Facial paralysis refers to a problem in the function of the facial nerve that moves the muscles of the face, resulting in paralysis of the face. According to statistics from the US National Institutes of Health, the annual incidence of facial palsy is 15-20 per 100,000, with 40,000 new cases per year, with a lifetime risk of 1 in 60 and a recurrence rate of 8-12%. 70% of patients recover completely without treatment¹⁾. There is no gender or racial preference, but paralysis can occur at any age more cases are seen in middle-aged and older adults, with a median age of onset of 40 years or elder^2,3).

When facial paralysis occurs, the degree of movement of the facial muscles on one side is reduced, so that both sides become asymmetric when moving the face. In oriental medicine, it is called “Guanwasa”, and facial paralysis may or may not have a specific cause that caused it.

Depending on the location of the lesion of the facial nerve, it is divided into central facial palsy due to lesions in the brain caused by stroke or trauma and peripheral facial palsy caused by problems with peripheral nerves.

Central facial palsy is characterized by the ability to wrinkle the forehead on both sides and to close both eyes. In addition, it may accompany systemic symptoms such as upper and lower hemiplegia, sensory deterioration, and language disorder.

Peripheral facial paralysis is divided into idiopathic facial palsy and Ramsay Hunt syndrome caused herpes zoster, etc. depending on the cause. In the case of Ramsay Hunt syndrome, pain in the mastoid area 2-3 days before the onset is common, and it is known that the prognosis of paralysis is not good compared to idiopathic facial palsy^4,5).

Currently, the exact cause of facial paralysis is not known, but it is known to be caused by inflammation of the facial nerve in the geniculate ganglion such as due to viral infection, etc. and it is generally accepted as pathological mechanism that is disrupted blood supply of the facial nerve by inflammation, as result of demyelination and compression of axon^4-6).

For western treatment, patients are prescribed such as Corticosteroids or Antivirals for facial palsy at the acute stage. Within 3 days after the onset of the palsy, Prednisone in a class of medications called corticosteroids is used to treat the patient taking it from 60 mg for 10 days gradually reducing the dose. Antivirals such as valacyclovir (Valtrex) or acyclovir (Zovirax) are also used together with prednisone⁷⁾. For external use, patients who have difficulty closing their eyes on the side of the paralyzed face are advised to attach an eye patch, prescribe a lubricating fluid, and use eye ointment at night to help dry eyes⁸⁾. Physical therapy such as massage or exercise of facial muscles is performed to prevent the paralyzed face from becoming hard or contracted and remaining permanently. In severe cases, surgical treatment may be performed to open up the facial nerve passage and release the pressure, but there is a risk of permanent damage to the facial nerve and auditory nerve⁹⁾.

There are acupuncture treatments for facial paralysis includes such as acupuncture, herbs, Tui-Na manual techniques, pharmacopuncture, cupping therapy. As acupuncture treatment methods include Jung-An acupuncture, Mi-So facial rejuvenation acupuncture, Thread-Embedding acupuncture can be used. There are numerous cases reported with treating using pharmacopuncture as most commonly using Bee venom and Hominis placenta^10-14).

The effect of acupuncture are well known, however studies detailing which areas to stimulate and how to stimulate them were lacking.

The RSN acupuncture method of the Korean Medical Society of Soft Tissue Medicine aims to address this issue by using precise anatomical knowledge to perform acupuncture or Acupotomy techniques at the origin and insertion points or muscle attachment points of individual muscles or stimulate the point of the nerve outlet⁵⁾. Therefore, it is necessary to be familiar with the anatomical location of the muscles and nerves of the face to perform RSN acupuncture method.

