Ramsay Hunt syndrome (RHS), which is linked to herpes zoster oticus, typically leads to ear pain, blisters, and facial paralysis. RHS occurs when the dormant varicella zoster virus reactivates in the geniculate ganglion, affecting the facial nerve and sometimes causing symptoms, such as hearing loss, vertigo, and tinnitus [1].

Overall, peripheral facial paralysis occurs in 20–30 per 100,000 people, with a high prevalence in individuals in their 20s and 30s [2]. The incidence is relatively low in children and increases in people aged ≥ 60 years [3]. This is presumed to be related to the rapid decline in cellular immune function against viruses after the age of 60 years [4].

Studies have shown that Korean medicine treatment for RHS is effective until recently; however, one study focused on patients in the recovery phase, which is more than 4 weeks after disease onset, rather than those in the acute phase [5]. Another study was constrained, as it utilizes only Korean medicine, without integrating it with other medical approaches [6]. Herein, we report the good results of integrative Korean medicine treatments in patients with RHS in the acute phase.

1. Patient

A 64-year-old man.

2. Chief complaint

Right facial palsy.

3. Onset

March 14, 2024.

4. Medical history

He was diagnosed with hyperlipidemia in 2023 and on medications.

5. Current medical history

The patient experienced parietal pain after suffering from extreme stress on March 9, 2024. On March 12, he experienced right eyelid tremors and laryngeal pain. On March 14, he had facial shingles and twisting occurred and was diagnosed with facial paralysis after developing shingles (as RHS). He was then prescribed steroids. On March 17, he visited the Jaseng Korean Medicine Hospital.

6. Korean medical diagnosis and pattern identification

At the beginning of hospitalization, the pulse was thin and fast, the tongue was generally red, and there was little coating. When abdominal examination was performed, there was tenderness and pain in a specific area. Collectively, it was diagnosed as liver qi stagnation and Yin deficiency by extreme stress (Fig. 1).

Figure 1. The results of the tongue and abdominal examinations.

7. Treatment period

1) Inpatient treatment: The patient was hospitalized for a total of 24 days from March 18, 2024, to April 10, 2024.

2) Outpatient treatment: He had a total of 29 outpatient visits from April 11, 2024, to August 23, 2024.

8. Korean medicine treatment

1) Acupuncture: A sterilized single-use acupuncture needle (0.2 × 30 mm; Dongbang Medical) was used. Acupuncture was performed twice a day (morning and afternoon) during hospitalization and once a day during the outpatient treatment. Acupuncture was performed for 10 minutes, and the criteria used for selecting the acupoints were described elsewhere (Table 1) [2].

Table 1 . Summary of the treated muscles, acupoint, method, needle sizes, and side.

	Muscle	Acupoint	Method	Needle size (mm)	Side
1	Ocipitofrontalis	GB14	Pharmacoacupuncture (0.1 mL per acupoint) Acupuncture	20 × 30	Affected side
2	Orbicularis oculi	BL2, TE23, Ex-HN4	Pharmacoacupuncture (0.1 mL per acupoint) Acupuncture	20 × 30	Affected side
3	Temporalis	Ex-HN5	Pharmacoacupuncture (0.1 mL per acupoint) Acupuncture	20 × 30	Affected side
4	Zygomaticus major	ST7	Pharmacoacupuncture (0.1 mL per acupoint) Electroacupuncture (ST2-ST7)	20 × 30	Affected side
5	Levator labii superioris	ST2	Pharmacoacupuncture (0.1 mL per acupoint) Electroacupuncture (ST2-ST7)	20 × 30	Affected side
6	Levator labii superioris alaeque nasi	LI20	Pharmacoacupuncture (0.1 mL per acupoint)	20 × 30	Affected side
7	Orbicularis oris	CV24, GV26	Electroacupuncture (CV24-CV26)	20 × 30	Affected side
8	Masster	ST4, ST6	Pharmacoacupuncture (0.1 mL per acupoint) Electroacupuncture (ST4-ST6)	20 × 30	Affected side
9	Auricularis	TE17	Cupping therapy	-	Affected side

–, not available..

