Case Report

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Journal of Acupuncture Research 2024; 41(2): 121-128

Published online May 31, 2024

https://doi.org/10.13045/jar.24.0001

© Korean Acupuncture & Moxibustion Medicine Society

Improvement of Facial Paralysis after Parotidectomy with Integrated Korean Medicine Treatment: A Case Report

Choong Hyun Han , Young Han Nam , Young Kyung Kim , Youn Young Choi , Eun Sol Won , Hwa Yeon Ryu , Jae Hui Kang , Hyun Lee

Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, Cheonan, Korea

Correspondence to : Hyun Lee
Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, 4, Notaesan-ro, Seobuk-gu, Cheonan 31099, Korea
E-mail: lh2000@dju.kr

Received: April 1, 2024; Revised: April 20, 2024; Accepted: April 29, 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.

This study presents a case of facial nerve injury that occurred after parotidectomy for a benign tumor of the parotid gland that improved with integrated Korean medicine (IKM). On June 24, 2023, the patient presented with facial nerve injury based on a facial nerve conduction study after parotidectomy, with a score of five on Yanagihara’s unweighted grading system (Y-system) and a grade of five on the House–Brackmann facial grading scale (H–B scale). During the 15 days of admission, IKM treatments, including acupuncture, pharmacopuncture, moxibustion, herbal steam therapy, physiotherapy, herbal medicine, and thread embedding acupuncture treatment, were performed. After treatment, the strength of the orbicularis oculi, orbicularis oris, and masticatory muscles improved, with a Y-system score of 17 and an H–B scale of III. In conclusion, the findings of this study confirm the applicability and effectiveness of IKM in the treatment of facial paralysis following parotidectomy.

Keywords Facial nerve injury; Facial paralysis; Korean traditional medicine; Parotid gland

Facial nerve trauma (FNT) is the second most common cause of facial paralysis (FP), and its causes include plastic surgery, orthognathic surgery (such as bilateral sagittal split ramus osteotomy), skull fracture, temporal bone fracture caused by trauma, ear penetration, and tumor removal (13.8% of cases occur after tumor removal) [1,2]. When direct damage to the facial nerve occurs, approximately 33% of patients experience facial abnormalities, such as hypoesthesia, numbness, and tingling [1]. FP following FNT has a slower recovery rate than Bell’s palsy, and its prognosis is determined by the extent of paralysis rather than when it occurs [2]. The following risk factors are associated with FP after parotidectomy: (1) extent of surgery, (2) previous history of parotidectomy, (3) presence of malignancy, (4) lesion size, and (5) inflammatory conditions [3].

In integrated Korean medicine (IKM), acupuncture, moxibustion, herbal medicine, and thread embedding acupuncture (TEA) treatment are used to treat FP [4,5]. Although several studies have investigated the treatment of Bell’s palsy in patients with FP, to our knowledge, no case reports have focused on IKM for FNT following facial nerve injury caused by parotid surgery (PS). Thus, this study reports a case of a patient treated with IKM for FNT following parotidectomy.

1. Patient

OOO (female/48).

1) Chief complaints

The patient presented with right FP after partial parotidectomy for parotid gland tumor (PGT). Wrinkling of the forehead and nose was nearly impossible, and the patient also experienced dry eyes and difficulty closing her eyes. Her orbicularis oculi muscles were weak; food would frequently get stuck in her mouth and, while brushing her teeth, rinsing water would often leak from her mouth.

2) Present illness

The patient was diagnosed with a benign tumor of the right parotid gland via facial computed tomography and magnetic resonance imaging at the Soonchunhyang University Hospital in February 2023 and underwent partial parotidectomy at a local otolaryngology department on March 24, 2023. After surgery, she developed FP and was treated for approximately 3 months at the hospital where the surgery was performed. On June 24, 2023, the patient presented with symptoms of complete neuropathy of the right facial nerve as confirmed by a facial nerve conduction study and blink reflex test at the Dankook University Hospital, and she was diagnosed with facial nerve injury. Furthermore, on July 1, 2023, she was hospitalized at the Cheonan Korean Medicine Hospital of Daejeon University.

3) Duration of treatment

The patient received treatment between July 1 and July 15, 2023.

2. Treatment

1) Acupuncture

The acupuncture needles used were standard stainless steel disposable needles (0.20 × 30 mm; Dongbang Medical Co., Ltd.). Moreover, acupuncture was performed twice daily for 15 minutes in the morning and afternoon at EX-HN5, GB14, TE23, BL2, CV24, LI19, ST4, ST6, TE17, and SI19 on the paralyzed side.

