RU2796865C1 - Method of selecting the tactics of treatment of patients with isolated lesion of the borderal manibordial branch of the facial nerve - Google Patents

Abstract

FIELD: medicine; neurology.

SUBSTANCE: invention can be used for the treatment of patients with lesions of the marginal mandibular branch (CNV) of the facial nerve (FN) of various origins, which innervates the muscle that lowers the lower lip (MONG) and the mental muscle (PM), which leads to a significant deformation of the smile, causes its asymmetry. A complex of physiotherapy exercises (LFK) is carried out, which includes three stages with a targeted effect on the muscle that lowers the lower lip (MONG): general acupressure of the entire face and local self-massage of the MONG; stimulation of movement through the elements of stretching and contraction MONG to control the dosed contraction of the muscle.

EFFECT: method provides non-invasive painless recovery of patients with isolated lesions of the marginal mandibular branch of the facial nerve.

2 cl, 41 dwg, 2 tbl, 1 ex

Description

The field of technology to which the invention belongs

The invention relates to medicine, namely to neurology, functional diagnostics, rehabilitation, surgery, and can be used to determine the tactics of managing patients with damage to the marginal mandibular branch (MNV) of the facial nerve (LN) of various origins, innervating the muscle that lowers the lower lip (MONG) and the chin muscle (PM), which leads to a significant deformation of the smile, causes its asymmetry.

State of the art

An isolated lesion of the CNV of the FN is an important problem, since it causes a gross violation of the smile. Currently, there are no protocols for the treatment and rehabilitation of patients in this category. Accordingly, each doctor prescribes the type of treatment and rehabilitation at his own discretion.

It is known that a clinically impaired muscle function can be defined as paresis (reduced muscle strength, restriction of movement) or as plegia (lack of strength, lack of movement). In clinical practice, with muscle paresis, physicians are more likely to observe a favorable outcome (improvement in muscle function or its recovery) with conservative treatment. Even with plegia, the muscle in some cases can be relatively preserved in terms of function recovery (there is no total lesion of the CLF of the FN), therefore, with instrumental data of a favorable outcome (according to needle myography - a decrease in the amplitude of the PI of the affected side with IMG MONH from up to 90% compared with healthy side) usually prescribe conservative treatment. In cases of a high risk of an unfavorable outcome (according to needle myography - a decrease in the amplitude of the PI of the affected side with an IMG MONG of 90% or more compared to the healthy side), the possibility of surgical treatment is considered.

In the available sources of scientific literature, data on the treatment of isolated CLNV lesions are reduced to surgical treatment or the use of botulinum toxin type A (BTA) [Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol. 2011;32(1):1-7. https://doi.org/10.1016/j.amjoto.2009.08.011]. Restoration of facial symmetry is carried out by restoring the dynamic function of MONG on the affected side or relaxing this muscle on the healthy side.

The type of surgical treatment depends on the duration and extent of the lesion. Basically, surgical treatment is offered for clinical muscle plegia. With a short statute of limitations (up to 18 months), to restore muscle function on the affected side, a reinnervation operation is performed using a separate branch of the facial nerve. With plegia of a longer statute of limitations, the use of the following types of surgical intervention is known: autotransplantation of a vascularized muscle flap into the position of the muscle that lowers the lower lip; rotation of the digastric muscle to the position of the muscle that lowers the lower lip; static correction - excision of a fragment of the lower lip. The first two operations correct the affected side. The third operation involves the impact on the healthy side with the off function of the contralateral healthy muscle to create symmetry.

A known method of treatment in the early period with an isolated lesion of the CNF LN [Spira M. Anastomosis of masseteric nerve to lower division of facial nerve for correction of lower facial paralysis. Plast Reconstr Surg, 64 (1978), pp. 330-334], including reinnervation of the muscle by another nerve. However, this method does not guarantee recovery (nerve sprouting), it is traumatic, and there is a risk of loss of function of another nerve. The disadvantage of this method is also the unpredictability of the result and the irreversibility of possible adverse effects, the risk of postoperative complications, the need for total multicomponent anesthesia.

