Hye In Jeong ^{1 +}, Kyeong Han Kim ^{2 +}, Yong Taek Oh ³, Yoo Min Choi ⁴, Beom Yong Song ⁴, Jong Uk Kim ⁴, Tae-Han Yook ^{4 *}

The aim of this study was to analyze case reports on and to study Korean medicine treatments of facial palsy.

Studies published after 2000 were selected by searching for the terms “facial palsy” and “Guanwasa” in four databases and case reports using Korean medicine moderating variables were extracted by two individual researchers.

The House Brackmann (H-B) Scale (23 times, 65.7%), and Yanagihara Grading Scale (Y-system) (22 times, 62.8%) were used to assess facial palsy. All case reports used acupuncture, while 19 case reports (51.3%) used electro-acupuncture, and 8 case reports (21.6%) used pharmacopuncture. Main meridian points used were ST6, ST4, GB14, TE23, LI20, BL2. Thirty-two case reports used herbal medicine (86.4%) and both Ligigeo-poong-san, Bojunglkgi-tang were used frequently.

To treat facial palsy, acupuncture was mainly used in conjunction with electro-acupuncture and pharmacopuncture. Most case reports also used herbal medicine.

facial palsy, case report, traditional Korean medicine

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Facial palsy can be distinguished by two major types, central facial palsy and peripheral facial palsy. Most facial palsy occurs with the peripheral form [1]. Facial palsy mainly shows facial muscle paralysis to the affected side caused by facial nerve damage, along with pain in or behind the ear, altered sense of taste, sound hypersensitivity, tinnitus, drooling, and decreased tearing. The onset rate difference among age and sex shows clear distinction. Most facial palsy occurs on one side, and cases that affect both sides of the face occur rarely (0.3%) [2]. In Korea, facial palsy occurs at the rate of 20 people out of 100,000 per year. In Korean medicine, facial palsy is known as “Guanwasa” and is defined as the patient being unable to wrinkle the forehead on the affected side, unable to close the eyelid, with eye movement of the affected side moving upward and outward. Furthermore, abnormal tearing may occur, such as excessive or reduced tearing, drooping of the nosewing and nasojugal area which results in difficulty moving normally, altered sense of taste, decreased salivation, accompanied with pain in or behind the ear, headache, sound hypersensitivity and difficulty in hearing [3]. To diagnose facial palsy, various methods such as the House-Brackmann Grading System (H-B scale), Yanagihara Grading Scale (Y-system), and Weighted Regional Grading System (FEMA) are used. The H-B scale and Y-system are mainly used in the clinical field [4]. Treatment of facial palsy in conventional medicine includes corticosteroids or antivirus agents, and surgical treatments such as stellate ganglion block. When diagnosed with other diseases, internal treatment is initiated first, then followed by conservative treatment using steroid agents such as prednisone when no complications occur [5]. This type of treatment leads to shortening of the healing period, but the overall treatment results are still controversial [6]. The limits of conventional medicine treatment in facial palsy has led to increased interest in treatments with Korean medicine which focuses on conservative treatment. Korean medicine therapeutic methods include acupuncture, herbal medicine, physical therapy, and others. Case reports show acupuncture treatment using filiform acupuncture needle treatments with electro-acupuncture or pharmacopuncture [7], or various treatments such as thread embedding acupuncture, Jung-an acupuncture [8], and Mi-so facial acupuncture [9]. Studies based on combined treatment using laser treatments such as Infrared (IR), Silver Spike Point (SSP) are continuously being published [10]. Numerous clinical studies on Korean medicine treatment of facial palsy are ongoing but literature review focusing on case reports to measure the current status of treatment in the clinical field is insufficient, especially overall studies on measuring tools, acupuncture, and herbal medicine. Therefore, this study aimed to generally investigate research trends, diagnostic methods, and treatments of facial palsy.

The collected data were obtained using search engines including KISS (Korean Studies Information Service System), RISS (Research Information Service System), OASIS (Korean Medicine Information System), and NDSL (National Digital Science Library). Search words were “facial palsy” and “Guanwasa” and the retrieval date was July 2, 2018.