The recovery rate of facial paralysis can be negatively affected by several factors, including delayed initial recovery, older age, positive pain in the back of the ear, diabetes or high blood pressure, and severe nerve damage on a nerve conduction test. If facial paralysis does not fully recover, the aftereffects may include contraction and shortening of facial muscles, as the rigidity of the facial muscles prevents normal movement. This commonly leads to deeper wrinkles between the mouth and nose, and the corners of the mouth curling up less on the affected side of the face than on the unaffected side. As the facial nerve regenerates, symptoms such as adhesion or incorrect connection may arise, resulting in synkinesis. Synkinesis is the combined movement of facial expression muscles that move simultaneously when smiling or closing the eyes. Tearing during eating is also a symptom that may occur during the process of recovering fibers of the damaged facial nerve. This happens when nerves that are supposed to go to the salivary glands are incorrectly connected to the tear glands, resulting in tears when eating. In addition, facial spasm, abnormal expression, loss of taste, abnormal pronunciation, and facial asymmetry may be mentioned.

The degree of peripheral facial palsy can be diagnosed and observed using the House-Brackmann facial nerve grade or the Sunnybrook Scale. House-Brackmann facial nerve grade can be classified from stage 1 to stage 6 according to the degree of facial nerve paralysis. As the level of the paralysis increases the possibility of post-effects due to facial paralysis increases, so it is recommended to actively seek treatment in the early stages¹⁵⁾.

Accordingly, the author actively utilized the acupoints of the RSN acupuncture method of the Korean Medical Society of Soft Tissue Medicine, which was comprehensively organized for the anatomical structure of the acupoints, especially for patients with peripheral facial palsy who visited our office. Also, we tried to shorten the treatment time by using Electro-Acupuncture and cupping therapy. We tried to find out the progress of this treatment using the HBGS grading system.

1. Patient selection

Among the patients who visited our office between December 1, 2022 and January 31, 2023, patients with idiopathic facial palsy were selected.

A total of 2 patients were selected, and both patients were needled on the RSN acupuncture acupoints and electro-acupuncture was used. Cupping was performed after acupuncture.

2. General characteristics

Both selected patients were women in their 40 s. One patient had left facial palsy, and another had right facial palsy. Factors that could affect the patient’s prognosis were examined, including blood pressure (Hypertension) and pain around the ear. Both patients were prescribed oral steroids and antibiotics within 3 days of onset prior to the visit to our office and took them for 10 days (Table 1).

Table 1 . Summary of the clinical information and descriptive statistics in patients with Bell’s palsy.

Variable	Case 1	Case 2
Gender	Female	Female
Age	45 yrs old	43 yrs old
Affected side of face	Left	Right
Hypertension	Present	Absent
Postauricular pain	Present	Absent
Vertigo	Absent	Absent
Onset	12/05/2022	12/25/2022
Initial HBGS grading	VI	V

3. Inclusion criteria

Patients were selected who went to an urgent care and was diagnosed for Bell’s palsy within a week from the onset. Treatment was conducted twice a week for the first two weeks, and then once a week from the third week onwards.

4. Exclusion criteria

Patient with more than 1 month of onset were judged to have already passed the acute stage and were excluded from the study. Patients with central facial palsy or other factors were excluded.

5. Assessment methods

1) House-Brackmann Grading System (HBGS) (Table 2)

According to the overall symptoms of facial paralysis, it can be divided into stages 1-6 according to the following criteria. This criterion is not limited to the face but is widely used as an indicator that can evaluate the overall degree of paralysis symptoms and compare the improvement level. This evaluation method is relatively simple and can shorten the time. The contents of HBGS are shown in Table 2¹⁶⁾.

Table 2 . House Brackmann grading system.

Grade	Definition
I	Normal symmetrical function in all areas.
II	Slight weakness noticeable only on close inspection.
	Complete eye closure with minimal effort.
	Slight asymmetry of smile with maximal effort.
III	Obvious weakness, but not disfiguring.
	May not be able to lift the eyebrow.
	Complete eye closure and strong but asymmetrical mouth movements or spasms.
IV	Obvious disfiguring weakness.
	Inability to lift the eyebrow.
	Incomplete eye closure and asymmetry of the mouth with maximal effort.
V	Motion barely perceptible.
	Incomplete eye closure, slight movement of the corner of the mouth.
VI	No movement, loss of tone, no synkinesis, contracture, or spasms.