A known method of treatment in the late period with an isolated lesion of the CLNV FN [Conley J., Baker D.C., Selfe R.W. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg, 70 (1982), pp. 569-577; Microsurgical strategies in 74 patients for restoration of dynamic depressor muscle mechanism: a neglected target in facial reanimation. Plast Reconstr Surg, 105 (2000), pp. 1917-1931; Tan S.T. Anterior belly of digastric muscle transfer: a useful technique in head and neck surgery. Head Neck, 24 (2002), pp. 947-954], which includes the restoration of the dynamic function of the muscle due to another muscle, for which the digastric muscle is rotated to the MONG position. However, this method also does not guarantee the restoration of muscle function, it is traumatic. The disadvantage of this method is the unpredictability of the result and the irreversibility of possible adverse effects, the risk of postoperative complications, the intervention under total multicomponent anesthesia.

A known method of treatment for isolated lesions of the CNV LN - injection of BTA into the contralateral MONG [Clark R.P., Berris C.E. Botulinum toxin: a treatment for facial asymmetry caused by facial nerve paralysis. Plast Reconstr Surg, 84 (1989), pp. 353-355], which consists in temporary chemical denervation of a symmetrical muscle and the creation of its paresis, which restores symmetry. The method is relatively safe, but does not improve the function of the affected muscle, only corrects the symmetry. The action of the chemical preparation lasts 4-6 months, the effect is reversible. To maintain symmetry throughout life, the procedure must be repeated every 4-6 months. Also, patients are often psychologically unprepared for artificially created paresis. In addition, bilateral MONH paresis can cause speech and eating disorders.

A known method of treatment for isolated lesions of the CNV FN [Breslow G.D., Cabiling D., Kanchwala S., et al. Selective marginal mandibular neurectomy for treatment of the marginal mandibular lip deformity in patients with chronic unilateral facial palsies. Plast Reconstr Surg, 116 (2005), pp. 1223-1232; Hussain G., Manktelow R.T., Tomat L.R. Depressor labii inferioris resection: an effective treatment for marginal mandibular nerve paralysis. Br J Plast Surg, 57 (2004), pp. 502-510], including surgical denervation of the MONG on the healthy side or excision of a fragment of the lower lip. However, this method also does not allow to restore the function of the affected MONG, but only corrects the symmetry of the face. The disadvantage is the unpredictability of the result and the irreversibility of possible negative consequences, the risk of postoperative complications, the intervention under total multicomponent anesthesia. The patient may also experience discomfort associated with speech and eating disorders due to bilateral muscle paresis. Therefore, before carrying out this surgical intervention, BTA injections are most often preliminarily offered (see above).

Known methods of conservative treatment for lesions of the LN [van Landingham SW, Diels J., Lucarelli MJ Physical therapy for facial nerve palsy: applications for the physician. Curr. Opin. Ophthalmol . 2018;29(5):469-475], including the use of exercise therapy. However, the presented exercise therapy complexes include exercises for all facial muscles and, in most cases, do not include MONG. Thus, the patient loses time and motivation for treatment.

The technical problem is the development of an effective method of conservative treatment of patients with an isolated lesion of the marginal mandibular branch (CNV) of the facial nerve (FN), based on the use of exercise therapy with a targeted effect on MONG.

Disclosure of invention

The technical result of the invention is to enable the recovery of patients with an isolated lesion of the marginal mandibular branch of the facial nerve, with the potential for a favorable outcome of the disease, in a conservative way based on exercise therapy.

The inventive method has a highly effective targeted effect on MONG, is non-invasive, painless, does not require special training of doctors of relevant specialties.

The technical result is achieved by a method of conservative treatment of patients with an isolated lesion of the marginal mandibular branch (CNV) of the facial nerve (FN), including a clinical and instrumental examination of the patient, including an assessment of his neurological status and functional diagnostics of facial muscles, followed by treatment, including exercise therapy.

A distinctive feature of the invention is a set of exercises performed in three stages with a targeted effect on MONG: self-massage - general point of the entire face and local MONG, stimulation of movement through the elements of stretching and contraction of the MONG muscle, control of muscle contraction, while

general point self-massage of the face is performed with the index and middle fingers with moderate pressure from 3 to 5 circular movements along the massage lines, in total from 2 to 5 minutes;

local self-massage MONG is performed on the affected side with the index and middle fingers, moving the lower lip down at least 15 times from 1 to 2 minutes;

