甲状腺手术时喉返神经损伤的神经修复治疗

目的探讨甲状腺手术喉返神经损伤神经修复治疗。方法对病程 2年以内甲状腺手术喉返神经损伤声带麻痹 4 2例患者行单侧损伤神经减压 8例、颈袢喉返神经吻合 2 1例、喉返神经端端吻合 6例 ,双侧损伤膈神经移植联合术 7例 (一侧膈神经移植 ,另一侧行神经减压 2例、神经肌蒂植入术 5例 )。手术前后喉镜、嗓音声学参数、肌电图检查等评价手术效果。结果单侧损伤神经减压组病程 4个月内 5例恢复了正常的声带运动功能 ,4个月以内 1例、4个月以上 2例及颈袢吻合组、喉返神经端端吻合组则未恢复声带运动 ,但上述 3种术式均能使喉内收肌获有效的再神经支配 ,发音时声门闭合良好 ,嗓音恢复正常。双侧损伤膈神经移植术侧恢复明显吸气性声带外展功能 6例 ;其中2例对侧神经减压恢复了正常的声带运动功能 ,4例对侧肌蒂埋植术仅 2例轻微外展 ,获肌电图检查的证实 ,这些患者均顺利拔管。 1例双侧均无外展。结论甲状腺手术喉返神经损伤以神经减压效果最佳 ;颈袢吻合也能有效地恢复喉的发音功能 ;膈神经移植术治疗双侧损伤较肌蒂植入术效果更满意 ;喉神经修复术式选择应根据病程、神经损伤程度、类型而定。     

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喉返神经损伤引起的声带麻痹是甲状腺手术常见的严重并发症之一,以单侧多见,造成不同程度的声音嘶哑、误吸和呛咳等症状,影响病人的生活质量。传统的治疗方法如声带注射术、甲状软骨成形术和杓状软骨内收术等虽能改善发音,但这种声音缺乏音调、音量的调节功能,且远期疗效不满意。声带麻痹的最佳治疗方法是通过神经修复手术恢复麻痹喉的生理性功能。手术方法包括:喉返神经探查减压术、喉返神经端端吻合术、颈袢喉返神经吻合术、游离神经移植术、神经肌蒂埋植术或神经植入术、舌下神经转位术及喉神经修复联合声带内移术等。早期减压效果最佳,颈袢喉返神经吻合等神经修复术也能有效地恢复喉的发音功能。损伤病程长者宜采用神经修复联合声带内移手术。喉神经修复术式的选择应根据病程、神经损伤的部位、程度、类型而定。     

甲状腺手术中喉返神经损伤修复术要点与技巧

喉返神经损伤引起的声带麻痹是甲状腺手术常见的严重并发症之一,以单侧多见。单侧声带麻痹的主要症状为不同程度的声音嘶哑、误吸和呛咳等,严重影响病人的生活质量。目前单侧声带麻痹最理想的治疗方式为喉返神经修复手术,方法包括喉返神经探查减压术、喉返神经端端吻合术、颈袢喉返神经吻合术、游离神经移植术、神经肌蒂埋植或神经植入术等。其中,以颈袢-喉返神经吻合术效果最佳。若能把握好手术适应证且遵循一些手术技巧,术后可使98%以上的病人恢复正常或接近正常的嗓音功能。     

Role of motor unit number estimate electromyography in experimental canine laryngeal reinnervation.

Laryngeal electromyography has been used clinically to differentiate neuromuscular pathology from other causes of vocal fold immobility such as arytenoid dislocation, tumor invasion, or cricoarytenoid joint fixation. Electromyography has also been used to predict the prognosis for nerve recovery in laryngeal paralysis. Existing electromyographic techniques either record activity with voluntary motion or study nerve conduction. In this study a new technique, motor unit number estimation, a commercially available quantitative method of electromyographic analysis, is used to study the progress of recovery of vocal fold function after recurrent laryngeal nerve injury. Four dogs underwent transection and immediate reanastomosis of selected branches of the adductor and abductor branches of the recurrent laryngeal nerve on 1 side; the opposite side served as a control. Baseline electromyographic and videolaryngoscopic studies were performed. These measures were then repeated in a longitudinal fashion every 6 weeks after denervation. The motor unit number estimation technique indicated a return of motor unit numbers with time, along with estimates of their size. This was consistent with the expected progress of laryngeal reinnervation. These data and their predictive value for nerve recovery will be discussed.     

