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Hemimasticatory Spasm: Report of a Case and Review of the Literature

Authors:

Corina Christie ,

Instituto Argentino de Investigación Neurológica – IADIN, Buenos Aires, AR
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Sergio Alejandro Rodríguez-Quiroga,

Instituto Argentino de Investigación Neurológica – IADIN, Buenos Aires, AR
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Tomoko Arakaki,

Instituto Argentino de Investigación Neurológica – IADIN, Buenos Aires, AR
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Roberto Daniel Rey,

Instituto Argentino de Investigación Neurológica – IADIN, Buenos Aires, AR
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Nélida Susana Garretto

Instituto Argentino de Investigación Neurológica – IADIN, Buenos Aires, AR
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Abstract

Background: Hemimasticatory spasm is a very rare movement disorder characterized by unilateral, involuntary, paroxysmal contractions of the jaw-closing muscles, causing clinically brief twitches and/or spasms.

Case Report: A 62-year-old female consulted us with a 30-year history of unusual involuntary twitches in the preauricular region and spasms that hampered jaw opening. During these spasms, she could not open her mouth. On physical examination, we also observed hypertrophy of the masseter and temporalis muscles, which can be features of hemimasticatory spasm. She was treated with botulinum toxin type A, with excellent response. Here, we present her case and review the literature.

Discussion: Hemimasticatory spasm is a rare movement disorder. Given the excellent response to botulinum toxin type A treatment, it should be considered within the spectrum of facial spasms.

How to Cite: Christie C, Rodríguez-Quiroga SA, Arakaki T, Rey RD, Garretto NS. Hemimasticatory Spasm: Report of a Case and Review of the Literature. Tremor and Other Hyperkinetic Movements. 2014;4:210. DOI: http://doi.org/10.5334/tohm.205
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  Published on 04 Apr 2014
 Accepted on 27 Feb 2014            Submitted on 30 Oct 2013

Introduction

Unlike hemifacial spasm, hemimasticatory spasm (HMS) is a very rare disorder. Since the original description by Gowers in 1897,1 there have been very few cases described in the worldwide literature. In a recent study in a Movement Disorders Clinic, conducted between 2000 and 2010, there was only one HMS patient among 215 patients with hemifacial spasm.2 To our knowledge, only 36 HMS cases have been reported in the literature between 1980 and 2013 (Table 1).

Table 1

Summary of Reported Cases of Hemimasticatory Spam in the Literature

Authors Age at Onset Sex Involved Muscles Mechanism or Special Clinical Features Response to Botulinum Toxin Surgical Treatment
1 Kaufman, 198012 25 F Left masseter NA
2 Lapresle 198213 15 F Right masseter Linear scleroderma with right FHA NA
3 Thompson and Carroll 198314 57 F Left masseter and temporalis Idiopathic NA Cryosurgical lesion
4 Thompson, et al. 19866 31 F Right masseter Morphea with right FHA NA Myotomy
5 Parisi, et al. 198715 38 F Right masseter Linear scleroderma with right FHA NA
6 Yoshii and Alba 198916 44 M Left masseter and both (medial and lateral) pterygoids Idiopathic NA
7 Auger, et al. 19923 20 F Right masseter and temporalis Idiopathic Yes Transient response to trigeminal rootlets section
8 17 F Right medial pterygoid Idiopathic NA
9 20 F Right masseter and temporalis Idiopathic NA
10 Cruccu, et al. 19944 18 M Left temporalis Left FHA NA
11 44 F Right masseter and temporalis Morphea Yes
12 Kim, et al. 199417 44 M Right masseter FHA Yes
13 Ebersbach, et al. 199518 26 M Left masseter and temporalis Left FHA Yes
14 26 F Right masseter and temporalis Local scleroderma with FHA Yes
15 Kim, et al. 20007 34 F Right masseter Local scleroderma with FHA Yes
16 Esteban, et al. 200219 47 F Left masseter Idiopathic Yes
17 Teive, et al. 200211 44 F Right masseter and temporalis Idiopathic Yes
18 Wang, et al. 200420 38 F Left masseter NA NA
19 12 M Right masseter and temporalis Right linear scleroderma NA
20 33 M Right temporal NA NA
21 42 F Left masseter and temporalis NA NA
22 Cersosimo, et al. 200310 29 F Right masseter and temporalis Severe worsening during pregnancy Yes
23 Mir, et al. 200621 26 M Left masseter and temporalis Idiopathic Yes
24 Gunduz, et al. 200722 62 F Right masseter and temporalis Right pontine and cerebellar hemisphere infarction Yes
25 Jiménez-Jiménez, et al. 200723 40 M Right masseter and temporalis Biopercular infarct with previous Foix–Marie–Chavany syndrome Yes
26 Kumar, et al. 20085 49 F Left masseter, temporalis and lateral pterygoid Left morphea Yes
27 Yaltho and Jankovic 20112 63 F Left masseter Idiopathic Yes
28 Gopalakrishnan, et al. 201124 56 F Left masseter and temporalis Cerebellopontine angle hematoma Spontaneous remission
29 Sinha, et al. 201125 38 M Right masseter and temporalis Idiopathic Debulking and stripping masseter muscle
30 Chon, et al. 201226 40 M Right masseter and temporalis Idiopathic Yes MVD
31 Wang, et al. 20139 50 F Left masseter NA NA MVD
32 42 F Right masseter and temporalis NA NA MVD
33 38 M Right masseter NA NA MVD
34 48 F Right masseter NA NA MVD
35 57 F Left masseter and temporalis NA NA MVD
36 53 F Right masseter and temporalis NA NA MVD
37 This case Christie, et al. 2014 32 F Right masseter Idiopathic Yes

