Case Report

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Journal of Acupuncture Research 2024; 41:216-221

Published online October 17, 2024

https://doi.org/10.13045/jar.24.0029

© Korean Acupuncture & Moxibustion Medicine Society

A Case of Ramsay-Hunt Syndrome with Dysphagia Treated by a Comprehensive Traditional Korean Medicine Regimen Including Pharmacopuncture and Herbal Medicine

Geun-mo Kim1 , Hee-doh Kwon2 , So-hyun Pak3 , Ji-hong Park1 , Chang-min Shin1 , Hyun-Seob Park1 , Kyung-won Ha1 , Jong-Cheol Seo1 , Cheol-Hong Kim1 , Shin-young Kim1 , Hyun-Min Yoon1

1Department of Acupuncture & Moxibustion, Dong-Eui University College of Korean Medicine, Busan, Korea
2Department of Korean Medicine Rehabilitation, Dong-Eui University College of Korean Medicine, Busan, Korea
3Department of Korean Internal Medicine, Dong-Eui University College of Korean Medicine, Busan, Korea

Correspondence to : Hyun-Min Yoon
Department of Acupuncture & Moxibustion, Dong-Eui University College of Korean Medicine, 62, Yangjeong-ro, Busanjin-gu, Busan 47227, Korea
E-mail: 3rdmed@hanmail.net

Received: August 7, 2024; Revised: August 20, 2024; Accepted: August 20, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Herpes zoster, a disease caused by the varicella-zoster virus (VZV), is characterized by painful, blistering lesions. Ramsay-Hunt syndrome (RHS) is a complication of a VZV infection that affects the geniculate ganglion, causing facial paralysis and auricular lesions. We describe a case of RHS with dysphagia in a 66-year-old woman, which was treated with a traditional Korean medicine (TKM) regimen. Her treatments included acupuncture, moxibustion, pharmacopuncture, thread-embedding therapy, herbal medicine, and steroids. Significant improvement was observed in both facial paralysis and dysphagia, demonstrating the potential efficacy of TKM for such cases. The present report highlights the need for further research into the specific treatments and acupoint selection for RHS and its associated symptoms.

Keywords Dysphagia; Ganoderma lucidum herbal acupuncture; Hominis placenta; Pharmacopuncture; Ramsay-Hunt syndrome

Herpes zoster (HZ) is a cutaneous disease caused by the varicella-zoster virus (VZV), which lies dormant in the body and then reactivates, causing painful, blistering lesions in a dermatomal distribution [1]. Ramsay-Hunt syndrome (RHS) occurs when the VZV invades the geniculate ganglion of immunocompromised individuals, resulting in the development of HZ in the auricle or ear canal, postauricular pain, and facial nerve paralysis [2]. Although VZV has been commonly reported to invade the facial nerve, the invasion of other cranial nerves is relatively rare. VZV invasion into the glossopharyngeal and vagus nerves results in dysphagia and odynophagia.

Considering RHS with dysphagia is rarely treated using traditional Korean medicine (TKM), we report a case of RHS with dysphagia that improved with TKM treatments combined with herbal acupuncture.

On January 3, 2024, a 66-year-old woman presented with right facial paralysis and dysphagia, assessed using the House-Brackmann grading system (H-BGS) 4 and visual analog scale (VAS) of 10. On the same day, she was diagnosed with RHS based on the presence of simple peripheral facial nerve inflammation noted on cranial magnetic resonance imaging (MRI) performed at the Department of Neurology, Hospital A (Fig. 1), accompanied by vesicular blisters in the right auricular region. On January 5, 2024, a videofluoroscopic swallowing study (VFSS) performed by the Department of Rehabilitation at Hospital A yielded the following results: Liquid “7” and Puree “3” by using the Penetration-Aspiration Scale (Table 1). From January 3 to 10, 2024, she was admitted to the Department of Neurology of Hospital A. On January 11, 2024, she was seen at Acupuncture 1 Department of the Oriental Medicine Hospital of Dong-Eui Medical Center as an in-patient to receive TKM treatment. She was treated until February 1, 2024.

Fig. 1. T1-weighted brain magnetic resonance image. Enhancement along the cisternal, labyrinthine, geniculate, tympanic, and mastoid segments of the right facial nerve, suggesting the presence of probable neuritis.

Table 1 . Penetration-aspiration scale (PAS)

ScoreDescription
1Contrast does not enter the airway
2Contrast enters the airway, remains above the vocal folds; no residue
3Contrast remains above the vocal folds, visible residue remains
4Contrast passes glottis; no subglottic residue visible
5Contrast contacts the vocal folds; visible residue remains
6Contrast passes glottis; no subglottic residue visible
7Contrast passes glottis; visible subglottic residue despite patient’s response
8Contrast passes glottis; visible subglottic residue; absent patient response


1. Treatment method

1) Acupuncture and moxibustion therapy

Disposable stainless steel needles (Dongbang Medical; 0.20 × 30 mm) were inserted at a depth of 10–20 mm twice daily and left in place for 15 minutes without adjustment. The patient was treated on the ipsilateral EX-HN3, GV26, ST4, ST6, ST7, ST3, ST1, LI20, TE23, BL2, GB1, and EX-HN5 acupoints, as well as contralateral LI4, ST36, GB15, SP3, and ST43 acupoints.

