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Abstract Details

The “Drama Mask” Phenomenon in Craniofacial Dystonia
Movement Disorders
P8 - Poster Session 8 (5:30 PM-6:30 PM)
3-001
Dystonia involves sustained or intermittent muscle contractions that are often exacerbated by voluntary actions. Craniofacial dystonia can interfere with facial expression and social interaction, although this may be underappreciated and underreported in the literature. 
To highlight an interesting case of craniofacial dystonia, which caused the patient to have facial expressions incongruent with her emotions, and to demonstrate its response to botulinum toxin injections.
Case report.

The patient is a 52-year-old woman with a 4-year history of involuntary eyelid closure. Based on her complaint of “heavy” eyelids that wouldn’t stay open, she was initially diagnosed with seronegative myasthenia gravis and treated with medications and thymectomy. The lack of improvement led to subspecialty consult and a diagnosis of blepharospasm.  Her symptoms progressed to involve involuntary contractions of other facial muscles, consistent with craniofacial dystonia. When she chewed food, she had stereotyped eyelid clenching, nose elevation, and lip puckering. In pleasant social settings, people would consistently ask her if she was disgusted with her food. Conversely, when angrily scolding her children, she noticed paradoxical smiling, which diminished the emotion she was trying to convey. These “drama masks” resulted in a frustrating mismatch between her emotional state and outward expression. Clonazepam had minimal impact. Botulinum toxin injections were progressively tailored, and ultimately alleviated her craniofacial dystonia and “drama mask” phenomenon. Injections included the bilateral orbicularis oculi, corrugator supercilii, procerus, levator labii superioris aleque nasi, risorius, mentalis, orbicularis oris, masseters, temporalis, and sternocleidomastoid. Video will demonstrate facial muscle activation during eating, before and after botulinum toxin injections.

This case report shows that craniofacial dystonia can impact outward expression of emotions, even producing emotionally incongruent facial expressions. This “drama mask” phenomenon can be socially disabling, but is treatable with targeted botulinum toxin injections.

Authors/Disclosures
Irene Malaty, MD, FAAN (University of Florida)
PRESENTER
Dr. Malaty has received personal compensation in the range of $0-$499 for serving as a Consultant for Abbvie. The institution of Dr. Malaty has received research support from Abbvie. The institution of Dr. Malaty has received research support from Revance. The institution of Dr. Malaty has received research support from Neuroderm. The institution of Dr. Malaty has received research support from Parkinson Foundation. The institution of Dr. Malaty has received research support from SAGE. The institution of Dr. Malaty has received research support from Emalex. Dr. Malaty has received publishing royalties from a publication relating to health care. Dr. Malaty has received personal compensation in the range of $500-$4,999 for serving as a CME Speaker with Cleveland Clinic. Dr. Malaty has received personal compensation in the range of $500-$4,999 for serving as a Speaker & Center of Excellence Director with Parkinson Foundation. Dr. Malaty has a non-compensated relationship as a MAB member & Center of Excellence Directory with Tourette Association of America that is relevant to AAN interests or activities.
Matthew Remz, MD (University of Florida) Dr. Remz has nothing to disclose.
Jason L. Chan, MD, PhD (University of Florida) Dr. Chan has nothing to disclose.
Alfonso Enrique Martinez Nunez, MD (Lafayette Towers) Dr. Martinez Nunez has nothing to disclose.