6. Treatment methods

1) RSN acupuncture points

(1) Muscles of the face

Facial muscles can be functionally divided into masticatory muscles and facial expression muscles. The masticatory muscles are innervated by the trigeminal nerve, and include the temporalis, medial and lateral pterygoid muscle, and masseter muscle. Expression muscles are under control of the facial nerve and can be divide into superficial and deep muscles depending on the location of the muscles and how the facial nerve branches and controls these muscles. The superficial muscle is controlled by the facial nerve that runs below the muscle, and Facial nerve ramifies the deep muscles as it progresses over their surface (Fig. 1).

Figure 1. Layers of facial muscles.

The RSN acupuncture treatment point places the patient in the supine or lateral position and treats the origins and insertions of the muscles including frontalis, corrugator, temporalis, orbicularis oculi, levator labii superioris alaeque nasi, levator labii superioris, levatorangulioris, zygomaticus minor, zygomaticus major, depressor labii inferioris, and risorius (Table 3).

Table 3 . Facial muscles’ origin and insertion.

Name of muscles	Origin	Insertion
Frontalis	Galea aponeurotica	Subcutaneous tissue of eyebrows
Corrugator supercilii	Supraobital ridge	Subcutaneous tissue of eyebrows
Nasalis	Maxilla	Nasal bone
Procerus	From fascia over the lower part of the nasal bone	Into the skin of the lower part of the forehead between the eyebrows
Levator labii superioris	Medial infra-orbital margin	Labii superioris
Levator labii superioris aleque nasi	Nasal bone	Nostril and upper lip
Zygomaticus minor	Zygomatic bone	Skin of the upper lip
Zygomaticus major	Anterior of zygomatic bone	Modiolus of the mouth
Orbicularis oris	Maxilla and mandible	Skin around the lips
Buccinator	Alveolar processes of maxilla and mandible	Orbicularis oris
Risorius	Parotid fascia	Modiolus
Depressor anguli oris	Tubercle of mandible	Modiolus
Depressor labii inferioris	Mandible and the mental foramen	Orbicularis oris fibers
Mentalis	Anterior mandible	Chin
Masseter	Zygomatic arch	Angel and lateral surface of ramus of mandible
Temporalis	Temporal lines on the parietal bone of the skull and the superior temporal surface of the sphenoid bone	Coronoid process of the mandible
Medial pterygoid	Medial side of lateral pterygoid plate	Medial angle of the mandible
Lateral pterygoid	Infratemporal surface of sphenoid bone and lateral pterygoid plate	Anterior side of the condyle and pterygoid fovea

(2) Occipital muscles

To treat the occipital region, the RSN acupuncture place the patient in the abdominal position or lateral position, and palpate and treat the points focused on where the patient complains of severe tenderness at the origin and insertion muscles in the case of superficial muscles, the trapezius, splenius capitis, sternocleidomastoids, and in case of deep muscle, obliques capitis superior, obliques capitis inferior, rectus capitis posterior major, rectus capitis posterior minor⁵⁾.

(3) The courses and innervations of facial nerve

The facial nerve passes through the stylomastoid foramen, exits the base of the skull, and then enters the parotid gland. Once within the parotid gland, it divides into upper and lower branches. When it exits the parotid gland, it further divides into five branches: the temporal (frontal), zygomatic, buccal, marginal mandibular and cervical branches^16,17).

Generally, the temporal branch has 2-3 branches, the zygomatic branch has 4-5 branches, the buccal branch has 3 branches, the marginal mandibular branch has 2-3 branches, and the cervical branch has 2-3 branches (Fig. 2, Table 4)^5,17) .

Table 4 . Facial nerve’s branch and muscle innervations.

Name of branch	Muscle
Temporal branche	Frontalis, Orbicularis oculi, Corrugator supercilii
Zygomatic branches	Orbicularis oculi
Buccal branches	Orbicularis oris, Buccinator, Zygomaticus
Mandibular branches	Mentalis, Depressor labii inferioris, Depressor anguli oris
Cervical branches	Platysma

Figure 2. Shape and distribution of facial nerves.

