Improved Iatrogenic Facial Nerve Paralysis Based on House–Brackmann Facial Nerve Grading System by Using Acupuncture Therapy: A Case Report

(1)

Improved Iatrogenic Facial Nerve Paralysis Based on House–Brackmann Facial Nerve Grading

System by Using Acupuncture Therapy:

A Case Report

Andry Hartanto, MD, SpAk,

¹

Dwi Surya Supriyana, MD, MKes, SpAk,

²

and Christina Simadibrata, MD, SpAk

³

ABSTRACT

Background: Iatrogenic facial nerve paralysis is often caused by surgical procedures on temporomandibular joint due to temporomandibular disorder. It can affect the quality of life of the patient due to the facial nerve’s importance in communication and expressions.

Case: We hereby report a case of a 22-year-old man with right facial nerve paralysis after he had arthroplasty surgery. He received Mefenamic Acid 3 · 500 mg (if necessary) and Mecobalamin 1 · 500 mg. He was treated with manual acupuncture therapy for 3 times a week with 30 minutes of each session until he has reached the deqi sensation. Acupuncture points used were points on the affected side and several points on both sides.

Results: The patient underwent acupuncture treatments for 28 sessions in 4.5 months. On the eighth session, the patient had no visible right lagophthalmos. The patients’ jaws could open normally after the 12th session, and at the end of the sessions (28th) the patient could raise and lower his right eyebrow perfectly. We found that patient’s facial nerve function was improved to normal based on House–Brackmann facial nerve grading system. The nerve conduction velocity and electromyography test results also improved.

Conclusions: Acupuncture should be considered as one of the therapeutic tools for treating iatrogenic facial nerve paralysis.

Keywords:iatrogenic facial nerve paralysis, acupuncture, manual acupuncture, neurogenesis, anti-inflammation

INTRODUCTION

F

acial nerve is the seventh cranial nervethat is important for facial communication and expressions.

Damage to its functions can be very influential to the quality of life.^1,2The rate of nerve injury published in oral surgery procedure ranges approximately from 2% to 25%.³Arthroplasty is the selected surgery for treating bony ankylosis, dislocation or damage of articular disks, and severe joint adhesion.⁴

In their study, Liu and Granquist⁵found that of 21 patients suffering from facial nerve injuries, all of them had an injury on the temporal branch of facial nerve.

One of the standard methods to measure facial nerve functions is the House–Brackmann facial nerve grading system (HBFNGS).^5,6 HBFNGS has been considered as accurate in describing patient’s facial function and in su- pervising patient’s status periodically to assess the course of recovery and the effects of treatment.⁶

1Medical Acupuncture, Manyar Medical Centre Hospital Surabaya, Surabaya, Indonesia.

2Medical Acupuncture Division, UNS Teaching Hospital, Faculty of Medicine Universitas Sebelas Maret, Surakarta, Central Java, Indonesia.

3Medical Acupuncture Division, dr. Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Central Jakarta, Indonesia.

# Mary Ann Liebert, Inc.

DOI: 10.1089/acu.2021.0042

337

Downloaded by 152.118.231.30 from www.liebertpub.com at 01/18/23. For personal use only.

(2)

Acupuncture therapy has long been the basic therapy for neurologic disorders.⁷It has been shown to have neuropro- tective effects by activating and enhancing neurotrophic factor (NTF) expressions of the brain, including brain-derived neurotrophic factor (BDNF) and glial-derived neurotrophic factor (GDNF). Therefore, one neurophysiologic mechanism is the neuroplasticity arrangement, that is, neurogenesis. NTF level modulated is related to the life sustainability and proliferation and differentiation of neural stem cells (NSC).⁸

CASE PRESENTATION

A 22-year-old man came by referral of the oral surgery specialist with physical complaints in forms of inability to completely close the right eyelid, inability to contract right

eyebrow muscle, and difficulty in opening jaws (can only be opened with a gap of 1.5 patient’s finger). The patient de- veloped these symptoms a month post-gap arthroplasty for temporomandibular joint (TMJ) repair due to right TMJ ankylosis caused by motorcycle accident that happened 2 years before his current health condition.

