been little investigated. The aim of our study is to evaluate the presence of platysma synkinesis and its clinical evolution after onabotulinumtoxinA (BoNT-A) (BotoxV; Allergan Pharmaceuticals, Irvine, CA) injections. Study Design: Retrospective study. Methods: Sixty-nine patients were treated for synkinesis following facial palsy. Of those, 45 were affected by platysma synkinesis and thus were injected in the platysma muscle. The total number of sessions was 124. The Sunnybrook Facial Grading System (SFGS) and a specific platysmal evaluation for the presence and severity of synkinesis and local symptoms were performed before and after BoNT-A treatments. Results: Platysma synkinesis was present in 65.2% of the sample and was associated with subjective complaints in 85.5% of the cases. The facial expressions more related to platysma synkinesis were snarl, followed by open-mouth smile and lip pucker. After each BoNT-A treatment, there was an improvement in facial symmetry at rest and during voluntary movements, a global reduction of synkinesis, and a specific reduction of synkinesis and symptoms related to the platysma. No adverse reaction to BoNT-A occurred. Conclusion: Platysma involvement represents a recurring and symptomatic problem in patients affected by synkinetic recovery following facial palsy. After BoNT-A injections, there is a reduction in platysma synkinesis and related symptoms. Key Words: Facial palsy, platysma, synkinesis, onabotulinumtoxinA, BotoxV. Level of Evidence: 4. Laryngoscope, 124:2513–2517, 2014 R
R
INTRODUCTION Severe facial palsy with muscle denervation can lead to incomplete recovery with impairment in facial expressivity and functionality.1–3 Regeneration processes of facial nerve fibers can lead to aberrant nervous branches sprouting; this flawed reinnervation causes static and dynamic asymmetry of the face and synkinesis, that is, synchronous and involuntary movements during voluntary facial movements.4–8 Common facial synkinesis involves mouth movements and is triggered by blinking or eye narrowing while smiling or lip puckering.1,9,10 Many authors have investigated asymmetry and synkinesis following facial palsy, along with their possible solutions.1,8,11–14 Currently, treatment with botulinum toxin type A (BoNT-A) (BotoxV; Allergan Pharmaceuticals, Irvine, CA) is the gold standard.15–18 Although platysma muscle, innervated by the facial nerve, also is involved in facial palsy, it has been little
considered—even by the most widely used grading systems for the evaluation of facial palsy.19 Platysma synkinesis in facial palsy is reported in some articles without specific quantitative assessments.12,13,20–22 There are several studies in the literature about the esthetical use of BoNT-A platysma injections23–28; however, it seems that only one study considered the effect of botulinum toxin treatment on platysma synkinesis.12 Henstrom reported platysmectomy as an effective approach in treating neck synkinesis associated with chronic hypertonic activity of the platysma muscle.13 The aim of our study is to evaluate the presence of platysma synkinesis following facial palsy and to evaluate its clinical evolution after treatment with BoNT-A.
R
From the Physical Medicine and Rehabilitation (A.D’A., S.M., V.S., the Department of Brain and Behaviour Science (M.C.), University of Pavia; and the Rehabilitation Unit, Fondazione IRCCS Policlinico San Matteo (E.C., E.D.T.), Pavia, Italy. Editor’s Note: This Manuscript was accepted for publication April 21, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Professor Elena Dalla Toffola, Rehabilitation Unit, Fondazione IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100 Pavia, Italy. E-mail: [email protected] C.P., E.D.T.);
DOI: 10.1002/lary.24732
Laryngoscope 124: November 2014
MATERIALS AND METHODS Patients Enrollment Between January 2009 and March 2013, 69 patients with synkinesis following facial palsy were treated with BoNT-A in the outpatient clinic of the Physical Medicine and Rehabilitation Unit, San Matteo Care and Research Institute, Pavia, Italy. For this study, we considered all consecutive patients treated with BoNT-A injections for platysma synkinesis (45 patients, 35 females; 124 sessions).
Clinical Evaluation Clinical-functional evaluation was performed both before the treatment (on the same day) and after a median of 18 days (interquartile ranges [IQR] 14–23).
Dall’Angelo et al.: Platysma Synkinesis and Botulinum Toxin
2513
TABLE I. Number of Patients, Injection Sites, and BoNT-A (BotoxV) International Units per Session. R
Session Number
Number of Patients Per Session
Median (IQR) Number of Sites
Mean 6 SD BoNT-A Dose (IU)
All procedures complied with the standards established by the Declaration of Helsinki, and all patients signed an informed consent form stipulated according to the prescriptions of the Institutional Review Board of the San Matteo Care and Research Institute, Pavia, Italy.
1
45
2 (2–3)
6.8 6 3.6
Statistics
2
28
3 (2–3.5)
7.8 6 3.5
3 4
20 14
3 (2–4) 4 (2–5)
8.2 6 3.1 9.9 6 4.8
Each infiltration session was considered as a single case. Categorical variables are expressed by numbers and percentages, whereas quantitative variables are represented by means and standard deviations or medians and IQR, as appropriate. The comparison between preinfiltration and postinfiltration treatment was performed with the McNemar test for dichotomous variables and the Wilcoxon test for nonparametric paired samples. Two-sided P values < 0.05 were considered as statistically significant. MedCalc 11.2.1 for Windows (MedCalc Software bvba, Ostend, Belgium) was used for statistical analysis.