Electroacupuncture was performed every morning by applying current to ST6-CV24, ST4-LI19, and BL2-TE23 among the acupuncture points using an STN-110 device (Stratek). Moreover, the current frequency was set at 1.0 Hz.

2) Pharmacopuncture

A total of 1 cc Hominis Placenta pharmacopuncture (Yaksu Wonwoe Tangjeon) was injected at a depth of 0.3–0.5 cm using a 1 cc syringe (30 G × 12.7 mm needle; Jungrim Medical) once daily from July 4, 2023, to July 10, 2023, and once every 2 days from July 11, 2023, to July 15, 2023. Pharmacopuncture was performed to EX-HN5, GB14, TE23, BL2, CV24, LI19, ST4, ST6, TE17, and SI19 on the paralyzed side.

3) Thread embedding acupuncture treatment

The thread used for TEA treatment was a polydioxanone-based suture (30-gauge × 25.4 mm long disposable sterile needle; MAS Inc.). TEA treatment was performed at GB14, TE23, BL2, ST2, EX-HN5, CV24, LI19, ST, ST6, and ST7 on the paralyzed side once every two days for a total of two sessions.

4) Moxibustion

Moxibustion was performed twice daily using Onttum, an electric moxibustion device (TechnoScience Co., Ltd.) attached to PC5, PC6, and ST36 on both sides for 20 minutes per session.

5) Herbal steam therapy

The herbal steam therapy (HST) involves dissolving a bag of Ligigeopoongsan in distilled water and applying it to the facial area of the paralyzed side twice daily for 15 minutes each time using an SK-750 steamer (Hanebio) (Table 1).

Table 1 . Herbal composition of Ligigeopoongsan in a bag for herbal steam therapy

LigigeopoongsanDose (g)
Schizonepetae Spica0.76
Ledebouriellae Radix0.76
Bombycis Corpus0.76
Gastrodiae Rhizoma0.76
Angelicae Koreanae Radix0.38
Agastachis Herba0.38
Aconiti Koreani Radix0.38


6) Physiotherapy

Silver spike point therapy was performed as physiotherapy using a Pulselater PG-8 device (ITO Co., Ltd.) for 20 minutes once a day at a frequency of 3–5 Hz, with one pair of electrodes applied to the orbicularis oculi, orbicularis oris, and masticatory muscles on the paralyzed side.

7) Herbal medicine

Gamiligigyenjeong-san and Bojungikkitanggamibang were prescribed during admission. Each herbal medicine was prescribed at 120 mL, three times a day after meals (Table 2).

Table 2 . Herbal composition of GamiLigigyeonjeong-san and Bojungikkitanggamibang for daily dosage

GamiLigigyeonjeong-san
(2023.07.01–2023.07.03)
Dose (g)Bojungikkitanggamibang
(2023.07.03–2023.07.15)
Dose (g)
Uncaria rhynchophylla8Astragali Radix8
Schizonepetae Spica4Atractylodis Rhizoma Alba8
Angelicae Koreanae Radix4Angelicae Gigantis Radix8
Ledebouriellae Radix4Rehmanniae Radix Preparata4
Araliae Cordatae Radix4Ginseng Radix4
Aurantii Fructus4Cnidii Rhizoma4
Aurantii Immaturi Pericarpium4Angelicae Dahuricae Radix4
Cortex Fraxini4Paeoniae Radix4
Linderae Radix4Aurantii Nobilis Pericarpium4
Platycodi Radix4Poria Sclerotium4
Cnidii Rhizoma4Glycyrrhizae Radix4
Angelicae Dahuricae Radix4Pinelliae Rhizoma4
Gastrodiae Rhizoma4Arisaematis Rhizoma4
Pinelliae Rhizoma4Angelicae Koreanae Radix4
Arisaematis Rhizoma4Ledebouriellae Radix4
Glycyrrhizae Radix4Gentianae Macrophyllae Radix4
Aconiti Koreani Radix3Bombycis Corpus4
Bombycis Corpus3Amomi Fructus4
Scorpio2Plantaginis Semen4
Zingiberis Rhizoma4Bupleuri Radix4
Cimicifugae Rhizoma4
Zingiberis Rhizoma12


3. Evaluation

1) Yanagihara’s unweighted grading system

The Yanagihara’s unweighted grading system (Y-system) assesses FP and facial function daily. The assessment comprises 10 items for evaluating forehead, eye, oral, and nasal muscle functions. The system scores ranged from 0 (total paralysis) to 4 (normal function) for each item [6]. Moreover, photographs were taken at 7-day intervals for eight of the ten items (at rest, wrinkled forehead, closed eyes lightly, closed eyes tightly, wrinkled nose, whistle, grin, and depressed lower lip) to check the progress from admission to discharge.

