OVERVIEW

What is facial spasm?

Facial spasm refers to a group of disorders caused by compression of the facial nerve, characterized by recurrent, paroxysmal, and uncontrollable twitching of facial muscles.

It mostly occurs on one side of the face, worsens with emotional excitement or tension, and in severe cases, may lead to difficulty opening the eyes, mouth deviation, and ear noise. Oral medications and botulinum toxin injections can control symptoms, while microvascular decompression surgery may achieve a cure, though recurrence remains possible.

SYMPTOMS

What are the types of facial spasm and what are their manifestations?

Facial spasm includes typical facial spasm and atypical facial spasm. Clinically, atypical facial spasm is less common, with the vast majority being typical facial spasm.

In typical facial spasm, muscle twitching often starts from the eyelid and gradually spreads downward, affecting the lower facial muscles such as the cheek expression muscles.

Atypical facial spasm, on the other hand, begins in the lower facial muscles and gradually progresses upward, eventually involving the eyelid and frontal muscle.

Can facial spasm occur on both sides of the face simultaneously?

Facial spasm mostly occurs on one side, but bilateral facial spasm is not uncommon in clinical practice.

CAUSES

What is the cause of hemifacial spasm?

Hemifacial spasm can be understood as being caused by compression of the facial nerve. The reasons for this compression vary. Some patients are related to factors such as intracranial tumors, facial neuritis, craniocerebral injury, or vascular compression, while others may not have a clearly identifiable cause.

Who is more likely to develop hemifacial spasm?

Hemifacial spasm is more common in middle-aged and elderly individuals, with women slightly more affected than men. However, there is a trend of younger onset ages.

Is hemifacial spasm hereditary?

Hemifacial spasm itself is not hereditary unless the underlying cause of the condition is hereditary.

DIAGNOSIS

What tests are needed for hemifacial spasm?

The diagnosis of hemifacial spasm mainly relies on characteristic clinical manifestations, so experienced doctors can often confirm the diagnosis through clinical observation.

For patients lacking characteristic clinical manifestations, auxiliary examinations are needed for clarification, including electrophysiological tests and imaging studies.

What electrophysiological tests can help diagnose hemifacial spasm?

Electrophysiological tests that can assist in diagnosing hemifacial spasm include electromyography (EMG) and abnormal muscle response (also known as lateral spread response) detection.

• In patients with hemifacial spasm, EMG can record high-frequency spontaneous electrical potentials (up to 150 times per second).

• Abnormal muscle response is a unique abnormal electromyographic reaction in hemifacial spasm. A positive abnormal muscle response supports the diagnosis of hemifacial spasm.

What imaging tests can help diagnose hemifacial spasm?

Imaging tests commonly used to assist in diagnosing hemifacial spasm include head CT and head MRI to identify intracranial lesions that may cause the condition. Additionally, three-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA) can help assess vascular distribution around the facial nerve and its compression.

What diseases can hemifacial spasm be easily confused with?

Hemifacial spasm needs to be differentiated from facial dystonia disorders such as blepharospasm, Meige syndrome, and masticatory muscle spasm, which requires evaluation by a specialist.

TREATMENT

Which department should I visit for hemifacial spasm?

You can consult the Neurology Department. If surgical treatment is required, you should visit the Neurosurgery Department.

What are the treatment options for hemifacial spasm?

• Medication:

Common medications for hemifacial spasm include carbamazepine, oxcarbazepine, and diazepam.

Medication is often used as adjuvant therapy in the early stages of the condition, for patients who cannot tolerate or refuse surgery, or for those whose symptoms persist after surgery. It can alleviate symptoms in some patients. Long-term use may be considered for patients with mild symptoms, significant drug efficacy, and no adverse reactions.

However, it should be noted that the maximum daily dose of carbamazepine for adults should not exceed 1200mg. Carbamazepine may cause adverse reactions such as liver/kidney damage, dizziness, drowsiness, leukopenia, and rashes. Discontinue use immediately if adverse reactions occur. Severe exfoliative dermatitis, which can be life-threatening, may also occur. Therefore, patients should be monitored for rashes during treatment, and regular blood tests should be conducted.

• Botulinum toxin injections:

This method is mainly suitable for patients who cannot tolerate surgery, refuse surgery, experience surgical failure or recurrence, or for whom medication is ineffective or causes allergies.

Over 90% of patients respond well to the initial botulinum toxin injection, with effects lasting an average of 3–6 months. However, efficacy diminishes over time and with repeated injections.

Note that the interval between treatments should be no less than 3 months to avoid antibody formation and reduced efficacy. If treatment fails or efficacy declines with repeated injections, other treatment options should be considered.

Botulinum toxin injections are relatively safe. Common side effects include transient dry eyes, exposure keratitis, tearing, photophobia, diplopia, ptosis, reduced blinking, incomplete eyelid closure, and varying degrees of facial paralysis, most of which resolve naturally within 3–8 weeks.

