D E C O M P R E S S I O N OF T H E F A C I A L N E R V E I N C A S E S OF H E M I F A C I A L S P A S M
K A R S T E N K E T T E L *
H e m i f a c i a l s p a s m is a well defined disease, consisting of tonic-clonic contractions of all the m u s c l e s innervated by a s i n g l e n e r v e : the facial nerve. The m u s c l e s most c o m m o n l y afflicted are those around the eye and mouth. H e m i f a c i a l spasm m a y be divided into two g r o u p s : primary and post-paralytic.
a ) Primary hemifacial spasm, by s o m e authors termed "cryptogenic", " i d i o p a t h i c " or "autonomous". In reviewing 1 0 6 cases Ehni and Wolt-m a n5
gave the f o l l o w i n g characteristics of this g r o u p : ( 1 ) the spasms are of an intermittent, twitching nature, ( 2 ) the e y e l i d s on the ipsilateral side are a l m o s t a l w a y s involved, ( 3 ) the s p a s m s are u s u a l l y unilateral and when bilateral they are not s y n c h r o n o u s or equal in extent or severity,
( 4 ) the s p a s m s m a y persist in s l e e p , ( 5 ) the patient does not feel any c o m p u l s i o n to make the movement, ( 6 ) the patient is u n a b l e to stop the movement by exercise of the will, ( 7 ) the patient cannot reproduce the movement v o l u n t a r i l y , ( 8 ) psychic upsets of any sort, fatigue and vo-luntary movements of the face, make the condition worse, ( 9 ) children do not have h e m i f a c i a l spasm and ( 1 0 ) the s p a s m s are limited to m u s c l e s innervated by the facial nerve.
It might be added that the contractions generally start in m. orbicula-ris oculi, and during weeks or months they are spreading to the neigh-bouring muscles and are intensified in strength and duration. I have, how-ever, seen two cases where violent s p a s m s started s u d d e n l y and affected all the facial muscles from the start, on the side afflicted. The s p a s m s may be a c c o m p a n i e d by vasomotor and secretory disturbances of the same side of the face. P a i n is an u n c o m m o n s y m p t o m .
b ) Postparalytic or " s y m p t o m a t i c " hemifacial spasm. T h e cause of the s y m p t o m a t i c hemifacial spasm m a y be intracranial lesions (tumors, aneurism, m e n i n g o e n c e p h a l i t i s , injuries) causing irritation of the facial nerve or nucleus, resulting in s p a s m 1 T
. A m o n g A l a j o u a n i n e and Thurel's
R e l a t ó r i o a p r e s e n t a d o a o X I X C o n g r e s s o I n t e r n a c i o n a l d e O t o - N e u r o - O f t a l m o ¬ l o g i a , r e u n i d o e m S ã o P a u l o em 11-17 d e j u n h o d e 1954, s u b o r d i n a d o a o 2º t e m a o f i c i a l : Fisiopatologia do nervo facial.
5 2 c a s e s , 4 were c a u s e d b y a c e r e b e l l o - p o n t i n e tumor M o s t of the
post-p a r a l y t i c h e m i f a c i a l s post-p a s m s , h o w e v e r , are due to B e l l ' s i s c h a e m i c f a c i a l
p a l s y .
In a v e r y t h o r o u g h p a p e r b y W i l l i a m s , L a m b e r t a n d W o l t m a n2 0
the
w h o l e p r o b l e m is s u r v e y e d . T h e y state that "the a v a i l a b l e e v i d e n c e
suggests that the h e m i f a c i a l s p a s m w h i c h f o l l o w s B e l l ' s p a l s y a n d the h e m i
-f a c i a l s p a s m c a l l e d " c r y p t o g e n i c " are c l i n i c a l l y i n d i s t i n g u i s h a b l e e x c e p t b y
h i s t o r y , b e c a u s e m u s c u l a r w e a k n e s s and contracture are e q u a l l y p r e v a l e n t
in b o t h . T h e e v i d e n c e a l s o i n d i c a t e s that the e t i o l o g y of e a c h c o n d i t i o n
m a y be the s a m e " .
