Visual abstract

Introduction

Facial palsy, is characterized by sudden, unilateral facial nerve paralysis. Incidence increases during the 3^rd trimester of pregnancy, which is presumed to be related to changes in hormone levels, immunosuppression, and nerve compression as a result of perineural oedema [1]. However, the exact link between facial palsy and pregnancy is unclear. These patients have a significantly low early treatment rate, and a poor long-term prognosis [2].

The initial treatment for facial palsy is usually steroid therapy, but their use during pregnancy is controversial due to potential risks to the fetus [3]. This may lead clinicians to be more conservative and thus delay the start of treatment [1].

Acupuncture on the other hand is a safe and acceptable therapy for pregnant women with facial palsy, and has minimal risks such as minor bruising or discomfort [4].

The number of reported clinical cases of Korean medicine treatment for facial palsy during pregnancy is small, with reports from Shin et al [5], Lan et al [6], where the focus was on acupuncture and herbal medicine. Therefore, we present 2 cases of facial palsy in pregnant women entering the 3^rd trimester, who have received various Korean medicine treatments.

Case Report

1. Patient general characteristics

Among the patients who visited Bucheon Jaseng Korean Medicine Hospital between 2019 and 2024, a total of 2 pregnant patients who suffered from facial palsy were included in this retrospective study. The general characteristics are described in Table 1. In brief, facial palsy in both cases appeared to have been caused by stress or environmental factors. Neither case had a significant medical history. Case 2 had a history of iron supplementation to prevent anemia. Both cases shared similar obstetric history [Term-Preterm-Abortions-Living (1-0-0-1)], and gestational age (Case 1 was 25 weeks pregnant and Case 2 was 24 weeks) with proximity to the 3^rd trimester which is a period when facial palsy is most commonly observed during pregnancy. In Case 2, the patient was diagnosed with facial palsy at Bucheon St. Mary’s Hospital, based on blood tests and hearing tests, and she received 2 sessions of physical therapy before visiting our hospital.

2. Treatments

The treatments provided at Bucheon Jaseng Korean Medicine Hospital included acupuncture, electro-acupuncture, and pharmacopuncture which Case 1 received, and in addition Case 2 also received moxibustion, wet cupping therapy, and Chuna therapy. Furthermore, Case 2 received 2 sessions of physical therapy at St. Mary’s Hospital before receiving treatment (10^th day since onset) at our institution. Case 1 and Case 2 were treated by different Korean medicine doctors, resulting in variations in the treatments and techniques employed (Figure 1).

While Case 1 consistently received acupuncture, electro-acupuncture, and pharmacopuncture at each visit (following consultation Visit 1), for a total of 16 sessions, Case 2 underwent different treatment modalities over the sessions. Acupuncture, electroacupuncture, and moxibustion was consistently received for all 11 sessions. Chuna was performed at Visit 2–5. Pharmacopuncture was discontinued after a single session (Visit 2), due to financial reasons and patient complaints of treatment-related pain, and cupping therapy was also discontinued from Visit 7 for the same reasons. (Figure 1). The details of each treatment used in the 2 cases are described in Supplementary 1. No adverse effects were observed in either Case 1 or Case 2 after treatment.

3. Outcome measures

The assessments for each case were performed by a different clinician using the same evaluation tools listed below.

3.1. House-Brackmann scale

The House-Brackmann scale (H-B grade) is a gross scale used to assess overall facial function, from normal (Grade 1) to total paralysis (Grade 6; Supplementary 2).

3.2. Yanagihara grading system

The Yanagihara grading system (Y-score) is a 40-point facial nerve grading system of 10 facial movements whereby a total score of 40 indicates normal function (Supplementary 3). It is used to diagnose the severity of paralysis based on the dysfunction of each facial part.

3.3. Numeric rating scale

The numeric rating scale (NRS) is a scale used to assess the severity of pain, rating from 0 (no pain) to 10 (the worst pain imaginable). Facial palsy is often accompanied by pain in upper parts of the body such as neck, submaxilla, and ear [7]. This was observed in Case 1 where posterior neck pain was experienced, and in Case 2 where the patient’s hearing was normal, but she experienced intermittent pain behind her right ear.

4. Progress and outcome

4.1. Case 1

Case 1, a 39-year-old female presented with left-sided facial palsy accompanied by posterior neck pain after sleeping in a cold environment on December 1, 2019. She visited our clinic on December 3, (3^rd day after onset) and at the initial examination, she exhibited a complete inability to wrinkle her forehead on the left or close her left eye leading to excessive tearing from that eye. During the “ee” motion, her left lip failed to move, and the teeth on the right were clearly visible but none of the teeth on the left could be seen. Similarly, during the “oo” motion, asymmetry between the 2 sides was evident. She also complained of tinnitus in her left ear.