stimulation of movement through the elements of stretching and contraction of the muscle during plegia is performed on the affected side with the index and middle fingers of the hand, pushing the lower lip down, with the patient playing the sound “s-s-s”, and stretching the head forward and up; with paresis - the lower lip is lowered down when the sound “s-s-s” is played, followed by an increase in the amplitude of active movement with the help of the fingers, facilitating muscle contraction, and further pushing the lower lip down; then they grab the lip with the thumb and forefinger of the hand (pinch), continuing to lower the lower lip down, while resisting with the fingers against the movement; then they grab the lower lip with the thumb and forefinger of the hand (pinch), pulling it up to 3 seconds, then lower the lower jaw, pulling the lip out from under the fingers, each exercise is performed at least 5 times from 3 to 5 minutes;

control of muscle contraction is performed by stretching the lips into a tube, followed by a series of the following exercises:

"rolling" in the mouth of air from left to right and vice versa at least 5 times no more than 1 minute;

stretching the lips to the sides (smile), with stops during movement every few millimeters, followed by stepwise stretching of the lips into a tube; moving the lips to the right and left (the teeth are closed), with stops during movement every few millimeters; gripping a flat hard object (medical spatula) with the lips and holding for at least 10 seconds in this position and when moving the object with the hands in different directions (up, down, right, left, oblique, deepening inward, etc.), each the exercise of the series is performed at least 5 times from 2 to 5 minutes;

the complex is performed at least 2 times a day until the onset of a therapeutic effect.

Self-massage - general point and local MONG, carried out in the direction from top to bottom (from forehead to neck). The complex is performed within 4 months.

The use of exercise therapy is aimed at targeting the MONG, which can be implemented by the patient independently. The approximate duration of treatment with the achievement of a therapeutic effect is about 4 months, according to the results of which the patient, applying a minimum amount of effort, receives the maximum result - the restoration of muscle function.

Brief description of the drawings

The invention is illustrated by diagrams, diagrams and photographs, where figure 1 shows a photograph of the model indicating the location of the MONG; figure 2 shows the dependence of the IP obtained during the IMG, where the image A shows the unit potential of the motor unit with an arbitrary reduction in MONG, B - the complete absence of the potential of motor units in the reduction of MONG; figure 3 - an example of a comparison of the curves of the interference pattern (IP) of patient No. 2 with a favorable prognosis for recovery: blue curve (1) - IP of the muscle that lowers the lower lip of the healthy side, IP; red curve (2) - tension of the muscle that lowers the lower lip of the affected side, the ratio of the maximum amplitudes of the pattern is 0.45; figure 4 - An example of a comparison of the curves of the interference pattern (IP) of patient No. 5 with an unfavorable prognosis for recovery: the upper curve - IP of the muscle that lowers the lower lip of the healthy side; lower curve - IP of the muscle that lowers the lower lip of the affected side, the ratio of the maximum amplitudes of the pattern is 0.07; in Fig.5 - 7 presents three series of photographs showing the sequence of the patient's instructions to the doctor with the placement of needle electrodes at the identified points corresponding to MONG, PM and the circular muscle of the mouth, respectively; Fig.8 - two series of photographs showing the dynamics of recovery of the function of the muscle that lowers the lower lip, after conservative treatment: patient No. 1, patient No. 2; a - before treatment, b - after 1 month of exercise therapy, c - after 5 months of exercise therapy; in fig. 9 - layout of points for performing general point self-massage; in fig. 10-11 - an example of performing self-massage at certain points; in fig. 12-13 - an example of performing local self-massage MONG; in fig. 14-19 - an example of stimulation of the movement of MONG through the elements of stretching and contraction of the muscle; in fig. 20-41 are examples of exercises with muscle contraction control.

Implementation of the invention

The method of conservative treatment of patients with isolated lesions of the marginal mandibular branch of the facial nerve is as follows.

At the first stage, the patient undergoes a clinical examination with an assessment of the neurological status to exclude other symptoms of damage to the nervous system. Table 1 presents an algorithm for a step-by-step clinical examination of all mimic muscles. With a CLNV lesion, facial asymmetry will be evident when following the instructions "lower your lower lip, say 's-s-s'" and "lift your lower lip up".