P A T H O L O G Y
W i l l i a m s , L a m b e r t a n d W o l t m a n2 0
in t h e i r p a p e r s t a t e t h a t t w o h y p o t h e s i s h a v e been o f f e r e d a s t o t h e -cause of t h e p r i m a r y a s w e l l a s t h e p o s t p a r a l y t i c h e m i f a c i a l s p a s m : ( 1 ) t h e first s u g g e s t s t h a t h e m i f a c i a l s p a s m i s a c e n t r a l eff e c t d u e e i t h e r t o d e g e n e r a t i o n oeff c e l l s in t h e r o l a n d i c m o t o r c o r t e x or t o d e -g e n e r a t i o n of cells of t h e f a c i a l n u c l e u s in t h e m e d u l l a ; ( 2 ) t h e s e c o n d h y p o t h e s i s
is t h a t h e m i f a c i a l s p a s m is a d i s o r d e r of t h e l o w e r m o t o r neuron.
In r e v i e w i n g t h e e x p e r i m e n t a l w o r k p e r f o r m e d b y m a n y a u t h o r s t o e l u c i d a t e this q u e s t i o n , W i l l i a m s , L a m b e r t a n d W o l t m a n 2 0 c o n c l u d e t h a t t h e h y p o t h e s i s of the c e n t r a l o r i g i n of t h e s e s p a s m s is c o m p l e t e l y u n t e n a b l e . T h e f a c t s d e r i v e d f r o m t h e clinical a n d e x p e r i m e n t a l i n v e s t i g a t i o n s "make it s e e m h i g h l y p r o b a b l e t h a t t h e lesion c a u s i n g h e m i f a c i a l s p a s m l i e s s o m e w h e r e b e t w e e n t h e f a c i a l n u c l e u s and t h e s t y l o m a s t o i d f o r a m e n " .
A s a l r e a d y o u t l i n e d , t h e p r i m a r y ( c r y p t o g e n i c ) a n d t h e p o s t p a r a l y t i c h e m i -racial s p a s m a r e clinically i n d i s t i n g u i s h a b l e e x c e p t by history. A t p r e s e n t t h e r e is a g e n e r a l a g r e e m e n t t h a t Bell's p a l s y is d u e t o i s c h a e m i a n e a r t h e s t y l o m a s t o i d f o r a m e n 2 , 4 . 6 , 1 2 , 1 4 , 1 9 . In a d d i t i o n t o t h e a l t e r a t i o n s f o u n d in t h e f a c i a l n e r v e
( h a e m o r r h a g i c s t r e a k s in t h e sheath a n d a c o n s t r i c t i o n of t h e n e r v e a t t h e s t y l o -m a s t o i d f o r a -m e n w i t h o e d e -m a p r o x i -m a l t o this p o i n t ) I h a v e , in 2 0 of 108 c a s e s
( l a t e s t c h e c k - u p , 1 9 5 4 ) , f o u n d b o n y n e c r o s i s in the d i s t a l p a r t of t h e m a s t o i d cells, e s p e c i a l l y n e a r t h e s t y l o m a s t o i d f o r a m e n , n o u r i s h e d like t h e n e r v e b y t h e s t y l o m a s t o i d a r t e r y , f i n d i n g s w h i c h h a v e been c o n f i r m e d b y o t h e r S c a n d i n a v i a n s u r g e o n s 7
. 11
, i s a n d d r a w n t h e conclusion t h a t B e l l ' s p a l s y is a p a t h o g e n e t i c e n t i t y , t h e p r i m a r y a n d c e n t r a l f e a t u r e b e i n g a d i s o r d e r , a " d y s r e g u l a t i o n " of t h e c i r c u l a -tion, in m o s t c a s e s a f f e c t i n g only t h e n u t r i t i o n of t h e n e r v e a s t h e m o s t s u s c e p t i b l e t i s s u e , f r o m w h i c h an i s c h a e m i c p a r a l y s i s a r i s e s , b u t in o t h e r s a f f e c t i n g also t h e n u t r i t i o n of t h e f a c i a l canal a n d the m a s t o i d cells, c a u s i n g b o n y n e c r o s i s .
