Case Report

Acupuncture in the Treatment of Bell’s Palsy in the Acute Phase: Two Case Reports

Haiping Shi MM^1,2, Xinyuan Deng BM2, Fei Lu2, Xiaowei Li BM2, Yuling Shu BM2, Yu Zhang MD^1,2* and Jun Yang MD^1,2*

¹The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, Anhui, China

²Anhui University of Chinese Medicine, Hefei, Anhui, China

Submission:September 28, 2023;Published: October 09, 2023

*Corresponding author: Yu Zhang, Jun Yang, The First Affiliated Hospital of Anhui University of Chinese Medicine, Anhui University of Chinese Medicine, Hefei, Anhui, China

How to cite this article: Haiping Shi MM, Xinyuan Deng BM, Fei Lu, Xiaowei Li BM, Yuling Shu BM, et al. Acupuncture in the Treatment of Bell’s Palsy in the Acute Phase: Two Case Reports. J Yoga & Physio. 2023; 11(1): 555802.DOI:10.19080/JYP.2023.11.555802

Abstract

Introduction: Bell’s palsy is a sudden peripheral facial paralysis (PFP) that accounts for about 75% of acute facial paralysis. Although Bell’s palsy is a self-limiting disease, some patients have severe sequelae that affect physical and mental health and reduce quality of life. It has been shown that acupuncture treatment in the acute phase can promote facial nerve recovery. Professor Jun Yang recommended acupuncture interventions for the acute phase, and his academic ideology guided the clinical effects of acupuncture on Bell’s palsy.
Case Summary: The first patient was a 38-year-old man. After staying up late, he developed symptoms such as disappearance of forehead wrinkles on the right side of his face, hypophasis, and the corner of mouth tilted to the left. The course of the disease lasted five days. The second patient, a 47-year-old male, developed muscles movement disorder on the left side of his face after riding his bicycle to catch a breeze at night. The illness lasted four days. Both patients were diagnosed with acute phase of Bell’s palsy. Under the guidance of professor Yang, the acupuncture treatment was given based on pattern identification. Two patients had a treatment course of less than four weeks, and the treatment effect was remarkable. The facial nerve function was basically normal.
Conclusion: Acupuncture in acute phase interventional treatment of Bell’s palsy can be effective in improving clinical symptoms and promoting recovery of facial nerve function. However, more rigorous Randomized Controlled Trials (RCTs) are needed to further confirm the effectiveness and safety of acupuncture treatment in acute phase of Bell’s palsy, as well as whether it can shorten the course of the disease and accelerate the recovery of facial nerve.

Keywords: Acupuncture; Bell’s Palsy; Acute Phase; Case Report

Abbreviation: PFP: Peripheral facial paralysis; RCT: Randomized Controlled Trial; TCM: Traditional Chinese medicine; MM: Millimeter; MSUS: Musculoskeletal ultrasound; SEMG: Surface electromyography; RMS: Root mean square; H-B: House-Brackmann Facial Nerve Grading System; SFGS: Sunnybrook Facial Grading System; FDI: Facial Disability Index scale; FDIp: Physical function scale of FDI; FDIs: Social function scale of FDI.

Introduction

Bell’s palsy is a sudden acute idiopathic PFP, accounting for about 75% of acute facial paralysis [1]. Its incidence ranges from 11 to 53 cases per 100,000 people per year, accounting for 60% to 75% of all unilateral facial paralysis [2], and the age of onset is usually between 15 and 40 years [3,4]. The etiology and pathogenesis of Bell’s palsy remain unclear, which may be related to autoimmune system diseases, infections, ischemic injury, and genetic factors causing facial nerve edema [5-7]. Traditional Chinese medicine (TCM) believes that the cause of PFP includes two parts: one is the internal cause such as lack of healthy qi,the other is the external cause such as wind cold, windy heat, and other pathogenic factors. PFP is a lesion of the face, and the disease is Young’s syndrome; It is also a lesion of the muscles, and the disease is superficial syndrome.

The onset of Bell’s palsy within 7 days is called the acute phase, 8 - 20 days is called the resting phase, and beyond 21 days is called the recovery phase [8-11]. The disease has no apparent seasonal, mostly cold history, fatigue history, etc. Most clinical symptoms are one-sided muscle movement disorders such as decrease or disappearance of the forehead wrinkles, hypophasis, involuntary tears, restricted eyebrow raising, crooked the corner of mouth, etc., which may be accompanied by abnormalities in hearing and taste. In modern medicine, drug treatment for Bell’s palsy mainly includes hormones, antivirals, nutritional nerve, etc. [12,13] nondrug therapy includes surgery [14], acupuncture [15], tuina and other physical therapies. The World Health Organization has already recommended that PFP be one of the leading diseases treated with acupuncture.