During physical examination, a weakness in right facial nerve was found, marked by asymmetrical face expression, inability to lift right eyebrow muscle, inexistence of the right side of forehead wrinkles, asymmetric and leaking when puffing out cheeks, asymmetrical lip corner when smiling, as well as 7 mm right lagophthalmos.

HBFNGS examination showed medium to severe dysfunction (4th degree), regional HBFNGS examination showed 4, 4, 3, 3 degrees. During panoramic photograph examination, old fracture on the right caput mandibulae was accompanied

Table1. The Evaluation of House–Brackmann Facial Nerve Grading System and Nerve Conductivity and Electromyography Results

Session Level HBFNGS Regional HBFNGS Session Level HBFNGS Regional HBFNGS

1 4 4, 4, 3, 3 16 3 3, 1, 1, 1

2 4 4, 4, 3, 3 17 2 2, 1, 1, 1

3 4 4, 4, 2, 2 18 2 2, 1, 1, 1

4 4 4, 4, 2, 2 19 2 2, 1, 1, 1

5 4 4, 3, 2, 2 20 2 2, 1, 1, 1

6 4 4, 3, 2, 2 21 2 2, 1, 1, 1

7 4 4, 2, 1, 1 22 2 2, 1, 1, 1

8 4 4, 2, 1, 1 23 2 2, 1, 1, 1

9 3 3, 1, 1, 1 24 2 2, 1, 1, 1

10 3 3, 1, 1, 1 25 2 2, 1, 1, 1

11 3 3, 1, 1, 1 26 2 2, 1, 1, 1

12 3 3, 1, 1, 1 27 2 2, 1, 1, 1

13 3 3, 1, 1, 1 28 2 2, 1, 1, 1

14 3 3, 1, 1, 1 29 1 1, 1, 1, 1

15 3 3, 1, 1, 1 30 1 1, 1, 1, 1

EMG result First examination (14th session) Second examination (29th session)

Reflex blink examination

Left N.V1 stimulation R1 latency is normal, R2 latency is normal, normal R2C latency

R1 and R2 are normal, normal R2C Right N.V1 stimulation Elongated R1 latency, longitudinal

R2 latency, normal R2C latency

R1 and R2 are normal, normal R2C latency Immediate response

Left N.VII stimulation Normal CMAP amplitude —

Right N.VII stimulation Normal CMAP amplitude. CMAP

amplitude difference>0.5, right versus left

Normal CMAP amplitude EMG of the left frontal muscle Normal MUAP, normal recruitment,

spontaneous activity (-)

— EMG of the right frontal muscle Recruitment (-), spontaneous activity

(+), positive sharp wave form

Normal MUAP, recruitment (-), spontaneous activity (-)

Conclusion Examination of NCV and EMG showed

an image in accordance with the right peripheral right N.VII axonal lesion, still visible signs of denervation

Examination Bilnk reflex, NCV and EMG of the right facial nerve are currently within normal limits

CMAP, compound muscle action potential; EMG, electromyography; HBFNGS, House–Brackmann facial nerve grading system; MUAP, motor unit action potential; NCV, nerve conduction velocity.

(3)

by formation of periost that gave an impression of anky- losing on right caput mandibulae. Based on the results of nerve conduction velocity and electromyography (EMG), a description corresponding to the right peripheral N. VII axonal lesion was obtained, with still visible denervation.

The patient’s diagnosis was iatrogenic paralysis of right facial nerve post-gap arthroplasty due to TMJ ankylosis, given Mefenamic acid 3· 500 mg if necessary, and Meco- balamin 1· 500 mg.