O P E R A T I V E F I N D I N G S IN H E M I F A C I A L S P A S M S
D e c o m p r e s s i o n of the facial nerve was p e r f o r m e d b y W i l l i a m s , Lam-bert and W o l t m a n2 0
o n 7 patients s u f f e r i n g f r o m h e m i f a c i a l s p a s m and o n e f r o m b l e p h a r o s p a s m , with the f o l l o w i n g f i n d i n g s : a ) in two cases the nerve and the nerve sheath were m a c r o s c ó p i c a ! l y n o r m a l ; b ) in one case a fibrous n o d u l e about 2 m m . across was f o u n d attached to the inner sheath at the s t y l o m a s t o i d f o r a m e n ; c ) in 5 cases the nerve sheath near the s t y l o m a s t o i d f o r a m e n was t o u g h and resistant to slitting.
M y o w n material consist of 1 0 c a s e s of h e m i f a c i a l s p a s m ( 7 p r i m a r y and 3 p o s t p a r a l y t i c , a l l w o m e n ) a n d o n e of b l e p h a r o s p a s m . T h e idea of d e c o m p r e s s i o n in these cases occurred to m e ( 1 9 4 3 ) because I h a d seen 3 cases of B e l l ' s p a l s y who h a d s p o n t a n e o u s l y m a d e a partial recovery marked b y contracture, w h i c h d i s a p p e a r e d in i m m e d i a t e c o n j u n c t i o n with the o p e r a t i o n . I thought that if the contracture w a s due to a cfonslant irritation of the facial nerve within the F a l l o p i a n canal (Grindstein's t h e o r y1 0
) w h i c h e o u î d be r e l i e v e d b y d e c o m p r e s s i o n , this m i g h t be well worth trying in cases of h e m i f a c i a l s p a s m ( f i g . 1 ) .
The p r o m p t results which f o l l o w e d m y first d e c o m p r e s s i o n s m a d e m e operate on 11 patients in quick s u c c e s s i o n . The therapeutic disappoint-ments were to f o l l o w later. All the patients have been submitted to a very thorough m e d i c a l , s e r o l o g i c a l , n e u r o l o g i c a l , o t o l o g i c a l , o p h t a l m o l o g i c a l and r a d i o l o g i c a l e x a m i n a t i o n e x p r e s s l y to e x c l u d e intracranial l e s i o n s .
between 3 and 9 years. T h e last patient was operated o n l y one month after onset, b e c a u s e the contractions were violent, and because m y results from d e c o m p r e s s i o n at that time seemed to be e x c e l l e n t .
The operative findings were as f o l l o w s : a ) in 3 cases the mastoid c e l l s and the nerve l o o k e d p e r f e c t l y n o r m a l ; I must however admit that not until I read years later ( 1 9 5 2 ) the paper by W i l l i a m s , Lambert and W o l t m a n w
, was m y attention e s p e c i a l l y drawn to alterations of the nerve s h e a t h ; b ) in o n e case a circumscribed n o d u l e l o o k i n g like a dilated vessel, 2-3 m m . across, was seen within the nerve sheath just p r o x i m a l to the s t y l o m a s t o i d f o r a m e n ; in more than 2 5 0 operations on the facial nerve according to the procedure of B a l l a n c e and D u e l3
, I have never seen anyth-ing s i m i l a r ; c ) in one case, operated one m o n t h after the onset, the nerve was distinctly o e d e m a t o u s , and b u l g e d through the slit in the nerve sheath, e x a c t l y as noted in m a n y cases of Bell's p a l s y ; d) in one case the nerve sheath was very tough and resistant to s l i t t i n g ; e ) in the last case p r o n o u n c e d alterations were encountered.
