Patterns of involvement of facial muscles during epileptic and nonepileptic events: review of 654 events.

We reviewed the patterns of involvement of the orbicularis oculi and other facial muscles during 654 events recorded in 257 patients undergoing telemetry evaluation. Four hundred fifty-seven episodes represented epileptic seizures and 197 represented psychogenic seizures. Eyes were wide open in more than 90% of patients during the tonic phase of a generalized tonic clonic seizure. Lowering of the lid with partial closure of the eye, without contraction of the orbicularis oculi, was the predominant form of eye closure we observed. Eye closure in any form was uncommon during the ictal stage of epileptic seizures with motor accompaniment and occurred in 21 of 408 cases and in 2 of 49 simple partial seizures somatosensory type. Sustained, forceful eye closure with active opposition to opening was present in 41 of 75 cases of psychogenic seizures with motor symptoms and in 16 of 21 cases of psychogenic unresponsiveness and was much less common with psychogenic seizures with pure sensory symptoms (8 of 72 cases). The mouth is usually wide open during the tonic phase of a generalized convulsion. The presence of a clenched mouth during a "tonic spell" should raise the possibility of psychogenic seizures. Injuries to the tongue due to biting during the epileptic seizures usually affect the side of the tongue. Biting of the lip or tip of the tongue was not seen with epileptic attacks and is also suggestive of psychogenic seizures.