Modern studies have shown that acupuncture in treatment of PFP can adjust the functional recombination between the motor cortex of the brain and promote its functional recovery [16] Another study found that moderate acupuncture in patients with PFP could help repair damaged nerves [17] The intervention in the acute phase has a great influence on the course of the disease [18]. The lesion site of the acute phase of Bell’s palsy is relatively superficial and acupuncture can remove the evil and reconcile the qi and the blood. The distribution area of facial nerve extracranial segment is extensively stimulated by acupuncture to stimulate nerve excitability and promote the repair and regeneration of damaged nerve fibers and muscles [19].

Professor Jun Yang advocates treating Bell’s palsy in its acute phase. He proposed “early intervention and appropriate treatment”. Through the clinical experience in the treatment of PFP, Professor Yang summed up the theory of “based on the meridians”, “treatment based on pattern identification” and “pay attention to acupoints” to guide the acupuncture treatment of Bell’s palsy in the acute phase. This paper reports on two cases of acute phase of Bell’s palsy treated with acupuncture under the guidance of Professor Yang’s theory with promising results.

Case Reports

Case 1

Patient 1, a 38-year-old male, was seen at the Acupuncture and Rehabilitation Department of the First Affiliated Hospital of Anhui University of Chinese Medicine on October 30, 2022.Patient 1 stayed up until 1 a.m. on October 25, 2022, to work. He woke up the next morning and noticed that water was leaking from the right corner of his mouth while he was brushing his teeth but took no notice of it. In the afternoon, while consciously drinking water, he felt the leak in the right corner of his mouth worsen, his right forehead wrinkles disappeared, and his right eye failed to close properly. The patient did not take any medication and did not seek medical attention. After five days, the above symptoms did not improve in any way and seriously affected his daily life, preventing him from socializing properly. Therefore, he came to our hospital on 30th October 2022. It was the first time he had ever had the condition. He was usually in good health and had no previous underlying diseases such as hypertension, diabetes mellitus or coronary heart disease, and had no bad habits such as smoking or drinking. The patient had been staying up late and working frequent overtime in the last month.

The clinician at our Acupuncture and Rehabilitation Department examined the patient: His temperature was 36.7℃, his heart rate 78 beats/min, his respiratory rate 19 beats/min, and his blood pressure 130/76 mmHg.Patient 1 was conscious and fluent in answering, the right forehead wrinkles were missing, the eyebrow lift was limited, and the right eye could not be closed, revealing the white eye about 4 millimeter (mm); The right nasolabial groove was missing, the corner of mouth tilted to the left, and the right corner of mouth leaked water when drinking. No shingles were seen in the external auditory canal, and both sides of the mastoid process without obvious tenderness or abnormal taste. The patient accepted the following examinations.
1. Musculoskeletal ultrasound (MSUS) (FUJIFILM, Tokyo, Japan) was used to examine the main trunk of facial nerve from the foramina Stylomastoideum to the parotid gland. The diameter, echo characteristics and echo resolution of the facial nerve were measured. The diameter of the facial nerve on the patient’s healthy (left) side was observed to be 1.5 mm with uniform echogenic intensity. The diameter of the affected (right) facial nerve was 2.0 mm and the echogenic intensity was heterogeneous. Oedema was visible on the affected facial nerve. The results were shown in (Figure 1a, 1b).
2. Using surface electromyography (sEMG) (VISHEE, Nanjing, China) symmetrically measured the root mean square mean (RMS mean) of the frontal muscle group, zygomatic muscle group and orbicularis oris muscle group on the affected and healthy sides of the face of patients. When the muscle contractile force is weakened, the bioelectrical signal is weakened, and the RMS mean decreases. The RMS mean ratio between the affected side and the healthy side was calculated separately for each of the three pairs of muscle groups, and the higher the ratio, the better the patient’s recovery. The RMS mean of all three pairs of muscle groups was shown in (Figure 2) and Annex 1: The RMS mean of the affected (right) side was lower than that of the healthy (left) side, which showed that the muscle strength of the affected side was significantly weaker than that of the healthy side. The RMS mean was slightly higher on the healthy (left) side of the patient, with a possible compensatory excitation of the left facial muscle. The RMS mean ratio of the affected side to the healthy side was 0.824 for the frontal muscle group, 0.645 for the zygomatic muscle group and 0.889 for the orbicularis muscle group.
3. Facial nerve function scoring scales including House- Brackmann Facial Nerve Grading System (H-B), Sunnybrook Facial Grading System (SFGS), Facial Disability Index scale (FDI) (composed of the physical function scale of FDI (FDIp) and the social function scale of FDI (FDIs)), palpebral insufficiency scale and sagging mouth scale were used to evaluate facial nerve function. The results were shown below (Table 1) Grade Ⅳ on the H-B, a score of 33 on the SFGS, scores of 20 and 10 on the FDIp and FDIs respectively, grade Ⅱ on the palpebral insufficiency scale and gradeⅠon the sagging mouth scale, suggesting impairment of facial nerve function.

