Abstract
Background:
Bell's palsy is an acute idiopathic paralysis of lower motor neurons on only 1 side of the face without any identifiable etiology. The condition affects a patient's physical, social, and psychologic health. It is important for the patient to recover quickly and minimize the risk of long-term sequelae. Therefore, researchers recommend a combination of several therapeutic modalities to shorten the disease's course and improve curative effects.
Case:
A 34-year-old woman had with right facial weakness. She was diagnosed with House–Brackmann grade III Bell's palsy and received medical therapy. She was also given manual acupuncture at GB-20, BL-2, ST-36, LI-4, TE-5 bilateral, and GV-20. Penetrating needling was given at GB-14 toward Ex-HN-3, ST-7 toward SI-18, SI-18 toward LI-20, ST-6 toward ST-4, and ST-5 toward ST-4 on the affected area, with a 30-minute needle retention. Electroacupuncture (EA) was delivered at ST-7–SI-18, ST-6–ST-5, GB-14–Ex-HN-5, and ST-4–CV-24, with a dense–disperse wave, at a frequency of 10/50 Hz for 20 minutes. She had treatment sessions twice per week, for a total of12 sessions.
Results:
From her 7th to 12th visit, this patient had reached House–Brackmann grade I. No adverse effects occurred.
Conclusions:
In this patient, a combination of acupuncture penetrating needling technique and EA played a role to shorten her recovery time and minimize the risk of sequelae of Bell's palsy. The treatment combination used in this case report can be considered in other clinical cases.
Keywords: Bell's palsy, penetrating needling, electroacupuncture, case reports
INTRODUCTION
Bell's palsy is an acute mononeuropathy related to paresis of the facial nerve without any unidentifiable cause. This disease may impact a patient's physical, social, and psychologic life.1 The severity of Bell's palsy is rated on the 6-point House–Brackmann scale; grade I corresponds to normal facial nerve function and grade VI corresponds to complete paralysis.2 Bell's palsy may cause sequelae such as paresis, contracture, facial spasm, or synkinesis.1 Acupuncture has been widely used all over the world to treat Bell's palsy, with an effective rate of more than 90%, equivalent to conventional medicine, and without any serious adverse effects. A combination of acupuncture and Western medicine can improve the recovery rate of patients who have facial paralysis, shorten their healing time, and reduce the incidence of complications. The combination of more than 1 therapeutic modality is recommended to produce a better and faster clinical effect.3
CASE
A 34-year-old woman complained of weakness in the right side of her 2 days prior to presenting. Her right eyebrow had ptosis, the corner of her right lip was tilted and did not react when she smiled, and she drooled when gargling. She also had a complete right eyelid closure and lacrimation of the right eye. A week prior, she had experienced a right-sided headache with no throbbing. She did not have slurred speech nor a tilted tongue. She was often exposed to air conditioning on the right side of her face during sleep at night.
There was no history of fever, trauma, muscle weakness, or stiffness. She did have a history of varicella during high school, and her father had developed Bell's palsy 1 year prior.
A physical examination revealed the following: vital signs and sensory reactions were within normal limits. She had disappearance of a right forehead wrinkle, a flattened right nasolabial fold, occasional lagophthalmos of her right eye (which closed perfectly with minimal effort), ptosis of the right eyebrow, and a “hanging corner” of her mouth (Fig. 1). .
FIG. 1.
Several views of the patient's condition before acupuncture therapy. Photos published with patient permission.
When she visited a neurologist, she was diagnosed as having House–Brackmann III Bell's palsy. She was prescribed 4 mg of methylprednisolone and mecobalamin twice daily, and methisoprinol 500 mg 4 times daily by neurologist
This patient continued her medication as prescribed by the neurologist. In addition, she also received acupuncture therapy. Acupuncture therapy using filiform needles (Huanqiu, Suzhou, China), sizes 0.25 x 25mm and 0.25 x 40mm, twice per week. Manual acupuncture performed at GB-20, BL-2, ST-36, LI-4, TE-5 bilateral, and GV-20. Penetrating needling (Fig. 2) was applied at GB-14 toward Ex-HN-3, ST-7 toward SI-18, SI-18 toward LI-20, ST-6 toward ST-4, and ST-5 toward ST-4 on the affected area, with a 30-minute needle retention. During the patient's fourth treatment, an electroacupuncture (EA) machine (Hwato SDZ-V, Suzhou, China) was used to deliver EA at ST-7–SI-18, ST-6–ST-5, GB-14–Ex-HN-5, and ST-4–CV-24, with a dense-disperse wave, at a frequency of 10/50 Hz for 20 minutes. Treatment sessions were twice per week, for a total of 12 sessions.
FIG. 2.
Schematic picture of acupoints used in the penetrating needling technique.
RESULTS
From her 7th to 12th visit, this patient had reached House–Brackmann grade I. No adverse effects occurred (Fig. 3). Acupuncture sessions, progress, and acupuncture therapy given are shown in Table 1.
FIG. 3.
Patient's condition at the seventh acupuncture therapy session. Photos published with patient permission.
Table 1.