(4) RSN methods

In RSN methods, in the case of nerve outlets, superior trochlear nerve, supraorbital nerve, zygomaticofacial nerve, infraorbital nerve, mental foramen is stimulated. It is also a rule to palpate and treat the muscle belly where there is contraction or induration. Corresponding acupuncture points include GB14, Ex-HN4 (Yuyao), BL2, TE23, GB1-2, GB1-3, ST2 in orbit region, include SI18-2, SI8-1, GB3 in the zygoma region, and also include mental foramen, ST5, master muscle in mandible region (Table 5).

Table 5 . Facial nerve’s branch and RSN point locations.

Name of branch	RSN points
Temporal branches	Frontalis m, corrugator supercilii m, temporalis m, orbicularis oculi m, supraorbital n, GB14, Ex-HN4 (Yuyao), TE23, GB2-2, GB2-3, ST2
Zygomatic branches	Orbicularis oculi m, levator labii superioris alaeque nasi m, zygomaticus major m, zygomaticus minor m, zygomaticofacial n, infraorbital n, SI18-2, SI18-1, GB3
Buccal branches	Levator labii superioris m, levator anguli oris m, risorius m
Mandibular branches	Depressor labii inferioris m, depressor anguli oris m, mental foramen, ST5, masseter m
Cervical branches	Platysma
Posterior auricular branches	Trapezius, splenius capitis, SCM, obliquus capitis superior, obliquus capiti inferior, rectus capitis posterior major, rectus capitis posterior minor

2) Acupuncture points and methods

Two types of gamma-ray sterilized KM disposable needles (KMS corp., Cheonan, Korea), 0.20×30 mm and 0.30×60 mm, were used according to the needle points. Focusing on the muscle and nerve outlet points listed above, the treatment points were selected according to the patient’s symptoms on the paralyzed side of the face and retained for 20 minutes. The points were pressed for 10-20 seconds with cotton balls when the needles out to prevent bleeding or bruises.

(1) Temporal branches (frontal branches)

- BL2, GB14: acupuncture was performed on the tender points where the superior trochlear and supraorbital nerves passed.

- TE23: the point overlapped where supraorbital nerve outlet and temporal branch of facial nerve, needling superficially toward inward, palpate the pulse of the blood vessels passing down and avoid it.

- Between EX-HN5 (Taiyang)-GB1 (above GB3): needling toward the eyeball at the point overlapped where zygomatic branch of facial nerve and zygomaticofacial nerve of maxillary nerve of trigeminal nerve.

- Temporals fascia was divided to 4 regions and needling superficially toward the ear.

(2) Zygomatic branches

- ST1: acupuncture was performed on the tender point closed to the infraorbital nerve.

- LI20, ST3, SI18, ST7: the points are area of the muscles of levator labii superioris aleque nasi, zygomaticus minor, zygomaticus major corresponded to the zygomatic branch of facial nerve.

(3) Buccal branches

- ST3, ST4: needling toward ST7 superficially with 0.30×60 length of needle.

(4) Mandibular branches

- ST6: the point is relevant to buccal branch of facial nerve, palpate the tender point, acupuncture was performed pass over the parotid gland.

- ST5: the point is relevant to mandibular branches of facial nerve, acupuncture was performed on the tender point.

- Mental foramen: the point is relevant to ramus of mandible of trigeminal nerve.

(5) Cervical branches

- TE17: the point is relevant to cervical branch of facial nerve, was inserted deeply enough to feel a little tingling at the tender spot.

(6) Posterior auricular branches

- Needles are inserted superficially, divided the compartment, toward the ear from the behind the ear, the point locations could be GB9, GB10, GB11, GB12.

(7) Occipital region

- Needles are penetrated on the insertion of SCM, semispinalis capitis, upper trapezius, splenius capitis, and C1 transverse process.

3) Electro-Acupuncture method

ITC Partner-1 Electro Stimulator (ITC Co., Ltd., Daejeon, Korea) was used with setting of mix mode, mix frequency 15-90 Hz.

Electro-Acupuncture was performed for 20 minutes on the sets of TE23-BL2, SI18-LI20, ST7-TE17, mental foramen-ST6, and GB20-BL10 (Fig. 3).

Figure 3. Electro-Acupuncture for treating facial palsy.