Combined with the medical history, symptoms, physical signs and examination results, the patient was diagnosed with Bell’s palsy, which was acute for five days. The clinician informed the patient about the treatment plan of acupuncture for Bell’s palsy in the acute phase. The patient agreed and signed an informed consent for the first acupuncture therapy.

Use disposable sterile acupuncture needle (Tianxie Acupuncture needle, Suzhou Tianxi Acupuncture Instrument Co., Ltd., China) with a diameter of 0.25mm and a length of 25mm. The acupoints were mainly selected at hand and foot Yangming meridian. The main acupoints include: Qianzheng (Ex-HN 16), Touwei (ST 8), Hegu (LI 4). Secondary acupoints include: Yangbai (GB 14), Cuanzhu (BL 2), Yuyao (EX-HN 4), Sibai (ST 2), Yingxiang (LI 20), Shuigou (DU 26) and Chengjiang (EN 24). Zusanli (TB 36) was added based on pattern identification because of the patient’s illness after fatigue. For the above points, the healthy (left) side of Hegu was selected, the bilateral side of Zusanli was selected, and the other points of affected (right) side were selected. The patient naturally places his hands on his abdomen and lay supine on the treatment bed. Seventy-five percent alcohol was used to sterilize the local skin at the acupressure site.

The acupuncturist quickly inserted the acupuncture needle vertically or obliquely into the acupoints, and then combined with techniques such as twisting the needle, the needle was left for 30 minutes after deqi (there was a tight and astringent feeling under the needle, or the patient felt sore and swollen). The tip of the needle should be upward when acupuncture Yingxiang. When acupuncture Qianzheng, there should be a sense of sore and swollen around the ear. The (Figure 3) showed Patient 1 receiving acupuncture therapy. After acupuncture, asked the patient to keep his face warm and avoid getting cold. Acupuncture therapy was performed every other day. Two weeks was a course of treatment. There were no additional treatments except acupuncture (such as western medicine, electrical stimulation, moxibustion and so on). Facial nerve function was assessed weekly after treatment and the recovery of facial nerves was monitored.

The detailed results were shown in (Table 1). Patients’ facial symptoms did not improve significantly during the first two weeks of treatment. But in the third week, the patient developed small forehead wrinkles on the right forehead, and improved the degree of palpebral insufficiency gradually, and the mouth no longer leaked more water when drinking. These improvements had given patients a great deal of confidence. After two weeks of continued treatment, facial nerve function was largely restored, the forehead wrinkles and nasolabial groove appeared consistent with the left side, the right eyelid was able to close properly, and the corner of the mouth did not leak when drinking. Re-examination of MSUS (Figure 4a, 4b) showed that the diameter of the facial nerve on the affected (right) side of the patient was 1.4 mm, and the diameter of the healthy (left) side was 1.4 mm, the echo was uniform, and the edema of the nerve on the affected side disappeared and returned to the same as that on the healthy side.

Re-examination of sEMG showed that RMS mean of the three pairs of muscle groups was shown in (Figure 5) and Annex 2: The RMS mean of the affected (right) side was slightly lower than that of the healthy (left) side, and the difference was significantly reduced compared with before treatment, indicating that the muscle strength of the affected side was close to that of the healthy side; The RMS mean of both facial muscles decreased compared to pre-treatment values, suggesting reduced muscle excitability; The RMS mean ratio of the affected side to the healthy side was 0.870 for the frontal muscle group, 0.840 for the zygomatic muscle group, and 0.994 for the orbicularis oris muscle group. The increase in the RMS mean for the three pairs of muscle groups indicated that the facial nerve had recovered and the prognosis was good. See (Table 1) for a detailed evaluation of facial neural function. Two months later, the clinician made a follow-up telephone call to check on the patient’s condition. He indicated that the patient had made a good recovery. It was not different from before the disease and had not had a recurrence.