ACUPUNCTURE TREATMENT

Patient was prescribed manual acupuncture with Western medical acupuncture style. The acupoints selected were

BL2 Cuanzhu, EX-HN 4 Yuyao, GB1 Tongziliao, GB14 Yangbai, ST3 Juliao, ST4 Dicang, ST7 Xiaguan, and TE17 Yifeng on the affected side. The remote acupoints selected were GV20 Baihui, SP6 Sanyinjiao, ST36 Zusanli, LI11 Quchi, and LI4 Hegu bilateral. The penetration points selected from ninth therapy was EX-HN 3 Yintang toward the top and EX-HN 5 Taiyang to GB8 Shuaigu.

All of the needles were pricked in a perpendicular position, but TE17 was pricked toward posterosuperior until a sensation of deqi was felt. It was conducted for 3 times in a week; each session lasted for 30 minutes, and manipulation was conducted every 10 minutes by turning. On 19th therapy, acupuncture penetration technique for 15 minutes was added and manipulation every 5 minutes was conducted

FIG. 1. (a)Schematic diagram of the mechanism of acupuncture-induced NTF expression.⁸(b)Schematic diagram of the mechanism of neurogenesis induced by acupuncture.⁸NTF, neurotrophic factor.

(4)

by turning by using filiform needle with the dimension of 0.25· 25 mm. The results of therapy are presented in Table 1.

DISCUSSION

Research by Liu and Granquist⁵in Philadelphia reported that of 56.4% (22 patients) who experienced facial nerve dysfunction after undergoing TMJ arthroplasty, 19 of them had their facial nerve functions coming back to normal 18 months post-op, while the rest experienced persistent signs of nerve weakness 6 months post-op.

Repair of iatrogenic paralysis of facial nerve requires a physiologic process of growth known as neurogenesis.

Neurogenesis is a mechanism occurring throughout life and is a multistep process in which new neurons are generated by neural progenitor cells (NPCs), followed by maturation and advanced functional integration to the pre-existing circuits. It happens in the 2 areas of brain, subventricular zone of lateral ventricle and subgranular zone of dentate gyrus (DG) of the hippocampus.⁹

Method of acupuncture employed on this patient followed the steps of Bell’s palsy therapy in Korea, where in the healing stage (more than 3 weeks), acupuncture with fine needles or needle implantation was conducted.

In terms of acupoint selection, fewer local points were used than those used in Korea, local acupoints on the healthy side were not used,¹⁰ and SP6, LI11, and GV20 remote points were added for anti-inflammatory and neurogenesis effects.^7,11–14

Acupoint LI4 can reduce abnormal functional connectivity modulated on Bell’s palsy patients.¹⁵ Research by Kong et al.¹⁶showed that LI4 activates main region of the brain in the left cerebellum, BA22, BA20, BA5, BA8, BA1/2, and BA6.

Acupoints BL2, EX-HN4, GB1, and GB14 were selected based on the patient’s complaint, in which he experienced lagophthalmos and that his eyebrow muscles cannot be moved up and down. The points are local points and innervated by branches of facial nerve, namely frontal and temporal nerves.

Acupoint ST3 was used for normalizing mid region of the face that is also innervated by facial nerve. Acupoint ST4 was used for normalizing lip corners. Acupoint TE17 anatomically is the exit of facial nerve from stylomastoid fo- ramen, while acupoint ST7 anatomically is the start of zygomatic nerve branch.

Acupuncture can improve release of activation of glutamate receptors, such as N-methyl-d-aspartate, enhances the entry of Ca²⁺ into the cell and activates kinase, including calcium/calmodulin-dependent protein kinase II (CaMKII) and protein kinase C (PKC) proteins. These kinases are known to stimulate various transcription factors, such as cAMP response element-binding protein (CREB), nuclear factor-jB (NF-jB), activator protein-1 (AP-1) and Wnt/b- catenin/T-cell factor/lymphoid enhancer factor. BDNF is induced in the transcription level by CREB and NF-jB.⁸

GDNF promotor contains bond for transcription factor, including CREB and NF-jB. GDNF transcription is stim- ulated by phosphorylated CREB and activation of c-Fos, components of AP-1 transcription factor. CREB activation

FIG. 2. Acupuncture stimulation at GV20 and ST36 points to induce neurogenesis.¹⁷

(5)

is usually accompanied by BDNF expression enhanced after acupuncture stimulation. Hence, it can induce BDNF and GDNF in neurons and glial cells through glutamate trans- mitter stimulations⁸(Fig. 1a).