4) Cupping therapy

It diagnoses, prevents, and treats diseased by suction the cupping to the body surface to remove the air inside the cupping and generating negative pressure to cause congestion or elution. In addition, negative pressure stimulated capillaries to reduce deoxygenated hemoglobin in the blood, increase oxygenated hemoglobin, increase vascular density and oxygen saturation, increase metabolism, and help regenerate tissue in the negative pressure area. It is actively used for idiopathic peripheral facial palsy^18-24).

A cup with a cupping radius of 1 inch was used. Suction was performed once slightly, starting from the center of the side of nose and pulling toward the ear, but the cupping did not pull the skin for more than 1 second. If the skin is pulled with excessive pressure or for more than 1 second, cupping marks remain on the face and do not disappear for a long time, and may remain for up to several weeks, so cupping would be a light tug to quickly move and release. Instead, cupping per the area was repeated for 3-5 times to give the effect of massaging the superficial fascia (Fig. 4).

Figure 4. (A) The facial lymphatic system. (B) Direction of facial cupping. (C) Facial cupping.

5) Results

(1) Case 1

① Patient information

45 yrs old female. 5’ 1’’, 210 lbs.

② Patient history and diagnosis

Patient felt the sense of impotence on the left side of face since December 5th, 2022; she was not able to close her left eye, the mouth crooked to right side. Patient came to the office with cotton balls in both ears. Immediately after the onset, steroids and antibiotics were prescribed for a week. Patient had a history of hypertension and was measured at 140/90 mmHg at the initial visit.

Patient had pain in left ear, but it was confirmed by her primary doctor that there was no inflammatory reactionduring examination. She was not able to wrinkle on the left forehead at all, was hardly close her left eye, the lip was not able to be closed and was titling to right side when she speaks “Ah””Eh””I””Oh” and “Woo”. Even in the resting state, the angle of the left lip was dropped. The tongue appeared to be tilted to the right when she pulled out her tonguetotongue diagnosis. She was shocked mentally by the distorted face, showed emotionally unstable appearance, and was very worried that the face would not be returning. She complained of a stiffness and pulling sensation in the back of neck.

There were symptoms such as the wrinkle on one side of the forehead not forming, the left eye not closing, and the left eyebrow being unable to lift. In addition, movements for sounds such as “Ah””Eh””I””Oh” and “Woo” were minimal compared to the right side of the face. The patient complained of ear pain, but there were no changes in her sense of smell or hearing, nor did she experience dizziness or tinnitus. Because there were no blisters or inflammation in her ear, Ramsay Hunt syndrome was ruled out, and she was diagnosed with peripheral facial nerve palsy. HBGS grade: VI.

③ Treatments

It was planned to visit twice a week for the first two weeks and once a week from the third week during December 8th, 2022 to January 10, 2023. If the symptoms change, diagnosis and treatments were performed accordingly.

④ Progress

i) 12/08/2022

The above treatment points were retained Electro-Acupuncture for 20 minutes with supine or side lying position, removed needles, were retained manual acupuncture for 10 minutes on the occipital area with prone position. When the patient was not making an expression, the tip of the left lip was slightly lowered compared to the right. Sagging of the left lip was observed as the distance between the center of the lip and nasolabial folds appeared wider. She could not close her left eye at all, could not lift her left eyebrow, and did not move her left lip at all when making facial expressions. Result: Comparison of before and after treatment showed no significant change (HBGS grade: VI).

ii) 12/12/2022

The patient stated that she was not able to see any changes from the first treatment. She was still not able to close her left eye at all, was not able to lift her left eyebrow. When she was not making an expression, the tip of the left lip was slightly lower compared to the right. After taking a picture, it was seen that the left corner of the mouth began to move slightly, but the change was very slight (HBGS grade: V).

iii) 12/20/2022

The patient was able to lift her left eyebrow slightly. She said she felt a tingling sensation on the left side of her face. She felt that the pulling symptom in the left neck was considerably relieved. She was happy because she had hope that her face would gradually improve.