Table 1 Mimic muscle function assessment protocol Examined muscle Instruction for the patient Frontal abdomen of the supracranial muscle Raise your eyebrows up Eyebrow wrinkling muscle frown Circular muscle of the eye Close your eyes, close your eyes Muscle that lifts the upper lip and wing of the nose; muscle that lifts the corner of the mouth Show the "grin" of the teeth Minor and major zygomatic muscles Close your lips and smile buccal muscle Close the lips, stretch the corners of the mouth to the sides, pressing the inner surface of the cheeks to the teeth
Blow Laughter muscle Open your lips and smile wide Orbicular muscle of the mouth Pull your lips into a tube Muscle that lowers the corner of the mouth Show a sad smile Muscle that lowers the lower lip Lower your bottom lip, say "y-y-y" Chin muscle Lift your bottom lip up Subcutaneous muscle of the neck Say "y-y-y" and strain your neck

At the second stage, according to the standard protocol, stimulation ENMG is performed to exclude the involvement of other branches of the LN in the pathological process [Nikolaev S.G. Electromyography: clinical practice. Ivanovo: PressSto; 2014. 394 p. [Nikolaev S.G. Electromyography: clinical practice. Ivanovo: PressSto; 2019. 394 p. (In Russ.)].

At the third stage, IMG is performed to confirm the defeat of MONG and PM, its isolation and degree. IMG is performed in all cases where paresis or plegia of MONH or PM is clinically detected, regardless of the results of stimulation ENMG.

Conduct two-channel IMG MONG, then PM, then the circular muscles of the mouth.

The IMG technique is as follows. One monopolar electrode (reference electrode connected to both recording channels through a unipolar socket combiner) is placed subdermally along the lower surface of the mental symphysis so that there is a minimum amount of muscles around the recording surface. The position of this electrode will not change throughout the study.

Evaluate the function of MONG. To determine the location of the MONG, the patient is asked to perform a test: lower the lower lip, say “s-s-s”. Two active monopolar needle electrodes are injected into MONG symmetrically from the affected and healthy sides of the face. The face is at rest. Then the patient is asked to repeat the test: lower the lower lip as much as possible, say “s-s-s” (an attempt to voluntarily contract the muscle), while registering the values of the maximum amplitude of the interference pattern (IP) for MONG from the affected and healthy side of the face, determine the percentage relative decrease in the amplitude of the IP of the affected side relative to the healthy one. Figure 5 shows the sequence of execution by the patient of the doctor's instructions with the placement of needle electrodes at the identified points corresponding to the desired muscle.

Next, evaluate the function of the PM. To determine the location of the PM, the patient is asked to perform a test: "raise the lower lip up." Two active monopolar needle electrodes are alternately injected into the PM symmetrically from the affected and healthy side of the face. The face is at rest. Then the patient is asked to repeat the test: “raise the lower lip up” (an attempt to voluntarily contract the muscle), while registering the values of the maximum amplitude of the interference pattern (IP) for the PM from the affected and healthy side of the face, determine as a percentage the relative decrease in the amplitude of the PI of the affected side relative to the healthy . Figure 6 shows the sequence of execution by the patient of the doctor's instructions with the placement of needle electrodes at the identified points corresponding to the desired muscle.

To confirm the isolation of the lesions of MONH and PM, an additional IMG is performed from the upper portion of the circular muscle of the mouth. To determine the location of the circular muscle of the mouth, the patient is asked to perform a test: "pull your lips into a tube." Two active monopolar needle electrodes are alternately injected into the upper portion of the orbicular muscle of the mouth symmetrically from the affected and healthy side of the face. The face is at rest. Then the patient is asked to repeat the test: “pull the lips into a tube” (an attempt to voluntarily contract the muscle), while registering the values of the maximum amplitude of the interference pattern (IP) for the circular muscle of the mouth on the affected and healthy side of the face, determining the relative decrease in the amplitude of the IP on the affected side as a percentage relatively healthy. Figure 7 shows the sequence of execution by the patient of the doctor's instructions with the placement of needle electrodes at the identified points corresponding to the desired muscle.

At the fourth stage analyze the result and determine the tactics of treatment depending on the degree of damage to the muscles under study. If a relative decrease in the amplitude of IP by 15% or more for MONG and PM, and a decrease in the amplitude of IP up to 15% for the orbicular muscle of the mouth, a conclusion is made about an isolated lesion of the CNV of the FN, while in the case of a decrease in the amplitude of the IP of the affected side with IMG MONG by 90% or more, compared with the healthy side, decide on surgical treatment due to the presence of a high risk of an unfavorable outcome of conservative treatment, from 15 to 90% - conservative treatment using exercise therapy, with a decrease in the IP amplitude value by less than 15% - treatment is not recommended.

