Violent Facial Expressions : Causes, Symptoms, Diagnosis & Treatment

• General Characteristics
• Why Violent Mimicry Occurs
• Hemifacial Spasm
• Idiopathic Blepharospasm
• Secondary Blepharospasm
• Oral Hyperkinesis
• Other Neurological Causes
• Ophthalmic Diseases
• Mental Disorders
• Diagnostics
• Treatment
• Conservative Therapy
• Surgery

Violent facial expressions are contractions of certain muscles of the face that are not amenable to conscious control. It is more often caused by neurological pathologies: facial hemispasm, idiopathic blepharospasm, oromandibular dystonia, Huntington's chorea, multisystem atrophy, tics, tardive dyskinesia while taking antipsychotics. It is observed in some ophthalmic diseases and mental disorders. The cause is established on the basis of complaints, anamnesis, neurological examination data and additional diagnostic procedures. Treatment - botulinum therapy, muscle relaxants, neuroleptics, sometimes surgical interventions.

general characteristics

Violent facial expressions are involuntary movements of certain muscles or entire muscle groups. They are more common in neurological problems. May cover half of the face (hemispasm) or be symmetrical. In the second case, in the initial stages, there is a predominant involvement of the muscles of the eyelids or lower parts of the face. With progression, hyperkinesis often spreads to other muscle groups of the facial region, sometimes to the neck, shoulder girdle, and other areas. In ophthalmic diseases, the symptom has a reflex character, due to swelling and pain.

Why Violent Mimicry Occurs

Hemifacial spasm

It becomes a consequence of irritation of the central parts of the facial nerve. The defeat is one-sided. A typical paroxysm begins with repeated closing of the eyelid. Movements become more frequent, spread to the entire half of the face. With an atypical course, the buccal muscles contract first, then the muscles of the forehead, lips and periorbital region are involved in the process. The duration of the attack is 1-3 minutes. The number of episodes can reach 10 or more per day.

Facial hemispasm differs from other variants of violent mimic movements of neurological origin by the inability to consciously demonstrate the phenomenon, the absence of paradoxical kinesias and corrective gestures. The provocative factors of unusual facial expressions are:

• neurovascular conflict (proximity of a nerve and one of the cerebral arteries);
• aneurysms of vessels located in the region of the bridge and the cerebellum;
• benign and malignant neoplasia of the cerebellopontine angle;
• lacunar infarcts in the area of ​​passage of the facial nerve.

Idiopathic blepharospasm

It is considered a type of cranial muscular dystonia, develops in the second half of life. Symmetric. The main symptom of idiopathic blepharospasm is involuntary squinting of the eyes, which eventually turns into persistent spasms that persist for 3-5 minutes. Involuntary facial expressions also cover the lower part of the face and neck. Typical corrective gestures, stopping the attack when sucking sweets, smoking, expressive speech, strong emotions, drinking alcohol, closing the eyes.

Blepharospasm

Secondary blepharospasm

Occurs with organic cerebral pathologies. As with the idiopathic form, facial expressions become less pronounced when using corrective gestures, emotional arousal, and oral activity. May accompany the following diseases:

• Parkinson's disease. It is characterized by the presence of hypokinesia, rigidity, trembling and postural instability. Violent facial expressions are not an obligatory symptom, supplemented by hypomimia.
• Progressive supranuclear palsy. The disorder occurs 2-3 years after the appearance of the first signs of the disease, develops against the background of parkinsonian ataxia, stiff back muscles, ophthalmoplegia, pseudobulbar syndrome.
• Multisystem atrophy. Manifests at the age of 45-6 years. Violent movements may manifest as blepharospasm or facial hemispasm. Among other hyperkinesis, spastic torticollis, focal dystonia of the extremities are possible. The detailed clinical picture includes parkinsonian syndrome, cerebellar ataxia.
• Multiple sclerosis. Manifestations are polymorphic, there are paresis, cerebellar and pyramidal disorders, dysfunction of the pelvic organs. The involvement of the efferent pathways of the cerebellum is accompanied by the development of hyperkinesis of the limbs, sometimes extending to the face and body.

A list of other pathological conditions in which secondary blepharospasm may occur includes ischemic strokes in the thalamus and left frontal lobe, Arnold-Chiari malformation, and hepatolenticular degeneration. Sometimes the symptom is provoked by prolonged use of antiparkinsonian drugs and antidepressants.

Oral hyperkinesis

Violent facial expressions are found mainly in the mouth area, covering the lips, the lower jaw area, and the tongue. The most common variant is tardive dyskinesia, a type of neuroleptic syndrome that develops with long-term medication. Patients lick their lips, make chewing and sucking movements, smack their lips, stick out their tongue, and make faces.

With oromandibular dystonia, not only the muscles of the oral zone are involved in the process, but also the cheeks, chewing, and sometimes the cervical and respiratory muscles. Violent motor acts include clenching of the jaws, jaw movements from side to side, opening and closing of the mouth, curvature of the lips, involuntary smile, twitching of the cheeks. Patients actively use corrective gestures.