2) Electroacupuncture: Electrical stimulation was performed at a frequency of 3 Hz for 10 minutes with an acupuncture electrical stimulator (STN-111; Stratek) for a stronger stimulation [7].

3) Pharmacoacupuncture: Referring to previous studies [8,9]. Shinbaro2 pharmacoacupuncture and purified bee venom (eBV) pharmacopuncture (Jaseng’s Herbal Medicine Department, Seongnam, Korea) were chosen and injected in disposable syringes (26 G × 13 mm syringe, 1 mL; Benton Dickinson). During inpatient treatment, 1 mL of Shinbaro2 pharmacoacupuncture was administered. After the eBV test on the third day of hospitalization came out negative, 1 mL of eBV pharmacopuncture was administered.

4) Cupping therapy: Cupping (unit size of 5; Dongbang Medical) was performed once a day at acupoint TE17, which is the area close to the mastoid process where the facial nerve appears from the skull to the outside, to reduce nerve pressure.

5) Korean herbal medicine treatment: Based on the diagnosis, Haepyo-hwan was administered from 2 weeks before discharge, three times a day, with one pill each time (Table 2).

Table 2 . Prescription of Haepyo-hwan.

Scientific name	Dose (g)
Rehmanniae Radix Preparata	1.851*
Angelica gigas Nakai	1.111*
Zingiber officinale Roscoe	0.740*
Cinnamomum cassia Presl	0.370*
Glycyrrhizae Radix	0.370*
Dimocarpus longan	0.370
Lycopus lucidus	0.188
Total	5.000

*Composition of the Korean medicine “Ieum-Jeon.”.

9. Western medicine treatment

In the acute phase, the patient received treatments with steroids, antiviral drugs, peptic ulcer drugs, and so on. Some of these medicines were tapered to slowly reduced the drug’s dose until its discontinuation. The patient also took drugs for hyperlipidemia before the hospitalization (Table 3).

Table 3 . Prescription of Western medicines during hospitalization.

Date	Drug name, dose, and use	Remark
March 18, 2024–March 24, 2024	Prednisolone 5 mg 12T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	-
March 25, 2024	Prednisolone 5 mg 10T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	Steroid doses were tapered
March 26, 2024	Prednisolone 5 mg 8T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	Steroid doses were tapered
March 27, 2024	Prednisolone 5 mg 6T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	Steroid doses were tapered
March 28, 2024	Prednisolone 5 mg 4T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	Steroid doses were tapered
March 29, 2024	Prednisolone 5 mg 2T #1 QD PO Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	Steroid doses were tapered
March 30, 2024–April 2, 2024	Kallidinogenage 50 IU 2T #2 BID PO Lafutidine 10 mg 2T #2 BID PO Famciclovir 250 mg 3T #3 TID PO Acyclovir 5 g applied to the skin five times a day Ezetimibe 10 mg 1T #1 QD PO	-

QD, once a day; PO, oral administration; BID, two times a day; TID, three times a day; –, not available..

10. Evaluation method

The Yanagihara score was used in the evaluation during the treatment period (Appendix 1). Facial changes were assessed using photos. The patient’s House-Brackmann (HB) grade before and after recovery was measured (Appendix 2). Additionally, a numerical rating scale (NRS) was used to quantify the accompanying pain.

11. Treatment course

1) Facial paralysis symptoms: At the start of the treatment, the patient had facial paralysis, characterized by the absence of forehead wrinkles, minimal cheek and lip movements, and difficulty blinking on the affected side. The patient obtained an HB grade of 5 and a Yanagihara score of 13.

After discharge, on July 26, the patient showed only slight asymmetry at the resting state, as well as normal eye blinking movements and eye wrinkles. Additionally, the patient had normal facial movements, except for the slight asymmetry of the gum and teeth on affected side when whistling and laughing; he was then evaluated as having an HB grade of 2 and a Yanagihara score of 37 (Tables 4, 5, Fig. 2).

Figure 2. Pictures of the patient’s face.

Table 4 . Changes in the Yanagihara’s score by date.