At the fifth stage, exercise therapy is prescribed, which is carried out in three stages.

The first stage: general point self-massage of the whole face and local self-massage MONG.

General point self-massage of the face is performed, for example, 2 times a day for 2-5 minutes. Why at each point (Fig. 9) index and middle fingers with moderate pressure make 3-5 circular movements (Fig. 10-11);

Local self-massage MONG is performed, for example, 3-4 times a day for 1-2 minutes. Why in the area under the lower lip on the affected side (Fig. 1) have the index and middle fingers of the ipsilateral side and with moderate pressure shift (pull) the lower lip down, for example, 20 times (Fig. 12-13);

The second stage: stimulation of movement through the elements of stretching and contraction of the muscle.

The index and middle fingers of the hand are placed on the affected side (Fig. 1) and with moderate pressure the lower lip is pushed down, pronouncing the sound "s-s-s" (Fig. 14). Further, a complication is performed - during the exercise, the patient simultaneously stretches his head forward and upward (if there is movement in the muscle, then the fingers only help to increase the amplitude of movement, facilitating muscle contraction) (Fig. 15).

Each exercise is repeated, for example, 5 times.

Next, with the thumb and forefinger of the hand (pinch), the patient grabs the lower lip from the affected side (Fig. 16), after which 1) lowers the lower lip down, pronouncing the sound “s-s-s”, while resisting the fingers against the movement (Fig. 17), 2) pulls the lip up to 3 seconds (Fig. 18), 3) then pulls the lip up to 3 seconds and lowers the lower jaw, trying to pull the lip out from under the fingers (Fig. 19). Each exercise is repeated 5-10 times, in total from 3 to 5 minutes.

Third stage: control of muscle contraction.

At this stage, perform the following exercises.

1. The lips are pulled into a tube and the air is “rolled” in the mouth from left to right and vice versa (Fig. 20-21). The exercise is repeated 5-10 times, no more than 1 minute.

2. The lips are pulled into a tube (the teeth are closed) and the lips are first moved to the right, while during the movement they stop every few millimeters and continue stretching (5 steps); then - also to the left (Fig. 22-24). The exercise is repeated 5-10 times for each side, in total from 2 to 5 minutes.

3. The closed lips are stretched to the sides (smile), during the movement they stop every few millimeters and continue stretching (5 steps) (Fig. 25-27). Next, the lips are pulled back in the same step into a tube (5 steps) (Fig. 28-30). The exercise is repeated 5-10 times, in total from 2 to 5 minutes.

4. The medical spatula (or card) is grasped with the lips and held by them (Fig. 31), moving the spatula in different directions (straight - up - down, straight - right - left, straight - oblique up to the right - obliquely up to the left, straight - deepening inward - pushing outward) (Fig. 32-41). Each exercise is repeated 5-10 times, in total from 2 to 5 minutes.

Examples of the implementation of the invention

The data of a series of clinical observations of patients who applied to the Sklifosovsky Research Institute for Emergency Medicine with complaints of isolated smile asymmetry (n=6) are presented. The characteristics of the observation group are presented in Table 2. The ratio of women and men is 5:1, age 40 (33.8; 44) years, according to social status - working. The term for seeking medical care was 34.5 (13; 44) days from the onset of the disease. In the anamnesis, the patients had various medical manipulations - dental, cosmetic, surgical interventions in the neck and injuries followed by surgical intervention. Neuroimaging (magnetic resonance imaging) was performed, alternative diagnoses were excluded. There were no positive dynamics in patients at the time of the initial treatment. Patients underwent clinical and instrumental diagnostics according to the above method.

The clinical examination of the patient included an assessment of the neurological status and functional diagnostics of the facial muscles, including MONH and PM. All patients were diagnosed with an isolated disorder - MONH plegia.

Further, stimulation ENMG was performed and no decrease in M-wave amplitudes was recorded in all examined patients, thus, involvement of other branches of the FL in the pathological process was excluded.

Then IMG MONG and PM were performed to confirm the lesion and assess its degree. The ratio of the maximum amplitudes of IP MONG was estimated. It was revealed that in all patients the change in attitudes exceeded 15%. Moreover, in two patients it exceeded 90%. IMG was also performed with PM. A change in the ratio of the maximum IP amplitudes was revealed, however, total dysfunction of this muscle was not observed even in patients with a difference in the maximum MONG IP amplitudes between the healthy and the affected side of more than 90%.