FHA, Facial Hemiatrophy; F, Female; M, Male; MVD, Microvascular Decompression; NA, Not Available.

The cause of HMS is not fully known, but it is considered the result of a problem in the motor branch of the trigeminal nerve, and it is characterized by unilateral, involuntary, paroxysmal contractions of the jaw-closing muscles, causing clinically brief twitches and/or spasms.

We describe a patient with a severe form of HMS with good response to botulinum toxin type A treatment.

Aside from reporting a rare entity and reviewing the literature, we draw attention to the long natural history of the condition before the patient was correctly diagnosed and treated. This highlights two issues: firstly, the delay in diagnosis due to the rarity of the condition, and, secondly, the confirmation that spasms remained at the same topography for many years, during which time only the frequency and intensity of the spasms increased.

Case Report

A 62-year-old female presented with a 30-year history of strange sensations in the right preauricular region, and involuntary contractions of the jaw, causing sporadic biting injuries to her buccal mucosa. Initially, laughing, talking, or eating were the precipitant factors for these contractions.

The symptoms progressed gradually so that at present she has severe daily contractions, with up to 30 episodes per day. The episodes consist of spontaneous appearance of twitches in the preauricular region, or spasms that hamper jaw opening for as long as 20 seconds. Temporo-mandibular pain is only present during prolonged spasms or contractions (Video 1).

Video 1. 

Hemimasticatory Spasm in a 62-year-old Female.

The patient presents involuntary contraction of the right temporal and masseter muscles.

On physical examination, hypertrophy of the masseter and temporalis muscles was noted. Dental treatments were required in order to repair several broken teeth.

She has no other medical conditions or family history; she does not take any medications and has no laboratory evidence for connective tissue disease or thyroid dysfunction.

At present, computerized tomography scan of the brain, brain magnetic resonance imaging, and electroencephalography are normal. Electromyography (EMG) of the right masseter and temporalis muscles revealed spontaneous activity consisting of repetitive, spontaneous bursts of motor unit discharges, ranging from 100 to 200 Hz (Figure 1).

Figure 1 

Electromyographic recording.

Simultaneous electromyography recording (concentric needle electrodes) from right masseter and temporalis muscles shows continuous bursts of activity during the prolonged spasms.

Over the last years, she has been treated with injections of botulinum toxin type A, every 3–4 months, with 60 U in the right masseter muscle and 40 U in the right temporalis muscle, with an excellent response. To date, this treatment remains beneficial.