T h i s p a t i e n t , a 5 1 - v e a r - o l d w o m a n , had for 8 y e a r s s u f f e r e d from i n c r e a s i n g hemifacial s p a s m s r e s i s t a n t to all m e d i c a l t h e r a p y ; a p a r t f r o m this a t h o r o u g h e x a m i n a t i o n s h o w e d n o t h i n g a b n o r m a l ; t h e r e w a s no f a c i a l w e a k n e s s , she had n e v e r s u f f e r e d f r o m e a r t r o u b l e s , a n d t h e d r u m s a n d h e a r i n g w e r e p e r f e c t l y normal. T h e s u p e r f i c i a l m a s t o i d cells w e r e c o m p l e t e l y n o r m a l but the bone be-t w e e n be-the p o s be-t e r i o r o s s e o u s wall of be-the e x be-t e r n a l a u d i be-t o r y m e a be-t u s a n d be-the s i g m o i d sinus, as w e l l a s t h e m a s t o i d t i p , w a s c o m p l e t e l y n e c r o t i c ; the wall of the f a c i a l c a n a l w a s v e r y s o f t a n d w a s o p e n e d as f a r as the lateral s e m i c i r c u l a r canal in a f e w m i n u t e s ; t h e n e r v e w a s d i s t i n c t l y o e d e m a t o u s ; near the s t y l o m a s t o i d f o r a -m e n t h e -m a s t o i d cells c o n t a i n e d a y e l l o w t r a n s u d a t e or e x s u d a t e ; neither p u s , nor g r a n u l a t i o n t i s s u e w e r e f o u n d ; m i c r o s c o p y s h o w e d g r a n u l a r b o n y d e c a y and bony n e c r o s i s , while on direct e x a m i n a t i o n of the fluid no b a c t e r i a w e r e f o u n d . A facial w e a k n e s s f o l l o w e d the o p e r a t i o n b u t d i s a p p e a r e d soon, and for 10 m o n t h s t h e p a t i e n t w a s c o m p l e t e l y f r e e from h e m i f a c i a l s p a s m s a n d s y n k i n e s e s ; then they
recurred.
One y e a r a f t e r the first o p e r a t i o n a revision w a s p e r f o r m e d . T h e bony c a v i t y w a s normal and in it the facial n e r v e w a s l y i n g f r e e ; in its p r o x i m a l half, b e t w e e n the lateral s e m i c i r c u l a r canal and t h e s t y l o m a s t o i d f o r a m e n , it looked n o r m a l ; in the distal half, it l a y s u r r o u n d e d by c o n n e c t i v e t i s s u e f r o m which it w a s f r e e d . This t i m e no f a c i a l w e a k n e s s f o l l o w e d , but the h e m i f a c i a l s p a s m s w e r e n o t influenced by the n e u r o l y s i s . F i v e y e a r s l a t e r she w a s still s u f f e r i n g from s e v e r e hemifacial s p a s m .
Postparalytic hemifacial spasm ( 3 cases) — A l l the patients, w o m e n 3 2 , 4 0 and 5 7 years of age, had suffered from Bell's ischaemic p a l s y (for 8 months, 9 m o n t h s and 10 years, r e s p e c t i v e l y ) ; in the last two cases a contracture had d e v e l o p e d in addition to severe h e m i f a c i a l s p a s m .
h e m i f a c i a l spasm and a contracture, the superficial m a s t o i d c e l l s were large and c l e a r ; the c e l l s between the posterior w a l l of the auditory meatus
and the sinus, on the other h a n d , were s m a l l e r and soft, and the facial canal p r o p e r appeared so soft that the d e c o m p r e s s i o n was c o m p l e t e d in a few m i n u t e s ; in the part deep to the nerve a cavity larger than a hazel-nut was created after the e x c o c h l e a t i o n , and through this cavity the nerve has been running practically u n c o v e r e d ; the cavity passed d e e p l y toward the j u g u l a r f o r a m e n ; the nerve sheath was slit o p e n , and the nerve b u l g e d distinctly.