2) House–Brackmann facial grading scale

The House–Brackmann facial grading scale (H–B scale) was used to assess daily facial function. Depending on the degree of FP, the scale ranges from grade I to VI, with grade I indicating “normal” and grade VI indicating “complete paralysis” [7].

3) Digital infrared thermographic imaging

The digital infrared thermographic imaging (DITI) was used to compare the temperature distributions around the ophthalmic and orbicularis muscles on the normal and paralyzed sides to assess the degree and progression of FP [8]. The first DITI test was conducted in the outpatient department on June 28, 2023, two days before admission, and DITI progression was monitored on July 7, 2023, the seventh day of admission, and July 15, 2023, the day of discharge.

4. Progress of the patient under treatment

The Y-system score on the day of admission was 5, and on discharge, the score had improved to 17 (Table 3, Fig. 1). The H–B scale on admission was grade V, which improved to grade III at discharge (Table 3, Fig. 2). On July 15, 2023, DITI findings revealed that the temperatures around the orbicularis oculi and zygomaticus muscles on the paralyzed side were similar to those on the normal side during treatment. Furthermore, compared with June 28, 2023, the temperature around the orbicularis oris muscle on the paralyzed side showed a slight improvement (Fig. 3).

Table 3 . Changes in Yanagihara’s unweighted grading system score and House–Brackmann facial grading scale

July 1July 2July 3July 4July 5July 6July 7July 8July 9July 10July 11July 12July 13July 14July 15
Y-system score56791011121415161619212224
At rest111112222222233
Blink011111111112222
Wrinkling of the forehead000011111112222
Closure of eyes lightly001111222222222
Closure of eyes tightly000111112222222
Closure of eyes involved side only000000000001111
Wrinkling of the nose111222222223333
Whistle111111122222333
Grin111111111222223
Depress lower lip111111111111223
House–Brackmann facial grading scaleVVVIVIVIVIVIVIVIIIIIIIIIIIIIIIIII

Y-system, Yanagihara’s unweighted grading system.


Fig. 1. Changes in Yanagihara’s unweighted grading system (Y-system) score.
Fig. 2. Changes in the House–Brackmann facial grading scale (H–B scale).
Fig. 3. Digital infrared thermographic imaging. (A) Taken on June 28, 2023. (B) Taken on July 7, 2023. (C) Taken on July 15, 2023.

The aim of this study was to report a case of FP caused by FNT that occurred secondary to parotidectomy. PGTs are the most common type of salivary gland tumors, accounting for approximately 80% of all salivary gland tumor [9]. Most PGTs are benign (80%), with pleomorphic adenomas being the most common (50%) [10]. The causes of PGT have not been determined, but genetic and environmental factors, such as radiation exposure, smoking, and hormones, are known to play a role [11].

Surgical removal of PGTs is a common procedure. However, FP, which occurs in approximately 27% of such patients, is a potential complication of PGT removal. FP accounts for the largest percentage of complications after parotidectomy, with the prevalence of temporary paralysis ranging from 15% to 66% and permanent facial nerve damage ranging from 2.5% to 5.0% [9,12].

In this case, the patient received IKM treatments, including acupuncture, pharmacopuncture, moxibustion, TEA, HST, physiotherapy, and herbal medicine. Acupuncture and Hominis Placenta pharmacopuncture were performed to restore facial nerve function [13]. HST, which involves inhaling vapors from an herbal medicine and applying them to the skin or respiratory tract, has been reported to be effective in treating the symptoms of FP [14]. TEA treatment has some effects to relieve stiffness and contractures of the facial muscles [5]. Physiotherapy is performed to increase blood flow to damaged tissues and promote recovery [15]. Moreover, herbal medicines, such as GamiLigigyeonjeong-san and Bojungikkitanggamibang, are commonly prescribed for the acute or recovery phase of FP [4].