Patient Assessments and Therapy
| Session # | Assessment | Acupuncture therapy |
|---|---|---|
| 1st–3rd | Bell's palsy (right side) House–Brackmann class III |
Manual acupuncture at GB-20, BL-2, ST-36, LI-4, TE-5 bilateral, & GV-20; retention 30 min Manual acupuncture penetrating needling technique on the right face area at GB-14 to Ex HN-3, ST-7 to SI-18, SI-18 to LI-20, ST-6 to ST-4, & ST-5 to ST-4; retention 30 minutes. Thermal therapy with TDP lamp on the right face area for 15 min |
| 4th | Bell's palsy (right side) House–Brackmann class II |
Same as previous sessions Electroacupuncture at ST 7–SI-18, ST-6 –ST-5, GB-14–Ex-HN-5, & ST-4–CV-24; dense–disperse wave; 10/50 Hz frequency; intensity 2; duration: 20 min |
| 5th–6th | Bell's palsy (right side) House–Brackmann class II |
No TDP therapy Other therapies continued |
| 7th–12th | Bell's palsy (right side) House–Brackmann class I |
No TDP therapy Other therapies continued |
Min, minutes; TDP, teding diancibo pu, mineral heat lamp.
The patient signed informed consent for the acupuncture therapy and publication of this report. This case was reported according to the CARE guidelines.4
DISCUSSION
One of the prognostic factors for idiopathic facial paralysis is the condition of the facial nerve within 1 week of onset, and management in the acute phase of the disease determines the fate of the facial nerve and recovery of facial function.5 Acupuncture therapy for facial paralysis is performed as early as possible to reduce facial-nerve edema and prevent pathologic changes, as well as degeneration and demyelination of facial-nerve axons effectively.6 Therefore, this patient was given acupuncture therapy on the third day.
Penetrating needling is a safe, easy technique that can minimize the number of needles used.7 Modern anatomy shows that a branch of the auricularis-magnus nerve and a branch of the mandibular nerve of the facial nerve pass through ST-6. When ST-6 is needled toward ST-4, the facial mimetic (m.) muscles—such as the m. masseter, m. albinus, m. zygomaticus, m. depressor anguli oris, and m. orbicularis oris, which are innervated by the facial nerve—will be stimulated.8
Sequelae of peripheral facial-nerve paralysis are often associated with fibrosis or incomplete restoration of mimetic muscles' function (m. levator labii superior, m. orbicularis oris, and m. zygomaticus) innervated by the mandibular branch of the facial nerve. The penetrating needling from ST-7 to SI-18, from ST-6 to ST-4, and from ST-5 to ST-4 stimulates the mimetic muscles innervated by the mandibular, buccal, and zygomatic branches of the facial nerve in the lesion area. Thus, this treatment improved this patient's motor function of her cheeks and the area around her mouth.9,10
Facial acupoints work locally on muscles involved in facial expression. BL-2 is located at the m. orbicularis oculi, which is innervated by the temporal branch of the facial nerve. GB-14 is located at the m. frontalis, which plays a role in raising the eyebrows and forming transverse wrinkles on the forehead. The GB-14 point is innervated by the temporal branch of the facial nerve.10 BL-2 and GB-14 were chosen to treat the patient's lagophthalmos and disappearance of forehead wrinkles.
GV-20 and ST-36 were chosen because they could increase expression of brain-derived– and glial cell-line derived–neurotrophic factors and basic fibroblast growth factor. Addressing these points also reduces tumor necrosis factor–α production, increases macrophage activity, and reduces inflammation. LI-4 was chosen to modulate the cerebellum in order to reduce abnormal connection functions in this patient who had Bell's palsy.11
EA was chosen as a therapeutic modality because it has a prominent effect for treating Bell's palsy. EA objectively provides the amount of stimulation needed by a patient. However, using EA in the acute phase of Bell's palsy remains controversial. Some researchers have argued that EA should not be used in the acute phase of Bell's palsy because EA is more likely to aggravate facial-nerve edema and bioelectric-conduction disorders.12,13 Yet, some researchers have shown that early EA therapy shortens the disease course and improves the curative effect.13 Therefore, this patient was given EA during her fourth therapy session.
Low-frequency EA (2–4 Hz) can release endorphins and cortisol, which are important for the anesthetic and anti-inflammatory effects of acupuncture. High frequencies might cause muscle spasms because there is no time to relax between contractions. When low-frequency stimulation is used, strong intensity is required to ensure that the stimulation is delivered sufficiently to generate an action potential. However, strong intensity might cause muscle contractions to be too strong and the patient might feel pain. Thus, for this patient, a 10/50 frequency, dense–disperse wave was used to balance the need for low and high frequency.14
In the first 4 sessions of therapy, she was given TDP (teding diancibo pu, mineral heat lamp) therapy on the right side of her face. The combination of acupuncture and thermal therapy with TDP had anti-inflammatory benefits, improved her microcirculation, and enhanced her tissue healing.15 During TDP therapy, her eyes were covered with gauze to protect her corneas. She did not experience discomfort or adverse effects from the TDP.
CONCLUSIONS
This patient did not experience any adverse effects during acupuncture therapy. She reported that acupuncture helped her recover faster from Bell's palsy, and that, during the acupuncture sessions she did not feel any pain, felt relaxed, and sometimes fell asleep.
Her condition returned to House–Brackman grade I without any complaints since the her seventh treatment, and remained stable until the twelfth session. This combination of the acupuncture penetrating needling technique and EA helped shorten her recovery time and minimized her risk of sequelae of Bell's palsy. However, it is too early to conclude its effectiveness in larger clinical settings; thus, this case report is a demonstration to be considered in other clinical cases
AUTHORs' CONTRIBUTIONS
Viventius was the medical supervisor and, together with Nareswari, the physicians in charge of this case, Mardiana wrote the article and Djaali provided publication consultation
AUTHOR DISCLOSURE STATEMENT
No competing financial interests exist.
FUNDING INFORMATION
There was no financial support from any organization for work on this case or article.
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