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??Techniques and tips in reinnervation surgery for unilateral recurrent laryngeal nerve injury in thyroid surgery LI Meng, ZHENG Hong-liang.Department of Otolaryngology Head & Neck Surgery, Changhai Hospital, Navy Medical University, Shanghai 200433, China
Corresponding author??ZHENG Hong-liang??E-mail??zheng_hl2004@163.com
Abstract Unilateral vocal cord paralysis caused by injury to unilateral recurrent laryngeal nerve (RLN) injury is one of the most common and serious complications of thyroid surgery. Main manifestations include varying degrees of hoarseness??coughing??and aspiration??which greatly affect patients’ quality of life.The best treatment for vocal cord paralysis is reinnervation of the laryngeal muscles so as to recover the physiological function of the paralyzed larynx??which consists of nerve exploration and decompression??end to end anastomosis of RLN??ansa cervicalis to RLN anastomosis??free nerve graft transfer??reinnervation surgery combined with medialization of vocal cord. Among which ansa cervicalis to RLN anastomosis might be the most optimal option for the patients. Surgical indications should be strictly controlled and some surgical techniques and tips should be followed, which will be introduced in the present study.     

自体颈丛神经移植修复喉返神经缺损18例报告

目的 探讨采用自体颈丛神经移植一期或延迟一期修复喉返神经缺损的手术方法及其疗效.方法 18例声音嘶哑的甲状腺癌患者(包括6例肿瘤侵犯喉返神经患者,3例瘢痕包裹及线结缝扎喉返神经的患者及9例喉返神经离断患者)在行甲状腺癌根治性切除手术后,选用术中保留的颈丛神经深支或浅支移植修复喉返神经.治疗前后以喉镜、嗓音主观评估等评价手术效果.结果 全部患者均得到3个月至2年的随访(平均8个月),其中16例患者声带不同程度的恢复了外展运动,2例声带未恢复运动,声带外展运动恢复率为88.9%(16/18).结论 自体颈丛神经移植一期或延迟一期修复喉返神经缺损术式简便易行,能有效地恢复声带外展运动,成功率高.     

颈袢再神经支配喉内肌的比较研究

为了比较几种颈袢修复声带内收肌功能的方法的效果，选用犬２８只，随机分成主支吻合组、分支吻合组、神经植入组及肌蒂埋植组。建立单侧声带麻痹模型后即刻分别作颈袢主支或分支与喉返神经内收肌支吻合，颈袢主支的亚分支或其肌蒂植入声带内收肌中。术后６个月作喉镜、电生理学、肌力及组织形态学检查。发现四种修复术均能使声带内收肌获得有效的再神经支配，但在声带内收功能恢复程度，电生理学参数和肌收缩力上，颈袢主支吻合术均明显优于分支吻合术、神经植入术及肌蒂植入术，并得到形态学检查的证实。提示，颈袢支配喉内收肌应首选主支吻合术。     

Results of ansa to recurrent laryngeal nerve reinnervation.

OBJECTIVE: We sought to describe the results of ansa cervicalis to recurrent laryngeal nerve (ansa-RLN) reinnervation for unilateral vocal fold paralysis. STUDY DESIGN: A chart review was performed on patients undergoing ansa-RLN reinnervation for unilateral vocal cord paralysis at a tertiary care center. Patient perceptions of preoperative and postoperative voice quality was surveyed. Acoustic and visual parameters were assessed from videostroboscopy. RESULTS: From a total of 25 study patients, 15 patients underwent both preoperative and postoperativ video stroboscopies. In stroboscopies within 6 months, the average improvement in overall severity, roughness, and breathiness was 69, 79, and 100 percent, respectively. In stroboscopies after 6 months, the average improvement in overall severity, roughness, and breathiness was 63, 66, and 100 percent, respectively. Postoperatively, all patients had reinnervation of the vocal fold. CONCLUSIONS: Voice outcomes were improved in patients with preoperative and postoperative stroboscopies. SIGNIFICANCE: Ansa-RLN reinnervation should be considered as a treatment for unilateral vocal fold paralysis.     

Analysis of voice function following autologous fat injection for vocal fold paralysis.