Surgical treatment should be implemented for complete FNT paralysis, whereas conservative treatment is recommended for incomplete cases [16]. Transient FP after PS usually resolves within 6 months, with 90% of cases resolving within 1 month [17]. In the meantime, it is recommended to leave the nerve intact to prevent further nerve damage if the extent of nerve damage is less than 50% of the total cross-sectional area [18]. In meditation, corticosteroids, drops, ointments, and botulinum toxin are known to be used to treat FNT [17,19]. Park et al. (2023) [20] noted that acupuncture, pharmacopuncture, moxibustion, cupping, bloodletting, hyperbaric oxygen therapy, physiotherapy, TEA, and herbal medicine are used variably. In IKM, no study has reported PS-induced FNT cases; temporal fractures, zygomatic fractures, and skull fractures or head traumas are common [20]. In a 2018 review article by Jeong et al. [4], 37 cases of FP caused by FNT included otologic surgery and temporal fracture, whereas common treatments included acupuncture and Korean herbal medicine. Western medicine, pharmacopuncture, electroacupuncture, and physiotherapy were selectively applied depending on the case [4]. In this case, the patient developed FP shortly after parotidectomy and showed no improvement in FP for 3 months before IKM treatment was started. During the 15-day admission, the patient was treated with IKM and subsequently showed improvement in facial nerve function and orbicularis oculi muscle strength (Fig. 4). These findings suggest that IKM can improve FP following FNT.

Fig. 4. Right facial paralysis photograph of the patient. (A) At rest. (B) Wrinkling of the forehead. (C) Closure of eyes lightly. (D) Closure of eyes tightly. (E) Wrinkling of the nose. (F) Whistle. (G) Grin. (H) Depress lower lip.

However, this study has several limitations. First, because this is a single case study, no control group was established, and no cases of patients with IKM who had improved FNT in PS were included to compare these findings. Second, various treatments were administered simultaneously, which made it difficult to assess the effectiveness of each treatment. Third, there was a lack of follow-up data on the objective endpoints, such as electromyography. Fourth, because this study only shows the effect of treatment by IKM, the effect of treatment received during the 3 months before admission or environmental variables that may be present during treatment cannot be excluded. To address these limitations, further high-quality studies that involve control groups and randomized controlled trials are needed to confirm the findings of this study. Despite these limitations, this study is still relevant as it is the first to treat FP post-parotidectomy with IKM, and its findings suggest that conservative FNT treatment post-PS can restore facial muscle strength on the paralyzed side. Further case series and trials should be conducted to evaluate IKM’s efficacy and prognosis of IKM treatments and to determine the generalizability of our findings.

Conceptualization: CHH. Methodology: CHH. Formal investigation: CHH. Data analysis: CHH. Writing – original draft: CHH. Writing – review & editing: All authors.

To protect patients’ personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No.:DJUMC-2023-BM-17).

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Article

Case Report

Journal of Acupuncture Research 2024; 41(2): 121-128

Published online May 31, 2024 https://doi.org/10.13045/jar.24.0001

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

Improvement of Facial Paralysis after Parotidectomy with Integrated Korean Medicine Treatment: A Case Report

Choong Hyun Han , Young Han Nam , Young Kyung Kim , Youn Young Choi , Eun Sol Won , Hwa Yeon Ryu , Jae Hui Kang , Hyun Lee

Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, Cheonan, Korea

Correspondence to:Hyun Lee
Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, 4, Notaesan-ro, Seobuk-gu, Cheonan 31099, Korea
E-mail: lh2000@dju.kr

Received: April 1, 2024; Revised: April 20, 2024; Accepted: April 29, 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

This study presents a case of facial nerve injury that occurred after parotidectomy for a benign tumor of the parotid gland that improved with integrated Korean medicine (IKM). On June 24, 2023, the patient presented with facial nerve injury based on a facial nerve conduction study after parotidectomy, with a score of five on Yanagihara’s unweighted grading system (Y-system) and a grade of five on the House–Brackmann facial grading scale (H–B scale). During the 15 days of admission, IKM treatments, including acupuncture, pharmacopuncture, moxibustion, herbal steam therapy, physiotherapy, herbal medicine, and thread embedding acupuncture treatment, were performed. After treatment, the strength of the orbicularis oculi, orbicularis oris, and masticatory muscles improved, with a Y-system score of 17 and an H–B scale of III. In conclusion, the findings of this study confirm the applicability and effectiveness of IKM in the treatment of facial paralysis following parotidectomy.