The asymmetry of the lip was noticeable when her face was expressionless, and although she was able to close her eye with force, she still complained of discomfort in her eyes while sleeping. She was able to lift her left eyebrow about 20%. The tongue was still tilted to the right (HBGS grade: IV).

iv) 12/27/2022

It improved to the point where it was difficult to immediately recognize the distorted face when not making expressions, but the muscles on the left cheek seemed to have less strength than the right. When smiling, the shape of both eyes was seen about 70% similar. The eyebrows could be lifted with more force, and it was seen the forehead wrinkles were made 50% symmetrical when comparing both sides. The eyes closed, but not with the same force. Also, when she smiled, she was able to make about 30% of the expression on her left cheek (HBGS grade: III).

v) 01/02/2023

The patient was showing a smile from the time of visit and throughout the treatment. The eyebrows were able to lift more symmetrically on both sides, and there was an approximately 80% improvement in facial movements when smiling (HBGS grade: II).

vi) 01/10/2023

At the time of the visit, the patient was thinking herself that it is very hard to tell which side had the lesion (HBGS grade: I).

It was hard to see when closing and opening the eyes, raising the eyebrows, and smiling were the same as the healthy side, so the chart was checked again to see which side had the lesion. The treatment was not performed on the face, but rather on the patient’s back of the head and lower back, which had been experiencing discomfort. The patient was discharged. The tongue still showed tilted to the right side at discharged (Table 6, Fig. 5).

Table 6 . HBGS grading score for case 1.

Date	Symmetry at rest	Eye(s)	Mouth	Forehead	Synkinesis	HBGS grade
12/08/2022	Asymmetry	Incomplete closure	No movement	No movement	Absent	VI
12/12/2022	Asymmetry	Incomplete closure	Minimal movement	No movement	Absent	VI
12/20/2022	Asymmetry	With effort, complete closure	Asymmetrical with maximum effort	Slight movement	Absent	IV
12/27/2022	Symmetry but weak tone on the affected side	With effort, complete closure	Slightly affected with effort	Slight to moderate movement	Absent	III
01/02/2023	Symmetry but weak tone on the affected side	Complete closure	Slightly asymmetrical	Reasonable function	Absent	II
01/10/2023	Symmetry with tone	Complete closure	Normal	Normal	Absent	I

Figure 5. Progress for case 1 (45 years old female).

(2) Case 2

① Patient information

43 yrs old female. 5’ 4’’, 179 lbs.

② Patient history and diagnosis

On December 24, 2022, there was a tingling feeling on the right side of the face, but she thought she would be tired from spending year-end. On the morning of December 25th, she found her face was turn to one side when she woke up in the morning. She said that she could not close her right eye, her right cheek did not work, her lips and mouth and tongue felt numb, but she could not find the hospital right way because it was the Christmas holiday. There was no pain in the ear and no change in hearing.

On December 26th, she visited urgent care and was prescribed steroids and antibiotics for a week, however there was no change in the face for a week, so she came for acupuncture therapy.

The patient was diagnosed peripheral facial palsy based on the symptoms that wrinkle on one side of the forehead do not form, right eye does not close, and right eyebrow cannot be lifted, and movements for “Ah”“Eh”“I”“Oh” and “Woo” were minimal than the left side of face, and also there was no pain in the ear.

There was no change in the sense of smell and hearing, but there was numbness in the mouth and tongue, and a dry throat was complained of. There was no dizziness or tinnitus, and there were no blisters in the ear, so Ramsay hunt syndrome was ruled out. Diagnosed with peripheral facial nerve palsy. HBGS grade: V.

③ Treatments

It was planned to visit twice a week for the first two weeks and once a week from the third week during January 2nd, 2023 to January 13, 2023. If the symptoms change, diagnosis and treatments were performed accordingly.

