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Common Complaints

Synkinesis and Facial Spasms

Synkinesis and facial spasms are hyperkinetic facial syndromes, and both involve involuntary muscle contraction.

Synkinesis refers to the phenomenon whereby deliberate movement of one segment of the face results in movement in another segment of the face. Classic examples of this are when intended eye closure results in a turning up of the corner of the mouth, or when a spontaneous smile, or chewing action, results in involuntary eye closure. This occurs following facial nerve insult and recovery, when regenerating fibers are misdirected, ultimately reaching target muscles for which they were not intended.

Facial Spasms refer to involuntary, intermittent or persistent contractions of the facial musculature. It can involve selected muscles (orbicularis oculi in essential blepharospasm), or the entire hemiface (hemifacial spasm).


Tearing is a very common complaint following facial paralysis. It can be caused by many different things, including overproduction of tears by the lacrimal gland, poor drainage of the tearing system through the nasolacrimal duct into the nose, and corneal irritation from overexposure. Each of these causes can be managed, but the approaches to each of the problems is different. Therefore, it is important to understand the etiology of the tearing, so that the root cause can be addressed. For overproduction of tears at the level of the lacrimal gland, a small injection of botulinum toxin can dramatically improve this. This is also extremely effective in stopping the tearing associated with eating. This is known as crocodile tears, or Bogorad's syndrome. Tearing caused by problems with nasolacrimal drainage can be addressed by placing a stent into the nasal lacrimal system, called dacrocystorhinostomy. Problems with corneal exposure can be addressed through eyelid weight procedures, and sometimes by lower lid procedures designed to pull the lower lid back up against the eyeball.

Dry Eye

While many patients experience excess tearing after facial paralysis, some patients experience severe eye dryness. This is usually related to an underproduction of tears by the lacrimal gland, because fibers that trigger tear production can be disrupted or misrouted after skull base surgery with facial nerve manipulation. Therapy for this involves artificial tears, meticulous lubrication, usually with ointments that don't cause excessive visual blurriness, and occasionally, surgical intervention. Surgery involves placing small plugs into the tear drainage system, so that any tears that are produced are not immediately drained away. This permits the moisture to stay on the cornea for a longer period, thus alleviating the dry eye sensation.

Facial Pain and Tightness

Facial pain and tightness are extremely common following facial paralysis, particularly after Bell's palsy, Lyme disease, Ramsay Hunt syndrome, and the extirpation of skull base tumors. These can be managed with aggressive physical therapy maneuvers, with local massage, injections, and occasionally systemic medications. Rarely, it is necessary for us to involve a specialized Facial Pain Center in fully addressing the facial pain syndrome. Usually, however, simple office maneuvers here in the Facial Nerve Center can completely alleviate these symptoms.


Many patients experience drooling or loss of food from one corner of the mouth following facial paralysis. This can sometimes occur on the paralyzed side, and sometimes on the opposite side, based upon the imbalance of the position of the lower lip. There are many maneuvers that can address drooling and oral incompetence, ranging from physical therapy and soft tissue techniques, all the way through to surgical maneuvers to adjust the corner of the mouth if it sits too low or too high. Normally, it is a combination approach employing physical therapy, medical therapy, and surgery that fully addresses the problem.

Pronunciation Difficulties

Some patients complain of difficulty pronouncing the plosives, letters like "P" and "B". This occurs because they are not able to purse the upper lip against the lower lip in a forceful way. In order to address this, we teach neuromuscular reeducation, as well as physical therapy and soft tissue massage. These strategies sometimes work effectively to improve speech, but occasionally we also need to involve a specialized speech therapist, or a speech and language pathologist, to teach the patient additional strategies for managing these specific pronunciations. Rarely, surgery is indicated to actually elongate the upper lip so that it can meet the lower lip more effectively; this is most common in patients with congenital bilateral facial paralysis, as in Mobius syndrome.