Keywords: Facial nerve injury, Facial paralysis, Korean traditional medicine, Parotid gland

INTRODUCTION

Facial nerve trauma (FNT) is the second most common cause of facial paralysis (FP), and its causes include plastic surgery, orthognathic surgery (such as bilateral sagittal split ramus osteotomy), skull fracture, temporal bone fracture caused by trauma, ear penetration, and tumor removal (13.8% of cases occur after tumor removal) [1,2]. When direct damage to the facial nerve occurs, approximately 33% of patients experience facial abnormalities, such as hypoesthesia, numbness, and tingling [1]. FP following FNT has a slower recovery rate than Bell’s palsy, and its prognosis is determined by the extent of paralysis rather than when it occurs [2]. The following risk factors are associated with FP after parotidectomy: (1) extent of surgery, (2) previous history of parotidectomy, (3) presence of malignancy, (4) lesion size, and (5) inflammatory conditions [3].

In integrated Korean medicine (IKM), acupuncture, moxibustion, herbal medicine, and thread embedding acupuncture (TEA) treatment are used to treat FP [4,5]. Although several studies have investigated the treatment of Bell’s palsy in patients with FP, to our knowledge, no case reports have focused on IKM for FNT following facial nerve injury caused by parotid surgery (PS). Thus, this study reports a case of a patient treated with IKM for FNT following parotidectomy.

CASE REPORT

1. Patient

OOO (female/48).

1) Chief complaints

The patient presented with right FP after partial parotidectomy for parotid gland tumor (PGT). Wrinkling of the forehead and nose was nearly impossible, and the patient also experienced dry eyes and difficulty closing her eyes. Her orbicularis oculi muscles were weak; food would frequently get stuck in her mouth and, while brushing her teeth, rinsing water would often leak from her mouth.

2) Present illness

The patient was diagnosed with a benign tumor of the right parotid gland via facial computed tomography and magnetic resonance imaging at the Soonchunhyang University Hospital in February 2023 and underwent partial parotidectomy at a local otolaryngology department on March 24, 2023. After surgery, she developed FP and was treated for approximately 3 months at the hospital where the surgery was performed. On June 24, 2023, the patient presented with symptoms of complete neuropathy of the right facial nerve as confirmed by a facial nerve conduction study and blink reflex test at the Dankook University Hospital, and she was diagnosed with facial nerve injury. Furthermore, on July 1, 2023, she was hospitalized at the Cheonan Korean Medicine Hospital of Daejeon University.

3) Duration of treatment

The patient received treatment between July 1 and July 15, 2023.

2. Treatment

1) Acupuncture

The acupuncture needles used were standard stainless steel disposable needles (0.20 × 30 mm; Dongbang Medical Co., Ltd.). Moreover, acupuncture was performed twice daily for 15 minutes in the morning and afternoon at EX-HN5, GB14, TE23, BL2, CV24, LI19, ST4, ST6, TE17, and SI19 on the paralyzed side.

Electroacupuncture was performed every morning by applying current to ST6-CV24, ST4-LI19, and BL2-TE23 among the acupuncture points using an STN-110 device (Stratek). Moreover, the current frequency was set at 1.0 Hz.

2) Pharmacopuncture

A total of 1 cc Hominis Placenta pharmacopuncture (Yaksu Wonwoe Tangjeon) was injected at a depth of 0.3–0.5 cm using a 1 cc syringe (30 G × 12.7 mm needle; Jungrim Medical) once daily from July 4, 2023, to July 10, 2023, and once every 2 days from July 11, 2023, to July 15, 2023. Pharmacopuncture was performed to EX-HN5, GB14, TE23, BL2, CV24, LI19, ST4, ST6, TE17, and SI19 on the paralyzed side.

3) Thread embedding acupuncture treatment

The thread used for TEA treatment was a polydioxanone-based suture (30-gauge × 25.4 mm long disposable sterile needle; MAS Inc.). TEA treatment was performed at GB14, TE23, BL2, ST2, EX-HN5, CV24, LI19, ST, ST6, and ST7 on the paralyzed side once every two days for a total of two sessions.

4) Moxibustion

Moxibustion was performed twice daily using Onttum, an electric moxibustion device (TechnoScience Co., Ltd.) attached to PC5, PC6, and ST36 on both sides for 20 minutes per session.

5) Herbal steam therapy

The herbal steam therapy (HST) involves dissolving a bag of Ligigeopoongsan in distilled water and applying it to the facial area of the paralyzed side twice daily for 15 minutes each time using an SK-750 steamer (Hanebio) (Table 1).

Table 1 . Herbal composition of Ligigeopoongsan in a bag for herbal steam therapy.