Variable	Date
	March 17, 2024	April 2, 2024	July 26, 2024
At rest	1	2	3
Wrinkle forehead	1	2	4
Blink	2	3	4
Light closure of the eyes	3	4	4
Tight closure of the eyes	2	3	4
Closure of the eye in the involved side only	0	1	4
Wrinkle nose	1	2	4
Whistle	1	1	3
Grin	1	2	3
Depress the lower lip	1	3	4
Total	13	23	37

Table 5 . Changes in the HB grade and NRS score by date.

Date	HB grade	NRS score
March 18, 2024	5	5
March 21, 2024	5	4
March 24, 2024	5	3
March 26, 2024	5	2
March 28, 2024	5	0
April 2, 2024	4	0
May 10, 2024	3	0
July 26, 2024	2	0

HB, House-Brackmann; NRS, numerical rating scale..

2) Subjective symptoms: At the start of the inpatient treatment, he had hearing difficulties on his right ear, which improved quickly during hospitalization. His sense of taste was not affected.

He initially reported an NRS score of 5 for the pain in the back of his right ear. During the inpatient treatment period, ear pain decreased rapidly, and, at the time of discharge, he reported an NRS score of 0 for ear pain, which lasted even during the outpatient treatment period.

In 1904, Körner introduced the condition herpes zoster oticus, which is characterized by facial paralysis and accessory symptoms [10,11]. In 1907, Hunt [10] further reported symptoms, such as vertigo and nausea, accompanying herpes zoster oticus, which is now known as RHS. RHS is more severe with a low complete recovery rate as compared to Bell’s palsy [10,11].

In conventional treatments, steroids and antiviral drugs are used in combination, with a full recovery rate of facial paralysis being 54–67% [12]. The symptoms of RHS is generally severe at the start of treatment and during the disease course; in fact, in cases with an HB grade of 5 or 6, incomplete recovery with an HB grade of 2 or 3 is usually seen [13]. When treatment is started within 3 days of disease onset, the full recovery rate is 75%; however, when the treatment is started only after 8 days, the full recovery rate was only 30%, showing a significant difference in the recovery rate depending on the day of initiating treatment [14].

In the context of Korean medicine, RHS has not been explicitly classified. However, it can be considered to be within the categories of Guanwasa (Bell’s palsy) from the perspective of facial paralysis and Saguanchang (Snake-shaped sore) from the perspective of vesicular eruptions accompanied by pain [5]. Guanwasa is described as resulting from the invasion of wind-cold into the facial meridians, leading to spasms in the blood vessels associated with local nerves, subsequently causing neural edema and ischemia [15]. Meanwhile, Saguanchang can be differentiated into patterns, such as liver qi stagnation and qi stagnation with blood stasis, among others. In the present case, the herbal medicine, using the formula Ieum-Jeon, administered was based on a foundation of Yin deficiency. Additional medicinal herbs were added to address liver dysfunction caused by severe stress (Dimocarpus longan) and to enhance blood circulation (Lycopus lucidus), according to the patient’s pathological condition.

In clinical practice, most patients who visit Korean medical institutions for facial paralysis often go through Western medical institutions first and receive steroid treatments in various forms. Starting steroid treatment within 3 days of symptom onset has a higher recovery rate than starting it after 4 days [16]. The standard clinical practice guidelines (CPGs) for facial paralysis also recommend performing acupuncture with Western medicine, including steroids [17]. However, several studies also recommend dose tapering to gradually reduce the amount of steroids taken by patients [18]. In this respect, the present case receiving a Korean medicine-led treatment complied with CPGs.

Given the high levels of stress in modern society, the prevalence of facial paralysis is steadily increasing [17]. Therefore, Korean medicine can be considered a primary integrative treatment option along with Western medicine for patients with facial paralysis.

Conceptualization: HWC. Data curation: HWC. Formal analysis: HWC. Investigation: HWC. Methodology: HWC. Project administration: HWC. Resources: HWC. Supervision: HWC. Visualization: HWC. Writing – original draft: HWC. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This study was exempted from deliberation by the Institutional Review Board of Jaseng Hospital of Korean Medicine (approval no. JASENG 2024-08-025). A written informed consent was obtained from the patients for the publication of this case report.