Ramsay Hunt Syndrome (RHS) is a disorder of the geniculate ganglion that is caused by Herpes zoster virus. It occurs when the latent infection of varicella-zoster virus in the geniculate ganglion is reactivated, and causes inflammation in the nerve cells [1]. Typical symptoms of RHS are facial nerve paralysis, vesicular exanthema in the external auditory canal and other cortical areas, and mucous membranes of the mouth and pharynx, causing dizziness and hearing loss [2]. In addition, RHS exhibits brain-neuropathy symptoms, viral infection symptoms, auditory irritation, abnormal sensations of the neck, and pain that tends to be greater than that of Bell’s palsy [3]. In clinical practice, RHS is diagnosed during a medical, neurological and Digital Infrared Thermographic Imaging (DITI) or magnetic resonance imaging, if necessary [4]. The rates of autotherapy and complete recovery of Bell’s palsy are approximately 70% and 95%, respectively, whereas those of RHS are approximately 30% and 60%, respectively [1]. In addition, owing to a higher probability of complete degeneration of the nerve cells in RHS compared with Bell’s palsy, prevention of permanent deformation by facial nerve paralysis is an important treatment goal [4]. In Korean medicine, although active research on Bell’s palsy has been conducted, there is a lack of research on RHS treatment.

Sinbaro3 pharmacopuncture is mainly composed of Harpagide and cinnamic acid produced by hydrolysis of the secondary root of Harpagophytum procumbens [5]. Sinbaro3 inhibits the release, synthesis and production of inflammatory mediators including histamine, polypeptides, kinins, and prostaglandins, which are recruited to inflammatory sites [6]. It has been suggested that Sinbaro3 pharmacopuncture may possess analgesic properties and promote anti-inflammatory actions. Yun et al [7] and Park et al [8] have reported beneficial treatment effects on musculoskeletal disorders using Korean medicine in combination with Sinbaro3 pharmacopuncture. However, these treatment modalities have been limited to musculoskeletal disorders and have not been used in the treatment of patients diagnosed with RHS. Here we report the case of a patient diagnosed with RHS, an inflammatory facial nerve paralysis. The patient was treated using Korean medicine in combination with Sinbaro3 pharmacopuncture over the 15-day period of hospitalization and showed improvement of symptoms.

RHS is the result of reactivation of latent varicella-zoster virus in the sensory ganglion of patients with a previous history of varicella-herpes zoster virus infecting the geniculate ganglion. The disease is characterized by peripheral facial nerve palsy with blistering pain in the face, or around the ears. In addition, paralysis of the fifth, seventh, and eighth cranial nerves is frequent; however, it is rare in the fourth, sixth, ninth, tenth, and eleventh cranial nerves, leading to various symptoms such as hearing loss, tinnitus, dizziness, and nystagmus [10]. RHS is also referred to as Herpes zoster oticus because it is a lymphoid inflammatory disease of the facial nerve, and paralysis in the facial canal, which is not limited to the geniculate ganglion [11].

In Western medicine, oral steroids and antiviral agents are used for the improvement of paralysis, and the treatment of the Herpes infection, respectively, and facial nerve decompression is used for relief from nerve edema and postherpetic neuralgia. However, all of these are limited to the treatment of symptoms [12]. Antivirals and steroids may promote the treatment of Herpes zoster, but their effects on facial nerve palsy and postherpetic neuralgia recovery are unclear [13-15].

Most case reports in Korean medicine are limited to Bell’s palsy, and there is a lack of published case reports on RHS. Korean medicine including pharmacopuncture was effectively used for the treatment of facial nerve palsy compared with treatment excluding pharmacopuncture. It has been reported that treatment using Korean medicine including pharmacopuncture, resulted in beneficial improvements in the patient [16]. This study aimed to test the hypothesis that Korean medicine including Shinbaro3 pharmacopuncture would help to improve the symptoms of RHS. The pharmacopuncture was prepared via hydrolyzing Harpagophytum procumbens, which had been reported to be effective against inflammatory and painful diseases, degenerative diseases of musculoskeletal system, arthritis, and rheumatoid arthritis [5,17,18]. The patient received acupuncture and electroacupuncture, in combination with Sinbaro3 pharmacopuncture, and was prescribed herbal medicine treatments comprising the Kamidaibo decoction, which has an immunity-enhancing action [19].

After 15 days of inpatient treatment, the NRS score, which was applied to evaluate postherpetic neuralgia, decreased from a score of 6.0 at admission, to 2.0 at discharge, indicating that the treatment modality may have helped in pain relief. Furthermore, the House–Brackmann facial grading scale improved from Grade V to Grade II during hospitalization, and Yanagihara’s unweighted grading system improved from a score of 6.0 at admission, to 22.0 at discharge, suggesting improvement in facial paralysis. In addition, dizziness improved by 50% at discharge, and hearing loss, nystagmus, and abnormal facial sensation were improved by 80%. DITI was performed on the next day of hospitalization, and at discharge, to evaluate the degree of objective symptom improvement and prognosis. Bae et al [20] reported that the prognosis was worse when the temperature of the paralyzed side was lower than the unaffected side, and the prognosis was better as the temperature increased. In this study, the values obtained by subtracting the temperature from the left side to the right side of 6 acupoints were compared. Before treatment, the temperature of the left side acupoints were lower than that of the right side, except for TE17. After treatment, however, the temperature of the left side acupoints was higher than that of the right side, except for ST03. The ST03 temperature on the left side, however, was closer to the right value. This suggested that the prognosis of facial nerve palsy may improve after treatment.

In this study, the first case has been reported of a patient with RHS who has experienced improvement of facial nerve palsy, postherpetic neuralgia, hearing loss, dizziness, and other discomforts after receiving Korean medicine treatments including Sinbaro3 pharmacopuncture. However, the facts that the patient’s position and posture are not exactly the same and that the person directly sets the location and size of the ROI box are limitations of this study because it may make the DITI result different. In addition, it could be possible that the improvement in symptoms was not due to Korean medicine treatments, but natural progression, or the latent effect of previous Western medicines. Moreover, the effectiveness of a single treatment method cannot be isolated because several Korean medicine treatments were applied to only one patient. Due to these limitations, further studies of the comparative effect will be needed as well as more case reports.