LigigeopoongsanDose (g)
Schizonepetae Spica0.76
Ledebouriellae Radix0.76
Bombycis Corpus0.76
Gastrodiae Rhizoma0.76
Angelicae Koreanae Radix0.38
Agastachis Herba0.38
Aconiti Koreani Radix0.38


6) Physiotherapy

Silver spike point therapy was performed as physiotherapy using a Pulselater PG-8 device (ITO Co., Ltd.) for 20 minutes once a day at a frequency of 3–5 Hz, with one pair of electrodes applied to the orbicularis oculi, orbicularis oris, and masticatory muscles on the paralyzed side.

7) Herbal medicine

Gamiligigyenjeong-san and Bojungikkitanggamibang were prescribed during admission. Each herbal medicine was prescribed at 120 mL, three times a day after meals (Table 2).

Table 2 . Herbal composition of GamiLigigyeonjeong-san and Bojungikkitanggamibang for daily dosage.

GamiLigigyeonjeong-san
(2023.07.01–2023.07.03)
Dose (g)Bojungikkitanggamibang
(2023.07.03–2023.07.15)
Dose (g)
Uncaria rhynchophylla8Astragali Radix8
Schizonepetae Spica4Atractylodis Rhizoma Alba8
Angelicae Koreanae Radix4Angelicae Gigantis Radix8
Ledebouriellae Radix4Rehmanniae Radix Preparata4
Araliae Cordatae Radix4Ginseng Radix4
Aurantii Fructus4Cnidii Rhizoma4
Aurantii Immaturi Pericarpium4Angelicae Dahuricae Radix4
Cortex Fraxini4Paeoniae Radix4
Linderae Radix4Aurantii Nobilis Pericarpium4
Platycodi Radix4Poria Sclerotium4
Cnidii Rhizoma4Glycyrrhizae Radix4
Angelicae Dahuricae Radix4Pinelliae Rhizoma4
Gastrodiae Rhizoma4Arisaematis Rhizoma4
Pinelliae Rhizoma4Angelicae Koreanae Radix4
Arisaematis Rhizoma4Ledebouriellae Radix4
Glycyrrhizae Radix4Gentianae Macrophyllae Radix4
Aconiti Koreani Radix3Bombycis Corpus4
Bombycis Corpus3Amomi Fructus4
Scorpio2Plantaginis Semen4
Zingiberis Rhizoma4Bupleuri Radix4
Cimicifugae Rhizoma4
Zingiberis Rhizoma12


3. Evaluation

1) Yanagihara’s unweighted grading system

The Yanagihara’s unweighted grading system (Y-system) assesses FP and facial function daily. The assessment comprises 10 items for evaluating forehead, eye, oral, and nasal muscle functions. The system scores ranged from 0 (total paralysis) to 4 (normal function) for each item [6]. Moreover, photographs were taken at 7-day intervals for eight of the ten items (at rest, wrinkled forehead, closed eyes lightly, closed eyes tightly, wrinkled nose, whistle, grin, and depressed lower lip) to check the progress from admission to discharge.

2) House–Brackmann facial grading scale

The House–Brackmann facial grading scale (H–B scale) was used to assess daily facial function. Depending on the degree of FP, the scale ranges from grade I to VI, with grade I indicating “normal” and grade VI indicating “complete paralysis” [7].

3) Digital infrared thermographic imaging

The digital infrared thermographic imaging (DITI) was used to compare the temperature distributions around the ophthalmic and orbicularis muscles on the normal and paralyzed sides to assess the degree and progression of FP [8]. The first DITI test was conducted in the outpatient department on June 28, 2023, two days before admission, and DITI progression was monitored on July 7, 2023, the seventh day of admission, and July 15, 2023, the day of discharge.

4. Progress of the patient under treatment

The Y-system score on the day of admission was 5, and on discharge, the score had improved to 17 (Table 3, Fig. 1). The H–B scale on admission was grade V, which improved to grade III at discharge (Table 3, Fig. 2). On July 15, 2023, DITI findings revealed that the temperatures around the orbicularis oculi and zygomaticus muscles on the paralyzed side were similar to those on the normal side during treatment. Furthermore, compared with June 28, 2023, the temperature around the orbicularis oris muscle on the paralyzed side showed a slight improvement (Fig. 3).

Table 3 . Changes in Yanagihara’s unweighted grading system score and House–Brackmann facial grading scale.

July 1July 2July 3July 4July 5July 6July 7July 8July 9July 10July 11July 12July 13July 14July 15
Y-system score56791011121415161619212224
At rest111112222222233
Blink011111111112222
Wrinkling of the forehead000011111112222
Closure of eyes lightly001111222222222
Closure of eyes tightly000111112222222
Closure of eyes involved side only000000000001111
Wrinkling of the nose111222222223333
Whistle111111122222333
Grin111111111222223
Depress lower lip111111111111223
House–Brackmann facial grading scaleVVVIVIVIVIVIVIVIIIIIIIIIIIIIIIIII

Y-system, Yanagihara’s unweighted grading system..