Case 2

Patient 2, a 47-year-old male, was admitted to the Acupuncture and Rehabilitation Department of our hospital on Dec 28, 2022.

Four days ago, the patient came home from cycling (without wearing a hat or mask) feeling a little stiff on his face and did not care. The left corner of mouth was slightly crooked before going to bed, and the next day after rising the symptoms increased. Patient 2 showed the disappearance of the left forehead wrinkles, the restriction of the eyebrow lift, and the disappearance of the left nasolabial groove. He applied a hot towel to his face, but there was no improvement, so he went to our hospital. The patient has no underlying medical condition and is usually in good physical condition.

The clinician examined the patient: The left forehead wrinkles disappeared, unable to lift the eyebrow, the left eyelid could not be completely closed, revealing the white eye about 2 mm, the left nasolabial groove disappeared, the corner of mouth tilted to the right, water leakage when drinking, no obvious tenderness in the mastoid process behind the ears, taste disturbance. MSUS was performed on the patient, and the results showed that the healthy (right) side facial nerve had a diameter of 1.5 mm, and the echo was uniform, as shown in (Figure 6a). The facial nerve on the affected (left) side had a diameter of 1.9 mm, and the echo was uneven, as shown in (Figure 6b).

SEMG was performed, the specific results were shown in (Figure 7) and Annex 3: RMS mean of the affected (left) side was lower than that of the healthy (right) side, indicating that the muscle strength of the affected side was significantly weakened compared with that of the healthy side. The RMS mean of the frontal muscle, zygomatic muscle, and orbicularis oris muscle groups was 0.751, 0.858, and 0.896, respectively, on the affected and healthy sides. Facial nerve function was evaluated, and the results showed below (Table 2) Grade Ⅳ on the H-B, a score of 37 on the SFGS, scores of 21 and 10 on the FDIp and FDIs respectively, gradeⅠon the palpebral insufficiency scale and gradeⅠon the sagging mouth scale, indicating facial nerve function injury. Combined with the patient’s medical history, symptoms, physical signs, and examination results, the patient was diagnosed with Bell’s palsy in the acute phase. The clinician obtained the patient’s consent and signed an informed consent form before performing the acupuncture. The selection of primary and secondary acupoints were the same as in case 1. The patient had a history of cold exposure, therefore, Fengchi (GB 20) was also used.

The needle was kept for 30 minutes each treatment and was treated once every other day. Facial nerve function was assessed weekly. After the third therapy, the patient developed an aggravated condition of hypophasis, which may be related to his exposure to cold again. At the end of the second week of treatment, the above symptoms improved significantly. After the third week of treatment, the patient’s face was mostly back to normal and there was still a slight crooked corner of mouth when smiling. After two days of continued acupuncture therapy, the patient was fully recovered.

MSUS examination again indicated that the diameter of the facial nerve on the healthy (right) side was 1.5 mm, and that on the affected (left) side was 1.6 mm. The echoes were uniform, as shown in (Figure 8a, 8b). SEMG (Figure 9) and Annex 4 showed that RMS mean ratio of the frontal muscle, zygomatic muscle, and orbicularis oris muscle group were 0.790, 0.948 and 1.094 on the affected and healthy sides, both of which were higher than before treatment. Facial nerve function assessment showed that facial nerve function returned to normal, and the specific results of weekly facial nerve function scores were shown in (Table 2). The patient has not relapsed to date.

Discussion and Conclusions

Although Bell’s palsy is a self-limiting disease, about 20% of people still have serious sequelae [20,21] such as crooked corner of mouth, water leakage, etc. These sequelae can leave some patients unable to communicate normally and even have an inferiority complex, resulting in psychological problems. PFP that has not healed for more than 3 months is called refractory facial paralysis [22] and in severe cases, facial spasm, facial atrophy, facial inversion and other clinical symptoms appear. It is very important to find a safe and effective treatment that can shorten the course of the disease and promote the recovery of facial nerves.

