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Speech abnormalties in

facial paralysis:
What Works & What Doesn't?

F. Katzman, MA, CCC-SLP *


R. Simpson, MD, MBA, FACS
Millenium Speech Pathology
Long Island Plastic Surgical Group
Huntington, New York

2013 ASHA Convention


Chicago, November 14, 2013

*
Disclosures
F. Katzman, MA, CCL-SLP no conflict of interest
R. Simpson, MD, MBA, FACS no conflict of interest
Organization
• Analysis of facial paralysis and speech abnormalities.
• Case Studies and details of surgical and speech
management
• Information sharing and questions from participants
• Conclusion and Wrap-Up
Facial paralysis
dysfunction of structures
innervated by the facial
nerve by an abnormal nerve
conduction.

A mirror of the inner


emotions conveying love,
hate, and subtle, fleeting
gradations from joy to deep
despair.
Facial nerve branches
Facial paralysis - types
• Complete unilateral (proximal nerve)
• Incomplete or partial unilateral (facial nerve trunk)
• Congenital (unilateral or bilateral)
• Trauma (central and/or peripheral)
• Stroke (central)
Facial paralysis - signs
• Inability to lift brow
• Incomplete eyelid closure
• Asymmetry of smile
• Taste abnormalities
• Dysacousis
Level of involvement
Unilateral complete paralysis

Acoustic neuroma

• Incidence 1.1 per 100,000


• Mean age 53.1
• Facial nerve compressed by
VIII nerve benign tumor
• Surgery or radiotherapy
Unilateral incomplete paralysis

Bell’s Palsy

• Incidence 20 per 100,000


• Increases with age
• Inflammation facial nerve
• Mononeuropathy - one side
• Contributing factors
• Rapid onset
• 9% have sequellae
Congenital paralysis (unilateral or bilateral)

Moebius Syndrome

• Incidence 2-20 per 1,000,000


• VI and VII abnormalities
• Associated deformities
• Mask like appearance
• Delayed speech?
Stroke – cerebral vascular accident

• Loss of brain function due to


a disturbance of blood flow
• Cerebral crossover to nucleus
• Central v. peripheral
• Upper branch improvement
Speech abnormalities
• Loss ipsilateral half perioral musculature
• Altered psychosocial well being
• Decreased to absent muscle tone entire cheek
• Transfer may improve bilabial closure
• ? improvement of voiced and voiceless bilabial plosives
• Correction of placement and accommodation
• Lip rounding
• Glides and rounded back vowels
Speech abnormalities
Patient / observer perceptions

• Listeners’ perceptions exceed objective (Nelson, 2000)


• Children with BFP: /b/ and /d/ CV syllables
• Scores high for lingua-alveolar place for A and AV
• Significantly lower for bilabial place in A mode
• Lowest for bilabial place in AV mode
• Conflicting visual cues for /bV/ syllables
Speech abnormalities
Patient / observer perceptions
Speech abnormalities
Patient / observer perceptions
Speech abnormalities
Patient / observer perceptions
Unilateral complete paralysis

Patients describe the following:

• Loss of saliva
• Drinking embarrassment
• Unintelligible speech
• Facial fatigue/endurance
• Must physically support lip!
Unilateral incomplete paralysis

Bell’s Palsy
Symptoms as recovery proceeds:

• Increasing facial tone


• Stiffness and pain
• Synkinesis
• No salivary loss
Moebius Syndrome

• “…feeding, oral resting posture,


and speech clarity will improve
by providing appropriate sensory,
tactile, and motor input to the oral
musculature, in addition to
repetitive oral placement therapy
activities”
S.R. Johnston, MS, CCC-SLP
Moebius Syndrome

• Sensory
• Feeding
• Oral placement therapy
• Speech
• Syllable production
• Connected speech
• Clarity of vowels
Stroke – cerebral vascular accident
Speech symptoms

• Dysarthria- weakness or paralysis


• Consonants
• Slurred speech
• Vowel distortion
• Intelligibility deceased
Stroke – cerebral vascular accident
Early management

• Produce intelligible speech


• Reduced rate of speech
• Syllables one at a time
• Pacing board / Metronone
• Compensatory strategies bilabials
• Isometric exercise
• Visual feedback
• Neuromuscular electrical stim
Goals of Facial Reanimation