2) Pharmacopuncture therapy

The patient was undergone 0.4–0.8 mL of Hominis placenta pharmacopuncture on the bilateral GB21, GB20, BL43, and ST25 acupoints once a day. The ipsilateral ST4, ST6, EX-HN5, LI20, GB1, and ST7 acupoints were treated with 0.4 mL of sweet bee venom (SBV), which is a detoxified bee venom herbal acupuncture treatment. The patient was treated with approximately 1 mL of Ganoderma lucidum or H. placenta pharmacopuncture on the bilateral ST9, ST10, CV6, and CV22 acupoints. After receiving G. lucidum pharmacopuncture once daily for 4 to 5 consecutive days, the patient received H. placenta pharmacopuncture once daily for 1 day.

3) Other treatments

Thread-embedding therapy was performed on the affected side, targeting the frontalis, corrugator supercilii, nasalis, zygomaticus, and depressor labii inferioris muscles. Altogether, 15–20 threads were inserted at a direction parallel to the muscle fibers. The insertion depth was adjusted to ensure the threads were embedded within the soft tissue layer. The therapy was first performed on January 13, followed by five sessions at 1-week intervals, and concluded on February 20.

The patient received treatment with herbal medicines (Sayeoggaboglyeongsan, Table 2; Yeong-gyechulgamtang, Table 3; and Dongeui Hwalhyeoldan, Table 4 [Oriental Medicine Hospital of Dong-Eui Medical Center]) and steroids with a tapering regimen.

Table 2 . Prescription of Sayeoggaboglyeongsan

HerbLatin nameAmount (g)
Glycyrrhiza uralensisGlycyrrhiza uralensis6
Poncirus trifoliataPoncirus trifoliata6
Bupleurum falcatumBupleurum falcatum6
Paeonia lactifloraPaeonia lactiflora6
Poria cocosPoria cocos6
Citrus unshiuCitrus unshiu4
Pinellia ternataPinellia ternata4


Table 3 . Prescription of Yeong-gyechulgamtang

HerbLatin nameAmount (g)
Poria cocosPoria cocos8
Cinnamomum cassiaCinnamomum cassia6
Atractylodes japonicaAtractylodes japonica6
Glycyrrhiza uralensisGlycyrrhiza uralensis4


Table 4 . Prescription of Dongeui Hwalhyeoldan

HerbLatin nameAmount (g)
Rehmannia glutinosaRehmannia glutinosa0.76
Cervus nippon TemminkCervi Pantotrichum Cornu0.55
Dioscorea batatas DecneDioscoreae Rhizoma0.47
Ligusticum acutilobumLigustici Radix0.46
Cornus officinalis SiebCorni Fructus0.46
Paeonia suffruticosa AndrewsMoutan Cortex0.30
Alisma canaliculatum AllAlismatis Rhizoma0.30
Cibotium barometzCibotii Rhizoma0.23
Moschus moschiferusMoschi Moschus0.06
Dryobalanops aromaticaBorneol0.01


2. Instruments and scales

We utilized the H-BGS and Yanagihara’s unweighted grading system (Y-system), which is commonly used in clinical practice to assess facial nerve paralysis. For dysphagia, the level of discomfort during hospitalization was scored using a VAS, with a score of “10” indicating the highest level of discomfort and “0” indicating no discomfort at all.

3. Results

1) Facial nerve paralysis

On admission, the patient had grade IV facial nerve impairment based on the assessment using H-BGS, with no lip asymmetry in an expressionless state, incomplete closure of the eyes during eye opening and closing, and inability to form a complete right forehead wrinkle. Her symptoms included pooling of food when eating, leaking of water when drinking and brushing teeth, and entering of soapy water into the eyes when face washing.

After treatment, the patient’s facial paralysis grade improved from 8 to 38 on the Y-system scale (Table 4) after treatment with acupuncture, pharmacopuncture, and herbal medicine, which are commonly used for the abovementioned symptoms.

For detailed information, please refer to Table 5.

