Patients with Ramsay Hunt Syndrome have many treatment options to improve their facial function and symmetry. These treatments can improve smile symmetry, facial symmetry, facial synkinesis, and neck and face tightness. These treatments can typically be performed no matter how long you have lived with Ramsay Hunt Syndrome! It is important to work with a clinician who is familiar with working with patients with chronic Ramsay Hunt Syndrome. They will be able to meet with you and develop a personalized treatment plan based on your exam and goals for treatment.

Treatment options include:

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Selective Denervation Surgery

Selective denervation is a surgical procedure that can improve the smile, facial symmetry, and facial tightness in some patients with chronic Ramsay Hunt Syndrome. The procedure accomplishes this by mapping out different facial nerve branches, and then taking away the branches which innervate muscles restricting the smile, and branches causing synkinesis. Selective denervation has the potential to restore a balanced and spontaneous smile in patients while relieving some of the facial tightness that affects so many patients with chronic facial paralysis. 

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Depressor Anguli Oris (DAO) Excision

The depressor anguli oris (DAO) muscle attaches to the corner of the mouth and the bottom of the mandible (lower jaw), just to the side of the chin. It is one of the muscles which helps make a frown. Often, patients with chronic Ramsay Hunt Syndrome have too much activity in this muscle on the affected side of the face; the muscle becomes too strong. This increased DAO strength restricts the smile and can cause a feeling of tightness in the cheek. This muscle can be removed during a small surgical procedure to help improve smile symmetry in patients with chronic Ramsay Hunt Syndrome. 

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Asymmetric Facelift

Chronic Ramsay Hunt Syndrome affects the rate at which the affected side of the face ages. A facelift is a common aesthetic procedure that can help restore a youthful appearance of the face. An asymmetric facelift for facial paralysis is when facelifting surgery is performed on the paralyzed side of the face to restore overall facial symmetry and balance. A facelift can also be performed on the healthy side of the face, if necessary, to further enhance facial appearance.

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Botox for Chronic Ramsay Hunt Syndrome

Botulinum toxin (aka Botox®) is one of the simplest yet most effective treatments for patients with synkinesis, facial asymmetry, and facial tightness resulting from chronic Ramsay Hunt Syndrome. Botox® works by blocking release of a neurotransmitter called acetylcholine, which is what nerves use to tell muscles to contract, or tighten. Botox® relaxes muscles which are too tight and can prevent involuntary facial movements, or synkinesis. While the Botox® we use for facial paralysis is the same medication that is used for cosmetic purposes (to decrease wrinkling with facial movement), insurance typically covers Botox® for patients with facial palsy.

 

Dermal Filler

Patients with chronic Ramsay Hunt Syndrome frequently have asymmetric volume loss and soft tissue redistribution. This asymmetric aging is due to changes in muscle tone and soft tissue volume associated with facial paralysis. Dermal fillers such as Juvederm® and Restylane® can be used to improve facial symmetry. They can also be used sometimes in the lips to improve eating, drinking, and articulation in patients with chronic Ramsay Hunt Syndrome.

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Facial Therapy (aka Facial Neuromuscular Retraining)

Facial Therapy is provided by physical therapists, occupational therapists, or speech language pathologists. Patient should seek a provider who has experience working with facial paralysis and, if possible, a clinician who works as part of an interdisciplinary team that includes a facial nerve surgeon, a neurotologist, audiologist, vestibular therapist, and ophthalmologist, as needed. Specific therapy goals are created based on where the patient is in their healing journey. 

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Patients should expect to learn about facial muscle anatomy; stretches and techniques for protecting the eye; introduction to soft tissue mobilization and manually assisted facial movements to help encourage muscle movement; and compensatory strategies to help with issues that arise during eating and drinking, and with articulation of certain speech sounds.

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When a patient begins to have small but appreciable movement or muscle tone, therapy targets encouraging muscle movement. In addition to the techniques learned during the acute stage, soft tissue mobilization targets massage of muscles that have gone from feeling numb to feeling tender and stiff. At this point, targeted neuromuscular reeducation (NMR) is introduced.

• NMR involves relearning to move your affected side of the face in small, controlled movements without activating non targeted muscle groups.

• It is usually done with some sort of external feedback like a mirror, video or electromyography machine because the patient’s sense of movement and sensation is often impaired.​​

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As muscle groups become active along some or all of the facial nerve pathways, synkinesis appears.

• What is synkinesis? 

  • Syn- a prefix occurring in loanwords from Greek, having the same function as co- ( synthesis; synoptic ); used, with the meaning “with,” “together,” in the formation of compound words.

  • Kinesis [ ki-nee-sis, kahy- ] noun, Physiology. A movement that lacks directional orientation and depends upon the intensity of stimulation.

  • Facial synkinesis refers to involuntary and undesirable facial movements caused by the unpredictable neural pathways created during the facial nerve healing. An example of this is when one eye closes whenever a patient smiles. 

  • Synkinesis frequently develops in patients living with RHS.

• Movement control therapy techniques teach patients to produce symmetrical facial movements while actively working to relax and decrease unwanted muscle movements.

• Patients are encouraged to think about having one face that is working together to create facial expression rather than thinking about a “good” side and a “bad” side.

• Following a consistent home program that includes frequent self-massage and NMR education is key to improving during this stage. 

• Your therapist should consult with your physician about your plans and desires to undergo surgery and/or Botox injections. 

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Chronic Phase

• Patients who present with stiff, rigid muscles and significant synkinesis and have seen a plateau in their movement recovery at the beginning of therapy are said to have chronic, non-flaccid facial paralysis.

  • These patients are taught facial massage and active relaxation techniques to address tension, discomfort, and pulling on the affected side of the face.

  • Guided meditation and facial muscle education and release exercises are beneficial

• Once relaxation and tissue mobility have improved, it is then appropriate to begin NMR.

• Most physicians will wait until a patient is at least a year out from the onset of their facial paralysis. It is common for patients in this stage to have passed the one-year mark. Some of these patients will have had or have upcoming surgical consults.

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