Peripheral facial nerve palsy (FNP), a common disease of cranial nerve VII [1], is characterized by paralysis of the facial muscles on one side, causing facial asymmetry and dysfunction [2]. The most common cause of FNP is Bell’s palsy; however, it can also be caused by several other factors, such as infections (e.g., otitis media or herpes zoster), vestibular schwannoma, and trauma (e.g., fractures) [2]. The recovery time varies depending on the cause; however, in the case of Bell’s palsy, 71% of the patients make a complete recovery, whereas 29% suffer from sequelae of varying severity [3]. FNP progresses in prodromal, acute, plateau, and sequelae phases [4], with sequelae appearing, on average, 3–6 months after FNP onset [2-4]. Typical symptoms include synkinesis, contractures, crocodile tear syndrome, spasms, and unhealed facial palsy.

A strategy for the treatment of FNP symptoms is facial chuna manual therapy (FCMT), a manual therapy performed by Korean medicine doctors based on the concept of meridians and anatomical knowledge [4]. Various techniques are performed according to the FNP progression and symptoms [4,5]. Recently, studies have begun reporting improvements in the acute [6-8] and sequelae [9,10] stages of FNP after FCMT application. However, research on FCMT is still insufficient, and most studies involve a combination of FCMT and acupuncture, making assessment of the effectiveness of FMCT alone quite challenging.

This retrospective observational study presents good clinical results using FCMT as the main treatment method for several FNP sequelae, including synkinesis, contractures, crocodile tears, and spasms.

1. Case presentation

The patient was diagnosed in October 2022 with FNP (House–Brackmann Grading Scale 5, HBGS 5) due to acute otitis media. Steroid therapy was administered; however, it was tapered off quickly because of high levels observed in liver function tests. The symptoms did not improve. In November 2022, the patient underwent decompression surgery to reduce compression damage to the facial nerve, and his facial muscle strength recovered gradually (HBGS 3). However, in February 2023, he experienced several sequelae, including synkinesis, contractures, crocodile tears, and spasms. He began receiving physical therapy (silver spike point [SSP] and massage) twice a week for 2 weeks before visiting our hospital; however, he showed no further recovery of muscle strength or improvement in the symptoms of sequelae. On March 31, 2023, he visited Daegu Korean Medicine Hospital of Daegu Haany University and was initiated with FCMT and physical therapy 1–2 times a week. No invasive treatments, such as acupuncture or pharmacopuncture, were performed because the patient also had hemophilia B and C.

2. Treatments

1) Facial chuna manual therapy

FCMT was performed 1–2 times a week from March 31, 2023, to October 12, 2023, depending on the symptoms. For synkinesis, the patient was instructed to practice separating the adhered nerves by slowly moving the facial muscles [4]. When the patient moved one facial muscle, the practitioner fixed the muscles involved in the synkinesis to prevent unnecessary contractions of the other muscles (Fig. 1) [4]. For example, if the mouth muscles contracted when the orbital muscles were moved, the practitioner would hold the corners of the mouth, while the patient slowly closed his eyes [4]. In the case of contractures, the muscles that have contracted more than normal must be stretched; therefore, origin–insertion extension, a resistance technique, and a pinch technique are used [4]. The practitioner holds the origin of the paralyzed muscle with one hand and stretches the muscle to its insertion with the other hand, followed by pinching the entire muscle to prevent the stretched muscle from contracting (Fig. 2) [4]. For crocodile tears, the practitioner relaxes the occipital fascia and moves the styloid process subtly to secure the path of the facial nerve that passes near the styloid process (Fig. 3) [4].

Figure 1. FCMT for synkinesis. (A) Resistance for synkinesis when the eyes move. (B) Resistance for synkinesis when the mouth moves. The black arrows mean the directions of the agonist muscle when the patient moves the facial muscles. The gray arrows mean the directions of the synkinetic movement. The diagonal pattern arrows indicate resistance in the insertion region. FCMT, facial chuna manual therapy.

Figure 2. FCMT for contractures. (A) Origin–insertion extension. (B) Resistance. (C) Pinch technique. The dot pattern circles present the origin of the facial muscles. The dot pattern arrows mean the direction in which the muscles shrink. The black arrows indicate the directions of the agonist muscle when the patient moves the facial muscles. The diagonal pattern arrows mean resistance in the insertion region. The blue arrows signifies the direction of pinching the muscles. FCMT, facial chuna manual therapy.

Figure 3. FCMT for crocodile tears. The black arrows mean the direction of relaxing the facsia. FCMT, facial chuna manual therapy.

2) Physical therapy

At each visit, SSP and massage therapy were performed for approximately 15 minutes after FCMT. SSP suction electrodes were attached to two pairs of motor points of the degenerative muscle of the affected facial part and continuously energized at a frequency of 5–10 Hz (SPMI-330; Promedi Co., Ltd.).

3. Evaluation

The patient was assessed at approximately 4-week intervals.

1) House–Brackmann Grading Scale

This is classified from grades 1 to 6 according to the degree of facial nerve function and divided to evaluate the overall facial motor function and sequelae [11].

