TOPIC FEATURES
Types 1◦:Vascular compression [AICA, PICA, Internal auditory a, vertebrobasilar a
2◦: Demyelinating dz, tumors in CPO angle.
Etiology #1 is 2/2 vascular compression of facial nerve at the root exit
Epidemiology More common in females especially in 50’s
Risk Factors HTN
Sx + Progression Initially begins as periocular twitching then progresses to check + perioral muscles.
Typically unilateral [when B/L both sides are asynchronous]
May be worsened by emotion + stress
DDx: Blepharospasm: B/L, Sx stops during sleep [unlike hemifacial spasm]
Meige Syndrome: B/L blepharospasm AND involvement of some lower facial muscles
Facial myokymia: Rippling movement of facial muscles i.e 2/2 brainstem lesion
Oromandibular dystonia: Affects only lower facial muscle, Sx stops during sleep [unlike hemifacial
spasm]
Facial Tics: Premonitory urges and sense of relief afterwards [unlike hemifacial spasm]
Hemimasticatory spasm: Painful jaw closure spasms/contractions
Facial Synkinesiae: Misdrirected axonal sprouting s/p injury.
Treatment Botox rx [>90% success rate] Q 3 months [RTC in 3 weeks to observe efficacy]
Microvascualar decompression if applicable [88-97% success rates]
Muscle A. INITIAL MUSCLES INJECTED
Targeted
Orbicularis Oculi
Palpebralis Part [Closes eyelid]
Preseptal part
Pretarsal part
Orbitalis Part [Squeezes eye tight]
Injection Sites: [option 1]-PALPEBRAL PART
Lateral part of upper eyelid: 2.5-5 units
Medial part of upper eyelid: 2.5-5 units
Lateral part of lower eyelid: 2.5-5 units
Mid pupillary part of lower eyelid: 2.5-5 units
Injection Sites: [option 2]-ORBITALIS PART
Orbicularis Oris
Only injected in severe cases, due to risk of mouth paralysis
B. ADDITIONAL MUSCLES INJECTED [if initial injection not infected]
Frontalis: 10 units
Corrugator: 2.5-4 units
Procureus: 2.5 units
C. ADDITIONAL MUSCLES INJECTED [if in severe cases]
Zygomaticus minor: 1-1.5 units
Buccinator: 2 units
Depressor angularis oris: 1-1.5 units
Depressor labii oris: 1-1.5 units
Platysma: 15 units
Injection Sites
OPTION 1:
Summary Sites:
Medial part of upper eyelid: 2.5-5 units
Lateral part of upper eyelid: 2.5-5 units
Lateral part of lower eyelid: 2.5-5 units
Mid pupillary part of lower eyelid: 2.5-5 units
1cm lateral to the lateral cantus: 5-10 units
Zygomaticus Major [lower part]: 1-1.5 units
Zygomaticus Major [upper part]: 1-1.5 units
Zygomaticus Minor: 1-1.5 units
Risorius: 1-1.5 units
OPTION 2:
Medial part of upper eyelid: 2.5-5 units
Lateral part of upper eyelid: 2.5-5 units
Lateral part of lower eyelid: 2.5-5 units
Mid pupillary part of lower eyelid: 2.5-5 units
1cm lateral to the lateral cantus: 5-10 units
Zygomaticus Major [upper part]: 1-1.5 units [if needed]
Zygomaticus Major [lower part]: 1-1.5 units [if needed]
Depressor labi oriis: 1-1.5 units [if needed]
Platysma: 15 units [if needed]
OPTION 3:
Summary Sites:
Medial part of upper eyelid: 1.25 units
Lateral part of upper eyelid: 1.25 units
1cm lateral to the lateral cantus [X]: 2.5-5 units
1cm inferior to X [Z]: 2.5-5units
1cm inferior to the lateral cantus [Y]: 2.5-5 units
2cm below the mid pupillary line [A]: 1.2units
1 injection site medial to [A]: 1.2 units
2 injection site lateral to [A]: 1.2 units
Zygomaticus Major [lower part]: 1-1.5 units
Zygomaticus Major [upper part]: 1-1.5 units
Zygomaticus Minor: 1-1.5 units
Risorius: 1-1.5 units
Preparation 100 units of reconstituted Botox A in 4ml of 0.9% NS.
-2.5units per 0.1ml
-27 to 30 gauge needle
Follow Up Follow Up:
-Follow up in 3 weeks [to assess efficacy of rx: if need for future adjustment]
-Follow up in 3 months [to administer subsequent rx]
Patient PATIENT EDUCATION:
Education Educated patient that initial effect of the injections is seen within 3 days
Educated patient that peak response is seen within 1-2 weeks post rx
Educated patient that rx lasts for about 3 months
Educate patient not to lie down for 4hrs to prevent diffusion of botox to septal
region
CPT Code CODING:
Botox: 64612 [Bilateral add 50 modifier]