Acupuncture can act as a stimulator or NTF production enhancer, which will act as an autocrine or paracrine signal to promote proliferation of NSC/NPC and differentiation to neuroblast, as well as to promote cell life sustainability.

This can lead to the functional integration of new neurons to the central nerve system, resulting in functional recovery (Fig. 1b).⁸

Scientifically, acupoints GV 20 and ST36 enhance the expressions of BDNF, GDNF, basic fibroblast growth factor, and neuro peptide-Y.7,8,11,12,17,18 On depressed mice that were acupunctured on GV20 for 21 days, it was found that the treatment can induce enhancement in BDNF expression in hippocampus.¹² Acupoint ST36 significantly

increases bromodeoxyuridine (BrdU⁺) cells and improves proliferation in DG on gerbils with a stroke, decreases production of TNF-a induced by liposaccharide through vagal modulation, which improves macrophage activity as anti-inflammation measure in the lymph, and induces c-Fos (Fig. 2).^7,17,19

Acupoint SP6 was proven to increase interleukin (IL)-10, which functions as anti-inflammation and to decrease ex- travasation of plasma and neutrophil migration.¹³

Research by Wang et al.²⁰stated that after plug-and-pull stimulation of Acupoint LI11, levels of IL-1b and tumor necrosis factor (TNF)-a were found to be lower, while IL-4 level was found to be higher.

The results of therapy were as follows, right lagophthalmos became invisible after the 8th session, and jaws can open normally after the 12th session. Right eyebrow muscle’s functions came back perfectly after the 28th session. In

FIG. 3. Clinical picture of the patient showing before and after acupuncture therapy. (a–c) Before acupuncture therapy. (d–f) After acupuncture therapy. Patient photos published with permission.

(6)

the approximate period of 4.5 months, patient’s facial nerve functions came back to normal, proven by subsequent EMG results 6 months post-therapy, which stated that right facial nerve was found within normal limits (Fig. 3).

Acupuncture can stimulate the body in producing neurotrophic and anti-inflammation and reduce side effects and oral drugs usage. The usage and dosage of corticosteroids can be reduced, since they have side effects of immune suppression, blood glucose increase, and peptic ulcer.² Neurotrophic if consumed continuously can also cause gastrointestinal disorders.

CONCLUSION

Acupuncture should be considered as one of the therapeutic treatments for iatrogenic facial nerve paralysis.

Its effects on the patients, especially neurogenesis and anti-inflammatory processes, can be explained by scientific evidence. In neurogenesis acupuncture stimulates the expression of neurotransmitters, neuropeptides, neurotrophic, and growth factors, while in the anti-inflammatory process it stimulates IL-10, IL-4, c-Fos and reduces levels of TNF-a, IL-1b, cyclooxygenase-2.

ACKNOWLEDGMENT

The authors thank Arsita Eka Prasetyawati, MD, for her assistance in writing this case report.

INFORMED CONSENT

Written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article.

ETHICAL STATMENT

Our institution does not require ethical approval for re- porting individual cases or case series.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

No funding was received for this article.

REFERENCES

1. Yoshioka N, Rhoton AL. Atlas of the Facial Nerve and Re- lated Stuctures, 1st ed. New York: Thieme Medical Pub- lishers, Inc.; 2015.

2. Masterson L, Vallis M, Quinlivan R, et al. Assessment and management of facial nerve palsy. BMJ. 2015;351:

h3725.

3. Hohman MH, Bhama PK, Hadlock TA. Epidemiology of iatrogenic facial nerve injury: A decade of experience. Lar- yngoscope. 2014;124(1):260–265.

4. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. 2015;27(1):109–124.