Discussion

HMS is characterized by involuntary movements, consisting of brief twitches and/or spasms, resembling cramps. It is considered a disorder of the motor branch of the trigeminal nerve, and is characterized by unilateral, involuntary, paroxysmal, sometimes painful, violent, and prolonged contractions of the jaw-closing muscles.3,4

Typically, HMS involves the masseter and the temporalis muscles, with the medial pterygoid muscle also rarely being involved. There is usually no involvement of the jaw-opening muscles, but there are at least two cases describing involvement of the lateral pterygoid (Table 1), one of them with associated lateral deviation of the jaw.5 There are no reports of bilateral involvement. HMS more commonly presents in females in the third and fourth decade, as observed in our patient.4

The most frequent triggers that precipitate spasms are talking, laughing, or chewing; these triggers are always voluntary movements rather than sensory stimuli, as in trigeminal neuralgia.4 Brief spasms are generally painless; prolonged spasms can be painful, as occurs with cramps. Severe or violent spasms can result in temporo-mandibular joint dislocation, and some patients, such as ours, may even bite their tongue or break teeth.6

The neurological examination should be normal in HMS, except for the spasm, the hypertrophy of the involved muscles or the atrophy of the subcutaneous tissue that may occur in cases associated with localized scleroderma.7 Facial sensation is always spared and no other cranial nerves should be compromised.

The pathophysiologic mechanisms that produce HMS are not entirely clear. There is an impaired inhibition of the muscle contraction that can be evidenced electrically by loss of the silent period, which is almost unique to HMS, and so can be a very useful aid for differential diagnosis.4,6 The characteristic EMG findings of HMS include irregular bursts of motor unit potentials (MUPs) that correlate with the involuntary masseter spasms.

MUPs are often morphologically normal but with very high frequency. Cruccu et al.4 noticed a delay in the conduction speed of the motor branch of the trigeminal nerve, localized at the infratemporal fossa between the lateral pterygoid and skull surface. This could explain a focal demyelination of the trigeminal motor fibers in these cases, as well as the hemifacial atrophy seen in almost 70% of cases.

In HMS, unlike unilateral jaw closing oro-mandibular dystonia, there is no agonist/antagonist muscle co-contraction during the voluntary movement of jaw opening.3 Furthermore, electrophysiological studies have demonstrated that the masseter inhibitory reflex and the silent period were absent during periods of spasm in the affected side, independent of the stimulated trigeminal nerve. The complete absence of the silent period in one or more muscles of one side of the face is an almost exclusive feature of HMS.8

The fact that in almost all informed cases the muscles affected were the masseter and temporal, sometimes the medial pterygoid, but only on two occasions the lateral pterygoid, suggests that the site generator of ectopic impulses should be at the distal fibers of the trigeminal nerve.4 This is also supported by previous reports showing relief by microvascular decompression of the trigeminal nerve.9

The hypertrophy of jaw-closing muscles, as in our patient, suggests that the generator of ectopic impulse may be at the motor root of the trigeminal nerve or at its motor nucleus, as can be seen in hemifacial spasm.68

Botulinum toxin type A injection is the most effective available treatment.10,11

In summary, HMS is a rare movement disorder. Given the excellent response to botulinum toxin type A treatment, it should be considered within the spectrum of facial spasms.

Notes

All authors contributed equally to this work. 

2 Funding: None. 

3 Financial Disclosures: None. 

4 Conflict of Interests: The authors report no conflict of interest. 

References

  1. Gowers, WR (1897). A manual of diseases of the nervous system. 2nd edition.Philadelphia: Blakiston, Vol 2. p.pp. 221–224.  

  2. Yaltho, TC and Jankovic, J (2011). The many faces of hemifacial spasm: Differential diagnosis of unilateral facial spasms. Mov Disord 26: 1582–1592, DOI: https://doi.org/10.1002/mds.23692 [PubMed]  

  3. Auger, RG, Litchy, WJ, Cascino, TL and Ahlskog, E (1992). Hemimasticatory spasm: Clinical and electrophysiologic observations. Neurology 42: 2263–2266, DOI: https://doi.org/10.1212/WNL.42.12.2263 [PubMed]  

  4. Cruccu, G Inghilleri, M Berardelli, A et al. (1994). Pathophysiology of hemimasticatory spasm. J Neurol Neurosurg Psychiatry 57: 43–50, DOI: https://doi.org/10.1136/jnnp.57.1.43 [PubMed]  

  5. Kumar, N, Krueger, BR and Ahlskog, JE (2008). Hemimasticatory spasm with lateral jaw deviations. Mov Disord 23: 2265–2266, DOI: https://doi.org/10.1002/mds.22304 [PubMed]  