Table 5 . The patient’s Yanagihara’s score throughout the disease course

DateJanuary 11, 2024January 18, 2024January 27, 2024February 20, 2024
At rest2234
Wrinkle forehead1224
Blink2344
Light closure of eye1234
Tight closure of eye1344
Closure of eye on the involved side only1124
Wrinkle nose0123
Whistle0013
Grin0334
Depress lower lip0334
Total8202738


2) Dysphagia

The patient choked when swallowing solids and liquids and was unable to take in liquid herbal medicines and pills. On January 18, 2024, as the symptoms of dysphagia improved, she began taking pill “Dongeui Hwalhyeoldan,” which improved her kidney and liver functions. Then, on January 20, 2024, she was switched from a blended to a regular diet. On January 22, 2024, given the decreased frequency of choking incidents when consuming liquids, the daily dose of the liquid herbal medicine was increased from twice daily to thrice daily. On January 27, 2024, the patient’s dysphagia disappeared, and the treatments related to the abovementioned symptoms were discontinued (Fig. 2).

Fig. 2. Visual analog scale (VAS) of dysphagia.

For detailed information on the pharmacopuncture treatment and progress related to dysphagia, please refer to Table 6.

Table 6 . The improvement in patient’s dysphagia after receiving pharmacopuncture treatments

DatePharmacopuncture therapyVASNote
January 11, 20241 mL of Ganoderma lucidum10Blended diet
The patient choked on liquid, and the medication was administered twice daily
January 12, 20241 mL of Ganoderma lucidum9No special notes
January 13, 20241 mL of Ganoderma lucidum9No special notes
January 14, 20241 mL of Ganoderma lucidum8No special notes
January 15, 20241 mL of Hominis placenta8No special notes
January 16, 2024-8No special notes
January 17, 20241 mL of Ganoderma lucidum7No special notes
January 18, 20241 mL of Ganoderma lucidum5The patient began to take Dongeui Hwalhyeoldan
January 19, 20241 mL of Ganoderma lucidum5No special notes
January 20, 20241 mL of Ganoderma lucidum5The patient’s diet was switched from a blended to a regular one
January 21, 20241 mL of Ganoderma lucidum5No special notes
January 22, 20241 mL of Ganoderma lucidum5As the patient began choking less on liquid, the medication was administered thrice daily
January 23, 20241 mL of Hominis placenta4No special notes
January 24, 2024-3No special notes
January 25, 20241 mL of Ganoderma lucidum3No special notes
January 26, 20241 mL of Ganoderma lucidum2No special notes
January 27, 2024-2End of therapy

VAS, visual analog scale.


Although RHS can be diagnosed by VZV detection on polymerase chain reaction or immunofluorescence staining, our patient was diagnosed with RHS due to the presence of auricular vesicles, no central brain lesions on cranial MRI, and symptoms of facial paralysis, without performing any other tests.

Although RHS is not clearly categorized as a disease in the field of TKM, the facial nerve paralysis and vesicular rash associated with RHS have traditionally been treated using treatments for Bell’s palsy and HZ, respectively. Bell’s palsy is considered to be caused by the invasion of the facial meridians by the bad cold wind, causing edema and ischemia of the corresponding nerves [3]. Meanwhile, HZ is considered to be due to the stagnation of qi in the liver, dampness-heat in the spleen, and blood stasis due to qi stagnation.

Swallowing has traditionally been described according to the “oral,” “pharyngeal,” and “esophageal” phase and involves multiple cranial nerves, especially glossopharyngeal and vagus nerve. These nerves are interconnected, thereby stimulating the nucleus tractus solitarius triggers the swallowing reflex.

Although the mechanism for descending invasion of the lower cranial nerves is uncertain, several hypotheses exist. The most plausible hypothesis is that multiple anatomically adjacent cranial nerves can be infected by a virus, because the facial nerve joins the vestibular cochlear nerve and popliteal ganglion, and the vagus nerve is anatomically close to the glossopharyngeal nerve [4]. However, the mechanism of dysphagia with RHS is unclear, and the lack of other tests has prevented further identification of the cause.

In the present case, the onset of dysphagia coincided with the onset of RHS, with the dysphagia not caused by any disease. Therefore, VZV may have invaded the geniculate ganglion and simultaneously infected the trigeminal, hypoglossal, and vagus nerves involved in swallowing.

H. placenta and SBV pharmacopuncture has been proven effective in treating facial paralysis [5-8]. However, the efficacy of other pharmacopuncture treatments, including G. lucidum pharmacopuncture, for dysphagia is not as well documented.

The main components of G. lucidum include polysaccharides and triterpenoids. G. lucidum is involved in regulating innate and adaptive immunities and has anti-cancer, antibacterial, antioxidant, anti-inflammatory, and anti-obesity effects [9]. Particularly, it combats viral infections by activating macrophages, T lymphocytes, natural killer cells, and cytokines. It has been proven effective against viruses, including influenza virus, dengue virus, enterovirus 71, human immunodeficiency virus, hepatitis, herpes simplex virus, and respiratory syncytial virus [10].

Studies on white rats have demonstrated the effect of G. lucidum pharmacopuncture on capsaicin-induced atopic dermatitis and its protective effect on the gastric mucosa in ethanol-induced acute gastric ulcer [11,12]. However, research on the effect of G. lucidum pharmacopuncture on viral and neuroinflammation remains scarce.