To confirm the isolation of the lesions of MONG and PM, an additional IMG was performed from the upper portion of the orbicular muscle of the mouth. The difference in the change in relations did not exceed 15%.

In accordance with the results obtained, the prognosis for recovery was determined and the tactics of management were chosen. The prognosis of functional recovery in patients with a difference in the ratio of the maximum amplitudes of IP less than 90% was defined as favorable, and more than 90% - as unfavorable. Patients with a favorable outcome were referred for conservative treatment (exercise therapy), and patients with an unfavorable outcome - for surgery with subsequent rehabilitation. Description of examples (patients #1 - 6) is presented in Table 2.

Patient #4 reported that she did not perform exercise therapy.

Patients with a poor prognosis of the disease (patient No. 5 and patient No. 6) were recommended surgical treatment. The scope of the surgical intervention was the plasty of the CNV FN with an insert from the greater ear nerve. Patient No. 5 consented to surgical treatment, in the postoperative period for a period of 2 weeks after the removal of sutures, he was also recommended a complex of exercise therapy. Patient No. 6 refused surgical treatment, so she was trained in exercise therapy.

Patients were monitored once a month until full recovery or up to 1 year, conclusions were drawn about the outcomes of the disease. Patients No. 1, No. 2, No. 3 with a favorable outcome and regular exercises noted a positive dynamics of smile symmetry for a period of 1 month, a complete recovery occurred at a period of 4-5 months (Fig. 8). Patient No. 4, despite a favorable prognosis, refused exercise therapy, a year after the moment of treatment there was no positive dynamics, therefore, a smile correction was performed - reversible chemical denervation of the MONH of the healthy side using BTA injections. Patient No. 5 with an unfavorable prognosis after surgical treatment noted an improvement for a period of 4-5 months. Patient No. 6 with an unfavorable prognosis was referred for surgical treatment, but refused it, therefore she was trained in the exercise therapy complex, despite regular classes - no positive dynamics were observed. Figure 8 shows the dynamics of recovery of muscle function, lowering the lower lip after conservative treatment: patient No. 1, patient No. 2; a - before treatment, b - after 1 month of exercise therapy, c - after 5 months of exercise therapy.

Exercise therapy patients No. 1, 2, 3, 5, 6 performed according to the scheme shown in Fig.9 - 41.

At the first stage, patients performed general and local self-massage.

General point self-massage of the face was performed 2 times a day for 5 minutes. In each of the points shown in Fig.9 (in the forehead area, 4 points on each half of the face, in the cheek area, 2-3 points were determined along 3 massage lines, in the chin area, 1 point in the middle) with the index and middle fingers with moderate pressure made 3-5 circular motions (Fig.10, 11); the sequence of displacement by points was from the center to the periphery, from top to bottom. At the beginning of treatment, patients needed more time to perform general acupressure self-massage, however, already on the 3rd-4th day of treatment, patients noted progress in the technique of performing self-massage;

Further, after acupressure self-massage, patients performed local MONG self-massage 3-4 times a day for 1-2 minutes. In the area under the lower lip on the affected side (figure 1) had the index and middle fingers from the ipsilateral side and with moderate pressure shifted (pulled) the lower lip down about 20 times (fig. 12, 13). The exercise was performed against the background of complete relaxation of the face, slowly, holding the MONG in the extreme position.

At the second stage, MONG movement was stimulated through the elements of muscle stretching and contraction.

The index and middle fingers of the hand were placed on the affected side and with moderate pressure they pushed the lower lip down, pronouncing the sound "y-y-s". Further, a complication was performed - during the exercise, the patient simultaneously stretched his head forward and upward (if there is movement in the muscle, then the fingers only help to increase the amplitude of movement, facilitating muscle contraction) (Fig. 14, 15, 16, 17). Each exercise was repeated 5 times.

Next, with the thumb and forefinger of the hand (pinch), the patient grabbed the lower lip from the affected side, after which

1) lowered the lower lip down, pronouncing the sound "s-s-s", while resisting the fingers against the movement (Fig. 18), and

2) pulling the lip up to 3 seconds, then lowering the lower jaw, trying to pull the lip out from under the fingers (Fig. 19).