Blepharospasm, ( m a n 19 years o l d ) — N o t h i n g abnormal was found in the mastoid c e l l s or in the nerve.
To s u m up W i l l i a m s , Lambert and W o l t m a n ' s cases, the nerve and nerve sheath were normal in 2 cases, w h i l e in 6 p a t h o l o g i c a l alterations were found near the s t y l o m a s t o i d f o r a m e n . Concerning m y own cases, it is seen that the mastoid cells in 9 cases were n o r m a l , w h i l e in 2 cases they were the site of severe alterations as described above. The facial nerve was normal in 6 cases, w h i l e in 5 cases alterations of varying nature were encountered at or just above the s t y l o m a s t o i d foramen.
C O M M E N T S
The most interesting results of d e c o m p r e s s i o n in cases of h e m i f a c i a l s p a s m are ( a ) the p a t h o l o g i c a l alterations, and ( b ) the disappearance of associated m o v e m e n t s of the facial m u s c l e s .
Pathological findings — Three c l i n i c a l entities are known in w h i c h all the subjective and objective f i n d i n g s are strictly confined to the r e g i o n innervated b y the facial n e r v e : ( 1 ) B e l l ' s p a l s y ; ( 2 ) Melkersonn's
syn-drome, w h i c h consists of a peripheral facial palsy, exactly like Bell's i s c h a e m i c , but c o m b i n e d with a n g i o n e u r o t i c o e d e m a of the lips and cheek, a n d sometimes with a lingua p l i c a t a ; and ( 3 ) h e m i f a c i a l spasm.
In Bell's p a l s y and Melkersson's p a l s y the weakness is the essential feature, the postparalytic s p a s m a rare and secondary p h e n o m e n o n . Syn-kineses, more or less p r o n o u n c e d , are, however, a practically constant s y m p t o m . In hemifacial s p a s m contractions are the dominant s y m p t o m , weakness being slight or c o m p l e t e l y lacking. By d e c o m p r e s s i o n , however, I have found e x a m p l e s of e x a c t l y the s a m e p a t h o l o g i c a l alterations in the mastoid cells near the stylomastoid f o r a m e n and in the facial nerve.
hemi-facial s p a s m . In 5 6 cases the nerve was distinctly o e d e m a t o u s , in 3 ( l o n g standing p a l s i e s ) atrophic.
2 ) Melkersson s syndrome: In 10 cases the m a s t o i d cells were normal, in one a l i m i t e d area of b o n y necrosis was f o u n d near the s t y l o m a s t o i d f o r a m e n . T h e nerve in 3 cases looked n o r m a l , in 8 it was o e d e m a t o u s and b u l g e d distinctly after slitting of the sheath. The last case (described in detail p r e v i o u s l y ) was quite e x c e p t i o n a l :
In a p a t i e n t 3 0 y e a r s of a g e , s u f f e r i n g f r o m a c o m p l e t e p e r i p h e r a l p a l s y of 3 m o n t h s d u r a t i o n , d e c o m p r e s s i o n r e v e a l e d t h e f o l l o w i n g a l t e r a t i o n s : "The s u p e r
-ficial cells a r e l a r g e a n d g l o s s y . I n t h e d e p t h a r o u n d t h e a n t r u m and in the cells b e t w e e n t h e p o s t e r i o r w a l l of t h e a u d i t o r y m e a t u s and the s i n u s t h e bone is soft, i n c r e a s i n g l y so t o w a r d t h e p a r t a r o u n d the s t y l o m a s t o i d f o r a m e n . T h e e n t i r e f a c i a l c a n a l is c o m p l e t e l y n e c r o s e d in its d i s t a l half, a n d t h e r e m a i n i n g p a r t is o p e n e d . N e i t h e r knife nor s c i s s o r s w a s u s e d , b u t the n e r v e sheath is seen to be o p e