Meridian pharmacopuncture, a theory developed by Dr. Nam Sang-cheon, involves injecting pharmacopuncture needles, categorized as yun (enrichment) and qi (energy) agents, into the meridians affected by excess or deficient yun and qi in the body. This facilitates the production and circulation of yun and qi. G. lucidum pharmacopuncture is a qi agent used in “meridian pharmacopuncture,” whereas H. placenta pharmacopuncture is known to be a yun agent.

From the perspective of Dr. Nam Sang-cheon’s “meridian pharmacopuncture,” the patient with dysphagia caused by a viral infection was deficient in both “qi” and “yun,” considering various aspects such as body shape and skin glow [13]. RHS occurs due to the inflammation caused by the viral infection; thus, G. lucidum pharmacopuncture is used as a qi agent as treatment. However, supplying only qi properties may cause yun deficiency. As such, after four to five treatments of G. lucidum pharmacopuncture, H. placenta pharmacopuncture with yun properties was used in parallel.

Acupoints ST9, ST10, CV6, and CV22, which are located around the throat area, were selected for pharmacopuncture to treat dysphagia.

The present report presents a rare case of dysphagia-associated multiple cranial neuropathies caused by VZV. Given the lack of literature on herbal treatments for cases similar to our patient this study is significant because it has demonstrated that these treatments produced good outcomes for the abovementioned symptoms. However, one study limitation is the selection of acupoints in the throat, as there is a lack of previous case studies mentioning about the selection of acupoints. It is also unclear which therapy has been most helpful in treating dysphagia-associated multiple cranial neuropathies caused by VZV, given that a comprehensive TKM treatment regimen has been used.

Conceptualization: GMK, HMY, SYK. Data curation: GMK, SYK. Formal analysis: GMK, JHP, HDK, SHP. Investigation: All authors. Methodology: All authors. Project administration: GMK, HMY. Visualization: All authors. Writing – original draft: GMK, SYK, HMY. Writing – review & editing: All authors.

This study was approved by the Dong-Eui University Institutional Review Board (IRB no.: DH-2024-07). Prior to study participation, the patient provided us with written informed consent on the academic use of her medical records and for answering the questionnaire.

  1. Lee SB, Lee DK. Vagus nerve palsy in Ramsay-Hunt syndrome. Ann Clin Neurophysiol 2014;16:42-44. doi: 10.14253/kjcn.2014.16.1.42.
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  9. Ahmad MF, Ahmad FA, Khan MI, Alsayegh AA, Wahab S, Alam MI, et al. Ganoderma lucidum: a potential source to surmount viral infections through β-glucans immunomodulatory and triterpenoids antiviral properties. Int J Biol Macromol 2021;187:769-779. doi: 10.1016/j.ijbiomac.2021.06.122.
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  12. Li C, Kim JH, Ji BU, Lee JE, Kim Y, Yoon HM, et al. Inhibitory effects of Ganoderma lucidum pharmacopuncture on atopic dermatitis induced by capsaicin in rats. J Dermatol Sci 2015;80:212-214. doi: 10.1016/j.jdermsci.2015.09.010.
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Article

Case Report

Journal of Acupuncture Research 2024; 41(): 216-221

Published online October 17, 2024 https://doi.org/10.13045/jar.24.0029

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

A Case of Ramsay-Hunt Syndrome with Dysphagia Treated by a Comprehensive Traditional Korean Medicine Regimen Including Pharmacopuncture and Herbal Medicine

Geun-mo Kim1 , Hee-doh Kwon2 , So-hyun Pak3 , Ji-hong Park1 , Chang-min Shin1 , Hyun-Seob Park1 , Kyung-won Ha1 , Jong-Cheol Seo1 , Cheol-Hong Kim1 , Shin-young Kim1 , Hyun-Min Yoon1

1Department of Acupuncture & Moxibustion, Dong-Eui University College of Korean Medicine, Busan, Korea
2Department of Korean Medicine Rehabilitation, Dong-Eui University College of Korean Medicine, Busan, Korea
3Department of Korean Internal Medicine, Dong-Eui University College of Korean Medicine, Busan, Korea

Correspondence to:Hyun-Min Yoon
Department of Acupuncture & Moxibustion, Dong-Eui University College of Korean Medicine, 62, Yangjeong-ro, Busanjin-gu, Busan 47227, Korea
E-mail: 3rdmed@hanmail.net

Received: August 7, 2024; Revised: August 20, 2024; Accepted: August 20, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Herpes zoster, a disease caused by the varicella-zoster virus (VZV), is characterized by painful, blistering lesions. Ramsay-Hunt syndrome (RHS) is a complication of a VZV infection that affects the geniculate ganglion, causing facial paralysis and auricular lesions. We describe a case of RHS with dysphagia in a 66-year-old woman, which was treated with a traditional Korean medicine (TKM) regimen. Her treatments included acupuncture, moxibustion, pharmacopuncture, thread-embedding therapy, herbal medicine, and steroids. Significant improvement was observed in both facial paralysis and dysphagia, demonstrating the potential efficacy of TKM for such cases. The present report highlights the need for further research into the specific treatments and acupoint selection for RHS and its associated symptoms.