• Microvascular decompression (MVD) surgery:

Neither medication nor botulinum toxin injections can cure hemifacial spasm. Microvascular decompression surgery, pioneered and standardized by Jannetta, is the only method that can cure the condition. Due to its high success rate (over 90%) and relative safety, MVD has been widely adopted worldwide.

Which patients with hemifacial spasm are suitable for MVD surgery?

• Patients with no identifiable cause for hemifacial spasm, where CT or MRI scans reveal no clear abnormalities.
• Patients with severe symptoms that affect daily life and work, and who strongly desire surgery.
• Patients for whom medication or botulinum toxin treatment is ineffective, or who experience allergies or toxic side effects from medication.
• Patients with postoperative recurrence may undergo repeat surgery.
• Patients with no improvement after surgery, especially if inadequate decompression was the cause and abnormal muscle response tests are positive, may consider early repeat surgery.
• Patients under follow-up whose symptoms show no improvement or worsen may also consider repeat surgery.

Which patients with hemifacial spasm are unsuitable for MVD surgery?

• Patients unsuitable for craniotomy under general anesthesia.
• Patients with severe hematologic diseases or major organ dysfunction (heart, lungs, kidneys, or liver).
• Elderly patients should be evaluated carefully.

How is the efficacy of MVD surgery evaluated for hemifacial spasm?

The postoperative efficacy of MVD is classified into four levels:

• Complete recovery: Symptoms disappear entirely.
• Significant relief: Symptoms mostly disappear, occasionally recurring under stress or specific facial movements. The patient is satisfied. Both levels are considered "effective."
• Partial relief: Symptoms improve but remain frequent. The patient is dissatisfied.
• No effect: Symptoms remain unchanged or worsen.

When should a patient consider repeat MVD surgery for hemifacial spasm?

For patients with no effect or partial relief, abnormal muscle response tests should be repeated. If positive, early repeat surgery is recommended. If negative, follow-up or adjuvant therapy (medication or botulinum toxin injections) may be considered.

What are the potential risks of MVD surgery for hemifacial spasm?

Possible postoperative complications include:

• Cranial nerve dysfunction: Mainly facial paralysis, tinnitus, or hearing impairment. A few patients may experience facial numbness, hoarseness, difficulty swallowing, or diplopia. Over 90% of facial paralysis cases occur within one month post-surgery, possibly due to surgical factors or viral infections. Patients should stay warm post-surgery to reduce risk. If paralysis occurs, steroids, antivirals, and neurotrophic drugs may be administered.
• Cerebellar or brainstem injury: MVD has a 0.1% mortality rate, primarily due to cerebellar or brainstem infarction or hemorrhage.
• Cerebrospinal fluid leakage: May result from incomplete dural suturing, manifesting as clear fluid discharge from the nose or ears, potentially causing headaches.
• Low intracranial pressure syndrome: Caused by prolonged surgical exposure, excessive cerebrospinal fluid drainage, or reduced post-op secretion. Symptoms include headache, dizziness, nausea, non-projectile vomiting, low blood pressure, and rapid pulse, alleviated by lowering the head.
• Other complications: Infections, poor wound healing, balance issues, incision pain, distant hematomas, vertebral artery injury, etc. Some patients experience postoperative vertigo, usually resolving within 1–2 weeks, though rarely persisting beyond a month without affecting mobility.

Can hemifacial spasm be completely cured?

Medication and botulinum toxin injections cannot cure hemifacial spasm. MVD surgery removes vascular compression on the facial nerve, eliminating symptoms, though recurrence is possible.

Is recurrence of hemifacial spasm likely?

Most patients treated with medication or botulinum toxin injections experience recurrence. Those undergoing MVD surgery have a very low recurrence rate.

DIET & LIFESTYLE

What should patients with facial spasm pay attention to in daily life?

Avoid factors that may trigger or worsen symptoms, such as fatigue, tension, or agitation. Other than that, there are no special precautions—just maintain a healthy lifestyle.

• Do not smoke;
• Exercise regularly, avoid prolonged sitting, and prevent overweight or obesity. Aim for 3–5 exercise sessions per week, about 30 minutes each, combining aerobic and strength training at a moderate intensity without overexertion;
• Ensure sufficient sleep daily, whether going to bed early or late;
• Learn to manage stress and emotional tension.

What should patients with facial spasm pay attention to in their diet?

There are no specific dietary restrictions—just maintain a healthy, balanced diet.

• Use less salt, oil, and high-sodium seasonings when cooking, and limit intake of pickled vegetables and meats;
• Avoid relying solely on refined grains; replace some staple foods with whole grains, legumes, potatoes, or pumpkin;
• Balance meat and vegetables, prioritizing white meats like chicken, duck, or fish over fatty meats. Eggs and milk are important sources of protein and other nutrients;
• Vegetarians can increase intake of beans and bean products for protein;
• Eat more fruits and vegetables;
• Avoid alcohol as much as possible.

PREVENTION

Can facial spasm be prevented?

Most causes of facial spasm are difficult to avoid artificially, so it is hard to prevent facial spasm. Early treatment after diagnosis is the best approach.