OBJECTIVE: This study demonstrates that intravocal fold injection of autologous fat obtained by liposuction technique is simple, and the functional results durable for patients with unilateral vocal fold paralysis due to injury to the recurrent laryngeal nerve. STUDY DESIGN: 41 patients with unilateral paralysis of the vocal fold due to injury to the recurrent laryngeal nerve received intravocal fold injection of autologous fat. Autologous fat, harvested from the lower abdomen by liposuction technique, was filtered out and injected through a needle into the vocal fold by using endolaryngeal microsurgery. Clinical follow-up after the injection was carried out from 1 month to 2 years. RESULTS: Voice function dramatically improved compared with the parameters examined before the operation. Vocal function continued to improve as time passed during the second year after injection. CONCLUSIONS: Intravocal fold injection of autologous fat obtained by liposuction technique is simple, and the functional results durable for patients with unilateral vocal fold paralysis due to injury to the recurrent laryngeal nerve. SIGNIFICANCE: The effectiveness continued for more than 2 years in most patients.     

Immobilités laryngées unilatérales après chirurgie de la glande thyroïde

Background

The authors studied a cohort of 154 patients with unilateral vocal cord paresis following thyroidectomy, analyzing the pathogenesis, symptomatology, spontaneous evolution, and management of this complication.

Objective

This retrospective study distinguished between vocal cord paresis due to recurrent laryngeal nerve injury or due to injury of the cricoarytenoid articulation. We assessed the influence multiple variables on therapeutic management. The results and complications of currently-employed surgical techniques to remedy unilateral vocal cord paresis were defined.

Patients and methods

Injury to the recurrent laryngeal nerve was the cause of vocal cord paresis in 98% of cases; injury to the cricoarytenoid articulation accounted for only 2% of cases. When the recurrent laryngeal nerve had not been actually transected, spontaneous recovery of vocal cord function occurred in 36% of cases. No spontaneous recovery was noted when the nerve had been divided. The interval to recovery of cord function ranged from 2 to 15 months (median: 4 months). Spontaneous recovery of vocal cord function had occurred in 90% of these patients by the 9th postoperative month. Three factors significantly influenced the decision to perform a median transposition of the injured vocal cord: known transection of the recurrent laryngeal nerve, the interval to consultation with an ENT specialist, and the severity of dysphonia. Medial transposition of the injured vocal cord resulted in an immediate improvement in the quality of voice and speech with no major complications.

Conclusion

Unilateral vocal cord paresis occurring after thyroidectomy is not always symptomatic and is not uniformly due to injury of the recurrent laryngeal nerve. Management does not always require surgical reintervention. The practical and medico-legal consequences of these injuries are discussed.     

Preservation of recurrent laryngeal nerve invaded by differentiated thyroid cancer.

OBJECTIVE: This study was undertaken to determine whether the recurrent laryngeal nerve involved in differentiated thyroid carcinoma could be preserved. SUMMARY BACKGROUND DATA: Few investigations have provided definitive results concerning preservation of the recurrent laryngeal nerve involved in thyroid cancer. Complete excision with resection of the recurrent laryngeal nerve reportedly did not improve survival over incomplete excision in differentiated thyroid carcinoma. METHODS: A retrospective study was performed with the medical records of 50 patients with differentiated carcinoma and preoperative normal vocal cord function to investigate outcomes of recurrent laryngeal nerve preservation including local recurrence, prognosis, and postoperative vocal cord function. The recurrent laryngeal nerves on 1 or both sides were preserved in 23 patients (the preserved group), whereas the involved recurrent laryngeal nerve of the other 27 patients was resected (the resected group). RESULTS: Backgrounds of patients were similar between the resected and preserved groups. The number of patients with recurrences in each group was similar, and incidence of local, regional, and distant metastatic recurrences were not different between the groups. Postoperative overall survival of the preserved group was similar to that of the resected group (p = 0.1208). More than 60% of patients or of nerve at risk in the preserved group restored normal vocal cord function within 6 months. Some functional vocal cord movement was recognized in 80% of patients or of nerve at risk. All patients in the resected group including patients with nerve anastomosis showed permanent paralysis of the ipsilateral vocal cord. CONCLUSIONS: These results suggested that the recurrent laryngeal nerve, even if infiltrated by differentiated thyroid cancer, is worthwhile to preserve for maintenance of postoperative vocal cord function without affecting the incidence of local recurrence or prognosis.     