Keywords: Dysphagia, Ganoderma lucidum herbal acupuncture, Hominis placenta, Pharmacopuncture, Ramsay-Hunt syndrome

INTRODUCTION

Herpes zoster (HZ) is a cutaneous disease caused by the varicella-zoster virus (VZV), which lies dormant in the body and then reactivates, causing painful, blistering lesions in a dermatomal distribution [1]. Ramsay-Hunt syndrome (RHS) occurs when the VZV invades the geniculate ganglion of immunocompromised individuals, resulting in the development of HZ in the auricle or ear canal, postauricular pain, and facial nerve paralysis [2]. Although VZV has been commonly reported to invade the facial nerve, the invasion of other cranial nerves is relatively rare. VZV invasion into the glossopharyngeal and vagus nerves results in dysphagia and odynophagia.

Considering RHS with dysphagia is rarely treated using traditional Korean medicine (TKM), we report a case of RHS with dysphagia that improved with TKM treatments combined with herbal acupuncture.

CASE REPORT

On January 3, 2024, a 66-year-old woman presented with right facial paralysis and dysphagia, assessed using the House-Brackmann grading system (H-BGS) 4 and visual analog scale (VAS) of 10. On the same day, she was diagnosed with RHS based on the presence of simple peripheral facial nerve inflammation noted on cranial magnetic resonance imaging (MRI) performed at the Department of Neurology, Hospital A (Fig. 1), accompanied by vesicular blisters in the right auricular region. On January 5, 2024, a videofluoroscopic swallowing study (VFSS) performed by the Department of Rehabilitation at Hospital A yielded the following results: Liquid “7” and Puree “3” by using the Penetration-Aspiration Scale (Table 1). From January 3 to 10, 2024, she was admitted to the Department of Neurology of Hospital A. On January 11, 2024, she was seen at Acupuncture 1 Department of the Oriental Medicine Hospital of Dong-Eui Medical Center as an in-patient to receive TKM treatment. She was treated until February 1, 2024.

Figure 1. T1-weighted brain magnetic resonance image. Enhancement along the cisternal, labyrinthine, geniculate, tympanic, and mastoid segments of the right facial nerve, suggesting the presence of probable neuritis.

Table 1 . Penetration-aspiration scale (PAS).

ScoreDescription
1Contrast does not enter the airway
2Contrast enters the airway, remains above the vocal folds; no residue
3Contrast remains above the vocal folds, visible residue remains
4Contrast passes glottis; no subglottic residue visible
5Contrast contacts the vocal folds; visible residue remains
6Contrast passes glottis; no subglottic residue visible
7Contrast passes glottis; visible subglottic residue despite patient’s response
8Contrast passes glottis; visible subglottic residue; absent patient response


1. Treatment method

1) Acupuncture and moxibustion therapy

Disposable stainless steel needles (Dongbang Medical; 0.20 × 30 mm) were inserted at a depth of 10–20 mm twice daily and left in place for 15 minutes without adjustment. The patient was treated on the ipsilateral EX-HN3, GV26, ST4, ST6, ST7, ST3, ST1, LI20, TE23, BL2, GB1, and EX-HN5 acupoints, as well as contralateral LI4, ST36, GB15, SP3, and ST43 acupoints.

2) Pharmacopuncture therapy

The patient was undergone 0.4–0.8 mL of Hominis placenta pharmacopuncture on the bilateral GB21, GB20, BL43, and ST25 acupoints once a day. The ipsilateral ST4, ST6, EX-HN5, LI20, GB1, and ST7 acupoints were treated with 0.4 mL of sweet bee venom (SBV), which is a detoxified bee venom herbal acupuncture treatment. The patient was treated with approximately 1 mL of Ganoderma lucidum or H. placenta pharmacopuncture on the bilateral ST9, ST10, CV6, and CV22 acupoints. After receiving G. lucidum pharmacopuncture once daily for 4 to 5 consecutive days, the patient received H. placenta pharmacopuncture once daily for 1 day.

3) Other treatments

Thread-embedding therapy was performed on the affected side, targeting the frontalis, corrugator supercilii, nasalis, zygomaticus, and depressor labii inferioris muscles. Altogether, 15–20 threads were inserted at a direction parallel to the muscle fibers. The insertion depth was adjusted to ensure the threads were embedded within the soft tissue layer. The therapy was first performed on January 13, followed by five sessions at 1-week intervals, and concluded on February 20.

The patient received treatment with herbal medicines (Sayeoggaboglyeongsan, Table 2; Yeong-gyechulgamtang, Table 3; and Dongeui Hwalhyeoldan, Table 4 [Oriental Medicine Hospital of Dong-Eui Medical Center]) and steroids with a tapering regimen.