In addition to facial asymmetry, sensory examination revealed reduced facial sensation on the left compared with the right. During meals, food tended to become stuck on the left side, and she reported drooling whilst drinking. She experienced posterior neck pain on the left side during cervical flexion, extension, and rotation, further complicating her left-sided facial palsy symptoms.

The patient received treatment (acupuncture, electro-acupuncture, and pharmacopuncture) from the 3^rd day of onset of facial palsy symptoms until the 46^th day. Progress was observed from the 3^rd visit (6^th day since onset), where excessive tearing decreased, leading to the 1^st improvement in the Y-score from 14 to 16. By the 6^th visit (11^th day since onset), the patient showed no excessive tearing, and other facial symptoms, such as those involving the eyes and tongue, remained stable without further deterioration (Y-score 18, H-B Grade 4). Forehead wrinkles began to appear by the 8^th visit (13^th day since onset) showing an improvement in the Y-score to 21, and the H-B grade showed the 1^st improvement in score to Grade 3. This was followed by an improvement in nose movement (Y-score 24, H-B Grade 3) on the 9^th visit (17^th day since onset) and lip movement(Y-score 35, H-B Grade 2) on the 13^th visit (26^th day since onset). By the 14^th visit (34^th day since onset), most facial movements had been restored (Y-score 40, H-B Grade 2) leading to the conclusion of treatment after a total of 16 sessions, 46 days since the onset of symptoms. All assessment indicators showed improvement by the end of treatment, with the H-B grade decreasing from Grade 4 to 2, and the NRS score decreasing from 4 to 2 points, and the Y-score increasing from 14 to 40, compared with the initial status. Detailed treatment outcomes for each visit are outlined in Table 2.

4.2. Case 2

Case 2, a 27-year-old female, presented with right-sided facial palsy on July 31, 2023, after being significantly stressed and physically tired of taking care of her 1^st child. She visited our clinic on August 9, 10 days after the onset of facial palsy symptoms. On the initial examination, she was unable to wrinkle her forehead on the right, and her right eye could not fully close, resulting in excessive tearing. During the “ee” motion, movement of the right lip was minimal compared with the left, allowing only 1 upper tooth on the right side to be visible. Similarly, during the “oo” motion, facial asymmetry was evident. The patient’s hearing was normal, but she experienced intermittent pain behind her right ear. She also reported reduced taste perception and a dull sensation on the right side of her face. She expressed discomfort with her drooling during meals, and headaches localized near her right temple.

Treatment (acupuncture, electroacupuncture, pharmacopuncture, moxibustion, wet cupping therapy, and Chuna) began on August 11, 2023 (12^th day after the onset). By the 4^th visit (15^th day since onset), when Chuna therapy was being administered, forehead movement had begun, which led to the 1^st recovery observed in both the H-B grade and the Y-score from Grade 5 to 4 and 9 to 11, respectively. This was followed by the resolution of ear pain and nasal movement, leading to an improvement in the Y-score to 16 by the 6^th visit (19^th day since onset), shortly after the completion of Chuna therapy. Lip movement was observed (H-B Grade 3, Y-score 25) by the 8^th visit (26^th day since onset), and by the 10^th visit (29^th day since onset), nearly all facial movements had been restored (H-B Grade 2, Y-score 29). Treatment was completed after a total of 12 sessions, 38 days since the onset of symptoms. All assessment indicators showed improvement by the end of treatment, with the H-B grade decreasing from 5 to 2, the NRS score decreasing from 6 to 0 points and the Y-score increasing from a score of 9 to 34, compared with the initial status. Detailed treatment outcomes for each visit are outlined in Table 3.

Discussion

Incidence of facial palsy in pregnancy increases during the 3^rd trimester [1]. Steroid therapy during pregnancy is controversial due to potential risks to the fetus [3]. Conversely, acupuncture is safe for pregnant women [4]. This study reports 2 cases of Korean medicine treatment and improvement in symptoms of facial palsy during pregnancy.