2) Facial nerve grading system 2.0

This is a modified and supplemented version of HBGS, and the function of the facial nerve is evaluated with a total score through the evaluation of each part and of the score for synkinesis [12].

3) Peitersen scale

The facial paralysis sequelae symptoms of contractures and synkinesis are evaluated on a scale of 0–4 at five levels [3].

4) Murata scale

The symptoms of facial paralysis sequelae are divided into 13 items and evaluated on a scale of 0–2 according to symptom severity [13].

5) Mehta scale

The sequelae of facial paralysis are divided into nine items and evaluated on a scale of 5, from 1 to 5, according to symptom severity [14].

6) Numeric rating scale

The overall discomfort felt by the patient is assessed in relation to the symptoms of facial paralysis. The patient rates the degree of discomfort from 0 to 10 [15].

4. Results

After approximately 6 months of FCMT, the facial muscle strength improved overall, decreasing the HBGS score from 3 to 2 and the facial nerve grading system 2.0 (FNGS) score from 3 to 2. During the 6 months of treatment, the Peitersen, Murata, and Mehta scale scores also decreased from 2 to 1, 9 to 4, and 14 to 1, respectively (Table 1, Fig. 4). The overall patient discomfort due to FNP symptoms also improved significantly, decreasing from an numeric rating scale (NRS) score of 8.5 at the first visit to 2.5 on October 12, 2023 (Fig. 5).

Figure 4. Changes in FNGS, HB, Peitersen, Murata, and Mehta scale scores. FNGS, facial nerve grading system 2.0; HB, House–Brackmann.

Figure 5. Change in NRS scores. NRS, numeric rating scale.

Table 1 . Changes in the FNGS, HB, Peitersen, Murata, and Mehta scale scores.

	2023.03.31	2023.04.26	2023.05.29	2023.06.23	2023.07.28	2023.09.18	2023.10.12
HB	3	2	2	2	2	2	2
FNGS	3 (12)	3 (10)	2 (9)	2 (8)	2 (8)	2 (8)	2 (7)
Peitersen	2	2	2	1	1	1	1
Murata	9	7	7	6	5	4	4
Mehta	14	11	7	3	1	1	1

FNGS, facial nerve grading system 2.0; HB, House–Brackmann..

Current treatments for the sequelae of facial paralysis include surgery, invasive treatments such as Botox treatment [2], and various noninvasive manual techniques [5]. However, surgical treatments are performed to make the paralyzed side move symmetrically with the normal side, not to restore mobility on the paralyzed side [16]. Side effects of Botox injections include ptosis, pseudofacial paralysis, and double vision when excessive doses are injected into the muscles or when Botox seeps into the orbit [2,17]. Noninvasive manual therapies, such as cervical spinal spine therapy, temporomandibular joint chuna, proprioceptive neuromuscular facilitation, neuromuscular reeducation, facial exercise, mime therapy, and nonresistance therapy are not tailored to each FNP symptom [5,8]. By contrast, FCMT, a noninvasive treatment, does not have the above side effects, nor does it incur bleeding, and various techniques can be applied, depending on the symptoms that cause patient complaints [4]. Therefore, the technique can be applied according to the symptoms that cause the most patient discomfort and to patients who also cannot undergo surgery or invasive treatments, such as acupuncture or pharmacopuncture.

The change in improvement from 3 to 2 on the HBGS scale is not large; however, the changes in Mehta scale scores from 14 to 1 and NRS scores from 8.5 to 2.5 are meaningful because the patient mainly complained of discomfort with the symtoms of sequelae, particularly synkiness. FCMT stimulates the facial muscles and nerves with a combination of voluntary facial muscle movements, assisted or resistance massage depending on the patient’s condition, breathing to relax the muscles, and pressure application on the acupoints and meridians of the face [4,8]. FCMT is also performed differently depending on the FNP stage, particularly in the sequelae phase, by considering each symptom, pathological mechanism, and each patient’s symptoms [4].

This study had one key limitation, that is, the difficulty in determining the clinical significance because the results were based only on a single case. However, in actual medical treatment, FCMT is generally performed together with invasive treatments, such as acupuncture and pharmacopuncture, and no previous studies have used FCMT as the main treatment, without invasive protocols, for the relief of the sequelae of FNP. The presented case is unique because it symptoms of sequelae of FNP were significantly improved by applying FCMT to a patient who could not undergo invasive treatment and symptoms continuously improved in response to FCMT after approximately 30 consultations for 6 months. The patient demonstrated high satisfaction during the treatment. If symptom improvement is maintained during long-term follow-up and large-scale studies can verify these findings, FCMT could be a highly effective treatment for FNP.

Conceptualization: GML, JHL, JSK, HJL. Data curation: All authors. Formal analysis: All authors. Investigation: All authors. Methodology: GML, GYC, JHL, JSK, HJL. Project administration: All authors. Visualization: All authors. Writing – original draft: GML, GYC, JHL, JSK, HJL. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This research did not involve any human or animal experimentation. Hence, this study was exempt from approval by the Institutional Review Board of Daegu Korean Medicine Hospital at Daegu Haany University (IRB no.: DHUMC-D-23016-ETC-01).