Figure 1. Changes in Yanagihara’s unweighted grading system (Y-system) score.
Figure 2. Changes in the House–Brackmann facial grading scale (H–B scale).
Figure 3. Digital infrared thermographic imaging. (A) Taken on June 28, 2023. (B) Taken on July 7, 2023. (C) Taken on July 15, 2023.

DISCUSSION

The aim of this study was to report a case of FP caused by FNT that occurred secondary to parotidectomy. PGTs are the most common type of salivary gland tumors, accounting for approximately 80% of all salivary gland tumor [9]. Most PGTs are benign (80%), with pleomorphic adenomas being the most common (50%) [10]. The causes of PGT have not been determined, but genetic and environmental factors, such as radiation exposure, smoking, and hormones, are known to play a role [11].

Surgical removal of PGTs is a common procedure. However, FP, which occurs in approximately 27% of such patients, is a potential complication of PGT removal. FP accounts for the largest percentage of complications after parotidectomy, with the prevalence of temporary paralysis ranging from 15% to 66% and permanent facial nerve damage ranging from 2.5% to 5.0% [9,12].

In this case, the patient received IKM treatments, including acupuncture, pharmacopuncture, moxibustion, TEA, HST, physiotherapy, and herbal medicine. Acupuncture and Hominis Placenta pharmacopuncture were performed to restore facial nerve function [13]. HST, which involves inhaling vapors from an herbal medicine and applying them to the skin or respiratory tract, has been reported to be effective in treating the symptoms of FP [14]. TEA treatment has some effects to relieve stiffness and contractures of the facial muscles [5]. Physiotherapy is performed to increase blood flow to damaged tissues and promote recovery [15]. Moreover, herbal medicines, such as GamiLigigyeonjeong-san and Bojungikkitanggamibang, are commonly prescribed for the acute or recovery phase of FP [4].

Surgical treatment should be implemented for complete FNT paralysis, whereas conservative treatment is recommended for incomplete cases [16]. Transient FP after PS usually resolves within 6 months, with 90% of cases resolving within 1 month [17]. In the meantime, it is recommended to leave the nerve intact to prevent further nerve damage if the extent of nerve damage is less than 50% of the total cross-sectional area [18]. In meditation, corticosteroids, drops, ointments, and botulinum toxin are known to be used to treat FNT [17,19]. Park et al. (2023) [20] noted that acupuncture, pharmacopuncture, moxibustion, cupping, bloodletting, hyperbaric oxygen therapy, physiotherapy, TEA, and herbal medicine are used variably. In IKM, no study has reported PS-induced FNT cases; temporal fractures, zygomatic fractures, and skull fractures or head traumas are common [20]. In a 2018 review article by Jeong et al. [4], 37 cases of FP caused by FNT included otologic surgery and temporal fracture, whereas common treatments included acupuncture and Korean herbal medicine. Western medicine, pharmacopuncture, electroacupuncture, and physiotherapy were selectively applied depending on the case [4]. In this case, the patient developed FP shortly after parotidectomy and showed no improvement in FP for 3 months before IKM treatment was started. During the 15-day admission, the patient was treated with IKM and subsequently showed improvement in facial nerve function and orbicularis oculi muscle strength (Fig. 4). These findings suggest that IKM can improve FP following FNT.

Figure 4. Right facial paralysis photograph of the patient. (A) At rest. (B) Wrinkling of the forehead. (C) Closure of eyes lightly. (D) Closure of eyes tightly. (E) Wrinkling of the nose. (F) Whistle. (G) Grin. (H) Depress lower lip.

However, this study has several limitations. First, because this is a single case study, no control group was established, and no cases of patients with IKM who had improved FNT in PS were included to compare these findings. Second, various treatments were administered simultaneously, which made it difficult to assess the effectiveness of each treatment. Third, there was a lack of follow-up data on the objective endpoints, such as electromyography. Fourth, because this study only shows the effect of treatment by IKM, the effect of treatment received during the 3 months before admission or environmental variables that may be present during treatment cannot be excluded. To address these limitations, further high-quality studies that involve control groups and randomized controlled trials are needed to confirm the findings of this study. Despite these limitations, this study is still relevant as it is the first to treat FP post-parotidectomy with IKM, and its findings suggest that conservative FNT treatment post-PS can restore facial muscle strength on the paralyzed side. Further case series and trials should be conducted to evaluate IKM’s efficacy and prognosis of IKM treatments and to determine the generalizability of our findings.