Studies of facial palsy using Korean medicine moderating variables were extracted by two individual researchers by reviewing the title and abstract of each study. The extract- ed studies were reviewed once again based on the original document to decide whether the research contents were suitable for this study. Case studies published after 2000 and before the retrieval date (June 2018) were included in this study. The number of cases within one case report was not considered and were all included for study. Studies on complications associated with facial palsy such as pain in or behind the ear, otitis media, difficulty hearing, and strabismus were considered within the category of facial palsy and were included. Case studies in which Korean medicine treatment was not the main method or was not included were excluded.

Facial palsy studies using Korean medicine moderating variables were classified by the characteristic of moderating variables. Due to the lack of prior research, the classification criteria was based on internal discussions among researchers and was categorized mainly by use of acupuncture, herbal medicine, and other treatment (physical therapy, conventional medicine medication). Most studies used various therapeutic methods simultaneously, therefore the case reports were first classified, and the frequency of therapeutic methods were later observed. Diagnostic and measuring tools documented in the study included tools used for evaluating facial palsy, and for measuring tools that are not related with facial palsy were additionally documented. Case reports that clarified the affected side and non-affected side were all documented within the study, and case reports that did not clarify the affected side recorded the acupuncture points. If the number of acupuncture points included more than four points, the first four acupuncture points were documented. For conventional medicine medication, medicine taken only during the treatment period was documented. Past history which was recorded with the specific year was documented without particular marking, and past history without the specific year was documented with Hx (History). For cases that involved different therapeutic methods in one study, each therapeutic method was documented with marks such as #1 and #2. Case reports that included more than two cases, or the evaluation tool, acupuncture points, and other therapeutic methods involved were identical, were analyzed as one case. Acupuncture treatment studies clarified whether treatment was administered on the affected side, non-affected side, or both sides. Additional studies used acupuncture points without directional consideration. Therefore, when counting the acupuncture points, directions were not considered, and acupuncture treatment that was applied on both sides was considered as a one-time treatment instead of two treatments. Electro-acupuncture used two types of methods. One connected two different acupuncture points, and the other was applied electro-acupuncture on separate acupuncture points. The frequency rate was analyzed by each method. If acupuncture treatment was used but the name of the muscle was documented instead of the acupuncture point, the case report was excluded from ac upuncture point analysis. Case reports using herbal formulas consisted of cases that used a different formula on each case, or an identical formula for all cases. Therefore, if several cases in one paper used the same formula it was considered as one case. Additionally, a formula that was adjusted by adding or subtracting contents was considered as the original formula. For other therapeutic methods, the expression of treatment tools differed among the case reports and therefore was standardized and analyzed.

Based on the database results 1,087 articles published domestically were collected. After removing duplicated articles, 583 studies remained. Furthermore, 204 references were excluded, which were published before 2000, leaving 379 articles to review for the abstract. Based on revision, 205 studies using conventional medicine moderating variables, 3 animal experimental studies, 5 trend analysis studies, and 118 clinical studies which are not case reports were excluded. As a result, a total of 37 references were selected for the analysis.

Chronological analysis of the 37 case reports selected showed 10 case reports of facial palsy were published from 2000-2004, 8 published from 2009-2012, and 11 published from 2013-2017. The number of cases included in each case report differed and showed 23 (62.1%) studies with one case, 7 studies (18.9%) with two cases, and 7 studies (18.9%) with more than three cases. All studies included acupuncture treatment, 19 studies (51.3%) used electro-acupuncture additionally, and 8 studies (21.6%) used additional pharmacopuncture. Six studies (16.2%) used acupuncture, electro-acupuncture, and pharmacopuncture simultaneously. Thirty-two case reports (86.4%) used herbal medicine and 13 studies (35.1%) used conventional medicine medication simultaneously. Eleven case reports (29.7%) used conventional medicine medication and herbal medicine simultaneously. Thirty-five case reports (94.5%) used measuring tools to evaluate patient improvement rate. (Table 1)

Thirty-five case reports out of 37 used evaluation tools. The H-B Scale (23 times, 65.7%) and Y-system (22 times, 62.8%), and Digital infrared thermal imaging (DITI) (5 times, 14.2%) were used in sequence. Numeral rating scale (NRS) was used in 3 studies (8.5%), and visual analog scale (VAS) was used in 6 studies (17%) to evaluate pain in or behind the ear or tinnitus.