  6. Thompson, PD, Obeso, JA, Delgado, G, Gallego, J and Marsden, CD (1986). Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm. J Neurol Neurosurg Psychiatry 49: 651–656, DOI: https://doi.org/10.1136/jnnp.49.6.651 [PubMed]  

  7. Kim, HJ, Jeon, BS and Lee, KW (2000). Hemimasticatory spasm associated with localized scleroderma and facial hemiatrophy. Arch Neurol 57: 576–580, DOI: https://doi.org/10.1001/archneur.57.4.576 [PubMed]  

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  9. Wang, YN Dou, NN Zhou, QM et al. (2013). Treatment of hemimasticatory spasm with microvascular decompression. J Craniofac Surg 24: 1753–1755, DOI: https://doi.org/10.1097/SCS.0b013e318295025a [PubMed]  

  10. Cersosimo, MG, Bertoti, A, Roca, CU and Micheli, F (2004). Botulinum toxin in a case of hemimasticatory spasm with severe worsening during pregnancy. Clin Neuropharmacol 27: 6–8, DOI: https://doi.org/10.1097/00002826-200401000-00004 [PubMed]  

  11. Teive, HA Piovesan, EJ Germiniani, FMB et al. (2002). Hemimasticatory spasm treated with botulinum toxin: Case report. Arq Neuropsiquiatr 60: 288–289, DOI: https://doi.org/10.1590/S0004-282X2002000200020 [PubMed]  

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  13. Lapresle, J and Desi, M (1982). Sclerodermie avec hemiatrophie faciale progresive et atrophie croisee de 1 hemicorps. Rev Neurol (Paris) 138: 815–822. [PubMed]  

  14. Thompson, PD and Carroll, WM (1983). Hemimasticatory and hemifacial spasm: A common pathophysiology?. Clin Exp Neurol 19: 110–119. [PubMed]  

  15. Parisi, L, Valente, G, Dell'Anna, C, Mariorenzi, R and Amabile, G (1987). A case of facial hemiatrophy associated with linear scleroderma and homolateral masseter spasm. Ital J Neurol Sci 8: 63–65, DOI: https://doi.org/10.1007/BF02361438 [PubMed]  

  16. Yoshii, K, Seki, Y and Aiba, T (1989). A case of unilateral masticatory spasm without hemifacial atrophy. No To Shinkei 57: 43–50.  

  17. Kim, YH, Lee, KS, Na, JH, Kim, BS and Ko, YJ (1994). A case of hemimasticatory spasm. J Korean Neurol Assoc 12: 175–178.  

  18. Ebersbach, G, Kabus, C, Schelosky, L, Terstegge, L and Poewe, W (1995). Hemimasticatory spasm in hemifacial atrophy: Diagnostic and therapeutic aspects in two patients. Mov Disord 10: 504–507, DOI: https://doi.org/10.1002/mds.870100417 [PubMed]  

  19. Esteban, A, Traba, A, Prieto, J and Grandas, F (2002). Long term follow up of a hemimasticatory spasm. Acta Neurol Scand 105: 67–72, DOI: https://doi.org/10.1034/j.1600-0404.2002.00119.x [PubMed]  

  20. Wang, YW, Ma, X, Zhang, ZK, Shen, D, Su, F and Fu, K (2004). [Hemimasticatory muscle spasm: An electromyogram analysis]. Zhonghua Kou Qiang Yi Xue Za Zhi 39: 155–157. [PubMed]  

  21. Mir, P Gilio, F Edwards, M et al. (2006). Alteration of central motor excitability in a patient with hemimasticatory spasm after treatment with botulinum toxin injections. Mov Disord 21: 73–78, DOI: https://doi.org/10.1002/mds.20653 [PubMed]  

  22. Gunduz, A, Karaali-Savrun, F and Uluduz, D (2007). Hemimasticatory spasm following pontine infarction. Mov Disord 22: 1674–1675, DOI: https://doi.org/10.1002/mds.21406 [PubMed]  

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  25. Sinha, R and Chattopadhyay, PK (2011). Hemimasticatory spasm: A case report with a new management strategy. J Maxillofac Oral Surg 10: 170–172, DOI: https://doi.org/10.1007/s12663-010-0162-0 [PubMed]  

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