Each exercise was repeated 5-10 times.

The time for performing the exercises of the second stage did not exceed 5 minutes. However, the process of training at this stage is quite dynamic and required attention and effort on the part of the patient.

At the third stage, the patients performed several exercises with the control of muscle contraction.

1. The lips were stretched into a tube and air was “rolled” in the mouth from left to right and vice versa (Fig. 20, 21). The exercise was repeated 5-10 times no more than 1 minute.

2. The lips were stretched into a tube (teeth closed) and moved first to the right, while during the movement they stopped every few millimeters and continued stretching (5 steps); then also to the left (Fig. 22, 23, 24). The exercise was repeated 5-10 times for each side, no more than 5 minutes.

3. The closed lips were stretched to the sides (smile), during the movement they stopped every few millimeters and continued stretching (5 steps). (Fig. 25, 26, 27). Next, the lips were pulled back into a tube in the same step (5 steps). (Fig. 28, 29, 30). The exercise was repeated 5-10 times, no more than 5 minutes.

4. The medical spatula (or card) was grabbed with the lips and held by them, moving the spatula in different directions (straight - up - down, straight - right - left, straight - obliquely up to the right - obliquely upwards to the left, straight - deepening inward - pushing out outside). (Fig. 31 - 41). Each exercise was repeated 5-10 times, no more than 5 minutes. This exercise caused the greatest difficulty in performing, so at first the patients held the spatula for no more than 3 seconds, but over time, the holding time of the object increased to 10 seconds.

Thus, the claimed method of conservative treatment of patients with an isolated lesion of the marginal mandibular branch (CNV) of the facial nerve makes it possible to restore smile symmetry in patients with the potential for a favorable outcome of the disease, is non-invasive, painless, does not require special training of doctors of the relevant specialties.

Claims (14)

1. A method of conservative treatment of patients with an isolated lesion of the marginal mandibular branch (CNV) of the facial nerve (FN), characterized in that a complex of physiotherapy exercises (exercise therapy) is carried out, which includes three stages: at the first stage, a general point self-massage of the face is carried out at each point, in accordance with figure 9, the index and middle fingers perform 3-5 circular movements, 2 times a day for 2-5 minutes; and also carry out local self-massage of the muscle that lowers the lower lip (MONG), while in the area under the lower lip on the affected side, the index and middle fingers of the ipsilateral side are placed and the lower lip is pulled down 20 times, performed 3-4 times a day, 1- 2 minutes; at the second stage, the index and middle fingers of the hand are placed on the affected side and the lower lip is pushed down, pronouncing the sound “s-s-s”, the exercise is repeated 5 times, then the patient simultaneously stretches his head forward and up during the exercise, the exercise is repeated 5 times ; then, with a thumb and forefinger, the patient grabs the lower lip from the affected side with a pinch, after which: lowers the lower lip down, pronouncing the sound “s-s-s”, while resisting the fingers against the movement; pulls the lip up to 3 seconds; then pulls the lip up to 3 seconds and lowers the lower jaw, trying to pull the lip out from under the fingers, each exercise is repeated 5-10 times, in total from 3 to 5 minutes; At the third stage, the following exercises are performed: lips are stretched into a tube and air is rolled in the mouth from left to right and vice versa, the exercise is repeated 5-10 times, no more than 1 minute; the lips are pulled into a tube, the teeth are closed and the lips are first moved to the right with stops during movement, followed by a stepwise extension of the lips into a tube, then also to the left, the exercise is repeated 5-10 times for each side, in total from 2 to 5 minutes; closed lips are stretched to the sides in a smile with stops during stretching, followed by stepwise stretching of the lips into a tube, the exercise is repeated 5-10 times, in total from 2 to 5 minutes; the medical spatula is grasped with the lips and held by them, moving the spatula in different directions, namely straight - up - down, straight - right - left, straight - obliquely up to the right - obliquely upwards to the left, straight - deepening inward - pushing outwards, each exercise repeat 5-10 times, only from 2 to 5 minutes; the complex is performed at least 2 times a day until the onset of a therapeutic effect. 2. The method according to claim 1, characterized in that self-massage - general point and local MONG - is carried out in the direction from top to bottom - from the forehead to the neck. 3. The method according to claim 1, characterized in that the complex is performed for at least 4 months.

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