Table 2 . Prescription of Sayeoggaboglyeongsan.

HerbLatin nameAmount (g)
Glycyrrhiza uralensisGlycyrrhiza uralensis6
Poncirus trifoliataPoncirus trifoliata6
Bupleurum falcatumBupleurum falcatum6
Paeonia lactifloraPaeonia lactiflora6
Poria cocosPoria cocos6
Citrus unshiuCitrus unshiu4
Pinellia ternataPinellia ternata4


Table 3 . Prescription of Yeong-gyechulgamtang.

HerbLatin nameAmount (g)
Poria cocosPoria cocos8
Cinnamomum cassiaCinnamomum cassia6
Atractylodes japonicaAtractylodes japonica6
Glycyrrhiza uralensisGlycyrrhiza uralensis4


Table 4 . Prescription of Dongeui Hwalhyeoldan.

HerbLatin nameAmount (g)
Rehmannia glutinosaRehmannia glutinosa0.76
Cervus nippon TemminkCervi Pantotrichum Cornu0.55
Dioscorea batatas DecneDioscoreae Rhizoma0.47
Ligusticum acutilobumLigustici Radix0.46
Cornus officinalis SiebCorni Fructus0.46
Paeonia suffruticosa AndrewsMoutan Cortex0.30
Alisma canaliculatum AllAlismatis Rhizoma0.30
Cibotium barometzCibotii Rhizoma0.23
Moschus moschiferusMoschi Moschus0.06
Dryobalanops aromaticaBorneol0.01


2. Instruments and scales

We utilized the H-BGS and Yanagihara’s unweighted grading system (Y-system), which is commonly used in clinical practice to assess facial nerve paralysis. For dysphagia, the level of discomfort during hospitalization was scored using a VAS, with a score of “10” indicating the highest level of discomfort and “0” indicating no discomfort at all.

3. Results

1) Facial nerve paralysis

On admission, the patient had grade IV facial nerve impairment based on the assessment using H-BGS, with no lip asymmetry in an expressionless state, incomplete closure of the eyes during eye opening and closing, and inability to form a complete right forehead wrinkle. Her symptoms included pooling of food when eating, leaking of water when drinking and brushing teeth, and entering of soapy water into the eyes when face washing.

After treatment, the patient’s facial paralysis grade improved from 8 to 38 on the Y-system scale (Table 4) after treatment with acupuncture, pharmacopuncture, and herbal medicine, which are commonly used for the abovementioned symptoms.

For detailed information, please refer to Table 5.

Table 5 . The patient’s Yanagihara’s score throughout the disease course.

DateJanuary 11, 2024January 18, 2024January 27, 2024February 20, 2024
At rest2234
Wrinkle forehead1224
Blink2344
Light closure of eye1234
Tight closure of eye1344
Closure of eye on the involved side only1124
Wrinkle nose0123
Whistle0013
Grin0334
Depress lower lip0334
Total8202738


2) Dysphagia

The patient choked when swallowing solids and liquids and was unable to take in liquid herbal medicines and pills. On January 18, 2024, as the symptoms of dysphagia improved, she began taking pill “Dongeui Hwalhyeoldan,” which improved her kidney and liver functions. Then, on January 20, 2024, she was switched from a blended to a regular diet. On January 22, 2024, given the decreased frequency of choking incidents when consuming liquids, the daily dose of the liquid herbal medicine was increased from twice daily to thrice daily. On January 27, 2024, the patient’s dysphagia disappeared, and the treatments related to the abovementioned symptoms were discontinued (Fig. 2).

Figure 2. Visual analog scale (VAS) of dysphagia.

For detailed information on the pharmacopuncture treatment and progress related to dysphagia, please refer to Table 6.

Table 6 . The improvement in patient’s dysphagia after receiving pharmacopuncture treatments.

DatePharmacopuncture therapyVASNote
January 11, 20241 mL of Ganoderma lucidum10Blended diet
The patient choked on liquid, and the medication was administered twice daily
January 12, 20241 mL of Ganoderma lucidum9No special notes
January 13, 20241 mL of Ganoderma lucidum9No special notes
January 14, 20241 mL of Ganoderma lucidum8No special notes
January 15, 20241 mL of Hominis placenta8No special notes
January 16, 2024-8No special notes
January 17, 20241 mL of Ganoderma lucidum7No special notes
January 18, 20241 mL of Ganoderma lucidum5The patient began to take Dongeui Hwalhyeoldan
January 19, 20241 mL of Ganoderma lucidum5No special notes
January 20, 20241 mL of Ganoderma lucidum5The patient’s diet was switched from a blended to a regular one
January 21, 20241 mL of Ganoderma lucidum5No special notes
January 22, 20241 mL of Ganoderma lucidum5As the patient began choking less on liquid, the medication was administered thrice daily
January 23, 20241 mL of Hominis placenta4No special notes
January 24, 2024-3No special notes
January 25, 20241 mL of Ganoderma lucidum3No special notes
January 26, 20241 mL of Ganoderma lucidum2No special notes
January 27, 2024-2End of therapy

VAS, visual analog scale..