Other neurological causes

Along with the above diseases, violent facial expressions are observed in the following conditions:

• Tourette's syndrome, some isolated tics;
• chorea in the face with Huntington's disease, rheumatism (chorea minor), a number of hereditary pathologies;
• brain stem tumors.

Ophthalmic diseases

Violent movements of the eyelids in ophthalmic diseases are easy to differentiate from dystonia, due to a clear connection with symptoms from the organ of vision, the absence of corrective gestures and paradoxical kinesias. The causes of blepharospasm are:

• conjunctivitis;
• keratitis;
• trichiasis;
• papillomas of the eyelids;
• snow blindness;
• loiasis.

Mental disorders

Elements of involuntary facial expressions can be observed in schizophrenia. A proboscis smile indicates a functional lesion of the corticonuclear level, indicating probable intoxication with antipsychotics. A forced smile occurs with coldness and emotional impoverishment, is an imitation or is aimed at eliminating communication difficulties, is combined with hypomimia.

Briquet's syndrome is characterized by a pronounced variety of manifestations. One of the rare variants of the course are hyperkinesis, including violent facial expressions with a predominance of blepharospasm and the development of eyelid paralysis. Perhaps a combination with paresis and paralysis of the limbs, astasia-abasia, gait disturbances, seizures, and other movement disorders.

Diagnostics

Determining the cause of violent facial expressions in most cases is the responsibility of neurologists. Patients with eye involvement are examined by ophthalmologists. If you suspect a mental pathology, a psychiatric consultation is required. As part of the conversation with the patient, the specialist establishes when the symptom appeared, how it changed over time, what other manifestations it was accompanied by. The examination program may include such diagnostic manipulations as:

• Neurological examination. The doctor determines the affected area, evaluates the nature of facial expressions, the presence of corrective gestures, clarifies the possibility of control and conscious reproduction of hyperkinesis. Detects other neurological disorders: parkinsonism, paresis, cerebellar ataxia, etc.
• Neuroimaging. MRI of the brain is performed to determine the cause of hemifacial spasm (detection of vascular malformations, neoplasms, foci of demyelination), to detect signs of degenerative diseases. If a vascular nature of the pathology is suspected, cerebral MR angiography is performed.
• Functional research. During electromyography, a pathognomonic sign of facial hemispasm is determined - electrical stimulation of one branch of the nerve causes a contraction of the muscles innervated by other branches. With violent facial expressions, presumably of vascular origin, rheoencephalography is performed.
• Ophthalmological examination. Depending on the characteristics of the disease, it is possible to perform visometry, biomicroscopy, ophthalmoscopy, pachymetry, keratometry, fluorescein test, and other procedures. If an allergic etiology of the disease is suspected, a scarification, application or intradermal test is performed to establish the allergen, less often a conjunctival provoking test.

Schizophrenia is diagnosed when certain established criteria are met. Briquet's syndrome is detected on the basis of the medical history, complaints, and the results of an objective examination, indicating the polymorphism of clinical manifestations when they do not correspond to neurological and somatic pathologies.

Introduction of botulinum toxin

Treatment

Conservative therapy

Treatment tactics are chosen taking into account the etiology of violent facial expressions:

• Hemifascial spasm. In the initial stages, the introduction of botulinum toxin is effective. It is possible to use muscle relaxants and antiepileptic drugs, however, the effectiveness of drug therapy has not been sufficiently proven.
• Idiopathic blepharospasm. Patients are injected with botulinum neurotoxin. Apply benzodiazepines, anticholinergics, muscle relaxants, neuroleptics, sedatives.
• Oromandibular dystonia. Recommended anticonvulsants, centrally acting muscle relaxants, tranquilizers. Electrosleep, laser therapy, water procedures are prescribed as additional methods of treatment. Due to the risk of developing dysarthria and dysphagia, botulinum toxin injections are carried out only in severe cases.
• tardive dyskinesia. It is necessary to cancel or adjust the dosage of the antipsychotic. To reduce manifestations, beta-blockers, antioxidants, anticholinergics, and vitamins are used. The effectiveness of drug therapy has not been precisely determined. Sometimes botulinum therapy is performed.
• Ophthalmic pathologies. Preference is given to local funds. For allergies, corticosteroids and antihistamines are used. With bacterial inflammation, drops and ointments with antibiotics, immunomodulators are indicated. To prevent glaucoma, mydriatics are prescribed; to accelerate the epithelization of defects, regeneration stimulants are recommended.
• Mental disorders. Drug therapy includes antipsychotics (more often - atypical antipsychotics), benzodiazepines and mood stabilizers. If there is no improvement, insulin coma or electroconvulsive therapy may be required. After normalization of the condition, psychotherapy and social rehabilitation are carried out. With Briquet's syndrome, long-term work with a psychotherapist is shown, sometimes taking antidepressants.

Surgery

In diseases accompanied by violent facial expressions, the following surgical interventions are performed:

• Facial hemispasm: microvascular decompression for neurovascular conflicts, endovascular occlusion or clipping of the aneurysm neck, removal of cerebral neoplasms.
• Blepharospasm: eyelid surgery, intersection of the branches of the facial nerve.
• Orofacial dystonia: implantation of electrodes in the area of ​​the pale ball.