AUTHOR CONTRIBUTIONS

Conceptualization: CHH. Methodology: CHH. Formal investigation: CHH. Data analysis: CHH. Writing – original draft: CHH. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

To protect patients’ personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No.:DJUMC-2023-BM-17).

Fig 1.

Figure 1.Changes in Yanagihara’s unweighted grading system (Y-system) score.
Journal of Acupuncture Research 2024; 41: 121-128https://doi.org/10.13045/jar.24.0001

Fig 2.

Figure 2.Changes in the House–Brackmann facial grading scale (H–B scale).
Journal of Acupuncture Research 2024; 41: 121-128https://doi.org/10.13045/jar.24.0001

Fig 3.

Figure 3.Digital infrared thermographic imaging. (A) Taken on June 28, 2023. (B) Taken on July 7, 2023. (C) Taken on July 15, 2023.
Journal of Acupuncture Research 2024; 41: 121-128https://doi.org/10.13045/jar.24.0001

Fig 4.

Figure 4.Right facial paralysis photograph of the patient. (A) At rest. (B) Wrinkling of the forehead. (C) Closure of eyes lightly. (D) Closure of eyes tightly. (E) Wrinkling of the nose. (F) Whistle. (G) Grin. (H) Depress lower lip.
Journal of Acupuncture Research 2024; 41: 121-128https://doi.org/10.13045/jar.24.0001

Table 1 . Herbal composition of Ligigeopoongsan in a bag for herbal steam therapy.

LigigeopoongsanDose (g)
Schizonepetae Spica0.76
Ledebouriellae Radix0.76
Bombycis Corpus0.76
Gastrodiae Rhizoma0.76
Angelicae Koreanae Radix0.38
Agastachis Herba0.38
Aconiti Koreani Radix0.38

Table 2 . Herbal composition of GamiLigigyeonjeong-san and Bojungikkitanggamibang for daily dosage.

GamiLigigyeonjeong-san
(2023.07.01–2023.07.03)
Dose (g)Bojungikkitanggamibang
(2023.07.03–2023.07.15)
Dose (g)
Uncaria rhynchophylla8Astragali Radix8
Schizonepetae Spica4Atractylodis Rhizoma Alba8
Angelicae Koreanae Radix4Angelicae Gigantis Radix8
Ledebouriellae Radix4Rehmanniae Radix Preparata4
Araliae Cordatae Radix4Ginseng Radix4
Aurantii Fructus4Cnidii Rhizoma4
Aurantii Immaturi Pericarpium4Angelicae Dahuricae Radix4
Cortex Fraxini4Paeoniae Radix4
Linderae Radix4Aurantii Nobilis Pericarpium4
Platycodi Radix4Poria Sclerotium4
Cnidii Rhizoma4Glycyrrhizae Radix4
Angelicae Dahuricae Radix4Pinelliae Rhizoma4
Gastrodiae Rhizoma4Arisaematis Rhizoma4
Pinelliae Rhizoma4Angelicae Koreanae Radix4
Arisaematis Rhizoma4Ledebouriellae Radix4
Glycyrrhizae Radix4Gentianae Macrophyllae Radix4
Aconiti Koreani Radix3Bombycis Corpus4
Bombycis Corpus3Amomi Fructus4
Scorpio2Plantaginis Semen4
Zingiberis Rhizoma4Bupleuri Radix4
Cimicifugae Rhizoma4
Zingiberis Rhizoma12

Table 3 . Changes in Yanagihara’s unweighted grading system score and House–Brackmann facial grading scale.

July 1July 2July 3July 4July 5July 6July 7July 8July 9July 10July 11July 12July 13July 14July 15
Y-system score56791011121415161619212224
At rest111112222222233
Blink011111111112222
Wrinkling of the forehead000011111112222
Closure of eyes lightly001111222222222
Closure of eyes tightly000111112222222
Closure of eyes involved side only000000000001111
Wrinkling of the nose111222222223333
Whistle111111122222333
Grin111111111222223
Depress lower lip111111111111223
House–Brackmann facial grading scaleVVVIVIVIVIVIVIVIIIIIIIIIIIIIIIIII

Y-system, Yanagihara’s unweighted grading system..


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May 31, 2024 Vol.41 No.2, pp. 75~142

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