Currently, physical therapy, in addition to oral hormones, is widely accepted in the treatment of Bell’s palsy by patients due to its wide audience and the advantages of no side effects. Physical therapy [23-25] includes acupuncture, moxibustion, tuina, cupping, electrical stimulation, Chinese herb, etc., among which acupuncture has a significant effect and has the most clinical studies. Whether acupuncture can be used in the acute phase of Bell’s palsy is still debated. Some scholars believe that acupuncture treatment in acute stage may aggravate facial nerve edema [26]. However, previous studies have shown that the acute phase is the best treatment opportunity for Bell’s palsy [27]. Acupuncture treatment can shorten the course of the disease, reduce facial nerve inflammation, and promote functional recovery [28].

Bell’s palsy belongs to the category of “Deviation of the mouth corner” in TCM. Due to the lack of healthy qi, wind cold, windy heat and other pathogenic factors invade the human body, causing blocked qi and blood operation, meridian obstruction, and a series of symptoms. In case 1, Patient 1 felt ill due to long-term fatigue, staying up late for nearly a month, loss of healthy qi and an imbalance of yin and yang. In case 2, Patient 2 was cold due to the wind blowing on his bicycle, and the wind cold attacked the meridians of his face, causing the meridians to become clogged.

Professor Jun Yang is a renowned state-level TCM doctor. He is the director of the Chinese Acupuncture and Moxibustion Society and has received government subsidies from the State Council. Professor Yang has spent more than 40 years in clinical work and teaching. He has extensive experience in acupuncture for PFP. Based on TCM theory, he summarized the characteristic guiding ideology. Professor Yang thinks that the treatment of Bell’s palsy should be “based on the meridians”, “treatment based on pattern identification”, and “pay attention to acupoints”. The theory of meridians and collaterals holds that the circulation of meridians in the cheek is mainly the Yangming meridian of hands and feet, and Yangming meridian is the “multi-qi and multi-blood” meridian, which can treat muscle-related diseases.

Professor Yang proposed the guiding idea of “based on the meridians” to follow the Yangming meridians, and most points are selected on the foot Yangming meridian. He attaches great importance to “treatment based on pattern identification” therapy, giving different acupoint selection and treatment methods for patients with different actual conditions. Note the pattern differentiation of the meridians when the acupuncture points are chosen. The key points are Qianzheng (Ex-HN 16), Touwei (ST 8), Hegu (LI 4), Yangbai (GB 14), Cuanzhu (BL 2), Yuyao (EX-HN 4), Sibai (ST 2), Yingxiang (LI 20), Shuigou (DU 26) and Chengjiang (EN 24). Points should be matched based on the patient’s specific condition. The patient of case 1 felt tired, so he added bilateral Zusanli (ST 36) to notify qi. The patient of case 2 had suffered from wind cold, so the Fengchi (GB 20) was added to release wind and dissipate cold.

Professor Yang believes that the earlier the treatment of PFP intervention, the better the effect [29]. In both cases, acupuncture was administered during the acute phase and the results were remarkable. The course of treatment took less than four weeks before recovery. MSUS before and after treatment showed that acupuncture intervention in acute phase could restore the edema of facial nerve to normal. SEMG before and after treatment showed that acupuncture promoted the rejuvenation of facial muscles on the affected side during the acute phase, and that there was little difference between the affected and healthy side after treatment. Based on weekly changes in facial neural function scores, both patients showed significant improvement in their symptoms within two weeks of treatment, so treatment should be continued.

The two cases reported in this paper have shown that acupuncture can be performed in the acute phase of Bell’s palsy with significant efficacy, but more RCTs are needed to prove this point. Therefore, we intend to design an RCT to further verify whether acupuncture in the acute phase of interventional treatment of Bell’s palsy can shorten the course of the disease and promote the recovery of facial nerve function by comparing the acupuncture treatment in the treatment group with the western medicine treatment in the control group, in order to provide new ideas and methods for the treatment of Bell’s palsy.

Ethical Approval

We submitted an application to the ethics committee of the First Affiliated Hospital of Anhui University of Chinese Medicine and obtained consent. The number was 2022AH-22.

Authors’ Contribution

Jun Yang put forward the theory of “following the classics”, “syndrome differentiation” and “emphasizing acupoints”. Haiping Shi was responsible for the acupuncture treatment of case 1 and case 2; Xinyuan Deng collected the data and co-wrote the manuscript with Fei Lu, Xiaowei Li and Yuling Shu. Yu Zhang made revisions to the manuscript. All authors have read the manuscript and agreed with the content and author ranking.

Funding

The University Synergy Innovation Program of Anhui Province: GXXT-2021-083.

Acknowledgements

Both patients were thanked for their cooperation in acupuncture treatment.

Consents of Patients

The figures and personal information shown in this article were obtained with the patient’s consent.

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