Out of 37 case reports, acupuncture was used a total of 453 times. For acupuncture treatment, the name of acupuncture points and number of acupuncture points used for treatment is as follows: ST6 (38 times, 8.3%), ST4 (34 times, 7.5%), TE23 (27 times, 5.9%), GB14 (27 times, 5.9%), GV26 (27 times, 5.9%), LI4 (26 times, 5.7%), LI20 (23 times, 5%), BL2 (23 times, 5%), ST2 (20 times, 4.4%), SI18 (18 times, 3.9%), CV24 (18 times, 3.9%), TE17 (16 times, 3.5%), ST36 (16 times, 3.5%), ST7 (12 times, 2.6%), EX-HN4 (10 times, 2.2%), EX-HN5 (10 times, 2.2%), ST1 (8 times, 1.7%), LR3 (8 times, 1.7%), EX-HN3 (7 times, 1.5%), GB20 (7 times, 1.5%). Nineteen (51.3%) case reports used electro-acupuncture 26 times. The use of ST4-ST6 was the most frequently used (13 times, 50%), followed by TE23-BL2 (3 times, 11.5%), ST7-SI18 (2 times, 7.6%). In the method of using electro-acupuncture for each acupuncture point, ST6 was the most frequently used point (9 times, 11.2%), followed by GB14, ST4 (8 times, 10%), LI20, BL2 (7 times, 8.7%), SI18 (6 times, 7.5%), ST7, and EX-HN3 (4 times, 5%). Case reports that used pharmacopuncture totaled 8 (21.6%), 12 times. Types of pharmacopuncture mainly used were Hominis Placenta, Hwangryunhaedok-tang, and bee venom acupuncture, each used 3 times (25%).

Out of 37 case reports, case reports that used herbal medicine totaled 32 (86.4%), 49 times. Frequently used herbal medicines were Ligigeopoong-san (15 times, 16.8%), Bojunglkgi-tang (9 times, 10.1%), and Gyeonjeong-san, Bogigeopung-san, Ligigyeonjeong-san (5 times, 5.6%).

Twenty-nine case reports used other treatments, and out of 29 cases, IR was used most frequently (15 times, 51.7%), followed by facial massage (13 times, 44.8%) and SSP (Silver spike point) (13 times, 44.8%). Facial massage, hot-pack (5 times, 17.2%), moxibustion, carbon, and laser were also used (4 times, 13.7%).