n , a n d f r o m it a highly o e d e m a t o u s piece of the n e r v e b u l g e s out, being c o n i c a l l y p o i n t e d d o w n w a r d a n d of a g r a y i s h pink color. T h e p o i n t of the n e r v e , h o w e v e r , is of a much d a r k e r red color than the r e m a i n i n g part. T h e piece of t h e n e r v e p r o j e c t i n g from t h e o p e n i n g in t h e sheath is 7 mm. long. I t is r e s e c t e d a n d e x a m i n e d m i c r o s c o p i c a l l y . A n e r v e t r a n s p l a n t t a k e n f r o m t h e ilioi n g u ilioi n a l n e r v e iliois g r a f t e d " ( a n d t h e m o b ilioi l ilioi t y r e a p p e a r e d t e n m o n t h s l a t e r ) . M ilioi c r o s c o p y s h o w e d : "oedema of t h e n e r v e t r u n k , f i b r i n o u s e x s u d a t i o n , f r e s h h a e m o r -r h a g e a n d m a -r k e d d e g e n e -r a t i o n of a x i s - c y l i n d e -r s a n d m e d u l l a -r y s h e a t h s , a small vein c o n t a i n i n g o r g a n i z e d r e m n a n t s of a t h r o m b u s , a n d b e t w e e n n e r v e a n d its sheath an a c c u m u l a t i o n of fluid c o n s i s t i n g of o e d e m a and fibrin". T h e r e is n o t the s l i g h t e s t d o u b t t h a t these a l t e r a t i o n s are d u e to d i s t u r b a n c e of t h e b l o o d s u p p l y . N e i t h e r m i c r o or m a c r o s c o p i c s i g n s of i n f e c t i o n w e r e e n c o u n t e r e d .
3 ) Hemifacial spasm: A s described above, 2 cases were encountered in w h i c h p r o n o u n c e d or very p r o n o u n c e d alterations of the mastoid c e l l s were f o u n d . I n 3 cases the nerve was o e d e m a t o u s . Everything points to ischaemia b e i n g the cause of the a l t e r a t i o n ; in no case were signs of infection f o u n d .
T h u s B e l l ' s p a l s y , Melkersson's s y n d r o m e and h e m i f a c i a l s p a s m have c l i n i c a l as w e l l as p a t h o l o g i c a l features in c o m m o n , and are both p r o b a b l y due to vascular disorders near the s t y l o m a s t o i d f o r a m e n .
The disappearance of associated movements of the facial muscles — T h i s is considered by W i l l i a m s , Lambert a n d W o l t m a n 2 0
the most interest-ing result of d e c o m p r e s s i o n in h e m i f a c i a l s p a s m .
A s pointed out by W i l l i a m s , Lambert and W o l t m a n 2 0
In discussing the paper cited, L a t h r o p1 3
expressed his belief that it is injury to the f a c i a l nerve, which h a s resulted in m i n o r temporary de-pression of function, w h i c h affords the patient the relief f r o m the hemi-facial s p a s m that he obtains.
I am not disinclined to agree with Lathrop l õ
. The e x p l a n a t i o n w h y s p a s m a n d s y n k i n e s e s do not return i m m e d i a t e l y with return of function after the postoperative weakness f o l l o w i n g d e c o m p r e s s i o n , may be, as stated by W i l l i a m s , Lambert and W o l t m a n2 0
, that after all axon d i c h o t o m y is the e x p l a n a t i o n of associated m o v e m e n t s , and that i m p a i r e d nerve fibres are more v u l n e r a b l e to additional injury, so that if o n l y a f e w a x o n s were i n v o l v e d in this process these might be destroyed b y the trauma of surgery or at least be the last to recover.
T H E R A P Y
O n l y the treatment of those cases in which medical and neurological therapy had f a i l e d shall be discussed here.