The acupuncture points used included the ipsilateral facial points Xiaguan (ST7), Yifeng (TE17), Dicang (ST4), Jiache (ST6) to stimulate the facial nerve pathway and facial muscles [8], and contralateral Hegu (LI4) which is widely used in treating facial disorders to balance the circulation of blood throughout the body [9]. Electroacupuncture was also used as it has shown greater effectiveness than standard acupuncture alone [10]. Hominis placenta pharmacopuncture was included for its regenerative, antiviral, hormone-like, antistress, and neuro-stabilizing effects, and to enhance cure rates compared with standard acupuncture alone [11,12]. Moreover, Case 2 received moxibustion and cupping which have been reported to improve blood circulation in facial palsy [13,14].

In this case report, complete restoration of facial movements was achieved by Day 34 in Case 1 and Day 29 in Case 2. The H-B grade decreased from 4 to 2 in Case 1 and from 5 to 2 in Case 2. Despite the generally poor prognosis in pregnant women who develop facial palsy, this case showed effective outcomes, and recoveries comparable to nonpregnant patients treated early with steroids.

Adding Chuna therapy, during the early stages of palsy, may enhance the favorable outcomes gained from the other Korean medicine treatments used for facial palsy in pregnant women. Supine JS Cervical Therapy improves blood flow in the vertebral artery which can be effective even in the 1^st week of treatment, a period when improvements in facial palsy are often minimal [15]. In addition, the use of nonresistance therapy has also been reported by Lee et al [16] and Kyung et al [17] to beneficially contribute to treatment outcomes. Case 2 demonstrated faster improvement compared with Case 1, with recovery times of 38 days and 46 days, respectively. This was also reflected in Case 2 where the H-B grade improved following 4 treatment sessions, whereas Case 1 began to show improvement after eight treatment sessions (Figure 2). Moreover, despite having a worse initial Y-score evaluation compared with Case 1, Case 2 demonstrated a greater rate of early improvement, with the Y-score increasing by 7 points, compared with a 4-point improvement in Case 1, both after 6 treatments (Figure 3).

This study has several limitations. Firstly, the practitioners for Case 1 and Case 2 were different and the treatment regimens were different. This makes it challenging to directly compare cases and certain aspects of the treatment outcomes, such as tongue sensation. Secondly, this report lacks visual measurements as this hospital typically does not include photographs or electromyography results. Though not critical, these tools offer a fuller assessment of the patients’ condition and progress. Thirdly, the age difference between the 2 cases may have influenced the speed of recovery since Case 1 was of advanced maternal age at 39 years as opposed to Case 2 where the mother was 27 years old.

This case report is significant in that it shows Korean medicine treatment for facial palsy in pregnant women and incorporates Chuna therapy, a treatment not previously documented for this condition. This study may provide foundation for further research to introduce a new therapeutic approach.

Conclusion

Despite the limited number of cases, the results of this study indicate positive outcomes, highlighting the potential of Korean medicine treatments for managing facial palsy during pregnancy. Although facial palsy in pregnant women is generally associated with a poor prognosis, both cases in this study demonstrated significant improvement within 3 months. Notably, a comparison of these 2 cases suggests that the addition of Chuna therapy, specifically, Supine JS Cervical Therapy and non-resistance technique, may contribute to a slightly faster initial recovery, warranting further investigation. Given the limited treatment options for facial palsy during pregnancy, Korean medicine treatments may provide an effective approach to managing facial palsy.

Supplementary Materials

Article information

Author Contributions

Conceptualization: HP and JK. Data curation: HP and SY. Formal analysis: HP. Investigation: JK and SY. Methodology: JMY. Supervision: GS. Writing - original draft: HP. Review and editing: JMY.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Use of AI Tools Statement

The authors used ChatGPT (OpenAI) solely for grammar and language improvement during the revision of this manuscript. The AI tool did not contribute to the scientific content, data analysis, or interpretation. The authors take full responsibility for all content.

Funding

This research received no external funding.

Ethical Statement

This study has been reviewed by the Institutional Review Board (IRB) of Jaseng Hospital of Korean Medicine (no.: JASENG 2024-12-003).

Data Availability

Figure 1

Treatment timeline for each visit in Case 1 and Case 2.

NB. Case 1 is described above the X-axis; Case 2 is described below the X-axis.

*Hominis Placenta extract, 0.5 cc per point.

LI4 = Hegu, ST4 = Dicang, ST7 = Xiaguan, ST6 = Jiache, ST3 = Juliao, TE17 = Yifeng.

Figure 2

House-Brackmann scale results by visit for (A) Case 1 and (B) Case 2.

NB. Values are expressed according to the House-Brackmann grading scale (Grade 1–6).

Figure 3

Yanagihara grading system results by visit for (A) Case 1 and (B) Case 2.

NB. Values are expressed according to the Yanagihara grading system scale (0–40 points).

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References

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