This study collected and analyzed case reports of facial palsy using Korean medicine treatment. As a result, chronological analysis showed that continuous publication of case reports on facial palsy has been ongoing. Ten case reports of facial palsy were published from 2000-2004, 8 published from 2009-2012, and 11 published until 2017, indicating that Korean medicine treatment of facial palsy has been continuously used and related research has also been conducted. Evaluation tools of facial palsy used in clinical practice should be able to accurately evaluate the level of paralysis in a short period of time, and also requires high reproductibility [4]. Electric diagnostic findings such as electromyogram (EMG) and electroneuronography (ENoG) are insufficient evaluating the level of facial function recovery, therefore grading systems to measure functional recovery levels are frequently used [12]. Grading systems used to evaluate facial palsy consist of two types; the general method that measures the overall condition of facial palsy and accompanied symptoms simultaneously, and the special method that first measures the paralysis condition by each area and then grades the overall disability level and accompanied symptoms. The H-B scale is mainly used in the general method, while the Y-system is used in the special method [13]. Based on the analysis in this study, like preceding studies, the H-B scale (23 times, 65.7%) and Y-system (22 times, 62.8%) are used with high frequency. The H-B scale shows low deviation between measures and has simple evaluation methods which are easy to use and quickly evaluated. The Y-system seems to be frequently used in clinical practice since it enables objective and quantitative evaluation of facial function without a specific tool, and can sensitively measure a patient’s change of condition [4]. Other evaluation tools such as Sunnybrook facial grading system (SFGS) or detailed evaluation of facial symmetry (DEFS) were used, but the frequency and reproducibility were very low and the measuring time is long compared to the H-B scale and Y-system. The most frequently used acupuncture points for acupuncture and electro-acupuncture treatment were ST6 followed by ST4, GB14, TE23, LI20, BL2, and GV26. In Korean medicine literature, it is recorded that ST4, ST6, and LI4 are used for Guanwasa [14] and it is thought that these acupuncture points are located in the meridians (stomach channel of foot Yangming, gallbladder channel of foot Shaoyang, bladder channel of foot Taiyang, large intestine channel of the hand Yangming) that passthrough the facial area. Among the frequently used acupuncture points, LI4, although not located in the facial area, especially the starting point of Stomach Channel of Foot Yangming, shows skin temperature changes in the facial area when acupuncture needles are placed there. this shows the correlation of LI4 and the facial area. Considering that Guanwasa is a disease caused by wind-cold in the facial nerve, controlling cold and heat by skin temperature can be related to the treatment of facial palsy [11]. Studies indicate that electro-acupuncture shows significant treatment effects on facial palsy [16]. Electro-acupuncture is also used frequently since it can be used at any part of the human body by applying intensive stimulation for chronic pain or paralysis diseases [17] and shows advantage in paralyzed nerves or myoatrophy [18]. Hominis Placenta, Hwangryunhaedok-tang, and bee venom acupuncture were mainly used for pharmacopuncture. Hominis Placenta pharmacopuncture is used for regenerating tissues, developing antibodies, enhancing resistance and supplementing lacking yoon in meridians [19]. Bee venom acupuncture can cause side effects such as anxiety, rashes, and vomiting when allergic reaction occurs, but is widely used in inflammation and paralysis diseases due to the analgesic effect, anti-inflammation and effectively removing wind-dampness [20]. Hwangryunhaedok-tang pharmacopuncture has wind factor scattering effect and anti-inflammation effects [21]. The facial nerve has a long pathway compared to other cranial nerves. It passes through a narrow pathway which leads to the facial nerve being easily damaged during surgery of the middle ear or temporal bone, injury or infection, which is why anti-inflammation pharmacopuncture is used frequently [22]. Ligigeopoong-san, the most frequently used formula, is documented in <Donguibogam> [23]. It also influences removing and scattering wind-cold and moderating qi and vitalizing meridians and used for early stage symptoms of Guanwasa [13]. Bojunglkgi-tang was frequently used for fundamental treatment of deficient-type Guanwasa after general symptoms improved [24]. Ligigeopoong-san was also used in some cases until symptoms were improved, and Gamiboik-tang was used when facial area movement occurred [25]. Gyeonjeong-san is a formula frequently used in Donguibogam, well-known for Guanwasa caused by stroke. Medication in conventional medicine was used to treat preexisting diseases, often combining steroids or antivirus agents with herbal medicine. However, most of the cases did not document the purpose of the medication, which caused difficulty in conducting research based on the reference. Other treatments included IR, facial massage and SSP. When infrared light is exposed to the affected area it is shown to have calming effect and relieve pain, and is considered to be a main treatment of facial palsy [26]. SSP is a low frequency electric-stimulating treatment device using silver plate electrodes on the body surface. Studies show that when electro-acupuncture is used with SSP treatment the treatment rate increases which is why SSP treatment is used frequently [27]. This study has analyzed 18 years of studies on facial palsy treatment and has reviewed diagnosis, evaluating tools, and treatment tools related with facial palsy treatment. However, it has limits since an international database was not used within the study, and the searching words were limited to ‘facial palsy’ and ‘Guanwasa’ which does not cover all studies on facial palsy. This study shows case reports and the diagnosis, evaluating tools and treatment tools used for facial palsy and the frequency of use. Based on this study, additional research is needed on the use of common treatment tools to review how the treatment rate differs.

To review the domestic trend of facial palsy and the diagnosis, evaluating tools, and treatment tools, 37 case reports were analyzed (1) Thirty-five studies (94.5%) used evaluating tools to measure the patients’ improvement rate. The H-B scale (23 times, 65.7%) and Y-system (22 times, 62.8%) were frequently used. (2) All studies used filiform acupuncture needles, 19 studies (51.3%) used additional electro-acupuncture, and 8 studies (21.6%) used additional pharmacopuncture. Frequently used acupuncture points were ST6, ST4, GB14, TE23, LI20, BL2, and GV26. (3) Thirty-two studies (86.4%) used herbal medicine while 12 studies (32.4%) used conventional medicine medication. Ligigeopoong-san, Bojunglkgi-tang, and Gyeonjeong-san were frequently used. (4) Twenty-nine studies (78.3%) used other treatments including IR, facial massage and SSP. Facial palsy treatment uses a wide-range of therapeutic methods, mainly acupuncture with electro-acupuncture and pharmacopuncture, mostly combined with herbal medicine.

This research achievement is conducted with assistance from Ministry of Health and Welfare through the Korea Health Industry Development Institute (HB16C0028).

The authors declare that there are no conflicts of interest.

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