④ Progress

i) 01/02/2023

It was shown that the right eyebrow was placed slightly lower than the left when she is not making facial expressions. The tip of the left lip was slightly lowered compared to the right. Patient could not to close her right eye, could not raise the right eyebrow, and did not move her right lip at all when making facial expressions. Result: Comparison of before and after treatment showed no significant change. Based on the experience of the patient in the above case, the outcome was good, the patient was encouraged to hold cotton balls in the ears (HBGS grade: V).

ii) 01/06/2023

The patient stated that she started to have a twitching sensation in the right side of the neck. It was observed that the right eyebrow was placed slightly lower than the left when she is not making facial expressions. The tip of the right lip was slightly lowered compared to the left. She was able to lift her right eyebrow slightly, the right lip started to move to the right about 10% when making “Eh” and “I” facial expressions (HBGS grade: IV).

iii) 01/09/2023

The patient stated that she started to have a twitching sensation in the right side of the cheek. She felt like her right cheek is moving little by little.

When she was not making an expression, the tip of the right lip was slightly lower compared to the left.However, the depth of nasolabial fold began to show on the right face as well. She could close her eyes but not with equal force on both sides. She was able to lift her right eyebrow about 30%, the right lip started to move to the right about 30% when making “Eh” and “I” facial expressions (HBGS grade: III).

iv) 01/13/2023

The patient reported that she felt more movements of the right side of her face. She started to feel a poking sensation in the lower jaw area, but said it was not discomfort. She could close her eyes with equal force on both sides. She was able to lift her right eyebrow about 30%, the right lip started to move to the right about 30% when making “Eh” and “I” facial expressions. It was shown that 70% of the lips look the same on both sides when laughing or pronouncing “Eh”“I”“Oh” and “Woo” (HBGS grade: II).

v) 01/19/2023

When there is no expression, both sides look the same, and eye closing, and expression muscle movements showed the same movements as the unaffected side. But she said that the numbness of the tongue stillremained a little. 90% of the lips were the same on both sides when pronouncing “Eh” and “I”, and the movements were similar to that of the unaffected side, with almost no difference when she is smiling (HBGS grade: I) (Table 7, Fig. 6).

Table 7 . HBGS grading score for case 2.

Date	Symmetry at rest	Eye(s)	Mouth	Forehead	Synkinesis	HBGS grade
01/02/2023	Asymmetry	Incomplete closure	No movement	No movement	Absent	V
01/06/2023	Asymmetry	Incomplete closure	Minimal movement	Mild movement	Absent	IV
01/09/2023	Asymmetry with weak tone on the affected side	With effort, complete closure	Asymmetrical with maximum effort	Slight movement	Absent	III
01/13/2023	Symmetry but weak tone on the affected side	Complete closure	Slightly affected with effort	Moderate movement	Absent	II
01/19/2023	Symmetry with tone	Complete closure	Slightly asymmetrical	Normal	Absent	I

Figure 6. Progress for case 2 (43 years old female).

Facial nerve palsy is a disease caused by damage to the seventh cranial nerve, the facial nerve, and the main symptom is paralysis of the facial muscles on the damaged side.

Facial palsy is differentiated into central and peripheral palsy. In central palsy, the lesion is located in the upper part of the nerve nucleus, and in peripheral palsy, the lesion is located in the lower part of the nerve nucleus. Central and peripheral facial palsy can be identified by the presence or absence of wrinkles on the patient’s forehead. Facial paralysis, as the name suggests, is paralysis of the facial muscles, but other symptoms such as loss of taste in the front 2/3 of the tongue, hearing impairment, pain in the ear, tears or salivary secretion may occur¹⁷⁾.

The cause of these symptoms is paralysis of the ‘facial nerve’. In addition to Bell’s palsy, which is the most common cause, head trauma, herpes zoster oticus, tumors, and infections can also be the cause.

The facial nerve is largely divided into two, the first is the sensory nerve and the second is the motor nerve. The sensory nerve in charge of the facial nerve is responsible for taste in the anterior 2/3 of the tongue, and the trigeminal nerve is in charge of general sensory except for taste in the anterior 2/3 of the tongue. The glossopharyngeal nerve, the ninth cranial nerve, is responsible for taste and general sensation in the posterior third of the tongue²⁵⁾.