DISCUSSION

Although RHS can be diagnosed by VZV detection on polymerase chain reaction or immunofluorescence staining, our patient was diagnosed with RHS due to the presence of auricular vesicles, no central brain lesions on cranial MRI, and symptoms of facial paralysis, without performing any other tests.

Although RHS is not clearly categorized as a disease in the field of TKM, the facial nerve paralysis and vesicular rash associated with RHS have traditionally been treated using treatments for Bell’s palsy and HZ, respectively. Bell’s palsy is considered to be caused by the invasion of the facial meridians by the bad cold wind, causing edema and ischemia of the corresponding nerves [3]. Meanwhile, HZ is considered to be due to the stagnation of qi in the liver, dampness-heat in the spleen, and blood stasis due to qi stagnation.

Swallowing has traditionally been described according to the “oral,” “pharyngeal,” and “esophageal” phase and involves multiple cranial nerves, especially glossopharyngeal and vagus nerve. These nerves are interconnected, thereby stimulating the nucleus tractus solitarius triggers the swallowing reflex.

Although the mechanism for descending invasion of the lower cranial nerves is uncertain, several hypotheses exist. The most plausible hypothesis is that multiple anatomically adjacent cranial nerves can be infected by a virus, because the facial nerve joins the vestibular cochlear nerve and popliteal ganglion, and the vagus nerve is anatomically close to the glossopharyngeal nerve [4]. However, the mechanism of dysphagia with RHS is unclear, and the lack of other tests has prevented further identification of the cause.

In the present case, the onset of dysphagia coincided with the onset of RHS, with the dysphagia not caused by any disease. Therefore, VZV may have invaded the geniculate ganglion and simultaneously infected the trigeminal, hypoglossal, and vagus nerves involved in swallowing.

H. placenta and SBV pharmacopuncture has been proven effective in treating facial paralysis [5-8]. However, the efficacy of other pharmacopuncture treatments, including G. lucidum pharmacopuncture, for dysphagia is not as well documented.

The main components of G. lucidum include polysaccharides and triterpenoids. G. lucidum is involved in regulating innate and adaptive immunities and has anti-cancer, antibacterial, antioxidant, anti-inflammatory, and anti-obesity effects [9]. Particularly, it combats viral infections by activating macrophages, T lymphocytes, natural killer cells, and cytokines. It has been proven effective against viruses, including influenza virus, dengue virus, enterovirus 71, human immunodeficiency virus, hepatitis, herpes simplex virus, and respiratory syncytial virus [10].

Studies on white rats have demonstrated the effect of G. lucidum pharmacopuncture on capsaicin-induced atopic dermatitis and its protective effect on the gastric mucosa in ethanol-induced acute gastric ulcer [11,12]. However, research on the effect of G. lucidum pharmacopuncture on viral and neuroinflammation remains scarce.

Meridian pharmacopuncture, a theory developed by Dr. Nam Sang-cheon, involves injecting pharmacopuncture needles, categorized as yun (enrichment) and qi (energy) agents, into the meridians affected by excess or deficient yun and qi in the body. This facilitates the production and circulation of yun and qi. G. lucidum pharmacopuncture is a qi agent used in “meridian pharmacopuncture,” whereas H. placenta pharmacopuncture is known to be a yun agent.

From the perspective of Dr. Nam Sang-cheon’s “meridian pharmacopuncture,” the patient with dysphagia caused by a viral infection was deficient in both “qi” and “yun,” considering various aspects such as body shape and skin glow [13]. RHS occurs due to the inflammation caused by the viral infection; thus, G. lucidum pharmacopuncture is used as a qi agent as treatment. However, supplying only qi properties may cause yun deficiency. As such, after four to five treatments of G. lucidum pharmacopuncture, H. placenta pharmacopuncture with yun properties was used in parallel.

Acupoints ST9, ST10, CV6, and CV22, which are located around the throat area, were selected for pharmacopuncture to treat dysphagia.

The present report presents a rare case of dysphagia-associated multiple cranial neuropathies caused by VZV. Given the lack of literature on herbal treatments for cases similar to our patient this study is significant because it has demonstrated that these treatments produced good outcomes for the abovementioned symptoms. However, one study limitation is the selection of acupoints in the throat, as there is a lack of previous case studies mentioning about the selection of acupoints. It is also unclear which therapy has been most helpful in treating dysphagia-associated multiple cranial neuropathies caused by VZV, given that a comprehensive TKM treatment regimen has been used.