5
8
3.5 (3–4.3)
9.9 6 3.3
6 7
5 3
4 (3–4) 4 (3.5–5.5)
10.7 6 1.2 12 6 4.4
8
1
4
10 R V
BoNT-A 5 botulinum toxin type A (Botox ; Allergan Pharmaceuticals, Irvine, CA); IQR 5 interquartile range; IU 5 international units; SD 5 standard deviation.
At each assessment, a global facial function evaluation was performed with the Italian version of the Sunnybrook Facial Grading System (SFGS).29 The scale is comprised of three specific sections with partial scores (resting symmetry: from 220 to 0; symmetry of voluntary movement: 20 to 100; synkinesis associated with five specified voluntary movements: 215 to 0) and a composite score ranging from 0 (5 complete palsy) to 100 (5 normal facial function).29,30 The SFGS encompasses the functions of the facial muscles involved in five standard expressions: forehead wrinkle (frontalis), gentle eye closure (orbicularis oculi), open-mouth smile (zygomaticus/risorius), snarl (levator labii superioris alaeque nasi), and lip pucker (orbicularis oris superior/orbicularis oris inferior). Furthermore, we carried out a specific evaluation structured as follows: Symmetry at rest: The presence or absence of asymmetric platysmal “bands” or “cords” was reported; Platysma synkinesis during voluntary movement: Platysma synkinesis was reported and scored according to the degree of involuntary muscle contraction (0 5 none; 1 5 slight; 2 5 obvious but not disfiguring; 3 5 disfiguring synkinesis) associated with the five standard expressions of the SFGS (forehead wrinkle; gentle eye closure; snarl; open-mouth smile; lip pucker). Whenever a patient presented more than one synkinesis, we considered the most serious one; Subjective evaluation: No complaint, aesthetic loss, cramps/ muscle tightness, pain, or combined complaints were reported.
Procedure We administered BoNT-A, 100 international units (IU) diluted in 4 mL of 0.9% saline. Injections were administered subcutaneously in platysmal bands with a 25-gauge, 16-mm needle. We started the treatment with an initial dose of BoNT-A of approximately 2.5 IU per injection site, which is similar to the dose used in other studies.12,15 In the following sessions, we gradually adjusted the BoNT-A dose and the number of injection sites according to the resulting therapeutic response. Exclusion criteria were ongoing anticoagulant therapy, pregnancy, breast-feeding, active infection in the area to be treated, neuromuscular junction disorders, or known hypersensitivity to any BoNT-A constituent. The occurrence of side effects was also investigated at follow-up evaluations.
Laryngoscope 124: November 2014
2514
RESULTS Population Forty-five patients (mean age 44 6 15 years; 35 females) were treated for facial and platysma synkinesis for a total of 124 sessions. Of these, 28 patients underwent more than one BoNT-A treatment (mean number of sessions per person 5 2, 8; range 1–8). The number of sessions per patient depended on when each patient began the BoNT-A treatment; those who previously underwent the first infiltration were more likely to participate in a greater number of sessions. Moreover, the frequency of treatments was related to the personal needs and determinations of the single patients. Reinjection only took place after the effect of the previous session had already vanished. The population data is as follows: The aetiology of palsy was Bell’s palsy in 18 patients (40%), Ramsay-Hunt in 7 (15.6%), post-neuroma surgery in 14 (31.1%), post-meningioma surgery in 2 (4.4%), posttraumatic in 4 (8.9%). None of the patients underwent dynamic facial nerve reanimation; Palsy affected the right side of the face of 25 patients (55.6%); The median time lapse between the facial palsy onset and the first infiltration with BoNT-A was 18 months (IQR 13.4–29.3); At each session, the median total dose of BoNT-A was 17.7 IU (7.5–33.5); the median number of platysmal sites was three sites (2–7); and the median platysmal BoNT-A dose was 8.2 IU (5–17). In Table I, for each infiltration session we report the number of patients, the median number and IQR of injection sites, and the average number and standard deviation of BoNT-A IU injected; The median time of BoNT-A action, reported by patients, was 4 months (IQR 3–4).
No adverse effects were reported during the follow-up assessments, except for transient bruising in three patients.
Clinical Evaluation Sunnybrook Facial Grading System. After BoNT-A treatment, all patients presented an improvement of SFGS composite score, with an amelioration of the symmetry at rest and during voluntary movement and a reduction of synkinesis, as shown in Table II. Dall’Angelo et al.: Platysma Synkinesis and Botulinum Toxin
TABLE II. Sunnybrook Facial Grading System Scores Before and After BoNT-A (BotoxV) Treatment. R
Symmetry Of Voluntary Movement
Resting Symmetry
Median IQR P
Before
After
25
25
Before
210 to 0 25 to 0