5. Liu F, Granquist EJ. Retrospective study of facial nerve function following temporomandibular joint arthroplasty using the endaural approach. J Oral Maxillofac Surg. 2013;

71(9):e94.

6. Reitzen SD, Babb JS, Lalwani AK. Significance and reli- ability of the House-Brackmann grading system for regional facial nerve function. Otolaryngol Head Neck Surg. 2009;

140(2):154–158.

7. Nam MH, Ahn KS, Choi SH. Acupuncture Stimulation In- duces Neurogenesis in Adult Brain, 1st ed. In: Bai-Yun Z, Kaicun Z, Fan-rong L. Neurobiology of Acupuncture, Else- vier, Inc.; 2013.

8. Shin HK, Lee SW, Choi BT. Modulation of neurogenesis via neurotrophic factors in acupuncture treatments for neurological diseases. Biochem Pharmacol. 2017;141:132–

142.

9. Aguilar-Arredondo A, Arias C, Zepeda A. Evaluating the functional state of adult-born neurons in the adult dentate gyrus of the hippocampus: From birth to functional integration. Rev Neurosci. 2015;26(3):269–279.

10. Lee SMK, Lee S, Park JH, Park JJ, Lee S. A close look at an integrative treatment package for Bell’s palsy in Korea.

Complement Ther Clin Pract. 2017;26:76–83.

11. Lu L, Zhang XG, Zhong LLD, et al. Acupuncture for neurogenesis in experimental ischemic stroke: A systematic re- view and meta-analysis. Sci Rep. 2016;6:19521.

12. Xiao LY, Wang XR, Yang Y, et al. Applications of acupuncture therapy in modulating plasticity of central nervous system. Neuromodulation. 2018;21(8):762–776.

13. da Silva MD, Guginski G, de Paula WMF, Baggio CH, Marcon R, Santos ARS. Involvement of interleukin-10 in the anti-inflammatory effect of Sanyinjiao (SP6) acupuncture in a mouse model of peritonitis. Evid Based Complement Altern Med. 2011:2011:217946.

14. da Silva MD, Bobinski F, Sato KL, Kolker SJ, Sluka KA, Santos ARS. IL-10 cytokine released from M2 macrophages is crucial for analgesic and anti-inflammatory effects of acupuncture in a model of inflammatory muscle pain. Mol Neu- robiol. 2015;51(1):19–31.

15. Bian Y, He X, Hu S, et al. Functional connectivity modulation by acupuncture in patients with bell’s palsy. Evid Based Complement Altern Med; 2016:2016:5928758.

16. Kong SP, Tan QW, Liu Y, et al. Specific correlation between the hegu point (LI4) and the orofacial part: Evidence from an fMRI study. Evid Based Complement Altern Med. 2015;2015:

585493.

(7)

17. Nam MH, Yin CS, Soh KS, Choi SH. Adult neurogenesis and acupuncture stimulation at ST36. J Acupunct Meridian Stud.

2011;4(3):153–158.

18. Nam MH, Ahn KS, Choi SH. Acupuncture: A potent therapeutic tool for inducing adult neurogenesis. Neural Regen Res. 2015;10(1):33–35.

19. Lim HD, Kim MH, Lee CY, Namgung U. Anti-inflammatory effects of acupuncture stimulation via the vagus nerve. PLoS One. 2016;11(3):1–15.

20. Wang F, Cui GW, Kuai L, et al. Role of acupoint area col- lagen fibers in anti-inflammation of acupuncture lifting and thrusting manipulation. Evid Based Complement Altern Med.

2017:2017:2813437.

Address correspondence to:

Dwi Surya Supriyana, MD, MKes, SpAk Medical Acupuncture Division, UNS Teaching Hospital Faculty of Medicine Universitas Sebelas Maret Ahmad Yani Street No. 200, Makamhaji, Kartasura, Sukoharjo, Central Java Surakarta 57161 Indonesia

E-mail: [email protected];

[email protected]