Facial muscles can be functionally divided into masticatory muscles and facial expression muscles. The masticatory muscles are innervated by the trigeminal nerve, and include the temporalis, medial and lateral pterygoid muscles, and master muscles. Expression muscles are controlled by the facial nerve and can be divided into superficial and deep muscles depending on the location of the muscles and how the facial nerve branches and controls these muscles. Superficial muscles are controlled by the facial nerve that runs beneath the superficial muscle, while deep muscles are controlled by the facial nerve that runs on the surface of the deep muscles¹⁷⁾.

Bell’s palsy has four phases based on the progression of symptoms: acute (progressive) phase, plateau phase, convalescence phase, and aftereffect phase. The acute phase typically lasts for a period of seven days after onset, during which the paralysis may worsen. Prognosis can vary depending on the severity of symptoms during this stage. Therefore, it is essential to provide aggressive treatment in the acute phase to prevent serious progression²⁶⁾. Moreover, due to the nature of the disease, the treatment period for Bell’s palsy may be longer depending on the severity of the condition. Some patients may never fully recover, and others may experience aftereffects. In addition, patients often complain of psychological anxiety because of their appearance²⁷⁾. Therefore, minimizing the symptoms of Bell’s palsy, which can progress in the acute phase, should be the main goal of this phase of treatment.

The facial nerve exits from the stylomastoid foramen and branches into the facial muscle, and about 70% of peripheral facial paralysis is caused by unspecified inflammation or swelling of the neural tube or stylomastoid site. Because of this, pain is frequent at the mastoid area in the peripheral facial nerve palsy²⁷⁾. A steroid agent such as prednisone is administered in anticipation of a decompressive effect to reduce the inflammatory response and edema of the facial nerve damaged area in western medicine²⁸⁾.

Patients who visited our clinic, they did not show any improvement even after taking the prescribed medicine, so they came in anticipation of oriental medical treatment. The treatment for the facial palsy is usually performed with acupuncture, herbs, facial Tui-Na manual therapy, pharmacopuncture, and cupping. Among them, the RSN acupuncture method of the Korean Society of Soft Tissue Medicine is treating the patient based on accurate anatomical knowledge, for examples, stimulate the muscle at the point of origin, insertion and attachment with manual acupuncture or acupotomy methods, or stimulate the nerve outlet to increase the effectiveness of treatment. In addition, by using an Electro-Acupuncture, it removes the excessive pressure stress of the tissue and relieves the entrapment of blood vessel and nerve root, the cupping seems to have played a positive role in the recovery of facial nerve paralysis by stimulating viral or aseptic inflammatory lesions to generate new microscopic damage to the tissue, thereby relieving inflammation as the body’s self-repair mechanism.

At the visit, pre-treatment photographs were taken to record changes in facial expression, and progress was observed, such as wrinkles on the forehead, the corners of the mouth moving, and nasolabial fold being the same on both sides. Based on the facial movements, the change in function was examined suing the House-Brackmann Grading Scale. Both patients started Acupuncture treatment within 1 week after onset, and a significant improvement was observed in the HBGS grading scale from V or higher to I with 5 treatments in 3 weeks.

It is judged that the use of Electro-Acupuncture on the RSN points selected on an anatomical basis helped to increased stimulation to individual muscle and nerve outlet, and cupping also helped the recovery of peripheral facial paralysis by helping blood circulation. When not receiving active treatment, the patient put cotton balls in her ears to prevent external temperature changes from affecting her face. So, I wonder if the treatment time could be shorter than I was expected.

This study was conducted based on the hypothesis that stimulation of individual muscles and nerve exit points using RSN acupuncture points and needling, which were selected based on anatomical considerations, as well as adjuvant therapies to improve blood circulation, could help in the recovery of peripheral facial paralysis. The effects were confirmed, and patient satisfaction was achieved through the use of a combination of acupuncture points, needling, herbal medicine, and adjuvant therapies. However, this study has clear limitations. Although patient’s symptoms improved using this treatment method, it is difficult to clearly determine the effects of a single intervention due to the complex treatment. Additionally, the number of cases treated in this study was limited to only two. Nevertheless, it is hoped that this case report will lead to further follow-up studies using the RSN method to treat patients with peripheral facial paralysis, which will ultimately help clarify its effectiveness.

The authors declare no conflict of interest.