Is d e c o m p r e s s i o n of the facial nerve the right operation for resistant and severe cases of hemifacial s p a s m ? W i l l i a m s , Lambert and W o l t m a n 2 0 state that the o p e r a t i o n of n e u r o l y s i s for h e m i f a c i a l spasm has proved s o m e w h a t d i s a p p o i n t i n g in that there is a tendency for recurrence of - the s p a s m after a time, although most patients report considerable relief from the procedure.
W i l l i a m s in a recent personal c o m m u n i c a t i o n to O ' D o n n e l l1 T
, advised him of the final results in 9 cases, all observed over two years. Five cases had had a short period of relief but the spasm then reappeared as severely as before the operation. T h i s gives three good results and one fair out of nine.
My results are c o m p l e t e l y in accordance with this statement. All the patients operated o n 8-10 years a g o have been re-examined 2-10 years after the operation. The number in parenthesis indicates the number of years after the operation when I saw the patient last.
A m o n g 7 cases of primary h e m i f a c i a l s p a s m , o n e patient h a d recovered c o m p l e t e l y ( 1 0 y e a r s ) ; 2 patients were o n l y troubled by faint contractions, and o n l y when they were in a nervous state of m i n d ( 8 ½ - 1 0 years) ; 4 patients were relieved of the spasms for l ^ - l year, the recurrence took place and the condition is as bad as before operation (3-5-10-10 y e a r s ) . The same a p p l i e s to the man with b l e p h a r o s p a s m ( 9 y e a r s ) . A m o n g the 3 cases of p o s t p a r a l y t i c spasm, 2 were o n l y troubled very little by con-tractions ( 2 - 1 0 y e a r s ) , but in one case the condition was as bad as before
S U M M A R Y
A m o n g 1 1 p a t i e n t s a c o m p l e t e c u r e w a s o b t a i n e d in o n e c a s e , a f a i r
r e s u l t i n 4 c a s e s , w h i l e i n 6 c a s e s t h e effect of t h e o p e r a t i o n h a s o n l y
b e e n t e m p o r a r y a n d f u l l r e c u r r e n c e h a s t a k e n p l a c e . E v e n if d e c o m p r e s
-s i o n h a -s t h u -s r e -s u l t e d in a few r e c o v e r i e -s a n d i m p r o v e m e n t -s , t h e r e -s u l t -s
in t h e m a j o r i t y of c a s e s h a v e b e e n d i s a p p o i n t i n g .
E v e r y t h i n g p o i n t s to h e m i f a c i a l s p a s m b e i n g d u e to a d i s o r d e r of
t h e l o w e r m o t o r n e u r o n . I n t r a c r a n i a l l e s i o n s in t h e v i c i n i t y of t h e f a c i a l
n e r v e a r e k n o w n to h a v e r e s u l t e d i n i r r i t a t i o n a n d s p a s m . It m a y b e
p e r f e c t l y t r u e t h a t t h e m a j o r i t y of c a s e s of h e m i f a c i a l s p a s m a r e d u e to
a l e s i o n , t h e n a t u r e of w h i c h m a y v a r y , in t h e F a l l o p i a n c a n a l n e a r t h e
s t y l o m a s t o i d f o r a m e n , n o t l e a s t t h e p o s t p a r a l y t i c f o l l o w i n g B e l l ' s p a l s y .
B u t t h e d i s a p p o i n t i n g r e s u l t s of d e c o m p r e s s i o n s e e m s to i n d i c a t e t h a t
a t t h e t i m e of o p e r a t i o n i r r e p a r a b l e d a m a g e to t h e n e r v e h a s in t h e m a j o r i t y
of c a s e s b e e n a l r e a d y d o n e . C o n s e q u e n t l y I g a v e u p d e c o m p r e s s i o n in
c a s e s of h e m i f a c i a l s p a s m s o m e y e a r s a g o .
G o o d r e s u l t s f r o m i n j e c t i o n s of a l c o h o l i n t o t h e n e r v e h a v e b e e n r e
-p o r t e d1 3
b u t I p r e f e r s e l e c t i v e s e c t i o n s of t h e b r a n c h e s to t h e m u s c l e s
i n v o l v e d a s d e s c r i b e d b y G e r m a n a n d G r e e n w o o d8
.