• Symmetric facial motion


• Spontaneous smile
• Improved cheek contour
• Eyelid closure
• Chew on the paralyzed side
Speech related goals
• Improved facial muscle tone / movement
• Articulation – lip out of the occlusal plane
• Intelligibility of speech
• Lip contact
• Decreased loss of saliva
LONG ISLAND PLASTIC
SURGICAL GROUP
Temporalis & Masseter Muscles

LONG ISLAND PLASTIC


SURGICAL GROUP
temporalis dissection
preparation of fascia

LONG ISLAND PLASTIC


SURGICAL GROUP
cheek dissection
setting the tension
commissure overcorrection

LONG ISLAND PLASTIC


SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
Cross Face Nerve Grafting
• Facial nerve for reanimation
• Synchronous emotional smile
• Synkinetic motion can occur
• Setting the tension difficult
• Two stage procedure
Second stage gracilis

LONG ISLAND PLASTIC


SURGICAL GROUP
Crossface graft completion
Partial paralysis:
local muscle plication

LONG ISLAND PLASTIC


SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
Partial facial paralysis

LONG ISLAND PLASTIC


SURGICAL GROUP
Partial facial paralysis

LONG ISLAND PLASTIC


SURGICAL GROUP
XII to VII Transfer

• Complete left paralysis


• Etiology: acoustic
• Surgery at 1 month
• Excellent tone at 6 months
• Use in other procedures

LONG ISLAND PLASTIC


SURGICAL GROUP
XII to VII Transfer

Quality and balance of the smile? LONG ISLAND PLASTIC


SURGICAL GROUP
XII-VII tongue deformity

Severe ipsilateral
Z plasty correction LONG ISLAND PLASTIC
SURGICAL GROUP
Moebius: muscle transfers
LONG ISLAND PLASTIC
SURGICAL GROUP
LONG ISLAND PLASTIC
SURGICAL GROUP
Moebius Syndrome:
microsurgical muscle transfer
Unilateral congenital

LONG ISLAND PLASTIC


SURGICAL GROUP
Speech related therapies
• Assessment of paralysis v. paresis
• Evaluation of improvement expected
• Sharing goals of maximum improvement / plateau
• Understanding transition to post surgical management
• Therapy plan to complement patient recovery
Muscle transfer / transplantation
• Temporalis – begin day 7
• Transplant – as motion
begins (5-18 months)
• Forceful exercises
• Clench teeth
• Mirror feedback
• No massage
XII to Vll followed by temporalis
Post surgical rehabilitation
Hypoglossal to facial nerve
• Paralysis /atrophy tongue
• Disorders
• Articulation
• Chewing
• Swallowing
• Lingual exercise restores
function (Gatignol, 2006)
• Articulation problems
related to the facial paralysis
(Diels, 1997) Start early!
Bell’s Palsy recovery
Symptoms Management
• Increased facial tone • EMG biofeedback
• Decreased muscle excursion • Neuromuscular retraining
• Facial pain and stiffness • Articulation
• Synkinesis • Avoid ipsilateral overusage
• Strengthen lip weakness
• Assymetry of motion
• Massage - warmth
• Alteration of smile
• Botox injections
• Lip closure and oral
continence intact • Surgical rebalancing (late)
Neuromuscular retraining
• Coordinating facial muscle movements.
• Inhibiting the activity of the abnormal movement patterns
• Out of sequence movements are inhibited.
• Small steps to gradually retrain the muscles as there needs to be
significant changes at the neurologic (brain) level for success.
• Electrical stimulation is avoided as it increases the overactive
muscles.
• Muscles actively massaged and stretched.
• Patients are discouraged from strong muscle strengthening
exercises as again this is more about re-coordination rather than
stimulation.
Neuromuscular retraining
Moebius
Feeding Speech clarity
• Oral motor exercises • Near normal language
• Upper lip mobility • Poor clarity
• Lip rounding • Insufficient lip mobility
• Safe swallow • Incomplete lip closure
• Using straws • Poor lip rounding
• Control drooling

S. Rosenfeld-Johnson, MS, CCC_SLP, 1999


Conclusions
• Facial paralysis is a diverse condition affecting
children and adults
• Early therapy intervention needed for feeding
• Detailed protocols for management of recovering
partial paralysis
• Coordination between therapist and surgeon to
formulate post operative plan
• Defined timeline that patient can expect to reach
maximum medical improvement

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