Sensitivity and Specificity of Intraoperative Recurrent Laryngeal Nerve Stimulation Test for Predicting Vocal Cord Palsy after Thyroid Surgery

INTRODUCTION Recurrent laryngeal nerve (RLN) palsy after thyroidectomy, although infrequently encountered, can decrease quality of life. In addition to the hoarseness that occurs with unilateral RLN palsy, bilateral RLN palsy leads to dyspnea and often to life-threatening glottal obstruction. Therefore, intraoperative awareness of the nerve’s status is of great importance. This study examined the sensitivity and specificity of a palpation technique to detect contraction of the posterior cricoarytenoid muscle (PCA) through the posterior hypopharyngeal wall while the RLN was being stimulated with a disposable nerve stimulator during thyroid surgery (the laryngeal palpation test) to predict postoperative RLN deficits. Methods A total of 2197 RLNs in 1376 patients were identified to be at risk of injury during thyroidectomy performed between July 2003 and August 2004. Postoperative RLN integrity was assessed using direct laryngoscopy or laryngofiberoscopy to visualize vocal fold mobility. Results Altogether, 76 RLNs failed to elicit a PCA contraction in response to nerve stimulation, and 80 cases of temporary vocal cord palsy and 21 cases of permanent vocal cord palsy were recognized on postoperative evaluation. For postoperative vocal cord palsy, the sensitivity and specificity of the laryngeal palpation test were 69.3% and 99.7%, respectively, with a positive predictive value of 92.1% and negative predictive value of 98.5%. For permanent vocal cord palsy, the sensitivity and specificity were 85.7% and 97.3%, respectively, with a positive predictive value of 23.7% and negative predictive value of 99.8%. Conclusions The laryngeal palpation test is not a particularly useful method for predicting the level of RLN function after thyroidectomy. All patients must be examined postoperatively by direct laryngoscopy or laryngofiberoscopy to check vocal cord mobility. Even if there is no contraction of the PCA and we detect vocal cord palsy immediately after surgery, vocal cord palsy often recovers within 1 year when visual preservation of RLN is successful.     

Vocal cord paralysis after open-heart surgery.

Vocal cord paralysis is a known entity often described as a complication of neck surgery. A less frequent site of injury to the recurrent laryngeal nerve is the chest. The left side is usually more affected than the right side in view of its long intrathoracic segment. Only few cases of right vocal cord paralysis following open-heart surgery are reported in the literature. The purpose of this article is to review the common possible mechanisms of injury to the right recurrent laryngeal nerve following open-heart surgery in order to draw the attention of the caring physician to the clinical significance of such a complication. In fact, transient hoarseness following open-heart surgery may be an ominous sign of recurrent laryngeal nerve injury. It should not be assumed to be secondary to intralaryngeal edema. Several mechanisms of injury to the recurrent laryngeal nerve have been suggested: (1) through central venous catheterization; (2) by traction on the esophagus; (3) by direct vocal cord damage or palsy from a traumatic endotracheal intubation; (4) trauma by compression of the recurrent laryngeal nerve or its anterior branch at the tracheoesophageal groove by an inappropriately sized endotracheal tube cuff; (5) by a faulty insertion of a nasogastric tube; (6) median sternotomy and/or sternal traction pulling laterally on both subclavian arteries; (7) direct manipulation and retraction of the heart during open-heart procedures; (8) hypothermic injury with ice/slush. If vocal cord paralysis was overlooked as a possible complication of open-heart surgery, the patient may suffer from dysphonia in addition to problems of paramount importance such as inefficient cough and aspiration. Although it is true that the incidence of vocal cord paralysis remains very low, yet its presence is alarming and necessitates close follow up on the patient for the possible need of surgical intervention if recovery fails.     

