Case 20 - Facial twitching
Case
A 55 year old woman developed involuntary twitching movements in the right side of her face.
The movements came in short bursts, typically between 5-30 seconds, involving the right periorbital muscles (causing eye closure), cheek muscle (with her face pulling to the right), and elevation of her right eyebrow. The movements were not sustained contractions – they were brief, repetitive twitches, without the muscles remaining contracted for more than a moment. After the contractions ceased there was no remaining issue in the right face, such as weakness or numbness.
These were initially happening once a day, and at first only involved eye closure, but increased over several weeks, becoming several times daily and then eventually happening multiple times per hour, and as they became more frequent the number of involved facial muscles increased, with the cheek and forehead muscles becoming involved.
They were disruptive, with the eye intermittently closing and opening causing disruption to vision (e.g. when driving), and had some social consequences, with colleagues and strangers often assuming she was having a stroke.
The movements were only in the face, were only ever on the right, and were painless. They did not involve jaw contraction, tongue movement, eye or neck movements, and the limbs were unaffected. Her consciousness and level of awareness were not altered during or after these. She lived alone, so was unable to comment if the movements occurred during sleep. There were no triggers, and she was unable to suppress the movements.
She felt well in herself. In between the episodes she felt normal, and had no progressive symptoms other than the escalating intermittent bouts of facial twitching.
She had no past medical history and took no medications. She had no history of previous neurosurgery, significant head injuries, nervous system infections, or facial palsy.
Examination was normal in the appointment, but she had brought video footage showing the following:
Where is the lesion?