B I B L I O G R A P H Y
1 . A l a j o u a n i n e , T h . ; T h u r e l , R . — L e s s p a s m e s d e la f a c e e t l e u r t r a i t e m e n t . Paris Méd., 114:165, 1939.
2. Audibert, V.; Mattei, C; Paganelli, A. — La pa-r a l y s i e f a c i a l e p é pa-r i p h é pa-r i q u e d i t e " a f pa-r i g o pa-r e " e s t f o n c t i o n d ' u n e a t t e i n t e a pa-r t é pa-r i e l l e des vasa nervorum. Presse Méd., 44:1049, 1936.
3. Ballance, C; Duel, A. B. — T h e o p e r a t i v e t r e a t m e n t of f a c i a l p a l s y . A r c h . O t o l a r y n g . , 15:1-70 ( J a n u a r y ) 1932.
4. Cawthorne, T. — a) Peripheral facial paralysis: some aspects of its p a t h o l o g y . L a r y n g o s c o p e , 56:653, 1 9 4 6 ; b) T h e r ô l e of s u r g e r y in t h e i n v e s t i g a -tion and treatment of peripheral facial palsy. Lancet, pg. 1219 (June 21) 1952.
5. Ehni, G.; "Woltman, H. W. — Hemifacial spasm: review of one hundred and six cases. Arch. Neurol, a. Psychiat., 53:205-211 (March) 1945.
6. Findlay, J. P . — F a c i a l P a r a l y s e . A n g u s & R o b e r t s o n L t d . , 89 C a s t l e r e a g h S t . , S y d n e y ,
1950.
7. Flodgren, E. — Contributions to the surgery of facial palsy. Acta Oto¬ laryng., suppl. 74, pg. 188, 1948.
8. German, W. J. — Surgical treatment of spasmodic facial tic. Surgery, 11:912-914, 1942.
9. Greenwood Jr., J. — The surgical treatment of hemifacial spasm. J. Neurosurg., 3:506, 1946.
10. Grind¬ s t e i n , A . — Ü b e r C o n t r a c t u r e n d e s N . f a c i a l i s . Z e n t r a l b l a t t f. H a l s - , N a s e n - u .
Ohrenh., 8:299, 1926. 11. Hall, A. — Pathology of Bell's palsy. Arch. Otolaryng.,
54:475 (November) 1951. 12. Hilger, J. A. — The nature of Bell's palsy.
La-ryngoscope, 59:228-235 (March) 1949. 13. Jessen, H. — Oni hemispasmus facialis
og dens behandling. Ugeskr. f. Laeger, no. 42, pg. 1081, 1940. 14. Kettel, K. —
p g . 3 5 3 , 1953. 1 5 . L a t h r o p , F . D . — D i s c u s s i o n of p a p e r b y W i l l i a m s , L a m b e r t and Woltman20
.
16. Melkersson, E. — Hygiea, 90:737, 1928
17. O'Donnell, M. C. — Hemifacial spasm. Ann. Otol., Rhin. a. Laryngol., 62:969 (December) 1953.
18. Skoog, T. — Personal communication to the author.
19. Sullivan, J. A. — R e c e n t a d v a n c e s i n t h e s u r g i c a l t r e a t m e n t of f a c i a l p a r a l y s i s a n d B e l l ' s p a l s y .
Laryngoscope, 62:449 (May) 1952.
20. Williams, H. L.; Lambert, E. H.; Wolt-m a n , H . W . — T h e p r o b l e Wolt-m of s y n k i n e s i s a n d c o n t r a c t u r e in c a s e s of h e Wolt-m i f a c i a l spasm and Bell's palsy. Ann. Otol., Rhin. a. Laryng., 61:850, 1952.
21. Woltman, H . W . : W i l l i a m s , H . L . ; L a m b e r t , E . H . — A n a t t e m p t t o r e l i e v e h e m i f a c i a l