Effects of vecuronium and rocuronium in antagonistic laryngeal muscles and the anterior tibial muscle in the cat

BACKGROUND: Adequate vocal cord paralysis and full recovery of laryngeal muscle function are important when muscle relaxants are used perioperatively. This study was designed to compare the effects of vecuronium and rocuronium at the vocal cord abductor and adductor muscles and the anterior tibial muscle in cats. METHODS: Twelve adult cats were studied under pentobarbitone-N2O/O2-anesthesia. After supramaximal electrical stimulation of the peroneal nerve and the recurrent laryngeal nerve (0.1 Hz and intermittent train-of-four) evoked electromyographic responses were obtained from the anterior tibial muscle, the posterior cricoarytenoid muscle (vocal cord abductor) and two vocal cord adductor muscles, the lateral cricoarytenoid and the vocal muscle. Six cats received bolus doses of increasing size of vecuronium (ED90 22.5 microg x kg(-1)) and six cats rocuronium (ED90 90 microg x kg(-1)). RESULTS: Equipotent doses of vecuronium and rocuronium caused a similar degree of paralysis in all muscles (vecuronium ED90: 70% blockade at the posterior cricoarytenoid, 83% at the lateral cricoarytenoid, 84% at the vocal muscle and 90% at the anterior tibial muscle; rocuronium ED90: 71% at the posterior cricoarytenoid, 67% at the lateral cricoarytenoid, 78% at the vocal muscle and 90% at the anterior tibial muscle; vecuronium 2 x ED90: 93% blockade at the posterior cricoarytenoid, 95% at the lateral cricoarytenoid, 97% at the vocal muscle and 99% at the anterior tibial muscle; rocuronium 2 x ED90: 89% blockade at the posterior and lateral cricoarytenoid, 93% at the vocal muscle and 100% at the anterior tibial muscle). Onset time was significantly shorter at the posterior cricoarytenoid muscle (290 s) compared to the lateral cricoarytenoid muscle (400 s) after vecuronium ED90 and to the vocal muscle (150 s versus 210 s) after rocuronium ED90. Compared to the anterior tibial muscle (interval 25-75%: 6.5 min after vecuronium 2 x ED90 and 3.3 min after rocuronium 2 x ED90 and to the posterior cricoarytenoid muscle (interval 25-75%: 7 min after vecuronium 2 x ED90 and 4.3 min after rocuronium 2 x ED90), recovery of laryngeal adductor muscle function was markedly delayed with both neuromuscular blocking drugs (interval 25-75% at the lateral cricoarytenoid and vocal muscle: 14 min and 15.8 min after vecuronium 2 x ED90 and 10.3 min and 11.6 min after rocuronium 2 x ED90 respectively). CONCLUSION: In cats, the time course of neuromuscular blockade after vecuronium and rocuronium differs in antagonistic laryngeal muscles. The protective laryngeal function of glottis closure recovers later than vocal cord abduction after both vecuronium and rocuronium.     

A functional evaluation of ansa cervicalis nerve transfer for unilateral vocal cord paralysis: future directions for laryngeal reinnervation

There are a variety of methods for treating unilateral vocal cord paralysis, but to date there are few objective studies that evaluate the functional results of nerve transfer from the ansa cervicalis. Six dogs underwent unilateral recurrent laryngeal nerve section with immediate reanastamosis to the sternothyroid branch of the ansa cervicalis. After 5 to 6 months, measurements of vocal efficiency and acoustic parameters, videolaryngoscopy, videostroboscopy, and evoked electromyography were performed. Identical measurements were made in eight control dogs during normal electrically induced phonation and a simulated unilateral recurrent laryngeal nerve paralysis. Histologic analysis of both vocalis muscles, recurrent laryngeal nerves, ansa cervicalis, and the ansa-recurrent laryngeal nerve anastamosis site was performed. Evidence of reinnervation was found in all of the animals that underwent nerve transfer. The vocal efficiency and acoustic quality after ansa cervicalis nerve transfer were dependent on the degree of electrical stimulation from the transferred nerve to the reinnervated cord during phonation. In the absence of electrical stimulation to the nerve transfer, physiologic vocal cord motion could not be elicited from the reinnervated cord.     

A method for intraoperative identification of the recurrent laryngeal nerve

Thyroid and parathyroid surgery is associated with a 1 to 6 percent incidence of injury to the recurrent laryngeal nerve. Electrical stimulation of the recurrent laryngeal nerve produces vocal cord motion that can be monitored by means of a double-cuffed endotracheal tube. Twelve patients underwent prospective evaluation with this monitoring system, and in all 12, the recurrent laryngeal nerve was accurately identified and localized. The nerve could be stimulated from a mean distance of 1.7 cm by a mean amperage of 1.3 mA. Postoperative indirect laryngoscopy demonstrated normal vocal cord function in all patients.     