AUTHOR CONTRIBUTIONS

Conceptualization: GMK, HMY, SYK. Data curation: GMK, SYK. Formal analysis: GMK, JHP, HDK, SHP. Investigation: All authors. Methodology: All authors. Project administration: GMK, HMY. Visualization: All authors. Writing – original draft: GMK, SYK, HMY. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

This study was approved by the Dong-Eui University Institutional Review Board (IRB no.: DH-2024-07). Prior to study participation, the patient provided us with written informed consent on the academic use of her medical records and for answering the questionnaire.

Fig 1.

Figure 1.T1-weighted brain magnetic resonance image. Enhancement along the cisternal, labyrinthine, geniculate, tympanic, and mastoid segments of the right facial nerve, suggesting the presence of probable neuritis.
Journal of Acupuncture Research 2024; 41: 216-221https://doi.org/10.13045/jar.24.0029

Fig 2.

Figure 2.Visual analog scale (VAS) of dysphagia.
Journal of Acupuncture Research 2024; 41: 216-221https://doi.org/10.13045/jar.24.0029

Table 1 . Penetration-aspiration scale (PAS).

ScoreDescription
1Contrast does not enter the airway
2Contrast enters the airway, remains above the vocal folds; no residue
3Contrast remains above the vocal folds, visible residue remains
4Contrast passes glottis; no subglottic residue visible
5Contrast contacts the vocal folds; visible residue remains
6Contrast passes glottis; no subglottic residue visible
7Contrast passes glottis; visible subglottic residue despite patient’s response
8Contrast passes glottis; visible subglottic residue; absent patient response

Table 2 . Prescription of Sayeoggaboglyeongsan.

HerbLatin nameAmount (g)
Glycyrrhiza uralensisGlycyrrhiza uralensis6
Poncirus trifoliataPoncirus trifoliata6
Bupleurum falcatumBupleurum falcatum6
Paeonia lactifloraPaeonia lactiflora6
Poria cocosPoria cocos6
Citrus unshiuCitrus unshiu4
Pinellia ternataPinellia ternata4

Table 3 . Prescription of Yeong-gyechulgamtang.

HerbLatin nameAmount (g)
Poria cocosPoria cocos8
Cinnamomum cassiaCinnamomum cassia6
Atractylodes japonicaAtractylodes japonica6
Glycyrrhiza uralensisGlycyrrhiza uralensis4

Table 4 . Prescription of Dongeui Hwalhyeoldan.

HerbLatin nameAmount (g)
Rehmannia glutinosaRehmannia glutinosa0.76
Cervus nippon TemminkCervi Pantotrichum Cornu0.55
Dioscorea batatas DecneDioscoreae Rhizoma0.47
Ligusticum acutilobumLigustici Radix0.46
Cornus officinalis SiebCorni Fructus0.46
Paeonia suffruticosa AndrewsMoutan Cortex0.30
Alisma canaliculatum AllAlismatis Rhizoma0.30
Cibotium barometzCibotii Rhizoma0.23
Moschus moschiferusMoschi Moschus0.06
Dryobalanops aromaticaBorneol0.01

Table 5 . The patient’s Yanagihara’s score throughout the disease course.

DateJanuary 11, 2024January 18, 2024January 27, 2024February 20, 2024
At rest2234
Wrinkle forehead1224
Blink2344
Light closure of eye1234
Tight closure of eye1344
Closure of eye on the involved side only1124
Wrinkle nose0123
Whistle0013
Grin0334
Depress lower lip0334
Total8202738

Table 6 . The improvement in patient’s dysphagia after receiving pharmacopuncture treatments.

DatePharmacopuncture therapyVASNote
January 11, 20241 mL of Ganoderma lucidum10Blended diet
The patient choked on liquid, and the medication was administered twice daily
January 12, 20241 mL of Ganoderma lucidum9No special notes
January 13, 20241 mL of Ganoderma lucidum9No special notes
January 14, 20241 mL of Ganoderma lucidum8No special notes
January 15, 20241 mL of Hominis placenta8No special notes
January 16, 2024-8No special notes
January 17, 20241 mL of Ganoderma lucidum7No special notes
January 18, 20241 mL of Ganoderma lucidum5The patient began to take Dongeui Hwalhyeoldan
January 19, 20241 mL of Ganoderma lucidum5No special notes
January 20, 20241 mL of Ganoderma lucidum5The patient’s diet was switched from a blended to a regular one
January 21, 20241 mL of Ganoderma lucidum5No special notes
January 22, 20241 mL of Ganoderma lucidum5As the patient began choking less on liquid, the medication was administered thrice daily
January 23, 20241 mL of Hominis placenta4No special notes
January 24, 2024-3No special notes
January 25, 20241 mL of Ganoderma lucidum3No special notes
January 26, 20241 mL of Ganoderma lucidum2No special notes
January 27, 2024-2End of therapy

VAS, visual analog scale..


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Aug 01, 2024 Volume 41:143~266

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