Erscheinungsbilder von fazialen Masseninnervationen

Facial synkinesis is one of the most distressing consequences of facial nerve injury or paralysis. Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group. The pathophysiologic basis appears to be aberrant regeneration of facial nerve fibers to a different facial muscle group. We report on a patient with occulo-oral synkinesis, meaning specific oral commissure movement during voluntary eye closure. The treatments of choice are botulinum toxin injections and neuromuscular retraining.     

Laryngeal reinnervation by ansa cervicalis nerve implantation for unilateral vocal cord paralysis in humans

BACKGROUND: Ansa cervicalis (AC)-recurrent laryngeal nerve anastomosis (RLN) is usually not desirable for correction of paralytic dysphonia when it is difficult to find a viable distal stump of the recurrent laryngeal nerve. Nerve implantation of the thyroarytenoid muscle with the ansa cervicalis is a simple alternative method. STUDY DESIGN: Ten patients with unilateral vocal cord paralysis were prospectively designed to receive nerve implantation. A minimum period of 12 months after onset of paralysis was allowed to elapse to permit possible spontaneous reinnervation or compensation. Patients were followed long enough (at least 2 years) to determine if the procedure was successful. All patients were subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them underwent laryngeal electromyography. RESULTS: Ten patients underwent nerve implantation of the thyroarytenoid muscles by using the ansa cervicalis, and 8 of 10 (80%) had improved phonatory quality. Laryngeal electromyography showed that the procedure produced satisfactory reinnervation of the thyroarytenoid muscle. CONCLUSIONS: Nerve implantation of the thyroarytenoid muscle by the anso cervicalis is a simple and efficient alternative to nerve transfer if dense scarring at the cricothyroid articulation and lack of a viable distal stump of the recurrent laryngeal nerve preclude the procedure of nerve transfer. But careful selection of the appropriate candidate seems to be the earliest prerequisite for a successful procedure.     

Transcutaneous electrical stimulation of the recurrent laryngeal nerve: a method of controlling vocal cord position

This study was designed to examine the feasibility of transcutaneous stimulation of the recurrent laryngeal nerve. Electrical activation of the recurrent laryngeal nerve was achieved by applying a blunt electrode to the intact neck skin at specific points along the tracheoesophageal groove in anesthetized adult dogs. The stimulus consisted of 10 mA cathodal pulses, each of 1 msec duration, delivered at a frequency of 10 Hz and increased by 10 Hz increments up to 100 Hz. Vocal cord excursion was directly related to the frequency of applied current. In all six dogs studies, stimulation at 30 Hz resulted in maximal ipsilateral vocal cord abduction, while stimulation at frequencies greater than 40 Hz resulted in ipsilateral vocal cord adduction up to or across the midline. Vocal cord movement was immediate and persisted for the duration of the stimulus train. Surrounding neck muscles were not visibly activated. We propose that the observed frequency-dependent movement of the vocal cords occurred because of the difference between the contraction times of the intrinsic abductor and adductor muscles of the larynx. Transcutaneous recurrent laryngeal nerve stimulation appears promising, both as a diagnostic aid in laryngoscopy and as a therapeutic tool in controlling the glottic aperture.     

Management of synkinesis

Facial synkinesis is one of the most distressing consequences of facial paralysis. Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group. The pathophysiologic basis of facial synkinesis is likely multifactorial although the predominant mechanism appears to be aberrant regeneration of facial nerve fibers to the facial muscle groups after facial nerve injury. Patients experience hypertonic contractures and synkinetic movements such as eye closure with volitional movement of the mouth or midfacial movement during volitional or reflexive eye closure. Synkinesis can cause functional limitation with activities such as eating, drinking, smiling, and may even lead to social isolation. Evaluation of synkinesis is primarily subjective with facial grading scales such as the Sunnybrook scale. Objective measures of synkinesis using computerized video analysis show promise although no objective techniques are currently widely used. The most common therapeutic modalities for the treatment of facial synkinesis include (1) botulinum toxin type A (BTX-A) injections for selective chemodenervation of affected muscle groups and (2) facial neuromuscular retraining. Biofeedback using mirrors or electromyography has been used both for the treatment and prevention of facial synkinesis. Other treatment options include surgical therapies, such as selective neurolysis or myectomy, although these have been rendered nearly obsolete with the advent of BTX-A.